Every finding on record at University Heights Care Center

Based on observations, record review and interviews, the facility failed to maintain an effective pest control program so the environment was free of pests.Specifically, the facility failed to prevent and take adequate measures to eliminate cockroaches within the facility kitchen, the resident dining room, resident rooms, resident shower rooms and in the facility hallways. Findings include:I. Professional referenceAccording to the Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by:-Routinely inspecting incoming shipments of food and supplies-Routinely inspecting the premises for evidence of pests-Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and,-Eliminating harborage conditions. (Chapter 6)II. Facility policy and procedureThe Pest Control policy, undated, was provided by the nursing home administrator (NHA) on 12/16/25 at 3:42 p.m. The policy read in pertinent part, The facility shall maintain an effective pest control program.III. ObservationsOn 12/15/25 at 6:54 a.m. there was a large spill of a red syrup liquid on a tray. The tray was on a shelf underneath the counter. The floor in the main kitchen and the shelves were soiled with crumbs and food debris. On 12/15/25 at 7:50 a.m. multiple cockroaches were seen crawling on the wall near the baseboard in shower room two. Threw were also dead cockroaches near the baseboard in shower room twoOn 12/15/25 at 8:02 a.m. a cockroach was crawling on the floor in the resident common area.On 12/16/25 at 9:05 a.m. a dead cockroach was in the middle of the hallway near the resident common areaOn 12/16/25 at 9:24 a.m. a glue based cockroach trap was observed in shower room two. The trap was about three by six inches and was covered in cockroaches. Most of the cockroaches appeared to be dead, however one was seen wriggling on the trap.IV. Resident interviews and observations Resident #5 was interviewed on 12/15/25 at 7:32 a.m. Resident #5 said there were a lot of cockroaches in her room and she would watch them crawl on her wall all night. Resident #5 said the last few days have been slightly better and there have been less cockroaches. She said she still saw several in her room every night. Resident #5 said she did not feel enough was being done to combat the cockroaches.Resident #7 was interviewed on 12/15/25 at 8:02 a.m. Resident #7 said cockroaches were a problem throughout the facility. He pointed to the wall in the hallway lounge bringing attention to a live cockroach crawling around where he was sitting. Resident #7 said he also saw a lot of them in the shower room and his room.Resident #18 was interviewed on 12/16/25 at 1:02 p.m. Resident #18 said there were cockroaches everywhere in the facility. Resident #18 said he had lived in the facility for multiple years and said the cockroach infestation began about a year ago. He said the roaches had never been eliminated. Resident #18 said he has found cockroaches in his bed, saw them on the dining room tables during meal time and crawling all over the floor. The resident said a friend in the facility had found a cockroach in her food.Resident #18 said the facility had closed some rooms down for cockroach treatment, but had told him they did not have enough money to close and treat the entire facility aggressively.V. Record reviewPest control records were provided by the NHA on 12/18/25. Records for the last four visits revealed cockroach activity throughout the facility. The records documented the following treatments:-Pest control service on 10/24/25 revealed multiple areas had cockroach activity including the kitchen, bathroom, breakroom and basement. -Pest control service on 11/7/25 revealed both rodent and cockroach activity was found in the kitchen interior areas. The area was treated with boractin powder and a full flush was recommended.-Pest control service on 11/19/25 revealed cockroach and mice activity had been found and the kitchen was specifically treated. -Pest control service on 12/1/25 revealed cockroach activity in the kitchen. The kitchen area was closed and treated. One resident room was also treated.Resident council minutes from 10/8/25 documented the about concerns about cockroaches in the facility. The facility responded they were seeking a different pest control provider. The November 2025 and December 2025 resident council meetings revealed the residents continued to complain about the cockroach problem despite some minor improvement.VI. Staff interviewsThe dietary manager (DM) was interviewed on 12/15/25 at 7:02 a.m. The DM said the facility had problems with cockroaches. The DM said the cockroaches were mainly in the residents' rooms, but sometimes they came into the kitchen area. The DM said the facility was serviced by a pest control provider She said the cockroach problem in the kitchen during service hours was slowly improving. The DM said they had a cleaning schedule for the kitchen which targeted different areas each day for a deeper cleaning. The DM said she would have staff clean up the juice machine counter area and would consider increasing the frequency of the target area for deeper cleaning. Housekeeper (HK) #2 was interviewed on 12/16/25 at 9:11 a.m. HK #2 said although he did not clean the showers he saw some cockroaches in other areas of the facility including in the resident's rooms while cleaning. Certified nurse aide (CNA) #3 was interviewed on 12/16/25 at 9:30 a.m. CNA #3 said he saw most of the cockroaches inside the residents' rooms. CNA #3 said he had recently returned from vacation and said he thought they were much better since he had returned.HK #1 was interviewed on 12/16/25 at 9:40 a.m. HK #1 said she saw the most cockroaches in the shower room. She said she saw about three cockroaches per day in the shower room.Registered nurse (RN) #5 was interviewed on 12/16/25 at 10:34 a.m. RN #3 said she saw a few cockroaches in the building while working the day shift but thought they were probably more active at night.The maintenance director (MTD) was interviewed on 12/16/25 at 11:28 a.m. The MTD said the cockroach infestation had begun a few months ago. He said it got especially bad about three months prior, which led to the facility changing pest control services about two months ago. The MTD said since the new pest control service took over they had closed the kitchen and fumigated certain areas of the facility to eliminate the cockroach problem. The MTD said he thought there were far fewer cockroaches now than there were previously. He said there were still likely some in the building. The MTD said he believed they were on the right track and were continuing to see less and less cockroaches.

Based on record review and interviews, the facility failed to ensure a thorough investigation of alleged misappropriation of funds for two (#1 and #4) of two residents out of 18 sample residents.Specifically, the facility failed to maintain thorough documentation that an alleged violation was thoroughly investigated for the misappropriation of Resident #1 and Resident #4's funds/property. Findings include:I. Facility policy and procedureThe Community Standard Operating policy and procedure, dated 9/4/25, was provided by the nursing home administrator (NHA) on 12/16/25. It read in pertinent part, This policy outlines the community's zero-tolerance stance against resident abuse, neglect, misappropriation of resident property, and exploitation 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. Resident and family training and education is offered at least annually. A Concern/Complaint Report form is completed, in writing, when missing items (clothing, personal care items, jewelry,) are reported. Staff and families are encouraged to complete the reports as necessary. Management staff completes a thorough investigation. The social services director/designee maintains a file of concern/complaint reports and the community action taken. In addition to an investigation by the police department, the community 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. Occurrence of misappropriation of funds for Resident #1 on 8/1/25A. Facility investigationThe facility's investigation, dated 8/2/25, was provided by the NHA on 12/16/25. The investigation revealed the following: On 8/2/25 Resident #1 reported to the NHA that two unidentified individuals entered her room and asked Resident #1 for her debit card to purchase snacks. Resident #1 gave the two individuals her debit card and they never returned with Resident #1's debit card or snacks.Resident #1 described the two assailants as one individual wearing business attire and the other person in nursing clothes. Camera footage reviewed by the NHA revealed no pertinent information matching the description of the two individuals entering Resident #1's room at the time of the alleged incident. The investigation documented the business office manager wrote a letter that documented the resident did not have a debit card while at the facility. -However, the resident had a bank account prior to admission and the details of which bank and what type of account the resident held was unknown to the facility. The facility failed to document if they took any action to obtain the resident's banking information to investigate whether or not the resident had a debit card for her account and to determine if there were any unauthorized charges on her account (see record review and interviews below).The facility investigation documented six other residents who were interviewed regarding the incident. -However, the facility failed to interview facility staff or family.The incident was reported to the police; however the facility did not follow up with the police to see if the case was still active or closed. The facility investigation was closed because the resident was discharged to the hospital before the investigation was completed and did not return to the facility. For this reason, the facility concluded the investigation was unsubstantiated.-However the facility did not continue the investigation to determine if there were any other residents at risk of being victimized by financial exploitation. B. Resident #1 (victim)1. Resident statusResident #1, age less than 65, was admitted on [DATE] and discharged to the hospital on 8/11/25. According to the December 2025 computerized physician orders (CPO), diagnoses included drug induced polyneuropathy, unspecified asthma, depression and hypothyroidism.The 7/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial assistance with all of her activities of daily living (ADL). 2. Record reviewReview of progress notes dated 8/1/25 to 8/4/25 failed to document: -When Resident #1 alerted facility staff of the missing debit card; and, -Attempts to contact Resident #1's family to obtain the resident's banking documentation for the investigation. 3. Staff interviewsThe business office manager was interviewed on 12/16/25 at 3:52 p.m. The business office manager said she had no involvement in the facility's investigation into Resident #1's allegation of misappropriation of funds but was working with the resident to complete a health insurance application. The business office manager said, during the time Resident #1 was in the facility, the resident did not have a debit card in her possession. The business office manager said Resident #1 moved from another state and the facility was trying to get a hold of Resident #1's husband by telephone to obtain bank statements. The business office manager said Resident #1's husband would not contact the facility. The business office manager said she also attempted to contact Resident #1's daughter to obtain bank statements. The business office manager said Resident #1 was sent out to the hospital and transferred to a different facility upon her discharge from the hospital and the application process ended. -However, the facility's investigation did not document any of the business office manager's efforts to work with the resident to gain banking information (see facility investigation above).The NHA was interviewed on 12/16/25 at 4:07 p.m. The NHA said the social services director (SSD) was the designated facility investigator and conducted the investigations and reported the findings for his review. The NHA said the facility made attempts to contact Resident #1's family by telephone but never received any calls back. -However the facility's investigation failed to document who the facility tried to contact or how many times they tried to contact the resident's family and what, if any, information they left for the family member in the messages left. III. Occurrence of misappropriation of funds for Resident #4's on 11/4/25 by Resident #17A. Facility investigationThe facility's investigation, dated 11/3/25, was provided by the NHA on 12/16/25. The investigation revealed the following: On 11/3/25 Resident #4 reported to the SSD that he voluntarily provided his bank account and card information to Resident #17, as Resident #17 assisted Resident #4 with placing orders for fast food and online purchases. The investigation documented Resident #4 told the SSD that he later reviewed his bank statements and found multiple unauthorized transactions, including several Cash App (an online money payment system letting users send and receive money for purchases) money transfers being sent directly to Resident #17 as the recipient. Resident #4 said those transfers were made without his consent. Resident #4 reported an Uber eats (meal delivery system) transaction totaling over $375.00, which he did not authorize. -However, the investigation failed to document the facility's efforts to find out who received this money or what the transaction paid for. The investigation documented Resident #17 was interviewed on 11/3/25 by the SSD and Resident #17 said that all transactions made using Resident #4's account were authorized by Resident #4. Resident #17 said she did not have a Cash App account and was unaware of the nature of the Cash App transactions or why her name appeared in connection with them. The investigation documented that the SSD interviewed two other residents in the facility and one resident told the SSD that Resident #4 was constantly buying food and other things for some of the residents in the facility. The second resident said Resident #4 had Resident #17 ordering from his bank account everyday. The facility reported the incident to the police.-However there was no documentation of follow-up with the police to obtain the status of the investigation.The facility's investigation identified several staff members to interview for the investigation but the staff interviews never occurred. The facility determined they did not need to interview staff because the residents interviewed revealed Resident #4 was willingly purchasing items for them (see NHA interview below). -However, Resident #4 said he did not authorize the Cash App or Uber eats transactions. -The facility's investigation failed to include an interview statement with the business office manager, the staff member who was managing the residents' funds (see business office manager interview below).The facility ended the investigation without documentation of a review of Resident #4's banking records or any investigation into Resident #17's funds and the facility concluded the allegation of misappropriation of Resident #4's funds was unsubstantiated (see NHA interview below). B. Resident #4 (victim)1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, diabetes mellitus with chronic kidney disease and bipolar disorder. The 11/19/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required moderate assistance with dressing, and bathing. 2. Resident #4 interviewResident #4 was interviewed on 12/16/25 at 10:09 a.m. Resident #4 said the social services staff had been helping with the investigation process. He said it had been three or four months now and nobody had followed back up with him to let him know what they found out. Resident #4 said that he had put a freeze on his debit card while the matter got sorted out.Resident #4 said he did not feel pressured by any of the residents in the facility to make purchases using her debit card. He said he did not want to say anything more and did not want other residents finding out he was talking because he had to live with the people in here and did not want any problems. Resident #4 denied giving other residents his banking information or allowing other residents to use his debit card without his permission.3. Record reviewResident #4's care plan, revised on 11/19/25 following the facility's investigation, revealed Resident #4 had a history of poor money management and would often misplace or forget that he had spent his money and then he made accusations the money was stolen.-However the facility's investigation documented the resident's allegation of stolen funds was not a pattern of behavior and failed to document how they came to the conclusion other than possibly based on other resident interviews obtained during the investigation. -Interviews obtained on 12/16/25 from facility staff revealed more information than what was in the facility's investigation dated 11/3/25. The facility was not able to provide sufficient evidence that they fully investigated and held documentation that they thoroughly investigated the allegation of misappropriation of funds by interviewing staff members who possibly witnessed the incident and made efforts to examine banking and financial information that could help the investigator make a most accurate determination of findings (see interviews below).C. Resident #17 (assailant) 1. Resident statusResident #17, age less than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included multiple sclerosis, unspecified asthma, anxiety disorder and lymphedema.The 11/19/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required substantial assistance with all ADLs. 2. Resident #17's interviewResident #17 was interviewed on 12/16/25 at 1:50 p.m. Resident #17 said that she had not been asked by other residents to make purchases from their accounts. Resident #17 said she had not felt pressured by staff or other residents to make purchases. Resident #17 said no one had ever tried to offer her money. Resident #17 said she banked outside of the facility and had three different debit cards. She said she had had no issues with her debit cards. D. Staff interviewsThe business office manager was interviewed on 12/16/25 at 11:05 a.m. The business office manager said the facility managed Resident #4's income. The business office manager said Resident #4 did not frequently requested to take out large amounts of money out of his facility account. The business office manager said instead, he usually asked for $10.00 or $20.00 at a time. The business office manager said she was aware of Resident #4's allegation of stolen funds from his outside bank account but she did not participate in the investigative process for that allegation. The business office manager said the facility had taken Resident #4 to his bank multiple times so he could straighten out his account and manage the small amount he had left in the account. The business office manager was unsure of the current amount in Resident #4's outside bank account and thought it could be at zero, since he had no regular income going into that account. The business office manager had no documentation of the resident's outside account in his financial records. The SSD was interviewed on 12/16/25 at 11:14 a.m. The SSD said the facility offered to assist Resident #4 with his finances, but he refused any assistance. The SSD said the facility staff were aware that Resident #4 gave out his banking information to his peers. The SSD said the facility's process for investigating misappropriation of property included notifying the business office manager to see if the resident had taken money out of their account recently. The SSD said she would determine if the resident had the mental capacity to manage and keep money in their room. The SSD said she would trace the residents actions to see if the money and spending could be accounted for. The SSD said the facility had offered to help Resident #4 with his finances including managing his outside banking account but he refused the assistance. The SSD said Resident #4 had a pattern of giving his bank information to other residents to treat his friends in the facility to a meal. The SSD said there had also been times where Resident #4 could not recall how he spent his money. The SSD said the facility attempted to obtain bank statements from him, but Resident #4 would not provide documentation. The SSD said at times, Resident #4 became difficult to work with. The SSD said Resident #4 had a pattern of misappropriating his money and reporting to the facility. The SSD said Resident #4 appeared not to care about the issue anymore due to his lack of participation with the investigation process. The NHA was interviewed on 12/16/25 at 2:35 p.m. The NHA said the SSD began the investigation. The NHA said he finalized the investigation and reported to the State Agency. The NHA said either he or the SSD reported incidents to law enforcement. The NHA said a good investigation would include interviewing the residents involved and determining if the item was lost, stolen or misplaced. The NHA said Resident #4 and Resident #17 both used each other for money. He said it all depended on who got their money first each month. The NHA said fast food purchases were a common and frequent purchase for both residents. The NHA said Resident #4 often forgot what he purchased and when he saw the charges on his account he assumed someone stole his money. The NHA said all facility staff were aware of the residents using each other's funds and debit cards for various purchases, including food and other items. The NHA said the facility had a recent town hall meeting where staff re-educated the residents on the importance of not using their money on other residents and the effects it could have on their insurance and retirement benefits. The NHA said he would attach the sign-in sheet for town hall meetings to future investigations of misappropriation to show the facility was addressing the issue and providing a thorough investigation. The NHA said the blank staff interview forms were never completed for Resident #4's investigation because after staff interviewed other residents in the facility, the investigative staff determined this was a pattern of mutual spending between Resident #4 and Resident #17.-However the facility failed to document the pattern of mutual spending in the investigation report or how they came to that conclusion in order to document a complete and thorough investigation.

Based on record review and interviews, the facility failed to ensure one (#6) of three residents reviewed were free from abuse out of 18 sample residents. Specifically, the facility failed to protect Resident #6 from physical abuse by certified nurse aide (CNA) #7. Findings include:I. Facility policy and procedureThe Abuse policy, revised September 2025, was provided by the nursing home administrator (NHA) on 12/16/25 at 3:42 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's medical symptoms.The Resident Rights policy, revised February 2021, was provided by the NHA on 12/16/25 at 3:42 p.m. The policy read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; and,i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.II. Resident #6A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included multiple contractures and reduced mobility.The 9/9/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident was dependent on staff for activities of daily living (ADL).B. Facility investigationThe 10/22/25 facility investigation revealed the following:The social services director (SSD) was notified that CNA #7 refused to stop care when Resident #6 had asked the CNA to. The resident yelled out for the CNA to stop. Resident #6 reported pain at the time of this incident but the facility found no lingering physical or mental injury. CNA #7 was suspended following the incident. The SSD interviewed Resident #6 on 10/22/25. The resident told the SSD that CNA #7 entered his room and asked if he was ready to be changed. The resident said CNA #7 pushed him really hard against the wall. The resident said he told CNA #7 that he was hurting him and that he tried to lay back. The resident said CNA #7 then pushed him harder into the wall and his knees were pushed into the window. The resident said he asked CNA #7 to stop and he did not. The resident said he was yelling out and CNA #7 still did not stop. Resident #6 told the SSD that nobody should be treated like that and said he was afraid of CNA #7. The resident said he no longer wanted to be in the facility if CNA #7 was around. The SSD asked the resident if he would feel alright if CNA #7 cared for other residents at the facility and not him. Resident #6 said he would be okay if he never saw CNA #7 again. The investigation documented Resident #15 was interviewed on 10/22/25 by the SSD. Resident #15 was Resident #6's roommate at the time of the incident and was present at the time of incident. Resident #15 said he was behind a curtain during the incident, but heard his roommate yell and ask CNA #7 to stop. Resident #15 said CNA #7 continued despite Resident #6's requests. Resident #15 said he did not believe CNA #7 had any business caring for people. The investigation documented CNA #7 provided a written statement, dated 10/28/25, describing the details of the incident and Resident #6's allegation. The statement documented CNA #7 asked Resident #6 if she could change him and the resident responded that he did not need to be changed. CNA #7 then asked Resident #6 if it was okay if she checked the resident for incontinence. CNA #7 said the resident responded that he did not need to be changed. CNA #7 documented the resident was wet and smelled of feces. CNA #7 wrote that she educated the resident about the importance of being changed to protect the skin. CNA #7 said Resident #6 responded that he did not need to be changed. CNA #7 documented that the resident made a personal attack against her, identified her as a man and then asked for a female CNA. CNA #7 wrote that she then changed the resident. CNA #7 said the resident said stop and that she responded that she was almost done and would not bother him again. C. Resident #15 interviewResident #15 (roommate of Resident #6) was interviewed on 12/16/25 at 12.10 p.m. Resident #15 said he had overheard the incident (on 10/22/25) from behind a curtain. Resident #15 said CNA #7 had continued to change Resident #6's briefs, despite Resident #6 refusing help from CNA #7. Resident #15 said CNA #7 then pushed Resident #6 into a wall following his refusal, causing Resident #6 to scream loudly. Resident #15 said the scream caused a nurse to come in from the hall to see what was going on. III. Staff interviewsCNA #2 was interviewed on 12/16/25 at 9:49 a.m. CNA #2 said Resident #6 was pleasant to work with and did not generally refuse care. CNA #2 said Resident #6 could be a bit hesitant and nervous about receiving care when being assisted, but she personally had a good rapport with the resident.The NHA and the interim director of nursing (DON) were interviewed together on 12/16/25 at 4:07 p.m. The NHA said the facility had not received any previous concerns regarding CNA #7. The NHA said several residents did not like to work with her. The NHA said Resident #6 had reported pain in his knee at the time of the event, but had no continuing health effects from the incident on 10/22/25. The NHA said all staff received training on abuse and resident rights, but no additional training was provided following the incident. The NHA said CNA #7 was fired following the incident and was reported to the Department of Regulatory Agencies ([NAME]). The NHA said he believed this to be an isolated incident and they had no other staff complaints.

Based on observations, interviews and record review, 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 disease and infection. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were followed;-Ensure hand hygiene was performed during medication administration;-Ensure hand hygiene was performed during cleaning of resident rooms; and,-Ensure urine collectors were bagged, dated and labeled when not in use. Findings include: I. Failure to ensure enhanced barrier precautions were followed A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions about EBP in Nursing Homes (6/28/24), retrieved on 8/12/25 from: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters (PICCs)), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. The presence of an indwelling device is a major risk factor for being colonized with or acquiring a MDRO. Therefore, the safest practice would be to wear a gown and gloves for any care (dressing changes) or use (injecting or infusing medications or tube feeds) of the indwelling medical device. B. Observations and staff interview On 8/5/25 at 9:08 a.m., licensed practical nurse (LPN) #1 was providing tube feeding for Resident #78 through her feeding tube. LPN #1 had a mask on. She gathered supplies and entered Resident #78's room. She washed her hands and donned (put on) clean gloves. She removed the cap to the feeding tube and hooked an empty syringe to Resident #78's feeding tube. She measured out 30 milliliters (ml) of water. She pushed the water into the syringe. She poured 240 ml of tube feeding formula into the syringe and let it drain into the tube by gravity. She pushed 30 ml of water into the syringe. She clamped the feeding tube and removed the syringe. She screwed the cap onto the feeding tube and unclamped the feeding tube. -LPN #1 did not wear a gown during the tube feeding procedure. LPN #1 said she should have worn a gown during the administration of tube feeding formula. II. Failure to ensure hand hygiene was completed during medication administration A. Professional reference According to CDC's Clinical Safety: Hand Hygiene for Healthcare Workers (February 2024), retrieved on 7/28/25 from: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, Recommendations to clean your hands include immediately before touching a patient, before performing an aseptic technique, before moving from work on a soiled body site to a clean body site, after touching a patient or patient's surroundings, after contact with body fluids and immediately after glove removal. B. Observations On 8/5/25 at 8:54 a.m. registered nurse (RN) #2 was administering medications. She was preparing medications for Resident #42. RN #2 gathered supplies and entered Resident #42's room. RN #2 donned clean gloves. RN #2 checked Resident #42's blood glucose level. RN #2 administered an insulin injection to Resident #42's abdomen. RN #2 removed her gloves and left the room. RN #2 donned clean gloves and sanitized the blood glucose machine. RN #2 removed the gloves and walked to locate another staff member to help her translate in Resident #42's native language. RN #2 and the other staff member walked into Resident #42's room together and discussed the medications. RN #2 walked out to the medication cart and gathered the additional medications which consisted of a cup of pills and another insulin injection. RN #2 entered Resident #42's room and donned clean gloves, without performing hand hygiene RN #2 handed Resident #42 the cup of pills and administered the insulin injection into Resident #42's lower abdomen. RN #2 removed the gloves and went back out to the cart to put the insulin pen away and began to prepare another resident's medications. -RN #2 failed to perform hand hygiene between gloves changes. III. Failure to ensure hand hygiene was completed during cleaning of resident rooms A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy and procedure, revised August 2013, was received from the nursing home administrator (NHA) on 8/4/25 at 10:05 a.m. It documented in pertinent part, Perform hand hygiene after removing gloves. B. Observations During a continuous observation on 8/7/25, beginning at 8:05 a.m. and ending at 8:23 a.m., the following was observed: Housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER]. HK #1 began by donning clean gloves. She removed used trash bags from the bedroom and bathroom. HK #1 sprayed down the sink and toilet. HK #1 wiped down the high touch surfaces on side A of the room with purple top disinfectant wipes. HK #1 wiped down the sink with a rag. HK #1 disposed of rag. HK #1 wiped down the toilet with a new rag. HK #1 disposed of rag. HK #1 removed gloves and donned clean gloves, without performing hand hygiene. HK #1 wiped down door handles with purple top disinfectant wipes. HK #1 swept the floor. HK #1 mopped the bedroom floor. HK #1 changed the mop head and mopped the bathroom. HK #1 said she was finished cleaning the room and pushed the cart down the hallway. -HK #1 failed to perform hand hygiene between glove changes. IV. Staff interviews The infection prevention nurse (IP) and the nurse consultant were interviewed together on 8/7/25 at 11:00 a.m. The IP said hand hygiene should be completed before resident care, during care if there are gloves changes and after resident care. He said residents should be offered hand hygiene before each meal. He said the importance of hand hygiene is to reduce the transmission of disease. The nurse consultant said residents who have chronic wounds, catheters, ostomies, feeding tubes and tracheostomies should be placed on EBP. She said staff should wear a gown and gloves at minimum when providing resident care to these residents on EBP. She said the importance of this is to reduce the risk of spreading MDROs. The director of nursing (DON) was interviewed on 8/7/25 at 2:25 p.m. She said hand hygiene should be performed by staff before resident care, before gloves were donned and after removing gloves. She said the importance of hand hygiene was to decrease the risk of infection. She said there was no process for offering hand hygiene to residents prior to meals. She said residents who had a feeding tube, wounds, catheters and ostomies should be on EBP and the staff should be wearing a gown and gloves during resident care. She said EBP helped reduce the risk of infection. V. Failure to ensure urine collectors were stored appropriately A. Facility policy and procedures The Cleaning and Disinfection of Resident Care Items and Equipment policy, revised September 2022, was provided by the director of clinical risk management on 8/6/25 at 3:48 p.m. The policy revealed that resident-care equipment, including reusable items and durable medical equipment would be cleaned and disinfected according to current centers for disease control (CDC) recommendations for disinfection and the occupational safety and health administration (OSHA) Bloodborne Pathogens Standard. Critical items consisted of items that carried a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (urinary catheters) or the vascular system (intravenous catheters) were considered critical items and must be sterile when used, based on acceptable sterilization procedures. Sterilization destroyed all viable microorganisms to prevent disease transmission associated with the use of that item. Reusable items (such as stethoscopes and durable medical equipment) were cleaned and disinfected and/or sterilized between residents. B. Observations On 8/4/25 at 9:50 a.m. observations of resident room [ROOM NUMBER] (two female residents) revealed two urinal collectors in the bathroom. One sat upright on the toilet tank lid and the second one was on its side on the wood shelf above the toilet. Neither urine collectors were dated, labeled or bagged. The urine collectors contained brown discoloration on the inside plastic. On 8/4/25 at 11:31 a.m. observations of resident room [ROOM NUMBER] revealed two urine hat collectors (one clear and one white). The urine collectors sat on the wood shelf above the toilet tank lid. Neither urine hat collectors were dated, labeled, or bagged. The white urine hat collector contained brown discoloration on the inside plastic. On 8/6/25 at 9:30 a.m. observations of resident room [ROOM NUMBER] revealed two urinal collectors in the bathroom. One sat upright on the toilet tank lid and the second was on its side on the wood shelf above the toilet. Neither urine collectors were dated, labeled, or bagged. The urine collectors contained brown discoloration on the inside plastic. On 8/6/25 at 11:35 a.m. observations of resident room [ROOM NUMBER] revealed two urinal collectors in the bathroom. One sat upright on the toilet tank lid and the second was on its side on the wood shelf above the toilet. Neither urine collectors were dated, labeled, or bagged. The urine collectors contained brown discoloration on the inside plastic. On 8/6/25 at 11:38 a.m. observations of resident room [ROOM NUMBER] revealed two urine hat collectors (one clear and one white). The urine collectors sat on the wood shelf above the toilet tank lid. Neither urine hat collectors were dated, labeled, or bagged. The white urine hat collector contained brown discoloration on the inside plastic. C. Staff interviews The director of nursing (DON) was interviewed on 8/6/25 at 11:35 a.m. The DON said she observed the urinal collectors in the bathroom. The DON said neither urine collector was dated, labeled or bagged. The DON said they should have been dated, labeled or bagged. The DON said the urinals contained brown discoloration on the inside plastic. The DON said she did not know why urinals were in female rooms. The DON said observed resident room [ROOM NUMBER]. The DON said there were two urine hat collectors. The DON said they should have been dated, labeled, or bagged. The infection preventionist (IP) was interviewed on 8/7/25 at 11:00 a.m. The IP said male urine collectors and urine hat collectors should be labeled with date and room number. The IP said they were starting a new process for disposing of urinals and collector hats. The IP said the facility would replace them weekly. The assistant director of nursing (ADON) was interviewed on 8/7/25 at 12:43 p.m. The ADON said urine collectors should be labeled with the resident's name, date, and room number. The ADON said she was unsure if they should be bagged. The ADON said the urine collectors should be cleaned after each use.

Based on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#12) of two residents reviewed for catheter care out of 43 sample residents.Specifically, the facility failed to ensure Resident #12's catheter tubing and catheter bag were positioned below the resident's bladder. Findings include:I. Facility policy and procedureThe Urinary Catheter Care policy, revised August 2022, was provided by the director of clinical risk management on 8/6/25 at 3:48 p.m. The policy revealed the purpose of this policy was to prevent urinary catheter-associated complications, including urinary tract infections. The staff were to check the resident frequently to be sure he or she was not lying on the catheter and to keep the catheter and tubing free of kinks. Staff were to position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Staff were to notify the supervisor if the resident refused the procedure.II. Resident #2A. Resident statusResident #2, age less than 65, admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), the diagnoses included multiple sclerosis, anxiety, weakness, need for assistance with personal care and neuromuscular dysfunction of the bladder.The 5/29/25 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) of 13 out of 15. The resident required staff setup or clean up assistance for toileting. The assessment indicated the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube) related to a neurogenic bladder. The resident had a urinary tract infection within the last 30-days.B. ObservationsOn 8/4/25 at 9:50 a.m. the resident was sitting in her wheelchair in her room. The resident had a catheter bag attached to the back part of her wheelchair. The catheter bag hung approximately at the location of the resident's mid back. The resident's catheter tubing was positioned on the resident's left thigh and was coiled in two loops. The tubing contained clear fluid with a yellow sediment.On 8/6/25 at 9:30 a.m. the resident was sitting in her wheelchair in her room. The resident had a catheter bag attached to the back part of her wheelchair. The catheter bag hung approximately at the location of the resident's mid back. The resident's catheter tubing was positioned on the resident's left thigh and was coiled in two loops. The tubing contained clear fluid.On 8/6/25 at 11:35 a.m. the resident was sitting in her wheelchair in her room. The resident had a catheter bag attached to the back part of her wheelchair. The catheter bag hung approximately at the location of the resident's mid back. The resident's catheter tubing was positioned on the resident's left thigh and was coiled in two loops. The tubing contained clear fluid.C. Record reviewReview of the August 2025 CPO revealed the following physician's orders:Suprapubic catheter: 16 French (is completely inert for less tissue irritation and encrustation during extended periods of indwelling use) 30 cubic-centimeters balloon for a neurogenic bladder, ordered 5/29/25. Staff were to monitor for placement and function every 24-hours as needed, ordered 5/29/25. Staff were to change the catheter for complication and prior to obtaining a urine sample, ordered 5/29/25. Each shift the staff were to provide catheter care. The staff could apply a drain sponge as needed and ensure the privacy bag was in place. Staff were to ensure the catheter was unobstructed, secured and draining appropriately, ordered 5/25/25. Every Sunday night shift the staff were to replace the graduated cylinder or urinal used for draining the catheter bag. Staff were to as needed change catheter tubing and bag prior to obtaining urine sample, ordered 5/25/25.The suprapubic catheter care plan, revised 12/20/24, revealed due to the resident's neurogenic bladder related to multiple sclerosis the resident required a catheter. The interventions included positioning the catheter bag and tubing below the level of the bladder, providing catheter care every shift to ensure the catheter was unobstructed, secured, and draining appropriately and checking the catheter tubing for kinks with cares and on each shift.III. Staff interviewsThe director of nursing (DON) was interviewed on 8/6/25 at 11:35 a.m. The DON observed Resident #2 sitting in her wheelchair in her room [ROOM NUMBER]. The DON said the resident's catheter bag was attached to the back of the resident's wheelchair at approximately mid back level of the resident. The DONsaid the resident's catheter tubing was coiled, rested on the resident's left leg lap area and contained clean fluid. The DON said the catheter bag and the catheter tubing should not be positioned above the resident's bladder.The infection preventionist (IP) was interviewed on 8/7/25 at 11:00 a.m. T The IP said Foley and suprapubic catheters should be positioned free of coils and kinks so the urine can flow into the drainage bag. The IP said catheter bags should be positioned below the bladder so the urine could flow and the catheter was not obstructed.The assistant director of nursing (ADON) was interviewed on 8/7/25 at 12:43 p.m. The ADON said the catheter bag and tubing should be positioned below the resident's bladder.

Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#38) of three residents reviewed for pressure injuries out of 43 sample residents.Specifically, the facility failed to ensure staff consistently provided care planned interventions to Resident #38, who was admitted to the facility with a stage 4 pressure injury to his sacrum (a triangular bone at the base of the spine that is formed by the fusing of the sacral vertebrae).Findings include:I. Professional reference 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 on 8/11/25 from https://www.internationalguideline.com/guideline, 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 LossPartial 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 LossFull 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 LossFull 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 palpableUnstageable: Depth UnknownFull 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 UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.II. Facility policy and procedureThe Pressure Injury policy and procedure, revised 2/29/24, was received from the nursing home administrator (NHA) on 8/4/25 at 10:05 a.m. It read in pertinent part, Protect skin against the effects of pressure, friction, and shear by reducing pressure over bony prominences by offloading and positioning, and develop turning and repositioning plans for residents in bed or in their chair. Provide dressings and treatments as ordered by the physician and per the plan of care.III. Resident #38A. Resident statusResident #38, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (chronic autoimmune disease that affects the central nervous system), stage 4 pressure ulcer to the sacral region, paraplegia (paralysis of the legs and lower body) and muscle weakness.The 7/15/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was dependent on staff for most activities of daily living (ADL). The assessment documented the resident was dependent on staff for rolling left and right in bed.The assessment indicated the resident was at risk of developing pressure ulcers. The assessment indicated the resident had a stage 4 pressure ulcer present on admission. The assessment indicated the resident was not on a turning or repositioning program. The assessment documented the resident had a pressure-reducing device for his bed.B. Resident interview and observationsResident #38 was interviewed on 8/4/25 at 10:55 a.m. Resident #38 said he had a wound on his bottom. Resident #38 said the facility staff cleaned his wound and changed the dressing every day. Resident #38 said the wound was a little bit painful. Resident #38 said he always laid on his back and the staff did not try to help him roll over.During the interview, Resident #38 was lying on his back on an air mattress. The air mattress was set to the 600 pound (lb)to 1000 lb weight setting on a 30-minute alternating pressure cycle.During a continuous observation on 8/5/25, beginning at 11:08 a.m. and ending at 3:58 p.m., the following was observed:At 11:08 a.m. Resident #38 was lying on his back in bed. Resident #38's mattress was set to the 600 lb to 1000 lb weight setting.At 11:29 a.m. certified nurse aide (CNA) #4 knocked on Resident #38's door and entered his room. CNA #4 asked Resident #38 what he wanted to drink with his lunch and prepared a glass of juice for the resident. CNA #4 set the juice glass on Resident #38's tray table and gave him his bed remote before leaving to continue passing out drinks.At 11:31 a.m. CNA #5 delivered Resident #38's lunch tray and set it up for the resident on his tray table. Resident #38 adjusted his bed so he was sitting at a higher angle, and CNA #5 left the room to continue passing lunch trays.At 11:56 a.m. Resident #38 activated his call light. CNA #5 answered the call light, asked what Resident #38 needed and began cutting the entree on the resident's plate into smaller pieces. CNA #5 left the room promptly after he finished cutting the food.At 12:00 p.m. registered nurse (RN) #4 entered Resident #38's room with a nutritional supplement bottle, opened the bottle and left the bottle on Resident #38's tray table. RN #4 left the room shortly thereafter.At 12:10 p.m. CNA #3 asked Resident #38 if he was finished with his lunch tray. CNA #3 collected Resident #38's lunch tray and left the room.-CNA #3 did not offer to reposition the resident.At 12:15 p.m. Resident #38 activated his call light. CNA #3 and RN #4 entered the room together. Resident #38 requested he be shifted over in his bed and RN #4 left the room. CNA #3 donned a pair of gloves and pulled Resident #38's sheets to the left to pull his body over to the left side of the bed.-However, Resident #38 continued to lie flat on his back and CNA #3 did not encourage the resident to reposition off of his back.At 12:31 p.m. Resident #38 activated his call light. CNA #3 entered the room and asked Resident #38 what he needed. Resident #38 requested for his tablet to be plugged in. CNA #3 plugged the tablet in and asked Resident #38 if he needed anything else before leaving the room. At 12:41 p.m. Resident #38 activated his call light. CNA #5 entered Resident #38's room and the resident told him his wound vacuum was beeping. CNA #3, who was in the hallway outside the resident's room, told CNA #5 the nurse on shift was going to turn off the wound vacuum because it kept malfunctioning.At 12:47 p.m. RN #4 performed hand hygiene, donned a pair of gloves and entered Resident #38's room. RN #4 turned off Resident #38's wound vacuum and left the room. At 12:57 p.m. RN #4 entered Resident #38's room with wound dressing supplies and said she was going to remove the resident's negative pressure dressing. RN #4 left the room to don a gown and gloves and then re-entered the room. RN #4 removed Resident #38's negative pressure dressing and placed a wet-to-dry dressing on an abdominal (wound dressing) pad. RN #4 helped Resident #38 turn back over in bed and laid him flat on his back before leaving the room.-RN #4 did not adjust Resident #38's air mattress settings to the physician ordered and care planned setting of less than 250 pounds (see record review below) before or after providing wound care to the resident. Resident #38's air mattress remained set to the 600 lb to 1000 lb weight setting.At 1:29 p.m. Resident #38 activated his call light and CNA #3 entered the room. Resident #38 requested he be pulled toward the head of his bed. CNA #3 donned gloves and pulled Resident #38 up closer to the head of his bed by pulling his sheets. -However, Resident #38 remained lying flat on his back and CNA #3 did not encourage the resident to reposition off of his back At 1:33 p.m. Resident #38 activated his call light. An unidentified staff member entered Resident #38's room and placed a pillow under his head before promptly leaving.At 1:55 p.m. RN #1 entered Resident #38's room, and the resident requested she help him shift in bed. RN #1 pulled Resident #38 over slightly in bed. -However, Resident #38 was still lying flat on his back and RN #1 did not encourage the resident to reposition off of his back At 2:01 p.m. Resident #38 activated his call light and RN #4 entered the room. RN #4 donned a gown and gloves and briefly entered Resident #38's room to adjust the resident's colostomy bag. RN #4 left the room shortly thereafter and Resident #38 continued lying flat on his back in bed.At 2:24 p.m. the director of rehabilitation (DOR) entered Resident #38's room and began working on breathing exercises with the resident. At 2:40 p.m. the DOR left Resident #38's room. Resident #38 was still lying flat on his back.At 3:58 p.m. Resident #38 was lying flat on his back in bed asleep. Resident #38's air mattress was still set to the 600 lb to 1000 lb weight setting.-Resident #38 was not repositioned, or encouraged to reposition, off of his back and the setting for his air mattress was on the 600 lb to 1000 lb setting for the entirety of the four hour and 50 minute continuous observation.On 8/6/25 at 8:10 a.m. Resident #38 was lying on his back in his bed. Resident #38's air mattress was set to the 600 lb to 1000 lb weight setting.At 10:38 a.m. CNA #7 entered Resident #38's room to clean his wound vacuum and left shortly afterward. Resident #38 continued to lie on his back in bed.At 10:51 a.m. RN #1 entered Resident #38's room and asked him what he needed. RN #1 spoke with Resident #38 briefly before exiting his room. At 11:05 a.m. an unidentified wound care physician was in the hallway speaking with one of the facility's staff members. The unidentified wound care physician asked the staff member if Resident #38 was still refusing to be repositioned. The staff member's answer was not audible.At 11:12 a.m. the unidentified wound care physician exited Resident #38's room. The unidentified wound care physician said Resident #38's wound looked a little bit better.At 11:42 a.m. an unidentified staff member donned a gown and gloves and entered Resident #38's room to ask the resident what he wanted to drink for lunch. The staff member asked Resident #38 if he was comfortable, and the resident said he was. Resident #38 was lying flat on his back.On 8/7/25 at 8:54 a.m. Resident #38 was lying on his back in bed. Resident #38's air mattress was set to the 600 lb to 1000 lb weight setting.At 9:56 a.m. the assistant director of nursing (ADON) entered Resident #38's room. The ADON asked Resident #38 if he was in any pain and the resident said he was. The ADON asked Resident #38 if he wanted any pain medications before she looked at his wound but the resident declined to take anythingResident #38 was turned to his side by an unidentified nursing staff member. The ADON said there was a wound vacuum to Resident #38's coccyx and black foam covered Resident #38 from his coccyx to his hip. The wound vacuum was set to 125 millimeters of mercury (mmHg).-However, Resident #38's air mattress was set to the 600 lb to 1000 lb weight setting, which was not the physician ordered and care planned setting for the mattress (see record review below).C. Record reviewThe skin integrity care plan, revised 7/24/25, revealed Resident #38 admitted to the facility with a stage 4 sacral pressure injury and was at increased risk for alteration in skin integrity due to decreased mobility. Pertinent interventions included using an air mattress set to 250 pounds (lbs) firmness, following facility protocols for the treatment of Resident #38's pressure injury and using caution during transfers and bed mobility.Review of Resident #38's August 2025 CPO revealed the following physician's orders:Alternating pressure mattress to bed, set at less than 250 lbs firmness. Check the mattress each shift for proper setting and function. May adjust for resident comfort, ordered 7/11/25.Encourage resident to turn and reposition as tolerated every shift for wound care, ordered 7/17/25.Review of the July 2025 treatment administration record (TAR), from 7/9/25 through 7/30/25, revealed the physician's orders to encourage Resident #38 to turn and reposition and to monitor the resident's air mattress for setting and function were documented as completed each day, as ordered. There were no documented refusals from Resident #38 for repositioning or turning.Review of Resident #38's August 2025 TAR, from 8/1/25 through 8/7/25, revealed the physician's orders to encourage Resident #38 to turn and reposition and to monitor the resident's air mattress for setting and function were documented as completed each day, as ordered. There were no documented refusals from Resident #38 for repositioning or turning.A wound progress note, dated 7/17/25 at 12:41 p.m., revealed Resident #38's sacral wound had been evaluated by the wound care physician (WCP). Interventions in place included an air mattress which was functioning properly, a side bar to the right side for independent mobility in bed, nutritional supplements and wound debridement. Updates included following up with a plastic surgeon for a procedure to close the wound. A wound progress note, dated 7/23/25 at 7:21 p.m., revealed Resident #38's sacral wound had been evaluated by the WCP and had improved. Interventions in place included an air mattress which was functioning properly, a side bar to the right side for independent mobility in bed, nutritional supplements and wound debridement. Updates included following up with a plastic surgeon for a procedure to close the wound and discontinuing the negative pressure dressing (wound vac) due to the wound size getting too small.A wound progress note, dated 7/30/25 at 6:55 p.m., revealed Resident #38's sacral wound had been evaluated by the WCP and had worsened. Interventions in place included an air mattress which was functioning properly, a side bar to the right side for independent mobility in bed, nutritional supplements and wound debridement. The note documented Resident #38 did not like to turn and reposition.A wound progress note, dated 8/7/25 at 11:57 a.m., revealed Resident #38's sacral wound had been evaluated by the WCP and had improved. Interventions in place included an air mattress which was functioning properly, a side bar to the right side for independent mobility in bed, nutritional supplements and wound debridement. Updates included following up with a plastic surgeon for a procedure to close the wound. The WCP visit note, dated 7/16/25, revealed Resident #38's sacral wound was a stage 4 pressure ulcer. The wound measured 4.6 centimeters (cm) in length, 3.4 cm in width and 0.3 cm in depth. Tunneling of the wound (a wound that extends into the surrounding tissue, forming a channel or tract beneath the skin's surface) was noted at the 12:00 position with a maximum distance of 0.5 cm. The wound bed was 90% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 10% slough (a type of tissue that is not actively healing and can delay the wound healing process and typically appears as yellow or white, soft, and moist material in the wound bed). The periwound skin (the area of skin immediately surrounding a wound, typically extending about 1.5 inches from the wound's edge) exhibited maceration (refers to the softening and breakdown of skin due to prolonged exposure to moisture). Orders included cleansing the wound with wound cleanser and applying a negative pressure dressing (wound vacuum). Additional orders included turning and repositioning Resident #38 frequently while he was in bed or in his chair and shifting his weight frequently, placing the resident on an air mattress and checking for mattress function each shift.-However, observations revealed staff did not reposition, or encourage Resident #38 to reposition off of his back, for nearly five hours on 8/5/25 (see observations above).The WCP visit note, dated 7/23/25, revealed Resident #38's sacral wound was a stage 4 pressure ulcer. The wound measured 3.5 cm in length, 2.4 cm in width and 0.3 cm in depth and had improved. The wound bed was 90% granulation and 10% slough. The periwound skin was normal. Orders included cleansing the wound with wound cleanser, applying a periwound skin protectant, applying a silver alginate dressing with barrier cream followed by bordered foam every day. Additional orders included turning and repositioning Resident #38 frequently while he was in bed or in his chair and shifting his weight frequently, placing the resident on an air mattress and checking for mattress function each shift.-However, observations revealed staff did not reposition, or encourage Resident #38 to reposition off of his back, for nearly five hours on 8/5/25 (see observations above).The WCP visit note, dated 7/30/25, revealed Resident #38's sacral wound was a stage 4 pressure ulcer. Nursing staff reported to the WCP that Resident #38 had refused to turn and reposition in bed despite encouragement from the wound care team and staff. The wound measured 4.4 cm in length, 2.5 cm in width and 0.4 cm in depth and had deteriorated. There was tunneling at the 7:00 position with a maximum distance of 1 cm. Bone was exposed. The wound bed was 80% granulation and 20% slough. The periwound skin exhibited maceration and erythema. Orders included cleansing the wound with wound cleanser and applying a negative pressure dressing. Additional orders included turning and repositioning Resident #38 frequently while he was in bed or in his chair and shifting his weight frequently, placing the resident on an air mattress and checking for mattress function each shift.-However, observations revealed staff did not reposition, or encourage Resident #38 to reposition off of his back, for nearly five hours on 8/5/25 (see observations above).The WCP visit note, dated 8/6/25, revealed Resident #38's sacral wound was a stage 4pressure ulcer. The wound measured 4.4 cm in length, 2.5 cm in width and 0.4 cm in depth and had improved. There was tunneling at the 12:00 position with a maximum distance of 0.5 cm. The wound bed was 70% granulation 20% slough and 10% epithelialization. The periwound skin exhibited erythema. Orders included cleansing the wound with wound cleanser and applying a negative pressure dressing. Additional orders included turning and repositioning Resident #38 frequently while he was in bed or in his chair and shifting his weight frequently, placing the resident on an air mattress and checking for mattress function each shift.-However, observations revealed staff did not reposition, or encourage Resident #38 to reposition off of his back, for nearly five hours on 8/5/25 (see observations above).Review of Resident #38's CNA bed mobility task records, from 7/9/25 through 8/7/25, revealed there were no refusals of bed mobility documented for Resident #38 during the time period. The records revealed Resident #38 was dependent on staff or required partial to substantial assistance with bed mobility almost every day during the time period.IV. Staff interviewsCNA #5 was interviewed on 8/7/25 at 9:13 a.m. CNA #5 said Resident #38 had a lot of needs he needed assistance with. CNA #5 said Resident #38 used his call light whenever he wanted his meal trays removed, his colostomy bag checked or his legs moved over in bed. CNA #5 said Resident #38 mostly listened to his music and kept to himself. CNA #5 said Resident #38's legs turned to the left, so the staff had to help him adjust his legs and put a pillow under his neck. CNA #5 said Resident #38 was not able to roll to the left or right by himself. CNA #5 said once the staff put Resident #38 into a certain position, he stayed that way. CNA #5 said Resident #38 was not on any repositioning or turning programs.The ADON was interviewed on 8/7/25 at 9:56 a.m. The ADON said Resident #38's air mattress was set to the 600 lb to 1000 lb weight setting because the mattress was changed to auto-firm when they were about to perform wound care. The ADON said the auto-firm setting on the air mattress automatically adjusted the weight setting to the 600 lb to 1000 lb, and the nursing staff had to manually change it back to the correct less than 250 lb setting when they were done.-However, observations revealed the mattress was left on the 600 lb to 1000 lb weight setting on multiple occasions when wound care was not being provided (see observations above).The ADON was interviewed a second time on 8/7/25 at 3:01 p.m. The ADON said Resident #38 had admitted to the facility with a stage 4 pressure ulcer to his coccyx. The ADON said Resident #38 did not have a wound vacuum when he first admitted to the facility, but the WCP ordered a wound vacuum after his first assessment of the wound. The ADON said the WCP had discontinued Resident #38's wound vacuum a few weeks prior because the resident's wound had gotten smaller. The ADON said the week prior (week of 7/27/25) Resident #38's wound had gotten a bit bigger so the wound vac was replaced. The ADON said Resident #38's wound looked a bit better the week of the survey (8/7/25). The ADON said the interventions in place for Resident #38 included having an air mattress and turning and repositioning the resident as tolerated. The ADON said Resident #38 was noncompliant with repositioning and turning. The ADON said the facility staff had talked to Resident #38 about repositioning and told him if he wanted his wound to heal he needed to turn on his side.-However, record review did not reveal documentation that the resident refused to reposition (see record review above). The ADON said Resident #38 needed assistance from the staff to turn on his side, as he could not turn on his own but could shift his weight independently. The ADON said the nursing staff were expected to go into Resident #38's room and encourage him to reposition or turn. The ADON said the nursing staff offered repositioning/turning every time they went into his room.-However, repositioning was not offered, nor did staff encourage Resident #38 to reposition off of his back, during observations throughout the survey process (see observations above). The ADON said Resident #38's air mattress was supposed to be set to less than 250 lbs. The ADON said the air mattress was set to the 600 lb to 1000 lb weight setting whenever the nursing staff were doing wound care, but it required unlocking the mattress, setting it to that weight and then relocking the mattress. The ADON said it did not make sense that Resident #38's mattress would stay set at the 600 lb to 1000 lb weight setting.-However, during multiple observations on several occasions, Resident #38's mattress was set to the 600 lb to 1000 lb setting (see observations above).The DOR was interviewed on 8/7/25 at 10:54 a.m. The DOR said he had worked with Resident #38 for physical therapy. The DOR said Resident #38 was assessed by the therapy team on 7/17/25. The DOR said Resident #38 required minimal staff assistance for bed mobility during his assessment and was able to turn left and right in bed with minimal staff assistance. The DOR said Resident #38 had a grab bar in place in his room to help him roll over. The DOR said Resident #38 did about 75% of the work in rolling over and needed an additional 25% of work from the staff in order to roll over.RN #5 was interviewed on 8/7/25 at 12:33 p.m. RN #5 said Resident #38 had a wound on his sacrum and she had changed out his wound vac the day prior. RN #5 said Resident #38 sometimes used his call light to ask for help with repositioning. RN #5 said Resident #38 needed help from the staff to turn over. RN #5 said Resident #38 was repositioned whenever he used his call light and told the nursing staff how he wanted to be repositioned.-However, Resident #38 was supposed to be offered repositioning and turning throughout the day (see interviews below and record review above).The WCP was interviewed on 8/7/25 at 2:48 p.m. The WCP said Resident #38 initially had a wound vacuum, but his wound was too small for the wound vacuum so it was removed. The WCP said the following week Resident #38's wound had deteriorated, so the wound vacuum was put back in place. The WCP said Resident #38's wound had improved during the week of the survey process (8/7/25). The WCP said he had discussed offloading weight and nutrition for Resident #38, and he was in contact with a surgeon at a hospital regarding surgically closing the resident's wound. The WCP said he documented any resident care refusals in his notes. The WCP said Resident #38 had an air mattress in place. The WCP said the air mattress redistributed pressure over the body's pressure points, as hard pressure points pinched bony prominences. The WCP said the air mattress settings were based on weight and physician's orders for the weight settings were done by the facility.The nurse consultant was interviewed on 8/7/25 at 2:55 p.m. The nurse consultant said the WCP had the facility staff raise the pressure of the air mattress high before wound rounds so the resident did not sink into the mattress during his exam and so he could see the full extent of the wound. The nurse consultant said the nursing staff were supposed to decrease the air mattress settings back to what they were normally after completing their care.The director of nursing (DON) was interviewed on 8/7/25 at 3:31 p.m. The DON said Resident #38 had physician's orders in place for a wound vacuum for his sacral wound. The DON said Resident #38 had interventions including an air mattress, wound rounds with the WCP once per week, a grab bar on the wall to help with repositioning and nutritional supplements. The DON said Resident #38 was partially to substantially dependent on help from staff for bed mobility. The DON said Resident #38's air mattress was supposed to be set to less than 250 lbs normally, but the air mattress was set to auto firm or 600 lb to 1000 lbs for wound care. The DON said Resident #38's physician's orders and the care plan both specified his air mattress should be set to less than 250 lbs firmness. The DON said the nursing staff should offer Resident #38 repositioning and turning whenever they were in his room and talking with him. The DON said the nursing staff would ideally offer repositioning for Resident #38 every two hours, or at least between mealtimes and when providing other cares. The DON said the staff could document Resident #38's refusals to reposition in the TAR under the physician's order to offer and encourage repositioning.-However, review of Resident #38's TARs did not reveal any documented refusals for repositioning (see record review above).

Based on interviews and record review, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#82) of three residents out of 43 sample residents.Specifically, the facility failed to:-Ensure an assessment was completed to identify potential trauma behaviors for Resident #82, who had a diagnosis of post-traumatic stress disorder (PTSD); and,-Develop a care plan for Resident #82's PTSD that included possible escalating triggers (stimuli that cause a person to experience intense emotional distress or for the person to react in ways that were reminiscent of past traumatic experiences) and appropriate interventions.Findings include:I. Facility policy and procedureThe Trauma-Informed and Culturally Competent Care policy, revised August 2022, was provided by the nursing home administrator (NHA) on 8/7/25 at 11:55 a.m. The policy revealed that it guided staff in providing care that was culturally competent and trauma-informed in accordance with professional standards of practice. The policy was to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma resulted from an event, series of events, or set of circumstances that was experienced by an individual as physically or emotionally harmful or life threatening and that had lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Trauma-informed care was an approach to delivering care that involved understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognized the widespread impact, signs and symptoms of trauma in residents, and incorporated knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.Triggers were highly individualized. Some common triggers might include experiencing a lack of privacy or confinement in a crowded or small space; exposure to loud noises, or bright/flashing lights; certain sights, such as objects; and/or sounds, smells, and physical touch.The staff would perform universal screening of residents, which included a brief, non-specialized identification of possible exposure to traumatic events. Staff would utilize screening tools and methods that were facility-approved, competently delivered, culturally relevant and sensitive. Screening might include information such as a trauma history, including type, severity and duration; depression, trauma-related or dissociative symptoms; risk for safety (self or others); concerns with sleep or intrusive experiences; behavioral, interpersonal or developmental concerns; historical mental health diagnosis; substance use; protective factors and resources available; and physical health concerns.The assessment involved an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. The assessment utilized licensed and trained clinicians who had been designated by the facility to conduct trauma assessments. The staff would use assessment tools that were facility-approved and specific to the resident population.The staff would develop individualized care plans that addressed past trauma in collaboration with the resident and family, as appropriate. The staff would identify and decrease exposure to triggers that might re-traumatize the resident and recognize the relationship between past trauma and current health concerns (substance abuse, eating disorders, anxiety and depression). The staff would develop individualized care plans that incorporated language needs, culture, cultural preferences, norms and values. These values might include food preparation and choices; clothing preferences such as covering hair or exposed skin; physical contact or provision of care by a person of the opposite sex; and/or cultural etiquette, such as avoiding eye contact or not raising the voice.II. Resident #82A. Resident statusResident #82, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Parkinsonism, schizoaffective disorder bipolar type, depression, moderate intellectual disability and PTSD.The 6/24/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment indicated the resident had no behaviors. The assessment indicated the resident had a diagnosis of PTSD.B. Record reviewA psychological follow up note, dated 7/2/25 at 8:15 a.m. and written by a nurse practitioner (NP), revealed Resident #82 continued to have severe cognitive deficits with behavioral disturbances secondary to dementia. The resident had diagnoses of dementia with behavioral disturbances, schizoaffective disorder and PTSD.-Review of Resident #82's electronic medical record (EMR) failed to reveal an assessment for trauma behaviors. -Review of Resident #82's EMR failed to reveal a care plan for the resident's diagnosis of PTSD which included identified triggers and appropriate interventions.III. Staff interviewsThe social worker quality mentor was interviewed on 8/7/25 at 11:31 a.m. The social worker quality mentor agreed Resident #82's 6/24/25 MDS assessment revealed the resident had a diagnosis of PTSD. The social worker quality mentor said she was unable to find the original trauma behavior assessment in the resident's EMR. She agreed the Resident Trauma Behavior assessment was completed on 8/6/25 at 9:10 a.m., during the survey. She said this assessment should have been completed in 2022 when the regulation for trauma informed care was initiated. The social worker quality mentor said the facility completed a care plan for Resident #82's PTSD on 8/6/25, during the survey. She said since the resident's MDS assessment had a diagnosis of PTSD, a care plan with triggers and interventions should have been developed prior to 8/6/25. The director of nursing (DON) was interviewed on 8/7/25 at 12:13 p.m. The DON agreed Resident #82's 6/24/25 MDS assessment revealed the resident had a diagnosis of PTSD. The DON said the PTSD diagnosis should have generated a care plan for PTSD. The DON said a care plan for PTSD was developed on 8/6/25, during the survey. She said trauma informed assessments should be completed within the first seven days after a resident was admitted to the facility.The assistant director of nursing (ADON) was interviewed on 8/7/25 at 12:43 p.m. The ADON said for a resident with a diagnosis of PTSD, such as Resident #82,, a trauma assessment should have been completed and a care plan developed. The ADON said the PTSD assessment and care plan should be developed within the first seven days after admission to the facility.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#14) of two residents reviewed for hospice services out of 43 sample residents.Specifically, the facility failed to ensure the hospice agency notes regarding Resident #14's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency.Findings include:I. Facility policy and procedureThe Hospice Care policy and procedure, revised 2/29/24, was received from the nursing home administrator (NHA) on 8/7/25 at 3:25 p.m. It read in pertinent part, When a facility resident elects to have hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based upon an assessment of the resident's needs and living situation in the facility. Hospice communication will be reviewed and added to the medical record.II. Facility-Hospice contractThe contract between the facility and the hospice services company, dated 5/27/25, was found in Resident #14's electronic medical record (EMR). It read in pertinent part, The hospice and nursing facility shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving services. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each hospice patient. The nursing facility and the hospice shall promptly document in the resident's records the services rendered.III. Resident #14A. Resident statusResident #14, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included pulmonary embolism (a blood clot in the lungs), malignant neoplasm of the esophagus (cancer in the throat), symptoms and signs involving cognitive functions and awareness, depression, bipolar disorder and adult failure to thrive.The 5/28/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent for most activities of daily living (ADL). The assessment documented the resident was receiving hospice care. B. ObservationsDuring a continuous observation on 8/5/25 from 1:19 p.m. to 3:58 p.m., the following was observed:At 2:50 p.m. an unidentified member of the therapy team entered Resident #14's room to see if his roommate was there before promptly leaving the room.At 2:58 p.m. RN #4 briefly entered Resident #14's room, checked in with him, and left the room.At 2:59 p.m. an unidentified member of the therapy team entered Resident #14's room with his roommate.At 3:03 p.m. unidentified member of the therapy team left Resident #14's room and continued working on therapy skills with his roommate in the hallway.At 3:48 p.m. Resident #14 was lying on his side and wearing an incontinence brief. At 3:55 p.m. an unidentified hospice staff member entered Resident #14's room, closed the door, then left the room one minute later.C. Record reviewThe August 2025 CPO revealed a physician's order for Resident #14 indicating he was receiving hospice care, ordered 5/23/25.The hospice care plan, revised 5/28/25, revealed Resident #14 was receiving additional support through hospice care. Pertinent interventions included the hospice nurse visiting one to two times per week, the hospice CNA visiting twice weekly to assist with showers, grooming and hygiene, the hospice chaplain and social worker to visit monthly and as needed, and adjusting the provision of ADLs to compensate for Resident #14's changing abilities.Resident #14's hospice binder was provided by an unidentified nursing staff member on 8/6/25 at 10:25 a.m. The hospice binder revealed two hospice nurse visits, dated 5/23/25 and 5/24/25. Review of the hospice CNA documents in the binder revealed the hospice CNAs were scheduled to visit twice a week on Tuesday and Thursday afternoons. There were documented CNA visits on 6/17/25, 6/19/25, 7/10/25, 7/15/25, 7/17/25, 7/24/25, 7/29/25, 7/31/25 and 8/5/25. -The 8/5/25 CNA visit documented the hospice CNA visited Resident #14 from 1:55 p.m. to 2:15 p.m. -However no staff members were observed entering Resident #14's room during that time (see observations above).A progress note, dated 5/23/25 at 5:43 p.m., revealed hospice staff were at the facility to evaluate Resident #14.A progress note, dated 6/10/25 at 1:06 p.m., revealed Resident #14 refused all of his medications. The hospice provider was notified.A progress note, dated 6/16/25 at 1:35 p.m., revealed Resident #14 refused all of his medications. The hospice provider was notified.A progress note, dated 6/19/25 at 9:05 a.m., revealed Resident #14 refused all of his medications. The hospice provider was notified.A progress note, dated 6/24/25 at 8:47 p.m., revealed Resident #14 refused all of his medications. The hospice provider was notified.A progress note, dated 6/27/25 at 9:47 a.m., revealed Resident #14 was receiving hospice care and refused to work with staff at times.A progress note, dated 7/7/25 at 10:54 p.m., revealed Resident #14 refused all of his medications. The hospice provider was notified.A progress note, dated 7/14/25 at 4:12 p.m., revealed a CNA called the nurse to evaluate Resident #14's bottom. The nurse noted Resident #14 had hemorrhoids. The hospice nurse was notified when she was in the building that day and said she would fax over a new order to the facility.A progress note, dated 7/18/25 at 10:03 p.m., revealed Resident #14 refused all of his meals and fluids. The hospice nurse was notified.A progress note, dated 7/18/25 at 10:14 p.m., revealed Resident #14 refused all of his meals and fluids. The hospice nurse was notified.A progress note, dated 7/25/25 at 4:58 p.m., revealed Resident #14 had bruised areas on his bilateral forearms. Resident #14 said they were caused by him sleeping with his arm under his bed. Resident #14 was offered another pillow and declined it. The hospice nurse was notified.A progress note, dated 7/28/25 at 1:49 p.m., revealed Resident #14 refused all of his medications. The hospice nurse was notified.-Review of Resident #14's EMR failed to reveal any documentation from the hospice provider regarding hospice services and/or hospice visits provided to the resident IV. Staff interviewsCNA #5 was interviewed on 8/7/25 at 9:13 a.m. CNA #5 said a staff member from the hospice services team came to check in on Resident #14 sometimes. CNA #5 said the facility staff let the hospice staff member know how Resident #14 had been.CNA #4 was interviewed on 8/7/25 at 9:44 a.m. CNA #4 said Resident #14 was on hospice, so the facility CNAs were there just to make sure the resident was clean and fed. CNA #4 said the hospice staff came in to talk with him and sometimes offered him a shower. CNA #4 said the hospice staff members came in every day. CNA #4 said the hospice staff checked in with the nurse to tell them what they did for Resident #14 and what he still needed, and the nurse then told the facility CNAs what they still needed to do for him.-However, there were only documented hospice CNA visits for Resident #14 on 6/17/25, 6/19/25, 7/10/25, 7/15/25, 7/17/25, 7/24/25, 7/29/25, 7/31/25 and 8/5/25 (see record review above). Registered nurse (RN) #5 was interviewed on 8/7/25 at 12:33 p.m. RN #5 said Resident #14 was receiving hospice care. RN #5 said hospice visits were usually documented in a hospice binder.The director of nursing (DON) was interviewed on 8/7/25 at 3:31 p.m. The DON said Resident #14 was receiving hospice services. The DON said the hospice CNAs visited the facility multiple times per week and the hospice nurses visited one to two times per week. The DON said Resident #14's care plan specified the hospice CNAs would visit twice per week. The DON said the hospice nurses checked in with her or the assistant director of nursing (ADON) before they left the facility. The DON said she did not know if there was anyone at the facility that monitored and saw how often the hospice staff members visited the facility. The DON reviewed Resident #14's hospice binder and said there were missing hospice visits for the resident. The DON said she would call the hospice provider and get Resident #14's records.The NHA was interviewed on 8/7/25 at 4:15 p.m. The NHA said he or the DON oversaw the hospice visits for the residents. The NHA said a hospice caseworker had recently checked in with the facility staff. The NHA said he was not aware of any missing hospice CNA or nurse documentation for Resident #14.V. Facility follow-upAdditional hospice documents were provided by the NHA via email on 8/10/25 at 11:47 a.m. The documents revealed Resident #14 had been visited by a hospice nurse at least twice per week from 5/23/25 through 8/7/25. The hospice documents additionally documented that a CNA had visited Resident #14 on 6/17/25, 6/19/25, 6/24/25, 7/10/25, 7/15/25, 7/17/25, 7/22/25, 7/24/25, 7/29/25, 7/31/25 and 8/5/25.-However, the hospice documents were obtained from the hospice provider during the survey process and were not readily available to nursing staff during the survey. -Additionally, there were no documented hospice CNA visits on 6/26/25, 7/1/25, 7/3/25, 7/8/25 and 7/10/25 provided in the additional information sent by the NHA.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication storage carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts. Findings include: I. Professional ReferencePharMerica (1/12/25) Abridged List of Medications with Shortened Expirations Dates, was retrieved on 8/12/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. it revealed in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's Package Insert (PI) under the 'How Supplied/Storage & Handling' section. A drug product's Beyond Use Date (BUD) is the manufacturer supplied expiration date OR the shortened date after opening (see BUD Notes below), whichever comes first. These In-Use medications should be labeled such that the 'date opened' is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration.Pharmcare USA (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 8/12/25 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/#:~:text=As%20an%20experienced%20healthcare%20professional,a%20legal%20and%20ethical%20obligation. It revealed in pertinent part, When medications are not disposed of correctly, they can pose serious threats to bother human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death.II. Failure to ensure medications were labeled with the date they were openedA. Observations and staff interviews On 8/6/25 at 1:59 p.m., the South back medication cart was observed with licensed practical nurse (LPN) #1. The following items were found: -An open inhaler of Trelegy 200 micrograms (mcg)/62.5 mcg/25 mcg (long term maintenance inhaler for asthma and chronic obstructive pulmonary disease) was labeled with a resident's name and dosage information, but no open date. -An open inhaler of Trelegy 100 mcg/62.5 mcg/25 mcg was labeled with a resident's name, but no open date. -An open inhaler of Spiriva (medication to relax the muscles in the airway) 2.5 mcg was labeled with a resident's name, but no open date. -An open inhaler of Airsupra (medication for asthma) 90 mcg/90 mcg was labeled with a resident's name, but no open date.-An open inhaler of Albuterol (medication to relax the muscles in the airway) 90 mcg was labeled with a resident's name, but no open date.LPN #1 said she was not aware that the inhaler medications should have been labeled with an open date. On 8/6/25 at 3:15 p.m., the North front medication cart was observed with LPN #2. The following items were found:-An open inhaler of Albuterol 90 mcg was labeled with a resident's name, but no open date.-An open bottle of Dorzolamide-timolol 2%/0.5% (eye drop) was labeled with a resident's name, but no open date.-An open bottle of Polymyxin B sulfate and trimethoprim (eye drop) was labeled with a resident's name, but no open date.-An open bottle of Timolol malate 0.25% (eye drop) was labeled with a resident's name, but no open date.-An open bottle of Simbrinza 1%-0.2% (eye drop) was labeled with a resident's name, but no open date.LPN #2 said he did not know the inhalers or the prescription eye drops should have been labeled with an open date.IV. Failure to ensure expired medications were removed and discarded from medication cartsA. Observations and staff interviews On 8/6/25 at 1:59 p.m., the South back medication cart was observed with LPN #1. The following items were found: -An open bottle Biofreeze (pain relief) gel 4% was labeled with a resident's name and had an expiration date verified with LPN #1 of 7/20/25. -A partially used medication card containing duloxetine (antidepressant) was labeled with a resident's name and had an expiration date verified with LPN #1 of 3/29/25. LPN #1 said they no longer used that medication for that resident. She said expired medication should be discarded. On 8/6/25 at 3:15 p.m., the North front medication cart was observed with LPN #2. The following was observed: -An open bottle of Biofreeze gel 4% was labeled with a resident name and had an expiration date verified with LPN #2 of July 2025. -An open bottle of ferrous sulfate (iron pills) 325 milligrams (mg) had no expiration date verified with LPN #2 on the bottle. -A partially used medication card containing hydralazine (blood pressure medication) 25mg was labeled with a resident's name and had an expiration date verified with LPN #2 of 6/29/25. -An open bottle of guaifenesin (mucous relief medication) 600 mg had an expiration date verified with LPN #2 of April 2025. -An open bottle of calcium 600 mg had an expiration date verified with LPN #2 of March 2025. -A partially used medication card containing furosemide 40 mg labeled with a resident name had an expiration date verified with LPN #2 of 8/2/25. LPN #2 said it was not best practice to keep expired medications in the medication carts. He said night shift nurses audit the medication carts and storage rooms. III. Additional staff interviews The director of nursing (DON) was interviewed on 8/7/25 at 2:26 p.m. She said she was not sure of the previous DON's process for auditing medication carts and storage rooms. She said the new process going forward would be for the nurse managers to audit the carts and rooms on a weekly basis and for the DON to audit them on a monthly basis. She said it was important to dispose of expired medications to decrease the possibility of medication errors and for the availability of space in the medication cart and storage rooms. She said eye drops should be labeled with an open date because they were generally good for 30 days. She said inhalers should be labeled with an open date. She said she was not aware about the specific time frames each inhaler was good for after the open date (see professional references above).

Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#42) of two residents reviewed for medications errors out of 42 sample residents.Specifically, the facility failed to ensure that Resident #42 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.Findings include: I. Facility policy and procedureThe Medication Administration policy and procedure, revised 8/4/25, was received from the nursing home administrator (NHA) on 8/7/25 at 3:25 p.m. It documented in pertinent part, Medication is to be given in compliance with the physician orders and/or the manufacturer's recommendations.II. Manufacturer's recommendationsThe Lantus Solostar (prefilled insulin pen) medication package insert (2022) was retrieved on 8/11/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.sanofi.com/assets/countries/canada/docs/products/prescription-products/lantus-solostar-en.pdf. It revealed in pertinent part, Solostar is a prefilled pen for the injection of insulin. Always use a new sterile needle for each injection. Wipe the rubber seal with alcohol. Remove the protective seal from a new needle. Line up the needle with the pen and keep it straight as you attach it (screw or push on, depending on the needle type). Always perform a safety test before each injection. This ensures that you get an accurate dose by ensuring the pen and needle work properly and removing air bubbles. You must always perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you see insulin coming out of the needle tip, the pen is ready to use. If you do not see insulin coming out before taking your dose, you could get an underdose or no insulin at all. This could cause high blood sugar.III. Resident #42A. Resident status Resident #42, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (high blood sugar levels) with neuropathy (nerve damage).The 4/3/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score (BIMS) score of 12 out of 15. The MDS assessment indicated the resident was on daily injection medication for diabetes. B. ObservationsOn 8/9/25 at 8:54 a.m. registered nurse (RN) #2 was preparing Resident #42's medications for administration. RN #2 prepared the medications and went to the refrigerator for a new Lantus insulin pen. She said she was going to administer the other medications to the resident and let the pen warm up to room temperature. She checked Resident 42's blood glucose level which was 155 milligrams (mg)/deciliter (dl). She administered Resident #42's Humalog insulin. Resident #42 was eating breakfast and started to speak in Spanish. RN #2 said she did not speak that language and went to find another staff member who could translate for her. While RN #2 was waiting for the other staff member to come translate, she prepared the Resident #42's Lantus insulin pen. She sanitized the rubber stopper, applied the needle and turned the dose meter dial to 24 units of insulin. She went back into Resident #42's room with another staff member who assisted with translation. RN #2 explained to Resident #42 that she was giving her the morning medications and insulin. RN #2 administered the resident's pills and then injected the Lantus insulin into Resident #42's lower abdomen. -RN #2 failed to prime the Lantus insulin pen prior to drawing up the 24 units of insulin. C. Record review A review of Resident #42's August 2025 CPO revealed the following physician's order: Insulin glargine solution 100 units/milliliter (ml), inject 24 units subcutaneously one time a day for diabetes with breakfast and inject 20 units subcutaneously at bedtime for non-insulin dependent diabetes mellitus (NIDDM), ordered 7/14/25.IV. Staff interviewsRN #2 was interviewed on 8/5/25 at 9:15 a.m. RN #2 said she primed Resident #42's Lantus insulin pen with two units of insulin before she put the needle on. The director of nursing (DON) was interviewed on 8/6/25 at 10:46 a.m. The DON said all insulin pens should be primed with two units of insulin, with the needle in place, prior to drawing up the insulin dose to administer to the resident. She said this was important to do so the resident got the full correct dose of insulin.

Based on observations, record review and interviews, the facility failed to provide two (#63 and #31) of three residents reviewed for activities with an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being out of 43 sample residents.Specifically, the facility failed to ensure Resident #63 and #31 received a personalized activity program.Findings include: I. Facility policy and procedure The Activity policy, revised 3/14/23, was received from the nursing home administrator (NHA) on 8/7/25 at 3:25 p.m. It read in pertinent part, The facility will provide daily activities that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies, and culture of the participants and community. Daily activities include community-sponsored group and individualized activities, in addition to assistance with independent daily activities. Activities will be designed to meet and support the participants physical, mental, intellectual, and psycho-social well-being. Activities will create opportunities for each participant to have a meaningful life by supporting their domains of wellness. Activities will be designed to meet participants' best ability to function, incorporating their strengths and abilities. Participants will have advanced notice of when activities take place, including the location where they are taking place. Activity offerings, in addition to spiritual services/events, shall be provided on the weekends. II. Resident #63 A. Resident status Resident #63, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, major depressive disorder, chronic kidney disease, unsteadiness on feet, reduced mobility and history of falling. The 5/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required moderate assistance with personal hygiene and supervision or touch assistance with bathing, toileting and lower body dressing. The 9/20/24 MDS assessment documented the resident's activity preferences included listening to preferred music, being around animals, keeping up with the news, doing activities with groups of other people and going outside when the weather was good. B. Resident interview Resident #63 was interviewed via the language line on 8/4/25 at 3:30 p.m. Resident #63 said she liked bingo when it was conducted in her native language. She said she attended bingo a few times, but she stopped attending because the bingo activity was conducted in the English language so she did not understand, and it did not meet her preference. Resident #63 said her previous facility conducted bingo in Spanish and she did enjoy attending. Resident #63 said if the facility had bingo in Spanish, she would be interested in attending. Resident #63 said all activities were conducted in English, so it was not beneficial to her. Resident #63 said she spent more time with her family when they visited, but they were unable to visit every day, so she spent more time in her room. Cross-reference F676 for failure to provide effective communication tools to ensure residents who spoke a language other than English were able to effectively communicate their needs to staff. During the interview, an activity calendar printed in Spanish, in normal size print, was observed approximately six feet high up on the west wall of Resident #63's room. The resident used a wheelchair and needed assistance to stand. Resident #63 said she was unable to read the activities calendar C. Observations On 8/5/25 at 1:46 p.m. Resident #63 was sitting on her bed in her room. She was not involved in any meaningful activities while there was a bingo activity going on in the main dining room. During a continuous observation on 8/5/25, beginning at 3:00 p.m. and ending at 4:01 p.m., Resident #63 was lying in her bed with her television turned off. She was not participating in any meaningful activities. During a continuous observation on 8/6/25, beginning at 10:05 a.m. and ending at 11:30 a.m., Resident #63 was sitting in her wheelchair by her bed. Several staff members walked by but did not offer to assist the resident to the activities in the dining room or offer to provide the resident with the facility's language line for translation of the activities being offered in the dining room. On 8/6/25 at 2:15 p.m. Resident #63 was sitting by herself on her side of the shared room while bingo was going on in the main dining room. Certified nurse aide (CNA) #10 entered the resident's room to pick up a food tray. -CNA #10 did not speak to the resident and did not invite Resident #63 to go to the bingo activity. D. Record review The 9/13/25 activity assessment documented that Resident #63 enjoyed listening to music of her preference, being around animals/pets, keeping up with the news, going out for fresh air when the weather permitted, religious activities and group activities. -The activities assessment did not indicate that independent activities were Resident #63's preference. The activities care plan, initiated 10/7/24, documented that Resident #63 enjoyed activities like games such as cards, arts and crafts, exercise, Spanish Mexican music, going outdoors when the weather was nice, cooking, keeping up with current events, getting her nails done, watching television, Spanish western movies and religious activities. The activity care plan revealed Resident #63 spoke Spanish and needed Spanish-speaking staff, family, or a google translator for communication and assistance with activities. The care plan intervention included reminding and inviting Resident #63 to activities of interest, such as games, social outings and religious activities. -However, per the resident's interview, staff did not provide activities in Spanish and observations revealed staff did not offer to provide a translator for the resident to attend activities (see resident interview and observations above). -The activities care plan, initiated on 10/7/24, identified Resident #59 had vision difficulties and would need large print during activities. -However, the activities calendar was posted six feet high on the resident's wall and printed in normal size print (see observations above). E. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 8/6/25 at 1:50 p.m. CNA #10 said Resident #63 only spoke Spanish. She said the resident stayed in her room most of the time, except when her family visited her. CNA #10 said the resident kept to herself a lot of the time and refused activities. CNA #10 said she believed Resident #10 refused activities due to the language barrier. Licensed practical nurse (LPN) #3 was interviewed on 8/6/25 at 2:00 p.m. LPN #3 said Resident #63 only spoke Spanish and refused activities most of the time. LPN #3 said the facility had a translation line to assist with communication with the resident. LPN #3 said all activities were held in English and she believed that was the reason Resident #63 refused to participate. Activities assistant (AA) #1 and AA #2) were interviewed together on 8/7/25 at 8:50 a.m. AA#1 said Resident #63 had never expressed concerns about not understanding English. She said the resident refused several activities and preferred to remain in her room and go out with her family. AA#1 said all activities were conducted in English, though a member of the activities team, AA#2, spoke fluent Spanish and could interpret activities in Spanish. AA #1 said she often used other staff members and an online translator tool to interpret when she could not understand Resident #63. AA#2 said when a resident refused activities frequently, she usually would ask again, and if the resident continued to refuse, she would honor the refusal and document it in the resident's chart. The activities director (AD) was interviewed on 8/7/25 at 9:25 a.m. The AD said she reviewed the activities chart every quarter, but was not aware of Resident #63 refusing group activities and other activities. She said Resident #63's activities calendar was posted too high on the wall in the resident's room. She said she expected the activities assistants to inform her when they noticed a pattern of refusal by any resident. The AD said there was an initial activities assessment done upon admission and annually for all residents. She said she expected the activities staff to follow the resident's care plan. She said she did not know why the activities staff was not reporting Resident #63'd refusals of her preferred activities. The social worker quality mentor was interviewed on 8/7/25 at 10:00 a.m. The social worker quality mentor said Resident #63's care plan should be followed by the activities staff. She said if the resident's preferred language was Spanish, she expected the staff to offer interpretations of activities and also report patterns of refusals to the AD. The social worker quality mentor said the facility staff should be utilizing the translator line. She said she would immediately offer education to the activities staff and ensure the AD reviewed the residents' activities logs for patterns of refusals and developed interventions to assist the residents. III. Resident #31 A. Resident Status Resident #31, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included schizoaffective disorder, bipolar type (combination of schizophrenia and bipolar disorder symptoms), retention of urine and atrial fibrillation (abnormal heart rhythm). The 5/21/25 MDS assessment documented the resident was cognitively intact with a BIMS score of 12 out of 15. The MDS assessment documented Resident #31's preferred language was Spanish. He was independent with all ADLs other than toileting. He required partial assistance with toileting. The 2/20/25 annual MDS assessment revealed it was very important for Resident #31 to listen to music he liked, be around animals, do things with groups of people, do his favorite activities, go outside for fresh air when the weather was good and participate in religious services. B. Resident interview Resident #31 was interviewed via the language line on 8/4/25 at 12:41 p.m. Resident #31 said he primarily spoke Spanish. He said there were no activities offered in Spanish. He said he would like to go to more activities if they were offered in Spanish. He said he enjoyed bingo, going outside, religious services, listening to music, watching television and talking with others. He said there was an activity calendar in his room but it was printed in English. He said it would be nice to have one in Spanish so he could read it. During the interview, an activities calendar printed in English was observed in the resident's room. Resident #31 was interviewed again on 8/6/25 at 10:08 a.m. Resident #31 said he knew about the coffee social and the church service going on, but he said he did not want to go participate because they were in English. C. Observations On 8/5/25 during a continuous observation, beginning at 2:55 p.m. and ending at 4:13 p.m., the following was observed: At 2:55 p.m. Resident #31 was lying on his bed in his room. At 3:11 p.m. Resident #31 got up to go shut off the wander guard alarm by the smoker's patio. He sat down in the living room and watched the television that was turned on with no sound or subtitles on. At 3:15 p.m. the activity assistants were walking around inviting residents to pray the rosary activity. -No staff members invited Resident #31 to the rosary activity. At 3:37 p.m. the rosary activity was going on in English in the chapel. At 3:50 p.m. Resident #31 walked back into his room from the living room to use the bathroom and lie down in his bed. On 8/6/25 during a continuous observation, beginning at 8:50 a.m. and ending at 10:08 a.m., the following was observed: At 8:50 a.m. Resident #31 was walking around in his room. He then went to lie down on his bed. At 9:00 a.m. the activity assistants were walking around inviting residents to a coffee social in the dining room. -No staff members went into Resident #31's room to invite him to the coffee social. At 9:15 a.m. the coffee social was going on in the dining room. At 10:00 a.m. a church service was going on in the chapel. -No staff members went into Resident #31's room to invite him to the church service. D. Record review The 2/20/25 activity assessment revealed that Resident #31 preferred to participate in indoor, outdoor, group, independent and one-on-one activities. It documented that Resident #31 preferred action television and movies, listening to Mexican music, being around pets, doing things with groups of people, participating in his favorite activities, going outside when the weather was good and participating in religious activities. The activities care plan, revised 9/13/24, revealed that Resident #31 enjoyed both group and independent activities such as exercises for his abdominal muscles and walking, sports such as soccer, music such as Norteña (type of Mexican music), spiritual services for Catholics, movies such as action movies, being outdoors for fresh air, table games such as cards, blackjack poker and bingo, some arts and crafts on occasion, pets such as dogs, surfing the internet online, parties and social events and spending time with his family. Interventions included inviting Resident #31 to outings, reminding and escorting him to and from groups of interest, inviting and reminding him to go to spiritual services for Catholics and offering him independent material of interest. -The care plan failed to reveal documentation that the resident spoke primarily Spanish and preferred activities in Spanish. E. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 8/7/25 at 12:30 p.m. CNA #4 said Resident #31 was independent with most things. She said he mostly watched television in his room or in the living room by himself. She said the only group activity she saw him participate in consistently was bingo. She said he primarily spoke Spanish. She said he knew a little English. She said to communicate, he understood most things she would say in English or she could get a staff member who spoke Spanish. She said there was always a staff member working who spoke Spanish. The AD was interviewed on 8/7/25 at 12:40 p.m. The AD said the facility was trialing passing out a daily list of activities each morning to residents in their preferred language (starting the week of the survey). She said they were getting good feedback from the residents they tried it with, so they were going to continue it. She said residents got monthly activity calendars with each activity listed in their preferred language. -However, observations and resident interview revealed Resident #31's calendar was printed in English (see resident interview and observations above). The AD said Resident #31 was friends with other Spanish speaking residents and they sat by each other at group activities. She said they did not currently offer activities in languages other than English. The director of nursing (DON) was interviewed on 8/7/25 at 2:26 p.m. The DON said every resident should have an activity calendar printed in their preferred language and get personal invitations to activities they preferred. She said each resident should get a daily chronicle in the language of their preference and they should be offered books/magazines in their language of preference. She said the facility currently did not offer activities in languages other than English. She said if a resident spoke a language other than the language staff spoke, the expectation would be to utilize a translator service or another staff member who spoke that language.

Based on observations, record review and interviews the facility failed to provide the necessary services for one (#14) of four residents reviewed for services to maintain highest practicable quality of life out of 43 sample residents.Specifically, the facility failed to ensure Resident #14 consistently received assistance with dining. Findings include:I. Facility policy and procedureThe Supporting Activities of Daily Living policy and procedure, revised March 2018, was received from the nursing home administrator (NHA) on 3/10/25 at 10:46 a.m. It read in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out activities of daily living (ADL) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing and grooming) and dining. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem.II. Resident #14A. Resident statusResident #14, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included pulmonary embolism (a blood clot in the lungs), malignant neoplasm of the esophagus (cancer in the throat), symptoms and signs involving cognitive functions and awareness, depression, bipolar disorder (mental illness) and adult failure to thrive.The 5/28/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent for most activities of daily living (ADL). The assessment documented the resident was occasionally incontinent and had less than seven episodes of incontinence in the assessment lookback period.-However, record review and interviews revealed Resident #14 frequently needed staff assistance for ADLs including toileting hygiene and eating (see record review and interviews below).B. ObservationsDuring a continuous observation on 8/5/25 from 11:08 a.m. to 1:00 p.m., the following was observed:At 11:21 a.m. an unidentified housekeeping staff member delivered laundry to Resident #14's room.At 11:26 a.m. certified nurse aide (CNA) #5 delivered a lunch tray to Resident #14's roommate.At 11:37 a.m. CNA #5 delivered a drink to Resident #14's roommate.At 11:40 a.m. CNA #6 entered Resident #14's room and took out his breakfast tray from that morning, still with the cover on. CNA #6 delivered Resident #14's lunch tray and left the tray covered on Resident #14's bedside table several feet away from the resident's bed. Resident #14 was lying in bed on his side and was awake but still lying down.-CNA #6 failed to set up the lunch tray for Resident #14 and encourage him to eat.At 11:45 a.m. registered nurse (RN) #4 entered Resident #14's room and delivered medications to the resident. RN #4 asked Resident #14 if he needed anything else and left the room. RN #4 did not encourage Resident #14 to eat his lunch or ensure he was able to reach it.At 11:48 a.m. RN #4 entered Resident #14's room to deliver medications to his roommate.At 12:41 p.m. CNA #3 entered Resident #14's room and retrieved his lunch tray from his bedside table. The lunch tray was still covered and untouched.On 8/6/25 at 11:53 a.m. CNA #7 delivered Resident #14's lunch tray to his room, left it covered on his bedside table and left the room.-CNA #7 failed to set up Resident #14's tray for him or encourage him to eat.At 11:57 a.m. Resident #14 was lying in bed asleep on his side. Resident #14's lunch tray was on his tray table several feet away from his bed and still had the cover on.On 8/7/25 at 11:14 a.m. Resident #14 was lying in bed. An unidentified staff member entered Resident #14's room and offered a drink to the resident's roommate but did not speak with Resident #14.C. Record reviewThe ADL care plan, revised 5/30/25, revealed Resident #14 had an ADL self-care performance deficit due to his esophageal cancer. Pertinent interventions included monitoring, documenting and reporting any changes or declines in function.-The ADL care plan did not include any interventions to assist with the resident's eating.The hospice care plan, revised 5/28/25, revealed Resident #14 was receiving additional support through hospice care. Pertinent interventions included adjusting the provision of ADLs to compensate for Resident #14's changing abilities.A progress note, dated 6/20/25 at 11:15 a.m., revealed Resident #14 was being followed by the facility's nutrition at risk team. Resident #14 had poor meal intakes and was refusing meals at times. Staff were to encourage intakes as Resident #14 was able and willing to accept. A progress note, dated 6/25/25 at 11:06 a.m., revealed Resident #14 was being followed by the facility's nutrition at risk team. Resident #14 had poor meal intakes and was refusing meals at times. Staff were to encourage intakes as Resident #14 was able and willing to accept. A progress note, dated 7/11/25 at 12:12 p.m., revealed Resident #14 was being followed by the facility's nutrition at risk team. Resident #14 had poor meal intakes for most meals. Staff were to encourage intakes as Resident #14 was able and willing to accept. A progress note, dated 7/18/25 at 12:24 p.m., revealed Resident #14 was being followed by the facility's nutrition at risk team. Resident #14 had poor meal intakes for most meals. Staff were to encourage intakes as Resident #14 was able and willing to accept. A progress note, dated 7/25/25 at 12:09 p.m., revealed Resident #14 was being followed by the facility's nutrition at risk team. Resident #14 had poor meal intakes for most meals. Staff were to encourage food and fluids as Resident #14 was able and willing to accept. -However, observations revealed the staff failed to consistently encourage the resident to eat at meals (see observations above).Review of the eating resident ability task from 7/9/25 through 8/7/25 revealed the following:-Resident not available was marked four times;-Resident refused his meal was marked 11 times;-Not applicable was marked ten times;-Independent with eating was marked 23 times;-Setup/clean-up assistance with eating was marked seven times;-Partial/moderate assistance with eating was marked three times;-Substantial/maximal assistance with eating was marked three times; and,-Dependent on staff for eating was marked 14 times.D. Staff interviewsCNA #5 was interviewed on 8/7/25 at 9:13 a.m. CNA #5 said Resident #14 often refused meals. CNA #5 said the staff brought Resident #14 his tray and let him know it was in his room, but his willingness to eat ebbed and flowed. CNA #5 said Resident #14 sometimes ate cereal but never finished his whole tray.CNA #4 was interviewed on 8/7/25 at 9:44 a.m. CNA #4 said the facility staff made sure Resident #14 was clean and fed him. CNA #4 said Resident #14 needed help with eating. CNA #4 said Resident #14 was getting up when he first got to the facility, but now they had to help him since he was getting weaker. CNA #4 said the facility CNAs set up Resident #14's meal trays for him but the resident could drink and feed himself. CNA #4 said Resident #14 refused his meals most of the time.RN #5 was interviewed on 8/7/25 at 12:33 p.m. RN #5 said the nursing staff usually needed to help Resident #14 with eating. The director of nursing (DON) was interviewed on 8/7/25 at 3:31 p.m. The DON said Resident #14's ADL self-care abilities ranged from needing substantial assistance to being dependent on nursing staff. The DON said Resident #14 needed setup assistance from staff for eating and needed substantial assistance to complete dependence on staff for toileting. The DON said setup assistance for meals involved the staff uncovering the tray, opening any containers the resident needed opening.

Based on observations, record review and interviews, the facility failed to ensure two (#59 and #63) of three residents reviewed for activities of daily living (ADL) received the necessary care and services to maintain their ADL abilities out of 43 sample residents.Specifically, the facility failed to:-Ensure Resident #59 consistently received assistance with personal hygiene, such as showering, shaving and trimming his nails; and,-Provide language communication tools for Resident #63 in order for her to effectively communicate her needs.Findings include:I. Failed to ensure Resident #59 consistently received assistance with personal hygiene, such as showering, shaving and trimming his nailsA. Facility policy and procedureThe Supporting Activities of Daily Living policy and procedure, revised March 2018, was received from the nursing home administrator (NHA) on 3/10/25 at 10:46 a.m. It read in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out activities of daily living (ADL) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing and grooming) and dining.B. Resident #591. Resident statusResident #59, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), depressive disorder, history of traumatic brain injury, anxiety disorder, dependence on a wheelchair and contracture of the right wrist and hand.The 5/30/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. The resident required moderate assistance with personal hygiene, toileting and maximal assistance with showers. The MDS assessment revealed the resident had no behavior problems and did not refuse care. 2. ObservationsOn 8/4/25 at 2:14 p.m. Resident #59 was in his bed in his room. His hair was unkempt and uncombed. His hair was long and shiny with varying lengths sticking out in different directions. The resident had facial hair that was not shaped. The resident's beard covered a significant portion of the lower face, including his cheeks, chin, and neck. The resident's fingernails were untrimmed and about one and a half inches long. On 8/5/25 at 10:15 a.m., Resident #59 was lying in his bed. His hair and beard were long and uncombed and were scattered in various directions. The resident was wearing black sweatpants with a white long sleeved t-shirt. The white t-shirt had food debris on it.At 3:20 p.m. the resident was in bed wearing the same clothes (black as the day before. His hair was stringy, shiny and greasy in appearance. His fingernails remained black sweatpants with a white long sleeved t-shirt) long and untrimmed.On 8/6/25 at 2:14 p.m. the resident was sitting partially up on his bed, leaning against the wall. His fingernails remained long. The nail on his index finger was missing.3. Resident interviewThe resident was interviewed on 8/6/25 at 3:00 p.m. Resident #59 said he had not had a shower in a long time. He said his fingernails were too long and he preferred them short and trimmed. The resident said a few days ago he was going through his drawer and he bumped his fingernail against an object in his drawer. He said this caused him to loose his nail on his index finger. The resident said that it hurt and he would like his nails cut and trimmed. Resident #59 said he would like to be shaved and also get a haircut. He said he did not get assistance from the staff to shave his facial hair. He said he had not been shaved or received a haircut for a long time. He said he preferred keeping his hair short and with no facial hair. The resident said he needed assistance with personal hygiene. 4. Record reviewThe ADL care plan, revised on 8/1/23, revealed Resident #59 had an ADL self-care performance deficit related to a history of traumatic brain injury and limited physical mobility related to contractures and weakness. The care plan indicated the resident needed limited assistance with showers. Interventions included checking nail length and trimming and cleaning on bath day, and as needed. -The care plan failed to include interventions for refusal of showers and shaving.Review of the resident's progress notes from 1/1/24 through 8/6/25 did not include documentation regarding the resident refusing to shower. The 3/11/24 behavior services note documented the resident was happy to be shaved, he was in a good mood, having adequate sleep and his weight and appetite were stable.Review of Resident #59 electronic medical record (EMR) revealed the resident preferred to shower twice a week on Tuesday and Thursday evenings. Further review of Resident #59's EMR did not include any documentation indicating the resident had received a shower, was shaved or had his fingernails clipped. -A request for Resident #59's shower, fingernail care and shaving records were requested for the previous six months. The documentation was not provided during the survey. C. Staff interviewsCNA #11 was interviewed on 8/7/25 at 2:00 p.m. CNA #11 said Resident #59 required moderate assistance with his ADLs, which included showers, shaving, and fingernail care. She said the CNA's were responsible for providing showers and personal hygiene care for dependent residents. CNA #11 said when a resident refused to shower, she would offer it at a different time, and if still unsuccessful, then she would inform the charge nurse. CNA #11 said charge nurse would attempt to speak to the resident and offer education about the importance of good personal hygiene. She said if all attempts were unsuccessful, they would offer the resident a bed bath and document refusal for showers in the resident's EMRLicensed practical nurse (LPN) #4 was interviewed on 8/7/25 at 2:39 p.m. LPN #4 said Resident #59 had a right hand contracture and required assistance with ADL's. LPN #4 said the resident stayed in his room a lot of the time. She said the CNA's were responsible for showers and personal hygiene care for dependent residents. LPN #4 said completed showers, fingernail care, shaving, including refusals, were documented in the EMR. LPN #4 said she did not know why the records were not showing for Resident #59. LPN #4 said long and jagged fingernails could cause a skin tear. She said poor personal hygiene had several adverse effects, such as illness due to germs.The DON was interviewed on 8/7/25 at 3:03 p.m. The DON said during admission, a new resident was asked how many showers they wanted a week, and it was added to the resident's bathing profile/choices. She said residents' bathing choices were reviewed at the quarterly care conferences. She said if a resident refused a shower, the staff would try to accommodate them. She said shower refusals were documented on the shower sheet, and verbal notification given to the assigned nurse by the CNA. The DON said the nurse was to attempt to offer a shower to the resident. She said if the resident continued to refuse, the nurse was to document the refusal in the progress notes. The DON said the facility was in the process of hiring a beautician to render services such as haircuts, fingernail care and shaving at no cost to the residents. The DON said she did not know why the shower records were not showing on the PCC. She said she would immediately offer education for the facility staff.II. Failed to provide language communication tools for Resident #63 in order for her to effectively communicate her needsA. Facility policy and procedureThe Communication With Persons With English As A Second Language (ESL) policy and procedure, dated 2/29/24, was received from the nursing home administrator (NHA) on 8/7/25 at 3:25 p.m. It revealed in pertinent part, The facility will take reasonable steps to ensure that persons with English as a second language (ESL) have meaningful access and an equal opportunity to participate in our services, activities, programs and and other benefits. The policy of this facility is to ensure meaningful communication with ESL residents and their authorized representatives involving their medical conditions and treatment. Language assistance will be provided through the use of technology and telephonic interpretation services. The facility will conduct a regular review of the language access needs of our resident population, as well as update and monitor the implementation of this policy and this procedure as necessary.B. Resident #631. Resident statusResident #63, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnosis included type 2 diabetes mellitus, major depressive disorder, chronic kidney disease, unsteadiness on feet, reduced mobility and history of falling.The 5/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required moderate assistance with personal hygiene and supervision or touch assistance with bathing, toileting and lower body dressing.The MDS assessment indicated Resident #63's communication preference was in her native language of Spanish.2. Resident interviewResident #63 was interviewed on 8/4/25 at 3:40 p.m. Resident #63 said she preferred to speak in her native language of Spanish. She said it had been difficult for her to communicate with staff and attend activities because the staff did not understand her when she spoke. Resident #63 said she stopped attending her preferred activities, such as bingo, religious groups and social interactions. She said the staff have never used a communication line or any device to assist her in communicating her needs. Resident #63 said all activities, religious services and social interactions were conducted in English, making it difficult to understand.Cross-reference F679 for failure to provide a personalized activity program.3. Observations On 8/6/25 at 10:46 a.m. Resident #63 was in her bedroom after lunch, sitting in her wheelchair. Licensed practical nurse (LPN) #3 entered the resident's room to administer her medication. Both LPN #3 and Resident #63 could not understand each other, however, the resident took her medication. LPN #3 left the resident's room without attempting to use the translator line to communicate with the resident. On 8/6/25 at 2:15 p.m. Resident #63 was sitting by herself on her side of the shared room while bingo was going on in the main dining room. Certified nurse aide (CNA) #10 entered the resident's room to pick up a food tray. CNA #10 did not say a word to the resident. 4. Record reviewThe activities care plan, initiated 10/7/24, revealed Resident #63 spoke Spanish and would require Spanish-speaking staff, family or an online translator for communication and assistance with activities. The care plan intervention included staff would utilize Spanish-speaking staff, family, translation line or an online translator when communicating with the resident.C. Staff interviewsCertified nurse aide (CNA) #10 was interviewed on 8/6/25 at 1:50 p.m. CNA #10 said Resident #63 only spoke Spanish. She said the resident stayed in her room most of the time, except when her family visited her. CNA #10 said the resident kept to herself a lot of the time and refused activities. CNA #10 said she believed Resident #10 refused activities due to the language barrier. CNA #10 said she did not speak Spanish, but she tried her best to make sense of what Resident #63 said to her in Spanish.LPN #3 was interviewed on 8/6/25 at 2:00 p.m. LPN #3 said Resident #63 only spoke Spanish. LPN #3 said the facility had a translation line to assist with communication with the resident. AA #1 and AA #2 were interviewed together on 8/7/25 at 8:50 a.m. AA #1 said she did not speak Spanish, but AA #2 spoke Spanish. Both activities assistants agreed that all of the facility's activities were conducted in English. AA #2 said she could speak to Resident #63 in Spanish, but she was not aware the resident had a language barrier. The activities director (AD) was interviewed on 8/7/25 at 9:20 a.m. The AD said Resident #63 had a language barrier and preferred speaking Spanish.

Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#16) out of five residents reviewed for unnecessary medications out of 43 sample residents.Specifically, the facility failed to obtain consent prior to the administration of an antipsychotic antidepressant medication for Resident #16. Findings include:I. Facility policy and proceduresThe Psychopharmacological policy, dated 3/10/23, was provided by the nursing home administrator (NHA) on 8/4/25 at 10:05 a.m. The policy revealed the community supported the appropriate use of psychopharmacological drugs that are therapeutic for residents suffering from mental illness. The interdisciplinary team would proceed to care planning for the use of psychopharmacological drugs, and the care plan for psychopharmacological medications would be implemented. The care plan conference summary (CPCS) would be utilized to document discussions with the resident and/or resident representative about the resident's diagnosis, behaviors, and medications, including the use of psychopharmacological drugs.The Psychpharm Committee members would review residents on psychopharmacological drugs on admission, quarterly, and any change of status. The committee members would ensure the resident was on the most appropriate psychopharmacological drug for specific behavior symptoms and/or diagnosis and at the lowest possible dose to control these symptoms. The committee would ensure dosages were within the guidelines provided by federal regulations or for appropriate treatment of resident's diagnosis, behavioral symptoms and past mental health history. A licensed pharmacist would review residents' psychopharmacological drug regimen on a monthly basis and document his/her findings on the Pharmacy Consultant Report. The pharmacist would report any irregularities to the director of nursing (DON). The policy did not specify that a consent for the use of an antipsychotic medication was necessary/required before the administration of the medication.II. Resident #16A. Resident status Resident #16, greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), the resident's diagnoses included dementia with anxiety, depression and adjustment disorder with mixed disturbance of emotions and conduct.The 6/19/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of ten out of 15 with no behaviors. The assessment indicated the resident was administered an antidepressant antipsychotic medication on a routine basis only.B. Record reviewA care plan for the use of an antidepressant related to depression was revised on 3/31/25. Interventions included monitoring the resident for the use of an antidepressant medication, staff were to educate the resident/family/caregivers about the risks, benefits and the side effects and/or toxic symptoms of anti-depressant medications, staff were to monitor/document/report as needed adverse reactions to the antidepressant therapy such as a change in the resident's behavior/mood/cognition; hallucinations/delusions and social isolation. Staff were also to monitor for suicidal thoughts, withdrawal; decline in activities of daily living, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, dry mouth, dry eyes. The resident's medications would be reviewed by the interdisciplinary team (IDT) quarterly and as needed to attempt a gradual dose reduction when clinically indicated.A care plan for the resident's use of an anti-psychotic medication for the symptoms/behaviors associated with the diagnosis of depression was revised on 6/10/25. The interventions included for staff to administer psychotropic medications as ordered by a physician and for staff to monitor for side effects and effectiveness.A physician order dated 5/9/25 at 8: 37 a.m. revealed to administer two tablets of 50 milligrams of Sertraline (antidepressant) HCl orally once a day for depression.The medication administration record (MAR) for June 2025, July 2025 and August 2025 (8/1/25 to 8/6/25) revealed the resident was administered the two tablets of 50 milligrams of Sertraline HCL daily according to the physician's order. The resident received a total of 57 doses of this medication.Review of Resident #16's electronic medical record (EMR) did not reveal documentation that the resident or their representative provided consent prior to the administration of the Sertraline. IIII. Staff interviewsThe social worker quality mentor was interviewed on 8/7/25 at 11:32 a.m. She said the MDS dated [DATE] revealed the resident was administered an antidepressant antipsychotic medication on a routine basis only. She said a consent for the use of two tablets of 50 milligrams of Sertraline HCL daily for depression was completed on 8/6/25 during the survey. The social worker quality mentor said consent should be obtained prior to the administration of the antidepressant medication. She said according to the MAR for June 2025, July 2025 and August 2025 the resident was administered the medication.The director of nursing (DON) was interviewed on 8/7/25 at 12:28 p.m. She said the MDS dated [DATE] revealed the resident was administered an antidepressant antipsychotic medication on a routine basis only. The DON said the consent for the use of two tablets of 50 milligrams of Sertraline HCL daily for depression was completed on 8/6/25 (during the survey). The DON said the consent for the antidepressant should have been obtained prior to administration. She agreed with the administration documentation on the resident's MARs for June, July and August 2025.The assistant director of administration (ADON) was interviewed on 8/7/25 at 12:43 p.m. The ADON said a consent should be obtained before the administration of a psychoactive medication. The ADON agreed the MDS dated [DATE] revealed the resident was administered an antidepressant antipsychotic medication on a routine basis only.

