Every finding on record at The Lodge at Red Rocks

Based on record review and interviews, the facility failed to maintain accurate and complete medical records for four (#1, #8, #15 and #16) of six residents reviewed out of 16 sample residents.Specifically, the facility failed to ensure that Resident #1, Resident #8, Resident #15 and Resident #16's medications were documented promptly in the residents' medication administration record (MAR) at the time the medications were administered.Findings include: I. Facility policy and procedure The Medication Administration policy, dated 6/20/25, was provided by the director of nursing (DON) on 5/20/26 at 3:10 p.m. It read in pertinent part, Medications are administered as ordered by the physician. Include the six rights of medication administration, including the right time and right documentation. By signing in the MAR after administration.II. ObservationsOn 5/19/26, beginning at 12:06 p.m., licensed practical nurse (LPN) #1 was observed passing medications to residents. LPN #1's electronic medication administration record (eMAR) screen was red, indicating that medications were past due and/or not documented (see interviews below). During the medication administration observation, LPN #1 administered the following medications:LPN #1 administered one Baclofen 10 milligram (mg) tablet, which was scheduled to be administered at 9:00 a.m., and three Lactaid tablets, which were scheduled to be administered at 12:00 p.m., to Resident #1. -However, LPN #1 did not document the 10 mg Baclofen medication as administered until 1:31 p.m. (see record review below).-Additionally, LPN #1 did not document the Lactaid medication as administered until 1:30 p.m. (see record review below).Order: Lactaid fast act tablets 9000 units at noon dose for lactose intolerance.LPN #1 administered an injection of insulin Lispro 5 units, given subcutaneously in the abdomen, which was scheduled to be administered at 11:00 a.m., to Resident #8.-However, LPN #1 did not document the medication as administered until 12:51 p.m. (see record review below).LPN #1 administered one divalproex sodium (Depakote) tablet 500 mg, an antiseizure medication which was scheduled to be administered at 1:00 p.m., to Resident #15-However, LPN #1 did not document the medication as administered until 3:09 p.m. (see record review below).LPN #1 administered one divalproex sodium tablet 500 mg, which was scheduled to be administered at 12:00 p.m., to Resident #16. -However, LPN #1 did not document the medication as administered until 3:13 p.m. (see record review below).III. Resident #1 A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS - autoimmune disorder affects the central nervous system), quadriplegia (paralysis of all four limbs), dysphagia (swallowing disorder), cerebral infarction with right dominant side (stroke left side of the brain), hypertensive heart disease(chronic high blood pressure), cardiac arrhythmia (an issue with the rate or rhythm of the heart beat) and neuromuscular dysfunction of the bladder(nerve damage disrupts the electrical communication signals between the brain, spinal cord, and the bladder). The 3//26/26 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 maximum assistance with bed mobility and transfers. She required maximal assistance with activities of daily living (ADL).B. Record reviewOn 5/21/26 at 10:45 a.m. the regional clinical resource provided a medication administration audit report for Resident #1. The medication administration audit report revealed the following medications for Resident #1 were not documented as administered in a timely manner by LPN #1 on 5/19/26:Levaquin oral tablet 750 mg for urinary tract infection: one tablet one time a day; scheduled at 7:00 a.m. and documented as administered at 1:31 p.m.Norvasc oral tablet 2.5 mg for hypertension: one tablet one time a day; scheduled at 8:00 a.m. and documented at 1:30 p.m. Amiodarone HCL 200 mg tablet for SVT (supraventricular tachycardia - rapid, racing heartbeat); scheduled at 8:00 a.m. and documented as administered at 1:30 p.m.Acidophilus oral capsule give one capsule one time a day for prevention of harmful pathogens; scheduled at 8:00 a.m. and documented as administered at 1:30 p.m.Ascorbic acid oral tablet 500mg: give two tablets twice a day for acidification of urine to prevent urinary tract infection; scheduled at 8:00 a.m. and documented as administered at 1:30 p.m.Aspirin chewable tablet 81 mg: give one tablet once a day to prevent a stroke; scheduled at 8:00 a.m. and documented as administered at 1:30 p.m. Famotidine tablet 20 mg: one tablet twice a day for gastroesophageal reflux disease (GERD), scheduled at 8:00 a.m. and documented as administered at 1:30 p.m.Lactaid fast act tablet 9000 units: three tablets for lactose intolerance; scheduled at 12:00 p.m. and documented as administered at 1:30 p.m.Keppra tablet 500 mg: one tablet twice a day for prevention of seizures; scheduled at 8:00 a.m. and documented as administered at 1:30 p.m.Methenamine hippurate 1 gram, one tablet every twelve hours to prevent urinary tract infection (UTI); scheduled at 8:00 a.m. and documented as administered at 1:31 p.m. Lisinopril 10 mg tablet one time a day for hypertension (HTN); scheduled at 8:00 a.m. and documented as administered at 1:31 p.m.Baclofen 5 mg, one tablet three times a day for MS, scheduled at 12:00 p.m. and documented as administered at 1:31 p.m.Sennosides-docusate sodium tablet 8.5-50 mg: give one tablet twice a day for constipation; scheduled at 8:00 a.m. and documented as administered at 1:31 p.m.Protein modular liquid 30 milliliters (ml) twice daily for wounds; scheduled at 9:00 a.m. and documented as administered at 1:31 p.m.Metoprolol tartrate oral tablet 25 mg: one tablet twice a day for HTN; scheduled at 9:00 a.m. and documented as administered at 1:31 p.m.Baclofen 10 mg tablet twice a day for MS; scheduled at 9:00 a.m. and documented as administered at 1:31 p.m. IV. Resident #8 A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included alcoholic polyneuropathy (damage to the peripheral nerves), thrombocytopenia (low levels of platelets), hepatitis (inflammation of the liver) without ascites, spinal stenosis (narrowing of the spaces within the spine), pancreatitis (inflammation of the pancreas) and diabetes type 2 (the body becomes resistant to insulin, or can not produce enough of it).The 4/17/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required minimal assistance with dressing and hygiene.B. Record reviewOn 5/21/26 at 10:45 a.m. the regional clinical resource provided a medication administration audit report for Resident #8. The medication administration audit report revealed the following medications for Resident #8 were not documented as administered in a timely manner by LPN #1 on 5/19/26:Lispro insulin 5 units subcutaneous before meals, for diabetes; scheduled at 6:30 a.m. and documented as administered at 12:55 p.m.Gabapentin capsule 300 mg, one capsule three times daily for neuropathic pain; scheduled at 7:00 a.m. and documented as administered at 9:08 a.m.Lyrica 25 mg, one capsule, twice daily for neuropathy, scheduled at 9:00 a.m. and documented as administered at 12:56 p.m.Carboxymethylcellulose sodium ophthalmic solution, one drop four times a day in each eye, for dry eye; scheduled at 9:00 a.m. and documented as administered at 2:36 p.m.Lispro insulin 5 units subcutaneous before meals, for diabetes, scheduled at 11:00 a.m. and documented as administered at 12:51 p.m.Carboxymethylcellulose sodium ophthalmic instillation, one drop four times a day in each eye, for dry eyes; scheduled at 1:00 p.m. and documented as administered at 2:36 p.m.Gabapentin capsule 300 mg, one capsule three times daily for neuropathic pain; scheduled at 2:00 p.m. and documented as administered at 4:02 p.m.V. Resident #15A. Resident statusResident #15, age less than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included respiratory failure (lungs can not adequately supply oxygen to the blood), bipolar disorder (mental health condition that causes extreme, cyclical shifts in mood), diabetes type 2 (body is resistant to insulin or cannot produce enough), anxiety (normal stress response), depression (serious mood disorder) and seizure disorder (neurological condition of abnormal electrical activity). The 5/20/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required minimal assistance for set up and clean up with dressing and bathing. He required supervision and cueing to perform ADLs.B. Record reviewOn 5/21/26 at 10:45 a.m. the regional clinical resource provided a medication administration audit report for Resident #15. The medication administration audit report revealed the following medications for Resident #15 were not documented as administered in a timely manner by LPN #1 on 5/19/26:Risperidone 2 mg tablet twice a day for bipolar disorder; scheduled at 7:00 a.m. and documented as administered at 8:57 a.m.Oxcarbazepine 600 mg tablet, one tablet twice a day for seizures; scheduled at 7:00 a.m. and documented as administered at 9:00 a.m.Saccharomyces boulardii capsule 250 mg, give one tablet twice a day for probiotic; scheduled at 7:00 a.m. and documented as administered at 3:07 p.m.Divalproex sodium 500 mg tablet, one tablet three times a day for bipolar disorder; scheduled at 1:00 p.m. and documented as administered at 3:09 p.m.VI. Resident #16 A. Resident statusResident #16, age less than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing a terrifying, deeply traumatic event), diabetes mellitus type 2, anxiety disorder , chronic pain (pain that last for three to six months), hypertension (high blood pressure), epilepsy (seizure disorder), depressive disorder and borderline personality disorder (mental health characterized by intense mood swings).The 4/30/26 MD) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required maximum assistance with dressing and incontinence care. She required maximal assistance with transfers.B. Record reviewOn 5/21/26 at 10:45 a.m. the regional clinical resource provided a medication administration audit report for Resident #16. The medication administration audit report revealed the following medications for Resident #16 were not documented as administered in a timely manner by LPN #1 on 5/19/26:Lidocaine patch 4% applied to bilateral ankles for treatment of pain; scheduled at 7:00 a.m. and documented as administered at 11:53 a.m.Lidocaine patch 4% applied to back topically for pain management; scheduled for 7:00 a.m. and documented as administered at 11:54 a.m.Insulin deglu[DATE] units, subcutaneously, for diabetes; scheduled at 7:00 a.m. and documented as administered at 11:54 a.m.Tirzepatide subcutaneous solution 2.5 mg/0.5 ml, give every Tuesday for diabetes: scheduled at 7:00 a.m. and documented as administered at 3:13 p.m.Polyethylene glycol 3350 powder 17 grams by mouth one time a day in four to eight ounces of fluid; scheduled at 7:00 a.m. and documented as administered at 3:13 p.m.Humalog solution 20 units subcutaneously before meals: scheduled at 11:30 a.m. and documented as administered at 3:49 p.m.Depakote tablet 500 mg, one tablet, three times a day for seizure activity; scheduled at 1:00 p.m. and documented as administered at 3:13 p.m.Buspirone HCL one 10 mg tablet, give two tablets three times a day for anxiety; scheduled at 12:00 p.m. and documented as administered at 3:13 p.m.VII. Staff interviews LPN#1 was interviewed on 5/19/26 at 12:45 p.m. LPN #1 said he would be starting to document his morning medication administrations. , He said the residents' medications had been administered but he had not yet documented them as administered in Resident #1, Resident #8, Resident #15 and Resident #16's eMAR. LPN#1 said the eMAR was red because he had not documented the medications as administered at their scheduled times. He said it had been a busy morning and he got behind on his documentation. LPN #1 said he should prepare the medications, administer them and then document the medications as given to the resident right after administering the medications. LPN #1 said documenting medication administration late increased the potential for possible medication errors. The DON and the regional clinical resource were interviewed together on 5/21/26 at 2:00 p.m. The DON said that medication administration documentation should be completed at the time specified in the physician's order. The DON said the nurse should prepare the medication, administer it and immediately document the administration of the medication. The DON said the nurses should never administer medications and document the medication administration at a later time. The DON said documenting medication administration at a later time could lead to potential medication errors. The regional clinical resource said documenting medication administration late was a documentation error. She said the nurses should be documenting medication administrations in real time as the medications were administered to the residents. She said education was initiated for medication administration (during the survey). VIII. Facility follow-upOn 5/20/26 at 3:10 p.m. the DON provided a copy of an inservice titled Medication Management and Administration. The education was conducted on 5/19/26, during the survey, and was signed by 16 staff members.The education read in pertinent part, Medications are to be prepared according to their scheduled administration times. Immediately following administration, the medication must be documented on the MAR to confirm receipt by the resident. Documentation must occur in real time, concurrent with administration, to ensure accuracy and accountability.-However, the education was not conducted until the concern was brought to the facility's attention during the survey.

Based on observations, record review and staff interviews, the facility failed to ensure garbageand refuse was properly disposed of and the dumpster lid was closed to prevent harborage topests and insects. Specifically, the facility failed to:-Ensure all dumpster lids were closed and not overflowing with garbage; and,-Ensure garbage was cleaned up around and under the dumpsters.Findings include:I. Facility policy and procedureThe Disposal of Garbage and Refuse policy and procedure, dated 6/1/25, was provided by the nursing home administrator (NHA) on 1/16/26 at 12:13 p.m. It revealed, in pertinent part, Containers and dumpsters shall be kept covered when not being loaded. The surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. Dumspters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside of the dumpster. The schedule for garbage pickup should be revised, as needed, based on the volume of refuse.II. ObservationsOn 1/12/26 at 9:56 a.m. the dumpster had both lids open. The dumpster was overfilled, trash bags were hanging over the edge and piled over the edge of the dumpster. There were approximately four bags of trash on the ground next to the dumpster.On 1/13/26 at 8:26 a.m. the bags of trash on the ground around the dumpster had been removed. The dumpster was still overfilled, with bags of trash piled over the edge of the dumpster, and both lids to the dumpster were open. Debris including used gloves and pieces of plastic were scattered around on the ground around the dumpster area.On 1/14/26 at 5:36 p.m. one lid of the dumpster was open. The dumpster had been emptied and only contained a few bags of trash. One trash bag containing restaurant take-out trash was on the ground near the dumpster. Debris including used gloves and pieces of plastic were scattered around on the ground around the dumpster area.On 1/15/26 at 8:07 a.m. one lid of the dumpster was open. Debris including used gloves and pieces of plastic were scattered around on the ground around the dumpster area.III. Record reviewReview of pest control records, dated 10/29/25 through 1/13/26, revealed the following:On 11/11/25 rodent activity was determined to be low. The pest control service recommended keeping storage and staff areas clean and free of food residue to discourage rodent activity.On 11/19/25 rodent activity was determined to be low. The pest control service recommended keeping exterior areas free of clutter and debris to reduce pest harborage.On 12/9/25 rodent activity inside the facility was determined to be moderate. A rodent bait station was added to a resident's room due to reported rodent activity and confirmed rodent droppings in a drawer, along with two other rooms. No recommendations were made.On 12/22/25 no interior services were provided. The pest control service recommended keeping exterior areas clean and free of debris, and avoiding leaving food waste or clutter near the building perimeter.On 1/13/26 minor insect activity and medium rodent activity were reported by the pest control service.IV. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 1/12/26. CNA #4 said she was concerned about the dumpster area. CNA #4 said she had just taken trash out to the dumpster and saw the dumpster was overflowing and trash was scattered everywhere in the area (see observation above).The dietary manager (DM) was interviewed on 1/15/26 at 10:52 a.m. The DM said there should not be any trash left around the outside of the dumpster and the dumpster lids should remain closed. The DM said the dumpster looked like a mess on 1/11/26, so she and the maintenance director ordered a larger dumpster.The maintenance director and the NHA were interviewed together on 1/15/26 at 1:05 p.m. The maintenance director said the dumpster was being emptied three times per week. The maintenance director said the facility had been going through and getting rid of furniture in their basement and cleaning, which had added to the amount of trash in the dumpster. The maintenance director said he had worked with the DS to get a larger dumpster. The maintenance director said one of the biggest points was education, as the staff had not been using the cardboard recycling bins and throwing cardboard into the trash, which added to the amount of items in the dumpster.The maintenance director and the NHA both said the area around the dumpster was supposed to be maintained by the trash pickup service. The NHA said the trash pickup service did not stop to pick up any bags which may have fallen off during trash pickup. The NHA said the dumpster had not specifically been identified as an issue in the pest control reports, but said the dumpsters being overly-full and not sealed was not helping the facility's pest control efforts.

Based on observations, record review and interviews, the facility failed to ensure food wasprepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to:-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination; and,-Ensure safe and appropriate storage of food items in the main kitchen walk-in refrigerator.Findings include:I. Failure to handle ready-to-eat foods in a sanitary mannerA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 1/21/26, revealedin pertinent part, Food employees may not contact exposed, ready-to-eat food with their barehands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, ordispensing equipment. (3-301.11)B. Facility policy and procedureThe Food Safety Requirements policy and procedure, dated 6/1/25, was received from the nursing home administrator (NHA) on 1/16/26 at 12:14 p.m. It read in pertinent part, Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.C. ObservationsDuring a continuous observation of the lunch meal service on 1/13/26, beginning at 11:00 a.m.and ending at 12:20 p.m. the following was observed:At 12:00 p.m. cook (CK) #2 was reheating two corn dogs in the microwave. When CK #2 took the plate containing the two corndogs out of the microwave, he slid a meal ticket under one of the corndogs on the plate and sent it out to be served on the tray line.At 12:02 p.m. CK #2 repeated the same process above, placing another meal ticket under a corndog before sending it out on the tray line.At 12:03 p.m. dietary aide (DA) #1 was cutting the vegetables in the vegetable medley into smaller pieces on the tray line. DA #1 scooped a spoonful of vegetables onto a cutting board, used her gloved hand to hold the vegetables in place while cutting them, then used her gloved hand to scoop the vegetable pieces onto a plate. DA #1 had previously been handling meal tickets and serving utensils with the same gloved hand. DA #1 repeated this process several times throughout the lunch service.At 12:12 p.m. CK #2 was preparing three hamburgers. CK #2 donned a pair of gloves and adjusted one of the hamburger buns. CK #2 then handled several meal tickets, and using the same gloved hands adjusted the next hamburger bun. CK #2 grabbed two single-serving chip bags and put them on the plates next to the cheeseburgers. CK #2 then used the same gloved hand to adjust the final top bun of the hamburgers.On 1/14/26 at 2:06 p.m. an unidentified activity aide was preparing for an ice cream social. The activity aide used her bare hands to pick up a waffle cone bowl and place it into a paper bowl. The activity aide repeated this process several times, each time using her bare hands. At 2:11 p.m. the activity aide was handing out bowls of ice cream to residents. The activity aide touched a resident's shoulders and adjusted his silverware, then fixed her hair. The activity aide then grabbed a waffle bowl with her bare hands and put it in a paper bowl to be served to a resident.D. Staff interviewThe dietary manager (DM) was interviewed on 1/15/26 at 10:52 a.m. The DM said she had done education with the dietary staff after 1/13/26 (during the survey) regarding ready-to-eat foods. The DM said ready-to-eat foods could be handled with single-task gloves, tongs or utensils. The DM said bare hands should absolutely not touch ready-to-eat foods. The DM said meal tickets should not touch ready-to-eat foods.II. Failure to safely and appropriately store food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 1/21/26. Itrevealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared andheld in a food establishment for more than 24 hours shall be clearly marked to indicate the dateor day by which the food shall be consumed on the premises, sold, or discarded when held at atemperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day ofpreparation shall be counted as day one. (3-501.17) Food shall be protected from cross contamination by storing the food in packages, covered containers or wrappings. (3-302.11)B. Facility policy and procedureThe Food Safety Requirements policy and procedure, dated 6/1/25, was received from the NHA on 1/16/26 at 12:14 p.m. It read in pertinent part, Practices to maintain safe refrigerated storage include labeling, dating and monitoring refrigerated food; and keeping foods covered or in tight containers.C. ObservationsAn initial tour of the kitchen was conducted on 1/11/26 at 12:18 p.m., which revealed a sheet pan in the main walk-in refrigerator containing six gallon-sized plastic bags of raw chicken cutlets. The bottom of the sheet pan contained a clear fluid, and each of the bags of chicken cutlets were undated and unlabeled.A second tour of the kitchen was conducted on 1/13/26 at 11:00 a.m. and revealed the following:The same sheet pan in the main walk-in refrigerator containing six gallon-sized plastic bags of raw chicken cutlets. The bottom of the sheet pan contained a clear fluid, and each of the bags of chicken cutlets were undated and unlabeled.One glass container which contained tomato slices, undated and unlabeled.One glass container with chicken and rice, undated and unlabeled.One metal container of cheese sauce, dated 1/12/26, without any covering on it.Two gallon-sized plastic bags of cooked, shredded chicken, dated 1/8/26.One plastic bag containing two muffins, dated 1/5/26.D. Staff interviewsThe DM was interviewed on 1/15/26 at 10:52 a.m. The DM said everything in the refrigerators and freezers should be labeled and dated. The DM said all prepared foods were thrown away after three days.

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 infections. Specifically, the facility failed to: -Ensure proper infection control practices were followed for wound care;-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms; and, -Ensure catheters were not stored on the floor. Findings include: I. Wound care A. Facility policy and procedure The Clean Dressing Change policy, dated 6/1/25 was received from the nursing home administrator (NHA) on 1/16/26 at 12:12 p.m. It read in pertinent part, The facility is to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Set up a clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape). Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (clean outward from the center of the wound). B. Observations On 1/13/26 at 9:35 a.m. licensed practical nurse (LPN) #1 was providing wound care to Resident #3. LPN #1 collected supplies from the treatment cart outside Resident #3's room. LPN #1 applied personal protective equipment (PPE) consisting of a gown and gloves. LPN #1 said the wound care was a clean procedure and not a sterile procedure to complete. LPN #1 entered the resident's room with all of the supplies tucked into her arms and against her scrub top. LPN #1 moved Resident #3's personal items off the bedside table. The bed side table was visibly soiled with a white residue. LPN #1 went to the sink, wet a paper towel with water and pumped hand soap out of the soap dispenser one time. She then wiped the table down. LPN #1 placed the wound care supplies directly onto the bedside table. The bedside table still had white residue on it even after she wiped it down. -LPN #1 failed to properly disinfect the bedside table and place a barrier between the table and the wound care supplies. LPN #1 needed assistance from another staff member to assist with turning Resident #3. LPN #1 stepped out of the resident's room and walked down the hall past the next room to get a certified nurse aide (CNA) to assist. -LPN #1 wore personal protective equipment (PPE) in the hallway. LPN #1 used the same PPE while completing the dressing change only changing her gloves when needed. LPN #1 and the CNA #6 turned resident on to his right side. CNA #6 said the resident was wet and would need a brief change. LPN #1 removed the old dressing which had a moderate amount of serosanguinous (clear and bloody) drainage, performed hand hygiene with alcohol based hand rub (ABHR) and applied clean gloves. LPN #1 then sprayed the wound directly with a wound cleanser. LPN #1 placed the gauze that was sitting directly on the soiled bedside table below the wound to help catch any fluids from the wound. LPN #1 then cleaned the wound with the same piece of gauze ten times. -LPN #1 failed to place a barrier pad under the resident prior to starting a wound dressing change. LPN #1 failed to have a mask on while spraying the resident wound. LPN #1 failed to wipe the wound in a hygienic manner. LPN #1 then completed applying the new dressing according to physician's orders. C. Staff interviews LPN #1 was interviewed on 1/13/26 at 10:00 a.m. She said she had recently become the wound nurse for the facility. LPN #1 said the wound care was a clean procedure and not a sterile one so she was not required to drape the area around the wound. LPN #1 said she cleaned the table with soap and water she applied to a paper towel. LPN #1 said the soap was an antibacterial and was enough to disinfect the table. LPN #1 said she did not know she should not clean the wound with the same piece of gauze. LPN #1 said she did not know she needed to place a clean working area on the table, under the resident or wear a mask during wound care due to possible splashback. The director of nursing (DON) and the infection preventionist (IP) were interviewed on 1/15/26 at 12:09 p.m. They said during wound care the bedside table was to be cleaned with bleach wipes and follow the recommended dwell time (amount of time the surface must remain wet in order to properly disinfect), then apply a barrier pad to place the supplies on. The DON said the nurse should also place a pad under the resident to have a barrier for drainage not to get on the resident's bed. The IP said the wound should be cleaned from the middle out or one piece of gauze to wipe then a new piece can be used each time it was cleaned to prevent infections. The DON said the nurse should wear a mask in case splashing occurred. II. Housekeeping A. Facility policy and procedure The Routine Cleaning and Disinfection policy, dated 6/1/25, was received from the NHA on 1/16/26 at 12:13 p.m. It read in pertinent part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Clean from areas that were visibly clean and least likely to be contaminated to areas usually visibly dirty. Clean from top to bottom (bring dirt from high levels down to floor levels). Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: a. Toilet flush handles b. Bed rails c. Tray tables d. Call buttons e. television remote f. Telephones g. Toilet seats h. Monitor control panels, touch screens and cables i. Resident chairs j. IV poles k. Blood pressure cuffs 1. Sinks and faucets m. Light switches n. Door knobs and levers. Disinfectant solutions will be prepared fresh daily and changed frequently in order to ensure effectiveness. a. Follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution. b. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection. The Hand Hygiene policy, dated 6/1/25, was received from the NHA on 1/16/26 at 12:13 p.m. It read in pertinent part. All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. B. Observations On 1/14/26 at 1:33 pm Housekeeper (HK) #1 was cleaning room [ROOM NUMBER]. He donned (put on) gloves. HK #1 entered the room and emptied the trash under the sink and next to the residence beds and replaced the liners. HK#1 then placed the trash bags onto the housekeeping cart. He removed his gloves and donned clean ones. -HK #1 failed to perform hand hygiene between glove changes. HK #1 removed the spray bottle with pink fluid that was labeled Airlift Fresh and a green rag. HK #1 removed items from bed A's bedside table and sprayed the pink spray and wiped it clean. He did the same with the top and front of her dresser. HK #1 used the same pink spray to spray the countertop and wipe it clean. The same rag was used to wipe the soap dispenser, towel dispenser and door knobs. HK #1 placed the soiled green rag onto the cart and removed a yellow rag. HK #1 used the pink spray to spray the wheelchair and then wiped the wheelchair wheels with the yellow rag. HK#1 returned the pink spray bottle and the yellow rag to the housekeeping cart. -HK #1 failed to use a disinfectant to clean the room and wheelchairs. HK#1 removed the acid bathroom cleaner which was a purple spray and a red rag. HK#1 flushed the toilet three times and sprayed the toilet riser and set it to the side. HK #1 sprayed the toilet with the acid bathroom cleaner and used the red rag to wipe the rim of the toilet, under the seat, the top of the seat and the tank. The inside of the toilet with the toilet brush. He flushed the toilet and returned the acid bathroom spray and the red rag to the cart. HK #1 removed a clean red rag from the housekeeping cart and wiped the toilet seat riser, the seat first and then the sides and the arms and placed the riser back over the toilet. He returned to the housekeeping cart and put the red rag into the trash bag. He removed his gloves and donned clean ones. -HK #1 failed to clean the bathroom from clean to dirty. HK #1 failed to perform hand hygiene during glove changes. HK #1 said bed B did not like her things touched and did not clean her side of the room. He removed the broom from the cart and swept the room starting from the B side to the A side. He swept the debris to the entrance of the door and picked it up with a dustpan. HK #1 removed a mop handle from the cart and place it in the room. He returned to the cart and removed a mop rag from the mop water and dropped it on the floor. He mopped the room starting at bed B to bed A towards the door. Then he mopped the bathroom last. HK#1 removed his gloves. HK #1 failed to use a clean mop pad for the bathroom and failed to disinfect high touch surfaces. HK #1 was then went to room [ROOM NUMBER] at 2:03 p.m. HK #1 applied gloves, knocked and entered the room. He collected the trash, replaced liners and then changed gloves. -HK #1 failed to perform hand hygiene between room and glove changes. HK #1 collected spray bottle with pink solution labeled Airlift Fresh and one rag. HK #1 started to spray the sink, wiped the handle, sink rim, sink bowl and then the vanity counter. A resident was present in the room and was using her bedside table. HK #1 said he could not clean the table as it was in use. -HK #1 failed to clean areas from clean to dirtiest. HK #1 continued cleaning the room with the same rag he cleaned the sink he wiped down the air conditioner and the oxygen concentrator. He returned to his cart, collected a new rag, went back to bed B side spraying the blinds with the Airlift Fresh spray and immediately wiped the blinds after spraying. The room had a strong fragrant smell. HK #1 collected a new rag from the cart and sprayed and wiped down bed B wheelchair then bed A wheelchair with the same rag. HK #1 wiped down the bed and the oxygen concentrator with the same rag used for the wheelchairs. -HK #1 failed to clean bed A and bed B sides with different rags and failed to use a disinfectant. HK #1 collected a new rag and a spray bottle with purple solution (acid bathroom cleaner). He entered the bathroom and moved the toilet riser off the toilet. HK #1 sprayed the toilet then riser. He wiped the hand rails with the dry cloth then wiped the toilet riser seat then handles then wiped toilet handles flushed the toilet, HK #1 then sprayed the toilet seat hinges then moved the riser back over the toilet. HK #1 flushed the toilet again, collected the toilet bowl brush, put it into the bowl and scrubbed the bowl no cleaner in the bowl. HK #1 then smacked the toilet bowl brush three times on the inner portion of the toilet riser. Water splashed onto the toilet riser and the wall. HK #1 flushed the toilet a third time. HK #1 returned to the cart, changed his gloves and collected the broom. -HK #1 failed to clean the bathroom in a hygienic manner going from cleanest to dirtiest, failed to use a disinfectant on high touch areas, failed to not splash water on already clean surfaces and failed to perform hand hygiene between glove changes. HK #1 swept the bathroom then bed B side of room and last bed A side sweeping all debris to the entrance of the room. HK #1 collected debris with a dust pan, immediately collected a mop stick and reached into the mop bucket rung out one mop pad. HK #1 mopped the bathroom floor, returned to the cart and removed the soiled mop pad with gloves. HK #1 then reached into the mop bucket with soiled gloves rung out a second mop pad, he mopped bed B then bed A side of the room to the door. HK #1 removed his gloves and performed hand hygiene with alcohol based hand rub. -HK #1 failed to not contaminate the mop bucket water with soiled gloves. On 1/14/26 at 2:33 p.m. HK #1 went to the housekeeping closet. The automated dispenser was observed in the closet to have only the Airlift Fresh and the acid bathroom cleaner. C. Staff interviews HK #1 was interviewed on 1/14/26 at 2:29 p.m. He said he had been working in the facility for four or five months and had not been given proper training. HK #1 said he was told to use the pink solution on certain areas and the purple solution was for the bathroom. HK #1 said he did not know what the dwell time was. HK #1 said he did not know what cleaner was in the mop solution. HK#1 said he only needed to complete hand hygiene when moving from one room to another. He said he did not know how many rags needed to be used from a double occupancy room. He said he knew he only had to use different rags when cleaning the bathroom. The housekeeping supervisor (HKS) was interviewed on 1/15/26 at 9:32 a.m. He said he had only been working at the facility for three weeks. The HKS said they staffed housekeepers seven days a week. The HKS said the pink solution was air freshener, the clear solution was the disinfectant with a three minute dwell time and the acid bathroom cleaner had no kill time. HKS said he did not know why HK#1 did not have the disinfectant solution on his cart or why it was not found in the housekeeping closet. The HKS said HK#1 should be using the disinfectant. The HKS said hand hygiene should be completed when the housekeepers changed their gloves and they entered another room. The HKS said the mop pad should be changed after mopping the bedroom and before mopping the bathroom. The HKS said HK #1 should clean top to bottom. The HKS said HK #1 should use three rags: red, blue, and beige. The HKs said the red rags were for the bathroom, blue for the mirrors and beige were all purpose use. The HKS said high touch areas were: door handles, light switch, call button, overbed table, bed rails, television remote and bed remote. The HKS said the toilets should be cleaned from top to bottom and should be cleaned daily because of the germs on them. III. Catheter failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Guideline for Prevention of Catheter Associated Urinary Tract Infections (UTIs), retrieved on 1/20/26 from https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html#:~:text=Recommendations%20for%20Proper%20urinary%20catheter%20maintenance%20techniques%20by%20ID%20number,II, facilities may prevent UTIs by performing the following: Keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor. B. Facility policy and procedure The Catheter Care policy, dated 6/1/25, was provided by the NHA on 1/16/26 at 12:12 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. -The catheter care policy did not specify catheters should not be touching the ground. C. Observations On 1/12/26 at approximately 2:50 p.m. Resident #16 was in her wheelchair. Her catheter tubing was lying on the floor. On 1/14/26 at 8:19 a.m. Resident #16 was in her bed. The catheter tubing was lying on the floor. D. Staff interviews and observations CNA #3 was interviewed on 1/13/26 at 10:32 a.m. CNA #3 said Resident #16 had a catheter and the CNAs emptied the catheter every shift. LPN #2 was interviewed on 1/14/26 at 8:30 a.m. LPN #2 confirmed Resident #16's catheter was on the floor. LPN #2 repositioned the catheter on the bed so the tubing was no longer touching the floor. LPN #2 said the catheter should not have been on the floor because the floor was dirty. LPN #2 said catheter tubing on the floor increased the risk for the resident to get an infection. The infection preventionist (IP) was interviewed on 1/14/26 at approximately 3:00 p.m. The IP said catheters should be kept off the ground. The IP said there should be a barrier between the catheter and the floor in order to prevent urinary tract infections (UTIs).

Based on observations, record review and interviews the facility failed to provide the necessaryservices to maintain personal hygiene for one (#17) of two residents reviewed for services tomaintain the highest practicable quality of life out of 47 sample residents. Specifically, the facility failed to ensure Resident #17 received timely incontinence care.Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs) policy and procedure, dated 6/1/25, was received fromthe nursing home administrator (NHA) on 1/16/26 at 12:12 p.m. It read in pertinent part, Careand services will be provided for the following activities of daily living including toileting. A resident who is unable to carry out activities of daily living will receive the necessaryservices to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with mood disturbance and shortness of breath. The 12/12/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and never or rarely made decisions about tasks of daily living per staff assessment. The resident was dependent on staff for most activities of daily living (ADL), including toileting and personal hygiene. The assessment documented the resident was always incontinent of bladder and frequently incontinent of bowel. B. Resident representative interview Resident #17's representative was interviewed on 1/12/26 at 11:59 a.m. The resident's representative said she wondered if the facility staff helped Resident #17 with her hygiene whenever she visited, such as brushing her teeth or washing her hands. The representative said she had noticed there were a lot of staff watching residents one-to-one. The resident's representative said she had visited the facility and seen residents who needed help, but the staff were watching other residents on one-to-one and could not help the other residents. The resident's representative said she felt like the unit staff had too many residents with specific needs on their unit for what they could handle. C. Observations and interviews During a continuous observation on 1/14/26, beginning at 8:38 a.m. and ending at 2:51 p.m., thefollowing was observed: At 8:40 a.m. Resident #17 was sitting in a recliner in the common area eating breakfast. At 8:58 a.m. licensed practical nurse (LPN) #4 approached Resident #7 and encouraged her to keep eating. At 9:18 a.m. Resident #17 was asleep in a recliner in the common area. At 9:25 a.m. certified nurse aide (CNA) #3 woke Resident #17 up and encouraged her to keep eating her breakfast. Resident #17 cried out stood up, and began ambulating with her walker in a loop around the common area before ambulating down the hallway. At 9:32 a.m. Resident #17 re-entered the common area, sat down in a recliner, stood up and ambulated back down the hallway. Resident #17 walked back down the hallway, entered the common area and sat in a recliner. At 9:44 a.m. LPN #4 gave Resident #17 a small plastic cup containing MedPass (nutritional supplement). At 9:48 a.m. LPN #4 unwrapped a cookie and gave it to Resident #17, who immediately ate it. At 10:38 a.m. Resident #17 continued to sit in a recliner in the common area. At 11:28 a.m. Resident #17 was awake and sitting in a recliner in the common area. At 12:12 p.m. Resident #17 stood up from her recliner and walked toward one of the dining tables in the center of the room. An unidentified nursing staff member attempted to assist Resident #17 to one of the seats at the table, but Resident #17 repeatedly said to leave her alone. The unidentified nursing staff member provided Resident #17 with her walker, and Resident #17 began ambulating down the hallway. At 12:16 p.m. Resident #17 ambulated back to the dining room, sat in a recliner and was served lunch. Resident #17 was provided with one reusable plastic cup with juice in it, which she drank immediately, then began eating her meal. Resident #17 attempted to eat the bread pudding on her meal tray but did not take off the plastic wrap covering the bowl, and instead attempted to eat the bread pudding through the plastic wrap. At 12:22 p.m. Resident #17 attempted to open a bag of chips on her meal tray but was unable to do so. At 12:30 p.m. LPN #4 gave Resident #17 a mug of coffee and removed the empty juice cup from her tray. At 1:07 p.m. Resident #17 was sitting in a recliner in the common area dipping her sandwich into her bread pudding and eating it. At 1:28 p.m. LPN #4 gave Resident #17 a small plastic cup containing MedPass. At 1:38 p.m. Resident #17 was shaking her bag of chips, still unable to open the bag. LPN #4 approached her and opened the bag of chips for her. At 1:50 p.m. Resident #17 stood up and began ambulating around the common area and down the hallway. At 2:18 p.m. Resident #17 was sitting in a recliner eating ice cream as part of an activity. At 2:21 p.m. Resident #17 stood up and began ambulating around the common area and down the hallway. At 2:31 p.m. Resident #17 continued ambulating through the hallway. CNA #3 asked Resident #17 if she could take her empty ice cream bowl. Resident #17 answered unintelligibly and continued walking. At 2:36 p.m. Resident #17 wandered into another resident's room. CNA #3 went into the room and attempted to redirect Resident #17 back to her room. CNA #3 was interviewed on 1/14/26 at 2:37 p.m. CNA #3 said Resident #17 needed to have her incontinence brief changed as the resident was incontinent, and said she probably needed to have her brief changed soon. At 2:40 p.m. CNA #3 and CNA #4 directed Resident #17 to her room, closed the door and provided incontinence care (see interviews below). At 2:45 p.m. CNA #3 and CNA #4 left Resident #17's room with a trash bag, and Resident #17 left her room wearing a new pair of pants. -The facility failed to provide incontinence care for Resident #17 for six hours during theobservation period. C. Record review The ADL care plan, revised 9/30/24, revealed Resident #17 had an ADL self-care performance deficit due to her dementia and deconditioning. Pertinent interventions documented Resident #17 was totally dependent on staff for dressing and personal hygiene. The incontinence care plan, revised 12/18/24, revealed Resident #17 had bowel and bladder incontinence due to her deconditioning, impaired mobility and dementia. Pertinent interventions included checking Resident #17 every two hours and assisting with toileting as needed, and providing peri-care after each incontinence episode. D. Staff interviewsCNA #3 was interviewed again on 1/14/26 at 2:48 p.m. CNA #3 said the incontinence brief Resident #17 had just been wearing, contained only urine. CNA #3 said Resident #17's urine output varied, as she tended to sip on beverages throughout the day. LPN #3 was interviewed on 1/15/26 at 9:34 a.m. LPN #3 said for incontinent residents, the nursing staff checked the resident every two hours to see if they were soiled. LPN #3 said they checked the residents with that frequency as if the residents sat in a soiled brief for too long they could get pressure ulcers. LPN #3 said Resident #17 was incontinent and unable to tell the nursing staff if or when she was wet, so they checked her every two hours. CNA #2 was interviewed on 1/15/26 at 9:23 a.m. CNA #2 said she tried to check on incontinent residents every two hours to try to prevent skin breakdown and reposition the resident. CNA #2 said Resident #17 needed help with oral care, showers, and was incontinent, so the nursing staff checked her brief every hour or two. The director of nursing (DON) was interviewed on 1/15/26 at 2:41 p.m. The DON said for residents who were dependent on staff assistance for ADL care, the staff provided their showers and toileting needs and documented this in their medical records. The DON said incontinent residents needed to be checked frequently, typically every two hours, but the timing depended on the person and their needs. The DON said the nursing staff should check and change Resident #17 frequently. The DON said she would have expected the nursing staff to have offered to check and change Resident #17 at least once during the six hour observation period on 1/14/26 (see observations above).

Based on observations, record review and interviews, the facility failed to provide services in accordance with accepted professional standards for one (#2) of five residents reviewed for medication management out of 47 sampled residents. Specifically the facility failed to ensure:-Acetaminophen (pain medication) was administered to Resident #2 were given within pain level parameters; and,-Oxycodone (pain medication) was administered to Resident #2 were given within pain level parameters. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication. II. Facility policy and procedure The Unnecessary Drugs policy, dated 6/1/25, was received from the nursing home administrator (NHA) on 1/16/26 at 12:12 p.m. It revealed in pertinent part, Each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Documented clinical rationale for administering a medication that was based upon an assessment of the resident's condition and therapeutic goals and after any safer treatments have been deemed clinically contraindicated. Attending physicians will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: a. Dose (including duplicate therapy); b. Duration of use; c. Indications and clinical need for medication; d. Adequate monitoring for efficacy and adverse consequences;e. Preventing, identifying and responding to adverse consequences; f. Any combination of the reasons stated above. The facility will notify the attending physician regarding a significant change in the resident's condition in relation to a potential adverse consequence of a medication, or if the resident has not responded to medication therapy as anticipated and/or indicated. III. Resident #2 A. Resident status Resident #2, younger than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included necrotizing fasciitis (skin eating bacteria), pressure ulcers (skin break down over bony prominences), hypertension (high blood pressure), above the knee right leg amputation, left below the knee amputation and sepsis (systemic infection). The 12/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She received scheduled pain medication and as needed pain medications and non medication pain interventions. B. Record Review Review of the November 2025 CPO revealed the following physician's ordersTylenol 500 milligram (mg) two tablets every eight hours as needed for pain level one to three. Ordered on 9/10/25. Review of the medication administration record (MAR) revealed the following: On 9/11/25 at 10:56 p.m. Tylenol was administered for pain 9 out of 10.-The pain level was above the ordered pain level of one to three. -Review of Resident #2's progress notes did not reveal the physician was contacted when the resident's pain level was outside the parameters within the physician's order.Review of the December 2025 CPO revealed the following physician's orders: Oxycodone 10 milligram (mg) one tablet every four hours for a pain level four to 10, ordered on 9/10/25. Tylenol 500 mg, give two tablets every eight hours as needed for pain level one to three, ordered on 9/10/25. Review of the December 2025 medication administration record (MAR) revealed the resident was administered medications outside the physician prescribed parameters on the following dates:On 12/6/25 at 5:00 p.m. Oxycodone was administered for a pain level of two out of 10. On 12/6/25 at 9:10 p.m. Oxycodone was administered for a pain level three out of 10. On 12/18/25 at 2:21 p.m. Oxycodone was administered for a pain level zero out of 10. On 12/19/25 at 3:05 p.m. Oxycodone was administered for a pain level of three out of 10. On 12/23/25 at 1:00 p.m. Oxycodone was admitted for a pain level of three out of 10. On 12/27/25 at 10:40 a.m. Oxycodne was administered for a pain level of two out of 10. -Review of the December 2025 MAR did not reveal Tylenol was administered for the entire month, despite pain levels within range where oxycodone was given outside of parameters. C. Staff interviews Licensed practical nurse (LPN) #7 was interviewed on 1/15/26 at 1:30 p.m. She said pain medication orders have a pain level which nurses were to follow as it was ordered by the physician. LPN #7 said not following the pain level would be a medication error and should be reported to the physician and management team. LPN #7 said a pain medication could result in making a resident sleepy if given incorrectly. The director of nursing (DON) was interviewed on 1/15/26 at 1:45 p.m. She said the nurse was to administer the lowest effective dose for pain level per the physician's order. The DON said if the dose was stronger then the pain level it would be effective in lowering the pain level but could increase the risk of side effects.

Based on observations, record review, and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#90) of seven residents out of 47 sample residents. Specifically, the facility failed to ensure staff provided appropriate supervision and implemented care-planned interventions for Resident #90 while smoking. Findings include: I. Facility policy and procedure The Resident Smoking policy, revised 12/29/25, was received from the nursing home administrator (NHA) on 1/16/26 at 1:33 p.m. It read in pertinent part, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Smoking materials may not be shared between independent smoking residents and those residents requiring supervision. II. Resident #90 A. Resident status Resident #90, age less than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), the diagnoses included bipolar 2 disorder (mood disorder), generalized muscle weakness, nicotine dependence, hemiplegia (paralysis) affecting left side, need for assistance with personal care, epilepsy (seizure disorder) and anxiety disorder. The 10/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She had no behaviors and did not reject care. She had impairments in her upper and lower extremities. B. Resident interview and observation Resident #90 was interviewed on 1/12/26 at 10:47 a.m. She said she was able to smoke when she wanted to. She said her roommate/partner, an independent smoker, stored cigarettes and a lighter for her. Resident #90 said she would occasionally drop cigarettes while smoking. During the interview Resident #90 was wearing a jacket with two approximately pea-sized burn holes on the upper right chest area. During the interview, Resident #90 reached into her right jacket pocket, removed two cigarette butts and threw them away. Resident #90 had visible full-body tremors (involuntary movements). C. Observations On 1/12/26 at 2:47 p.m. Resident #90 was sitting in her wheelchair on the smoking patio holding a lit cigarette in her right hand. Resident #90 was wearing the same jacket she had worn during her interview (see above). Resident #90 was not wearing a smoking apron. There were no facility staff present to supervise smoking. Resident #90's roommate/partner was sitting in a chair on the patio across from her. On 1/13/16 at 10:03 a.m. revealed Resident #90 sitting in her wheelchair on the smoking patio. Her roommate/partner and another unidentified resident were standing near her. Resident #90 held a cigarette in her mouth, which was lit then lit by her roommate/partner. Resident #90 was unable to securely hold the cigarette without it shaking while raising and lowering her right arm due to her tremors. Resident #90 was not wearing a smoking apron. No facility staff were on the patio supervising. D. Record reviewThe supervised smoking care plan, initiated on 7/30/25, documented Resident #90 was at risk for smoking related injuries due to her tremors and her ability to safely light cigarettes. Interventions included providing a smoking apron while smoking (initiated 7/30/25) and assuring smoking material was extinguished prior to the resident leaving the smoking area (initiated 7/30/25).The skin integrity care plan, initiated on 8/6/25, documented Resident #90 had potential/actual impairment to skin integrity due to smoking. Interventions included completing weekly skin assessments (initiated 1/8/26), encouraging good nutrition and hydration (initiated 8/6/25), and identifying/documenting potential causative factors and eliminating/resolving where possible (initiated 8/6/25). The smoking safety assessment, dated 12/31/25 at 4:34 p.m., documented Resident #90 had balance problems, jerking movements, tremors, and a seizure disorder. It documented the resident displayed the following safety concerns: dropping ashes on herself and the inability to safely hold/light/extinguish a cigarette, or use an ashtray to extinguish a cigarette. It documented Resident #90 was able to smoke with supervision and required a smoking apron. It documented Resident #90 displayed no non-compliant smoking behaviors. -However, observations revealed the resident was not provided supervision or a smoking apron while smoking (see observations above). III. Staff interviews Certified nurse assistant (CNA) #5 was interviewed on 1/15/26 at 8:35 a.m. CNA #5 said the facility had CNAs scheduled to supervise residents who smoked. CNA #5 said the smoking supervisors were the ones who knew if residents were supervised smokers or not. CNA #5 said there should always be a staff member monitoring the smoking patio. CNA #5 said he had received training on safe smoking practices, however, he was unsure when the last training he received was. CNA #5 said he had not been scheduled to supervise the smoking patio and was unsure which residents were supervised/unsupervised. Licensed practical nurse (LPN) #6 was interviewed on 1/15/26 at 11:59 a.m. LPN #6 said she had received training from the facility on resident preferences, smoking, and safety procedures. LPN #6 said smoking safety assessments should be completed upon admission, and repeated as needed to ensure residents were following the facility's smoking policy. LPN #6 said the CNAs were responsible for supervising smoking. LPN #6 said she did not know Resident #90 was a supervised smoker and had been observed smoking unsupervised. The social services director (SSD) was interviewed on 1/15/26 at 12:16 p.m. The SSD said the facility's process was to assess the resident while smoking to see whether they could safely smoke. The SSD said if a resident could not safely smoke, the resident would be set up with a smoking apron, smoking interventions would be care planned, and staff would discuss the plan with the resident. The SSD said the facility generated a smoking list stating which residents were supervised/unsupervised smokers, and the lists were distributed to each nurse's station, the front desk, and to the scheduled smoking attendant. The SSD said staff should remind independent smokers not to distribute smoking materials to unsupervised smokers, and staff should seek management assistance in escalating situations.The director of nursing (DON) and regional clinical resource #1 were interviewed together on 1/15/26 at 3:30 p.m. The DON said residents who required supervision during smoking were supposed to be assisted to the smoking patio during scheduled smoking times. The DON said facility staff were trained on safe smoking practices, including safe smoking settings, using a smoking apron, and the safe lighting/extinguishing of cigarettes. Regional clinical resource #1 said non-supervised smokers should not assist supervised smokers due to potential safety risks. The DON and the regional clinical resource #1 were unaware Resident #90 was smoking without supervision.

Based on observations, record review and interviews, the facility failed to ensure one resident (#7) of two reviewed for dialysis care, out of 47 sample residents, received dialysis services consistent with professional standards of practice. Specifically, the facility failed to:-Ensure the dialysis communication forms were consistently sent with Resident #7 to the dialysis center; and, -Ensure post-dialysis assessments on Resident #7 were completed and documented per professional standards. Findings include: I. Facility policy and procedure The Care Planning Special Needs - Dialysis policy, dated 6/1/25, was provided by the nursing home administrator (NHA) on 1/16/26 at 12:12 p.m. It read in pertinent part, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. The care plan will reflect the coordination between the facility and the dialysis provider and will identify nursing home and dialysis responsibilities. Intervention will include, but not limited to:-Documentation and monitoring of complications;-Pre (before) and post (after) dialysis weights;-Assessing, observing, and documenting care of access sites, as applicable;-Nutrition and hydration, including the provision of meals and snacks on treatment days;-Lab tests;-Vital signs;-Provision of medications on dialysis treatment days;-Transportation arrangements; and,-Addressing any identified psychosocial needs. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. II. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2026 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (ESRD), type 2 diabetes mellitus, and dependence on renal dialysis. The 10/3/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He had no impairment in his upper or lower extremities. He received dialysis care. B. Observations On 1/13/26 at 9:25 a.m. Resident #7 returned from dialysis treatment. Resident #7's dialysis communication binder was resting on the seat of the resident's four wheeled walker. Licensed practical nurse (LPN) #5 met Resident #90 in the hallway, collected his dialysis binder, opened and reviewed the first page. LPN #5 asked an unidentified certified nurse assistant (CNA) to obtain a full set of vital signs and the resident's weight. After reporting he would like to eat breakfast in the dining room, LPN #5 advised the unidentified CNA to obtain the resident's weight prior to him eating. Resident #90 was wearing a long flannel shirt, which covered the fistula site upon his return from dialysis. LPN #5 did not assess the resident's dialysis fistula (implanted device for dialysis treatments) upon his return from dialysis or before he went to the dining room for breakfast. C. Record review Review of Resident #90's January 2026 CPO revealed no physician's orders for pre/post dialysis assessments and/or monitoring. The dialysis care plan, initiated 7/5/22, documented Resident #90 was at risk for complications related to hemodialysis treatments and ESRD. Interventions included checking the dressing at the access site (initiated 7/5/22), monitoring bruit/thrill at fistula site on right upper extremity (initiated 7/5/22) and monitoring/documenting/reporting to the provider any signs/symptoms of renal insufficiency as needed (initiated 7/5/22). Review of Resident #90's dialysis communication binder revealed facility dialysis communication forms inside. Each form had three sections which were read and revealed: The general information section was to be filled out by the facility with the date, resident's name, attending provider, medications given prior to dialysis, whether a meal/snack was sent, vital signs, and the resident's weight. The information to be completed by the dialysis center included the amount [of fluid] removed from the resident, dialysis post weight, whether the resident was able to complete full treatment, lab work drawn, noted issues with dialysis access, medications given during dialysis, and any post treatment recommendations. The third was to be completed by the facility after the resident completed their dialysis session. The section included vital signs, whether bleeding was present from the access site, whether a meal was given to the resident upon return to the facility, new orders, and new skin issues. The dialysis communication forms from November 2025 to January 2026 revealed the following incomplete communication forms: -On 10/28/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/1/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/6/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/8/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/11/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/15/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/18/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/20/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/25/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/26/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 11/29/25, 12/2/25, 12/4/25, and 12/6/25 there was not a dialysis communication form s were completed due to Resident's #90 hospital admission from 11/29/25 to 12/8/25.-On 12/9/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 12/13/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 12/16/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 12/18/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 12/20/25 and 12/23/25 there was not a dialysis communication forms were completed due to Resident's #90 hospital admission from 12/18/25 to 12/23/25.-On 12/24/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 12/27/25 there was no communication form sent with the resident to dialysis. A handwritten note on printer paper, signed by the resident's dialysis nurse, listed the date, vital signs and a dialysis post weight.-On 12/30/25 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 1/1/26 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 1/3/26 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 1/6/26 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 1/8/26 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 1/10/26 the facility did not complete the post dialysis assessment section of the dialysis communication form.-On 1/13/26 the facility did not complete the post dialysis assessment section of the dialysis communication form. III. Staff interviews LPN #5 was interviewed on 1/13/26 at 11:42 a.m. LPN #5 said the night shift was responsible for filling out a dialysis communication form with the pre dialysis information due to Resident's #90 early dialysis chair time. LPN #5 said upon returning from dialysis, the nurse should assess the resident's access site, obtain a set of vital signs and the resident's weight. LPN #5 said there was not a physician's order in Resident #90's prompting the nurses to put in pre/post dialysis weights and vital signs. LPN #5 said post dialysis assessments and vital signs should be documented in the electronic medical record (EMR). LPN #5 said the post dialysis section of the dialysis communication form did not need to be filled out since assessments were documented in the EMR. LPN #5 said the dialysis communication forms were done until the resident's next dialysis treatment. The director of nursing (DON) was interviewed on 1/15/26 at 3:30 p.m. The DON said dialysis assessments should be documented in the medication administration record (MAR). The DON said her expectation was for nursing staff to fill out the dialysis communication forms completely for each treatment. -However, review of Resident #90's CPO revealed no active physician' orders for pre/post dialysis assessments and/or monitoring (see record review above).

Based on observations, record review and interviews, the facility failed to act upon the pharmacist's recommendations in a timely manner for two (#17 and #2) of five residents out of 47 sample residents. Specifically the facility failed to: -Ensure a pain scale was added to Resident #17's morphine order to exclude its use for mild pain per pharmacist recommendation;-Ensure Resident #2's monthly medication reviews (MMR) were reviewed by the physician; and,-Act upon the the pharmacist's recommendations for amitriptyline (antidepressant), sertraline (antidepressant) and an echocardiogram (EKG) for Resident #2. Findings include: I. Facility policy and procedure The Unnecessary Drugs policy and procedure, dated 6/1/25, was provided by the nursing home administrator (NHA) on 1/16/26 at 12:12 p.m. It read in pertinent part, It is the facility's policy that each resident's entire drug/medication regime is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. The attending physician will assume leadership in medication management by monitoring and modifying the medication regime in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regime will be reviewed on an ongoing basis. III. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with mood disturbance and shortness of breath. The 12/12/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and never or rarely made decisions about tasks of daily living per staff assessment. The resident was dependent on staff for most activities of daily living (ADL). The assessment documented Resident #17 was receiving hospice care. B. Record review Review of Resident #17's January 2026 CPO revealed the following physician's order: Morphine sulfate (an opioid pain medication) 20 milligrams per milliliter (ml), give 0.5 ml by mouth every two hours as needed for shortness of breath or pain, ordered 4/15/25. Review of Resident #17's December 2025 medication administration record (MAR) revealed the resident received one dose of morphine on 12/21/25 at 7:45 p.m. for a pain level of 1 on a scale of 1 to 10. Review of Resident #17's medication regiment reviews (MRR) 11/1/25 from through 1/8/26, conducted by the pharmacist, revealed the following: On 11/13/25 the pharmacist recommended adding a pain scale to the directions for Resident #17's as-needed morphine order to exclude its use for mild pain (under 6 on the 1 to 10 pain scale). On 12/14/25 the pharmacist made a second request to add a pain scale to the directions for Resident #17's as-needed morphine order to exclude its use for mild pain (under 6 on the 1 to 10 pain scale). On 1/7/26 the pharmacist made a third request to add a pain scale to the directions for Resident #17's as-needed morphine order to exclude its use for mild pain (under 6 on the 1 to 10 pain scale), and noted residents on hospice were not exempt from this. -However, review of Resident #17's electronic medical record (EMR) revealed the facility failed to respond to the pharmacists recommendation. C. Staff interviews The director of nursing (DON) and regional clinical resource RCR #1 were interviewed together on 1/15/26 at 3:56 p.m. The DON said another staff member had been in charge of reviewing the MRRs, but the DON had found there was a lack of facility follow-up. The DON said she would make sure the MRRs were done in the future. The DON said she had noticed the facility had an issue with implementing pain scales for physician orders. Regional clinical resource #1 said the facility staff were going to go back through the previous 90 days of pharmacy recommendations to ensure they were sent to the provider. The DON said the assistant director of nursing would go through the physician orders daily, and the DON would do routine audits to ensure orders were put in correctly going forward. III. Resident #2 A. Resident status Resident #2, younger than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included necrotizing fascitis (skin eating bacteria), pressure ulcers (skin break down over bony prominences), hypertension (high blood pressure), above the knee right leg amputation, left below the knee amputation and sepsis (systemic infection). The 12/18/25 MDS assessment revealed the resident was cognitively intact with a BIMs score of 15 out of 15. She received scheduled pain medication and as needed pain medications and non medication pain interventions. B. Record review Review of Resident #2's November 2025 CPO revealed the following physician's orders: Amitriptyline 50 milligram (mg) one time a day for depression, ordered on 9/10/25. Sertaline 50 mg one tablets at bedtime for depression, ordered 9/10/25. The 11/14/25 MMR revealed the resident had amitriptyline 50 mg ordered for depression. The pharmacist documented the only use for this medication was for diagnoses of pain. The pharmacist also recommended increasing sertraline and decreasing amitriptyline and performing an electrocardiogram (EKG). -Review of the CPO failed to show a change in dose for either sertraline or amitriptyline. -Review of Resident #17's EMR revealed no documentation indicating the physician declined or accepted the recommendations. There was no order or documentation to indicate the physician reviewed the recommendation of the EKG. The 12/14/25 MMR revealed the same recommendations as the 11/14/25 MMR. -Review of the EMR did not document if the resident's physician declined or accepted changes as recommended. There was no order for EKG and there were no dose changes to sertraline or amitriptyline.

