Every finding on record at Thornton Care Center

Based on observations, record review and interviews, the facility failed to ensure one (#5) of three residents reviewed for accidents out of seven sample residents remained as free from accidents and hazards as possible.Specifically, the facility failed to: -Ensure staff implemented care planned fall interventions to prevent a fall for Resident #5;-Implement new fall interventions in a timely manner for Resident #5 following a fall on 8/14/26;-Ensure staff documented in the electronic medical record (EMR) a fall for Resident #5, including documentation of neurological assessments and ongoing monitoring following the fall on 8/14/26; and,-Ensure staff documented in the EMR notification to Resident #5's representative of the resident's fall and documented notification regarding the resident's ER transfer and findings to the resident's representative and the physician.Findings include:I. Facility policy and procedureThe Fall Management policy and procedure, dated 6/15/26, was provided by the nursing home administrator (NHA) on 8/27/26 at 3:03 p.m. It read in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program. Risk factors that are internal to the resident include the resident's physical health and functional status. External risk factors include medication side effects, the use of appliances, and environmental conditions. To be effective, a fall reduction program is characterized by four components: fall risk evaluation; care planning and implementation of interventions; ongoing evaluation process Quality Assurance Performance Improvement (QAPI); and commitment by caregivers to make it work. If a resident experiences a fall with head injury, or unwitnessed fall with unknown head injury; neurological checks will be initiated. Falls review will include the following: review the risk management incident to ensure complete and appropriate parties have been notified regarding the incident; review the interdisciplinary team (IDT) risk management to ensure complete and appropriate interventions have been implemented; review that a care plan has been initiated; and provide revisions to the plan of care as necessary after falls.II. Resident #5A. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included dysphagia following cerebral infarction, flaccid hemiplegia, bipolar disorder, dementia, anxiety disorder, and quadriplegia.The 6/19/26 minimum data set (MDS) assessment revealed the staff assessment for mental status was conducted and revealed the resident had short-term and long-term memory problems. The resident was able to recall staff names/faces, that he was in a nursing home and he had moderate impairment for daily decision-making. The MDS assessment indicated the resident was dependent on staff for assistance with eating, bathing, upper/lower body dressing, bed mobility, and all transfers. He was non ambulatory and did not use a wheelchair. B. Resident observationsOn 8/26/26 at 11:30 a.m. Resident #5 was observed sleeping in bed. A fall mat was out in front of the bed and the bed was in the lowest position. There was no signage in the room regarding the proper height for the resident's bed.-However, according to the resident's fall care plan, a sign was supposed to be posted to inform staff of the height the resident's bed was to be in when the resident was in bed. (see care plan below).C. Facility investigation of Resident #5's fall on 8/14/26The fall investigation, which was not part of the resident's medical record, for Resident #5's fall on 8/14/26 was provided by the nursing home administrator (NHA) on 8/27/26 at 11:04 a.m. The investigation revealed Resident #5 was found on the floor on 8/14/26 at 11:00 a.m. The resident was reported to have fallen out of bed. The physician's assistant (PA) was present in the building and came to the resident's bedside, with the staff, to assist with the assessment. Due to the unwitnessed fall from the bed to the floor and concern for potential injury, Resident #5 was transferred to the hospital for further evaluation and observation. No injuries were observed at the time of the incident, and the resident was non-verbal. Resident #5 was bedridden and alert and oriented to the situation. There were no predisposing factors identified. Per staff report, Resident #5's bed was positioned at an elevated height above the recommended level. Given the reported height of the bed and the unwitnessed nature of the fall, there was concern for potential injury warranting further medical evaluation. The resident's family member was notified on 8/14/26 at 11:15 a.m. -However, a review of the resident's EMR failed to reveal documentation related to the resident' fall (see record review below).D. Record reviewResident #5's care plan revealed he was at risk for falls related to incontinence, impulsiveness, decreased safety awareness, behaviors, and a history of falls, revised 3/19/26. Pertinent interventions included to encourage Resident #5 to ask for assistance, provide touch pad call light to residents hip, staff to ensure Resident #5 was properly positioned in the middle of bed after care to ensure enough space on both sides of the bed to prevent rolling out; and new interventions included signage in room for proper bed height, staff education for proper bed height (initiated 8/17/26). -The facility failed to update Resident #5's fall care plan with a new intervention until 8/17/26, three days after the resident fell on 8/14/26. The 4/30/26 quarterly nurse fall risk evaluation revealed Resident #5 was a high fall risk-Review of Resident #5's nurse progress notes in the resident's EMR revealed there was no documentation related to the resident's fall on 8/14/26, including notification about the fall to the resident's representative.The 8/14/26 PA assessment note revealed the reason for the visit was a follow-up after a fall. The PA documented a resident came to the nurses' station to report Resident #5 was on the floor after falling out of bed. Resident #5's bed was normally lowered to the floor level due to his high fall risk, however a certified nurse aide (CNA) had left the resident's bed in an elevated position and Resident #5 was presumed to have fallen from approximately three feet, landing on a fall mat. His supplemental oxygen was displaced during the event. Resident #5 was able to nod yes, indicating he was okay, but continued to grip at his head as if he were in pain. Resident #5 was nonverbal at baseline. Due to the unknown duration of time the resident was on the ground without supplemental oxygen, he was sent out to the emergency room (ER) for further evaluation. Staff reported he appeared to be at his neurological baseline at the time of the transfer to the hospital. On examination after the fall, the resident was found lying on his side with chorea/tremoring of the left extremities and head; his pupils were equal and reactive to light with extraocular movement intact. Otherwise the neurological exam was difficult to assess due to the resident's baseline deficits. A head injury was suspected and further evaluation was obtained at the ER.The assessment/plan for the resident's fall from bed was to await the results of external evaluation; reinforce staff education on ensuring the resident's bed was lowered to floor level at all times, given the resident's high fall risk; monitor oxygen saturation levels closely; monitor for any delayed neurological changes, as the resident was gripping at his head suggesting possible head pain or discomfort; and, monitor for any new neurological deficits following the fall. -However, review of Resident #5's EMR failed to reveal any documentation of the fall on 8/14/26, including ongoing monitoring and neurological assessments following the resident's fall.The 8/21/26 nurse skin integrity note (completed seven days after the resident's fall) revealed the Resident #5 presented with bruising to his face and arms due to a recent fall.-However, review of the resident's EMR did not reveal documentation to indicate a skin assessment or a pain assessment was completed following the resident's fall on 8/14/26.The 8/19/26 IDT risk management review note revealed Resident #5 had an unwitnessed fall on 8/14/26 and the root cause was the resident was unable to verbalize how he fell. The PA was in the facility at the time of the fall and upon the PA's recommendation, Resident #5 was sent to the ER for further evaluation. Interventions were to send the resident to the ER for further evaluation and education was provided to the nursing staff related to the resident's bed height.-However, the IDT did not review the resident's fall until five days after the fall and the root cause analysis did not identify that the resident's bed height was too high.The 8/14/26 ER report revealed that Resident #5 presented to the ER after an unwitnessed fall from his bed, landing on a pad adjacent to the bed. The primary complaint was left ankle and leg pain. The duration of time on the ground was unknown. After receiving the results of the testing and scans there was a re-evaluation which revealed no signs of acute trauma on imaging. The CT (computerized tomography) scan of the resident's head revealed no intracranial hemorrhage (brain bleed). The 8/14/26 hospital CT scans and X-rays were negative for new fractures or dislocations to the cervical spine, head, left foot, left leg, chest and pelvis. -Review of Resident #5's EMR failed to reveal documentation to indicate the resident's representative was notified of the resident's transfer to the ER for further evaluation or the resident's return to the facility and the findings from the hospital. -Review of the resident's EMR failed to reveal documentation to indicate the physician was notified of the resident's return to the facility and the findings from the hospital.III. Staff interviewsThe director of nursing (DON), the NHA, and the regional clinical resource were interviewed together on 8/27/26 at 1:10 p.m. The DON said she had no record of neurological assessments for Resident #5 after his unwitnessed fall (on 8/14/26) because the initial assessment was completed by the PA; however, they never resumed neurological assessments after Resident #5 returned from the ER. The DON said the process for when someone returned from the hospital was there should be neurological assessments for three days after a fall. The DON and the regional clinical resource said they completed staff education on 8/18/26 that reviewed post-fall neurological monitoring requirements and that every unwitnessed fall required a completed neurological assessment monitoring record for 72 hours. The DON and the regional clinical resource said the staff education additionally included that after any fall, residents were to be placed on alert charting every shift for 72 hours for documentation purposes and monitoring. The DON said there should have been alert charting for Resident #5 for 72 hours after his fall to monitor for changes from the resident's baseline, such as increased pain, because issues could arise later after a fall. The DON said the ER assessment and discharge documents were not uploaded to the resident's EMR until 8/20/26, but the facility was notified Resident #5 had no head injury. The DON said when a resident returned from the ER, the floor nurse would review the paperwork and look for new physician's orders or changes. The DON said after review of the paperwork, the floor nurse should let the physician know the findings and document in the progress notes; however, she did not see the documentation that the physician was made aware of the ER visit results or that Resident #5 had returned from the ER. The DON said it would be important to let the physician know about any changes and to keep them updated. The DON said it would be important to have documentation after a resident returned from the ER or after a fall for continuity of care and monitoring. The DON said there was no nursing documentation in Resident #5's progress notes regarding the resident's fall on 8/14/26, when the resident was sent to the ER, or when he returned from the ER. She said there was no documentation in the resident's EMR for three days after the resident's fall that demonstrated ongoing monitoring of the resident. The DON said she would want documentation to ensure the best quality of care and to prove that monitoring was being done. The DON said after Resident #5's fall, the facility conducted a risk management (which was not part of the resident's medical record) and an IDT risk management note on 8/19/26. The DON said the IDT assessment note was completed five days after the resident's fall, which was not typically the time frame she wanted. She said she tried to complete a review of a fall by the next day in order to update the fall interventions. The DON said the new fall prevention interventions were not implemented in Resident #5's fall care plan until 8/17/26 (three days after the resident's fall). The DON said the care plan's purpose was to allow the staff member to know how to take care of Resident #5, but the staff did not have the new intervention related to the resident's bed height immediately after the fall.The DON said the facility had instituted nursing education concerning alert charting and monitoring after a fall, and she had updated the huddle meetings to add a 24-hour report to implement initial/immediate post fall interventions. The DON said the facility additionally updated the discharge checklist, family notifications and charting that notification was completed, added more oversight of unit managers with a lengthy review of falls, injuries, and anyone who went out to the hospital. She said the additional education was started today (8/27/26), during the survey.

Based on observations, record review and interviews, the facility failed to ensure two (#1 and #4) of five residents reviewed for accident hazards received adequate supervision out of 14 sample residents.Resident #1 was admitted to the facility with diagnoses of neurocognitive disorder, brain injury with loss of consciousness and arthritis. According to documentation, Resident #1 had four falls from 6/6/25 to 7/9/25. Two falls required evaluation and treatment at the hospital emergency department. The fall on 6/21/25 caused a pelvic fracture, and after a fall on 7/9/25, the resident was monitored and was allowed to go on an activity trip to a local restaurant for lunch on the same day. While at the restaurant, the resident had another fall on 7/9/25 and was transferred to the emergency department. The hospital physician determined Resident #1 had fainted due to dehydration. On 6/8/25 at 11:00 a.m., a staff member found Resident #1 on the floor in the main entrance common area. A nurse assessed Resident #1 and determined Resident #1 was not injured from the fall. The risk management fall review note was reviewed and documented the root cause of the fall was from an unsteady balance. Resident #1's fall prevention care plan interventions were updated 6/18/25 (10 days later) and included calling staff for assistance when she felt weak or dizzy. On 6/21/25 at 11:21 a.m., staff found Resident #1 on the floor in the main entrance common area. A nurse assessed the resident and notified the provider that Resident #1 complained of head and neck pain. Resident #1 was transferred to the emergency room and was diagnosed with a pelvic fracture. The 6/21/25 risk management fall review note was reviewed and revealed the root cause of the fall was due to a personal history of traumatic brain injury with a loss of consciousness. There were no changes made to Resident #1's fall prevention care plan after the fall.On 7/9/25 at 5:25 a.m., Resident #1 fell and was found by staff in a non-verbal condition. A nurse assessed Resident #1 and documented Resident #1 was verbally responsive after a few minutes. There was no documentation of ongoing nursing assessments after the fall, and there were no immediate changes to the resident's fall prevention care plan.On 7/9/25 at 11:01 a.m., Resident #1 traveled on a facility sponsored outing to a restaurant. While at the restaurant, Resident #1 was found on the floor in the bathroom and was transferred to the emergency department. The resident had not been assisted by staff to use the restroom during the outing. The resident was diagnosed with syncope (fainting) from dehydration. The 7/16/25 risk management fall review note documented Resident #1 fell twice on 7/9/25 due to poor safety awareness and having an unsteady gait. The 7/23/25 interdisciplinary team (IDT) progress note documented a physical therapy evaluation was initiated for Resident #1, which was 14 days after the fall.Additionally, Resident #4, who was assessed to have Alzheimer's disease, history of a stroke, right sided paralysis, history of falling, sepsis and cognitive communication deficits was transported by her spouse to an optometry appointment on 8/4/25. While at the appointment, Resident #4 fell from her motorized scooter and sustained a head laceration and thoracic spine fracture. Upon initial facility admission, the facility assessed Resident #4 to be independent while operating a manual wheelchair. However, the resident had a power-wheelchair. There was no documentation the facility completed an assessment to determine if Resident #4 had the cognitive or physical ability to operate a power-mobility equipment/wheelchair/scooter safely. There was no documentation the IDT reviewed or revised Resident #4's care plan after the 8/4/25 fall. Specifically, the facility failed to: -Ensure Resident #1, who was assessed to have a fall history, a history of brain injury, moderate cognitive impairment, memory impairment and required teaching in segments, remained free of falls with injury; and,-Ensure Resident #4, who had fractured joints upon arrival to the facility was assessed for an ongoing ability to safely operate her power-mobility equipment/scooter to prevent Resident #4 from falling from the scooter while at an appointment.Findings include:I. Facility policy and procedureThe Fall Management policy, dated 2/29/24, was provided by the nursing home administrator (NHA) 8/20/25 at 2:20 p.m. It revealed in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained to assess all residents to determine their risk for falls. A plan will be implemented based on the resident's assessed needs.To be effective a fall reduction program will include a fall risk evaluation, care planning and implementation of interventions, and ongoing evaluation of the process. A fall risk evaluation will be completed within 24 hours of admission and a baseline care plan will be initiated for residents determined to be at risk for falls. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy. Educate and communicate implemented interventions to direct care staff via verbal report. Document the residents' response to fall prevention interventions and revise interventions if the interventions are not successful. If a resident experiences an unwitnessed fall, neurological checks will be initiated. The facility will review all falls daily during the morning quality meeting. The fall review will include review of the incident report, review that a care plan was initiated, revise the plan of care after a fall as necessary.II. Resident # 1A. Resident statusResident #1, age greater than 65, was admitted on [DATE], discharged to the hospital on 7/9/25 and was readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included neurocognitive condition without behavioral disturbance, unspecified intracranial injury with loss of consciousness, insomnia, osteoarthritis and history of falling.The 4/24/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent from staff assistance for bed mobility, sitting and standing, transferring and walking with a walker. B. Resident interview and observationResident #1 was interviewed on 8/20/25 at 12:10 p.m. Resident #1 said she was happy at the facility. Resident #1 said she enjoyed walking to activities, to visit with her friends and to the dining room for meals. Resident #1 said if she needed help in the common areas she was not sure what she should do and said she would sit and rest on a chair. Resident #1 said she did not need very much assistance and said she was unsure when she should request assistance from staff. Resident #1 said staff gave her several instructions that were confusing. Resident #1 was observed ambulating independently on 8/18/25, 8/19/25 and 8/20/25 throughout the facility using a front-wheeled walker. Resident #1 ambulated slowly with short jerking steps and had a limp on her right side. Resident #1 was observed sitting at a table by herself in the common area, near the main entrance, where she made flower arrangements. The common area did not have access to a call light to use if a resident needed assistance, and the resident was not provided with a way to notify staff if she needed help. C. Record reviewResident #1's fall care plan, initiated 4/18/25, revealed Resident #1 was at risk for falls related to a neurocognitive disorder, intracranial injury with loss of consciousness, impaired balance, poor safety awareness, history of falls and osteoarthritis in her right knee. Interventions included ensuring Resident #1 wore appropriate footwear when ambulating (initiated 4/18/25), ensuring Resident #1 had her call light in reach, encouraging Resident #1 to use her call light, responding promptly to requests for assistance, encouraging Resident #1 to participate in activities to promote exercise for strengthening (initiated 4/23/25), calling for assistance with feeling weak and dizzy (initiated 6/18/25), assessing and meeting Resident #1's needs, providing adaptive devices as needed, educating Resident #1 about safety reminders and what to do when a fall occurs, encouraging rest periods when signs of fatigue are noted, requesting a medication review with the pharmacist (initiated 7/18/25), using a wheelchair on all outings for fall prevention, and a physical therapy evaluation (initiated 7/23/25).Resident #1's functional performance care plan, initiated 4/18/25, revealed Resident #1 had a self-care deficit related to epilepsy, neurocognitive disorder, intracranial injury with loss of consciousness, impaired balance, poor safety awareness, history of falls and osteoarthritis in her right knee. Interventions included using the call bell to call for assistance (initiated 4/18/25), transferring independently between surfaces (initiated 4/23/25) and using a walker for ambulation (initiated 5/1/25).Resident #1's cognitive care plan, initiated 4/23/25, revealed Resident #1 had impaired cognition or thought processes related to cognitive disorder, history of traumatic brain injury and moderate cognitive impairment. Interventions included using task segmentation to support short term memory deficits and breaking tasks into one step at a time.-Resident #1 had a fall prevention care plan that identified Resident #1 was assessed to have moderate cognitive impairment. The resident was not assessed to determine if she understood the fall prevention and safety awareness interventions included on the care plan. Resident #1 walked independently throughout the facility with her walker and there were no assessments to indicate that Resident #1 had the cognitive ability to locate and activate a call light to request assistance from her room or common areas when she felt weak or dizzy.D. Falls1. Fall #1 The 6/11/25 nurse progress note, documented on 6/8/25 at 11:00 a.m., revealed Resident #1 was found on the floor, in the common area of the main entrance, sitting on her buttocks. The nurse completed an assessment and found no injuries. The nurse documented Resident #1 said she felt unsteady on her feet and sat down on the floor. The 6/16/25 IDT progress note revealed the IDT determined the cause of the fall was due to Resident #1's clinical diagnoses. The IDT recommended a new intervention for Resident #1 to call for assistance when she felt weak or dizzy. -However, the IDT made no referrals to the therapy department for evaluation of Resident #1's unsteadiness and weakness in an attempt to prevent future falls.2. Fall #2 The 6/21/25 at 12:36 p.m. nurse progress note, documented on 6/21/25 at 11:21 a.m., revealed that Resident #1 was found on the floor, in the common area of the main entrance. The nurse completed a physical assessment and documented Resident #1 was non-verbal. The nurse documented neurological assessments were initiated, however, the facility was unable to provide the documentation of the neurological assessments. The progress note documented that Resident #1 complained of head and neck pain, and was transported to the emergency department for evaluation. The 6/21/25 hospital discharge summary revealed Resident #1 was diagnosed with a hip bruise, a pelvic fracture and sacroiliac (pelvis) joint dysfunction.General discharge instructions included: -Rest as needed, return to your normal activities as told by your health care provider, ask your health care provider what activities are safe for you;-Do exercises as told by your health care provider or physical therapist;-Keep all follow-up visits; and,-Call 911 if you have increased pelvic swelling, pain or redness of a leg or chest pain. -The 6/24/25 IDT progress note revealed there were no new care plan interventions initiated to include the discharge instructions and there were no changes made to Resident #1's fall prevention care plan. 3. Fall #3The 7/9/25 at 6:00 a.m. nurse progress note documented Resident #1 was found on the floor in the hallway outside the nurses' station. The nurse documented Resident #1 denied pain during assessment, was assisted to her feet and went to the common area by the main entrance. -The nurse documented neurological assessments were started; however, there were no neurological assessments in the resident's electronic medical record (EMR) for the fall. -Further, there was no documentation to indicate that Resident #1 had ongoing monitoring after the fall, which might reveal changes to vital signs or a change in condition.The 7/9/25 5:25 a.m. fall investigation revealed Resident #1 had a predisposing physiological factor of a walking imbalance, had her walker with her and was carrying several personal belongings. There were no changes made to the resident's plan of care after the fall.4. Fall #4The 7/9/25 11:01 a.m. fall investigation revealed Resident #1 fell at a local restaurant while she was on an outing with the facility's activities department. The progress note revealed emergency services were contacted while at the restaurant. Resident #1 was evaluated at the hospital and was diagnosed with recurrent syncope with falls from dehydration. The 7/9/25 fall investigation revealed Resident #1 had predisposing factors of gait imbalance and a recent change in cognition. The 7/10/25 hospital discharge summary revealed Resident #1 told the hospital physician the syncope episodes happened upon standing up after being seated. Review of Resident #1's EMR revealed the facility failed to provide the resident with increased supervision for timely intervention from staff to prevent falls upon standing. The 7/16/25 at 7:58 p.m. IDT progress note revealed the IDT determined the cause of the 7/9/25 falls were poor safety awareness and an unsteady gait. The 7/23/25 IDT note documented Resident #1 was educated to use a wheelchair on future outings to prevent falls due to the unsteady gait and disease processes. The progress note further documented the IDT initiated a referral for physical therapy, which was 14 days after the falls on 7/9/25.III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease, stroke, right side paralysis, history of falling, sepsis and cognitive communication deficit.The 8/2/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. Resident #4 was independent from staff assistance for bed mobility and sitting up in bed, and required set-up assistance from staff for sitting and standing, and transferring from a chair to a bed. Resident #4 was independent from staff assistance for mobility using a manually propelled wheelchair. Resident #4's ability for car transfers was not assessed. B. Record reviewResident #4's fall care plan, initiated 6/22/25, revealed Resident #4 was at risk for falls related to encephalopathy (a group of conditions that cause brain dysfunction), type 2 diabetes mellitus, Alzheimer's disease and a history of falling at home. Interventions included ensuring Resident #4 had a call light in reach and encouraging Resident #4 to use the call light for assistance as needed and responding promptly to all requests for assistance (initiated 6/22/25), encouraging Resident #4 to participate in activities to promote exercise for strengthening (initiated 6/22/25), ensuring adequate lighting and visual aids were in place (initiated 6/22/25), ensuring Resident #4 wore appropriate footwear when mobilizing in a wheelchair (initiated 6/22/25) and physical therapy as ordered (initiated 6/22/25). Resident #4's impaired cognitive function care plan, initiated 8/8/25, revealed Resident #4 had impaired thought processes related to Alzheimer's disease. Interventions included discussing concerns about confusion, disease processes and facility placement with Resident #4 (initiated 8/8/25) and monitoring for changes in cognitive function (initiated 8/8/25). Resident #4's functional mobility care plan, initiated 6/22/25, revealed Resident #4 had a self-care deficit related to Alzheimer's disease, encephalopathy and limited mobility. Interventions included using a power wheelchair for mobility throughout the facility (initiated 6/22/25) and encouraging Resident #4 to use the call bell to call for assistance (initiated 6/22/25).The 8/4/25 at 3:04 p.m. nurse progress note documented Resident #4 was out of the facility with her spouse for an optometry appointment. While at the appointment, Resident #4 fell from her wheelchair and was transported to the emergency department for evaluation. The 8/4/25 at 3:01 p.m. hospital summary documented Resident #4 was evaluated in the emergency department. The emergency department physician ordered computed tomography (CT) scans for Resident #4. The 8/4/25 CT scan revealed Resident #4 sustained a thoracic spine compression fracture. The treatment recommendation was for Resident #4 to wear a thoracic brace and return to the facility. The 8/4/25 at 6:47 p.m. nurse progress note documented the social services director (SSD) asked the nurse to obtain a pass for Resident #4 to attend an optometry appointment. The progress note documented that Resident #4 left the facility, accompanied by her spouse. The spouse returned to the facility later and informed the nurse that Resident #4 was left unattended while he parked his vehicle, and while unattended, Resident #4 fell to the ground. The spouse told the nurse Resident #4 had an open area on her head and was transported by paramedics to the hospital. On 8/5/25, the IDT outing evaluation for a pass was completed. The IDT determined Resident #4 had poor safety awareness and recommended Resident #4 not leave the facility independently, but she could have a therapeutic pass when accompanied by an adult. -There was no documentation to indicate the facility provided education to the resident's spouse for safe car transfers and to not leave Resident #4 unattended while on outings. Review of Resident #4's EMR revealed there was no documentation to indicate the IDT reviewed the fall or updated Resident #4's plan of care for fracture care or completed a wheelchair/scooter use and safety evaluation at the time of admission or after the fall on 8/4/25.IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 8/19/25 at 12:55 p.m. RN #1 said that he was aware Resident #1 had a history of falls and said Resident #1 was independent with walking around the facility. RN #1 said Resident #1 participated in therapy and appeared to be stronger when she walked with her walker. RN #1 said staff monitored Resident #1 frequently and provided assistance as needed. RN #1 said he was unsure why Resident #1 had repeated falls.Licensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 1:10 p.m. He said Resident #4 used a wheelchair and had a brace for her spine fracture. LPN #1 said Resident #4 required narcotic pain medication for pain in her spine. LPN #1 said nurses kept up-to-date report sheets with important notes for each resident. LPN #1 said that after a resident had a fall, the status of each fall and monitoring should be included in the shift report. LPN #1 said that if documentation in the EMR was not immediate, the shift report was the only way for nurses to track resident status. LPN #1 said it was important for staff to know why residents fell so that staff could monitor the residents and provide safe care.The activities director (AD) was interviewed on 8/20/25 at approximately 2:45 p.m. The AD said that on 7/9/25, he took residents on a scheduled activity/outing to a local restaurant. The AD said Resident #1 fell while inside the restaurant and paramedics were contacted. The AD said staff did not update him on Resident #1's status before the outing and he was unaware that Resident #1 had a fall earlier in the day.The NHA and the director of nursing (DON) were interviewed together on 8/20/25 at 1:20 p.m. The NHA said the IDT reviewed every fall, the day after a fall occurred. The DON said the IDT was responsible for reviewing care plan interventions and updating residents' care plans when appropriate. The DON said she was unable to locate documentation of the IDT fall reviews, but she said she documented the risk reviews for each fall in the residents' EMR. The DON said Resident #1 liked to walk to the common area to socialize and arrange flowers. The DON said staff found the resident on the floor after her falls on 6/8/25 and 6/21/25 and the IDT determined Resident #1 had an unsteady balance. The DON said Resident #1 was educated to use her call light to ask for assistance from staff or to call out for assistance because call lights were not available in common areas. The DON said the IDT reviewed the 7/9/25 at 5:25 a.m. fall and determined the cause of the fall was because Resident #1 had poor safety awareness because she was carrying personal belongings while trying to ambulate with her walker to the common area. The DON said it was important for nurses to monitor residents after they had a fall in case the resident had any injury. She said residents that were being monitored after a fall should not attend outings away from the facility. The DON said Resident #4 went to an appointment at Walmart on 8/4/25 and was accompanied by her spouse. She said she was unable to locate who made the appointment and who arranged and approved for the spouse to provide transportation. The DON said the IDT did not review the fall because Resident #4 fell at a store, was treated by paramedics, and was transferred to the hospital. The DON said neurological assessments were completed after unwitnessed falls or when a resident had a head injury. The DON was unable to locate neurological assessments for the 8/4/25 fall. The NHA said he recalled discussing Resident #1 and Resident #4 after their falls but was unsure of corresponding recommendations made by the IDT. The NHA said the documentation of the reviews that were completed by the IDT were not documented in either residents' EMRs, but he had a daily log that indicated the reviews had occurred. The NHA said he was unable to find IDT documentation pertinent to falls for Resident #1 and Resident #4. The NHA said the IDT needed to improve documentation of clinical discussions.

Based on observations, record review and interviews, the facility failed to ensure three (#10, #11 and #14) of 14 residents reviewed for grievances were provided prompt efforts by the facility to resolve a grievance out of 14 sample residents.Specifically, the facility failed to respond to grievances from Resident #10, Resident #11 and Resident #14 when they reported to facility staff that room temperatures were uncomfortable and hot.Findings include:I. Facility policy and procedureThe Resident Rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/18/25 at 1:45p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the right to voice grievances and have the facility respond to the grievances.II. ObservationsOn 8/19/25 at 12:45 the following temperatures were taken throughout the facility:On the west unit: -room [ROOM NUMBER], was 81.1 degrees Fahrenheit (F).-room [ROOM NUMBER] was 83.7 degrees F.-The hallway common area was 84.4 degrees F.-The hallway was 82.2 degrees F.-room [ROOM NUMBER] was 88.9 degrees F.The main entryway was 81.7 degrees F.The [NAME] unit had two water coolers in the hallway. One water cooler was off and the water cooler at the end of the hallway was blowing warm air. Five residents sat in wheelchairs in the common area, where the room temperature was 84.4 degrees F.On the east unit:-room [ROOM NUMBER] was 87.4 degrees F. III. Resident interviewsResident #11 and his representative were interviewed together on 8/19/25 at 12:55 p.m. Resident #11 said his room was uncomfortably warm, even with a floor fan. He said the floor fan did not help to keep his room cool and he had to sit directly in front of it to stay cool. The resident's representative said the room felt too warm. Resident #11 said he had complained about hot room temperatures to staff and said he felt that staff did not care. Resident #14 was interviewed on 8/19/25 at 5:10 p.m. Resident #14 said his room and hallways were very warm during the summer days. Resident #14 said his room could not be cooled because the air coolers were located at opposite ends of the hallway and the cool air did not effectively reach his room. He said he had a fan in his room, but it was small and only moved the hot air around his room.Resident #10 was interviewed on 8/20/25 at 9:45 a.m. Resident #10 said her room was hot and the thermometer hanging on her inside wall frequently registered temperatures in the upper 80's and up to 94 degrees F. Resident #10 said she had reported her concerns about room temperatures to facility staff and management several times and the room temperature had remained uncomfortable and hot. She said her room was located at the end of a hallway and far away from the water coolers.IV. Record reviewA request for grievances regarding the temperature of the residents' rooms and the common area was made on 8/19/25 at 1:09 p.m. The NHA said there were no documented grievances regarding the temperatures of the facility. -However, Resident #10 said she had reported her concerns to the staff regarding the temperatures of her room (see interview above).V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 1:10 p.m. LPN #1 said the room temperatures in the facility's hallways were always high. She said she was unsure when the water cooler was turned off and said only maintenance personnel were authorized to adjust the cooling fans. LPN #1 said on hot days, residents were provided with extra ice. Certified nurse aide (CNA) #1 was interviewed on 8/19/25 at 1:05 p.m. CNA #1 said the facility hallways were hot and he said the cooler fan was off because a resident complained it was cold in the hallway. The NHA was interviewed on 8/19/25 at 1:15 P.M. The NHA said he was unaware of acceptable room temperatures and said he had no current complaints from residents about room temperatures.The NHA was interviewed again on 8/19/25 at 2:40 p.m. The NHA said the maintenance director (MTD) was aware the cooling fan was not working in the morning (on 8/19/25) on the [NAME] unit and replaced a fan motor. The NHA said the cooling fan was now operational and the MTD had verified that all the facility's water coolers were operational. The NHA said on hot days, the facility provided extra ice and popsicles to the residents, closed dark shades, checked on residents frequently and offered outdoor activities. The NHA was interviewed a third time on 8/20/25 at 9:40 a.m. The NHA said the facility had rented two large water coolers for the [NAME] and East units because the residents' room temperatures remained high on 8/19/25. The MTD was interviewed on 8/20/25 at 2:25 p.m. The MTD said the facility was an old building and the water coolers were old and inefficient. The MTD said the two rented water coolers were effective to cool the facility hallways and residents' room temperatures to safe temperatures.

Based on record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#1) of two residents reviewed for medication documentation out of 14 sample residents.Specifically, the facility failed to ensure Resident #1's electronic medical record (EMR) contained complete and accurate documentation related to the administration of the resident's scheduled levetiracetam (a medication used to treat epilepsy, a seizure disorder) medication.Findings include:I. Facility policy and procedureThe Administering Medications policy, dated 8/4/25, was provided by the nursing home administrator (NHA) on 9/2/25 at 11:05 a.m. The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications. Record the results of medications administered per facility policy and procedure. Each time a medication is administered it must be documented.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE], discharged to the hospital on 7/9/25, and was readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included epilepsy (a seizure disorder), neurocognitive condition without behavioral disturbance, unspecified intracranial injury with loss of consciousness, insomnia, osteoarthritis, sacrum (pelvic) fracture and history of falling.The 4/24/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent from staff assistance for bed mobility, sitting and standing, transferring and walking with a walker.B. Record reviewReview of Resident #1's August 2025 CPO revealed the following physician's orders:Levetiracetam 1000 milligrams (mg) twice a day for seizures, administer at 6:00 a.m. and 4:00 p.m., ordered on 6/5/25.A review of Resident #1's July 2025 (from 7/1/25 to 7/31/25) medication administration record (MAR) revealed that a code of 9 was documented for the administration of levetiracetam on 7/8/25 and 7/9/25. According to the MAR, the code of 9 indicated other/see progress notes.-A review of Resident #1's progress notes on 7/8/25 and 7/9/25 failed to reveal documentation to indicate whether or not the levetiracetam medication was administered to the resident as ordered on those dates.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/2/25 at 4:27 p.m. LPN #1 said he was the nurse assigned to administer medications to Resident #1 on 7/8/25 and 7/9/25. He said he documented a code of 9 for the resident's levetiracetam on both of those dates because he had been unable to locate the medication in order to administer it. He said on 7/8/25 and 7/9/25, another nurse had been able to find the medication in the facility's supply of emergency medications. LPN #1 said he had administered the medication to Resident #1 after receiving the doses from the nurse. LPN #1 said he should have documented a corresponding progress note in the EMR after the medication was administered. The director of nursing (DON) was interviewed on 8/25/25 at 4:27 p.m. The DON said LPN #1 should have documented a corresponding progress note in the EMR after Resident #1's levetiracetam was administered on 7/8/25 and 7/9/25. The DON said LPN #1 was a new employee at the facility and he had been unsure how to document that the medication was administered after he had already entered a code of 9 on the MAR.

Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for two (#2 and #5) of three residents reviewed for abuse out of six sample residents. Specifically, the facility failed to: -Protect Resident #2 and Resident #5 from sexual abuse by Resident #3; and, -Ensure staff report an incident of sexual abuse in a timely manner. Findings include: I. Facility policy and procedure The Abuse policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 4/1/25 at 10:00 a.m. It read in pertinent part, Sexual abuse is non-consensual sexual contact of any type with a resident. If resident abuse, neglect, or exploitation is suspected, the suspicion must be reported immediately to the administrator. The facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents or family members who may have knowledge of the incident. II. Incident of sexual abuse of Resident #2 by Resident #3 on 1/1/25 A. Facility investigation Review of the facility's investigation revealed that on 1/2/25 Resident #2 reported that on 1/1/25, Resident #3 lifted his shirt when she passed him in the hallway. She said he lifted his shirt and his genitals were exposed. Resident #2 said Resident #3 was making her very uncomfortable and he was laughing and smiling while exposing himself. Resident #2 said her roommate, Resident #5, told Resident #3 to leave Resident #2 alone. Resident #2 said she was trying to stay away from Resident #3 because he made her uncomfortable and he left his pants unzipped so when he lifted his shirt his penis was exposed. Resident #3 was interviewed by the facility on 1/2/25 and he denied lifting his shirt around other residents or exposing his genitals. The facility interviewed additional residents and staff and there were no witnesses to Resident #3's behavior and no other residents were concerned with their safety or expressed fear of Resident #3. The facility unsubstantiated the abuse because there were no witnesses and Resident #3 denied the allegation. -However, abuse occurred as Resident #2 and Resident #5 (see interview below) both said Resident #3 had a history of exposing his penis to them on multiple occasions. -Additionally, it was identified on Resident #3's care plan, revised 9/20/24, that he had a history of masturbating and exposing himself in public (see care plan below). B. Resident #3 (assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (brain disorder), alcohol induced dementia and impulse disorder. The 2/28/25 minimum data set (MDS) assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment indicated the resident had physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing and abusing others sexually) on one to three days during the assessment review look-back period. 2. Record review Resident #3's impulse control care plan, revised 9/20/24, documented Resident #3 had the potential to be verbally aggressive, flip people off, masturbate in public spaces and show his privates (penis) to female residents and staff. Interventions included administering medications as ordered, analyzing triggers, assessing for sensory deficits, anticipating the resident's needs, giving the resident as many choices as possible about care and activities, monitoring observed behaviors and monitoring signs of the resident posing danger to himself or others. -The facility failed to have person-centered interventions to keep Resident #3 from exposing himself to others. C. Resident #2 (victim) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included stage 4 chronic kidney disease, depression, dependence on supplemental oxygen, acute on chronic diastolic (congestive) heart failure and difficulty walking. The 3/17/25 MDS assessment revealed Resident #2 was cognitively intact with a BIMS score of 13 out of 15. 2. Resident interview Resident #2 was interviewed on 3/31/25 at 3:15 p.m. Resident #2 said Resident #3 often stood in his bedroom doorway with the door and privacy curtain open. She said Resident #3 would lift his shirt and expose his penis when she walked by his room. Resident #2 said Resident #3 exposed himself to her numerous times and when she reported it to a staff member, she was told the staff would talk to Resident #3 but she said nothing ever came from it and Resident #3 continued to expose himself to her. Resident #2 said she was scared and did not feel safe and comfortable around Resident #3. Resident #2 said Resident #3 was a few doors down around the corner and she said she faced the wall whenever she walked to the dining room so she could not see anything Resident #3 was doing. Resident #2 said she feared that Resident #3 would escalate and do something more and the facility was not keeping her safe. III. Resident #5 (victim) A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included respiratory failure with hypoxia (low oxygen in the blood), schizoaffective (mental illness) disorder, acute right heart failure and anxiety. The 3/28/25 MDS assessment revealed Resident #5 had moderate cognitive impairment with a BIMS score of 12 out of 15. B. Resident interview Resident #5 was interviewed on 3/31/25 at 3:20 p.m. Resident #5 said Resident #3 often stood in his bedroom doorway with the door and privacy curtain open. She said Resident #3 would lift his shirt and expose his penis when she walked by his room. Resident #5 said Resident #3 exposed himself to her numerous times and when she reported it to a staff member, she was told the staff would talk to Resident #3 and she said nothing ever came from it. Resident #5 said the incidents made her uncomfortable and mad. Resident #5 said she told Resident #3 she would chop it off and Resident #3 laughed at her. She said Resident #3 always laughed or smiled while exposing himself and it was disgusting. IV. Staff interviews The activity assistant (AA) was interviewed on 3/31/25 at 4:10 p.m. The AA said she was aware that Resident #2 had reported that Resident #3 exposed himself to her in January 2025. She said she overheard Resident #2 telling another resident that Resident #3 exposed himself to her the first week of February 2025. The AA said she did not report what she overheard Resident #2 say in February 2025 to management because Resident #2 giggled about the situation and did not seem upset. The activity director (AD) was interviewed on 3/31/25 at 4:15 p.m. The AD said he had seen Resident #3 in his room with the door open, exposing himself. The AD said he did not report it because the resident was in his room, but he said he probably should have reported it because if he could see Resident #3, that meant other residents could too. The NHA, corporate consultant (CC) #1 and CC #2 were interviewed together on 3/31/25 at 3:42 p.m. The NHA said Resident #2 reported the situation to a staff member and there was a little delay in the incident being reported to the NHA. He said he provided the staff education on reporting abuse allegations to management. He said Resident #2 and Resident #3 were separated and placed on frequent checks and other residents were interviewed to see if anyone else saw what happened. He said Resident #5 was not interviewed during the investigation because the incident occurred in the dining room and she was not there when it happened. The NHA said the allegation was unsubstantiated because a witness was not able to be located. The NHA said he was unaware the incident was still occurring, but he said he would start a new investigation, based on Resident #2 and Resident #5's comments (see resident interviews above). He said he was going to move Resident #3 to a room away from Resident #2 and Resident #5 to make them more comfortable. Certified nurse aide (CNA) #1 was interviewed on 4/1/25 at 12:10 p.m. CNA #1 said Resident #3 had behaviors that included showing his penis to others. CNA #1 said she was unsure of any interventions in place to prevent Resident #3 from exposing himself to others, but she said she could check the care plan, if needed, for interventions. -However, Resident #3's care plan failed to include interventions to prevent the resident from exposing his genitals to others (see care plan above). The NHA and CC #1 were interviewed together again on 4/1/25 at 12:15 p.m. The NHA said he started an investigation immediately after being informed Resident #3 continued to expose himself to Resident #2 and Resident #5. The NHA said all of the residents in the facility were interviewed and no one else had concerns about Resident #3 or reported witnessing the resident exposing himself to others. The NHA said the staff were asked to remind Resident #3 to zip-up in the dining room. -However, Resident #2 and Resident #5 said Resident #3 exposed his genitals to them on multiple occasions when they were walking in the hallway, not in the dining room (see resident interviews above).