Based on record review and interviews, the facility failed to ensure three (#13, #1 and #6) of five residents out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #13 and Resident #1 were kept free from physical abuse by Resident #2; and, -Ensure Resident #6 was kept free from physical abuse by Resident #7. Findings include: I. Facility policy and procedure The Abuse policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, 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. 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. II. Incident of physical abuse by Resident #2 towards Resident #1 and Resident #13 A. Facility investigation of physical abuse by Resident #2 towards Resident #13 on 1/2/25 The 1/2/25 incident report documented Resident #13 was walking next to Resident #2 in the hallway when Resident #2 stopped and hit Resident #13 for no reason. Resident #13 put his hand on her head to stop her. After the incident, Resident #13 stated I was not afraid of her hitting me again; it is not a big deal; she is just a confused, mean old lady. The incident report documented the incident was witnessed by the admissions coordinator. The witness statement and interviews substantiated the physical abuse by Resident #2 toward Resident #13. The facility called the police and notified the ombudsman, the director of nursing (DON), the attending physician and the state health department. B. Facility investigation of physical abuse by Resident #2 towards Resident #1 on 2/26/25 The 2/26/25 incident report documented Resident #1 was passing in the hallway when Resident #2 was self-propelling her wheelchair in the opposite direction. Resident # 1 stopped and stood to the side so that Resident #2 could pass by him. When Resident #2 passed by Resident #1, she slapped Resident #1 on his left cheek with her open hand. Resident #1 then pushed her to the side, stating, What the hell, lady. Both residents were immediately separated, assessed and placed on frequent checks. Dietary aide (DA) #1 witnessed the incident and reported that Resident #2 wanted Resident #1 to back up, but he cussed her out. DA #1 stated, I moved Resident #1 forward and away. During a post-incident interview, Resident #1 responded, I do not know why she slapped me; she is crazy. Interviews substantiated the physical abuse by Resident #2 toward Resident #1. C. Resident #2 - assailant 1. Resident status Resident #2, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder (depressive type), anxiety disorder and Alzheimer's disease. The 1/21/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required the assistance of one person with transfers, dressing, showering, toileting, and personal hygiene. The MDS assessment documented Resident #2 had physical behavioral symptoms directed toward others which occurred every one to three days during the assessment period. 2. Record review The behavioral care plan, initiated on 12/24/19 and revised on 1/21/25, documented Resident #2 had targeted behaviors of paranoia and could have a short temper. The care plan documented when the resident was cycling, she would make false accusations, believing staff were talking about her and making fun of her. Resident #2 had hit people in the past due to being short tempered and having impulsive responses. The interventions included providing one-to-one conversations with staff to discuss her feelings, assisting the resident out of the middle of the hallway, encouraging her to travel on one side of the hallway to mitigate disruptive interactions with others, assigning a one-to-one caregiver for emotional support, speaking to the resident calmly, educating the resident to stay away from people she did not get along with and administering and monitoring medications as ordered. -The facility failed to update Resident #2's care plan after the incident of physical abuse on 2/26/25. The 1/2/25 progress note documented Resident #2 was in the hallway self-propelling in her wheelchair. Resident #13 was waiting for Resident #2 to pass when Resident #2 hit him in the middle of his chest. Resident #2 yelled Get out of my way. Resident #13 said he put his hand on Resident #2's head to stop her and said, stating What the hell old lady. Resident #2 stated she was trying to stop Resident #13 from bumping into her. An assessment was completed and no injuries were noted. Both residents were placed on frequent safety checks. The 2/26/25 progress note revealed Resident #2 slapped Resident #1 in the face while passing in the hallway to the dining room. Resident #2 refused to talk about the incident and continued yelling at the staff. A head-to-toe assessment was completed for both residents and no physical injuries were noted. Both residents were separated and placed on frequent checks. The facility notified the residents' families and the ombudsman and made an online police report. D. Resident #13 - victim 1. Resident status Resident #13, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included type 1 diabetes mellitus and end-stage renal disease. The 2/12/25 MDS assessment documented Resident #13 was cognitively intact with a BIMS score of 13 out of 15. He was independent with bed mobility, eating, toileting, personal hygiene and dressing. E. Resident #1 - victim 1. Resident status Resident #1, age 70, was admitted on [DATE]. According to the March 2025 CPO, the diagnoses included acute and chronic respiratory failure, unspecified encephalopathy, alcohol use disorder and an acquired absence of right leg above the knee. The 1/16/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. He required assistance from two people with transfers. He required assistance of one to two people with dressing, toileting and personal hygiene. F. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/25/25 at 5:10 p.m. CNA #3 said Resident #2 yelled, screamed, and tried to scratch other residents and staff members often. She said she would give Resident #2 space when she was having a bad day. CNA #3 said every time Resident #2 had a bad day, the facility staff did not walk with the resident down the hallway. She said it was easier to give her space so they did not get hit or scratched. She said she did not try to walk between Resident #2 and any other residents coming down the hallway to ensure another resident was not targeted by Resident #2. She said was concerned if she was too close to Resident #2 during those episodes, she would get hit or scratched. CNA #3 said Resident #2 did not always like it when other residents invaded her personal space and got too close. She said Resident #2 could become physically aggressive if that happened. Registered nurse (RN) #3 was interviewed on 3/25/25 at 5:25 p.m. RN #3 said the facility staff gave Resident #2 space and would backup away from her when she was upset. She said Resident #2 was physically aggressive when she was having a bad day. She said Resident #2 could be physically aggressive with facility staff or toward other residents. She said she was concerned if she got too close to Resident #2 during a bad day, she would be hit. RN #3 said the facility staff did not provide Resident #2 with a one-to-one supervisor when she moved about the facility. She said facility staff did not walk down the hallway to follow the resident and stand between Resident #2 and another resident coming down the hallway if Resident #2 was having a bad day. She said Resident #2 did not like other residents getting too close to her. RN #3 said if Resident #2 was physically aggressive with another resident, she would be placed on 15-minute safety checks for three days. The DON, the NHA, the clinical consultant (CC) and the regional operations manager (ROM) were interviewed together on 3/26/25 at 1:36 p.m. The DON said Resident #2 had a history of physically aggressive behavior towards other residents and staff members. She said she had been institutionalized at a young age and had a difficult time trusting others. She said Resident #2 was very protective of her belongings and personal space. She said Resident #2 did the best when she was regimented in a daily routine. The DON said Resident #2 would get triggered by what she perceived as another resident getting too close to her, especially in areas such as the hallway. She said the resident had a large personal bubble that was not always obvious to others and she was paranoid about people whispering or talking about her behind her back. The NHA said there were a few staff she trusted and she had built a good relationship with them. He said she was part of a program through her insurance that would provide a one-to-one companion once or twice a week for one to two hours. The DON said if Resident #2 was having a bad day, the floor staff should notify management and someone she trusted and had a good rapport with would go down and sit with her. She said staff should keep an eye on Resident #2 when she left her room often, because that could be a sign of a bad day. She said the floor staff should walk down the hallway in between Resident #2 and another resident to ensure the other resident did not get too close to Resident #2 in order to prevent an altercation. Cross reference F744: the facility failed to provide effective dementia care to Resident #2 to prevent potential physical altercations toward other residents. The NHA said Resident #2 was willful in the incidents of physical abuse toward Resident #1 and Resident #13. 48114 III. Incident of physical abuse by Resident #7 towards Resident #6 on 2/12/25 A. Facility investigation The 2/12/25 facility incident report was provided by the NHA on 3/26/25 at 10:30 a.m. The report revealed Resident #7 came into the dining room and yelled at Resident #6. Resident #6 began yelling back at Resident #7. Resident #7 hit and pushed Resident #6's head causing him to tip over backwards in his wheelchair. The residents were immediately separated, placed on frequent checks and assessed. Resident #6 was assessed by the DON and no injuries were noted. Resident #6 was interviewed by the facility on 2/12/25 and said that crazy (explicit word) just came over and hit me. I was just sitting here and she came and knocked me over. When asked if he was hurt or if he was afraid he stated, No, I' m not hurt and I am not afraid of that crazy (explicit word), she is just mental. Resident #7 was interviewed by the facility on 2/12/25. Resident #7 stated, I just came to the dining room to ask for something and he came up behind me and when I turned around he hit me, so I hit him back defending myself. He has a loud mouth and everyone is tired of hearing it. The cook (CK) was interviewed by the facility on 2/12/25. The CK said Resident #6 went to the kitchen window and asked the staff for salsa. Resident #7 approached the window and began arguing with him. Resident #7 hit Resident #6 and his wheelchair fell and knocked Resident #7 on the ground. The CK said staff stood between the residents and called for assistance. A dietary aide DA was interviewed by the facility on 2/13/25. The DA said Resident #6 went to the kitchen window and asked the staff for salsa. Resident #7 approached the window and began arguing with him. Resident #7 hit Resident #6 and his wheelchair fell and knocked Resident #7 on the ground. The staff stood between residents and called for assistance. The conclusion of the investigation revealed Resident #7 was educated to avoid interactions with those that annoy her. The incident report was substantiated as it was witnessed by staff. B. Resident #7 - assailant 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included mood disorder and dementia. The 2/5/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. She was independent with all activities of daily living (ADLs). The assessment indicated Resident #7 did not exhibit any physical or verbal behavioral symptoms directed towards others. 2. Record review The behavior care plan, revised 2/28/25, documented Resident #7 had the potential to be physically aggressive with other residents related to anger and anxiety, dementia processes related to traumatic brain injury (TBI), history of harm to others, poor impulse control and low frustration tolerance related to her TBI. Pertinent interventions included: -Analyzing times of day, places, circumstances, triggers, and what de-escalates behavior; -Providing physical and verbal cues to alleviate anxiety; -Encouraging the resident to seek out of staff members when agitated; -Encouraging the resident to share her frustrations about other residents to staff members; -If agitated, providing the resident with a safe, quiet place to discuss her feelings openly; -Modifying the environment by reducing noise, dimming the lights and keeping the door closed; -Encouraging the resident to eat in another area if she was upset; -Monitoring observed behavior and attempted interventions in behavior log every shift; -Monitoring/documenting/reporting as needed any signs or symptoms of resident posing danger to self and others; and, -Offering the resident assistance with calling her son when she was having periods of frustration. The cognition care plan, revised 9/18/23, documented Resident #7 had impaired cognitive function/dementia or impaired thought processes related to status post head injury and bipolar disorder. Pertinent interventions included asking yes/no questions in order to determine the resident's needs, identifying self at each interaction, facing the resident when speaking and making eye contact and providing the resident with necessary cues. The nursing progress note, dated 2/12/25, documented that at approximately 9:10 a.m. Resident #7 was screaming very loudly towards Resident #6 at the corner of the dining room. Resident #7 was on the floor in a sitting position. Resident #7 said while she was walking, Resident #6 started cursing her out, so she stopped and said do not curse me out. Resident #7 said right after she told Resident #6 to stop cursing, he pushed her to the floor. Resident #7 said they were friends and she would ask Resident #6 for an apology. A head to toe assessment was completed and no injury was noted. The behavior note, dated 2/13/25, documented Resident #7 was involved in a reportable physical resident-to-resident altercation with no injury noted on 2/12/25. Resident #7 initiated the physical aggression and upon interview stated it was Resident #6 who initiated the aggression. Resident #7 said she had no fear of Resident #6 or any other person at the facility. C. Resident #6 - victim 1. Resident status Resident #6, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included spina bifida (a condition that occurs when the spine and spinal cord do not form properly) and Wernicke's encephalopathy (a degenerative brain disorder caused by a lack of vitamin B1). The 2/6/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. He required partial and moderate assistance with showering and personal hygiene. According to the MDS assessment the resident had verbal behavioral symptoms directed toward others that occurred on one to three days during the assessment review period. 2. Resident interview Resident #6 was interviewed on 3/26/25 at 11:56 a.m. Resident #6 said he could not recall the incident with Resident #7 on 2/12/25. Resident #6 said if someone pushed him he would not be happy and he would want to get that person out of the facility. He said if a resident was really aggressive and pushed him, he would be afraid. He said he would not be happy at all. Resident #6 said he did not have any problems with staff or residents. He said he did not feel threatened by anyone and felt safe at the facility. 3. Record review The behavior care plan, revised 3/9/24, documented due to his diagnosis of Wernicke's encephalopathy, Resident #6 had frequent outbursts of cursing, sometimes the outbursts had a direct cause, other times they did not. Pertinent interventions included: -Anticipating and meeting the residents' needs; -Assisting the resident to develop more appropriate methods of coping and interacting by having him remove himself from the situation when he became frustrated and working on calming himself down; -Encouraging the resident to express his feelings appropriately; -Providing an opportunity for positive interaction and attention; and, -Discussing the resident's behavior, explaining why his behavior was inappropriate and/or unacceptable and how there were better ways to discuss his frustrations. The cognition care plan, revised 7/19/23, documented Resident #6 had impaired cognitive function related to TBI. Pertinent interventions included communicating with the resident/family/caregivers regarding the resident's capabilities and needs, using the resident's preferred name, identifying self at each interaction and facing the resident when speaking and making eye contact. The progress note, dated 2/12/25, documented Resident #6 was angry and speaking very loudly towards another resident at the corner of the dining room. Upon arrival the nurse observed Resident #6 on the floor in a sitting position beside his wheelchair. Resident #6 did not say anything about how he ended up on the floor. A head to toe assessment was completed and the resident was alert and oriented times two to three with periods of confusion and forgetfulness. The note documented the resident did not have a mental status change. Resident #6 denied hitting his head and there was no bump or skin issue observed. The resident's vital signs were within normal limits. Resident #6 was assisted off the floor and was sitting in his wheelchair. Neurological follow up was initiated. The physician and the DON were notified. The progress note, dated 2/12/25, documented at 9:10 a.m. Resident #6 was angry and screaming very loudly towards another resident at the corner of the dining room. Resident #6 was on the floor in a sitting position besides his wheelchair. Resident #6 was wheeled back to his room. Resident #6 apologized to Resident #7. 4. Staff interviews CNA #2 was interviewed on 3/26/25 at 9:51 a.m. CNA #2 said Resident #7 was friendly with staff and residents. She said Resident #7 would notify staff if a resident was hollering and would intervene and tell the resident to stop hollering. CNA #2 said she had not seen Resident #7 become aggressive with staff or residents. CNA #2 said she was working the day of the physical altercation on 2/12/25. She said she was not in the dining room when the incident happened. She said she heard about the incident. She said that Resident #7 and Resident #6 had never had any history of verbal or physical aggression towards each other. CNA #2 said the DON and the supervisor told her to keep an eye on both residents and if she saw something to report it right away to the nurse. CNA #2 said Resident #6 used his call light frequently and if no one answered he would come out of his room and shout. CNA #2 said he would yell for help, saying he needed a nurse, needed coffee or needed his bed made. CNA #2 said Resident #6 cursed a lot. CNA #2 said when Resident #6 did not get attention right away he would get upset. CNA #2 said when staff saw Resident #6 out of his room they would go over and talk to him. She said when she passed the resident's room that she checked in on him all the time. RN #2 was interviewed on 3/26/25 at 10:17 a.m. RN #2 said Resident #7 had never had any aggressive behaviors. RN #2 said that Resident #7 would get upset, but not to the point of hitting anyone. RN #2 said she was working the day of the 2/12/25 incident. RN #2 said she was in the break room and was coming out and she heard screaming. RN #2 said the kitchen staff told her to come to the dining room. RN #2 said Resident #7 was on the floor and was calm. She said Resident #6 was cursing at Resident #7. She said she took vital signs on both residents. RN #2 said Resident #7 said when she was walking by Resident #6 he pushed her. Resident #6 said Resident #7 was combative towards him. She said she did not know what exactly happened as she responded after the incident happened. She said both residents were safe. She said she assisted Resident #6 in his wheelchair back to his room. She said Resident #6 had apologized for his behavior. RN #2 said both residents had never had any issues with each other. RN #2 said both residents were friendly with each other and had not had any other issues. RN #2 said Resident #6 was easily redirected with his behaviors. RN #2 said if his needs were not met right away he would start yelling. RN #2 said he got upset and frustrated with being in a wheelchair and being in a nursing facility. RN #2 said Resident #6 was not a difficult person to work with but he would repeatedly ask the same question over and over again. RN #2 said she was not aware of Resident #6 having any incidents of being verbally or physically aggressive towards staff or residents. The social services director (SSD) was interviewed on 3/26/25 at 12:34 p.m. The SSD said Resident #7 had a history of being verbally aggressive. The SSD said Resident #7 intervened with other residents about their eating habits. She said Resident #7 had a history of making false accusations and being sexually inappropriate. The SSD said she watched the video of the incident on 2/12/25. The SSD said the video showed Resident #7 going in the dining room and yelling at Resident #6. The SSD said witnesses said they heard Resident #7 telling Resident #6 to stop yelling. She said Resident #7 had hit Resident #6 in the face/neck area with an open hand. She said Resident #7 hit Resident #6 and he fell backwards in his wheelchair. She said Resident #7 was the aggressor as she approached Resident #6. She said Resident #6's wheelchair hit Resident #7 which made her fall to the ground. She said staff acted right away and separated the two residents and both residents were assessed. The SSD said she was not aware of the two residents having any issues with each other in the past. The SSD said currently the two residents were cordial with each other. She said she did not think they remembered what happened. She said she was surprised that Resident #7 was the aggressor. The SSD said Resident #6 was very friendly and easy going. The SSD said if Resident #6 did not get something immediately he would yell and curse. She said Resident #6 cursed a lot. She said when the resident felt like he was getting upset he would ask for one-to-one conversations and go to his room. She said Resident #6 liked to go outside and get fresh air. She said those interventions seemed to be successful for the resident. The SSD said Resident #6 had never been physically aggressive towards other residents. The DON was interviewed on 3/26/25 at 2:43 p.m. The DON said Resident #7 had a TBI and had impulse control issues. The DON said Resident #6 was in the kitchen by the window and Resident #7 came up the hall and was talking with her hands. The DON said both residents were talking and Resident #7 reached out with an open hand and smacked Resident #6. She said when Resident #6 was trying to get away from Resident #7, he caught Resident #7's leg and she also fell . She said Resident #6 was trying to get away from Resident #7 and he fell to the side of his wheelchair. She said the residents did not sustain any injuries. She said Resident #6 did not have redness from where Resident #7 made contact. The DON said Resident #7 had hit Resident #6 because she was frustrated because he was yelling explicit language. The DON said Resident #7's solution was to hit Resident #6. The DON said both residents were monitored for three days. The DON said the staff charted resident behaviors by exception and if they noticed an issue. The DON said that both residents had not had any other issues. She said both residents got along well with each other. The DON said Resident #6 had low frustration tolerance and when he did not get the answer he wanted, he would start yelling and cursing.

Based on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 13 sample residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility staff failed to implement person-centered interventions to prevent Resident #2 from displaying physically aggressive behaviors toward other residents related to her diagnosis of dementia. Findings include: I. Facility policy and procedure The Dementia-Clinical Protocol policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, The staff will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments. The IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. The facility will strive to optimize familiarity through consistent staff-resident assignments. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. II. Resident #2 A. Resident status Resident #2, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), the diagnoses included schizoaffective disorder (depressive type- mental disorder), anxiety disorder and Alzheimer's disease. The 1/21/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required the assistance of one person with transfers, dressing, showering, toileting and personal hygiene. The MDS assessment documented Resident #2 had physical behavioral symptoms directed toward others which occurred every one to three days during the assessment period. A. Observations During continuous observation on 3/25/25, beginning 9:25 a.m. and ending at 5:00 p.m. the following was observed: At 9:25 a.m. Resident #2 was in her room. At 1:15 p.m. Resident #2 exited her room and began self-propelling herself down the hallway. Staff members were at the nursing station did not follow Resident #2 while she was wheeling herself down the hallway on her way to the facility's candy store and then returned to her room. She passed close to two residents and interacted with one staff member. At 3:10 p.m. Resident #2 exited her bedroom, self propelled herself down the hallway toward the dining room and stayed there until it was dinner time. She passed by residents in the hallway. Staff did not step in between Resident #2 and other residents as they were passing. During continuous observation on 3/26/25, beginning 8:45 a.m. and ended at 12:00 p.m., the following was observed: At 8:45 a.m. Resident #2 was in the physical therapy gym. At 9:00 a.m. Resident #2 self propelled herself out of the physical therapy gym and went to her bedroom. She passed close to other residents and staff members while wheeling herself down the hallway to her room. Staff members did not step in between Resident #2 and any other resident she passed by in the hallway. At 10:20 a.m. Resident #2 self propelled herself from her room to the management offices and then to the dining room without supervision. She passed close by other residents and staff members while she wheeled through the hallway. Staff members did not step in between Resident #2 and any other resident she passed by in the hallway. B. Record review The behavioral care plan, initiated on 12/24/19 and revised on 1/21/25, documented Resident #2 had targeted behaviors of paranoia and could have a short temper. The care plan documented when cycling, she would make false accusations, believing staff were talking about her and making fun of her. Resident #2 hit people in the past due to being short tempered and impulsive responses. The interventions included one-to-one conversations with staff to discuss her feelings, assisting the resident out of the middle of the hallway, encouraging her to travel on one side of the hallway to mitigate disruptive interactions with others, assigning a one to one caregiver for emotional support, speaking to the resident calmly, educating the resident to stay away from people she does not get along with and administering and monitoring medications as ordered. -However, observations revealed Resident #2 was not encouraged to travel on one side of the hallway as indicated on her care plan (see observations above). The 11/6/24 nursing progress note documented Resident #2 continued to have irritability towards other residents at times in the hallways and would become verbally aggressive when provoked. The 11/24/24 nursing progress note documented Resident #2 grabbed another resident's hair after contact between wheelchairs in the hallway. The 1/2/25 progress note documented Resident #2 was in the hallway self-propelling her wheelchair. Resident #13 was waiting for Resident #2 to pass when Resident #2 hit him in the middle of his chest. An assessment was completed and with no injury noted. Both residents were placed on frequent safety checks. The 1/2/25 incident report documented when Resident #2 was next to Resident #13 in the hallway, she stopped and hit him for no reason. Resident #2 said, stating get out my way. Resident #13 said he put his hand on Resident #2's head to stop her and said, stating What the hell old lady. Resident #2 said she was trying to stop Resident #13 from bumping into her. The 2/3/25 nursing progress note documented Resident #2 tried to hit and scratch the nurse when he asked how he could help Resident #2. The 2/26/25 incident report documented Resident #1 was passing in the hallway when Resident #2 was self-propelling her wheelchair in the opposite direction. Resident # 1 stopped and stood to the side so that Resident #2 could pass him. When Resident #2 passed by Resident #1 him, she slapped him on his left cheek with her open hand. The incident was witnessed by a dietary aide. Cross reference F600: the facility failed to prevent physical abuse by Resident #2 toward other residents. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/25/25 at 5:10 p.m. CNA #3 said Resident #2 yelled, screamed, and tried to scratch other residents and staff members often. She said she would give Resident #2 space when she was having a bad day. CNA #3 said every time Resident #2 had a bad day, the facility staff did not walk with the resident down the hallway. She said it was easier to give her space so they did not get hit or scratched. She said she did not try to walk between Resident #2 and any other residents coming down the hallway to ensure another resident was not targeted by Resident #2. She said was concerned if she was too close to Resident #2 during those episodes, she would get hit or scratched. CNA #3 said Resident #2 did not always like it when other residents invaded her personal space and got too close. She said Resident #2 could become physically aggressive if that happened. CNA #4 was interviewed on 3/26/25 at 10:00 a.m. CNA #4 stated that Resident #2 gets frustrated when she could not move. CNA #4 said that changed her mood and the behaviors began. CNA #4 said when incidents happened, the staff usually addressed the cause of the issue and gave her some space. CNA #4 said in order to protect other residents during these incidents, the staff separated them and took Resident #2 to her bedroom. Registered nurse (RN) #3 was interviewed on 3/25/25 at 5:25 p.m. RN #3 said the facility staff gave Resident #2 space and would backup away from her when she was upset. She said Resident #2 was physically aggressive when she was having a bad day. She said Resident #2 could be physically aggressive with facility staff or toward other residents. She said she was concerned if she got too close to Resident #2 during a bad day she would be hit. RN #3 said the facility staff did not provide Resident #2 with one-to-one supervisor when she moved about the facility. She said facility staff did not walk down the hallway to follow the resident and stand between Resident #2 and another resident coming down the hallway if Resident #2 was having a bad day. She said Resident #2 did not like other residents getting too close to her. RN #3 said if Resident #2 was physically aggressive with another resident, she would be placed on 15-minute safety checks for three days. The director of nursing (DON), the NHA, the clinical consultant (CC) and the regional operations manager (ROM) were interviewed together on 3/26/25 at 1:36 p.m. The DON said Resident #2 had a history of physically aggressive behavior toward other residents and staff members. The DON said she had been institutionalized at a young age and had a difficult time trusting others. She said Resident #2 was very protective of her belongings and personal space. The DON said Resident #2 does the best when she is regimented in a daily routine. The DON said Resident #2 was triggered by what she perceived as another resident getting too close to her, especially in areas such as the hallway. She said the resident had a large personal bubble that was not always obvious to others and was paranoid about people whispering or talking about her behind her back. The NHA said there were a few staff she trusted and had built a good relationship. He said she was part of a program through her insurance that will provide a one-to-one companion once or twice a week for one to two hours. The DON said if Resident #2 was having a bad day, the floor staff should notify management and someone she trusted and had a good rapport with would go down and sit with her. She said staff should keep an eye on Resident #2 when she left her room often, because that could be a sign of a bad day. She said the floor staff should walk down the hallway in between Resident #2 and another resident to ensure the other resident does not get too close to Resident #2 to prevent an altercation. The NHA said the facility staff should be aware of Resident #2's triggers and the interventions identified on the care plan. The DON said staff should be walking in between Resident #2 while she wheeled herself down the hallway to ensure she does not have a physically aggressive incident with another resident. The NHA confirmed the interventions identified on the comprehensive care plan could not be evaluated to be effective or ineffective without implementation by all staff.

Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #4 was provided with the supervision necessary to prevent elopement; and, -Ensure Resident #4's elopement on 3/2/25 was investigated thoroughly. Findings include: I. Facility policy and procedure The Elopement and Wandering policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/26/25 at 3:36 p.m. It read in pertinent part, It is a goal of the facility to provide a safe environment using the least restrictive measures available in care for residents who are exhibiting elopement behavior. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. II. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia and schizophrenia. The 3/12/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He was independent with most activities of daily living (ADL) but required supervision/touching assistance with showering. According to the assessment, Resident #4 had a wander/elopement alarm. B. Record review The elopement care plan, revised 3/17/25, documented Resident #4 was an elopement risk. He was unsafe to be in the community independently related to an unsteady gait and history of falling when ambulating to the gas station. The resident had a wander guard in place and his picture and information was in the facility's wander/elopement binder. Resident #4 liked to sit on the couch in the common area at times. Resident #4 would attempt at times to remove his wander guard and would ask staff to remove it. Interventions included ensuring the resident's current identification form was in the elopement binder, reassuring the resident that he had enough cigarettes and that he did not have to buy any at that time had been a successful intervention in the past with redirecting exit seeking behaviors, the resident liked to drink Mountain Dew and eat Lay's potato chips, offering these snacks may also assist in redirecting him, identifying patterns of wandering, intervening as appropriate, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, providing structured activities, such as toileting, walking inside and outside, reorientation strategies including signs, pictures, calling his sister, a wander guard for safety and checking placement of the device, which was located on the resident's right wrist every shift. The 9/13/24 physical restraint/safety device informed consent form for a wander guard due to safety reasons to prevent Resident #4 from going out of the facility unassisted documented Resident #4 gave verbal consent to have a wander guard placed. The wander/elopement risk evaluation, dated 3/10/25, documented Resident #4 routinely wandered or paced and had previous attempts to elope at the facility. Review of Resident #4's electronic medical record (EMR) revealed the following progress notes: The nursing progress note, dated 3/2/25 at 7:22 a.m., documented Resident #4 left the facility at about 5:30 a.m. through the back door of the smoking area. The nurse and a certified nurse aide (CNA) went outside to look for the resident around the block but did not find him. The nurse called the on-call nurse who then notified the NHA and the director of nursing (DON) about the situation. The NHA told the nurse to call 911 and report that Resident #4 was missing. The on-call nurse practitioner was notified, and a message was left for the resident's emergency contact. A couple of police officers came to the facility at about 7:15 a.m. and asked the nurse questions about the resident. The police said they were going to look at the cameras and try to find the resident. The nursing progress note, dated 3/2/25 at 1:33 p.m, documented Resident #4 was reported to have left the facility at 5:30 a.m., according to the night nurse. The nurse spoke to the local police department about Resident #4's contacts, where he could be going and was able to provide a photo of the resident. Resident #4 returned to the facility about 11:30 a.m. Resident #4's vital signs were taken upon his return to the facility and he was assessed to have no new skin wounds or contusions. The police officers followed up around 2:15 p.m. and spoke to the resident. Resident #4 said he wanted to open a bank account and get a bank card. He said he left the facility to go to the bank but the bank was closed. The nurse informed Resident #4 that staff could help facilitate him opening a bank account. The facility's investigation report for Resident #4's 3/2/25 elopement incident was requested from the NHA on 3/26/25 at 11:40 a.m. -On 3/26/25 at 1:40 p.m. the NHA said the facility did not have an investigation report for the 3/2/25 elopement incident and the elopement was not reported to the State Agency. III. Staff interviews CNA #1 was interviewed on 3/25/25 at 4:39 p.m. CNA #1 said Resident #4 was a smoker and went outside to smoke during smoking times. CNA #1 said Resident #4 was a supervised smoker. She said staff had to be outside with Resident #4 and watch him while he smoked. She said Resident #4 only liked to go outside to smoke but would not sit outside and hang out. CNA #1 said Resident #4 had a wander guard on for his safety and because he liked to elope. CNA #1 said she did not know if Resident #4 had eloped from the facility. CNA #1 said the facility had a smoking schedule and had to remind Resident #4 of the times. She said Resident #4 was able to go outside when he wanted. She said the wander guard alarmed when he exited the door to go outside. She said the resident did not stay outside and would come back inside right after he was done smoking. Registered nurse (RN) #1 was interviewed on 3/25/25 at 4:17 p.m. RN #1 said Resident #4 was fairly independent. RN #1 said Resident #4 got up pretty early and would be up by 5:00 a.m. RN #1 said Resident #4 stayed in his room and only came out to smoke. RN #1 said Resident #4 was a supervised smoker. RN #1 said the facility had smoking times and when it was time to go out to smoke, a CNAwent outside with the residents. She said the CNA was outside the whole time the residents were outside smoking. She said Resident #4 did not like to hang out outside and usually came back inside when he was done smoking. She said Resident #4's biggest behaviors were around him being able to smoke. She said Resident #4 had done better with knowing the smoking times. She said Resident #4 was developing a routine. RN #1 said Resident #4 had a wander guard on for his safety and elopement reasons. RN #1 said Resident #4 had had a couple of attempts of leaving the facility. RN #1 said there were alarms on the outside gates and if Resident #4 tried to leave, the alarm would go off. RN #1 said Resident #4 had not tried to elope while he was outside smoking. RN #1 said Resident #4 had eloped during other times of the day. RN #1 said Resident #4 was fixated on going to the bank and getting more cigarettes. She said Resident #4 was confused about the time of day. The NHA, the DON, the social services director (SSD), and the clinical consultant (CC) were interviewed together on 3/26/25 at 1:40 p.m. The NHA said Resident #4 had eloped and went to the bank on 3/2/25. The NHA said Resident #4 was focused on going to the bank and getting cigarettes. He said Resident #4's cigarettes were provided to him by the facility. He said Resident #4 had exited through the back door and then through the wood fence. The NHA said Resident #4 had a wander guard. The NHA said he did not know how long the resident had had the wander guard. The NHA said Resident #4 had a wander guard because staff did not know Resident #4's baseline. He said Resident #4 was a high elopement risk. The DON said Resident #4 did not have cigarettes. The DON said Resident #4's family was not willing to provide the cigarettes for him. The DON said the facility bought packs of the cigarettes for Resident #4 but it got expensive. She said they bought tobacco and started rolling his cigarettes. The DON said during the weekends, Resident #4 was afraid that he was going to run out of cigarettes. She said that was one of the resident's biggest fears. The DON said activities thought about putting Resident #4 on a work program to keep him busy. The DON said she spoke to activities but they did not offer Resident #4 a work program. The DON said on 3/2/25 Resident #4 eloped from the back gate. The DON said staff noticed the alarm was going off. The DON said she did not know if staff just turned off the alarm and did not know Resident #4 had left. She said she could not speak to what occurred that day. The DON said when the alarms sound, staff are supposed to look for whichever resident set the alarm off. She said that morning (3/2/25), it was dark outside. She said Resident #4 was fast and staff were not able to see where he had gone. The DON said staff called the NHA and let him know what was going on. The DON said staff searched the block and could not find the resident, so they called 911. The DON said Resident #4 came back to the facility on his own. The DON said she could not speak on behalf of the staff who were working that morning as to whether they responded to the alarm quickly or not. She said she could not speak to what a reasonable amount of time staff should have before they turn the alarm off. She said she did not know what staff were doing at the time the alarm went off. She said the response time for the alarms should be less than five minutes. The NHA said the back gate had a different alarm on it. The NHA said staff should know the difference between the door alarm and the gate alarm. The NHA said there was a key by the nurses station and staff had to go to the fence alarm to turn it off with the key.

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure The Facility Assessment policy, dated October 2018, was provided by clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The facility assessment includes a detailed review of the resident population. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation. II. Record review The facility assessment was last reviewed in August 2023 by the previous nursing home administrator (NHA), the director of nursing (DON), the medical director and the governing body. The facility assessment failed to: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population; -Identify facility resources needed to provide competent resident support during day to day operations and emergencies; and, -Include the facility-based and community-based risk assessment, utilizing an all-hazards approach. III. Staff interviews Corporate consultant (CC) #1 and CNC #1 were interviewed together on 1/24/24 at 12:25 p.m. CC #1 said the previous NHA had reviewed the facility assessment a few months ago. CC #1 and CNC #1 said the facility assessment needed to be more detailed. CNC #1 said the facility assessment had several sections that included prompts but the prompts were not filled out to capture the needs of the facility. CC #1 and CNC #1 reviewed the facility assessment and confirmed the assessment did not have specific training staff needed to help the residents at the facility. CC #1 said the assessment did not include a facility-based risk hazard approach. CC #1 said he would assist in ensuring the facility assessment was updated.