Based on observations, record review and interviews, the facility failed to ensure one (#94) of three residents reviewed received food and fluids prepared in a form designed to meet his or her needs out of 47 sample residents. Specifically, the facility failed to ensure Residents #94 was served a mechanically altered diet per physician's orders.Findings include:I. Professional referenceThe International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) (January 2019), retrieved on 1/20/26 from https://iddsi.org/Resources/Patient-Handouts read in pertinent part, Miniced and Moist foods: soft and moist, but with no liquid leaking/dripping form the food, biting is not required, minimal chewing required, lumps of 4 mm (millimeter) in size, lumps can be mashed with the tongue, food can be easily mashed with just a little pressure from a fork and should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Level 5 - Minced and Moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food, but are not able to chew it down into little pieces that are safe to swallow. Minces and Moist foods only need a small amount of chewing and for the tongue to 'collect' the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or a fork. No regular dry bread due to high choking risk.II. Facility policy and procedureThe Food Preparation Guidelines policy and procedure, dated 6/1/25, was provided by the nursing home administrator on 1/16/26 at 12:14 p.m. It read in pertinent part, Food shall be provided in form that meets each resident's individual needs in accordance with his or her assessment and care plan.III. Resident #94A. Resident statusResident #94, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included dementia, dysphagia (difficulty with swallowing), diabetes mellitus, and cognitive communication deficits.The 12/25/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and rarely or never made decisions regarding tasks of daily life per staff assessment. The resident required substantial to maximal assistance with eating.The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. B. ObservationsOn 1/14/26 at 9:57 a.m. licensed practical nurse (LPN) #4 entered Resident #94's room and provided him with a fig cookie bar and encouraged the resident to drink water before leaving the room.At 10:00 a.m. LPN #4 entered Resident #94's room with a second fig cookie bar. Resident #94 had already finished eating the first cookie and quickly ate the second bar.C. Record reviewThe January 2026 CPO revealed the following physician's order: Carbohydrate control diet, minced and moist texture, thin liquids, ordered on 10/2/25.Resident #94's nutrition care plan, revised 12/28/25, revealed Resident #94 was at risk for altered nutritional status due to his diagnoses of dementia, diabetes and needing a mechanically altered diet. Pertinent interventions included providing Resident #94 his diet as ordered, offering the resident his favorite foods and fluids within the ordered diet texture and liquid thickness, and a referring to speech therapy as needed.IV. Staff interviewsLPN #4 was interviewed on 1/14/26 at 9:57 a.m. LPN #4 said she had given Resident #94 a fig bar (see observations above). LPN #4 said she was not sure what diet texture Resident #94 needed, but said she knew his food was pureed. LPN #4 said the fig bar was soft enough for him to eat.Certified nurse aide (CNA) #3 was interviewed on 1/14/26 at 1:12 p.m. CNA #3 said residents who needed a pureed texture diet could have snacks including applesauce, pudding, oatmeal cookies or fudge cookies. CNA #3 said if a resident had trouble swallowing, she could mush the cookies up with some milk, but the cookies themselves were soft enough to chew. CNA #3 said the oatmeal cookies were soft enough for all diet textures to eat.LPN #3 was interviewed on 1/15/26 at 9:34 a.m. LPN #3 said residents who were on altered texture diets could have oatmeal cookies, pudding or applesauce. LPN #3 said residents on mechanically altered diets could not eat the fig cookie bars, just the oatmeal cookies.CNA #2 was interviewed on 1/15/26 at 9:23 a.m. CNA #2 said residents on mechanically altered diets could have pudding or softer cookies, such as the oatmeal cookies. CNA #2 said there was probably a list of what diet each resident needed, but said she just knew what the residents' diets were.CNA #1 was interviewed on 1/15/26 at 8:59 a.m. CNA #1 said residents on pureed texture diets could have applesauce and yogurt, while the other textures could have cookies and crackers. CNA #1 said if she was not sure whether a resident could receive a snack because of their diet, she would ask the nurse.The registered dietitian (RD) was interviewed on 1/15/26 at 12:16 p.m. The RD said the nursing staff were trained on the different diet textures through an online training program. The RD said residents on minced and moist diet textures could have snacks including yogurt, ice cream, pudding, and applesauce. The RD said oatmeal cookies or fig bars were not appropriate for the minced and moist diet texture. The RD said they were not appropriate as bread separated when swallowed, and it would be like inhaling sawdust and could potentially lead to it going into the resident's lungs if they had dysphagia.The RD said sometimes the speech therapist would add to the resident's diet order and say the resident could have bread. The RD reviewed Resident #94's medical record and said he was on a minced and moist diet, and did not have any notes allowing bread. The RD said Resident #94 had a diagnosis of dysphagia and probably should not have gotten the fig bars.The director of nursing (DON) and regional clinical resource #2 were interviewed together on 1/15/26 at 2:41 p.m. The DON said residents on minced and moist diets could receive snacks including pudding, applesauce, and any pureed texture snacks. The DON and regional clinical resource #2 said a fig bar could be an appropriate snack for Resident #94 because it contained some moisture, and said the same with oatmeal cookies. -However, the fig bars did not meet the criteria for the minced and moist diet texture as prescribed by Resident #94's physician (see professional reference above).

Based on observation, interview and record review, the facility failed to ensure residents maintained adequate hydration for one (#17) of three residents reviewed for hydration out of 47 sample residents. Specifically, the facility failed to encourage fluid intake for Resident #17.Findings include:I. Facility policy and procedureThe Food Preparation Guidelines policy and procedure, dated 6/1/25, was provided by the nursing home administrator (NHA) on 1/16/26 at 12:13 p.m. It read in pertinent part, drinks, including water and other liquids, shall be provided in sufficient amounts to maintain resident's hydration. Residents will be offered additional fluids throughout the day, consistent with the resident's plan of care.II. Resident #17A. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with mood disturbance and shortness of breath.The 12/12/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and never or rarely made decisions about tasks of daily living per staff assessment. The resident was dependent on staff for most activities of daily living (ADL) and required supervision or touching assistance for eating.B. Resident representative interviewResident #17's representative was interviewed on 1/12/26 at 11:59 a.m. The resident's representative said one of her concerns was Resident #17's hydration status. The resident's representative said the nursing staff filled the residents' water pitchers, however the water pitchers were often left in their rooms rather than the common areas with the residents. The resident's representative said she was not sure how much Resident #17 was drinking.C. ObservationsOn 1/13/26 at 8:38 a.m. Resident #17 left another resident's room and began walking toward the common area. Resident #17 did not have her water pitcher with her. Resident #17 began looking at and grabbing items in the meal tray cart containing partially-eaten breakfast trays. An unidentified nursing staff member redirected Resident #17 away from the cart by asking if she wanted a fresh cup of coffee. Resident #17 then sat in a recliner in the common area and began to fall asleep.-However, the staff member did not provide Resident #17 with a cup of coffee or any other fluids.At 1/13/26 at 10:22 a.m. a hospice nurse approached Resident #17 and began talking to her and assessing her vitals. Resident #17 was drifting in and out of sleep. No beverages were near Resident #17.During a continuous observation on 1/14/26, beginning at 8:38 a.m. and ending at 2:51 p.m., thefollowing was observed:At 8:40 a.m. Resident #17 was sitting in a recliner in the common area eating breakfast and did not have any beverages near her. A staff member told another staff member Resident #17 had previously had a glass of juice but had spilled it.At 8:58 a.m. licensed practical nurse (LPN) #4 approached Resident #7 and encouraged her to keep eating. At 9:03 a.m. Resident #17's water pitcher was full of ice and water and was sitting on her bedside table in her room. Resident #17 was sitting in a recliner in the common area with no beverages near her.At 9:18 a.m. Resident #17 was asleep in a recliner in the common area.At 9:25 a.m. certified nurse aide (CNA) #3 woke Resident #17 up and encouraged her to keep eating her breakfast. Resident #17 cried out, stood up and began ambulating with her walker in a loop around the common area before ambulating down the hallway.At 9:32 a.m. Resident #17 re-entered the common area, sat down in a recliner, stood up and ambulated back down the hallway. Resident #17 walked back down the hallway, entered the common area and sat in a recliner.At 9:44 a.m. LPN #4 gave Resident #17 a small plastic cup containing MedPass (nutritional supplement).At 9:48 a.m. LPN #4 unwrapped a cookie and gave it to Resident #17, who immediately ate it.At 10:38 a.m. Resident #17 continued to sit in a recliner in the common area. At 11:28 a.m. Resident #17 was awake and sitting in a recliner in the common area.At 12:12 p.m. Resident #17 stood up from her recliner and walked toward one of the dining tables in the center of the room. A nursing staff member attempted to assist Resident #17 to one of the seats at the table, but Resident #17 repeatedly said to leave her alone. The nursing staff member provided Resident #17 with her walker, and Resident #17 began ambulating down the hallway.At 12:16 p.m. Resident #17 ambulated back to the dining room, sat in a recliner and was served lunch. Resident #17 was provided with one reusable plastic cup with juice in it, which she drank immediately, then began eating her meal. Resident #17 attempted to eat the bread pudding on her meal tray but did not take off the plastic wrap covering the bowl, and instead attempted to eat the bread pudding through the plastic wrap.At 12:22 p.m. Resident #17 attempted to open a bag of chips on her meal tray but was unable to do so.At 12:30 p.m. LPN #4 gave Resident #17 a mug of coffee and removed the empty juice cup from her tray. At 1:07 p.m. Resident #17 was sitting in a recliner in the common area dipping her sandwich into her bread pudding and eating it.At 1:28 p.m. LPN #4 gave Resident #17 a small plastic cup containing MedPass.At 1:38 p.m. Resident #17 was shaking her bag of chips, still unable to open the bag. LPN #4 approached her and opened the bag of chips for her.At 1:50 p.m. Resident #17 stood up and began ambulating around the common area and down the hallway.At 2:18 p.m. Resident #17 was sitting in a recliner eating ice cream as part of an activity.At 2:21 p.m. Resident #17 stood up and began ambulating around the common area and down the hallway. At 2:31 p.m. Resident #17 continued ambulating through the hallway. CNA #3 asked Resident #17 if she could take her empty ice cream bowl. Resident #17 answered unintelligibly and continued walking.At 2:36 p.m. Resident #17 wandered into another resident's room. CNA #3 went into the room and attempted to redirect Resident #17 back to her room.At 2:40 p.m. CNA #3 and CNA #4 directed Resident #17 to her room, closed the door and provided incontinence care (see interviews below). At 2:45 p.m. CNA #3 and CNA #4 left Resident #17's room with a trash bag, and Resident #17 left her room wearing a new pair of pants. -The facility failed to encourage adequate additional fluid intake for Resident #17 for six hours during the observation period.On 1/15/26 at 9:05 a.m. Resident #17 was sitting in a recliner in the common area with no beverages nearby. Resident #17's water pitcher was not within reach, nor was it in her room.At 9:33 a.m. CNA #1 handed Resident #17 a small disposable plastic cup of water, and the resident immediately began drinking.D. Record reviewThe nutrition care plan, revised 12/12/25, revealed Resident #17 was at risk of nutrition problems due to her underweight status and low body mass index. Pertinent interventions included providing Resident #17 cranberry juice and apple juice, monitoring the resident for any changes in her food or beverage preferences, providing her diet as ordered, and providing supervision and assistance with meals as needed.A nutritional evaluation, dated 12/12/25, revealed Resident #17 required an estimated 1833 ml of fluids each day based on her ideal body weight.Review of the January 2026 CPO revealed an order to encourage 360 ml of fluid each shift and document acceptance or decline every day and night shift for hydration monitoring, ordered 9/10/25.Review of the January 2026 medication administration record (MAR) revealed the order to encourage 360 ml of fluid each shift had been marked accepted twice daily from 1/1/26 through 1/15/26. No refusals were documented.Review of Resident #17's meal fluid intake task, dated 12/18/25 through 1/15/26, revealed the following:Of the 30 days recorded, Resident #17 drank around 240 ml each meal three times per day. One refusal was documented on 1/10/26 at 5:01 p.m.Review of Resident #17's fluid intake task, dated 12/18/25 through 1/15/26, revealed the following:Of the 30 days recorded, Resident #17 received an average of 881 ml additional fluids per day, ranging from 480 ml to 1740 ml. No refusals were documented during this period.-Review of the resident's fluid intakes for 30 days revealed the resident consistently consumed less than her estimated fluid needs (see RD assessment above).E. Staff interviewsCNA #3 was interviewed on 1/14/26 at 2:48 p.m. CNA #3 said Resident #17's urine output varied, as she tended to sip on beverages throughout the day.LPN #3 was interviewed on 1/15/26 at 9:34 a.m. LPN #3 said Resident #17 was a good eater, and ate and drank anything you gave her. LPN #3 said Resident #17 needed reminders to drink, but would drink anything that was given to her. LPN #3 said she charted in Resident #17's medical record that she offered the resident fluids. LPN #3 said Resident #17 should have her water pitcher with her, but she may have left it in her room. LPN #3 then searched Resident #17's room and could not find her water pitcher. LPN #3 said the dietary staff may have grabbed the water pitcher to wash it.CNA #2 was interviewed on 1/15/26 at 9:23 a.m. CNA #2 said Resident #17 drank pretty well and was pretty good about drinking but sometimes needed reminders. CNA #2 said Resident #17 had her water pitcher between meals, which the nursing staff filled up each day. CNA #2 said Resident #17 normally had her water pitcher with her between meals, but thought she may have left it in her room. CNA #2 said the nursing staff also gave Resident #17 small cups of water for her to have as well.CNA #1 was interviewed on 1/15/26 at 8:59 a.m. CNA #1 said the facility CNAs had to document the amount each resident ate and how much liquid they drank. CNA #1 said the nursing staff encouraged the residents to drink, and passed out ice and water in the morning. CNA #1 said the nursing staff also gave the residents two drinks at their meals. CNA #1 said the nursing staff always asked the residents if they wanted snacks or drinks as the residents would otherwise forget.The registered dietitian (RD) was interviewed on 1/15/26 at 2:03 p.m. The RD said the resident's most recent nutritional assessment indicated she needed 1800 milliliters (ml) of fluid per day. The RD said Resident #17's last nutritional evaluation based her fluid needs on her ideal body weight, as the resident was chronically underweight. The RD said the nursing staff offered Resident #17 a minimum of 360 ml of fluids per shift and documented it in the input and output task. The RD said the MedPass nutritional supplement did count for fluid intake. The RD said the coffee mugs contained 240 ml of fluid, the reusable plastic cups contained 240 ml of fluid, and the small disposable plastic cups contained 120 ml of fluid. The RD said residents were typically provided with 480 ml of fluids at meals, and Resident #17 typically only consumed about 50% of her meals, so she needed to get about 600 to 700 ml of fluid between meals. The RD said the nursing staff needed to encourage Resident #17 to drink the additional 600 to 700 ml of fluids throughout the day. The RD said she would want to order laboratory diagnostics for Resident #17 to ensure her hydration levels were okay based on the observations during the survey process (see observations above).-Based on the RD's measurements the resident consumed approximately 480 ml of fluid at lunch and 280 ml of Medpass during the observation.The director of nursing (DON) and regional clinical resource #2 were interviewed together on 1/15/26 at 2:41 p.m. The DON said she expected the nursing staff to offer residents with dementia fluids during medication administration, and to encourage the residents to drink water throughout the day and with meals. The DON said the CNAs should offer the residents fluids throughout the day.Regional clinical resource #2 said the nursing and activities staff should offer the residents fluids. Regional clinical resource #2 said the nurses charted each shift in the MAR when they offered a full glass of water during medication administration. Regional clinical resource #2 said the CNAs also should offer the residents fluids throughout the day.

Based on observations, record review and interviews, the facility failed to protect three (#7, #3 and #5) of seven residents reviewed for abuse out of 10 sample residents. Resident #8 was admitted to the facility on [DATE] and was moderately cognitively impaired. He had a history of traumatic brain injury, dementia and diabetes. Resident #7 was admitted to the facility on [DATE] and had a history of dementia, was dependent on staff for all cares and was non-verbal. On 9/29/25 the facility was looking for Resident #8, who was identified as missing. The facility located Resident #8 in Resident #7's room by staff. Resident #8 was found lying on top of Resident #7 with his pants and incontinence brief pulled down below his knees and hips directly over the face of Resident #7.Resident #7 and Resident #8 were separated by staff and police. Resident #7 was sent to the hospital where a sexual assault nurse exam (SANE) was conducted. Hospital records indicated a male (Resident #8) was found with his penis around her mouth and he had stated he attempted vaginal intercourse with Resident #7.Resident #8 was given an immediate discharge notice. Resident #8 was removed from the facility on 9/29/25 by police and was taken to jail.Resident #4 was admitted to the facility on [DATE] and had moderate cognitive impairments. He had a history of dementia, viral hepatitis C and sexually inappropriate behaviors towards female staff. Resident #3 was admitted to the facility on [DATE] and was discharged on 8/29/25. She was cognitively intact and had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis and weakness). On 8/14/25, Resident #4 requested Resident #3 to have sex with him. Resident #3 informed the facility that Resident #4's actions upset her. The facility implemented 15-minute checks starting on 8/14/25 until 8/16/25. However, the facility did not reassess to ensure if it was appropriate to discontinue the checks. On 8/20/25, Resident #4 again requested Resident #3 to have sex, which Resident #3 declined.The facility failed to implement effective interventions regarding Resident #4's sexual behaviors, which resulted in Resident #4's continued sexual comments on three occasions that were upsetting to the residents. After the incident on 8/20/25, the facility placed both Resident #3 and Resident #4 on 15-minute checks for 72 hours. The facility discontinued the 15-minute checks after 72 hours with no documentation to indicate the residents were reassessed for safety prior to discontinuing the checks. Resident #5, was admitted on [DATE] and had severe cognitive impairments. Resident #5 had diagnoses of unspecified dementia without behavioral disturbance, moderate intellectual disabilities and cognitive communication deficit. On 8/26/25 Resident #5's representative notified the facility that Resident #4 had approached Resident #5 and asked her if she wanted to go to his room to have sex. The facility unsubstantiated the allegations and determined Resident #4 had the right to ask other residents any questions. However, Resident #5's representative said Resident #5 was upset for about a week following the incident.On 8/26/25 the facility implemented a one-to-one caregiver for Resident #4. However, documentation and interviews revealed inconsistencies with a continuous one-to-one caregiver for Resident #4.Specifically, the facility failed to:-Protect Resident #7 from sexual abuse by Resident #8;-Protect Resident #3 from sexual harassment by Resident #4; and, -Protect Resident #5 from sexual harassment by Resident #4.Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #8 was admitted to the facility with diagnoses of dementia and a traumatic brain injury. When Resident #8 was reported missing, the facility staff found Resident #8 in Resident #7's room. Resident #7 had severe cognitive impairments and was non-verbal. Resident #7's pants and brief were pulled down and his hips were above Resident #7's face. The facility failed to protect Resident #7 from sexual abuse from Resident #8. Resident #4 who admitted to the facility on [DATE] had a history of being sexually inappropriate with female staff. The facility's failure to implement effective, long term interventions to address Resident #4's sexually inappropriate behaviors, resulted in Resident #4 sexually harassing Resident #3 and Resident #5. The facility's failure to ensure all staff members were aware of Resident #4 behaviors, what to monitor for and how to address the behaviors resulted in further incidents that made Resident #3 and Resident #5 uncomfortable and upset. After Resident #7 was sexually abused, the facility began taking Resident #4's behaviors into consideration and implemented a one-to-one caregiver for Resident #4. B. Facility notification of immediate jeopardy On 10/30/25 at 2:28 p.m., the nursing home administrator (NHA) was notified the facility's failure created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 10/30/25 at 6:33 p.m. the facility submitted a plan to remove immediate jeopardy. The plan read: Identification of residents affected or likely affected: the director of nursing (DON), the social services director (SSD), and designee were to interview/assess residents with brief interview for mental status (BIMS) assessment scores of eight or above for potential abuse, concerns were not identified and completed on 10/30/25. For residents who had a BIMS score below eight, the power of attorney (POA) or residents' representatives would be contacted to identify any concerns regarding abuse, initiated 10/30/25. Resident #8 was issued an immediate discharge notice on 9/29/25 to prevent further abusive behaviors. The following actions were taken to prevent Resident #4 from perpetrating additional abusive behaviors: He was placed on a one-to-one caregiver on 10/1/25 until alternate placement can be found. The one-to-one caregivers were provided resident specific education defining what they were watching for (sexually inappropriate comments, monitoring for any inappropriate responses in sexual nature, with history of sexual assault allegations). The one-to-one caregivers were educated on who to notify if any behaviors were identified/observed. The education would be completed prior to the next scheduled shift. The nursing supervisors, the SSD and designee updated Resident #4's behavior monitoring sheets to describe specific behaviors and staff response, completed on 10/30/25. Clinical resource completed a review and updated Resident #4's Kardex (staff directive tool), care plan and physician's orders on 10/30/25. Resident #4 was evaluated by the primary care provider on 10/21/25 and was scheduled to re-visit the resident on 10/31/25. Resident #4 received psychology consultation orders on 10/30/25, a medication adjustment on 8/23/25 to address sexual hyperactivity and a follow-up medication review was scheduled for 10/31/25. Therapy sessions began on 11/3/25 (during the survey) for Resident #4 to begin working with licensed mental health professionals. One-to-one supervision had been in place for Resident #4 since 10/1/25. Updated education was initiated on 10/30/25 with all one-to-one caregivers. Education was also provided to all staff on abuse, abuse prevention, behavior management, how to report new behaviors, how to locate information in the Kardex and care plan, and any one-to-one resident specific education prior to initiation of their next shift. The goal completion date for the education was 11/7/25 for all regularly scheduled employees. All as needed (PRN) employees would receive the education prior to the start of their next shift. Resident #4 could not be seated near female resident(s) at activities or dining when at all possible initiated on 10/30/25. The interdisciplinary team (IDT) reviewed and revised Resident #4's care plan to identify patterns in the resident's behaviors and implemented interventions for Resident #4 on 10/30/25. The care plan revisions and interventions were communicated to front line staff caring for Resident #4 on 10/30/25. Interventions were Resident #4 was not to sit next to a female resident when at all possible. All residents with known behaviors would be reviewed by the IDT team with updates as indicated to their care plans and Kardex. The facility took the following actions to prevent an adverse outcome from reoccurring on 10/30/25: updated the one-to-one education binder to detail residents' behavior pattern/risk; updated Resident #4's care plan; and, updated Resident #4's Kardex. The Abuse policies were reviewed/updated to include all sources of abuse, including resident-to-resident on 10/30/25. The abuse investigation procedure and documentation process were reviewed and revised as needed. The NHA and the DON educated all staff on changes to the policies on 10/30/25. The social SSD, the DON and the NHA re-educated all staff on facility abuse policies during the survey on 10/30/25. The plan documented that in the event of any future resident-to-resident sexual abuse, the perpetrating resident would immediately be placed on one-to-one supervision until the primary care physician, nursing, and psychology evaluations were completed. Outcomes of these evaluations would result in continued one-to-one supervision or the initiation of discharge planning to a facility with a focus on behavior management. This was provided to the IDT team in the form of education on 10/30/25. D. Removal of immediate jeopardy On 10/30/25 at 7:10 p.m. the NHA was notified the facility plan to remove immediate jeopardy was accepted based on the facility's plan and evidence of implementation of the measures outlined in the plan. However, the deficient practice remained at a G level, actual harm that is not immediate. II. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 6/1/25, was received on 10/28/25 at 10:44 a.m. from the DON. It revealed in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Criminal sexual abuse is serious bodily injury/harm and shall be considered to have occurred if the conduct caused the injury. In other words, serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act. Sexual Abuse is non-consensual sexual contact of any type with a resident. The facility will develop and implement written policies and procedures that: prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property; policies and procedures to investigate any such allegations; includes training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and, establishes coordination with the quality assurance and performance improvement (QAPI) program. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Possible indicators of abuse include, but are not limited to: resident, staff or family report of abuse; p marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body; physical injury of a resident, of unknown source; verbal abuse of a resident overheard; physical abuse of a resident observed; psychological abuse of a resident observed; sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; protection from retaliation; providing emotional support and counseling to the resident during and after the investigation, as needed; revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. III. Incident of sexual abuse towards Resident #7 by Resident #8 on 9/29/25 A. Facility investigation The 9/29/25 facility investigation was provided on 10/28/25 at 3:41 p.m. by regional clinical resource #1. The investigation documented Resident #8 was found in Resident #7's room lying in her bed facing her. His pants and briefs were pulled down and his pelvis was near her face. The investigation documented Resident #7 was unable to give consent. The investigation documented the police were on-site at the time of discovery and one officer provided one-to-one care over each resident involved. Resident #7 was transported to the hospital and Resident #8 was taken to jail. The investigation documented the facility issued Resident #8 an immediate discharge notice prior to leaving the facility with the police. Resident #8 refused to sign the discharge paperwork, stating it was consensual. The investigation documented the facility began providing cares in pairs for Resident #7. The staff were instructed to leave the door open to Resident #7's room when care was not being provided. Additionally, Resident #7's bed was moved to be in view from the hallway. The investigation documented the facility attempted to interview Resident #7 on 9/29/25, however Resident #7 was noninterviewable. She did not show an attempt to respond to questions and the resident did not appear to be in pain/discomfort. The resident was lying in bed with her index finger in her mouth. The staff were unable to perform a skin assessment as police instructed the staff should not touch the resident. Resident #8 was interviewed on 9/29/25 at 10:20 p.m. by the interim DON prior to being arrested. Resident #8 said he was in Resident #7's room because she invited him in and they were two consenting adults who had sex. He reported he had sat with the resident in the dining room and she invited him to her room. Resident #8 reported he thought that the resident's name was (provided name that was not consistent with Resident #7 but did match another resident in the facility). The other resident that Resident #8 identified was interviewed by facility staff and she reported she did not know who Resident #8 was and did not have a desire for a sexual partner. The investigation documented the facility substantiated sexual abuse for the incident on 9/29/25 involving Resident #7 and Resident #8. The facility provided education to the staff on 9/29/25 regarding the definition of abuse, how to prevent abuse, how to monitor for changes in behaviors, what consent was and how to identify if a resident was able to consent to sexual activities. The facility also implemented a door tag to identify residents at increased risk due to inability to make their needs known related to cognition, nonverbal or bed bound. The tag was implemented to add a visual reminder that the resident in the room was at increased risk for potential falls and/or abuse. All residents who had the tag were to have increased rounding with visual inspection of the room to ensure resident safety. The staff were also provided education regarding elopement on 9/29/25, as Resident #8 was initially missing when he was found in Resident #7's room. The facility initiated audits to include residents at high risk for abuse to receive increased monitoring starting on 9/29/25 and were ongoing at the time of the survey (10/27/25). A whole house audit was conducted on 9/29/25 where skin assessments were completed along with asking residents or their POA if they felt safe and assessing for sexual advancements from another resident (due to Resident #4's sexual advances below). -However, during the survey, staff interviews revealed the staff did not know what the door tags were or that there was an education binder available, despite the documentation the facility provided that indicated the staff were educated on the door tags and binder (see interviews below) education was provided to staff. -The facility failed to educate staff on identifying residents who may be seeking a sexual partner within the facility. B. Resident #8 (assailant) 1. Resident status Resident #8, age younger than 65, was admitted on [DATE]. According to the September 2025 computerized physician's orders (CPO), diagnoses included type 1 diabetes (abnormal glucose control), chronic kidney disease stage four (abnormal kidney function), traumatic brain injury and dementia (abnormal memory). The 9/9/25 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairments with a BIMS score of nine out of 15. He needed set-up assistance with eating, dressing and personal hygiene. He was independent with bed mobility, transfers ambulation. 2. Record review Review of Resident #8's comprehensive care plan did not identify that the resident displayed behaviors prior to the altercation. A nurse progress note, documented on 9/29/25 at 12:22 a.m., revealed Resident #8 was found in another resident's (Resident #7) room lying on top of her. The staff immediately separated the two residents and notified the police. One-to-one care was provided to both residents. A nurse progress note, documented on 9/29/25 at 3:37 a.m., revealed Resident #8 was transported to the county jail at 3:30 a.m. An immediate discharge noticed was issued to Resident #8 prior to him being handcuffed. The note documented that he refused to sign the immediate discharge notice. The assistant administrator was present during refusal. Review of Resident #8's electronic medical record (EMR) revealed the facility ran a sexual offender report on Resident #8 after the incident and it was negative. C. Resident #7 (victim) 1. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included fracture of left malleolus of left fibula (broken bone of the lower leg), dementia(abnormal memory), depression, chronic kidney disease and chronic obstructive pulmonary disease (abnormal oxygen exchange). The 8/29/25 MDS assessment revealed the resident had cognitive impairments with short and long term memory issues per staff assessment. She was dependent on staff assistance with eating, toileting, dressing, personal hygiene, bed mobility and transfers. The resident used a manual wheelchair and was dependent on staff for assistance with mobility. 2. Observations On 10/28/25 at 1:12 a.m. Resident #7 was lying in her bed and was seen from the hallway with the door open. 3. Resident #7's representative interview Resident #7's representative was interviewed on 10/28/25 at 12:52 p.m. The representative said Resident #7 had been non-verbal for two years and would not be able to consent to a sexual relationship. The representative said Resident #7 was sent to the hospital and underwent a SANE exam after being found with a male resident in her room. The representative said the assailant was being pursued for criminal charges for assaulting an at-risk adult. 3. Record review Resident #7's September 2025 CPO revealed the following physician's order: Doxycycline hyclate 100 milligram (mg) capsule twice daily for seven days, an antibiotic therapy for possible sexually transmitted disease exposure, ordered on 9/30/25. Review of Resident #7's comprehensive care plan, dated 9/29/25, revealed Resident #7 had potential recent trauma that may impact her psychosocial wellbeing. Pertinent interventions, initiated on 9/30/25, included providing cares in pairs and leaving the resident's bedroom door open when care was not being provided. A nursing progress note, documented on 9/29/25 at 12:31 a.m., revealed that at approximately 10:15 p.m. staff found another resident (Resident #8) lying on top of her. Staff immediately separated the two residents and one-to-one care was provided to each of them. Resident #7's guardian and APS were notified. Resident #7 sustained a skin tear to her right arm. The resident was transferred to hospital for further evaluation. A nursing progress note documented on 9/29/25 at 8:52 a.m. revealed the resident returned to the facility on a new prophylactic antibiotic. The adult protective services (APS) case worker reported that there was no indication for a pelvic exam as it did not appear vaginal sex occurred. It was unclear if oral sex occurred and she was waiting for a call back from the forensic nurse examiner. The resident was stable and appeared to be at baseline A psychosocial note, dated 9/29/25 at 2:46 p.m., documented the resident was resting in bed with no visible signs of pain or discomfort. There was no redness around the resident's mouth, as was reported by the hospital. Staff reported Resident #7 consumed 100% of her breakfast and lunch. A physician's progress note, dated 9/29/25 at 5:01 p.m., documented the physician saw Resident #7 at the facilty's request after a sexual assault. The note documented the incident involved a male resident (Resident #8), who was found in Resident #7's room with his pants down and uncovered. The male resident that was found in her room reported that they were having a consensual relationship. However, the resident was nonverbal and unable to provide consent. F. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 10/28/25 at 3:42 p.m. CNA #1 said she did not know what the colored door tags meant on residents' rooms. CNA #1 said she was not aware there was an education binder available to her. Licensed practical nurse (LPN) #4 was interviewed on 10/30/25 at 9:46 a.m. LPN #4 said she did not know what the colored tag on the residents' rooms were for. LPN #4 said she was not aware that there was a binder available to her that contained education material. -The facility failed to educate all staff on the implementation of the colored tags on the residents' doors to indicate residents that required frequent rounding, per their correction plan, following the incident of sexual abuse on 9/29/25 (see facility investigation above). Regional clinical resources #1 was interviewed on 10/28/25 at approximately 4:45 p.m. Regional clinical resources #1 said Resident # 7 stayed in her room and she was receiving hospice services. Regional clinical resource #2 was interviewed on 10/28/25 at 4:53 p.m. Regional clinical resources #2 said Resident #7 had been on hospice services on and off since her admission to the facility. She said Resident #7 was non-verbal and relied on staff for needs. Regional clinical resource #2 said the facility staff completed an in-house audit of sexual abuse and feeling safe questions after the 9/29/25 occurrence to ensure residents were safe and no other residents had experience sexual abuse. The social service assistant (SSA) was interviewed on 10/29/25 at 12:46 p.m. The SSA said Resident #7 was non-verbal. She said she checked in with Resident #7 after the sexual abuse incident on 9/29/25. She said during the check-in, she observed non-verbal body language that could indicate fear, such as jumping when touched. The SSA said Resident #7 may not have been aware of the sexual encounter due to her disease process. The SSA said Resident #8 had not had any issues in the facility to her knowledge until the day he left in police custody. IV. Incidents of abuse towards Resident #3 by Resident #4 on 8/14/25 and 8/20/25 A. Facility investigation on 8/14/25 The 8/14//25 facility investigation documented Resident #4 poured coffee on Resident #3 after she denied his advances to go to his room. The investigation revealed Resident #4 did pour coffee on Resident #3 after she declined his offer to join him in his room. Resident #3 was visibly upset by Resident #4's requests. The investigation documented the facility determined there was no intention of harm from Resident #4. -However, Resident #3 was observed to be upset and crying after the incident. The investigation documented the facility placed Resident #4 on 15-minute checks from 8/14/25 to 8/16/25. The 15-minute checks were discontinued after an IDT team discussion. -However, there was no documentation to indicate why 15-minute checks were discontinued. -Review of Resident #4's care plan on 10/30/25 revealed the facility did not update Resident #4's with any interventions to prevent further sexual abuse or for sexually inappropriate advances towards female residents. The investigation documented the facility substantiated the abuse towards Resident #3 by Resident #4 on 8/14/25. B. Facility investigation on 8/20/25 The 8/20/25 facility abuse investigation, documented at 4:28 p.m., revealed Resident #3 reported that Resident #4 asked to engage in sexual behavior with her. Immediate safety measures included temporarily moving Resident #3's room and placing both residents on 15-minute checks. The police were notified on 8/20/25 at 3:47 p.m. The investigation documented Resident #3 was assessed by the assistant director of nursing (ADON) on 8/20/25 with no new concerns. Resident #3 was interviewed and said she had previously consented with Resident #4 but did not want to at the time. Resident #4 was interviewed and denied the allegation. He said he did not remember this happening. Interviews with staff and other residents revealed Resident #3 and Resident #4 were often together in the smoking area communicating with each other. The investigation documented that Resident #3's care plan was updated to reflect her behavior and wishes and Resident #4 remained on 15-minute checks. -However, review of Resident 3's care plan on 10/30/25 did not reveal updates to the care plan following the 8/20/25 incident. The investigation concluded the occurrence was unsubstantiated. -However, abuse occurred due to Resident #4's continued sexual harassment towards Resident #3, despite Resident #3 not wanting to engage in sexual activity with Resident #4. B. Resident #4 (assailant) 1. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included dementia with behavioral disturbance and viral hepatitis C without hepatic coma (blood borne disease). The 10/7/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15. He required partial assistance with bathing. He was independent with other activities of daily living (ADL). The MDS assessment documented no behavioral symptoms toward others. 2. Observations On 10/28/25 at 10:45 a.m. Resident #4 was in his room while staff was seated outside the room and provided continuous one-on-one supervision. On 10/28/25 at 4:17 p.m. Resident #4 stepped out of his room and asked CNA #5, who was providing one-on-one supervision, if he could go to the smoking area. He received a cigarette from the nurse and he was escorted outside to the designated smoking area. A 4:22 p.m. Resident #4 was escorted back inside the building and he sat in the lobby area while CNA #5 continued to provide one-on-one supervision. At 4:30 p.m. CNA #5 escorted the resident back to his room. On 10/29/25 at 9:40 a.m. an unidentified staff member was seated outside Resident #4's door while he was in his room. On 11/3/25 at 11:30 a.m. Resident #4 was walking back from the smoking area with a one-on-one caregiver next to him. 3. Record review The behavioral care plan, initiated 8/5/24 and revised 11/15/24, documented Resident #4 had dementia and at times displayed inappropriate behaviors related to his diagnosis. The care plan indicated the resident occasionally made unwelcome and inappropriate, sometimes sexual, comments directed toward female staff. Pertinent interventions, initiated on 11/4/24, included documenting each instance of inappropriate comments, noting any potential triggers, time of day, location, and response strategies that were effective, responding to inappropriate comments with a calm, neutral tone, monitoring behavior episodes to determine underlying causes and intervening as necessary to protect the rights and safety of others. The care plan included interventions, initiated on 11/4/24, for staff to monitor Resident #4 closely when in common areas, especially around female staff or residents, and to provide frequent redirection. The care plan documented additional interventions, initiated on 10/10/25, which included that Resident #4 was to receive one-to-one care from staff and was to be closely monitored at all times with readiness to de-escalate any behaviors. The 7/14/25 IDT note revealed Resident #4 was able to make his needs known verbally and effectively. The note revealed Resident #4 had demonstrated inappropriate behavior toward female residents and continued to ha

Based on interviews and record review, the facility failed to ensure residents had adequate supervision to prevent accidents for one (#2) of three residents reviewed for accident hazards out of 10 sample residents.Specifically the facility failed to provide adequate supervision to prevent an elopement for Resident #2 after he informed staff he was not staying at the facility on the day he was admitted to the facility. Resident #2, who had diagnoses of dementia, Alzheimer's disease and history of a traumatic brain injury, was admitted to the facility on [DATE]. Upon the resident's admission, during initial completion of admission paperwork with the resident and his family, Resident #2 stated to licensed practical nurse (LPN) #5 that he was not staying at the facility.-However, LPN #5 failed to notify the appropriate staff regarding the resident's comment or put immediate interventions in place to prevent the resident's elopement.Upon completion of the admission paperwork, Resident #2's family left the facility. The resident followed his family outside when they left and was redirected back into the facility by the admissions coordinator. The admissions coordinator sat with the resident briefly in the lobby and then left. When she returned to the lobby, Resident #2 was gone. -The admissions coordinator failed to notify staff that Resident #2 followed his family outside and failed to ensure he was further supervised.Resident #2 was found by bystanders at a gas station near the facility where he had fallen. The resident was transported by emergency medical services (EMS) to the hospital where it was discovered he had a fracture of his right hand. The resident did not return to the facility. Findings include:I. Facility policy and procedureThe Elopements and Wandering Residents policy, dated June 2025, was received on 10/30/25 from the director of nursing (DON). It read in pertinent part, The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Adequate supervision will be provided to help prevent accidents or elopements.The New admission Dementia Protocol, undated, was received on 11/3/25 at approximately 4:40 p.m. from the regional clinical resource. It read in pertinent part, Review with resident and family dementia protocol prior to admission. Request wander guard (a device which tracks the location of the resident and alarms at exit points) placement for the first seven days for any mobile resident with or without an assistive device. Review the increased risk for elopement. Explain that the skilled admit unit has easy access to the outside and that to increase safety and security while we get to know their loved ones this is our protocol. Ensure wander guard consent is signed. admission assessment to be completed by floor nurse that includes the elopement assessment. Order placed for wander guard including location and to check placement and functioning every shift. Order to be placed for review of ongoing need for a wander guard after seven days of behavior tracking. On day seven, the interdisciplinary team (IDT) will review all documentation, update elopement evaluations and evaluate the ongoing need for wander guard.II. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, Alzheimer's disease (a brain disorder that causes memory loss and confusion), history of traumatic brain injury (damage to the brain caused by a sudden external force) and conversion disorder with seizures or convulsions (a mental health condition where a person experiences physical symptoms such as seizures or convulsions).The minimum data set (MDS) assessment was not completed. Progress notes revealed Resident #2 was alert and was walking and talking upon his arrival to the facility.B. Facility investigation of Resident #2's elopement incident on 8/12/25 Review of the facility's investigation of Resident #2's elopement incident, dated 8/12/25, revealed the resident was admitted to the facility on [DATE] and was ambulatory without an assistive device. The investigation revealed Resident #2 was admitted to an unsecured unit. He was in his room with family and a nurse while the admission paperwork was completed. He then went to the lobby to say goodbye to his family and followed them outside the facility. Resident #2 was redirected to come back inside the facility by the admissions coordinator who then sat with Resident #2 in the lobby briefly. The admissions coordinator left and upon her return to the lobby, she noticed the resident was gone. The resident was reported missing and an immediate search was initiated at 3:45 p.m. Resident #2 was found at a gas station in town at 3:55 p.m. The investigation indicated staff conducted an assessment on the resident and he was observed to have minor abrasions (superficial wearing off of skin) to bilateral (both) knees and a laceration (cut) to the forehead.The facility investigation documented Resident #2 exhibited no behaviors indicating elopement risk and had no known history of elopement, and as such, no enhanced oversight or safety interventions were put in place.-However, Resident #2 stated to staff that he was not staying at the facility and attempted to follow his family out of the facility (see below). The investigation included a statement from LPN #5. She said she was going back and forth to the resident's room to ask Resident #2 and his family admission questions (on 8/12/25). She said the resident stated he was not staying here.The investigation included a statement from the admissions coordinator. She said that upon meeting Resident #2, he seemed to be cognizant. She said the resident's family seemed sad to say goodbye and the resident followed his family outside and she redirected him back into the facility. The admissions coordinator said she sat with the resident in the lobby area. She left and returned to the lobby to find the resident was not there. She alerted the facility team and began the search to locate the resident.C. Record reviewA progress note, dated 8/12/25 at 2:16 p.m., documented Resident #2 was admitted to the facility at 1:30 p.m. He arrived with family and was alert and was walking and talking.A progress note, dated 8/12/25 at 6:35 p.m., documented the nurse was notified at approximately 3:45 p.m. that Resident #2 was missing after the family had left and the nursing and administration staff began looking for the resident. The note documented that Resident #2 was found at around 4:15 p.m. at a gas station near the facility where he had fallen and had been taken to the hospital for evaluation and treatment. Family was notified and was instructed to go to the hospital. The note documented the family decided to take the resident home instead of bringing him back to the facility.The 8/28/25 progress note documented that on 8/13/25 at around 3:45 p.m. Resident #2 was missing from the facility. The staff immediately started to search for the resident inside and outside the building and the resident was found at a gas station near the facility at around 4:15 p.m. The resident had fallen at the gas station and went to the hospital for evaluation and treatment. The resident's family was notified and went to the hospital. The family decided to take the resident home from the hospital and Resident #2 was discharged from the facility.-The progress note documented that Resident #2 went missing from the facility on 8/13/25, however, the resident eloped from the facility on 8/12/25 (see facility investigation above and interviews below).Review of the 8/12/25 emergency department physician notes revealed Resident #2 was seen stumbling around near a gas station and then was found on the ground by bystanders. Resident #2 had abrasions to his head and swelling to his right hand. EMS stated that bystanders thought the resident may have come from a nearby memory care facility. EMS contacted the memory care facility who confirmed the resident was admitted to their facility approximately two hours prior to his elopement. The resident made it one mile down the road prior to having his unwitnessed fall. EMS brought Resident #2 to the hospital emergency department. Resident #2 received an Xray of his right hand which revealed a closed nondisplaced fracture of the fourth metacarpal (bridging bone between the wrist and finger bones) bone. Recommendations included a splint and outpatient hand surgery for follow-up. III. Staff interviewsLPN #6 was interviewed on 11/3/25 at approximately 1:20 p.m. LPN #6 said in order to identify a newly admitted resident as an elopement risk, she would find out whether or not they had a history of elopement and wandering. She said she would assess the resident within 15 to 20 minutes of their arrival to the facility and complete a head-to-toe assessment, cognitive assessment and an elopement assessment. LPN #6 said if she found a resident to be at high risk of eloping, she would immediately notify nursing management and the physician to see if a wander guard needed to be placed or whether to place the resident in a secured unit. She said if she heard a resident make any comment about wanting to go home, she would try to identify why they made the comment, redirect the resident and inform nurse management about the comment. She said she was unaware of the facility's specific elopement prevention protocols.LPN #7 was interviewed on 11/3/25 at approximately 12:30 p.m. LPN #7 said the admissions coordinator would let her know she was getting a new resident admission. She said immediately upon admission, someone from management would help her get paperwork done and she would confirm physician's orders and medications. She said the nursing staff would do a head-to-toe assessment. She said she would let the physician know the resident had dementia and the physician would evaluate the resident. She said if she had a newly admitted resident who made a statement about wanting to leave, she would call the physician and family member to address the appropriate place for the resident, depending on the resident's dementia state. She said the facility could put a wander guard on the resident if needed, but they had to call the physician before they could place it. She said she would write a change of condition note in the resident's progress notes and communicate with staff to keep an eye on the resident. The front desk receptionist was interviewed on 11/3/25 at approximately 2:00 p.m. The receptionist said the facility used a sign-in book. She said residents wanting to go outside were asked to sign out when they went outside and were to sign back in upon returning. She said if residents wanted to leave with a family member, they would sign out and sign back in upon return. She said she knew the residents well. She said during new admissions, she used the group chat with the assistant director of nursing (ADON), the DON, and other staff members to confirm whether or not a resident could leave the facility or she would ask management. She said if other staff members could not locate a resident, the facility had a team chat they used to communicate about the situation. She said in general, staff tried to let her know necessary information about new admissions as they could. Regional clinical resource #1 was interviewed on 11/3/25 at 4:08 p.m. Regional clinical resource #1 said if a resident was admitted to the facility and stated they were not staying here, she would expect staff to notify nurse management immediately and to put interventions in place to keep the resident safe. She said she would expect staff to call the physician and family, complete an elopement risk assessment and update the resident's care plan. She said she would expect staff to place a wander guard on the resident if appropriate, and place the resident in the secured unit if approved. She said all staff were educated on elopement prevention through the New admission Dementia protocol and the elopement policy and procedures. She said the facility would use the New admission Dementia protocol to help prevent newly admitted residents from eloping. She said agency (temporary) staff would have the help of admissions staff to guide them through this process if/when there was a new admission. She said the facility did not currently have any residents who were utilizing a wander guard.The admissions coordinator was interviewed on 11/4/25 at 11:39 a.m. The admissions coordinator said Resident #2 was found at a gas station. She said she was unable to confirm which staff member assessed the resident after he was found.Regional clinical resource #1 was interviewed a second time on 11/4/25 at approximately 11:40 a.m. She confirmed Resident #2 was located at a gas station on 8/12/25. She said Resident #2 never went back to the facility after he was located at the gas station because EMS took him to the hospital. She said she was therefore unable to confirm which staff member assessed Resident #2 for his minor abrasions to his bilateral knees and a laceration to the forehead.Regional clinical resource #1 confirmed the facility was unable to access hospital records after the resident's elopement and transfer to the hospital. She said the facility was unaware Resident #2 fractured his hand during his elopement from the facility on 8/12/25.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for staff based on the facility assessment and resident population for four of five certified nurse aides (CNA) reviewed. Specifically the facility failed to:-Ensure CNA #6 and CNA #7 had dementia training;-Ensure CNA #6, CNA #7 and CNA #8 had behavioral health management training;-Ensure CNA #5 and CNA #7 had resident rights training;-Ensure CNA #5 and CNA #7 had infection control training;-Ensure CNA #5, CNA #6 and CNA #7 had quality assurance performance improvement (QAPI) training; and,-Ensure CNA #7 had effective communication. Findings include:I. Record reviewA request for abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics, and resident rights training was made on 11/3/25 at 10:30 a.m. for CNA #5, CNA #6, CNA #7 and CNA #8.The facility was unable to provide documentation that CNA #5 (hired on 6/1/25) had received QAPI training upon hire.The facility was unable to provide documentation that CNA #6 (hired 6/1/25) had received dementia, behavioral health, QAPI training upon hire. The facility was unable to provide documentation for CNA #7(hired on 8/15/25) had received effective communication, resident rights, dementia, QAPI, Infection control and behavioral health management training upon hire.The facility was unable to provide documentation for CNA #8 (hired 6/1/25) had behavioral health training upon hire. II. Staff interviewsThe staff development coordinator (SDC) was interviewed on 11/4/25 at 9:20 a.m. The SDC said she had only worked at the facility since late June 2025. The SDC said she provided education and in services to staff as education opportunities arose. She said she provided education during monthly staff meetings, and by placing an education binder at the nurses' station and providing tests to ensure the staff knew the information. The SDC said staff education was important to ensure staff were aware of what they were required to do and how to complete their job duties.The SDC said the facility held a skills fair at the end of June 2025 where different departments educated the staff on different topics.The nursing home administrator (NHA) was interviewed on 11/4/25 at 10:04 a.m. He said he had only worked at the facility a month. The NHA said he was informed there were gaps in staff education requirements and would be working with human resources to ensure staff files were up to date, which would include mandatory education. The NHA said they had recently set up an online training platform to help improve tracking of education. He said currently education was provided at staff meetings and at time of hire.