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure dishes were sanitized correctly in the three compartment sink; and, -Ensure safe and appropriate storage of food items in the walk-in refrigerator. Findings include: I. Failed to ensure dishes were sanitized correctly in the three compartment sink A. Professional reference The Food and Drug Administration (FDA) Food Code, January 2023, was retrieved on 12/24/24 from https://www.fda.gov/food/fda-food-code/food-code-2022. It read in pertinent part, Manual warewashing, sink compartment requirements: The three compartment requirement allows for proper execution of the three step manual warewashing procedure. If properly used, the three compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual warewashing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same three steps: application of cleaners and the removal of soil; removal of any abrasive and removal or dilution of cleaning chemicals; and, sanitization. Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. The Oasis 146 multi-quat sanitizer directions for use, dated 2015, were observed posted above the three compartment sink in the main kitchen on 12/17/24 at 11:30 a.m. The directions read in pertinent part, Apply Oasis 146 Multi-Quat Sanitizer at proper use solution. Expose all surfaces of the equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry. B. Facility policy and procedure The Warewashing policy, revised February 2023, was provided by the director of clinical services (DCOS) on 12/16/24 at 11:15 a.m. The policy read in pertinent part, The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. Temperature and/or sanitizer concentration logs will be completed, as appropriate. B. Sanitizer instructions The Oasis 146 multi-quat sanitizer directions for use, dated 2015, were observed posted above the three compartment sink in the main kitchen on 12/17/24 at 11:30 a.m. The directions read in pertinent part, Apply Oasis 146 Multi-Quat Sanitizer at proper use solution. Expose all surfaces of the equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry. C. Resident interview Resident #47 was interviewed on 12/12/24 at 5:30 p.m. Resident #47 said the dishes were frequently dirty and when he received his meals there were sometimes spots of dried food on the plates from the facility 's dish washing process. C. Observations On 12/11/24 at 10:05 a.m. the following was observed: At 10:05 a.m. an unidentified dietary aide (DA) washed a rack of plate covers. The unidentified DA placed the rack of plate covers on a rolling cart. The dietary manager (DM) pushed the rolling cart and dish rack to rest in front of the sanitizer compartment of the three compartment sink. The DM removed the plate covers from the dish rack two at a time and submerged them in the sanitizer compartment of the three compartment sink. The DM immediately removed the plate covers one by one and placed them back on the dish rack to dry. -The DM failed to leave the plate covers in the sanitizer for at least one minute according to the directions. The plate covers were submerged from five to twenty-five seconds instead of at least one minute according to the instructions in the posted dishwashing procedure. D. Staff interviews The DM was interviewed on 12/11/24 at 10:05 a.m. The DM said the dietary staff were washing the dishes in the dish machine and sanitizing the dishes in the three compartment sink until their chemical sanitizer for the dish machine arrived. The DM said the dishes needed to be in contact with the sanitizer for more than 30 seconds. -However, according to the manufacturer 's recommendations the dishes needed to be submerged into the sanitizer for at least one minute. The DM was interviewed again on 12/18/24 at 3:00 p.m. The DM said she thought she had left the plate covers submerged in the sanitizer compartment for at least a minute. II. Failed to store food items appropriately in the walk in refrigerator A. Professional reference The Cold Food Storage Chart (expires 10/31/26) was retrieved on 12/23/24 from https://www.foodsafety.gov/food-safety-charts/cold-food-storage-charts. It revealed in pertinent part, Follow the guidelines below for storing food in the refrigerator and freezer. The short time limits for home-refrigerated foods will help keep them from spoiling or becoming dangerous to eat: Hamburger and ground meats store one to two days under refrigeration. Fresh poultry such as chicken, whole or in pieces, stored one to two days under refrigeration. B. Facility policy and procedure The Labeling and Dating policy, undated, was provided by the DOCS on 12/16/24 at 11:15 a.m. The policy read in pertinent part, Items removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date. Leftovers must be labeled and dated with the date they are prepared and the use by date. The Food Retention and Storage guide, undated, was provided by the DOCS on 12/16/24 at 11:15 a.m. It read in pertinent part, A time/temperature control for safety food (TCS): a food that required time/temperature control for safety to limit pathogenic microorganism growth or toxin formation. Raw meat, poultry, and seafood once thawed can be refrigerated for one to two days. C. Observations On 12/11/24 at 9: 25 a.m. the following was observed on one shelf in the walk in refrigerator in the main kitchen: -An undated, clear five pound (lb) bag of raw chicken breasts; -An undated clear bag of raw chicken thighs under the bag of chicken breasts; -A clear lexan container raw of chicken thighs covered with plastic wrap, labeled with the date 11/29 and 12/10; -Three undated five lb tubes of raw ground beef in a metal baking pan; -Shredded parmesan cheese in a clear lexan container covered with a red lid with no date, not labeled or dated; -Raw chicken thighs in a metal baking pan labeled with the date 12/8. D. Staff interviews The DM was interviewed on 12/17/24 at approximately 1:30 p.m. The DM said the proteins were pulled from the freezer and placed in the walk in refrigerator a day prior to use. The DM said the meat was not labeled because the staff removed the meat from the box to cook for resident meals and the unlabeled meat in the walk-in refrigerator was leftover. The DM said the facility cooked the leftover meat to cook for staff meals. The DM said the ham on the shelf next to the raw chicken was used for sandwiches and salads and should be on a different shelf. -However, the chicken thighs dated 12/8, and 12/10 did not indicate if these dates were pull date or expiration dates. District supervisor (DS) #1 was interviewed on 12/17/24 at approximately 1:30 p.m. DS #1 said the facility should use a pull thaw system to label the meat with the date it was pulled from the freezer and the meat 's expiration date and the facility was planning to implement that practice.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to operate a quality assurance (QA) program in a manner to identify and address concerns related to quality of care. Findings include: I. Facility policy and procedure The Quality Management Plan/Quality Assurance and Performance Improvement (QMP/QAPI) Plan policy, dated 9/29/23, was provided by the director of clinical services (DOCS) on 12/19/24 at 2:43 p.m. It read in pertinent part, The facility has an on-going quality management and quality assurance and performance improvement (QAPI) program designed to objectively and systematically monitor and evaluate the residents' care and health care services. The comprehensive program is designed to provide care that is optimal within the available resources and is consistent with the achievable goals. The objectives include to ensure that monitoring quality of residents' care is performed systematically and continuously, ensure communication among all departments in improving resident care and identifying programs through the use of on-going monitors by focusing on identification, analysis and resolution of problems, and evaluate the results of actions taken by each department and maximize the use of resources available within the facility. It is the goal of the facility to integrate QMP/QAPI into all care and service areas of the organization. The following will be key areas of focus of the facility: clinical care, quality of life, resident choice and care transitions. Effective performance improvement efforts will focus on the development, maintenance and periodic improvement of systems that influence organizational outcomes. II. Cross-referenced citations Cross-reference F561 self-determination: The facility failed to honor resident choices. Cross-reference F566 right to perform facility services or refuse: The facility failed to ensure residents were compensated timely for work performed. Cross-reference F567 management of personal funds: The facility failed to ensure personal funds accounts were managed adequately. Cross-reference F584 safe, clean, comfortable and homelike environment: The facility failed to ensure residents were provided with a safe, clean, comfortable and homelike environment. Cross-reference F610 investigation of an alleged violation: The facility failed to investigate allegations of abuse. Cross-reference F622 transfer and discharge requirements: The facility failed to ensure residents were allowed to remain in the facility. Cross-reference F626 permitting residents to return to the facility: The facility failed to ensure a resident was able to return to the facility. Cross-reference F661 discharge summary: The facility failed to ensure an appropriate discharge summary was in place. Cross-reference F677 activities of daily living for dependent residents: The facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living. Cross-reference F679 activities meet the interests and needs of each resident: The facility failed to ensure residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Cross-reference F684 quality of care: The facility failed to provide treatment and care in accordance with professional standards of practice. Cross-reference F685 treatment or devices to maintain hearing and vision: The facility failed to ensure proper treatment and services to maintain hearing and vision. Cross-reference F689 free of accident hazards: The facility failed to ensure residents remained as free from accident hazards as possible. Cross-reference F698 dialysis communications: The facility failed to ensure residents received dialysis services consistent with professional standards of practice. Cross-reference F760 significant medication errors: The facility failed to ensure residents were free from significant medication errors. Cross-reference F761 storage and labeling of medications: The facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled. Cross-reference F800 diet meets the needs of each resident: The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Cross-reference F804 nutritive value and food palatability: The facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Cross-reference F812 kitchen sanitation: The facility failed to prepare and serve food in a sanitary manner. Cross-reference F880 infection control: The facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. III. Staff interviews The nursing home administrator (NHA), the regional director of operations (RDO) and the DOCS were interviewed together on 12/19/24 at 2:17 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and over video call if the medical director could not attend in person. The NHA said the QAPI format reviewed various topics on a worksheet that were marked as compliant or non-compliant. The RDO said if the facility identified a major issue that could not wait to be addressed until the next QAPI meeting, the facility called a meeting sooner rather than later. The DOCS said the facility identified smoking assessments were not completed and reviewed the process multiple times but had not identified the assessments as a systemic issue. The DOCS said enhanced barrier precautions (EBP) was identified as an issue under the previous director of nursing (DON) and said it was an oversight due to changing facility leadership positions. The NHA said the facility had not identified residents needing assistance at meal time as an issue. The NHA said the facility had a schedule for managers to be present in the dining room at meal time and observe if residents needed additional assistance. The NHA said the facility had discussed activities but had not identified it as a concern and activities had their own section to complete on the QAPI form. The RDO said the facility team did discuss residents scheduled for one-to-one activities. The DOCS said the new activity director (AD) had been with the facility for about a month and was trying to create some stability and revamp the activity department. The RDO said the facility instituted floor huddles to discuss with the facility staff what issues the staff had identified, to build culture and create an open environment for staff to discuss concerns.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically the facility failed to: -Ensure staff wore appropriate personal protective equipment (PPE) while changing a resident's bedding who was on enhanced barrier precautions (EBP); -Ensure the water management program (WMP) identified specific areas where legionella could grow and spread and decided where and how to monitor control measures to prevent legionella and waterborne pathogen growth and document the monitoring; -Ensure staff followed appropriate hand hygiene during resident care and ensure shared vital signs equipment was sanitized between use; and, -Ensure residents were offered hand hygiene at meals and staff performed appropriate hand hygiene during room tray delivery. Findings include: I. Failure to ensure staff wore the appropriate personal protective equipment A. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 12/23/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy, dated 1/6/23, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m The policy read in pertinent part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents. Residents with MDRO or who have indwelling medical devices will have an order written for initiation of EBP. A care plan will be initiated for the use of EBP. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and complicated wound care. EBPs are indicated if contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBP's remain in place for the duration of the resident's stay or discontinuation of the indwelling medical device that placed them at increased risk as they can still serve as a source of transmission. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. C. Resident interview and observation Resident #1 was interviewed on 12/12/24 at 9:25 a.m. Resident #1 said he went to dialysis appointments on three days a week. Resident #1 had a fistula on his right arm. D. Observations On 12/16/24 the following was observed: Resident #1 had an EBP sign on his door. The sign read in pertinent part, Providers and staff must also wear gloves and a gown for the following high contact resident care activities: dressing, transferring, providing hygiene, changing briefs or assisting with toileting. The cart is labeled with an EBP cart with an orange label. Certified nurse aide (CNA) #7 entered room Resident #1's room at 10:03 a.m. and carried two clear trash bags into the room. CNA #7 while wearing gloves, removed an incontinence pad from Resident #1's bed and placed it in the trash. CNA #7 then pulled up the blankets on Resident #1's bed toward the head of the bed and pulled the blankets back again. CNA #7 placed two new incontinence pads on the bed and then pulled the blankets up over the bed and incontinence pads. On Tuesday 12/17/24 the following was observed: At 9:56 a.m. Resident #1 was seated in his wheelchair in his room. CNA #7 and an unidentified staff member assisted Resident #1 in putting on his coat while Resident #1 was seated in his wheelchair. Neither staff member wore a gown. CNA #7 assisted Resident #1 inside his room and closed the door to Resident #1's room. At 9:57 a staff member opened the door and the Resident #1 had his coat fully on and the (mechanical lift) sling was on the back of his chair. The resident said he was going to dialysis. The unidentified staff member assisted the resident down the hallway in his wheelchair. CNA #7 continued to work in Resident #1's room and removed the bed sheets from Resident #1's bed and placed them against the wall in the room. CNA #7 was not wearing a gown. He removed his gloves and exited the room. -CNA #7 and the unidentified staff member failed to wear a gown while they assisted Resident #1 to put on his coat and while CNA #7 changed Resident #1's bedding. D. Staff interviews Registered nurse (RN) #2 was interviewed on 12/16/24 at 2:25 p.m. RN #2 said she did not remember if CNA #7 had on a gown when he assisted Resident #1 the morning of 12/16/24. RN #2 said CNA #7 had assisted the resident to get dressed for dialysis and she entered the room to be a second person for Resident #1's transfer. RN #2 said she did not don (put on) a gown because she did not provide direct care to Resident #1 and was only the second person in the room for his transfer. RN #2 said a Resident #1 was on EBP because he received dialysis treatment. She said CNA #7 had dressed Resident #1 and put him in the sling. CNA #6 was interviewed on 12/17/24 at 10:15 a.m. CNA #6 said staff should wear a gown when changing a resident's sheets if the resident was on EBP. CNA #6 said if a resident was on EBP there was a sign on the door with EBP instructions, especially if the resident had a catheter. CNA #6 said once care was completed, the staff removed the PPE and left the used PPE in the trash in the resident's room. She said everything inside the trash was removed when she exited the room. CNA #6 said staff should not don a gown if they did not provide direct care to a resident on EBP, only if staff provided patient care and handled sheets. CNA #7 was interviewed on 12/17/24 at 11:52 a.m. CNA #7 said he should have a gown on when he changed a resident's sheets and a resident was on EBP. CNA #7 said EBP were to decrease the chance of infection spreading. CNA #7 said he thought because Resident #1 left the room he no longer needed to wear a gown when he changed the resident's bedding. The DOCS was interviewed on 12/18/24 at 1:00 p.m. The DOCS said the facility had some new CNAs working. The DOCS said EBP training was done electronically. He said the EBP training was part of the onboarding process and should be reviewed on an ongoing basis. The DOCS said he identified EBP needed attention on an audit prior to the survey and assigned it to the previous DON to follow up on. The DOCS said EBP were discussed daily in the facility's morning meeting. 47960 II. Water management program A. Professional reference The CDC recommendations for Legionella (3/15/24) were retrieved on 12/20/24 from https://www.cdc.gov/control-legionella/php/wmp/index.html. It read in pertinent part, Many buildings need a water management program (WMP) for their building water system or specific devices. WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens. Developing and maintaining a WMP is a multi-step process that requires continuous review. The seven steps of a Legionella WMP are to: Establish a WMP team; describe the building water systems; identify areas where legionella could grow and spread; decide where to apply and how to monitor control measures; establish interventions when control limits are not met; ensure the program runs as designed and is effective and document and communicate all the activities. Use flow diagrams and a written description to describe the building water systems. Include details like: How water enters the building, how water is distributed in the building, location of hot tubs, water heaters or boilers, and cooling towers, and where the building connects to the municipal water supply. Identify where potentially hazardous conditions could occur in the building water systems. Examples include areas where water temperature could promote Legionella growth or where water flow might be low. Establish control measures and limits for each hazardous condition. Control measures are actions taken in the building water systems to limit growth and spread of Legionella. They can include adding disinfectant, cleaning, and heating. Control limits are acceptable values for the control measures being monitored. They can include a maximum, minimum, and range of values. Control points are locations where control measures are applied. B. Facility policy and procedure The Legionella Surveillance policy, not dated, was provided by the nursing home administrator (NHA) on 12/16/24 at 1:30 p.m. The policy read in pertinent part, Legionella surveillance is one component of the facility's water management plans for reducing the risk of legionella and other opportunistic pathogens in the facility's water systems. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. Primary prevention strategies include: Cooling towers and potable water systems shall be routinely maintained. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations. Non-potable water systems shall be routinely cleaned and disinfected. Nebulation devices shall be filled only with sterile fluid. Cold water shall be stored above 140 degrees Fahrenheit (F) and circulated at a minimum return of 124 (F). Stagnate - dead legs - Areas not in use by residents and staff are identified by maintenance and placed on a weekly flush and disinfection schedule. -The Legionella Surveillance policy did not identify specific areas and locations where legionella could grow and spread; and decide where to apply and how to monitor and document control measures. The policy failed to include specific facility locations monitored such as water filters, pipes, valves and fittings, and medical devices (such as CPAP machines). The policy did not include how to monitor and document the control measures. C. Observations On 12/16/24 at 9:30 a.m. the southeast wing, resident rooms #55, #56, #57, #59, and #60, were observed to be empty of residents. The rooms were not occupied. D. Record review The water flush log was reviewed on 12/19/24. It revealed the unoccupied rooms were flushed in July 2024 and October 2024. E. Staff interviews The regional director of operations (RDO) was interviewed on 12/16/24 at 2:08 p.m. The RDO said the facility's legionella surveillance policies were reviewed annually and as needed in monthly quality assurance and performance improvement meeting (QAPI). -However, the policy did not contain a date it was reviewed. The maintenance director (MTD) was interviewed on 12/19/24 at 9:55 a.m. The MTD said the facility had a hallway of unoccupied resident rooms and these rooms contained dead legs (plumbing system with infrequent water flow). The MTD said these rooms had been unoccupied for several months. The MTD said he ran the water from one of the sinks in the southeast wing to check the water temperature and he maintained a log of his findings. He was not aware of any requirements to track the rooms or amount of time to run the water for legionella surveillance. The MTD said he went weekly to one of the unoccupied resident rooms to temperature check the water but he did not flush the toilets or run the faucets for any length of time outside of getting an accurate water temperature. -However, documentation of monitoring and disinfection were not available. 20287 III. Ensure staff followed appropriate hand hygiene during resident care and ensure shared vital signs equipment was sanitized between use A. Professional reference According to the CDC Recommendations for Hand Hygiene for Healthcare Workers, (2024), retrieved on 12/24/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: immediately before touching a patient and after touching a patient or a patient's surroundings. According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 12/11/24 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin. C. Observations Certified nursing aide (CNA) #7 was observed on 12/11/24 at 10:30 a.m. taking the blood pressure of a resident. CNA #7 then continued to the next task to answer a call light while still holding the blood pressure cuff and the thermometer. He did not perform handwashing after he left the room. CNA #7 then went into another resident's room to take the vital signs of another resident. The CNA did not clean the blood pressure machine prior to taking the vitals of the other resident. D. Staff interviews The IP was interviewed on 12/16/24 at 2:00 p.m. The IP said the staff should perform hand hygiene after each task and especially in between residents. She said she would provide education regarding hand hygiene. IV. Ensure staff followed appropriate hand hygiene during delivery of the meal trays. A. Professional reference The CDC (2024), Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 12/24/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Perform hand hygiene before touching a patient, after touching a patient or their surroundings, immediately after glove removal. According to Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022.) Basic Nursing: Thinking, Doing and Caring, (Third edition), pages 1601, 1604-1605, Use standard precautions to prevent the transmission of infection. Implement measures to prevent healthcare-associated infections (HAIs). HAIs are the leading complication of healthcare and one of the ten leading causes of death in the United States. Hand hygiene can remove transient flora (microbes acquired by touching objects or people). B. Observations During a continuous observation of the lunch on 12/11/24, beginning at 12:01 p.m. and ending at 12:28 p.m. the following was observed: At 12:01 p.m., the room trays were delivered to the East unit. Certified nurse aide (CNA) #8 delivered a tray to room [ROOM NUMBER]. She assisted the resident into the chair at the table by holding his hand for assistance. She did not offer hand hygiene to the resident. She did not perform hand hygiene when she left the room. At 12:07 p.m., CNA #8 proceeded to pass a room tray to room [ROOM NUMBER]. She put gloves on and assisted the resident in bed with positioning. She did not offer hand hygiene to the resident. There was no handwipe on the tray. At 12:10 p.m., CNA #7 was pouring drinks and placing them on the room trays. At 12:21 p.m., CNA #7 went into room [ROOM NUMBER]B and delivered the resident's meal. The CNA did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. At 12:23 p.m., CNA #7 entered room [ROOM NUMBER]A, and delivered the resident's meal. The CNA did not offer hand hygiene to the resident, did not perform hand hygiene for himself when he left the room. At 12:26 p.m., CNA #7 entered room [ROOM NUMBER]B and delivered the resident's meal. The CNA did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. At 122:7 p.m., CNA #7 went into room [ROOM NUMBER]A and delivered the resident's meal. CNA #7 did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. At 12:28 p.m., CNA #7 went into room [ROOM NUMBER]A and delivered the resident's meal. He did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. On 12/16/24 at t 12:03 p.m., CNA #9 served room [ROOM NUMBER] his meal. She did not offer hand hygiene to the resident. She did not perform hand hygiene when she left his room. At 12:05 p.m. the CNA #9 then proceeded to serve room [ROOM NUMBER] his tray. She assisted him to sit in the chair. She did not offer him hand hygiene prior to leaving the room. C. Staff interviews CNA #7 was interviewed on 12/11/24 at 12:31 p.m. CNA #7 said he did not touch anything in the room when he dropped off meal trays. He said he should have performed hand hygiene before and after each meal delivery. The IP was interviewed on 12/16/24 at 2:00 p.m. The IP said residents should be offered hand hygiene prior to receiving their meals. She said the staff had been educated about offering hand hygiene prior to meals. The IP said the staff should also perform hand hygiene after each task and especially in between residents. She said she would provide education again.

Based on observations, record review and interviews, the facility failed to honor resident choices for five (#35, #39, #6, #23 and #33) of 28 residents out of 41 sample residents. Specifically, the facility failed to honor Resident #35, Resident #39 and Resident #6, Resident #23 and Resident #33's preferences including shower frequency and times. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, revised December 2021, was received from the nursing home administrator (NHA) on 12/19/24 at 11:54 a.m. It revealed in pertinent part At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing, of their rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The resident has the right to reside and receive services in the facility with reasonable accommodations of resident preferences except when to do so would endanger the realty and safety of the resident or other residents. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. The Bath, Shower/Tub policy, revised February 2018, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. The policy read in pertinent part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident, all assessment data, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, the signature and title of the person recording the data. Notify the supervisor if the resident refuses the shower/tub bath. II. Resident #35 A. Resident status Resident #35, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease, type 2 diabetes mellitus and major depressive disorder. The 10/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with transfers, toileting, dressing and showering. She did not have any behaviors or refusals of care. B. Resident interview Resident #35 was interviewed on 12/18/24 at 9:09 a.m. Resident #35 said she wanted to have a shower at least once a week. She said she had not had a shower in the past four weeks. Resident #35 did not know why she was not given a shower weekly as she requested. She said she was incontinent of bowel and bladder and she often felt dirty and like no one cared about her when she did not receive her showers. C. Record review A review of Resident #35's bath record revealed the resident last received a shower on 11/18/24. Documentation did not reveal the resident had refused any showers. On 11/25/24, 11/28/24, 11/30/24 and 12/5/24 the residents shower was documented as not applicable. III. Resident #39 A. Resident status Resident #39, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included congestive heart failure, chronic respiratory failure and chronic kidney disease. The 10/30/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with transfers, toileting, and dressing and required supervision with showers. She did not have any behaviors or refusals of care. B. Resident interview Resident #39 was interviewed on 12/18/24 at 9:10 a.m. Resident #39 said she did not get two showers a week as she preferred. She said she knew it bothers her roommate because she made the room smell bad. Resident #39 said it made her feel bad when she smelled bad and like no one at the facility cared about her. She said she only refused showers when they were offered in the morning because she preferred to have them in the late afternoon or evening. C. Record review A review of Resident #39's bath record revealed the resident received four showers in the past 30 days on 11/20/24, 11/27/24, 11/29/24 and 12/11/24. The resident refused showers on 11/17/24, 11/24/24, 12/1/24 and 12/4/24. Showers were documented as not applicable on 11/13/24, 11/15/24, 11/22/24, 12/6/24 and 12/8/24. 20287 IV. Resident #6 A. Resident status Resident #6, age less than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included atherosclerotic heart disease, borderline personality disorder and chronic obstructive pulmonary disease (COPD). The 10/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for showers. C. Resident interview Resident #6 was interviewed on 12/11/24 at 3:15 p.m. Resident #6 said she had requested a shower three times a week. The resident said she typically received her shower on Sundays, however she did not always receive the other two. She said it was related to staffing. C. Record review The care plan last updated on 7/30/24 identified the resident had a self care deficit related to activity intolerance, morbid obesity and COPD. Pertinent interventions included the resident preferred her showers on Wednesday and every other day in the mid day. The 10/27/23 personal bathing preference form documented the resident preferred to bathe three times a week. -However, the care plan indicated the resident liked to shower every other day. The care plan last updated on 7/30/24 identified the resident had a self care deficit related to activity intolerance, morbid obesity and COPD. Pertinent interventions included the resident preferred her showers on Wednesday and every other day in the mid day. The bath records for November 2024 (11/1/24 to 11/30/24) revealed the resident received eight (11/3/24, 11/10/24, 11/12/24, 11/14/24, 11/19/24, 11/24/24, 11/26/24 and 11/28/24) showers out of 12 opportunities for three times a week. D. Resident group interview A group interview was conducted on 12/17/24 at 1:05 p.m. with five residents (#115, #28, #4, #16, and #17) who were interviewable based on assessment and facility. The residents said they did not get a choice on how many showers they received or the time of day they received their showers. The residents said they were lucky to get one shower a week. E. Staff interview The director of nursing (DON) was interviewed on 12/17/24 at 6:10 p.m. The DON said when a resident was admitted to the facility the resident filled out a preference sheet form that indicated how many showers a week they would like. She said the residents should get as many showers as they had requested. The DON said she identified the staff were not documenting showers and was going to develop a plan to provide staff education regarding documentation of showers received. 48458 IV. Resident #23 A. Resident status Resident #23, age 69, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included hemiplegia (paralysis or weakness on one side of the body), malnutrition, peripheral vascular disease (circulation condition with narrowing of blood vessels) and neurogenic (nerve) dysfunction of the bladder. The 9/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required set-up assistance from staff with oral hygiene, supervision for toileting and substantial to moderate assistance with showering/bathing. B. Resident interview and observation Resident #23 was interviewed on 12/11/24 at 11:56 a.m. Resident #23 said he had not had a shower in two weeks because the facility did not have enough staff to help him shower. Resident #23 said he had been using wipes to wash himself. He said he was supposed to have a shower twice per week and he needed help to get him into the shower each time. C. Record review Resident #23's care plan, revised 4/8/24, revealed Resident #23 preferred to shower on Monday, Wednesday and Fridays and he required supervision by one staff member. Review of the shower schedule posted at the nurse's station revealed Resident #23 was scheduled to receive showers every week on Monday and Friday. -However, Resident #23's care plan indicated he preferred to shower Monday, Wednesday and Friday. Resident #23's bathing/showering record from 9/1/24 to 11/30/24 was provided by the DOCS on 12/17/24 at 1:33 p.m. The bathing/shower records provided and the treatment administration record (TAR) for December 2024 were reviewed from 10/16/24 to 12/16/24. The records revealed the following: Resident #23 refused one shower on 11/4/24. -There was no other documentation to indicate Resident #23 had refused other scheduled showers. Per the bathing/showering record documentation from 10/16/24 to 12/16/24, Resident #23 received eight showers out of 16 opportunities. There was no documentation indicating the resident had received a shower since 11/29/24, indicating the resident had not received a shower in 17 days. -Other than the documented refusal on 11/4/24, review of the resident's bathing records revealed no documentation to indicate why the resident missed his showers or what interventions were attempted for Resident #23's missed showers. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 12/17/24 at 10:38 a.m. CNA #4 said Resident #23 required assistance with showering. She said Resident #23 liked showering and did not refuse them. CNA #1 said it did not surprise her that Resident #23 had not received regular showers as there was not always enough staff to provide showers to every resident. CNA #3 was interviewed on 12/17/24 at 10:56 a.m. CNA #3 said Resident #23 did not refuse showers. CNA #3 said Resident #23 liked CNA #3 to provide assistance with showers as she also shaved the resident. The DON and the DOCS were interviewed together on 12/17/24 at 3:46 p.m. The DOCS said there was no documentation in Resident #23's electronic medial record (EMR) that indicated the resident had received a shower from 11/29/24 to 12/13/24. The DON said she would expect Resident #23 to receive two showers each week, or eight showers in a four week period. The DON and the DOCS said they recognized the staff were not documenting showers and were going to develop a plan to provide staff education regarding documentation of showers received. III. Resident #33 A. Resident status Resident #33, age 67, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia, cerebral infarction (stroke), post traumatic stress disorder (PTSD) and depression. The 10/11/24 MDS assessment revealed Resident #33 had moderate cognitive impairments with a BIMS score of 10 out of 15. The resident was independent with oral hygiene and toileting. He required partial to moderate assistance with showering. B. Resident interview Resident #33 was interviewed on 12/19/24 at 2:12 p.m. Resident #33 said he cleaned himself up at the sink in his room. C. Record review Resident #33's care plan, revised 10/30/23, revealed Resident #33's shower preference sheet was updated and Resident #33 preferred to shower three times per week. Review of the shower schedule posted at the nurse's station revealed Resident #33 was scheduled to receive showers every week on Monday, Wednesday and Friday. Resident #33's bathing/showering record from 9/1/24 to 11/30/24 was provided by the DOCS on 12/17/24 at 1:33 p.m. The bathing/shower records provided and the TAR for December 2024 were reviewed from 10/16/24 to 12/16/24. The records revealed the following: Resident #33 refused three showers on 10/28/24, 11/4/24 and 11/18/24. Resident #33 received 11 showers out of 24 opportunities. There was no documentation indicating the resident had received a shower since 11/29/24, indicating the resident had not received a shower in 17 days. -Other than three refusals, review of the resident's bathing records revealed no documentation to indicate why the resident missed his showers or what interventions were attempted for Resident #33's missed showers, particularly since 11/29/24. D. Staff interviews CNA #4 was interviewed on 12/17/24 at 10:28 a.m. CNA #4 said Resident #33 always wanted to take his showers and said she did not think Resident #33 ever refused showers. CNA #4 said Resident #33 was always ready for showers and sometimes waited in the hallway with his shower items. CNA #3 was interviewed on 12/17/24 at 11:00 a.m. CNA #3 said Resident #33 did not refuse showers. CNA #3 said she thought she had helped him shower the previous week. The DON and the DOCS were interviewed together on 12/17/24 at 3:48 p.m. The DOCS said he did not find any documentation for Resident #33's showers from 11/29/24 until 12/16/24. The DON said she would expect Resident #33 to receive 12 showers in a four week period (three per week). The DON said she would expect staff to document every shower provided and every refusal by residents in their EMRs.

Based on observations and interviews, the facility failed to ensure residents' personal funds accounts were managed adequately for the facility and accessible to the residents for four (#23, #6, #46 and #47) of four residents out of 41 sample residents. Specifically, the facility failed to ensure residents were able to access their personal funds accounts during banking hours, after hours and on the weekends. Findings include: I. Resident interviews Resident #23 was interviewed on 12/11/24 at 12:02 p.m. Resident #23 said he did not have access to his money on weekends. Resident #23 said sometimes he also could not access his money on weekdays, including times the facility had run out of money to provide the residents during regular banking hours. Resident #6 was interviewed on 12/11/24 at 3:18 p.m. Resident #6 said she was unable to access her money on weekends. Resident #46 was interviewed on 12/11/24 at 4:45 p.m. Resident #46 said he was able to access his personal funds Monday through Friday, but the money was not available on weekends. Resident #47 was interviewed on 12/11/24 at 7:45 p.m. Resident #47 said he was unable to obtain money when he needed it. Resident #47 said he had to cancel plans with a friend because his personal funds were not available to him. II. Resident group interview The resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted of five residents (#115, #28, #4, #16 and #17) who were identified as interviewable by the facility and assessment. The residents said they wanted their personal funds to be available on the weekends. III. Observation On 12/17/24 at 1:04 p.m. a sign was observed on the door of the activity department office. The sign indicated the resident banking hours were Monday through Friday from 9:30 a.m to 3:30 p.m. IV. Staff interviews The business office manager (BOM) was interviewed on 12/16/24 at 3:30 p.m. The BOM said the resident council had voted for banking hours and had also voted to not have money available to the residents on weekends in September 2024. The activity director (AD) was interviewed on 12/18/24 at 11:21 a.m. The AD said the residents came to the activity department to obtain personal funds. The AD said the personal funds that were available were limited a week ago. The AD said there were times he could not give the residents the amount of money they requested. The AD said a resident requested $50.00 a week ago and the AD was only able to give the resident $30.00. The AD said the resident said they would wait to obtain the money until they could receive the full $50.00. The AD said the resident received the $50.00 requested the next day. The AD said the resident council voted on banking hours and availability of funds, which did not include weekends. The BOM was interviewed a second time on 12/18/24 at 11:50 a.m. The BOM said it was her understanding that residents needed to have access to funds on weekends. The BOM said there had been times during banking hours when the residents could not access $50.00 and she did not know how often this had occurred. The BOM said there was not an established minimum balance to initiate obtaining additional money. The nursing home administrator (NHA) and the regional director of operations (RDO) were interviewed together on 12/18/24 at 5:19 p.m. The RDO said the facility did not have a set amount of money that needed to be in the personal funds box on a daily basis. The RDO said he had not heard there were issues with personal funds availability at the facility. The RDO said the facility's prior administrator had been concerned about theft and had made a decision to limit the availability of personal funds after hours. The RDO said the residents should be able to access personal funds on weekends. The RDO said the resident council could not vote to restrict personal funds further than what was required and there was a plan in place for the facility to have the resident council restrictions removed. The RDO said the facility was going to ensure there was resident access to personal funds after banking hours and on weekends. The RDO said it was important to establish a process for replacing money available when the bank balance decreased to a certain level as the replacement process could take up to two days. The RDO said the BOM and the AD might have been waiting too long to initiate this process when funds were getting too low.

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for 14 out of 65 resident rooms. Specifically, the facility failed to ensure: -Residents were provided clean washcloths and hand towels in their rooms on the East and [NAME] units; -Resident #6's closet was cleaned timely; and, -The clogged toilet in a resident's bathroom was cleaned timely and appropriately. Findings include: I. Facility policy and procedure The Homelike Environment Policy, revised 2021, was provided by the director of clinical services (DCOS) on 12/17/24 at 6:58 p.m The policy read in pertinent part, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment, personalized room furniture and room arrangements, clean bed and bath linens that are in good condition, pleasant neutral scents, and comfortable sound levels. II. Failed to ensure residents were provided clean washcloths and hand towels A. Observations On 12/11/24 at 3:15 p.m., room [ROOM NUMBER] had no hand towels or washcloths. On 12/12/24 at 9:44 a.m. room [ROOM NUMBER] had no hand towels or washcloths. On 12/12/24 9:40 a.m., room [ROOM NUMBER] had no hand towels or washcloths. On 12/16/24 beginning at 2:12 p.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 12/17/24 at 6:25 p.m. the linen closets on the East and [NAME] units contained linen towels. B. Resident group interview The resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted of five residents (#115, #28, #4, #16, and #17) who were interviewable based on assessment and facility. The residents said they continued to have concerns about the lack of towels. The residents said linen towels were not available. The residents said the housekeepers would remove the dirty towels and not replace them with clean towels. The residents said there were not enough towels and they had to use paper towels to wash and dry their faces. C. Resident interview Resident #49 was interviewed on 12/16/24 at 2:20 p.m. Resident #49 said he was not offered any towels. He said that he wished he had linen towels available. D. Staff interview The director of nursing (DON) was interviewed on 12/17/24 at 6:10 p.m. The DON said the nursing staff were responsible for passing out towels to the residents. She said towels should be passed out on each shift. She said she was not aware the towels were not being passed out. She said she would correct the issue immediately. The nursing home administrator (NHA) was interviewed on 12/17/24 at 6:19 p.m. The NHA said the facility had recently purchased quite a lot of towels. He said there was no shortage of towels. III. Failed to ensure Resident #6's closet was cleaned appropriately On 12/11/24 at 3:15 p.m., Resident #6's closet had remnants of dried feces on the floor of the closet, on the door and along the wall. A. Resident interview and observation Resident #6 was interviewed on 12/11/24 at 3:15 p.m. Resident #6 said in September 2024 a few months ago she was scheduled for a colonoscopy. She said when she was completing the preparation for the colonoscopy, she got up to go to the bathroom and fell . She said when she fell , feces sprayed all over the floor. She said there continued to be bowel movement on the closet floor and splattered on the wall. She said she had requested it to be cleaned up, however it had not been cleaned. Resident #6's closet had remnants of dried feces on the floor of the closet. There was also dried feces on the door and along the wall. B. Staff interviews The regional director of operations (RDO) was interviewed on 12/18/24 at approximately 2:00 p.m. The RDO said he observed the dried feces on the floor of Resident #6's closet and the wall. He said it would be cleaned immediately. An unidentified houskeeper was interviewed on 12/19/24 at approximately 8:30 a.m. an She said the resident's rooms were cleaned daily. 47151 III. Failure to ensure the clogged toilet in a residents bathroom was cleaned timely and appropriately A. Observation and resident interviews On 12/12/24 the following was observed in Resident #51's room and the East unit: At 9:33 a.m. an unidentified housekeeper exited room [ROOM NUMBER] and placed a wet floor sign in front of the door to the room. After the unidentified housekeeper exited the area, the toilet in the bathroom was observed to have a backup of water approximately an inch from the toilet seat. The water in the toilet was dark brown and contained feces, and toilet paper was visible in a mound on top of the water. A plunger was in the corner of the bathroom with plastic wrapped around the rubber end of the plunger. A resident that resided in room [ROOM NUMBER] said he reported that the toilet was plugged to the housekeeper who cleaned his room. At 11:19 a.m. the toilet in room [ROOM NUMBER] was observed and revealed the same concern as the previous observation (at 9:33 a.m.) At 1:31 p.m. the toilet in room [ROOM NUMBER] was observed and the water had receded to a normal level in the toilet and the toilet paper was no longer visible. The toilet water was dark brown and contained fecal matter. A resident who resided in room [ROOM NUMBER] said a staff member tried to work on the toilet but he was not sure who the staff member was. B. Staff interviews The maintenance director (MTD) was interviewed on 12/12/24 at 3:10 p.m. The MTD said he had not received training on how to clean bodily fluids so he followed up with the nurse in the east hall where room [ROOM NUMBER] was located. The MTD said he received a work order for a plugged toilet in room [ROOM NUMBER], so he told the nurse in the east hall that there was a toilet that needed to be unplugged. The MTD said the certified nurse aides (CNA) were told to glove up and have a trash bag to unplug the toilet. The MTD said this was the process at the facility for the last four years. Registered nurse (RN) #2 was interviewed on 12/16/24 at 2:25 p.m. RN #2 said the MTD asked her on 12/12/24 where the CNA was working. RN #2 said the MTD told her (RN# 2) the toilet in room [ROOM NUMBER] was clogged and the facility staff had put in a work order for the clogged toilet. RN #2 said the MTD told the nurse go into room [ROOM NUMBER]'s bathroom, reach in the toilet and remove the paper and stool from the toilet. RN #2 said the MTD did not instruct the staff which PPE to use and told RN #2 that the nursing staff were trained on bodily fluids so it was a nurse or CNAs job to unplug the toilet. RN #2 said a CNA unplugged the toilet in room [ROOM NUMBER]. The RDO was interviewed on 12/18/24 at 12:30 p.m. The RDO said after speaking to the facility's regional plant operations support, plunging or unplugging a toilet was something all staff could do. The RDO said if staff were unable to repair a toilet in a timely manner, the residents could use another bathroom in the facility. The RDO said there were plungers in the facility that could be used to plunge the toilets. The RDO said the housekeeping staff could plunge the toilet. The RDO said while the nursing staff was able to plunge a toilet, the preference was the CNA to prioritize resident care as it was a more specialized area, although a CNA could plunge the toilet if needed.

Based on observation, interview and record review the facility failed to provide adequate supervision during use of assistive devices to keep residents free from safety hazards for three (#9, #26 and #24) of seven residents out of 41 sample residents. Specifically, the facility failed to: -Ensure care planned fall interventions were utilized consistently for Resident #9; -Ensure foot pedals were attached to Resident #9 and Resident #26's wheelchairs when facility staff were pushing the residents in their wheelchairs; -Ensure Resident #26 was transferred appropriately from her chair to her wheelchair using a gait belt (a device used to help prevent falls); and, -Ensure Resident #24 was assessed appropriately for safe smoking. Findings include: II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, history of falling and dementia. The 9/20/24 minimum data set (MDS) assessment revealed the resident had both short term and long term memory impairments. The resident had severely impaired daily decision making skills. The resident was dependent on staff for activities of daily living (ADL). The MDS assessment indicated the resident had not experienced any recent falls. B. Failure to ensure care planned fall interventions were utilized consistently 1. Facility policy and procedure The Fall Management policy, dated 2/29/24, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. It read in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. Research has shown that structured fall reduction programs can substantially reduce the rate of falls and fall related injuries in nursing facilities; however falls may likely occur. Risk factors that are internal to the resident included the resident's physical health and functional status. External factors include medication side effects, the use of appliances, and environmental conditions. To be effective, a fall reduction program is characterized by four components: Fall risk evaluation, care planning and implementation of interventions, ongoing evaluation process and a commitment by caregivers to make it work. Each resident will be reevaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy. Document in the resident's electronic medical record (EMR) the resident's response to interventions and revise the interventions if they are not successful. Monthly the quality assurance and performance improvement (QAPI) committee will review residents with falls for updated interventions and/or recommendations. 2. Observations On 12/12/24 at 10:22 a.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/12/24 at 2:30 p.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/16/24 at 10:15 a.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/16/24 at 3:35 p.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/17/24 10:36 a.m. licensed practical nurse (LPN) #1 observed Resident #9 was in bed with no fall mat beside the resident's bed. LPN #1 looked in Resident #9's room and was unable to find the fall mat that was supposed to be beside the resident's bed when the resident was in bed. 3. Record review Review of Resident #9's December 2024 CPO revealed the resident had a physician's order to have a fall mat on the floor next to her bed while she was in the bed, revised 12/16/24 (during the survey). The care plan, initiated 9/9/24, identified Resident #9 was at high risk for falls. Pertinent interventions were to have a fall mat to the side of the bed when she was lying down. 4. Staff interviews LPN #1 was interviewed on 12/17/24 at 10:36 a.m. LPN #1 reviewed Resident #9's care plan and confirmed the resident was to have a fall mat next to the bed when she was lying in bed. LPN #1 said the resident had not had any recent falls, however, she said she was a contracted agency nurse who had only been at the facility for three months. After confirming the fall mat was not beside Resident #9's bed, LPN #1 said she would locate a fall mat for the resident. The director of nursing (DON) was interviewed on 12/17/24 at 6:10 p.m. The DON said Resident #9 was on hospice services and was at risk for falls. She said the fall mats were available in the facility. She said she would ensure Resident #9 received the fall mat. C. Failure to have wheelchair foot pedals attached during transport 1. Observations On 12/12/24 at 11:00 a.m. Resident #9 was being pushed into the dining room in her wheelchair by an unidentified staff member. There were no foot pedals attached to her wheelchair, which caused the resident to hold her feet up off the floor. On 12/12/24 at 4:23 p.m. Resident #9 was being pushed to the dining room in her wheelchair by certified nurse aide (CNA) #11. The resident did not have any foot pedals on her wheelchair, which caused the resident's feet to dangle. 2. Record review The care plan, initiated 9/9/24, identified the resident was a high risk for falls. Pertinent interventions were to ensure the resident had proper footwear when mobilizing in her wheelchair. -The care plan did not include an intervention to ensure Resident #9's foot pedals were in place when transporting the resident in her wheelchair in order to prevent potential falls. III. Resident #26 A. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included atherosclerotic heart disease, hypertension, dementia and cognitive communication deficit. The 10/23/24 MDS assessment revealed the resident had both short term and long term memory impairments. The resident had severely impaired daily decision making skills. The resident was dependent on staff for ADLs. B. Failure to have wheelchair foot pedals attached during transport 1. Observations On 12/12/24 at 4:23 p.m. Resident #26 was being pushed to the dining room in her wheelchair by CNA #5. The resident did not have any foot pedals on her chair which caused the resident's feet to dangle. On 12/16/24 at 8:57 a.m. Resident #26 was being pushed to her room in her wheelchair by CNA #6. The resident did not have any foot pedals on her wheelchair which caused the resident's feet to dangle. On 12/16/24 at 11:26 a.m. Resident #26 was being pushed into the dining room in her wheelchair by an unidentified staff member. There were no foot pedals on her wheelchair which caused the resident's feet to dangle. On 12/17/24 at 4:32 p.m. Resident #26 was being pushed to the dining room in her wheelchair by CNA #5. The resident did not have any foot pedals on her chair which caused the resident's feet to dangle. 2. Record review The care plan, revised 7/30/24, identified Resident #26 was at risk for falls related to dementia, unsteady gait and history of falls. Pertinent interventions were to ensure the resident had proper footwear when mobilizing in her wheelchair. -The care plan did not include an intervention to ensure Resident #26's foot pedals were in place in order to prevent potential falls when the resident was being pushed in her wheelchair. The fall risk assessment dated [DATE] revealed Resident #26 as a high fall risk. 3. Staff interview The DON was interviewed on 12/17/24 at 6:10 p.m. The DON said Resident #9 and Resident #26's feet should not have been dangling while they were being transported in their wheelchairs (see Resident #9 and Resident #26's observations above). She said foot pedals needed to be used and all residents' wheelchairs should have the foot pedals. The DON said staff should not push a resident in their wheelchair if they had to hold their feet up. She said there was no system in place as to where the foot pedals were kept so they were easily accessible to staff for the transportation of residents. C. Failure to ensure resident was transferred appropriately from her chair to her wheelchair using a gait belt 1. Facility policy and procedure The Safe Lifting and Movement of Residents policy, revised July 2017, was received from the DOCS on 12/18/24. The policy read in pertinent part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts and lateral boards) and mechanical lifting devices. 2. Observations On 12/12/24 at 11:56 a.m. Resident #26 was assisted from her stationary chair to her wheelchair by an unidentified CNA. The CNA held both of the resident's hands while she pulled her to a standing position. The resident then pivoted to the wheelchair. -The CNA failed to use a gait belt on Resident #26 during the transfer. On 12/12/24 at 4:26 p.m. Resident #26 was assisted from her stationary chair to her wheelchair by CNA #5. CNA #5 held both of the resident's hands while she pulled her to a standing position. The resident then pivoted to the wheelchair. -CNA #5 failed to use a gait belt on Resident #26 during the transfer. On 12/17/24 at 4:29 p.m. Resident #26 was assisted from her stationary chair to her wheelchair by CNA #5. CNA #5 held both of the resident's hands while she pulled her to a standing position. The resident then pivoted to the wheelchair. -CNA #5 failed to use a gait belt on Resident #26 during the transfer. 3. Record review The care plan, updated 10/29/24, identified Resident #26 was at risk for falls related to unsteady gait. Pertinent interventions included transferring the resident with supervision to substantial assistance. -The care plan failed to include the use of a gait belt during transfer. 4. Staff interviews The DON was interviewed on 12/17/24 at 6:10 p.m. The DON said when a resident was assisted to a standing position, a gait belt was to always be used for the safety of the resident. She said the nursing staff were trained to use the gait belt, however, she was not sure when the last training related to gait belt use was. The occupational therapist (OT) was interviewed on 12/18/24 at 4:53 p.m. The OT said a gait belt should be used when assisting a resident to a standing position. She said the trunk (upper body) had the best control and pulling on a resident's arms was not good, as there were a lot of muscles which could get injured. IV. Resident #24 A. Resident status Resident #24, age less than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included type 2 diabetes, history of other venous thrombosis (a condition where a blood clot, or thrombus, forms in a vein and blocks blood flow) and embolism (occurs when a blockage, called an embolus, lodges in a blood vessel and prevents blood from flowing). The 11/13/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was independent in ADLs B. Failure to ensure the resident was assessed for safe smoking 1. Facility policy and procedure The Traditional Tobacco and Electronic Smoking Device Policy, revised on 5/10/23, was provided by the DOCS on 12/19/24 at 1:03 p.m. It read in pertinent part, All residents who smoke or desire to smoke will be appropriately assessed to determine if the resident requires supervision and protective equipment during smoking. The assessment tool used for this purpose is the (name of the electronic medical record) Smoking Risk Assessment. Smoking assessment and potential restrictions shall be completed upon admission, quarterly at the time of unsafe smoking behavior or suspicion of smoking in an undesignated area or upon any change of condition, which would impact the residents ability to smoke and or smoke safely. 2. Resident observation and interview On 12/11/24 at 9:49 a.m. Resident #24 was sitting on his bed near his bedside table. There was black ash on the table. The resident's room and the resident smelled of cigarette smoke. Resident #24 said he smoked cigarettes and that he was independent with smoking and could go out to smoke whenever he wished. 3. Record review The care plan, revised 8/19/24, identified Resident #24 was an independent unsupervised smoker. Pertinent interventions included instructing and informing the resident about the facility policy on smoking, locations, times and safety concerns, monitoring the resident for any unsafe smoking practices and observing the resident's clothing and skin for signs of cigarette burns. The 9/23/24 progress note documented Resident #24 continued with his normal daily habit of smoking outside. The 11/23/24 progress note documented Resident #24 was observed going into the [NAME] charting room, grabbing another resident's box containing cigarettes, putting the other resident's box of cigarettes into his pants and walking out of the nurses station. The nurse and the manager on duty went into Resident #24's room and requested the box back. The resident gave the cigarettes back to the nurse. The 12/5/24 psychological follow up note documented Resident #24 had a history of smoking cigarettes in his room. Review of Resident #24's smoking assessments revealed the following: The 5/3/24 smoking risk evaluation documented the resident was safe and independent with smoking. The 11/13/24 smoking risk evaluation documented the resident did not smoke cigarettes. The evaluation form documented the resident said he did not currently have any cigarettes to smoke. The 12/16/24 progress note documented the resident was observed smoking in his room. Resident #24 denied smoking in his room and denied having cigarettes or lighters. The 12/18/24 smoking risk evaluation (completed during the survey) documented Resident #24 did not smoke only in designated areas and did not follow the smoking rules. The evaluation conclusion was the resident was supervised while smoking. 4. Staff interviews The social services consultant (SSC) was interviewed on 12/17/24 at 11:53 a.m. The SSC said the social worker for the facility was out of the facility. The SSC said she was not familiar with Resident #24 but would review the resident's records for the smoking assessment. The DON was interviewed on 12/17/24 at 6:10 p.m. The DON said the smoking evaluation was to be completed when the resident was admitted and on a quarterly basis or change of condition. The DOCS was interviewed on 12/19/24 at approximately 12:00 p.m. The DOCS said the DON was completing an assessment on the resident. He said he did not understand how the resident was not assessed for smoking.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of two medication storage rooms and two of four medication storage carts. Specifically, the facility failed to: -Dispose of medications from the medication storage refrigerators and medication carts after residents had been discharged ; -Ensure medications were labeled with dates opened; -Ensure expired medications were removed and discarded from medication carts and storage refrigerators; and, -Maintain temperature logs for the medication refrigerators. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised November 2020, was provided by the director of clinical services (DOCS) on 12/17/24 at 9:39 a.m. The policy read in pertinent part, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Observations and interview On 12/12/24 at 2:05 p.m. the [NAME] hall medication storage room refrigerator was observed with registered nurse (RN) #1. A temperature log for the medication refrigerator was not present in the room. The temperature reading inside of the refrigerator was observed to be 40 degrees fahrenheit (F). RN #1 said she would find the temperature log for the refrigerator. The following items were found in the medication refrigerator: -An opened vial of Tuberculin Purified Protein Derivative 10 milliliters (ml) which was not labeled with the date opened. RN #1 said the medication had been opened and used. RN #1 said she was not sure how long the medication could be used once it was opened. RN #1 said the medication should be discarded because she did not know when it was opened. -An opened Insulin Glargine (Basaglar) 100 units/ml pen which was not labeled with the date it was opened. RN #1 said she thought the insulin would be good for 30 days after opening, but was going to discard it since it did not have a date opened label on it. On 12/12/24 at 2:26 p.m. the East hall medication storage room was observed with licensed practical nurse (LPN) #2. A temperature log for the medication refrigerator was not present in the room. LPN #2 said she would ask where the temperature log was located. The following items was found in the refrigerator: -An opened vial of Tuberculin Purified Protein Derivative 10 ml which was not labeled with the date opened. LPN #2 said the medication was good for 30 days after opening, but since it was not labeled with a date opened, it should be discarded. -A Cathflo 2 milligram (mg) package (for dissolving blood clots) was labeled with a discharged resident's name. LPN #2 said the resident had been discharged on [DATE]. -An unopened Cathflo 2 mg package with an expiration date of December 2023. -Six Phenalephrine (hemorrhoid) 0.25 mg suppositories with an expiration date of May 2023. -A vial of Retacrit 10,000 units was labeled with a discharged resident's name. LPN #2 said the resident had been discharged on [DATE]. -Two vials of Engerix B 20 micrograms (mcg)/ml with an expiration date of June 2024. -One container of Prevnar 20 injectable medication was labeled with a discharged resident's name. LPN #2 said the resident had been discharged on [DATE]. -A Lantus Solostar insulin pen was labeled with a discharged resident's name. The LPN said the resident had been discharged on [DATE]. LPN #2 said medications should be removed from the refrigerator within 48 hours of a resident's discharge. LPN #2 said tuberculin and Engerix medications should be labeled with a date upon opening. LPN #2 said nursing staff should be checking the medication refrigerator and medication carts for expired medications at least weekly. On 12/12/24 at 3:11 p.m. the East hall medication cart #1 was observed with RN #2. The following items were found: -An opened Combivent Respimat 20 mcg/100 mcg inhaler was not labeled with the date opened. RN #2 said she would discard the medication if it was not dated when opened because she did not know how long it could be used after opening. -An opened Trelegy Elipta 200 mcg inhaler was not labeled with the date opened. RN#2 said she would check with the nursing supervisor to see how long the inhaler could be used. -A bottle of Amlactin lotion with an expiration date of October 2023. On 12/12/24 at 3:35 p.m. the [NAME] hall medication cart #2 was observed with LPN #1. The following item was found: -An opened Wixela fluticasone propionate and salmeterolinhaler 250/50 mcg inhaler was not labeled with the date opened. LPN #1 said the inhaler should have a date opened label on it. III. Additional staff interviews LPN #1 was interviewed on 12/12/24 at 3:29 p.m. LPN #1 said she knew there was a thermometer in the west medication refrigerator, but did not know who checked the temperatures or maintained the log of refrigerator temperatures. The director of nursing and the DOCS were interviewed together on 12/17/24 at 3:19 p.m. The DON said staff brought her expired medications, undated medications and medications from residents who were discharged . The DON said the opened insulin pen, tuberculin purified protein and inhalers needed to be labeled with the date opened or they should be discarded. The DOCS said the facility would provide a temperature monitoring log for the refrigerators if one was available. (The log was not provided by the completion of the survey). The DON said it was the responsibility of the night shift nurses to check and record the medication refrigerator temperatures. The DON said medications should be removed from the refrigerator or medication cart on the day of a resident's discharge. The DON said expired medications should be discarded immediately. The DON said the expiration dates in the refrigerators should be checked by nursing staff when temperatures were checked daily.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for two (#48 and #61) of six residents out of 41 sample residents. Specifically, the facility failed to: -Provide a balanced menu with a variety; and, -Provide alternate items of preference for Resident #61 and #48 when requested. I. Provide a balanced menu with a variety of starch options A. Facility policy and procedure The Resident Food Preferences policy, revised July 2017 was provided by the director of clinical services (DOCS) on 12/18/24 at 9:42 a.m. The policy read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Upon the resident's admission or within 24 hours after his/her admission, the dietitian or nursing staff will identify a resident's food preferences. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. The resident has a right not to comply with therapeutic diets. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's quality assessment and performance improvement (QAPI) committee will periodically review the issues related to food preferences and try to identify more widespread concerns about meal offerings, food preparation. B. Resident interviews Resident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The resident's representative said the food was repetitive and it looked like the same thing over and over, and the menu lacked variety. Resident #24 was interviewed on 12/11/24 at 4:44 p.m. Resident #24 said the food was repetitive and that he did not like the taste of the food. He said the facility served too much chicken. He said the food was not good. Resident #47 was interviewed on 12/11/24 at 5:30 p.m. Resident #47 said the food quality was poor and attending the food meetings did not make a difference. Resident #47 said he talked to the new dietary manager (DM), who had been at the facility for almost three months, about various things and he was told to give it time. C. Resident group interview The resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted of five residents (#115, #28, #4, #16 and #17) who were interviewable based on assessment by the facility. The residents said they continued to have concerns about the food. The residents' concerns were as follows: -The menu was repetitive and carrots, rice and potatoes were served too much; and, -Mixed vegetables were served too frequently. The residents said they had a food committee and they had complained about the food during resident council meetings. However, the group said they felt they were not listened to by the facility. The residents said the kitchen staff needed to take pride in their cooking. D. Record review The 10/21/24 resident council meeting minutes were provided by the DOCS on 12/17/24 at 10:00 a.m. The minutes documented the residents voiced that too much rice was being served at meals and residents wanted more of a variety in menu choices. A four week cycle menu was provided by the nursing home administrator (NHA) on 12/12/24 at 11:12 a.m. A review of the week two menu (served during the survey) revealed repeated menu items. Potatoes were a repeated side item for three of the four lunch and dinner meals on the following days: -On 12/15/24 the dinner menu was shepherds pie as the main entree and contained potatoes. -On 12/16/24 the lunch menu was Salisbury steak served with a side of mashed potatoes. -On 12/16/24 the dinner menu was breaded fish on a bun and served with potato wedges. Pasta was a repeated side item for four of the six lunch and dinner meals on the following days: -On 12/19/24 the lunch menu was Italian sausage with parmesan noodles. -On 12/20/24 the lunch menu was cornflake chicken breast with macaroni and cheese. -On 12/20/24 the dinner menu was meatballs with marinara sauce and spaghetti noodles. -On 12/21/24 the lunch menu was chicken alfredo with spaghetti noodles. E. Staff interviews The dietary manager (DM) was interviewed on 12/17/24 at approximately 1:30 p.m. The DM said the facility staff had not mentioned to her that the residents had complained the menus were repetitive. The DM said normally if a resident complained a CNA would inform the dining staff, and bring the resident's initial meal tray to the kitchen to get the resident something else to eat. District supervisor (DS) #2 was interviewed on 12/17/24 at approximately 1:30 p.m. DS #2 said she had previously helped the facility with menu management and had consulted with the regional dietitian to review the menus including the residents' likes and dislikes. DS #2 said if the residents prefer, for example, to have fish removed from the menu, the residents could list another preferred menu item, give the managers that feedback and then make the changes to the menu. DS #2 said she would start reviewing the menus to change out some of the repetitive options. II. Failed to provide items of preference for Resident #61 and Resident #48 A. Resident #61 1. Resident status Resident #61, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), acute respiratory failure, pulmonary fibrosis (scarring of lung tissue) and late onset dementia. The 11/24/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. Resident #61 was dependent on assistance for bathing, needed substantial assistance with transfers, dressing, toileting hygiene and oral hygiene, supervision with personal hygiene and set up help with eating. 2. Resident representative interview and observations Resident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The representative said she was worried about Resident #61's weight because he did not eat well. The representative said she complained about the food to multiple staff at the facility and told a staff member Resident #61 was not eating well and needed encouragement to eat. The representative said she requested a menu and the certified nurse aides (CNA) told her they were unsure where to find a menu. The representative said Resident #61 finished the Mexican food the family brought him from home and the resident preferred Mexican food. The following was observed during the 12/11/24 noon meal: At 12:01 p.m., the room trays were delivered to the east unit.CNA #8 delivered a tray to Resident #61. She assisted the resident into his chair by the bedside table by holding his hand for assistance. CNA #8 set the tray in front of the resident and left the room. The following was observed during the 12/16/24 noon meal: At 12:05 p.m. CNA #9 brought Resident #61 his tray. She assisted him to sit in a chair. CNA #9 set a meal tray in front of Resident #61 and left the room. -However, staff did not offer Resident #61 any items of preference or encouragement. 3. Record review Resident #61's nutrition care plan, initiated 11/27/24, documented he had a nutritional problem or potential nutritional problem related to sepsis, Alzheimer's disease, polyneuropathy (nerve disease causing numbness and pain), polyosteoarthritis (arthritis in multiple joints), GERD and fatty liver. The family reported a history of weight loss prior to his admission to the facility. Pertinent interventions initiated 11/27/24 included obtaining the resident's food preferences and offering as able and offering food alternates of equal nutritional value. A review of the resident's electronic medical record (EMR) revealed the following: An 11/27/24 progress note written at 4:25 p.m. documented Resident #61's family member asked if there was an alternate menu and if the resident could have a banana and yogurt for breakfast, and Mexican food only for lunch and dinner to eat. An 11/27/24 progress note documented written at 5:47 p.m. documented Resident #61's daughter brought food for the resident to eat at dinner and said she would try to contact the dietary department to figure out food options for Resident #61. A 12/1/24 progress note written at 5:36 p.m. documented the facility told Resident #61's representative the facility could offer choices available in the kitchen but could not force feed the resident. If the resident had favorite food items he would eat, the facility could provide them and make sure the resident had them to eat. Resident #61's food and nutrition food preferences, dated 12/9/24 were provided by the DOCS on 12/17/24 at 9:39 a.m. The food preferences revealed the resident preferred Mexican foods, bananas, yogurt, beans, rice, cheese, chicken, sweets and fruit. The resident's least favorite foods were listed as pasta, carbohydrates and red meat. He had recently lost weight. -However, Resident #61's care plan was not updated to reflect Resident #61's preferences. 4. Staff interviews CNA #9 was interviewed on 12/17/24 at 11:00 a.m. CNA #9 said Resident #61 needed encouragement to eat. CNA #9 said she heard Resident #61 had complained about the food quality previously and she would tell the dietitian if she received a complaint about food quality. The district supervisor (DS) #1 was interviewed on 12/17/24 at approximately 1:30 p.m. DS #1 said a resident's food preferences were usually captured within 24 hours of the resident's admission to the facility. DS #1 said the DM would then enter the preferences into the menu system so they appeared on the resident's meal card. The DM was interviewed on 12/17/24 at approximately 1:30 p.m. The DM said she was not familiar with Resident #61's meal preferences or that he preferred Mexican food. 20287 B. Resident #48 1. Resident status Resident #48 age 68, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified macular degeneration (decreased vision), dysphagia, depression and cognitive communication deficit. The 9/27/24 MDS assessment showed the resident had cognitive impairments with a BIMS score of three out of 15. The resident was prescribed a therapeutic mechanically altered diet. 2. Record review The December 2024 CPO revealed a physician's order for a regular diet, dysphagia advanced texture and regular consistency. The order documented she could have a regular grilled cheese. 3. Observation On 12/16/24 at 5:24 p.m., the resident had not eaten her meal. She said she would like to have a grilled cheese with ham sandwich.CNA #10 was alerted that Resident #48 wanted a a ham and grilled cheese sandwich. CNA #10 went to the kitchen window to put in the request. The registered dietitian (RD) went to the kitchen window and said Resident #48 could not have the ham on the grilled cheese. At 5:36 p.m., the resident received a grilled cheese sandwich. The resident asked if there was ham on her sandwich. CNA #10 said no, and the resident asked why she did not get ham on her sandwich the CNA said it was because of her diet order. 4. Staff interviews CNA #10 was interviewed on 12/16/24 at 5:27 p.m. CNA #10 said she had requested a ham and cheese grilled cheese sandwich for Resident #48 however, the RD told him she could not have one and ordered only a grilled cheese sandwich. The RD was interviewed on 12/17/24 at 6:02 p.m. The RD said Resident #48 was prescribed a dysphagia diet and she could have a grilled cheese sandwich. She said she could not have the ham for safety reasons. She said she reached out to the speech therapist and she did update the diet so that she was able to have chopped ham. The RD was interviewed again on 12/18/24 at 4:00 p.m. The RD said when Resident #48 requested ham on her sandwich, she thought the resident was only approved to have a grilled cheese sandwich and not ham because of the residents prescribed modified texture diet. The RD said she was being over cautious when she said the resident could not have ham on her sandwich.