Based on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects for two of three dumpster areas. Specifically, the facility failed to ensure garbage and potentially hazardous medical waste was disposed of in the proper receptacles or dumpster. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) the Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/30/24, read in pertinent part, Receptacles and waste handling units for refuse, recyclables, and returnable used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. Cardboard or other packaging material that does not contain food residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem. II. Observations On 1/22/24 at 12:44 p.m., the garbage dumpster could be observed from the common area, through a window, on the north unit. From the window, the dumpsters were towards the back of the parking lot. The dumpster on the right side was open and had trash bags overflowing from the top. On 1/23/24 at 10:56 a.m., observation of the dumpster area in the north parking lot revealed the following: -Trash, including gloves, empty bottles, cardboard and other items were on the ground near the dumpster; -There were four grocery carts overflowing with trash near the dumpsters; -The dumpster on the right near the canal did not have a lid; and, -The dumpster on the left had a broken lid and the side door was open. On 1/24/24 at 8:22 a.m., the dumpsters remained open and there was garbage on the ground surrounding the dumpsters. III. Staff interviews The maintenance director (MTD) was interviewed on 1/23/24 at 10:56 a.m. The MTD said the trash was picked up on Mondays, Wednesdays and Fridays. The MTD said there were homeless people that often got into the dumpsters and made it a mess. The MTD said he tried to keep the area clean, but there was nothing he could do regarding the mess the homeless people made. The MTD said the two dumpsters were used for all of the facility's trash. The MTD said he was not aware the dumpster lids were not properly functioning. The MTD said he would call the dumpster company and have them replaced. The MTD said there were frequently pests, including racoons, getting into the dumpster. The MTD said the facility had not discussed moving the dumpsters or placing a fence around the dumpsters to help keep the area clean. Clinical nurse consultant (CNC) #1 was interviewed on 1/23/24 at 2:47 p.m. CNC #1 said the facility frequently called the police because homeless people went through their dumpsters. She said the dumpsters should have lids on them. CNC #1 said she would ensure the dumpsters got new lids so they could be closed.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms. Specifically, the facility failed to: -Ensure frozen nutritional supplements and thickened liquids were dated appropriately; -Ensure timely cleaning of the ice machine; -Ensure food was labeled and dated in the nourishment rooms; -Ensure food was properly cooled; and, -Ensure food was reheated appropriately. Findings include: I. Ensure frozen nutritional supplements and thickened liquids were dated appropriately A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, retrieved 1/29/24, read in pertinent part, Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. B. Observations On 1/17/24 at 8:51 a.m. in the main dining room there was a drink cart with an opened container of thickened juice. The thickened juice did not have an open date. During the initial kitchen tour on 1/17/23 at 8:52 a.m. the following was observed: -In the main walk-in refrigerator there was an opened container of thickened apple juice and an opened container of thickened orange juice with no opened date; and, -There was a box of mighty shakes (frozen nutritional supplement) with no pull date. During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed: -There was a metal container with mighty shakes on the service line with no pull date. On 1/22/24 at 4:11 p.m. in the south side nourishment room refrigerator the following was observed: -An opened container of nectar thick water and a container of nectar thick cranberry juice with no open date and a mighty shake with no pull date. At 4:12 p.m. there was a drink cart on the south side hallway that had an opened container of nectar thick water with no open date. At 4:16 p.m. in the north side nourishment room refrigerator the following was observed: -An opened container of honey thick liquid with no opened date. The liquid was semi-solid. C. Staff interviews The nutrition services director (NSD) and the corporate registered dietitian (CRD) were interviewed on 1/22/24 at 4:40 p.m. The NSD said thickened liquids needed to be labeled with an opened date. The CRD said thickened liquids needed to be disposed of 10 days after being opened. The CRD said mighty shakes needed to be labeled when they were pulled from the freezer. The CRD said mighty shakes were only good for 14 days after they were thawed. The CRD said she would provide education to the staff on thickened liquids and mighty shakes. The NDS said the staff typically wrote the pull date on the box that the mighty shakes were delivered in. The NSD said the mighty shakes should not be stored in the nourishment room refrigerators. II. Ensure timely cleaning of the ice machine A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved 1/29/24, read in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. B. Observations and record review During the initial kitchen tour on 1/17/23 at 8:52 a.m. the following was observed: -The ice machine had hard water stains on the sides of the machine; and, -On the inside of the ice machine there was a brown and orange build-up where the ice was dispensed for resident use. During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed: -The ice machine remained with water stains and the brown and orange build-up. On 1/22/24 at approximately 4:50 p.m., the NSD looked into the ice machine and said it looked like there was rust in the ice machine and there were hard water stains on the outside of the machine. A copy of the most recent cleaning of the ice machine was requested on 1/22/24. The NSD said she would have to contact the outside company for a copy of the receipt showing the machine was cleaned in October 2023. -The NSD did not provide a copy of the receipt during the survey process. C. Staff interviews The NSD was interviewed on 1/22/24 at 4:50 p.m. The NSD said the ice machine needed to be cleaned. The NSD said the machine was last professionally cleaned in October 2023. The NSD said an outside company cleaned the ice machine every six months. The NSD said the dining staff wiped off the outside of the ice machine, but dido not clean the inside of the machine. III. Ensure food was labeled and dated in the nourishment rooms A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/29/24, read in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Facility policy and procedure The Food from Outside Sources policy, revised 7/28/23, was provided by the clinical nurse consultant (CNC) #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, Purpose: All foods may be permitted from outside sources if deemed safe and wholesome per state and federal guidelines and within medical advice. If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, resident anime and item description if needed. Suitable containers properly seal foods to prevent dryness or drainage. Examples of suitable containers are plastic with tight fitting lid, clamshells for restaurant leftovers and tight closing plastic storage bags. Resident's food stored under refrigeration shall have name, date, and expiration date on the label. Perishable food is discarded within three days from any resident refrigerator source unless the food item is safe until a printed expiration date. C. Observations On 1/22/24 at 4:11 p.m. in the south side nourishment room refrigerator the following was observed: -A bag of sausages with no label or date At 4:16 p.m. in the north side nourishment room refrigerator the following was observed: -An opened container of yogurt with no open date; -An opened can of Spam labeled 1/13/24; and, -A peanut butter and jelly sandwich labeled 1/17. D. Staff interviews The NSD was interviewed on 1/22/24 at 4:40 p.m. The NSD said opened foods needed to be disposed of three days after being opened. The NSD said she was unsure where the bag of sausages came from and disposed of them. The NSD said the Spam, peanut butter and jelly sandwich and yogurt needed to be thrown away. IV. Ensure food was properly cooled A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, retrieved 1/29/24, read in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan. B. Facility policy and procedure The HACCP (Hazardous Analysis and Critical Control Points) procedure, dated 2020, was provided by CNC #2 on 1/24/24 at 4:30 p.m. It read in pertinent part, Instructions: record temperatures every hour during the cooling cycle. Record corrective actions taken if applicable. The supervisor of food operation will verify proper cooling procedures by routinely monitoring work activity. Cooling guidelines, you must demonstrate that the temperature, has moved from 135? (fahrenheit) to 70? within 2 hours, has moved from 70? to 41? within the remaining 4 hours, if the temperature for the first 2 hours was not cooled to 70?, the temperature must be cooled completely through the danger zone (41?) in the next 2 hours. Any food not properly moved through the two-stage process and cooled to 41? must be discarded. C. Observations During the initial kitchen tour on 1/17/23 at 8:52 a.m. the following was observed: -A container of cooked hard boiled eggs that were hot to the touch; -A container of cooked soup with no label or date; -A container of cooked sausage patties that were still hot; and, -A container of cooked chicken tenders. During a continuous observation on 1/22/24, beginning at 11:00 a.m. and ending at 12:45 p.m., the following was observed: -A container of cooked soup; -A container of cooked mechanical soft vegetables; -A container of cooked pureed vegetables; and, -A container of cooked beans. D. Record review On 1/24/24 at approximately 4:30 p.m. CNC #2 provided a copy of the cooling log. -The cooling log was last utilized on 9/30/23. E. Staff interviews The NSD was interviewed on 1/22/24 at 4:40 p.m. The NSD said foods needed to be cooled properly and logged on the food cooling sheet. The NSD said the food cooling monitor log had not been utilized since September 2023. The NSD said foods needed to be cooled properly to prevent bacteria growth. V. Ensure food was reheated appropriately A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 1/29/24,t read in pertinent part; The food shall have an initial temperature of 41 F or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. Reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. B. Facility policy and procedure The Food from Outside Sources policy, revised 7/28/23, was provided by CNC #1 on 1/27/24 at 4:58 p.m. It read in pertinent part, Food from a home source must be heated to 165 degrees for 15 seconds and served at 150 degrees or less. Food temperatures are recorded for service. Food may be cooled for several minutes to 150 degrees. C. Observations On 1/23/24 at 4:58 p.m. certified nursing assistant (CNA) #1 was walking down the hallway with a frozen lasagna. CNA #1 said she did not take the temperature of the lasagna. CNA #1 said the resident instructed her to cook the lasagna for eight minutes in the microwave. CNA #1 entered the resident's room and gave him the microwaved lasagna. D. Record review and staff interviews The NSD was interviewed on 1/23/24 at 5:00 p.m. The NSD entered the nourishment room and said there was a microwave for resident use. The NSD said the facility staff needed to microwave the item and take the temperature of the food. The NSD said the food needed to be heated to 165 degrees fahrenheit. The NSD said the staff needed to log the food item's temperature on the clipboard in the nourishment room. The NSD said the temperature log was not filled out and the lasagna was served to the resident prior to ensuring the food was at the correct temperature. CNC #1 was interviewed on 1/23/24 at 6:03 p.m. CNC #1 said the resident told the facility staff that the lasagna was not warm enough and needed to be heated more.

Based on interviews and record review, the facility failed to protect and keep safe from abuse and neglect two (#1 and #3) residents out of six sample residents. On 6/12/23 the facility failed to send an escort to a medical appointment outside of the facility with Resident #1 who had cognitive impairment, Parkinson's Disease and autism. The facility had evaluated Resident #1 was unsafe to go out of the building by herself three different times (11/7/22, 1/22/23, and 4/18/23) prior to the appointment on 6/12/23. Resident #1 was dropped off at a medical office building by herself, and was found wandering down a hallway not in the physician's waiting area by the medical office personnel. The medical personnel called the facility to come and help Resident #1. A facility staff person who answered the phone responded that they would see what they could do but they (the facility) could not promise anything. The medical personnel at the physician's office then called the corporation who owned the facility. The corporation made phone calls to get a van driver to come pick up Resident #1 and return her to the facility. The medical appointment building was on a busy street which posed a potential threat had Resident #1 not been found and had she wandered out of the building. It took approximately one and a half hours from the time Resident #1 was dropped off at the medical building until she was returned to the facility. The facility's appointment scheduler for the residents was not a clinical medical staff member, and said he based his evaluations of the resident's safety on his own observations. Even though Resident #1 had documentation of the need for an escort for her safety, the appointment scheduler said he did not read the evaluations, or consult with the facility's nursing staff to determine the resident's needs for an escort when out in the community. The former nursing home administrator (FNHA) knew of the situation on 6/12/23 and did not put interventions in place to prevent the incident from occurring again. The facility did not put interventions in place to make sure residents who needed escorts had that provision until a survey began in the building 10 days later on 6/22/23. The facility failed to provide Resident #1 the escort and supervision necessary while out in the community at a medical appointment, which created the likelihood of serious harm or injury if not immediately corrected for Resident #1. In addition, the facility failed to protect Resident #3 from physical abuse from Resident #4 who pulled Resident #3's hair out of her head. Resident #4 said she would continue physical violence on Resident #3 under certain conditions. The facility did not investigate the incident thoroughly and implement interventions for the two residents or take action for the safety of other residents in the facility. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 6/12/23 the facility failed to send an escort to a medical appointment outside of the facility with Resident #1 who had cognitive impairment, Parkinson's Disease and autism. The resident had been evaluated to have an escort when she went anywhere out into the community. The resident was dropped off at a medical appointment in the community, left on her own with no escort and she was not taken to the area where her appointment was located by the van driver. The resident was found wandering down a hallway in a medical office by the medical office staff. The medical office was close to a busy street. The facility failed to provide Resident #1 the escort and supervision necessary while out in the community at a medical appointment, which created the likelihood of serious harm or injury if not immediately corrected for Resident #1. B. Facility notice of immediate jeopardy On 7/18/23 at 1:31 p.m. the regional director of operations (RDO) and the new NHA were notified that the failures to ensure the safety of residents who needed escorts being transported outside of the facility, placed residents at risk for of serious harm. C. Plan to remove immediate jeopardy On 7/18/23 at 3:08 p.m the RDO and NHA presented the following plan to address the immediate jeopardy situation, which read in part: On 6/22/23 (a) facility wide review was done to ensure transport will be provided (with) all information regarding what the needs of the resident are and if an escort is needed to ensure the safety of the resident during transport and appointment. On 6/22/23 when (the) facility NHA was suspended then eventually terminated, (the) facility staff was notified that they were to notify the RDO and/or QI (Quality Improvement person) of any and all community emergency (ies) involving residents until facility hired a full time NHA. On 6/13/22 in the a.m. the organization sent out a community wide email to address this concern. Specifically, (corporate name) shared with all communities: When an emergency occurs with (a) resident or escort during transport and/or appointment (the) escort is to call the NHA/DON (director of nursing) to deploy help to escort and/or resident. Escorts will have (a) cell phone to reach (the) facility if needed. 4. On 6/22/23 (name of facility scheduler for outside appointments) was removed from the appointment process, facility nursing team replaced (name) in appointment process, this was done to ensure adequate clinical evaluation would be completed. 5. The facility implemented a system for scheduling, arranging transportation, and assessing the type of transport needed (wheelchair/stretcher). a. Upon admission, orders are reviewed for appointments, following admission residents or nurses notify a nurse or member of the nurse management team of appointment, nurse or member of the nurse management team will input information into (the name of the electronic medical record system) under clinical communications. IDT (interdisciplinary team) and nurse managers will assess for (the) required type of transport, and if an escort is required. b. Nursing will evaluate (a) resident upon changes of condition to ensure a safe appointment and needs are met during appointment and transport. c. Nurse assesses for (the) required type of transport and if an escort is required. d. Centralized driving provided additional education related to resident drop off/pick up with van drivers on 6/26/23. e. On 6/29/23 centralized driver did additional training with the three unit managers specifically related to date, the time, the address, phone number, patient's mobility and if an escort is required. All scheduled appointments will be reviewed in (the) morning meeting to ensure that proper preparation is completed. f. The appointment is scheduled. g. A nurse has determined the type of transport that is required and if an escort is required. h. Transportation is arranged. i. Any orders that are required (prep, preop, labs, holding of meds) are implemented. j. Equipment that is required for transport is available and ready and checked the day prior to transport. All incidents or issues identified with a transport will be reviewed by the clinical team and supervisor and reviewed using the QAPI (quality assurance and performance improvement) process. D. Removal of immediate jeopardy On 7/18/23 at 3:13 p.m. the NHA and RDO were notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at a D scope, isolated with a potential for more than minimal harm. E. Facility follow up The RDO was interviewed on 7/18/23 at 4:10 p.m. The RDO said after his investigation into the incident with Resident #1 the company decided the former NHA, DON and the social service assistant (SSA) were no longer employees at the facility. The RDO said the SSA was the one who answered the phone when the medical office personnel called to notify the facility that Resident #1 was unescorted. He said the facility staff person who scheduled appointments for the residents outside of the facility in the community was no longer the facility scheduler. He said when the state survey began in his building last month he and the quality improvement (QI) looked into incidents that had happened in the facility. He said on 6/22/23 it was discovered what had happened with Resident #1 and he began interventions immediately to fix the situation for all of the residents. II. Facility policy and procedure The Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 6/21/23 at 12:05 p.m. It revealed in pertinent part, Communities do (sic) not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents. Residents have the right to be free from abuse, neglect. Standards 1. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. 2. Employees have a unique position of trust with vulnerable residents. 3. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents. 4. Identification of abuse shall be the responsibility of every employee. Physical abuse is defined as abuse that results in physical harm with intent. It includes hitting, slapping, pinching, kicking. Common area is expanded to recognize the inclusion of living rooms or other similar areas where residents gather. Neglect is the failure of the facility, its employees or service provider to provide goods, and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Facility will take action when identifying events such as suspicious bruising or skin tears. Occurrences, patterns and trends that may constitute abuse will be identified and appropriate action taken. 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. Abuse By Other Residents If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. III. Resident #1 A. Resident status Resident #1, age under 70, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), the diagnoses included paranoid schizophrenia, bipolar disorder, autism, pseudobulbar affect (uncontrollable laughing or crying), secondary Parkinsonism, anxiety disorder, gastro-esophageal reflux disease (GERD), other chronic pain and an overactive bladder. The 4/18/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required supervision with bed mobility, dressing, toilet use and personal hygiene. She was occasionally incontinent of urine. B. Record review The independent outing pass evaluations for Resident #1 revealed the following: -On 11/7/22 it was not recommended for Resident #1 to have independent passes at this time due to her mental and physical disabilities. -On 1/22/23 due to Resident #1's cognitive deficits it was not recommended that she have an independent pass. -On 4/18/23 due to Resident #1's cognitive status it was not recommended to go out independently. The comprehensive care plan, initiated 11/2/22 and revised on 5/16/23, revealed the resident had a communication problem with autistic disorder. -Interventions (for) communication (were to) allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off (the) television/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple/brief consistent words/cues. Use alternative communication tools as needed. -Remind and escort Resident #1 to activities in the facility, and (remind and escort) to outings in the community. -The 4/19/23 nursing care plan revealed it was recommended that Resident #1 have supervised passes due to her cognitive status. The goal was Resident #1 would be safe and comfortable during therapeutic outings. Social services (staff) and the interdisciplinary team (IDT) would work in concert with the resident and family/friends to provide maximum wellbeing for the resident. C. Interview with the hospital case worker (HCW) The HCW (where Resident #1 went to her medical appointment) was interviewed on 6/21/23 at 8:19 a.m. She said Resident #1 was dropped off at the hospital for a medical appointment and was found wandering around the hospital all alone. She said she called the facility to come and help Resident #1. She was told by a facility staff person they would see what they could do, and they could not promise anything. She said the resident had Parkinson's disease and dementia. She said the resident should not be left alone with her conditions. She said the hospital did not have the resources to provide a caretaker for her. She said the medical center for the appointment was on a very busy street. She said it would not be safe if Resident #1 had wandered out of the building because of the busy street. She said the hospital staff found Resident #1, who had wandered down a hallway, not by her appointment place. She said she told the facility that the resident could not return to the hospital for an appointment until they called the hospital to communicate that a caregiver would be sent in the future. She said as of 6/21/23 no staff from the facility called the medical office to let them know that in the future the facility would send a caregiver with Resident #1 for her medical appointments. D. Family interview and Resident #1 observation with attempted interview The legal guardian and sister of Resident #1 was interviewed on 6/21/23 at 11:00 a.m. She said she tried as often as she could to attend medical appointments with her sister. She said on 6/12/23 she forgot about the scheduled appointment and did not go to the doctor's visit to meet her sister. She said her sister was unable to attend anything outside of the facility without an escort due to her physical and mental disabilities. She said her sister often got agitated. She said when people asked Resident #1 a question she often just responded with no, because she was unable to communicate with a conversation. Resident #1 was observed and an interview was attempted on 6/26/23 at 12:30 p.m. She continually swayed her torso back and forth from seated upright to bent over her knees. She said she liked her hamburger. She was unable to answer any other questions. E. Staff interviews The social service (SS) person was interviewed on 6/21/21 at 4:34 p.m. She said Resident #1 went into the community to a doctor's appointment on 6/12/23. She said the company van with a driver brought her to the appointment. She said Resident #1 did not have a caregiver or any escort with her for her appointment. She said Resident #1 should have had an escort the entire time when leaving the facility to go to her medical appointment. She said she thought Resident #1 was found at the medical office an hour after she was dropped off. She said she did not know which day she informed the resident's sister of the event but she said she thought it was later in the same week as the incident. She said if she could find documentation of the phone call to notify the sister who was the legal guardian she would provide the date. -No documentation was provided by exit on 6/26/23. The central transport scheduler (CTS) was interviewed on 6/22/23 at 12:30 p.m. He said one of the drivers took Resident #1 to her medical appointment and another driver picked her up and returned her to the facility. He said his team was not informed that Resident #1 needed an escort. He said the person who scheduled medical appointments with the corporate van drivers would put on the driver's calendars that a resident needed an escort. He said he was going to have a meeting with the van drivers on Monday 6/26/23 to discuss residents who needed escorts into the community. He said he did not know why the meeting would happen two weeks after the event but he would get it handled with his team. The transportation driver assistant (TDA) was interviewed on 6/22/23 at 12:47 p.m. He said he did not know that Resident #1 was to have an escort when he took her to her medical appointment on 6/12/23. He said he had forms that were to tell the drivers if someone needed an escort. He said no escort was listed for Resident #1. He said he brought Resident #1 to the front inside of the medical building but he did not stay with her because he was not told to do so. The medical records director was interviewed on 6/22/23 at 12:31 p.m. He said he was the person responsible for all transport scheduling in the facility for the residents. He said he wrote down on a centralized calendar for the van drivers what resident needed the appointment, where the appointment was located, what time the appointment was and what doctor the resident was to visit. He said he was the one responsible to determine the qualifications if a person needed a caregiver or escort to a medical appointment. He said he did not work with nursing or the director of nursing to determine who needed an escort. He said he walked around the facility and he could tell by a resident's behavior if they needed an escort to a medical appointment or not. He said he may look in the medical records to see if a resident had dementia and needed an escort. He said he made the decision about escorts and no other staff made the decision in the facility. He said he decided if a resident needed a certified nurse aide (CNA). He said if he saw a resident with behaviors in the facility he would send an escort. He said it had been some time since someone in the facility went out with an escort. He said Resident #1 did not go out with an escort on 6/12/23. CNA #1 was interviewed on 6/22/23 at 2:42 p.m. She said at the nurses station there was a list of residents who had appointments each day and at what time the appointment was scheduled. She said the CNAs got the residents ready and brought them to the front of the facility to meet the van driver. She said she had not gone to any appointments with Resident #1. She said Resident #1 needed daily guidance in the facility to do all of her daily care. CNA #2 was interviewed on 6/22/23 at 2:45 p.m. She said she worked with Resident #1. She said Resident #1 needed prompting to do all of her daily cares. She said Resident #1 had to be helped to take a shower because she could not cognitively take a shower on her own. F. Facility follow-up The regional director of operations (RDO) and corporate consultant (CC) were interviewed on 6/22/23 at 11:45 a.m. The RDO and CC said that as of today 6/22/23 the facility began a plan to make sure residents who needed escorts out into the community would have that service provided. They said previous management in the facility had not fixed the situation after the incident happened with Resident #1. The RDO and CC provided documentation of the plan to fix the situation that had happened with Resident #1 (10 days later). The plan included the following in pertinent part: -Interventions - The facility would implement a system for scheduling, arranging transportation, and assessing the type of transportation needed. Nurses (would) assess (the) required type of transportation and if an escort was necessary. All scheduled appointments would be reviewed in the morning meeting to ensure that proper preparation was completed. IV. Resident to resident physical abuse between Resident #4 and Resident #3 A. Incident on 5/22/23 The facility had used 5/22/23 and 5/23/23 interchangeably for when the event occurred. On 5/22/23 Resident #4 and Resident #3 were in a common area waiting to go outside with staff for a supervised smoking break. Resident #4 grabbed Resident #3 by her hair and pulled it out of her head. -The facility did not do a complete investigation after the incident and did not implement any measures for Resident #4, Resident#3, nor did the facility implement any safety measures for the other residents in the facility (cross-reference F610). In an interview with Resident #4 during the survey she said she would be aggressive again at Resident #3 if needed (see below). On 6/21/23 (during survey) the facility RDO and CC began an investigation into the incident, conducted interviews and began to put interventions into place for the residents. The CC provided a company email of a conversation on 6/6/23 from the corporate social services quality mentor to the NHA. (During the survey, the NHA was suspended). On 6/6/23 (12 days after the incident) the NHA was given a list of suggestions and ideas to put interventions into place for Resident #4. The interventions were ideas to help with increased behaviors and how to implement and help the resident. The CC said on 6/26/23 at 2:36 p.m., that the NHA had instructions of what to do for Resident #4 (provided in the email above), but he did not do what was asked of him to do. The RDO and CC during survey on 6/22/23 began an investigation into the physical abuse between Resident #4 and Resident #3, which included interviewing residents and staff and putting interventions into place (see facility follow-up below). B. Resident #4 1. Resident status (assailant) Resident #4, age under 70, was admitted on [DATE]. According to the June 2023 CPO, the diagnoses included bipolar disorder, anxiety disorder, borderline personality disorder, nicotine dependence, alcohol abuse and unspecified dementia. The 6/8/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toilet use. She required limited assistance with locomotion off the unit. She self propelled in a wheelchair. She did not reject care from staff. 2. Record review The behavior comprehensive care plan, initiated 10/25/19 and revised on 5/23/23, revealed: Focus: Resident had a history of bipolar disorder, borderline personality disorder, and dementia with behavioral disturbances. She could be verbally and physically aggressive towards staff. She received pleasure out of getting a reaction out of others often in a negative way. History of false accusations which regarded staff and residents. Resident #4 had become more aggressive to staff and other residents by cursing, throwing water/coffee, (and) pulling hair. Goal: Will not cause harm to self or others, will not have aggression through review date. (9/2/23) Interventions: Educate Resident #4 on appropriate boundaries. Encourage her not to involve herself in other residents' concerns. Offer cigarettes when she is out, to help with escalation in behaviors. Nursing facility staff should provide ongoing evaluation and documentation of moods, participation in care, treatment, medication management, and psychiatric stability. On 5/4/21 Resident #4 was documented as a supervised smoker. The 5/23/23 nursing progress note revealed Resident #4 pulled out Resident #3's hair yesterday, placed on frequent checks, informed staff to keep her away from the south station unless it was designated smoking times. The May 2023 behaviors treatment administration record (TAR) revealed: -The behavior tracking question was: did the resident have a behavior directed at another resident? It was documented that the resident had no behaviors directed towards others on 5/23/23 and 5/30/23. -However, Resident #4 did have behaviors directed at other residents on 5/23/23 and 5/30/23. Dietary progress notes on 5/30/23 revealed Resident #4 and her tablemate at lunch yelled at each other. Resident #4 threw milk at the other resident. Incident progress notes on 6/3/23 revealed Resident #4 threw food on another resident during breakfast. She was educated to treat others as she would like to be treated and Resident #4 said she did not care. 3. Resident interview Resident #4 was interviewed on 6/22/23 at 2:45 p.m. She said she pulled Resident #3's hair because she was a (expletive). She said because she pulled her hair and dumped oatmeal on another resident, she was being punished by the NHA. She said she agreed to wear a patch to help her not smoke for now. She said she planned on smoking in the future. She said for now she agreed to not smoke because of hurting Resident #3. Resident #4 was interviewed again on 6/26/23 at 1:35 p.m. She said she could propel herself in her wheelchair in the facility. She said the CNAs helped to put her in bed and helped her out of bed. She said it was up to her and Resident #3 to get along with each other. She said Resident #3 sat by the bird cages and she passed her from her room while going to the dining room. She said if Resident #3 talked to her in a way she did not like she would, Hit her and plug her right in the nose. She said that she was currently not smoking but she planned to start up again on 7/4/23. 4. Staff interviews Registered nurse (RN) #1 was interviewed on 6/22/23 at 2:40 p.m. She said Resident #4 quit smoking. She said because Resident #4 quit smoking there would be no more incidents between Resident #3 and Resident #4. CNA #1 was interviewed on 6/26/23 at 3:00 p.m. She said she had seen Resident #4 kick other residents. She said Resident #4 used bad words at others often. RN #2 was interviewed on 6/26/23 at 3:05 p.m. She said Resident #4 was verbally aggressive to her. She said Resident #4 could really cuss staff and residents out. She said Resident #4 was very difficult to redirect at times. CNA #2 was interviewed on 6/26/23 at 3:10 p.m. She said Resident #4 was very verbally and physically aggressive to staff and other residents. She said when CNAs witnessed Resident #4 being verbally aggressive at another resident, the CNAs moved her wheelchair to try and move her away from others before something bad happened. She said when the CNAs put Resident #4 to bed they knew that she could not be aggressive to any other residents because she needed help to get out of bed. She said the only time CNAs knew others were safe was when Resident #4 was in bed. C. Resident #3 1. Resident #3 (victim) Resident #3, age under 70, was admitted on [DATE]. According to the June 2023 CPO, the diagnoses included hemiplegia (stroke), schizoaffective disorder, chronic pulmonary obstructive disease (COPD), depressive disorder, psychoactive substance abuse, depression, vascular dementia, seizures and a traumatic brain injury (TBI). The 5/30/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She had unclear speech. She sometimes was able to understand others. She required extensive assistance with bed mobility, transfers, personal hygiene, dressing and toilet use. She was independent with locomotion on and off the unit. She did not reject care from staff. 2. Record review On 5/12/22 Resident #3 was documented as a supervised smoker. The comprehensive care plan, initiated 8/12/22 and revised on 6/19/23, revealed the following for behaviors: Focus: Resident #3 will call out loudly when upset, and has the potential to disturb other residents when she calls out loudly. Interventions: Assist to develop more appropriate methods of coping and interacting. Encourage her to express her feelings appropriately. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine (the) underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. The 2/6/23 nurse practitioner (NP) note revealed Resident #3 was difficult to assess due to expressive aphasia (loss of ability to understand or express speech) but able to make her needs known with yes or no answers to questions. The 5/22/23 administrative progress note documented Resident #3 had a large piece of hair ripped out by Resident #4, (an) abuse investigation (was) started. The 6/5/23 social service assessment documented the resident was unable to speak. 3. Resident and representative interview and resident observation The legal guardian (LG) of Resident #3 was interviewed on 6/26/23 at 11:00 a.m. She said she was assigned as the legal guardian for Resident #3 and she visited with Resident #3 one time per month. She said she did not remember what exact day she was contacted about the hair pulling incident but the facility did call her. She said she told the facility social worker that if the police came in to interview Resident #3 that she (the LG) must be present with the resident. She said Resident #3 could not communicate well. She said because the facility never called her back she assumed the police never came to the facility to investigate the situation. She said she was never told why the facility did not stop the situation in the first place. Resident #3 was observed on 6/26/23 at 1:00 p.m. She was seated in the common area watching the birds in the birdcage. The common area was located where Resident #4 would need to pass by to get to her room. Resident #3 was unable to communicate by way of a conversation. When asked if her hair was pulled out, she responded yes. D. Staff interviews RN #1 was interviewed on 6/22/23 at 2:40 p.m. She said the altercation between Resident #3 and Resident #4 happened in the common area as residents waited to go out and smoke. She said Resident #3 was to be supervised while she was smoking in the smoking area. She said Resident #3 would propel herself throughout the building unsupervised. She said Resident #4 quit smoking so there should be no more incidents between the two women as long as Resident #4 did not smoke. The RDO was interviewed on 6/26/23 at 2:21 p.m. He said the former NHA did not handle the situation and follow the directions from the corporate social service clinical resource person. He said the NHA was suspended during the survey. He said during the survey on 6/21/23 an investigation was completed. He said on 6/21/23 all staff and residents were interviewed about physical and verbal abuse. He said Resident #4 had been interviewed. He said Resident #3 (the victim) was not interviewed because she was nonverbal. He said he felt both women were wanting to smoke and possibly staff was late to get the smokers outside. He said he felt that may be what agitated the women. He said he understood that the victim should be interviewed and he would make sure Resident #3 would be interviewed. He said he did not know if a physician or psychiatric care was provided for Resident #3 after the incident. E. Facility follow-up On 6/26/23 at 2:20 p.m. the RDO and CC gave documentation to show that on 6/21/23 the facility began interviews and an investigation of the 5/23/23 resident to resident physical abuse between Resident #3 and Resident #4. The documentation contained the following: Occurrence date and time 5/23/23 (time was not listed). Resident #4 peddled backwards in her wheelchair in hallway, bumped into Resident #3. Resident #4 ripped a large piece of hair out of Resident #3. Resident

Based on record review and interviews, the facility failed to ensure one (#74) of three out of 39 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being. Resident #74 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted with one stage 4 pressure ulcer to her sacrum and later developed three additional pressure ulcers. Dietary interventions included Mighty Shakes and Ensure Plus (nutritional supplements) with no additional interventions trialed as the resident's wounds continued to deteriorate (cross-reference F686 for pressure injuries). In August 2022, a 34.2 pound weight loss was noted with a reweight requested to verify weight loss. The 9/13/22 and 9/28/22 weights indicated the resident had a 25.2 pounds (lbs) weight loss over six months, which was 22.7% considered significant. No additional dietary interventions were added due to previous resident refusals of other supplements. No documentation of education or discussions with the resident regarding other supplements were provided. Even though the resident was admitted to hospice care since admission, the resident was not offered any additional nutritional interventions when she had significant weight loss and with the development of the facility acquired pressure injuries. Findings include: I. Facility policy The Weight Management policy, revised 1/17/2020, was provided by the director of clinical services on 9/29/22 at 5:45 p.m. It read in pertinent part, Residents are monitored (per physician orders) for significant weight change on a regular basis. Results are reviewed and analyzed by the facility for intervention as appropriate. Residents identified with significant weight change will be assessed by the IDT (interdisciplinary) team; and further interventions will be implemented to minimize the risk for further weight change where possible and promote weight stability. Residents with weight variance (loss or gain) are reweighed. Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD (registered dietitian) evaluation, assisted dining etc. II. Resident status Resident #74, age 82, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/26/22 minimum data set (MDS) assessment indicated the resident had a mild cognitive impairment with a brief interview of mental status score of 12 out of 15. It indicated the resident required one person assistance for eating. It indicated the resident did not have a swallowing disorder. It did not indicate the resident's latest weight and the areas related to weight loss or weight gain were incomplete. No dental abnormalities were noted. It indicated the resident had skin and ulcer treatments that included nutrition and hydration interventions. It indicated the resident received hospice care. III. Record review Weights since admission revealed the following: -On 12/4/21 the resident weighed 104.6 pounds; -On 12/29/21 the resident weighed 108.0 pounds; -On 2/22/22 the resident weighed 108.8 pounds; -On 3/22/22 the resident weighed 109.4 pounds; -On 4/26/22 the resident weighed 109.8 pounds; -On 5/24/22 the resident weighed 110.8 pounds; -On 6/21/22 the resident weighed 110.8 pounds; -On 7/19/22 the resident weighed 110.8 pounds; -On 8/9/22 the resident weighed 118.8 pounds; -On 8/23/22 the resident weighed 84.4 pounds; a 34.4 lbs weight loss in two weeks; -On 9/13/22 the resident weighed 84.4 pounds; -On 9/28/22 the resident weighed 85.6 pounds; a 25.2 lb weight loss over six months, 22.7% weight loss considered significant. The nutrition care plan, revised 3/9/22, indicated Resident #74 had a nutritional problem related to declining health status secondary to numerous comorbidities, hospice care, skin breakdown, bi polar disorder, personality disorder, and dementia. All interventions in the care plan had initiation dates of November to December 2021. Interventions included following the resident in the nutrition and skin team, obtaining preferences and offer as able, providing and serving supplements as ordered, and providing and serving diet as ordered and monitor intake and record every meal. -The care plan did not indicate any revisions following the development of multiple pressure ulcers and resident's weight loss. Per staff interview (see below) the resident required assistance with eating, which was not indicated on her care plan. The September 2022 CPO revealed the following: -Mighty Shake with meals for supplement, ordered 11/6/21; -Weekly weights every Tuesday day shift for weight monitoring, ordered 12/9/21; -Ensure Plus two times a day to promote wound healing, ordered 1/4/22. The initial nutritional assessment was completed on 11/19/21. It indicated Resident #74 was on a regular diet with regular texture and thin liquids. It noted the resident had 4 ounce Mightyshakes three times a day and 30 milliliters of liquid protein twice a day. It indicated the resident had a dislike of undercooked red beef and an allergy to scallops. The resident had her own teeth and vision and hearing were adequate. It noted the resident was on hospice care and remained in bed and was unable to be weighed. It noted intakes were 50-75% for breakfast and dinner and 25-50% for lunch. It indicated the amount of assistance needed with meals was variable. Risks of altered nutrition were identified as decreased appetite, self-feeding difficulty, pressure ulcers, and dementia. Estimated caloric needs were 1500-1750 calories and 65-75 grams of protein based on ideal body weight. No ideal body weight was indicated on the assessment. The most recent weight was 143 pounds from September 2021, while the resident was in the hospital. A quarterly nutritional assessment was completed on 2/8/22. It indicated Resident #74 was on a regular diet with regular texture and thin liquids. It noted the resident had orders for Mighty shakes three times a day and Ensure Plus twice a day. It indicated intakes were 75-100% for breakfast and lunch and 50-75% for dinner. Current body weight was 108 pounds with a November 2021 weight of 104 pounds. It indicated to continue with the current care plan. A nutritional reassessment was completed on 3/29/22 and indicated it was completed due to a change of condition. It indicated the resident continued on a regular diet with regular texture and thin liquids. It noted the resident had orders for four ounce Mighty Shakes three times a day and eight ounce Ensure Plus twice a day. It indicated the resident disliked undercooked beef and liked well done beef. No other food preferences were listed. It noted the resident's weight 30 days ago was 108.8 pounds. No other weight was listed. Intakes for breakfast and dinner were 25% and lunch was 25-50%. The assessment indicated the resident's weight increased slightly and she was followed by the nutrition and skin team for her wound on her sacrum and new wound on knee. It indicated her body mass index was 20.1 and within a desirable range. It indicated staff was assisting with dining. It noted weight loss, potential for wound decline, and potential for further skin breakdown was likely and expected due to physical condition. A quarterly nutritional assessment was completed on 6/16/22. It indicated the resident continued on a regular diet with regular texture and thin liquids. It indicated the resident continued on Mighty Shakes three times a day and Ensure Plus twice a day. Meal intakes were noted at 75-100% for all meals. Current body weight was 110.8 pounds which indicated a 7.2% increase since December 2021. The assessment indicated the resident had wounds on her knee, back, and coccyx and to continue on current supplements for wound healing. On 8/26/22 a weight change note was completed. It indicated the resident was followed by nutrition for skin concerns related to wounds on her sacrum, knee, scapula, and ischium. It indicated her weight was 84.4 pounds which was down from 118.8 pounds. It indicated a request for a reweight to verify accuracy as the weight was down 34.4 pounds in two weeks. It indicated to continue with Mightyshakes and Ensure Plus to increase calories and protein for wound healing. On 8/31/22 a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated her weight continued to drop and was on comfort care. Her weight was noted as 84.4 pounds. A quarterly nutritional assessment was completed on 9/5/22. It indicated the resident continued on a regular diet with regular texture and thin liquids. It indicated the resident continued on Mighty Shakes three times a day and Ensure Plus twice a day. It did not indicate a current body weight. It indicated on 8/23/22 the resident weighed 84.4 pounds. It indicated on 3/29/22 the resident weighed 109.8 pounds which was a 23.13% weight loss over the past 180 days. -The assessment indicated no follow up weights had occurred in order to verify weight loss. No updates to the care plan were indicated. On 9/6/22 a weight change note was completed. It indicated the resident was followed by nutrition for skin concerns related to wounds on her sacrum, knee, scapula, and ischium. It indicated a weight for the week was not available and the last weight was 84.4 pounds which was down from 118.8 pounds. It indicated a reweight was requested to verify weight loss but resident often stayed in bed. It indicated to continue with a regular diet with Mightyshakes at meals and Ensure Plus twice a day. On 9/16/22 a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated her weight was 84.4 pounds. The meal and supplement intake records from August to September 2022 revealed the following: -The resident typically consumed 26-75% of breakfast, lunch and dinner. -The resident typically consumed 50-100% of Mighty Shake with meals. -The resident was provided with Ensure Plus twice daily but there was no documentation of intake percentages. IV. Interviews Certified nurse aide (CNA) #2 was interviewed on 9/29/22 at 11:25 a.m. She said Resident #74 required assistance with eating. She said occasionally the resident could use her own hands to self feed. She said for breakfast that day the resident ate 75% of her meal. CNA #1 was interviewed on 9/29/22 at 11:38 p.m. He said the resident required one-on-one assistance for eating. He said she would occasionally refuse food and he would offer an alternative and made sure she was given an Ensure. The registered dietitian (RD) was interviewed on 9/29/22 at 2:20 p.m. She said Resident #74 had weight gain and weight loss since admitting in December 2021. The RD said the resident went up in weight since admission and then in August 2022 had two weights that were 84 pounds. She said these weights were on the Hoyer (mechanical lift) scale while the other weights had been obtained on wheelchair scale. She said the latest weight, 9/28/22, was obtained using the wheelchair scale and was 85.6 pounds which indicated a weight loss. She said over the last six months the resident had lost 24 pounds which was a 22% weight loss. She said she questioned the accuracy of the weight that was recorded around 118 pounds. She said the resident was on a regular diet, regular texture, and thin liquids. She said the resident was on liquid protein, for a time, for wound healing and supplement but did not like it so it was discontinued. She said this was around the spring when the resident had an increase in wounds. She said she discussed other options, such as Boost or fortified foods, with the resident, but the resident declined. She said there should be documentation of these refusals and discussions. She said the resident had an allergy to scallops and disliked undercooked beef but did not know her preferred foods. She said no additional interventions were provided following the weight loss observed on 8/26/22 due to the resident's previous refusals to try other supplements. -The facility was unable to provide documentation of discussions of alternative supplements, resident refusals and additional dietary preferences with the significant weight loss. The director of nursing (DON) was interviewed on 9/29/22 at 4:33 p.m. She said Resident #74 was discussed at length during nutrition at risk meetings. She said alternative options for supplements were offered and educated on but residents refused. She said this information should be documented. She said some of the discrepancy in weights may have been due to Hoyer scale needing to be recalibrated and this was only recently brought to her attention.