Based on record review and interviews, the facility failed to ensure two (#5 and #12) of 14 residents were free from verbal abuse out of 27 sample residents.Resident #5 was admitted to the facility's secured unit with diagnoses of frontal temporal neurocognitive disorder (type of dementia that leads to changes in personality, behavior and language), Huntington's disease (progressive breakdown of the nerve cells in the brain), dementia with behavioral disturbances, tremors, and depression on 6/25/25. Despite the prison referral paperwork that identified Resident #5 had aggressive behaviors, the facility admitted the resident to the secured unit from prison. The resident had spent the majority of his life in prison or homeless. The prison's physician recommended that the resident have a one-on-one caregiver for an adjustment period. However, record review and observations revealed the facility did not consistently implement the one-to-one caregiver.Documentation revealed Resident #5 had verbally aggressive behaviors towards other residents on the secured unit. Observations revealed Resident #5 was aggressive, yelling, screaming and shaking his fists in the faces of residents and staff. He was observed placing his face inches away from Resident #12's face while screaming profanities at him. The facility staff were unable to redirect Resident #5 effectively. Resident #4 said she was afraid of Resident #5 and hid in her room. A staff member locked another resident out in a courtyard due to the concern that their PTSD (post traumatic stress disorder) would be triggered due to Resident #5's behaviors. On 7/21/25 the facility staff called the local police department to come help with Resident #5. Resident #5 was taken to a local hospital and placed on an M1 hold (a mental health hold due to someone being at risk of harm to themselves or others). Specifically, the facility failed to protect Resident #4, Resident #12 and other residents on the secured unit from verbal and physical abuse by Resident #4, which led to Resident #4 hiding in her room due to fear. Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy 6/1/25, was provided by the nursing home administrator (NHA) on 7/24/25 at 2:42 p.m. via email. It read in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Possible indicators of abuse include, but are not limited to: Verbal abuse of a resident overheard. Psychological abuse of a resident observed. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.II. Resident #5 (assailant)A. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included frontal temporal neurocognitive disorder, Huntington's disease, dementia with behavioral disturbances, tremors and depression. The 6/30/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of zero out of 15. He had hallucinations. He had physical behavioral symptoms directed towards others such as hitting, kicking, pushing, scratching and grabbing. He had verbal behavioral symptoms directed toward others such as screaming, threatening, and cursing. The resident required supervision with oral hygiene and bathing. B. Record reviewThe admissions paperwork from the State Department of Corrections revealed the following:Resident #5 had been incarcerated on 7/20/23 until he was admitted to the facility on [DATE]. On 12/4/24 the prison physician wrote Resident #5 was not appropriate for the general prison population given his severe dementia and erratic behaviors around others that were consistent with those seen in dementia patients.On 6/23/25 the facility sent an invoice to the prison for $4,200 for a one-to-one sitter, for five hours a day, for four weeks, for 30 hours. The NHA said the facility decided against billing the prison for a one-to-one sitter for Resident #5. The NHA said the facility did not collect money from the prison for the one-to-one service (see interview below). On 6/24/25 the prison physician's discharge letter was sent to the facility's admission department. It documented Resident #5 required a one-to-one caregiver and he had a diagnosis of alcohol abuse disorder with mental, behavioral and neurological disorders. The discharge letter suggested a one-to-one caregiver for Resident #5 until he acclimatized to the new environment. Resident #5 had severe dementia with intermittent agitation. The comprehensive care plan, implemented 6/29/25, revealed Resident #5 had behavioral problems and impulsivity due to his dementia. The care plan documented he displayed physical/verbal outburst due to his history of dementia with behavioral disturbance. He frequently paced in the hallway, common area, and in his room. The care plan documented the resident could become increasingly agitated with eye contacts, overstimulation, lights, wandering residents into his room or private space. The goal for Resident #5 was to have fewer behavior episodes daily and weekly. The interventions included anticipating and meeting the resident's needs and assisting him to develop appropriate methods of coping and interacting.The 6/30/25 secured unit placement progress note documented the resident exhibited severe behavioral symptoms including frequent physical and verbal aggression toward staff and other residents, such as hitting walls, throwing objects, and using threatening language. These behaviors posed a significant safety risk that could be managed safely on the facility's general unit despite ongoing non-pharmacological interventions and medication adjustments. The resident demonstrated cognitive impairment with poor impulse control, unpredictable agitation and required constant supervision to prevent harm to self or others. Attempts at redirection and de-escalation had been insufficient, necessitating a more controlled and secure environment to ensure the safety and well-being of the resident and others in the facility.No alternatives were attempted prior to the secure unit placement, as this was deemed the least restrictive and necessary approach to ensure the resident's safety and well-being.Review of the progress notes from his admission on [DATE] through his discharge on [DATE] revealed the following: The 6/25/25 admission note documented Resident #5 made many strange vocalizations, when agitated he swears and hits walls. He was known to throw his food tray. He had a preadmission assessment screening and resident risk review (PASARR) Level II, which indicated the resident had a potential serious mental illness (SMI), intellectual disability (ID) or developmental disability (DD).The 6/25/25 social services progress note documented Resident #5 was somewhat cognitively scattered, fidgety, flighty and rambunctious. The 6/26/25 incident progress note documented at approximately 6:10 p.m. revealed Resident #5 started to slam his room door and screamed at his roommate to get out of his bed. The roommate started a heated argument with Resident #5. The nurse stood in between the residents and called for help. No physical violence occurred. The roommate of Resident #5 was moved to another room until the morning.The 6/28/25 nursing progress note documented at 3:41 p.m. revealed Resident #5 swore at one of the residents and told other residents that he was going to kill you. Resident #5 continued to call a resident obscenities. The 6/28/25 nursing progress note documented at 5:00 p.m. revealed Resident #5 exhibited escalating agitation, which included yelling, using profanities toward staff and other residents, banging on walls and he removed pictures from the walls. Multiple nursing interventions were implemented, including redirection, one-to-one supervision, a quiet environment was provided for the resident with calming music and snacks were offered. These measures were not successful in de-escalating the resident's behavior. Prior to dinner, the resident's agitation intensified. He began pacing and roaming the hallways and ultimately threw a chair over the nurses' station barrier. The chair did not strike anyone and no injuries occurred. The medical director (MD) was notified. The 6/28/25 nursing progress note documented at 8:31 p.m revealed the resident's agitated behavior persisted through the dinner hour with continued verbal outbursts and restlessness.The 6/29/25 behavioral progress note documented at 9:50 a.m. revealed Resident #5 was verbally and physically aggressive towards residents and staff. The note documented that all attempts to de-escalate and distractions were ineffective. Resident #5 was spitting, kicking the wall and nurses' station entry door. Resident #5 also punched walls and opened other residents' doors. The resident was observed physically swinging at different residents as they passed by or attempted to enter or exit their own rooms. The resident continued being very agitated and was yelling obscenities at various staff members. The resident entered his room and barricaded the door, and continued hitting the doors and walls while in his room, also he forced the roommate out, denying him access to his room.The 6/29/25 nursing progress note documented at 11:15 a.m. revealed Resident #5 was observed kicking other residents' doors and he punched the wall near the dayroom. He exhibited erratic and aggressive behaviors and made some negative statements toward staff. The resident was placed on 15-minute checks for his safety.The 6/29/25 behavioral progress note documented at 3:18 p.m. revealed Resident #5 was on 15-minute checks. He had punched the wall, kicked doors, verbally abused staff and used obscenities. The nurse instructed the certified nurse aides (CNA) to maintain a safe distance from Resident #5 because his actions were unpredictable. The resident continued to walk from his room to the common area while he screamed, punched a wall and punched doors of various residents. The staff attempted verbal redirection but Resident #5 resisted their attempts. The 6/30/25 nursing progress note documented at 2:25 p.m. revealed Resident #5 was agitated when another resident tried to get into his room. Resident #5 swore and called the resident obscenities. The 7/1/25 social services progress note documented at 2:29 p.m. revealed Resident #5's mood and behaviors escalated quickly without minimal observable triggers. Redirection interventions were only temporarily effective. The care plan was updated to reflect current behaviors and interventions.The 7/2/25 nursing progress note documented at 11:04 a.m. revealed while the nurse was seated with residents in the common area, Resident #5 yelled at another resident who had wandered in the hallway towards his room. Resident #5 attempted to swing at another resident and the nurse intervened to keep the residents from fighting. Resident #5 had paced the hallway all shift and was not easily redirected.The 7/2/25 social services progress note documented at 4:33 p.m. revealed Resident #5 had been aggressive towards staff and also had a verbal altercation with another resident who had accidentally wandered into his room. The 7/3/25 nursing progress note documented at 6:02 a.m. Resident #5 had been aggressive on the overnight shift, used profanities towards staff and threw a chair and a cup at staff. Resident #5 slammed doors on the unit and started flooding a sink. The nurse was concerned for the safety of other residents. The nurse attempted to calm him down but he continued to throw chairs while other residents were near. Resident #5 threw items at the CNAs. The CNAs attempted to keep the residents away from him. The 7/3/25 nursing progress note documented at 12:03 p.m. revealed Resident #5 walked down the hallway and urinated in the hallway three times. He swore at two residents who were seated together. The social services director (SSD) came to the secured unit to help and redirect Resident #5 to his room, where he urinated on the SSD. The CNAs said Resident #5 attempted to throw coffee on other residents.The 7/3/25 social services progress note documented at 1:16 p.m. revealed Resident #5 sat in the common area agitated and he cursed. The 7/4/25 nursing progress note documented at 2:37 p.m. revealed Resident #5 was agitated, swore and called another resident obscenities. Resident #5 continued to urinate on the floor of his room and in the hallway.The 7/8/25 nursing progress note documented at 8:06 p.m. revealed Resident #5 was put a on-one to-one caregiver due to increased agitation.The 7/9/25 nursing progress note documented at 7:51 p.m. revealed Resident #5 was on a one-to-one caregiver due to increased agitation. The 7/11/25 nursing progress note documented at 6:18 p.m. revealed Resident #5 called another resident profanities, ripped a board off of a wall and threw it and a chair towards the nurses' station. Resident #5 tried to swing and kick at a resident but missed the resident.The 7/12/25 nursing progress note documented at 9:48 a.m. revealed Resident #5 yelled obscenities at a female resident. Staff tried to intervene but Resident #5 kept yelling at a female resident, Why are you here (profanity)? The 7/12/25 nursing progress note documented at 3:27 p.m. revealed Resident #5 yelled racial obscenities at other residents. The CNA tried to protect a resident but Resident #5 continued with his agitation and said why are you protecting him? Staff were unable to redirect Resident #5. The 7/13/25 nursing progress note documented at 9:37 a.m. revealed Resident #5 threw a coffee cup at a CNAs arm. The 7/13/25 nursing progress note documented at 11:42 p.m. revealed Resident #5 had behavior issues all through the shift and was not easily redirected. Resident #5 called staff and other residents swear words and racial slurs. Resident #5 slammed doors, threw chairs, tables, and plates without provoked reasons. Resident #5 was not able to be redirected and became a threat to staff and other residents. The 7/14/25 nursing progress note documented at 5:34 a.m. revealed Resident #5 threw chairs at other residents. Resident #5 urinated on the floors and walls.The 7/14/25 nursing progress note documented at 9:41 a.m. revealed Resident #5 was restless, agitated, hit doors and walls and swore. Resident #5 went behind a male resident who was seated at a table and swore at the resident and attempted to pull the chair out from under the male resident. The 7/14/25 nursing progress note documented at 11:59 a.m. revealed Resident #5 slammed doors, yanked on curtains and attempted to kick another resident but staff intervened. The 7/15/25 nursing progress note documented at 2:06 p.m. revealed Resident #5 urinated in the dining room and swore at another resident. The 7/15/25 nursing progress note documented at 9:32 p.m. revealed Resident #5 made continued remarks at another resident and said Why are you praying (profanity)? and then proceeded to call the resident racial slurs. The 7/18/25 nursing progress note documented at 3:19 p.m. revealed Resident #5 and another resident shoved each other. The nurse and a CNA intervened and there were no injuries. The 7/18/25 nursing progress note documented at 7:47 p.m. revealed Resident #5 called residents several obscenities. Staff were unable to redirect Resident #5. The 7/19/25 nursing progress note documented at 9:17 a.m. revealed Resident #5 was in the hallway, slammed and kicked doors and called people obscenities. The 7/19/25 nursing progress note documented at 9:20 a.m. revealed Resident #5 backhanded a CNA.The 7/19/25 nursing progress note documented at 4:15 p.m. revealed Resident #5 threw dishes down the hallway on the secured unit at employees and screamed obscenities. The MD was notified who stated he could not do anything else for Resident #5. The 7/21/25 nursing progress note documented at 3:26 p.m. revealed Resident #5 became more active after 3:00 p.m. and intermittently made inappropriate comments to other residents and staff. The 7/21/25 nursing progress note documented at 7:41 p.m. revealed the staff thought Resident #5 stated he would end his life tonight and the staff thought he had a butter knife. The police were called and they took Resident #5 out of the facility. Resident #5 was taken to a local hospital and placed on an M1 hold for suicidal ideation. Resident #5 did not return to the facility.C. Observations On 7/21/25 at approximately 4:00 p.m. Resident #5 was in the common area of the secured unit. Resident #5 was agitated and moved frantically throughout the common area. Resident #5 continued to run throughout the common area while residents were also in the room. Registered nurse (RN) #1 made several unsuccessful attempts to redirect Resident #5. Resident #5 was not on a one-to-one caregiver for supervision. RN #1 and two CNAs were on the unit who were also caring for the other residents. Resident #5 stopped several times and put his face within three to six inches of Resident #12's face and yelled profanities at Resident #12. Another resident was observed outside in the courtyard and he attempted to open the glass door to reenter the common area but the door was locked. RN #1 said she kept that resident locked outside while Resident #5 was frantic and yelling obscenities. RN #1 said the resident that was outside had PTSD (post traumatic stress disorder) and he was kept outside for his safety. RN #1 said she was concerned that Resident #5 would trigger the PTSD of the resident that was outside. All three staff members tried to redirect Resident #5 without success.D. Resident #5's representatives interviewResident #5's representative was interviewed on 7/21/25 at 3:00 p.m. via telephone. The representative said they had not seen Resident #5 in many years. The representative said Resident #5 had spent most of his life in prison and if not in prison, he preferred to be homeless. The representative said Resident #5 often lived on the streets until he was found by police to have broken his parole and then he returned to prison. The representative said she hoped he was not threatening other residents. III. Resident #4 (victim) A. Resident statusResident #4, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the July 2025 CPO, diagnoses included hypertension (high blood pressure), renal insufficiency, anxiety disorder, bipolar disorder (mental disorder), and dementia. The 7/16/23 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required substantial assistance with showering. She was independent with eating, toileting, and dressing. B. Resident interviewResident #4 was interviewed on 7/21/25 at 11:00 a.m. Resident #4 said she had a mental health situation and preferred to live in a secured unit because it was safe and calm. Resident #4 said that she and the others were often threatened verbally by Resident #5. Resident #4 said Resident #5 could get all of the residents on the secured unit in a nervous uproar. Resident #4 said Resident #5 threw items such as coffee cups and used profanities at her, calling her several different swear words. Resident #4 said she did nothing to provoke Resident #5. Resident #4 said she was afraid of Resident #5 so she stayed in her room more to avoid him.Resident #4 was interviewed again on 7/22/25 at 10:15 a.m. (the day after Resident #5 was removed from the facility by the police). Resident #4 said she was in the dining room last night, when all of the residents were moved into a corner of the dining room for their safety when Resident #5 was frantically moving around the room and yelling. Resident #4 said the police came into the secured unit and the police tried to speak to Resident #5. Resident #4 said Resident #5 punched the policeman. Resident #4 said the police immediately put handcuffs on Resident #5 and made him sit on the floor against the wall. Resident #4 said the ambulance workers came into the unit with a gurney, put Resident #5 on the gurney and took Resident #5 away. Resident #4 said she was relieved that she and the other residents were now safe. Resident #4 said it was not fair to the residents or the staff to put a man like that in the facility. IV. Resident #12 (victim)A. Resident statusResident #12, age less than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included slurred speech, hypertension (high blood pressure), a history of falling, anxiety disorder, cognitive communication deficit, and unspecified dementia with other behavioral disturbances. The 7/10/25 MDS assessment revealed the resident had short and long term memory problems. The resident had severe impairment with cognitive skills for daily decision making, delusions, behavioral symptoms not directed at others, and wandered daily. He was dependent on staff for oral hygiene, toileting, and showering.V. Staff interviewsCNA #1 and CNA #2 were interviewed together on 7/21/25 at 10:30 a.m. Both CNAs said Resident #5 was dangerous to the residents and staff. The CNAs said he was very hard to redirect. The CNAs said generally on the secured unit there were two CNAs and one nurse. The CNAs said Resident #5 was not usually watched by another staff member for one-to-one care. The CNAs said the secured unit generally had three staff members, one nurse and two CNAs. The CNAs said it was up to the three staff members on the secured unit to care for all of the residents as well as to watch Resident #5 closely because of his aggressive behaviors.RN #1 was interviewed on 7/21/25 at 10:40 a.m. She said the general staffing of the secured unit was two CNAs and one nurse. RN #1 said the three staff members were expected to care for all the residents as well as help with Resident #5's behavioral outbursts. RN #1 said when the social worker did stay with Resident #5 one-to-one, it helped keep Resident #5 calm but that did not happen every day. RN #1 was interviewed again on 7/21/25 at 4:00 p.m. RN #1 said the staff tried to do their best to redirect Resident #5, but it was very difficult to do and care for the other residents on the secured unit at the same time. RN #1 said Resident #5 was a toddler times 24 with his behaviors. RN #1 said in order to keep residents safe from Resident #5 she locked a male resident outside in the memory care courtyard. RN #1 said she was concerned the resident outside had PTSD and Resident #5's behavior might trigger a response.The director of marketing was interviewed on 7/22/25 at 4:55 p.m. The director of marketing said she did a zoom call to interview Resident #5 from prison to determine if he was okay to admit to the memory care unit of the facility. The director of marketing determined he should be admitted to the facility. The DON was interviewed on 7/23/25 at 10:45 a.m. The DON said the director of marketing accepted Resident #5 from the department of corrections. The DON said she was told Resident #5 would be admitted to the facility into the memory care unit. The DON said she disapproved of the admission of Resident #5. The DON said she watched a video of Resident #5 in his prison cell. The DON said Resident #5 did not do an interview with facility staff before his admissions that she was aware of. The DON said she did not think Resident #5 was able to provide an interview due to his cognition.The SSD was interviewed on 7/22/25 at 3:35 p.m. The SSD said she was not included in the decision making process to admit Resident #5 into the facility, nor the memory care unit. The SSD said she had sat with Resident #5 one-to-one, but it was not ongoing.The clinical nurse consultant (CNC) was interviewed on 7/23/25 at 1:00 p.m. The CNC said she did not know why the director of marketing accepted Resident #5 from prison with his behaviors. The CNC said the facility now had a plan for admissions into the facility and admissions onto the memory care unit (see facility follow-up below). The CNC said the plan would fix the situation so that accepting someone with aggressive behaviors did not happen again. The NHA was interviewed on 7/23/25 at 4:30 p.m. The NHA said she did not know why the director of marketing accepted Resident #5 for admission into the facility's memory care unit. The NHA said she trusted the director of marketing's decision. The NHA said the facility did not implement a one-to-one caregiver. The NHA said she did not remember why the facility decided not to bill the prison for a sitter. The NHA said the invoice was in Resident #5's electronic medical records (EMR) but it was never acted upon. The NHA said Resident #5 was not provided with a one-to-one caregiver while Resident #5 was admitted to the facility, but it was not consistent. The NHA said Resident #5 would not return to the facility from the hospital. VI. Facility investigation and follow-upOn 7/22/25 at 2:30 p.m. the CNC provided a facility plan for admissions. The document revealed in pertinent part, On 7/21/2025, Resident #5, who had a known history of behavioral issues, exhibited repeated episodes of aggressive behavior on the secure memory care unit. While no physical harm was reported, Resident 5's behavior had the potential to cause emotional distress and fear among other residents. The staff failed to implement immediate behavioral interventions or relocate the resident, resulting in the potential for an unsafe environment for vulnerable residents and failure to ensure their right to live free from abuse and distress. This constituted a concern for the psychological well-being and safety of residents in the secure unit.The plan documented that all affected residents would be assessed by nursing and social services for emotional or psychological distress (implemented 7/22/25).The plan documented that weekly behavioral rounds would be conducted by the interdisciplinary team and resident-to-resident incidents would be reviewed daily in stand-up meetings.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of three residents reviewed for medications errors out of 27 sample residents. Specifically, the facility failed to ensure Resident #1 received intravenous (IV) vancomycin (an antibiotic used to treat bacterial infections) for a diagnosis of staphylococcus hominis bacteremia (a bloodstream infection) per physician's orders. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment.Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights:-The right medication;-The right dose;-The right patient;-The right route;-The right time;-The right documentation; and,-The right indication.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included status epilepticus (seizure lasting longer than five minutes), bacteremia (infection of the blood stream), acute aspiration pneumonia (pneumonia caused by inhaled substances such as food or liquids) and acute encephalopathy (altered mental state).The 6/26/25 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15 the resident was unable to participate. The BIMS was completed by staff assessment and scored moderately impaired. He required total assistance with all of his activities of daily living (ADL).B. Resident #1's representative interviewResident #1's representative was interviewed 7/22/25 at 7:00 p.m. She said when she visited the resident on 6/20/25, the evening after his readmission from the hospital, she had noticed there was not an IV pole in his room. She asked an unidentified nurse about the IV vancomycin and was informed the medication had not been delivered from the pharmacy. The representative said the resident did not receive any doses since his return from the hospital on 6/19/25. Resident #1's representative said the resident was to receive a dose on 6/19/25 and two doses on 6/20/25. She said she had not been notified about the missed doses and was not able to get an answer on when the IV vancomycin would be delivered from the pharmacy. She said she was frustrated with the situation and insisted the resident return to the hospital so he could receive the IV vancomycin. C. Record reviewA review of Resident #1's electronic medical record (EMR) revealed the resident had been in the hospital from [DATE] through 6/19/25. The hospital discharge orders included sodium chloride 0.9% Actbag 250 milliliter (ml) with vancomycin 1.25 gram recon solution 1250 milligram (mg) (medication infused with fluids) every 12 hours for six days for the diagnosis of staphylococcus hominis bacteremia. The June 2025 medication administration record (MAR) revealed the physician's order had been placed 6/19/25 with a start date of 6/20/25. The MAR indicated the resident did not receive IV vancomycin on 6/19/25 or 6/20/25.The nursing progress note, dated 6/19/25, documented the medications were verified with the provider and the pharmacy, including the IV vancomycin. The 6/20/25 nursing progress note documented at 10:01 a.m. revealed the facility was still waiting for the pharmacy to deliver the medication. The 6/20/25 nursing progress note documented at 11:00 p.m. revealed Resident #1's representative expressed her frustration that the resident had not received the medication since his return and demanded the resident return to the hospital. The 6/21/25 nursing progress note documented at 7:50 a.m. the resident was sent to the emergency room.-The resident was admitted to the hospital on [DATE] for three days. The 6/21/25 nursing progress documented at 3:51 p.m., revealed the assistant director of nursing (ADON) was notified the IV vancomycin was not available. The ADON called the pharmacy and was told the pharmacy had not received the order. The ADON informed the resident's physician of the situation.-The physician was not called until 6/21/25, after the resident had missed three doses and after the resident returned to the hospital. -The pharmacy was not called until 6/21/25, after the resident had missed three doses and after the resident returned to the hospital. III. Staff interviewsThe ADON was interviewed on 7/23/25 at 8:38 a.m. The ADON said Resident #1 should have received the first dose on 6/19/25 when he returned from the hospital. She said she had placed the order for the IV vancomycin on 6/19/25. She said he was not notified of the missed doses until 6/21/25. She notified the physician on 6/21/25, after the resident missed three doses.The ADON said the resident's physician should have been notified immediately when medication was missed in order to receive instruction on how to manage the medication going forward. She said the pharmacy should have been called 6/20/25 when the medication had not been delivered.

Based on observations, interviews and record review, the facility failed to ensure supervision, and monitor assistive devices and interventions to prevent accidents for three (#1, #8 and #9) of 10 residents reviewed for accidents out of 12 sample residents. Resident #1 was admitted to the facility for long term care on 9/13/23 with a diagnosis of dementia and repeated falls. The resident's care plan directed the staff to utilize a hoyer lift (mechanical lift) for transfers. On 2/25/25 Resident #1 was noticed to have an injury of unknown origin which was discovered to be a fractured ankle. The facility investigation revealed the staff had not been utilizing a hoyer lift to transfer Resident #1, which was indicated on the resident's plan of care and physician's orders. The facility failed to follow physician's orders and properly transfer Resident #1, which led to the resident sustaining a fracture of the left ankle. Resident #8 was admitted to the facility for long term care on 5/16/24 with a diagnosis of dementia. The resident's care plan identified the resident often sat on the floor next to her bed and would crawl on the floor. The care plan indicated a fall mat was to be placed next to the resident's bed at all times when she was in bed. On 3/21/25 certified nurse aide (CNA) #4 was providing care to Resident #8. CNA #4 did not place the fall mat on the ground when he left Resident #8's room. The resident fell out of bed and onto the floor which resulted in a right shoulder clavicle fracture, a fracture of the nasal bone, a large skin tear to the right elbow and superficial abrasions to both knees. The facility failed to ensure the identified person-centered interventions were consistently implemented for Resident #8, which led to the resident sustaining a fall with major injury. Resident #9 was admitted to the facility for long term care on 3/20/25 with a diagnosis of dementia and nicotine abuse. On 3/30/25 the facility implemented a wander guard due to the resident's increased wandering. On 4/6/25, another resident provided Resident #9 with a cigarette and deactivated the door alarm so Resident #9 could leave the facility without sounding the alarm. While Resident #9 was outside, he fell and sustained multiple closed fractures of the facial bone, a closed head injury, multiple abrasions and a closed fracture of one rib on the left side. The facility implemented a plan of correction after Resident #1 sustained a fracture of the left ankle and after Resident #8 sustained a clavicle fracture, nasal bone fracture, a large skin tear to the right elbow and superficial abrasions to both knees. However, the facility failed to implement an effective plan to address accident hazards. Findings include: I. Facility policy and procedure The Accident and Supervision policy, revised April 2025 was provided by the interim nursing home administrator (INHA) on 4/7/25 at 3:03 p.m. via email. It revealed in pertinent part, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); implementing interventions to reduce hazard(s) and risk(s); and monitoring for effectiveness and modifying interventions when necessary. Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident. Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Identification of hazards and risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. Implementation of interventions - using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes communicating the interventions to all relevant staff, assigning responsibility, providing training as needed, documenting interventions, ensuring that the interventions are put into action and ensuring interventions are based on the results of the evaluation. II. Resident #1 A. Resident status Resident #1, age 84, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, anorexia, major depressive disorder, chronic obstructive pulmonary disease (COPD), chronic kidney disease, repeated falls and muscle weakness. The 2/17/25 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory problems and was severely impaired in decision making skills, per staff assessment. The resident was dependent on staff for eating, oral hygiene, toileting, bathing, personal hygiene and upper and lower body dressing. B. Incident investigation The facility investigation was provided on 4/7/25 at 12:00 p.m. by the director of nursing (DON). The investigation documented that on 2/27/25 at approximately 7:15 a.m. a CNA went to assist Resident #1 to get out of bed and into her wheelchair. The CNA said, along with another CNA, they transferred the resident with two people. The CNAs put their arms into a locked position on either side of Resident #1 and lifted her into her wheelchair. The two CNAs did not use a hoyer lift, per physician's orders or the resident's plan of care. After they transferred the resident, one of the CNAs noticed Resident #1's ankle appeared abnormal. The CNAs notified the registered nurse (RN). Upon the RNs assessment it was determined to send Resident #1 to the hospital. C. Record review The activities of daily living (ADL) care plan, revised 10/31/24, revealed Resident #1 had a self-care performance deficit related to Alzheimer's dementia, fatigue and impaired balance. Pertinent interventions included the resident was dependent on two or more staff for all transfers using a hoyer lift and the staff were to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. D. Record review The 2/27/25 hospital record documented Resident #1 sustained a closed fracture of the lower end of her left tibia (shin bone). The note documented the resident had severe dementia. A splint was applied to the resident's leg as it was determined the resident was on hospice services and was not a surgical candidate. E. Plan of Correction The facility's plan of correction was provided by the DON on 4/7/25 at 12:00 p.m. It read in pertinent part, On 2/27/25 Resident #1 was sent to the emergency room and was diagnosed with a fracture of her left ankle. The DON and the INHA initiated an investigation. The facility conducted a full house audit to determine which residents required extensive and total assistance. The resident's care plans were reviewed. The facility determined all residents that required extensive/total assistance were at risk. The facility provided education to the nursing staff that included utilizing the residents' care plan. The facility implemented a flow sheet that was driven by the residents' plan of care. The flow sheet indicated the residents' transfer statuses and other personalized safety interventions. The DON or designee conducted random audits following the injury. F. Staff interviews CNA #1 and licensed practical nurse (LPN) #1 were interviewed together on 4/7/25 at 12:30 p.m. They said after Resident #1 sustained a broken ankle, all of the nursing staff were trained to use the hoyer lift for Resident #1's transfers at all times. The assistant director of nursing (ADON) was interviewed on 4/7/25 at 1:55 p.m. The ADON said after Resident #1 sustained an ankle fracture, several staff members were interviewed in regards to how they transferred Resident #1 from her bed to her wheelchair and from her wheelchair to her bed. The ADON said all of the staff that were interviewed revealed no one used a hoyer lift to transfer the resident. The ADON said the staff said they transferred the resident with a two person assist. The ADON said that meant two staff members conducted the transfer, where there was a staff member on either side of the resident. She said the two staff members locked arms with the resident and transferred Resident #1. The ADON said the staff had not read the care plan or the physician's order that indicated the resident was to be transferred by a hoyer lift. The DON was interviewed on 4/7/25 at 12:00 p.m. The DON said she interviewed all of the nursing staff that provided care to Resident #1 after the resident sustained an ankle fracture. The DON said none of the staff were aware that Resident #1's ankle was swollen prior to 2/27/25. The DON said all of the staff said they transferred the resident with a two person assist and did not utilize the hoyer lift. The DON said after interviewing the nursing staff, she determined the resident sustained an ankle fracture due to the staff not following the care plan, which indicated to use a hoyer lift to transfer Resident #1. The DON said the problem was the facility staff's fault due to miscommunication with staff not utilizing the hoyer lift. The DON said no other injuries had occurred in the facility since 2/27/25 due to improper transfers. III. Resident #8 A. Resident status Resident #8, age 90, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included anxiety disorder, adult failure to thrive, cerebral infarction (stroke), vascular dementia, muscle weakness and insomnia. The 2/5/25 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of four out of 15. The resident was dependent on staff for eating, oral hygiene, toileting, bathing, personal hygiene and upper and lower body dressing. The resident was always incontinent of bowel and bladder. B. Incident investigation The incident investigation was provided on 4/8/25 at 11:11 a.m. by the DON. The investigation documented that on 3/31/25 at approximately 3:05 a.m. Resident #8, who resided on the secured unit, was found on the ground next to her bed by a CNA. The bed was in the lowest position. The CNA notified the LPN and the RN. Upon assessment, the resident was lying on her right side with a hematoma to the right side of her head. There was also blood noted on the ground around the resident. Resident #8 was complaining of head pain. The staff did not move the resident and called 911. Resident #8 was transported to the hospital emergency department. C. Record review The fall care plan, revised 5/6/24, revealed Resident #8 was at risk for falls, had impaired balance and mobility and poor safety awareness due to cognitive decline. The care plan indicated the resident wished to sit on her fall mat and would crawl on the floor. Pertinent interventions included placing a fall mat on the floor next to the bed when the resident was in bed. The 11/24/24 fall risk assessment revealed the resident was at a high risk for falls. The resident was at high risk due to intermittent confusion and a prior history of falls. The assessment documented the resident was legally blind or the resident's sight ability was unable to be determined. The 3/21/25 hospital record documented Resident #8 sustained a right shoulder clavicle fracture, a fracture of the nasal bone, a large skin tear to the right elbow and superficial abrasions to both knees. D. Facility plan of correction The facility's plan of correction was provided by the DON on 4/9/25 at 11:11 a.m.via email. It read in pertinent part: The plan of correction documented Resident #8 fell and the fall mat was not in place. Resident #8 was transferred to the hospital on 3/21/25 and was diagnosed with a minimally displaced fracture of the left clavicle, minimally displaced right sided nasal bone fracture. The resident's plan of care was reviewed. A new task was entered into the resident's electronic medical record (EMR) that indicated staff was to complete safety checks every two hours. The facility conducted a full house audit and determined that all residents that utilized a fall mat, had fall interventions in place or used an air mattress, had the potential to be affected. The INHA was interviewed on 4/9/25 at 2:00 p.m. The INHA said the DON educated the two CNAs that did not put Resident #8's fall mat on the floor next to the bed when the fall occurred. The INHA said that all nursing staff would be trained about fall mats in an upcoming staff education meeting. E. Staff interviews LPN #2 and CNA #2 were interviewed together on 4/8/25 at 1:15 p.m. They said when Resident #8 fell , the fall mat was not next to her bed. They said when Resident #8 was in bed, the fall mat was to be placed on the floor next to the bed in case Resident #8 fell out of bed. CNA #4 was interviewed on 4/8/25 at 3:26 p.m. via the phone. CNA #4 said he did not put the fall mat on the ground prior to Resident #8 falling out of bed. CNA #4 said he and another CNA went into Resident #8's room because the air mattress was not working properly. CNA #4 said he crawled on the ground and saw some wires that were unplugged. CNA #4 said he plugged the wires back in and the air mattress began to immediately work correctly. CNA #4 said the CNA that was with him left Resident #8's room to go help another resident. CNA #4 said he placed Resident #8's bed in the low position. CNA #4 said he had worked with Resident #8 prior to the fall, and he knew she needed her floor mat next to her bed. CNA #4 said he was distracted, because he heard another resident call for help and forgot to put the fall mat on the floor next to her bed. CNA #4 said shortly after he left Resident #8's room, he heard a noise from Resident #8's room. CNA #4 said when he went back into the resident's room and he saw Resident #8 was on the floor without the fall mat in place. CNA #4 said he noticed Resident #8 was hurt, so he then called for the nurse and Resident #8 was sent to the hospital. CNA #4 said he did not put the floor mat back next to the bed and that was the reason Resident #8 had been injured. IV. Resident #9 A. Resident status Resident #9, age 75, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included COPD, alcohol and cannabis abuse, obstructive sleep apnea, unspecified dementia, epilepsy (seizure disorder), other specified forms of tremors, dependence on supplemental oxygen and cognitive communication deficits. The 3/24/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS of eight out of 15. He required partial to moderate assistance with oral hygiene, toileting and upper and lower body dressing. The MDS assessment indicated it was very important for him to go outside when the weather was warm. The assessment documented the resident did not wander and did not have a wander guard. B. Record review The smoking care plan, initiated 3/21/25 and revised 3/31/25, revealed the resident required supervision with smoking. Interventions included ensuring Resident #9's cigarettes were stored in a locked smoking storage container and providing staff assistance to get Resident #9's cigarettes. The 3/26/25 social service assessment revealed, since the last evaluation, Resident #8's behavior symptoms had increased. The resident displayed wandering tendencies. The resident made statements about wanting to leave the facility grounds. He expressed frustrations, anxiety and challenges with adjusting to placement. Non-pharmacological interventions were attempted. The 3/31/25 interdisciplinary team (IDT) progress note revealed the IDT and Resident #9's representative made a decision to place Resident #9 on the secured unit from 3/29/25 to 3/30/25. The 3/30/25 social service progress note revealed Resident #9 expressed that he wanted to move off of the secured unit and return back to live in the original room he was admitted into. Resident #9 said he had no desire to leave the property. Resident #9 agreed to trial a wander guard alarm. Resident #9 was moved into the original room and a wander guard was placed on him. The 3/31/25 physician's assessment revealed the resident received a wander guard alarm that was placed on his right ankle due to poor safety awareness. The 4/6/25 incident progress note, documented at 11:58 a.m., revealed the resident went outside to smoke unsupervised. Resident #9 was brought back into the facility by a nurse and other residents. Resident #9's face and hands were noted to be covered in blood. Resident #9 was sent to the hospital. The 4/6/25 nursing progress note revealed Resident #9 was transferred back to the facility from the hospital at 6:00 p.m. via a stretcher. Resident #9 had multiple bruises and swelling to the face and skull. Resident #9 had multiple bruises and a skin tear to the arms and legs. Resident #9 was placed on one-to-one monitoring. The 4/6/25 hospital record documented the resident sustained multiple closed fractures of the facial bones, a closed head injury, multiple abrasions and a closed fracture of one rib on the left side. C. Staff interviews The INHA was interviewed on 4/9/25 at 2:00 p.m. The INHA said an investigation was underway for the fall that Resident #9 sustained on 4/6/25. The INHA said on 4/6/25 at approximately 7:30 a.m. Resident #9 went to the front lobby unescorted by staff members. The INHA said while he was in the lobby a resident gave him a cigarette and the same resident turned off the front door alarm to help Resident #9 go outside to smoke.He said Resident #9 went out the front door without setting off any alarms. The INHA said while Resident #9 was outside, he fell and sustained injuries. The INHA said the alarm code was immediately changed. The INHA said an electrician would come to the facility as soon as possible to ensure the doors and alarms were working properly. He said it was not certain yet how a resident knew the door alarm code, but it was possible the resident overheard staff members discussing the code and the resident remembered it. The INHA said Resident #9 would be on one-to-one monitoring until further notice. The DON was interviewed on 4/9/25 at 2:35 p.m. The DON said on 4/9/25 the facility had three residents with wander alarms and all three alarms worked correctly.

Based on record review and interviews, the facility failed to ensure one (#3) of three residents reviewed out of 15 sampled resident representatives were immediately informed of an accident involving the resident. Specifically, the facility failed to notify Resident #3's representative following the resident's low blood pressures that created a change of condition ultimately resulting in the resident being transferred out to an acute care hospital. Findings include: I. Facility policy and procedure The Notification of Changes policy, revised January 2023, was received from the nursing home administrator (NHA) on 2/26/25 at 9:08 a.m. It read in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification, as a transfer or discharge of the resident from the facility. II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and discharged to the hospital on 2/19/25. According to the December 2024 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease, dementia with moderate behavioral disturbance, hypertension, depression, anxiety, and difficulty in walking. The 12/13/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of six out of 15. He required minimal assistance with activities of daily living (ADL). B. Record review The 2/19/25 nursing note, documented at 9:53 a.m., revealed Resident #3 sustained a change of condition and was shaking and jerking uncontrollably. Registered nurse (RN) #1 assessed Resident #3 and identified the resident's blood pressure had significantly dropped from the prior set of vital signs that were taken at 7:53 a.m. At 7:53 a.m. the resident's blood pressure was 130/68 milliliters of mercury (mmHg) and at 9:53 a.m. the resident's blood pressure was 80/50 mmHg. RN #1 contacted the nurse practitioner, who was in the facility, for direction on care. After the nurse practitioner provided care, it was decided to transfer Resident #3 to the hospital as treatment was ineffective. -Review of the resident's electronic medical record (EMR) did not reveal documentation indicating the resident's representative was notified of the resident's change of condition or that the resident was transferred to the hospital. The 2/19/25 transfer/discharge form revealed the resident's representative was notified of the resident's change of condition on 2/20/25. -The resident's representative was not notified until the following day after Resident #3 experienced a change of conditioning and was transferred to the hospital. The NHA provided documentation that revealed the resident's representative emailed the NHA on 2/20/25 at 3:40 p.m. after she had received a text message from the local hospital regarding Resident #3's stay in the hospital. The email documented, the resident's representative said she had not been notified by the facility staff that Resident #3 had been transferred to the hospital. III. Staff interviews RN #1 was interviewed on 2/25/25 at 1:02 p.m. RN #1 said RN #2 had told him that he did not attempt to contact Resident #3's representative on 2/20/25 after the resident was transferred to the hospital. RN #1 said that RN #2 told him that after Resident #3 left the facility, he moved on to the next resident task and forgot to complete the notification to Resident #3's representative. RN #1 said he asked RN #2 if he should notify Resident #3's representative and RN #2 said that she had just spoken to Resident #3's representative and it was not needed. RN #1 said RN #2 also told him that the interim director of nursing was going to contact Resident #3's resident representative. RN #1 said the physician and family should always be notified immediately following an incident involving a resident. RN #1 said Resident #3 had dementia and the resident's representative made all medical decisions. He said the resident's representative should be notified with any change in condition. The NHA was interviewed on 2/25/25 at 4:00 p.m. The NHA said Resident #3's representative was not notified when Resident #3 had a change of condition and was transferred to the hospital on 2/19/25. She said she expected the nursing staff to notify the physician and resident's representative after a change of condition. The NHA was interviewed again on 2/26/25 at 11:08 a.m. The NHA said the process for notifying resident representatives depended on the type of change in condition the resident had experienced. The NHA said if the resident was experiencing an emergent change that required immediate transfer to hospital, then the notification was made when the resident left the facility and was in transit to hospital, but it must occur prior to resident arriving at hospital. The NHA said if the change in condition was not emergent then the resident's representative should be called immediately. The NHA said a clinical meeting occurred every Monday through Friday to review risk management to ensure notifications to responsible parties were completed. The NHA said the supervisor on the weekend mimicked this process. The NHA said when a resident was admitted to the facility the resident's representative's contact information was obtained. The NHA said that nursing staff received initial training related to notification of changes upon new hire and annually. The NHA said RN #1 was verbally counseled and reeducated on 2/20/25 after the email was received from Resident #3's resident representative.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#2) of two residents reviewed for dialysis out of 15 sample residents. Specifically, the facility failed to consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center for Resident #2. Findings include: I. Facility policy and procedure The Hemodialysis Policy, dated March 2019and revised April 2024, was provided by the nursing home administrator (NHA) on 2/26/25 at 11:42 a.m. via email. It revealed in pertinent part, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. The nurse will ensure that the dialysis access site (AV (arteriovenous) shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit (an abnormal sound in the blood that can indicate a partial blockage in an artery) and palpating for a thrill (a vibration or buzzing sensation felt at the site where the artery and vein have been surgically connected to create an access point for hemodialysis). If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included type 1 diabetes mellitus with hyperglycemia (unusually high blood glucose levels), stage four chronic kidney disease, tachycardia (abnormally fast heart beats), cerebral infarction (stroke), traumatic brain injury (TBI), seizures, unspecified cirrhosis of the liver, cognitive communication deficit and dependence on renal dialysis. The 1/21/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 11 out of 15. He did not reject care from staff. He used a front wheel walker to ambulate. He was independent with eating, and oral hygiene. He required set up or cleaning assistance with toileting. The MDS assessment indicated the resident received dialysis treatments. B. Resident interview Resident #2 was interviewed on 2/25/25 at 11:55 a.m. Resident #2 said he had attended dialysis for about six years. He said he went to dialysis three times per week. He said sometimes he forgot to return to the facility with his dialysis book that the facility sent him with on each visit. He said today (2/25/25) he did not remember where he left his dialysis communication book. He said at one time, his dialysis book was the color purple but now it is white and he said, who knows what color it is. C. Record review Review of Resident #2's February 2025 CPO revealed the following physician's orders related to dialysis: Resident #2 was to go to dialysis Tuesday, Thursday, and Saturday. Make sure the resident took his dialysis folder, ordered 2/25/25. Review of Resident #2's dialysis care plan, initiated 11/5/24, revealed the resident needed hemodialysis for the disease process. Interventions were to monitor weights for pre- and post-dialysis three times per week. -However, the care plan did not identify what disease process the hemodialysis was needed for. Review of Resident #2's February 2025 medical treatment administration record (MAR) and treatment administration record (TAR) revealed the following: Make sure the resident takes his dialysis folder and snacks one time a day every Tuesday, Thursday, and Saturday for ESRD (end stage renal disease). The dialysis communication log books were provided by the interim director of nursing (IDON) on 2/26/25 at 2:19 p.m. Each log had three sections on one sheet of paper which revealed the following: The pre-dialysis section was to be filled in by the facility with the date and the resident's vital signs which included, temperature, pulse, respirations, blood pressure, weight and oxygen saturation levels. There was a section to write in the medications given to the resident prior to dialysis, and if a meal or snack was sent with the resident and if no, why not. A nurses' signature was required to validate that the information was completed. The middle section of the communication form was to be filled out by the dialysis center staff. The documentation was to include the amount removed from the resident (waste products and excess fluids from the blood), post-dialysis weight, if the dialysis was completed with a full cycle, and if not an explanation was to be given. Also included was any laboratory (lab) work completed and any issues with accessing graft or catheter. Medications given at dialysis were to be listed, along with any recommendations from the dialysis center. A nurses' signature from the dialysis center was required to validate the information. This section was returned with the resident to the facility. The post-dialysis section was to be completed by the facility when the resident returned after receiving dialysis. The post-dialysis section repeated all the vital signs to be recorded again as in the pre-dialysis section. The post-dialysis section further included the following questions: Any bleeding from the access site, was there a meal given at the resident's return, were there any new orders sent with the resident and were there any new skin issues. A nurses' signature was required to validate the post-dialysis information was completed. Resident #2's dialysis communication logs from 2/1/25 through 2/25/25 were provided by the social services assistant (SSA) on 2/26/25 at 1:20 p.m. The dialysis communication logs revealed the following: Resident #2 was scheduled to attend dialysis 11 times from 2/1/25 to 2/25/25. -The facility was not able to provide dialysis communication forms for 2/4/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25 and 2/18/25. The five dialysis communication forms the facility was able to provide documented the following: On 2/1/25 all three dialysis communication form sections were fully completed. On 2/6/25 the pre-dialysis section did not include the medications given prior to dialysis, whether or not a meal or snack was sent with the resident and the resident's weight was not provided. The facility nurse did not sign the communication form to validate the information was completed. On 2/20/25 Resident #2 refused to go to his dialysis appointment. On 2/22/25 the post-dialysis section information was not documented by the facility. On 2/25/25 the communication form was incorrectly dated. It was dated 2/24/25 instead of 2/25/25. The pre-dialysis section of the form did not include the medications given prior to dialysis, whether or not a meal or snack was sent with the resident and the resident's weight was not provided. The post-dialysis section was not documented on a separate form when the resident did not return with his dialysis log book that day. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/25/25 at 10:45 a.m. LPN #1 said he was the nurse today (2/25/25) for Resident #2. LPN #1 said he filled out the communication form log sheet and made sure Resident #2 took his dialysis log book to dialysis. -However the dialysis communication form was dated 2/24/25, instead of 2/25/25 (see record review above). LPN #1 said when a resident on dialysis returned from a dialysis center, the facility nurse was responsible for filling in the post-dialysis communication section on the daily sheet. LPN #1 said it was important to take a resident's vital signs when they arrived back at the facility to ensure the resident was doing well. LPN #1 said whatever the dialysis center wrote in their section was pertinent information for the nursing staff to read about the resident. LPN #1 said Resident #2 consistently had high blood sugars that needed to be closely monitored because he was on an insulin sliding scale which meant Resident #2 might need extra units of insulin to be administered if his blood sugars were high. LPN #1 said if Resident #2's blood sugars were high, insulin would be administered, and then after a waiting period, Resident #2 would be monitored again to see if his blood sugar levels came down from the administered insulin. He said if his blood sugars levels were over 400 the nurse was to immediately notify the physician, and let the physician determine what may be needed for the resident. The SSA was interviewed on 2/25/25 at 2:55 p.m. The SSA said it was brought to the facility's attention (during the survey) that Resident #2 did not return from dialysis with his communication log book. The SSA said she called the transportation company who said he left his book in their vehicle. The SSA said the book with the dialysis communication forms would be returned to the facility the following day on 2/26/25 between 10:00 a.m. and 12:00 p.m. The nurse practitioner (NP) was interviewed on 2/26/25 at 10:15 a.m. The NP said he had worked with Resident #2 for a few years. The NP said Resident #2 had erratic blood sugars. The NP said Resident #2 was a brittle diabetic which could cause him to have unpredictable blood sugar swings. The NP said Resident #2 had been hospitalized at times due to this dangerous condition. The NP said Resident #2 had been losing weight which also needed to be monitored. The IDON was interviewed on 2/26/25 at 3:00 p.m. The IDON said she did not know where all of Resident #2's dialysis communication logs were for the month of February 2025. She said what was found were only four sheets that were in his dialysis book. The IDON said all three sections of the dialysis communication form should be filled out completely for each resident that attended dialysis. The IDON said she would begin an education about dialysis communication for all of the nursing staff which would begin on 2/26/25. The IDON said dialysis binders for the residents were purple. She said Resident #2's lost binder was returned to the facility today (2/26/25)per the SSA's request to the transportation company. IDON said the returned binder was white not purple and she did not know why. She said she was unaware another resident's dialysis binder was white also. The IDON said yesterday (2/25/25) when Resident #2 returned from dialysis, the information for the post-dialysis information was not written down on a separate form to document his vital signs were taken. The IDON said it was important for the facility to fill in the post-dialysis section as well as read what the dialysis center wrote in their section on the log sheet. The IDON said Resident #2 rarely refused to go to his dialysis appointments. The IDON said on 2/20/25 Resident #2 refused to go to dialysis because he was tired from a hospital stay on 2/19/25. The IDON said if she was able to locate the missing communication log sheets for Resident #2 she would provide them via email. -However, the facility did not provide any further dialysis communication forms for Resident #2. IV. Facility follow up On 2/27/25 at 12:46 p.m. the NHA provided a policy performance improvement plan (PIP) for hemodialysis via email. On 2/27/25 at 1:23 p.m. the NHA provided, via email, the PIP education that was given to the nursing staff at the facility. The education included a sample of how the dialysis communication form was to be correctly filled out. The NHA further provided the five question quiz provided to the nursing staff about dialysis. The NHA said all dialysis residents from now on would have a uniform (same) color binder. The PIP documented the following in pertinent part: Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Continuous monitoring and oversight before, during, and after dialysis treatments, including observation of the resident's condition, monitoring for complications, implementing appropriate interventions, and using infection control practices. Regular communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will monitor changes in behavior that could impact dialysis safety before and after treatments and communicate these changes with the attending physician and dialysis facility. Immediate education initiated to all relevant nursing and facility staff on the dialysis policy's guidelines, highlighting pre/post dialysis assessments, completion of dialysis flow sheets, maintenance of binders and communication with dialysis center and transportation. Documentation of dialysis-related care (binders/assessments) will be reviewed 6 (six) times a week (Monday through Saturday) for accuracy and completeness in collaboration with dialysis providers. Trends will be discussed in quality assurance and performance improvement (QAPI) committee meetings monthly until substantial compliance is achieved. The staff education documented the following in pertinent part: It is very important that the appropriate dialysis communication form is filled out pre- and post-dialysis. Attached is a dialysis communication form and how it is to be filled out. The form will be sent with the resident and returned with the resident. Any new doctor orders will be written on this form. Post-dialysis vital signs must be done immediately upon return. Make sure fistula or chest port is observed upon return and documented in a nurse's note.

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 temperatures in five of 14 resident rooms and the resident's activity room were within the safe range of 71 degrees F (Fahrenheit) to 81 degrees F. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised April 2022 was provided by the interim nursing home administrator (INHA) on 12/3/24 at 8:13 a.m. It read in pertinent part, Definitions Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/ hyperthermia and is comfortable for the residents. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. If and when a resident prefers his or her room temperature be kept below 71 degrees Fahrenheit, or above 81 degrees Fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate. II. Resident interviews The resident who resided in room [ROOM NUMBER] was interviewed on 12/2/24 at 11:00 a.m. The resident said his room was always cold. He said he had told staff and the maintenance director many times that his room was too cold but nothing was ever fixed. The resident said he had to wear a jacket in his room, as well as use several extra blankets, to keep warm. He said his room was ice cold at all times. The resident said It sucks that it is so cold in here. The resident who resided in room [ROOM NUMBER] was interviewed on 12/2/24 at 11:30 a.m. The resident had a large white blanket rolled up in the windowsill. He said his room was always cold and extra cold at night. He said he complained to the maintenance director several times that his room was bold but nothing was ever fixed. The resident said he rolled up towels in his windowsill to help prevent cold air from coming in. He said he used to have his bed next to the window where he preferred to have it but he had to move his bed to the opposite side of the room so that he was warm. The resident said he wore his jacket in his room and requested extra blankets from the facility. A frequent visitor in room [ROOM NUMBER] was interviewed on 12/2/24 at 3:15 p.m. Both the frequent visitor and the resident were wearing winter coats. The frequent visitor said she hoped the heat would get fixed in her loved one's room. She said she visited almost daily and both she and the resident had to wear their jackets during their visits because the room was too cold to sit in without wearing a jacket. The resident who resided in room [ROOM NUMBER] was interviewed on 12/3/24 at 10:15 a.m., after the heat was fixed during the survey (see below). The resident said the heat was finally fixed in her room. She said, even with the extra heater above her door, it never worked and she was always cold. The resident said she always wore her jacket in her room and covered herself with two blankets when she sat in her recliner and when she was in her bed. She said she had not wanted to take showers because her room was so cold, but she said today (12/3/24) she would finally take a shower because she was finally warm. III. Observations and staff interview On 12/2/24 at 2:15 p.m. a tour was conducted throughout the facility in various rooms with the director of maintenance (DM). The MTD initially put the heater gun sensor light directly into a heating unit at the floor board level six times, until he was requested to put the sensor light on a wall for an accurate temperature reading. The following temperatures were observed in residents' rooms: -room [ROOM NUMBER] was 66 degrees F; -room [ROOM NUMBER] was 66 degrees F; -room [ROOM NUMBER] was 65 degrees F; -room [ROOM NUMBER] was 69 degrees F; and, -room [ROOM NUMBER] was 68 degrees F. -The residents' activity room was recorded at 65 degrees F. During the temperature reading in the activity room, a resident was observed requesting a blanket because she was too cold. The MTD said he did not know what the appropriate temperature range was for comfortable room temperatures in the facility. IV. Additional staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/2/24 at 1:00 p.m. LPN #1 said she had worked in the facility for many years and the heat was always an on and off again problem. LPN #1 said some of the thermostats in the residents' rooms worked and some did not work. LPN #1 said the staff were often asked by residents for extra blankets. LPN #1 said when a resident complained about the heat, the staff had a group texting chat on their phones to let the management know. LPN #1 said sometimes when staff texted about heat problems, they were told to put it into the computer's maintenance work order request system. LPN #1 said the rooms at one end of the Elk Run unit had packaged terminal air conditioners (PTAC) for heat mounted above seven room doors for extra heat. LPN #1 said only one or two of the PTAC were working today(12/3/24) out of the seven rooms. Certified nurse aide (CNA) #1 was interviewed on 12/2/24 at 1:10 p.m. CNA #1 said the residents often complained about being cold. CNA #1 said he would provide the residents with extra blankets. CNA #1 said he was told to record in the computer maintenance log system when a resident complained about their room being cold. The INHA and corporate consultant (CC) were interviewed on 12/2/24 at 3:00 p.m. The INHA and the CC said the heat situation in the building would be handled immediately. The INHA said a company would be called in as soon as possible to work on the heat and to check that the boiler was working properly. The INHA said there were no records of thermostats being checked in the building prior to her doing during the survey. The INHA and the CC were interviewed on 12/3/24 at 11:00 a.m. The CC said all of the residents' care plans were updated to indicate if a resident preferred temperatures in their room above or below 71 to 81 degrees F. The INHA said between last night (12/2/24) and today (12/3/24), she and her team did an all-house audit of the facility and fixed the heat in residents' rooms. The INHA said all thermostats were checked, the PTAC units on the Elk Run unit had the batteries replaced and those units were now producing heat. The INHA said some valves on residents' room heaters needed to be opened or adjusted to allow the heat to flow. The INHA said an outside service company was called in to examine and fix any concerns with the boiler system in the facility to ensure the heat was working properly. The CC said a plan was put in place for facility staff to check residents' room temperatures She said the plan would be implanted immediately. The CC said all rooms would be temperature checked daily, Monday through Friday, for one month. She said after one month, all rooms would be temperature checked three times per week for one more month. The CC said after the second month of audits, each room would be temperature checked one time weekly for three months to ensure the rooms were the appropriate temperatures. V. Facility follow up On 12/3/24 at 8:01 a.m. the INHA said, via email, that the facility did not have any grievances or resident complaints from resident council meetings related to room temperatures. She said an in-house audit of temperatures had been conducted (beginning 12/2/24, during the survey). The INHA said any room that was not meeting appropriate temperatures or rooms where resident dissatisfaction with the room temperature was identified, would be monitored every two hours until substantial compliance for appropriate room temperatures was determined. Additionally, the INHA said all thermostats were checked, reprogrammed and batteries were replaced if necessary on 12/3/24. The INHA said the facility was in the process of purchasing 12 heaters for rooms which were not meeting the appropriate temperature range. The INHA indicated the heaters would be delivered to the facility that day (12/3/24). On 12/3/24 at 2:04 p.m. the INHA said, via a second email, that the temperatures in the resident rooms which had not been meeting the appropriate temperature had been rechecked and the temperatures were all now 71 degrees F or above. On 12/3/24 at approximately 3:00 p.m. the INHA provided documentation of the last 30 days of phone texts sent to a group management phone text which revealed the following: On 11/17/24 four residents reported they were all freezing. The staff gave them more blankets and made sure the windows were shut. One resident requested for the MTD to fix the heat because it was supposed to be colder that night and tomorrow (11/17/24 and 11/18/24). -The facility did not have documentation to indicate the resident's concern was addressed. On 11/29/24 a resident complained about being cold by a window and the staff said they would move the resident's bed away from the window. -The facility did not have documentation to indicate the resident's concern was further addressed. On 12/5/24 at 12:33 p.m. (after the survey exit) the INHA said, via email, that the facility had secured two outside contracts for ceramic heaters for the facility.