Based on interviews, observations and record review, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, were palatable in taste, appearance and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance and temperature. Findings include: I. Resident interviews Resident #13 was interviewed on 12/11/24 at 10:38 a.m. Resident #13 said the food was not hot. Resident #35 was interviewed on 12/11/24 at 2:17 p.m. Resident #35 said the food was never hot. Resident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The resident's representative said Resident #61 told her the food had no flavor. Resident #6 was interviewed on 12/11/24 at 3:25 p.m. Resident #6 said the food was not good. Resident #6 said the grilled cheese sandwiches were not cooked correctly and were not grilled, but microwaved instead. Resident #6 said the food was often served cold and had no flavor. Resident #24 was interviewed on 12/11/24 at 4:44 p.m. Resident #24 said the food was repetitive and that he did not like the taste of the food. He said the facility served too much chicken. He said the food was not good. Resident #47 was interviewed on 12/11/24 at 5:30 p.m. Resident #47 said the food quality was poor and attending the food meetings did not make a difference. He said a hamburger patty could be thrown at the wall and it would put a hole in the wall. Resident #47 said he talked to the new dietary manager (DM), who had been at the facility for almost three months, about various things and he was told to give it time. Resident #47 said the food was overcooked and crusty. II. Observations During a continuous observation on 12/12/24, beginning at 4:15 p.m. and ending at 5:05 p.m., the following was observed during the meal preparation and service in the main kitchen: At 4:25 p.m. cook (CK) #1 took the temperature of the hot food. The philly cheesesteak sandwiches were in a food service pan fully assembled for meal service. The temperature of the tater tots was 99 degrees F. The temperature of the mixed vegetables was 160 degrees F. At 4:30 p.m. assembly of resident meal trays for the west hall room tray delivery started and the meal trays were delivered to the west hall at 4:39 p.m. At 4:40 p.m. assembly of resident meal trays for the east hall room tray delivery started. At 4:44 CK #1 pulled a second pan of assembled philly cheesesteak sandwiches out of the hot holding pan and placed the sandwiches in the hot holding table for service. Resident meal trays were assembled and placed in the cart. At 4:45 p.m. the test tray was assembled and placed in the east hall room delivery cart. At 4:45 p.m. the cart with the test tray left the kitchen and arrived in the east hall at 4:46 p.m. At 4:47 p.m. the first room tray was delivered to a resident. At 4:56 p.m. the test tray was removed from the cart. The test tray was immediately evaluated by three surveyors after the last resident had been served their room try for dinner. The test tray consisted of a philly cheesesteak sandwich, tater tots, mixed vegetables and canned fruit for dessert. -The tater tots were 108 degrees F. -The mixed vegetables were 119.7 degrees F. -The tater tots were over-salted. The vegetables were overcooked and limp, with a bland flavor and dull color. The bun on the philly cheesesteak was hard and chewy on each end of the bread. A small portion of the cheese was burned. On 12/12/24 at 5:00 p.m., Resident #115 received her meal in the dining room. The resident attempted to eat the philly cheesesteak sandwich, but she did not. Resident #115 asked for a new sandwich because she said the bread was too hard. III. Resident group interview The resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted of five residents (#115, #28, #4, #16 and #17) who were interviewable based on assessment by the facility. The residents said they continued to have concerns about the food. The residents' concerns were as follows: -The meals were often served cold; -The quesadillas and grilled cheese sandwiches were often served burnt; -The food had no flavor and was bland in taste; -The meat was tough, particularly the pork chops and chicken; -The tater tots served on the 12/12/24 evening meal were too salty; -The philly cheesesteak sandwich which was served 12/12/24 during the evening meal had hard bread and the residents did not the like cheddar cheese that was used rather than the traditional swiss cheese; -The vegetables were under cooked; -The menu was repetitive and carrots, rice and potatoes were served too much; and, -Mixed vegetables were served too frequently. The residents said they had a food committee and they had complained about the food during resident council meetings. However, the group said they felt they were not listened to by the facility. The residents said the kitchen staff needed to take pride in their cooking. IV. Record review Resident council meeting notes were reviewed for October 2024 and November 2024. The 10/31/24 resident council minutes documented the following comments from residents: -The chicken and pork were overcooked and tough; -Too much rice was served at meals; and, -The residents would like to have more variety. The 11/21/24 resident council minutes documented the following comments from residents: -The food was horrible. Residents left the dining room in disgust; -The pork and chicken were still too tough to eat; -Alternative meals were not offered; and, -Food was served cold. V. Staff interviews The nursing home administrator (NHA) was interviewed on 12/18/24 at 12:25 p.m. The NHA said he had heard concerns about food quality and it was discussed during resident council meetings. The NHA said he had sampled some random meals and the meals he sampled had been good. The NHA said he had not sampled a meal sent in the room tray cart. The NHA said the facility had recently switched food vendors and some residents perceived that the food quality might be different but he had not noticed a difference. The DM was interviewed on 12/18/24 at 3:00 p.m. The DM said when the facility held the food committee meeting with the residents, residents said there were concerns about the temperature of the food. The DM said the dietary staff, including herself, had tasted the food. The DM said the main issue she heard from the residents was about oatmeal in the morning and a few things from the menu were not as hot as they could be. The DM said she tasted a test tray about a week ago and there were no concerns with the test tray. District supervisor (DS) #1 was interviewed on 12/18/24 at 3:00 p.m. DS #1 said the facility completed a test tray audit before the 15th of every month to assess food quality. The DM said she thought the facility needed to build the sandwiches on the line during meal service instead of assembling them ahead of time for better quality. The DM said she was trying to train the staff to batch cook the tater tots and the tater tots served for the evening meal on 12/12/24 were cooked in one batch ahead of time. 20287

Based on record review and interviews, the facility failed to ensure one (#13) of one resident out of 41 sample residents was compensated for paid services at or above prevailing rates. Specifically, the facility failed to ensure Resident #13 was paid in a timely manner. Findings include: I. Facility policy and procedure The Resident Therapeutic Stipend Program (TSP) policy, dated 6/1/23, was provided by the nursing home administrator (NHA) on 12/19/24 at 4:55 p.m. It read in pertinent part, The task/duties/activities performed by the resident are appropriate, and the resident has the mental and physical capacity to perform the task/duties/activities. The plan of care specifies the nature of the services performed. All services performed under TSP (therapeutic stipend program) are paid. Duties will be outlined, and the resident must agree to the description of duties prior to starting the program. The resident will be trained/educated on the program duties to be provided, as well as safety protocols and safe work practices (infection control, proper body mechanics), prior to beginning the program. The resident and community understand that the resident has the right to decline to participate in the Resident Therapeutic Volunteer/Stipend Program or to provide services to the community at any time. There is documentation in the plan of care regarding the need or desire for the resident to participate in the program and provide services to the community. The Care Team (Social Service designee, Activities Director or another designee), will track program participation and quality of commitments each week. The compensation to the resident, for the services performed, will never exceed $50.00 per month. The statement of agreement specifies the stipend rate for the services completed as well as the location, frequency and requirements to receive the stipend. II. Resident #13 A. Resident status Resident #13, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, type 2 diabetes mellitus, heart failure and schizoaffective disorder (mental illness). The 10/1/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required maximum assistance from staff with dressing and toileting and used a motorized wheelchair for mobility throughout the facility. B. Resident interview Resident #13 was interviewed on 12/11/24 at 10:36 a.m. Resident #13 said she participated in a work program at the facility. Resident #13 said she worked three days a week calling Bingo and also worked in the resident soda store. The resident said she was supposed to be paid 50 dollars a month. The resident said she had not been paid at all for her time in November 2024. The resident said she did not know when she would get paid. C. Record review A review of the resident's comprehensive care plan included participation in a therapeutic stipend program by calling and organizing weekly bingo games and running the soda store. The goals were for the resident to complete her commitment log by the assigned due date with initials of care partners for each day she participated. -The work program commitment log was completed for November 2024 however the resident was not paid until 12/12/24 (see interview below). III. Staff interviews The business office manager (BOM) was interviewed on 12/18/24 at 10:20 a.m. The BOM said the work stipend program was run by the activity director (AD). She said she printed the checks from corporate as soon as she received them but there was no consistency to when they were received. The AD was interviewed on 12/18/24 at 11:14 a.m. The AD said he had been working at the facility in this role for two months and was new to the process. The AD said he was responsible for submitting the request for residents to be paid for the work stipend program. He said he submitted the request to corporate by email and then the vendor sent a check to the business office at the facility. The AD said he did not submit the request correctly for November 2024 and it caused a delay in the payment to the residents. He said the check was cashed for November on 12/12/24 (during the survey) and deposited into the residents petty cash accounts.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of verbal abuse for two (#37 and #21) of five residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to thoroughly investigate allegations of verbal abuse for Resident #37 and #21. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was received from the nursing home administrator (NHA) on 12/11/24. The policy read in pertinent part, This community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. In addition to an investigation by the police department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 (five) working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. II. Resident #37 A. Resident #37 Resident #37, age less than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included fluid overload, cognitive communication deficit and hypertension. The 11/19/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. She was dependent on staff for activities of daily living (ADL). B. Resident interview Resident #37 was interviewed on 12/12/24 at 9:38 a.m. Resident #37 said Resident #31 yelled at her and scared her. She said it made her feel unsafe. On 12/12/24 at 2:44 p.m. the NHA was informed of Resident #37's report of not feeling safe because Resident #31 yelled at her. C. Record review A complaints concern card, dated 12/12/24, documented that Resident #37 reported she did not feel comfortable/safe with another resident (Resident #31) who yelled at her. The form documented the facility would make sure the two residents did not sit near each other in the dining room. -The complaints form did not include any further documentation to indicate the facility completed an investigation of Resident #37's allegation. -The form failed to include staff interviews, interviews from other residents, or further interviews with Resident #37 or Resident #31. -The facility was unable to provide documentation of an investigation related to Resident #37's allegation of verbal abuse from Resident #31. D. Staff interviews The social services consultant (SSC) was interviewed on 12/16/24 at 11:55 a.m. The SSC said anytime there was an allegation of abuse, an investigation should be completed and interventions put into place to make residents feel safe. The NHA was interviewed on 12/19/24 at 10:09 a.m. The NHA said he spoke with Resident #37 on 12/12/24 about her concern with Resident #31. He said she did not report feeling afraid, but she wanted to be kept separated from Resident #31. He said his interview with Resident #37 constituted an investigation of the allegation. He said based on the findings of his interview with a resident he would determine if the facility needed to complete an investigation of the incident. The NHA said based on what Resident #37 told him when he interviewed her, he did not think the incident needed to be investigated as an allegation of abuse. -The NHA did not provide documentation of his interview with Resident #37 before the survey exit on 12/19/24. E. Facility follow up The director of clinical services (DOCS) provided additional information via email on 12/20/24 at 3:01 p.m. The email documented that, upon notification of a potential concern, the facility had acted timely and interviewed Resident #37. The email indicated the interview conducted by the NHA was completed and at no time did Resident #37 claim to have been the victim of abuse. The concern was transcribed to a grievance form and the resident signed to express satisfaction with the proposed resolution to the concern. -However, the facility did not provide documentation of the NHA's interview with Resident #37 or documentation of further investigation into the incident. 47960 III. Resident #21 A. Resident status Resident #21, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included congestive heart failure, major depressive disorder and anxiety disorder. The 11/19/24 MDS assessment revealed Resident #21 was cognitively intact with a BIMS score of 13 out of 15. He was independent with personal hygiene, dressing and eating. The assessment documented the resident did not exhibit any behavioral symptoms. B. Observations On 12/12/24 at 3:09 p.m. Resident #21 requested his scheduled Lyrica medication (a prescription medication used to treat nerve and muscle pain). Resident #21 was very upset and yelled, This place does not care, I would rather die than be here. At 3:13 p.m., Resident #21 left his room in his wheelchair to go outside to smoke. As he approached the outside door, Resident #44 got in front of him and told him he looked guilty. Resident #21 began yelling at Resident #44 and told her to shut up and get out of the way. Resident #21 was very angry and told Resident #44 if he wanted her opinion he would give it to her. Resident #21 moved past Resident #44 and went outside. Resident #44 followed Resident #21 outside and continued talking to him. At 3:14 p.m., Resident #21 got more angry, moved closer to Resident #44 and waved his hands in front of Resident #44's face aggressively. At 3:16 p.m. registered nurse (RN) #1 was summoned after yelling for her attention for two minutes. RN #1 went outside to address the situation between Resident #21 and Resident #44. At 3:18 p.m., Resident #21 returned inside. At 3:35 p.m. the NHA was informed of the incident between Resident #21 and Resident #44. C. Record review A review of Resident #21's electronic medical record (EMR) on 12/19/24 did not reveal any documentation of the reported incident between Resident #21 and Resident #44 reported to RN #1 and the NHA on 12/12/24. The facility investigation was requested on 12/18/24 and again on 12/19/24. The NHA provided a grievance form that he completed on 12/12/24. The grievance form documented Resident #21 was agitated but did not have any concerns. The grievance form did not include any interviews with Resident #44, staff or other residents. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 12/12/24 at 3:40 p.m. CNA #2 said when residents were agitated and aggressive towards another resident, the staff attempted to separate the residents and redirect them. She said it was also the staff's responsibility to report the incidents to the NHA. CNA #2 said she was not aware of any incident that occurred between Resident #21 and Resident #44 on 12/12/24. The SSC was interviewed on 12/17/24 at 11:47 a.m. The SSC said any time an allegation of any type of abuse was reported, an investigation should be done. She said the investigation should include interviews with the parties involved, staff and witnesses. The SSC said once the interviews were completed, the facility should follow up with interventions, education with staff and anything else that would help the residents feel safe. The NHA was interviewed on 12/19/24 at 9:57 a.m. The NHA said any time allegations were made of verbal or physical abuse, they should be investigated. He said the residents involved should be interviewed to determine if the investigation should proceed. The NHA said he, or his designee, were responsible for investigating all allegations. The NHA said he interviewed Resident #21 and Resident #44 and neither resident expressed any concerns. He said he followed up a couple of days after the incident and both residents reported that they felt uncomfortable. The NHA said he reviewed reports for each resident for 24 hours after the incident to look for changes in the residents and did not find anything that would have increased either residents' agitation on the day of the incident. -However, the facility did not provide documentation of the NHA's interview with Resident #21 or Resident #44 or documentation of further investigation into the incident.

Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#216) of three residents out of 41 sample residents. Specifically, the facility failed to provide Resident #216 with an appropriate discharge process. Findings include: I. Facility policy and procedure The Discharge Planning policy, dated 2/29/24 was provided by the director of clinical services (DOCS) on 12/19/24 at 1:34 p.m. It read in pertinent part, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identity changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications.The results of the evaluation and the final discharge plan will be discussed with the resident or the resident's representative. All relevant information will be provided in a discharge summary to avoid delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living arrangement. If discharge to community is determined to not be feasible, the facility will document who made the determination and why. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge. II. Resident status Resident #216, under the age of 65, was admitted on [DATE] and discharged on [DATE] to the emergency department. According to the October 2024 computerized physician orders (CPO), diagnoses included diverticulitis (inflamed pouches in the large intestine), frontal lobe deficit following cerebral infarction (disrupted blood flow to the brain), hemiplegia and hemiparesis, major depressive disorder, anxiety disorder and acute kidney failure. The 10/19/24 minimum data set (MDS) assessment documented the resident required set up assistance with eating and was independent with all other activities of daily living (ADL). The assessment documented the resident had physical and verbal behaviors directed at others. The assessment documented there was no active discharge planning in place. A review of the resident's electronic medical record (EMR) revealed on 8/20/24 the resident was documented as moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. III. Record review The 30-day notice of involuntary discharge, dated 9/24/24, was provided by the DOCS on 12/18/24. The discharge notification documented the letter informed Resident #216 the facility issued an involuntary discharge in the interest of Resident #216's safety and welfare as well as the safety and welfare of other residents who resided within the facility. Resident #216 was to be discharged from the facility on 10/24/24. A review of Resident #216's EMR documented in a 10/19/24 provider note at 2:19 p.m. that a nurse called to report the facility was immediately discharging Resident #216 from the facility as he assaulted a staff member who was injured and the nurse reported the resident was given a final warning 30 days ago (9/24/24) for violent behavior. The nurse on duty requested to send Resident #216 with his medications. A review of Resident #216's EMR revealed a progress note written on 10/19/24 at 4:50 p.m. that Resident #216 left the facility at 4:30 p.m. with staff transportation to a local hospital. Resident #216 took his belongings with him, which included: wallet, phone, phone charger, hat, slippers, pictures and cross necklaces. The emergency department (ED) provider notes, dated 10/19/24, documented Resident #216 was apparently hostile with his care facility so he was not allowed back that night (10/19/24). The ED had anticipated Resident #216 was to be transferred back to his long-term care facility, however the facility had refused to take the resident back because of his behavior. -However, a review of Resident #216's EMR failed to reveal documentation which indicated the resident had been provided education related to his immediate discharge or that the resident understood his immediate discharge from the facility. IV. Staff interviews The regional director of operations (RDO) was interviewed on 12/19/24 at 10:30 a.m. The RDO said Resident #216 had fallen on 10/19/24 and initially refused to go to the emergency department and returned to his room. The RDO said while Resident #216 was in his room, the facility management team had a call to discuss Resident #216. The RDO said the facility wanted to ensure that Resident #216 received proper care because the resident took coumadin (a blood thinner) and had fallen. The RDO said the facility determined, because of the numerous previous conversations with the resident regarding his behavior, the facility needed to figure out an immediate discharge because Resident #216 was putting other residents at risk. The RDO said Resident #216 agreed later the same day (10/19/24) to be sent to the hospital to be assessed. The RDO said because the manager on duty was involved in an occurrence earlier in the day with Resident #216 where he assaulted a staff member, the facility had the charge nurse on duty discuss Resident #216's discharge with the emergency department. The RDO said any manager on duty could and should document conversations and refusals of care in the resident's EMR.

Based on record review and interviews, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for one (#216) of three residents reviewed for discharge out of 41 sample residents. Specifically, the facility failed to reassess Resident #216's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and directed the hospital that the resident was not allowed to return to the facility. Findings include: I. Facility policy and procedure The Discharge Planning policy, dated 2/29/24 was provided by the director of clinical services (DOCS) on 12/19/24 at 1:34 p.m. It read in pertinent part, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identity changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications.The results of the evaluation and the final discharge plan will be discussed with the resident or the resident's representative. All relevant information will be provided in a discharge summary to avoid delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living arrangement. If discharge to community is determined to not be feasible, the facility will document who made the determination and why. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge. II. Resident status Resident #216, under the age of 65, was admitted on [DATE] and discharged on [DATE] to the emergency department. According to the October 2024 computerized physician orders (CPO), diagnoses included diverticulitis (inflamed pouches in the large intestine), frontal lobe deficit following cerebral infarction (disrupted blood flow to the brain), hemiplegia and hemiparesis, major depressive disorder, anxiety disorder and acute kidney failure. The 10/19/24 minimum data set (MDS) assessment documented the resident required set up assistance with eating and was independent with all other activities of daily living (ADLs). The assessment documented the resident did not have an active discharge plan. The assessment documented the resident had physical and verbal behaviors directed at others. A review of the resident's electronic medical record (EMR) documented on 8/20/24 the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. III. Record review A review of Resident #216's EMR revealed a progress note written on 10/19/24 at 4:50 p.m. that Resident #216 left the facility at 4:30 p.m. with staff transportation to a local hospital. Resident #216 took his belongings with him, which included: wallet, phone, phone charger, hat, slippers, pictures and cross necklaces. The emergency department (ED) provider notes, dated 10/19/24, documented Resident #216 was apparently hostile with his care facility so he was not allowed back that night (10/19/24). The ED had anticipated Resident #216 was to be transferred back to his long-term care facility, however the facility had refused the resident because of his behavior. -However, review of Resident #216's EMR revealed there was no documentation to indicate the facility had reassessed the resident after his transfer to the ED to determine if the resident was able to return to the facility. -There was no documentation in Resident #216's EMR to indicate what needs the facility could not meet after the resident's transfer to the ED. IV. Staff interviews The regional director of operations (RDO) was interviewed on 12/19/24 at 10:30 a.m. The RDO said Resident #216 had fallen on 10/19/24 and initially refused to go to the emergency department and returned to his room. The RDO said while Resident #216 was in his room, the facility management team had a call to discuss Resident #216. The RDO said the facility wanted to ensure that Resident #216 received proper care because the resident took coumadin (a blood thinner) and had fallen. The RDO said the facility determined, because of the numerous previous conversations with the resident regarding his behavior, the facility needed to figure out an immediate discharge because Resident #216 was putting other residents at risk. The RDO said Resident #216 agreed later the same day (10/19/24) to be sent to the hospital to be assessed. The RDO said because the manager on duty was involved in an occurrence earlier in the day with Resident #216 where he assaulted a staff member, the facility had the charge nurse on duty discuss Resident #216's discharge with the emergency department. The RDO said any manager on duty could and should document conversations and refusals of care in the resident's EMR.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#32 and #48) of eight residents reviewed out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #32, who was dependent on staff for bathing, received her scheduled showers. -Ensure Resident #48, who was blind, received meal assistance. Findings include: I. Facility policy and procedure The Bath, Shower/Tub policy, revised February 2018, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. The policy read in pertinent part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident, all assessment data, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, the signature and title of the person recording the data. Notify the supervisor if the resident refuses the shower/tub bath. II. Resident #32 A. Resident status Resident #32, age less than 65, was admitted on [DATE]. According to the December 2024 computerized physician's orders (CPO), diagnoses included dementia, kidney disease, anxiety, cerebral aneurysm (bulge or ballooning of a blood vessel in the brain) and blindness. The 11/5/24 minimum data set (MDS) assessment revealed Resident #32 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set-up assistance from staff with oral hygiene and was dependent for toileting and showering/bathing. B. Resident interview and observation Resident #32 was interviewed on 12/11/24 at 10:23 a.m. Her hair was disheveled and there was a large amount of tangled hair on the back of her head, approximately two inch by two inch area. The resident had body odor. Resident #32 said she had knots in her hair and had not showered in at least a week. Resident #32 said the staff had to use a lift to assist her with showering. Resident #32 said the staff frequently missed providing her showers. C. Record review Resident #32's care plan, revised 10/30/24, revealed Resident #32's shower preference sheet had been updated and she was dependent on one staff to provide showers, and one to two staff to assist with personal hygiene and oral care. Review of the shower schedule posted at the nurse's station revealed Resident #32 was scheduled to receive showers every week on Monday and Friday. Resident #32's bathing/showering record from 9/1/24 to 11/30/24 was provided by the DOCS on 12/17/24 at 1:33 p.m. The bathing/shower records provided and the treatment administration record (TAR) for December 2024 were reviewed from 10/16/24 to 12/16/24. The records revealed the following: Resident #32 refused one shower on 12/13/24 (during the survey). -There was no other documentation to indicate Resident #23 had refused other scheduled showers. Resident #32 received 13 showers out of 16 opportunities. There was no documentation indicated the resident had received a shower since 11/29/24, indicating the resident had not received a shower in 17 days -Other than the documented refusal on 12/13/24, review of Resident #32's bathing records revealed no documentation to indicate why the resident missed her showers or what interventions were attempted for Resident #32's missed showers. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/17/24 at 9:58 a.m. LPN #1 said Resident #32 was very cooperative and did not refuse any care, including bathing. Certified nurse aide (CNA) #4 was interviewed on 12/17/24 at 10:14 a.m. CNA #4 said Resident #32 was dependent on staff and the staff used a lift to provide her showers. CNA #4 said Resident #32 did not refuse showers. CNA #4 said there was often one day per week when there were not enough staff present to complete all of the residents' showers. CNA #4 said when a resident did not receive a shower, staff tried to provide the shower the following day. CNA #4 said she reported to the nurse when a resident did not receive a shower. CNA #3 was interviewed on 12/17/24 at 10:52 a.m. CNA #3 said Resident #32 did not usually refuse to shower, however, CNA #3 said Resident #32 told her that she refused to shower on 12/16/24 because CNA #3 was not working that day. The director of nursing (DON) and the DOCS were interviewed together on 12/17/24 at 3:39 p.m. The DOCS said Resident #32's shower record contained multiple entries of not applicable and he did not understand why this was documented. The DOCS said there were no showers documented for Resident #32 between 11/29/24 and 12/16/24. The DOCS said there were no additional documented shower refusals. The DON said she would expect Resident #32 to receive showers as scheduled. 20287 III. Resident #48 A. Resident status Resident #48, age 68, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified macular degeneration (decreased vision), dysphagia, depression and cognitive communication deficit. The 9/27/24 MDS assessment showed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident had moderately impaired vision. The resident was independent in eating. B. Resident interview Resident #48 was interviewed on 12/11/24 at approximately 3:00 p.m. Resident #48 said she was legally blind and she could only see shadows. C. Observations During a continuous observation of the dinner meal on 12/12/24, beginning at 5:09 p.m. and ending at 5:11 p.m. the following was observed: At 5:09 p.m.,Resident #48 received her meal. An unidentified CNA served the resident her meal. The unidentified CNA told the resident what was on her plate, but did not tell her where the food was located on the plate. Resident #48 was putting her hands over the plate attempting to locate the fish sandwich. At 5:11 p.m., the resident said out loud, I do not know where my food is but I will try to eat it. During a continuous observation of the dinner meal on 12/16/24, beginning at 5:06 p.m. and ending at 5:08 p.m., the following was observed: dinner meal At 5:06 p.m., the resident received her meal. CNA #5 told the resident what was on her plate, but not the location of the food on the plate. At 5:08 p.m., the resident was provided a packet of salt and pepper with her meal. The resident opened the salt packet. She did not know which each packet was, so she held the packet over her food and put her finger into the salt that was pouring out to identify if it was salt or pepper. When she received her meal and the salt and pepper packets the staff did not identify. D. Record review The care plan, revised on 5/9/24, identified the resident had impaired visual function related to cataracts. Pertinent approaches included to tell the resident where her food items were located and to be consistent. E. Staff interviews CNA #8 was interviewed on 12/18/24 at 5:00 p.m.CNA #8 said Resident #48 was blind and that she needed to know the location of her food. She said she was able to eat independently, but needed to be told where the food was located. The assistant director of nursing (ADON) was interviewed on 12/18/24 at 5:29 p.m. The ADON said Resident #48 was legally blind. She said the staff needed to tell the resident where her food was on her plate, not just what was on the plate. She said she would provide training to the staff.

Based on observations, record review, and interviews, the facility failed to provide four of four residents (#3, #4, #5, and #12) out of 12 sample residents, with the necessary treatment and services to manage pressure injuries and minimize pressure injury risks. RESIDENT #3 Record review and interview revealed Resident #3 was hospitalized seven times and readmitted to the facility six times between January and June 2024. During this time, the resident developed pressure injuries to his sacrum, ischium, left and right heels, left ankle, and scrotum which ranged from stage 2 (partial thickness skin loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), as well as osteomyelitis (inflammation of the bone due to infection) of the sacral wound. Record review revealed the facility failed to assess the resident's pressure injuries on his readmission to the facility from the hospital on at least five occasions (1/18, 3/7, 3/19, 4/29, and 5/20/24) and failed to obtain and implement treatment orders timely. -In January, upon the resident's readmission on 1/18/24, nursing documented open wounds to the resident's right and left clavicle and coccyx per interview with the director of nursing (DON). However, the wounds were not assessed and no treatment orders were obtained until the following week. Further, the resident's skin assessments on 1/19, 1/20, and 1/21/24 incorrectly documented no skin issues. -In March, upon the resident's first readmission on 3/7/24, nursing documented a stage 2 sacral wound and an unstageable right heel wound, but the wounds were not assessed and no treatment orders for the wounds were obtained. Upon the resident's second readmission on 3/19/24, the resident's wounds were described as right heel stage 3, left heel deep tissue injury, and sacrum macerated and red. There was no documentation of dressing changes and no wound treatment orders until 3/27/24. Per record review and interview, in March, the resident was in the facility for 13 days (3/7 - 3/12/24 and 3/19 - 3/27/24) without treatment orders for wounds on his sacrum, and right and left heels. On 4/1/24, the resident was readmitted to the hospital with a diagnosis of osteomyelitis of the sacral wound. The resident was hospitalized for almost a month. In April, upon the resident's readmission on 4/29/24, there were treatment orders for his sacrum, heels, and new ischial wound and documentation of treatments, but no evidence the wounds were assessed and monitored before he returned to the hospital on 5/15/24. In May, upon the resident's readmission on 5/20/24, the readmission nursing assessment documented ankle stage 3, right heel unstageable, left heel stage 3, sacral stage 4, right gluteal fold unstageable, and scrotum stage 2. The assessment documented the initiation of a wound vacuum for the sacral wound but no new wound orders. There was no monitoring or description of the wounds by nursing staff before the resident's readmission to the hospital on 6/13/24. The facility's repeated failures to assess Resident #3's wounds on readmission, monitor the wounds, and ensure timely treatment orders created the likelihood of serious harm to Resident #3, as well as other current and future residents at risk for pressure injuries if the facility's failures were not immediately corrected. RESIDENTS #5, #12, AND #4 Further record review and interview revealed additional failures in the facility's management of residents' pressure injuries. Specifically, the facility failed to ensure: -Resident #5's wounds were assessed on admission, the resident was accurately assessed for risk of pressure injury development, and timely pressure prevention interventions and treatment were put in place; -Resident #4, who had four pressure injuries from stage 3 (full-thickness tissue loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), had an air mattress that was inflated appropriately to prevent increased pressure; and, -Resident #12's pressure injuries were assessed on admission and treatment was ordered timely and provided. Findings include: I. IMMEDIATE JEOPARDY A. Findings of immediate jeopardy Record review and interview revealed Resident #3 was hospitalized seven times and readmitted to the facility six times between January and June 2024. During this time, the resident developed pressure injuries to his sacrum, ischium, left and right heels, left ankle, and scrotum which ranged from stage 2 (partial thickness skin loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), as well as osteomyelitis (inflammation of the bone due to infection) of the sacral wound. Record review revealed the facility failed to assess the resident's pressure injuries on his readmission to the facility from the hospital on at least five occasions (1/18, 3/7, 3/19, 4/29, and 5/20/24) and failed to obtain and implement treatment orders timely. -In January, upon the resident's readmission on 1/18/24, nursing documented open wounds to the resident's right and left clavicle and coccyx per interview with the director of nursing (DON). However, the wounds were not assessed and no treatment orders for the wounds were obtained until the following week. Assessments 1/19, 1/20, and 1/21/24 incorrectly documented no skin issues. -In March, upon the resident's first readmission on 3/7/24, nursing documented a stage 2 sacral wound and an unstageable right heel wound, but the wounds were not assessed and no treatment orders for the wounds were obtained. Upon the resident's second readmission on 3/19/24, the resident's wounds were described as right heel stage 3, left heel deep tissue injury, and sacrum macerated and red. There was no documentation of dressing changes and no wound treatment orders until 3/27/24. Per record review and interview, in March, the resident was in the facility for 13 days (3/7 - 3/12/24 and 3/19 - 3/27/24) without treatment orders for wounds on his sacrum, right and left heels. On 4/1/24, the resident was readmitted to the hospital with a diagnosis of osteomyelitis of the sacral wound. The resident was hospitalized for almost a month. In April, upon the resident's readmission on 4/29/24, there were treatment orders for his sacrum, heels, and new ischial wound, but no evidence the wounds were assessed and monitored before he returned to the hospital on 5/15/24 for severe sepsis. In May, upon the resident's readmission on 5/20/24, the readmission nursing assessment documented ankle stage 3, right heel unstageable, left heel stage 3, sacral stage 4, right gluteal fold unstageable, and scrotum stage 2. The assessment documented the initiation of a wound vacuum for the sacral wound but no new wound treatment orders. There was no monitoring or description of the wounds by nursing staff before the resident's readmission to the hospital on 6/13/24. The facility's repeated failures to assess Resident #3's wounds on readmission, monitor the wounds, and timely obtain and implement treatment orders created the likelihood of serious harm to Resident #3, as well as other current and future residents at risk for pressure injuries if the facility's failures were not immediately corrected. B. Facility notice of immediate jeopardy On 6/18/24 at 3:42 p.m., the nursing home administrator (NHA) was informed of the findings of immediate jeopardy under F686, Pressure Injuries. C. Facility plan to remove immediate jeopardy The facility plan to remove immediate jeopardy read: The identified Resident (#3) is currently at the hospital; therefore, no individualized plan of correction is indicated. This Resident will not be returning to the community. The community has identified two other Residents with pressure injuries. The director of nursing (DON) completed pressure injury assessments on these 2 Residents and updated the plans of care as indicated. Current treatment orders were verified and treatment was completed as ordered. On 6/19/2024, a community-wide audit of all residents was completed by the DON or designee to obtain a baseline on current skin concerns in the community. Any identified area was corrected upon discovery. On 6/19/2024, the DON completed an audit to ensure all treatments, supplies, and equipment were readily available for pressure injury treatments. Additionally, the Director of Clinical Operations completed an audit of all air mattresses and support surfaces to ensure proper use in accordance with (the) manufacturer's recommendations or resident preferences. All identified areas were corrected upon discovery. Beginning 6/18/2024, the DON or designee initiated education with nursing staff regarding proper identification, documentation, and monitoring of pressure ulcers, as well as implementing interventions to prevent breakdown and completion of treatments as ordered for resident's skin injuries. Education to be provided to agency staff prior to the next scheduled shift. Beginning 6/19/2024, (the) DON or designee (is) to complete wound rounds weekly and ensure documentation is inputted in (the) electronic health record weekly. Beginning 6/19/2024, DON or designee (is) to complete wound dressing change observations and complete chart review two times a week for one month, then weekly for two months wound documentation for two residents to ensure that orders in place and are being followed as written, that staff is following appropriate infection control practices, that the physician is notified as needed, and that documentation is consistent throughout the chart. Identified concerns to be addressed with staff. Beginning 6/19/2024, (the) Nurse consultant or designee (is) to complete (a) monthly review of (the) resident's wound documentation to ensure that it is consistent with documentation from the wound physician and that the physician is being contacted as necessary for the wound. Identified concerns to be addressed with DON/designee. Beginning 6/19/2024, any residents admitted to the facility or returning from the hospital will be assessed for any area of skin breakdown. Any areas identified requiring treatment will have orders verified or obtained and wound care appointments will be transcribed and overseen by nurse leadership. A review to include an additional skin check will be completed. DON or designee to report on wound data monthly in the quality assurance performance improvement QAPI meeting. Identified concerns to be tracked and trended as needed. D. Removal of immediate jeopardy The facility plan was accepted by the state survey agency on 6/19/24 at 12:48 p.m., based on the systemic changes outlined in the plan to ensure pressure injuries would be assessed, monitored, and treated, and oversight planned to ensure compliance. The immediate jeopardy situation was removed; however, the deficient practice remained at level G, isolated, actual harm. II. PRESSURE INJURIES - CLASSIFICATION OF INJURIES AND FACILITY EXPECTATIONS A. Classification of pressure injuries According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 6/23/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Facility expectations in the management of pressure injuries and pressure injury risks. 1. Facility policy The facility's Pressure Injury Policy, dated 3/10/23, was received from the regional director of clinical services (RDCS) on 6/20/24 at 2:12 p.m. The policy read, in pertinent part: Purpose: To assess and implement interventions as appropriate to reduce the likelihood of (the) development of pressure injuries and that a resident who has a pressure injury receives appropriate care and services to promote healing and to prevent additional pressure injuries. Assessment: Using a standardized Braden Risk Assessment Tool, assess a resident's pressure injury risks upon admission. Conduct a thorough skin assessment. The facility will complete this assessment upon admission and weekly thereafter unless otherwise indicated. Daily monitoring with accompanying documentation. Protecting against the effects of pressure, friction, and shear. Reduce pressure over bony prominences by offloading and positioning. Evaluate the need for a pressure-reducing mattress or overlay. The facility will initiate and follow treatment modalities as ordered by the primary physician. 2. Staff interviews a. The DON and the regional director of clinical services (RDCS) were interviewed on 6/18/24 at 9:28 a.m. The DON said she expected a wound assessment would be completed within the first few hours after the resident was admitted . She said the assessment should include general size, color, and whether there was drainage or signs of infection. The DON said nurses were responsible for obtaining orders before the wound physician rounds. She said the nurse should check for any orders sent with the resident from the hospital and the nurse should call the doctor for orders if the resident had a wound and no orders existed. The DON said measurements should be obtained each week by the wound team with measurements and a description of the resident's wounds, even if the resident is being seen by an outside wound clinic. The DON said nursing staff should monitor and assess the resident's wounds as dressing changes are performed. Treatments and dressing changes should be documented on the treatment administration record (TAR) b. Licensed practical nurse (LPN) #1 was interviewed on 6/20/24 at 12:55 p.m. LPN #1 said the skin assessment should be done the same day as the resident's admission. LPN #1 said she prioritized this and completed it within an hour of admission. LPN #1 said if there was something abnormal, she reported the observations to the registered nurse (RN) for a thorough assessment and the RN would call the physician. c. Registered nurse (RN) #1 was interviewed on 6/20/24 at 1:00 p.m. RN #1 said she assessed residents' skin condition at admission and readmission and tried to complete the assessment within an hour of admission. RN #1 said if a resident's skin condition was abnormal, she would measure and document a description of the wounds and contact the physician to obtain orders the same day. III. RESIDENT #3 A. Resident status Resident #3, age 69, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), the resident's diagnoses included leukemia, diabetes, kidney disease, and cerebrovascular disease (conditions affecting blood vessels and flow in the brain). The 3/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. It documented that the resident was at risk for the development of pressure injury and had three unhealed, unstageable pressure ulcers. Resident #3 required a pressure-reducing device for his chair and bed, nutrition interventions to manage skin problems, and pressure injury care, including the application of ointments/medications. Resident #3 required partial assistance with eating and was dependent on staff for repositioning in bed, transferring, and bathing. B. Record review and interviews revealed Resident #3 developed six wounds. The facility failed to provide the resident with the necessary care and services to prevent the pressure wounds from developing and worsening. Specifically, the facility failed repeatedly to assess Resident #3's wounds on readmission, monitor the wounds, and timely obtain and implement treatment orders as expected. 1. January - February 2024 a. The resident was hospitalized ,d+[DATE] - 1/8/24 for sepsis. On 1/8/24, Resident #3 was readmitted to the facility. On 1/9/24, the wound physician's progress note revealed Resident #3 had developed a non-pressure wound on the left buttock, described as moisture-associated skin damage (MASD) partial thickness which measured 1.3 cm by 1.3 cm by 0.1 cm. Treatment orders to use a foam silicone border every two days were initiated. b. The resident was hospitalized ,d+[DATE] - 1/18/24 for urinary retention On 1/18/24, Resident #3 was readmitted to the facility. The hospital physician's note revealed Resident #3 had a neck/collar area pressure injury which started at the nursing facility on 1/12/24 from his cervical collar. (The note did not mention a non-pressure wound on the left buttock noted 1/8/24.) Assessment failures: Record review revealed no assessment of Resident #3's wounds upon readmission to the facility on [DATE]. See facility policy above. In an interview on 6/18/24 at 9:28 a.m. with the DON and the regional director of clinical services (RDCS), the DON confirmed the 1/18/24 nursing assessment documented three open wounds (left clavicle, right clavicle, and coccyx) but there was no documentation these wounds were assessed. Moreover, the RDCS said the nurse on 1/19/24 and 1/20/24 documented the resident's skin was intact and the DON said an assessment completed on 1/21/24 documented no skin issues. Treatment failures: The resident's record revealed no treatment orders until 1/23/24. See facility expectations above. In the interview on 6/18/24 at 9:28 a.m., the DON said nurses were responsible for obtaining orders before the wound physician rounds. She said the nurse should check for any orders sent with the resident from the hospital and the nurse should call the doctor for orders if the resident had a wound and no orders existed. c. Documentation of the presence of additional wounds 1/31/24, 2/6/24, 2/13/24 On 1/31/24, the wound physician's progress note revealed: -Non-pressure wound left buttock, partial thickness, MASD, 0.8 cm by 0.3 cm by 0.1 cm. -Non-pressure wound left neck, full thickness, 5.5 cm by 1.2 cm by 0.3 cm. -Pressure wound of right heel, full thickness, unstageable, 2.2 cm by 2.2 cm x non-measurable depth. The heel wound was noted to be greater than 13 days in duration. However, the 1/25/24 wound notes did not reveal a heel wound. On 2/6/24, the wound physician's progress note revealed: -Non-pressure wound left buttock had resolved. -Non-pressure wound left neck healing and measured 3.0 cm by 0.7 cm by 0.3 cm. -Non-pressure wound of right heel resolved. On 2/13/24, the wound physician's progress note revealed: -Non-pressure wound left neck full thickness, cauterization procedure for abnormal granulation tissue. -Non-pressure wound left ischium full thickness, measured 3.9 cm by 2.0 cm by 0.1 cm. -Pressure wound right heel, undetermined thickness, unstageable measured 1.1 cm by 1.5 cm by non-measurable. 2. March 2024 a. The resident was hospitalized from 2/14 to 3/7/24, for a urinary tract infection and surgical revision. He was readmitted to the facility on [DATE] until 3/12/24 when he was hospitalized again until 3/19/24 for urinary retention and suprapublic catheter placement. The resident was readmitted to the facility on ,d+[DATE] until 4/1/24 when he returned to the hospital. Failures on readmission 3/7/24 and 3/19/24. Assessment failures 3/7 to 3/12/24 and 3/19 to 3/27/24: The nursing admission assessment on readmission 3/7/24 at 5:50 p.m. revealed a stage 2 sacrum wound and an unstageable right heel wound. The nursing assessment on readmission on 3/19/24 revealed a right thigh skin tear, right heel stage 3, left heel deep tissue injury, and sacrum macerated and red. See facility policy above. In an interview on 6/18/24 at 9:28 a.m. with the DON and the regional director of clinical services (RDCS), the DON confirmed there was no description of the resident's wounds on his readmission from 3/7/24 to 3/12/24. Further record review revealed no description of the resident's wounds on readmission from 3/19/24 to 3/27/24 when Resident #3 was seen by the wound physician (see below). On 3/30/24, nursing notes at 4:03 p.m. and on 3/31/24 at 5:42 a.m. described the resident's coccyx wound as having odor. However, there was no documentation of an assessment or follow-up. Treatment failures 3/7 to 3/12/24 and 3/19 to 3/27/24: Record review revealed no wound treatment orders during the resident's first readmission in March. Further, record review revealed no treatment orders during the resident's second readmission on 3/19 until 3/27/24 when the resident was seen by the wound physician. See facility expectations above. In the interview on 6/18/24 at 9:28 a.m., the DON confirmed there were no wound treatment orders from the resident's readmission from 3/7/24 to 3/12/24 and no wound treatment orders from his readmission from 3/19 until 3/27/24. She said nurses were responsible for obtaining orders before the wound physician rounds. She said the nurse should check for any orders sent with the resident from the hospital and the nurse should call the doctor for orders if the resident had a wound and no orders existed. In addition, a review of the treatment administration record (TAR) revealed it did not have documentation of dressing changes from 3/19 to 3/26/24. See facility expectations above. The DON said in the interview on 6/18/24 at 9:28 a.m., that all treatments and dressing changes should be documented on the TAR. c. Documentation of wounds 3/27/24 The wound physician's progress note included the following description: sacrum, unstageable due to necrosis 10 centimeters (cm) x 11 cm x 0.1 cm depth; right heel unstageable 2.0 cm x 3.0 cm, depth not measurable; and left heel unstageable 2.5 cm x 3.0 cm, depth not measurable. The physician also identified a non-pressure wound (moisture-associated skin damage) greater than seven days on the resident's scrotum 3.0 x 2.0 x 0.1 which was not previously identified by the facility. 3. April 2024 a. The resident was hospitalized from 4/1/24 to 4/29/24 for pressure ulcers and osteomyelitis of the sacral wound. The hospital admission history and physical revealed a computerized tomography (CT) on 4/1/24 demonstrated coccygeal osteomyelitis (from sacral ulcer) as the primary infectious source. Failures on readmission to the facility 4/29/24: Record review revealed there were treatment orders for his sacrum, heels, and new ischial wound, but there was no evidence the wounds were assessed and monitored before he returned to the hospital on 5/15/24. The DON in the interview on 6/18/24 at 9:28 a.m. said the resident was being seen by an outside wound clinic after 4/30/24; however, she said the resident should have continued to be seen by the wound team weekly at the facility. The DON said measurements should have been obtained each week by the wound team with a description of the resident's wounds at the facility. The DON said nursing staff should have monitored and assessed the resident's wounds as dressing changes were performed. On 5/6/24, Resident #3's outside facility wound clinic visit physician progress note revealed the following: sacral pressure injury stage 4; left ischial pressure injury, unstageable; left heel pressure injury, unstageable; right heel pressure injury, unstageable; left ankle pressure injury, unstageable and left foot (metatarsal) pressure injury, unstageable. 4. May - June 2024 a. The resident was hospitalized on [DATE] for severe sepsis and readmitted to the facility on [DATE]. He was readmitted to the hospital on 6/13/24 and remains hospitalized . The resident's readmission nursing assessment on 5/20/24 documented: ankle stage 3; right heel unstageable; left heel stage 3; sacral stage 4; right gluteal fold unstageable; and scrotum stage 2. The assessment also documented the initiation of a wound vacuum (wound vac) for the sacral wound. Treatment orders were resumed from the resident's previous admission without new orders. Failures on readmission to the facility from 5/20/24 to 6/13/24: Assessment failures: There was no monitoring or description of the wounds by nursing staff before the resident's readmission to the hospital on 6/13/24. See above. The DON in the interview on 6/18/24 at 9:28 a.m. said the resident was being seen by an outside wound clinic after 4/30/24. However, she said the resident should have continued to be seen by the wound team weekly at the facility. The DON said measurements should have been obtained each week by the wound team with a description of the resident's wounds at the facility. The DON said nursing staff should have monitored and assessed the resident's wounds as dressing changes were performed. The outside wound clinic RN (WCRN) was interviewed on 6/18/24 at 1:00 p.m. The WCRN said Resident #3 was seen at the clinic by the wound physician once per week and was last seen at the clinic on 6/5/24. She said Resident #3's wounds were: sacral, stage 4; left heel, stage 3, right heel, unstageable; left ankle, stage 3, and ischial, stage 4. The WCRN said if there were gaps in the treatment of the wounds, it could have led to the worsening of Resident #3's wounds. Treatment failures: The WCRN said the wound vacuum (initiated on 5/20/24) was not on the resident when he arrived for the visit on 6/5/24. The WCRN said the facility sent the wound vac machine the week prior, however, it was not working and was out of batteries. Certified nurse aide (CNA) #3 was interviewed on 6/20/24 at 12:36 p.m. CNA #3 said she sometimes noticed residents' bandages that needed replacement and she told the nurse when this occurred. CNA #3 said she bathed Resident #3 on 6/11/24 and his dressings were labeled with the date of the last dressing change on 6/7/24. CNA #3 said she notified the nurse and the DON that Resident #3's dressings had not been changed. The DON and RDCS were interviewed a second time on 6/20/24 at 1:16 p.m. The DON said a CNA told her Resident #3's dressings had not been changed for several days last week. The DON said she did not remember the name of the CNA, the nurse, or the dates. The DON said she told the nurse and the dressing was changed. The DON said she told all staff that dressings needed to be changed as ordered. She said she provided education and began monitoring staff for dressing change completion but she did not have documentation of the education provided or the monitoring she had completed. The DON said she did not know if Resident #3's wounds had progressed before his hospitalization on [DATE]. The RDCS said there was no documentation describing the wounds after the missed dressing changes. IV. Resident #5 A. Resident status Resident #5, less than age 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included infection of the right upper extremity stump, sacrum pressure ulcer, diabetes mellitus, and left and right above-the-knee amputation. According to the 4/23/24 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. Transfers did not occur according to the assessment. Resident #5 required substantial to maximum assistance with bed mobility and supervision with personal hygiene. She was dependent on staff for toileting. The assessment documented Resident #5 had a pressure injury to the sacrum. It further documented the resident's pressure injury was unstageable and pressure injury care and treatment were in place. The assessment documented the resident was frequently incontinent. B. Record Review On 4/19/24 the Nursing Admit Data Collection Tool documented the resident had pressure injuries to the right and left gluteal folds. There was no further description of the wounds. The Braden assessment, dated 4/22/24, documented the resident was not at risk for pressure injuries. The assessment documented the resident had no sensory impairment, was rarely moist, chairfast, had slightly limited mobility, adequate nutrition, and had no problems with friction. -However, the resident had current pressure injuries as documented on 4/19/24 and had diabetes mellitus. Further, she required substantial assistance with bed mobility and was frequently incontinent. On 4/22/24 at 12:15 a.m. the provider documented the resident still did not have an air mattress. The provider spoke with the DON about getting an air mattress. The provider documented that wound treatment orders were given. On 4/23/24 at 12:15 a.m. the provider documented the air[TRUNCATED]

Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#7, #8, #9 and #10) of four residents reviewed for abuse out of 12 sample residents. Resident #7 was admitted to the facility on [DATE] with diagnoses that included a history of mood disorder, depression and alcohol abuse. On 3/9/24 Resident #7 called certified nurse aide (CNA) #1, who was an agency CNA, a racial slur. CNA #1 went to Resident #7's bed, placed his forearm across the resident's left side and leaned on top of the resident. CNA #1 repeatedly told Resident #7 he needed to apologize for calling him a racial slur. CNA #1 then left the room. Resident #7 reported he cried out in pain all night following the incident. On the morning of 3/10/24 Resident #7 was transferred to the hospital when his oxygen saturation level (level of oxygen in the blood) dropped into the 70 percent (%) to 79% range. At the hospital, Resident #7 was diagnosed with multiple rib fractures and a pneumothorax (collapsed lung). Additionally, the facility failed to: - Prevent physical abuse between Resident #8 and Resident #9, both with known physical aggression, which resulted in an eye injury to Resident #8; and, - Prevent physical abuse by Resident #11, a resident with known aggressive behaviors, to Resident #10 which resulted in skin injuries to Resident #10's neck and arm. Findings include: I. Facility policy The Abuse policy, dated 2/29/24, was received from the regional director of clinical services (RDCS) on 6/20/24 at 2:12 p.m. The policy documented in pertinent part, Employees have a unique position of trust with vulnerable residents. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. Pre-assessment of potential residents is done during the admission process to screen for potential signs of abusive behavior. Residents at risk for abusive situations are identified and appropriate care plans are developed. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials, according to state law. Reporting can be completed verbally or in writing. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The facility assesses each potential resident prior to admission. This assessment includes a behavior history. Persons with a significant history or high risk of violent behavior are carefully screened and assessed for appropriateness of admission. If a resident experiences a behavior change resulting in aggression toward other residents, the facility will implement interventions for protection of the alleged assailant and other residents. II. Physical abuse by certified nurse aide (CNA) #1 toward Resident #7 on 3/9/24 A. Facility investigation The facility investigation was received from the nursing home administrator (NHA) on 6/17/24 at 12:40 p.m. The investigation documented the abuse by CNA #1 toward Resident #7 occured on 3/10/24 and an investigation was started on 3/11/24. The investigation further documented the following: Resident #7 had a history of aggression. Resident #7 was interviewed by the facility on 3/12/24. Resident #7 said (CNA #1) came into his room and he called CNA #1 a racial slur. He said CNA #1 put his forearm on the resident's chest and pressed down. CNA #1 was interviewed on 3/12/24. He said he was assigned to the resident's room. He said he had helped Resident #7's roommate to and from bed. He said Resident #7 reported some difficulty breathing and he had notified the night nurse. Resident #7's roommate was interviewed. The facility's investigation documented the roommate said he was not aware of what happened with his roommate. Registered nurse (RN) #1 was interviewed by the facility on 3/12/24. RN #1 said, at approximately 6:15 a.m., she went to assess Resident #7 who had complaints of pain. The resident said he had pain in his chest where a CNA had fallen on him. The resident could not elaborate due to his shortness of breath. -The facility's investigation did not include an interview with the night nurse, RN #3, who worked from 6:00 p.m. on 3/9/24 to 6:00 a.m. on 3/10/24, according to the facility's nursing schedule. The investigation documented that there were no witnesses to the event and CNA #1 said he had only gone in to assist Resident #7's roommate and nothing else. It documented Resident #7 could be resistant to care. The investigation further documented there was no mention of abuse in CNA #1's statement. The investigation documented the facility staff were educated on abuse and the police were notified on 3/12/24. The investigation documented the abuse was unsubstantiated by the facility. -However, according to the interview with the NHA, the abuse was substantiated (see interview below). A document titled Abuse Education (no date) was attached to the facility's investigation of the incident. Seventeen staff names and signatures were listed as receiving the education. B. Resident #7 1. Resident status Resident #7, age 69, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included multiple rib fractures, traumatic hemopneumothorax (blood and air in collapsed lung), depression, mood disorder and alcohol abuse. According to the 3/29/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #7 required substantial to maximal assistance with transfers and toileting and supervision with personal hygiene and bed mobility. 2. Resident interview Resident #7 was interviewed on 6/18/24 at 2:01 p.m. Resident #7 said in the beginning of March 2024, in the evening, he had a male CNA (CNA #1) providing his care. Resident #7 said CNA #1 had been in his room, on his side of the room, multiple times that evening when his roommate called for assistance. He said he repeatedly told CNA #1 that his roommate had called, not him. Resident #7 said he called CNA #1 some bad names as CNA #1 was leaving his room. Resident #7 said CNA #1 came back into the room and laid across the left side of his chest, with his forearm pressed into the resident's left chest. He said CNA #1 yelled at him, in his face, to apologize. Resident #7 said CNA #1 then left his room. Resident #7 said he had pain in his left rib cage and was short of breath the entire evening and night. Resident #7 said he put his call light on several times but CNA #1 would come back in the room and turn it off. He said another resident in close proximity to him also turned on the call light throughout the night, but no staff came to help him. Resident #7 said he was nervous and anxious that he could be harmed again by another staff person. 3. Additional resident interview A resident, who wished not to be identified, was interviewed on 6/18/24 at 2:08 p.m. The resident resided in close proximity to Resident #7. The resident said he did not see what happened to Resident #7. He said he heard a commotion and then Resident #7 cried out in pain. He said Resident #7 cried in pain all night. The unidentified resident said both he and Resident #7 put on their call lights for help throughout the night but no one responded. He said he did not know if someone shut the call light off or the staff just did not come. He said both he and Resident #7 were up all night. 4. Record review A chest x-ray in Resident #7's electronic medical record (EMR), dated 3/7/24, two days before the incident with CNA #1, documented the resident had right airspace lung disease. He had no pneumothorax and there was no mention of an issue with his ribs. A nurse progress note, dated 3/10/24 at 12:32 a.m., documented Resident #7 had shortness of breath, dyspnea (difficulty breathing) and wheezing but no pain. The resident had a diagnosis of pneumonia and was on antibiotics. However, in report to the day nurse on the morning of 3/10/24, the night nurse reported the resident was in pain (see RN #1's interview below). Resident #7's medication administration record (MAR) for March 2024 was reviewed. The MAR documented the resident had no pain on 3/9/24. However, in report to the day nurse on the morning of 3/10/24, the night nurse reported the resident was in pain (see RN #1's interview below). The hospital note dated 3/20/24 documented Resident #7 had trauma to the left chest and had multiple rib fractures with a large left pneumothorax due to someone sitting on him. On 4/2/24 the facility's provider documented Resident #7 returned from the hospital after a traumatic pneumothorax with a chest tube and multiple rib fractures. The resident said someone sat on him. The provider documented the hospital records were unclear but laboratory results revealed evidence of a possible myocardial infarction (heart attack) as well. 5. Staff interviews A voice mail message was left on 6/17/24 at 1:56 p.m. for the agency RN (RN #3) who worked from 6:00 p.m. on 3/9/24 to 6:00 a.m. on 3/10/24. There was no return call from RN #3 by the end of the survey on 6/20/24. A voice mail message was left on 6/19/24 at 1:09 p.m. for the agency CNA (CNA #2) who worked with CNA #1 on 3/9/24 in the evening. There was no return call CNA #2 by the end of the survey on 6/20/24. RN #1 was interviewed with the nursing home administrator (NHA) on 6/17/24 at 1:35 p.m. RN #1 said on the morning of 3/10/24 she was getting report from the night shift nurse (RN #3) who said Resident #7 had been in pain throughout the night. RN #1 said RN #3 told her it was generalized pain. RN #1 said soon after, a CNA came to her and asked her to go see Resident #7 because his oxygen saturation level was in the 70% to 79% range. RN #1 could not recall who the CNA who reported the information to her was. She said she went to see the resident and he was short of breath and had chest pain. She said she put 10 liters per minute (lpm) of oxygen on him and called 911. RN #1 said Resident #7 could hardly speak but said CNA, my chest, my fault. RN #1 said she did not look at his chest. She said the resident was then transferred to the hospital. RN #1 said she called the hospital for a report and was told Resident #7 had multiple rib fractures to the left side and a pneumothorax. RN #1 said the resident's comment about the CNA was reported to the NHA that day. The NHA said the hospital case manager called him on 3/11/24 and notified him that Resident #7 said a CNA had injured him. He said he went to the hospital and interviewed the resident on 3/11/24. The NHA said Resident #7 told him the male CNA (CNA #1) on 3/9/24 sat on him and pressed his forearm into the resident's chest. The resident admitted to having called CNA #1 names. The NHA said the allegation of abuse was substantiated and he notified the police and board of nursing. Additionally, he said he called CNA#1's agency and notified them that he could not return to the facility. The medical director (MD), who was contacted prior to the end of the survey on 6/20/24 at 9:40 a.m. and was interviewed on 6/24/24 at 9:57 a.m. The MD said she became the medical director at the beginning of June 2024. The MD said a resident with fractured ribs would most likely have had pain immediately when the ribs were fractured. She said the pain could have been delayed if the resident was in shock. The MD said Resident #7's pneumothorax could have affected his oxygenation levels as well the pain. She said the pneumothorax could have happened at the time of the rib fractures or later in the night if he had taken a deep breath. III. Resident to resident physical abuse between Resident #8 and Resident #9 on 4/14/24 A. Facility investigation A facility investigation of physical abuse between Resident #8 and #9 on 4/14/24 was received from the NHA on 6/19/24 at 2:52 p.m. The investigation documented the following: Resident #9 was interviewed on 4/15/24 and said Resident #8 did not like her cell phone ring tone and Resident #8 shoved her in the chest so she decided to hit him. Resident #8 was interviewed on 4/15/24. He said Resident #9 asked him for cigarettes earlier that day (4/14/24). He said when he heard her phone ring, he did not like the ring tone and told her to change it. She said no. Resident #8 said Resident #9 began to leave and he followed her and tried to hit her, and she turned around and hit him in the face. A staff witness said she was going to the kitchen and she saw Resident #8 run his wheelchair into Resident #9. She said she then saw Resident #9 hit Resident #8 in the face. She said she and other staff members pulled the residents apart. -The investigation documented both residents had a history of physical and verbal aggression. -The investigation documentation revealed the assailant was placed on frequent checks. It was unclear which resident was the assailant. B. Resident #8 1. Resident status Resident #8, age less than age 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included alcohol abuse, anxiety and seizures. According to the 4/5/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #8 was independent with bed mobility, transfers, toileting, dressing and personal hygiene. 2. Record review The behavior care plan, initiated 1/18/24, documented Resident #8 had a history of drinking at the facility, physical and verbal aggression and poor impulse control. He had a history of yelling, screaming, cursing, making verbal threats, hitting and pushing. Interventions included administering medications as ordered, assisting the resident to develop more appropriate methods of coping, encouraging expression of feelings, behavior monitoring, providing positive interactions, explaining procedures, discussing the resident's behavior, intervening as necessary to protect the rights and safety of others, approaching the resident in a calm manner, diverting the resident's attention and removing the resident from the situation. -There were no new interventions added to the care plan after the altercation on 4/14/24. C. Resident #9 1. Resident status Resident #9, age less than age 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included anxiety, depression, cocaine dependence and adult physical abuse. According to the 3/29/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #9 required substantial to maximal assistance with transfers and toileting and supervision with personal hygiene and bed mobility. 2. Record review On 3/30/24 at 11:29 a.m. the nursing progress notes documented Resident #9 was yelling and cursing at the nurse. On 4/13/24 at 10:44 a.m., one day prior to the physical abuse, the nursing progress notes documented Resident #9 was cursing at the nurse, physically attempted to remove the nurse from the room and attempted to stand and go after the nurse. The staff had to hold the resident back. The nurse documented the resident was unsafe to herself and to be around. -The nursing progress notes were reviewed between 4/13/24 and 4/14/24. No additional monitoring or intervention for Resident #9's behavior was put in place. The physical and verbal aggression care plan, initiated 8/22/23 was reviewed. The care plan documented Resident #9 had poor impulse control and a history of yelling, cursing and hitting others. Interventions included assessing and anticipating the resident's needs, monitoring behaviors, and when the resident was agitated, intervene before the agitation escalated, guiding the resident away from sources of distress and using calm conversation. -There were no new interventions added to the care plan after the altercation on 4/14/24. D. Staff interviews The NHA was interviewed with the RDCS on 6/19/24 at 2:52 p.m. The NHA said on 4/14/24 Resident #9's cell phone rang in the dining room. Resident #8 did not like the ringtone. Resident #9 attempted to leave the dining room but Resident #8 followed her and hit her in the chest. Resident #9 had sternal pain. Resident #8 then hit Resident #9 in the face resulting in broken blood vessels in Resident #8's right eye. The NHA said Resident #8 and Resident #9 had a history of verbal and physical aggression. He said there was no plan for monitoring behaviors in the dining room. The NHA said after the incident occurred, both residents were put on frequent monitoring. -However, there was no frequent monitoring documented on the care plan or in the progress notes for Resident #8 or #9. The NHA said the physical abuse toward both residents was substantiated and witnessed by staff in the dining room. IV. Resident to resident physical abuse of Resident #10 by Resident #11 on 5/31/24 A. Facility investigation An investigation of physical abuse to Resident #10 by Resident #11 on 5/31/24 was received from the NHA on 6/19/24 at 2:52 p.m. The investigation documented the following: Resident #10 and #11 were roommates. Resident #10 said Resident #11 had grabbed her arm and put the call light cord on her neck. A staff member interview on 5/31/24 documented she heard Resident #10 calling for help and when she went in the resident's room Resident #11 had a call light on the neck of Resident #10. Additionally the skin on the arm of Resident #10 looked like it had been twisted. A licensed nurse interview on 5/31/24 documented she went to the resident's room after a CNA came to get her. She said Resident #10 had redness to her neck and arm. Resident #11 was placed on frequent checks and then sent out to the hospital due to the risk she posed to other residents (see below). B. Resident #10 1. Resident status Resident #10, age less than age 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included major depression, heart failure and diabetes mellitus. According to the 6/13/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #10 required substantial to maximal assistance with bed mobility, transfers, toileting, personal hygiene and dressing. 2. Record review On 5/31/24 at 8:05 a.m. the nursing notes documented at 12:30 a.m. a CNA heard Resident #10 calling out for help. Upon entering room Resident #10's roommate Resident #11 was twisting skin on Resident #10's arms and had the call light wrapped around Resident #10's neck. Resident #10 was extremely frightened. Slight redness was noted on the resident's arms and on the neck. Resident #10 reported slight pain that quickly resolved. Frequent checks were performed to reassure Resident #10 throughout the night. Resident #10 reported anxiety which improved when the resident was informed a CNA would stay until the roommate was removed and that staff would check on her through the night. -There was no care plan in the resident's EMR related to the abuse. C. Resident #11 1. Resident status Resident #11, age less than age 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia, anxiety and agitation. According to the 3/31/24 MDS assessment, the resident had severe cognitive impairment and a BIMS score was not completed. She had short and long term memory loss with moderate impairment of daily decision making, disorganized thinking and physical behavior toward others. Resident #11 required substantial to maximal assistance with toileting, personal hygiene, dressing and supervision with transfers and bed mobility. 2. Record review On 5/22/24 at 7:36 p.m. the provider documented the resident had increased aggression and a history of aggressive behavior. On 5/30/24 at 5:09 p.m. the nursing notes documented the resident was fascinated by an ambulance that had come to the facility and she tried to get on the gurney brought by the emergency medical services (EMS) staff. The resident could not be redirected and became aggressive, pushing and pinching the staff. The nurse tried to comfort the resident but was pushed away. -There was no behavior care plan in place until 6/10/24, after the physical altercation with Resident #10, despite Resident #11 exhibiting aggressive physical behaviors prior to the incident (see Resident #11's care plan below). On 5/31/24 at 7:53 a.m. the nursing progress notes documented that at approximately 12:30 a.m., Resident #10 called out for help. Resident #11 was found by a CNA with the call light wrapped around the neck of Resident #10 and she was pulling the call light. Resident #10 said Resident #11 had also grabbed her by the forearms and twisted her skin. The nurse called administration and a decision was made to send Resident #11 to the hospital for the safety of Resident #11 and other residents. On 5/31/24 at 8:15 a.m. an SBAR (situation, background, assessment recommendation) note documented Resident #11 was sent to the hospital due to her behavior. The note documented she needed close observation for resident, staff, and other resident safety. The resident returned that afternoon at an undocumented time. On 5/31/24 at 6:12 p.m. The nursing notes documented the resident was moved to a different unit due to the incident and was monitored. The behavior care plan, initiated 6/10/24 (10 days after the incident with Resident #10) documented Resident #11 had potential to be physically aggressive with a history of harm to others. The goal was the resident would seek out a staff member when agitation occurred. Interventions included administering medications, analyzing time of day, places , triggers, circumstances and what deescalated behaviors, assessing and addressing sensory deficits, anticipating the resident's needs, Modifying the environment, such as dim lights and keeping the door closed, monitoring and documenting behaviors and interventions, monitoring and documenting signs and symptoms of the resident posing danger to herself or others, when the resident was agitated, intervening before agitation escalated, guiding the resident away from distress, engaging with the resident calmly and re-approaching the resident later. D. Staff interview The NHA was interviewed with the RDCS on 6/19/24 at 2:52 p.m. He said Resident #10 reported Resident #11 put a call light on her neck and pinched her arm. The NHA said Resident #11 had a history of pacing and grabbing furniture. He said Resident #10 had redness to her arm and neck. He said the abuse was unsubstantiated because Resident #11 had dementia. He said he moved Resident #11 to a private room after the altercation.

Based on record review, and interviews, the facility failed to ensure two (#61 and #53) out of three residents reviewed out of 33 sample residents, as well as other facility residents, were protected from resident-to-resident abuse by Residents #54, #120, and #31. Residents #54 and #61 According to a sexual abuse investigation dated 8/8/23, Resident #61 reported Resident #54 had sexually assaulted her. Resident #54 had a known history of child abuse, was on the sex abuse registry due to an assault of an elderly person, and had recently gotten off parole for crimes he had committed in the past. A 4/12/23 behavioral assessment documented that facility staff reported Resident #54 had made inappropriate sexual comments since his admission on 3/23/23. Notwithstanding Resident #54's current and past history, the facility failed to take steps, before Resident #61 reported sexual abuse, to develop and implement person-centered, sufficient, and effective interventions to prevent potential sexual abuse. The facility's failure to take steps to prevent abuse contributed to Resident #61 becoming fearful, and triggered the initiation of psychosocial support to address her fear. Residents #120, #31 and #53 Interview revealed Resident #53 was verbally abused and physically abused by Residents #120 and #31. Findings include: I. Facility policy The Abuse policy and procedure, revised May 2023, was provided by the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part that: -(The facility) does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. -Providing a safe environment for the resident is one of the most basic and essential duties of our facility . Residents must not be subjected to abuse by anyone . including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. -When residents who have been admitted exhibit behavior that presents a danger to others, interventions shall be taken to ensure the safety of other residents and staff. II. Resident #54 and Resident #61 A. Residents' status 1. Resident #54 Resident #54, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included heart disease and chronic kidney disease. According to the 10/8/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial/moderate assistance with dressing and putting on footwear. The resident was independent in all other activities of daily living (ADLs). The resident used a motorized wheelchair. The resident did not exhibit psychosis. Resident #54 did not receive psychological therapy. 2. Resident #61 Resident #61, age 72, was admitted on [DATE]. According to the October 2023 CPO, the diagnoses included dementia with behavioral disturbances. According to the 9/25/23 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a BIMS score of 7 out of 15. She required extensive assistance of one person with all activities of daily living (ADLs) except eating and locomotion. The resident had no signs of depression. 3. Report of sexual abuse According to a sexual abuse investigation dated 8/8/23, Resident #54 allegedly touched Resident #61 on her breasts and private areas. Resident #61 said, he's so nasty. He touched me here, here, and here, anywhere he could grab. Resident #61 repeatedly said Resident #54 was a nasty man. The investigation read that Resident #61 was an at-risk adult with a BIMS of 1 and wheelchair assisted. Resident #54 was a registered sex offender from 2014 and finished probation in 2023. He goes to meetings monthly with the (local) Police Station. The resident also has a history of potentially using verbal slurs towards other residents. The investigation read that the care plan for Resident #54 read staff should monitor unsafe situations and redirect residents as needed along with continuing to monitor Resident #54 secondary to a history of sexual crimes against children. The investigation further read that Resident #54 was suspected of sexual assault. Resident #61 initially did not show any fear once the alleged assailant was placed on 1:1 (supervision) but after a couple of days, the alleged victim started making comments that she was afraid of a man. The investigation concluded the facility was unable to substantiate or unsubstantiate that the allegation had occurred as (the facility) could not determine when or if this incident happened since the alleged victim was a poor historian. However, with the reaction of the alleged victim (Resident #61), the facility was going to treat the incident as if it had happened. The alleged assailant (Resident #54) will stay on a 1:1 (supervision) until he (is) able to be placed in an appropriate placement. The victim has been referred to Mental Health Services since she was making statements of fear. Resident #54 was placed on 1:1. Referrals were sent out to multiple facilities that had all-male units. Resident #61 was at physical baseline but has increased statements of being afraid. Mental Health Services had been ordered for the resident. B. The facility failed to take sufficient steps before Resident #61 reported sexual abuse to protect residents, including Resident #61, from potential abuse. 1. Record review revealed the facility had prior knowledge of Resident #54's inappropriate behavior. A review of a behavioral health assessment, dated 4/12/23, revealed Resident #54 was referred for psychotherapeutic services and evaluations due to sexual assault and a history of sexually inappropriate behavior. It documented the resident was a registered sex offender due to the assault of an elderly person. The facility staff reported Resident #54 had made inappropriate sexual comments since admission (3/23/23). Recommendations included for the resident to participate in evidence-based psychotherapy four times a month for four months. According to a progress note dated 7/7/23, Resident #54 was found in a female resident's room when another male resident came into the room to ensure the female resident was alright. The male resident said, he had to protect the female resident from (Resident #54). 2. Notwithstanding evidence of Resident #54's current and past history of sexually inappropriate behavior, the facility failed to develop a sufficient and effective resident-centered care plan to protect at-risk residents from potential abuse by Resident #54. As noted in the facility's sexual abuse investigation above, the resident's care plan dated 7/18/23, read the resident had a history of sexual crimes against children. It further read the resident finished parole in 2023. The resident had monthly meetings with a local police station on the 8th of every month. The resident was a registered sex offender. Interventions included: -Monitoring for unsafe situations and intervening if needed. -Staff should be made aware of stipulations required, like monthly check-ins. However, the care plan was neither resident-centered nor adequate. -The care plan failed to identify what constituted an unsafe situation, whether it was an unsafe situation for others or the resident and failed to include what level of supervision was expected based on his known history of inappropriate sexual behavior and sexual crimes. Monitoring was not defined. -The care plan failed to instruct staff how to intervene given his history, failed to identify effective interventions, and failed to outline what steps staff were expected to take when inappropriate behaviors occurred, including how to intervene, who to notify, and where to document his behavior so that it could be monitored and interventions developed and revised when ineffective. -The care plan failed to include any reference to the incident on 7/7/23 and failed to trigger new interventions to prevent further incidents of potential sexual abuse. C. Staff interviews Staff interviews confirmed the facility's knowledge of Resident #54's inappropriate behavior and the facility's failure to take steps to protect residents, including Resident #61. 1. Certified nurse aide (CNA) #2 was interviewed on 10/26/23 at 10:56 a.m. CNA #2 said Resident #54 was a registered sex offender. CNA #2 said the resident had been inappropriate with staff and other residents. CNA #2 said they verbally told the nurses when the resident was inappropriate, but there was no documentation of it. CNA #2 said the staff had not had extra training on how to work with a resident who had a criminal record of sexual abuse. CNA #2 said Resident #54 did not have interventions put in place until after the incident with Resident #61. CNA #2 said before that incident, Resident #54 would go into female residents' rooms and staff did not redirect him. The social services assistant (SSA) was interviewed on 10/26/23 at 12:39 p.m. The SSA said the facility was aware that Resident #54 had been incarcerated for sexual abuse against a child. The SSA said they did not have specific education for the staff when working with an individual who was a registered sex offender. The SSA said they did not put specific interventions into place for Resident #54 until after the incident with Resident #61. The SSA said since the incident, Resident #54 was on one-on-one supervision and the facility had tried to place him in a different facility. The SSA said Resident #61 was fearful of Resident #54 and was teary after the incident calling the resident a bad man. The nursing home administrator (NHA) was interviewed on 10/26/23 at 3:30 p.m. The NHA said the facility was aware on admission, that Resident #54 had been incarcerated for sexual abuse and was on the sex offender registry. The NHA said they did not have additional training for staff on how to work with a registered sex offender. The NHA said staff should tell somebody if they saw Resident #54 being inappropriate. The NHA said there was not a specific place to document this and it was done verbally. The NHA said they did not put interventions in place until after the incident with Resident #61. The NHA said Resident #54 was allowed to go into female residents' rooms and roam freely throughout the facility. The NHA confirmed Resident #61's severe cognitive impairment and recognized it placed the resident at risk for abuse. The NHA said they got Resident #61 mental health care because she was teary and afraid after the event. The NHA said residents have the right to remain abuse-free. The NHA said after the incident with Resident #61, Resident #54 was put on one-on-one and they are trying to get him placed in a different facility. 37166 III. Resident #53 and Residents #120 and #1 - failure to prevent resident-to-resident abuse A. Resident #53's status 1. Resident #53, age under 60, was admitted to the facility on [DATE]. According to the October 2023 CPO, diagnoses included lymphoma and kidney disease. The 9/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with all daily activities. He did not display physical or verbally aggressive behavior toward staff or other residents. B. Failure to prevent resident-to-resident abuse involving Resident #53 Resident #53 was interviewed on 10/23/23 at 2:30 p.m. He said he was verbally abused and physically assaulted by two different residents in the facility. He said more than six months ago he was beaten by Resident #120, who was no longer in the facility. He said Resident #120 previously used foul language towards him and disliked the sound of his TV which was too loud in his opinion. He said one day, Resident #120 aggressively walked into his room, threw him on the floor, and hit him in the face several times before staff were able to intervene. The second incident of physical abuse occurred less than six months ago. He said he was approached in the hallway by Resident #31, who threatened to hurt him and used a walking cane to hit him on the head. He said Resident #31, like Resident #120 was no longer in the facility and he felt safe. C. Record review A review of the facility investigations of the above incidents revealed the facility investigated and substantiated abuse and reported both incidents to the police and the state agency. The investigations included interviews with the victim and alleged perpetrators, as well as staff who worked at the time of the incident and other residents in the facility. Skin assessments in both instances revealed minor injuries that did not require hospitalization . Both residents no longer were residing in the facility at the time of the survey. Resident #120 was discharged in January 2023 and Resident #31 in September 2023. B. Staff interviews CNA #2 was interviewed on 10/26/23 at 11:15 a.m. She said she used to work with all three residents. She said they all had their good and bad days. Resident #120 disliked loud noises and was particularly sensitive to them in the afternoon. Resident #31 did not have any aggressive behaviors toward her or other residents. Licensed practical nurse (LPN) #2 was interviewed on 10/26/23 at 11:45 a.m. She said she did not observe any aggressive behaviors with the above residents. She said she was aware of the incidents but did not work at the time when they occurred. The nursing home administrator (NHA) was interviewed on 10/26/23 at 4:41 p.m. He said all residents in the building should be free from abuse. He said the incident with Resident #120 occurred prior to his time as NHA in the building. The second incident, with Resident #31, was in September 2023. He said the facility investigated both incidents and took actions to make sure residents in the building were free from abuse.

Based on record review and interviews, the facility to provide one (#1) of three sample residents, adequate supervision and an environment as free from accident hazards as possible, contributing to an accident involving harm. Specifically, the facility failed to ensure certified nurse aide (CNA) #1 followed proper procedure while operating a Hoyer (mechanical) lift (Hoyer lifts allow a person to be lifted and transferred with a minimum of physical effort) and failed to ensure Resident #1 was provided a safe transfer with the Hoyer lift. On 9/24/22 at 3:52 p.m. CNA #1 and #2 were assisting Resident #1 out of bed. Staff fitted the resident with her Hoyer sling and fastened straps to the Hoyer lift. However, while being transferred, the straps that were holding Resident #1's legs slipped off the metal rings (which were attached to the Hoyer lift), and Resident #1 slid to the floor. Resident #1 landed on top of the Hoyer lift legs, then onto the floor. Resident #1 suffered multiple fractures. The facility investigation documented CNA #2 asked CNA #1 not to transfer the resident due to the lift not being properly secure. However, CNA #1 continued to operate the Hoyer lift and transferred Resident #1 anyway as she was distracted, and was seen and heard talking on her phone via earbuds (see record review below). Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/21/22, resulting in the deficiency being cited as past noncompliance with a correction date of 10/12/22. I. Professional reference The Patient Lifts Safety Guide, undated, retrieved on 11/28/22 from https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf read in pertinent part, Before lifting the patient perform safety check: -Examine all hooks and fasteners to ensure they will not unhook during use; -Double-check position and stability of straps and other equipment before lifting patient; and, -Ensure clips, latches and bars are securely fastened and structurally sound. Lift patient two inches off the surface to make sure patient is secure. Check the following: -Sling straps are confined by guard on sling bar and will not disengage; -Weight is spread evenly between straps; and, -Patient will not slide out of sling or tip backward or forward. II. Resident Status Resident #1, age less than 60, was admitted on [DATE] and discharged to the hospital on 10/22/22. According to the October 2022 computerized physician orders (CPO), diagnoses included morbid obesity, malignant neoplasm (cancer) of endometrium, diabetes mellitus, chronic kidney disease; and multiple fractures of the right and left tibia (shin), left femur (hip), sacrum (base of the spine), thoracic and lumbar spine and pelvis (added after the incident on 9/24/22). The 6/28/22 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She did not exhibit behaviors or reject care. She required extensive two-person assistance with most activities of daily living (ADLs). III. The facility failure to ensure CNA #1 followed proper procedure while operating a Hoyer lift and ensure Resident #1 was provided a safe transfer during a Hoyer lift transfer The nursing note dated 9/24/22 documented at approximately 3:52 p.m. a CNA called the nurse to Resident #1's room. Resident #1 was observed lying supine with her shoulders across one leg of the Hoyer lift and her thighs across the other leg of the Hoyer lift. Resident #1's head was elevated on pillows. Resident #1's right lower extremity (RLE) was upright on top of covers (linens) and left lower extremity (LLE) was on the floor. The left side of the Hoyer sling was observed attached to the Hoyer lift. Resident #1 stated she had pain at 10 out 10 (excruciating), and she had heard something pop in her back and felt like her legs were broken. Resident #1 was assessed and vital signs were obtained. The physician was notified, paramedics were called and Resident #1's emergency contacts were notified. The paramedics assisted Resident #1 up with the Hoyer lift and transported the resident to the hospital. The 9/24/22 hospital documentation revealed Resident #1 was diagnosed with an acute left femur fracture, right medial tibial plateau fracture, possible left medial tibial fracture, superior and inferior endplate compression fractures at thoracic (T12), and sacral fractures. The fall prevention care plan, initiated 7/20/22 and revised on 9/27/22, revealed Resident #1 was at risk for falls related to medication use, impaired mobility and an actual fall. Interventions included to use full body mechanical lift for all transfers with two-person assistance, ensure appropriate sling was being used and ensure it was properly secured prior to transfer. The facility investigation was provided by the nursing home administrator on 11/21/22 at 12:50 p.m. It revealed the following. Resident #1 was lying in bed and wanted to get out of bed into her wheelchair. Two staff were present when Resident #1 was fitted with the Hoyer sling. When she was being transferred from the bed, via the Hoyer lift, to her wheelchair, the straps that were holding her legs slipped off of the metal rings on the lift, which caused Resident #1 to slide out of the sling and onto the floor. She landed on top of the Hoyer legs and on the floor in her room. The Hoyer lift was removed on 9/24/22 after the incident. It was put back into service on 9/30/22 after the safety checks and testing were completed. Initially, the equipment was inspected twice by the maintenance director on different occasions. This particular piece of equipment had been inspected by (name of company) on 9/8/22 in which it had passed the inspection. The Hoyer passed (name of company's) calibration and safety test. The maintenance director, director of nursing (DON), and nursing home administrator (NHA) checked the equipment on 9/24/22, 9/26/22, and 9/30/22. The police department, primary care physician (PCP), durable power of attorney (DPOA), DON and NHA were notified. Interviews were conducted with 10 residents and 10 staff. No new concerns presented from the interviews conducted. Resident #1 was transported to the hospital for further evaluation. The primary CNA (CNA #1) was suspended pending investigation. Resident #1's statement revealed on 9/24/22 she was in the Hoyer sling, and CNA #1 was on her phone while operating the lift. CNA #2 stated the sling did not look right, but CNA #1 said there was nothing wrong with the sling. After that I fell . CNA #1 said, I should have never used this sling. Resident #1 said CNA #1 was on her phone the whole time, talking and laughing during the Hoyer lift transfer. CNA #2 was interviewed on 9/24/22. He said on 9/24/22 he returned from his break around 4:00 p.m. He said while walking down the hallway, CNA #1 waived him down to help assist with a Hoyer transfer. He said he entered the room and was on stand by while CNA #1 proceeded to latch the sling on the Hoyer. He said he noticed something was wrong and mentioned it to CNA #1; however, she proceeded how she wanted to. Then she started to lift the resident up in the Hoyer lift, and he noticed it was not properly secure and he mentioned it to CNA #1 again. CNA #1 stated, It's fine, it's going to be fast. He said he demanded CNA #1 place the resident back down in the sling and put her back on the bed so they could secure the latch. Then CNA #1 told him, Baby it's fine, don ' t worry, I got this. That was when she pulled the Hoyer away from the bed to get closer to the chair and that was when the Hoyer sling broke loose approximately three to four feet in the air where the resident's legs were secured. He then ran to get the nurse. CNA #2 was interviewed a second time on 9/26/22. He said CNA #1 was on the phone with someone via earbuds while providing care (as she placed the Hoyer lift sling straps and operated the Hoyer lift). CNA #1 was interviewed on 9/24/22. She said she dressed Resident #1 and placed the Hoyer sling underneath the resident. She called CNA #2 to help assist her. When he came she checked the sling three times to ensure it was fastened/placed correctly because it did not look right, so she checked it again. She said when she lifted the resident off the bed, the sling came loose and the resident fell on to the Hoyer lift then the floor. CNA #1 was interviewed a second time via email on 9/25/22. She recounted the same information as in her first interview and added that when she applied the sling underneath Resident #1, the sling appeared to be too large (it was green instead of blue). -However, CNA #1 continued to use the green sling and continued with the transfer anyway and Resident #1 slid out of the sling to the floor. The primary CNA (CNA #1) was distracted due to using her phone via earbuds so she did not connect the sling straps securely on the Hoyer rings. Immediate staff education was provided to CNA #1 and CNA #2, training with Hoyer application videos. All staff (76 staff) were provided education on the transfer training policy and procedures. CNA #1 was suspended immediately and was not allowed to return to the facility. Through the investigation, it was determined that the equipment was not malfunctioning. However, the lack of attention by the agency CNA #1 caused the unsafe transfer and the fall of Resident #1. CNA #2 would not be returning to the facility as he was moving out of the state. It was determined through the investigation and documentation review that the one CNA (CNA #1) was maintaining a conversation on her cell phone via earbuds when she was connecting the Resident #1's sling to the Hoyer lift. Upon review and interviews, it was determined that she did not secure the straps through the loops correctly on the equipment. When she was lifting Resident #1 out of the bed and moving her from the bed to the wheelchair, a piece of linen was wedged within the sling and tugged upon when Resident #1 was suspended and moving with the Hoyer. This caused the sling and Resident #1 to sway, which caused the straps to come off of the rings of the Hoyer, as they were not correctly placed within the rings. This caused the legs to loosen and Resident #1 slid out of the sling onto the floor. All residents that used the Hoyer lift had been measured and the facility ordered slings that were resident specific. Zip Tie plastic tabs had been ordered and the resident name written on the tab and secured to the sling to ensure that the resident was using the correct sling that was measured and fitted for them. All staff would complete a competency checklist and education on proper Hoyer lifting and the use of personal cell phones while on shift. Any cluttered areas in resident rooms that may interfere with Hoyer movements would be cleared prior to transfer completion. In addition, the facility started a performance improvement project (PIP) dated 10/14/22 to include all staff training. The performance improvement project (PIP) dated 10/14/22 with return demonstration completed by all staff on 10/15/22 documented the following: Baseline Measure: All nursing and therapy staff, anyone who may use a mechanical lift will complete training 100% in person and/or in classroom. Root Cause: Patient negative outcome as demonstrated by patient injury Obstacle: Conflict with schedules Projected Outcome: 100% all nursing staff to be trained in mechanical lifts in person and/or in classroom. Return demonstration of mechanical lift training by the driver and DON was started on 10/15/22; target date of completion 12/31/22. Resources: mechanical lift manufactured guidelines, appropriate sling, competency checklist completed. All new nursing hires were to have this training prior to working the floor independently and had to be signed off by the DON and chief executive officer (CEO). Started 10/15/22 and date of completion 12/31/22. Five audits completed/week of observation of staff using mechanical lift correctly and turned in to CEO every Friday end of business day. Started 10/15/22 date of completion 12/31/22. Review of the facility's PIP dated 10/14/22 revealed the facility Hoyer lift training and competency return demonstration was started on 10/12/22. IV. Staff interviews The NHA, DON and consultant NHA were interviewed on 11/21/22 at 5:07 p.m. The DON said she felt there was nothing malicious or intentional that CNA #1 did. However, they understood the failure to use the Hoyer lift equipment correctly, as CNA #1 was distracted while talking on her phone via earbuds which caused the resident harm. The NHA said during quality assurance performance improvement (QAPI), the team reviewed the incident on 9/30/22 and reviewed it again along with completion of their PIP on 10/27/22. Training and competencies prior to the incident were requested for all facility and agency staff; however, they stated there were no training or competencies available. They verified the facility did not have a system in place to ensure competency of staff with Hoyer lift training prior to the incident on 9/24/22. They said since the incident, the scheduler had ensured newly hired staff were set up to complete competencies prior to working the floor. They said they also had a system in place to ensure agency staff had current competencies prior to hire, which included obtaining competency upon hire, which was included in the facility's check off list. They acknowledged their actual training and competencies to include return demonstration of Hoyer lift use did not start until 10/12/22 (when the incident with Resident #1 was on 9/24/22).

Based on observations, interviews, and record review, the facility failed to ensure seven residents (#55, #45, #5, #1, #71, #21, and #130), out of a total sample of 47 residents, received adequate supervision and assistive devices to prevent accidents. Specifically: The facility failed to take steps to ensure the safety of three residents identified at risk for elopement and/or to require a WanderGuard (#55, #45, and #5) after Resident #55 eloped from the facility. Specifically: -Resident #55 eloped from the facility undetected on 7/10/22, and was discovered a block away from the facility by the police. Resident #55 wore a WanderGuard device, an electronic monitoring system that triggered should he exit the facility through a door armed with the WanderGuard system. Yet, on 7/10/22, the facility investigation revealed no alarm was heard by staff when the resident exited the facility. -The facility failed to take steps following Resident #55's elopement to review, revise and sufficiently educate staff on how to protect Resident #55 as well as Residents #45 and #5, who, like Resident #55, wore a WanderGuard device. While Resident #55's care plans were updated and his WanderGuard device replaced, there was no evidence the facility thoroughly investigated the incident to uncover and address why no alarm was heard, and to review the facility's use and reliance on the WanderGuard system to prevent resident elopements. Staff interviews revealed staff lacked knowledge of which residents and how many residents had a WanderGuard device, how to check whether the WanderGuard device was functioning properly, and which facility doors were armed with the WanderGuard system; facility leadership and floor staff were unaware all exit doors were not armed with the WanderGuard system. The facility's failure to take an immediate and comprehensive review of the facility's WanderGuard system and its response to Resident #55's elopement on 7/10/22 put Resident #55, as well as Residents #45 and #5, at risk for serious harm if immediate corrections were not implemented. The facility also failed to provide care for four residents (#1, #71, #21, and #130) in a manner to prevent falls and to identify post-fall decline. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Review of the elopement investigation from 7/10/22 for Resident #55, observations conducted from 7/18/22 through 7/19/22, and staff interviews, revealed the facility failed to provide Residents #55, #45 and #5 with a safe environment and adequate supervision to avoid preventable accidents. Specifically, the facility failed to take immediate and comprehensive steps following Resident #55's elopement on 7/10/22, to review, revise and sufficiently educate staff on how to protect Resident #55, as well as Residents #45 and #5, who, like Resident #55, had been identified as an elopement risk and/or wore a WanderGuard device. While Resident #55's care plans were updated and his WanderGuard device replaced, there was no evidence the facility thoroughly investigated the incident to uncover and address why no alarm was heard, and to review its use of the WanderGuard system. Staff interviews revealed staff lacked knowledge of which residents and how many residents had a WanderGuard device, how to check whether the WanderGuard device was functioning properly, and which facility doors were armed with the WanderGuard system; facility leadership and floor staff were unaware all exit doors were not armed with the WanderGuard system. B. Facility notice of immediate jeopardy On 7/19/22 at 4:10 p.m. the nursing home administrator (NHA) and regional clinical resource (RCR) #1 and #2 were notified that the facility's failure to provide residents with a safe environment and adequate supervision to avoid preventable accidents created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 7/20/22 at 2:30 p.m. the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: The facility would complete elopement assessments on all residents in the facility by 7/22/22. Any resident who would be identified as high-risk with a desire to leave the facility would be placed on 15 minute checks. The unit manager would be assigned to complete the 15 minute checks log on each shift. The director of nursing (DON) or other designee would audit the 15 minute check logs. The DON or designee would review and update care plans for those residents identified as at risk of elopement. Wander/Elopement binders would be placed at each nurse's station as well as the front lobby to include any residents deemed at risk with an updated picture, face sheet, and the elopement and wandering residents policy. Binders would be placed by 7/22/22. WanderGuard would be checked daily and documented on the treatment administration record by the unit manager or other designee to ensure functioning and placement. The DON or other designee would audit for compliance. The DON or other designee would provide education to all staff on 7/19/22 on the Wanderguard system. Training would include how the WanderGuard activates, how to check the functioning of the WanderGuard, checking the placement of the WanderGuard, and documentation for the WanderGuard. Training would also include education on 15 minute checks for all residents deemed at risk for elopement. Training would also include education on the location of the wanderer/elopement binders and the contents of the binder. Education would also be provided on the elopements and wandering residents policy. This would include how to properly respond if an alarm goes off and what to do if a resident elopes from the facility. The education would continue until all staff were educated by 7/22/22. On 7/19/22 the maintenance director tested the doors with the WanderGuard system as well as egress exit doors to ensure proper functioning. All exit doors were currently functioning properly. The maintenance director would complete daily checks of all WanderGuard and egress exit doors for proper functioning. The NHA or designee would audit the daily checks for compliance. D. Removal of Immediate Jeopardy The above plan was accepted and, based on the facility plans above, the immediate jeopardy was removed on 7/20/22 at 2:38 p.m. However, deficient practice remained at an E level. II. The facility failed to ensure the safety of three residents identified at risk for elopement/ and or requiring a WanderGuard monitoring device (#55, #45 and #5). A. Facility policy and procedure The Elopements and Wandering Residents policy and procedure, undated, was provided by the NHA on 7/21/22 at 1:33 p.m. It read, in pertinent part, Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 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. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. B. Resident #55 - wanderer and elopement risk 1. Resident status Resident #55, age 66, was admitted on [DATE] and resided in the facility's east unit. According to the July 2022 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, altered mental status, and depression. The 6/8/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview for a mental status score of three out of 15. It indicated the resident had daily wandering and the wandering placed the resident at significant risk of getting to a potentially dangerous place. It indicated the resident required supervision for locomotion on and off the unit and needed extensive assistance for dressing, toileting, and personal hygiene. The 6/20/22 wandering/elopement risk assessment indicated the resident scored 14 which represented a high risk for wandering. It indicated Resident #55 could not follow directions, could not communicate, was ambulatory, had a history of wandering, had a medical diagnosis of dementia and diagnosis impacting mobility, and indicated wandering in the past month. It indicated Resident #55 could be redirected but was occasionally resistant. 2. Review of 7/10/22 incident On 7/19/22 at 12:00 p.m. the NHA provided the investigation of the resident's elopement on 7/10/22. The investigation included the final report, a change of condition completed for the resident, and the service order completed on the facility exit doors. The final report revealed the following: -Law enforcement called the facility on 7/10/22 at 5:42 p.m. and asked the receptionist if the resident lived at the facility. Law enforcement stated they found the resident one block away from the building. They brought the resident back to the facility uninjured. The report indicated the level of oversight that was provided at the time of the incident was routine skilled nursing facility care. It indicated the facility became aware of the incident at 5:42 p.m. Observations of camera footage noted the resident in the back parking lot of the building at 5:16 p.m. -The facility confirmed all exit doors were operational and the WanderGuard system was checked by an outside security system company and was found to be functioning correctly. Staff that were interviewed said they did not hear alarm sounds in the building at the time of the elopement. The report indicated the WanderGuard alarm would need to be manually shut off at a keypad once engaged. -Staff reported the resident was in the dining room at 4:45 p.m. and was escorted to his unit shortly after. The report indicated the receptionist did not see the resident at the front of the building and staff did not see the resident on the west unit which indicated the east doors were the suspect. The report indicated the resident was fitted for a new WanderGuard device, placed on one to one supervision, and the 6/2/22 wander/elopement assessment and care plan were reviewed and deemed current. -The conclusion of the report indicated it was substantiated that the resident left the facility unattended and was located by law enforcement. 3. Record review - steps taken after the resident's elopement on 7/10/22 A change in condition form was completed on 7/10/22 following his elopement. It indicated no mental or functional status changes were observed. It indicated increased physical aggression and agitation following the event. A progress note completed on 7/10/22 at 8:08 p.m. read a new WanderGuard device was placed on the resident's right ankle. It read the DON and the maintenance director checked the functioning of the device. Resident #55's care plan was revised 7/11 and 7/12/22: -The elopement care plan, revised 7/12/22, indicated the resident was an elopement risk and wanderer. Interventions included WanderGuard to the left leg, checks of placement and functioning of safety monitoring device every shift, distraction from wandering with pleasant diversions, structured activities, food, conversation, television, or books, and observation of location at regular and frequent intervals with documentation of wandering behavior and attempted diversion interventions. -The behavior care plan, initiated 7/11/22, indicated Resident #55 was an elopement risk. Interventions included attempting to redirect with food and assisting the resident to the bathroom when wandering, if needed. Fifteen minute checks were completed on Resident #55 from 7/10/22-7/14/22, per documentation provided by the NHA on 7/20/22 at 10:29 a.m. The NHA also provided documentation of education provided to staff that consisted of elopement prevention tips and a review of the Elopements and Wandering Residents policy. A progress note on 7/14/22, written in conjunction with an interdisciplinary team meeting, documented Resident #55 had eloped from the building and was found two blocks away and law enforcement brought the resident back to the facility. It read that the resident's WanderGuard was replaced and referrals were sent out for a secure unit placement. Another wandering/risk assessment was completed for Resident #55 on 7/20/22 (during survey). It revealed the resident scored 17 which represented a high risk for wandering. It indicated Resident #55 could not follow directions, could not communicate, was ambulatory, had a history of wandering, had a medical diagnosis of dementia and diagnosis impacting mobility, had wandered off the grounds, and had wandered over the past month. A progress note was completed by social services on 7/20/22. It read Resident #55's power of attorney was called and a message was left regarding the resident's recent elopement and concern for secure unit placement. C. Resident #45 and #5 - additional residents at risk for elopement and/or utilizing a WanderGuard monitoring device. Record review revealed two additional residents with WanderGuard devices. 1. Resident #45, under 65, was admitted on [DATE] and resided in the facility's west unit. The 5/22/22 MDS assessment indicated diagnoses included dementia, [CONDITION(S)], and anxiety. It indicated the resident had a moderate cognitive impairment with a brief interview for a mental status score of 11 out of 15. The resident required supervision for activities of daily living. The resident wandered daily and his wandering significantly intruded on the privacy of the activities of others. He wore a WanderGuard daily. The care plan initiated on 12/24/19, and revised on 10/1/21 revealed that resident was at risk for an elopement related to dementia. Interventions included checking the placement and function of wanderguard, distracting the resident from wandering, reorienting and redirecting as needed. 2. Resident #5, age 76, was admitted on [DATE]. He resided in the west unit. The 4/11/22 MDS assessment indicated diagnoses included dementia. It indicated the resident had a moderate cognitive impairment with a brief interview for a mental status score of eight out of 15. The resident required supervision for activities of daily living. Although the MDS indicated the resident did not have a wandering behavior, he did have a wander/elopement alarm that was used daily. D. Facility failures - individual 1. Although the facility took several steps after 7/10/22 to address Resident #55's elopement (see above), observations of Resident #55 revealed his care planned interventions to address wandering were not being implemented. (Cross-reference F744 - dementia care). Specifically: 7/18/22: Between 9:00 a.m. and 2:00 p.m., Resident #55 was observed wandering in the front lobby area and east hallway. He was wearing a long sleeve shirt, shorts and one shoe on his left foot. He had no footwear on his right foot with a WanderGuard devise visible at the ankle. Resident #55 would randomly stop, bend forward, pick up something from the floor and continue to wander the hallways. He was not observed being distracted from wandering with diversions, structured activities, food, conversation, television, or books and he was not always in sight of staff. Between 2:10 p.m. and 4:55 p.m. the resident was in his room with the door closed. 7/19/22: Between 9:00 a.m and 2:30 p.m. Resident #55 was in his room with the door closed. 7/21/22: Between 8:00 a.m. and 7:30 p.m. Resident #55 was observed walking in the hallways, followed by the business office manager. He was not observed being distracted from wandering with diversions, structured activities, food, conversation, television, or books. E. Facility failures - systemic failures that affected all three residents who utilized the WanderGuard for their safety. 1. Review of the facility's investigation of the 7/10/22 incident revealed no evidence the facility thoroughly investigated the incident to uncover and address why an alarm was not heard when Resident #55 left the facility, and no evidence of review, revision, and sufficient education of staff on the facility's use and reliance on the WanderGuard system to prevent resident elopements. See above; while the investigation revealed all exit doors were operational and the WanderGuard system was functioning correctly, the facility did not investigate further how to prevent a recurrence and what new measures the facility could take to ensure the appropriate alarm would sound with an elopement attempt. In addition, there was no evidence of other measures, such as review of the location of doors armed with the WanderGuard system, given where residents known to wander resided or of consideration whether enhanced supervision for residents who wander needed to be implemented. The director of maintenance (DOM) was interviewed on 7/19/22 at 3:02 p.m. He stated the facility had eight doors that lead outside from residential areas. Out of eight doors, only three doors had the WanderGuard system in place (main entrance door, door next to the physical therapy gym and door in the common area of the unit where Resident #55 resided). All other doors were equipped only with an egress alarm system. The DOM said the egress alarm system would sound for 15 seconds after force was applied to the door and become unlocked after 15 seconds allowing exit. The egress alarm system would reset itself in 30 seconds, meaning the door would stay unlocked for 30 seconds. He explained the difference between the WanderGuard system and egress alarm system was that the WanderGuard had a louder alarm and, in addition, the alarm was wired to the nurses' station. Egress alarms were localized to the door area. The DOM stated video cameras were reviewed after Resident #55's elopement and it was determined that the resident eloped from the door on the east side of the building. He took the surveyor to the door and stated the door currently did not have a WanderGuard system installed and had never had one. He said the door only had an egress alarm system. He said it was unclear how the resident eloped but this was the door he had left from. Observations revealed the egress door was located at the end of the unit that occasionally hosted residents in isolation and was separated from the rest of the building by double doors. The double doors were closed at the time of the observation and, per the DOM, closed anytime the rooms were occupied by residents in isolation. The double doors lacked windows and, therefore, restricted the view of the egress door from the nurses' station. The facility investigation failed to include and consider the above information. 2. Staff interviews confirmed a systemic failure by the facility to take an immediate and comprehensive review of the WanderGuard system following Resident #55's elopement, including review, revision and effective staff education, on the facility's use of the WanderGuard system. Specifically: Interviews revealed staff lacked knowledge of which residents and how many residents had a WanderGuard device, how to check whether the WanderGuard device was functioning properly, and which facility doors were armed with the WanderGuard system; facility leadership and floor staff were unaware all exit doors were not armed with the WanderGuard system. a. The NHA was interviewed in the presence of the regional clinical resource (RCR) #1 and #2 on 7/19/22 at 3:20 p.m. The NHA stated the incident on 7/10/22 occurred during the previous administration and was investigated at that time. The NHA said she did not know how many residents in the building were wearing WanderGuards and which doors in the building were equipped with the WanderGuard system. She was not aware what steps the facility had taken since the incident to prevent additional elopements. RCR #1 stated he was familiar with the incident of elopement on 7/10/22. He said after the incident, the facility conducted an assessment of all doors and alarms and all door alarms were found to be in good condition and functioning. He said the resident's WanderGuard was checked by the security system company and it was found to be functioning appropriately. He said out of precaution Resident #55's WanderGuard was replaced with a new one. He said it was unclear how Resident #55 eloped from the building on 7/10/22. He said since the incident, staff have received education on making sure Resident #55 was within sight. RCR #1 and #2 stated during the interview they, too, did not know how many residents in the building were wearing WanderGuards and how many and which doors in the building were equipped with the WanderGuard system. CNA #5 was interviewed on 7/19/22 at 3:30 p.m. She said she was not sure which residents on the west unit were an elopement or wandering risk. She said she did not know which residents on the unit had a WanderGuard. She said, contrary to administrative staff and the DOM, that all of the doors in the facility were alarmed with a WanderGuard system. RN #2 was interviewed on 7/19/22 at 3:32 p.m. She said Resident #45 was at risk for elopement on the west unit. She said he was the only resident that had a WanderGuard on that unit; however, Resident #5 also resided on this unit and he, too, wore a WanderGuard device. RN #4 was interviewed on 7/19/22 at 3:34 p.m. She said there was one resident who wandered in the east unit. She said the resident had a WanderGuard. She said all the doors at the facility should have a WanderGuard system. She said she was unsure how to check the functioning of the system and added she could take the resident to the door to check if it was working. She said there was a box to check the functioning of the system but she was unsure where the box was located. LPN #1 was interviewed on 7/19/22 at 3:39 p.m. She said she was not aware which residents were at risk for elopement or which residents had a WanderGuard device. She was not sure how to check the function of the WanderGuard. RCR #1 was interviewed on 7/20/22 at 9:31 a.m. and said it was suspected that Resident #55 left the facility using a door that did not have a WanderGuard system. He said the CNA on that unit was passing dinner trays at the time and did not hear any alarms go off. He reported that the previous NHA said it was a door failure and the security system company completed checks on all the doors of the facility to ensure they were in working order. There was no evidence at the time of survey exit that the facility had taken steps to arm all exits with the WanderGuard system or evidence that staff had been adequately educated on the WanderGuard system when Resident #55 returned to the facility following his elopement, including which residents were at risk of elopement and/or utilized a WanderGuard device, which doors were armed with the WanderGuard system and how to check the functionality of the device. II. The facility also failed to provide care for four residents (#1, #71, #21, and #130) in a manner to prevent falls and to identify post-fall decline. A. Resident #1 1. Resident #1, age 85, was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), the diagnoses included history of falling, repeated falls and unspecified dementia without behavioral disturbance. The 7/3/22 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 required extensive assistance of one person with bed mobility, transfers, toileting and dressing. It indicated the resident sustained one fall with no injury since the previous assessment period. 2. Record review The fall care plan, initiated on 5/10/22, documented the resident sustained an actual fall with no injury. The interventions included encouraging the resident to ask for assistance, offering and assisting the resident with toileting frequently, reminding the resident to lock the brakes on his wheelchair before transferring and educating the resident to use the call light to ask for assistance. The 5/10/22 nursing progress note documented that the resident was found on the floor after sliding from his wheelchair. The 5/10/22 fall investigation documented the resident had an unwitnessed fall and was found on the floor beside his bed and wheelchair. The resident slid out of the wheelchair because he forgot to lock it. The 5/10/22 neurological check was documented as completed at 4 on 4:35 p.m. -The resident's medical record did not reveal any further documentation that showed neurological checks had been completed in increments for 72 hours for the fall the resident sustained on 5/10/22. -The facility was unable to provide additional documentation to show neurological checks had been completed during the survey process. 3. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/21/22 at 10:45 a.m. She said neurological checks were started when a resident fell and hit their head or sustained an unwitnessed fall. She said neurological checks were documented on a form and should be completed for 72 hours at documented intervals. The assistant director of nursing (ADON) was interviewed on 7/21/22 at 3:10 p.m. She said neurological checks should be initiated if a resident sustained a fall and hit their head or had an unwitnessed fall. She said neurological checks should be started immediately following the fall and should be documented on a written neurological form for every 72 hours in the documented time intervals. The interim nursing home administrator (INHA) was interviewed on 7/21/22 at 2:00 p.m. She said she was unable to locate documentation that neurological checks had been completed for Resident #1 for the unwitnessed fall on 5/10/22. B. Resident #71 1. Resident status Resident #71, under the age of 65, was admitted on [DATE]. According to the July 2022 CPOs, diagnosis included [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], diabetes mellitus type two, [CONDITION(S)], [CONDITION(S)] disorder (hallucinations and delusions), anxiety, abnormal posture, and anxiety. The 6/28/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance of two people with bed mobility, transfers, personal hygiene and supervision for eating. 2. Observations and resident interview Resident #71 was interviewed on 7/19/22 at 11:51 a.m. She said a nurse and a CNA were transferring her using the mechanical lift over the weekend. The CNA told the nurse that the mechanical lift was malfunctioning and not to move the lift. She said the nurse moved the lift and it was unsteady. Resident #71 said the mechanical lift wheels were under her bed and would not move. She said this caused the mechanical lift to become unsteady and it tipped, causing her to fall into the wall. The resident pointed out a gash on the wall next to her bed from the mechanical lift and an indent from where she hit her head. The resident had a bump on the left side of her head. Resident #71 was interviewed again on 7/21/22 at 11:18 a.m. She said her head was still tender when touched, but the bump was resolving. She said the staff told her she would be alright and did not check her head for any injury after the resident hit her head when the lift fell into the wall. Resident #71 said the facility continued to use the mechanical lift that malfunctioned until 7/20/22. The resident said no further issues occurred after the event. 3. Record Review The activities of daily living (ADL) care plan, initiated on 8/25/16 and revised on 2/23/22, documented Resident #71 required assistance with ADLs related to diagnosis of obesity, asthma, diabetes mellitus type two and anxiety. The interventions included, in pertinent part, that the resident required a mechanical lift with two person assistance for all transfers. 4. Incident on 7/17/22 The 7/17/22 change in condition assessment documented the resident bumped the left side of her head on the grab bar that was lined with stuffed animals next to her bed. No changes were observed to her mental or functional status. The assessment documented that the resident reported she had no complaints of pain. There were no injuries noted. The physician was notified and no new orders were obtained. The 7/17/22 nursing progress note documented that the CNAs were transferring the resident from her wheelchair to her bed using a mechanical lift. The mechanical lift tipped and the resident bumped her head on the grab bar next to her bed that was lined with stuffed animals. The note documented the resident said, no it is ok, it is nothing. 5. Staff interviews confirmed the facility failed to implement neurological checks after the resident hit her head, failed to educate staff on transferring the resident, and failed to remove the mechanical lift from use for several days after the incident. The director of maintenance (DOM) was interviewed on 7/21/22 at 12:35 p.m. He said he was notified on 7/20/22 (three days after the incident) that the mechanical lift had malfunctioned. He said he removed the mechanical lift from use and requested an outside company to service the lift. The ADON was interviewed on 7/21/22 at 1:23 p.m. She said she was notified the mechanical lift had malfunctioned on the day when nursing staff transferred Resident #71. The ADON said nursing staff should have initiated neurological checks, since Resident #71 hit her head. She confirmed the facility failed to initiate neurological checks. The ADON said she was going to begin an investigation immediately on the incident on 7/17/22. The ADON was interviewed again at 3:07 p.m. She confirmed Resident #71 had a hematoma (bump) to the back of the left side of her head and complained of pain to the touch. -The ADON said she had the nursing staff initiate neurological checks immediately and contacted the physician. -The ADON said the facility had not completed education with the nursing staff on safe resident transfers, after the incident with Resident #71, but she would begin this immediately. -The ADON said the mechanical lift should have been removed from use and inspected immediately after the incident on 7/17/22. The INHA was interviewed on 7/21/22 at 4:25 p.m. The INHA said neurological checks should be initiated when a resident hits their head or has an unwitnessed fall. The INHA did not comment on the status of the mechanical lift that was said to have been malfunctioning. C. Resident #21 1. Resident status Resident #21, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 CPOs, diagnoses included [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction affecting the left side (limited movement of the left side following a stroke), heart failure, obesity, repeated falls, [CONDITION(S)] ([CONDITION(S)] disorder) and chronic pain. The 4/20/22 MDS assessment revealed the resident was cognit[TRUNCATED]

Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development of pressure injuries for one (#65) of three residents reviewed for pressure injuries out of 47 sample residents. Resident #65 was admitted to the facility on [DATE] for long term care due to the progression of dementia. The resident was admitted with intact skin and three weeks later, on 7/7/22, she was identified as having two unstageable pressure injuries. Upon admission, the facility identified multiple risk factors for the resident's development of pressure injuries. However, the facility failed to ensure Resident #65 received care and services to minimize her known risk factors and prevent the development of pressure injuries. Further, the facility failed to implement measures to promote healing of the pressure injuries. Findings include: I. Facility policy and procedure The Skin Assessment policy and procedure was provided by the nursing home administrator (NHA) on 7/21/22. The policy did not include pressure injury assessment and care. II. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 2/10/22. An unstageable pressure injury is described as follows: 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. III. Resident #65 Resident #65, age 94, was admitted to the facility 6/16/22. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A note by the facility medical director, received on 7/25/22 at 7:43 p.m. read that Resident #65 had a complex medical history including [CONDITION(S)] cardiovascular disease, peripheral vascular disease, advanced Alzheimer's dementia and severely limited mobility, as well as elevated blood urea nitrogen levels and [CONDITION(S)]. A 6/23/22 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of 4 out 15. It also read the resident had no behavioral problems, [CONDITION(S)], or rejection of care. Per a registered dietitian note, Resident #65 was admitted to hospice care on 7/5/22, although no corresponding physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Skin integrity 6/16 - 7/7/22 The resident's initial skin assessment on admission, dated 6/16/22, indicated the resident's skin was intact, as did the 6/23/22 MDS, which documented the resident had no pressure injuries at the time of admission, but was at risk for developing pressure injuries. The Braden Scale Observation/Assessment (for predicting pressure sore risk), dated 6/16/22 (on admission), revealed a score of 14, which indicated the resident was at moderate risk for the development of pressure injuries. Additional Braden Scale Observation/Assessments performed on 6/23 and 6/30/22, revealed the resident continued to score at moderate risk for the development of pressure injuries. The only risk factor changes were on the 6/23/22 assessment which identified the resident as confined to bed, nutrition was adequate (previously inadequate) and although confined to bed, mobility was assessed slightly limited (previously very limited) The MDS assessment 6/23/22 and the resident's care plan for activities of daily living (ADL) also documented the resident's limited mobility with the MDS documenting the resident required extensive assistance from two people. B. Skin integrity 7/7/22 - two unstageable pressure injuries 1. Record review A skin assessment on 7/7/22 revealed the resident had two new open areas. One on the left inner buttock measuring one centimeter (cm) by three cm., and one on the coccyx measuring two cm. by two cm. The wounds were treated with [MEDICATION(S)] and covered with dry dressing. An air mattress was requested, and an assessment was requested from the wound care physician for the assessment of shearing noted on the left buttock. Braden Scale Observation/assessment dated [DATE] again scored the resident at 14, at moderate risk for the development of pressure injuries. The assessment did not indicate new interventions were considered. On 7/8/22 a pressure [injury] assessment revealed the resident had an acquired unstageable pressure injury to right buttock measuring 10.4 cm by 6 cm. The area was documented as a cluster of two wounds with 20 percent of necrotic tissue and 80 percent skin. The wound on the coccyx was assessed on the same day, and was documented as an unstageable new pressure injury measuring 3 cm by 1.3 cm. The area had 100 percent necrotic tissue. Special intervention for identified wounds was listed as bed. However, the type of bed was not identified. The wound care physician's assessment on 7/8/22 documented the same findings as above. Recommendations included to apply calcium alginate and leptospermum honey daily, and cover with gauze island dressing. A note read that debridement was refused and patient/surrogate made aware of risks of not removing necrosis including infection, [CONDITION(S)], limb loss, or death. (However, see below; interviews with the resident's representative on 7/17/22 at 9:41 a.m. and the wound physician (WCP) on 7/19/22 at 7:30 p.m. revealed debridement had only been discussed with the resident.) 2. Observations Wound care observations were conducted on 7/19/22 at 4:57 p.m. in the presence of director of nursing (DON) and registered nurse (RN) #4. The resident was positioned on her right side. One medium size dressing was observed on the coccyx and second dressing on the right buttock. Both dressings were undated. The wound on the coccyx was 100 percent yellow slough, with moderate drainage on the dressing. The wound measured 3 cm. by 2 cm. Removal of the dressing from the right buttock revealed two wounds. One on the upper buttock and one on the lower buttock. Wound #1 on the upper buttock was 100 percent yellow slough, measuring 4 cm by 5 cm., with reddened irregular edges. Wound #2 on the lower buttock was 100 percent yellow slough, measuring 2.5 cm by 2 cm. All wounds were cleaned with normal saline and treated with [MEDICATION(S)] and covered with foam dressing. C. Record review revealed the facility failed to ensure Resident #65 received care and services to minimize her known risk factors and prevent pressure injury development. 1. Record review revealed no evidence that any interventions were initiated for Resident #65 on admission to minimize her identified risks for pressure injury development. Risk factors identified in the Braden Scale Observation/Assessment on 6/16/22 included slightly limited sensory perception, skin occasionally moist, chairfast, ability to walk severely limited or nonexistent, cannot bear own weight and be assisted into chair or wheelchair, very limited mobility (makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently), inadequate nutrition (rarely eats a complete meal) friction and shear potential problem. While a care plan was initiated 6/17/22 for the resident's limited activities of daily living (ADL) ability, interventions in this care plan were to provide assistance with bed mobility and meals. There was no information to alert staff that friction and shearing were potential problems and no instructions to staff to reposition the resident, even though it was known she was unable to make frequent or significant position changes independently. It was not until 7/11/22, four days after the identification of her pressure injuries on 7/7/22, that an intervention was added to make sure the resident spent no more than two hours at a time in a wheelchair to prevent pressure injury. In addition, there was no care plan for skin integrity to promote the prevention of pressure injury until 7/11/22, again, three weeks after her risks were identified (see above) and four days after the resident's pressure injuries were identified on 7/7/22. Review of the care plan for unstageable pressure injury to right buttock and coccyx revealed an intervention to frequently reposition resident in a chair for comfort and pressure reduction. Frequency, however, was not defined and record review revealed no documentation of a repositioning schedule for the resident or any documentation that frequent repositioning occurred. Further, there was no information about the resident's bed or wheelchair, although the 6/23/22 MDS documented the resident had pressure reducing devices for her chair and bed and, as noted above, the 7/8/22 pressure [injury] assessment mentioned bed without description. D. Record review and observations revealed the facility failed to ensure Resident #65 received care and services after pressure injury development to promote wound healing. 1. Record review Review of the resident's treatment administration record (TAR) revealed an air mattress was added to the TAR on 7/14/22. Per physician orders, however, it was added 7/15/22, a week after the resident was identified with pressure injuries. There was no evidence on the resident's care plans or elsewhere, that the air mattress had been placed prior to 7/14/22. Review of wound care treatments on the TAR for July 2022 revealed the resident's wounds were monitored every shift for drainage, redness and odor. However, there were no dressing change orders until 7/20/22. See above; this was a day after the wounds were observed during the survey. 2. Resident observations Resident #65 was observed continuously on 7/18/22 between 9:35 a.m. and 2:10 p.m. The resident sat in the wheelchair in front of the nurses' station. At 12:32 p.m. the resident was offered a meal at the nurses' station. At 2:10 p.m. the resident was taken to her room and was put to bed. The resident spent a total of five hours sitting in her wheelchair in front of the nurses' station from 9:35 a.m. to 2:10 p.m. Resident was not offered an opportunity or encouraged to change positions or to lie down. The resident's chair was not reclined at any time. E. Resident representative interview The resident's representative was interviewed on 7/17/22 at 9:41 a.m. She said she was a resident's power of attorney (POA), but not a family member as the resident had no living children. She said she did not know about the resident's wounds until the primary care physician brought it to her attention; she said staff did not notify her about the wounds. She said hospice staff provided an air mattress just a few days ago, and said the resident should not be in her chair for more than two hours at a time. She reviewed a wound care note dated 7/8/22 regarding the refusal to proceed with wound debridement, and stated she had never met the wound care physician or talked to him on the phone. She said she did not decline any type of wound care treatments and had not been contacted to discuss it. She said even though the goal was comfort care for the resident, she did not decline any treatments for her. F. Staff interviews 1. Certified nurse aide (CNA) #4 was interviewed on 7/19/22 at 12:09 p.m. She said the resident was confused and only oriented to herself and the family that visited her. She said the resident spent most of her days in a wheelchair next to the nurses' station because she was at risk for falls. She said the resident was dependent on staff for all cares; she was not able to ambulate and she required extensive assistance with transfers. 2. CNA #14 was interviewed on 7/19/22 at 5:15 p.m. She said the resident required extensive assistance with all daily tasks. She, too, said the resident spent her time at the nurses' station because she was at risk for falls. She said the resident should only be up for no more than two hours in her chair because she had wounds on her bottom. 3. RN #4 was interviewed 7/19/22 at 5:20 p.m. She said she was a unit manager and participated in wound care rounds with a wound care physician (WCP) every Friday. She said the resident developed wounds a few weeks ago and was overall declining. She said the resident was admitted to hospice care for comfort and had a low appetite. She said she did not know why wound care orders were not on the TAR. She said she followed notes from the wound care physician for orders and signed on the TAR the section that read observe the wound. She said she changed wound dressing earlier in the morning, but did not date the dressing. 4. The WCP was interviewed on 7/19/22 at 7:30 p.m. He reviewed the record for the resident and stated the resident had extensive comorbidities, including [CONDITION(S)]. He said the resident was receiving hospice care and was physically declining. He said it was inconclusive at the moment to say if her wounds were the result of care or her overall decline. He said considering the resident's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he certainly expected staff to follow his treatment order and recommendations. Regarding refusal of the debridement (see 7/8/22 wound care physician assessment above), he said he discussed the treatment with the resident and she was not comfortable with the debridement. He said even though the resident had dementia, he still has to ask her about the treatment. He said the software in the computer automatically adds POA/family any time he marks refusal. He said he will discuss future treatments with POA. 5. The director of nursing (DON) was interviewed on 7/21/22 at 5:30 p.m. in the presence of regional clinical support (RCS) #1. She said she was new to the position, however, she was familiar with Resident #65 and her POA who visited almost daily. She said she believed Resident #65 had received appropriate care and the development of her wounds was probably the result of her decline. She said she was aware the resident should not be in the chair for longer than two hours which was contrary to observations on 7/18/22 (see above). She said she expected CNAs and nurses to follow that care requirement for the resident. 6. RCS #1 stated that they recently reviewed facility acquired pressure injuries with the management team. He said he would submit that review by email. G. Facility follow up after survey exit 7/21/22 at 5:27 p.m. 1. On 7/21/22 RCS #1 forwarded an email on the management team's review of facility acquired pressure injuries. The information was addressed to the former DON and dated 7/13/22: It read, Review of Braden Scores: Any resident identified at-risk should be reviewed for interventions. If there are no interventions in place, initiate appropriate interventions and update care plan. Round [on] all air mattresses and review settings. Tag the air pump with appropriate settings so the nurses know [the setting]. Schedule education for preventative measures (hydration, nutrition, incontinence care, off-loading etc.) and interventions for both nurses and CNAs. This should also include a skills fair to complete competencies with nurses on wound care. Continue sending wound log to RCS #1 weekly. However, RCS #1 did not provide any additional supporting information to show if the above recommendations were implemented after 7/13/22, such as care plan updates and education to of staff, as well as other measures listed in the note. 2. On 7/26/22 at 6:13 p.m. (more than 24 hours after a survey exit), the NHA submitted an email with following information: The facility maintains interventions were in place to prevent pressure injury to the resident through use of high back reclining chairs allowing for positional changes as needed. The resident had a foam cushion in the wheelchair at the time she was up, and has been switched to a pressure relieving cushion. Additionally, the [resident] was laid down, after breakfast, and again after lunch before returning to wheelchair to visit with family. However, the NHA statement did not include the date or time of day that she was referring to in her statement. Observations were completed on 7/18/22. The resident's POA was visiting and interviewed in the morning on 7/19/22. 3. On 7/25/22 at 7:43 p.m. (more than 24 hours after a survey exit) RCS #3 provided an email with a medical director note that read, as noted above, Resident #6 has a complex medical history, and wrote, contrary to the WCP, that the resident developed a pressure wound as a consequence of her complex medical history after a review of the resident's medical records. The medical director further wrote the resident was on hospice care at this time, her nutritional intake is quite poor, her mobility is quite limited by a combination of her cognitive impairment as well as a stable burst fracture of the lumbar spine. He wrote he had reviewed the resident's care plan and all interventions possible have been initiated including appropriate supplements, protein supplementation, a modified sitting and sleeping surface. It was his clinical opinion that the pressure injury was a consequence of end-stage skin failure and hence was unavoidable in light of this clinical scenario. Yet, see above; preventive measures were not implemented timely for a resident with a complex medical history as well as with many risk factors for pressure injury identified on admission. Further, record review and observations revealed a failure to timely implement measures to promote wound healing. The facility's failure to implement interventions consistent with the resident's needs contributed to her development of unstageable pressure injuries three weeks after admission.

Based on observations, record review and interviews, the facility failed to address one resident's dementia care needs in a manner designed to address the resident's known behaviors and cognitive and physical limitations. This failure affected one out of five residents reviewed with dementia (#55), out of a total sample of 47 residents. The failure resulted in Resident #55's inability to achieve his highest level of physical, mental and psychosocial functioning. Record review revealed Resident #55 was severely cognitively impaired. He was known to wander daily, known to be at high risk for falls, and known to be at high risk to elope. His thought processes and memory were impaired, and he could not follow instructions. Record review, observations, and interview revealed the facility failed to develop, implement and revise person-centered care plans with individualized interventions related to Resident #55's behaviors and cognitive and physical limitations. The facility also failed to identify and support ongoing opportunities for meaningful engagement that promoted his interests and preferences. On 7/10/22, the resident left the facility undetected, was found a block away, and was returned to the facility by the police. (Cross-reference F689). On 7/18/22 (from 2:15 p.m. to 4:55 p.m.) and 7/19/22 (from 9:00 a.m. to 2:30 p.m.), the resident was in his room alone with the door closed. Over these hours, the environment in the room became unsafe and undignified. Staff entered the room on 7/19/22 only to deliver the breakfast and lunch meal trays and offer medication. Staff did not respond to the condition of the room or attempt to engage the resident in meaningful activities. Findings include: I. Facility policy and procedure The Dementia Care policy was provided on 7/21/22 by the nursing home administrator (NHA). The policy read: Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary. II. Professional reference The Gerontologist (February 2018), retrieved from: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/ 59?login=true The Alzheimer's Association Dementia Care Practice Recommendations included the following foundations for person-centered care, in pertinent part: (1) Know the person living with dementia, including his/her values, beliefs, interests, abilities, likes, and dislikes-both past and present; (2) Identify and support ongoing opportunities for engagement that meaningful to the resident with dementia, support interests and preferences, and allow for choice and success; (3) Regularly evaluate interventions and make changes. III. Resident #55 A. Resident status Resident #55, age 66, was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 6/8/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview for a mental status score of three out of 15. It indicated the resident had daily wandering and the wandering placed the resident at significant risk of getting to a potentially dangerous place. It indicated the resident required supervision for locomotion on and off unit and needed extensive assistance for dressing, toileting, and personal hygiene. He required assistance from one person with eating for cueing and encouragement. 1. Review of facility assessments, progress notes and care plans revealed the resident was known to wander daily, known to be at high risk for falls, and known to be at high risk to elope. His thought processes were impaired, his memory was impaired, and he could not follow instructions. The facility failed to develop, implement and revise the resident's care plans with individualized interventions related to Resident #55's behaviors and cognitive and physical limitations, past life history, interests, beliefs, values, abilities, likes and dislikes. a. Dementia care A care plan for dementia care initiated on 1/7/22, indicated Resident #55 was physically aggressive with others due to dementia. Interventions included administering medications, de-escalate behavior, monitor every shift, observe and document behaviors in the behavior log. This care plan did not identify the resident's cognitive and physical limitations due to dementia and how staff should address them. Likewise, there was no information on the resident's values, beliefs, interests, abilities like and dislikes. There were no updates to this care plan. Further, there were no directives to staff on how to de-escalate his aggression and how to prevent his aggression. The behavior log was requested to review the frequency and character of the resident's behaviors and whether his dementia symptoms had increased or changed such that they would trigger a revision of his care plan. However, the log was not provided by the facility. b. Impaired cognition and thought process The resident had a care plan for impaired cognition and thought process. And, he had a communication problem and had trouble with his memory due to vascular dementia. This care plan did not include resident-specific intervention to address the above issues, including instructing staff how to effectively communicate with the resident. b. Falls A care plan for falls initiated on 3/30/22 revealed the resident was at risk for falls due to poor balance, use of psychoactive medications and unsteady gait. Interventions included frequent checks, encourage resident to ask for assistance, assist to bathroom frequently as accepted, frequently use items in reach and to provide activities. The care plan failed to identify for staff what activities to provide to the resident. See below: The resident did not have a care plan for activities and his daily preferences for activities were not documented. Further, there was no indication in the resident's record that he would remember to ask for assistance, given his cognitive and memory impairments. There were no revisions to this care plan until 7/12/22 when an intervention was added, encouraging the resident to use non-skid socks. This revision followed a note on 7/11/22 at 2 p.m. that documented, Resident at high risk for falls. He holds on to furniture for support when ambulating. Resident exhibits impaired gait. Resident forgetful of own safety limits. Again, it was unclear that encouraging the resident to wear non-skid socks would be understood, remembered, or followed, as per his 6/2/22 elopement assessment (see below), it was known he did not follow instructions. c. A behavior care plan, initiated 7/11/22, indicated Resident #55 was combative with staff and other residents, and he would become combative upon redirection. He was wandering and rummaging through other residents' rooms and meal trays. He also had exit seeking behavior. Interventions included attempting to redirect with food, assess the environment, and assisting the resident to the bathroom when wandering, if needed. This care plan identified the resident was combative with staff and wandered, but failed to identify which foods he liked and therefore are effective in redirecting the resident. Further, it failed to identify what staff should assess in the environment to minimize the resident's combative behavior as well as how to protect him from harm when he rummaged through other residents' rooms and meal trays. A nursing note on 7/18/22 documented it had been reported to her that Resident #55 was in another resident's room. Resident #55 refused to leave upon the nurse's request and became combative. An interview with Resident #42 on 7/18/22 p.m. at 1:09 p.m. revealed that one day when he had his family and friends over for a visit, Resident #55, who he said always wandered throughout the building, came into his room and urinated next to his bed. He said staff did not come and redirect Resident #55 for about 30 minutes. There were no additional notes by nurses or social services to indicate what interventions were put in place to make sure the resident was not entering other residents' rooms. d. Elopement A 6/2/22 assessment for elopement risk indicated the resident was at high risk. He was unable to follow the instructions, was ambulatory and was able to communicate. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] An interdisciplinary team review on 6/2/22 documented: IDT met to review resident for elopement. Resident was a high risk for elopement, he had a wanderguard in place, care plan in place and reviewed and updated as needed. Resident wandered frequently throughout the day and is redirectable at times but is resistive at times. Not always able to understand and . make self understood. The resident eloped on 7/10/22. Despite wearing a WanderGuard device, he left the facility undetected. He was found in a parking lot a block away from the facility and returned to the facility by the police. (Cross-reference F689) The resident was seen by a physician assistant on 711/22, who documented that the resident eloped from the facility yesterday and was found across the street in the Safeway parking lot. He is definitely wandering more and although generally easily and calmly redirected - he has had some recent escalating interactions with staff. It further documented the social worker was working on a transfer of the resident to a secure unit for his safety. The resident's elopement care plan was revised 7/12/22, and read Resident #55 was an elopement risk and wanderer. Interventions included WanderGuard to left leg, checking the placement and functioning of safety monitoring device every shift, distracting from wandering with pleasant diversions, structured activities, food, conversation, television, or books, and observation of location at regular and frequent intervals with documentation of wandering behavior and attempted diversion interventions. This care plan did not reference his elopement 7/10/22, did not instruct staff on the level of monitoring he required and did not note an escalation in both his wandering and interactions with staff. In addition, it did not identify effective interventions to distract the resident from wandering. There was no information on what were pleasant diversions for him based on his likes and dislikes, and his past and current history. Further, no information on what structured activities, as well as foods, were effective in minimizing his behavior. 2. Record review and observation revealed the facility failed to identify and support ongoing opportunities for meaningful engagement that promoted his interests and preferences. On 7/18/22 (from 2:15 p.m. to 4:55 p.m.) and 7/19/22 (from 9:00 a.m. to 2:30 p.m.), the resident was in his room alone with the door closed. Over these hours, the environment in the room became unsafe and undignified. Staff entered the room on 7/19/22 only to deliver the breakfast and lunch meal trays. Staff did not respond to the condition of the room or attempt to engage the resident in meaningful activities. a. Record review The 6/8/22 MDS preferences for activities assessment documented it was very important for the resident to have books, magazines and newspapers, listen to the music he liked, participate in favorite activities and to go outside to get fresh air when the weather was good. However, record review revealed the resident did not have a care plan for activities; therefore, what music he liked and what activities he favored were not identified for staff. His daily preferences for activities were not documented. The activities log was reviewed between May 2022 and June 21, 2022. On a daily basis, the log was marked with I (independent walking and relaxation), and P (passive conversation and family visits). No other activities were documented. Further record review revealed a note on 7/11/22 at 2 p.m. that documented the resident was found on knees in front of his recliner by housekeeping staff. The administrator had been notified that the floor was dirty and slick due to food, drinks and urine being on the floor due to the resident toileting in the room. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Observations 7/18/22: Resident #55 was observed on 7/18/22 between 9:00 a.m. and 2:00 p.m. The resident was wandering in the front lobby area and east hallway. He was wearing a long sleeve shirt, shorts and one shoe on his left foot. He had no footwear on his right foot with a WanderGuard visible at the ankle. Resident #55 would randomly stop, bend forward, pick up something off the floor and continue to wander the hallways. The resident was not observed being distracted from wandering with diversions, structure activities, food conversation, television or books and he was not always in sight of staff. Between 2:10 p.m. and 4:55 p.m. the resident was in his room with the door closed. The temperature in the room at 2:07 p.m. was 85.3F degrees. Standing outside the resident's door and observations into his room through the door revealed: -At 2:10 p.m. there was a strong smell of urine from the room. -At 3:04 p.m. the resident was in bed, sideways, in a fetal position with legs hanging off the bed with one shoe on his left foot. -At 3:55 p.m. the resident was awake, taking clothes out of his dresser and dropping them on the floor. -At 4:55 p.m. the resident was awake in the room, sitting at the edge of the bed looking at the wall in front of him. From 2:10 p.m. and until 4:55 p.m., no staff was observed entering the room to engage the resident in meaningful activities. And, no staff was observed entering the room to encourage the resident to engage in any activities outside the room. 7/19/22: Resident #55 was in his room with the door closed between 9:00 a.m. and 2:30 p.m. Standing outside the resident's door and observations into his room through the door revealed: -At 9:00 a.m. the resident was wearing the same clothes as the day before. He stood next to an adjustable table with a meal tray. The adjustable table was tilted to one side. His meal tray was on the tilted table and food was on the table and floor around the table. Resident #55 was eating alone in his room with his hands. He picked up food from the plate, meal tray and table while standing next to the table wearing a shoe only on his left foot. His bare right foot had a wanderguard on his ankle. Leftovers of food that fell off the tray. A plastic plate cover was on the floor. There was a strong smell of urine present when the room door was opened. -At 9:12 a.m. CNA #4 entered the room, took the meal tray away, and closed the door as she left. -At 9:43 a.m. the resident was on the bed in a fetal position with both legs hanging off the bed. One shoe was on his left foot. The sole of his right foot was brown to black and his toenails were long and brown. -At 12:12 p.m. CNA #10 delivered the meal tray, put it in front of the resident, and closed the door as she left. The resident was sitting in a recliner looking at the wall in front of him. -At 12:33 p.m. CNA# 10 opened the door, looked at the resident, did not enter the room, closed the door and left. -At 12:50 p.m. CNA #4 entered the room, took the meal tray away and closed the door. -At 1:56 p.m. registered nurse (RN) #4 entered the resident's room. The room had a strong odor of urine. The resident was in bed in a fetal position, with both legs hanging off the side of the bed, footwear only one foot. The resident had no blanket or pillow on his bed. One of his end tables was blocked by another end table. The resident opened his eyes when called by name, but did not take the medications the nurse brought. RN #4 left the room and closed the door. -At 2:30 pm. the resident observed in his room, awake. CNA #10 was sitting outside his room in the hallway. ] From 9:00 a.m. until 2:30 p.m., no staff was observed entering the room to engage the resident in meaningful activities. And, no staff was observed entering the room to encourage the resident to engage in any activities outside the room. A progress note 7/19/22 at 3:25 p.m. and 6:18 p.m. read the resident spent all day in the room, refused to get changed, ate his meals and slept most of the day. 7/21/22: Between 8:00 a.m. and 7:30 p.m. Resident #55 was observed walking in the hallways, followed by the business office manager. He was not observed being distracted from wandering with diversions, structured activities, food, conversation, television, or books. C. Staff interviews confirmed the facility failed to develop, implement and revise person-centered plans with individualized interventions related to Resident #55's behaviors and cognitive and physical limitations, and identify and support ongoing opportunities for meaningful engagement to promote his interests and preferences. 1. RN #4 was interviewed on 7/19/22 at 2:00 p.m. She said Resident #55 had advanced dementia and was aggressive towards staff when they tried to redirect him. She said he broke furniture in his room and pointed to the tilted table. She said one of the end tables was blocked with another end table because the resident threw all the stuff from the drawers. She said the resident frequently urinated on the floor and floor material was saturated with a smell of urine even though it was cleaned daily. She said the resident refused care and did not want to wear a shoe on his one foot. She said she did not know why the resident did not have a pillow or blanket on his bed. She said his baseline behavior was to wander around the building. She said his door was always kept closed for his comfort to reduce the stimulation. She said she was not aware if the resident was at risk for falls or had any falls in the past. Regarding dementia care, she said a resident was redirected if he wandered into a place he should not be. She said she did not know what the resident liked and what kind of activities he preferred. 2. CNA #4 was interviewed on 7/19/22 at 12:30 p.m. She said Resident #55 was always wandering through the building and this was his baseline behavior. She said he also wandered in other residents' rooms and they had to redirect him. She said sometimes it was easy to redirect, but sometimes he became combative and would not want to be redirected. She said the resident was left alone and re-approached later. She said the resident was able to eat independently and did not require assistance with meals. She said the resident did not have any falls and was not at risk for falls; he walked independently without assistance through the building. 3. CNA #10 was interviewed on 7/19/22 at 2:30 p.m. She was sitting outside the resident's door (see above observations). She said this was because the resident was at risk for elopement and she was making sure he would not elope. She said his door always kept closed, but she did not know why. She said everyone closed the door to his room. She said she was new to the position and this was all she knew about the resident. 3. The social services assistant (SSA) was interviewed on 7/21/22 at 2:14 p.m. She said she had been helping with social services tasks for about a year. She said she knew Resident #55 well. She said he usually walked around the building during the day. She said he was not able to maintain any meaningful conversation, but was able to respond to simple questions and redirection. She said she was not aware if the resident entered any other resident's rooms. She said she was not sure what kind of person centered dementia care the resident was receiving. 4. The activities director (AD) was interviewed on 7/21/22 at 2:45 p.m. He said due to the advanced dementia, a conversation with the resident was the most meaningful activity. He did not recall any specifics about conversation with the resident. He said he also tried aromatherapy and sensory blanket activity with Resident #55, but the resident was not receptive to it. 5. Licensed practical nurse (LPN) #5 was interviewed on 7/21/22 at 3:24 p.m. She said Resident #55 had advanced dementia and at times was combative with care but most of the times was approachable. She said this facility was not the best place for the resident and he would benefit from more stimulation appropriate for dementia. She said Resident #55 used to read magazines, but no longer was doing that. She did not know what else he liked to do during the day. 6. The clinical social services consultant (CSSC) was interviewed over the phone on 7/26/22 at 3:30 p.m. She said she was providing weekly support to the facility since SSD left last Friday (7/15/22). She said she was not aware of the resident's elopement (7/10/22) and was not notified about it at the time it occurred. Rather, she said she learned about the incident at the time of the survey. She said Resident #55 required individualized dementia care activities that should be provided to him by activity personnel and staff who take care of him on a daily basis. 7. The resident's power of attorney (POA) was interviewed over the phone on 7/26/22 at 4:00 p.m. She said she visited Resident #55v often. She said the resident has advanced dementia and does not remember many things. She said when he was living independently prior to the nursing home admission he struggled finding keys or even doors. She said closing the door to his room was not a good intervention because, due to his poor memory, he might not remember where the exit was unless he saw it. She said her brother would benefit from being outdoors more in a safe environment and would probably enjoy more meaningful activities.

Based on record review, observations, and staff and resident interview, the facility failed to ensure four incidents of abuse involving eight residents (#2, #3, #4, #5, #11, #12, #15, and #16) were thoroughly investigated and residents remained free from abuse. Specifically: -The facility failed to thoroughly investigate resident-to-resident verbal altercations involving residents #2 and #4. -The facility failed to identify interventions and approaches to minimize and prevent recurrence of resident-to-resident altercations. -The facility failed to follow-up with reported concerns related to resident behaviors. Residents #11 and #12 had expressed to facility staff feelings of being fearful of resident #4. An effective system of follow-up on such concerns could not be identified. -The facility failed to follow-up on resident #4's documented behaviors. The resident continued to exhibit behaviors that were distressing to other residents. -The facility failed to have an effective system to ensure staff understood the verbalizations, actions and situations that necessitated abuse reporting and investigation. I. Immediate Jeopardy A. Findings Triggering Immediate Jeopardy Interviews and record review conducted on 12/7/17 demonstrated resident #4 was involved in three verbal altercations in the dining room from 10/10/17 through 12/6/17 with five resident (#5, #12, #13, #15 and #16). (See incidents #1, #3 and #4 below for descriptions of each resident-to-resident verbal altercation.) Resident #12, who was involved in incident #1 and #4, said staff did not protect her from resident #4. Resident #12 felt harassed by and fearful of resident #4. Although not directly involved in any of the incidents, resident #11's reported of being fearful of resident #4 because of resident #4's aggressive behavior and wandering (see below). Review of incident #1 (see below) revealed it was not thoroughly investigated and the investigation was not completed timely. Incident #4 (see below) was witnessed by certified nurse aide (CNA) #14. The CNA did not report the incident to the nursing home administrator (NHA) for investigation and follow-up. Record review and interviews (see below) demonstrated resident #4 had documented behaviors from 10/10/17 through 12/7/17 that were unaddressed with new interventions to protect resident #4 from retaliation by others resulting from his known behaviors. On 12/3/17 (see incident #3 below) resident #4 had a verbal altercation in the dining room with resident #5, which resulted in resident #5 throwing orange juice at resident #4. Additionally, the facility failed to protect others from resident #4's aggression. Another resident-to-resident altercation occurred on 12/6/17 (see incident #4 below) involving resident #4 in the main dining room. Review of incident #2, reported to the Colorado Department of Public Health and Environment (CDPHE) as a complaint, showed resident #2 was involved in a resident-to-resident altercation with her roommate on 11/2/17. The facility failed to investigate resident #2's altercation with her roommate. On 11/3/17 resident #2 pushed resident #3 (who was not resident #2's roommate) causing resident #3 to fall and sustain a [MEDICAL CONDITION]. The facility's failure to keep facility residents safe created a situation of immediate jeopardy (IJ) with the potential for serious harm. B. Imposition of Immediate Jeopardy Based on staff and resident interviews (see below), which revealed inconsistent staff training on residents with dementia and aggression, and no indication by staff they had been specifically trained on resident #4's behaviors, the NHA was notified on 12/7/17 at 7:01 p.m., that the facility's failure to develop a specific plan for supervision of resident #4, no plan to train staff on recognizing resident #4's behavioral triggers and aggression, and no specific approaches on how to safely and effectively intervene to protect fearful residents #11 ,#12 and others from resident #4's aggression, created a situation of immediate jeopardy with the potential for serious harm. C. Facility Response and Removal of Immediate Jeopardy On 12/11/17 at 11:01 a.m., the district director of clinical services (DDCS) submitted the following removal plan (draft six): Request for Removal of Immediacy of Immediate Jeopardy F600 immediate Jeopardy December 7, 2017. IMMEDIATE PLAN AND STEPS TAKEN - Resident (medical record # for resident #4) was immediately placed on a 1:1 (one-to-one) on December 7, 2017 at 1901 (7:01 p.m.) to ensure there will be no further inappropriate interactions with any other residents, and to ensure that all other residents feel safe and secure in the facility. - 1:1 Intervention will continue until a behavior plan specific to this resident can be developed. An Ad Hoc QAPI meeting will be held with the interdisciplinary team to discuss the resident's target behaviors, triggers, behavior monitoring, and interventions to ensure appropriateness. Further the resident's progress notes, staff and resident interviews, care plan and staff/resident interviews will be reviewed until an appropriate behavior plan can be developed. When the behavior plan is implemented, 1:1 intervention may be lifted but can be reinstated as needed upon an escalation in aggressive behaviors. Staff will utilize the resident centered plan of care as a guide for behavior management and appropriate intervention. - NHA began investigation on alleged verbal abuse incident between resident # 58 and # 74 on 12/7/17. - The facility's interdisciplinary team interviewed 90 interviewable residents residing in the facility beginning December 7, 2017 and ending at 10:00 p.m. December 7, 2017 assuring that all residents feel safe and secure. There were no residents that alleged fear or had any concerns with feeling unsafe in the facility. - The facilities interdisciplinary team will attempt to interview responsible parties for residents that were un interviewable beginning on December 8, 2017 and will be completed as facility is able to get in touch via phone or in person. As of December 8, 2017, the social service director has interviewed ten responsible parties for non interviewable residents. No concerns of safety or fear were identified. - Should the facility be made aware of any concerns of fear or resident safety, the facility will protect the involved resident(s) and initiate an investigation as indicated. - The facilities interdisciplinary team will review current facility residents to assure that residents with behaviors that affect others have interventions in place and care plans have been updated as such. This will begin on December 8, 2017 and completed by December 8, 2017. - The District Director of Clinical Services (DDCS) will provide education to the NHA and DON (Director of Nursing) on December 8, 2017 on the facilities policies and procedures for abuse and neglect, including what to do if abuse is reported to them and/or they witness abuse and which steps to take immediately to keep resident safe. - The DON or Designee will then educate all facility and agency staff on the facilities policies and procedures for abuse and neglect, including what to do if they witness abuse and which steps to take immediately to keep residents safe, all other staff members will be re-educated prior to clocking in for their next shift starting on December 8, 2017 and ending when all staff have received the education. The education will include interventions to consider and alternatives to interventions that do not work. - NHA or Designee will monitor the effectiveness of the provided education by interviewing 10 random staff members a week over different shifts to ensure they understand the policies and procedures of abuse and neglect, including what to do if they witness abuse and which steps to take immediately to keep residents safe. - NHA will investigate any allegation of abuse that is reported to and/or witnessed and finish the investigation within 5 working days of the incident, these working days include weekends and holidays. Any interventions put into place will be communicated to the staff via 24 hours report, care plan, kardex and verbal education if indicated. At 11:24 a.m., on 12/11/17 the DDCS was notified that the sixth draft of the final abatement plan signed by the NHA had been accepted and the IJ had been removed at 11:01 a.m. on 12/11/17. The findings included: I. Facility Policy In pertinent part, the facility's abuse and neglect prohibition policy, revised August 2017, included: -Each resident had the right to be free from abuse. - The facility administrator is the Abuse Prevention Coordinator. - Abuse meant the willful (intention to perform the action) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. - Physical abuse included hitting, kicking, pinching and slapping. - Verbal abuse included oral, written or gestured language that was disparaging or derogatory, regardless of their ability to comprehend or disability. - Sexual abuse was non-consensual sexual contact of any kind, including sexual harassment, coercion, or sexual assault. - The facility would address all concerns in accordance with 'truly listening to our customers' policy. Residents, families, and staff would be able to report incidents and concerns without fear of retribution. - Facility supervisors would immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property was at risk for occurring. - Residents identified as exhibiting abusive behavior would be reviewed by the physician and treatment modified as appropriate. - The facility would protect residents from harm during the investigation. - The facility would make referrals to the appropriate state agencies as necessary. - The facility would timely conduct an investigation of any alleged abuse. - The facility would report all allegations and substantiated occurrences of abuse to the administrator, state survey agency, and law enforcement officials and adult protective services in accordance with Federal and state law. II. Resident Status A. Resident #2 Resident #2, under the age of 45, admitted to the facility on [DATE] and was discharged on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The 8/28/17 MDS assessment the resident had mild cognitive impairment as evidenced by a BIMS score of 12 out of 15. The resident rejected care on occasion. The resident required limited assistance with most ADLs but did require extensive assistance with dressing, personal hygiene and bathing. B. Resident #3 Resident #3, age 84, admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. According to the face sheet she had [DIAGNOSES REDACTED]. The 10/18/17 MDS assessment documented the resident was cognitively impaired as indicated by a BIMS score of four out of 15. The resident had no behaviors during the review period. She required the assistance of one staff for ADLs. C. Resident #4 Resident #4, age 77, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the December 2017 computerized physician orders [REDACTED]. The minimum data set (MDS) assessment dated [DATE] documented his cognitive status had moderate impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident did not exhibit verbal, physical or other maladaptive behaviors during the MDS observation period. The resident did exhibit rejection of care on to three days of the MDS observation period. The resident did not exhibit signs and symptoms of [MEDICAL CONDITION] as evidenced by a patient health questionnaire 9 (PHQ-9) score of one. The resident was able to use a wheelchair for independent mobility throughout the facility, was not stable when moving from a seated to a standing position, and required extensive assistance with all activities of daily living (ADLs) except eating (supervision only). D. Resident #5 Resident #5, age 79, was admitted to the facility on [DATE]. According to an 11/15/17 minimum data set (MDS) assessment, [DIAGNOSES REDACTED]. The 11/15/17 MDS assessment documented the resident was cognitively intact as evidenced by a BIMS of 13 out of 15. The resident required supervision for all ADLs. The resident was mobile using a walker and a wheelchair. E. Resident #11 Resident #11, age 63, was admitted to the facility on [DATE]. According to the CPOs, [DIAGNOSES REDACTED]. The 10/20/17 MDS assessment documented the resident was cognitively intact as evidenced by a BIMS of 15 out of 15. The resident did not exhibit verbal, physical or other maladaptive behaviors during the MDS observation period. The resident had signs and symptoms of mild depression as evidenced by a score of seven on the PHQ-9 evaluation. The resident required supervision when eating and walking in the room and corridor. The resident required one-person, extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The resident used a walker and a wheelchair for mobility. F. Resident #12 Resident #12, age less than [AGE] years, was admitted to the facility on [DATE]. According to the CPOs, [DIAGNOSES REDACTED]. The 10/17/17 MDS assessment documented the resident was cognitively intact as evidenced by a BIMS of 15 out of 15. The resident did not exhibit verbal, physical or other maladaptive behaviors during the MDS observation period. The resident had signs and symptoms of moderately severe depression as evidenced by a score of 17 on the PHQ-9 evaluation. The resident was independent with bed mobility, transfers, and walking in room and corridor. The resident required supervision with locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The resident used a walker for mobility. G. Resident #15 Resident #15, age 80, was admitted to the facility on [DATE]. The 10/3/17 MDS assessment documented the resident had moderate cognitive impairment as evidenced by a BIMS of nine out of 15. The resident exhibit verbal behavior one to three days of the MDS observation period. The resident had signs and symptoms of no to minimal depression as evidenced by a score of two on the PHQ-9 evaluation. The resident required supervision with bed mobility, transfers, locomotion on and off the unit, eating, and personal hygiene. The resident used a wheelchair for mobility. H. Resident #16 Resident #16, age less than [AGE] years, was readmitted to the facility on [DATE]. The 11/6/17 MDS assessment documented the resident was cognitively intact as evidenced by a BIMS of 15 out of 15. The resident did not exhibit verbal, physical or other maladaptive behaviors during the MDS observation period. The resident had signs and symptoms of mild depression as evidenced by a score of nine on the PHQ-9 evaluation. The resident required supervision with locomotion on and off the unit, eating, and personal hygiene. The resident required limited assistance with bed mobility, transfers, dressing and toilet use. The resident used a wheelchair for mobility. III. Failures with Incident Follow-up A. Incident #1 Resident #4 initiated a verbal altercation with residents #12 and #15. The investigation into the incident was not thorough. No interventions to address resident #4's verbal behaviors towards others were identified. No approached to were implemented. The failures contributed to resident #12 feeling harassed by and fearful of resident #4. 1. Resident Interview Resident #12 was interviewed on 12/7/17 at 3:30 p.m. The resident said a male resident, resident #4, yelled at her and called her a foul name. She said she was tired of being harassed by resident #4. Resident #12 said she informed staff of the incident and had requested staff to keep resident #4 from bothering her, however the staff failed to protect her from harassment. Resident #12 said resident #4 had physically hit staff and other residents. Resident #12 stated that she believed resident #4 was going to hit her. 2. Record Review a. Investigation Report The 10/10/17 investigation report documented resident #4 had initiated a verbal altercation at lunch time in the main dining room with residents (#15 and #12). The investigation revealed resident #4 was cussing and yelling at resident #15, who then started to yell and cuss back at resident #4. CNA #10 reported very bad language was thrown back and forth, with both residents threatening to hit one another. Then, resident #12 became upset that resident #4 continued to curse, so she got up and started to yell and cuss at resident #4. -The investigation follow-up was completed 12 days later on 10/22/17. Resident #12 was interviewed and information was received that the resident was tired of being harassed and cursed at by resident #4. - A witness interview, dated 10/22/17, conducted with another resident, revealed resident #12 was observed leaving the dining room in tears after the incident on 10/10/17. The interview documented resident #12 stopped and spoke to the night nurse and told her what had happened. The night nurse responded by telling resident #12 to just stay away from him (referring to resident #4). b. Progress Notes According to the 10/10/17 progress note, resident #4, was verbally combative with another resident in the dining room while waiting for his meal. 3. Staff Interview Licensed practical nurse (LPN) #4, who reported consistently working with resident #4 on the West unit where the resident resided, was interviewed on 12/7/17 at 4:08 p.m. The LPN reviewed documentation related to the incident on 10/10/17. She said that resident #4 had been witnessed in the dining room yelling obscenities at other residents. She said the residents involved were separated and then resident #4 was taken to his room. The LPN said the documentation did not say what the intervention implemented in response to the incident was. She said on 10/10/17 resident #4 was not on one-to-one supervision or checks and it seemed like an isolated incident. B. Incident #2 1. Record Review Review of investigation report record documented resident #2 exhibited aggressive behaviors toward her roommate. According to the incident report investigation, the registered nurse (RN) #6 failed to implement interventions that protected the residents. Subsequently, on 11/3/17 at 1:00 p.m. resident #2 pushed resident #3, which was not her roommate, to the ground which caused resident #3 to have hip pain. Resident #3 was immediately sent to the hospital where she was treated for [REDACTED].#2 was immediately discharged from the facility. 2. Staff Interview The NHA was interviewed on 11/29/17 at 10:30 a.m. He stated, following incident #2, the facility educated the staff regarding verbal abuse. Prior to that on 9/13/17 the facility had conducted behavior management training with the staff (initiated as a plan of correction to a previous abbreviated survey). He said he expected staff to report anything that could potentially be abuse and would retrain on that topic. C. Incident #3 Resident #4 was involved in a verbal altercation with resident #5 in the dining room. Resident #5 reported having multiple altercations with resident #4 and feeling of frustration as a result. Resident #5 threw orange juice at resident #4. Resident #5 was placed on 15-minute checks after the incident. No interventions were put in place for resident #4 after this incident. 1. Resident Interviews Resident #5 was interviewed on 12/7/17 at 3:20 p.m. The resident said the incident in the dining room at breakfast on 12/3/17 was the third time resident #4 had yelled at him. Resident #5 said he was sick of it. Resident #5 said he he threw the orange juice at resident #4 because he felt frustrated at the repeated altercations. Resident #5 said resident #4 was always doing having verbal altercations with others. He said he was not afraid of resident #4 but tired of being yelled at by him. Resident #5 was aware that someone had to check on him after the incident on 12/3/17. Resident #4 was interviewed on 12/7/17 at 3:20 p.m. Resident #4 stated he did not know about the incident with orange juice. 2. Record Review a. Investigation Report Review of the unfinished investigation into the 12/3/17 incident revealed resident #4 cussed at resident #5. Resident #5 responded by throwing a glass of orange juice at resident #4. The incident occurred in the main dining room. The police were notified on 12/3/17 at 8:35 a.m. Both of the residents stated they were not fearful. Resident #5 was put on 15 minute checks. b. Progress Note On 12/3/17 an interdisciplinary progress note documented resident #5 had a verbal altercation with resident #4, where resident #4 was yelling obscenities at resident #5 while in the dining room. Resident #5 proceeded to leave the dining room and as he was walking out he threw orange juice at resident #4. Documentation revealed both residents were placed on 15 minute checks. E. Incident #4 Resident #4 was involved in verbal altercation in the dining room with multiple residents. Staff reported resident #4 was very angry, getting up from his chair to confront the other residents, before he was redirected from the dining room by CNA #9. CNA #14 reported she did not inform the NHA of the incident. 1. Resident Interview Resident #12 was interviewed on 12/7/17 at 4:55 p.m. The resident said she was yelled at by resident #4 last night (12/6/17) in the dining room. CNA #14 witnessed the incident, however, did not report it. The resident said no one had approached her to follow up on the incident. 2. Record Review There was not an investigation of this incident available for review. 3. Staff Interviews LPN #4, who regularly worked on the same unit as residents #4 and #5, was interviewed on 12/7/17 at 8:20 a.m. She said resident #5 was on frequent checks and mentioned another female resident was on frequent checks. The LPN was not aware of any other resident that required resident frequent checks. The LPN was not aware of any residents on a one-to-one monitoring program. CNA # 15, who regularly worked on the west unit where resident #4 resided, was interviewed on 12/7/17 at approximately 4:20 p.m. She said she was not aware of any residents on the west side of the facility that required any one-to-one supervision or that had frequent or 15 minute checks. CNA #14 was interviewed on 12/7/17 at 6:04 p.m. CNA #14 said she had observed that something had happened last night (12/6/17) between resident #13, #16, #12 and #4. Resident #4 was sitting at the table near the west entrance to the dining room, and the other three residents were sitting towards the center of the dining room. The CNA said the residents all started cussing at each other and yelling. Resident #4 escalated and became really angry. She said resident #4, got up from his chair and was ready to go for it. She stated she and CNA #9 intervened and assisted resident #4 out of the dining room. She said she did not report the incident to anyone. The CNA said she said she probably should have reported the incident, but did not because she was just used to it. CNA #9 was interviewed on 12/7/17 at 6:12 p.m. CNA #9 stated once in a while he heard resident #4 yelling at other residents and getting angry for no reason. The resident would then get mad when other residents yelled back at him. He said he would intervene by assisting the resident to his room or by offering him coffee. The nursing home administrator (NHA) was interviewed on 12/7/17 at 7:01 p.m. The NHA said he was unaware of the incident that occurred on 12/6/17 between resident #12 and resident #4. IV. Failures with Concern Follow-up A. Resident #11 1. Resident Interviews Resident #11 was interviewed on 12/7/17 at 6:20 p.m. The resident reported that she had heard resident #4 yell and curse at other residents. The resident said was aware that resident #4 had hit both residents and staff and she was afraid of him entering her room. According to the resident, CNA #9 had redirected resident #4 out of her room several times. The resident said she had told staff she was scared. She said the facility had tried one-on-one supervision with resident #4, however he was no longer on one-on-one supervision. Resident #11 was re-interviewed on 12/11/17 at 8:42 a.m. The resident stated she had told staff she was fearful of resident #4 and anyone that wandered or was aggressive a couple of times during ambassador rounds. She said ambassador rounds were completed every other day. Resident #11 was interviewed a second time on 12/11/17 at 12:00 p.m. The resident confirmed she told the activity assistant (AA), she was afraid of resident #4 two or three weeks ago when the AA asked about resident #4. She said she had mentioned resident #4 to the AA the other day, which she believed to be Friday or Saturday. The resident said she told the AA of her frequent fear. The resident was adamant she had told the AA about her concerns with resident #4 when the AA asked if the resident felt safe in the building. Moreover, the resident said she had told CNAs to watch that resident #4 did not come in her room. She said CNA #9 knew about her problem with resident #4. 2. Record Review Review of the 9/13/17 abuse training (see below regarding abuse training) revealed the AA was present and received education about identifying and reporting potential abuse. Ambassador rounds documentation for resident #11 for the week of 10/29/17 - 11/3/17 was completed by the AA. This document recorded that the resident still did not like it when other resident's wandered into her room. Review of the concern logs and grievance forms revealed the wandering concerns reported by the resident the week of 10/29/17 were documented after the ambassador rounds. No additional documentation about resident #11's fear of resident #4 was identified. 3. Staff Interviews CNA #9 was interviewed on 12/7/17 at 6:12 p.m. He stated resident #11 was afraid of resident #4 and constantly told him she was afraid. He said he was aware resident #11 was afraid, and not had reported it. The director of nurses (DON) was interviewed on 12/7/17 at 7:25 p.m. The DON said she was unaware of resident #12 and resident #11 feeling fearful of resident #4. She was informed (by the surveyor) of the residents who had expressed fear (resident #12 and resident #11) and CNA #14 who witnessed the verbal altercation and CNA #9 who was aware that resident #11 was fearful. The AA was interviewed on 12/11/17 at 11:43 a.m. The interview revealed: -The AA was the ambassador for resident #11. She said ambassadors completed a form during rounds. The forms reviewed a variety of areas including the resident environment, satisfaction assistance with activities of daily living, and making sure residents felt safe. The AA conducted rounds three times per week. When a concern was identified, the AA completed a grievance or concern form and reported the concern to the appropriate staff member. -The AA said when a resident was afraid, she would fill out a grievance form, notify nursing, and call the nursing home administrator (NHA). She stated she recently called the NHA when a resident did not feel safe, but she had not filled out a form because she notified the nurse and NHA right away. -The AA said resident #11 had last reported feeling fearful approximately a month ago when the resident had told the AA about medication issues and wandering resident problems. She said she put this on a concern form. She said resident #11 was talking about resident #3, and that was the only resident she was worried about wandering into her room. She said resident #11 had not reported resident #4 to her or she would have told the NHA. She said resident #11 never said a word about resident #4, she only said resident #3 was wandering in and using her bathroom. The AA was interviewed on 12/11/17 at 2:30 p.m. Regarding the grievance form from 10/29/17, she said she had assumed the wandering was about resident #3 but never knew for sure, so she had not reported resident #3's name. B. Resident #12 1. Resident Interview Resident #12 was interviewed on 12/11/17 at 2:10 p.m. She said resident care advisor #1 was her ambassador. The resident said she told care advisor #1 her fear of of resident #4. The resident stated she had not said anything since the last altercation. 2. Record Review There was no grievance, concern or ambassador documentation of resident #12 reporting fear of resident #4. V. Failures with Addressing Behavior Contributing to Concerns of Abuse During the investigation beginning on 12/7/17 at 3:30 p.m., it was discovered that resident #4 had exhibited physically aggressive behaviors toward other residents. Residents #11 and #12 were fearful of resident #4. The facility failed to implement interventions to protect residents. Record review and staff interviews beginning on 12/7/17 substantiated resident #4's verbally and physically aggressive behaviors, including yelling and cursing, as well as physical aggression toward residents 1. Record Review A review resident #4 of the behavior tracking from 10/1/17 through 12/6/17 revealed the following: October 2017 - Resident #4 was documented to have behaviors related to aggression on 10/19/17 day, evening and night shifts, and on the 10/23/17 evening shift. - Resident #4 was documented to have behaviors in general on the 10/1/17 evening shift, and on 10/13/17, 10/19/17 and 10/29/17 day shifts. - Resident #4 was documented to have had episodes of impulsiveness on 10/1/17, 10/19/17, and 10/23/17. - Resident #4 was documented to have had refusal of cares all day on 10/1/17, in the evening of 10/12/17, and all day on 10/19/17. November 2017 - Resident #4 was documented to have been physically abusive to staff and residents on the day and evening shift on 11/10/17 and 11/12/17, as well as on the day shift of 11/25/17. - On 11/25/17 resident #4 was documented to have episodes of aggression on the day shift. - Resident #4 was documented to have been verbally aggressive to staff and residents on the evening shift of 11/10/17 and 11/12/17, and on the day shift of 11/25/17. - Resident #4 was documented to have had refusal of cares on 11/10/17 and on 11/25/17. - Resident #4 was documented to have had impulsive behaviors on 11/10/17 evening shift and 11/25/17 day shift. December 2017 - On 12/6/17 resident #4 was documented to have had five episodes of behaviors. - On 12/6/17 resident #4 was documented to have behaviors on the day shift and evening shift. Review of the care plan, progress notes and remaining clinical record showed no interventions were put into place to protect residents from aggressive behavior exhibited by resident #4. 2. Staff Interviews: LPN #4 was interviewed on 12/7/17 at 4:08 p.m. She said she had to look up if they were doing anything to monitor resident #4. She said they were all just assigned to resident #4, and especially with him it was common knowledge he had physical and verbal outbursts. She said if he refused care they just made sure he was safe and th (TRUNCATED)