Based on observations, interviews, and record review, the facility failed to ensure the necessary care and treatment to prevent the development of pressure injuries for one (#74) of two residents reviewed of 39 sample residents. Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted with hospice care and was followed by the wound physician. The resident was admitted with one stage 4 pressure ulcer to her sacrum. On 3/29/22 the resident developed a stage 2 pressure ulcer to her right lateral knee. On 4/19/22 the right lateral knee wound had developed to a stage 4 and a stage 2 pressure ulcer to the right scapula had developed. On 5/17/22 the right scapula wound had developed to a stage 4. On 5/31/22 an unstageable pressure ulcer to the right ischium was noted. Interventions to address the wound included dietary supplements, repositioning, weekly wound care, and an air mattress. The resident stated she was not repositioned frequently and there were no documented refusals of repositioning. Dietary interventions included Mighty Shakes and Ensure (nutrition supplements) with no additional interventions trialed as the resident's wounds continued to deteriorate (cross-reference F692 for nutritional parameters). A new alternating air mattress was provided in May following the development of the three additional wounds. The wound physician stated the wounds were unavoidable should the facility be repositioning the resident frequently and providing additional protein. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 10/3/22, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate ' at risk ' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] 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 [CONDITION(S)] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Pressure Injury Prevention policy and procedure, revised 7/22/2020, was provided by the director of clinical services on 9/29/22 at 5:00 p.m. It read in pertinent part, A pressure injury can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure injury prevention and healing include: identifying the individual resident at risk for developing pressure injuries, identifying and evaluating the risk factors and changes in the resident's medical condition, identifying and evaluating factors can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. The first step in prevention is the identification of the resident at risk for developing pressure injuries and the resident with existing pressure injury areas of skin that are at risk for breakdown. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of those interventions. III. Resident #74 A. Resident status Resident #74, age 82, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/26/22 minimum data set (MDS) assessment indicated the resident had a mild cognitive impairment with a brief interview of mental status score of 12 out of 15. It indicated the resident required extensive, two person assistance for bed mobility and transfers. It indicated the resident was at risk for pressure ulcers and had three stage 4 pressure ulcers with one of those three present at admission and one unstageable pressure ulcer that was not present at admission. It indicated skin and ulcer treatments were pressure relieving devices for her chair and bed, a turning and repositioning program, nutrition and hydration interventions, pressure ulcer care, and applications of ointments and medications. B. Resident interview An attempt to interview Resident #74 was made on 9/26/22 at 3:27 p.m. The resident said she was overwhelmed and did not want to answer questions at that time or the following day. She said she was in pain and requested a nurse come to check on her. Resident #74 was interviewed on 9/28/22 at 3:05 p.m. She said she had pain associated with her wounds. She said repositioning helped the pain but the repositioning should be completed every four hours and staff were repositioning every six hours. She said she liked to have her pillows a specific way and staff would not always place the pillows in the way she requested. The resident then became upset and said she did not want to answer any additional questions. Resident #74 was interviewed again on 9/28/22 at 4:45 p.m. She said her preferred position was on her back but she could tolerate being positioned on her sides. She said she was unable to reposition on her own. C. Observations On 9/28/22 at 9:55 a.m., Resident #74 was observed in her room. Certified nurse aide (CNA) #1 was in the room and seen taking the resident's vitals. Resident #74 was on her back with her heels on a pillow. CNA #1 assisted with moving the resident further up in the bed though Resident #74 remained on her back. On 9/28/22 at 11:25 a.m., Resident #74 was observed in her room, positioned on her back. Her lunch tray was brought in and the resident remained positioned on her back while waiting for meal assistance. On 9/28/22 at 2:00 p.m., Resident #74 was observed in her room in bed. She was on her back with a pillow below her heels. On 9/29/22 at 8:35 a.m., Resident #74 was observed positioned on her right side with pillows under her left side. At 8:36 a.m., CNA #1 was observed entering the room to provide care. At 8:42 a.m., CNA #1 left the room and Resident #74 was observed positioned on her back. D. Wound observations On 9/28/22 at 10:25 a.m., wound care was provided for Resident #74. The assistant director of nursing (ADON), licensed practical nurse (LPN) #2, and CNA #3 were present for wound care. The sacrum and right scapula wounds were cleansed and dressings were changed. During the repositioning of the resident, a chapstick was observed under her right shoulder blade and LPN #2 removed it and an indent in the resident's skin was observed. The scapula dressing was saturated with serosanguinous (blood and serum) drainage that seeped through the dressing and onto the draw sheet of the bed. The wound bed appeared clean and gray in color. The sacral wound appeared beefy red and moist. Both wounds were cleansed and new dressings were applied. On 9/29/22 at 1:45 p.m., wound care was provided for Resident #74. The ADON, LPN #3, and CNA #3 were present for wound care. The right ischium and right knee wounds were cleansed and dressings were changed. The right ischial wound had yellow slough in the wound bed and a moderate amount of serous drainage. The area was cleansed and appeared to have yellow slough post cleansing. A new dressing was applied. The right knee wound had yellow slough and was weeping serous fluid. After the area was cleaned the wound bed had 50% slough and 50% pink tissue. A new dressing was applied. E. Record review Resident #74 was initially seen by the wound physician on 11/22/21, shortly after she was admitted to the facility. The notes indicated the resident had one wound, a sacral stage 4 pressure ulcer. The wound was debrided during the encounter and post debridement measurements were 5.2 cm by 6 cm with a depth of 0.5 cm. On 3/29/22 a nursing pressure injury initial and weekly monitoring note was completed. It indicated a facility acquired stage 3 right lateral knee pressure ulcer with an onset date of 3/28/22. The measurements were 1.5 cm by 1.4 cm with a depth of 0.2 cm. On 4/5/22 the wound physician's notes addressed the right lateral knee pressure ulcer. The note indicated the wound was a stage 3 and measurements were 1.1 cm by 1.2 cm with a depth of 0.2 cm. The wound bed had 100% granulation. On 4/19/22 a nursing pressure injury initial and weekly monitoring note was completed. It indicated a facility acquired stage 2 pressure ulcer to right lateral back with an onset date of 4/19/22. The measurements were 1.4 cm by 1.7 cm with a depth of 0 cm. On 4/19/22 the wound physician's notes indicated the right lateral knee pressure ulcer changed from a stage 3 to a stage 4. The measurements were 1.6 cm by 0.7 cm with a depth of 0.4 cm. The wound bed had 20% slough and 80% granulation. The note indicated an additional pressure ulcer to the right scapula that was a stage 2. The measurements were 1.5 cm by 1.9 cm with no measurable depth. The wound bed had 100% epithelialization. On 5/17/22 the wound physician's notes indicated the right scapula pressure ulcer was now at a stage 4. The measurements were 3.2 cm by 3.1 cm with a depth of 0.4 cm. It indicated a mild odor with 40% epithelialization and 60% slough. It indicated the wound was deteriorating. The note indicated the stage 4 sacral wound had no changes and the stage 4 right lateral wound was improving. On 5/31/22 a nursing pressure injury initial and weekly monitoring note was completed. It indicated a facility acquired, unstageable pressure ulcer with an onset date of 5/31/22. The measurements were 4.0 cm by 1.5 cm with a depth of 0 cm. Additional wound documentation from this date indicated a new alternating pressure mattress was in place and functioning. On 6/7/22 the wound physician's notes indicated a right ischial unstageable pressure ulcer. The measurements were 3.4 cm by 1.5 cm with no measurable depth. It indicated the wound bed had 100% eschar. The note indicated the stage 4 sacral wound was improving, the stage 4 right scapula wound was improving, and the stage 4 right lateral knee wound was deteriorating. On 9/20/22 the most recent wound physician's notes indicated the stage 4 sacral wound had measurements of 3.7 cm by 5 cm and a depth of 0.1 cm. It indicated 10% slough and 90% granulation. It indicated no changes in wound progression. The stage 4 right lateral knee wound had measurements of 1 cm by 1 cm with a depth of 0.1 cm. It indicated 100% epithelialization. It indicated the wound was improving. The stage 4 right scapula wound had measurements of 4 cm by 2.5 cm with a depth of 0.2 cm. It indicated 15% slough and 85% granulation. It indicated there were no changes in the wound progression. The unstageable right ischial wound had measurements of 1.5 cm by 1.2 cm with a depth of 0.4 cm. It indicated 50% slough and 50% granulation. It indicated the wound was deteriorating. The September CPO revealed the following: -Mighty Shake with meals for supplement, ordered 11/6/21; -Ensure Plus two times a day to promote wound healing, ordered 1/4/22; -Monitor sacral wound area and document evaluation on the daily wound monitoring progress note every shift, ordered 1/27/22; -Monitor right lateral knee stage 4 pressure ulcer and document evaluation on the daily wond monitoring progress note every evening shift every other day, ordered 4/20/22; -Monitor right scapula stage 4 pressure ulcer and document evaluation on the daily wound monitoring progress note in the morning, ordered 5/18/22; -Monitor right ischial unstageable pressure ulcer and document evaluation on the daily wound monitoring progress note every shift, ordered 6/15/22; -For right scapula, cleanse wound with dakins solution, pat dry, protect periwound tissue with skin prep, sprinkle crushed [MEDICATION(S)] and apply alginate to wound bed, and cover with dry dressing every day shift for wound care, ordered 6/22/22; -For sacrum, cleanse wound with dakins solution, pat dry, protect periwound tissue with skin prep, sprinkle crushed [MEDICATION(S)] and apply alginate to wound bed, and cover with dry dressing every shift for wound care, ordered 6/22/22; -For right ischium, cleanse area with dakins solution, pat dry, protect periwound tissue with skin prep, sprinkle crushed [MEDICATION(S)] and apply alginate to wound bed, and cover with dry dressing every day shift for wound care, ordered 6/28/22, -Check to ensure air mattress is plugged in, powered on, and functioning properly every shift for imparied skin integrity, ordered 8/12/22; -For right lateral knee, cleanse wound with dakins solution, pat dry, protect periwound with skin prep, apply honeygel to wound bed, and cover with dry dressing every other day shift for wound care, ordered 9/20/22. The skin care plan, revised 8/1/22, indicated Resident #74 was admitted to the facility on hospice care with a stage 4 pressure ulcer with [CONDITION(S)] to the sacral area. It indicated her wounds were unavoidable due refusal of repositioning and decreased oral intake. It indicated a stage 4 pressure ulcer to the right lateral knee was first observed on 3/28/22, a stage 4 pressure ulcer to the right scapula was first observed on 4/14/22, and an unstageable pressure ulcer to the right ischium was first observed on 5/17/22. Interventions included avoidance of positioning the resident on her right side as tolerated, education with the resident on causes of skin breakdown such as good nutrition and frequent repositioning, determining why resident refused treatment and trying alternative methods to gain compliance, weekly visits with wound physician, and use of pressure relieving mattress. -However, the facility was unable to provide documentation that indicated the resident refused repositioning. The activities of daily living care plan, revised 4/1/22, indicated Resident #74 had a self care performance deficit related to impaired mobility, weakness, and end of life care. Interventions included encouraging and assisting the resident to turn and reposition every two hours and staff assistance of one to two people for bed mobility. -However, review of bed mobility task documentation from CNAs from April 2022 to September 2022 indicated bed mobility was offered every shift and on average documented to have occurred for three out of the four shifts. F. Staff interviews LPN #1 was interviewed on 9/28/22 at 2:20 p.m. She said Resident #74's initial wound was doing better and she had weekly visits with the wound physician. She said the resident did not refuse repositioning or treatments. She said the resident liked to have her pillows in a specific position and could be particular about that. She said the resident was on hospice care and so comfort was important. The ADON was interviewed on 9/28/22 at 4:09 p.m. She said she was the wound nurse and rounded with the wound physician every Tuesday. She said worked with the registered dietitian to address skin concerns, completed weekly assessments and documentation, and educated the nurses on how to change dressings. She said Resident #74 was admitted with a stage 4 sacral pressure ulcer. She said the wound had improved since admission. She said the right knee pressure ulcer was a stage 3 on 3/28/22 and developed to a stage 4 on 4/19/22. She said the right scapula pressure ulcer was stage 2 on 4/3/22 and developed to a stage 4 on 5/17/22. She said the pressure ulcer to the ischium had always been unstageable. She said the pressure ulcers were on the right side because the resident had a preference to position on her right side. She said staff would encourage her to position on her left side but the resident refused. She said the resident had an air mattress since admission and a new one was purchased around April or May due to the increase in wounds. She said the resident had poor intake which could impact wound development and healing. She said the resident received Mighty Shakes as a supplement since admission and Ensures were added in January. She said she was unsure if any other interventions were added. She said the wounds were getting smaller and were kept clean. The wound physician was interviewed on 9/28/22 at 4:25 p.m. He said the resident was admitted to the facility with a wound to her sacrum about a year ago. He said she had four wounds at his last encounter with her. He said the wounds were unavoidable since she had the preventative measure of repositioning and, from what he had been told, the facility was repositioning frequently. He said he provided education to the resident about the importance of repositioning and had told the facility to document everything such as refusals related to repositioning. He said all the wounds were doing great and the right ischium and right knee were almost healed. He said the resident should be on a liquid protein to further help with wound healing. He said since the wounds were improving, he believed the resident was receiving the interventions that were necessary. CNA #2 was interviewed on 9/29/22 at 11:25 a.m. She said Resident #74 refused to be repositioned and she would try to encourage her. She said the resident did not say that it was painful to be repositioned, she just assumed the resident liked to be positioned in a way to look out the window. CNA #1 was interviewed on 9/29/22 at 11:38 a.m. He said he did not regularly go into Resident #74's room to reposition but today he did. He said he did not typically go in every two or four hours. He said Resident #74 could not reposition independently and was very particular about her positioning. He said when he provided care to her, he would leave her in her preferred position which was on her back. He said today was the first time in a while she was positioned on her side. The registered dietitian (RD) was interviewed on 9/29/22 at 2:20 p.m. She said Resident #74 was on a regular diet with regular texture and thin liquids. She said the resident had weight loss since admission and had wounds. She said the resident preferred to have her meals in bed and she did not know the resident's preferred foods. She said the resident consumed about 50% of her meals and comfort was the goal for the resident. She said the resident received Ensures twice a day and Mighty Shakes three times a day as supplements. She said the resident used to receive liquid protein but did not like it and refused. She said other options were discussed with the resident such as fortified foods, Boost supplements, or Ensure Clear and the resident was not interested. She said once the resident began to develop additional pressure ulcers and lose weight, these interventions were not offered again due to the previous conversations with the resident. -The interventions that were discussed with the resident and refused were not documented (cross-reference F692). The director of nursing (DON) was interviewed on 9/29/22 at 4:33 p.m. She said she did not have a lot of involvement in Resident #74's wounds as the wound nurse handled this area. She said repositioning expectations depended on the resident and what other interventions were in place. She said Resident #74 often refused to be repositioned so her air mattress was the best intervention. She said she would expect staff to continue to go offer repositioning to the resident and document refusals. She said Resident #74's care was also discussed at the nutrition at risk meetings and different supplements had been offered. She said the resident refused dietary interventions that could have aided in wound healing or prevention.

Based on record review and interview, the facility failed to ensure one (#72) of two residents out of 38 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure Resident #72's intravenous (IV) medication was administered as ordered; that [MEDICATION(S)] lab trough levels were obtained as ordered prior to medication administered as ordered by the physician; and sufficient medication was on hand to administer. Resident #72 was on IV [MEDICATION(S)] antibiotic medications to treat a severe infection in his legs and feet. The infectious disease physician ordered regular lab testing of the [MEDICATION(S)] medication levels in the resident's blood. The labs were to be sent to the physician and the pharmacy. The pharmacist was to adjust the [MEDICATION(S)] dosing based on the trough label levels obtained prior to medication administration. Trough lab levels indicated the lowest level of [MEDICATION(S)] medication in the resident blood prior to starting the medication. When new orders were received the facility did not specify designated times to start the [MEDICATION(S)] IV administration and the medication was given too soon in less than the prescribed frequency; this caused a medication error. The previous orders were not properly discontinued and removed from the resident's medication administration orders and some nurses were following the old orders; this caused a medication administration error. Labs were not taken timely so the pharmacy was delayed in providing orders for IV [MEDICATION(S)] dosing; this caused a medication error.The facility ran out of IV [MEDICATION(S)] for the resident causing a delay in the resident's medication being administered timey, this caused a medication error. Due to the facility failures, the resident was sent to the hospital for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/16/21 to 6/22/21, resulting in this deficiency being cited at past non-compliance with a correction date of 2/22/21. The practice of administering [MEDICATION(S)] to the other resident reviewed for IV antibiotic use was not found to be deficient. I. Professional reference According to [NAME] Pharmaceuticals, Inc., (January 2017), [MEDICATION(S)] Label Prescribing Information, retrieved from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/ 0s047lbl.pdf, on 7/1/21. It read in pertinent part: [MEDICATION(S)]® HCl ([MEDICATION(S)] [MEDICATION(S)] for injection) is a lyophilized powder, for preparing intravenous (IV) infusions .used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The risk of AKI increases as systemic exposure/serum levels increase .Dosage adjustment must be made in patients with impaired renal function .greater dosage reductions than expected may be necessary because of decreased renal function. Measurement of [MEDICATION(S)] serum concentrations can be helpful in optimizing therapy, especially in seriously ill patients with changing renal function . II. Facility policy The Medication Administration Policy, revised in April 2019, was provided by the corporate consultant (CC) on 6/22/21 at 3:30 p.m., it read in pertinent part; Medications are administered in a safe and timely manner, and as prescribed. -Factors that are considered include: Enhancing optimal therapeutic effect of the medication III. Resident #72's status Resident #72, under the age of 65, was admitted [DATE] and was in the hospital from 1/15/21 to 2/3/21. The resident returned to the facility before being discharged a final time to the hospital on 2/19/21. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/8/21 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not display any behaviors and did not reject care during the assessment. The resident needed extensive assistance from two staff with bed mobility, transfers, and dressing and toileting use. He was no longer walking due to lower leg impairment on both sides. The resident had a newly acquired right sided below the knee amputation and a left outer toe amputation with an infection in the left foot. The resident was on daily IV antibiotics, daily insulin and required daily wound care for a surgical wound, pressure ulcers and other wounds. IV. Record review A. Hospital and infectious disease physician notes Hospital discharge report dated 2/3/21, read in pertinent: .Presenting after he was febrile at his facility, in the setting of ongoing chronic bilateral leg wounds .Acute kidney injury, suspect is due to low oral intake .found to have bilateral feet ulceration complicated by [CONDITION(S)] (inflammation in the bone caused by staphylococcus bacteria). -Procedures Performed: right below the knee amputation with formalization and left 5th ray resection (toe amputation). -Will need IV [MEDICATION(S)] for six weeks from 1/26/21-3/8/21 (please check labs weekly: complete blood count with differential (CBC w/ diff), chemistry metabolic profile (CMP), c reactive protein (CRP) and [MEDICATION(S)] trough on Mondays and fax to the infectious disease clinic. Will monitor. Needs infectious disease follow up in two (2) weeks. B. Treatment notes Progress note dated 2/3/21 at 4:30 p.m., read in part: Resident is being readmitted after hospitalization . Nursing note dated 2/6/21 at 3:04 p.m., read in part: Resident's IV [MEDICATION(S)] was increased to 1G (gram) twice a day, 8:00 a.m. and 8:00 p.m. There is also a new order for [MEDICATION(S)] labs for a trough level on Monday 2/8/21 at 7:30 a.m. Communication note from the infectious diseases physician office dated 2/10/21, read in pertinent part: Unable to reach anyone at the facility to check on status of ordered lab work; next called the pharmacy. The pharmacy received results for the [MEDICATION(S)] trough blood level and based on lab results on 2/6/21 had increased the [MEDICATION(S)] dose to administer 1 gram (g) every 12 hours, awaiting next trough result which was drawn 2/8/21 in order to follow treatment goals. Nursing note dated 2/11/21 at 6:18 a.m., read in part: [MEDICATION(S)] lab trough level was 21.5 microgram/milliliter (ug/ml) (an abnormal high level) (normal lab range is 5.0-15.0 ug/ml) and result was called and faxed to the pharmacy. Spoke with a pharmacist who ordered to hold the [MEDICATION(S)] IV antibiotic dose this morning on 2/11/21 at 8:00 a.m. The pharmacist will call back with a new order. Nursing note dated 2/11/21at 10:45 a.m., read in part: [MEDICATION(S)] lab trough level stat lab order redraw this evening due to critical high result. New results came back with 15.6 ug/ml, results called and faxed into the pharmacy. Pharmacy will call back with a new order, night nurse to follow up. Nursing note dated 2/12/21 at 5:31 a.m., read in part: This nurse called the pharmacy to follow up with [MEDICATION(S)] lab trough level result 15.6 ug/ml. Spoke a pharmacist who did not give any new order at this time; but said she will consult with the resident's physician. The pharmacist will call back and will fax a new order to the facility. Will pass it on to the day shift nurse for follow-up. Nursing note dated 2/14/21 at 10:15 p.m., read in part: Resident remain on antibiotic therapy for [CONDITION(S)]. IV [MEDICATION(S)] infusing and potent. IV antibiotic therapy tolerated well and no adverse reactions noted on this shift. Nursing note dated 2/15/21 at 9:35 p.m., read in part: Called the pharmacy to get clarification for the [MEDICATION(S)] order and the IV team said discontinue the [MEDICATION(S)] 1g order and continue with 1250 milligrams (mg) of [MEDICATION(S)] every 36 hours. Requested to refill [MEDICATION(S)] medication. -This was a decrease in the medication dosage as well as a decrease in the frequency of administration of the medication. Nursing note dated 2/16/21 at 10:05 p.m., it read in part: Resident didn't get [MEDICATION(S)] dose this night. He does not have any dose left, called the pharmacy to get more doses and the pharmacist said you have to collect a [MEDICATION(S)] lab trough level before they would send the medication out. Physician/medical provider note dated 2/17/21 at 12:27 p.m., read in part: Medical necessity of visit: change of condition Elevated [MEDICATION(S)] lab values: [MEDICATION(S)] trough 24.1 ug/ml, the latest level on 2/16/21 was 14.14 ug/ml .Assessment and Plan: Elevated white blood cell count, unspecified: recheck complete blood count levels and worked with pharmacy on [MEDICATION(S)] dosing changed to 1250mg every 36 hours. Nursing note dated 2/19/21 at 1:39 p.m., read in part: Received a called from the infectious diseases physician about Resident #72's labs indicating kidney functions abnormality. The physician requested the facility to send the resident to the hospital for evaluation and treatment. (see the interview with the infectious disease physician written below). C. Care plan The comprehensive care plan revised 2/6/21 revealed the resident was receiving IV antibiotic therapy related to an infection of wounds with a goal to minimize the resident's risk for any discomfort or adverse side effects. Interventions included in part: Administer antibiotic medications as ordered by physician; monitor and document treatment; and report pertinent lab results to the physician. D. Medication orders and administration of IV [MEDICATION(S)] The February 2021 CPO documented the following orders of Resident #72's [MEDICATION(S)]: [MEDICATION(S)] HCl solution reconstituted 1g. Use one (1) gram intravenously one time a day for [CONDITION(S)] until 3/8/21; order date 2/3/21 at 5:54 p.m.; discontinued on 2/6/21 at 2:31 p.m. [MEDICATION(S)] HCl solution reconstituted 1g. Use one (1) gram intravenously every 12 hours for [CONDITION(S)] until 3/8/21. Order date 2/6/21 at 2:31 p.m., hold from 2/10/21 at 1:58 p.m. to 2/10/21 at 11:59 p.m., hold from 2/11/21 at 6:34 a.m. to 2/12/21 at 6:33 a.m., hold from 2/12/21 at 2:52 p.m. to 2/14/21 at 2:51 p.m., discontinue on 2/15/21 at 9:09 p.m. [MEDICATION(S)] HCl solution 1250 mg/12.5ml. Use 1250mg intravenously every 36 hours for [CONDITION(S)] until 02/17/2021 at 10 p.m. -Order date 2/12/21 at 6:09 p.m. discontinued on 2/15/21 at 8:59 p.m. -Reorder date 2/15/21 at 10:59 p.m. discontinued on 2/17/21 at 10:38 p.m. -Reorder date 2/17/21 at 8:38 p.m. The February 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -On 2/13/21 at 10:06 a.m., IV [MEDICATION(S)] 1250mg was administered and then administered again on 2/14/21 at 8:57 p.m.; 34 hours and 51 minutes after the previous dose. -On 2/16/21 at 9:08 p.m., IV [MEDICATION(S)] 1250mg was administered and then administered again on 2/17/21 at 10:04 p.m.; 24 hours and 56 minutes after the previous dose. -On 2/19/21 at 1:13 p.m., IV [MEDICATION(S)] 1250mg was administered and then administered again on 2/20/21 at 6:26 p.m.; 29 hours and 13 minutes after the previous dose. Additionally, there were orders from the pharmacy to hold the IV [MEDICATION(S)] 2/12/21 at 2:52 p.m. to 2/14/21 at 2:51 p.m., the medication dose on 2/13/21 and 2/14/21 should not have been administered. V. Interviews The unit manager (UM) was interviewed on 6/21/21 at 11:46 a.m. The UM said the nurses were to check the orders for accuracy and administer the resident IV [MEDICATION(S)] as ordered. They were to make sure all ordered labs were obtained prior to starting the resident IV [MEDICATION(S)] medication being administered to ensure the lab had accurate lab results in order to adjust the [MEDICATION(S)] dose correctly. After an error in the administration of the residents IV [MEDICATION(S)] medication was discovered, all nurses were in-serviced on proper administering of IV antibiotics ([MEDICATION(S)]) and the facility implemented a new policy back in February 2021 that only a registered nurse were to administer IV [MEDICATION(S)]. The director of nursing (DON) and corporate consultation (CC) were interviewed on 6/21/21 at 12:02 p.m. The DON said the facility recognized an error in Resident #72's IV [MEDICATION(S)] administration and developed a plan of corrective action immediately with consultation with the CC. Resident #72 had been in and out of the hospital due to vascular wounds due to poor compliance with care and treatment. The resident started to see the infectious disease physician (IDP) at the end of January (2021) and was prescribed IV [MEDICATION(S)] to treat infected wounds in his lower extremities. The resident was noncompliant with recommendations and continued to walk on his feet despite recommendations not to. His wounds progressed and he developed a severe infection in his lower extremities and underwent amputations. Following hospitalization for the infection, the resident was prescribed IV [MEDICATION(S)]. The [MEDICATION(S)] dosing was determined by frequent lab testing; the dosage of the resident's [MEDICATION(S)] was subject to change. When the resident's condition worsened an investigation revealed that there was an error in the manner in which the resident's [MEDICATION(S)] orders were entered into the resident's MAR. It was discovered that a newly ordered [MEDICATION(S)] dose was entered in the resident's MAR; the old order was not discontinued timely and the start date was incorrect. The nursing administering the medication followed the incorrect orders. Additionally, there was an error in entering the correct start time of the medication administration and medication was given too soon. She said it was difficult to pinpoint which nurses administered the medication because when the licensed practical nurses (LPN), who were in charge of the medication cart, had requested that one of the registered nurses on duty administer the medicine to the resident. The LPN signed for the administration of the medication when they did not administer the medication since the registered nurse administered the medication. All medication errors were identified, investigated and reported to the prescribing physician. All nurses regardless of involvement in administering the resident's [MEDICATION(S)] were in-services on proper administration and signing off on administering medication. The pharmacist consultant (PC) was interviewed on 2/21/21 at 2:02 p.m. The PC said the pharmacy was adjusting Resident #72's IV [MEDICATION(S)] doses based on ordered lab results. In cases where the protocol orders permit the pharmacy to adjust doses based on res lab results the nurse would report the lab results to the pharmacist and the pharmacist would use the standard dosing protocol to adjust and determine the proper dosing and administration schedule for the residents needs. If the lab results were out of acceptable range, the pharmacy would consult with the prescribing physician to dose the resident correctly. The most common side effects of a high [MEDICATION(S)] trough lab value was abdominal pain [CONDITION(S)] (decreased potassium in the blood) which can result in fatigue, muscle cramps, and abnormal heart rhythms, nausea and [CONDITION(S)] (abnormally low white blood cell count which can increased vulnerability to infection). The PC said if the resident IV [MEDICATION(S)] was given to soon; for example given sooner than every 36 as prescribed this resident, the [MEDICATION(S)] trough level could potentially increase above therapeutic level. Once out of the therapeutic windows, the resident could suffer side effects. For some individuals the side effects were slow to develop, for others the side effects could develop and happen quickly; but it very from person to person and there would be no way to tell how severe or which side effects a person would present with. The most common side effects of an elevated [MEDICATION(S)] trough level were hearing loss (ototoxicity) and kidney damage (nephrotoxicity) if high doses of [MEDICATION(S)] were to be given frequently. This effect however was not common and occurred in less than 7% of individuals with preexisting conditions of kidney disease. The infectious diseases physician (IDP) was interviewed on 6/21/21 at 3:31 p.m. The IDP said the facility was not administering Resident #72's IV [MEDICATION(S)] medication correctly. This caused the resident to have severe side effects as evidenced by lab values. The IDP had not been receiving lab results as requested and had to track down the lab result on several occasions through the facility pharmacy. When the IDP finally received the resident lab results on 2/19/21 there was concern in the results indicating the resident had acute kidney injury. The IDP identified the concern and the facility was contacted with orders to send the resident to the hospital immediate assessment and treatment. Per the IDP, the resident missed two appointments 2/15/21 and 2/18/21 and said the resident health decline and hospitalization would most likely have been preventable had he shown for his appointments and received physician assessment. The IDP said based on conversations with a facility nurse and the pharmacy the resident had not been receiving IV [MEDICATION(S)] as ordered; and there were errors in dosing based on a failure to obtain timely blood samples for the [MEDICATION(S)] lab results. There was a delay on at least one occasion on 2/16/21 because lab work was not taken timely and the pharmacy was then delayed in ordering and sending the correct medication dose to administer to the resident. The IDP said the consequences of not getting correct doses of [MEDICATION(S)] due to inaccurate labs or administration errors were acute kidney injury which if left untreated could have irreversible effects. The only way to restore a person's kidney function was with proper treatment. When the resident arrived at the hospital on 2/19/21 several lab values were out of range, he was dehydrated and had increased mental confusion; his condition started to improve, with treatment. VI. Follow-up The facility plan of correction included an in-service on 2/22/21 for all nurses. The in-service included education and instruction on proper medication administration rights, who was permitted to administer IV medication; proper procedures for reviewing newly obtained IV orders; and expectations for shift report and IV medications. The facility provided a list of nurse attendees for this training. All facility nurses participated. The facility developed action plan dated 2/21/21 read in part: -Identification of problem or concern: While receiving IV [MEDICATION(S)] Resident #72 received three extra doses of [MEDICATION(S)] (totaling 3250mg) on 2/14/21. The order for every 12-hour dose 1gm was not discontinued on 2/12/21 when the order for 1250mg Q36 hours was received and the every 36 hour dose was not entered correctly to reflect 36 hours on the MAR. Corrective actions: -The [MEDICATION(S)] order was corrected on 2/16/21 and again 2/17/21. -The resident was sent to the hospital on 2/19/21. -The [MEDICATION(S)] trough on 2/16/21 was within normal limits (2 days after the extra doses) but slightly elevated on the results from 2/12/21 (prior to the extra doses). -A review was conducted of other residents receiving IV medications- One resident was on IV Medications; no additional issues were found. -Nurses were educated on 2/22/21 regarding the need to have an RN review all IV orders when entered into the residents MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Nurses will be educated that only RN or nurses with peripherally inserted central catheter (PiCC) certified nurses can administer IV medications -The seven (7) rights of medication administration will be followed. -The DON or designee will review new orders daily and audit all IV medication orders to ensure that the order is entered correctly and nurses administer the doses as ordered. -A review of a resident who received IV [MEDICATION(S)] medication in April 2021 revealed no errors in dosing or administration of the medication. The DON was interviewed on 6/22/21 at 5:01 p.m. The DON confirmed they had completed all action items in the performance improvement plan. The facility had a resident on IV [MEDICATION(S)] antibiotics this past April 2021. The DON said she performed regular checks of the resident's dosage and lab result and found no administration errors. The facility had no current resident on IV medication.