Based on record review and staff interviews, the facility failed to thoroughly investigate allegations that certified nurse aide (CNA) #1 physically and verbally abused two of four residents (#28 and #111) reviewed for abuse out of 66 sample residents. Staff interview revealed allegations of abuse involving CNA #1. Staff stated that during care, Resident #28, although severely cognitively impaired, pointed to CNA #1, stating the staff member had pulled her hair. When interviewed during the survey on 9/11/23, Resident #28, who was appropriately responsive to questions, said she was grabbed, shaken, and her hair pulled by a staff member, hurting the back of her head. Staff interviews further revealed Resident #111, who was moderately cognitively impaired, alleged CNA #1 had verbally abused her. When interviewed during the survey on 9/18/23, Resident #111 said CNA #1 would not stop yelling accusations in her face which scared her. Although staff stated the incident involving Resident #28 was reported to leadership by more than one staff member, and Resident #111 said she reported the incident with CNA #1 to the front office, Resident #111 said she never heard back from leadership and the facility lacked evidence that either allegation against CNA #1 was thoroughly investigated by the facility and that steps were taken to prevent further potential abuse. Staff interviews also indicated the incidents above were not isolated; staff reported they had observed CNA #1 provide rough treatment (getting close, yelling and screaming and pointing fingers) to several residents in the facility, and had overheard CNA #1 and CNA #2 yelling at residents down the hall from the other units. Staff who wished to remain anonymous reported that CNA #1 was observed yelling, cursing and sticking her middle finger in the face of Resident #10, telling the resident (expletive) you. The facility's failure to initiate a thorough investigation into the allegations of abuse of Residents #28 and #111 and take corrective action, as well as reports that these incidents were not isolated, created a situation of immediate jeopardy for serious harm. Cross-reference F609 for failure to reporting allegations Findings include: I. Immediate Jeopardy A. Findings triggering immediate jeopardy Staff interview revealed allegations of abuse involving CNA #1. Staff stated that during care, Resident #28, although severely cognitively impaired, pointed to CNA #1, stating the staff member had pulled her hair. When interviewed during the survey on 9/11/23, Resident #28, who was appropriately responsive to questions, said she was grabbed, shaken, and her hair pulled by a staff member, hurting the back of her head. Staff interviews further revealed Resident #111, cognitively intact, alleged CNA #1 had verbally abused her. When interviewed during the survey on 9/18/23, Resident #111 said she remembered CNA #1 would not stop yelling accusations in her face which scared her. She said she had reported the incident but never heard anything back. Although staff stated the incident involving Resident #28 was reported to leadership by more than one staff member, and Resident #111 said she reported the incident with CNA #1 to the front office, Resident #111 said she never heard back from leadership and the facility lacked evidence that either allegation against CNA #1 was thoroughly investigated by the facility and that steps were taken to prevent further potential abuse. Staff interviews also indicated the incidents above were not isolated; staff reported they had observed CNA #1 provide rough treatment (getting close, yelling and screaming, and pointing fingers) to several residents in the facility, and had overheard CNA #1 and CNA #2 yelling at residents down the hall from the other units. Staff who wished to remain anonymous reported that CNA #1 was observed yelling, cursing, and sticking her middle finger in the face of Resident #10, telling the resident (expletive) you. The facility's failure to initiate a thorough investigation into the allegations of abuse of Residents #28 and #111 and take corrective action as well as reports that these incidents were not isolated, created a situation of immediate jeopardy for serious harm. B. Facility notice of immediate jeopardy On 9/14/23 at 2:15 p.m., the director of nursing (DON) and the nursing home administrator (NHA) were notified that the facility's failure to investigate allegations of abuse by facility staff placed residents at risk for serious harm. C. Plan to remove immediate jeopardy On 9/14/23 at 6:48 p.m., the NHA presented the following plan to address the immediate jeopardy situation. It read in part: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. -The Administrator or designee immediately ensured the safety and well-being of the resident(s) who alleged abuse by removing the accused staff members(s) from the facility. They were suspended pending investigation. -The Administrator or designee immediately initiated a Resident council meeting and Individual resident interviews. -Nursing Supervisors completed physical assessments/skin audits on residents identified to have concerns to identify any injuries of unknown origin and/or evidence of abuse or neglect. -Concerns were not identified. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. -Disciplinary action was taken with staff member accused of abuse -All federal and state protocols were followed in investigating and reporting abuse allegation(s). Maintain policies related to reporting allegations of abuse or neglect Immediately take steps to ensure safety of residents pending investigation Timely reporting of mandatory reporting events to the Colorado Department of Public Health and Environment Investigation initiation including notification of ombudsman Submit final report findings into Colorado Facilities Interactive (COHFI) Ongoing staff education -Residents with Brief Interview for Mental Status (BIMS) scores of 8 or higher were interviewed/ assessed by Social Services Director and/or Nursing Supervisors to identify if they felt safe and if they had experienced abuse while living at the facility. All Residents with a BIMS of 7 or lower, the power of attorney (POA) was called to identify any concerns. Any concerns of abuse and neglect that were noted by residents will be addressed immediately. -Abuse policies were reviewed -Abuse investigation procedures and documentation process were reviewed with regional director of operations (RDO) -Director of nursing and designee educated all staff on abuse policies -DON or designee reviewed facility abuse policies and procedures with any agency staff prior to their shift -Staff members were not permitted to work a shift until education was completed -The regional/corporate/hired consultant team member will visit the facility weekly to provide oversight, audits and additional training as needed. The designated team will visit the facility starting 9/18/23, every week for the next four weeks and as needed thereafter -The Activities Director held a Resident Council meeting in which the residents were educated on the facility's abuse policies and procedures -The Social Service Director began discussing facility abuse policies with residents and families at the initial care plan conference (upon admission) -The administrator or designee will continue to interview residents with BIMS scores of 8 or higher on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the Quality Assessment and Assurance (QAA) committee. D. Removal of immediate jeopardy On 9/19/23 at 10:30 a.m. the DON and NHA were notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at a D scope, isolated with the potential for more than minimal harm. II. Resident and staff interviews revealed allegations of abuse by CNA #1 A. Resident #28 and Resident #111 1. Resident #28, over 65, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, atherosclerotic heart disease, and unspecified dementia, unspecified severity without behavioral disturbance. The 9/12/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required one-person assistance with bed mobility, dressing, toilet use, and personal hygiene; and was incontinent of bowel and bladder. 2. Resident #111, under 65, was admitted on [DATE]. According to the September 2023 CPO, diagnoses included diabetes mellitus, depression, and heart disease. The 7/24/23 MDS assessment revealed the resident had moderately impaired cognition with a BIMS score of nine out of 15. The resident needed extensive assistance to complete activities of daily living (ADL), used a wheelchair, and was unable to walk. B. Allegations of abuse by CNA #1 1. Allegation of abuse of Resident #28 Resident #28, who was able to appropriately respond to questions, was interviewed on 9/11/23 at 1:30 p.m. The resident said a facility staff came into her room, grabbed her left arm, shook her body, and pulled her hair which hurt the back of her head. The resident said she did not know why the staff acted badly toward her or why that staff wanted to hurt her. The resident said she could not recall the staff's name or the date and time the incident happened. The resident said she could not hear without her hearing aids and maybe the staff was trying to tell her something that she was unable to hear. She said she was not fearful of any other staff. CNA #7, in an interview on 9/13/23 at 4:00 p.m., said there was a noticeable change in Resident #28's behavior this past June after the allegation of abuse of Resident #28. CNA #7 said every time the resident saw CNA #1 she would yell at CNA #1 saying Get out of here (expletive). CNA #14, in an interview on 9/21/23 at 6:17 p.m., said that while working with Resident #28 a week after the allegation of abuse of Resident #28, the resident pointed at CNA #1 and said That's the one who pulled my hair, keep her away from me. 2. Allegation of abuse of Resident #111 Resident #111 was interviewed on 9/18/23 at 11:48 a.m. Resident #111 said she remembered a time when CNA #1, who was carrying for her at the time, was yelling in her face and calling her a racist which offended her. She said she tried to explain to CNA #1 that she was not a racist, but the CNA did not stop yelling accusations at her. Resident #111 said CNA #1's behavior scared her at the time. Resident #111 said she reported the incident to the front office but never heard anything back from any of the facility's leadership team and CNA #1 continued to work in the facility. CNA #7, in an interview on 9/13/23 at 4:00 p.m., said Resident #111 alleged CNA #1 had verbally abused her and had said no one talked to her about her experience working with CNA #1. 3. Additional allegations of abuse by CNA #1 Staff interviews also indicated the incidents above were not isolated. CNA #7, interviewed on 9/13/23 at 4:00 p.m. said she worked several shifts with CNA #1 and had observed CNA #1 provide rough treatment (getting close, yelling and screaming, and pointing fingers) to several residents in the facility. CNA #14, interviewed on 9/21/23 at 6:17 p.m., said she observed CNA #1 and CNA #2 yelling and cursing at residents in an angry way. LPN #4, interviewed on 9/18/23 at 7:15 p.m. said CNA #1 could be heard yelling at residents down the hall from the other units. Staff who wished to remain anonymous reported that CNA #1 was observed yelling, cursing, and sticking her middle finger in the face of Resident #10, telling the resident (expletive) you. III. The facility failed to initiate a thorough investigation into the allegations of abuse of Residents #28 and #111 and take corrective action to protect Resident #28 and Resident #111, as well as other facility residents, from further potential abuse by CNA #1, as required and expected. A. Regulatory and facility expectations Consistent with regulatory requirements to thoroughly investigate all allegations of abuse, to take appropriate corrective actions, and to prevent further potential abuse, the facility's Abuse, Neglect, and Exploitation policy, revised April 2022, and provided by the nursing home administration (NHA) on 9/11/23 at 9:33 a.m. read in part: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriations of resident property. It further read: The facility will implement policies and procedures to prevent and prohibit all types of abuse . (and) that achieves: -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; -Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and -Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. B. Facility failure to meet regulatory and facility expectations to initiate a thorough investigation into the allegations of abuse of Residents #28 and #111 and take corrective action to protect Resident #28 and Resident #111, as well as other facility residents, from further potential abuse by CNA #1. 1. On 9/13/23 at approximately 2:00 p.m., a request was made for the facility's investigation into the allegations of staff abuse toward Resident #28 was made to facility leadership. -The nursing home administrator (NHA) said she was unable to find any evidence that the previous administrator who was in the position at the time of the alleged incident had conducted an investigation. -The director of nursing (DON) said she was a weekend supervisor at the time of the alleged allegations and not a part of leadership. She said she had no direct knowledge of Resident #28 being abused by a staff member, although she had heard chatter about the possibility of staff being abusive towards residents in the facility. The DON said she was never made aware of leadership's actions in regard to the chatter she had heard, as she was not included in the leadership's discussion and decisions on how to handle the allegations that were circulating within the facility. The DON said she was partially aware that the prior facility leadership (none of whom were still working in the facility) had been in discussions about the alleged incident with Resident #28 because she was told CNA #1 was being reassigned to a different unit and was not to be scheduled to work on the unit where Resident #28 resided. She said no other information was given to her. The DON provided a schedule that showed CNA #1 was reassigned to a new unit starting 6/8/23. 2. On 9/18/23 at approximately 12:00 p.m., Resident #111's allegation of abuse by CNA #1 was reported to the NHA. A review of the State reporting portal revealed no documentation of Resident #111's allegation of abuse prior to 9/18/23 or as of 9/26/23. See below: The facility conducted an investigation of the allegation on 9/18/23 after immediate jeopardy was identified on 9/14/23. Cross-reference F609. 3. Registered nurse (RN) #5 was interviewed on 9/17/23 at 3:05 p.m. RN #5 said if a nurse observed or heard that a resident was abused physically or otherwise, the nurse's responsibility would be to listen to the resident; get a description of what occurred; complete a head-to-toe assessment to locate injuries; and report the abuse to the nurse supervisor, DON or NHA. However, a document review revealed the facility failed to carry out these responsibilities. Specifically: -There was no documentation in either Resident #28 or Resident #111's medical record, documenting the incident or assessing the resident's condition after the incident. C. Facility follow-up after notification of immediate jeopardy 9/14/23 at 2:15 p.m. 1. After reporting concerns about the facility's failure to investigate the allegation of abuse by staff toward a resident, the facility leadership immediately suspended CNA #1 and CNA #2 pending the facility investigation. The facility started its investigation on 9/14/23. a. On 9/14/23 the facility interviewed 12 staff and asked if they had ever suspected abuse or neglect in the workplace or witnessed a colleague displaying abusive or neglectful behavior to a resident. Eleven staff wrote statements that they had not witnessed or suspected that any residents were being abused. One staff member wrote a statement: No I have not suspected abuse; however, there have been instances where residents were soaked through each layer of the bed sheets when the day shift came in the morning. However, there was no indication this staff member identified this situation as potential abuse for neglecting to provide a resident needed care. b. On 9/14/23 the facility interviewed 13 of 113 residents in the facility. Four of the 13 residents interviewed were on the unit CNA#1 previously worked (unit 300 unsecured unit ) and five lived on the unit she was reassigned to (unit 200); the other four residents were on unit 100 where CNA#1 was not typically assigned to work. Each resident was asked four questions: 1. Has any staff been rude or disrespectful to you recently? 2. Have any staff members treated you roughly or caused you pain recently? 3. Are you afraid of any staff member/caregiver? 4. Are you satisfied with the care you receive? None of the 13 residents interviewed felt disrespected or that they were treated roughly by staff. c. The facility interviewed the alleged victims of staff-to-resident abuse. (1) On 9/14/23 Resident #28 was interviewed by the DON and NHA and asked the following four questions: -Were there any instances in the past, specifically in June with CNAs that made you feel unsafe? -Do you have any overall concerns with the CNAs who take care of you? -Do the CNAs answer our call light quickly and help you with what you need? -Do you feel safe here? Resident #28 had no concerns in regard to the questions asked and answered each question in one word. However, the interviewer did not document asking the resident any specific questions about how CNA #1 treated her or if any staff had ever pulled her hair or yelled at her. (2) On 9/14/23, Resident #10 was interviewed by a facility investigator who asked the resident the four basic questions (see above) and she responded by saying that she did not feel that staff had been rude or disrespectful lately and did not have any staff members treat her roughly or cause her any pain lately. However, the facility did not ask Resident #10 any specific questions about the allegation including if any of the facility's CNAs had ever yelled, screamed, or cursed at her in the past several months. (3) As of survey exit on 9/21/23, the facility had not provided an interview with Resident #111 about her allegation that CNA #1 had verbally abused her after it was reported to the NHA on 9/18/23 (see above). 2. On 9/21/23 the NHA reported the facility's investigative findings. The findings document, undated, read in pertinent part: facility investigators re-interviewed Resident #28 due to conflicting interview findings. It further read, Resident #28 said someone with red hair pulled her hair. The resident could not recall the name of the person. The alleged assailant denied the incident. There were no witnesses who confirmed or corroborated (the incident) from the tangible information the facility has been physically able to review. Based on the immediate information available, the allegation was unsubstantiated. The facility investigation was based on the documentation available. The employee will not be returning to the facility. 47351

Based on observation, record review, and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two resident victims (#12 and #106) from being physically abused (#53 and #174) resident in a resident to resident physical altercation in four resident to resident abuse allegations out of 66 sample residents. The facility failed to provide adequate supervision and effective interventions to prevent two separate incidents of resident or resident altercations resulting in one or more residents being injured. On 9/1/23 at 12:00 p.m. Resident #12 was physically abused by Resident #53. Resident #12 sustained deep scratches and cuts to his right arm from the physical attack on his person by Resident #53 which required ongoing medical treatment by a wound care physician and nursing staff. Resident #12 experienced pain immediately following being injured by Resident #53's aggressive actions. Resident #53 had a history of being physically and verbally aggressive towards others. Starting 7/28/23 the resident's medical record documented that the resident had been in a physical altercation with another resident other than Resident #12. The resident physician along with interdisciplinary team (IDT) input made a determination to increase the resident's antipsychotic medication to help the resident better manage his behavioral aggressions. Nursing staff were to monitor and document the effect of the medication. The resident's behavior continued to escalate and Resident #53 started to refuse medications including his antipsychotic medications on a couple of occasions. On 8/13/23 Resident #53 went after staff with verbal and physical aggression because they removed soiled laundry from his room. Several nursing staff had to intervene to keep him from directing his aggression to other residents who were in the common areas where the resident's aggressive actions occurred. Another resident witnessing the event called 911. The police responded and in that time the resident was able to start to calm down. Despite the resident's increasing agitation and physical aggression, the facility did not revise the resident's care plan or show other documentation that they assessed the effectiveness of the care plan interventions initiated 4/10/23. The facility failed to reassess the resident's care needs and develop more effective interventions to prevent resident #53 from getting physically and verbally aggressive Resident #12 sustained serious injuries requiring ongoing medical treatment by a wound care specialist. Additionally, the facility failed to: -Reassess the resident's unsafe wandering behavior and revise, develop, and implement effective behavior interventions to effectively manage Resident #174's aggressive and violent behaviors towards other residents; -Respond timely to prevent Resident #174 for unsafe wandering; -To protect several residents from being verbally abuse but Resident #174 when he engaging in unsafe wandering and was not supervised or redirected timely; and, -Prevent Resident #106 from being physically abused Resident #174. Findings include: I. Facility policy The Abuse, Neglect, and Exploitation policy, revised April 2022, was provided by the nursing home administration (NHA) on 9/11/23 at 9:33 a.m. The policy read, in pertinent part: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriations of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. The facility will develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. The facility will implement policies and procedures to prevent and prohibit all types of abuse. Identification, ongoing assessment, care, planning for appropriate interventions, and monitoring of residents with needs and behaviors, which might lead to conflict or neglect. II. Resident #53 and Resident #12 1. Resident #12 A. Resident status Resident #12, age 73, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the diagnoses included osteoarthritis (arthritis) and depression. According to the 6/30/23 minimum data set (MDS) assessment, the resident was unable to complete a brief interview for mental status. According to the staff's assessment of the resident's cognition revealed the resident did not have short or long-term memory loss. The resident was able to recall the current season, the location of his room, and knew that he was in a nursing facility. The resident was independent with decision-making and made consistent and reasonable decisions. The resident was independent in all activities of living but needed setup assistance with eating. The resident did not walk and used a wheelchair at all times. 2. Resident #53 A. Resident status Resident #53, age 89, was admitted on [DATE]. According to the September 2023 CPO diagnoses included dementia with agitation and acute kidney failure. According to the 8/18/23 MDS assessment, the resident was unable to complete a brief interview for mental status. Staff's assessment of the resident's cognition revealed the resident had short or long-term memory loss but the resident knew the location of his room and the names of staff. The resident needed some assistance making decisions in new situations. The resident had potential indications of psychosis as evidenced by hallucinations and delusions. The resident displayed physical and verbal behavior directed toward others one to three times a week. The resident needed limited support from one staff member to complete activities of daily living (ADL) except he did not receive assistance with eating. The resident needed limited assistance walking short distances and used a wheelchair as a primary mode of transportation. B. Record review According to the resident's comprehensive care plan the resident had a care focus, revised 4/10/23, for aggressive behaviors. The care focus documented the resident was aggressive towards others and had poor impulse control and aggressive behaviors that included yelling, hitting, striking out and kicking. Interventions included allowing the resident to make decisions about his care to provide a sense of control; approaching the resident in a calm, gentle manner; assessing, reviewing, and documenting behaviors; and listening to the resident's concerns. According to the progress note dated 7/28/23 at 12:03 p.m. the resident was very agitated, was grabbing at, and trying to hit staff. At 2:30 p.m. the resident started grabbing another resident causing two small skin tears on the other resident's hand. According to a progress note dated 8/2/23, the resident had a medication change to increase Seroquel (an antipsychotic medication) from 25 milligrams (m)g to 50 mg due to increased aggressive behaviors; The nursing staff were to monitor the resident for side effects and effectiveness of the medication therapy. According to a progress note dated 8/8/23 at 10:35 a.m., the resident angrily refused his psychotropics and other medications. According to a progress note dated 8/13/23 at 10:42 a.m., the resident yelled at a certified nurse aide (CNA) about the aide taking dirty linen from the resident's room. The resident got onto the floor. A nurse attempted to help the resident off the floor. The resident grabbed the nurse's ankle attempting to scratch and hit the nurse. According to a progress note dated 8/30/23 at 10:42 a.m. the resident had worsening behaviors over the weekend. The staff was concerned about physical violence. According to a progress note dated 8/30/23 at 7:33 p.m., the resident refused medication that was offered four times. According to the progress note dated 8/30/23 at 9:35 p.m. the resident's wheelchair was next to a vehicle parked in the parking lot and the staff's vehicle the resident was found inside the vehicle smoking a cigarette. The staff who discovered the resident brought the resident back into the facility and put a wander guard bracelet (a bracelet that has a sensor on it to help prevent residents from leaving the facility without staff being alerted by an alarm wandering) onto the resident. 3. Resident-to-resident altercation 9/1/23 A. Resident interview and observations Resident #12 was interviewed on 9/11/23 at 11:20 a.m. Resident #12 said he was attacked by Resident #53 for no reason. Resident #12 said he had just finished smoking and was heading back into the building when Redidnet #53 came out of nowhere and attacked him by grabbing him and scratching at his arms leaving deep wounds on his right hand and forearm. Resident #12 said there were no staff outside when the attack started but after hearing the altercation staff came from the building to help get Resident #53 off of him. The resident showed his wounds. He had had several baseball-sized bruises, with long and deep scratches on his right arm and forearm. B. Record review According to a progress note dated 9/1/23 at 12:00 p.m. there was a resident-to-resident altercation in front of the building between Resident #53 and Resident #12. Resident #12 had skin tears and blood on him. Resident #12 said I was coming down the sidewalk to smoke and this lunatic rammed into me (with his wheelchair); I turned around and he attacked me. I want him thrown in jail. According to a resident witness statement dated 9/1/23 Resident #12 was coming down the sidewalk and Resident #53 was in his wheelchair on the sidewalk. Resident #12 started to turn around in his wheelchair and Resident #53 lunged at Resident #12. Resident #53 hit and clawed at Resident#12. Resident #12 started to bleed. Resident #53 grabbed Resident #12's arm and started beating on Resident #12. Two staff members came from the building and broke up the fight. According to the admissions director's (ADD) witness statement dated 9/1/23, the ADD was walking with another heading back into the facility when he heard yelling. The ADD walked around the corner and saw Resident #53 being held back by staff members. Resident#12 yelling and had blood running down his arm. There were no additional staff witness statements from the staff that initially arrived to break up the resident-to-resident altercation. According to a progress note in Resident #53's medical record, dated 9/1/23 at 1:30 p.m., Resident #53 was sent out to the hospital for a mental health assessment, because he did not seem well. The resident was unable to respond appropriately to staff questions and was moaning when responding. According to the progress note Resident #12 medical record, dated 9/2/23, Resident #12 had multiple skin injuries including deep scratches, skin tears, bruises and was experiencing pain from the injuries to his right forearm. Resident #12 said his pain level was 8out of 10 (with 10 being the worst) and it decreased to 2 out of 10 after taking a hydrocodone (a narcotic pain medication). According to the wound note dated 9/6/23 Resident #12 was seen by a wound physician for the wounds he got during the altercation with Resident #53. The wound treatment note documented that Resident #12 had a traumatic wound to his right forearm measuring 3 centimeters (cm) by 2 cm by 0.1 cm in depth on his right hand and a wound on his right forearm measuring 4 cm by 2 cm by 1 cm. According to a wound care note dated 9/13/23 Resident #12 was seen by the wound physician for wounds he got during the altercation with Resident #53. Resident #12 had a traumatic wound on his right hand and forearm. The wound had to be debrided (a bedside surgical procedure to remove dead tissue). New wound measurements for the right forearm were 2.5 cm by 2 am by 2 cm, and the wound on the right hand measured 4 cm by 2 cm by 2 cm. 5. Staff Interviews CNA #8 was interviewed on 9/18/23 at 10:54 a.m. CNA #8 said when there was a resident-to-resident altercation staff should notify a nurse after they separated the residents that were fighting and ensure everyone's safety. CNA #8 said when a resident showed signs of aggression the CNA should let the nurses before another resident was injured. The nurse would assess the resident and let the CNAs know which interventions to implement. Sometimes CNA #8 said he heard about the altercation between Resident #53 and Resident #12 through gossip but facility leadership did provide the direct care staff with any information about how to prevent future displays of aggression by Resident #53 toward other residents or towards the staff. The director of nursing (DON) was interviewed on 9/20/23 at 2:26 p.m. The DON said that all resident-to-resident altercations need to be investigated and the care plan should be reviewed for effectiveness. The DON said they should have interventions in place for residents who have shown previous aggression. The DON said they would have an IDT meeting if a Resident showed signs of aggression and update care plan interventions as appropriate. The DON said Resident #53 was not showing signs of aggression prior to this incident between Resident #53 and #12 nor did Resident #53 have issues with unsafe wandering prior to the altercation on 9/1/23. III. Resident #106 and Resident #174 A. Resident status 1. Resident # 106 Resident #106, age 81 was admitted on [DATE]. According to the September 2023 CPO, the diagnoses included Alzheimer's disease and anxiety disorder. According to the 8/1/23 MDS assessment, the resident had moderately impaired cognition with a BIMS score of nine out of 15. The resident needed set-up help only with all activities of daily living. 2, Resident # 174 Resident #174, under the age of age 65, was admitted on [DATE] and discharged on [DATE]. According to the May 2023 CPO, the diagnoses included anxiety and depression. According to the 5/14/23 MDS assessment, the resident was unable to complete the BIMS exam. Staff's assessment of the resident's cognition revealed the resident had short-term memory loss and needed extensive assistance from one staff member to perform dressing, toileting, and hygiene tasks and limited assistance with all other ADLs. The resident had difficulty making decisions and presented with disorganized thinking. The resident displayed verbal aggressions directed toward others and other behavioral symptoms not directed toward others for one to three days, additionally, the resident wandered four to six days a week. B. Record review According to the resident comprehensive care plan the resident had a care focus for wandering revised 2/9/23. The care plan revealed that Resident #174 wandered into other residents' rooms and wandered behind the nurse's station. Interventions included allowing Resident #174 to freely wander through the facility; determining the root cause of wandering and documenting unsafe wandering. There were no interventions to address resident-to-resident altercations as a result of the staff allowing the resident to wander freely and there was no behavioral care to address Resident #174 verbal and other behavioral symptoms. According to a progress note dated 4/13/23 at 11:13 a.m. Resident #174 had threatening behavior towards another resident. Resident #174 stood over another resident telling the resident to shut up and that they were annoying. According to a progress note dated 4/16/23 at 11:31 a.m. Resident #174 continued to have bouts of yelling, screaming and pulling his arm back with his hand in a fist ready to strike. Staff had to physically remove the resident from other residents to keep the other residents safe. According to a progress note dated 4/17/23 at 3:48 a.m. Resident #174 wandered into a female resident's room. The female resident woke up and yelled at Resident #174 to get out and Resident #174 responded with verbal aggression yelling at the female resident who was in bed. According to a progress note dated 4/17/23 at 6:48 p.m. Resident #174 was aggressive and pointed his finger towards other residents. Resident #174 had to be separated from another resident. According to an IDT note dated 4/19/23, the IDT discussed the resident's wandering habits with Resident #174, but according to this note did not discuss the inappropriateness of his aggressive behaviors with him. According to a progress note dated 4/19/23 at 6:06 p.m. Resident #174 was found in another resident's room. Resident #174 got upset when staff tried to redirect him and began yelling at other residents and staff. According to a progress note dated 4/22/23 at 8:52 a.m., Resident #174 was angry, aggressive and yelling at staff and residents. According to a progress note dated 4/22/23 at 9:36 a.m. Resident #174 was escalating with displays of verbal aggression. Staff were able to redirect the resident and put the resident on one-to-one supervision but documented that they were scared of Resident #174 behaviors. According to a progress note dated 4/23/23 at 7:27 a.m. another resident called 911 on Resident #174. Resident #174 was in the other resident's room displaying aggressive behavior and rummaging through the other resident's closet. According to a progress note dated 4/23/23 at 2:13 p.m. Resident #174 was agitated and aggressive towards staff and residents. According to a progress note dated 4/24/23 Resident #174 was given an Ativan (antianxiety medication) for agitation for seven days, due to verbally aggressive behaviors towards other residents and staff. When that was ineffective the facility sent Resident #174 to the hospital for a mental health evaluation on a M1 hold (an involuntary inpatient hold in a hospital for individuals who are in danger of harming themselves or others). According to a progress note dated 4/26/23, the resident remained in the hospital and was not safe to come back. The resident was readmitted to the facility on [DATE]. According to a progress note dated 5/3/23 Resident #174 continued to wander into other residents' rooms with displays of increasingly aggressive behaviors. According to a progress note dated 5/4/23 Resident #174 was eating on his roommate's bed. Resident #174 became angry and combative towards the roommate when the roommate asked Resident #174 to move. Staff put signs above Resident #174's bed to remind him which was his bed. According to a progress note dated 5/5/23 Resident #174 was threatening his roommate over snacks. According to a progress note dated 5/6/23 Resident #174 continues to wander in and out of other residents' rooms. Resident #174 was unable to redirect at this point. According to a progress note dated 5/7/23 Resident #174 had his side of the room extremely disheveled. Resident #174 had shredded pillows and trash scattered in his room. Resident #174's roommate said he was scared because of Resident #174's irrational behavior. The facility moved the roommate to another room. According to a physician's note dated 5/8/23 Resident #174 got a new roommate. The new roommate was upset because he found Resident #174 in his bed eating his personal food. Staff said Resident #174 had become more aggressive and combative at night. Resident #174 was moved to another room because he had threatened to kill his new roommate. According to a progress note dated 5/9/23 at 4:11 p.m. Resident #174 was behind the nursing station ruffling through a staff's purse. A CNA tried to redirect Resident #174 he swatted at the CNA and called her name. According to a progress note dated 5/10/23 Resident #174 was found trying to urinate in the dining room sink. Resident #174 continued to wander into other residents' rooms. According to a nursing note dated 5/11/23 Resident #174 continues to wander in and out of other residents' rooms. Resident #174 ripped his briefs off in the common areas. According to a nursing note dated 5/11/23 at 3:51 p.m. Resident #174 attempted to open the emergency door. Staff tried to redirect him, but Resident #174 said he was going to beat somebody up. The resident continued to wander in and out of other residents' rooms. According to a progress note dated 5/12/23 Resident #174 had a behavior that needed to be directed by a registered nurse (RN). According to a progress note dated 5/13/23 Resident #174 was urinating in a trash can. Resident #174 was wandering in other residents' rooms and was aggressive towards staff. -Despite all the documentation by nursing staff documenting that Resident #174 displayed unsafe wandering behavior as evidenced by the number of examples written above the facility failed to reassess the resident's wandering care plan and ineffective interventions and develop a care plan focus for the resident's aggressive and violent behaviors towards other residents. C. Resident-to-resident altercation According to a progress note dated 5/14/23 at 5:20 p.m. a CNA heard a loud noise and voices coming out of Resident #106's room. The CNA entered Resident #106 to find him with his wheelchair between him and Resident #174. Resident #106 said Resident #174 came into his room and sat in his wheelchair and would not leave. Resident #106 said he asked Resident #174 to get out of his wheelchair. Resident #174 hit Resident #106 on his cheek. Resident #106 put his fist up to protect himself. The CNA was able to redirect Resident #174 out of Resident #106's room. Resident #174 continued to be hostile. Resident #174 was placed on 15-minute checks. According to progress notes dated 5/14/23 at 7:40 p.m. Resident #174 was placed on a M1 hold and sent to the hospital for a mental health evaluation. According to an incident report dated 5/15/23 Resident #106 had a mild red mark on his cheek. D. Staff interviews CNA #9 was interviewed on 9/18/23 at 11:10 a.m. CNA #9 said he did not know if Resident #174 was aggressive or if he wandered into other residents' rooms. CNA #9 said when a resident has an altercation other CNAs were not told about the altercation unless they were on shift at the time of the altercation. CNA #9 said he did not know where to find interventions for residents who have aggressive or wandering behavior. The director of nursing (DON) was interviewed on 9/20/23 at 2:26 p.m. The DON said if a resident had aggressive behaviors or wanders the facility would set up an IDT meeting to put interventions into place to keep other residents safe. The DON said Resident #174 was ramping up. The DON said they had talked to providers and the provider did not want to make any medication changes. The DON said Resident #174 did not respond well to non-pharmaceutical interventions. The DON said Resident #174 was sent on an M1 hold to the hospital. Resident #174 had remained in the hospital since.

Based on observations, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent development and worsening of pressure injuries for two (#29 and #8) of three residents reviewed for pressure injuries out of 66 sample residents. Resident #29 who required extensive assistance with activities of daily living (ADL) from staff members for bed mobility, positioning, transfers, toileting and dressing, was known to be at risk for skin impairment due to impaired mobility and had inability to self reposition and relieve pressure points. Resident #29 developed a deep tissue injury (DTI, a pressure injury to underlying tissue below the skin's surface caused by prolonged pressure (of the body being left against a hard surface) leading to restricted blood flow resulting in skin tissue death and other damage deep in the underlying skin tissue), to the plantar (sole of the foot) surface of the left foot with an initial measurement of 3 centimeters (cm) by 6 cm, depth undetermined and a bruised toe. There was a delay in the resident being assessed and receiving treatment from the wound care physician as evidenced by an email from licensed practical nurse (LPN) #3 who documented that while working shifts on 8/27/23 and 8/28/23 the resident's representative made notification that Resident #29 had a skin problem to the bottom of his left foot (see documentation of LPN #3 email below). LPN #3 documented in the email that following the notification from the resident's representative the facility wound care nurse was notified; however, there were no notes or assessment provided by the facility wound care nurses at that time. It was not until 9/5/23 when the director of nursing (DON) was provided information about the resident's wound that the resident was assessed by the wound care nurse and referred to the wound care physician. Upon notification of the resident's DTI wound to the DON on 9/5/23, days after LPN #3 was made aware of the resident DTI by the resident representative and the wound care physician assessed the resident's new wound. Per the resident medical record and interviews with staff, the facility failed to ensure the resident consistently wore proper foot ware to protect his feet from undue pressure; failed to ensure the resident was positioned properly so that his sock covered foot did not rest constantly against the foot rest of his wheelchair; and failed to conduct routine skin checks of the resident's feet for skin concerns. The facility's failures to ensure the resident was positioned properly to off load pressure points and ensure the resident feet were not resting for extended periods on a hard surface lead to the resident sustaining a DTI to the bottom of the left sole of his foot. Due to the nature of a DTI pressure injury being a closed wound with the damage occurring deep under the skin the extent of damage is unknown. This type of injury puts the resident at risk for other related complications to develop. Specifically, for Resident #8 the facility failed to: -Provide the resident positions assistance to prompt healing of pressure ulcer; -Followed wound physician orders to provide interventions to treat pressure injury; and, -Failed to revise the resident's care plan with up to date interventions to treat pressure injury. 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 Pressure Ulcers: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 9/26/23. Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with nonblanchable redness of a localized area usually over a bony prominence.Darkly pigmented skin may not have visible blanching; its color may differ from the surroundingarea. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.-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 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. Risk Factors and Risk Assessment -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries; -Consider individuals with a Category/Stage 1 pressure injury to be at risk of developing a Category/Stage 2 or greater pressure injury; -Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries; and, -When conducting a pressure injury risks assessment: Use a structured approach; Include a comprehensive skin assessment; Supplement use of a risk assessment tool with assessment of additional risk factors; Interpret the assessment outcomes using clinical judgment; Skin and Tissue assessment -Assess the pressure injury initially and as soon as possible after admission/transfer to the healthcare service; -Rre-assess at least weekly to monitor progress toward healing; -Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment; and, -Monitor the pressure injury healing progress. Support Surfaces For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury.Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policies and procedures The Skin Assessment policy, revised January 2023, was provided by the corporate nurse consultant (CNC) #1 on 9/21/23 at 11:44 a.m. The policy read in pertinent part: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury and prevention management. A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse on admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure ulcer. Considerations for darkly pigmented skin is not always possible to identify redness Indicators for pressure related damage, include, localized heat, edema, bogginess, induration, temperature differences in surrounding skin, and skin discolorization. The Wound Management policy, revised October 2022, was provided by the corporate clinical nurse (CNC) on 9/21/23 at 11:44 a.m. The policy read in pertinent part: To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physicians orders. Treatment decisions will be based upon 1). Etiology of the wound, 2). Size of the wound, 3). Volume and characteristics of exudate, 4). Presence of pain, 5). Presence of infection, 6). Condition of the tissue of the wound bed, 7). Condition of peri-wound area, location of the wound, and the preference of the resident/representative. III. Resident #29 A. Resident status Resident #29, under the age of 65, was admitted on [DATE]. According to the computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis (partial weakness), cerebral vascular infarction (stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of the bladder and paranoid schizophrenia. According to the 8/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident required extensive assistance and was dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The MDS assessment revealed the resident was at risk for pressure ulcers/injuries but did not have any unhealed pressure injuries at the time of the assessment. IV. Observations On 9/11/23 at 9:00 a.m. the resident was seated in a Broda chair (specialized high back wheelchair with positioning features to reduce the strain placed on the skin). The head of the Broda chair was positioned upright in alignment with the resident's back. The resident was wearing tennis shoes on his feet; the resident's feet were elevated in alignment with the resident's waist, with both feet pressed against the foot rests. -At 4:15 p.m. the resident's feet were lowered below his waist while remaining in an upright position. The resident was wearing tennis shoes on his feet which were pushed up against the foot rests of the Broda chair. On 9/12/23 at 9:42 a.m. the resident was seated upright in the Broda chair; the resident's spine was in alignment with the back of the chair. The resident was wearing tennis shoes and his feet were elevated to waist level with his covered feet pressed against the foot rests. -At 11:18 a.m. the resident was fully dressed with socks and tennis shoes on his feet. The resident was seated in a Broda chair with the foot peddles elevated to waist level. The resident's feet were pressed against the foot rests. On 9/13/23 at 8:19 a.m. the resident was fully dressed with socks and tennis shoes on his feet. The resident's feet were elevated at waist level and were pressed against the foot rests of the Broda chair. -At 10:08 a.m the resident was seated in the commons area in the Broda chair, the resident was wearing tennis shoes on his feet and the footrests were lowered about eight inches from the floor. The resident remained in this position throughout the day until dinner at 5:00 p.m. On 9/14/23 at 9:18 a.m. the resident was seated in the common area in the Broda chair with his feet elevated to waist level and his feet pressed against the foot rests, the resident was dressed and had socks and tennis shoes on his feet. -At 12:42 p.m. the resident was seated in the Broda chair with the leg rests lowered down approximately six inches from the floor. The resident was wearing tennis shoes and his feet were pressed against the foot rests. -At 3:34 p.m. the resident was seated in the Broda chair with the head of the wheelchair reclined back at a 30 degree angle. The resident leg rests were in the same position as earlier (see above). On 9/18/23 from 10:00 a.m. to 12:00 p.m. the resident was seated in the Broda chair with the footrests elevated to waist level, the resident had the same tennis shoes on his feet that were pressed against the foot rests. V. Record review A. Care plan The comprehensive care plan last revised on 9/6/23, revealed the resident was at risk for skin breakdown and documented resident has actual impaired skin integrity and was at risk for further skin breakdown related to frail fragile skin, incontinence and immobility. Resident has a DTI. The goal resident will have improved wound healing. Interventions included provide preventive skin care, lotion, barrier cream as ordered; apply barrier cream with each cleansing; turn and reposition as tolerated; observe skin for signs/symptoms of skin breakdown, redness, cracking, blistering, decreased sensation, skin that doesn't blanche easily; off load/float heels while in bed; monitor both lower extremities for any pain, heat, edema or erythema. Pressure redistribution surface to bed and low air loss matters; offloading boots while in bed and weekly skin checks by license nurse. B. Facility progress notes, treatment records Nursing note dated 7/21/23 at 4:37 p.m. documented the resident was temporarily placed in a facility Broda chair (as resident's representative had been asking for a new chair for the resident to use). The resident will not be able to stay in the chair long term but was placed in it for a trial period. The resident appears to enjoy the chair. Nursing skin assessment documentation revealed skin checks had occurred on 7/15/23, 7/22/23, 7/29/23, 8/3/23, 8/10/23, 8/17/23, 8/24/23, and 8/31/23 with no observed injury or wounds to the resident's skin. Nurses note dated 8/30/23 at 9:46 a.m., revealed the wound care physician evaluated the resident for skin integrity issues, (a left elbow trauma wound), there were no other wounds present. Nurse practitioner (NP) #1 visit note dated 9/5/23 at 11:07 a.m. revealed the resident was seen for an assessment of the left foot where a bruise like mark was observed. The assessment documented that the resident had a new unstageable pressure ulcer to the underside of left foot that measured at 5.0 cm x 2.5 cm x 0.1 cm. Appears to be due to the resident resting his left foot on the foot of the bed overnight. Wound care to follow. Plan of care included wear shoes during the day and pressure relieving boots overnight while in bed. Wound physician progress note dated 9/6/23 read in pertinent part: Patient presents for an evaluation of a new wound to the foot. Decreased strength and range of motion (ROM) with contractures. Decreased ROM and strength to the left lower extremity with contractures. Wound: Left Foot is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. -Initial wound encounter measurements are 3 cm length by 6 cm width with no measurable depth, with an area of 18 square (sq) cm. The patient reports a wound pain of level 0/10. Wound bed has 100% epithelialization. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Tretment plan: Cleanse and protect wound. Cleanse with wound cleanser. Additional Orders: Preventive measures: low loss air mattress mattress in place (for) offloading. Wheelchair cushion evaluated. General Orders: Monitor for signs and symptoms of infection. Offer moisturizing cream twice a day for dry skin. Provide calorie and protein supplements per registered dietician as needed. Pressure injury interventions: Tum and reposition frequently while in bed and in chair. Shift weight frequently while in bed and/or when in a chair. Place the patient on a low air loss or alternative pressure mattress, if not contraindicated, and check for proper placement and function every shift. Ensure seat or wheelchair cushion in place, if not contraindicated, and check for proper placement and function every shift. Float heels while in bed. Data reviewed/discussions: care coordination provided involving the organization of the patient's care and the sharing of information with nursing staff in order to achieve safe, effective care. Increased physical activity. Healing is expected to be delayed due to identified factors:impaired mobility, inevitable effect of aging, and medications that inhibit optimal wound healing. An email, dated 9/9/23 at 12:23 a.m., from LPN #3 to the DON read in part: Approximately two weeks ago, this writer was the nurse to resident in room (number for resident #29). CNA (certified nurse aide) notified this nurse of the compromised area on (the resident's) left foot. Upon observation, it was noted that the resident had an impression/ mark on the bottom of the lateral (outside away from the middle of the body) side of left foot. The area was intact and not open. This nurse elevated bilateral (both) feet on a pillow and repositioned the resident. Upon morning, the wound care nurse was notified. Wound care nurse stated they would assess the area. -This email correspondence revealed that the wound to the resident's foot was observed over a week before the resident's representative reported the wound and before the wound care physician was consulted. An email, dated 9/13/23 at 11:19 a.m. from the DON to the nursing home administrator (NHA) read in part: On Tuesday September 5th at 8:02 a.m., this writer was made aware via text message from resident's (responsible party) in a group text message with the resident's NP (nurse practitioner), that Resident #29's power of attorney had observed that the bottom of Resident #29's left foot has what looks like a purple bruise. This writer, in the morning meeting, at approximately 9:00 a.m. made the wound nurse, (wound care nurse's name) aware.The resident's representative alerted staff on 9/5/23 at 1:59 p.m. that the resident's left great toe was bruised while she was placing lotion on the resident's feet. Nursing staff completed an assessment of the bruised left great toe and found the resident also had developed a 3 centimeter (cm) deep tissue injury to the plantar surface of the resident's left foot. Nursing note dated 9/5/23 at 3:10 p.m., revealed the resident has a 3 cm by 3 cm DTI on the resident's left foot. The resident rests his feet on the wheelchair Resident was frequently repositioned to avoid this. Writer has moved the resident multiple times throughout the shift. Nutrition assessment dated [DATE] at 11:36 a.m., documented for new deep tissue injury to the left foot, recommending protein supplement four times per day to aid healing. VI. Resident representative interview The resident's representative was interviewed on 9/18/23 at 12:55 a.m. The resident's representative said she was very involved in the resident's care and tried to visit the resident on a daily basis. The resident's representative said she had many concerns about the resident's care related to the facility's lack of skin assessments, primarily because she was the one to find a deep tissue injury on the resident's left foot. The resident's representative said the resident had been complaining of pain to the left foot for at least two weeks prior. If the facility would taken the time to apply lotion and look at the resident's feet as she asked, the left foot wound would have been caught earlier. VII. Staff interviews Registered nurse (RN) #2 was interviewed on 8/14/23 at 8:40 a.m. RN #2 said the resident was placed into the Broda chair every morning between 8:00 a.m. and 8:30 a.m. and remained in the Broda chair until after dinner. RN #2 said the resident slept in the Broda chair if he got tired. RN #2 said restorative staff taught the nursing staff how to adjust the footrests to control pressure points while the resident was up in the Broda chair. RN #2 said the footrests were adjusted every two to three hours and staff took turns helping the resident to remain comfortable. RN #2 said the resident's representative asked the staff to get the resident up by breakfast and put on the resident's tennis shoes immediately after he rose. Certified nurse aide (CNA) #3 was interviewed on 9/14/23 at 10:01 a.m. CNA #3 said the resident's representative had created a helpful hints flier for the nursing staff to guide the resident's care and CNAs use it to reduce the resident's agitation. CNA #3 said the resident's representative wanted foot straps placed over the resident's feet while in the Broda chair to prevent the resident's feet from slipping off but the restorative staff did not agree. CNA #3 said the resident had worn tennis shoes since May 2023 per the resident's representative preference. CNA #3 said all skin alterations including bruising, scratches and pressure injuries noticed during bathing/showering were immediately reported to the nurse. The DON was interviewed on 9/14/23 at 2:42 p.m. The DON said the resident was immobile and was dependent on staff for repositioning while upright in the Broda chair. The DON said it was her understanding that the resident's pressure points were relieved by adjusting the footrests on the Broda chair. The DON said the resident made his needs known with cueing and supervision. The DON said due to the resident's immobility the resident was at greater risk for developing deep tissue injuries/wounds and the resident's skin was monitored weekly to identify injuries/wounds early. The DON said that the CNA staff were often the staff members who noticed skin injuries/wounds due to their role to provide toileting, pericare and bathing/showering assistance to the residents. The CNAs were expected to report any skin integrity issues immediately to the nurse on duty. Restorative aide (RA) #1 was interviewed on 9/18/23 at 11:55 a.m. RA #1 said the restorative program made recommendations on off-loading pressure to the resident pressure points with repositioning to off load pressure points while in bed and while up in a chair. This included bed wedge pillows; arranged for seating cushions and back cushions for the Broda chair. The RA said the restorative program made recommendations on how the resident's feet should be placed on the footrests and lowering the resident's feet and adjusting his legs every two to three hours. The RA said the resident was cooperative with repositioning and would express through facial expression or would grab staff's arm if he felt pain with positioning. The resident was dependent on the nursing staff to ensure his feet were positioned properly and repositioned frequently. 46851 III. Resident #8 A. Resident status Resident #8, age 72, was admitted [DATE]. According to the September 2023 CPO, diagnoses included chronic respiratory failure, radiculopathy (injury or damage to nerve roots in the area where they leave the spine) and stage 3 pressure ulcer on left buttocks. The 8/29/23 MDS assessment revealed the resident was mildly cognitively impaired with a BIMS score of nine out of 15. She required extensive assistance from one person with dressing; supervision of one person with locomotion on unit and personal hygiene; limited assistance of one person with bed mobility, toilet use and transfers. The resident used a wheelchair and a walker. The resident was frequently incontinent of bladder and bowel and was at risk for developing pressure ulcers. The resident had one unhealed stage 3 pressure ulcer and one venous and arterial ulcer. Skin and ulcer treatments included pressure reducing devices for her chair and bed; a repositioning program; a nutrition or hydration program; and pressure ulcer and wound care services. The resident's wounds were treated with the application of ointments and non-surgical dressings. B. Resident interview and observations Resident#8 was interviewed on 9/11/23 at 12:04 p.m. Resident #8 said she did not have pressure ulcers (however, she did have a pressure ulcer, see record review below). Resident #8 said she did not have any cushion in her wheelchair and her wheelchair was not comfortable to sit in. On 9/11/23 at 12:04 p.m. Resident #8 was sitting in her wheelchair. The resident's mattress was a standard hospital mattress not an air mattress or specialized pressure relieving mattress. The wheelchair cushion looked flat. On 9/13/23 from 9:09 a.m. until 2:45 p.m. continuous observations of Resident #8 revealed: -At 9:09 a.m. the resident was in her room sitting in her wheelchair. -At 10:13 a.m. the resident propelled herself outside to smoke. She passed by staff; they did not interact with her or ask her about repositioning. -At 10:39 a.m. the resident propelled herself back to her room. Staff did not interact with the resident as she went back to her room. The resident did not reposition herself or transfer herself to an alternative surface to off load the consistent pressure on her bottom from sitting for an extended period of time in her wheelchair. -At 11:59 a.m. the resident remains in the same position. The resident did not reposition herself. Staff had not entered the resident's room. -At 12:23 p.m. an unknown nurse went into the resident's room to give her medication. The nurse did not offer to reposition or encourage the resident to offload pressure to her bottom. -At 12:28 p.m. the resident continued to sit in her wheelchair in the same position but was sleeping. An unknown certified nurse aide (CNA) walked past the resident's room and did not encourage the resident or reposition. -At 12:35 p.m. an unknown CNA brought the resident her lunch into her room. The CNA put the resident's food on the table and did not communicate with the resident. -At 1:05 p.m. the resident remained in her wheelchair in the same position. Staff had not entered the residents room or encouraged her to reposition. -At 2:20 p.m. the resident remained in the same position. Staff had not entered the resident's room. -At 2:45 p.m. the resident remained in the same position sitting on her wheelchair. Staff had not encouraged the resident to reposition. C. Record review According to the Braden Risk assessment dated [DATE] the resident was at mild (low) risk for the development of pressure ulcers. -However, the resident had developed pressure injury prior to this assessmnet which would make her at risk (see below). The comprehensive care plan initiated on 8/9/23 documented the resident had impairment to skin integrity related to decreased mobility and incontinence. The resident had a stage 3 pressure ulcer on her right buttock measuring 3 centimeters (cm) by 1 cm by 0.1 cm. Interventions included staff should anticipate the resident's needs for pain relief and respond immediately to any complaint of pain. Monitor and document location, size and treatment of skin injury. Report infection and abnormalities. Wound care for bilateral buttocks included cleaning the wound with spray, pat dry with gauze, cover with dry bordered foam and reinforce with retention tape. According to the wound note dated 5/3/23 the resident had an unavoidable facility acquired pressure ulcers on her buttocks. The wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 3 centimeters (cm) in length, 2 cm width and 0.1cm in depth. There is a small amount of sero-sanguineous drainage (watery bloody drainage). The resident's stage 3 pressure wound on her right buttock measured 3 cm in length, 1 cm width and 0.1 cm depth.The resident was on hospice care due to respiratory failure. According to the wound note dated 5/31/23 the wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 2 cm in length, 2 cm width and 0.1cm in depth. There is a small amount of sero-sanguineous drainage. The residents stage 3 pressure wound on her right buttock measured 3 cm in length, 0.5 cm width and 0.1 cm depth. The wound care orders for treatment of the pressure injury on the right buttock included cleanse with wound cleanser, apply foam every other day and reinforce with tape. Turn and reposition frequently while in bed and in a chair. Shift weight frequently while in bed and in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated and check for proper placement and function every shift. Ensure a seat or wheelchair cushion was in place. Float heels while in bed. According to the wound note dated 6/28/23 the wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 2 cm in length, 2 cm width and 0.1cm in depth. There was a small amount of sero-sanguineous drainage. The resident's stage 3 wound on her right buttock measured 3 cm in length, 2 cm width, and 0.1 cm depth. The wound care orders for treatment of the pressure injury on the right buttock included cleanse with wound cleanser, apply foam every other day and reinforce with tape. Turn and reposition frequently while in bed and in a chair. Shift weight frequently while in bed and in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated and check for proper placement and function every shift. Ensure a seat or wheelchair cushion was in place. Float heels while in bed.If the resident wears briefs and was incontinent, check briefs frequently. According to the wound note dated 7/19/23 The wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 1.2 cm in length, 1.5 cm width and 0.1cm in depth. There is a small amount of sero-sanguineous drainage. The resident's stage 3 wound on her right buttock measured 3 cm in length, 1.5 cm width, and 0.1 cm depth. The wound care orders for treatment of the pressure injury on the right buttock included cleanse with wound cleanser, apply foam every other day and reinforce with tape. Turn and reposition frequently while in bed and in a chair. Shift weight frequently while in bed and in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated and check for proper placement and function every shift. Ensure a seat or wheelchair cushion was in place. Float heels while in bed. If the resident wears briefs and was incontinent check briefs frequently. According to the wound note dated 8/23/23 the wound on the residents left buttock was a stage 3 pressure ulcer. The pressure ulcer measured 0.5 cm in length, 0.5 cm width and 0.1cm in depth. There is a moderate amount of sero-sanguineou[TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure effective pain management for one (#82) of two out of 66 sample residents. Resident #82 experienced an exacerbation of pemphigus, an autoimmune disease in which the immune system mistakenly attacks cells in the top layer of the skin (epidermis) and the mucous membranes in the skin and the inside of the mouth, nose, throat, eyes and genitals. Typical symptoms begin with painful blisters in the mouth that could spread to other mucous membranes. Oral blisters in the mouth or throat making it hard to swallow and eat. The resident had been complaining of blisters and oral pain for over a month and rather than seeking specialized assessment to determine the root cause of the resident's pain and oral blisters the resident was treated with over the counter symptom management. The resident's family had offered past medical history to help the resident physician seek treatment. The physician's assistant chose to wait to see if less aggressive treatments improved the resident's symptoms. In that time the resident's symptoms worsened and the resident had increased pain that affected her eating and daily comfort level. The resident began seeking out visitors to the facility to request assistance in getting relief for her symptoms. During the time of the survey 9/11/23 to 9/21/23 the facility took a more aggressive approach to consider a diagnosis of pemphigus and the family suggested and reported a historical diagnosis for the resident. The resident's primary care provider moved beyond over the counter medications to prescription level medication treatment to better manage the resident's symptoms. At the time of survey exit 9/21/23 the resident continued to complain of pain and discomfort. The facility's failure to manage the resident's symptoms causes the resident worsening of symptoms and unnecessary pain and anguish leading. The resident asked for help in resolving her pain. Findings include: I. Facility policies and procedures The Pain Management policy and procedure, revised August 2023, was provided by the corporate nurse consultant (CNC) on 9//21/23 at 11:44 a.m. It revealed in pertinent part, The facility must ensure that pain management is provided to residents' who require such services, consistent with professional standards of practice, the comprehensive person centered care, plan, and the residence goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psycho, social well-being, and to prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain in care, upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident goal in preferences. facility, staff will observe for nonverbal indicators, which may indicate the presence of pain if indicators include but are not limited to, changing gait skin color, vital signs, perspiration. Loss of function, or an ability to perform activities of daily living. Fidgeting increased, or recurring, restlessness. Facial expressions. Behaviors such as resisting care, distressing, pacing, irritability, depression, mood, or decreased participation, and usual physical and/or social activities. Difficulty eating or loss of appetite, weight loss, difficulty, sleeping, negative, vocalizations, declining activity, level, or skin conditions. Facility staff will be aware, verbal descriptors a resident may use to report or describe their pain. Descriptors include, but are not limited to, heaviness of pressure, throbbing, hurting, cramping, burning, numbness, tingling, shooting, radiating, spasms, soreness, tenderness, discomfort, pins, and needles, or feeling rough, tearing or ripping. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health professionals, and the resident and/or the residence representatives will develop, implement, monitor and revise as necessary interventions for event or manage each individual residence pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions, or situations that may be associated with the pain or may be included as specific pain management needs or a goal. The interdisciplinary team of resident and or residence representatives will collaborate to arrive at pertinent, realistic, and measurable goals for treatment. Factors influencing the choice of treatment include the cause, location and severity of residents' pain. Pharmacological interventions will follow a systematic approach for selecting medication and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regime that is specific to each resident who has the potential for pain. Evaluate the residents, medical condition, current medication, regime, cause, and severity of the pain and course of illness to determine the most appropriate and Ology tick therapy for pain. consider administering medication around the clock and see if PRN (as needed) or combining longer acting medication with PRN medication for breakthrough pain. Facility staff will notify the practitioner, if the residence pain is not controlled by the current treatment regime. II. Resident #82 A. Resident status Resident #82, over the age of 65, was admitted [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (ischemic stroke) and heart failure. The 8/17/23 minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision from one person with dressing, toilet use and transfers. The resident received as needed (PRN) pain medications and non-pharmacological interventions. The resident occasionally experiences pain at a four out of 10 level. The resident's pain did not affect the resident's functioning such as sleep and day-to-day activities B. Resident observations and interviews On 9/11/23 at 9:15 a.m. the resident was observed in her room crying and grimacing and holding her mouth. Her breakfast was in the room completely untouched. The food had a regular texture. Resident#82 was interviewed on 9/11/23 at 9:25 a.m. Resident #82 said she had tears in her eyes and said she was in extreme pain. Resident #82 said she had pain for months and asked for help to relieve the pain. Resident #82 said she could not eat or sleep because of the pain. Resident #82 said they gave her Orajel and she used to use a special mouthwash but was not using it now. Resident #82 said they would give her Tylenol if she was in too much pain but the pain came back. Resident #82 said she could not handle the pain any longer. Resident #82's daughter was interviewed on 9/11/23 at 9:45 a.m. Resident #82's daughter said Resident #82 has been in pain for a month or maybe longer and did not eat or sleep well because of the pain. The resident's daughter said she talked to nurisng staff about her mom's symptoms but noting was done to resolve Resident #82 pain. The resident's daughter said she asked for her mother to see a specialist to figure out what was wrong but the facility only referred Resident #82 to the primary care physician and the physicain's assistant came to examin the resident. The resident's daughter said that her mom had been diagnosed with pemphigus and she believed it was resurfacing but the facility staff did not take that seriously. She said the nurse and certified nurse aides (CNAs) were ignoring her mom's unresolved pain. On 9/12/23 at 10:10 a.m. the resident was observed sitting in her doorway. The resident motioned to come closer to her. Resident #82 was grimacing and pointing to her mouth. The resident opened her mouth to point to the sores in her mouth and said please help me. On 9/18/23 at 1:55 p.m. the resident was observed sitting in her wheelchair crying and holding her face. Her lunch was in the room and completely untouched. The food was pureed. On 9/19/23 at 3:13 p.m. the resident was crying out moaning. She began sticking out her tongue and motioned to her mouth. The resident had six pea-sized and dime-sized lesions in her mouth. The lesions were white in the middle and bright red around them and were spread through her mouth. C. Record review According to dental notes dated 7/7/23 Resident #82 had a follow-up visit regarding the tooth that had been extracted. The extraction site had healed. According to a progress note dated 8/11/23 the resident had two canker sores on the right side of her tongue and under her tongue. The nursing staff notified the physician. According to a progress note dated 8/25/23 the resident had open sores on her tongue. According to a progress note dated 9/16/23 the resident's mouth sores had worsened. The sores had increased in size and intensified in pain. The resident's daughter said that her mom had pemphigus years ago. According to a progress note dated 9/17/23 the resident's POA was contacted. The POA told the facility his mom had this condition before and it was diagnosed as Pemphigus. The POA said Resident #82 took Valtrex (antiviral medication) and it cleared her sores. The August 2023 CPO the resident was prescribed nystatin mouth throat suspension, 5 milliliters (ml) by mouth for ten days for treatment of oral thrush (yeast infection), starting 8/18/23. The August 2023 pain assessment revealed the resident had six episodes of pain at 2 out of 10 (with 10 being the worst pain) and five episodes of pain at a level 3 out of 10. No other episodes of pain were documented, despite the above observations. The September 2023 CPO the resident was prescribed: -Diet orders: Regular diet, *Pureed texture, Thin consistency, please provide natural purees as possible, order start date 9/13/23. Medication orders: -Tylenol 325 mg two tablets given for pain, as needed, for pain level of 5 out of 10 to start 9/3/23, tapering down to; Tylenol 325 mg two tablets given for pain, as needed, for pain level of 4 out of 10 to start 9/8/23, to; Tylenol 325 mg two tablets given for pain, as needed, for pain level of 5 out of 10 to start 9/11/23, to; Tylenol 325 mg two tablets given for pain, as needed, for pain level of 10 out of 10 to start 9/12/23. -Orajel (instant pain relief for toothaches and sore gums, for nine days, to comfort and the treatment of oral lesions to the left side of the tongue, starting 9/9/23. -Prednisone one tablet one time a day for pemphigus, starting 9/15/2. -Tylenol 325 mg two tablets given for pain, as needed, for a pain level of 4 out of 10 to start 9/10/23. According to the nutrition dated 9/19/23 the resident's weight was fairly stable but the resident was at nutritional risk related to disease and advanced age. The resident experienced a small weight loss in the last 30 days with a 1.6 percent loss from weighing 124.0 pounds on 8/1/23 to weighing 122.0 pounds on 9/1/23. The resident was eating 25 to 75 percent of meals. She was placed on a pureed diet due to mouth soreness during an exacerbation of pemphigus. Other interventions included med pass nutrition supplement and monitoring weight. According to the pain scale documentation the resident did not have pain other than these specific dates. -However, the progress note dated 9/16/23, observations and interviews indicate the resident had worsened pain. -The resident was never prescribed Valtrex (oral medication used to treat infections caused by certain types of viruses like cold sores and shingles) the resident's POA had recommended as a past effective medication. III. Staff interviews Certified nurse aide (CNA) #9 was interviewed on 9/18/23 at 11:10 a.m. CNA #9 said the CNAs were to report to the nurse when a resident complained of pain. CNA #9 said Resident #82 was very hard of hearing and did not always understand. CNA #9 said the resident had been in pain in her mouth for about a month. CNA #9 said Resident #82's daughter would usually be the one to tell the CNAs that her Resident #82 was in pain. Registered nurse (RN) #5 was interviewed on 9/18/23 at 10:58 a.m. RN #5 said when a resident expresses they were in pain or appeared to be in pain the CNAs should tell a nurse the nurse can assess and provide prescribed interventions or notify the resident's physician. RN #5 said Resident #82 had been in pain for some time and had not been able to eat very well or sleep well. RN #5 said the resident was able to eat better because the facility put her on a pureed diet due to her mouth pain. The director of nursing (DON) was interviewed on 9/20/23 at 2:26 p.m. The DON said staff determined the level of pain on a 1 to 10 pain scale. The DON said staff should recognize when a resident could not provide a number and analyze pain by the resident's behaviors, such as crying or not eating. The DON said when a resident was in pain the facility started with medications on an as needed schedule and changed medication if pain did not decrease. The DON said Resident #82 had pain in her mouth. The DON said the resident was on an antibiotic for thrush and was using Orajel for temporary pain relief but the pain was not improving. The DON said the physician saw the resident on 9/18/23 and ordered magic mouthwash. The DON said the physician assistant wanted to wait to see if prescribed prednisone helped before giving the resident a referral to see a rheumatologist (a doctor with specialized treating conditions of inflammation).