Based on record review, observations, and staff and resident interview, the facility failed to ensure four incidents of abuse involving six residents (#22, #23, #24, #29, #30 and #31) were thoroughly investigated and residents remained free from abuse. Specifically: - The facility failed to thoroughly complete investigations of physical abuse, verbal abuse and two incidents of alleged sexual abuse. - The facility failed to prevent further potential abuse by ensuring residents were safe from resident #22 and resident #29. - The facility failed to report an incident of physical abuse and an incident of verbal abuse to the state agency. - The lack of a thorough investigation, resident assessment, care planning, interventions and supervision created a situation of immediate jeopardy to the health and safety of all residents in the facility. I. Immediate Jeopardy A. Findings triggering Immediate Jeopardy Interviews and record review conducted 8/11/17 demonstrated resident #22 had initiated one physical altercation on 7/30/17 where he left the facility, returned intoxicated and struck resident #23 (see incident #1 below). Resident #22 then verbally threatened and used derogatory terms toward resident #24 on 8/9/17 (see incident #2 below). Following each incident, the facility failed to implement interventions and provide appropriate supervision and monitoring, to prevent recurrence of the incidents. The lack of assessment and interventions led to both resident #23 and resident #24 expressing they remained fearful of resident #22. A review of the two investigations revealed facility staff had not completed thorough investigations, interviewed staff and residents, or notified the state agency. An interview with the nursing home administrator (NHA) on 8/11/17 revealed she was unaware that she needed to notify the state agency regarding allegations of abuse and stated during her interview she did not know what to do with resident #22 after the physical altercation. B. Imposition of Immediate Jeopardy On 8/11/17 at 7:20 p.m. the NHA and the director of nursing (DON) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to address the resident to resident altercation and the NHA admission of not knowing what to do with resident #22 after the physical altercation created a situation of immediate jeopardy to resident health and safety. C. Facility Response and Removal of Immediate Jeopardy On 8/14/17 at 1:54 p.m., the division director of clinical services (DDCS) submitted the following removal plan (draft five): Request for Removal of Immediacy of Immediate Jeopardy: F 225 Protection From Abuse Immediate Jeopardy August 11, 2017 at 1920 (7:20 p.m.) IMMEDIATE PLAN AND STEPS TAKEN - Corrective Action: Resident (#22) was immediately placed on a 1:1 on August 11, 2017 to ensure there will be no further inappropriate interactions with any other residents, and to ensure that all other residents feel safe and secure in the facility. - Identification of others: The facility's interdisciplinary team interviewed all residents residing in the facility beginning August 11, 2017 and completed by August 13, 2017 assuring that all residents feel safe and secure. The team called and interviewed family/responsible parties of residents that are not interviewable. Any resident that alleged fear will have appropriate interventions to ensure their safety is maintained throughout and after investigation. The facility's interdisciplinary team will review current facility residents to assure that residents with behaviors that affect others have interventions in place and care plans have been updated as such. This will begin on August 14, 2017. - System Changes: 1:1 education provided to Nursing Home Administrator and Director of Nursing on August 13, 2017 by District Director of Clinical Services in regards to Abuse and Neglect Policy, Appropriate Investigation Protocol and Follow Up after an abuse investigation is completed. The DON or Designee will educate all facility staff on the facilities policies and procedures for abuse and neglect, including what to do if they witness abuse and which steps to take immediately to keep residents safe, grievance, concern and ambassador programs, all other staff members will be re-educated prior to clocking in for their next shift starting on August 11, 2017. The DON or Designee will educate all facility staff on appropriate interventions to take to assure the safety of the resident and other residents when a resident returns to the facility intoxicated. This education will begin on August 14, 2017 and will continue until all staff is educated. Care Plans for resident # 58, # 18 and # 52 were updated on August 13, 2017. DON/Designee began education to all facility staff on August 14, 2017 regarding the care plan updates for these residents this will continue until all facility staff have received education and will be done prior to clocking in for their next shift. - Monitoring: The NHA/Designee and DDCS will review all concerns and grievances daily during morning meeting to rule out that no abuse or neglect allegations have been made and ensure that investigations are complete and interventions are implemented, appropriate and ongoing. Weekend review of abuse allegations will be handled by NHA and/or DON and DDCS via communication from facility staff if a concern arises to ensure appropriate investigations and interventions are put into place. The NHA/designee and DDCS will audit the concerns and grievances daily to assure that a complete and thorough investigation and resolution has occurred. On 8/14/17 at 1:54 p.m. the NHA, DDCS and DON were notified the immediate jeopardy had been lifted effective 1:54 p.m. However, based on observation, interviews and record review, the deficient practice remained at an H level. II. System Failures Identified After the Immediate Jeopardy Was Removed On 6/25/17, a progress note documented resident #31 allegedly was awakened by his roommate, resident #29, who was rubbing his stomach, his leg and inner thigh. The NHA failed to investigate the incident or implement interventions to protect residents. On 8/15/17, after a complaint was submitted to CDPHE, it was identified that resident #30 reported on 7/2/17 that resident #29 had raped him. The NHA was aware of the incident per staff report however, the incident was not investigated and the NHA failed to implement interventions to protect residents. The findings included: I. Facility Policy The facility's abuse and neglect prohibition policy, revised January 2017, included: - Each resident had the right to be free from abuse. - The facility administrator is the Abuse Prevention Coordinator. - Abuse meant the willful (intention to perform the action) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. - Physical abuse included hitting, kicking, and slapping. - Verbal abuse included oral, written or gestured language that was disparaging or derogatory. - Sexual abuse was non-consensual sexual contact of any kind, including sexual harassment, coercion, or sexual assault. - Residents identified as exhibiting abusive behavior would be reviewed by the physician and treatment modified as appropriate. - Facility supervisors would immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriate of resident property was at risk for occurring. - The facility would protect residents from harm during the investigation. - The facility would timely conduct an investigation of any alleged abuse. - The facility would report all investigative findings to the state within five working days of the incident. II. Resident Status A. Resident #22 Resident #22, under age 60, was admitted to the facility on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. The 8/2/17 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He had no indicators of depression and no behaviors were present. The resident required supervision with all activities of daily living (ADLs) but was able to ambulate throughout the facility independently. B. Resident #23 Resident #23, under the age of 60, was admitted to the facility on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. The 6/18/17 MDS assessment documented the resident had no cognitive impairment with a BIMS of 15 out of 15. The resident had no reports of depression and no behaviors were present. The resident required supervision with all activities of daily living. The resident used a wheelchair for ambulation. C. Resident #24 Resident #24, under age 60, originally admitted to the facility on [DATE]. According to the computerized physician orders, the resident had diagnoses, which included [MEDICAL CONDITION], major [MEDICAL CONDITION] and [MEDICAL CONDITION]. The 7/12/17 MDS assessment documented the resident had no cognitive impairment with a BIMS of 15 out of 15. The resident had minimal reports of depression and no behaviors. The resident required extensive assistance with dressing, eating, personal hygiene and supervision for locomotion throughout the facility. The resident used a power wheelchair for mobility. D. Resident #29 Resident #29, [AGE] years old, was admitted to the facility on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. The 6/20/17 MDS assessment documented the resident had no cognitive impairment with a BIMS of 15 out of 15. The resident reported he was feeling down and depressed. He had no behaviors during the review process. The resident required supervision with ADLs and ambulates throughout the facility independently. E. Resident #30 Resident #30, [AGE] years old, originally admitted to the facility on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. The 8/6/17 MDS assessment documented the resident was not interviewable and staff completed the BIMS. The BIMS indicated he had both short and long-term memory problems. The MDS documented the resident had no signs of depression or behaviors. The resident required limited to extensive assistance with ADLs. F. Resident #31 Resident #31, under the age of 60, was admitted to the facility on [DATE] and discharged from the facility on 7/20/17. According to the computerized physician orders, [DIAGNOSES REDACTED]. The 6/7/17 MDS assessment documented the resident had no cognitive impairment with a BIMS of 15 out of 15. The resident reported he had minimal feelings of depression. The resident had no behaviors during the review process. The resident required limited to extensive assistance with ADLs. He used a wheelchair for ambulation. III. Incident #1 A. Resident Interview On 8/11/17 at 6:20 p.m., resident #23 was interviewed. He said resident #22 had hit him several times all over my head during the incident. He said it was so hard that he had knocked him over in his wheelchair backwards and he had hit his head on the brick wall. Resident #23 said he was told by LPN #1 that if he reported he was scared he would have to be discharged from the facility. He said he was afraid of resident #22 and believed resident #22 could assault him again. Resident #23 said he felt vulnerable because he could not walk and believed resident #22 drank alcohol daily. He said facility staff had not said anything to him about keeping him safe. I am afraid if I were to complain the facility staff would retaliate. B. Record Review 1. Investigation Summary In pertinent part, a review of the investigation between resident #22 and resident #23 revealed the following: - The incident between resident #22 and resident #23 occurred on 7/30/17 at 5:15 p.m.; the investigation was initiated at 7:30 p.m. - The NHA reported the incident to the police, the physician, the division director of clinical services (DDCS) and the division director of operations (DDO). The incident was not reported to the state agency. - The incident summary, completed by the NHA, documented resident #23 was hit by resident #22 on 7/30/17 at 5:00 p.m. in front of the building. resident #22 said he had flipped resident #23's wheelchair back against the wall but did not punch him. When resident #23 was interviewed he said he was punched in the face 20 times by resident #22 and fell back in his wheelchair but did not hit the floor. Both residents stated there was no fear of the other and neither resident wanted to press charges. Neither resident had pain or any visible swelling, redness, or bruises at the time of the investigation. - The conclusion, completed by the NHA, documented to monitor both the witness (resident #24) and the victim (resident #23) for 24 hours after the incident. Discussed with resident #23 whether he wanted to press assault charges against resident #22 but resident #23 refused. - The plan of action, completed by the NHA after the facility was notified of the immediate jeopardy (IJ), documented resident #22 was placed on one-to-one observation at 7:00 p.m. on 8/11/17. - The NHA was made aware that both resident #23 and resident #24 felt unsafe. - Resident #22 was to remain on one-on-one supervision until a discharge plan was put into place for resident #22 and resident #23 and resident #24 felt safe. - Fifteen minute checks were completed for resident #23 and resident #24 from 7/31/17 through 8/1/17. Witness Statements - On 7/30/17 resident #23 was interviewed; he said he could take care of himself. - On 7/31/17 resident #23 said he wanted to know when (the facility) was kicking resident #22 out of the building. He said he was not afraid or hurt but he had a headache. He said we (the facility) always gets rid of the other drunks and said resident #22 was drunk. - On 7/31/17 at 1:00 p.m. resident #23 said to the social worker and the customer service director that he had a headache, pain and was fearful. Later the resident said to drop it as he was just venting. - On 7/31/17 the SSA (social services assistant) interviewed resident #23. He said he initially said he was not afraid because he had no place to go. Later he said he was very scared to sleep at the facility because he believed resident #22 may come after him again. He said since he was not mobile and resident #22 was, he could not defend himself. 2. Telephone Order (TO) The telephone order, for resident #22, dated 7/31/17 documented X-Ray Left wrist/hand rt (related to) increased swelling and pain. 3. X-Ray Results The x-ray results, for resident #22, dated 7/31/17, documented no definite radiographic evidence of acute fracture or dislocation. C. Staff Interviews Certified nurse aide (CNA) #7 was interviewed on 8/11/17 at 2:55 p.m. She said when the incident occurred between resident #22 and resident #23 she knew they were split up and staff were to ensure they remained apart. She said she had heard it was a physical altercation where resident #22 had thrown resident #23 off his chair. She said just for that night they were separated, because they lived at opposite ends of the hall but she never heard anything more about it. She said the police came the next day and she knew resident #22 was drunk at the time of the incident with resident #23. She said she had never received any type of training on what to do if a resident came into the facility drunk. She said she had not received any other instructions about Resident #22 or resident #23. The NHA was interviewed on 8/11/17 at 6:18 p.m. She said after the 7/30/17 incident they kept an eye out for him (resident #22) and alerted staff. She said none of this was in writing and she said she knew staff didn't know what she meant about keeping an eye on resident #22. She said when conducting the investigation, they obtained witness interviews only. She said no resident interviews were completed to determine whether residents felt safe in the facility. She said she had not asked anyone to be placed on 15-minute checks, however a nurse initiated checks for both resident #23 (victim) and resident #24 (witness). She said she was aware this indicated the facility was concerned for their safety. She said interventions for resident #22 were not implemented but staff did ask resident #22 to not speak to other residents unless he could be nice. She confirmed they had never done any one-to-one supervision for resident #22 after the 7/30/17 or 8/9/17 incidents and confirmed no interventions had been started until the one-to-one supervision was initiated on 8/11/17 (immediately before the IJ was called). She said she was unsure whether she had residents in the building that were afraid of resident #22. She said, I really didn't know what to do or what I could have done (with resident #22). She said, I am the abuse coordinator for the building and it lies on me. On 8/11/17 at 7:20 p.m., when they were notified of the IJ, the DON and the NHA said the NHA had started one-to-one supervision for resident #22. This was initiated after the interview with the NHA on 8/11/17 at 6:18 p.m. Licensed practical nurse (LPN) #1 was interviewed on 8/14/17 at 8:35 a.m. He confirmed he was the nurse working when the physical altercation between resident #22 and resident #23 occurred. He said he initially called the NHA and DON and let them know the status. He said resident #22 appeared drunk and he let the resident's doctor know. He said he had been called to go outside and resident #23 was leaning against the wall, tipped backwards in his wheelchair. The LPN said he noticed resident #23 had a walking stick on the side of his wheelchair. Resident #23 said he was assaulted and was hit 20 times. He said he brought resident #23 to his room and completed a skin check. He then completed a skin check on resident #22 who immediately went to be afterwards. He said he originally did not see any skin issues on either resident. Later that evening resident #22's right elbow had [MEDICAL CONDITION], his left hand was red and swollen, and the next day an X-ray was ordered. He said he asked resident #23 if he was scared, and he said, I have this (walking stick). He said he took the walking stick from resident #23 and also looked in his drawers and found a screwdriver, which he removed. He said the resident appeared agitated and anxious. He said resident #22 reported resident #23 was talking to resident #22's girlfriend at Safeway and then resident #22 and resident #23 had an altercation at the facility. LPN #1 said he called the DON and told her he had taken the walking stick away from resident #23 and resident #22 appeared drunk. He said the only thing he did was to encourage them both to use their call light if they wanted to leave their room. He said resident #23 went out to smoke but resident #22 stayed in bed. LPN #1 left the facility at 10:30 p.m. He returned at 5:30 a.m. He completed another skin check for each resident upon his return. He found [MEDICAL CONDITION] on resident #22's elbow and redness on his left hand. He said he thought the NHA had called 911 that next day but was not sure if anything else had happened. He said there were no other safety checks in place and everything went back to normal. He said, I probably could have done more. He said he was certain resident #22 had come back to the facility drunk several times in the past. LPN #1 was interviewed on 8/14/17 at 3:15 p.m. He said the night of the altercation was a rough night. He said he had obtained one set of vitals for resident #23 after the incident, but neuros were not completed. He said normally if a resident had a possible head injury (see incident report above and interview with resident #23 indicating resident #23 sustained a possible head injury during the altercation with resident #22), neuros would be completed. IV. Incident #2 A. Record Review 1. Investigation Summary A review of the investigation between resident #22 and resident #24 revealed the following, in pertinent part: - The incident between resident #22 and resident #24 occurred on 8/9/17 at 5:45 p.m.; the investigation was initiated at 5:55 p.m. - The incident was not reported to the ombudsman, police, DDO or DDCS or the state agency. - Resident #22 verbally threatened resident #24 that he would physically hurt him and called him derogatory names. - There were no injuries but resident #24 expressed fear. - No other residents, besides the two involved in the incident, were interviewed. B. Resident Interviews Resident #24 was interviewed on 8/11/17 at 6:55 p.m. He said he had observed resident #22 punch resident #23 in the face and push him backwards while in his wheelchair. He said he told the NHA who told him not to worry about it and that she would take care of it. He said the NHA told him she would talk to him about it later but he said she had not talked with him since the night of the incident. resident #24 said resident #22 would walk by his room and call him names and resident #22 had told resident #24's roommate that on one occasion resident #22 threatened to hurt him after he woke up. He said he had told LPN #1 about the verbal threats resident #22 had made. He said LPN #1 told him if he did not feel comfortable, resident #24 would have to leave the facility. He said he did not feel safe in the facility and told the social services assistant (SSA) who said she would help him find a place to go. He said he liked where he was living but did not like that there was a resident who would walk by his room calling him names and he could not fight back. He said the SSA had told him if he did not feel safe on his current side of the facility (the same side as resident #22) he could move to the other side. He said he had told staff that moving to the other side of the facility would not make a difference as resident #22 could come over there. He said he thought the resident would do it again, since every time he leaves and drinks and comes back he acts macho when he comes back from drinking. V. Incident #3 (Identified after the IJ was removed) CDPHE received a complaint on 7/26/17 that resident #30 reported he was raped by resident #29 and the facility had not implemented any interventions. A. Record Review Review of both resident #30's and resident #29's medical records revealed no documentation of any interactions between the two residents. B. Staff Interview An interview with the DDCS (see below) revealed that, after the investigation was initiated for the fourth incident occurring on 6/25/17, an incident between resident #29 and resident #30 was identified. The approximate date of the incident was late June 2017 or early July 2017. VI. Incident #4 (Identified after the IJ was removed) A. Record Review The behavior note dated 6/25/17 documented in pertinent part, (resident #31) came to his nurse reported around 2100 (9:00 p.m.) he was sleeping in his bed and (resident #29) came and sat down next to him on his bed and woke (resident #31) touching his stomach and his inner thigh/private area. (resident #31) told (resident #29) to stop and get away from him. (Resident #31) immediately started to get up to leave room. (resident #31) initially did not want to report that had happened to anyone and was just going to try and let it go but this resident kept following him outside and yelling at him and using profanities towards him. (resident #31) was moved to (another room). (resident #31) states that he does not want the cops to be called. (resident #29) was intoxicated at the time of the incident, stumbling all over the place, slurring his words and had the smell of ETOH on his breath. DON was notified of the incident. B. Staff Interviews On 8/16/17 at 10:35 a.m. the DON and the DDCS were interviewed. The DDCS said both investigations (incident #3 and incident #4) had been initiated on 8/15/17 at 5:28 p.m. All residents in the facility had been interviewed as a result of the immediate jeopardy being called. The DDCS reported the following pertinent facts regarding the investigation between resident #29 and resident #30 and the investigation between resident #29 and resident #31. - Resident #29 had immediately been placed on one-to-one supervision effective 8/15/17 at 5:28 p.m. - Both investigations were initiated at 4:00 p.m. on 8/15/17 and had been reported to the state and police had been notified. - The DDCS had interviewed 16 members of the leadership team and 13 of the 16 staff had reported to the DDCS that the NHA was present during conversations related to both allegations involving all three residents. - The NHA had been in the position since the beginning of June and was suspended on 8/15/17 at 6:08 p.m. - Resident #30 could not be interviewed due to cognitive changes and resident #31 had been discharged from the facility. - An interview with resident #29 was not provided. The DON reported the following pertinent facts during the interview: - She recalled receiving a phone call at 1:00 a.m. on 6/26/17 regarding the incident between resident #29 and resident #31 (see progress note above). - She said staff told her, during the phone call, there would be an immediate room change because resident #29 and resident #31 were fighting. She said the nurse that made the call did not mention to her the allegation of inappropriate touching. - She said during the morning meeting on 6/26/17 the allegation of inappropriate touching between resident #29 and resident #31 was discussed. - She said she was not aware of any other mention regarding the incident. - She said regarding any incident, she would complete the tasks, related to an abuse investigation, that were assigned to her by the NHA. - She recalled hearing in morning meeting that resident #29 had touched resident #31 inappropriately. - She recalled hearing in another morning meeting that resident #30 had said that he was raped by resident #29. The DDCS said the rehabilitation program manager (RPM) reported to her that she believed an investigation had been completed because she was asked by the NHA to go speak to resident #30 on 7/2/17. The interview revealed resident #30 thought he was raped but was uncertain what exactly had happened. During the interview he also reported he was afraid to be in the facility and afraid to ask for a room move and afraid of retribution. The RPM reported to the DDCS that she thought the NHA was aware because she had asked her to complete the interview and had given the interview to her upon completion. Both the DDCS and the DON were unsure of the time frame for the incident between resident #29 and resident #30. Based on the interview provided by the RPM the incident occurred sometime between the end of June 2017 through July 2017.

Based on observations, record review and interviews, the facility failed to ensure the resident environment was free from accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#11) of six residents reviewed for falls and four (#8, #14, #33 and #34) residents who smoked tobacco of 36 sample residents. Specifically, the facility failed to: -Timely implement planned interventions following six falls, including falls with injury, for resident #11. The facility's failure to timely implement planned interventions resulted in resident #11 experiencing falls with ensuing loss of consciousness, head injury and hospitalization . And, -Ensure resident #s 8, 14, 33 and 34 were free from accident hazards in the smoking area and had safe smoking interventions that were re-evaluated. The findings included: I. Falls A. Facility Policy The facility's fall management policy and procedure (revised 7/17) directed, in pertinent part: -The facility will provide the resident with adequate supervision, assistive devices, and/or functional programs to minimize the risk for falls. B. Fall Packet Review According to the fall packet, provided by the unit manager (a registered nurse, UMRN), it read in pertinent part: -Every fall required an intervention and the interventions were to be documented on the care plan; -The fall risk care plan was to be updated after each fall. C. Failure 1. Resident #11 a. Resident Status Resident #11 was admitted on [DATE], and readmitted on [DATE]. According to the August 2017 computerized physician orders [REDACTED]. The 7/1/17 nursing admission data collection tool documented, the resident had both short and long term memory impairments and had cognitive impairments. He was anxious and agitated. He required extensive assistance with activities of daily living. The 7/1/17 fall risk assessment identified him as having a high risk for falls. The resident had three or more falls in the past three months and he had balance problems. b. The facility failed to put interventions in place after the resident sustained [REDACTED]. Fall #1 The fall incident report documented, the resident fell on [DATE], no injury occurred, and one-to-one monitoring was the intervention recommended. The nurs progress note dated 6/21/17 at 2:52 a.m., documented, the resident was confused, impulsive, and had weakness due to a subdural hematoma. The nurse progress note written on 6/21/17 at 5:53 p.m., documented, the resident had swelling and redness to right thumb with tenderness to touch per resident #11, x-ray of the right thumb was ordered. The nurse progress note dated 6/22/17 documented, the resident had a bruised left hip and the x-ray results revealed a compound fracture of his right thumb. The 6/22/17 hospital record documented, the resident had a fracture to his right thumb and was to wear a splint for two to three weeks to immobilize it. Fall #2 A fall incident report was not completed for the fall on 6/25/17 at 6:30 a.m. The post fall report dated 6/25/17 documented, he sustained a bruise on his left hip, and the intervention was to downgrade him from one to one monitoring to 15 minutes check monitoring. According to the 6/25/17 SBAR (situation, background, assessment, response) progress note written at 8:44 a.m., the resident fell and hit his head. The resident complained of a headache and was sent to the emergency room (ER) for evaluation. The administration note dated 6/25/17 documented, the resident required one-to-one supervision due to restlessness, agitation, being a high risk for falls and his unsteady gait. Fall #3 The post fall report dated 6/25/17 documented, the resident fell a second time on 6/25/17 at 9:50 p.m He had a bump on the back of his head with bleeding, and the intervention was to educate the resident to stay in his chair and ask for help. Falls #4 and #5 TheSBAR progess note indicated the resident fell twice on 6/30/17, one was witnessed and one was unwitnessed, one of the falls resulted in a scratch to his right cheek The 6/30/17 SBAR progress note at 2:29 p.m., documented, the resident fell as he was left alone without supervision. The intervention that was to be in place was one-to-one monitoring. The second SBAR progress note, dated 6/30/17 noted the resident fell a second time. This fall was a witnessed fall. Fall #6 A fall incident report documented, the resident fell on [DATE] and hit his head. He was sent to the hospital for treatment. The report documented he was restless and did not use his call light, he had no safety awareness, poor gait and poor balance. Interventions included direction to keep him in high traffic areas when possible to anticipate his needs. The SBAR communication form and progress note, for 8/4/17 documented the following: -Resident's roommate witnessed fall and stated he (resident #6) walked to the sink, fell hard, and hit his head on the floor. -Resident was alert on initial evaluation, but after being assisted back to bed, there was a significant change in his level of consciousness. The resident was sent to the ER for evaluation. The resident was in the hospital for injuries sustained during fall #6 and was unavailable for observation and interview at the time of the investigation. c. Failure to update care plan The initial care plan dated 7/1/17 identified the resident was at risk for falls related to a history of falls, disease process and decreased safety awareness. The plan of care, initiated on 8/1/17 and revised on 8/9/17, identified the resident had an actual fall with no injury/minor injury due to poor balance and unsteady gait. It further identified the resident was impulsive and anxious due to [DIAGNOSES REDACTED]. Interventions included encourage the resident to ask for assistance and for staff to keep the resident in high traffic areas when possible to anticipate needs. The care plan was not updated after falls with injuries to include the added interventions of one-to-one supervision and 15 minute checks. d. Nurse practitioner progress notes review The 8/1/17 nurse practitioner's (NP) progress note, documented the resident required a one-to-one sitter and restraints in the hospital. The note further documented the resident required very frequent rounding and that he had sustained a right eye and head injury due to a fall from bed. The 8/2/17 NP progress note documented the resident had repeated falls and was sent to the ER for a three inch head laceration and head trauma evaluation due to a fall, which resulted in unresponsiveness. The note further documented that this was his third fall for the week and that the resident required one- to-one care; however, staffing ratios at the facility were insufficient to provide that type of care. The note documented the NP's opinion that residence at the facility represented inappropriate placement for the resident. e. Staff interview The director of nursing (DON) was interviewed on 8/11/17 at 11:25 a.m. The DON said the nurses determined which immediate interventions were to be put in place after a resident fell . She said the interdisciplinary team (IDT) reviewed the initial fall interventions, determined their appropriateness, and finalized the fall interventions to be implemented. The DON said resident #11 required one-to-one monitoring which meant a staff member remained with him for their entire shift and within an arm's reach of the resident. She said the facility did not document one-to-one monitoring for resident #11 because the facility had no one-to-one form on which to document. She said the facility did not have the staffing capability for long term one to one monitoring; which resident #11 required to prevent future falls. She said she knew resident #11 required long term one-to-one monitoring within the first or second day of his admission due to his continuous movement, his anxiety, his impulsive behavior, his inability to transfer safely and his impaired balance. Licensed practical nurse (LPN) #5 and #6 were interviewed on 8/11/17 at 1:13 p.m. They said the facility did not have enough staff (certified nurse aides, CNA) to provide one-to-one monitoring of their residents. The director of nursing (DON) was interviewed a second time on 8/11/17 at 1:57 p.m. She confirmed the care plan had not been updated to reflect the resident's current interventions. She said fall interventions, such as the 15-minute checks, should have been documented in his care plan. f. Follow up The care plan was revised on 8/9/17 and included, one-to-one monitoring, and 15 minute checks upon his hospital return on 7/30/17. II. Smoking A. Facility Policy and Procedures The undated Smoking Tobacco Use policy provided on 8/9/17 at 3:00 p.m. by the director of nursing (DON), documented in pertinent part: Smoking is only allowed in the designated smoking area. Smoking is not allowed anywhere else on the property. This includes when there is inclement weather. No exceptions. Conduct Violations: 1. Smoking anywhere other than the approved smoking area will be counted as a violation, 2. Providing or sharing smoking materials with staff or other residents will be counted as a violation, 3. The policy is in effect 24 hours per day, 7 days per week, no exceptions. B. Safe Smoking Contracts On 8/10/17 at 5:00 p.m., the DON provided smoking contracts for 11 of the 44 residents who smoke in the facility. C. Failure 1. Resident # 33 a. Resident Status Resident #33, age 66, was admitted on [DATE] and readmitted on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. According to the 8/5/17 MDS assessment, the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident mood assessment documented the resident had trouble falling or staying asleep and felt tired or having little energy. The resident did not exhibit any behaviors of concern during the review process. The resident received extensive one-person assistance for all activities of daily living (ADLs) b. Record Review Care Plan The smoking care plan, initiated 8/9/17 and revised 8/9/17, identified the resident was a smoker and had a personal history of traumatic brain injury, essential primary hypertension, chronic obstructive pulmonary diseases and unspecified diagnoses. Interventions included supervision while smoking while wearing oxygen and noted the resident must have help removing his oxygen prior to exiting into the smoking courtyard. Medication Administration Record (MAR) The July 2017 MAR documented the resident required oxygen via nasal cannula at 3.5 liters per minute (LPM) continuous every shift for chronic obstructive pulmonary disease with a start date of 7/21/17. Safe Smoking Evaluations The 8/2/17 smoking evaluation deemed the resident with a visual deficit was a safe smoker. Another smoking evaluation was completed on 8/9/17, following the reported observation (see below) where the resident engaged in unsafe smoking behavior. Progress Notes The 7/21/17 nursing note documented the resident was dependent on oxygen related to chronic obstructive pulmonary disease. He was pleasant and required reorientation to remove oxygen before cigarette smoke breaks. Smoking Contracts Upon request, the facility was unable to provide evidence of a smoking contract with the resident. c. Observation On 8/9/17 at 9:02a.m., resident #33 was observed in the smoking area, in his wheelchair with the oxygen nasal cannula on his nose and the oxygen concentrator on the back of his chair. The resident's oxygen concentrator was not observed to be turned on. d. Resident Interview Resident #33 was interviewed on 8/9/17 at 9:44 a.m., He said he sometimes forgot to take off his nasal cannula and oxygen concentrator when going into the smoking area. He said staff needed to remind him. He said he did not remember signing a safe smoking contract when he arrived at the facility. 2. Resident #34 a. Resident Status Resident #34, under the age of 60, was admitted on [DATE] and readmitted on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. According to the 8/2/17 MDS assessment, the resident had minimum cognitive impairment with a BIMS score of 13 out of 15. Resident mood impairment was described as trouble falling or staying asleep, or sleeping too much. No behaviors were noted. She required supervision and setup help for activities of daily living (ADLs). The resident was frequently incontinent for bladder and bowel. b. Record Review Care Plan The care plan, initiated 2/9/16 and revised 3/16/17, identified the resident was a smoker and required supervision. The resident was aware of the facility's smoking policies. Interventions included instruct the resident about the facility policy on smoking, locations, times and safety concerns; complete the smoking assessment upon admission, quarterly, and when necessary (PRN); resident requires supervision while smoking; and, resident requires a smoking apron while smoking. Medication Administration Records The July 2017 MAR documented the resident required oxygen at five liters per minute (LPM) to maintain oxygen levels at an established level by the physician and it was to be monitored every shift. Smoking Evaluations The 3/15/17, 5/4/17, 6/7/17 and 8/7/17 smoking evaluation deemed the resident an unsafe smoker who required constant supervision as the resident did not remain alert. Smoking contracts The facility provided a copy of the resident's smoking contract which documented the above c. Observations On 8/9/17 at 2:00 p.m.,. resident #34 was observed in the smoking area smoking, unsupervised. d. Resident interview Resident #34 was interviewed on 8/9/17 at 2:15p.m. She said she would sneak outside to the smoking area because staff never took her out to smoke. She said she passed several staff on her way to the smoking area and no one told her not to go into the area. 3. Resident #14 a. Resident Status Resident #14, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. According to the 6/2/17 MDS assessment of the resident's capabilities, she was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive two-person assistance for ADLs. The resident required supervision/setup help for eating. b. Record Review Care Plan The smoking care plan, initiated 6/18/15 and revised 2/20/17, documented the resident was legally blind. The resident was a smoker who required supervision. She was aware of the facility smoking policy. Interventions included complete safe smoking assessments upon admission, quarterly, and as needed (PRN); instruct the resident about the facility policy on smoking to include locations, times, and safety concerns; notify charge nurse immediately if it was suspected the resident has violated the facility smoking policy; and, observe clothing and skin for signs of cigarette burns. The resident required a smoking apron while smoking and supervision while smoking. Safe Smoking Evaluations The 2/20/17, 3/25/17, and 6/3/17 smoking evaluation described the resident as an unsafe smoker who required constant supervision. Smoking contracts There was no smoking contract provided by the facility for this resident. c. Observations During a continuous observation on 8/9/17 from 9:05 a.m. to 9:10a.m., resident #14 was observed being pushed to the smoking area by certified nurse aide (CNA) #4. The resident was given a cigarette by staff who were monitoring the area. The resident was not given a smoking apron while smoking. d. Resident interview Resident #14 was interviewed on 8/9/17 at 9:23a.m. She said staff did not ask her about wearing protective gear. She said she needed staff assistance with the smoking apron because she was blind. 4. Resident #8 a. Resident Status Resident #8, age 68, was admitted on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. According to the 7/25/17 MDS assessment, the resident was cognitively intact with a brief interview for mental status BIMS score of 15 out of 15. No moods or behaviors noted. The resident was coded as an extensive one-person assist for activities of daily living (ADL). The resident was frequently incontinent for bladder and always incontinent for bowel. b. Record Review Care Plan The care plan, initiated 6/2/17, documented the resident had helicobacter pylori due to traumatic subarachnoid hemorrhage without loss of consciousness. Interventions included educate the resident of the needed lifestyle changes to decrease irritation and damage the stomach and avoid alcohol, avoid caffeine and quit smoking. Safe Smoking Evaluation There was no smoking assessment upon admission included in the resident's medical record. The 8/9/17 smoking evaluation (following the observation below) deemed the resident was a safe smoker. Smoking Contract There was no smoking contract provided by the facility. c. Observations On 8/9/17 at 5:00p.m., resident #8 was observed smoking on the eastside of the building in the outdoor courtyard while sitting in his wheelchair. d. Resident Interview Resident #8 was interviewed on 8/9/17 at 5:08p.m. He said he was an unsupervised smoker and could smoke outside in any area. He said staff had never told him to put out his cigarette. He also said he did not remember signing a smoking contract. 5. Staff interviews CNA #4 was interviewed on 8/9/17 at 9:11a.m. She said the staff supervising the smoking area were responsible to ensure residents used protective gear. She said they were also responsible for ensuring that residents who wear oxygen have it removed prior to going outside to the smoking area. She said CNAs do not watch the smoking area unless they are asked by nursing staff. She said CNA's do not document unsafe smoking violations nor are they assigned to watch residents smoking around the building. The Health Information Coordinator (HIC) was interviewed on 8/9/17 at 9:14 a.m. She said she was supervising the smoking area during the 9:00 a.m. observation. She said, she knew residents should not wear oxygen outside and that residents who wore protective gear should be assisted by CNAs who bring residents out to the smoking area because they knew what the resident required. The unit manager registered nurse (UMRN) was interviewed on 8/9/17 at 9:30 a.m. She said residents who planned to smoke were evaluated with a smoking assessment upon arrival at the facility by unit manager or a nurse. She said a progress note would be completed when there were issues. Licensed practical nurse (LPN) #6 was interviewed on 8/9/17 at 12:00 p.m. She said every resident, whether requiring supervision or not, should smoke only in the smoking area. She said she did not know if staff went around outside to see if residents were smoking in non-smoking areas. She said she had not heard any concerns from staff regarding residents smoking away from the designated area. CNA #5 was interviewed on 8/9/17 at 1:00 p.m. She said residents who require supervision can smoke every other hour and must go outside, into smoking area to receive their cigarettes. She said residents who were unsupervised were able to smoke at anytime. She said staff only assisted residents that need to be taken to the smoking area. She said she did not know who monitored the smoking area to ensure residents complied with the smoking policy. CNA #8 was interviewed on 8/9/17 at 1:15 p.m. She said residents that were safe to smoke and did not require supervision can go outside at anytime. She said CNAs only watch the smoking area if asked. She said the person in the smoking area had a list of residents who needed supervision. LPN #1 was interviewed on 8/9/17 at 1:30 p.m. He said cigarettes for supervised smokers were kept at the west nurses' station and the supervised smokers were taken outside according to the schedule by the department staff assigned to that task. The MDS Coordinator (MDSC) was interviewed on 8/9/17 at 2:05 p.m. She said resident smoking evaluations were completed during their admission, quarterly review and as needed. She said if a smoking incident occurred with a resident, a new smoking evaluation would be completed. The social services coordinator (SSA) was interviewed on 8/9/17 at 3:00 p.m. She said residents who violated the smoking policies were given a verbal warning on their first offense. She said if it happened again the resident would have a written violation documented in their record. The customer service coordinator (CSC) was interviewed on 8/10/17 at 3:40 p.m. She said she re-educated residents regarding the use of the smoking area and noted facility staff would be watching the perimeter around the facility to ensure safe smoking policies were being followed. The business office coordinator (BOC) was interviewed on 8/9/17 at 5:10 p.m. She said she would be watching the smoking area during supervised and unsupervised hours. She said she was instructed to watch the area over a twenty-four hour period after the smoking incident during the day. The nursing home administrator (NHA) was interviewed on 8/9/17 at 6:00 p.m. She said, residents were only allowed to smoke in the designated smoking area. She said staff would be re-educated regarding residents who were not safe to be unsupervised, and stated facility staff would check around the building every hour to prevent residents from smoking in unsafe areas. She also said she did not have a documented list of resident violations from previous infractions. The NHA was interviewed on 8/10/17 at 10:00a.m., after residents were observed smoking around the building, in non-smoking areas. She said her previous plan was not working and she would have the CSC educate residents again and inform them there would be violations for being caught smoking in unsafe areas. The DON was interviewed on 8/9/17 at 9:41 a.m. She said staff should monitor the smoking area to ensure residents were not taken outside, by staff, with oxygen on and were provided protective gear. She said smoking assessments and progress notes would be completed whenever unsafe smoking behavior was noticed. 6. Facility Follow-Up In-service Report On 8/9/17 an in-service was conducted for all facility staff on safe smoking. The in-service included: - Any resident wearing oxygen must have oxygen removed before exiting building onto smoking patio. - Oxygen should be placed on hooks with nasal cannula placed off the floor. - Oxygen tubing should not touch any surface. - Staff were expected to perform hand hygiene by using foam disinfectant dispenser on the way back into building and before re-applying oxygen to residents. - Offer apron to all supervised smokers. Resident Education On 8/10/17 customer service director provided 34 unsupervised smokers, and 10 supervised smokers' re-education on the safe smoking policy. The re-education provided on the smoking tobacco use policy included: - Residents can only smoke in designated smoking areas. - Increased in staff rounds of the facility and grounds. - The smoking policy signed would be enforced.