Based on observations, record review and interviews the facility failed to ensure that residents were free from abuse, for three (#124, #15 and #2) out of five residents reviewed for incidents of abuse out of 38 sample residents. The facility failed to ensure Resident #124 had the right to be free from abuse, when a staff member of the facility took an unauthorized video/recording of the resident on a personal cell phone after the resident had fallen out of bed and was in a state of undress; and shared the eight minute video with other facility staff over social media. The video of Resident #124 was taken during a time when personal care for the resident was needed after the resident fell out of bed. The resident was not fully clothed, had only an adult brief on and was in a compromised state, with the rest of her body being exposed. In addition, the resident had impaired cognition and was assessed just after the fall to be alert with mild confusion and oriented only to her own person. After taking the video, the staff members shared the video with at least two other staff members over social media. The staff member denied sharing the video with any other persons, the investigation revealed other staff had received the video of Resident #124. Resident #124 had impaired cognition and it was not believed that the resident realized the staff member was videotaping her, however; this video could be seen as demeaning and humiliating and considered emotionally abusive as the resident was taunted with profanity from the staff member who was videotaping her. The facility failed to protect Resident #124 from abuse perpetuated by staff. Additionally, the facility failed to recognize and prevent resident-to-resident altercations involving verbal and physical aggression between Resident #15 and #2. I. Resident #124 being treated in a demaning and humiliating way A. Facility policy The Quality of Life-Dignity policy, revised February 2020, was provided by the nursing home administrator (NHA) on 6/21/21 at 1:15 p.m. It read in pertinent part: Residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. -Staff promotes, maintains and protects resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The Confidentiality of Information and Personal Privacy policy, revised October 2017, was provided by the NHA on 6/22/21 at 2:15 p.m. It read in pertinent part: Our facility will protect and safeguard resident confidentially and personal privacy . -Release of resident information including video, audio will be handled in accordance with resident rights and privacy policy . The Videotaping, Photographing and Other Imaging of Residents policy, revised April 2017, was provided by the NHA on 6/22/21 at 2:15 p.m. It read in pertinent part: Residents will be protected from invasion of privacy and or abuse that might occur from photographs, videotapes, digital images and recordings during resident care of other facility activities. -Staff may not take or release images or recordings of any resident without explicit written consent. -Transmitting unauthorized images of any resident through email, internet or social media if considered a violation of a resident's rights. -Any image or recording taken that may be constructed as humiliating demining to a resident is considered abuse and will be reported and investigated as such. B. Resident #124 status Resident #124, under the age of 65, was admitted on [DATE]. According to the June 2021 computerized physicians orders (CPOs), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/18/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a three out of 15 on the brief mental scale assessment. The resident's speech was often slurred and was only sometimes able to express ideas and wants and only sometimes understood verbal content, the resident needed extensive assistance from staff for all activities of daily living. C. Record review Review of progress notes revealed Resident #124's was discovered lying on the floor beside her bed on 6/11/21 at approximately 2:00 p.m. Certified nurse aide (CNA) #4 reported finding Resident #124 lying on the floor leaning up against the wall. The nurse on duty was notified and the resident was assessed for injuries and helped back to bed. Nursing note dated 6/11/2021 at 9:13 p.m. read in part: at 2:00 p.m. CNA found Resident #124 on the floor at the bedside .The registered nurse (RN) assessed the resident and assisted the resident back to bed, no head injury or physical injury involved.Resident could not explain how she fell . Mild confusion was noted, the resident is alert and oriented only to person . It was later that the facility discovered the CNA #4 had taken a video of the resident as she laid on the floor in nothing but an adult diaper and sent the video by Facebook messenger to two other CNAs who worked in the facility. Once this was discovered, CNA #4 was suspended and an investigation was initiated. -CNA #4 no longer is employed with the facility, see NHA interview below. D. Facility investigative report The facility investigation report revealed the CNA #4 said she walked into the room; the resident was on the floor so she took a video to share with staff to help understand how this happened. The resident was not interviewed about the incident until 6/15/21, four days after the event and she was not able to give details of the incident. The UM reported that the resident showed no signs of distress and felt safe. The UM did not specifically ask the resident if she was ever videotaped by a staff member. CNA#3 said CNA #4 sent the video of Resident #124 to her by Facebook messenger. The video opened with Resident #124 sitting on the floor leaning against the bed. The resident was unclothed. CNA #4 was heard saying how the F*** did you end up there and then told the resident you know you are not supposed to get up on your own. CNA #3 said she reported the video to the human resources manager; and was not aware of any other videos circulating around. CNA #5 said she had received a video of Resident #124 through Facebook messenger from CNA #4 she immediately deleted the video and did not comment on the video. There was no indication if the facility investigator asked the staff if anyone else was included in the messenger thread or if they saw this video in any general Facebook threads. The investigation report contained a transcript of the video. Per the director of nursing's (DON) account of the video. The video showed Resident #124 sitting on the floor leaning against the wall in nothing but an incontinent brief. In the audio portion of the video CNA #4 could be heard saying Help me understand how the F*** this sh** happens. How did you get out of bed? Resident #124 responded I fell out of bed., the rest of what the resident said was not understandable. CNA #4 responded You're not supposed to! Resident #124 said I know it., the rest was not understandable. The video lasted a full eight minutes before ending. E. Resident interview Resident #124 was interviewed on 6/21/21 at 10:22 a.m. Resident #124 observed lying in bed. The resident was unable to remember falling or anyone taking her picture recently and had no current concerns about staff. F. Staff interviews The NHA was interviewed on 6/21/21 at 11:30 a.m. The NHA said the resident had impaired cognition and based on the video he did not believe the resident knew she was being videotaped. When the resident was interviewed about the incident, she was unable to focus on the questions being asked. The staff who took the video CNA #4 was suspended immediately upon discovery that she had taken an unauthorized video of Resident #124. An investigation was initiated immediately. Based on investigative findings CNA #4 was separated from the facility for gross misconduct and failure to follow facility policy. The DON was interviewed on 6/21/21 at 11:32 p.m. The DON said after this incident they provided staff education on customer services and the expectation to treat all residents with dignity and respect. No staff were to take pictures of residents during care or use their personal phones to take resident pictures of videos. The only time any staff were permitted to take a resident picture was with signed and verbal consent form the resident, or the resident legal representative when the resident had impaired decision managing ability. CNA #5 was interviewed on 6/22/21 at 12:05 p.m. CNA #5 said staff were to ensure resident privacy at all times. Staff were never permitted to take a picture of staff particularly when they were exposed or not wearing clothing. It was not ok for staff to share pictures of residents on their personal phones or over social media. CNA #5 said if staff had knowledge of such activity, they were to report the activity to management immediately. The activities director (AD) was interviewed on 6/22/21 at 12:20 p.m. The AD said staff were only permitted to take pictures of a resident with a signed consent form the resident or the resident's guardian/responsible party. Residents were always free to change their mind and refuse to permit a picture from being taken so staff were to ask for verbal consent for each photo. Staff were never permitted to take pictures of residents during care or when a resident was not fully dressed. Staff were never permitted to take a photo on their personal phones; the facility had a designated camera to take photos of residents during recreational programming. Licensed practical nurse (LPN) #5 was interviewed on 6/22/21 at 12:39 p.m. LPN #5 said staff were not permitted to take any picture of a resident without consent and were never to take a resident's picture on their personal phones for any reason. The NHA was interviewed on 6/22/21 at 5:05 p.m. The NHA said CNA #4 said she would delete the video she took of the resident form her phone and Facebook messenger account, as did the other two CNA who received the video in Facebook messenger. The only known video of the resident was being held by the facility legal department. II. Resident #15 and Resident #2 A. Facility policy The Abuse policy, revised 10/28/2020, was provided by the nursing home administration (NHA) on 6/16/21 at 9:30 a.m. The policy read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents . -Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. -Standards: Providing a safe environment for the residents is one of the most basic and essential duties of our facility. -Resident abuse is defined as the willful infliction of injury .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. -If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. B. Resident to resident altercation between Resident #15 and #2 Facility reported incident investigation dated 5/15/21 for an allegation of resident-to-resident physical abuse was provided by the director of nursing (DON) on 6/21/21 at 9:13 a.m. The investigation report revealed Resident #15 was sitting in her electric wheelchair by the activities sponsored store talking to activities assistant (AA) #1; Resident #2 was a few feet away trying to get AA #1's attention by calling out hey, hey. AA #1 asked Resident #2 to wait his turn but he continued to try to get AA #1's. Resident #15 then said to AA #1 that Resident #2 only had a 5th grade education. Resident #2 heard the comment and rolled his wheelchair over to Resident #15 and punched Resident #15 closed fist in the left shoulder. Facility Investigative interviews Resident #15 told the investigator she was sitting at the store talking to AA #1, when Resident #2 started to holler at AA #1. Resident #15 said she told AA #1 do not worry Resident #2 only had a 5th grade education; then Resident #2 came closer. Resident #15 said she told AA #1 Resident #2 needed to mind his own business and then he hit her. Resident #2, was unable to express what occurred; and just said, Oh baby!. AA #1 said Resident #2 was in the hallway yelling at another resident ' Resident #15 told Resident #2 to mind his own business and Resident #2 went over to Resident #15 yelling what, what and proceeded closer and punched Resident #15 in the left arm with a closed fist. Licensed practical nurse (LPN) #6 said Resident #15 was in the hall by the activities store; she did not see what happened but heard Resident #15 say don't you fu**ing touch me again and continued to say other insulting words to Resident #2. LPN and other staff intervened and Resident #15 and #2 were separated. The social services director (SSD) did not see the event but talked to Resident #15 after the event. The SSD's interview did not document what Resident #15 told her or Resident #25's demonor or behavior during the interview. C. Residents #15 1.Resident interview Resident #15 was interviewed on 6/16/21 at 10:50 a.m. Resident #15 said Resident #2 punched me yesterday. Resident #15 said Resident #2 was in the hall making weird noises; I leaned over to talk to AA#1 and told her I don't think he has more than a 5th grade education. Resident #2 yelled out what did you say? and he rolled over and punched me in the arm. Resident #15 pointed to her left upper arm and said it still hurts. She did not have any bruises in the area of her arm she identified as where Resident #2 hit her. Resident #15 was not sorry for her comment about Resident #2 and was surprised he could hear her form where he was sitting. Resident #15 said Resident #2 was very abusive and he went around punching people when he got angry with them. 2. Resident status Resident #15, under the age 65, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/31/21 minimum data set (MDS) assessment revealed the resident had intact cognition with a score of 15 out of 15 on the brief interview for mental status (BIMS); and exhibited no behaviors during the time of the assessment. The resident needed one-person assistance with transfers and set up assistance with other activities of daily living; and used a power wheelchair to get around the community. 3. Record review Resident #15's comprehensive care plan revealed a care focus for borderline personality disorder, last revised 6/2/21. The care focus indicated the resident was resistant to care and that she called certain staff members inappropriate names as she passed them in the halls. The care plan failed to document a specific care focus for negative behaviors directed towards other residents such as derogatory negative comments which may have a negative effect on the other person's emotional state and/or lead to a resident to resident altercation. Progress notes revealed the facility was aware of the resident's tendency to make inappropriate and negative comments towards peers and the need to intervene and redirect such behaviors. Progress notes revealed: -Activity note dated 3/30/21 at 11:48 a.m., read in part: .Mood and behaviors that affected participation: At times tend to get angry at peers, or yell at peers. Needs redirection from inappropriate language being used at activity staff . -Psychosocial note 4/16/21 at 2:25 p.m., read in part: Resident #15 was leaving her room today when she made judgmental statements to two residents. Social Services offered to transfer her to somewhere she would be more comfortable and she declined. -Incident note dated 6/15/21 at 5:36 p.m., read in part: Per report at approximately 2:00 p.m. Resident #15 was talking to an employee in activities during activities store hours (by the activity store). Per report, Resident #2 approached her aggressively asking 'what?' assuming she was talking about him. Resident stated she did not reply to him but he approached her and punched her on her left upper arm with a closed fist. Resident currently not complaining of pain to the area, skin intact with no discoloration, intact baseline range of motion. Educated res on safety, de-escalation incases of arguments and conflict resolution, res verbalized understanding of teaching. Will continue to monitor this resident. -Interdisciplinary team (IDT) risk management note dated 6/17/21 10:36 a.m., read in part: Date of incident: 6/15/21; type of incident: physical aggression received; root cause: Resident #15 made a derogatory statement to a staff member about another resident within earshot and it upset that resident. Treatment required: none indicated. Interventions put into place: Resident #15 is alert and oriented and at times knowingly makes hurtful comments to and/or about other residents; re-educated Resident #15 about not making these sort of statements that hurt others. D. Resident #2 1. Resident interview Resident #2 was interviewed on 6/21/21 at 9:10 a.m. Resident #2 was unable to explain any resident-to-resident altercations he was involved in. When asked how he was getting along with others Resident #2 said yeah, yeah, and some other non-understandable phrases. 2. Resident status Resident #2, under the age of 65, was admitted on [DATE]. According to the June 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/1/21 MDS assessment revealed the resident had severely impaired cognition as evidenced by a score of three out of 15 on the BIMS. The resident had difficulty communicating some works or finishing thoughts and missed some parts or intent of messages but comprehended most conversations. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident needed extensive assistance from staff to complete activities of daily living but was able to move about the community in a manual wheelchair. 3. Record review -Resident #2's comprehensive care plan revealed a care focus for behavior, last revised on 3/10/21. The care focus indicated: -Resident #2 had behavior challenges related to anger issues. Resident #2 was easily riled and exhibited shakiness, crying and could become verbally and physically aggressive. -Resident #2 had potential to be verbally aggressive towards other residents and staff related to ineffective coping skills and poor impulse control. -Resident #2 had potential to be physically aggressive towards other residents and staff members related to anger, depression, a history of harm to others, and poor impulse control. -Resident #2 displays aggressive behaviors of kicking toward staff and other residents; grabbing staff arm; teasing, placing himself to block resident/visitor/staff way to get through. Resident #2 has verbal behaviors such as cussing and yelling at staff and other residents. Care planned interventions included, in part: -Give medication as needed; -Behavior monitoring for mood stabilizer medication; -Review behaviors/interventions and alternate therapies attempted and their effectiveness; -Minimize potential for Resident #2's disruptive behaviors, such as yelling, by offering tasks which divert attention; -When the resident becomes agitated, intervene before agitation escalates; -Guide away from sources of distress; -Engage calmly in conversation; -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior; and, -Encourage seeking out a staff member when agitated . Progress notes from 10/8/2020 through 6/17/21 were reviewed. The notes revealed Resident #2 had a number of incidents involving both verbal and physical altercation with other residents. Additionally, the facility had documented the incidents and intervention assessments (see a partial list of current intervention to prevent Resident #2 from becoming aggressive towards other residents as documented above). The latest facility reported incident notes read: -Incident note dated 6/15/21 at 5:58 p.m., it read: Per report at approximately 2:00 p.m., Resident #15 was talking to an employee in activities during activities store hours (by the activity store). Per report, Resident #2 approached Resident #15 aggressively asked 'what?' and punched her on the left upper arm with a closed left hand fist. Resident #2 declined to give his side of the incident story. Residents were assessed and no apparent injuries were noted. Resident #2 was not complaining of any pain, skin intact with no discoloration .educated Resident #2 on safety, de-escalation of arguments and conflict resolution. -IDT risk management review note dated 6/17/21 at 10:18 a.m., read: Date of incident: 6/15/21; type of incident: physical aggression. Root cause: overstimulation related to outside construction; inability to go to a quiet place; and poor impulse control. Treatment required: none. Interventions put into place: monitor for signs of increased agitation and encourage going to a quiet place if noted. The facticity investigation did not document any findings for environmental overstimulation. See incident summary above); and the IDT did not document the Resident #2's aggressive response in relationship to Resident #15's comments about Resident #2's cognitive abilities and how that may have affected Resident #2 mood and emotional state. E. Staff interviews The NHA was interviewed on 6/21/21 at 9:30 a.m. the NHA said he expected staff to intervene immediately when any resident showed aggression towards another resident. Residents were to be separated and monitored for any additional signs of aggression. The DON was interviewed on 6/21/21 at 10:10 a.m. The DON said as soon as a resident to resident altercation was observed or identified, staff were expected to intervene and redirect the residents, ensure safety, check for injury and treat as necessary, and educate the resident on acceptable behavior as appropriate. Behavior was assessed and the resident's care plans were updated immediately if new interventions were necessary. AA #1 was interviewed on 6/22/21 at 12:50 p.m. The AA said she was with Resident #15 at the facility store on 6/15/21 at approximately 1:45 p.m. Resident #2 was a few feet away in the hall. Resident #2 was yelling at another female resident also in the hall. Resident #15 yelled to Resident #2 to mind his own business and commented that he only had a 5th grade education. Resident #2 responded to Resident #15 saying what?!; Resident #15 responded to Resident #2 by repeating mind your own business. Resident #2 rolled his wheelchair to Resident #15 and punched her on the side of her left arm. The punch made a smacking sound as his closed fist hit Resident #15's arm. AA #1 demonstrated by making a fist and hitting it into her palm and said it sounded like this (there was a loud audible smacking sound). Resident #15 responded by saying, hey don't touch me! AA #1 said it happened so quickly that she did not have time to prevent Resident #2 from punching Resident #15 but she reacted as quickly as possible to intervene and prevent any further physical altercation between the two residents. Other staff also intervened and helped to separate Resident #2 and #15. AA #1 said she could tell that Resident #2 was upset over Resident #15's negative comments because Resident #15's face showed anger and his body was very tense. Staff took Resident #2 outside and he was able to calm down. Since the altercation, Resident #15 and #2 had been able to stay away and avoid contact with each other.

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and residents received adequate supervision and assistive devices to prevent accidents. The facility failure affected two (#9 and #23) of four residents sample for falls and nine (#3, #4, #5, #6, #10, #16, #17, #25 and #26) of 25 residents sample for smoking hazards out of a total of 27 sample residents. Falls: The facility failed to take sufficient steps to prevent Resident #9 from falling repeatedly and sustaining injuries. Resident #9 experienced ten falls between April and August, 2020, sustaining a pelvic fracture as well as head injuries, a laceration, bruising and skin tears. Review of the resident's record revealed the facility failed to develop and implement effective measures to prevent falls with injury. Eight of the falls were unwitnessed, despite a plan for frequent checks. At least five of the falls were around toileting, yet care plan review revealed no toileting assessment or toileting schedule. There was insufficient evidence root causes were thoroughly considered in an effort to develop effective preventive measures. Smoking: The facility failed to address Residents #3, #4, #5, #6, #10, #16, #17, #25 and #26 unsafe smoking behaviors. Findings include: I. Falls A. Facility policy and procedure The Fall Documentation policy, dated [DATE], was provided by the director of nursing (DON) on [DATE] at 2:10 p.m. It read in pertinent part, To have complete, accurate, and timely documentation for residents who have sustained a fall and/or preventive measures taken to prevent a fall. B. Resident #9 1. Resident status Resident #9, age 87, was admitted to the facility on [DATE]. She expired at the facility on [DATE]. The [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 8 out of 15. The resident required extensive one-person physical assistance with bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. The resident was not steady and required staff assistance during transfers and locomotion. The updated care plan, [DATE], documented the resident was at risk for falls related to gait/balance problems, history of falls, incontinence, and psychoactive drug use. Documented interventions included anticipate the needs of the resident ([DATE]), call light within reach and prompt use ([DATE]), hospice collaboration ([DATE]), non-slip cushion in wheelchair ([DATE]), non-skid footwear ([DATE]), floor mat at the bedside ([DATE]), provide toileting and incontinence care as needed ([DATE]), physical therapy evaluation ([DATE]), frequent monitoring (discontinued [DATE]) and bed in lowest position at night with items in reach ([DATE]). 2. Record review Record review revealed the resident fell ten times between April and August, 2020, sustaining a pelvic fracture as well as head injuries, a laceration, bruising and skin tears. Review of the resident's record revealed the facility failed to develop and implement effective measures to prevent falls with injury. Eight of the falls were unwitnessed, despite a plan for frequent checks. At least five of the falls were around toileting, yet care plan review revealed no toileting assessment or toileting schedule. There was insufficient evidence root causes were thoroughly considered in an effort to develop effective preventive measures. [DATE]: A [DATE] nursing note documented an unwitnessed fall. The resident was found on the floor by her bedside with an abrasion to her right elbow at 10:47 p.m The resident denied pain and was able to move limbs within normal limits. A registered nurse (RN) assessed the resident and neurological (neuro) checks were initiated and completed. The fall investigation for the [DATE] fall, received from the director of nursing (DON) on [DATE] at 11:00 p.m., revealed an abrasion to the right elbow, no pain, the resident was oriented to person and place, predisposing physiological factors of gait imbalance, high risk for falls, incontinence and poor safety awareness, predisposing situational factors included resident was on way to the restroom and was using her wheeled walker. Failure: There was no evidence the resident's predisposing risk factors (see above) were investigated or or new interventions considered to minimize them. No interventions were put in place after this unwitnessed fall to minimize her predisposing risk factors. [DATE]: A [DATE] nursing note documented an unwitnessed fall at 1:18 a.m The resident reported falling to a certified nurse aide (CNA) and stated her hip hurt. The nurse assisted the resident to the restroom and back to bed and noted the resident was limping. The nurse asked the CNA if she usually limped and the CNA confirmed the resident does not usually limp. A licensed practical nurse (LPN) assessed the resident, neuro checks were initiated, the nurse practitioner (NP) was notified, pain medication was administered (pain level 5 with 10 being the worst pain), and an x-ray was ordered for the resident's right hip. However, the x-ray was not performed by third-party radiology services until [DATE]. Results were received on [DATE] and forwarded to the physician who returned his [DIAGNOSES REDACTED]. (Cross-reference F658) The [DATE] interdisciplinary team (IDT) meeting note for the resident's fall on [DATE] revealed the cause of the resident fall to be weakness. An intervention of a physical therapy evaluation was planned, but the resident refused. Failures: There was no evidence other interventions to minimize the safety risk posed by the resident's weakness were considered and documented, such as monitoring the resident to determine if there were periods of the day when she was weak, specific times when she was likely ambulating to the bathroom or increasing staff supervision. [DATE]: A [DATE], two days following her fall with fracture, a nursing note documented another unwitnessed fall at 6:44 a.m. The CNA on duty walked into the resident's room and found her on the floor between the bed and night stand with her legs facing the doorway. The resident was wearing her non-skid footwear. A physical assessment by the RN revealed several bruises on the resident's left elbow, and three on her right elbow (pain level of 2 per fall investigation), Neuro checks were initiated (but not completed). The resident was assisted back to bed and reminded to use her call light if she needed assistance. Frequent checks were initiated for safety. The family and physician were notified. The [DATE] IDT meeting note for the resident's fall on [DATE] revealed the cause of the fall as increased confusion of the resident after a room change. No treatment was required for this fall. Interventions initiated included frequent checks for safety and neurological checks. Failures: Although frequent checks were initiated for safety, the meaning of frequent checks was not defined, this intervention per care plan (see above) was discontinued on [DATE], and there was no documentation to show if frequent checks were done and/or done consistently. [DATE]: The [DATE] nursing note documented an unwitnessed fall at 11:16 a.m. The resident was heard yelling for help and staff found her on the floor, lying on her left side. The resident said she was trying to go to the bathroom. Her call light was not on. A small scratch was noted on the resident's left thigh and the resident reported right hip and knee pain (per LPN assessment). Neuro checks were initiated (but not completed). She was wearing non-skid footwear. Staff assisted her back to bed and re-educated her about using her call light and placed it with her reach. The fall investigation noted the resident was complaining of pain to her right knee and hip and had a fractured pelvis from a previous fall. No pain level was documented The resident was oriented to person. No predisposing factors were documented. Failures: Effective interventions were not initiated to keep the resident safe. Although on frequent checks (per IDT note following the resident's [DATE] fall, the resident experienced a fourth unwitnessed fall. As noted above, the meaning of frequent checks was not defined, the intervention was noted as discontinued on the care plan, and there was no documentation to show frequent checks were done and/or done consistently. Moreover, the resident was known to not use her call light, yet the facility continued to utilize this intervention (remind and re-educate to use the device), despite knowledge it was ineffective. Finally, there was no evidence the facility evaluated the resident's incontinence or attempted to develop a toileting schedule, even though a number of her falls referenced the resident was heading to the bathroom when she fell . [DATE]: The [DATE] nursing note documented a fifth unwitnessed fall at 6:57 a.m. The resident was yelling for help and the night nurse walked into her room and found the resident sitting on the floor on her buttocks. The resident reported trying to go to the restroom and hit her head on the side of her bed as she fell . An LPN assessed the resident and the resident reported mild pain in her buttocks. She also had an open skin injury. Neuro checks initiated, but incomplete. Failures: As above; effective interventions were not initiated that would keep the resident safe. Although on frequent checks per the IDT note after the [DATE] fall, the resident experienced a fifth unwitnessed fall. This intervention was discontinued on the care plan, and there was no documentation to show frequent checks were done and/or done consistently. Further, there was no evidence the facility evaluated the resident's incontinence or attempted to develop a toileting schedule, even though this was another fall while the resident was trying to go to the bathroom when she fell . [DATE]: The [DATE] nursing note documented an unwitnessed fall at 11:38 a.m. The resident was found sitting on the floor next to her wheelchair by the bathroom door. Resident said she was trying to use the restroom and fell out of her wheelchair. The resident's call light was not on. The resident denied hitting her head and no injuries were apparent. An RN assessed the resident and initiated neuro checks. The resident was assisted back to bed and re-educated about using her call light to call for assistance. The resident verbalized understanding. The [DATE] IDT meeting notes for the resident's fall on [DATE] revealed the cause of the fall was the resident attempting to use the restroom independently and slid out of her wheelchair. Interventions initiated included continued collaboration with hospice services, offer toileting before meals and place a no-slide cushion in her wheelchair. Failures: While interventions included to offer toileting before meals, there was no evidence this toileting plan was based on an assessment of the resident's toileting needs and no evidence this intervention was added to the care plan. Moreover, reminding the resident to use her call light, even if the resident indicated understanding, was known to be ineffective in keeping the resident from ambulating without assistance. [DATE]: The [DATE] nursing note documented a sixth unwitnessed fall at 7:12 a.m. The CNA on duty found the resident bleeding on the floor of her room. The resident was found sitting on the floor with blood on her face, hands, legs and gown. A fall assessment was completed by a RN; neuro and neurological and physical assessments were done immediately. The fall resulted in a laceration to the resident's forehead that was bleeding slowly and continuously. The resident reported a pain level of seven out of ten. Staff helped the resident into a new gown and back into her wheelchair. Her wound was cleaned, band-aid applied and an ice pack provided for pain. The [DATE] IDT meeting notes for the resident's fall on [DATE] revealed the cause of the fall as a history of falls, weakness, poor safety awareness and hospice care. Treatment included wound care. Interventions included a fall mat to be placed at bedside. Failures: Effective interventions to keep the resident from falling were not implemented as she continued to fall unwitnessed. There was no evidence the facility considered increasing supervision of the resident to keep her safe. Moreover, there was no evidence whether the resident fell from bed or fell during ambulation, a factor in developing an effective intervention. [DATE]: The [DATE] nursing note documented a seventh unwitnessed fall at 3:56 a.m. The resident was heard shouting from her room. The CNA went to check on her and reported to the nurse that the resident was on the floor. She was observed sitting on her buttocks by her bed and her wheelchair was 10 feet away from the bed. The resident was assessed by a RN; neuro checks were initiated (but incomplete) and two skin tears were noted to the resident's left elbow. The resident reported a pain level of five out of 10 on the back of her head. The resident was assisted to the restroom and then back to bed by staff. Her wounds were cleaned and bandaged. The resident was reminded to use her call light for assistance, the fall mat was on the floor next to bed and non-skid footwear was on. Frequent checks were initiated for safety. The [DATE] IDT meeting notes from the resident fall on [DATE] revealed the root cause of the fall as confusion. Treatment included first aid rendered to reopened abrasion. Interventions put into place included a fall mat, neurological checks and frequent checks. Failures: As above; the facility failed to ensure the resident received adequate supervision; frequent checks had been in place since the resident's fourth fall per IDT notes, yet she continued to fall, unwitnessed. Interventions continued to include reminders to use her call light, another intervention known to be ineffective. [DATE]: The [DATE] nursing note documented a witnessed fall at 6:05 a.m A CNA on duty called for help from another staff member. The first CNA responded to the resident's cries for help and when she opened the door, the CNA witnessed the resident fall on the floor and land on her buttocks. The CNA was too far from the resident to intervene in the fall. The resident complained of a pain level of five out of ten. The laceration on her forehead reopened, was cleaned and bandaged. The resident was assisted to bed and reminded to use her call light, fall mat at bedside, non-skid footwear on, and fluids offered. Frequent checks initiated for safety. Failures: The [DATE] IDT meeting notes from the resident's fall on [DATE] revealed no root cause of fall, no treatment and no new interventions. [DATE]: The [DATE] nursing note documented an eighth unwitnessed fall at 10:03 p.m. A staff member heard calls for help coming from the resident's room. The staff member went into her room and found the resident laying on her right side next to her bed on the floor mat. Blood was noted on the resident's face from the existing wound. A RN assessed the resident; neuro checks initiated (but incomplete) and the staff member assisted the resident back to bed and cleaned and bandaged her wound. The [DATE] IDT meeting notes for the resident's fall on [DATE] revealed the fall was reviewed. No specifics were documented. Failure: No fall investigation was provided for this unwitnessed fall. No new interventions considered. [DATE]: An [DATE] nursing note documented the resident's passing. 3. Staff interviews LPN #1 was interviewed on [DATE] at 5:20 p.m. She said if a fall was witnessed, a skin check was done and the RN comes to assess the resident. If the fall is unwitnessed, neurological checks are initiated and vital signs and cognitive functions are monitored. She said an investigation and interventions were done after every fall. She said investigations and interventions were important to determine the cause and prevent future falls. She said if no injury is present, the resident is assessed and does not go out to the hospital. She said if the fall was serious and there was a possibility of injury the resident should be sent to the emergency department via ambulance. She said Resident #9 had multiple falls due to confusion, lack of safety awareness, and not recognizing her need for assistance. She said she had a sitter briefly after the fall resulting in the head wound, although see above, record review revealed no consideration or documentation regarding a sitter. She said staff would take her to the restroom and remind her to use her call light, then find her out of her room a few minutes later. She said Resident #9 had a couple of x-rays. She said she was not aware of the fracture resulting from one of the resident's fall on [DATE]. She said the resident used both a walker and a wheelchair. She said the staff would sit her next to the nurses' station for safety. She said the resident had a 24 hour sitter near the end of life. LPN #4 was interviewed on [DATE] at 9:55 a.m. She said if an x-ray was ordered it is usually done the same day. She said the results are typically available the same day as well. She said Resident #9 had many falls at night. She said nursing staff assessed her every shift, fall or not. The nursing home administrator (NHA) was interviewed on [DATE] at 11:40 a.m. He said the facility was having issues getting the x-ray company into the facility in May due to the Coronavirus. He said the facility was dealing with an outbreak and the x-ray company was as well. He said he should have sent Resident #9 to the hospital after the fall on [DATE], but didn't think to do so at the time. The DON was interviewed on [DATE] at 4:19 p.m. She said unwitnessed falls should be accompanied by neurological checks. She said they were having some issues with the radiology company in May that resulted in delay of care. She said they should have had a conversation with the resident about being sent to the hospital for acute care. She said IDT meetings should be held within 24 hours of an incident so interventions can be put in place right away. She could not explain why the IDT meeting and interventions were not put in place for Resident #9 after each fall event. C. Resident #23 1. Resident status Resident #23, age 92, was admitted to the facility on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was severely impaired cognitively with short and long-term memory loss. He had no behaviors. He required extensive assistance with two-person care for bed mobility, transfers, dressing, toileting and hygiene. He had one fall since admission with no injury. 2. Record review Record review revealed sustained two falls which were not thoroughly investigated to determine cause in order to develop effective interventions. [DATE]: A nurse progress note, written by LPN #5 for Resident #23 was reviewed on [DATE] at 3:30 p.m. It revealed a nurse's note dated [DATE] at 4:01 a.m. that read: Roommate witnessed the fall, resident fall with no injury noted upon assessment, assisted resident back to bed with two-person assist. [DATE]: A nurse progress note written by LPN #6, dated [DATE] at 12:34 a.m., read: Resident had unwitnessed fall in his room. Head to toe assessment performed by registered nurse (RN), no apparent injury noted, no head injury involved. Denied complains of pain. Resident assisted back to his bed. Bed in low position. Neuro(logical) checks initiated per facility protocol. Documentation was requested on [DATE] at 1:39 p.m. for facility investigations related to Resident #23's falls on ,[DATE] and [DATE] in order to identify root causes and to develop effective interventions. No such documentation was provided. II. Smoking A. Facility policy and procedure The Traditional Tobacco and Electronic Cigarette Smoking Policy, last reviewed [DATE], provided by the facility on [DATE], included 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. Smoking assessment and potential restriction shall be made 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 resident ' s ability to smoke and/or smoke safely. Should the incidence of unsafe smoking behavior occur, the community will attempt to: educate the resident on safe smoking practices, offer smoking cessation assistance, including pharmacological and behavioral support for smoking cessation and implementation of the behavior management plan. Unsafe smoking behaviors will also result in the resident immediately becoming a supervised smoker for a period of up to 30 days. After the supervised smoking period, the resident will be re-assessed for safety. If another offense occurs, the resident will be immediately placed on supervised smoking and may be subject to a 30 day or immediate involuntary discharge. Existing smoking care plans will be amended and updated to reflect any unsafe smoking incidents and any new interventions that the interdisciplinary team (IDT) has developed to keep the community and the resident safe and prevent reoccurrence of unsafe smoking. Supervised smokers will have their smoking supplies kept at the nursing station, secured. Staff will be responsible for distributing smoking materials during designated smoking times. Any resident, who has been classified as unsafe, shall not be permitted to smoke without direct supervision of a designated staff member, family member or volunteer. Direct supervision will be provided throughout the entire smoking period. At no time may residents who smoke share, trade or sell their supplies with their peers. B. Facility documents and resident record reviews On [DATE], the facility provided a list of residents that smoke as of [DATE] per the most recent smoking assessments in the electronic records. The first column was the resident ' s name, the second column documented if the resident was safe or unsafe, supervised or unsupervised and the third column documented needed smoking equipment. The DON said if a resident was marked as safe/supervised, it meant the resident was able to smoke safely but needed some type of assistance such as lighting their cigarette or putting it in the ashtray. Review of this document on [DATE] revealed it was not updated with the current resident information in the electronic record. 1. Resident #16 Resident #16, age 59, was admitted on [DATE]. According to the [DATE] CPO, [DIAGNOSES REDACTED]. Further review of the CPO revealed the resident was ordered to receive oxygen at 3 liters/minute per nasal cannula. The [DATE] MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident required extensive assistance of two people with her activities of daily living (ADLs). Tobacco use was not indicated. The [DATE] smoking risk assessment revealed the resident was an unsafe smoker who must be supervised at all times when smoking. The care plan, last revised [DATE] (during survey), revealed the resident was a supervised smoker and was at risk for smoking in her room. Interventions included: -Monitor for any unsafe smoking practices. Observe clothing and skin for signs of cigarette burns, initiated [DATE]; -Instruct resident about smoking risks and hazards and about smoking cessation aids that are available, revised [DATE]; -Notify charge nurse immediately if it is suspected the resident has violated the facility smoking policy, revised [DATE]; -The resident requires a smoking apron while smoking, revised [DATE]; -The resident ' s smoking supplies are stored in the designated smoking box located at the south nurse ' s station, revised [DATE]; -Instruct and inform the resident about the facility policy on smoking: locations, times, safety concerns, and any changes, revised [DATE]; -Re-evaluate the resident for safe smoking abilities on a quarterly and as needed basis, making changes as needed, revised [DATE]; -The resident requires SUPERVISION while smoking, revised [DATE]; and -Alarm attached to oxygen tank to assist in reminding the resident to remove oxygen prior to entering the smoking area, revised [DATE] (during survey). Observations and record review revealed the resident engaged in unsafe smoking behavior that had not been addressed. Specifically: -On [DATE] at 1:47 p.m. and [DATE] at 11:04 a.m., the resident was outside on the smoking patio, smoking a cigarette without a protective smoking apron on, contrary to her care plan. -A [DATE] nursing progress note revealed the resident had a strong odor of marijuana in her room with a suspicion of the resident smoking while in bed since the resident was a Hoyer lift and her purse was next to her in bed. -A [DATE] incident progress note revealed the resident was smoking cigarettes and it smelled very strongly of marijuana in her room even after the resident had sprayed an air freshener to conceal the odor. It indicated the resident had a pack of cigarettes on her chest and asked the CNA to discard her cigarette butt. The note indicated the resident was educated and reminded of the danger of smoking in her room with an oxygen tank; however, the resident denied smoking in her room and understanding the education provided. However, according to the [DATE] facility list of residents that smoke (see above), the resident was a safe smoker who needed supervision. It indicated she needed assistance but did not specify what type of assistance and it did not indicate the resident was to have a smoking apron on when she was smoking. Further review of her record on [DATE] revealed the resident ' s smoking risk assessment was not completed after unsafe smoking behaviors were documented, no interventions were put into place to prevent reoccurrence and the care plan was not updated timely. Observations revealed the resident was not wearing a smoking apron while smoking as care planned. 2. Resident #25 Resident #25, age 64, was admitted on [DATE]. According to the [DATE] CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She required extensive assistance of one person for her ADLs. Tobacco use was not indicated. The [DATE] smoking risk assessment revealed the resident must wear a protective non-flammable vest/apron when smoking. The care plan, last revised [DATE], revealed the resident was a supervised smoker. Interventions included: -Instruct and inform the resident about the facility policy on smoking: locations, times, safety concerns, and any changes, revised [DATE]; -Monitor for any unsafe smoking practices. Observe clothing and skin for signs of cigarette burns, initiated [DATE]; -Notify charge nurse immediately if it is suspected the resident has violated the facility smoking policy, initiated [DATE]; -The resident ' s smoking supplies are stored in the designated smoke box at the south nurse ' s station, revised [DATE]; -Re-evaluate the resident for safe smoking abilities on a quarterly and as needed basis, making changes as needed, revised [DATE]; -The resident is supervised with a smoking apron, revised [DATE]; and -She requires a cigarette extension when smoking, initiated [DATE] (during survey). According to the [DATE] facility list of residents that smoke, the resident was an unsafe, supervised smoker, and required the use of an apron and extension. Observations and record review revealed the resident engaged in unsafe smoking behavior that had not been addressed. Specifically: -On [DATE] at 4:00 p.m., the resident was outside on the smoking patio, smoking a cigarette unsupervised and without an apron or extender. On [DATE] at 9:15 a.m. and 5:00 p.m., the resident was outside on the smoking patio, smoking a cigarette without an apron on or an extender. -A [DATE] risk management review progress note revealed the resident burnt her finger on [DATE] while smoking. It indicated the resident was to be reviewed for a cigarette holder and verbal education was given to the CNA to stay close and help the resident with ashing her cigarette. -An [DATE] nursing progress note revealed a staff member reported Resident #5 gave Resident #25 marijuana to smoke. It indicated the DON was notified. Review of the record on [DATE] revealed the smoking risk assessment was not updated when unsafe smoking behavior occurred, new interventions were not initiated to prevent the behavior from reoccurring and the care plan was not updated with this behavior. Observations revealed the resident was not being provided supervision while smoking and the resident was smoking without the use of an apron or extender. 3. Resident #3 Resident #3, age 61, was admitted on [DATE]. According to the [DATE] CPO, [DIAGNOSES REDACTED]. Further review of the CPO revealed the resident was ordered to receive oxygen 6 liters/minute via nasal cannula. The [DATE] MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15 and the resident used tobacco. The resident required supervision with all of her ADLs. The smoking care plan, initiated [DATE] and last revised [DATE] (during the survey), revealed the resident was a supervised smoker and had a history of [REDACTED]. Interventions included: -Instruct and inform the resident about the facility policy on smoking: locations, times, safety concerns, and any changes, initiated [DATE]; -Instruct resident about smoking risks and hazards and about smoking cessation aids that are available, initiated [DATE]; -Monitor for any unsafe smoking practices. Observe clothing and skin for signs of cigarette burns, initiated [DATE]; -Re-evaluate the resident for safe smoking abilities on a quarterly and as needed basis, making changes as needed, initiated [DATE]; -The resident requires SUPERVISION while smoking, revised [DATE]; -Notify charge nurse immediately if it is suspected the resident has violated the facility smoking policy, revised [DATE]; and -Alarm monitor on oxygen tank as a reminder to leave in building when smoking, initiated [DATE] (during the survey). The resident's most recent smoking risk assessment, dated [DATE], revealed the resident was a safe smoker and was capable of smoking without physical assistance but must be supervised per facility policy. Likewise, on the [DATE] facility list of residents that smoke, the resident was a safe smoker who needed supervision. Observations and record review revealed the resident engaged in unsafe smoking(TRUNCATED)