Based on record review and interviews, the facility failed to ensure three (#1, #3 and #2) of six out of eight sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #1 was admitted to the facility on [DATE]. Resident #1 had a diagnosis of traumatic subdural hemorrhage (brain bleed). Hypertension (high blood pressure), multiple fractures of ribs, history of traumatic brain injury and dementia. Upon admission on [DATE] Resident #1 weighed 178.2 pounds (lbs). On [DATE] Resident #1 weighed 170 lbs. This weight revealed, Resident #1 had a significant weight loss of 4.3% (7.6 lbs) in one week. The family began providing Ensure (nutritional supplement) on [DATE]. Speech therapy was involved in the resident's care, but no additional nutritional interventions were implemented. The only nutritional intervention provided was initiated by the family providing Ensure. The facility failed to implement a nutritional intervention to prevent further weight loss, for Resident #1. Therefore, Resident #1 sustained a 11% weight loss (19.6 lbs) in five months, which was considered significant. Resident #3 was admitted to the facility on [DATE]. Resident #3 had a diagnosis of type two diabetes mellitus, hypothyroidism (reduced thyroid function), hyperlipidemia (high cholesterol) and personal history of traumatic brain injury. Upon admission on [DATE] Resident #3 weighed 248 lbs. Resident #3 was hospitalized from [DATE] through [DATE]. During this time he was diagnosed with pneumonia related to a COVID-19 infection. The [DATE] discharge summary from the hospital documented the resident weighed 240 lbs and the resident was no longer on Hospice comfort care and the wife wanted to have the resident's medical issues treated. Upon Resident #3's readmission to the facility on [DATE], the facility failed to obtain a readmission weight to determine if the resident sustained weight loss while in the hospital and create a baseline for the resident after the hospitalization . Resident #3 sustained a 10.4% (28.4 lbs) weight loss in one month from [DATE] through [DATE], which was considered significant. Although the resident spent six days in the hospital the facility failed to weigh the resident timely upon readmission to determine if nutritional interventions should be put into place. Resident #3 was not weighed for 22 days after being readmitted to the facility. The resident sustained a 8.5% (20.4 lbs) weight loss from his hospitalization until he was weighed again at the facility on [DATE]. Additionally, the facility failed for Resident #2 to: -Obtain an admission weight for Resident #2 and follow physician's orders to for weekly weights for the resident's first four weeks after admission; -Document attempts made to weigh the resident; and, -Provide clarification on documented weights in Resident #2's medical record. Findings include: I. Facility policy and procedure The Nutritional Management policy, revised February 2023, was provided by the nursing home administrator (NHA) on [DATE] at 4:38 p.m. It revealed in pertinent part, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status: identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. Identification/assessment: nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy, the dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay and a comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Care plan implementation: the resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care, interventions will be individualized to address the specific needs of the residents, real food will be offered first before adding supplements and tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. The physician will be notified of: significant changes in weight, intake, or nutrition status, lack of improvement toward goals and any complications associated with interventions. Informed consent: the resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status, the facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives and the comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative. II. Resident #1 A. Resident status Resident #1, age 86, admitted on [DATE] and expired on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included traumatic subdural hemorrhage (brain bleed), hypertension (high blood pressure), personal history of traumatic brain injury and dementia. The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of six out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. He required supervision of one person assistance for walking in his room and in the corridor. He required supervision with no set-up or assistance for locomotion on and off the unit and he required supervision with set-up assistance for eating. The MDS assessment documented the resident did not have any swallowing difficulties. The resident weighed 167 lbs. The resident did not have any weight changes and was on a mechanically altered diet. -However, Resident #1's electronic medical record weight data documentation revealed the resident had sustained weight changes. B. Record review 1. Nutritional care plan The nutritional care plan, initiated on [DATE], revealed Resident #1 was at nutritional risk related to dysphagia (difficulty swallowing). He was tolerating a dysphagia advanced diet with nectar thick liquids. The interventions included: monitoring for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated, monitoring for signs or symptoms of aspiration, providing diet as ordered, weighing resident per protocol and alerting physician and RD (registered dietitian) of any significant weight loss or gain. -All interventions on the nutritional care plan were implemented on [DATE]. -Resident #1's comprehensive care plan was not updated after he had significant weight loss from [DATE] to [DATE] and from [DATE] through [DATE] (see below). 2. Resident #1's weights Resident #1's weights were documented in the resident's medical record as follows: -On [DATE], the resident weighed 178.2 lbs. -On [DATE], the resident weighed 178 lbs. -On [DATE], the resident weighed 176.4 lbs. -On [DATE], the resident weighed 177.6 lbs. -On [DATE], the resident weighed 170 lbs. -On [DATE], the resident weighed 163.8 lbs. -On [DATE], the resident weighed 166.6 lbs. -On [DATE], the resident weighed 158.6 lbs. -The resident had 4.3% (7.6 lbs) weight loss, which was considered significant from [DATE] to [DATE] in one week. -The resident had an 11% (19.6 lbs) weight loss, which was considered significant from [DATE] through [DATE] in five months. 3. Physician orders The [DATE] CPO revealed Resident #1 had the following physician orders related to nutrition: -Weigh weekly X4 (times four) weeks then monthly, ordered [DATE]. -Resident #1 was not weighed weekly upon admission for four weeks as ordered. (See above). The [DATE] CPO revealed Resident #1 had the following physician orders related to nutrition: -Dysphagia diet, dysphagia advanced texture, thin liquids, ordered on [DATE] and discontinued on [DATE]. The [DATE] CPO revealed Resident #1 had the following physician orders related to nutrition: -Family has provided Ensure (nutritional supplements) drinks in the fridge, please offer with breakfast and dinner, ordered [DATE] , discontinued on [DATE]. The [DATE] CPO revealed Resident #1 had the following physician orders related to nutrition: -Family has provided Ensure (nutritional supplement) drinks in the fridge, please offer with breakfast and dinner. Please make sure to thicken if not cold, ordered [DATE] and discontinued on [DATE]. -Regular/liberalized diet, dysphagia advanced texture, nectar consistency, ordered [DATE] and discontinued on [DATE]. -Hospice eval (evaluation) and treat (treatment), ordered [DATE], discontinued on [DATE]. 4. Nutritional assessments/progress notes The [DATE] admission nutritional assessment documented in part, the resident weighed 178 lbs on [DATE] and was 70 inches tall on [DATE]. The resident's body mass index (BMI) was 25.5. The resident was on a regular liberalized diet, dysphagia advanced texture (limit very hard, sticky or crunchy foods) and nectar thick liquids. The resident did not have any food allergies or cultural, ethnic or religious preferences with food. The nutrition history documented the RD met with the resident in the dining room and he was pleasant. The resident was tolerating his diet and was working with speech therapy. The resident was dining in the main dining room and the family requested him to eat there for supervision. The resident was able to feed himself and benefited from set-up assistance. The resident's family was unsure of his usual weight and his current weight was health. The goal was weight maintenance for the resident. The family frequently visited and brought in special foods for the resident. Resident #1 enjoyed smoothies and chili. The assessment documented the resident displayed coughing or choking during meals or when swallowing medications and was tolerating his current diet texture. There was coughing with thin liquids, which promoted the recommendation of nectar thick liquids. The resident had no significant weight weight changes and his BMI was less than 19 or greater than 25. The intake observation said the resident had variable intakes and accepted an average of ,d+[DATE]%. The assessment documented he had no skin issues and was not appropriate for diet education. The assessment summary documented an [AGE] year old male was admitted for long term care after a hospitalization for traumatic subdural hematoma (brain bleed). His prior medical history included hypothyroidism (overactive thyroid) and hypertension (high blood pressure). Resident #1 was tolerating his diet. Medications and labs were reviewed. The assessment documented further assessment was needed. The resident's nutritional needs were 1950 calories, 81 grams protein and 2430 fluid ounces. The assessment documented the resident's intake was meeting his nutritional needs compared to his calculated needs and had generally good meal intakes and the family was also providing snacks. The nutritional evaluation and plan section documented the resident was admitted for long term care and was on a texture modified for dysphagia. He was eating generally well at this time. There were no nutrition related concerns to address at this time. There was no identified nutrition problem. The [DATE] nutritional assessment documented the resident weighed 166.6 lbs on [DATE] and his BMI was 23.9. The resident was on a regular/liberalized diet with dysphagia advanced and nectar thick liquids. The nutrition history section documented the resident was being seen due to a change in condition by admitting to hospice services. Resident #1 was tolerating his diet and his meal intakes were variable and accepted partial bottles of Ensure brought in by family. The resident was no longer eating in the main dining room and the family was requesting to offer that he eat in the main dining room if able. Resident #1 was able to feed himself independently, but benefited from set-up assistance. The family was unsure of his usual weight. His current weight was within a healthy BMI range. Weight maintenance was an appropriate goal for the resident moving forward, but had seen a 6% weight loss in the last three months. The swallowing section documented the resident was tolerating current diet texture and thickened liquids. The resident lost 6% weight in three months. It documented the resident had not had any significant/severe loss or gain, the resident had weight loss and the resident did not have a BMI that was less than 19 or greater than 25. The resident had variable intakes that average about ,d+[DATE]%. The resident's skin was intact and was not appropriate for diet education at that time. The assessment summary documented an [AGE] year old male was admitted for long term care status post hospitalization for traumatic subdural hematoma. He was admitted to hospice per power of attorney decision. The resident tolerated his diet and the family provided Ensure which he usually accepted at least 25%. The resident's medication and labs were reviewed. The evaluation and nutrition plan documented Resident #1 was seen for a change in condition due to family opting hospice services. The resident consumed at least half of his meals most days. The assessment documented the staff will continue to encourage intake as able and offer Ensure at least twice a day. Comfort was the goal. The assessment documented to continue to monitor the resident per protocol and make changes as needed. The nutrition assessment documented there was not a nutrition problem. -However, Resident #1 had a 4.3% (7.6 lbs) weight loss, which was considered significant from [DATE] to [DATE] in one week. -The assessment mentioned the resident was tolerating his prescribed diet at that time and was accepting nutritional supplements. The assessment did not document the families desire to not provide nutritional interventions (see interview below). In addition, the assessment did not document the resident's wishes for nutritional interventions. -A request was made for the at risk meeting notes (see interview below) for Resident #1 on [DATE] and they were not provided by the facility. III. Resident #3 A. Resident status Resident #3, admitted on [DATE] and readmitted on [DATE]. According to the [DATE] CPO, the diagnoses included type two diabetes mellitus without complications, hyperlipidemia (high cholesterol, personal history of traumatic brain injury, viral pneumonia, pneumonia due to coronavirus disease 2019 and history of malignant neoplasm of prostate (prostate cancer). The [DATE] MDS assessment documented the resident was moderately impaired with inattention per staff interview for cognitive impairment. He required supervision with one person assistance for bed mobility, walking in the corridor, locomotion on and off the unit, eating and personal hygiene. He required extensive assistance of two people for transfers, supervision with set-up assistance for walking in his room, extensive assistance of one person for dressing and limited assistance of one person for toileting. The MDS assessment documented the resident did not have any swallowing difficulties. The resident weighed 219 lbs. Resident #3 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a prescribed weight loss regimen. He was on a therapeutic diet. B. Record review 1. Nutritional care plan The nutritional care plan initiated on [DATE] and revised on [DATE] revealed Resident #3 was at nutritional risk related to type two diabetes. Resident #3 had significant weight loss over six months consistent with overall decline. Resident #3 was overweight per his BMI, but weight loss was not a goal of care. The interventions included: encourage 100% consumption of all fluids provided, encouraging the resident to sit up for meals as tolerated, providing supervision and cueing at meals, monitoring for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicted, monitoring for signs and symptoms of hyper/hypoglycemia (high or low blood sugars) and report abnormal findings to physician, offering Boost (nutritional supplement) or house supplement three times a day, providing diet as ordered and encouraging to dine in restorative dining and weighing resident per protocol, alerting RD and physician of any significant weight loss or gain. 2. Resident #3's weights Resident #3's weights were documented in the resident's medical record as follows: -On [DATE], the resident weighed 248 lbs. -On [DATE], the resident weighed 243.4 lbs. -On [DATE], the resident weighed 237 lbs. -On [DATE], the resident weighed 244.4 lbs. -On [DATE], the resident weighed 219.6 lbs. -On [DATE], the resident weighed 217.6 lbs. The resident had a 10.2% (24.8 lbs) weight loss in one month, which was considered significant from [DATE] to [DATE]. The resident had not been weighed in [DATE], at the time of the survey ([DATE]). 3. Physician orders The February 2023 CPO revealed the following physician orders related to nutrition: -House supplement three times a day for supplemental nutrition. Give with meals, ordered [DATE] and discontinued on [DATE]. The [DATE] CPO revealed the following physician orders related to nutrition: -Sugar free house supplement PO (by mouth) BID (twice a day) after meals for DMII (diabetes type two), ordered [DATE] and discontinued on [DATE]. -House supplement three times a day for ongoing supplementation ordered [DATE] and discontinued on [DATE]. -Offer three times a day; offer resident Boost or Premier Protein (nutritional supplement) (provided by family, located in the fridge). If these supplements are unavailable please offer a house supplement, ordered [DATE] and discontinued on [DATE]. -The nutritional supplement orders failed to document how much of the supplement to provide to the resident. The [DATE] CPO revealed the following physician orders related to nutrition: -Sugar free house supplement PO, BID after meals for DMII, ordered [DATE] and discontinued on [DATE]. -Offer three times a day; offer resident Boost or Premier Protein (provided by family located in the fridge). If these supplements are unavailable please offer a house supplement, ordered [DATE] and discontinued on [DATE]. -The nutritional supplement orders failed to document how much of the supplement to provide to the resident. The [DATE] CPO revealed the following physician orders related to nutrition: -Weigh weekly x4 (times four) weeks then monthly, ordered [DATE]. -Offer three times a day offer resident Boost or Premier Protein(provided by family located in the fridge). If these supplements are unavailable please offer a house supplement, ordered [DATE] and discontinued on [DATE]. -House supplement, three times a day offer resident 4 oz (four ounces) house supplement. Please assist with completion as needed. Document % (percent) completed in the MAR (medication administration record), ordered [DATE]. -Upon readmission [DATE], the resident was not weighed for 14 days, per physician's orders. The resident was not weighed weekly after readmission, per physician's orders. 4. Nutritional assessments/progress notes The [DATE] admission/readmission nutritional assessment documented the resident weighed 243.4 lbs on [DATE] and was 72 inches. The resident's BMI was 33 and he was [AGE] years old. The resident received a consistent carbohydrate diet with no food allergies. The resident had no cultural, ethnic or religious preferences. The nutrition history section documented the resident was on a consistent carbohydrate diet and was eating in the dining room for most meals. Resident #3 was consuming ,d+[DATE]% of his meals and enjoyed meat. The resident reported no strong dislikes. The resident was unsure of his weight history, but currently weighed 243.3 lbs and his admission weight was 248 lbs. The resident had no recent labs and received Lasix (diuretic). The resident had no swallowing concerns or had any significant weight changes. The residents BMI was less than 19 or greater than 25. The intake section documented the resident's BMI was 33 (sic) and his oral intake was ,d+[DATE]% for three meals a day. The resident's skin was intact. Diet education was not provided to the resident as he was not interested at that time, but the RD was available upon request. The assessment summary documented the resident had a history of hypertension (high blood pressure), hyperlipidemia (high cholesterol, diabetes type two, hypothyroidism (overactive thyroid), anemia (low blood count), prostate cancer, benign prostatic hyperplasia (enlarged prostate gland), traumatic brain injury and obstructive sleep apnea. The resident was admitted from home for respite care and was currently on a carbohydrate diet with adequate oral intakes. The [DATE] admission/readmission nutritional assessment documented the resident weighed 244.4 lbs on [DATE] and was 72 inches. His BMI was 33.1. The resident was on a consistent carbohydrate diet with no food allergies. The nutrition history documented the RD attempted to meet with the resident, but the resident was sleeping during the visit. The resident remained on a consistent carbohydrate diet with generally good meal intakes. The resident had been eating in his room due to COVID-19 precautions. The resident was able to feed himself independently and enjoyed meat. The resident had not been weighed upon admission although the RD suspected that the resident lost weight when he was hospitalized for COVID-19. The resident had no significant weight changes and had a BMI less than 19 or greater than 25. The residents' meals intakes were generally good and he consumed ,d+[DATE]% of his meals per the documentation. The assessment summary documented the resident was recently hospitalized for COVID-19. The resident remained on a consistent carbohydrate diet with good intakes. The resident's medications were reviewed and there were no recent labs to review. The resident's nutritional needs were calculated, ,d+[DATE] calories, 88 grams of protein and ,d+[DATE] milliliters of fluid per day. The assessment evaluation and plan documented the resident was recently hospitalized . Weight loss may be anticipated when the residents monthly weight was obtained related to hospitalization . The RD was to continue to monitor and make changes as needed. -The RD suspected weight loss, but did not recommend obtaining a weight to confirm suspected weight loss or implement a nutritional intervention to prevent further weight loss. The [DATE] interdisciplinary (IDT) note documented the IDT team discussed the resident's 11.5% weight loss, which was significant in three months. The resident was requiring more assistance with food and fluid intake. The resident was offered Boost after meals. The resident's fluid intake appeared to be adequate, but the resident was frequently declining food. The resident sustained a general functional decline after having COVID-19. The resident was receiving therapy services to restore previous function. The physician and wife were made aware. The RD was to evaluate and make recommendations for further interventions. The [DATE] weight change note documented, Resident #3 was reviewed by the RD for significant weight loss of 11.2% in three months. The resident's weight loss was discussed with the interdisciplinary team and the wife. The resident's current weight was 219.6 lbs. The resident's estimated nutrition needs were calculated at 2495 calories, 99 grams protein and 2495 milliliters of fluid. He was on a carbohydrate diet with overall poor oral intakes. The resident recently had COVID-19, which required a hospitalization . Resident #3 was occasionally offered Boost by his wife. A new intervention was to implement a house supplement three times a day and encouraging the resident to join restorative dining to receive one-on-one observation, cueing and encouragement during meals. The resident was receiving physical, occupational and speech therapy services. The resident was having ongoing diarrhea since the hospitalization . The RD reviewed the resident's medications list and discontinued the magnesium supplement, which could contribute to loose stools. The note documented there were no new or recent nutrition related labs to review. The resident's stool sample was negative for clostridium difficile (C. Diff, a bacterium that causes diarrhea and inflammation of the colon). The RD was to continue to monitor the resident's weight and meal intakes to determine if further interventions were needed. The [DATE] IDT note documented the IDT team discussed that the resident continued to have poor oral intake. The resident was offered a house supplement twice a day. The resident had a functional decline since having COVID-19. -However, the IDT team noted the resident had poor oral intake, but did not recommend new nutritional interventions to help promote oral intake. The [DATE] nursing progress note documented the resident was now receiving hospice care. -The resident sustained significant weight loss prior to admission to hospice services. The [DATE] IDT note documented the IDT team discussed the residents' continued poor appetite. The resident accepted supplements intermittently. The [DATE] IDT note documented the IDT team discussed the wife's concerns over the resident's poor oral intake. The wife requested a notebook with concerns and challenges to be available for staff to use as a communication aide for daily struggles with intakes, which was provided and nursing staff was made aware of the process. The resident continued with a poor appetite and was encouraged to eat and offered hands-on assistance with meals. The resident tested positive for C. Diff. The [DATE] comprehensive MDS nutritional assessment documented the resident weighed 217.6 lbs on [DATE] and was 72 inches tall. His BMI was 29.5 and he was on a consistent carbohydrate diet with no food allergies. The nutrition history documented the resident had not been weighed in the month of May (2023). The resident's weight in April (2023) suggested the resident's weight had stabilized following a significant weight loss trend. The resident remained overweight per BMI, though weight loss was not a goal of his care. Weight loss was likely inevitable with the diagnosis progression. The resident remained on the same diet and had generally poor intakes. The resident often did not get up for meals even when encouraged. The resident had been dining in his room due to C. Diff. The IDR felt the resident required assistance with meals. Nursing staff was to assist the resident with meals in his room until he was off isolation. The resident had no swallowing difficulties. The resident had 8.2% weight loss in three months. The resident had significant/severe loss or gain, had a weight loss/gain trend and had a BMI less than 19 or greater than 25. The resident had variable intakes and was less than 50% at most meals. The resident's skin was intake and he was not appropriate for diet education. The resident nutritional labs were reviewed. The evaluation and plan section of the assessment documented the resident was recently admitted to hospice with comfort as an overall goal of care. The resident had significant weight loss since admission, which appeared to be stabilizing. The resident had inadequate oral intake related to sleeping through meals and poor appetite as evidenced by poor documented meal intakes. The nutrition prescription was to continue with the consistent carbohydrate diet. The nutrition interventions included encouraging the resident to sit up for meals and offer one on one assistance as tolerated and continuing to offer the resident Boost or house supplement three times a day. The nursing staff was to obtain weights and provide assistance with meals. The care plan goals were for the resident to safely consume food and beverages that bring comfort. The [DATE] IDT note documented the IDT team discussed the residents' continued poor oral intakes. The resident was sleeping often. Staff continued to document activities of daily living and nutrition assistance attempts in a notebook which was helpful for the wife. The resident was being followed by hospice services. IV. Resident #2 A. Resident status Resident #2, age 88, admitted on [DATE]. According to the [DATE] CPO, the diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (left hip fracture), dementia unspecified severity with agitation and cerebral infarction (stroke). The [DATE] MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of eight out of 15. He required limited assistance of one person for bed mobility, walking in room and walking in the corridor, locomotion on and off the unit, toileting and personal hygiene. He required extensive assistance from one person for transfers and dressing. He required supervision with set-up assistance for eating. The MDS assessment documented the resident had coughing or choking during meals or when swallowing medications; but did not have loss of liquids or solids from his mouth when eating or drinking, did not hold food in his mouth or cheeks or have residual food in his mouth after meals or had complaints of difficulty or pain when swallowing. The resident weighed 175 lbs. The resident did not have any weight changes. B. Record review 1. Nutritional care plan The nutritional care plan, initiated on [DATE], revealed Resident #2 was at nutritional risk related to dementia and a left femur fracture. The interventions included: encouraging 100% consumption of all fluids provided and providing the diet as ordered. 2. Resident #2's weights -On [DATE], the resident weighed 175 lbs. -On [DATE], the resident weighed 161.6 lbs. -On [DATE], the resident weighed 166.4 lbs. -The resident sustained a 7.7% (13.4 lbs) weight loss, which was considered significant in two months from [DATE] through [DATE]. 3. Physician orders The [DATE] CPO revealed Resident #2 had the following physician orders related to nutrition: -Regular/liberalized diet, regular texture, thin consistency, ordered [DATE]. -Weigh weekly X4 (times four) weeks then monthly, ordered [DATE]. -However, the resident was not weighed until [DATE] which was 19 days after the resident was admitted to the facility (see interviews below). 4. Record review The [DATE] admission nutritional assessment documented the resident weighed 175 lbs on [DATE] and was 72 inches. The resident had a BMI of 23.7. The resident was on a regular/liberalized diet and had no food allergies or cultural, ethnic or religious preferences with food. The nutrition history section documented the resident was reviewed by the RD for a new admission and was on a re[TRUNCATED]

Based on observations, record review, and interviews, the facility failed to take measures to prevent and heal pressure injuries and to prevent the development of additional pressure injuries, affecting four (#9, #7, #19 and #6) of six residents reviewed out of 37 sample residents. Specifically: IMMEDIATE JEOPARDY IN PRESSURE INJURY MANAGEMENT Resident #9, whose age, clinical condition and assistance needs put her at risk for pressure injuries, was identified with moisture associated skin damage (MASD) on her coccyx on 7/8/21. An order was obtained 7/10/21 for barrier cream. However, a skin check revealed the skin damage progressed to a pressure injury (not further described by staff) on 7/15/21, and then, per a change of condition evaluation, to a pressure injury with black eschar, tunneling, and foul smell on 8/1/21. On 8/12/21, a skin integrity report documented the pressure injury as a stage 4 pressure injury. The initial wound physician evaluation of the injury on 8/20/21 (during survey) confirmed a stage 4 wound with exposed muscle and undermining. There was an additional deep tissue pressure injury to the resident's left heel. Record review and interviews with administrative and direct care staff revealed the facility failed to take measures to prevent and heal the resident's pressure injury to her coccyx and to prevent the development of the additional pressure injury to her left heel. The facility failed to comprehensively assess the resident's risk of pressure injuries on admission and failed to develop a care plan with interventions to minimize these risks. Further, the facility failed to properly assess, document and monitor the coccyx pressure injury from 7/15/21 until 8/1/21, and, although the assessment 8/1/21 indicated the pressure injury was worsening, this failed to trigger notification to the resident's physician, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON)/facility wound nurse and placement of the resident on the wound round list to be seen by the wound physician. This, in turn, failed to trigger evaluation of interventions and revision of treatment orders. The treatment order for barrier cream to buttocks remained in place until 8/12/21 and as of 8/19/21, the resident lacked a care plan with measures to promote healing of the coccyx injury and to prevent the development of additional pressure injuries. In addition, although treatment orders 8/12/21 included to ensure the resident is off the coccyx every two hours, and the wound physician documented on 8/20/21 that the pressure areas should be offloaded throughout the day, observations 8/19/21 for four hours and 8/24/21 for approximately two hours, revealed this order was not being implemented. The resident remained on her back with pressure on her coccyx. Finally, observations of wound care on 8/25/21 revealed care inconsistent with infection control measures to promote healing and prevent infection. The findings above represented systemic failures in the facility's management of Resident #9's pressure injuries. Resident #9's coccyx pressure injury was inadequately assessed, documented and monitored, care planned and treated to promote healing and prevent infection. The facility's management of the resident's coccyx pressure injury contributed to actual harm for Resident #9, and the potential for further, serious harm if not immediately corrected. ADDITIONAL FAILURES IN PRESSURE INJURY MANAGEMENT Residents #7, #6, and #19 also developed pressure injuries that were not accurately assessed, documented, monitored and treated to promote healing and prevent infection. Cross reference F692 (nutrition), F600 (neglect), F835 (administration), and F867 (QAPI). Findings include: I. Immediate jeopardy A. Situation of immediate jeopardy Resident #9, whose age, clinical condition and assistance needs put her at risk for pressure injuries, was identified with moisture associated skin damage (MASD) on her coccyx on 7/8/21. An order was obtained 7/10/21 for barrier cream. However, a skin check revealed the skin damage progressed to a pressure injury (not further described by staff) on 7/15/21, and then, per a change of condition evaluation, to a pressure injury with black eschar, tunneling, and foul smell on 8/1/21. On 8/12/21, a skin integrity report documented the pressure injury as a stage 4 pressure injury. The initial wound physician evaluation of the injury on 8/20/21 (during survey) confirmed a stage 4 wound with exposed muscle and undermining. There was an additional deep tissue pressure injury to her left heel. Record review and interviews with administrative and direct care staff revealed the facility failed to take measures to prevent and heal the resident's pressure injury to her coccyx and to prevent the development of the additional pressure injury to her left heel. The facility failed to comprehensively assess the resident's risk of pressure injuries on admission and failed to develop a care plan with interventions to minimize these risks. Further, the facility failed to properly assess, document and monitor the coccyx pressure injury from 7/15/21 until 8/1/21, and, although the assessment 8/1/21 indicated the pressure injury was worsening, this failed to trigger notification to the resident's physician, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON)/facility wound nurse and placement of the resident on the wound round list to be seen by the wound physician. This, in turn, failed to trigger evaluation of interventions and revision of treatment orders. The treatment order for barrier cream to buttocks remained in place until 8/12/21 and as of 8/19/21, the resident lacked a care plan with measures to promote healing of the coccyx injury and to prevent additional pressure injuries. In addition, although treatment orders 8/12/21 included to ensure the resident is off the coccyx every two hours, and the wound physician documented on 8/20/21 that the pressure areas should be offloaded throughout the day, observations 8/19/21 for four hours and 8/24/21 for about two hours, revealed this order was not being implemented. The resident was positioned on her back, placing pressure on her coccyx. Finally, observations of wound care on 8/23 and 8/25/21 revealed care inconsistent with infection control measures to promote healing and prevent infection. The findings represented systemic failures in the facility's management of Resident #9's pressure injuries. Resident #9's coccyx pressure injury was inadequately assessed, documented and monitored, care planned and treated to promote healing and prevent infection. The facility's management of the resident's coccyx pressure injury contributed to actual harm for residents #9, and the potential for further, serious harm if not immediately corrected. B. Imposition of immediate jeopardy On 8/19/21 at 2:50 p.m. the nursing home administrator (NHA), director of nursing (DON) and regional resource nurse manager (RRNM) were notified of the immediate jeopardy situation created by the facility's failure to prevent and heal pressure injuries and to prevent the development of additional pressure injuries. C. Facility plan to remove immediate jeopardy On 8/23/21 at 3:10 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: 1. Corrective action -The skin integrity coordinator/assistant director of nursing, the resident's primary certified registered nurse practitioner, and therapy completed an assessment on Resident #9 on August 19, 2021. Development of the care plan has been initiated. Assessment and treatment documentation will be developed after the certified registered nurse practitioner (NP) completes an assessment by 8/20/21. The wound NP or medical doctor to do an assessment of the resident by August 20, 2021. 2. Identification of others -The center nurse executive and/or designee will complete a 100% skin sweep and implement the skin management policy and procedure for any identified skin impairments by August 21, 2021. The center's wound NP will conduct an assessment of all skin concerns identified during the skin sweep to determine the appropriate treatment and develop the plan of care. The wound NP will assess any resident that is identified by the skin sweep by August 23, 2021. -The wound NP will conduct a skin sweep of all residents on or before August 25, 2021. 3. Systemic changes -On August 19, 2021, the center nurse executive, unit managers, and/or designee initiated education with staff on skin management/prevention of avoidable pressure injuries. Education includes: skin assessment, documentation, treatment, notification and monitoring of skin impairments. Skin assessment education includes: assessing on admission, weekly and as needed (PRN). Documentation education includes: documentation of findings from skin assessment on skin check assessment, change in condition assessment, risk management system and weekly wound documentation. Furthermore, education for documentation also includes: development of comprehensive care plan addressing resident's risk in development of pressure injuries and resident centered interventions to prevent the development of avoidable pressure injuries and/or healing of pressure injuries. Treatment education includes: obtaining appropriate and timely treatment orders, entering orders timely into PCC and implementing orders per physician orders. Notification education includes notifying the following individuals upon new skin impairment and/or decline in skin impairment, center nurse executive, and/or designee, resident, residents ' responsible party and residents ' provider. Monitoring skin impairment education includes the following: nurse educated to check skin with cares, weekly and during skin treatments and/or PRN, wound nurse and/or wound nurse designee to complete weekly measurements, staging and status of the wound (improvement, decline or healed). All nursing staff will be re-educated by August 25, 2021. Employees with scheduled time off, on leave of absence, vacation or PRN staff will be re-educated prior to returning to duty. -If non-compliance is identified during reviews the center executive director, center nurse executive, and/or wound nurse will be notified and on the spot education will be provided on adherence to skin management practices. 4. Monitoring -On August 23, 2021, center executive director and center nurse executive will conduct a root cause analysis on skin management program and submit findings to the quality assurance performance improvement committee. The quality assurance performance improvement committee will review findings and make recommendations to promote changes and compliance of skin management practices. The quality assurance performance improvement committee will review and analyze findings from audits and observations monthly and develop additional measures on an ongoing basis to sustain compliance on August 26, 2021. D. Removal of the immediate jeopardy The above plan was accepted on 8/23/21 at 3:45 p.m. and the immediate jeopardy was removed. However, record review, observations and interviews revealed deficient practice remained at a G level, actual harm that is isolated. II. Facility policy and procedures A. Document review The Skin Integrity Management policy and procedure, revised June 2021, was provided by the NHA on 8/25/21 at 3:51 p.m. It read, in pertinent part: The implementation of an individual patient's skin integrity management occurs within the care and delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Purpose: to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Include all patients who have newly identified skin impairments on the 24 hour summary report. Perform skin inspection on admission, readmission and weekly. Perform wound observations and measurements and complete the skin integrity report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. Implement pressure ulcer prevention for identified risk factors. Document daily monitoring of the ulcer site, with or without the dressing. B. Administration interviews 1. The assistant director of nursing (ADON) #1 was interviewed on 8/19/21 at 12:12 p.m. She said she was the assigned wound nurse for the facility. She said upon the development of a new skin concern or pressure injury, the nursing staff should notify her and the director of nursing (DON) immediately to ensure the wound was properly assessed and an appropriate treatment in place. She said each resident's skin should be assessed weekly and documented in the weekly skin check. She said each nurse should put eyes on the resident before completing the skin check. She said the skin check was not accurate unless the nurse physically evaluated the resident. 2. The director of nursing (DON) was interviewed on 8/19/21 at 1:30 p.m. She said a skin assessment should be completed, at a minimum, weekly for each resident. She said ideally, it should be completed with every care being provided and shower/bath given. She said if the nurse or CNA identified a new skin concern, an assessment should be completed along with the physician, DON and ADON #1 being notified immediately. 3. The regional resource nurse manager (RRNM) was interviewed on 8/19/21 at 1:37 p.m. and again on 8/26/21 at 1:01 p.m. She said each resident's skin should be assessed on their bathing day. She said the nurse should physically assess each resident's skin and complete a skin check. She stated when a nurse received a report about a resident's skin, they should immediately view, assess, measure and describe the area in a note. She stated the nurse should complete a risk management, a change in condition and a skin assessment and notification made to the physician, DON and ADON #1 immediately. She said once notified, ADON #1 should put the resident on the wound round list to be seen by the wound physician. She said the wound physician rounded weekly on those residents with identified skin concerns. She stated once orders from the physician were obtained, the treatment should be completed according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Failure in pressure injury management - Resident #9 A. Resident status Resident #9, age 88, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment revealed the resident did not have any pressure injuries on admission. The 7/20/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of one person with bed mobility, dressing, toileting and limited assistance of one person with personal hygiene. The resident was incontinent of bowel and bladder. The MDS further documented the resident was at risk for developing pressure injuries and had a pressure reducing device for a chair and the bed. Although it read the resident did not have any identified pressure injuries, this was incorrect per the 7/15/21 skin check (see below). B. Record review and interview revealed the facility failed to take measures to prevent and heal the resident's pressure injury to her coccyx and to prevent the development of the additional pressure injury to her left heel. The resident's electronic medical record was reviewed on 8/19/21 at 10:51 a.m. 1. Record review 6/10/21 to 7/8/21 - Facility failure to comprehensively assess the resident's risk of pressure injuries on admission and failure to develop a care plan with interventions to minimize these risks. Record review did not reveal documentation the facility had conducted a comprehensive assessment of the resident's pressure injury risk on admission or as of 7/8/21. Further, the review revealed a comprehensive care plan had not been developed with interventions to minimize the resident's risk of skin breakdown due to age, clinical condition, incontinence and immobility. Interview with nurse practitioner (NP) #2 on 8/26/21 at 12:20 p.m., revealed Resident #9 was immobile and was unable to reposition herself without staff assistance. However, review of the June medication administration record (MAR) revealed no order for repositioning the resident and there was no evidence the nursing staff initiated a turning and repositioning schedule for the resident. 2. 7/8/21-7/29/21 - Development of a pressure injury and facility failure to properly assess, document and monitor the coccyx pressure injury. -Although the 7/1/21 skin check documented the resident did not have any skin injuries or wounds identified, the 7/8/21 skin check documented the resident had a skin injury/wound identified as moisture associated skin damage (MASD) to the coccyx and the July MAR revealed moisture barrier to the coccyx was ordered 7/10/21 two times per day for skin integrity. -The 7/15/21 skin check documented the resident had a pressure injury identified to the coccyx. Contrary to facility policy and administration interviews (see above), there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 or that the resident was put on the wound round list to be seen by the wound physician. Further, although staff indicated the treatment continued to the coccyx, no treatment was documented on either the MAR or treatment administration record (TAR). And, contrary to facility policy and administration interviews, the resident's electronic medical record did not reveal evidence of a comprehensive care plan, identifying the pressure injury on the resident's coccyx or reveal any interventions to assist in the healing of the pressure injury. -The 7/22/21 skin check documented the resident had a previously noted skin injury/wound recorded as MASD to the coccyx. It indicated lotion was applied to the coccyx. However, there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 or that the resident was put on the wound round list to be seen by the wound physician. -The 7/29/21 skin check revealed the resident had a previously noted skin injury/wound recorded of MASD and a pressure injury to the coccyx. As on 7/15 and 7/22/21, there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 or that the resident was put on the wound round list to be seen by the wound physician. Although the RRNM said each resident's skin should be assessed on their bathing day, a review of the certified nurse aide (CNA) task point of care (POC) documentation for July 2021 revealed the resident did not receive bathing services for the entire month of July. (Cross-reference F676)] 3. 8/1/21 to 8/20/21 - Worsening pressure injury - failure to conduct an assessment, timely communicate changes to the pressure injury and failure to implement a treatment to prevent the worsening of the pressure injury to a stage 4. Wound physician consult and discovery of two pressure injuries. 8/1/21 to 8/12/21: -A 8/1/21 change of condition evaluation revealed there was a change in the resident's wound from the previous week. It documented the pressure injury to the coccyx was 1 cm (centimeter) in size, was larger with black eschar, tunneling, a foul smell and a green tint to the wound bed. RN #4 documented she cleansed the pressure injury with wound cleaner, applied a Mediplex dressing and repositioned the resident for comfort. The documentation indicated the NP would see the resident in the morning for a wound evaluation, diet evaluation and a recommendation for treatment orders for the pressure injury to the coccyx. However, record review revealed no treatment orders were obtained the next day and review of the NP progress note 8/2/21 documented the resident was seen due the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It read to monitor the resident for open wounds and to provide local wound care if needed but did not document the NP was notified of the pressure injury to the coccyx or that she assessed the pressure injury while at the facility. Further, review of the resident's medical record did not provide documentation that a treatment order had been obtained to treat the pressure injury. Interview with the wound NP on 8/26/21 at 12:20 p.m. confirmed the NP did not assess the resident's pressure injury or order treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said if she had been notified, she would have assessed the wound that day and put a treatment order in place. She also confirmed she had not heard about the resident's pressure injury on her coccyx until it had already worsened to a stage 4 (8/12/21), stating if she had known about the resident's wound, she would never have waited that long to address it and it would not have worsened. -The 8/5/21 skin check documented the resident had a previously noted pressure injury to the coccyx. It indicated a treatment continued to the coccyx area. However, despite the documentation of the pressure injury worsening, there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 of the wound or that the resident was put on the wound round list to be seen by the wound physician. There was no description of the treatment that was continued. -The 8/12/21 skin integrity report documented Resident #9 had a stage 4 pressure ulcer to the coccyx with 5% (percent) necrotic tissue and 95% epithelial tissue. The pressure injury was 1 cm (centimeter) x 1 cm x 1 cm with tunneling at 4 and 8 o ' clock. The report indicated the wound was cleaned with wound spray, packed with impregnated gauze and covered with a foam dressing. New orders were obtained. The August 2021 MAR and TAR documented the following treatment: Stage 4 pressure ulcer with 2x1x1 tunneling wound to coccyx. Clean with wound spray, pack tunneling wound with thin packing, then apply skin prep to periwound. Apply a foam bandage. Ensure the resident is off the coccyx every two hours - ordered 8/12/21 discontinued on 8/19/21. Yet, contrary to facility policy and administration interviews, no care plan to address the resident's coccyx injury was initiated with measures to address the resident's stage 4 pressure injury, including the new order to ensure the resident was off her coccyx every two hours. 8/12/21 to 8/20/21 There were no further skin checks or documentation of the resident's pressure injury after 8/12/21 until 8/20/21, contrary to facility policy for daily monitoring of the site, with or without the dressing. On 8/20/21 (during survey), the resident was seen by the wound physician for an initial consultation and evaluation of her pressure injuries. The notes indicated two wounds: -Wound #1 (coccyx) was a stage 4 pressure injury with a status of non-healed. The wound measurements were as follows: 2.6 cm length x 1.5 cm width x 1/6 cm depth, with an area of 3.9 square cm and a volume of 6.24 cubic cm. The muscle was exposed and undermining was noted at the 12:00 and ends at 12:00 with a maximum distance of 1.8 cm. There was a moderate amount of drainage noted and the wound bed had 20% slough and 80% granulation. -Wound #2 (left heel) was documented as a deep tissue pressure injury to the left heel with persistent non-blanchable deep red, maroon or purple discoloration. The measurements included: 2.5 cm length x 3.5 cm width with no measurable depth, with an area of 8.75 sq cm. The wound bed has 100% epithelialization. The wound physician documented the pressure areas should be offloaded throughout the day for continued preventative measures and documented the following treatments were to be completed: -Apply skin prep to both heels two times per day for a deep tissue injury (DTI) to the left heel and prevention to the right heel - ordered 8/20/21; -Wound care: pack wound with silver alginate packing and cover with a foam dressing every other day and as needed for a stage 4 pressure ulcer - ordered 8/21/21, and discontinued on 8/24/21; -Cleanse sacral wound with wound cleanser. Apply skin prep to the periwound. Pack the wound with Dakins soaked packing strip. Cover with a foam dressing. Change daily and as needed/soiled for a stage 4 sacral wound - ordered 8/25/21. C. Observations and interviews revealed continued failure of the facility to take measures to heal the resident's pressure injury to her coccyx and to prevent infection. 1. 8/19/21 - Failure to position resident off her coccyx for approximately four hours, contrary to orders 8/12/21. A continuous observation was conducted on 8/19/21 beginning at 9:14 a.m. and ending at 1:30 p.m. The following was observed: -At 9:14 a.m. Resident #9 was observed lying on her back in the middle of the bed. The head of the bed was raised to a 45-degree angle with a Potus boot to the left foot. -At 10:26 a.m. Resident #9 continued to lay in bed in the same position. Staff have not entered the resident's room to provide repositioning. -At 11:05 a.m. two certified nurse aides (CNAs) entered the resident's room and closed the door. The staff left the room at 11:15 a.m. CNA #2 said they provided incontinence care for Resident #9. -At 11:15 a.m., after the CNAs left the resident's room, Resident #9 was lying on her back in the middle of the bed. The head of the bed was raised to a 45-degree angle. The resident was not repositioned following incontinence care. -At 12:50 p.m. CNA #1 entered the room with the lunch tray. The meal was set up on the over bed table. CNA #1 left the room. -At 1:30 p.m. Resident #9 was lying in the same position, on her back in the middle of the bed. CNA #2 was interviewed on 8/19/21 at 11:15 a.m. She said she had been the primary day shift CNA for Resident #9 for the past few months. She said she would provide incontinence care and showers for the resident. She did not indicate she had been instructed to reposition the resident and review of the CNA POC did not reveal it was documented there to turn and reposition the resident. She said Resident #9 had a wound to the buttocks for a while, and when she would provide care to Resident #9, sometimes the wound would be covered with a treatment and sometimes it would not be covered. 2. 8/23/21 - Failure to reposition the resident and dress her pressure injury, as ordered. The regional resource nurse manager (RRNM) was observed on 8/23/21 at 3:30 p.m. to complete a skin assessment of Resident #9. The resident was positioned on her back. Her left foot had a small raised dry area and her left heel was blackened and measured 4 x 2.5 cm. The right heel was boggy and red. Her coccyx had a very large wound, red and open to air underneath the briefs she had on. The RRNM said the resident had a shower today and the nurse had not redressed the wounds yet. The wound measured 4 x 2 cm and 3/4 cm deep. The red area around the wound was large and measured 13 by 10 cm with three smaller open wound areas around that. Posterior to the large wound was an open area that measured 1 x 1 cm. The open area next to that was 1 x 2 cm and another open area that measured 3 x 1.5 cm. RRNM put a clean brief on the resident but did not redress the wounds to the coccyx. She said the nurse would do that. She said the wound doctor was there on Friday (8/20/21) and wrote new orders but she did not have time yet to put those orders into the system for the nurses to follow. The resident's spine was red (blanchable) and measured 10.5 x 5.5. She had a small red area to the right of the spine that looked like a red line. Although a reddened area on the resident's spine was found during the assessment, an area not identified 8/20/21 by the wound physician (see above), after the skin assessment, the resident was positioned on her back. 3. 8/24/21 - Failure to reposition the resident off her coccyx for approximately two hours and reports of the resident consistently not repositioned and a report that pressure injury was worsening. -At 8:45 a.m., Resident #9 was observed lying on her back in the middle of the bed. The head of the bed was slightly raised at a 45-degree angle. The resident had a Potus boot to the left foot. A continuous observation began at 10:45 a.m. and ended at 12:30 p.m. -At 10:45 a.m., Resident #9 was lying in the center of the bed with the head of the bed raised to a 45-degree angle. The resident's shoulders were halfway up the top of the mattress with the top of the resident's head lying on the bottom portion of the pillow, putting pressure on the resident's coccyx area. The resident's feet were uncovered by the blanket. A Potus boot covered the resident's left foot. No pressure relief measures were in place for the resident's right heel which was observed to be boggy and red the day before. Further, no pillows or other devices were observed to assist with positioning of the resident off her back. -At 11:00 a.m. Resident #9's roommate was interviewed. She said the facility staff usually only entered their room when Resident #9 required changing. She said Resident #9 laid in bed all day and did not sit in her wheelchair very often. She said the resident's current position was the position she was in on a regular basis. She said she had never seen the facility staff enter the room to reposition Resident #9. -At 12:01 p.m. nurse practitioner (NP) #1, at the nursing station, asked registered nurse (RN) #4 for a description of the resident's wound to the coccyx. RN #4 responded she had not seen the wound that day. She said Resident #9 was in bed and thought the CNAs would be getting her out of bed soon. NP #1 walked down the hallway and entered Resident #9's room and closed the door. -At 12:04 p.m. NP #1 exited Resident #9's room and asked RN #4 if she could assist in rolling Resident #9 on her side so she could assess the resident's wound. RN #4 said she did not have time and for NP #1 to push the call light so a CNA would come and assist. NP #1 re-entered the resident's room and pushed the call light. -At 12:07 p.m. Resident #9's roommate exited the room and walked down the hallway, looking for a CNA. A CNA was observed walking down the hallway, pushing a mechanical lift. Resident #9's roommate said the CNA said she was busy assisting another resident and told her to go to the front of the facility to look for another CNA to assist Resident #9. -At 12:10 p.m. NP #1 walked out of Resident #9's room and asked an agency nurse to assist her with turning Resident #9. The agency nurse and another nurse entered Resident #9's room to assist NP #1. NP #1 exited the resident's room at 12:18 p.m. NP #1 was interviewed on[TRUNCATED]