Based on observations, record review and interviews, the facility failed to ensure the medically-related social services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (#4) out of ten sample residents. Specifically, the facility failed to: - Coordinate with the interdisciplinary team to identify, assess, and care plan resident's mental health needs related to loss of independence; - Obtain optometrist's services for resident's double vision evaluation; - Ensure consistent psychiatric sessions for resident's behaviors, verbal and physical aggression were conducted to ensure appropriate continuation; - Ensure appropriate assistance devices were provided; - Initiate appropriate monitoring for suicidal ideations; - Initiate behavior monitoring related to pertinent [DIAGNOSES REDACTED]. - Identify, communicate and arrange for discharge to a facility that would be able to meet the resident's unique psychosocial needs; and - Appropriately communicate and provide timely updates on resident's health status to interested family members/responsible party. The social service department's failure to provide medically related social services contributed to a significant decline in the resident's psychosocial well-being, as evidenced by increased signs and symptoms of depression and care refusals which contributed to self-isolation, escalation of aggressive behaviors and verbalizing suicidal ideations. Cross reference to F272 (Resident Assessment). The facility failed to conduct initially a comprehensive, accurate, standardized reproducible assessment of resident's functional capacity and health status. Cross reference to F285 (PASRR Requirements) The facilityfailed to ensure a PASRR Level II screen was completed immediately after the resident's mental illness [DIAGNOSES REDACTED]. Cross reference to F319 (Mental and Psychosocial Functioning). The facility failed to adequately communicate the resident's increased signs and symptoms of depression to his health care providers, and family members; identify approaches to assist facility staff in meeting the resident's needs; timely seek supports for the resident inside and outside the facility; and address resident's decline in mental and psychosocial functioning resulting in care refusals which contributed to self-isolation. The findings include: Resident #4, under age 55, was admitted on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Resident's record review was initiated on 11/29/16 at 4:00 p.m. The medical records did not include the resident's comprehensive, admission, minimum data set (MDS) assessment. 1. Staff Interview On 11/29/16 at 5:15 p.m. the Director of Nursing (DON) was interviewed. She confirmed the resident's admission assessment was not completed and was past due three months. She said due to recent staff turn over, the facility was unable to complete MDS assessments on time because the nurses had to provide resident care and pass medications. 2. Resident interview and observations: On 11/29/16 at 9:30 a.m. the resident was observed in bed, in his room, undressed, with only an incontinence brief on. His eyes were closed. After a greeting and introduction, the resident was asked how long he had been in the facility and how he was treated by staff. He immediately started shouting he had been in the facility too long and he hated here. The resident became more agitated and angry when asked if he was planning on getting out of bed and yelled he will never get on his wheelchair and he hated it, then he turned himself towards the wall. On 11/30/16 at 8:30 a.m. the resident was observed in bed, in his room, undressed. His sheets were observed wet around his waist. Two certified nurses' aides (CNAs) who were walking by the resident's room were asked to check if the resident needed help with incontinence care. As soon as they asked the resident if he needed to be changed he started yelling, cussing and told the CNAs to get out of his room. On 12/1/16 at 2:30 p.m. the resident was observed in his room, in bed. His mother was present. The resident was asked by his mother if he would like to take a shower today and he responded yes, this minute. He was asked to turn his call light on and he did push the button. Within one minute a nurse and three CNAs came to the room. The resident started raising his voice, cursing and told everyone in the room to get out. He refused to get out of bed and take a shower. 3. Family interview a. On 11/29/16 at 3:00 p.m. and on 12/1/16 at 2:20 p.m. the resident's mother/power of attorney (POA) was interviewed. She said she regularly visited her son in the facility and was involved with his care. -She said the family had requested assistance at care conferences with locating a facility that was more suitable for her son. She stated he did not like being here in an old folks' home since his admission and wanted to be around younger people or go back home. She said the resident experienced a decline in mood during his time at the facility. She said she was concerned he was withdrawn and depressed and she had talked with facility staff about getting the resident a psychiatric evaluation, but she did not know if that had occurred. She said the family had brought the concerns about the resident's declining mental status to the nursing staff but did not feel the concerns were addressed. -She said the resident was odorous and unkempt and when she brought her concern about the resident's condition to staff, they told her the resident refused bathing and other cares. She said staff had not made her aware of the resident's refusals. She said the resident's room was not cleaned. -She said her son was complaining of double vision since admission to the facility. She said she was asking the social worker for help. She said when she learned the optometrist will be in the facility and should see her son for his vision evaluation on 11/9/16, she was waiting in the resident's room for several hours until 2:30 p.m. when she learned from a nursing staff that the optometrist had left the facility. She said her son had not been getting out of bed for several weeks now, had screamed and yelled at her and other family members and was very angry and aggressive. b. On 11/29/16 at 5:30 p.m. resident's significant other and his primary POA was interviewed. She said she knew the resident well and had lived with him for the past ten years. She said she came to the facility and spent time with the resident every evening after work and on the weekends. -She said the resident no longer carried on conversations and had declined in mood to the point of giving one word answers if a response was offered and then turned towards the wall. She said he was very aggressive, yelling at her, other family members and staff. -She said she was asking for psychiatric care services to help restore the resident's mental state back to the previous baseline. She said she now viewed the resident's care refusals and withdrawal as a kind of cry for help. -She said he was able to feed himself with very little help; however, he required a scoop plate with a guard and built up utensils and the facility was not providing it. She said each time she came to his room he would yell how much he hated being here and wanted to go home. She said the resident told her he would like to kill himself. She said she reported this to one of the nurses; however she never heard anything back. (see below; nurse practitioner (NP) note dated 11/29/16) 4. Record review Record review confirmed the family members reported the resident had difficulty adjusting to the facility and began to exhibit increasing signs and symptoms of depression as evidenced by self-neglect (care refusals contributing to self-harm). Record review also confirmed the facility failed to adequately communicate the resident's increasing signs and symptoms of depression to his health care providers and interested family members, failed to identify approaches to assist facility staff in meeting the resident's needs, and failed to timely seek supports for the resident inside and outside the facility. Review of the resident's facility record revealed in pertinent part: a. Physician's Telephone Order On 9/2/16 Physician's Telephone Order documented in part, Psych consult for depression. b. Nurses' Notes A 8/31/16 nursing note documented: Family here and had several concerns that we discussed. Worried that (resident) did not get a bath, discussed with staff and pt (patient) had refused. Pt was bathed today while family was here. Also requested to SS (social service) that family needed a care conference. And therapy has completed an eval(uation) on Pt. Pt linen changed and pt shaved. Reassured family that he is getting his BP (blood pressure) medicine and water flushes scheduled and is now getting a scheduled supplement. A 9/7/16 nursing note documented: Family here with behavior concerns. This nurse requested Psych eval and Depression meds and MD (physician) never received call back last week. (physician) in building and family spoke with her. Pt had shower today and later yelling at staff, hit therapy staff and refusing therapy and did not want to sit up in chair. A 9/16/16 nursing note documented: resident was in dining room for lunch when he became very agitated began to yell out and then started throwing cups, plate, silverware, staff was able to intervene and removed resident from the dining room without further incidents. An 11/9/16 nursing note documented: Refusing care and yelling at staff. Refused meds and breakfast and lunch. Able to give nutritional drink in AM (morning) but refused in Afternoon. Would not let me wash his face, especially L (left) eye. Thinking he needs to go to work. (family) here and she states he is hallucinating; I did not observe this. The nurse did not document communication with the physician or social services for assistance on any of the above occasions. c. Social Services' Notes On 9/13/16, the social worker (SW) documented: Late entry for 9/2/16. Care conf(erence) held on 9/2/16. SW, Director of Nurses (DON), Rehab Director, res(ident) (family) attended. Res invited but did not attend. Discussed concerns and noted through concerns process. Requested f/u (follow-up) care conf. Discussed expectations for res. Res currently LTC (long term care) with desire to go home after reaching goals. SW referred res to CCT (counseling) program. Discussed approaches that are best for res, calm, slow and explaining each step before taking the step helps keep res from hitting and yelling. Will monitor and provide support as needed. On 9/26/16, the SW documented: SW completed assessments with res. Res scored a 21 on the SLUMS (St. Louis Univerity Menal Status) assessment indicating mild neurocognitive disorder per the assessment scale. Res scored a 04 on the PHQ-9 (Patient Health Questionnaire) assessment indicating mild s/s (signs and symptoms) of depression per the assessment scale. Res scored a 06 on the geriatric depression scale indicating a score suggestive of depression per the assessment scale. Res has been referred to (provider name) for counseling and has been seen by them. Res scored a 12 on the BIMS (brief interview for mental status) assessment indicating moderate cognitive impairment per the assessment scale. Res(ident's) (family member) was present during interviews. Res calm and cooperative during assessments. Nurse checked on res during interviews. No concerns at this time. Care conf to be held this afternoon. Will monitor and provide support as needed. On 9/27/16, the SW documented: Care conf held on 9/26/16. Res(ident), res(ident's) (family), SSD (social service director), SSA (social service assistant), DON, PT (physical therapist) attended. Noted res prefers meds crushed in med pass rather than applesauce. Res also likes meds in ice cream. Noted res prefers therapy either prior to lunch or after lunch. Res understands the need to participate in therapy and is willing to try working with speech therapy again as he dislikes the puree texture. Res prefers calm slow approaches explaining actions prior to taking them. Noted dietary concerns, dietary manager notified. Noted, POA prefers communication to be through second POA and (family member) due to busy schedule. Will monitor and provide support as needed. On 9/27/16, the SW note documented: SW called to assist as res is being combative. SW approached res with nurse and res became upset with nurse presence. Allowed assistance off floor and continued to refuse medications, food, liquids or help putting on clothes. Res stated 'I want nothing from this place' repeatedly. Res states he wants to be 'anywhere but here.' SW left res quiet and laying down. SW spoke with res (family member) in regards to possible transfer per res request, (family) stated OK to try. Will monitor and provide support as needed. On 10/11/16, the SW note documented: SW f/u (follow up) with therapy regarding scoop plate and utensils and they stated they provided the plates to the kitchen. Kitchen states they were never given proper dishware. SW unable to locate proper dishware in kitchen. Communicated to therapy. Communicated to therapy res would like to see ST when available. Will monitor and provide support as needed. On 10/17/16, the SS note documented: SW met with res and ST (Speech Therapist). ST was attempting to deescalate a situation that the res stated to CNA (certified nurse aide) new to his case that his diet had been upgraded from puree. Res diet has not been upgraded by ST. SW and ST explained to res that he must complete swallowing exercises outside of meal times and be willing to participate rather than only call ST names. Res proceeded to call ST (expletive) and stated ST does not want to work with him. ST and SW explained ST does want to work with him but is unable to waste therapy time on continuous behavioral outbursts to avoid the work. SW acknowledged res frustration but reminded res of his request to meet with ST and attempt to make progress. Res willing to calm down to eat breakfast but was still cursing under his breath. RCS (CNA) assisted with breakfast and after res ate a few bites he calmed down. Will monitor and provide support as needed. On 10/19/16 SS note documented: SW spoke with res (family/POA) and provided updates regarding optometry visits, built up dishware, and res behaviors towards staff specifically therapy. Res (family/POA) stated she understood the res participation is crucial and how his behaviors have interfered with proper therapy progress that family and res expect. SW worked with res earlier in the week and informed res (family/POA) of this conversation. Res (family/POA) stated she was pleased that therapy and SW were attempting and understands the limits res is placing on his progress. Will monitor and provide support as needed. d. Behavioral and Psychological Consultation Notes The Behavioral Consultation Evaluation was completed on 9/20/16 and documented the resident hated here, was quick to get irritable, would cuss at the therapist, and yell out. The plan was for the therapist to return in one week or earlier if needed. On 9/28/16 the Psychological Consultation Progress Note documented, read in part: He rarely or never participates in regularly scheduled activities. There have been no outbursts or expressions of anger. Impulsive behaviors are not reported . The plan was to return in one week, or earlier if needed. -The therapist was not appropriately communicated/informed by the facility staff/social worker(s) about resident's aggressive behaviors documented above. On 10/25/16 the Psychological Consultation Progress note revealed the therapist spoke with resident's mother who said that he continued to be angry towards family members. The plan was to return in one week, or earlier if needed. -However, according to the resident's record, the therapist did not return to the facility for four weeks, from 9/28/16 until 10/25/16. According to the following progress note dated 11/8/16, the therapist returned two weeks later and documented the resident's participation was rare or nonexistent. His impulsive behaviors were occurring, but less frequently, and some anger had been displayed. The therapeutic focus of the session was on reducing symptoms. He was sad looking, minimally communicative, casually groomed and anxious. The plan was to return in one week, or earlier if needed. -The therapist did not acknowledge the [DIAGNOSES REDACTED]. On 11/17/16 the Psychological Progress Note documented the resident continued to have a hard time, was resistant to the therapist and easily irritable when asked certain questions. Plan included return in one week, or earlier if needed. There were no other psychological progress notes in the resident's record. The records did not contain any social service notes related to resident's care, his behaviors, follow-up on optometrist's appointment, updated discharge planning, psychiatric evaluation, missed psychological consultation visits or assistive devices for eating, since 10/19/16. e. Rehabilitation Note On 10/12/16, a Rehab Note read: Rehab Manager was notified by SW and DON that no scoop plates were available to the kitchen staff when plating resident's meals. Rehab Manager placed order for requested scoop plates on this day and will deliver to kitchen staff upon arrival. f. Physician and Physician's Assistant (PA) Notes Review of the Physician's and Physician's Assistant (PA) notes revealed: -10/5/16, the physician documented the resident was very depressed, however the family requested medication change from the antidepressant Remeron to an anticonvulsant medication Depakote for the bipolar diagnosis. -10/6/16, the PA documented the resident continued to swear at staff and family, and she discussed with his family and social services transfer to another facility. -10/18/16, the PA documented the resident was very combative and angry, did not participate in therapy and fired every staff member. -11/1/16, the PA documented, Continue to have angry outbursts, combative .He is placing himself at risk for failure and comorbidities. The PA documented she prescribed an antipsychotic Abilify, however (insurance) won't cover it despite being a good choice for this patient. -11/29/16, the PA documented, patient will not cooperate with my exam and cussed me out .his mood is consistently poor and inappropriate behaviors are consistent .he made comments about wanting to be dead for several months . f. Medication Administration Record Review of the medication administration records (MARs) and treatment administration records (TARs) revealed the resident was administered the following psychoactive medications: September (2016): -Remeron (antdepressant) tablet 30 mg, via [DEVICE] at bedtime for depression (9/3/16-9/15/16) -Remeron tablet 15 mg, give one tablet by mouth, one time a day for depression for five days (9/16/16-9/20/16) -Depakene Syrup (Valproate Sodium) (antimanic), give 250 mg via [DEVICE] two times a day for bipolar mood disorder (9/23/16-9/30/16) The resident did not receive any medication to manage his behaviors for two days (9/21/16 and 9/22/16) October (2016): -Depakene Syrup, 250 mg via [DEVICE], two times a day (10/1/16-10/6/16) -Depakene Syrup, 500 mg via [DEVICE], two times a day (10/6/16-10/31/16) -Abilify (antipsychotic), 15 mg, one tablet by mouth in the morning for bipolar disorder (10/19/16-10/31/16) -Ativan (anxiolytic), 0.5 mg via PE[DEVICE] every 12 hours as needed (PRN) for anxiety (10/10/16, 10/11/16 and 10/17/16) November (2016): -Abilify 15 mg, every morning (11/1/16-11/8/16) -Depakene Syrup 500 mg, two times a day (11/1/16-11/8/16) -Depakene Syrup 250 mg/5ml, give 5 ml via [DEVICE] one time a day for bipolar disorder (11/9/16-11/30/16) -Zyprexa (antipsychotic) 5 mg by mouth at bedtime for bipolar disorder (11/8/16-11/9/16) -Zyprexa 2.5 mg, one tablet by mouth at bed time for bipolar disorder (11/10/16-11/29/16) According to the most recent Mosby's Nursing Drug Reference, all of the above medications had been associated with increased risk of suicidal thinking and behavior. Review of the MARs and TARs for the above period revealed no documentation the above medications were monitored for side effects, target behaviors, and effectiveness. g. Care Planning Resident's comprehensive plan of care was reviewed on 12/1/16 and included: - History of refusing meals (initiated 8/29/16). Interventions included: re-approach at another time if meal is refused, and offer snacks periodically. - Nutritional risk (initiated 8/30/16). Interventions included (in part): encourage family members to bring in specialty food items as desired, encourage juice and milk with meals for added calories, adaptive equipment, scoop plate, built op utensils. - Activities (initiated 9/6/16) and documented the resident enjoys listening to country music and likes to color and draw with pencils adult coloring books. - No plans for discharge (initiated 9/20/16). Not revised after family requested more appropriate placement. -Physical aggression (initiated 8/29/16). Interventions did not include psychiatric evaluation or communication with social services. - ADL self-care performance deficit (initiated 11/29/16) - Resistive to care (initiated 11/29/16). Intervention did not include social service and resident's family assistance. -Potential impairment to skin integrity related to incontinence (initiated 11/29/16). Interventions did not include resident's encouragement to get out of bed. 5. Staff interviews On 11/30/16 at 12:30 p.m. CNA #3 was interviewed. She said she frequently assisted the resident with eating. He didn't like his pureed food and ate only a few bites. She said he likes to drink two glasses of thickened milk. She said he frequently pushed the food tray away and started yelling at her to get out. She said he liked to eat peanut butter, yogurt and ice cream for snacks. The CNA said she was not trained on how to approach an aggressive resident. She said the best way was to leave him alone. She said she did not know she should report the resident's aggressive behaviors to the social worker and ask for help. On 11/30/16 at 1:42 p.m. the resident's physician was interviewed. She said she was most certain the resident should be evaluated by a psychiatrist; as a matter fact he should be placed in a psychiatric hospital for appropriate treatment. She said she tried to use different medications to help the resident with depression and behaviors, however the resident's family requested medications change. She said the resident will not be able to make any functional progress by lying in bed all the time. On 11/30/16 at 4:30 p.m. the therapy manager (PT) was interviewed. She said she did order requested plates and plate guards for the resident immediately when the need was reported to her. She said the assistance devices came to the facility and were given to the dietary staff approximately a month ago. She said the resident was evaluated by Physical, Occupational and Speech therapists. She said the resident was on the caseload for all three disciplines for approximately a month and half. In that time, he was treated outside of his room, in therapy gym, twice. She said most of the treatment time was education and to encourage participation. She said she tried different staff approaches, and the resident fired all of them. The nursing home administrator (NHA) was interviewed on 11/30/16 at 5:58 p.m. He said the facility recently went through significant staff turnover (approximately 50%) including the DON, social services and many nursing positions. He said he had been with the facility since August (2016). He said he did not identify the need to convene an interdisciplinary team to address resident's care refusals, need for psychiatric evaluation or more suitable facility choice. He said to the best of his knowledge, the social workers were communicating with the resident's family about all of his needs. He said the resident care conference with his family was scheduled on 12/1/16 to address the resident's care needs and to create more appropriate communication system. The Social Services Director (SSD) was interviewed on 12/1/16 at 5:18 p.m. She said she had been employed at the facility for one month. She said she was still learning the residents and their needs. She said her assistant was also new to the facility. -She said she did not know the resident needed psychiatric evaluation (see physician interview above). She said the resident's family was asking for different placement and said she called a couple facilities; however, they were not admitting new residents. -She said she did not communicate with the person who provided the psychological counsel with the resident and did not know the planned visits for resident's behaviors were not provided timely. -She said she scheduled the resident's eyes evaluation; however, she was out of the facility that day and did not know the resident was not seen by the optometrist. -She said the staff did not inform her of resident's refusals of care and increased aggressive behaviors. She said she did not know the resident was mentioning suicidal ideations to the POA and the PA and therefore, was not monitoring the resident for this.

Based on observations, record review, and staff interviews, the facility failed to ensure three (#1, #6, #5) of four out of ten sampled residents received the care and services necessary to prevent the development of pressure ulcers and to promote healing of pressure ulcers. Resident #1, assessed to be at moderate risk for skin breakdown, developed coccyx wounds with an abscess within two weeks of admission. Upon readmission following wound debridement, the resident developed additional stage III and stage IV wounds. There was insufficient evidence the facility identified and planned interventions to reduce the resident's risk for additional skin breakdown or consistently implemented treatment orders. Resident #6 developed three areas of skin breakdown after readmission; two areas developed into stage III and IV wounds. The resident's care plan was not resident-specific and treatment orders were not consistently implemented. Resident #5's preventive measures were not consistently implemented to promote healing of his heel ulcer. The findings included: A copy of the facility's policy and procedure on Skin Management, with revision date of 8/2012 was provided by the director of nursing (DON) on 11/29/16 at 4:45 p.m. The policy read, in part: -Appropriate preventive surfaces of beds, wheelchairs and so on, will be implemented on all residents identified at risk for pressure ulcer development. -A care plan would be developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan is to be updated to reflect the new problem and interventions with evaluation and revision documented on an ongoing basis. 1. Resident #1 Resident #1, age 56, was initially admitted on [DATE] for continued rehab per a physician note dated 7/25/16. She was transferred to the hospital on [DATE] and re-admitted [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. On 9/14/16, the resident was transferred to the hospital emergency room . The 7/1/16 minimum data set (MDS) assessment revealed the resident had no memory problems with a brief interview for mental status (BIMS) score of 15 out of 15. She required maximum assistance with transfers, bed mobility, and personal hygiene. Resident #1 was at risk for developing pressure injurys but did not have any pressure injury stage I or above on admission and no other skin issues. Resident #1 was incontinent of bowel and bladder. She was not enrolled in the bowel or toileting program. a. Resident Skin Condition 7/1/16 to 7/25/16 Record review: Record review revealed the resident entered the facility 7/1/16 without a pressure ulcer but as of 7/14/16, the resident had developed wounds and an abscess on her coccyx that required debridement. (1) Facility skin assessments and nurses' notes -Skin assessments and nurses' progress notes revealed a Braden Scale assessment was completed on admission which identified the resident was at moderate risk for pressure sore. See also the 7/1/16 MDS above. -A 7/2/16 nurses' note read the resident's skin was warm and dry. The 7/2/16 initial nursing plan of care on admission did not identify skin issues and the 7/2/16 nursing daily skilled charting section for skin was blank. -A note on 7/17/16 read, pressure injury to coccyx stage II and another note on 7/25/16 documented an open area to coccyx. (2) Review of wound clinic notes -A note on 7/14/16 read, wound #1 on coccyx, extremely large abscess cavity with loads of purulent discharge. Physician recommended evaluation by general surgeon for clean out and dry protective dressing to be changed twice a day and as needed. Wound #2 on right buttock does not appear to be pressure . patient mentioned she also might have scratched the area. Dry protective dressing was recommended to be changed once a day and as needed. -A note on 7/18/16 read, wound #1 on coccyx no changes. Wound #2 on right buttock improved. Same treatment was ordered to be continued for both wounds. -A note on 7/25/16 read the resident did not come to the appointment due to hospitalization for wound debridement. Resident returned to the facility 7/25/16 with wound VAC (vacuum) on the coccyx. (3) A physician note dated 7/25/16 confirmed the resident was sent to the hospital on [DATE] because she developed a wound and abscess on her coccyx. After the removal of the abscess, the resident was readmitted on [DATE] with the wound VAC on her coccyx. A skin assessment on the physician's note read, .abscess over coccyx, . now has a wound vac on it, I did not examine. Interview: In an interview with resident #1's family member on 11/30/16 at 2:14 p.m., the family member said the hospital treating physician reported to her that the resident's abscess was filled with fecal material. b. Resident status 7/26 - 9/14/16 Wound clinic notes and facility skin assessments revealed that the resident's coccyx wounds resolved as of 8/29/16; however, record review revealed documentation of multiple additional pressure wounds after her readmission. (1) Skin assessments and nurses' notes -A note on 7/29/16 abscess, osteo[DIAGNOSES REDACTED] to coccyx, stage IV. Resident had surgery to remove abscess, wound VAC in place; -A note on 8/25/16 resident continues with wound VAC to sacrum . -A note on 8/26/16 labia pressure injury, stage II -A note on 8/29/16 labia pressure injury, unstageable -A note on 9/2/16 coccyx, pressure injury stage II -A note on 9/6/16 labia, pressure injury, stage IV -A note on 9/12/16 left thigh, pressure injury, stage III -A note on 9/13/16 existing other issues, sacral wound-scattered areas to abdomen and legs/thighs. (2) Wound clinic notes also documented the development of additional wounds. -A note on 8/29/16 read, wound #1 on coccyx and right buttock resolved. Wound #3 on vaginal labia unstageable, more than 5 days old, from catheter. Physician recommended dry protective dressing twice daily and as needed. Wound # 4 on left medial thigh, unstageable. Dressing to be changed every three days and as needed. Dry protective dressing once a day and as needed. -A note on 9/6/16 Wound #3 on vaginal labia deteriorated. Wound # 4 on left medial thigh no change. -A note on 9/12/16 Wound #3 on vaginal labia improved. Wound # 4 on left medial thigh no change. c. Resident Status on 9/14/16 Record review revealed the resident was transferred to the hospital emergency roiagnom on [DATE]. The resident's hospital admission record dated 9/14/16 revealed that resident was picked up by emergency medical services (EMS) from the facility for routine MRI (magnetic resonance imaging) visit. However, the resident was found lying down in her own feces with wound VAC non-adherent to her wound, bed sores, and scissors under the resident's back. Her Foley catheter was obstructed, not draining with visible sediment build up. Skin assessment revealed stage I and II pressure ulcers to the lumbar spine. Due to her condition, the resident was transported to the hospital emergency room . d. Facility failures Family Interview: In an interview with resident #1's family member on 11/30/16 at 2:14 p.m., the family member said that when she would come for a visit, resident #1 would complain to her that she was not turned, cleaned and bathed. On one occasion, resident #1 reported to the family member that she had to wait two hours for change of shift; the certified nurse aide (CNA) on duty declined to provide her incontinence care so she had to wait for change of shift when another CNA was available to provide her care. Record review: (1) Care plan - neither comprehensive nor resident-specific The resident's comprehensive care plan initiated 7/8/16, and revised on 8/2/16 and 9/16/16 (after the resident's discharge from the facility on 9/14/16), revealed no notes regarding the resident's wound VAC, existing pressure injury to the coccyx or other locations, use of indwelling urinary catheter, or the resident's response to the care. There was no evidence staff was directed to turn and reposition the resident even though she required maximum assistance with bed mobility. Moreover, despite wounds on her coccyx, there was no resident-specific toileting plan for resident #1 and no interventions to ensure pressure relief from her catheter. (2) Treatment record - treatments not consistently completed According to treatment administration record (TAR) for 7/16, the resident's dressing on wound #1 (coccyx) was not changed 7/16 and 7/17. Dressing for wound #2 (right buttock) was not changed on 7/16. According to the TAR for 8/16, resident's dressing on wound #3 (vaginal labia) was not changed 8/31. The wound VAC was not checked for functioning on 14 occasions. According to the TAR for 9/16, resident's dressing on wound #3 (vaginal labia) was not changed on 11 occasions, and dressing on wound #4 (left medial thigh) was not changed on two occasions. The wound VAC dressing was not changed 9/6 and 9/10/16. According to the nurses' progress notes between 7/16 and 9/16, the resident refused care on multiple occasions. However, the resident had no care plan that identified care refusals and therefore no interventions on how staff was to address them. Moreover, on the above dates, the TARs were left unsigned by the nurse with no comments documenting whether the treatment was refused by resident or not provided by staff. Staff Interviews: The director of physical therapy was interviewed on 11/30/16 at 6:15 p.m. She stated she did not work with resident #1 as a physical therapist, but she attended several rounds of wound therapy for this resident. During those wounds rounds, resident #1 was pleasant and cooperative with care. The assistant director of nursing (ADON) was interviewed on 11/30/16 at 6:15 p.m. She stated that during the resident's stay, she was participating in wound rounds in the facility; however, she said she did not recall resident #1 and did not remember providing wound treatment to this resident. She said wound rounds were done by physical therapy director, physician and sometimes staff nurses that were working on the floor. Staff that had routinely cared for the resident prior to her discharge were not available for interview during the onsite visit. 2. Resident #6 Resident # 6, age 77, was admitted on [DATE] and re-admitted [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The resident's MDS on readmission 8/10/16 was not complete; the skin section was blank. According to the 10/12/16 MDS, the resident had no cognitive impairment; a brief interview for mental status (BIMS) was not conducted. Resident #6 required extensive assistance with bed mobility and dressing, and she required maximum assistance for toilet use and personal hygiene. a. Skin breakdown Record review: Skin assessment revealed no initial Braden skin assessment was located upon request -A note 8/29/16 read, right heel unstageable pressure injury 2.5-3.2 cm -A note 9/6/16 read, coccyx unstageable pressure injury 2.6-7.6 cm -A note 9/12/16 read, left buttock, pressure injury, stage III 2.7-1.7 cm -A note 9/21/16 read, right heel pressure injury, stage IV 0.9-1.9 cm -A note 10/18/16 read, right ankle pressure injury, stage II 2.4-3.3 cm -A note 10/27/16 read, left buttock, pressure injury, stage III 1.4-1.5-0.6 cm -A note 11/9/16 read, right ankle, pressure injury, stage II 1.1-1.4 cm According to the wound clinic assessments, resident acquired three pressure injuries: -Right heel wound assessed on 9/6/16 was more than 11 days old, was rated as unstageable pressure injury and progressed to stage IV by 9/12/16. The last assessment was done 11/14/16 with some improvement. -Coccyx/left buttock wound was assessed on 9/6/16 was more than 4 days old at the time of assessment, and was rated as unstageable. During the course of treatment, wound progressed to stage III, with last assessment on 11/14/16. -Right ankle wound was assessed on 10/10/16 was more than three days old at the time of assessment, and was rated as stage II. During the course of treatment wound remained stage II, until it resolved on 10/21 and re-opened as stage II on 11/7. b. Observations On 11/29/16 at 11:06 wound dressing change was observed. Resident #6's dressing on left buttock was changed by Licensed Practical Nurse (LPN) #1 and LPN #2. The wound was clean, no drainage no signs of inflammation or infection, pink healthy surrounding tissue. Wound was not measured during dressing change; LPN #1 stated the wound was measured every Monday by wound care team (physician, assistant director of nursing and physical therapy director). c. Facility failures Record review: (1) The resident's care plan, initiated 7/8/16 and revised 9/29/16, revealed resident #6 had pressure injury to her left buttock, venous -rt medial ankle and rt heel r/t (related to) immobility. Interventions included to follow facility protocols for the prevention of skin breakdown. administer treatment and complete full body checks weekly. Care plan was not resident-specific; it did not address resident's immobility and the resident's need for extensive staff assistance with bed mobility. (2) Delay in implementing pressure relief measures According to physician orders, an air mattress was ordered on [DATE], nine days after resident was diagnosed with [REDACTED]. (3) Inconsistent implementation of treatment orders According to treatment administration record (TAR) for 9/16, the physician order [REDACTED]. The dressing was not changed between 9/12 and 9/17, on 9/20, and 9/27/16. According to the TAR for 10/16, the physician order [REDACTED]. The dressing was not changed on 10/5, 10/9, and 10/15/16. According to the TAR for 11/16, the physician order [REDACTED]. The dressing was not changed on 11/7, 11/9, 11/10, 11/12, 11/14, 11/16 and 11/17/16. Staff interviews: The DON was interviewed on 11/30/16 at 5:30 p.m. she stated the expectation from every nurse on the unit was to complete a skin assessment, and Braden assessment on admission for every newly admitted resident. She stated she was aware that facility was behind on its care plans review and provided a QAPI (quality assurance) record indicating that issue have been recognized. She stated she was able to update care plans for the most recent admissions since she started working in the facility; however not all care plans were up to date. 3. Resident #5 Resident #5, age 76, was admitted to the facility on [DATE]. According to the November 2016 computerized physician orders [REDACTED]. There was no minimum data set assessment for the resident (cross reference F272). However, the activity of daily living tracking from 10/27/16 to 11/30/16 indicated the resident usually required extensive assistance of one staff member or was totally dependent on one staff member for bed mobility. a. Record Review Weekly pressure ulcer log: According to a weekly pressure ulcer log dated 10/31/16, the resident was admitted with a stage II pressure injury to his right heel. The log did not include measurements or a description of the wound. According to a weekly pressure ulcer log dated 11/7/16, the resident continued to have a stage II pressure injury to his right heel. The log indicated the wound had not been measured that week. According to a weekly pressure ulcer log dated 11/14/16, the resident continued to have a stage II pressure injury to his right heel. The log indicated the wound measured 1.2 cm x 1.4 cm. According to a weekly pressure ulcer log dated 11/21/16, the resident continued to have a stage II pressure injury to his right heel. The log indicated the wound measured 0.9 cm x 1.4 cm. According to a weekly pressure ulcer log dated 11/28/16, the resident continued to have a stage II pressure injury to his right heel. The log indicated the wound measured 1.0 cm x 1.4 cm. b. Physician orders According to computerized physician orders [REDACTED]. According to another CPO dated 11/4/16, the resident was to be given a Posey boot, (a soft cushioned boot designed to provide pressure relief) which was to be checked every shift. c. Observations The resident was observed on 11/30/16 beginning at 11:19 a.m. He was sitting in a wheelchair. He was wearing black socks. He was not wearing a Posey boot. A continuous observation was initiated. -At 11:22 a.m., certified nurse aide (CNA) #7 entered the resident's room. The resident requested to be taken down to the dining room for lunch. The CNA did not offer the resident his Posey boot before wheeling him down to the dining room. -At 11:27 p.m., the resident was sitting in the dining room in his wheelchair. The resident was wearing black socks and no shoes. He was not wearing his Posey boot. -The resident remained in the dining room until 12:47 p.m. when he was taken outside to smoke. He returned from smoking at 1:02 p.m. and was taken back to his room by CNA #7. -At 1:10 p.m., the resident was laid on his air mattress. His heels were not floated. The resident was observed a second time on 11/30/16 at 3:29 p.m. His heels were resting directly on his mattress. 2. Interview The resident was interviewed on 11/30/16 at 3:29 p.m. He said he had a sore on his right heel which was painful. He confirmed the Posey boot sitting in his room was his. He said he did not particularly like wearing it, but said he understood it was supposed to help heal the wound on his foot so he did wear it. However, he said the staff frequently did not ask him to put the boot on, and he was unable to do so himself because he was paralyzed (which he clarified to mean that he had limited range of motion in his arms). The DON was interviewed on 11/30/16 at approximately 6:00 p.m. She confirmed the resident had a pressure ulcer on his heel and said because the Posey boot was ordered to relieve pressure on his heel, the aides were supposed to put the boot on the right foot.

Based on record review and interview, the facility failed to ensure one of 37 sample resident's (#78) change in condition was comprehensively assessed and timely addressed. Specifically: Resident #78 was discovered unresponsive on [DATE] at 11:00 p.m. with periods of apnea. Although the nursing supervisor was notified, the resident was not comprehensively assessed at this time and the physician was not notified of the resident's loss of consciousness until the next morning at 5:30 a.m. Moreover, laboratory studies ordered the afternoon on [DATE] were not completed until the next morning; laboratory results revealed a critical blood sugar level of 22. The facility did not address the resident's critically low blood sugar until three hours later. The findings include: 1. Resident #78, age 75, was admitted to the facility on [DATE] from the hospital. Closed record review revealed that according to the facility's History and Physical report dated [DATE], the resident's [DIAGNOSES REDACTED].) with [MEDICAL CONDITION], gout, and impaired glucose tolerance. The hospital's History and Physical report, dated [DATE], included the following documentation: "This is a ...female who has a history of approximately 1 week of altered mental status ...He (the resident's husband) also noted over the last week that she had tremor so bad that she was unable to hold a cup of water and associated myoclonic twitching ...probable dehydration just by history, possibly also due to gastrointestinal illness. For this reason, I will give IV (intravenous) fluids). Intermittent [MEDICAL CONDITION] ...It is quite possible this is aortic insufficiency. Other possibilities might include depletion ..." 2. Status on Admission The admission minimum data set (MDS) assessment, dated [DATE], indicated the resident had moderate cognitive impairment, with a BIMS (brief interview for mental status) score of 12 out of 15, and she required extensive assistance for all activities of daily living, except for wheelchair mobility and eating, for which she required supervision (oversight, encouragement, or cueing). According to physician orders, the resident was receiving the following medications for hypertension: [MEDICATION NAME] 50 mg twice a day (reduced [DATE] to 25 mg twice a day) and [MEDICATION NAME] 20 mg every day since [DATE]. According to the resident's computerized physician orders, the resident's resuscitation status was 'full code,' meaning the resident wished to be resuscitated in the event of cardiac or [MEDICAL CONDITION] arrest. 3. Decline in Status beginning [DATE] - Facility Response Resident #78's record included the following documentation regarding the resident's declining condition and the facility's response. -Nurse's note: [DATE] -1415 (2:15 p.m.) - "Res experiencing dozing off more often, lethargy, diaphoretic. FSBS (finger stick blood sugar) = 91. MD came in to facility @ 1400 - will assess and write new orders." -physician progress notes [REDACTED].This AM pt's BP (blood pressure) low and she is lethargic, clammy, she is arousable, talks to me but just drifts back to sleep ...Plan: 1) ...BP instability, unknown cause. Pt is on [MEDICATION NAME] 1 mg q HS for SDAT with [MEDICAL CONDITION] and [MEDICAL CONDITION] ...I will reduce ([MEDICATION NAME]) dose back to 0.5 mg, but pt is really anxious; 2) [MEDICAL CONDITIONS] we changed from [MEDICATION NAME] to Xarelto, finally started Xarelto on [DATE]; check CBC today; give pt IVF. Reduce [MEDICATION NAME] to 25 mg BID and increase [MEDICATION NAME] 0.1 mg to BID (twice daily) .. " -Nurse's note: [DATE] - 1900 (7:00 p.m.) - "Resident on bed throughout shift. Res cont to doze off and on throughout shift and diaphoretic. New orders are now in place." -Nurse's note: [DATE] - 2300 (11:00 p.m.) - "...BP ,[DATE]. Res unresponsive. Supervisor notified. Steady pulse..color pale. Skin dry, warm ...breathing, apnea intermittent periods. Labs pending, did call to change to stat. No mottling of extremities ..." -Nurse's note: [DATE] - 0130 - (1:30 a.m.) - "..XXX,[DATE]. Cont unresponsive. Non-labored breathing. Lung sounds diminished ..." -Nurse's note: [DATE] - 0300 (3:00 a.m.) - "...steady pulse 50. Cont unresponsive ..." -Nurse's note: [DATE] - 0530 (5:30 a.m.) - "Call Dr. PA (physician assistant) notified of UA (urinalysis) and condition. PA will report to Dr of UA & cond. No new orders at this time. Pending C & S (urine culture and sensitivity labs)." -Nurse's note: [DATE] - 0755 (7:55 a.m.) - "Spoke with SW (social worker) early this AM. Updated on current status and reminded that res cont to be a full cor." -Nurse's note: [DATE] - 1030 (10:30 a.m.) - "Called labs over to urgent line at MDs office and BMP and also reported critical low glucose = 22. Spoke with (MD's office point of contact), was instructed to fax labs over and no new orders at this time." -Nurse's note: [DATE] - 1430 (2:30 p.m.) - "...Res cont to be unresponsive with labored breathing. Was reported to this NS (nursing supervisor) to be awaiting pending labs. Cont to check res every ? hour to monitor breathing, responsiveness and IV infusion ...reported labs to urgent line after receiving ....RN supervisor administered [MEDICATION NAME] IM (intramuscular) inj. FS + 35. DON spoke with MDs office and received orders to send res out ..." Resident Transfer Form: [DATE] - (no time) - "Res unresponsive, blood glucose at 30 at 1050 am, IM [MEDICATION NAME] given; blood glucose at 134 at 11:15 a.m." Interdisciplinary Discharge Summary: [DATE] - "transfer to (hospital) eval/tx ...went to hospital - passed away there...res dc'd (discharged ) to hospital for unresponsiveness and low blood sugar ..." 4. Failures in Facility Response to Resident's Declining Status Record review revealed: -There was no documentation in the nurse's notes or elsewhere in the resident's record that the physician was notified the resident was unresponsive with periods of apnea at 11:00 p.m. on [DATE]. While nurses continued to document through the early morning that the resident 'continued unresponsive,' the physician's office was not notified of the resident's status until 5:30 a.m. on [DATE]. -There was no documentation in the nurse's notes or elsewhere in the resident's record that the resident's condition, including her unresponsiveness, was comprehensively assessed by facility staff prior to her discharge on [DATE] at 2:30 p.m.. Specifically, there was no documentation the resident was comprehensively assessed by the nurse supervisor on [DATE] at 11:00 p.m. when she was discovered unresponsive, even though this represented a change in her level of consciousness. Moreover, there was no assessment of the resident's blood sugar until 10:30 a.m., triggered by a lab report, not a nursing assessment. -There was no evidence in the nurse's notes or elsewhere in the record that facility staff attempted to facilitate the lab tests ordered the afternoon on [DATE] as the resident continued to decline. Staff interviews (see below) revealed the lab results were available on [DATE] at 8:10 a.m. 14 hours after being ordered. Although the lab reported a critical glucose level of 22, there was no evidence facility staff notified the physician of this result until 10:30 a.m. Moreover, the resident's low blood sugar was not addressed until 10:50 a.m., approximately three hours after the resident's low blood sugar was known. 5. Interviews On [DATE] at 1:00 p.m., the nurse who completed the resident transfer form for resident #78 was interviewed. The nurse explained that labs ordered on [DATE] were drawn on [DATE] at 5:34 p.m.. She stated, "The results got in at 8:10 a.m. and were then faxed to us. We got the results at 10:50 a.m." The nurse reported that the resident was still unresponsive at that time, and finger stick test done then that showed the resident's blood glucose level to be 30. The IM [MEDICATION NAME] was given and at 11:15 a.m., the resident's blood glucose level was 134. The resident was then sent out to the hospital. On [DATE] at 1:30 p.m., the director of nursing (DON) confirmed that resident #78 did not have her blood sugars checked at the facility after she was found to be unresponsive on [DATE] at 11:00 p.m. Labs were collected on [DATE] at 5:34 p.m., and faxed to the facility on [DATE] at 8:15 a.m. There were no interventions for the resident's [DIAGNOSES REDACTED] until 10:50 a.m. on [DATE]. -When asked about the facility protocol with regard to a resident being unresponsive, the DON stated, "We initiate oxygen. If there's no pulse, we start CPR (cardiopulmonary resuscitation) and call 911 (if full code). I'd check blood sugars to rule it out, but other nurses may not get blood sugars if (the resident) is not diabetic - it depends on the nurse ...I was concerned about (the amount of) her blood pressure medications." The DON could not provide evidence a thorough assessment was conducted by the nursing staff when resident #78 first became unresponsive on [DATE] at 11:00 p.m. -The DON verbalized that the facility's nursing practice standards were based on Lippincott Manual. The Lippincott Manual of Nursing Practice, 9th edition, page 490, reads in pertinent part: 'Nursing Management of the Patient with an Altered State of Consciousness': "Unconsciousness is a condition in which there is a depression of cerebral function ranging from stupor to coma ...Both arousal and awareness are assessed when using the Glasgow Coma Scale (GCS) as a measure of LOC (level of consciousness) ...An altered state of consciousness may be caused by many factors...Nursing Interventions: Minimizing Secondary [MEDICAL CONDITION]: Monitor for change in neurologic status, decreased LOC ...Monitor laboratory data ...and communicate findings to medical staff.... " The facility's Medical Emergency Management policy, dated [DATE], included the following protocols: "The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency...Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedures, and calls 911. The staff continues to provide care and monitor the resident until the emergency personnel arrive..."

Based on observations, record review, and staff interviews, the facility failed to provide two of 37 sample residents (#116 and #117) the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to provide service to prevent the decrease in range of motion for residents #116 and #117. This contributed to decline in resident #116's range of motion in his right hand. Findings include: 1. Resident #116 Resident #116, age 83, was admitted to the facility on [DATE], according to the resident face sheet dated 10/11/12. His admission [DIAGNOSES REDACTED]. According to the admission minimum data set ((MDS) dated [DATE], resident #116 had severe memory problems, and did not display any behaviors. The MDS indicated that the resident was sometimes understood by others, and he usually understood others. The MDS indicated that the resident required extensive assistance of one to two staff members with activities of daily living (ADLs). According to the physician history and physical dated 1/24/12, resident #116 was at risk for contractures related to [MEDICAL CONDITION] disease with [MEDICAL CONDITION] (stroke with weakness on one side of the body). a. Resident Functional Status on Admission -The nursing admission assessment dated [DATE], indicated that resident #116 did not have any extremity abnormalities on admission. -The admission Minimum Data Set (MDS), dated [DATE], revealed in Section G, "Functional Status," documented no functional impairment. b. Resident Functional after Admission - Decline - Facility Response - Failure in Response (1) Decline -A physician progress notes [REDACTED]. -The 12/6/11 MDS indicated that the resident had impairment to one side of his body, which included the upper and lower extremities. (2) Facility Response According to the rehab to restorative transition record dated 12/30/11, resident #116 was referred to restorative nursing by physical therapy with a goal focused on ambulation. According to the restorative nurse aide note dated 6/1/12, resident #116 was discharged from the restorative program on 5/31/12. According to the in-service report with an unknown date (date blank) and completed by the restorative aide, the resident care staff was educated to wash and dry the resident's right hand, provide range of motion (ROM), and apply a right hand splint. (3) Failure in Facility Response See above rehab to restorative transition record 12/30/11, referring the resident to restorative nursing; there was no reference to the resident's [DIAGNOSES REDACTED] in his right upper and lower limbs and range of motion needs. See restorative nurse aide note 6/1/12; the discharge from restorative, while referencing ROM and a right had splint, failed to include any direction to staff on the frequency of ROM and application of the splint. A review of resident #116's care plans failed to show that the facility identified and initiated a comprehensive plan of care addressing the resident's range of motion or risk for contractures. c. Further Decline in Resident Function (1) Decline According to the physician nurse practitioner progress note dated 9/25/12, the resident's right hand had a contracture. This is a change from the nurse practitioner progress noted dated 6/28/12, which indicated that the resident was only at risk for a contracture. An Occupational therapy evaluation completed on 11/12/12, indicated that the resident has had a decrease in his wrist flexion and extension abilities, as compared to the occupational therapy evaluation completed on 9/9/11. Occupational therapy orders written on 11/28/12, indicated that services were added to the resident's plan of care which included electronic stimulation (e-stem) to right upper extremity secondary to [MEDICAL CONDITION] (weakness to one side of the body), hand splint to right hand and contracture secondary to weakness. (2) Facility Failures Review of the nursing weekly/monthly summaries dated 10/4/12, 11/8/12, and 12/3/12 revealed the summaries failed to identify that resident #116 had a contracture. See care plan failures above; the facility identified and initiated a comprehensive plan of care addressing the resident's range of motion, risk for contractures, or splint use per occupational therapy orders 11/28/12. Observations revealed staff failed to ensure the resident's splint was applied. Specifically: -Resident #116 was observed on 12/11/12 at 12:37 p.m. to have a contracture to his right hand; the hand was flaccid and rotated to the right and internally. The resident had a blue splint on his dresser, in front of his television and not in use. -Resident #116 was observed again on 12/13/12 at 8:08 a.m., at 1:13 p.m., and at 3:40 p.m., sitting in his recliner watching television. The resident had a blue hand splint on his dresser, in front of his television and not in use. -Resident #116 was observed on 12/14/12 at 9:05 a.m., at 10:00 a.m., and at 4:20 p.m. sitting in his recliner watching television. The resident had a blue hand splint on his dresser in front of his television and not in use. -Resident #116 was observed on 12/18/12 at 4:20 p.m. sitting in his recliner in front of television. The resident's blue hand splint was on his dresser in front of his television and not in use. d. Family interview The resident's family was interviewed on 12/10/12 at 4:54 p.m. The resident's family stated they were the ones who noticed a decline in the resident's range of motion. The family stated that they requested therapy services to evaluate and treat their father (see above 11/12/12 occupational therapy evaluation). e. Staff interviews The certified nurse aide (CNA) was interviewed on 12/17/12 at 1:23 p.m. and acknowledged that the resident had a splint in his room. However, she stated she had not received any training on how to apply it to the resident. Another CNA was interviewed on 12/18/12 at 1:00 p.m. and acknowledged that she was not providing range of motion for resident #116. She also acknowledged that she was not trained on the resident's splint. The resident's nurse practitioner (NP) was interviewed on 12/17/12 at 6:30 p.m. She said she recalled talking with nursing regarding the resident's contracture and there was "supposedly" a splint in place. However; the NP was not sure at this time, if the splint was in use. The NP confirmed that therapy services were ordered per the family request. The director of nursing services (DON) was interviewed on 12/17/12 at 2:15 p.m. and stated the resident was discharged from the restorative program on 5/31/12, because he refused to wear his splint. The DON stated the resident care staff was responsible for providing range of motion and for application of the hand splint and had received education on both. However, the DON was unable to provide any documentation that showed staff had been providing range of motion and or splint applications since the resident's discharge from restorative nursing. The therapy manager was interviewed on 12/17/12 at 2:20 p.m. and stated that during a recent resident care conference, the family requested therapy services to evaluate the resident's right hand contracture. 2. Resident #117 Resident #117 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment, dated 11/17/12, indicated the resident had moderate cognitive impairment, with a BIMS (brief interview for mental status) score of 10 out of 15. The resident required extensive assistance for all activities of daily living, except for wheelchair mobility and eating, for which he required supervision. The assessment further indicated the resident had both upper and lower limitations in range of motion (ROM). Observations: On 12/17/12 at 3:15 p.m., resident #117 was observed resting on his bed. His left arm and hand were flaccid. His left hand was curled. When asked if he was able to open his hand, he showed that he could open up his fingers with his other hand. He stated, "It's a little harder to open my thumb." He showed he was also able to extend his left thumb. The resident was then asked if he ever wore a splint on his arm and hand. The resident responded, "I had one when I first came in, but I haven't had one for a while." He did not know where the splint was. "Maybe it's in the therapy room." The resident explained that he needed assistance putting on the splint, and that he would like to have a splint put on every day. The resident further shared that his left leg was also contracted, and that his leg splint was put on once a week when a staff member assisted him with using a walker. He stated the leg splint was helpful during his weekly walk. The leg splint was observed in his drawer. Record Review: The resident's record included a Nursing Admission Assessment, dated 1/11/11, that indicated the resident had left-sided paralysis, and noted, "L side of body resident unable to move." The record did not contain a plan of care addressing the resident's left-sided [MEDICAL CONDITION] and limited range of motion, with listed problems, goals, and interventions to be implemented. There were no orders on the December 2012 computerized physician orders [REDACTED]. There was no indication the resident was currently receiving restorative nursing services for his limited range of motion. The Nursing Monthly Summaries for October and November 2012 indicated resident #117 was not receiving restorative services, and that he was not using any devices for range of motion limitations. The record contained one Occupational Therapy Evaluation, dated 7/13/11. The evaluation indicated the resident received services from an occupational therapist (OT) from 5/20/11 to 7/13/11. The OT wrote the following: Status at the End of Therapy Program: "Pt set up on restorative program for wearing splint 4-5 x week; Pt tolerates 3-4 hrs in splint; Pt I (independent) with doffing splint; Restorative aides trained on splint application with fit - staff trained so splint can be fixed if starts to come off;...Pt set up on restorative program for splinting..." The in-service report, dated 6/12/11, read, "Training nursing staff on how to donn/doff (Resident's) dynasplint correctly for safety so wrist and finger joints are repositioned correctly. Educated on proper placement of hand in splint and how bands should be positioned over joints." The resident's record revealed that resident #117 received restorative nursing services from 7/13/11 to 5/31/12. The Rehab to Restorative Transition Record, dated 7/13/11, included the following documentation: "Restorative to put on anti[DIAGNOSES REDACTED] splint on pt and pt to tolerate 3-4 hours 5 x/ week. Activities to be performed with Resident: place dynasplint on pt's L hand; Make sure fingers are in place and wrist is at correct place; ROM to L hand/wrist...pt does know how to doff splint if he needs to do so." On 5/31/12, the restorative nursing aide wrote a summary note on the Restorative Service Delivery Record: "Pt has met goals with restorative. Restorative RCS (resident care specialist) to educate staff with splint application and nursing to apply splints." There was no documented evidence resident #117 had splints applied to his left arm after 5/31/12. Interviews: On 12/17/12 at 5:25 p.m., the rehabilitation manager (RM) was asked about the role of the restorative nursing program and splints. -The RM stated, 'If muscle is flaccid, then they're taught to use adaptive equipment - usually for four weeks at a time (in skilled therapy). If they're hitting a wall we can transfer them over to restorative for ambulation, stretching, and strengthening, usually five times a week. We'd like for them to be able to maintain the level of activity - walking distance, strength, range." -When asked if there could be a decline in range of motion without any interventions, the RM explained, "It's possible they could lose range without it...you can develop tightness with positioning; it would probably tighten and stay in that position." On 12/17/12 at 5:45 p.m., the director of nursing (DON) confirmed that resident #117 was not currently obtaining services from the restorative nursing program. The DON stated, "If they're plateauing, restorative will train people. A physician's orders [REDACTED].the RCS should have told nursing that an order for [REDACTED]. On 12/18/12 from 8:05 a.m. to 8:15 a.m., three RCS's were interviewed. The first RCS stated she had not seen a splint on resident #117's hand for the past two months. The next RCS said, "I used to see him with a splint on his hand, but not recently." The third RCS verbalized, "I can't recall seeing a splint on him lately." The facility's undated Nursing Rehab/Restorative Care Programs policy included the following protocols: "Preparation of the resident and the unit staff are essential to ensuring a smooth transition from Nursing Rehabilitation/Restorative Care services to basic nursing care services...In preparation for the transition and/or once that decision is made, the Nursing Rehab/Restorative Care program staff should initiate the following steps: Provide unit staff with information and instruction about the activities to be provided; Identify unit staff who receive instruction/training and ensure that this information is noted in their individual file or in the unit's in-service training log; The resident's care plan is revised; A process/system is implemented to remind unit staff that the restorative activities must continue to be provided; The Rehab/Restorative Care Nurse Coordinator documents on the IDT (interdisciplinary) progress notes the resident's progress at 30-, 60-, and 90-day intervals; A master list is maintained....this provided an opportunity for continued oversight and identification of a resident who may again require or should be considered for involvement in a Nursing Rehab/Restorative Care Program service."