Based on interviews and record review, the facility failed to ensure one (#9) out of 37 sample residents were kept free from neglect. The facility failed to ensure Resident #9 was not neglected by staff by providing the care and services the resident required to maintain the highest practicable well-being. This is evidenced by the following statements. Specifically, the facility failed to ensure Resident #9 received the care and services required to prevent avoidable pressure injuries from developing and worsening. Resident #9, whose age, clinical condition and assistance needs put her at risk for pressure injuries, was identified with moisture associated skin damage (MASD) on her coccyx on 7/8/21. Record review, observations and interviews with administrative and direct care staff revealed the facility failed to take measures to prevent and heal the resident's pressure injury to her coccyx and to prevent the development of the additional pressure injury to the left heel. The facility failed to comprehensively assess the resident's risk of pressure injuries upon admission and failed to develop a care plan with interventions to minimize these risks. Further, the facility failed to properly assess, document, monitor the coccyx pressure injury, ensure the proper notifications, and implement an appropriate treatment order. Cross reference F686 (pressure injuries) Additionally, the facility failed to consistently monitor weights, identify significant weight loss and timely address Resident #9's nutritional needs. Resident #9 experienced a significant, unplanned weight loss of 9.3% in two months. Record review and interviews revealed the facility failed to monitor Resident #9's weight in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews confirmed the facility lacked a system to ensure resident weights were being obtained, which contributed to Resident #9's significant weight loss. Cross reference F692 (nutrition). Lastly, the facility failed to ensure Resident #9 received bathing services in accordance with her plan of care. Record review revealed Resident #9 did not receive any bathing services for July 2021, which was when the resident's pressure injuries developed. Cross reference F676 (activities of daily living) Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 8/25/21 at 3:51 p.m. It revealed, in pertinent part, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all patients. Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, will include: -providing patients, families, and staff with information on how and whom they may report concerns, incidents, and grievances without fear of retribution and provide feedback regarding the concerns that have been expressed; -identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur; and -establishing a safe environment that supports, to the extent possible, a patient's consensual sexual relationship. II. Resident #9 status Resident #9, age 88, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/20/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of one person with bed mobility, dressing, toileting and limited assistance of one person with personal hygiene. It documented the resident was at risk for developing pressure injuries. The resident had a pressure reducing device for a chair and the bed. It indicated the resident was not on a turning or repositioning program. It indicated the resident did not have any identified pressure injuries. Although it read that the resident did not have any identified pressure injuries, this was incorrect per the 7/15/21 skin check (see below). II. Failure to prevent avoidable pressure injuries from developing and worsening A. Observations During a continuous observation on 8/19/21 beginning at 9:14 a.m. and ended at 1:30 p.m. The following was observed: -At 9:14 a.m. Resident #9 was observed lying on her back in the middle of the bed. The head of the bed was raised to a 45 degree angle with a potus boot to the left foot. -At 10:26 a.m. Resident #9 continued to lay in bed in the same position. Staff have not entered the resident's room to provide repositioning. -At 11:05 a.m. two certified nurse aides (CNA) were observed entering the resident's room and closed the door. The staff left the room at 11:15 a.m. CNA #2 said they provided incontinence care for Resident #9. Resident #9 was observed after the CNAs left the room. She was lying on her back in the middle of the bed. The head of the bed was raised to a 45 degree angle. The resident was not repositioned following incontinence care. -At 12:50 p.m. CNA #1 entered the room with the lunch tray. The meal was set up on the over bed table. CNA #1 left the room. -At 1:30 p.m. Resident #9 was lying in the same position. On 8/24/21 at 8:45 a.m. Resident #9 was observed lying on her back in the middle of the bed. The head of the bed was raised at a 45 degree angle. The resident had a potus boot to the left foot. -At 9:30 a.m., 10:00 a.m. and 10:15 a.m. 10:45 a.m. and 11:00 a.m. the resident was observed lying in the same position, on her back, in the middle of the bed, with the head of the bed raised at a 45 degree angle. During continuous observations on 8/24/21 beginning at 10:45 a.m. and ending at 12:30 p.m. the following was observed: -Resident #9 was lying in the center of the bed with the head of the bed raised to a 45 degree angle. The resident's shoulders were halfway up the top of the mattress with the top of the resident's head lying on the bottom portion of the pillow, putting pressure on the resident's coccyx area. The resident's feet were at the end of the bed, not covered by the blanket. The blanket was covering the resident from the waist to the knees, and strewn half off the bed. A potus boot was covering the resident's left foot. No pillows or other devices were observed to assist with positioning of the resident. -At 11:00 a.m. Resident #9's roommate was interviewed. Resident #37 said the facility staff usually only entered their room when Resident #9 required changing. She said Resident #9 laid in bed all day and did not sit in her wheelchair very often. She said Resident #9's current position was the position she was in on a regular basis. She said she had never seen the facility staff enter the room to reposition Resident #9. -At 12:01 p.m. nurse practitioner (NP) #1, at the nursing station, asked registered nurse (RN) #4 for a description of the residents wound to the coccyx. RN #4 responded she had not seen the wound that day. She said Resident #9 was in bed and thought the certified nurse aides (CNA) would be getting her up out of bed soon. NP #1 walked down the hallway and entered Resident #9's room and closed the door. -At 12:04 p.m. NP #1 exited Resident #9's room and asked RN #4 if she could assist in rolling Resident #9 on her side so she could assess the resident's wound. RN #4 said she did not have time and for NP #1 to push the call light so a CNA would come and assist. NP #1 entered the resident's room and pushed the call light. -At 12:07 p.m. Resident #9's roommate (Resident #37) exited the room and walked down the hallway looking for a CNA. A CNA was observed walking down the hallway, pushing a mechanical lift. Resident #9's roommate said she was busy assisting another resident and told her to go to the front of the facility to look for another CNA to assist Resident #9. -At 12:10 p.m. NP #1 walked out of Resident #9's room and asked an agency nurse to assist her with turning Resident #9. The agency nurse said she was providing wound treatments that day and would assist NP #1. Her and another nurse entered Resident #9's room to assist NP #1. -At 12:18 p.m. NP #1 exited the resident's room. NP #1 was interviewed on 8/24/21 at 12:20 p.m. She said Resident #9's wound looked worse. She said the wound to the resident's coccyx was open, the bone was exposed and had a foul odor. She said, due to her recent lab work that was completed, she suspected the resident had an infection and would start the resident on antibiotics that day. She said she does not remember when she was notified of the resident's wound to the coccyx and the unstageable wound to the left heel. She said in the past few months she had a difficult time finding staff to assist her in assessing different residents. She said she felt the facility did not have enough staff. (cross-reference F725) B. Record review Record review did not reveal documentation that the facility had conducted a comprehensive assessment of the resident's pressure injury risk on admission or as of 7/8/21. Further, the review revealed a comprehensive care plan had not been developed with interventions to minimize the resident's risk of skin breakdown due to age, clinical condition, incontinence and immobility. Interview with nurse practitioner (NP) #2 on 8/26/21 at 12:20 p.m., revealed Resident #9 was immobile and was unable to reposition herself without staff assistance. However, review of the June medication administration record (MAR) revealed no order for repositioning the resident and there was no evidence the nursing staff initiated a turning or repositioning schedule for the resident. Although the 7/1/21 skin check documented the resident did not have any skin injuries or wounds identified, the 7/8/21 skin check documented the resident had a skin injury/wound identified as moisture associated skin damage (MASD) to the coccyx and the July 2021 MAR revealed moisture barrier to the coccyx was ordered 7/10/21 two times per day for skin integrity. The 7/15/21 skin check documented the resident had a pressure injury identified to the coccyx. Contrary to facility policy and administration interviews (see above), there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 or that the resident was put on the wound round list to be seen by the wound physician. Further, although staff indicated the treatment continued to the coccyx, no treatment was documented on either the MAR or treatment administration record (TAR). The resident's electronic medical record did not reveal evidence of a comprehensive care plan, identifying the pressure injury on the resident's coccyx or reveal any interventions to assist in the healing of the pressure injury. The 7/22/21 skin check documented the resident had a previously noted skin injury/wound recorded as MASD to the coccyx. It indicated lotion was applied to the coccyx. However, there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 or that the resident was put on the wound round list to be seen by the wound physician. The 7/29/21 skin check revealed the resident had a previously noted skin injury/wound recorded of MASD and a pressure injury to the coccyx. As on 7/15 and 7/22/21, there was no evidence staff assessed, measured and described the area in a note, completed a risk management, a change in condition and a skin assessment and notified the physician, DON and ADON #1 or that the resident was put on the wound round list to be seen by the wound physician. An 8/1/21 change of condition evaluation revealed there was a change in the resident's wound from the previous week. It documented the pressure injury to the coccyx was 1 cm (centimeter) in size, was larger with black eschar, tunneling, a foul smell and a green tint to the wound bed. RN #4 documented she cleansed the pressure injury with wound cleaner, applied a Mediplex dressing and repositioned the resident for comfort. The documentation indicated the NP would see the resident in the morning for a wound evaluation, diet evaluation and a recommendation for treatment orders for the pressure injury to the coccyx. However, record review revealed no treatment orders were obtained the next day and review of the NP progress note 8/2/21 documented the resident was seen due the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It read to monitor the resident for open wounds and to provide local wound care if needed but did not document the NP was notified of the pressure injury to the coccyx or that she assessed the pressure injury while at the facility. Further, review of the resident's medical record did not provide documentation that a treatment order had been obtained to treat the pressure injury. The 8/12/21 skin integrity report documented Resident #9 had a stage 4 pressure ulcer to the coccyx with 5% (percent) necrotic tissue and 95% epithelial tissue. The pressure injury was 1 cm (centimeter) x 1 cm x 1 cm with tunneling at 4 and 8 o'clock. The report indicated the wound was cleaned with wound spray, packed with impregnated gauze and covered with a foam dressing. New orders were obtained. The August 2021 MAR and TAR documented the following treatment: Stage 4 pressure ulcer with 2x1x1 tunneling wound to the coccyx. Clean with wound spray, pack the tunneling wound with thin packing, then apply skin prep to the periwound. Apply a foam bandage. Ensure the resident is off the coccyx every two hours - ordered 8/12/21 and discontinued on 8/19/21. Yet, contrary to facility policy and administration interviews, no care plan to address the resident's coccyx injury was initiated with measures to address the resident's stage 4 pressure injury, including the new order to ensure the resident was off her coccyx every two hours. There were no further skin checks or documentation of the resident's pressure injury after 8/12/21 until 8/20/21, contrary to facility policy for daily monitoring of the site, with or without the dressing. On 8/20/21 (during survey), the resident was seen by the wound physician for an initial consultation and evaluation of her pressure injuries. The notes indicated two wounds: -Wound #1 (coccyx) was a stage 4 pressure injury with a status of non-healed. The wound measurements were as follows: 2.6 cm length x 1.5 cm width x 1/6 cm depth, with an area of 3.9 square cm and a volume of 6.24 cubic cm. The muscle was exposed and undermining was noted at the 12:00 and ends at 12:00 with a maximum distance of 1.8 cm. There was a moderate amount of drainage noted and the wound bed had 20% slough and 80% granulation. -Wound #2 (left heel) was documented as a deep tissue pressure injury to the left heel with persistent non-blanchable deep red, maroon or purple discoloration. The measurements included: 2.5 cm length x 3.5 cm width with no measurable depth, with an area of 8.75 sq cm. The wound bed has 100% epithelialization. The wound physician documented the pressure areas should be offloaded throughout the day for continued preventative measures and documented the following treatments were to be completed: -Apply skin prep to both heels two times per day for a deep tissue injury (DTI) to the left heel and prevention to the right heel-ordered 8/20/21; -Wound care: pack wound with silver alginate packing and cover with a foam dressing every other day and as needed for a stage 4 pressure ulcer-ordered 8/21/21, and discontinued on 8/24/21; -Cleanse sacral wound with wound cleanser. Apply skin prep to the periwound. Pack the wound with Dakins soaked packing strip. Cover with a foam dressing. Change daily and as needed/soiled for a stage 4 sacral wound - ordered 8/25/21. C. Staff interviews Assistant director of nursing (ADON) #1, the facility's wound nurse, was interviewed on 8/19/21 at 12:12 p.m. She said she was not notified of the change of condition evaluation completed on 8/1/21 that described a significant worsening of Resident #9's coccyx wound. She said if she had been notified, she would have immediately assessed the wound, put a treatment in place and then referred the resident to the wound physician. She said she was first notified of the open area on Resident #9's coccyx on 8/12/21 in the morning management meeting. She said she assessed the wound that day and found it was a stage 4 to the coccyx with tunneling, slough and drainage. She said she put a treatment in place and notified the wound NP for the resident to be placed on the weekly rounds. However, she acknowledged the wound NP had not yet evaluated Resident #9's coccyx wound. She confirmed there was no formal assessment of the resident's coccyx pressure injury until 8/1/21 on the change of condition evaluation and then on 8/12/21 when she completed her assessment of the wound. She confirmed Resident #9 did not have a care plan to address her risk for skin breakdown or the actual skin breakdown with the wound to the coccyx. She confirmed Resident #9's medical record did not reveal documentation that showed the physician had been notified of the resident's wound. She said Resident #9's coccyx started out as MASD and worsened to a stage 4 pressure injury because the facility failed to accurately identify the wound, assess the wound timely, put an appropriate treatment in place, and provide preventative measures such as re-positioning the resident frequently. The DON was interviewed on 8/19/21 at 1:30 p.m. She said she was aware the facility had severe wounds and did not feel the system in place was functional because Resident #9's wound went so long without a proper assessment and treatment. The registered dietitian (RD) was interviewed on 8/25/21 at 11:46 a.m. She confirmed Resident #9 had a 9.3% weight loss in two months. She said she felt Resident #9's wounds were avoidable and the resident had not been provided frequent repositioning and wound management in accordance with accepted standards of practice. NP #2 was interviewed on 8/26/21 at 12:20 p.m. She said she was not notified of Resident #9's pressure injury on 8/2/21 and was not notified until the pressure injury had worsened to a stage 4. She said if she had known about the resident's wounds, she would never have waited that long to address the wound and it would not have worsened. She said she thought it would be beneficial for Resident #9 to be in the dining area and receive cueing and physical assistance with eating. She said it could increase her meal intake and assist with wound healing. She said Resident #9 was immobile and was unable to reposition herself without staff assistance. She said the resident should be repositioned every two hours for wound healing and preventive measures. She said wounds were only unavoidable if all interventions and preventive measures had been exhausted. She said she did not think all preventive measures had been completed and felt the resident's wound was avoidable. The RRNM was interviewed on 8/26/21 at 1:01 p.m. She said there was a complete breakdown in the system of wound care for Resident #9. She said neither ADON #1 and the DON nor the physician were notified of Resident #9's pressure injury. She said there was a breakdown in the identification of Resident #9's wound, based on the documentation indicated on the skin checks. She said the change of condition evaluation should have been caught on the electronic medical record dashboard. She said there was a breakdown in that system because the nurse who completed the change of condition evaluation did not complete a risk management form. She said the risk management form would have alerted the nurse management team. She said the nurses never followed up after the wound was identified to ensure an appropriate treatment was in place to heal the wound. She said barrier cream was not considered an effective wound treatment. She said the facility failed Resident #9 and the stage 4 wound to the coccyx and DTI to the left heel were avoidable and inhouse acquired. III. Failure to consistently monitor weight, timely identify significant weight loss and address Resident #9's nutritional needs A. Record review The resident's electronic medical record was reviewed on 8/19/21 at 10:51 a.m. It did not reveal documentation that a comprehensive care plan had been developed to address the resident's nutritional risk for potential nutritional deficiency and weight loss. The 6/16/21 admission nutritional assessment documented Resident #9's usual body weight was 130 lbs (pounds). The resident was placed on a CCHO (consistent carbohydrate) diet with fair intakes, able to eat independently and voice her needs and preferences. The registered dietician (RD) documented that the resident had not been weighed yet since being admitted to the facility and had requested nursing to obtain the resident's weight. It indicated the RD would follow up as needed once the resident's weight was obtained and add liquid protein one time per day to support healing. The weights and vitals record documented the resident's first weight was obtained on 6/17/21 (seven days following her admission to the facility), which indicated the resident weighed 129 lbs. The June 2021 meal intake records documented that the resident consumed the following: -100% of meals on seven occasions; -75% of meals on 11 occasions; -50% of meals on 33 occasions; -25% on four occasions; and - no documentation on five opportunities. The June 2021 medication administration record (MAR) documented the following physician orders: -Liquid protein: 30 cc of protein liquid one time per day for three months - ordered 6/17/21; -Weigh the resident every Thursday for two weeks - ordered 6/17/21. Record review showed the facility failed to adequately monitor the resident's weight according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2021 meal intake records documented that the resident consumed the following: -100% of meals on 11 occasions; -75% of meals on nine occasions; -50% of meals on 26 occasions; -25% of meals on three occasions; -0% of meals on one occasion; and -no documentation on 43 opportunities. The July MAR documented the following physician orders: -Weight weekly every Thursday and notify the physician of a weight gain of greater than five lbs in one week for [CONDITION(S)] - ordered on 7/8/21 and discontinued on 8/3/21. Record review showed the nursing staff signed off the MAR to indicate the weekly weight had been obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 meal intake records documented that the resident consumed the following: -100% of meals on three occasions; -75% of meals on 13 occasions; -50% of meals on two occasions; -25% of meals on 17 occasions; -0 % of meals on zero occasions; and -no documentation on 37 opportunities. Record review showed the facility failed to consistently monitor the resident's meal intake percentage to determine if the resident's meal intakes had a negative effect on her nutritional status. The weight and vitals record documented the resident's weight was obtained on 8/10/21 of 125.2 lbs,, a weight loss of 3.8 lbs./2.9%. The 8/11/21 nutrition progress note documented Resident #9 had a pressure ulcer to the coccyx and had a small amount of weight loss in the past two months, since her admission to the facility. The resident was under the desirable body mass index (BMI) range for older adults. Her current BMI was 21.4 and should be over 22. It indicated the resident was tolerating a CCHO (consistent carbohydrate) diet for diabetes mellitus with intakes that were generally poor with an average of 54% in the past week. The resident was able to feed herself independently. The resident benefited from setup assistance. It documented that the resident was falling short of increased energy needs. The RD checked in on the resident during several meals and determined Resident #9 was a slow eater, and did not eat a lot. The resident's responsible party indicated the resident was not a big eater and provided some food preferences for the resident. The resident's recent labs were reviewed which indicated a low [MEDICATION(S)] level, which the RD documented was from the resident's nutritional status. The interventions included adding a multivitamin, house supplement twice per day and trial some of the resident's favorite foods. The 8/13/21 nutritional progress note documented the RD stopped into the resident's room to see if she would accept dark chocolate. The resident declined and the RD left the candy at the bedside in case she changed her mind. The 8/17/21 at 5:30 p.m. nutritional progress note documented the RD brought a cheese sandwich to the resident's room. Resident #9 was sleeping when she arrived and the lunch tray was still sitting at the bedside, untouched. The RD asked the certified nurse aide (CNA) to ensure the resident was up for dinner. B. Staff interviews CNA #2 was interviewed on 8/19/21 at 11:15 a.m. and again on 8/24/21 at 2:24 p.m. She said she had been the primary day shift CNA for Resident #9 for a few months. She said she would deliver the room trays to Resident #9 in her room. She said she would provide setup assistance to the resident and leave the room. She said Resident #9 was not able to make her needs known or use the call light. She said Resident #9 was often forgotten because she could not make her needs known. She said Resident #9 would benefit from cueing during meals. She said, when she had time, she would attempt to go into the resident's room and encourage her to take a bite of food. She said Resident #9 usually responded well to encouragement. She said the resident should be sitting up in her wheelchair for all meals. She said she thought the resident would benefit from sitting in the dining area with staff providing cueing and physical assistance with eating. She said she thought the resident's poor intake was related to her not receiving enough assistance during meals. She said the RD had asked her to check on the resident that day, 8/24/21, and encourage the resident to eat. She said she did not have time that day to provide encouragement to the resident. C. Follow-up The 8/18/21 nutritional progress note documented that the RD dropped off the resident's lunch tray. Resident #9 was sleeping and the breakfast tray was sitting in front of the resident, untouched. The RD woke up Resident #9, raised the head of the bed and left the room. When the RD returned, the resident had eaten 50% of a peanut butter and jelly sandwich and drank 75% of a glass of whole milk. The 8/19/21 nutritional assessment, during the survey process, documented that the RD met with the resident to discuss wound healing and a nutrition plan. It indicated the resident had a worsened stage 4 pressure injury to the coccyx. The RD documented that the resident remained on a consistent carbohydrate diet (CCHO) with generally poor intakes. The RD indicated she checked in with the resident during meal times to ensure she was awake and eating. The interventions included liquid protein one time per day, house supplement twice per day, which was generally accepted 50-100% of the time. The RD added Cheerios with peaches on top for breakfast and to liberalize the resident's diet from CCHO to regular to allow for more menu options. The RD documented that the resident's weight loss was related to poor appetite and cognitive decline. The nutritional assessment did not address the lack of consistent documentation of the resident's meal intakes or the failure to obtain weekly weights as was ordered by the physician. Record review revealed the facility failed to evaluate the resident's functional limitations to determine if the resident required encouragement or physical assistance with meals following the RD's observations on two different occasions of the resident with an untouched meal in front of her, hours after it had been served. The weights and vitals documentation indicated Resident #9's weight was obtained on 8/23/21 of 117 lbs. The resident had a significant weight loss of 12 lbs/9.3% in two months. The 8/24/21 nutrition progress note documented that the RD set up the resident's lunch that day. The RD raised the head of the bed and made sure the resident was awake with the tray in front of her. The RD checked in several times after setting up the resident, had to wake her and remind the resident to eat. The RD asked the resident to take a bite and the resident did. The RD asked the CNA to continue to check in on the resident and encourage her to eat. Cross reference F692 (nutrition). IV. Failure to ensure Resident #9 received bathing services in accordance with her plan of care A. Observations Resident #9 was observed on 8/19/21 at 9:14 a.m. lying on her back in the middle of the bed. The head of the bed was raised to a 45 degree angle. The resident's hair was pushed up and in disarray in the back with debris by the hairline on the top of the head. The resident had a musky odor. Resident #9 was observed on 8/24/21 at 10:45 a.m. Resident #9 was lying in the center of the bed with the head of the bed raised to a 45 degree angle. The resident's shoulders were halfway up the top of the mattress with the top of the resident's head lying on the bottom portion of the pillow. The resident had Cheerio's on her shirt and debris on the chin and left corner of her mouth. The resident's hair was in disarray and had a musky odor. B. Record review The ADL care plan, initiated and revised on 7/1/21, revealed the resident was at risk for a decreased ability to perform bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion and toileting. The interventions included: monitor for decline in ADL function, refer to therapy if the decline in ADLs is noted and physical/occupational therapy as ordered by the physician. It did not include any person-centered approaches to maintaining the resident's level of care. The July 2021 CNA bathing documentation revealed the resident did not receive a shower, bath or bed bath in the month of July. The August 2021 CNA bathing documentation revealed the resident received a shower on 8/2/21, 8/18/21 and 8/23/21, which was three times out of 11 opportunities. C. Staff interviews CNA #2 was interviewed on 8/24/21 at 2:24 p.m. She said showers were supposed to be given according to the bathing schedule at the nursing station. She said it was hard to give residents showers or baths because of how busy the CNAs were throughout the day. She said showers and baths were not being provided as they should. She said she was the primary CNA for Resident #9. She said she was aware the resident had not received showers according to her plan of care. Assistant director of nursing (ADON) #1 was interviewed on 8/19/21 at 12:12 p.m. She said showers were not being given throughout

Based on observations, record review and interviews the facility failed to ensure for two (#9 and #5) of three residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 37 sample residents. Specifically, the facility failed to consistently monitor weights, identify significant weight loss and timely address Resident #9's nutritional needs. Resident #9 experienced a significant, unplanned weight loss of 9.3% in two months. In addition, Resident #9 developed a pressure injury which worsened to a stage 4. The facility failed to identify the resident was a nutritional risk and develop a comprehensive care plan. Record review and interviews revealed the facility failed to monitor Resident #9's weight in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews confirmed the facility lacked a system to ensure resident weights were being obtained to accurately monitor any significant weight loss or weight gain. The facility's failure to have a system that ensured timely weights were obtained and nutritional interventions in place contributed to Resident #9's significant weight loss. Cross-reference: F686 (pressure injuries), F600 (neglect), F725 (staffing), F835 (administration) and F867 (QAPI). Additonally, the facility failed to ensure Resident #5 was weighted according to RD recomendations. Findings include: I. Facility policy and procedure The Nutrition/Hydration policy and procedure, revised June 2021, was provided by the nursing home administrator (NHA) on 8/25/21 at 3:51 p.m. It revealed, in pertinent part, The implementation of an individual patient's nutrition/hydration management occurs within the care delivery process. Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed. Practice standards: -Review appropriate assessment information; -Address any changes in condition that affect or potentially affect the patient's nutritional status with the dietician and physician; -Use the diet order and communication form to initiate a consult with the dietician when indicated; -Review dietician recommendations on the nutritional care recommendations form; -Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutritional and hydration. Include interventions for patients who have functional difficulties which may affect ability to eat or drink independently; -Observe oral intake of meals, supplements and snacks and complete the meal monitor data collection sheet when ordered or indicated; -Monitor the patient's weight as ordered; -Review the dietician's progress notes to identify ongoing progress and recommendations; -Revise patient's care plan as needed. II. Resident #9 A. Resident status Resident #9, age 88, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/20/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of one person with bed mobility, dressing, toileting and limited assistance of one person with personal hygiene. -It documented that the resident was independent with eating. Based on record review and staff interviews this would be inaccurate. Resident #9 was not coded for weight loss and was not on a physician prescribed weight loss regimen. B. Record review Resident #9's record revealed she experienced a significant, unplanned weight loss of 12 lbs (pounds) and 9.3% from 6/17/21 to 8/23/21. 1. Resident #9's nutritional status upon admission to the facility in June 2021 The resident's electronic medical record was reviewed on 8/19/21 at 10:51 a.m. It did not reveal documentation that a comprehensive care plan had been developed to address the resident's nutritional risk for potential nutritional deficiency and weight loss. The 6/16/21 admission nutritional assessment documented Resident #9's usual body weight was 130 lbs (pounds). The resident was placed on a CCHO (consistent carbohydrate) diet with fair intakes, able to eat independently and voice her needs and preferences. The registered dietititian (RD) documented the resident had not been weighed yet since being admitted to the facility and had requested nursing obtain the resident's weight. It indicated the RD would follow up as needed once the resident's weight was obtained and add liquid protein one time per day to support healing. (cross-reference F686 failed to prevent the development of pressure ulcers) The weights and vitals record documented the resident's first weight was obtained on 6/17/21 (seven days following her admission to the facility), which indicated the resident weighed 129 lbs. 2. Resident #9's significant weight loss and the facility failure to reassess the resident's functional status for eating, effectively monitor the resident's weight and significant skin deterioration The June 2021 meal intake records documented that the resident consumed the following: -100% of meals on seven occasions; -75% of meals on 11 occasions; -50% of meals on 33 occasions; -25% on four occasions; and - no documentation on five opportunities. The June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Liquid protein: 30 cc of protein liquid one time per day for three months - ordered 6/17/21; -Weigh the resident every Thursday for two weeks - ordered 6/17/21. Record review showed the facility failed to adequately monitor the resident's weight according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cross reference F835: failure to ensure sufficient administrative oversight and F867: failure to identify areas of concern to prevent substandard care). The July 2021 meal intake records documented that the resident consumed the following: -100% of meals on 11 occasions; -75% of meals on nine occasions; -50% of meals on 26 occasions; -25% of meals on three occasions; -0% of meals on one occasion; and -no documentation on 43 opportunities. The July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Weight weekly every Thursday and notify the physician of a weight gain of greater than five lbs in one week for [CONDITION(S)] - ordered on 7/8/21 and discontinued on 8/3/21. Record review showed the nursing staff signed off the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 meal intake records documented that the resident consumed the following: -100% of meals on three occasions; -75% of meals on 13 occasions; -50% of meals on two occasions; -25% of meals on 17 occasions; -0 % of meals on zero occasions; and -no documentation on 37 opportunities. Record review showed the facility failed to consistently monitor the resident's meal intake percentage to determine if the resident's meal intakes had a negative effect on her nutritional status. The weight and vitals record documented the resident's weight was obtained on 8/10/21 of 125.2 lbs, a weight loss of 3.8 lbs./2.9%. 3. Nutritional assessments and documentation following the resident's initial weight loss The 8/11/21 nutrition progress note documented Resident #9 had a pressure ulcer to the coccyx and had a small amount of weight loss in the past two months, since her admission to the facility. The resident was under the desirable body mass index (BMI) range for older adults. Her current BMI was 21.4 and should be over 22. It indicated the resident was tolerating a CCHO (consistent carbohydrate) diet for diabetes mellitus with intakes that were generally poor with an average of 54% in the past week. The resident was able to feed herself independently. The resident benefited from setup assistance. It documented that the resident was falling short of increased energy needs. The RD checked in on the resident during several meals and determined Resident #9 was a slow eater, and did not eat a lot. The resident's responsible party indicated the resident was not a big eater and provided some food preferences for the resident. The resident's recent labs were reviewed which indicated a low [MEDICATION(S)] level, which the RD documented was from the resident's nutritional status. The interventions included adding a multivitamin, house supplement twice per day and trialing some of the resident's favorite foods. The August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -House supplement: 4 ounces of house supplement twice per day. Document the percentage on the MAR - ordered 8/10/21. It documented the following house supplement intakes from 8/10/21 to 8/25/21: -100% on 12 occasions; -75% on two occasions; -50% on six occasions; -20-25% on three occasions; and -zero percent on five occasions. The 8/13/21 nutritional progress note documented the RD stopped into the resident's room to see if she would accept dark chocolate. The resident declined and the RD left the candy at the bedside in case she changed her mind. The 8/17/21 at 5:30 p.m. nutritional progress note documented the RD brought a cheese sandwich to the resident's room. Resident #9 was sleeping when she arrived and the lunch tray was still sitting at the bedside, untouched. The RD asked the certified nurse aide (CNA) to ensure the resident was up for dinner. C. Staff interviews CNA #2 was interviewed on 8/19/21 at 11:15 a.m. and again on 8/24/21 at 2:24 p.m. She said she had been the primary day shift CNA for Resident #9 for a few months. She said she would deliver the room trays to Resident #9 in her room. She said she would provide setup assistance to the resident and leave the room. She said Resident #9 was not able to make her needs known or use the call light. She said Resident #9 was often forgotten because she could not make her needs known. She said when the resident first was admitted to the facility, she was able to feed herself independently. She said over the past month, Resident #9's physical abilities had declined. She said Resident #9 would benefit from cueing during meals. She said, when she had time, she would attempt to go into the resident's room and encourage her to take a bite of food. She said Resident #9 usually responded well to encouragement. She said the resident should be sitting up in her wheelchair for all meals. She said she thought the resident would benefit from sitting in the dining area with staff providing cueing and physical assistance with eating. She said she thought the resident's poor intake was related to her not receiving enough assistance during meals. She said the RD had asked her to check on the resident that day, 8/24/21, and encourage the resident to eat. She said she did not have time that day to provide encouragement to the resident. She said the dining area by the nursing station had a staff member present at all times. She said the resident would benefit from sitting in the dining area. She said staff would be able to provide encouragement and physical assistance. Nurse practitioner (NP) #2 was interviewed on 8/26/21 at 12:20 p.m. She said Resident #9 was immobile and was unable to reposition herself without staff assistance. She said she was aware the resident had decreased meal intakes. She said she had not been notified the resident had sustained a significant weight loss of 9.3% in two months. She said it would be beneficial if a staff member would sit with the resident, encourage her to eat and even provide physical assistance. She said Resident #9 was a very slow eater and thought it would help if staff sat and engaged the resident during the meal. She said the facility staff had not approached her regarding the resident's functional level. She said Resident #9 was immobile, which made it hard for her to understand how the resident was independent with eating. She said the resident did not make her needs known and would only answer yes and no questions. She said she felt Resident #9 would benefit from being in a restorative program for eating assistance. She said she felt if the resident had staff assistance with cueing and physical assistance, her meal intake would significantly improve. She said the resident's meal intake and gaining of weight was crucial in the healing of the stage 4 wound to the resident's coccyx and DTI (deep tissue injury) to the left heel. She said wounds were only unavoidable if all interventions and preventative measures had been exhausted. She said she did not think all preventative measures had been completed, including meal assistance and a re-evaluation of the resident's functional needs and felt the wounds were avoidable. The RD was interviewed on 8/25/21 at 11:46 a.m. She said obtaining weights had been a concern for a few months at the facility. She said she had brought up the concern in the morning management meetings, but the weights were still not being obtained. She said it had gotten to the point where it was just her problem and the facility management did not step in to assist. She said the social services director (SSD), who was also a CNA, and the occupational therapist assisted her in obtaining the weights on 8/23/21. She confirmed she was unable to properly monitor resident weights throughout the facility and potential significant weight loss. She said Resident #9 was admitted on [DATE] and she completed her nutritional assessment on 6/16/21. She said the facility staff had not obtained the resident's weight prior to her completing her assessment. She said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed she had not developed a nutritional comprehensive care plan upon the resident's admission to the facility. She said she had developed a nutrition care plan for Resident #9 during the survey process. She said she forgot to develop a nutrition care plan for Resident #9. She said Resident #9 did not have dementia, however would not answer appropriately when asked a question. She said the resident usually just stared at her and would not answer the question. She confirmed the physician had ordered for the resident to be weighed weekly. She said the facility staff had not followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] She said she assessed the resident on 8/10/21 and added a house supplement twice per day and on 8/19/21 added peaches on the top of her cereal to her breakfast preferences. She confirmed Resident #9 had a 9.3% weight loss in two months, which was considered significant. She said she encouraged the resident to eat on 8/24/21. She said Resident #9 was responsive to encouragement. She said she would take a bite of food only when prompted. She said she asked the CNA to continue throughout the meal to encourage the resident. She said she did not know if the CNA assisted the resident. She said the CNAs often did not listen to her when she asked them to do something. She said she felt the facility did not have enough staff and that affected residents like Resident #9 who would benefit from cueing and physical assistance. (cross-reference F725, failed to provide sufficient staffing to ensure residents needs were met) She said Resident #9's assessments indicated she only required set up assistance with eating. She said she had seen the resident on 8/24/21 for lunch. She said she prompted the resident and she would eat. She said she felt Resident #9 would benefit from being cued and even provided hands-on assistance with eating. She said Resident #9's functional status had not been re-evaluated for increased level of assistance. She said she had not discussed with Resident #9's family, coming into the facility during meals to see if that would increase the resident's meal intake. She said she had not put anything in place, other than the house supplement and adding to the resident's preferences on the meal ticket. The regional resource nurse manager (RRNM) was interviewed on 8/26/21 at 1:01 p.m. She said each resident should have their weight obtained upon admission, a nutrition assessment and a nutrition care plan in place. She said the dietician was responsible for the nutritional assessments for all residents and the development of each resident's nutritional care plan. She said each resident with identified weight loss should have interventions implemented in a timely manner, as well as consult the resident and responsible party for additional interventions. She said a root cause analysis should be conducted to determine the cause and beginning of the weight loss. She said the facility had a consistent problem with obtaining resident weights. She said the dietician wanted the weights to be completed on the same day and that was not possible. She said the RD had brought up the concern of weights not being obtained in the management meeting on many occasions. She said they had the lab tech, unit managers and therapy assisting, however the weights were still not being obtained. She said the facility was unable to monitor weight loss and implement interventions timely without resident's weights being obtained. She confirmed Resident #9 had a significant weight loss. She confirmed a nutritional care plan was not developed until the survey process. She said she was unable to determine what interventions had been put into place, other than a house supplement twice per day and peaches to cheerios, when the resident's weight loss had been discovered. She confirmed that facility staff did not weigh the resident weekly according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] D. Follow-up The 8/18/21 nutritional progress note documented that the RD dropped off the resident's lunch tray. Resident #9 was sleeping and the breakfast tray was sitting in front of the resident, untouched. The RD woke up Resident #9, raised the head of the bed and left the room. When the RD returned, the resident had eaten 50% of a peanut butter and jelly sandwich and drank 75% of a glass of whole milk. The 8/19/21 nutritional assessment, during the survey process, documented that the RD met with the resident to discuss wound healing and a nutrition plan. It indicated the resident had a worsened stage 4 pressure injury to the coccyx. Cross reference F686 (pressure injuries). The RD documented that the resident remained on a consistent carbohydrate diet (CCHO) with generally poor intakes. The RD indicated she checked in with the resident during meal times to ensure she was awake and eating. The interventions included liquid protein one time per day, house supplement twice per day, which was generally accepted 50-100% of the time. The RD added Cheerios with peaches on top for breakfast and to liberalize the resident's diet from CCHO to regular to allow for more menu options. The RD documented that the resident's weight loss was related to poor appetite and cognitive decline. The nutritional assessment did not address the lack of consistent documentation of the resident's meal intakes or the failure to obtain weekly weights as was ordered by the physician. Record review revealed the facility failed to evaluate the resident's functional limitations to determine if the resident required encouragement or physical assistance with meals following the RD's observations on two different occasions of the resident with an untouched meal in front of her, hours after it had been served. The weights and vitals documentation indicated Resident #9's weight was obtained on 8/23/21 of 117 lbs. The resident had a significant weight loss of 12 lbs/9.3% in two months. The 8/24/21 nutrition progress note documented that the RD set up the resident's lunch that day. The RD raised the head of the bed and made sure the resident was awake with the tray in front of her. The RD checked in several times after setting up the resident, had to wake her and remind the resident to eat. The RD asked the resident to take a bite and the resident did. The RD asked the CNA to continue to check in on the resident and encourage her to eat. III.Resident #5 A. Resident #5 status Resident #5, age 76, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/2/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of two people with bed mobility, transfers, and toileting. He required extensive assistance of one person with dressing, and personal hygiene. The resident did not reject care. B. Record review A review of the resident's electronic medical record from the time of admission (7/26/21) until the time of discharge (8/15/21) revealed no weights had been taken for the resident. The 8/3/21 Nutritional Assessment, completed by the registered dietitian (RD) revealed the following: Resident has not been weighed since admission. He reports a UBW (usual body weight) around 240 pounds and hospital weight was 252. He denies any recent chnages (sic) in weight. RD has requested weight from (the) nursing staff. C. Staff interview The registered dietitian (RD) was interviewed on 8/19/21 at 3:37 p.m. She said when a resident is first admitted to the facility she wants a weight as close to the date of admission as possible, and then weekly for the first month to establish a baseline weight. She said if the weights for the resident were stable, she would then want monthly weights after that. She said the certified nurse aides (CNAs) were responsible for resident weights, and just getting monthly weights had been a struggle. She attributed the lack of weights to their not having enough CNAs in the building, and those who were working simply having too much to do on a daily basis. She said Resident #5 should have been weighed on admission, and then weekly weights should have been completed for the first month. She said not having weights made it difficult for her to accurately monitor potential weight loss in the facility.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide an adequate number of nursing staff to address the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility failed to: -Provide necessary goods and services to prevent resident neglect (Cross-reference F600G) -Provide necessary care and services to maintain residents' hygiene (Cross-reference F676E) -Provide necessary care and services to prevent and heal residents' pressure injuries (Cross-reference F686J) -Provide necessary care and services to prevent resident significant weight loss (Cross-reference F692G) These failures contributed to Resident #9 experiencing actual harm, as evidenced by declines in the resident's physical well-being, specifically, the development of stage 4 and deep tissue pressure injuries and significant, unplanned weight loss of 9.3% in two months I. Resident census and conditions According to the 8/18/21 Resident Census and Conditions of Residents report, the resident census was 99. The following care needs were as identified: -88 residents needed assistance of one or two staff with bathing and 9 residents were dependent. Two residents were independent. -87 residents needed assistance of one or two staff members for toilet use and 12 residents were independent. -90 residents needed assistance of one or two staff members for dressing and nine residents were independent. -84 residents needed assistance of one or two staff members for transfers and one was dependent. Fourteen residents were independent. -79 residents needed assistance of one or two staff members with eating and 20 residents were independent. II. Staffing requirements for each unit The regional financial advisor (RFA) and staff scheduler (SS) were interviewed on 8/24/21 at 3:34 p.m. and provided the staff requirements for each unit in the facility based on the current census and resident needs. For all of the units in the facility, the licensed nurses worked 12 hour shifts from 6:00 a.m. to 6:00 p.m. The next shift worked 6:00 p.m. to 6:00 a.m. The certified nurse aides (CNAs) worked eight hour shifts from 6:00 a.m. to 2:00 p.m. for day shift and 2:00 p.m. to 10:00 p.m. for the evening shift, and 10:00 p.m. to 6:00 a.m. for the night shift. A. Bear Paw - the census at the time of the survey was 28 residents Day shift: Two licensed nurses (12 hours shift) and three CNAs. Evening shift: Two CNAs. Night shift: Two licensed nurses (12 hours shift) and two CNAs. B. Elk Run - the census at the time of the survey was 34 residents Day shift: Four licensed nurses (12 hours shift) and five CNAs Evening shift: Four CNAs. Night shift: Three licensed nurses (12 hours shift) and three CNAs. C. Solana - the census at the time of the survey was 15 residents Day shift: One licensed nurse (12 hours shift) and one CNA. Evening shift: One CNA. Night shift: One licensed nurse (12 hours shift) and one CNA. D. Deer Creek - the census at the time of the survey was 18 residents Day shift: One licensed nurse (12 hours shift) and two CNAs. Evening shift: Two CNAs. Night shift: One licensed nurse (12 hours shift) and one CNA. III. Working schedule Review of the facility working schedule from 8/16/21 to 8/21/21 revealed, at times, the working schedule did not have licensed nurses or CNAs scheduled according to resident needs and current census and as detailed in the staff requirements for each unit (see above). The regional financial advisor (RFA) and staff scheduler (SS) were interviewed on 8/24/21 at 3:34 p.m. The SS said his first day as the scheduler was 8/23/21, and the RFA had come to the facility on [DATE] to train him on how to correctly schedule the facility. The RFA said the first issue they had identified on 8/24/21 (during the survey), was in regard to the accuracy of the working schedule. -The RFA said the previous scheduler had left staff names on the schedule even if they were not scheduled to work. The RFA said when she looked at the schedule, the staffing ratios looked okay, but when she went to confirm if staff were in the facility working, it was identified they were not and all of the units, except Solana, were short-staffed for all shifts. -The RFA said after reviewing the schedules and comparing them to the actual working staff members, all of the units, except Solana, had half the required number of nursing staff scheduled to work. IV. Effect of working schedule - Cross-reference deficiencies F600G, F686J, F676E, and F692G A. F600G, F686J and F692G The facility failed to ensure Resident #9 was provided the goods and services necessary to maintain her physical well-being. Resident #9 sustained actual harm. Pressure injuries: The facility failed to provide care to prevent the development of a stage 4 pressure injury on the resident's coccyx and a deep tissue injury on her heel after admission. Observations revealed the resident was not turned and repositioned by staff. Interviews revealed the resident laid in the same position on her back much of the day, most days. During continuous observations on 8/24/21 beginning at 10:45 a.m. and ending at 12:30 p.m., Resident #9 was lying in the center of the bed with the head of the bed raised to a 45 degree angle. No pillows or other devices were observed to assist with positioning of the resident. Resident #9's roommate said the facility staff usually only entered their room when Resident #9 required changing. She said Resident #9 laid in bed all day and did not sit in her wheelchair very often. She said Resident #9's current position (lying on her back) was the position she was in on a regular basis. She said she had never seen the facility staff enter the room to reposition Resident #9. At 12:04 p.m. nurse practitioner (NP) #1 exited Resident #9's room and asked RN #4 if she could assist in rolling Resident #9 on her side so she could assess the resident's wound. RN #4 said she did not have time and for NP #1 to push the call light so a CNA would come and assist. NP #1 entered the resident's room and pushed the call light. At 12:07 p.m. Resident #9's roommate exited the room and walked down the hallway looking for a CNA. A CNA was observed walking down the hallway, pushing a mechanical lift. The CNA told Resident #9's roommate that she was busy assisting another resident and told her to go to the front of the facility to look for another CNA to assist Resident #9. At 12:10 p.m. NP #1 asked for and received assistance from an agency nurse. NP #1 was interviewed on 8/24/21 at 12:20 p.m. She said in the past few months she had a difficult time finding staff to assist her in assessing different residents. She said she felt the facility did not have enough staff. CNA #2 was interviewed on 8/24/21 at 2:24 p.m. She confirmed Resident #9 had been in the same position all day. She said she had not had time that day to reposition the resident. She said Resident #9 was usually in the same position all day, on her back with the head of the bed raised to about 45 degrees. She confirmed the resident's position put pressure on the coccyx. She said Resident #9 was unable to use the call light and never called out for help. She said Resident #9 was often forgotten because she did not make her needs known. She said she was really busy with the other residents on the hallway and would often forget to reposition Resident #9. She said it was not uncommon for Resident #9 to remain in the same position throughout the day. Weight loss: The facility failed to provide Resident #9 the care and services necessary to maintain her nutritional status; Resident #9 experienced a significant, unplanned weight loss of 9.3% in 2 months. Staff interviews revealed Resident #9 would benefit from cueing during meals and having staff provide physical assistance. CNA #2 said the registered dietitian (RD) had asked her to check on the resident today (8/24/21) and encourage the resident to eat. However, she said she did not have time today to provide encouragement to the resident. NP #2, who was aware of the resident ' s weight loss, said it would be beneficial if a staff member would sit the resident, encourage her to eat and even provide physical assistance. The RD said she felt the facility did not have enough staff and that affected Resident #9 who would benefit from cueing and physical assistance. Record review also revealed resident weights were not being taken. The RD said CNAs were responsible for resident weights, and just getting monthly weights had been a struggle. She attributed the lack of weights to their not having enough CNAs in the building, and those who were working simply having too much to do on a daily basis. See F600, F686 and F692 for detailed findings on the facility's failures. B. F676E The facility failed to ensure Residents #9, #19, #1, #20, #21, #22, #3 and #4 received regular bathing in accordance with their plan of care. Record review revealed all eight residents failed to receive baths in July and August as planned. Licensed practical nurses (LPN) #6 was interviewed on 8/18/21 at 10:25 a.m. She said she was the day shift nurse on the secure unit (Solona). She said she frequently did not have a day shift CNA on the unit, so she was frequently by herself with all 15 residents. She said when that happened, resident showers were not completed, and at best, she was able to complete just the basic resident cares. CNA #1 was interviewed on 8/18/21 at 11:00 a.m. She said she frequently worked short on every unit she worked on. She said the facility had a shower aide and that helped the CNAs get everything done during their shift, but about two weeks ago, the shower aide was moved to the staff scheduler role. The CNA said showers became the responsibility of the CNAs again. The CNA said showers were not consistently happening in the facility because there was not enough staff or time to complete them. The CNA said all of the residents had been eating in their rooms since the beginning of August. The CNA said between passing all the drinks, room trays, and trying to provide meal assistance, the CNAs were lucky to provide basic care to the residents. The assistant director of nursing (ADON) said showers had improved in the building a few months ago when the facility had a shower aide whose sole responsibility was to provide showers. She said about a month ago the staff was very short in the building and the shower aide was pulled to the floor as a CNA, and then was hired as the staff scheduler. She said during that month when shower aide was pulled to the floor, and then ultimately hired as the staff scheduler, showers in the facility were not occurring as they should, and residents were lucky to get one shower a week. Resident #1 was interviewed on 8/19/21 at 1:15 p.m. She said she used to be on hospice, and got a shower at least twice a week from her hospice aide. She said she had graduated from hospice, and was no longer being seen by them, so she was provided a shower one time a week, at best, and usually after she had asked the CNAs several times. IV. Additional resident and staff interviews confirmed the facility failed to have an adequate number of staff to meet the residents' needs. LPN #1 was interviewed on 8/18/21 at 10:40 a.m. She said the building was always short of nursing staff. She said it was difficult to get the basic resident care done when there was typically one CNA for 17 to 20 residents. The LPN said the staff in the facility had reported the staffing concerns to management, but nothing ever changed. Registered nurse (RN) #5 was interviewed on 8/18/21 at 10:47 a.m. She said staffing in the building was consistently short. She said the schedule was very inaccurate, and she never knew who was going to show up to work. She said management had been made aware of the continued staffing concerns, but there was consistent turnover in management so nothing seemed to change. The RN said the CNAs and nurses were doing their best to ensure the residents basic needs were met, but things like showers, consistent meal assistance, and consistent repositioning were difficult when there were one or two staff for 34 residents. ADON #2 was interviewed on 8/19/21 at 9:45 a.m. She said the staffing in the facility had been a consistent problem since she had started in February of 2021. She said she and other nursing managers had repeatedly told the facility corporate consultants of the staffing needs and concerns and nothing had changed. She said the basics were being completed for most residents, but if a resident was dependent and quiet, they would simply fall through the cracks, like what happened with Resident #9. The ADON said Resident #9 did not use her call light or call out for help, so she was often just forgotten in her room. Resident #30 was interviewed on 8/25/21 at 12:50 p.m. She said there was a long wait for staff to provide care, and at times she had to wait up to an hour before staff would come and assist her. She said she felt bad for the CNAs who had 30 residents to care for. Resident #26 was interviewed on 8/25/21 at 12:55 p.m. She said it took staff a long time to answer call lights, so she typically would yell down the hallway for staff assistance. She said her roommate needed more help than she did, and she was unable to call for help. She said it made her feel like no one cared about them. Resident #34 was interviewed on 8/25/21 at 1:07 p.m. She said her care needs were not always met, and it seemed like the staff called off a lot so there were not enough of them in the building for all of the residents. She said she was scared no one would come and care for her when she needed them, and that was a horrible feeling. Resident #32 was interviewed on 8/25/21 at 1:13 p.m. She said the facility needed more help, and it was terrible in the facility. She said she was more independent than other residents so she tried to help the other residents who needed more help as much as possible. Resident #31 was interviewed on 8/25/21 at 1:18 p.m. She said the only time there was enough staff in the facility was when the surveyors were in the building. She said it was bothersome, and she felt like she was just a number. V. Follow-up See above; during the interview with the regional financial advisor (RFA) and staff scheduler (SS) on 8/24/21 at 3:34 p.m., they said they had been comparing employees' timesheets with the current schedules and they were not matching up. -The RFA said when that was identified, she told the facility they needed to stop using the daily schedules since they were inaccurate. The RFA said moving forward, the facility would be utilizing a master pattern schedule which would include every nurse staff member's schedule for the month, and using that pattern, the scheduler would be able to identify when there was an open shift that needed to be filled. -The RFA said the facility had been using agency nursing staff and would continue to do so until their staffing needs had improved. The nursing home administrator (NHA) was interviewed on 8/24/21 at 5:00 p.m. He said the facility had put an admission hold in place since the beginning of August 2021, and would continue the admission hold until staffing had improved in the facility.

Based on record review and interviews, the facility failed to ensure the resident environment was kept as free from accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for one (#3) out of five sample residents. The facility failed to prevent two recent falls for Resident #3. One fall resulted in a [CONDITION(S)], and the second resulted in a left femur fracture which required hospitalization , surgical repair, and caused the resident pain (see record review, II under section B). Nursing standards of practice were not followed as Resident #3 was not assessed by a registered nurse as required prior to being moved and post fall procedures of neurological checks. Furthermore, fall prevention interventions were not consistently implemeted and the resident's fall risk was not identified properly after each fall. Findings include: I. Facility policy and procedure The Falls Management policy, revised 2/18/2020, was provided by the director of nursing (DON) on 4/16/21 at 1:35 p.m. It read, in pertinent part: Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. -Identify the patient's fall risk -Communicate the patient's fall risk status to caregivers -Develop individualized plan of care -Review and revise the care plan regularly -If a patient falls: Follow the'guidelines for managing a fall' if staff member is present when the fall occurs Utilize the 'all response protocol' for both witnessed and unwitnessed falls Perform neurological evaluations for all unwitnessed falls and witnessed falls with injury to the head or face Document the accident/incident 1. As a new event in risk management system 2. On a change of condition note 3. On the 24 hour report 4. Investigation using the fall investigation questions in the risk management system Update the care plan to reflect new interventions Conduct an interdisciplinary team meeting within 72 hours of the fall The center executive director and center nurse executive will conduct a post fall review. II. Resident #3 A. Resident status Resident #3, age 80, was admitted on [DATE]. According to the April 2021 computerized physician orders (CPO), the diagnoses included acute and chronic [CONDITION(S)] with [CONDITION(S)], hypertensive [CONDITION(S)] with heart failure, [CONDITION(S)] [CONDITION(S)], chronic systolic heart failure, [CONDITION(S)] (chronic obstructive pulmonary disease), difficulty walking, displaced intertrochanteric fracture of left femur, dysphagia (difficulty swallowing), depressive disorder, post traumatic stress disorder, metabolic [CONDITION(S)] and [CONDITION(S)] with behavioral disturbance. The 4/5/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of three out of 15. He required extensive assistance of two staff members with transfers and mobility activities of daily living (ADLs). He exhibited shortness of breath upon exertion and received supplemental oxygen. The resident had one fall with major injury since the prior assessment. B. Record review A risk management report, dated 3/14/21, revealed Resident #3 suffered a fall in his room at 9:30 p.m. He was discovered by a licensed practical nurse (LPN). The description of the event read, Unassisted ambulation in room. fell to the floor causing small laceration to head. Administered first aid, began neuro (neurological) checks, WNL (within normal limits), notified RN (registered nurse) supervisor. The investigation portion of the report revealed immediate interventions added would include: increased supervision, resident education on safety, encouragement to use call light for assistance, and return demonstration of use of the call light. The resident was wearing slippers at the time of the fall. -There was no record or documentation of the resident being assessed by an RN after the fall. -Review of the resident's record revealed no documentation of neurological evaluations completed for the fall on 3/14/21. -The resident fall risk assessment completed on 3/14/21 indicated the resident was not at risk for falls. -There was no nursing note in the record related to the fall on 3/14/21. The nurses documented change of condition follow up notes from 3/15/21 to 3/17/21. The resident's fall risk care plan was initiated on 7/7/2020 and revised on 12/30/2020, and read, The resident was at risk for falls for impaired mobility and assistance for mobility.(sic). The goal for the care plan was revised on 3/8/21 and read, Resident will have no falls with injury for 90 days. Interventions included: Medication evaluation as needed, initiated 5/31/2020, Place call light within reach while in bed or close proximity to the bed, initiated 5/31/2020, Increase rounding, staff to anticipate all needs, initiated 3/18/21; Personal items within reach initiated 3/18/21; Therapy evaluation as needed, initiated 3/18/21. The resident's fall risk assessment, completed on 3/24/21, indicated the resident was not at risk for falls. A risk management report on 3/25/21 revealed Resident #3 suffered a fall in his room at 1:50 a.m. He was discovered by an LPN. The description of the event read, Loud noise and a yell heard from resident's room at 1:50 this morning. Upon entering room with 2 CNAs (certified nurse aides) resident was found laying on the floor on his left side beside his closet. His bottom drawer was open and resident stated he was looking for something and fell . No visible injuries noted. No new bruises or abrasions to skin. He denies headache or hitting his head. Vitals WNL (within normal limits). Neurochecks WNL with the exception of resident not being able to move left lower extremity. Staff was able to lift resident and get him back in bed without difficulty. However; any movement caused resident to yell out in pain. He states his left hip is hurting. [MEDICATION(S)] and Tylenol was given per MD (medical doctor) order and RN was notified. This nurse then called on call for MD and spoke with PA (physician assistant). Verbal order received to send resident to ER (emergency room ). The investigation portion of the report revealed corrective actions of: Change of condition initiated, was receiving intravenous fluids and PT (physical therapy)/OT (occupational therapy), repeated lab work, more frequent rounding, bed in the lowest position, non-skid socks, and frequent reminders to wait for assistance. -There was no documentation of the resident receiving more frequent rounding, non-skid socks, or frequent reminders to use the call light and no interventions were added to the care plan. -There was no record or documentation of the resident being assessed by an RN after the fall. Resident #3 was admitted to the hospital for a left femur fracture with surgical repair. He was readmitted to the facility on [DATE]. -The resident's fall care plan had no revisions or interventions added for the fall on 3/25/21. -The resident's kardex as of 4/15/21 had no fall prevention directions. III. Interviews LPN #2 was interviewed on 4/15/21 at 10:34 a.m. She stated when a resident fell , the LPN should call the RN in the building immediately to assess the resident. She stated the RN would assess for injury and the resident should not be moved until an RN assessed. She stated if the fall was unwitnessed or if there was head involvement, the nurse should do neurological checks immediately and for three days after the fall to ensure there was no head injury and change of condition monitoring should also be documented every shift for 72 hours after the fall. She stated a risk management should be completed by the nurse and updates should be made to the resident's care plan to show the interventions to prevent further falls. RN #1 was interviewed on 4/15/21 at 10:47 a.m. She stated when a resident fell , the LPN had to call the RN to assess the resident for injury and neurological symptoms. She stated the resident should not be moved before the assessment was complete. She stated the neurological assessments should be completed and documented according to the schedule for three days. She stated a risk management and change of condition should be completed and the resident's care plan should be updated with new interventions each time the resident fell . The DON was interviewed on 4/16/21 at 11:50 a.m. She stated if a resident fell , and an LPN or other staff member found the resident, an RN needed to be called to assess the resident for injury. She stated the resident should not be moved until the RN had assessed the resident. She stated a fall risk assessment should be done, though she was unsure what assessment the facility used. She stated neurological assessments should be completed according to the schedule and there should be documentation of the neurological checks being completed. She stated the risk management reports for Resident #3's falls indicated the staff did not follow fall protocols, standards of practice or facility policy.

Based on observation, record review and interviews, the facility failed to provide care and treatment to prevent the development and worsening of pressure injuries for three (#18, #336, #54) of four residents reviewed for pressure injuries out of 53 sample residents. Specifically, the facility failed to: - Ensure Residents #18 and #336 pressure injury areas were positioned for offloading of their pressure injury areas. Residents #18 and #336 were regularly observed positioned on the pressure injury areas. - Ensure the turning and positioning care plan was consistently followed for Resident #18. - Address inconsistent use of pressure relieving devices in the facility and at the [MEDICAL TREATMENT] center in order to prevent recurring pressure injuries for Resident #18. - Develop and communicate pressure injury care plan approaches for Resident #336, who was admitted with a stage III pressure injury. - Obtain orders and provide treatment to promote the healing of a stage III pressure injury for Resident #336. -Prevent shear injuries for Resident #54. The facility's failures contributed to Resident #18's development of two avoidable stage III pressure injuries. The facility's failures created a 12 day delay in promoting the healing of Resident #336's painful stage III pressure injury. Findings include: I. Facility policy The Skin Integrity Management policy, dated 7/1/19, was received from the nursing home administrator (NHA) on 9/25/19 at 3:56 p.m. The policy read in pertinent part, Document daily monitoring of ulcer site, with or without dressing, implement pressure ulcer prevention for identified risk factors, choose products per wound treatment guidelines, determine the need for support surfaces for bed or chair. The policy included a Pressure Ulcer Support Algorithm. The algorithm guidelines directed staff to use a Dermafloat/[MEDICATION NAME] mattress (low air loss mattress used for wound healing and pain management) for stage III wounds. II. Resident #18 [NAME] Resident status Resident #18, age 86, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/18/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He did not exhibit behaviors of concern and did not reject care during the assessment period. The resident required extensive one-person assistance for bed mobility and hygiene and two-person assistance for transferring and toileting. He required a wheelchair for locomotion. He was frequently incontinent of bladder and always incontinent of bowel. The resident was at risk of developing pressure ulcers but did not have any at the time of the assessment. The resident required pressure reducing devices for his bed and chair to reduce the risk of developing a pressure ulcer. B. Family interview A member of the resident's family was interviewed on 9/25/19 at 12:57 p.m. The family member was concerned because the resident's low pressure mattress was removed from his bed after a previous wound had healed, causing the resident to develop another wound. C. Observations The resident was observed on 9/23/19 at 5:15 p.m., seated in a reclined position on his back on the bed in his room. He was in a position to potentially have pressure on his coccyx. A pressure reducing mattress was on his bed and there was a pressure reducing cushion on his chair. The resident was observed on 9/24/19 at 8:35 a.m., 10:22 a.m., 1:15 p.m., 3:25 p.m. 5:18 p.m. and 6:05 p.m., seated in a reclined position on his back on the bed in his room. He was in a position to potentially have pressure on his coccyx. The resident's wounds was observed on 9/25/19 at 1:02 p.m. - A wound on his coccyx, described as beefy red and moist with no odor or drainage, measured 2cm long x 0.5 cm wide x 0.1 cm deep. - A second wound, described as beefy red and moist with no odor or drainage, measured 1.5 cm long x 0.6 cm wide x 0.1 cm deep. The wounds were being treated with [MEDICATION NAME]. During the observation, licensed practical nurse (LPN) #1 said she thought the resident's wounds worsened because he did not have his wheelchair cushion at [MEDICAL TREATMENT]. D. Record review Care plans The care plan for pressure wounds, initiated 2/7/19 and revised on 9/24/19 after the survey entrance, identified the resident had a stage II pressure wound to his coccyx that resolved on 8/19/19. The care plan later identified the resident developed two stage III pressure wounds in his coccyx area on 9/19/19. Interventions included low loss air mattress to bed, initiated 7/29/19; preventative skin care such as lotions and barrier creams as ordered; provide wound treatment as ordered; reposition every two hours as resident allows, at times resident will turn on back to watch TV; reposition while in bed or in a wheelchair as needed and resident allows; tilt-in-space wheelchair with jay fusion cushion for positioning and pressure relief, initiated 6/20/19 and revised 9/24/19; weekly skin assessment by licensed nurse; weekly wound assessment to include measurements and description of wound status; and, wound related pain management interventions. The care plan for [MEDICAL TREATMENT], initiated 4/23/19, identified the resident received [MEDICAL TREATMENT] three times each week. Approaches included, in pertinent part, [MEDICAL TREATMENT] center required the resident to be sent with a sling for mechanical lift transfers (initiated 7/30/19) and an equagel cushion in the [MEDICAL TREATMENT] chair (initiated 9/24/19, after survey entrance). A behavior care plan, initiated 7/29/19 and revised on 9/24/19, identified the resident was sometimes resistive to care on the days he attended [MEDICAL TREATMENT]. The resident often refused to lay down when he returned from [MEDICAL TREATMENT] and sometimes refused to see the wound doctor. Interventions included observe for pain, using non-pharmacological interventions to alleviate pain, turn and reposition; postpone care and allow the resident time to regain composure, attempt at a later time. A review of care plans and progress notes failed to reveal the facility attempted to find an alternative to the resident reclining on his back in order to watch television. Physician orders The (MONTH) 2019 CPO included orders to apply [MEDICATION NAME] 2x2 wound dressing pads to left buttock every night for wound care; clean wound with wound spray and cover wound with [MEDICATION NAME] 2x2 and cover with foam dressing, order date 9/24/19. The CPO also included orders to use a Jay fusion cushion in the resident's tilt-in-space wheelchair, order date 9/24/19. Progress notes 8/9/19 care plan meeting notes read algorithms, protocols, rules and recommendations indicated residents should be turned every two hours and Airbeds should be changed to Promat to reduce fall risk. the note documented the facility planned to keep the resident on an air mattress once his wound resolved per the family's request. The note also documented the facility communicated with the [MEDICAL TREATMENT] center to leave his special cushion under him during treatment. The center requested the facility leave the resident seated on a sling so he could transfer to a [MEDICAL TREATMENT] chair. An 8/20/19 nurse's note documented wound rounds were completed with the wound doctor. The resident's wound was resolved and the plan was to continue to provide preventative measures. An 8/28/19 nurse's note revealed the resident's wound reopened during the night on 8/27/19. An 8/30/19 nurse's note documented the wound was slowly responding to treatment and was slightly smaller. Progress notes completed between 8/31/19 and 9/12/19 did not mention the resolution of this wound. A 9/15/19 nurse's note documented the resident had an unplanned transfer to the hospital on [DATE]. Upon his return on 9/15/19 his skin was described as free from redness, maceration or breakdown. A change of condition note documented the resident had a skin wound or ulcer beginning on the morning of 9/19/19. A 9/20/19 nurse's note documented rejection of care or behaviors of concern had not occurred in at least the last 30 days. A 9/21/19 nurse's note indicated the wound was not healing. A 9/23/19 nurse's note described the wounds as larger, measuring 1.5cm and 1 cm respectively. A 9/24/19 nurse's note described the wounds as larger still, measuring 2.2 cm and 1 cm respectively. The note also indicated the resident was developing an open area on the left side of his coccyx. The resident was strongly encouraged to have no pressure on his coccyx while in bed. Progress notes completed between 8/1/19 and 9/25/19 failed to reveal the resident exhibited behaviors of concern or rejected care. Wound/Skin assessments A 9/5/19 skin assessment revealed no skin injury/wounds were noted. An 8/29/19 skin assessment documented a wound on the resident's coccyx. An 8/22/19 skin assessment revealed no skin injury/wounds were noted. 8/8/19 and 8/15/19 skin assessments documented a wound on the resident's coccyx. An 8/1/19 skin assessment documented moisture associated skin damage to the resident's coccyx. A 7/25/19 skin assessment documented a stage II wound to the right gluteal fold. 7/11/19 and 7/19/19 skin assessment documented a wound to the resident's coccyx. A 7/4/19 skin assessment revealed the resident had opened areas on his coccyx and heel that had healed, leaving vulnerable scar tissue. A 6/20/19 skin assessment revealed no skin injury/wounds were noted. Skin integrity reports revealed the resident had a stage III pressure ulcer to his coccyx between 5/13/19 (initial date) and 8/20/19 (healed). There were no reports completed between 8/29/19 and 9/5/19. A 9/19/19 skin integrity report documented the resident had a pinpoint skin breakdown on his coccyx measuring 0.1cm long x 0.1cm wide x 0.1cm deep. A 9/24/19 skin integrity report documented the resident had a coccyx wound (no stage provided) with 100% granulation measuring 2.0 cm long x 1.5 cm wide x 0.1 cm deep. Care documentation Certified nurse aide (CNA) documentation of care failed to reveal the resident was repositioned between between 5 a.m. and 11 p.m. on 9/7/19 and between 5 a.m. and 11 p.m. on 9/8/19 and between 5.a.m. and 5 p.m. on 9/12/19, all non-[MEDICAL TREATMENT] days. Documentation of care did not include a record of repositioning between 9/13/19 and 9/25/19. CNA documentation of care failed to reveal the resident was repositioned between 5 a.m. and 11 p.m. on 8/4/19, between 5 a.m. and 11 p.m. on 8/18/19, between 5 a.m. and 3 p.m. on 8/25/19, and between 1 p.m. and 11:00 p.m. on 8/29/19, all non-[MEDICAL TREATMENT] days. The resident was scheduled for [MEDICAL TREATMENT] but was not repositioned between 1 p.m. and 11 p.m. on 8/26/19. E. Staff interviews CNA#1 was interviewed on 9/25/19 at 6:30 p.m. The CNA said the resident had recurring wounds. She said he used a seat cushion and an airbed to help prevent wounds. She said she thought the resident had the same mattress since the end of (MONTH) 2019. She said staff were supposed to reposition the resident every two hours because he was unable to do so himself. She said he spent a lot of time in bed and did not always cooperate with staying off his back. Unit manager (UM) #2, who was also a registered nurse, was interviewed on 9/25/19 at 6:40 p.m. The UM said the resident's wound recurred on 9/19/19. She said it started as a pinpoint but had become bigger. The UM said the resident had a new cushion and a new wheelchair. She said he had a previous chair with a different cushion that was sent to [MEDICAL TREATMENT]. The UM said the resident used a low air loss mattress until his previous wound was healed. She said the low loss air mattress was removed and the wound returned. The UM said the resident should be repositioned throughout the day in order to relieve pressure. She said she was not aware of the resident refusing care. The director of nursing (DON) and the nursing home administrator were interviewed on 9/25/19 at 7:08 p.m. The DON and NHA said the resident's low loss air mattress was removed when his wound healed in order to follow corporate algorithms. The NHA said the resident was at high risk for falling and continued use of the low air loss mattress would increase his risk for falling. The NHA said, after the resident had additional skin breakdown, the low loss air mattress was returned to the resident's bed and would not be removed in the future. The DON said the resident just received a new tilt-in-space chair but the center insisted on having a sling to transfer the resident to their own chair to receive [MEDICAL TREATMENT]. The DON said the resident remained seated on the sling during [MEDICAL TREATMENT] and then was moved back to his chair. The DON said she believed this contributed to his new wounds. The DON also said there were times when the resident returned to the facility carrying the wheelchair gel cushion in his hands. The NHA and DON said the facility talked to the [MEDICAL TREATMENT] center about leaving the resident in his chair so he would not need to transfer to the [MEDICAL TREATMENT] chair and would not need to be seated on the sling but they had not asked the resident's physician, the wound doctor or the facility's medical director to address the issue with the center when the concern was not resolved. III. Resident # 336 [NAME] Resident status Resident #336, age 71, was admitted on [DATE]. According to the physician's history and physical dated 9/18/19, [DIAGNOSES REDACTED]. The 9/19/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. He required supervision for bed mobility, transfers, dressing and eating. He required extensive assistance with toileting and bathing. He was frequently incontinent of bowel and occasionally incontinent of urine. He was on hospice care. The MDS documented he was not on a scheduled pain regime program and there were no non- pharmacological interventions used for pain. He had a stage III pressure injury and had a pressure relieving device to the bed and chair. The MDS documented he pressure injury care was in place. B. Resident interviews and observations Resident #336 was laying in bed, on his back, with his eyes closed on 9/22/19 at 9:08 a.m. This would have caused increased pressure to the sacral bone area. He was not on an air mattress. Resident #336 was interviewed on 9/23/19 at 11:00 a.m. He said he had a wound on his backside that was very painful. Resident #336 was laying in bed, on his back, with his eyes closed on 9/23/19 at 11:07 a.m. This would have caused increased pressure to the sacral bone area. He was not on an air mattress. The residents wound was observed with RN #2 on 9/24/19 at 10:37. The wound was in the sacral bone area. It was approximately 2 cm long by 1 cm wide. It was approximately 0.1 to 0.2cm deep. The entire right side of the wound was filled with yellow slough (dead tissue). There did not appear to be any drainage on his sheets from the wound. There was no dressing covering the wound. There was no odor and the edges were free of redness or maceration. The resident was interviewed again on 9/25/19 at 10:25 a.m. He said they began treating his wound . He said it was still uncomfortable, but the pain has improved with the mattress cover his family brought in. He further said he had not refused any treatment to the wound previously. C. Record review The (MONTH) 2019 physician orders [REDACTED]. There were no orders to treat a stage III wound to the sacral area. There were no discontinued orders to treat the wound to the sacral area. A physician's note dated 9/18/19 documented the wound was being treated with Santyl(ointment used to remove dead tissue from a wound). The note further documented the resident was getting around with his four wheel walker in his room and is happier now. The resident was sitting up watching TV. There were no orders for Santyl on the CPO or treatment administration record (TAR). The nurses notes and TAR were reviewed. There was no documentation that the resident refused to have the wound treated. A nurses note on 9/20/19 at 5:41 p.m. documented the residents bony prominences appear free from redness, maceration or breakdown. The note documented a bruise to the abdomen and coccyx. There was no description of a wound to the sacral bone area or description of the bruising. A nurses note on 9/23/19 at 4:12 p.m. documented the residents bony prominences appear free from redness, maceration or breakdown. The note documented a bruise to the abdomen and coccyx. There was no description of a wound to the sacral bone area or description of the bruising. The resident's care plan was reviewed on 9/25/19. There was no care plan for the stage III pressure injury to the sacral area (cross reference F-656 comprehensive care plans). A handwritten document titled Skin Integrity Report was received from the nursing home administrator (NHA) on 9/25/19 at 5:00 p.m. The document described a wound to the sacral area stage two to three on 9/12/19, 9/19/19, and 9/25/19. On 9/12/19 the wound measured 2 cm (centimeters) long by 1 cm wide. The depth was not documented. On 9/19/19 the wound had the same measurements, and the depth was 0.2 cm. On 9/25/19 the measurements were approximately the same, the width was 0.8 cm. The form documented the residents pain medications were effective on 9/19/19. The nurses notes were reviewed. There was no daily documentation of the wound per the facility's policy. D. Staff Interviews Registered nurse (RN) #2 was interviewed on 9/24/19 at 10:37 a.m. She said she reviewed the physician's orders [REDACTED]. RN #2 said he was not on an air mattress but he should be. The hospice nurse was interviewed on 9/24/19 at 10:19 a.m. She said the resident would not let her look at his wound last week when she was here. She said she was writing orders for the wound today. She further said she did not know if he should be on an air mattress because he is a high fall risk and could slide off. She said they would have to look at the cost versus benefit for an air mattress. The assistant director of nursing (ADON) was interviewed on 9/25/19 at 11:48 a.m. She said the resident had refused treatment when he first admitted because he was in too much pain. The ADON reviewed the nurses notes and was unable to find documentation that indicated the resident had refused treatment due to pain. She further said the physicians note on 9/18/19 must have been an error because she could not locate orders for Santyl for the wound. The director of nursing (DON) was interviewed on 9/25/19 at 11:51 a.m. She said the resident should have had a care plan for the wound within 24 hours of his admission. She said Resident # 336 did not have a care plan until 9/24/19. The DON said she was told they had not treated the wound because the resident was in pain and had refused treatment. She further said that was why there were no current or discontinued orders for treatment on the computerized physician orders. She reviewed the nurses notes and could not locate documentation that indicated the resident had refused treatment, or that treatment had been ordered and discontinued due to refusal. E. Facility follow up The facility obtained orders to treat the wound on 9/24/19, twelve days after admission. The orders were for [MEDICATION NAME] and Kerrafoam dressing, change every three to four days and as needed for excessive drainage or the dressing is not attached. IV. Resident #54 [NAME] Resident status Resident #54, age above 90, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/24/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. He required extensive two person assistance with transfers and bed mobility. He was incontinent of bowel and bladder and had moisture associated skin damage. He required a wheelchair for mobility. B. Observation On 9/24/19 at 4:45 p.m. Resident #54's lower right buttock was observed as a round wound, with a shallow crater, red moist center, and approximately 1.5 centimeters (cm) in diameter. There was no dressing observed on the wound. On 9/25/19 at 6:25 p.m. the wound was observed with unit manager (UM) #1 and licensed practical nurse (LPN) #1. The wound center was filled with yellow slough. The left buttock wound was closed, but still had pink fragile skin. UM #1 and LPN #1 slid the resident into position and failed to prevent friction when the resident was transferred into bed. C. Record review The activities of daily living (ADLs) care plan, revised 8/7/19, identified the resident required assistance to complete tasks due to impaired mobility. Interventions included provide the resident with extensive assist of two people for bed mobility, and provide extensive assistance for toileting. The care plan for skin care, revised 8/7/19, identified the resident was at risk for skin breakdown and had actual skin breakdown on his left great toenail. Interventions included apply barrier cream with each cleansing, assist resident with turning and repositioning to reduce friction and shear, observe skin for signs and symptoms of skin breakdown, pressure redistribution surface to bed as per guideline, and provide wound treatment as ordered. The skin integrity form was provided by the corporate nurse consultant (CNC) on 9/25/19. It revealed the following shear measurements: -On 9/6/19, measurements were 0.75 cm long, 0.5 cm wide, and less than 0.1 cm deep; -On 9/13/19, measurements were 1 cm long, 0.5 cm wide, and less than 0.1cm deep. It had 100% granulation. -On 9/20/19, measurements and granulation were the same as 9/13/19. -On 9/25/19, measurements were 1 cm long, 0.5 cm wide, and 0.1 cm deep. It had 90% slough and 10% granulation. The electronic medical records revealed the resident had a shear to his left buttock, however, observations revealed the left buttock was healed and pink The shear wound was located on the residents right buttock (see above). D. Interviews LPN #1 and UM #1 were interviewed on 9/25/19 at 6:25 p.m They said they did not know what precautions were in place to prevent the shear from worsening and said they should have used a draw sheet on his bed to help with bed mobility so his transfers did not cause additional friction to the wound area. The director of nursing (DON) was interviewed on 9/25/19 at 12:20 p.m. she said she did wound rounds with LPN #1 to review each resident. She said did not remember when she last reviewed the shear wound on Resident #54. The DON was interviewed again on 9/25/19 at 6:31 p.m. She said the resident required two people to reposition him to prevent friction on the shear. She said once the wound was identified on the resident there should have been an air mattress ordered for pressure reduction for Resident #54. She also confirmed the resident's wound was located on his right buttock and the left side was healed, and said the nursing notes and orders recorded the incorrect location.

Based on interviews and record review, the facility failed to have sufficient staff with the appropriate competencies on unit 2 (Elk Run) to ensure the residents attained and maintained their highest practicable physical, mental and psychosocial well-being, given their need for services. (Cross-reference F600, F686, and F838) This deficiency was cited previously during a complaint survey 12/21/18. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance and the scope and severity of the deficiency has increased to a level of immediate jeopardy for serious harm. Multiple licensed staff reported that on unit 2, there were too few staff, too many residents with too many care needs, and too short a time to complete resident care when certified nurse aide (CNA) staffing fell from a ratio of one staff to six residents (1:6) on day and evening shifts to 1:17 with three CNAs on duty and 1:24 with two CNAs on duty. Review of staffing records revealed this occurred 21 of 28 days in (MONTH) 2019 and 11 days in (MONTH) 2019 (through 3/21/19). Staffing levels on unit 2 in (MONTH) contributed to serious resident harm and the facility's continued failure in (MONTH) to provide sufficient staffing on the unit made it likely serious harm would continue if staffing levels on unit 2 were not immediately corrected. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Multiple licensed staff reported that on unit 2, there were too few staff, too many residents with too many care needs, and too short a time to complete resident care when certified nurse aide (CNA) staffing fell from a ratio of one staff to six residents (1:6) on day and evening shifts to 1:17 with three CNAs on duty and 1:24 with two CNAs on duty. Review of staffing records revealed this occurred 21 of 28 days in (MONTH) 2019 and 11 days in (MONTH) 2019 (through 3/21/19). In February, cares were delayed or skipped for Resident #3 who was not able to ask for help or tell staff what she needed. Resident #3, admitted to the facility 12/7/18, was severely cognitively impaired, dependent, incontinent and resistive to care. She was admitted to the hospital 2/12/19 with substantial pressure injuries on her heels and calves and tremendous breakdown on her sacrum. Her wounds smelled foul, her bandages were soiled, her mouth covered in oral thrush and her lips cracked and dry from dehydration. Resident #3's roommate throughout her stay at the facility reported to police that staff needed help to turn and care for Resident #3 and would just leave her in bed when the help was unavailable. The roommate said staff never brushed the resident's teeth and she laid in bed all day, not drinking and not eating. A former nurse of the facility made a statement to police that the facility had neglected the resident due to a staffing shortage. (Cross-reference F600 and F686) In March, cares continued to be delayed or skipped. Resident #2 entered the facility without pressure injuries. Although nurses' notes repeatedly referenced to advise/assist the resident with repositioning, the resident, who required such assistance per facility assessment, stated staff neither came in to help turn or reposition him nor told him to reposition. Staff was unable to locate documentation to show the resident was turned and repositioned. One staff was unaware the resident required such assistance. On 3/18/19, the resident was discovered with a pressure injury, stage 3, on his lower back and on 3/23/19, was discovered with pressure injuries on his ankles bilaterally. According to the director of nursing (DON) pressure injuries were not being tracked by the facility until 3/19/19. (Cross-reference F686) A potentially outdated and incomplete facility assessment to determine staff assignments as well as staff training, education and competencies, coupled with a 3/22/19 Census and Condition report on the service needs of the 51 residents residing on unit 2 that showed all 51 residents requiring some level of staff assistance with ADLs, made it likely serious injury would occur if staffing levels on unit 2 were not immediately corrected. B. Facility notice of Immediate Jeopardy On 3/22/19 at 1:47 p.m. facility staff, including the nursing home administrator (NHA), the director of nursing (DON), the clinical quality specialist (CQS) and the regional executive director (RED) were informed of findings of Immediate Jeopardy under F725, Sufficient Nursing Staff. C. Facility plan to remove Immediate Jeopardy On 3/22/19 at 10:50 a.m., the NHA provided the following plan to remove Immediate Jeopardy. The plan read: 1. Action: On 3/22/2019, Center Nurse Executive (CNE) and Center Executive Director (CED) began the process of auditing the level of care for all residents. The CNE and CED reviewed and updated the staffing for the weekend and have ensured appropriate staffing levels have been secured through 3/26/2019. This process will continue and will be ongoing with continuous evaluation based on level of care and needs of the residents. Completion date: 3/22/2019 Responsible: CED/CNE 2. Action: On (MONTH) 22, 2019, CNE/Unit Managers began the process of reviewing the level of residents' care, needs, and level of assistance based on nursing assessment and interviews conducted with direct care staff. Staff assignments have been re-evaluated and adjustments were made. The staff assignments have been adjusted based on work load and acuity not based on the structure of the building. This process will continue and will be ongoing with continuous evaluation based on level of care and needs of the residents. Completion date: 3\22\2019 Responsible: CNE/Unit Manager/Designee 3. Action: On (MONTH) 22, 2019, the CED stopped new resident admissions to the center and will re-evaluate decision based on staffing levels, resident care and needs. Interdisciplinary meeting to review staffing levels in order to meet resident care needs will be held prior to lifting admission hold. Completion Date: On-going - Admissions stopped on 3/22/19 Responsible- CED/CNE/Interdisciplinary Team 4. Action: On 3\22\2019, CED, CNE, Scheduler and/or designee will review staffing each shift to ensure that staffing is adequately meeting current and any changes in level of resident care needs. Completion Date: On-going Responsible-CED/CNE/Scheduler/Designee 5. Action: On (MONTH) 22, 2019, CNE/Unit Manager/Designee initiated education with direct care nursing staff related to assignment changes as a result of current review of residents' needs, documentation related to all areas of ADL care including oral care, toileting, pressure ulcer prevention, turning and repositioning, hydration, meal/snack offering. Direct care staff will not provide any care to residents until education has been completed. Completion date: On-going Responsible: CNE/Unit Manager/Designee 6. Action: On (MONTH) 22, 2019, CNE/Nursing Manager/Designee initiated the process to audit and revise residents care plans and ensure Kardex are updated to indicate current residents' needs based on the resident assessment, record, review and interviews with direct care staff. Completion Date: (MONTH) 26, 2019 Responsible: CNE/Unit Manager/Designee 7. Action: On (MONTH) 22 2019, CNE/Nurse Manager/Designee initiated education to direct care staff related to utilizing and updating the Kardex. Direct Care staff will not provide care until in-service has been completed. Completion Date: On-going Responsible: CNE/Unit Manger/Designee 8. Action: On (MONTH) 22, 2019, CNE/Unit Managers/Designee initiated education to direct care staff on the process to notify the CNE/designee when unable to complete any part of the care assignment to include oral care, toileting, pressure ulcer prevention, turning and repositioning, hydration, meal/snack offering. Direct care staff will not perform care until education has been completed. Completion Date: On-going Responsible: CED/CNE/Designee D. Removal of Immediate Jeopardy The facility's plan to remove Immediate Jeopardy was accepted and Immediate Jeopardy was lifted on 3/23/19 at 11:00 a.m. Record review revealed the facility had reorganized staffing assignments and redistributed staff more evenly according to both resident acuity and number of residents rather than by facility units. Assignments were to be re-evaluated every shift. However, deficient practice at an E level (pattern with the potential for more than minimal harm) remained. II. Resident population and assessed needs on unit 2. Review of the facility assessment revealed it was potentially outdated and was incomplete. (Cross-reference F838). However, the facility's Census and Condition of Residents report for unit 2 on 3/22/19 revealed 51 residents on the unit, all of whom needed some level of assistance from staff. A. The facility assessment was last reviewed on 11/15/18 by the former nursing home administrator (FNHA), the regional vice president (RVP), the regional executive director (RED), and the medical director (MD). The facility assessment read Acutity (sic) and distribution of case mix is evaluated daily and staffing redistributed as needed. Additionally, the facility assessment documented for direct care staff 1:6 ratio days, 1:6 ratio evenings, 1:11 ratio nights. However, a description of how the facility determines and reviews individual staff assignments for coordination and continuity of care for residents within and across staff assignments was not included in the facility assessment. Likewise, a description of the staff training, education, and competencies that are necessary to provide the care needed for the facility's resident population was not included in the facility assessment. B. Resident Conditions According to the 3/22/19 Census and Conditions of Residents report for unit 2, the resident census was 51 and the following care needs were identified: -36 residents needed assistance of one or two staff members and 13 were dependent for bathing. -51 residents needed assistance of one or two staff members and zero were dependent for dressing. -49 residents needed assistance of one or two staff members and one was dependent for transfers. -36 residents who were occasionally or frequently incontinent of bladder. -49 residents needed assistance of one or two staff members and zero were dependent for toileting. -47 residents needed assistance of one or two staff members and zero were dependent for eating. -22 residents were occasionally or frequently incontinent of bowel. -One resident had pressure injuries and 48 were receiving preventative skin care. IV. Nurse staffing A. Expectation The policy, Staffing/Center Plan, dated 9/1/13, was provided by the regional nurse on 12/21/18. It read, in pertinent part, The facility will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days a week. The purpose of the policy was, in part, to assure that appropriate staffing levels are scheduled and maintained. The process included, in part, - The center meets or exceeds the staffing levels mandated by state and federal staffing requirements. - Staffing levels are reviewed on an ongoing basis by center staff to evaluate compliance and provide appropriate levels of care by qualified employees. - The center maintains appropriate staffing levels, with qualified personnel, 24 hours/day, seven days/week on each shift to assure that patients are safe and their needs are met. See above; the facility assessment documented for direct care staff a 1:6 ratio days, 1:6 ratio evenings, 1:11 ratio nights. B. (MONTH) and (MONTH) 2019 staffing records Review of the daily census record for unit 2 revealed in (MONTH) and (MONTH) 2019, the resident census on unit 2 fluctuated between 48 and 53. Daily staffing records reflected unit 2 was not routinely staffed with five CNAs or even four CNAs in (MONTH) and (MONTH) 2019 on day and evening shift; instead, the unit was staffed with three CNAs (a 1:17 staff to resident ratio) and/or two CNAs (a 1:24 staff to resident ratio). This occurred on 21 of 28 days in (MONTH) 2019 and 11 days in (MONTH) 2019 (through 3/21/19). The (MONTH) staffing records revealed: On 2/1/19 the unit was staffed with two CNAs on day shift On 2/3/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 2/4/19 the unit was staffed with three CNAs on evening shift On 2/5/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 2/6/19 the unit was staffed with three CNAs on evening shift On 2/7/19 the unit was staffed with two CNAs on day shift and three CNAs on evening shift On 2/8/19 the unit was staffed with two CNAs on day shift On 2/13/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 2/14/19 the unit was staffed with three CNAs on day shift and two CNAs on evening shift On 2/15/19 the unit was staffed with three CNAs on day shift On 2/16/19 the unit was staffed with two CNAs on day shift On 2/17/19 the unit was staffed with three CNAs on day shift and two CNAs on evening shift On 2/18/19 the unit was staffed with two CNAs on day shift and three CNAs on evening shift On 2/19/19 the unit was staffed with two CNAs on day shift and three CNAs on evening shift On 2/20/19 the unit was staffed with three CNAs on day shift On 2/21/19 the unit was staffed with three CNAs on day shift On 2/22/19 the unit was staffed with three CNAs on day shift On 2/23/19 the unit was staffed with two CNAs on day shift On 2/24/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 2/26/19 the unit was staffed with three CNAs on day shift On 2/27/19 the unit was staffed with three CNAs on day shift The (MONTH) staffing records revealed: On 3/2/19 the unit was staffed with two CNAs on day shift On 3/3/19 the unit was staffed with three CNAs on evening shift On 3/6/19 the unit was staffed with three CNAs on day shift. On 3/7/19 the unit was staffed with three CNAs on day shift On 3/8/19 the unit was staffed with three CNAs on day shift On 3/11/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 3/12/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 3/17/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 3/19/19 the unit was staffed with three CNAs on day shift and three CNAs on evening shift On 3/20/19 the unit was staffed with two CNAs on day shift and three CNAs on evening shift On 3/21/19 the unit was staffed with three CNAs on day shift V. Effect of (MONTH) and (MONTH) 2019 staffing levels on residents residing on unit 2 A. Record review and interview revealed staffing levels on unit 2 in (MONTH) contributed to serious harm to Resident #3 and the facility's continued failure in (MONTH) contributed to serious harm to Resident #2. The facility's continued failure to provide sufficient staffing on the unit made it likely serious harm would continue if staffing levels on unit 2 were not immediately corrected. 1. Resident #3 a. Serious harm sustained by Resident #3 in February Resident #3 was admitted to the facility 12/7/18 with a [DIAGNOSES REDACTED]. Nurses' notes and change of condition reports after 1/31/19 revealed the resident's condition significantly declined in February. Identified with two pressure injuries as of 1/31/19, the resident was discovered with six pressure injuries on 2/11/19. She was admitted to the hospital the next day where she was diagnosed with [REDACTED]. Moreover, according to a police report dated 2/20/19, the emergency department nurse reported that in addition to her pressure injuries, the resident arrived at the emergency department with multiple bandages that were dirty and soiled and were only covering portions of the pressure ulcers; other pressure ulcers were open and exposed. The report went on to state the wounds had foul odors and the resident's heel boots were dirty, bloody and unsanitary and the resident's mouth was covered in oral thrush, her tongue was swollen, and her lips were cracked and dry from dehydration. The police report further read the nurse who took over the resident's care in the hospital after admission stated she could tell with the amount and severity of pressure ulcers the resident sustained [REDACTED]. She also stated that the condition of the resident's mouth showed that no oral care had been provided in some time. The police report also included information from a former facility nurse who stated the facility had neglected the resident due to a staffing shortage and a report from Resident #3's roommate in the facility. The roommate said the facility had been very short of certified nurse aides (CNAs). Staff would need help to turn and care for Resident #3 and would just leave her in bed when the help was unavailable. The roommate stated the nurses in the facility would check in on the resident and would tell the CNAs to check on and care for her, but they couldn't. The roommate stated staff never brushed the resident's teeth, she would lie in bed all day, not drinking and not eating. She stated the staff would fill the resident's water cup but did not come in to help her drink from the cup. Cross-reference F600 and F686 for further details. b. Serious harm sustained by Resident #2 in March Resident #2 was admitted to the facility 2/4/19. He required extensive assist from one staff for bed mobility and two staff for transferring. He was assessed at risk for pressure injuries but had no pressure injuries as of 2/11/19. Although nurses' notes between 2/4/19 and 3/14/19 read the resident was cooperative with care, continued to require extensive assistance with bed mobility and transfers, and no skin injuries were identified, a note and change of condition report documented the discovery of a pressure injury 3/18/19, described on 3/21/19 as a stage 3 pressure injury. Subsequently, on 3/24/19, he was discovered with a pressure injury on each lateral ankle. Record review revealed and interview with the resident confirmed he was not turned and repositioned by staff, although to do so was repeatedly referenced in the nurses' notes following discovery of his skin breakdown. Cross-reference F686 for further details. B. Record review and Interviews - confirmation of lack of sufficient staff on unit 2 to provide cares. 1. Record review Resident council minutes dated 2/13/19 read the residents requested that nurses help CNAs get duties completed, that staffing was a challenge, and that managers did help but were not trained or certified to complete some care duties. 2. Resident and family interviews Resident #5 was interviewed on 2/21/19 at 9:37 a.m. She stated staffing had been very low and the unit was lucky to have two CNAs on evenings. She went on to state the CNAs were so busy that they could be neglectful of some residents and some of their duties because they could not get everything done. Resident #2 was interviewed on 3/21/19 at 10:15 a.m. He stated staff did not come in to help him reposition or turn and he did not see much of staff throughout the day. Resident #3's family member was interviewed on 3/21/19 at 11:45 a.m. The family member stated Resident #3 was neglected and developed pressure injuries, a urinary tract infection and oral thrush as well as became dehydrated while in the facility. The family member said there was not enough staff to provide the resident with the care she needed. 3. Staff interviews Interviews with licensed staff working on unit 2 confirmed that with less than four CNAs, staff could not meet every residents' care needs, including those of Resident #3, who required two staff for all care. According to staff interviews, unit 2 would ideally be staffed with five or more CNAs. Staff reported four CNAs was doable but that three or less CNAs for the unit could result in lapses in care. CNA #1, interviewed on 2/21/19 at 10:00 a.m., stated when the unit was short staffed, it was very difficult to complete all the care required for each resident, especially residents who were totally dependent on staff and could not call for help when needed. He stated he knew residents should be checked and changed as well as repositioned or turned every two hours, but with the number of residents and staff levels, this was not always done. He stated when the resident was resistive to care when it was offered, care was not completed at that time and the nurse was notified. He said today there were three CNAs on and they were very busy answering call lights, toileting residents, getting residents to and from meals and activities. CNA #1 stated they could not always get all resident care completed each shift. CNA #2, interviewed on 2/21/19 at 12:35 p.m., stated when the unit was short staffed, there were not always two staff members available to attempt to provide Resident #3 with care including scheduled turning, changing, and other ADLs. She said it was impossible to complete all of the care and duties for the residents on the unit on schedule, every shift. She said there were simply too many residents with too many care needs and not enough staff to complete the care required. Registered Nurse (RN) #1, interviewed on 2/21/19 at 2:20 p.m., stated staffing had been so short in the facility that at times, some care had to be skipped. She said there was so much to do for so many residents it was impossible for all of the care to be completed each shift. She further stated when the unit was short staffed, care for Resident #3 could have been missed. RN #2, interviewed on 2/21/19 at 2:25 p.m., stated some ordered care items had to be delayed or skipped by both nurses and CNAs because there were too many resident for too few staff members. RN #1, interviewed again on 3/21/19 at 1:30 p.m. stated there were three CNAs caring for 52 resident today and the work load was overwhelming for three CNAs. Licensed Practical Nurse (LPN) #2, interviewed on 3/21/19 at 10:35 a.m., stated that at times there was one CNA to 20 residents on unit 2 and the CNAs would be lucky to be able to change all of their residents in the shift, let alone turn residents every two hours, answer call lights, feed residents, and shower residents. She said staffing on the unit had been really low recently and there was no way that all care needs and tasks were being completed for every resident when the unit was short staffed. She stated she did not think Resident #3's care was performed properly or on schedule, referring to checking and changing for incontinence, turning and repositioning, and personal and oral hygiene. The unit manager (UM) for unit 2, interviewed on 3/21/19 at 3:26 p.m., stated her unit was understaffed and three CNAs were not enough staff to properly take care of 52 residents. She stated there had been a staff call in which left the unit short staffed. She stated five CNAs would be ideal staffing for the unit and that four CNAs was doable but that three or fewer CNAs for the unit could result in lapses in care. LPN #3, interviewed on 3/22/19 at 3:35 p.m. stated staffing had been really low on day and evening shifts and at times there were only two CNAs to care for 60 residents. She stated when the unit was short staffed, residents could be forgotten and not cared for if they were not able to ask for help. She stated she knew of at least one day when a day shift CNA (who was no longer employed at the facility) admitted she completely forgot about Resident #3 and did not provide any care to her because she was so busy and the resident was so quiet. The LPN stated she and her CNA that shift went into the resident's room to find her lying on her back in an incontinence brief that was fully saturated and had leaked onto the bed through the sheets. LPN #1, interviewed on 3/22/19 at 3:50 p.m. stated low staffing was a big problem in the facility and all staff were so busy when the unit was short staffed that some necessary care did not get completed as scheduled or needed due to their not being enough time. She stated there needed to be at least four CNAs to get care completed on the unit; ideally, there would be five CNAs to complete care properly and when there were three or fewer CNAs, it was just running around answering call lights and other care was missed. The director of nursing (DON), interviewed on 3/21/19 at 3:26 p.m. and on 3/25/19 at 3:49 p.m., confirmed three CNAs caring for 52 residents was not an acceptable staffing level and said it would be very difficult for the CNAs to complete all the care for the residents on the unit. She stated that staff working short could result in lapses in care, caregiver fatigue and burn out. She stated she was not aware of an incident when Resident #3 was forgotten and not provided care. She stated she did not know if all care was always provided for the resident; she confirmed the care provided by the CNAs should be documented in the ADL (activity of daily living) charting but did not indicate she monitored or provided oversight to ensure staff were performing their assigned duties. Review of projected staffing schedules for the remainder of the (MONTH) 2019 revealed there were six days when four CNAs were scheduled for day shift and three days when three staff were scheduled on day shift. When asked about the facility's plan should staff call off on these day shifts, the DON said they would try to replace them. She did not indicate there was a long term plan to ensure the needs of the resident on unit 2 would be consistently met.

Based on interviews and record review, the facility failed to ensure one (#3) of eight sample residents received the services necessary to prevent neglect. (Cross-reference F686, F725, and F838) Resident #3 was admitted to the facility 12/7/18 with a [DIAGNOSES REDACTED]. While the resident's need for assistance with activities of daily living (hygiene, mobility, elimination, dining) and resistive behaviors were identified and services were planned to address her needs and behaviors, documentation review and interview revealed these services were not provided as planned and were not re-evaluated to ensure they were appropriate and adequate to meet the resident's needs, maintain her physical, mental and psychosocial level of well-being and prevent neglect. Resident #3, who entered the facility with her skin essentially intact (one area of black, calloused skin on her right heel), was discharged to the hospital just over two months later (2/12/19) at her family's request where she was assessed with [REDACTED]. Findings include: 1. Resident #3, [AGE] years old, was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. According to the 2/2019 computerized physician orders [REDACTED]. The resident resided on unit 2 (Elk Run) Nurses' notes for the resident's admission which were completed every shift for the first 72 hours (12/7 - 12/9/18) revealed: The resident exhibited both physical and verbal resistive behaviors when care was being provided; at times, the resident stayed in bed all shift; the resident's food and fluid intakes (with assistance and cueing) were 75 - 100%; and black, calloused skin was present on the resident's right heel. The minimum data set (MDS) assessment, completed seven days after admission, revealed the resident was severely cognitively impaired, scoring a 0 out of 15 on the brief interview for mental status (BIMS). Her decision making skills were moderately impaired, and the resident exhibited verbal behaviors one to three days that significantly interfered with the resident's care and significantly disrupted the living environment. The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was totally dependent on staff for bathing and was always incontinent of bowel and bladder. Per the MDS (and contrary to nurses' notes above) the resident was assessed with [REDACTED]. 2. Planned services to address the resident's need for assistance with activities of daily living (hygiene, mobility, elimination, dining) and resistive behaviors. Record review revealed the facility developed care plans to address the resident's needs identified in nursing notes and facility assessment in the areas of activities of daily living (ADLs), behaviors, nutrition, incontinence, and skin condition. a. The ADL care plan dated 12/11/18 read the resident was at risk for decreased ability to perform ADLs related to limited mobility and behavioral symptoms. -Goals included that the resident's ADL needs would be anticipated and met by staff and the resident would have minimal behavioral episodes. -Interventions included: monitoring of conditions that may contribute to ADL decline, monitoring for additional decline in ADL function, monitoring and medicating for pain, implementing established behavioral interventions or physician notification of behavioral changes, providing the resident with extensive or total assistance of one or two staff for bed mobility and transfers, and providing the resident with total assistance of one staff member for eating and dressing. b. The behavior care plan dated 12/10/18 read the resident exhibited or had the potential to demonstrate verbal behaviors related to cognitive loss and dementia, the resident often screams out and cries due to fear of falling. -The goal was the resident would not exhibit verbal outbursts directed towards others. -Interventions included: monitoring medications for side effects, monitoring for pain, explaining all care one step at a time and the reason for the care before initiating, providing consistent, trusted caregivers and structured daily routines when possible, and approaching the resident in a calm, unhurried manner and reassuring as needed. c. The nutrition care plan dated 12/12/18 read the resident was at nutritional risk and needed extensive assistance during meals related to [MEDICAL CONDITION]. It further read the resident was often unable to voice needs so they needed to be anticipated. -The goal was that the resident would consume 75% of at least three meals per day. -Interventions included: Weigh the resident per protocol and alert dietician and physician to any significant weight loss or gain, monitor for changes in nutritional status and report to food and nutrition as indicated, provide diet as ordered, offer snacks, and to supervise, cue and assist as needed with meals. d. The skin care plan dated 12/11/18 read the resident was at risk for skin breakdown related to impaired mobility, decreased activity, impaired cognition, and incontinence. -Goals included the resident would remain free of skin tears or bruising and would not show signs of skin breakdown for 90 days. -Interventions included: Pat skin dry, provide treatments to skin tear as ordered and observe for signs of infection, turn or reposition and check skin every two hours as determined by tissue tolerance, assist resident in turning and repositioning every two hours, encourage resident to consume all fluids of choice during meals, observe skin for signs and symptoms of skin breakdown (redness, cracking, blistering, decreased sensation, and skin that does not blanche easily), observe skin condition daily with ADL care and report abnormalities, offload or float heels while in bed with Prevalon boots and pillow, weekly skin assessment by licensed nurse, and weekly wound assessment to include measurements and description of wound status. e. The incontinence care plan dated 12/26/18 read the resident was incontinent of bladder and bowel and was unable to cognitively or physically participate in a retraining program due to cognitive loss. -The goal was the resident will have incontinence care needs met by staff to maintain dignity and comfort and to prevent incontinence related complications. -Interventions included: Assist the resident with perineal care as needed, monitor for signs and symptoms of infection and report to the physician, monitor for skin redness and irritation and report as indicated. 3. Resident decline - Facility failure to provide the planned services above and failure to evaluate whether the services planned were appropriate and adequate to address the resident's needs. Nurses' notes after admission and until Resident #3's discharge on 2/12/19 documented the resident's repeated and almost daily resistance to ADL cares, the resident's frequent screaming and yelling out and decline in her physical condition with documentation of poor food and fluid intake (2/3/19) and the discovery of skin breakdown on 1/8/19 (coccyx), on 1/31/19 (left heel), 2/7/19 (coccyx), other skin changes on 2/2/19 (discoloration and petechiae), and six pressure injuries 2/11/19 (right and left heels, coccyx, ankle, toe and right lower leg). The 2/12/19 MDS, completed upon the resident's discharge to the hospital, confirmed the resident's physical decline, documenting the resident had two unstageable slough or eschar injuries and five unstageable pressure injuries presenting as deep tissue injury. None of these skin conditions were present upon admission or when the previous MDS assessment was completed. The resident was transported to the hospital at the family's request due to her poor condition. The emergency department report read the resident was admitted due to multiple bedsores to sacrum and lower extremities, urinary tract infection, significant dehydration with acute kidney injury, and oral thrush with very poor oral hygiene. a. Record review revealed a facility failed to prevent neglect. Specifically, the facility failed to provide planned services to address the resident's need for assistance with ADLs and behaviors in order to maintain her mental, physical and psychosocial level of well-being: Review of the resident's record (nurses' notes, treatment records, medication administration records and care plans) revealed: no documentation to show the resident was turned and repositioned or assisted with turning and repositioning every two hours (see skin care plan above); no documentation of skin checks every two hours or documentation of daily skin checks during ADLs (see skin care plan above); no documentation of an assessment of the resident's toileting schedule in order to provide timely incontinence and perineal care as needed (see incontinence care plan above); no documentation food and fluids were encouraged, monitored or promoted during or between meals (see nutrition care plan above); no documentation of an assessment of the resident for non-verbal indicators of pain in order to effectively monitor her for pain (see behavior care plan above); no documentation to show the facility took steps to provide consistent, trusted caregivers, attempted to structure daily routines, or approached the resident in a calm, unhurried manner (see behavior care plan above). Finally, record review revealed a lack of weekly wound assessments that included measurement and description of wound status (see skin care plan above). Nurses' notes in February, 2019 rarely included details regarding the resident's activity, meal or fluid intake, whether the resident was up in her wheelchair or in bed, and whether care was completed for the resident. Moreover, nurses' notes did not include interventions, attempts to re-approach the resident, or any communication with the resident's family regarding the resident's behaviors and difficulties experienced when attempting to provide care. Review of the resident's ADL charting in (MONTH) (through 2/12/19) also revealed the resident did not receive ADL services as planned. Review of the charting revealed that in February, the resident was assisted with bed mobility 12/34 times, offered a drink and snack 5/34 times, assisted with oral care 7/23 times, assisted with personal hygiene 11/34 times, lotion was applied to her lower extremities 11/34 times, barrier cream was applied after incontinence care 10/34 times, assisted with transferring 6/34 times, assisted with meals 17/34, and was checked and changed 64/140 times. b. Record review revealed facility failed to re-evaluate services to ensure they were appropriate and adequate to maintain the resident's level of physical, mental, and psychosocial well-being. See care plans above; there was no indication the resident's planned services as set forth in her care plans for ADL care, incontinence care, skin care, and nutrition were reviewed or revised in any way during the resident's stay in the facility, even as her physical condition declined. Likewise, there was no documentation the resident's behavior care plan, which affected all the services planned under her care plans for skin, ADLs, nutrition and incontinence, was re-evaluated and new interventions considered in an attempt to minimize the resident's resistance to services which the facility, as early as the 12/14/19 MDS assessment, identified significantly interfered with her care. There was no documentation the interdisciplinary team met after 12/10/18 to confer about the resident's behaviors and no documentation the physician was notified of the resident's persistent resistance to services. In addition, there was no documentation the family was informed of the extent to which the resident's behavior impacted staff's ability to provide planned services and no documentation of outreach to the family for their assistance in developing a resident-specific behavior care plan to minimize the resident's resistance to cares. 4. Confirmation of the facility's failure to provide Resident #3 the services planned and necessary to prevent neglect. a. Police Records Police reports regarding the resident and her care in the facility were obtained on 2/21/19 at 4:30 p.m. Review of the reports revealed, in part: -The emergency department nurse who admitted the resident called the police department on 2/12/19 and reported concern regarding improper care of the resident at the facility. The nurse reported the resident had substantial pressure ulcers on her heels, calves, and tremendous breakdown on her sacrum and when the resident arrived to the emergency department she had multiple bandages that were dirty, soiled and were only covering portions of the pressure ulcers. Other pressure ulcers were open and exposed. The report went on to state that the wounds had foul odors and the resident's heel boots were dirty, bloody and unsanitary. The report also stated that the resident's mouth was covered in oral thrush, her tongue was swollen, and her lips were cracked and dry from dehydration. -The nurse who took over the resident's care in the hospital after admission reported she could tell with the amount and severity of pressure ulcers the resident sustained [REDACTED]. She also stated the condition of the resident's mouth showed that no oral care had been provided in some time. -A former nurse of the facility made a statement to police on 2/20/19 that the facility had neglected the resident due to a staffing shortage. -On 2/20/19, the resident's roommate in the facility for the duration of her stay was interviewed by police regarding the resident's care in the facility and stated that the facility had been very short of certified nurse aides (CNAs). Staff would need help to turn and care for the resident and would just leave her in bed when the help was unavailable. The roommate stated the nurses in the facility would check in on the resident and would tell the CNAs to check on and care for her, but they couldn't. The roommate stated to the police that the facility staff never brushed the resident's teeth, she would lie in bed all day, not drinking and not eating. She stated the staff would fill the resident's water cup but did not come in to help her drink from the cup. She told the police that she did not know of any other residents who had been treated the way her former roommate had been treated. b. Staff Interviews CNA #1 was interviewed on 2/21/19 at 10:00 a.m. and stated he had cared for Resident #3 when she was in the facility. He stated she was difficult to care for and required two staff members for all care. He stated that when the unit was short staffed, it was very difficult to complete all the care required for each resident, especially residents who were totally dependent on staff and could not call for help when needed. He stated he knew residents should be checked and changed as well as repositioned or turned every two hours, but with the number of residents and staff levels, this was not always done. He stated that when the resident was resistive to care when it was offered, care was not completed at that time and the nurse was notified. CNA #2 was interviewed on 2/21/19 at 12:35 p.m. and stated that she cared for the resident at times when she was in the facility. She, too, stated the resident was resistive to care and often refused to have care provided. She stated when the unit was short staffed, there were not always two staff members available to attempt to provide the resident with care including scheduled turning, changing, and other ADLs. Registered Nurse #1 was interviewed on 2/21/19 at 2:20 p.m. and stated she had been the resident's nurse when the resident resided in the facility. She stated she would check on the resident when providing ordered nursing care, such as medication pass, scheduled assessments, and scheduled treatments. She went on to state the CNAs were responsible for providing the resident's basic care needs. She stated the resident had dementia and her needs were anticipated by staff but the resident was resistive to care and would scream. She stated that when the unit was short staffed, it was impossible for the CNAs to complete all care for every resident on schedule, and care for Resident #3 could have been missed. Licensed Practical Nurse (LPN) #2 was interviewed on 3/21/19 at 10:35 a.m. and stated she worked as the wound and treatment nurse in the facility, but had been on leave for some time and returned to work in mid-February 2019. She stated she had heard the resident had been difficult to care for and that her needs were anticipated by staff because she could not ask for help or tell them what she needed. She stated staffing on the unit had been really low recently and there was no way that all care needs and tasks were being completed for every resident when the unit was short. She stated that she was present when the resident was seen by the wound doctor on 2/11/19. She said the only wounds identified for the resident prior to that visit were a small area on her coccyx and areas on her heels. She stated there were more wounds on 2/11/19, and the wounds were in much worse condition than she or the doctor had expected. She stated she did not think the resident's care was performed properly or on schedule, referring to checking and changing for incontinence, turning and repositioning, and personal and oral hygiene. LPN #3 was interviewed on 3/22/19 at 3:35 p.m. and stated she had been the resident's nurse frequently when the resident resided in the facility. She stated that staffing had been really low on day and evening shifts and at times there were only two CNAs to care for 60 residents. She stated that she knew of at least one day when a day shift CNA (who was no longer employed at the facility) admitted she completely forgot about Resident #3 and did not provide any care to her because she was so busy and the resident was so quiet. The LPN stated she and her CNA that shift went into the resident's room to find her lying on her back in an incontinence brief that was fully saturated and had leaked onto the bed through the sheets. She stated that this incident was the only time she knew this had happened but staffing had been so bad, she would not doubt this was not the only time care was not provided to the resident. The director of nursing (DON) was interviewed on 3/25/19 at 3:49 p.m. and stated she was not aware of an incident when Resident #3 was forgotten and not provided care. She stated she was aware the resident was resistive and difficult to care for. She confirmed that there was no family notification, meetings, or additional interventions documented to attempt to make caring for the resident easier. Further, she stated she did not know if all care was always provided for the resident; she confirmed the care provided by the CNAs should be documented in the ADL charting but did not indicate she monitored or provided oversight to ensure staff were performing their assigned duties. c. Resident interview Resident #3's roommate, approached three times during survey, declined to be interviewed.

Based on observations, interviews, and record review, the facility failed to provide the care and services necessary to prevent pressure injuries from developing and worsening for two (#2 and #3) of eight sample residents. (Cross-reference F600 and F725) Resident #3 was admitted to the facility 12/7/18 with a [DIAGNOSES REDACTED]. Record review and interviews revealed the facility failed to develop appropriate, individualized interventions to prevent pressure injuries. Specifically, the facility failed to develop measures to modify identified risk factors, failed to re-evaluate and revise interventions when pressure injuries were discovered, failed to adequately monitor the resident's skin condition and pressure injuries, and failed to ensure staff consistently implemented planned interventions. Resident #3, who had entered the facility with her skin essentially intact (one area of black, calloused skin on her right heel), was discovered just over two months later (2/11/19) with six pressure injuries to the sacrum and lower extremities. Resident #2 was admitted to the facility 2/4/19 without pressure injuries but at risk for pressure injuries. He required extensive assistance of one staff member for bed mobility and two staff for transferring. Record review revealed the resident developed a stage 3 pressure injuries on his lower back on 3/18/19 and bilateral ankles on 3/23/19 before being discharged to inpatient hospice on 3/24/19. Record review revealed a lack of description regarding his lower back pressure injury until 3/21/19, a delay in notifying hospice of the pressure injury until 3/20/19, a failure to update the resident's care plan until 3/20/19, and a failure to have evidence the resident was being assisted to turn and repositioned to relieve pressure. Interview with the resident confirmed staff failed to assist him to turn and reposition or to tell him to reposition. Findings include: I. Facility Policy The Skin Integrity Management policy revised on 11/28/16 was provided by the nursing home administrator (NHA) on 3/21/19 at 3:30 p.m. It read in pertinent part: -Staff continually observed and monitored patients for skin integrity changes and implemented revisions to the plan of care as needed. The purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The policy's practice standards included in pertinent part: Review pre-admission information to plan for resident needs, complete a comprehensive evaluation of patient upon admission, complete risk evaluation on admission, weekly for the first month, quarterly and with a change in condition, identify patient's skin integrity status and need for prevention intervention, perform skin inspection on admission and weekly, perform daily monitoring of wounds or dressings for presence of complications or declines and document, develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated, implement pressure ulcer prevention for identified risk factors, determine need for support surface on bed and chair, determine need for heel protectors and heel lift devices, Review care plan weekly and revise as indicated, document daily monitoring of ulcer site. II. Resident #3 A. Resident status on admission 12/7/18 Resident #3, [AGE] years old, was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. According to the 2/2019 computerized physician orders [REDACTED]. The resident resided on unit 2 (Elk Run). An admission assessment note 12/7/18 read the resident scored a 10 on the Braden scale for pressure injury risk. Her score indicated she was at high risk for pressure injury development. Another admission note 12/7/18 read the resident was resistive to care and screamed every time care was provided and a black callus was identified on her right heel. A minimum data set (MDS) assessment, completed seven days after admission, revealed the resident was severely cognitively impaired, scoring a 0 out of 15 on the brief interview for mental status (BIMS). Her decision making skills were moderately impaired, and the resident exhibited verbal behaviors one to three days that significantly interfered with the resident's care and significantly disrupted the living environment. The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was totally dependent on staff for bathing and was always incontinent of bowel and bladder. Per the MDS (and contrary to nurses' notes above) the resident was assessed with [REDACTED]. B. Resident status 1/8/19 to discharge 2/12/19 - significant decline in skin condition Weekly skin assessments in (MONTH) (YEAR) and the first week in (MONTH) 2019 indicated the resident had no injuries or wounds. However, change of condition notes revealed: an open area was discovered on her coccyx (.5 cm) on 1/8/19 which skin checks 1/10/19 and 1/19/19 indicated was reddened, blanchable, and healing (.5 cm x .5 cm) and a hard discolored pressure injury was discovered on the resident's left heel, (4 cm x 5 cm) on 1/31/19. No further pressure injury assessments were documented until a skin check on 2/7/19 which read the pressure injury on the resident's coccyx was open, and now 3 cm x 2 cm with mild drainage. No pressure injury assessments were documented between 2/7 and 2/11/19 when the wound doctor assessed the resident and discovered six pressure injuries: an unstageable wound to the resident's right heel with strong odor and red drainage, a deep tissue injury wound to her left heel, a deep tissue injury to her left lateral ankle, a deep tissue injury on her left fifth toes, an unstageable coccyx wound with strong odor, and a deep tissue injury to her right lower leg with odor. On 2/12/19 the resident was transported to the hospital at the family's request due to her poor condition. The emergency department report read the resident was admitted due to multiple bedsores to sacrum and lower extremities, as well as other medical conditions with the potential to impact her declining skin condition (urinary tract infection, significant dehydration with acute kidney injury, and oral thrush). C. Record review and interviews revealed the facility failed to develop appropriate, individualized interventions to prevent pressure injuries. Specifically, the facility failed to develop interventions to modify identified risk factors, failed to re-evaluate and revise interventions when pressure injuries were discovered, failed to adequately monitor the resident's skin condition and pressure injuries, and failed to ensure staff consistently implemented planned interventions. 1. Record review revealed the facility developed a care plan to address the resident's risk for skin breakdown, as well as plans to address behaviors, activities of daily living (ADLs), nutrition, and incontinence. a. The skin care plan dated 12/11/18 read the resident was at risk for skin breakdown related to impaired mobility, decreased activity, impaired cognition, and incontinence. -Goals included the resident would remain free of skin tears or bruising and would not show signs of skin breakdown for 90 days. Interventions included: Turn or reposition and check skin every two hours as determined by tissue tolerance, assist resident in turning and repositioning every two hours, encourage resident to consume all fluids of choice during meals, observe skin for signs and symptoms of skin breakdown daily with ADL care, offload or float heels while in bed with Prevalon boots and pillow, weekly skin assessment by licensed nurse, and weekly wound assessments that included measurements and description of wound status. b. The ADL care plan dated 12/11/18 read the resident was at risk for decreased ability to perform ADLs related to limited mobility and behavioral symptoms. Goals included that the resident's ADL needs would be anticipated and met by staff and the resident would have minimal behavioral episodes. Interventions included providing the resident with extensive or total assistance of one or two staff for bed mobility and transfers, and providing the resident with total assistance of one staff member for eating and dressing. c. The behavior care plan dated 12/10/18 read the resident exhibited or had the potential to demonstrate verbal behaviors related to cognitive loss and dementia, the resident often screams out and cries due to fear of falling. The goal was the resident would not exhibit verbal outbursts directed towards others. Interventions included providing consistent, trusted caregivers and structured daily routines when possible, and approaching the resident in a calm, unhurried manner and reassuring as needed. d. The nutrition care plan dated 12/12/18 read the resident was at nutritional risk and needed extensive assistance during meals related to [MEDICAL CONDITION]. It further read the resident was often unable to voice needs so they needed to be anticipated. The goal was that the resident would consume 75% of at least three meals per day. Interventions included: monitor for changes in nutritional status and report to food and nutrition as indicated. e. The incontinence care plan dated 12/26/18 read that the resident was incontinent of bladder and bowel and was unable to cognitively or physically participate in a retraining program due to cognitive loss. The goal was that the resident will have incontinence care needs met by staff to prevent incontinence related complications. Interventions included: Assist the resident with perineal care as needed, monitor for skin redness and irritation and report as indicated. 2. Failure to adequately monitor the resident's skin condition All documentation reflecting monitoring of the resident's wounds was requested 3/21/19 from the director of nursing (DON) and the following was provided: nurses' notes, skin checks and change of condition reports. Review of these documents revealed that after the resident was discovered with a second pressure injury 1/31/19, there was no evidence to show the resident's skin was assessed daily during ADLs as care planned or that either of her pressure injuries were assessed and their status documented during wound changes. Indeed, after the change of condition note on 1/31/19, no measurements of the resident's heel injury were documented prior to discharge 2/12/19, and only one measurement of the resident's coccyx wound was documented on a skin check completed 2/7/19. This weekly skin check did not address the resident's heel injury. Moreover, contrary to the resident's care plan, the facility failed to produce evidence of weekly skin wound assessments by the wound nurse that tracked the status of the resident's wounds, including wound measurements and descriptions. 3. Failure to develop measures to modify identified risk factors. Although the facility correctly identified the resident's risk for skin breakdown was related to impaired mobility, decreased activity, impaired cognition and incontinence, the facility failed to develop appropriate, individualized measures in an attempt to modify the risks these conditions presented. First, record review revealed no evaluation of interventions to minimize the effect of the resident's immobility. Rarely did the record document nurses' notes document any resident activity, such as the resident up in her wheelchair or out of her room. While notes documented to turn frequently or every two hours, there was no documentation to support this was being done and staff interviews (see below) indicated it was not possible. In addition, there was no evidence the facility assessed the two hour turning schedule to determine whether the resident's level of immobility, coupled with her cognitive impairment, required she be turned and repositioned more frequently than every two hours. Review of the resident's ADL charting for (MONTH) 2019 revealed the resident was assisted with bed mobility 12/34 times, assisted with personal hygiene 11/34 times, lotion was applied to lower extremities 11/34 times, barrier cream was applied after incontinence care 10/34 times, the resident was assisted with transferring out of bed 6/34 times, and she was checked and changed 64/140 times. There was no documentation of the resident being turned or repositioned every two hours as care planned. Second, nurses' notes documented the resident's repeated and almost daily resistance to ADL cares and the resident's frequent screaming and yelling out. Yet, there was no documentation in the resident's behavior care plan, which affected all the services planned under her care plans for skin, ADLs, nutrition and incontinence, was evaluated and new interventions considered in an attempt to minimize the resident's resistance to services which the facility, as early as the 12/14/19 MDS assessment, identified significantly interfered with her care. There was no documentation the interdisciplinary team met after 12/10/18 to confer about the resident's behaviors. Moreover, there was no documentation the family was informed of the extent to which the resident's behavior impacted staff's ability to provide the resident ADL care and pressure relief and no documentation of outreach to the family for their assistance in developing a resident-specific behavior care plan to minimize the resident's resistance to cares. Third, there was no documentation the resident's incontinence was evaluated in order to ensure the resident was checked and changed frequently enough to limit her exposure to incontinence even though the resident, due to her cognitive impairment, was unlikely to communicate to staff her need to be changed. The resident's incontinence care plan provided staff no instruction on how often to check on the resident; perineal care was as needed and there was no assessment of the resident's incontinence to determine the appropriate frequency of this ADL care. Finally, there was no evidence the facility developed interventions to address the resident's nutritional needs after her pressure injuries developed. There was no evidence her fluid and food intake was being monitored in February, even after she was identified on 2/3/19 with poor intake. There were no nutritional notes beyond the initial nutrition assessment on 12/12/18. 3. Failure to re-evaluate and revise interventions when pressure injuries were discovered As noted above, there was no evidence the resident's nutritional needs were reassessed in order to determine whether new interventions were necessary to promote healing of her pressure injuries. As noted above, there was no evidence the resident's turning and repositioning schedule was re-evaluated and monitored to ensure it was being implemented as often as needed to prevent further pressure injury development and to promote healing. As noted above, the frequency staff was checking and changing the resident was not re-evaluated even though she had a pressure injury on her coccyx. Finally, as noted above, there was no evidence the resident's behavior and staff's approach to the resident when she was resistant to cares was re-evaluated and new approaches considered and attempted. There was no evidence the resident's skin, incontinence, ADL, behavior and nutrition care plan were reviewed or revised in any way during the resident's stay in the facility. 4. Failure to ensure staff consistently implemented planned interventions. a. Information in a police report on the resident's care in the facility, obtained on 2/21/19 at 4:30 p.m., provided further evidence that the facility had failed to ensure staff consistently implemented planned interventions to prevent further skin breakdown and to promote healing of Resident #3's existing pressure injuries. The report read, in part: -The emergency department nurse who admitted the resident to the hospital on [DATE], called the police department that day and reported concern regarding improper care of the resident at the facility. The nurse reported that the resident had substantial pressure ulcers on her heels, calves, and tremendous breakdown on her sacrum and that when the resident arrived to the emergency department she had multiple bandages that were dirty, soiled and were only covering portions of the pressure ulcers. Other pressure ulcers were open and exposed. The report went on to state that the wounds had foul odors and the resident's heel boots were dirty, bloody and unsanitary. The report also stated that the resident's mouth was covered in oral thrush, her tongue was swollen, and her lips were cracked and dry from dehydration. -The nurse who took over the resident's care in the hospital after admission reported she could tell with the amount and severity of pressure ulcers the resident sustained [REDACTED]. -A former nurse of the facility made a statement to police on 2/20/19 that the facility had neglected the resident due to a staffing shortage. -On 2/20/19, the resident's roommate in the facility for the duration of her stay was interviewed by police regarding the resident's care in the facility and stated the facility had been very short of certified nurse aides (CNAs). Staff would need help to turn and care for the resident and would just leave her in bed when the help was unavailable. The roommate stated the nurses in the facility would check in on the resident and would tell the CNAs to check on and care for her, but they couldn't. The roommate stated to the police that the facility staff never brushed the resident's teeth, she would lie in bed all day, not drinking and not eating. She stated that the staff would fill the resident's water cup but did not come in to help her drink from the cup. b. Staff interviews further confirmed planned interventions were not consistently implemented to prevent further skin breakdown and to promote healing of Resident #3's existing pressure injuries Certified nurse aide (CNA) #1 was interviewed on 2/21/19. He stated the resident was very difficult to care for and resisted care when it was offered. He stated the resident required two staff members for bed mobility and transferring and said the staffing level had been so low, there were not always two staff members available to provide care to the resident. He stated dependent residents were supposed to be checked/changed and repositioned every two hours, though completing these tasks as scheduled was not always possible. CNA #2 was interviewed on 2/21/19 at 12:35 p.m. She stated that she cared for the resident at times when she was in the facility. She said the resident was resistive to care and often refused to have care provided. She stated that at times when the unit was short staffed, there were not always two staff members available to attempt to provide the resident with care including scheduled turning, changing, and other ADLs. Registered Nurse (RN) #1 was interviewed on 3/21/19 at 2:20 p.m. She stated she had been the resident's nurse when the resident resided in the facility. She said she would check on the resident and complete medication pass, scheduled assessments, and scheduled treatments. She went on to state the CNAs were responsible for providing the resident's basic care needs and that the resident's needs were anticipated. She stated that when the unit was short staffed, it was impossible for the CNAs to complete all care for every resident on schedule and said care for the resident could have been missed. Licensed Practical Nurse (LPN) #2 was interviewed on 3/21/19 at 10:35 a.m. She said she worked as the wound and treatment nurse in the facility but had been on medical leave for the past few months. She stated she knew the resident had been difficult to care for and that her needs had been anticipated by staff. She stated the staffing on the unit had been really low recently and there was no way that all care needs and tasks were being completed for every resident when the unit was short. She stated she was present when the resident was seen by the wound doctor on 2/11/19 and said the only wounds identified for the resident prior to the visit were a small area on her coccyx and areas on her heels. She stated there were more wounds that day and the wounds were in much worse condition than she or the doctor had expected. She stated that she did not think the resident's care had been performed properly. LPN #3 was interviewed on 3/22/19 at 3:35 p.m. and stated that she had been the resident's nurse frequently when the resident resided in the facility. She stated staffing had been really low on day and evening shifts and that at times there were only two CNAs to care for 60 residents. She stated she knew of at least one day when a day shift CNA (who was no longer employed at the facility) admitted she completely forgot about Resident #3 and did not provide any care to her because she was so busy and the resident was so quiet. She stated she and the CNA working with her went into the resident's room and found her lying on her back in an incontinence brief that was fully saturated and that had leaked onto the bed through the sheets. She stated this incident was the only time she knew of but staffing had been so bad, she would not doubt that was the only time care was not provided to the resident. The DON was interviewed on 3/25/19 at 3:49 p.m. She stated she had started a pressure injury tracking system 3/19/19 and acknowledged a tracking system had not been in place before that. She also stated she was not aware of an incident when Resident #3 was forgotten and not provided care. While aware the resident had been resistive to care, she confirmed there was no family notification, meetings, or additional interventions documented to attempt to make caring for the resident easier. Further, she stated she did not know if all care was always provided for the resident; she agreed the care provided by the CNAs should be documented in the ADL charting but did not indicate she monitored or provided oversight to ensure staff were performing their assigned duties. III. Resident #2 Resident #2, [AGE] years old, was admitted to the facility on [DATE] and was discharged on [DATE]. According to the 3/2019 CPO, [DIAGNOSES REDACTED]. The resident resided on unit 2 (Elk Run). A. Resident status on admission 2/4/19 On 2/4/19, an admission nursing assessment note read the resident required extensive assistance with bed mobility and transfers and the resident had blanchable redness to his buttocks and coccyx. His Braden score showed moderate risk for pressure injuries and a skin care plan was opened the same day. The note indicated the resident experienced pain with movement and turning in bed while certain positions made the pain better and others made the pain worse. According to the 2/11/19 MDS assessment, the resident was alert and oriented and scored a 15/15 on his BIMS, his decision making skills were intact and he did not exhibit behaviors, did not reject care, and did not exhibit signs of depression. He required extensive assistance of one staff member for bed mobility and two staff members for transferring. He was determined to be at risk for pressure injuries though no pressure injuries were present at the time of the assessment. The assessment indicated that the resident was receiving hospice services. A skin care plan was initiated 2/5/19 and interventions included: 2/5/19 provide preventative skin care; apply barrier cream with each cleansing; observe for signs and symptoms of skin breakdown; observe skin condition daily with ADL care and report abnormalities; utilize device to assist resident with turning and repositioning; 2/21/19 off load heels while in bed; pressure redistribution surfaces to bed and chair; An ADL care plan dated 2/21/19 read the resident required assistance with ADLs including bathing, personal hygiene, bed mobility, transfers, locomotion and toileting. The goal was to maintain the highest level of ADL ability. Interventions included: monitor for pain, monitor for shortness of breath, fatigue or change in condition and adjust ADL tasks accordingly, encourage the resident to pace himself, provide cueing for safety, and arrange the resident environment as much as possible to facilitate ADLs. B. Resident status after admission until discharge 3/24/19 Although nurses' notes between 2/4/19 and 3/14/19 read the resident was cooperative with care, continued to require extensive assistance with bed mobility and transfers, and no skin injuries were identified, a note and change of condition report documented the discovery of a pressure injury 3/18/19. 1. Resident observation and interview On 3/21/19 at 10:15 a.m. the resident was observed in bed on his back eating breakfast. He stated he was aware he had a pressure injury on his back and did not know if it was getting better or not. He stated staff neither come in to help turn or reposition him nor tell him to reposition. 2. Record review - development of pressure injuries beginning on 3/18/19 a. Facility response to discovery of Resident #2's pressure injury - failures in facility response. Review of nurses' notes and change of condition note revealed: a lack of description regarding the pressure injury discovered 3/18/19 until 3/21/19; a delay in notifying hospice of the pressure injury until 3/20/19; a failure to update the resident's care plan until 3/20/19; and a failure to document the resident was being assisted to turn and reposition. Specifically: -A change in condition note dated 3/18/19 read the resident was identified to have a pressure injury and that daily wound care orders were obtained. The pressure injury was not further described. -A nurses' note dated 3/19/19 read the resident had developed a new pressure injury on his back and he was non-compliant with keeping pressure off of the area or being on his side. Another note the same day read the open area to the resident's lower spine was cleansed/redressed per orders. Resident stated this is something that happens occasionally. Staff was advised to turn and reposition the resident every two hours. However, there was no description of the pressure injury in the notes and no documentation the resident was assisted with turning and repositioning. -Another nurses' note dated 3/20/19 read open area on lower spine cleansed/redressed per orders. Again, staff was advised to turn and reposition the resident every two hours; however, there was no documentation the resident was assisted with repositioning. Another note the same day documented that the hospice agency was notified, two days after its discovery, of the resident's pressure injury; at that time, the note read hospice would replace the resident's mattress with an air mattress and order protein liquid and multivitamins to help facilitate wound healing. The resident's skin care plan (as well as his hospice care plan) was updated on this date to read the resident had evidence of skin breakdown, a stage 3 pressure injury to his lower spine. The goal was the wound would heal and not become infected. An intervention, dated 3/21/19, was to assist the resident in turning and repositioning; how frequently this was to be done was left blank. -Another nurses' note dated 3/21/19 read the resident's wound dressing was changed and the resident needed reminding to get off of his back periodically. There was no description of the resident's pressure injury and no documentation the resident was assisted to reposition. A skin assessment note dated 3/21/19 documented the first description of the stage 3 open pressure injury, noting it measured 1 x 1.5 cm. A nurses' note also dated 3/21/19 read, Open area 1 x 1.5 cm on lower spine cleansed/redressed per orders. Again, staff was advised to turn and reposition the resident every two hours, but there was no documentation this was accomplished. b. Further skin breakdown - Pressure injuries to bilateral ankles A change in condition note dated 3/23/19 read a pressure injuries were found on the resident's bilateral ankles and that orders were obtained for Santyl and [MEDICATION NAME] daily. Pressure relief with boots and heels up on device. A nurses' note dated 3/23/19 read the DON had spoken to hospice regarding the resident's refusal of care related to positioning and dressing changes. The note indicated that hospice would provide additional support with CNA visits, a nurse assessment and a care conference. However, review of the resident's nurses' notes revealed only one instance when the resident had been non-compliant with care and review of the resident's medication and treatment records revealed treatments and dressing changes were all completed as ordered. A nurses' note dated 3/24/19 read the resident had unstageable open areas on his outer ankles and that he stated he was able to move his legs and reposition them without pain. Another note the same day read the resident would discharge to inpatient hospice care; he had current wounds to his spine and ankles. c. ADL documentation indicated a failure to ensure the resident was assisted with turning and repositioning. ADL documentation In (MONTH) 2019 documented the resident was assisted with bed mobility 20/74 times and was documented to have been independent with bed mobility 12/74 times, he was assisted with floating his heels 23/74 times, barrier cream was applied 22/74 times and refused once, and a pressure relieving device for the resident's bed and chair were used 23/74 times. ADL documentation in (MONTH) 2019 documented the resident was assisted with bed mobility 13/63 times and was documented to have been independent with bed mobility 8/63 times; he was assisted with floating his heels 20/63 times, barrier cream was applied 26/63 times, and a pressure relieving device for the resident's bed and chair were used 19/63 times. Additional review of the ADL documentation revealed no specific documentation of the resident being on a turning schedule or that turning and repositioning had been attempted or completed. 3. Interviews confirmed staff failed to turn and reposition the resident. On 3/21/19 at 10:20 a.m. RN #1 stated that the resident was on a repositioning schedule every two hours and the CNAs had been informed to implement the schedule. However, she was unable to locate the orders or documentation to show turning and repositioning was being completed for the resident. On 3/21/19 at 1:34 p.m. CNA #1 was interviewed and stated he did not know Resident #2 was on a turning schedule or that he needed assistance to turn. He stated he had not been turning or repositioning the resident as he was not aware of the need. On 3/21/19 at 2:20 p.m., RN #1 stated the staffing on the unit had been really low recently and there was no way that all care needs and tasks were being completed for every resident when the unit was short. On 3/21/19 at 3:26 p.m., the unit manager (UM) said there were not yet orders, documentation or care plan for the resident to be turned or repositioned every two hours or as needed. She stated that she would add this to the care plan (see above skin care plan update 3/21/19) and ADL documentation. On 3/21/19 at 3:30 p.m. and again on 3/25/19 at 3:49 p.m., the DON was interviewed and stated Resident #2's lower back pressure injury had been identified about a week ago and the delay in adding it to the care plan was because a MDS assessment was d