Based on observation, record review and interview, the facility failed to ensure hydration needs were met for 5 of 37 sample residents (#78, #83, #170, #123 and #116). Specifically, the facility: -Failed to ensure a resident #78, who was at high risk for dehydration upon admission to the facility, received adequate monitoring of fluid intake to prevent dehydration; -Failed to monitor residents #83, #170, #116 and #123, to ensure their hydration needs were being met. -Failed to ensure a resident #123, a [MEDICAL TREATMENT] resident, who was at high risk for dehydration, received adequate monitoring of fluid intake to prevent dehydration. The findings include: 1. Resident #78 was admitted to the facility on [DATE] from the hospital. According to the facility's History and Physical report, dated 6/30/12, the resident's [DIAGNOSES REDACTED].) with [MEDICAL CONDITION], gout, and impaired glucose tolerance. The resident was discharged to the hospital from the facility on 8/23/12. The admission minimum data set (MDS) assessment, dated 7/5/12, indicated the resident had moderate cognitive impairment, with a BIMS (brief interview for mental status) score of 12 out of 15, and she required extensive assistance for all activities of daily living, except for wheelchair mobility and eating, for which she required supervision (oversight, encouragement, or cueing). Record Review The hospital's History and Physical report, dated 6/18/12, included the following documentation: "This is a ...female who has a history of approximately 1 week of altered mental status ...He (the resident's husband) also noted over the last week that she had tremor so bad that she was unable to hold a cup of water and associated myoclonic twitching ...probable dehydration just by history, possibly also due to gastrointestinal illness. For this reason, I will give IV (intravenous) fluids). Intermittent [MEDICAL CONDITION] ...It is quite possible this is aortic insufficiency. Other possibilities might include depletion ..." The hospital's Nephrology Consultation report, dated 6/18/12, documented: " ...In discussion with the husband, who was the main historian available, as the patient is somewhat unreliable at baseline due to dementia as well as superimposed mental status changes, it is reported she has been able to maintain approximately 16 ounces of fluid a day. She did maintain urine output but did not pee more than twice a day as far as the husband can recall ...Patient presented hypotensive in the emergency room and received approximately 2 L (liters) of normal saline ...(Patient) able to answer questions although unable to recall much of any details. Her main complaint is of being shaky, unable to hold any fluid due to the fact that she would drop everything ...For now I would continue to hydrate, hold ACE (angiotensin converting enzyme), [MEDICATION NAME], and statin [MEDICAL CONDITION]ly of hypovolemic nature ..." The hospital's Discharge Orders and Instructions form, dated 6/28/12, indicated the discharge [DIAGNOSES REDACTED]. Resident #78's record included a nutritional assessment, dated 7/8/12, in which the dietitian wrote, "...estimated fluid needs 1800 - 2131 cc's. Current intake meets nutritional needs. Fluids encouraged ...wt changes and appetite changes placing resident at high risk for compromised nutritional status.." The next nutritional assessment was not conducted again until 8/9/12, when the dietitian wrote, "Wt review. As of Aug monthly, wt shows resident at a 18# wt loss ...Resident's been slightly declining and remains in room ...Resident needs to be encouraged to get out of bed and enter other areas of facility ..." The resident's Vital Sign and Weight Flow Sheet showed the following weights: 6/29/12 - 209; 8/8/12 - 181; 8/20/12 - 188. There were no weekly weights in the record. Fluid intake amounts were not recorded by the facility. A Fluid Deficit care plan, initiated on 6/28/12, indicated resident #78 was at risk for fluid deficit due to taking the medication [MEDICATION NAME]. (The resident's December 2012 computerized physician orders [REDACTED].) Approaches checked off on the care plan were: monitor vital signs as indicated; place fluids at bedside in resident's reach; referral to dietitian and speech therapist; notify physician on change of status as indicated; and monitor lab values." The care plan did not indicate the resident needed encouragement, cueing, or supervision for drinking. In a physician's progress note, dated 7/30/12, the physician's assistant wrote, "Altered mental status: more confused over the weekend. Recent [DIAGNOSES REDACTED]." The note included the order for "IV ? NS 75 cc/hour x 1 liter, then do BMP (basal metabolic panel)." The lab results on 7/31/12 showed a BUN (blood urea nitrogen) level of 33 and a creatinine level of 1.1. There was no documented evidence that the resident's fluid needs were reassessed after this lab report, and with the resident's new conditions affecting her hydration status. On 8/3/12, resident #78 was sent out to the hospital due to the resident having a low blood pressure of 60/40. The hospital report, dated 8/3/12, indicated the resident had altered mental status. The General Instructions form, dated 8/3/1, documented, "...You have been evaluated today by ___ for the following conditions: transient [MEDICAL CONDITION]; dehydration; lability of blood pressure; high INR. Instructions: Drink plenty of fluids." After resident #78 returned to the facility on [DATE], there was no documented evidence the facility's interdisciplinary team re-evaluated the resident's fluid needs, or reassessed interventions to ensure the resident's fluid intake was adequately maintained. The resident's Fluid Deficit care plan was not updated. The resident's significant weight loss was not evaluated or addressed until 8/9/12, when the dietitian initiated an order for [REDACTED]. Interviews On 12/18/12 at 1:00 p.m., the nurse unit manager was asked about resident #78's ability to drink from a cup. The nurse stated, "She needed reminders because she'd get confused, but then she was able (to drink from a cup)." On 12/18/12 at 2:20 p.m., the director of nursing (DON) confirmed that facility did not record fluid intake for residents or document if/when staff offered fluids to residents at high risk for dehydration. When asked how the facility monitored fluid intake, the DON indicated that if there was a concern about a resident being dehydrated, "You would do labs." The DON agreed that resident #78's Fluid Deficit care plan should have been updated on an ongoing basis. 2. Sample resident #83, age 98, was admitted to the facility on [DATE]. According to the 12/12 CPO [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), dated [DATE], the resident was coded as having cognitive impairments and severely impaired decision-making. The resident required total assistance with personal hygiene with assist of one staff members. The resident was coded as not having any behavior problems. The resident required extensive assistance with eating. The care plan, last reviewed on 11/27/12, identified the resident was unable to take liquids independently and had medications which contributed to a fluid deficit. --The goal was for the resident to have adequate hydration levels evidenced by moist mucus membranes and to have adequate urinary output and supple skin for the next 90 days. The pertinent approaches were to observe skin turgor, monitor lab values and to encourage fluids with meals, during snacks and also activities and at bedtime. --On 12/10/12 at 4:35 p.m., the resident was observed to have dry chapped lips and a dry tongue. The resident's arms and hands also appeared dry. a. Record Review - fluid requirements and documentation of fluid intake --Review of the medical record failed to show the resident's daily fluid was tracked. --The 12/12 CPO documented the resident had a physician order [REDACTED]. --The latest laboratory report, dated 10/28/12, showed the resident's sodium level (146), categorized as high. The normal range was 135-145. --The nutritional record documented the resident required 1700 cc of water a day. b. Observations - failure to encourage and cue to promote fluid intake -12/10/12 noon meal --At 11:30 a.m., the resident had been served 240 cc of milk. --At 11:40 a.m., the resident was observed to be assisted with her meal. The CNA failed to encourage the resident to drink the milk. --At 11:45 a.m., the resident continued to be assisted with her meal. --At approximately 12:00 p.m., the resident was done with her meal. The resident drank only 240 cc of milk. The resident was not offered any other fluid. c. Room Observations - failure to provide fluids during care and failure to keep fluids within reach -On 12/10/12 at 4:00 p.m., the resident was observed lying in bed. The resident's call cord was not within reach. The resident's water pitcher was on the dresser, not within reach of the resident. -On 12/12/12 at 2:32 p.m., the resident was observed lying in bed. The water pitcher was on the dresser and was not within reach of the resident. -An observation on 12/17/12 at 3:05 p.m., revealed the resident was assisted to bed by two certified nurse aides (CNAs). The CNAs failed to offer any water to the resident. The water pitcher was on the dresser, not within reach. -The resident was involved in an activity on 12/18/12 at 9:00 a.m., the resident did not have any fluids served to her. d. Staff Interviews --The licensed practical (LPN) was interviewed on 12/18/12 at 10:00 a.m. The LPN stated the resident was on [MEDICATION NAME] twice a day for [MEDICAL CONDITION]. She stated she had noticed especially in the morning, that the resident had a dry mouth and chapped lips. The LPN stated she encouraged the resident to drink water and that the resident would accept the water. She stated the resident was supposed to receive two glasses (240 cc) of fluid at each meal. The LPN stated the fluids were not tracked. She stated it was not the policy of the facility to track the intake and output of residents. She stated the resident was unable to obtain fluids herself. --The licensed practical nurse (LPN) was interviewed a second time on 12/18/12 at 10:30 a.m. The LPN stated she did know why the fluid intake was not completed. She said the policy was that the facility was the residents' home and that they would not have their hydration monitored at home so therefore the facility does not do it. She agreed that food was tracked, however, was unable to define the difference. The director of nursing (DON), registered dietitian (RD), and the food service manager (FSM) were interviewed on 12/18/12 at 11:07 a.m. The DON stated the residents were to be offered different fluids and encouraged to drink them. She also stated that the labs were to be reviewed. The DON stated fluid was to be offered anytime staff went into rooms. Fluids were only tracked for residents on fluid restrictions, otherwise fluid was not tracked. The RD stated the labs that she reviewed for hydration needs were the sodium level, the BUN (blood urea nitrogen). The RD was unaware the resident's sodium level was slightly high. The RD stated the [MEDICATION NAME] did put the resident at risk for fluid insufficiency. The FSM stated she also reviewed the labs, although she did not review the latest lab, dated 10/28/12, during her last quarterly review. 3. Policy for Hydration Oral nutrition and hydration policy with revised date of December 2005, read in pertinent part under "Guidelines" section seven and eight: a. Drinking water is provided to encourage adequate fluid intake. Provide fluids to resident during and in between meals and during activities as appropriate. Fresh water and ice are provided at bedside, within the residents reach, unless contraindicated. b. Residents on thickened liquids should have their water pitcher removed from the bedside or provide thickened liquids. Pre-thickened liquids should be utilized for hydration. 4. Policy for [MEDICAL TREATMENT] [MEDICAL TREATMENT], care of resident's policy and procedure with revised date of 2005, read in pertinent part under "documentation" section two: a. Key documentation elements include vital signs, intake and output, urine characteristics, change in voiding patterns, presence/absence of catheter, weight gain or loss, abnormal lab results (blood urine nitrogen, creatinine, white blood cell count, etc.), response to medication or treatment, [MEDICAL CONDITION], diet and fluid restriction and response. 5. Sample Resident #170 -Resident #170 Status Resident #170, age 90, was admitted to the facility on [DATE], according to her face sheet dated 9/14/12. Her admitting [DIAGNOSES REDACTED]. MDS The Minimum Data set (MDS), dated [DATE], indicated resident #170 was rarely or never understood by others, and rarely or never understood others. She had short-term and long-term memory problems, and was severely impaired in daily decision-making skills. The MDS indicated resident #170 required total assistance of two staff members for bed mobility, and was total assist of one staff member for dressing, toileting, eating, bathing, and personal hygiene. Diet Order According to the resident #170's diet order and communication form, dated 8/30/12, resident #170 was noted to have chewing/swallowing problems, and was receiving a pureed diet with nectar thickened liquids. Medical Nutritional Therapy Review According to the initial medical nutritional therapy review, dated 8/31/12, resident #170's nutritional needs were assessed to indicate an estimated fluid need of [PHONE NUMBER] milliliters per day. Care plan Resident #170's fluid deficit care plan initiated, on 8/30/12, indicated resident #170 was to have nectar thick liquids at her bedside. Fluids and snacks should be provided with medications, meals, activities, and as needed. Observations It was observed that resident #170 had no thickened liquids available at her bedside, and fluids were not being offered to the resident during cares on: 12/13/12 at 8:08 a.m., 1:13 p.m. and 4:40 p.m. and on 12/14/12 at 9:05 a.m. Meal Detail Report The meal intake report for resident #170 only showed the percentage of the meal resident #170 consumed. The record failed to identify the amount of fluid intake resident #170 received during her meals, to ensure that the resident was getting the daily requirements identified by the facility. 6. Sample Resident #116 -Resident #116 Status Resident #116, age 83, was admitted to the facility on [DATE], according to the resident face sheet dated 10/11/12. His admission [DIAGNOSES REDACTED]. Record Review MDS The Minimum Data Set (MDS), dated [DATE], indicated that resident #116 had severe memory problems, and did not display any behaviors. The MDS indicated that the resident was rarely or never understood by others, and he sometimes understands others. The MDS indicated that the resident required extensive assistance of two staff members for bed mobility, transfers and toileting. The resident required supervision of one staff member with eating. Physician Orders According to the physician order [REDACTED]. A line was crossed through the order on 12/12/12; and new order written for pureed diet with thin liquids per the resident's request. Care Plan The fluid deficit care plan, initiated 12/2/11, identified resident #116 as being at risk for fluid deficit related to resident's inability to take liquids independently. The care plan identified the resident was still receiving thickened liquids, even though the order was changed to thin liquids on 12/12/12. The resident care plan also identified that resident #116 should be encouraged, and provided fluids with medications, meals, snacks, activities, at the bedside, and as needed. The care plan was updated on 12/14/12, after facility was advised that resident #116 had no fluids available in his room. Observations The resident was observed on 12/13/12 at 8:08 a.m., 1:13 p.m. and 3:40 p.m.; on 12/14/12 at 9:05 a.m. and 10:00 a.m.; and on 12/18/12 at 4:20 p.m., the resident was sitting in his room watching television. There were no fluids noted in the resident's room, and staff did not offer fluids with cares. Meal Detail Report The resident's meal intake report indicated the percentage of the meal the resident consumed. The record failed to identify the amount of fluid intake the resident received during his meals to ensure that the resident was getting the daily requirements identified by the facility. 7. Sample Resident #123 Resident #123 Status Resident #123, age 70, was admitted to the facility on [DATE], according to the resident face sheet dated 10/18/12. Her admission [DIAGNOSES REDACTED]. MDS The Minimum Data Set, dated dated [DATE], indicated resident #123 was rarely or never understood by others, and rarely or never understood others. The MDS indicated resident #123 had short-term and long-term memory deficits, and was severely impaired in daily decision-making skills. The MDS indicated the resident did not display any behaviors and was not resistive to cares. The MDS indicated resident #123 required extensive assistance of one person with bed mobility, transfers, toileting, eating, and personal hygiene. The MDS indicated the resident was receiving [MEDICAL TREATMENT] services. Care Plan The fluid deficit care plan, initiated 4/1/11, identified resident #123 as being at risk for fluid deficit related to being unable to take liquids independently, use of diuretics, end stage [MEDICAL CONDITION], [MEDICAL TREATMENT], and senile dementia Alzheimer's type. The facility approaches included monitoring vital signs, observing skin turgor, monitoring lab values, notifying physician on changes, observe urinary output, and encouraging and providing fluids with meds, meals, and snacks, at bedside and as needed. The [MEDICAL TREATMENT] care plan, initiated 4/1/11, indicated the resident went to [MEDICAL TREATMENT] three times a week. The pertinent approaches included; [MEDICAL TREATMENT] communication record will be sent to the [MEDICAL TREATMENT] center with each appointment, and return of the form is ensured after appointment is completed, monitor lab work, notify physician as indicated. Medical Nutritional Therapy Review According to the medical nutritional therapy review, dated 2/29/12, the resident's nutrient needs were completed by the registered dietician (RD) on 3/1/12. The review indicated resident #123 had an estimated fluid need of 1,595 milliliters daily. The nutritional status review, dated 11/9/12, showed the resident had a weight increase of 12.4% in 30 days and 9.91 % in 180 days. The resident's average meal intake of a 7 day average was 50% plus glucerna 1 cup for supplement. The resident required total assistance with meals by staff and family. [MEDICAL TREATMENT] Communication Record Review of the [MEDICAL TREATMENT] communication records regarding information to be completed by the [MEDICAL TREATMENT] center dated: 10/17/12, 10/29/12, 10/31/12, 11/2/12, 11/5/12, 11/12/12, 11/14/12, 11/16/12, 11/19/12, 11/21/12, 11/23/12, 11/26/12, 11/28/12, 11/30/12, 12/3/12, 12/11/12, showed they were left blank upon returning from [MEDICAL TREATMENT]. The record failed to indicate that treatment was completed without incident, pre and post weight, labs completed, medications given, and any additional recommendation. Lab Findings Review of the resident's lab work completed in 2012 indicated that the facility was only monitoring labs provided by the [MEDICAL TREATMENT] center. These labs included: [MEDICATION NAME] (protein), hemoglobin (red blood cells), calcium, phosphorus, [MEDICAL CONDITION] hormone, potassium, urea reduction ratio (adequacy of [MEDICAL TREATMENT]), cholesterol, glucose and hemoglobin A1c (blood sugar levels). The lab work completed and being monitored failed to identify the hydration status of resident #123. Meal Detail Report The resident's meal intake report indicated the percentage of the meal the resident consumed. The record failed to identify the amount of fluid intake the resident received during meals to ensure that the resident was getting the daily requirements identified by the facility. Staff interviews The certified nurse aide (CNA) was interviewed on 12/14/12 at 10:05 a.m. She stated that residents were supposed to have liquids at their bedside and residents should be offered fluids at least hourly. The CNA was unable to state why resident #123 did not have any thickened liquids in her room or at the bedside. The licensed practical nurse (LPN) was interviewed, on 12/14/12 at approximately 10:30 a.m. The LPN stated residents were supposed to have liquids at their bedside, and fluids should be offered every hour. She stated, resident #123 slept most of the day, however, the LPN stated she did offer fluids when she gave resident #123's ordered medications. At 10:34 a.m., the LPN placed thickened liquids and a cooler at the resident's bedside after this was brought to the attention of the staff. The director of nursing (DON) was interviewed, on 12/14/12 at 10:20 a.m. The DON stated that residents should have fluids in their room; and, if they required thickened liquids, they should be placed in a small cooler next to their bed. Other residents should have a water pitcher in their room, which was filled by the CNAs every shift and as needed. The DON stated the staff should offer fluids throughout the day and with meals. The DON acknowledged that the facility did not track fluid intake unless they had a physician order [REDACTED]. The registered dietician (RD) and the dietary manager (DM) were interviewed, on 12/18/12 at 9:57 a.m., and stated residents were given approximately 760 cc of fluids with each meal to meet their fluid needs. The RD stated that 760 cc's of fluids with each meal would provide each resident with the daily required hydration they need. The RD stated that residents who were receiving [MEDICAL TREATMENT] were sent to the [MEDICAL TREATMENT] center with a packed lunch or nutritional supplement. If there were any concerns with [MEDICAL TREATMENT], the [MEDICAL TREATMENT] center will notify the RD or dietary manager, who will then follow up with the nursing staff or physician. The RD and DM acknowledged the staff did not record the amount of fluids each resident consumed, and that the facility monitors resident's lab diagnostics for abnormalities and notified the physician when indicated. In a follow-up interview with the DON, on 12/18/12 at 11:02 a.m., the DON stated residents were offered 3 different fluids with meals. Residents were encouraged fluids in between meals, and when staff were in the resident rooms. The DON stated "all I can do is offer the fluids, you can lead a horse to water, but you can't make her drink." The DON acknowledged [MEDICAL TREATMENT] residents would be considered at high risk for fluid deficits and would monitor lab diagnostics including blood urine nitrogen (BUN), and a complete metabolic panel (CMP) when indicated. The DON acknowledged that [MEDICAL TREATMENT] communication records should be received from the [MEDICAL TREATMENT] center upon the resident's return regarding the status of the resident and treatment.

Based on observations, record review, and interviews, the facility failed to ensure five of 14 sample residents (#3, #7, #9, #12 and #13) and three supplemental sample residents (#15, #16, and #17) received adequate supervision to prevent accidents. Specifically: I. FALLS The facility failed to implement safety interventions to prevent accidents that involved residents with known risk factors for falls and/or accidents. Specifically: -Resident #9 sustained a fracture and a head injury when ambulating without staff supervision, contrary to therapy instructions. -Resident #12 sustained a fracture during transfer. -Residents #7 repeatedly fell while self-transferring and -Resident #13 fell shortly after admission. II. SMOKING The facility failed to safely store smoking items belonging to residents #3, #15, #16 and #17. The findings include: I. FALLS A. Facility Policy The fall management policy was requested and provided by the Nursing Home Administrator (NHA) on 8/3/11. The policy read in pertinent part: "Facility will take a proactive approach for new residents and will consider new admissions at risk for falls until the resident is reviewed in IDT (interdisciplinary team) ...Upon admission, the admitting nurse will complete the fall Risk Assessment and then weekly for 3 additional weeks. The nurse will also complete the initial Care Plan and address risk factors related to the resident on the Plan of Care and implement appropriate interventions as identified ...All residents will be assessed for risk quarterly, annually, and for significant change using the fall assessment." B. Resident Failures 1. Resident #9 Resident #9's medical record was reviewed on 2/22/11, 4/18/11, 6/11/11 and 8/3/11 through 8/25/11. Resident #9, age 65, initially was admitted from the hospital to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The 3/1/11 Minimum Data Set (MDS) revealed the resident had no short-term or long-term memory impairments. The resident was understood by others and understood others. The resident had no behavioral symptoms. a. Functional Status on and shortly after admission - known fall risk (1) Physician Notes: Facility physician (MD) notes dated 2/17/11, read in pertinent part, "Transferred (from hospital to facility) for PT/OT (physical and occupational therapy) ..humerus fx (fracture) SP (status [REDACTED]. physician progress notes [REDACTED]." The MD notes further read, "Fall risk - Will discuss w/PT (with) PT" physician progress notes [REDACTED]." Physician notes dated 3/5/11 again read in pertinent part, "Still dizzy at times." (2) PT Evaluation: Review of the PT evaluation notes dated 2/18/11, revealed the PT marked under the subtitle Gait/Mobility, "Impaired." The notes indicated that the resident used a hand held assistive device and the resident was in pertinent part, "unsteady & dizzy." (3) MDS Assessment (3/1/11): The 3/1/11 MDS coded the resident as follows, for mobility, transfer, balance and ambulation: -The resident needed limited assistance of one staff with bed mobility, transfer, dressing, toilet use and personal hygiene. She needed supervision with set up for walking in the room or corridor and supervision of one staff with locomotion on the unit. -For balancing during transitions and walking, the resident was coded as not steady, only able to stabilize with human assistance with moving from seated to standing position, moving on and off toilet and surface-to-surface transfer. -The resident was not steady but able to stabilize without human assistance with walking (with assistive device if used) and turning around. No mobility devices were indicated, although (see below) the 2/18/11 care plan and PT assessment indicated a cane while ambulating. The resident was receiving PT/OT. b. Facility response to risks (1) Care Plan: Review of the care plan, initiated on 2/17/11, indicated that the resident was at risk for falls and had a recent fall. The care plan indicated that the resident was admitted with a (L) humerus fx (fracture) and had balance and walking problems. -The goal for the care plan read in pertinent part, "(resident #9) will be free of fall related injuries through the next 90 days." -The approaches in pertinent part read, "Encourage resident to ask for assistance ...Ensure resident has proper footwear as indicated and accepted ...Place call light within reach ...Offer/Assist to toilet frequently ...place frequently used items within reach." On 2/18/11 a care plan entitled, "Decreased independence with functional mobility ...secondary to weakness ... (decreased) balance ... (decreased) mobility, " was initiated. The goal was that the resident would be "independent with functional mobility and ambulation with a cane." (2) Therapy: Review of weekly therapy progress and update notes revealed PT notes dated 3/4/11. PT recommendations on that date were for supervision with ambulation. The therapy progress notes read in pertinent part, under the subtitle -"Assessment" (provide statements detailing progress; document to implement and what specific skilled interventions are being provided to address functional limitations- completed by licensed therapist only): "Pt (patient/resident) has progressed ... (with) ambulation tho (abbreviation unknown) facility ... (without) A.D. (assistive devices) needing supervision with ... (ambulation secondary to) ... (decreased) balance. . ." c. Fall 3/7/11 Review of a form entitled "INCIDENT/ACCIDENT FALL" revealed the resident fell on [DATE] at 6:30 p.m. The form indicated no restraints in use and that the resident sustained [REDACTED]. The location of incident was "hallway where incident happened." The incident was witnessed by another resident and no staff witnessed the incident. A form entitled "CHANGE IN CONDITION" read in pertinent part: -"About 1830 (6:30 p.m.), "Pt found on the floor screaming. Charge nurse, another RN (Registered Nurse) & CNAs (certified nurse aides) responded right away. Incident witnessed by another resident who was also in the hallway at that time. Noted a laceration on (R) eye brow ... (skin tears) x2 on RUE (right upper extremity). No problems on movement ...c/o (complaint of) head pain 10/10. No indication of abuse." -The physician was notified and ordered for discharge to the hospital for "stitches & further eval (evaluation)." Review of the hospital discharge summary dated 3/12/11, read in pertinent part: -PROCEDURES: "casting of right arm ...3/7/2011, CT of head showed a contusion...On 3/7/2011, right elbow x-ray showing a proximal ulnar fracture." -HOSPITAL COURSE: "This is a [AGE] year-old woman ...who presented with a fall ( 3/7/11 while at the facility) ...in the emergency room (ER) she (resident #9) was found to have a proximal ulnar fracture. She had been at the nursing home recovering from a left shoulder fracture. She was admitted (3/7/11) for casting of her fracture. She was admitted for pain control and casting of her fracture." The resident returned to the facility 3/12/11. d. Failure in facility response prior to fall 3/7/11 The facility failed to ensure the resident's risks and PT recommendations were communicated to staff and implemented. -Although the resident had dizziness (see physician notes above), the care plan box with the problem "vertigo (dizziness)" was not marked as a problem for the resident. -Neither of the resident's care plans (for falls or for functional mobility) included the PT recommendation from 3/4/11, that the resident required supervision, secondary to decreased balance. -There was no documentation that staff was instructed how to supervise the resident with ambulation, as described in the PT note 3/4/11. See interview below with the Rehabilitation Therapy Manager (RTM), interviewed on 8/17/11 at 1:45 p.m. e. Failures after the resident's fall 3/7/11 (1) Follow up of the resident's fall in the INTERDISCIPLINARY POST FALL REVIEW (IDPFR) did not address the issue that the resident fell while ambulating without staff supervision. Specifically: A form entitled "INTERDISCIPLINARY POST FALL REVIEW (IDPFR)" indicated that the resident sustained [REDACTED]. The IDPFR read in pertinent part, "Pt (patient/resident) was walking at hallway, grabbed ice from the ice bin & suddenly she felt dizzy while walking ..." -ACTIVITY AT TIME OF THE FALL ...Unassisted ambulation ... -CONDITION THAT MAY CONTRIBUTE ...dizziness ... -SUMMARY OF INTERDISCIPLINARY TEAM (IDT): Resident sent to hospital. Encourage to follow recommended diet for gastric bypass. Encourage to take supplements recommended." (2) Review of the resident's care plan revealed interventions continued to fail to include instructions to staff to supervise the resident's ambulation. On 3/12/11, a fall care plan was initiated after the resident was readmitted to the facility. This care plan read "Actual" fall. The goals for the care plan read in pertinent part, "(Resident #9) will be free of fall related injuries through review." However, no interventions were identified. On 3/14/11, a care plan was initiated for "Decreased independence with functional mobility ...secondary to (R) Ulnar fracture." The goal for this care plan was that the resident would be independent with functional mobility." This pre-printed care plan, too, failed to direct staff to provide supervision with ambulation. On 3/14/11, the resident's care plan for falls was updated; however, no further interventions regarding supervision with ambulation were identified to prevent further falls. f. Interviews On 8/17/11 at 1:45 p.m., the Rehabilitation Therapy Manager (RTM) who was in charge of the resident's care, and the Director of Nursing (DON) were interviewed at the same time. -The RTM stated, "(Resident #9) sometimes ambulated with or without a cane." The RTM clarified the PT assessment/notes dated 3/4/11 (see above), stating, "The resident was to ambulate without a device, the resident was to be supervised, meaning the resident was to be in line of site of staff without physical support, when ambulating ...no touching ... My expectation with ambulation was supervision ...she was supposed to have someone beside her when ambulating as of 3/4/11, and she was not supervised when she fell on [DATE]. " -The RTM acknowledged, "It's (supervision with ambulation) not in the care plan ...It should have been transcribed onto the care plan for implementation ...it should have been on the care plan .." -The RTM further acknowledged that staff were not educated regarding the resident's need for supervision with ambulation. The RTM stated, "There was no education of staff or initiation or revision of the care plan regarding supervision with ambulation for the resident was done." -The DON stated, "My expectation is to have a care plan. My expectation is education for staff to supervise impulsive residents." The DON stated that staff would be re-educated. 2. Resident #12 (closed record) Resident #12's closed medical record was reviewed 4/18/11, 6/11/11 and 8/3/11 through 8/25/11. Resident #12, age 68, initially was admitted to the facility from home for respite care on 4/9/11, and discharged home with family on 7/1/11. The resident's [DIAGNOSES REDACTED]. a. Resident Status - Fall Risk The 5/23/11 MDS revealed: -The resident had no short-term or long-term memory impairments. The resident was usually understood by others and usually understood others. The resident had no behavioral symptoms. -The resident needed extensive assistance of one staff with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. The resident was non-ambulatory. -The resident was occasionally incontinent of bowel and bladder. -The resident had a fall which resulted in a major injury and pain. b. Falls in the facility 4/17/11 and 5/7/11 Review of PT evaluation notes, revealed that the resident fell in the facility on 5/7/11, and sustained a (L) knee fracture with that fall. PT evaluation notes read in pertinent part, "Onset 5/7/11)." The resident was hosptalized on [DATE] through 5/9/11, after that fall with an injury. PT services began on 5/10/11, when the resident returned to the facility after treatment. PT notes read in pertinent part, "S/P fall ...unwitnessed ... (with) resultant nondisplaced fx patella ...also sustained previous fall ... (with) (R) wrist fx (while at facility on 4/17/11) which is casted." c. Facility Response to resident's safety needs Review of the fall risk care plan, initiated on 4/9/11, indicated that the resident was at risk for falls related to balance problems, walking problems and use of an assistive device. On 5/9/11, the fall risk care plan identified that the resident had (L) patella fracture. The goals indicated that the resident was to be free of falls with injuries for the next 90 days. The resident was to ask for assistance with any transfers. The approaches to the care plan included: -call light within reach, to encourage resident to obtain assistance for transfer. -referrals for Physical therapy (PT), occupational therapy (OT). -The care plan further indicated to educate the resident on safety measures, to ask for assistance and lock brakes. -weight bearing precaution & had a (L) patella splint (as of 5/9/11). -limited assistance from staff and to wear slip resistant footwear when ambulating or transferring. -modify environment to minimize fall risk. d. Failure to keep the resident safe from further injury. Review of a form entitled "INCIDENT/ACCIDENT REPORT" dated 5/31/11, indicated that the resident had left ankle swelling and bruising. The report indicated no falls in the last 30 days; however, PT notes above and incident report and nurses' notes dated 5/7/11, documenting an "unattended" fall, resident found lying on the floor in front of his bed on 5/7/11 at 5:30 a.m., resulting in a left patella fracture (see PT notes above). The 5/31/11 incident report further read in pertinent part, "DRT (daughter) VISITING. Noticed resident's (L) foot & ankle swollen & bruised. Res (resident) stated it looks worse than yesterday & ...got it during transfer. This affected foot is being dragged & twisted. Res c/o tenderness & pain when attempting ROM...E (evaluated) by PT & made recommendations how to prevent foot drop ....contributing to incident/accident: (L) patella fx (fracture)." A form entitled INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP dated 5/31/11 read in pertinent part, "Drt visiting & noticed resident's (L) foot & ankle ... (with) swelling & bruised. Resident stated it got worst since yesterday ...got it during transfer. This affected foot is being dragged & twisted during transfers. Res c/o tenderness & pain when attempted ROM." -Under the subtitle SUMMARY OF INVESTIGATION, documentation read in pertinent part, "Investigation held had no evidence of abuse." -Under the subtitle PAST INTERVENTIONS ATTEMPTED (include dates), documentation read, "0 (none)." -Under the subtitle RECOMMENDATIONS/NEW INTERVENTIONS, documentation read in pertinent part, "Seen and examined by PT & made recommendations how to prevent foot drop & future accidents/injuries & special kind of foot drop." Nurses' notes dated 5/31/11 at 10:00 p.m., read in pertinent part, "Left ankle and foot with swelling & bruising. C/O pain when moved. Pt assessed and evaluated & suggested some remedy to prevent further swelling and foot drop to affected foot." Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]." Facility failures: (1) Facility record review revealed an IN-SERVICE REPORT dated 6/2/11, that read in pertinent part, "Course title: Compressive ankle (bandaging) ...Brief outline or contents: Heel & ankle/foot. "Bandaging" to (L) ankle edema ...Conducted by (PT) name ...Evaluation, comments, suggestions: (RN name)." The in-service report did not include a sign in sheet, indicating which staff and how many staff had been in-serviced. Moreover, there was no documentation that staff received any education specifically, on how to safely transfer the resident. (2) Therapy weekly progress and update form dated 6/7/11 through 6/14/11, read in pertinent part, "staff and family trained to transfer continues. Under the subtitle: Update goals as follows: WC ...bed transfer ...(with) sliding board ...(with) NWB (non-weight-bearing) on LLE (left lower extremity) & NWB on (R) LE ...To do inservice ...(with) the nurses for the above transfer." During an interview with the RTM on 8/15/11 at 5:00 p.m., the RTM stated that there was no documentation to show staff were re-educated in regard to using a board for resident transfer to prevent foot drop or further injuries or NWB status for the resident, as indicated by PT notes dated 6/7/11 through 6/14/11. (3) Review of the care plan revealed the plan was updated 6/1/11, to read in pertinent part, "Follow weight bearing ...precautions as ordered by MD. Remind to use enabling device as ordered and proved (provide) assistance as needed. The resident was to be monitored for complications from bruises every 72 hours." However, the use of a board to transfer the resident or NWB was not identified on the ADL assistance care plan to ensure implementation of these precautions with every transfer. Documentation dated 6/1/11, 6/13/11 and 6/27/11, revealed that the family was educated on the above. However, there was no documentation or indication that staff was educated in regard to resident transfer after the resident's injury of 5/31/11. 3. Resident #7 Resident #7's medical record was reviewed on 2/22/11, 4/18/11, 6/11/11 and 8/3/11 through 8/25/11. Resident #7, age 64, initially was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. a. Resident Status The 6/29/11 MDS revealed: -The resident had no short-term or long-term memory impairments. The resident was usually understood by others and usually understood others. The resident had verbal behavioral symptoms towards others. -The resident needed extensive assistance of one staff with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. -The resident was frequently incontinent of urine and always of bowel. -The resident's mobility device included a wheelchair. b. Fall risks The 6/29/11 MDS assessment for balancing during transitions and walking indicated that the resident was not steady, only able to stabilize with human assistance with moving from seated to standing position, moving on and off toilet and surface-to-surface transfer. The MDS indicated that resident was non ambulatory and was unable to turn around and face the opposite direction while walking. The MDS further revealed the resident was impaired on one side with upper and lower extremities and had a history of [REDACTED]. c. Facility Response to Fall Risk Review of the care plan initiated on 3/7/08, updated on 4/22/11 then 6/28/11, 7/5/11 and 7/19/11, indicated that the resident had potential for injury, impaired ability to self-transfer related to mental status, weakness, history of falls and a history of cardiovascular accident (CVA) with left sided weakness. -The care plan indicated that a gait belt was to be used when transferring the resident. -Other problems identified included, balance problems, utilization of a wheelchair (WC), seizures and use of psychotropic medication. -The goal was, in pertinent part, "will be transferred with identified transfer devices/assistance through next review ...will have risk for injuries ...(with) xfer (transfers) minimized ...(with) interventions x90 days." The goals further indicated in pertinent part, "RESIDENT RISK FOR INJURY R/T (related to) FALLS WILL BE MINIMIZED OVER THE NEXT 90 DAYS THROUGH STAFF INTERVENTIONS." -The approaches to the care plan included in pertinent part, "Place call light within reach. Encourage resident to obtain assistance for transfer. Provide assistive devices for transfer ...Gait belt...WC ...referrals ...Physical therapy (PT), occupational therapy (OT), Restorative therapy, as needed (PRN)." The care plan further indicated to remind the resident to ask for assistance with transfers and ambulation. -The approaches included orientation of resident to the room, check Dilantin levels, reminding resident to unlock WC breaks before propelling, encourage resident to call for assistance with toileting (initiated on 2/14/11), remind resident to ask for assistance when items were out of reach. A cognitive care plan was initiated on 6/24/11, and updated on 7/19/11, indicated that the resident had cognitive loss/dementia as evidenced by short-term memory problems, long-term memory problems, impaired decision making ability and problems understanding others. The care plan indicated that the resident was able to make appropriate choices related to everyday care, but was usually impulsive and needed supervision to complete activities of daily activities (ADLs). d. Falls in or around bathroom - facility failed to develop effective safety interventions. (1) 1/26/11 A form entitled "CHANGE IN CONDITION," dated 1/26/11, read in pertinent part, "Unwitnessed fall ...(with) injury (L) hip pain ...symptoms started ...today ...symptom has gotten worse ...movement makes (L) hip hurt ...other things that have occurred with ...symptom are large indentation to (L) buttock ischium ...Stat x-ray to (L) hip." (The resident's record had been purged and x-ray results were not available for review.) Review of a form entitled "INCIDENT/ACCIDENT REPORT" indicated that the resident sustained [REDACTED]. Upon inspection Rt C/O (complained of) (L) hip pain ...indentation ...plum size," was noted on the resident's (L) hip. The report indicated that the resident's cognition was normal. A form entitled INCIDENT/ACCIDENT INVESTIGATION FOLLOW- UP dated 1/26/11, read in pertinent part, "Rt found on floor in BR by CNA states my (L) hip hurts." Under the subtitle SUMMARY OF INVESTIGATION, documentation read in pertinent part, "Rt attempted to transfer from toilet to WC unattended." Under the subtitle, PAST INTERVENTIONS ATTEMPTED (include dates), documentation read, "Instructed rt to use call light and ask for help." (No dates were included) Under the subtitle RECOMMENDATIONS/NEW INTERVENTIONS, documentation again, read in pertinent part, "Remind rt to use call light and ask for assistance," although the resident did not use the call light when he attempted to transfer self on 1/26/11, fell , and sustained injuries. (2) 2/12/11 A form entitled "CHANGE IN CONDITION," dated 2/12/11 at 5:20 p.m., read in pertinent part, "rt found on floor by the CNA in room, outside of bathroom ...states: Just came out of my wheelchair. Found lying on floor ...able to move neck and head." Review of a form entitled "INCIDENT/ACCIDENT FALL REPORT" indicated that the resident sustained [REDACTED]. The report read in pertinent part, "Rt lying on floor in front of BR next to WC." The form indicated a repeat fall and that the resident was confused. A form entitled "INTERDISCIPLINARY POST FALL REVIEW (IDPFR) also indicated that the resident sustained [REDACTED]. The form indicated that the resident was in his WC prior to the fall. Activity was unknown at the time of the fall. Under the subtitle of "Summary of Interdisciplinary Team (IDT)," documentation read in pertinent part, "Encourage Res (resident) to ask for assist," even though the resident was assessed with [REDACTED]. No new or revised safety interventions were identified and initiated after this at fall. (3) 7/18/11 A form entitled "CHANGE IN CONDITION," dated 7/18/11 at 9:00 a.m., read in pertinent part, "Unattended fall ... 0 (no) pain ...Primary [DIAGNOSES REDACTED]." A form entitled "INCIDENT/ACCIDENT REPORT" dated 7/18/11 at 9:00 a.m., revealed that the resident sustained [REDACTED]. The report read in pertinent part, "Unwitnessed fall ...Resident was on the floor in his room's bathroom." The form indicated a repeat fall for the resident. No assessment was done in regard to his cognition. A form entitled INTERDISCIPLINARY POST FALL REVIEW (IDPFR) dated, 7/18/11 at 7:00 p.m., read the resident sustained [REDACTED]." Resident stated: "I want to sit back on my WC." The form indicated that the resident was on the toilet prior to the fall and activity at the time of the fall was "Transferring himself." The form identified that the resident had unsteady gait and had a history of [REDACTED]." The resident's care plan was updated with toileting recommendations as indicated above. However, this was the first update regarding toileting even though the resident had fallen in or near the bathroom two times previously. Moreover, review of the 7/11 and 8/11 toileting assistance record, revealed that the resident received no consistent assistance to the toilet as identified or as care planned. e. Interviews On 8/15/11 at 2:50 p.m., the Rehabilitation Therapy Manager (RTM) was interviewed as she reviewed the resident's medical record. The RTM stated that on 7/29/11, after his third fall, the resident was referred for PT evaluation for bed mobility. The RTM stated that in reviewing the resident's chart, PT notes for 7/29/11 indicated that the resident needed minimal staff assistance to transfer from sitting to standing. However, staff were to stay with the resident for provision of "verbal cues ...as the resident will not remember instructions to use call light or ask for assistance prior to getting up." See above; this information was not on the care plan or the toiling assistance record. f. Action taken during survey After the surveyor brought it to the facility's attention, the resident's care plan was updated on 8/19/11, and read in pertinent part, under the subtitle of problems, "Will transfer self from bed to chair etc and to bathroom w/o (without) asking for help." Approaches were updated and read in pertinent part, "include staying with resident in BR 8/19/11 (initiated on 8/19/11) until done ...8/22/11.. Keep frequently used items within reach ...offer to use BR to res during each interaction." 4. Resident #13 (closed record) Resident #13's closed record was reviewed 4/18/11, 6/11/11 and 8/3/11 through 8/25/11. Resident #13, age 83, initially was admitted to the facility on [DATE]. The resident was discharged from the hospital to the facility on [DATE] for rehabilitation therapy and the resident was discharged from the facility back to the hospital after she sustained a fall on 4/3/11. The resident's [DIAGNOSES REDACTED]. a. Resident Status - post-op ORIF The resident's initial assessment dated [DATE], indicated the resident was admitted with a [DIAGNOSES REDACTED]. The resident was alert and oriented to time, self and place. The assessment indicated that the resident was not a high risk for falls, although the resident was post-op (R) hip ORIF. (see below) b. Facility response to resident's safety needs - failure to identify safety interventions Review of the initial plan of care dated 4/1/11, revealed that the resident had a potential for fall. The goals for the care plan read in pertinent part "Will have no falls related to injuries through next review." However, no interventions to prevent falls were identified on the initial care plan, contrary to the facility fall prevention policy (see above). c. Fall 4/3/11 Review of a form entitled INCIDENT/ACCIDENT REPORT dated 4/3/11 at 4:00 a.m., read in pertinent part, "Resident stated ...was reaching for WC and fell on floor. No injuries noted. C/O back pain ...denies hitting head. Call light not on." The report indicated that the resident, who was admitted without any cognition deficits, was confused on that date at that time. A form entitled INTERDISCIPLINARY POST FALL REVIEW (IDPFR) dated 4/3/11 at 4:00 a.m., also indicated that the resident stated that she was reaching for WC and fell on floor. No injuries noted and she c/o back pain. The form indicated that the resident was in bed prior to the fall and activity was "reaching for wheelchair," at the time of the fall. - The form indicated that the resident's gait was unsteady. (The initial assessment indicated no problems with ambulation, although the resident was admitted a day after hip surgery.) -Under the subtitle of "Summary of Interdisciplinary Team (IDT)," documentation read in pertinent part, "Resident sent to hospital. Remind to ask for assistance," although the incident report had indicated that the resident was confused on 4/3/11. The notes read in pertinent part, "had socks on was in middle of night." No further interventions were identified after the fall. Hospital x-rays revealed no injuries and no changes to recent surgery. Her care plan subsequently was updated with interventions, to include a bed alarm/chair alarm, orientation to room and encouragement to call for assistance. 5. Additional Staff Interviews On 8/9/11 at 4:15 p.m., the above findings were brought to the attention of the Director of Nursing (DON). The DON at that time stated, "The process is (that) after the resident falls, we then care plan ...We do not assume the resident is at risk for falls until something happens (they fall) ...when (a resident) falls, a risk assessment is done and then a care plan is put in place at that time." The DON stated that if a resident is identified on admission to be at risk for fall, "my expectation is that they (nursing staff) identify interventions immediately," as indicated by the facility policy. On 8/21/11 at 1:00 p.m., the above findings and issues related to supervision of residents to prevent falls, were brought to the attention of the Facility Medical Director. The Medical Director was interviewed and stated, "plan of care must be identified and set in place for each resident. Normal process is that those processes (evaluation/identification/ implementation of interventions) get handed off between PT/OT and nursing." The Medical Director further stated in pertinent part, "We need to come up with integrating falls - to come up with a plan of care and implement it to address falls." II. SMOKI

Based on clinical record review and staff and resident interviews, the facility failed to ensure care and services were provided for three (#1, #2 and #3) of seventeen sample residents. Specifically, the facility failed to ensure pharmaceuticals were consistently/appropriately provided for the residents. This failure resulted in resident #3 experiencing severe pain for a prolonged period of time. (cross reference F 425-provision of pharmaceutical services). The findings were: 1. Sample resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review The resident's clinical record was reviewed on 12/29/10 and 1/5/11. No Minimum Data Set (MDS) information was available because the resident was discharged from the facility prior to the MDS assessment completion. The resident's admission physician's orders [REDACTED]. The resident's plan of care, dated 12/3/10 read, in pertinent part, "Problem: Pain/Discomfort (Actual); Goal: {Resident} will have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain x 90 days; Approaches: Administer [MEDICATION NAME] as ordered. See physician's orders [REDACTED]. Frequency of monitoring: every 1 to 2 hours and prn (as needed)." The resident's Initial Pain Evaluation, dated 12/3/10 read, in pertinent part, "[DIAGNOSES REDACTED]. Been on a scheduled pain management regimen? (Answered YES), B. Received PRN (as needed) pain medications? (Answered YES), C. Received non-medication intervention for pain? (Answered YES). Pain Interview: A. Have you had pain or hurting at any time in the last 5 days? (Answered YES), B. How much of the time have you experienced pain or hurting in the last 5 days? (Answered FREQUENTLY), C. Over the past 5 days, has pain made it hard for you to sleep at night? (Answered NO...GETTING SLEEPING PILL), D. Over the past 5 days, have you limited your day-to-day activities because of pain? (Answered YES); Location of Pain/Hurting: Bone/Right groin." Nurses notes, dated 12/3/10 at 6:30 p.m. read, in pertinent part, "Meds faxed to pharmacy and spoke with pharmacy to request pharmacist to call Dr (doctor) for narcotics (pain medications)." Nurses notes, dated 12/3/10 at 6:45 p.m. read, in pertinent part, "Faxed pharmacy a request to obtain [MEDICATION NAME] (pain medication) from "E" Kit (emergency kit) secondary to client's pain level 8/10. Explained to client the process to obtain permission for narcotics that is was a several step process including the pharmacist and the MD (physician). Telephoned pharmacy and verbally requested [MEDICATION NAME], too. Client transferred into bed and the HOB (head of bed) and foot of bed elevated to promote equal weight distribution. Ice pack offered for comfort and declined by client." Nurses notes, dated 12/3/10 at 9:30 p.m. read, in pertinent part, "Up-dated client on the process of obtaining [MEDICATION NAME] from "E" Kit. Notified MD to call pharmacy for authorization which is pending. Diversional activities such as TV programs and book reading being utilized by client. Offered to obtain Tylenol order until [MEDICATION NAME] obtained which client declined since "It won't help me". Comfort measures provided while pharmacologic measures pending." Nurses notes, dated 12/4/10 at 10 p.m. to 6 a.m. read, in pertinent part, "{Resident} upset at 11:15 p.m. c/o (complaints of) pain level 8 (out of 10). Meds not here from pharmacy. Called and faxed pharmacy for permission to enter "E" Kit. At 11:45 p.m. attempted to reach pharmacy again. At midnoc (midnight) meds arrived from pharmacy. [MEDICATION NAME] given. At present resting in bed with eyes closed." Interviews During an interview, conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 1/5/11 at approximately 12:20 p.m., the NHA stated getting access to medications from the "E" Kit had been an on-going problem because of new pharmacy rules. The NHA stated staff was not allowed to access any type of medication (including pain medication/narcotics) from the "E" Kit without permission from the pharmacy, which could only be obtained after a physician gave an order directly to the pharmacy from the resident's medication. The NHA and the DON acknowledged resident #3 had waited too long for pain control (given she experienced pain at a level of 8 out of 10 for at least six hours) prior to receiving any medication to control her pain on 12/3/10. The NHA stated they were working on solving the problem. 2. Sample resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's clinical record was reviewed on 11/30/10. According to the Computerized physician's orders [REDACTED]. -[MEDICATION NAME] 15 mg by mouth every evening for depression -[MEDICATION NAME] 15 mg by mouth every other day for [MEDICAL CONDITION] The resident's Medication Administration Records (MARs), dated 11/10, were reviewed and revealed the resident did not receive her doses of [MEDICATION NAME] on 11/13 or 11/17, or her dose of [MEDICATION NAME] on 11/24. Hand written notes on the back of the MAR indicated was not available from pharmacy". There was no notation regarding the missed doses of the resident's [MEDICATION NAME]. During an interview conducted with the NHA on 11/30/10, she stated the facility had been having a lot of problems receiving medications from the pharmacy in a timely manner. She stated the missed doses of [MEDICATION NAME] were likely due to the drug not being available from pharmacy. 3. Sample resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's clinical record was reviewed on 11/30/10. According to the CPOs, dated 11/10, the resident had orders to receive the following medication: -[MEDICATION NAME] 5% patch to be applied to the skin every three days for pain -Imdur 90 mg by mouth every day for [MEDICAL CONDITION] -[MEDICATION NAME] 75 mg by mouth twice daily for prevention of [MEDICAL CONDITION] The resident's MARs, dated 11/10, were reviewed and revealed the resident did not receive [MEDICATION NAME] 11/9 or 11/10, the [MEDICATION NAME] on 11/9 or 11/10; and the [MEDICATION NAME] was not applied on 11/9, 11/10 or 11/11. Notations on the back of the resident's MAR indicated unavailable from pharmacy". During an interview conducted with the NHA on 11/30/10, she stated the facility had been having a lot of problems with obtaining medications from the pharmacy in a timely manner. She further stated the facility would be working to find a solution to the problem.