Based on observation, interview and record review the facility failed to ensure that one (#1) out of five sample residents was appropriately supervised to prevent an accident. Specifically,the facility failed to: - ensure resident #1, who resided on the secured unit, was not able to access an outside courtyard unattended - prevent resident #1, who was known to be at risk for falls, from sustaining injuries of multiple fractures, lacerations and bruises from a fall while in the outside courtyard unattended Facility policy: A facility policy provided on 12/5/12 titled, "Courtyard safety," Stated in pertinent part: Ensure there is a procedure in place to monitor residents while out in the courtyard, Ensure that pathways and walking paths are checked regularly for potholes or uneven surfaces that could pose a risk for falls. Seating areas should be set around the walking path to ensure that residents have resting places. The Findings include: RESIDENT PROFILE: Resident #1 was an [AGE] year old female admitted to the facility on [DATE]. According to her face sheet her [DIAGNOSES REDACTED]. According to the most recent minimum data set ((MDS) dated [DATE] the resident scored a nine out of 15 on her brief interview for mental status (BIMS) indicating that she was moderately cognitively impaired. It also indicated that the resident demonstrated a behavior of wandering. According to the resident care plan updated 9/5/12 the resident was at risk for falls related to a history of falls with a history of pelvic fracture. It documented that she had decreased safety awareness and often took herself to the bathroom. An intervention listed was to monitor and assist the resident with ambulation as needed. A care plan updated 6/14/12 read that the resident was at risk for wandering from secure locations related to confusion. The goals listed were the resident would not wander from the unit unattended, and the resident would be free from harm to herself. RECORD REVIEW: - Fall investigation: A document titled, "Fall investigation," read in pertinent part that on 10/28/12 at 8:05 a.m. resident #1 experienced a fall resulting in abrasions, bruises, cuts and lacerations. She was transported out of the facility by ambulance to the hospital. A description of the circumstances written by the nurse on duty detailed that the resident's wheelchair was seen by the locked unit door (to the) courtyard. The CNA (certified nursing aide) looked outside the door and noted the resident on the cement pathway. The CNA called the nurse to the area. The resident was noted to be on the left side with blood noted on the cement and the resident's face, hands and hair. When the resident was asked what happened she stated that she tripped. The resident was assessed and assisted by the nurse and CNA to her wheelchair and was able to take a few steps. She was taken to her room for cleaning up and assessment of skin. The nurse supervisor was called and assessed the resident. The physician was called and orders were given to send the resident to the emergency room . Medication was given to the resident and ice was applied to the left wrist and the wounds were cleaned prior to the ambulance arriving and transporting the resident to the hospital. The nurse and CNA who responded first were the only witnesses named on the report. (See interviews below.) - Change of condition: A change of condition form dated 10/28/12 detailed in pertinent part: The CNA saw a wheelchair by the back gated door, looked outside and saw resident (#1) on cement ground on walk way. She called the nurse to site. Resident was found on left side with blood noted on cement and on resident's hands, face and hair. Resident was taken to room and neurological checks were done and the resident was complaining of pain to the left wrist/hand area. Bruising was noted, the wrist was deformed and the resident was unable to move or let staff touch the area. An assessment to the skin revealed an abrasion to the left forehead and temple area, right peri-orbital area, and swollen and purple in color, skin tears to both knees. A small skin tear was noted to the right top of her hand, and her left outer shin had two abrasions. - Orthopedic follow up: A note dated 11/8/12 stated that the resident had a distal radius fracture of the left hand and wrist, and a fracture to the right hand and wrist on the 4th and 5th metacarpal shafts. - Nurse's notes: The only nursing note other than the change of condition on 10/28/12 prior to the resident's return from the hospital read, "Resident is up at 0300 (3:00 a.m.) episode of crying and wandering until 0500 (5:00 a.m.) assess for pain. Resident states she felt discomfort to her back, medicated prn (as needed) Vicodin (pain medication) resident went back to sleep after 40 minutes." A nurse's note dated 10/28/12 on the return of the resident from the hospital at 5:45 p.m. indicated that the resident had a [DIAGNOSES REDACTED]. The resident was wearing splints on both arms, had sutures to her chin, and multiple bruises and abrasions. - An in-service record dated 11/5/12, provided by the DON, in response to interventions implemented after the residents fall read, "All staff, please be aware that alarm over door leading to courtyard is to be on at all times to alert staff upon someone going outside. It is set on chime, if battery runs down nursing is to change it." INTERVIEWS: - An interview with the nurse on 12/4/12 at approximately 9:00 a.m., who was noted as a witness on the fall investigation, revealed that when asked if the resident often went outside the nurse responded that she could not say. She was unwilling to interview because she stated that it should be in her documentation. When asked if she was worried about having a conflicting interview she stated that she did not know what they would want her to say then stated that she wanted to talk to the director of nurses (DON) and left. She came back approximately ten minutes later with the DON and stated, other than going out with staff and her son the resident did not go into the courtyard. When asked how she was alerted when a resident went into the courtyard she stated a single chime sounding was the way she knew a resident was out there. When asked to describe the incident involving resident #1 being found in the courtyard she stated her shift had just started and she was the nurse who assessed the resident. The resident could not say what she was doing when she fell . She stated that she had found ambulatory patients outside before. The DON stated that the door was expected to be monitored but the CNA could be helping a resident who fell and have her back turned. The DON stated that the CNA was in a resident room and came out and saw the empty wheelchair at the door and it alerted her to look outside. The DON was asked what was done in response to a resident being found down on the ground, in the courtyard without staff noting the resident's exit, and she stated that an education sheet did go around in regards to the residents being checked on outside. (No education sheet was found or provided by the facility that detailed monitoring of the courtyard until 12/5/12 when an in-service dated 12/4/12 was provided.) - An interview with the CNA listed as a witness on the fall investigation on 12/11/12 at 3:15 p.m. revealed that she was the CNA working with the resident on the morning the resident fell . She stated that she started work at 6:30 a.m. and found the resident in another resident's bathroom, assisted the resident out and set her up to eat a continental breakfast. She then helped her back to her bed. The CNA went to assist the resident's roommate at 7:45 a.m. and saw resident #1 up in her wheelchair in the room eating a candy bar. The CNA was told by the roommate to come back in ten minutes (7:55 a.m.) to get her out of bed. The CNA stated that when she went back to help resident #1's roommate out of bed at approximately 8:00 a.m. she noted that resident #1 was gone. When asked she clarified that the last time she had seen resident #1 was at 7:45 a.m. when she was eating a candy bar. She left the room to look for the resident and saw an empty wheelchair at the door to the courtyard. She asked the nurse who was seated at the nurse's station several feet away from the door if she knew whose wheelchair was there? She stated that the nurse replied that she did not know, but she (the CNA) immediately thought it must be resident #1's. She looked outside and saw the resident on the ground in the courtyard and yelled for the nurse to help her. When asked how she was aware of a resident being in the courtyard she stated that before they had an alarm to make sound but no one realized that it was broken. She stated that it did not work the day the resident fell outside. She stated that they currently had an alarm but it could only let you know if someone went outside, but could not prevent residents from going outside. - Interview with the nursing home administrator (NHA) at 10:27 a.m. on 12/4/12 revealed that when residents got near the door a chime would go off. She added that when anything got next to the door including the dog the chime would sound. When asked if all residents in the secure unit were safe to be in the courtyard unattended she stated that at all times every resident is probably not. A post fall report that the NHA provided regarding resident #1's fall stated that equipment that was in the area of the fall was in need of repair and the NHA stated that it must have been regarding uneven surfaces and cracks in the concrete in the courtyard. When asked about the alarm or chime that alerted staff to a resident opening the door the NHA stated the chime was not something that they had in place 100% of the time. The DON came in and stated that the chime was not in place at the time of the fall. The NHA state there were cracks in the concrete but where the resident fell it was on a sloping pathway where no cracks were present. - Interview with the NHA on 12/5/12 at 9:05 a.m. revealed there was no set procedure which would notify staff if someone was outside but since the surveyor had entered the building, the facility had put in place for the nurses to check the alarm three times a day and record their checks in the medication administration record. When asked if the facility had policies and procedures in place to prevent the resident's fall and injuries in the courtyard area, the NHA stated that there was education provided to the staff to watch residents if they were outside, but she could not say that there had been a system in place when the resident fell . OBSERVATIONS: At 7:40 a.m. on 12/5/12 the resident was observed sitting at a dining table in the main room with a cup of coffee. An employee was sitting at the table with the resident. When the employee was asked if she worked, the night of the fall, she stated that she was not back in the secure unit often and was just sitting with the resident. When asked when she typically worked the employee stated that she was the van driver but was sitting with the resident. The resident had a wheelchair alarm and a lap tray on. She responded when asked basic questions but did not engage in conversation. On 12/5/12 at 8:15 a.m. the NHA walked through the courtyard where the resident was found. The courtyard was cemented with walkways stretching around the perimeter. She pointed out where the resident fell ; it was sloped gradually uphill with no chairs immediately available (see policy above which states there should be chairs by the walkway). Where the picnic table was there was a large crack in the concrete making it uneven. A grill and two chairs with wood planks were at the end of the walkway directly by the building. The NHA stated that they had a bid in to replace all of the concrete. FACILITY RESPONSE WHILE SURVEY WAS IN PROCESS: - On 12/4/12 the facility installed an alarm that sounded when the courtyard door was opened and would not stop sounding until a code was manually entered on the keypad at the door. - The resident had an order for [REDACTED]. - An in-service was conducted on 12/4/12 regarding door alarms. When asked if any of the in-servicing or alarming had been initiated prior to survey the DON could only provide the in-service dated 11/5/12 noted above.

Based on family, staff and resident interview and record review, the facility failed to ensure one of three sample residents (#1) was free from neglect. Specifically, the facility neglected to provide appropriate assistance and oversight with peri-care. Moreover, the lack of provision of peri-care resulted in a foreign body (a jingle bell) becoming embedded in the resident's labia requiring surgical removal. A facility staff member noticed this problem one month beforehand, and neglected to report it. Cross refer F157 and F312. Findings include: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], with current diagnoses, according to her face sheet, that included: dysphagia (difficulty swallowing), [MEDICAL CONDITIONS], hypertension, anxiety and depression. According to her annual assessment, a Minimum Data Set (MDS) completed on 12/15/10, she scored a four (indicating severe cognitive impairment) on her BIMs (Brief Interview for Mental Status). She was also coded to require the extensive physical assistance of one staff member with dressing, toileting and personal hygiene; and also required oversight and supervision of one staff member for transferring and bed mobility. She was coded to be incontinent of bladder and had a [MEDICAL CONDITION] in place for her bowels. 1. Record Review The closed record for resident #1 was reviewed upon entry to the facility on [DATE] as part of a complaint investigation. a. Interdisciplinary Progress Notes (IPNs) revealed the following, in pertinent parts: - 1/21/11 - 6:30 p.m. "CNA (Certified Nursing Aide) called me to sh rm (shower room). Resident has ornament on right labia. Assisted to bed for further exam. Ornament is a green jingle bell. (Name of on call physician) here for (name of primary care physician) & checked resident and says that ornament is embedded & unable to remove. Will need to see gynecology for excision. No swelling or discharge noted..." - 1/22/11 - 11 p.m. - 7 a.m. "Temp. 97.8 Resident cont (continues) with green jingle bell ordiment (SIC) to right side of labia. Asesed (SIC) area and skin in between slits in jingle bell...unable to remove. Peri care given. No S&S (signs and symptoms) of infection." - 1/22/11 - 7 a.m. - 3 p.m. "VS (vital signs) 97.3, 55, 20 - 138/72. 95% (oxygen saturation level) on RA (room air - without supplemental oxygen), pt. (patient) cont (continues) with silver/green bell to right side of labia, no S/S of infection to area. No discharge noted, peri-care given. No c/o (complaint of) pain or discomfort noted at this time..." - 1/23/11 - 11 p.m. - 7 a.m. "96.9, Cont with green/silver jingle bell on right side of labia. Up & down, out of bed this shift. Res. Self-propelled (in wheelchair) around facility, eating food & fluids. Refused sleeping pill or pill for nerves. Finally at 0345 (3:45 a.m.) asked for med. [MEDICATION NAME] (anti-anxiety medication) given. No S/S of infection noted." - 1/23/11 - 7 a.m. - 3 p.m. "...pt. cont. with green/silver bell attached to right side of labia, 0 S/S of infection, 0 redness or swelling noted. Peri-care given, no c/o pain or discomfort generally to area..." - 1/24/11 - 11 p.m. - 7 a.m. "Resident slept all night, no complaints of pain. Jingle bell still attached to right labia. Small amount of swelling, no signs of infection." NOTE: swelling can be a sign of infection...along with redness, drainage, foul odor, etc. - 1/24/11 - 10:30 a.m. "Notified (name of primary care physician) of unexpected event. Order received to send to ER for excision of metal object from labia minora. Called and informed dtr. (Name). (Name of ambulance provider) called non-emergent for transport..." According to the above documentation, this was the first time the family of resident #1 was made aware of the embedded foreign object. - 1/24/11 - 1600 (4:00 p.m.) "Dtr. At (name of another facility) called here and gave permission to nurse (name) to fax medical record info to (facility name) for direct admit there from (name of hospital). Information requested faxed. Director of Nursing notified." - 1/24/11 - 1800 (6:00 p.m.) "Daughter (name) here with husband to remove resident's personal belongings and medications. Resident is to be direct admit to (name of another facility) from (name of hospital) ER. Resident's daughter states mother's stay had been fine until today with late notification." b. Care Plan The Care Plan for resident #1 revealed in pertinent parts: "Focus: I have a history of extensive reddened peri-area and around [MEDICAL CONDITION] site...I at times require assistance for transfers onto toilet to void and remain continent of bladder when awake". It was dated as being initiated on 11/13/2009. "Goals:...I will remain dry during the day by using toilet to void... ...Interventions: Assure that I wear a brief. Keep area clean and dry. Monitor my [MEDICAL CONDITION] site and report any further redness noted..." "Focus: I am at a risk for skin breakdown due to a history of a rash and my decreased mobility. I have a history of excema (SIC) on my hands..." "...Goals: I will have no skin breakdown..." "...Interventions: Check and change me frequently...Monitor my skin with daily ADL (activities of daily living) cares and assure I receive a weekly skin assist with all ADL cares. I often refuse to shower and become extremely agitated with the caregivers if they persist... (Dated 11/2/2009)...1/4/11 I at times put items in and around me in my w/c, including under my shirt. I often become combative with staff if they try and remove articles. i.e., cups, dishes, small pretty items..." "...Goals: I will be cleaned and well-groomed daily. I will not take or place articles/items under clothing or in w/c. I will not take dishes from D.R..." "...Interventions: Please provide me with personal hygiene products as needed. Assist me with my [MEDICAL CONDITION] changes...Check and change me frequently and prn (as needed)..." c. Monthly Summary The DON stated, on 2/7/11 at approximately 9:45 a.m., that nurses completed a Monthly Summary each month for all residents. She stated it provided an up-to-date picture of their general overall status. The most recent Monthly Summary for resident #1 was dated 1/5/11, and read, in pertinent parts: "...Ambulation: Wheelchair, Most of Day...Bladder: Incontinent ...Incontinent Briefs: Worn at all times...Grooming: Needs Assistance...Hygiene: Shower..." d. MDS Cardex Report The form was generated by the MDS to provide a guidance of necessary care for the certified nurse aides (CNAs) to use as a guideline. The most current Cardex on file was dated 10/22/10; and read, in pertinent parts: - "...Cognitive ability: Short Term Memory Problem; Long term memory problem. Can recall room location and in a nursing home...Can make ADL decisions: Modified Independence...Vision: Impaired...Communication: Sometimes understands and sometimes is understood...ADL: toilet use: Extensive Assistance, one person physical assist...Mode of Transfer: Lifted manually...Bladder: Incontinent..." e. Physician's Progress Note The on-call physician that examined resident #1 on 1/21/11 wrote the following note, in pertinent parts: "...Reason for visit: Staff request...Staff reporting what appears to be a small Christmas ornament embedded in pt labia...about a 10 mm size green metallic, round object embedded in right labia minora. Not removable with gentle traction. No labial [MEDICAL CONDITION], discharge or odor...Assessment and Plan: Foreign body, genitals. To see gyn as outpatient next week for removal with local (anesthesia), Pt may need sedation due to her dementia...I advised staff does not to transfer to ER UNLESS acute signs of infection, i.e. increase [MEDICAL CONDITION] (swelling), discharge or fever..." Hospital Records The hospital ER records were obtained and reviewed, and revealed in pertinent parts: The Clinical Report was dated 1/24/11. The time seen was 11:30 a.m.... - History limited by dementia. Physical exam limited by dementia... "...History of Present Illness: Chief complaint: Foreign body. This started several days ago and still present and worsening...Per EMS (Emergency Medical Services), pt has small Christmas jingle bell imbedded in her labia and has been worsening, becoming red and mildly swollen...Review of systems: Unobtainable due to patient's altered mental status, poor comprehension and uncooperativeness. The patient has had altered mental status (chronic)..." "...Physical Exam...GU ([MEDICAL CONDITION]) bimanual exam normal, 1.5 cm green jingle bell stuck to labia minora with surrounding [DIAGNOSES REDACTED] (redness), [MEDICAL CONDITION] (swelling)... ...Progress and Procedures: Course of care 13:33 (1:33 p.m.). Foreign body removed with two forceps. Small tear to labia minora, no active bleeding... ...Instructions: Protect wound and keep wound area clean. You may wash wound briefly, then dry. Soak in warm water. Apply [MEDICATION NAME] daily. "Patient with labial foreign body." Will admit to different nursing home because of family concerns for neglect/abuse. (name of PCP ) on call notified." ...Prescription Medications: "Keflex 500 mg (antibiotic) take one capsule every 6 hours for 7 days..." "...Nursing Progress Notes...14:06 (2:06 p.m.) Daughter called and asked that pt. not be transferred back to home. Daughter is upset about incident and has a nursing home in (town where daughter lives) that will take the pt. Referred family concerns to (social services at hospital)..." 2. Administrative Staff Interviews On 2/7/11 at approximately 9:30 a.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were interviewed in regard to the findings. They both acknowledged no call to the state Occurrence Reporting Line was made. When asked why, the DON stated it was because they did not know what reportable category the incident would fall. When asked if the facility investigated the incident to rule out abuse or neglect, the DON stated she had; and provided documentation of their investigation. The documentation revealed in pertinent parts: - A facility form entitled, "Resident Abuse Investigation Report" was dated 1/25/11 and completed four days after the initial reported discovery of the foreign body. It read, in pertinent parts: - "...Type of Abuse: (Physical, sexual, verbal/mental, theft and neglect were all listed). Handwritten in was, "Not sure of what classification"...Resident Injured: (Choices were Yes, describe injuries and No. Neither Yes nor No box was checked, but handwritten was "Resident had a Christmas jiggle (SIC) bell embedded in labia...Injuries required medical attention: marked Yes, "resident was examined by MD rounding for Dr. (name of PCP). Could not remove bell and stated to make gyn appt (gynecology appointment) on Monday (1/24/11)..." There were no witnesses or persons involved listed on the form. The summary read, in pertinent parts: "CNA (name) reported to evening nurse that resident had a bell on labia. Discovered when she gave resident a shower and attempted to clean her peri-area (genitals). Stated that she hurt when CNA pulled at what she thought was a piece of colored paper. Res. Said it hurt, so she stopped and called nurse." The form revealed the resident denied any knowledge of what happened. The DON documented the resident was alert and oriented X 2 (to self and place) with "impulsive, jerky behaviors, unable to recall any details". It also noted that staff was "interviewed with varying answers as to length of time (the jingle bell was observed prior to it being reported). It also read: "Nurse and CNA re-educated on what/when/who to notify of incidents or unexpected events, family involvement in plan of care, competency on peri-care for CNAs, some nursing staff members received disciplinary action". There was a section to document who was called and when. The DON documented that she was notified on 1/21/11 at 8:30 p.m., 10 hours after the discovery was made; the NHA was notified on 1/24/11 at 8:45 a.m., three days afterwards; and that the resident's daughter was notified on 1/24/11, three days after the embedded jingle bell was discovered. The DON was asked about that date, and if it was correct for family notification. She stated it was an oversight, and that the facility staff failed to notify the responsible party/family member until three days later. The NHA stated she instructed the DON to call the physician and get an order to send the resident to the ER immediately. The DON provided two forms entitled, "(Initial of Facility) Investigation/Interviews. It showed 12 CNAs and one LPN (Licensed Practical Nurse) were interviewed. The DON wrote a summary of her investigation (undated). It read, in pertinent parts: "Investigation: I have interviewed CNAs that work on that unit and have taken care of (resident #1) for the last month. From these interviews I learned that (resident #1) was able to remain continent of bladder if staff assisted her on to toilet and was able to clean self after voiding. That during shower resident was able to do her own peri-care as staff would give her a soapy washcloth and she would wash between her legs. Only two CNAs admitted to seeing anything at all, one thought it was a piercing and thought it was cultural in nature. The other person thought it had to be something that was part of a medical treatment so he did not report it. The third person that noticed the small greenish color area thought it was a candy wrapper and tried to remove it and then discovered it was more and then did report it. Social Services (SS) did interview nearly everyone on the unit and did not identify any areas of concern...However, SS staff did not document which residents they spoke to, when they were interviewed or what was asked/answered. "Actions Taken: 1. Re-education for nurses on notification of families for both the usual and unusual happenings. 2. Re-education for CNAs on what, when to report to nurse. 3. SDC (Staff Development Coordinator) is at this time having check off for CNA competency skills with peri-care included on the agenda." The DON confirmed they had not done additional training with staff to address identifying abuse and/or neglect. She stated they would re-educate all staff in abuse training. The names of five nurses were listed, however, no formal interviews were documented. The DON wrote a note (on the back of one of the CNA interview forms )that read, "Nurses (five names) all state that no one reported the bell to them." The DON was asked why the foreign object embedded into a resident's labia was not discovered sooner. She stated the resident was independent in providing her own peri-care, and that she cleaned her own peri-area during showers. When asked about the CNA's documentation on the Resident Abuse Investigation Report (see above) that she, the CNA, was "cleaning her peri-area," The DON offered no response. The DON was asked to review the resident's records, specifically, the tools that direct care. Though the DON stated the resident was able to perform her own peri-care, was not incontinent of urine and was able to clean herself after voiding, documentation regarding the resident's assessments and care status listed above revealed specifically: - the resident's MDS showed resident #1 required extensive assistance with toileting and that she was incontinent of urine. - the resident's care plan revealed she had a history of [REDACTED]. - the Monthly Summary documented she was incontinent, had frequent mental changes, and specifically required assistance with grooming. - the Cardex showed she was incontinent and required extensive assistance with toileting and had poor short- and long-term memory. The DON acknowledged she would have expected staff to have noticed and reported the presence of any foreign object in the peri-area. The DON also confirmed the resident had a history of [REDACTED]. The DON stated the CNAs should have assisted resident #1 frequently, based on her history, dementia, skin sensitivity, inability to perform ADLs independently, and her incontinence issues. She also stated the resident had required more assistance than she was aware of. The NHA stated she had not been made aware of the incident until 1/24/11 in the morning. She immediately directed the DON to call the physician and get an order to transfer the resident to the ER. The NHA stated had she been aware on 1/21/11, when it was discovered, she would have directed the nurses to send the resident to the ER at that time. 3. Family Interview Two telephone interviews were conducted with the daughter of resident #1 on 4/12/11 at approximately 4:45 p.m. and at 9:00 a.m. on 4/13/11. She stated she was shocked to learn of the embedded jingle bell in her mother's labia, but more shocked at the delay in notifying her. She stated she was called on 1/24/11 at approximately 10:00 a.m. by a staff nurse notifying her that her mother had a foreign body embedded in her labia. The daughter stated the nurse's exact words were, "I don't know how to tell you this, and this is the most bizarre thing, but your mother has a jingle bell embedded in her labia." The daughter stated she was under the impression it had just been discovered, but later that day, the facility informed her they had been aware of it since 1/21/11. They could offer no explanation as to why she was not notified upon discovery. When they called her on 1/24/11, they stated they wanted to send her mother to the ER to have the foreign body removed from her labia. She stated she felt like her mother had been neglected because the foreign object was discovered because one CNA noticed the jingle bell a month prior and did not report it. She stated she felt the facility's lack of adequate care and assessment caused her mother harm, because the embedded foreign object would have been painful to the "reasonable person". She also stated her mother's confusion may have been a "blessing in disguise". She stated she expected the nursing home staff to assess her skin daily, adding that her mother was not able to properly clean her own genitalia, and could not physically transfer herself to toilet and then clean herself after voiding. The daughter stated the reason she had her mother transferred to another facility was because she felt her mother had been neglected. She stated there had been other incidents when she was not notified of changes in condition, such as an eye infection and after a fall. The daughter, who was the responsible party and the guardian, stated "I am supposed to be called...I was outraged that they did not call me and let my mom suffer like that for three additional days." 4. Direct Care Staff Interviews On 2/7/11, from approximately 1:40 p.m. until 3:30 p.m., a series of interviews with various staff members were conducted. Staff members were asked about their knowledge of the foreign body embedded in the labia of resident #1; if and when they had seen it; and when and to whom they reported their observation. The summary of the interviews was as follows: 1. At 1:40 p.m. on 2/7/11, a CNA who had been employed at the facility for five and a half years was interviewed. She stated slightly less than one month ago she noticed the bell on the right side of the resident's labia. She stated she thought it was a "cultural" thing that "older American women" did in this country. She stated she did not report it because the resident was a "very private lady." 2. On 2/7/11 at approximately 2:05 p.m., a LPN (Licensed Practical Nurse) who had been [MEDICATION NAME] for [AGE] years, specifically four years in the facility, was interviewed. She stated after being called to the shower to look at the resident by a CNA, around 8 p.m. (see interview #3 below) they assisted the resident into bed. She stated the resident indicated she was in pain, and that the foreign body looked like a "piece of jewelry". She stated the supervisor (a Registered Nurse-RN) on duty was called to assess the resident. She stated the RN attempted to remove it, and the resident stated it hurt. She then stated the on-call physician for resident #1's PCP was in the building making rounds so they paged the physician. The LPN stated the physician attempted to remove it but could not. The physician stated to get the resident an appointment with gynecology on 1/24/11 (the following Monday). When asked if the labia had been swollen, the LPN stated, "evidently not." 3. On 2/7/11 at approximately 2:30 p.m., the CNA who reported the foreign body on 1/21/11 was interviewed. She had worked at the facility for five years. The CNA stated she was assisting resident #1 with her shower on 1/21/11 at approximately 8:00 p.m. She stated, "I was cleaning her private parts and I saw something shiny and round. I called the nurse." She stated she did usually assist the resident with cleaning her private parts, "because she couldn't do it herself." The CNA stated the resident did do her own peri-care at times. 4. On 2/7/11 at 3:05 p.m. a CNA who had worked at the facility for approximately six months stated he had seen the foreign body in the labia of resident #1 the week before. He stated he thought it was part of a medical procedure, some type of implant, so he did not report it, though he had never seen anything like it. 5. On 2/7/11 at 3:15 p.m. a RN who had worked at the facility for one and a half years was interviewed. She stated she was working as the House Supervisor the evening of 1/21/11. She stated she was called by the LPN to come and assess resident #1 (see interview #2 above). She stated the LPN wanted a "second opinion". The RN said she was surprised, and that it looked like a jingle bell. She stated the on-call doctor was making rounds and so was asked to examine the resident. She stated the resident expressed pain when the physician attempted to remove the jingle bell, by saying "Ouch". She stated the area did not appear to be red or swollen, and that the physician stated to get her an appointment with gynecology on Monday, but to call if it worsened. She also stated she was the one who notified the DON via phone. She stated the DON "didn't direct me to call family. But it was my fault, I lost track of time."

Based on record review, and staff and family interviews, the facility failed to ensure one of three sample residents (#1) received the necessary services to maintain personal hygiene, due to the resident being unable to do her own ADL care independently. Specifically, the facility neglected to provide appropriate assistance and oversight with peri-care and showering, as specifically directed in her care plan and throughout her medical record (see below). This failure led to a foreign body (a jingle bell) becoming embedded in the resident's labia requiring surgical removal. Cross refer F157 and F224. Findings include: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with current diagnoses, according to her face sheet, that included: dysphagia (difficulty swallowing), [MEDICAL CONDITIONS], hypertension, anxiety and depression. According to her annual assessment, a Minimum Data Set (MDS), completed on 12/15/10, she scored a four (indicating severe cognitive impairment) on her BIMs (Brief Interview for Mental Status). She was also coded to require the extensive physical assistance of one staff member with dressing, toileting and personal hygiene; she required oversight and supervision of one staff member for transferring and bed mobility. She was coded as incontinent of bladder and had a [MEDICAL CONDITION] in place for her bowels. 1. Record Review The closed record for resident #1 was reviewed upon entry to the facility on [DATE] as part of a complaint investigation. a. Interdisciplinary Progress Notes (IPNs) revealed the following, in pertinent parts: - 1/21/11 - 6:30 p.m. "CNA (Certified Nursing Assistant) called me to sh rm (shower room). Resident has ornament on right labia. Assisted to bed for further exam. Ornament is a green jingle bell. (Name of on call physician) here for (name of primary care physician) & checked resident and says that ornament is embedded & unable to remove. Will need to see gynecology for excision. No swelling or discharge noted..." - 1/22/11 - 11 p.m. - 7 a.m. "Temp. 97.8 Resident cont (continues) with green jingle bell ordiment (SIC) to right side of labia. Asesed (SIC) area and skin in between slits in jingle bell...unable to remove. Peri care given. No S&S (signs and symptoms) of infection." - 1/22/11 - 7 a.m. - 3 p.m. "VS (vital signs) 97.3, 55, 20 - 138/72. 95% (oxygen saturation level) on RA (room air - without supplemental oxygen), pt. (patient) cont (continues) with silver/green bell to right side of labia, no S/S of infection to area. No discharge noted, peri-care given. No c/o (complaint of) pain or discomfort noted at this time..." - 1/23/11 - 11 p.m. - 7 a.m. "96.9, Cont with green/silver jingle bell on right side of labia. Up & down, out of bed this shift. Res. Self-propelled (in wheelchair) around facility, eating food & fluids. Refused sleeping pill or pill for nerves. Finally at 0345 (3:45 a.m.) asked for med. [MEDICATION NAME] (anti-anxiety medication) given. No S/S of infection noted." - 1/23/11 - 7 a.m. - 3 p.m. "...pt. cont. with green/silver bell attached to right side of labia, 0 S/S of infection, 0 redness or swelling noted. Peri-care given, no c/o pain or discomfort generally to area..." - 1/24/11 - 11 p.m. - 7 a.m. "Resident slept all night, no complaints of pain. Jingle bell still attached to right labia. Small amount of swelling, no signs of infection." - 1/24/11 - 10:30 a.m. "Notified (name of primary care physician) of unexpected event. Order received to send to ER for excision of metal object from labia minora. Called and informed dtr. (Name). (Name of ambulance provider) called non-emergent for transport..." The above note revealed it was the first time the family of resident #1 was made aware of the embedded foreign object. - 1/24/11 - 1600 (4:00 p.m.) "Dtr. At (name of another facility) called here and gave permission to nurse (name) to fax medical record info to (facility name) for direct admit there from (name of hospital). Information requested faxed. - 1/24/11 - 1800 (6:00 p.m.) "Daughter (name) here with husband to remove resident's personal belongings and medications. Resident is to be direct admit to (name of another facility) from (name of hospital) ER. Resident's daughter states mother's stay had been fine until today with late notification." b. Care Plan The care plan for resident #1 revealed, in pertinent parts: "Focus: I have a history of extensive reddened peri-area and around [MEDICAL CONDITION] site...I at times require assistance for transfers onto toilet to void and remain continent of bladder when awake". It was dated as being initiated on 11/13/2009. "Goals:...I will remain dry during the day by using toilet to void..." "...Interventions: Assure that I wear a brief. Keep area clean and dry. Monitor my [MEDICAL CONDITION] site and report any further redness noted..." "Focus: I am at a risk for skin breakdown due to a history of a rash and my decreased mobility. I have a history of excema (SIC) on my hands..." "...Goals: I will have no skin breakdown ..." "...Interventions: Check and change me frequently...Monitor my skin with daily ADL (activities of daily living) cares and assure I receive a weekly skin assist with all ADL cares. I often refuse to shower and become extremely agitated with the caregivers if they persist...(Dated 11/2/2009)...1/4/11 I at times put items in and around me in my w/c, including under my shirt. I often become combative with staff if they try and remove articles. i.e. cups, dishes, small pretty items..." "...Goals: I will be cleaned and well-groomed daily. I will not take or place articles/items under clothing or in w/c. I will not take dishes from D.R...." "...Interventions: Please provide me with personal hygiene products as needed. Assist me with me my [MEDICAL CONDITION] changes...Check and change me frequently and prn (as needed)..." c. Monthly Summary The DON stated on 2/7/11 at approximately 9:45 a.m., the nurses completed a Monthly Summary each month for all residents. She stated it provided an up to date picture of their general overall status. The most recent Monthly Summary for resident #1 was dated 1/5/11 and read, in pertinent parts: "...Ambulation: Wheelchair, Most of Day...Bladder: Incontinent...Incontinent Briefs: Worn at all times...Grooming: Needs Assistance...Hygiene: Shower..." d. MDS Cardex Report This report was generated by the MDS to provide a guidance of necessary care for the certified nurse aides (CNAs) to use as a guideline. The most current Cardex on file was dated 10/22/10 and read, in pertinent parts: - "...Cognitive ability: Short Term Memory Problem; Long term memory problem. Can recall room location and in a nursing home...Can make ADL decisions: Modified Independence...Vision: Impaired...Communication: Sometimes understands and sometimes is understood...ADL: Toilet use: Extensive Assistance, one person physical assist ...Mode of Transfer: Lifted manually...Bladder: Incontinent..." e. Hospital Records The hospital ER records were obtained and reviewed. They revealed, in pertinent parts: The Clinical Report, dated 1/24/11 revealed the time the resident was seen was 11:30 a.m...."History limited by dementia. Physical exam limited by dementia..." "...History of Present Illness: Chief complaint: Foreign body. This started several days ago and still present and worsening...Per EMS (Emergency Medical Services), pt has small Christmas jingle bell imbedded in her labia and has been worsening, becoming red and mildly swollen...Review of systems: Unobtainable due to patients' altered mental status, poor comprehension and uncooperativeness. The patient has had altered mental status (chronic)..." "...Physical Exam...GU ([MEDICAL CONDITION]) bimanual exam normal, 1.5 cm green jingle bell stuck to labia minora with surrounding [DIAGNOSES REDACTED] (redness), [MEDICAL CONDITION] (swelling)... ...Progress and Procedures: Course of care 13:33 (1:33 p.m.). Foreign body removed with two forceps. Small tear to labia minora, no active bleeding... ...Nursing Progress Notes...14:06 (2:06 p.m.) Daughter called and asked that pt. not be transferred back to home. Daughter is upset about incident and has a nursing home in (town where daughter lives) that will take the pt. Referred family concerns to (social services at hospital)..." f. physician progress notes [REDACTED]. "...Reason for visit: Staff request...Staff reporting what appears to be a small Christmas ornament embedded in pt labia...about a 10 mm size green metallic, round object embedded in right labia minora. Not removable with gentle traction. No labial [MEDICAL CONDITION], discharge or odor...Assessment and Plan: Foreign body, genitals. To see gyn as outpatient next week for removal with local (anesthesia), Pt may need sedation due to her dementia...I advised staff does not transfer to ER UNLESS acute signs of infection, i.e., increase [MEDICAL CONDITION] (swelling), discharge or fever..." According to the ER documentation, the resident had [MEDICAL CONDITION] and redness when seen inER on [DATE]. g. Administrative Staff Interviews On 2/7/11 at approximately 9:30 a.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were interviewed in regard to the investigation of the incident that occurred on 1/21/11. When asked if she had investigated to rule out any type of abuse or neglect, she stated she had, and provided the documentation of their investigation. It included, in pertinent parts: - A facility form entitled "Resident Abuse Investigation Report" was dated 1/25/11 and completed four days after the initial reported discovery of the foreign body by the DON. It read, in pertinent parts: "...Type of Abuse: (Physical, sexual, verbal/mental, theft and neglect were all listed). Handwritten in was "Not sure of what classification "...Resident Injured: (Choices were Yes, describe injuries and No. Neither Yes or No box was checked, but it was handwritten in "Resident had a Christmas jiggle (SIC) bell embedded in labia...Injuries required medical attention: marked Yes" resident was examined by MD rounding for Dr. (name of PCP). Could not remove bell and stated to make gyn appt (gynecology appointment) on Monday (1/24/11)..." There were no witnesses or persons involved listed on the form. The summary read, in pertinent parts: "CNA (name) reported to evening nurse that resident had a bell on labia. Discovered when she gave resident a shower and attempted to clean her peri-area (genitals). Stated that she hurt when CNA pulled at what she thought was a piece of colored paper. Res. Said it hurt, so she stopped and called nurse." The form revealed the resident denied any knowledge of what happened. The DON documented the resident was alert and oriented X 2 (to self and place) with "impulsive, jerky behaviors, unable to recall any details". It also revealed staff was interviewed with varying answers as to length of time (the jingle bell was observed prior to it being reported). It also read: "Nurse and CNA re-educated on what/when/who to notify of incidents or unexpected events, family involvement in plan of care, competency on peri-care for CNAs, some nursing staff members received disciplinary action". The NHA stated she instructed the DON to call the physician and get an order to send the resident to the ER immediately. The DON provided other documentation, two forms, entitled "(Initial of Facility) Investigation/Interviews". It showed 12 CNAs and one LPN (Licensed Practical Nurse) were interviewed. The DON wrote a summary of her investigation (undated). It read, in pertinent parts: "Investigation: I have interviewed CNAs that work on that unit and have taken care of (resident #1) for the last month. From these interviews I learned that (resident #1) was able to remain continent of bladder if staff assisted her on to toilet and was able to clean self after voiding. That during shower resident was able to do her own peri-care as staff would give her a soapy washcloth and she would wash between her legs. Only two CNAs admitted to seeing anything at all, one thought it was a piercing and thought it was cultural in nature. The other person thought it had to be something that was part of a medical treatment so he did not report it. The third person that noticed the small greenish color area thought it was a candy wrapper and tried to remove it and then discovered it was more and then did report it. Social Services (SS) did interview nearly everyone on the unit and did not identify any areas of concern..." However, the SS staff did not document which residents they spoke to, when they were interviewed or what was asked/answered. "Actions Taken: 1. Re-education for nurses on notification of families for both the usual and unusual happenings. 2. Re-education for CNAs on what, when to report to nurse. 3. SDC (Staff Development Coordinator) is at this time having check off for CNA competency skills with peri-care included on the agenda." The DON confirmed they had not done additional training with staff to address identifying abuse and/or neglect. She stated they would re-educate all staff in abuse training. The names of five nurses were listed, however, no formal interviews were documented. The DON wrote a note (on the back of one of the CNA interview forms that read, "Nurses (five names) all state that no one reported the bell to them". When asked why she did not document something more formal, as she had done with the CNA interviews, she stated she did not know. The DON was asked how a jingle bell could become embedded in the resident's labia and not be discovered sooner, given the resident's care needs. She stated the resident was independent in providing her own peri-care, and she cleaned her own peri-area during showers. When asked why the CNA documented on the Resident Abuse Investigation Report (see above) that she was "cleaning her (the resident's) peri-area," she offered no response. The DON was asked to review the resident's records, specifically, the tools that directed the resident's care. Though the DON stated the resident was able to provide care to herself as described in the above interview, the resident's documented assessment of care needs and direct care staff interviews did not match the DON's assessment of the resident's independent care status. Specifically, - Review of her MDS (see above) showed that resident #1 required extensive assistance with toileting and that she was incontinent of urine (and she had a [MEDICAL CONDITION]). - Review of her care plan (see above) revealed she had a history of [REDACTED]. - Review of the Monthly Summary (see above) documented she was incontinent, had frequent mental changes and specifically required assistance with grooming. - Review of the Cardex (see above) showed she was incontinent and required extensive assistance with toileting and had poor short and long term memory problems. The DON acknowledged she would have expected staff to have noticed and reported the presence of any foreign object in the peri-area. The DON also confirmed the resident had a history of [REDACTED]. When asked if the CNAs should have assisted resident #1 frequently, based on her history, dementia, skin sensitivity, inability to perform ADLs independently and her incontinence status, the DON stated yes. She stated the resident had required more assistance than she was aware of. h. Family Interview Two telephone interviews were conducted with the daughter of resident #1 on 4/12/11 at approximately 4:45 p.m. and at 9:00 a.m. on 4/13/11. She stated she was shocked to learn of the embedded jingle bell in her mother's labia, but more shocked by the delay in notifying her. She stated she was called on 1/24/11 at approximately 10:00 a.m. by a staff nurse stating that her mother had a foreign body embedded in her labia. The daughter stated the nurse's exact words were, "I don't know how to tell you this, and this is the most bizarre thing, but your mother has a jingle bell embedded in her labia." The daughter stated she was under the impression it had just been discovered, but later that day, the facility informed her they had been aware of it since 1/21/11. They could offer no explanation as to why she was not notified upon discovery. When they called her on 1/24/11, they stated they wanted to send her mother to the ER to have the foreign body removed from her labia. She stated she felt like her mother had been neglected, because it was discovered by one CNA who had noticed the jingle bell a month prior and did not report it. She felt the facility's lack of adequate care and assessment caused the resident harm, because it would have been painful to the "reasonable person". She also stated her mother's confusion may have been a blessing in disguise". She stated she expected the nursing home staff to assess the resident's skin daily, and that her mother was not able to properly clean her own genitalia, could not physically transfer to toilet and then clean herself after voiding. The daughter stated the reason she had her mother transferred to another facility was because she felt her mother had been neglected. She stated there had been other incidents when she was not notified of changes in condition, such as an eye infection and after a fall. The daughter was the responsible party, and the guardian. She stated, "I am supposed to be called...I was outraged that they did not call me and let my mom suffer like that for three additional days." i. Direct Care Staff Interviews On 2/7/11, from approximately 1:40 p.m. until 3:30 p.m., a series of interviews with various staff members was conducted. They were asked about their direct knowledge of the foreign body embedded in the labia of resident #1; if and when they had seen it; and when and to whom they reported their observation to. The summary of those interviews is as follows: 1. At 1:40 p.m. on 2/7/11 a CNA who had been employed at the facility for five and a half years was interviewed. She stated that slightly less than one month ago, she noticed the bell on the right side of the resident's labia. She stated she thought it was a "cultural" thing that "older American women" did in this country. She stated she did not report it because the resident was a "very private lady." 2. On 2/7/11 at approximately 2:05 p.m., a LPN (Licensed Practical Nurse) who had been [MEDICATION NAME] for [AGE] years, including four years in that facility, was interviewed. She stated that after being called to the shower to look at the resident by a CNA, around 8 p.m., (see interview #3 below) they assisted the resident to bed. She stated the resident indicated she was in pain and that it looked like a "piece of jewelry". She stated the supervisor (a RN-Registered Nurse) on duty was called to assess the resident. She stated the RN attempted to remove it and the resident stated it hurt. She then stated that the on-call physician for resident #1's PCP was in the building making rounds so they paged the physician. The LPN stated the physician attempted to remove it but could not. The physician stated to get the resident an appointment with gynecology on 1/24/11 (the following Monday). When asked if the labia had been swollen, the LPN stated "Evidently not." 3. On 2/7/11 at approximately 2:30 p.m., the CNA who reported the foreign body on 1/21/11 was interviewed. She had worked at the facility for five years. The CNA stated she was assisting resident #1 with her shower on 1/21/11 at approximately 8:00 p.m. She stated, "I was cleaning her private parts and I saw something shiny and round. I called the nurse." She stated she usually assisted the resident with cleaning her private parts "because she couldn't do it herself." The CNA stated the resident did do her own peri-care at times. 4. On 2/7/11 at 3:05 p.m. a CNA who had worked at the facility for approximately six months stated he had seen the foreign body in the labia of resident #1 the week before. He stated he thought it was part of a medical procedure, some type of implant, so he did not report it. 5. On 2/7/11 at 3:15 p.m. a RN who had worked at the facility for one and a half years was interviewed. She stated she was working as the House Supervisor the evening of 1/21/11. She stated she was called to come and assess resident #1 by the LPN (see interview #2 above) charge nurse on duty. She stated the LPN wanted a "second opinion". The RN said she was surprised and that it looked like a jingle bell. She stated the on-call doctor was making rounds and was asked to examine the resident. She stated the resident expressed pain when the physician attempted to remove the jingle bell, by saying "Ouch". She stated the area did not appear to be red or swollen at that time, and the physician stated to get her an appointment with gynecology on Monday, but to call if it worsened. She also stated she was the one that notified the DON via phone. She stated the DON "didn't direct me to call family. But it was my fault, I lost track of time." All of the above noted staff were asked what level of assistance resident #1 required. All, except for one CNA (see above-interview #3) maintained the resident did her own peri-care and personal hygiene (after toileting and during showers). The foreign body was found by the CNA while providing hands on peri-care. She stated she was providing the peri-care because the resident was unable to do so. She also confirmed resident #1 wore a brief constantly due to her urinary incontinence. The CNA also stated she provided peri-care for the resident frequently, and that the resident at times would attempt to wipe herself if she voided in the toilet, but definitely could not wash herself. When asked to further explain, the CNA stated, "Well, she is older, very hard for her to reach her private parts, and she has [MEDICAL CONDITION] and shakes a lot. She can't see very well either."