Based on interview and record review, the facility failed to ensure one (#9) of three residents reviewed for falls from the 12 sample residents received adequate supervision and assistance to prevent an accident. Specifically: Resident #9, who was fully dependent on two or more staff for transfers, was transferred by Hoyer lift with the assistance of one certified nurse aide (CNA) The resident fell and sustained a subdural hematoma that required continued hospitalization and contributed to a decline in his ability eat, drink and breath. Following the incident, the facility initiated a performance improvement plan (PIP) to address identified concerns in the resident's transfer. The facility had fully implemented corrective action prior to the onsite investigation. The deficiency is cited as past non-compliance. I. Facility policy The instructions for using a Hoyer lift (a mechanical lift that uses a sling attached to crossbars to raise and transfer the resident) provided by the nursing home administrator (NHA) on 7/3/18, revealed the use of mechanical lifts required two nursing staff at all times. And, prior to initiating a transfer using a mechanical lift, staff were to check the lift for function, ensure the safety catch was on, and ensure the slings were securely fastened to the lift. II. Resident #9 A. Resident status 1. Resident #9, age 61, was admitted to the facility on [DATE] and readmitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. 2. A minimum data set (MDS) assessment dated [DATE], demonstrated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 2 of 15. He required the extensive assistance of two or more people for bed mobility, and was fully dependent on two or more staff for transferring. He consumed food orally, but required an altered texture. He did not have any tubes for feeding. 3. Further record review revealed the resident had a dietary order dated 7/14/17 for a puree texture diet with thin liquids, a care plan dated 11/3/17 for Hoyer lift to transfer, and a care plan dated 11/6/17 (revised 2/4/18) for a history of breathing difficulty related to a prior [MEDICAL CONDITION], although the care plan did not indicate the use of respiratory equipment, such as a [MEDICAL CONDITION] or ventilator. B. Incident on 5/26/18 and resident decline 1. Facility record review A nursing note dated 5/26/18 (untimed) revealed the resident was found on the floor in his room. The resident was lying on his back at the base of a Hoyer sling lift with both of his legs bent under him. The lift was at the height of the bed, and three of the straps for the sling were attached to the lift. The strap that would have been under the resident's right shoulder was not attached to the lift. The resident was able to independently move his left arm and leg, and was able to move his right arm using his left arm (consistent with his baseline status). The facility initiated neurological checks and sent the resident to the emergency department for evaluation and treatment at 10:15 a.m. 2. Family interview A member of the resident's family was interviewed on 6/27/18 at 1:27 p.m She said her understanding of the incident on 5/26/18 was that certified nurse aide (CNA) #1 had initiated a transfer using a Hoyer lift by herself. She said the CNA had not attached the sling correctly and the resident had fallen out. She said the resident had been sent to the hospital following the fall and had been found to have a new injury to his brain. She said the resident remained hospitalized and now required a feeding tube for nutrition and a ventilator to breathe. She said he remained unable to safely return to a skilled nursing setting. 3. Hospital record review Hospital intake notes dated 5/26/18 revealed the resident was seen in the emergency department and was admitted to the neurological intensive care unit (NICU). Initial (CT) scans revealed the resident had a new area of bleeding to his brain. A hospital physician note dated 5/27/18 revealed the resident demonstrated increased bleeding. A [DIAGNOSES REDACTED]. A hospital speech therapy evaluation dated 5/27/18 revealed the resident was not able to safely consume food or fluid via oral intake. C. Facility investigation 1. A review of the facility's investigation of the incident completed 5/30/18 indicated the resident had been placed in the sling by CNA #1 for a transfer. The CNA had left the room and approached two other CNAs (CNA #2 and CNA #3) to ask for help. Both CNAs gave statements that when they had arrived in the room, the resident was already on the floor. CNA #3 reported that CNA #1 had asked her to say she also had been in the room helping. The CNA had told her she could not say that. CNA #1 acknowledged she had placed the resident in the Hoyer sling, and had attached the sling to the Hoyer lift, but had not done so correctly. She initially claimed she had left the room to find another CNA to help with the transfer and had not initiated the lift; however, at the conclusion of the investigation, she admitted to having transferred the resident by herself, stating I could do him by myself. 2. Staff interviews The nursing home administrator (NHA), assistant director of nursing (ADON) and corporate nurse consultant (CNC) were interviewed on 6/27/18 at approximately 12:00 p.m. (The DON was new to the facility and was not on staff at the time of the incident.) The NHA said the CNA had been transferring the resident from chair to bed, and he was not sure where she was in the process when the resident fell . The NHA said facility policy instructed that for resident safety, at least two staff were to be present during all parts of a transfer using a mechanical lift. He said that prior to initiating a transfer, the aides also were to double check the lift for safe function, including whether the sling was correctly hooked. He said CNA #1 had been trained in these procedures, including a training approximately a month ago. III. Facility actions following the 5/26/18 incident Following the facility investigation into Resident #9's fall, the facility initiated a performance improvement plan (PIP) to address concerns with the transfer. A. Individual correction Resident #9 did not return to the facility. No corrective action was available for him. However, CNA #1 was placed on suspension pending the investigation, and the facility ultimately terminated her employment. The NHA reported the incident to the state board of nursing, adult protection, and the police department for further investigation. This occurred on 5/30/18. B. Identification of others The facility audited the transfer assessments and care plans for all residents. They identified that any resident who used a mechanical lift to transfer was at risk. C. Systemic changes The facility initiated retraining on mechanical lifts for all CNA and nursing staff. The training was completed on 5/27/18. The facility documented the correct transfer method and number of staff required in each lift-dependent resident's care plan and Kardex. This was completed on 5/28/18. D. Monitoring The facility monitored all CNAs to ensure competence on lift transfers. Initial monitoring was completed by 5/30/18. The facility will continue to audit lift transfers quarterly and forward the results to the quality assurance committee. Two lift transfers were observed during the inspection on 6/30/18 at 7:48 p.m. and 9:06 p.m. Both transfers were done in a manner consistent with safe mechanical lift procedures.

Based on interviews, observation and record review, the facility failed to manage two (#11, #36) of six out of 30 sample residents' pain as ordered, as expected per the facility's policy, and as care planned. Specifically, the facility failed to: - Administer scheduled pain medications to resident #11 for three days which contributed to the resident experiencing a pain level that was well above her pain tolerance threshold and negatively impacted her quality of life. In addition, the facility failed to facilitate the resident's referral for a pain clinic consult. - Adequately manage resident #36's chronic pain as ordered, care planned and expected per facility policy. Findings include: I. Facility policies and procedures A. Pain management policy A copy of the Pain Management policy, revised on 2/18/16, was provided by the nursing home administrator (NHA) on 1/25/18 at 1:30 p.m. The policy read, in pertinent part, Pain was subjective and was what the resident said it was, existing when and where the resident said it did. - All residents will be evaluated for pain upon admission, readmission, and quarterly and with any change in significant change in condition. - The pain evaluation included the following: locations, quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. - When a resident complains of pain, ask the resident to rate the pain on a scale of 0 (no pain) to 10 (severe pain). - Considerations included: around the clock (ATC) dosing for continuous pain, whether the pain was chronic or acute, was the key to effective pain management. B. Medication administration policy A copy of the Medication Administration policy, developed on 9/30/13, was provided by the NHA on 1/25/18 at 1:30 p.m. The policy read, in pertinent part, Residents medications were administered in an accurate, safe, timely and sanitary manner. Medications were administered in accordance with written orders of the attending physician. II. Resident #11 A. Resident status Resident #11, age under 40, was admitted on [DATE] and readmitted [DATE] from the hospital after suffering from acute [MEDICAL CONDITION]. According to the January 2018 computerized physician orders [REDACTED]. According to the 11/1/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance for bed mobility, transfers and locomotion on the unit. The care plan, initiated 10/25/17 and revised 10/27/17, identified the resident was at risk for chronic pain due to [MEDICAL CONDITION]. Interventions included monitoring the resident's pain level and reporting to the physician if pain management interventions were unsuccessful, offer non-pharmacological interventions for pain prior to administering pain medications, and monitor pain level every shift. The 1/22/18 pain evaluation documented the resident's pain level was 8 out of 10 and her acceptable pain level was 3 out of 10. Interventions included medication and position change. The January 2018 medication administration records (MARs) reflected physician orders [REDACTED].>-[MEDICATION NAME] sulfate extended release 15 mg by mouth every 12 hours (twice a day) for chronic pain; -[MEDICATION NAME] sulfate immediate release 15 mg by mouth every 12 hours as needed for pain; and -[MEDICATION NAME] 20 mg by mouth four times a day for muscle spasms. A 12/16/17 order read the resident was to be seen in the pain clinic. A physician consultation form, dated 12/28/17, read the resident was to be seen by the pain clinic to treat pain. B. Resident interview Interviews with the resident revealed she was experiencing pain at a level well above her tolerance level that affected her quality of life. Interview further revealed ordered and expected interventions to address her pain had not been implemented, despite the resident reporting her pain to staff and her physician. 1. The resident was interviewed on 1/24/18 at 1:22 p.m. She said she had not been given her scheduled pain medication, which was [MEDICATION NAME] sulfate extended release 15 milligrams (mg) since she was readmitted to the facility on [DATE]. She said when she asked the nurse at least once a shift about her medication, the nurse told her the medication was on order from the pharmacy and it had not been delivered yet. - She said her pain level was exceeding her tolerance and she scored the pain level at 10 out of 10. She grimaced with every movement in the wheelchair. She apologized for not being able to turn her head to the side during the interview because she was in tremendous pain. - She said the staff had not offered non-pharmacological interventions while waiting for the pain medications to become available. She said she was not going to activities or doing her normal activities in her room because of how bad she hurt. She said she could not lift her arms to comb her hair. She guarded her left shoulder as she reached forward for the comb. She said the pain was affecting her relationship with her husband because they could not be intimate due to her high pain level. - She said she did not understand why the staff did not want to help her. 2. The resident was interviewed again on 1/25/18 at 12:23 p.m. She said she still had not received her scheduled pain medication. She said the nurse told her the medication was on order from the pharmacy and they were still waiting for it to be delivered. - She said it had been three days since she had received her scheduled pain medication. She said her pain level was 10 out of 10. She said again that the pain affected her relationship with her husband and daily routine activities. She said she could hardly stand sitting up in the wheelchair for longer than an hour at a time because of all the pain she was in around her shoulder, neck, back, and legs. - She said her skin hurt to touch because of the [MEDICAL CONDITION] to her bilateral upper and lower extremities. As she touched her skin, she grimaced and observations revealed pitting in her skin as she pressed fingerprints into her chest. She said it did not take much pressure on the skin to cause pain and the indentation of the skin. As she pressed on her left forearm, it left an indentation and she grimaced. She said she reported it to the doctor and the nurse but nothing had been done. - She said she spoke to the doctor soon after the first admission about the medications to control the [MEDICAL CONDITION] but nothing had been done. She said she spoke to the nurses daily about notifying the doctor to adjust the medications in order to decrease the [MEDICAL CONDITION] because she felt miserable and in pain. She thought injections might be helpful to abate some of the pain she experienced. - She said the physician had ordered she go to a pain clinic but that was a month ago on 12/16/17, and she had not been to the clinic yet. She said she had been reminding the nurse that she needed to go the pain clinic but nobody helped her to set-up the appointment. C. Observations and record review Observations revealed the resident's routine pain medication was unavailable 1/25/18 and record review confirmed the medications had not been administered since the resident's readmission 1/22/18. Record review further revealed no documentation regarding the 12/16/17 order for the resident to be seen at the pain clinic. 1. Observation On 1/25/18 at 11:45 a.m. registered nurse (RN) #4 was observed as she poured and administered the resident's morning medications several hours late. The medications did not include the resident's scheduled pain medications [MEDICATION NAME] sulfate extended release15 mg and [MEDICATION NAME] 20 mg. 2. Record review The January 2018 MARs reflected the physician order [REDACTED].>- [MEDICATION NAME] sulfate extended release 15 mg by mouth every 12 hours (twice a day) for chronic pain. It was not administered on 1/22/18, 1/23/18, 1/24/18 and 1/25/18. The reason given for not administering the medication was that medication was not available from the pharmacy. - [MEDICATION NAME] 20 mg by mouth four times a day for muscle spasms. It was not given on 1/25/18 in the morning because the nurse was late administering the medications. The January 2018 MARs also reflected the physician order [REDACTED]. It was administered once a day on 1/22/18, 1/23/18 and 1/24/18. The resident's average pain level was between 8 to 10 out of 10. The documentation did not include effectiveness of pain medication. An Incident Nursing Progress Note written on 1/25/18 at 2:41 p.m. during survey confirmed the resident's morning doses of [MEDICATION NAME] and [MEDICATION NAME] sulfate extended release were not administered to the resident. It read, The patient stated that she was always in pain even if she had her pain medication. Resident said her pain level was 10 out of 10. Record review revealed no documentation regarding the resident's pain clinic consult beyond the order dated 12/16/17 and the physician consultation form dated 12/28/17. D. Staff interviews Staff interviews revealed the resident's failure to receive her routine pain medication for three days was avoidable as was the delay in implementation of the order for a pain clinic consult. 1. Avoidable failure to administer routine pain medications a. RN #4 was interviewed on 1/25/18 at 11:48 p.m. She said the resident's pain medication had not been available on the unit since the resident's readmission on 1/22/18. She said another nurse had faxed the pain medication prescription to the pharmacy when the resident was admitted but it had not been delivered yet. She said the nurses were to call the pharmacy and the physician if the pain medications were not available to administer. She said she called the pharmacy and was told the medications would be delivered soon; they were waiting for the physician to approve the order. - She said she would be notifying the doctor the resident's medications had been administered late and that neither [MEDICATION NAME] nor [MEDICATION NAME] had been administered this morning. b. Licensed practical nurse (LPN) #2 was interviewed on 1/29/18 at 11:30 a.m. She said nurses were responsible for ensuring the medications were re-ordered from the pharmacy in a timely manner. She said when a resident was admitted to the facility, the physician orders [REDACTED]. The nurse was responsible for calling the pharmacy to ensure the orders were received. She said all nurses who worked with the resident were responsible for following up with the pharmacy to make sure the medications were delivered. - She said the resident should not have run out of medications. She said if the medications were not available, then the nurse would call the doctor to get an order for [REDACTED]. She said she called the pharmacy and was told the medication was being delivered shortly but pending the physician's approval. She said the pharmacy told her they were waiting for an authorization form the physician. She said she needed the authorization from the pharmacy to access the emergency pain medication supply. c. RN #1 was interviewed on 1/29/18 at 11:52 a.m. She said the nurses were responsible for ensuring medications were re-ordered from the pharmacy in a timely manner. She, too, said the resident should not run out of medications. She said she usually re-ordered medications three days prior to running out. - She said if the medication was not available from the pharmacy right away, then she would call the physician to get an order for [REDACTED]. She said she called the pharmacy but did not call the physician. She said the pharmacy told her they were waiting for the authorization from the physician in order to approve her access to the emergency supply. She said she did not call the physician. d. RN #2 was interviewed on 1/29/18 at 2:45 p.m. He said the pharmacy was delayed in filling the pain medication because they needed authorization from the physician. - He said the resident should had not been out of her medication because it was a scheduled. He said she was recently admitted so there would be no reason to be out of the scheduled pain medication this soon. He said the resident's pain was managed by giving the schedule [MEDICATION NAME] sulfate 15 mg. When the resident experience breakthrough pain, there was a physician's orders [REDACTED]. - He said he was aware the resident had a physician order [REDACTED]. e. The assistant director of nursing (ADON) was interviewed on 1/29/18 at 5:35 p.m. She said she was not aware the resident had not received her routinely scheduled [MEDICATION NAME] sulfate extended release for the past three days. She said the floor nurses working with the resident should have notified her or the director of nursing (DON) if the medication was not available. - She said the resident's pain was managed with pain medications as prescribed. She said if she or the DON had been aware the [MEDICATION NAME] sulfate extended release was not available, they would have gotten an order from the doctor to get the medication from the emergency supply. f. The ADON was interviewed again on 1/29/18 at 5:35 p.m. She said the unit manager cleaned the medication cart and removed the [MEDICATION NAME] sulfate extended release medication from the cart because the resident went to the hospital. After the resident was readmitted , the nurses should have asked the ADON and DON for the medication. She said the medication was locked up in the DON's office. g. The DON was interviewed on 1/29/18 at 6:00 p.m. She said she was not aware the resident had not received her ordered [MEDICATION NAME] sulfate extended release for three days. She said the nurses should have notified her. She said if she was aware, she would have called the doctor to get an order to obtain the [MEDICATION NAME] from the emergency supply. She said the failure to administer the medication for three days was concerning. 2. Avoidable delay in pain clinic consult The medical record coordinator was interviewed on 1/29/18 at 5:15 p.m. He said he was responsible for scheduling the appointments and arranging transportation for the residents. - He said the resident had an appointment scheduled for the pain clinic before she went to the hospital but did not believe it had been rescheduled since she was readmitted to the facility. He said it was his responsibility to reschedule but he said there was no system in place to notify him an appointment needed to be rescheduled. 2. The ADON was interviewed on 1/29/18 at 5:35 p.m. She said the physician order [REDACTED]. E. Facility follow-up On 1/29/18 at 5:45 p.m., during survey, the ADON and DON said they followed-up with the staff and the resident's pain clinic appointment was scheduled for 1/30/18. III. Resident #36 A. Resident Status Resident #36, below the age of 65, was admitted [DATE]. According to the January 2018 CPO, [DIAGNOSES REDACTED]. The 12/15/17 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with all of his activities of daily living (ADLs). He reported pain occasionally and received scheduled and PRN pain medications and non-medication interventions were provided. He reported his pain did not affect his sleep or day-to-day activities. B. Resident Interview and Observation The resident was interviewed on 1/24/18 at 9:00 a.m. He indicated his chronic pain was not being managed or relieved. He reported his history included a total knee replacement, compression fractures in his back and hardware in his leg due to a crushed femur bone. He said he has reported his concerns to the DON and has been told he was being referred to the pain clinic but he has not had an appointment yet. The resident was interviewed again on 1/25/18 at 3:23 p.m. He said he returned from the pain clinic and they were going to reinstate his pain medications. The resident was observed on multiple occasions during the survey. He did not appear to be in acute distress. C. Record Review Care Plan The pain care plan, revised 12/21/17, revealed the resident had acute and chronic pain related to compression fractures to the lumbar back, a history of left hip and femur repair with hardware and a left total knee replacement. The goal was his risk for interruptions in normal activities would be minimized. The interventions included: - Administer [MEDICATION NAME] per orders. - Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. - Notify the physician if interventions were unsuccessful or if current complaint is a significant change from the resident's past experience of pain. - Offer non-pharmacological interventions for pain prior to administering medication and PRN. Offer snack, drink, redirect to an activity, offer independent activity supplies, off to call a loved one, assist outside, sit with resident as needed, offer shower or a bath, active listening and validation, offer range of motion, massage, relaxation and breathing techniques, imagery and distractions techniques and repositioning. - The resident prefers to have pain controlled by medication. Pain Evaluation The 12/8/17 Pain Evaluation revealed the resident reported he did have pain and described the pain as aching, shooting and stabbing. He rated his pain at a 7 on a scale of 1 - 10 with 10 being the worst pain. He reported his acceptable level of pain was a 3. He reported his pain was relieved with medication and position changes. D. Pain Management Failures 1. December 2017 According to the December 2017 medication administration record (MAR) and nurses' notes on 12/9/18 and 12/10/18, the resident reported pain scale levels between 3 and 8. The documentation indicated the resident did not receive the physician ordered [MEDICATION NAME] 30 mg twice daily on either date because the medication had not been received from the pharmacy. Review of the nurses' notes failed to reveal the physician was notified of the delay in pain medication administration. Review of the December 2017 MAR and nurses' notes from 12/8/17 through 12/31/17 revealed the resident complained of pain greater than his acceptable level of 3, 44 times. According to the MAR, he received pain medication each time; however, 24 out of 44 times, he reported his follow up pain level was greater than his acceptable level of 3. Review of the nurses' notes failed to reveal non-pharmacological interventions were offered or attempted. The nurses' notes also failed to reveal the physician was contacted regarding his unrelieved pain. 2. January 2018 Review of the January 2018 MAR and nurses' notes from 1/1/18 through 1/24/18 revealed the resident reported a pain scale level greater than his acceptable level of 3, 43 times. According to the MAR, he received pain medications each time; however, 32 out of 43 times, he reported his follow up pain level was greater than his acceptable level of 3. Review of the nurses' notes failed to reveal non-pharmacological interventions were offered or attempted. The nurses' notes also failed to reveal the physician was contacted regarding his unrelieved pain. D. Staff Interviews LPN #2 was interviewed on 1/29/18 at 11:25 a.m. She said the resident always says his pain is 7-10. She said residents are assessed for their acceptable level of pain upon admission. She said the physician should be contacted if the resident's pain is not relieved through the use of non-medication interventions and pain medications. She said non-medication interventions used included relaxation and repositioning. She said if a pain medication is not received from the pharmacy, the nurse should contact the physician and report the alternative medications in the ekit and obtain an order until the pharmacy delivers the resident's ordered medication. The DON was interviewed on 1/29/18 at 11:30 p.m. She said the goal was to ensure all residents meet their acceptable levels of pain. She indicated there was some concern by the resident's physician regarding the use of opioids and it had been decided to send the resident to the pain clinic. She said nurses are expected to provide non-pharmacological interventions prior to the administration of pain medications. She said the physician should have been notified when the resident's pain was not reduced to his acceptable level. She said the process for sending residents to the pain clinic has been re-evaluated to ensure the residents receive adequate pain relief while waiting for the pain clinic to take over their care.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents. These failures affected three (#18, #44, and #21) of four out of 30 sample residents. Specifically: I. Record review and interviews revealed the facility failed to ensure residents were transferred safely. Resident #21 had a fall with injury 9/28/17 when she was transferred without a gait belt. In response, the facility conducted an in-service on gait belt use and resident transfers for all certified nurse aides (CNAs), verified all residents' transfer status and entered the residents' status into the facility's electronic care management system and the residents' kardex for CNA reference. Yet, on 11/7/17, Resident #21 was transferred in a manner contrary to her assessed transfer status. Following this transfer, she was diagnosed with [REDACTED]. Multiple interviews revealed residents' transfer status was not reliably communicated to all staff and staff were not adequately trained on transfer safety. Record review revealed Resident #44 was care planned to be transferred by Hoyer lift. On 9/28/17, the resident slid from her bed to the floor as the Hoyer sling was applied. II. Observations revealed an environmental hazard to Resident #18's safety. Findings include: I. Transfers A. Facility policies A copy of the facility policies Gait belts and Fall management were provided by the director of nursing (DON) on 1/29/18 at 3:15 p.m. The gait belt policy read in part that staff will receive education and training at time of hire on how to properly apply and utilize a gait belt. Gait belts were to be used when ambulating or transferring residents from bed to chair, chair to bed and chair to chair. The fall management policy read in part that individualized care plan interventions would be implemented for those residents found to be at high risk for falls, falls would be thoroughly analyzed (time of day, location of fall, causative factors) and direct care staff would be educated and informed of planned interventions. B. Individual Resident failure - Resident #21 transferred in a manner contrary to her assessed transfer status. 1. Resident #21, age 74, admitted to the facility on [DATE]. According to the January 2017 computerized physician orders [REDACTED]. According to 11/20/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behaviors were identified. The resident's care plan, initiated 8/11/17, identified activity of daily living (ADL) decline due to limited mobility and flaccid [MEDICAL CONDITION]. Review of therapy evaluations revealed the resident's transfer status had progressed from Hoyer lift (6/30 - 7/6/17), to slide board transfer (7/6/17), to assessment for stand pivot transfer (9/5/17). 2. Resident #21, interviewed on 1/23/18 at 4:40 p.m., said she had fallen in November, 2017 and broken several bones because of her [MEDICAL CONDITION]. She said the certified nurse aide (CNA) did not use the correct gait belt when she transferred her. She said she was transferring with the slide board and fell to her bottom. 3. Incident notes, facility investigations with facility interviews, and risk management reports revealed Resident #21 had three incidents during transfers on 9/28, 10/9 and 11/7/17. Two incidents were associated with fractures. a. Incident during transfer 9/28/17, associated with fracture. Incident notes dated 9/28/17 and 9/29/17 and a risk management report (internal facility investigation document) dated 9/28/18 at 4:00 p.m. revealed CNA #3 heard a pop to the resident's left shoulder when transferring the resident from her wheelchair to bed. The physician was notified, the resident was medicated for pain, an x-ray was obtained and the resident was sent to the emergency department. The final x-ray result was [MEDICAL CONDITION] humerus. The interdisciplinary team (IDT) review revealed the DON interviewed resident #21 and CNA #3 on 9/29/17 at 9:25 a.m. and 11:10 a.m. respectively. -Resident #21 reported she can complete stand pivot transfers in the morning but in the evening she transferred using a sit-to-stand lift or slide board. She said CNA #3 could not find batteries for the sit-to-stand and suggested they complete a stand pivot transfer. The resident said upon transferring, she felt something pop and had discomfort. -CNA #3 said she transferred the resident using a stand pivot transfer. She said she usually utilized a slide board or sit-to-stand lift to transfer the resident. She confirmed the resident's interview that there were no working batteries for the sit-to-stand lift. She said several residents had been asking for assistance and she felt she needed to rush. The 9/29/17 follow-up investigation revealed CNA #3 did not transfer the resident with a gait belt. In response to the 9/28/17 incident, the facility conducted an in-service training on 9/29/17 on gait belt use and proper transfers for residents. Gait belts were ordered for all CNAs. In addition, from 9/29/17 through 10/2/17, all residents transfer status was verified and entered into the facility's electronic care management system (point click care/PCC) and the residents' kardex for easy CNA reference. b. Incident during transfer 10/9/17 The 10/9/17 risk management report revealed the resident was being transferred from her wheelchair to bed utilizing slide board technique which, per care plan, was her transfer status. The resident stated her legs became weak and the CNA assisted her by lowering her to the floor. Physical therapy was to evaluate the resident for transfer safety. c. Incident during transfer 11/7/17, associated with fracture. The 11/7/17 risk management report revealed the resident was observed on the floor in a side lying position with a gait belt on; CNA #3 was present. The resident's bed was in appropriate position for transfer with the wheelchair parallel to bed at same height. The resident complained of pain to her left lower extremity. Per the CNA report the resident did not hit her head. The resident stated her legs were weak and she felt she needed to be lowered to the ground. The staff assisted the resident up using the Hoyer lift. The physician was notified. The 11/8/17 physician progress notes [REDACTED]. The 11/10 - 12/9/17 physical therapy evaluation revealed the resident was assessed after a transfer with injury and the resident was to transfer via Hoyer lift. The 11/15/17 IDT note read, The patient was sent to ortho(pedics) for follow up and was given brace. Suspected spontaneous fracture to be cause of her weakness. Therapy evaluated for change of transfers. Patient is now a Hoyer lift with standby of 2 staff. However, contrary to the 11/15/17 IDT note above, all of the therapy notes, physician notes and orthopedic notes indicated the resident's fracture was secondary to her fall during transfer from wheelchair to bed. 3. Facility failures a. Failure to take steps after 10/9/17, to minimize risk of another incident during transfer There was no evidence of a comprehensive analysis of the 10/9/17 incident as expected per facility policy (see above). There was no evidence of an IDT investigation and no evidence new safety interventions were considered and care planned. Although the resident was screened by therapy on 10/13/17, the screen revealed the resident required further assessment to determine transfer safety. However, no further assessments and recommendations from therapy on the resident's safety during transfer were found in the resident's record from 10/13/17 to 11/7/17. Per the resident's care plan, her transfer status remained via slide board. b. Failure of CNA #3 to transfer Resident #21 safely and as care planned. CNA #3 was interviewed on 1/24/18 at 3:24 p.m. She said she had worked for the facility for seven months. She said she had always worked on the south unit. She said she was the CNA who provided resident #21's transfers on 9/28/17 and 11/7/17. She said during the incident 11/7/17, she provided a stand pivot transfer. She said the wheelchair was next to the bed and was in a locked position and she had a gait belt on the resident. She said the bed was not locked and it moved when she went to assist the resident to bed. She said when she lifted the resident with the gait belt and had her maneuver to her right side, the resident's left leg got caught on the right wheel of the wheelchair. c. Failure to analyze the 11/7/17 incident Record review revealed no evidence the facility conducted a comprehensive investigation of the 11/7/17 incident and when a specific request was made for the investigation, none was provided. C. Systemic failures - Staff were not adequately trained on transfer safety and residents' transfer status was not reliably communicated to all staff. 1. Failure to adequately train staff on transfer safety a. Record review revealed that in addition to the unsafe transfer issues involving Resident #21 set forth above, Resident #44 was involved in a safety issue during transfer. Resident #44, age 71, was admitted [DATE]. [DIAGNOSES REDACTED]. She was care planned for ADL declines and interventions included the resident was to be transferred by Hoyer lift. A nursing note dated 9/28/17 revealed the resident was sitting on her bed being assisted to transfer with two-person total assistance using a Hoyer lift. The resident said her legs became weak and she slid and sat on the floor. A copy of their risk management form dated 9/28/17 revealed the assessing nurse provided education to the direct care givers to apply the Hoyer sling under the resident when she was lying down instead of when she was sitting up to prevent falls. Registered nurse (RN) #1 was interviewed on 1/25/18 at 3:04 p.m. She said she was the assessing nurse at the time resident #44 had her fall. She confirmed the resident's transfer status at the time of her fall was a Hoyer lift and that she had educated the CNAs involved on application of the Hoyer sling. b. Direct care staff and therapy staff interviews Although record review revealed actions were taken by the facility following Resident #21 and #44's transfer incidents to address safety, seven direct care staff interviews revealed the facility failed to ensure all staff received adequate training upon hire or annually. CNA #3, Resident #21's CNA during transfers on 9/28 and 11/7/17, was interviewed on 1/24/18 at 3:24 p.m. She said she had been educated on gait belt use after the incident 9/28/17, but had never received any specific training on transfer safety for Resident #21's transfers, such as using a slide board and or transferring toward her unaffected side. She said she also had never received any training on how to use the sit-to-stand or Hoyer lift. CNAs #5, #2, #1, and #4 were interviewed on 1/24/18 at 6:28 p.m. -CNA #5 said she had worked for the facility for six months. She said had not received any specialized training on transfers, but had education from nursing two months ago regarding gait belt use. - CNA #2 said she had worked for the facility for [AGE] years. She said she had received specialized training for a resident two to three months ago; however, could not recall the resident's name. She said she had not received any other transfer training. - CNA #1 said she had worked for the facility for [AGE] years. She said the only training she had received regarding transfers was for resident #42. - CNA #4 said she had worked for the facility for one month and she had not received any training regarding transfers or gait belt use. CNAs #7 and #10 were interviewed on 1/25/18 at 11:09 a.m. -CNA #7 said she had worked for the facility for three years as needed and always worked the south unit. She said she had not received any training regarding use of sit to stand or Hoyer lifts. She said two months prior she had received education on gait belt use. - CNA #10 said she worked for an agency. She said she had worked at the facility for one month on the south unit. She said two weeks ago she had received training from nursing on Hoyer lift use. The physical therapist was interviewed on 1/25/18 4:10 p.m. She said the therapists were on contract and did not provide any facility-wide education on transfers, or mechanical lifts. She said they often would provide education to the nursing staff during a therapy treatment; however, only that particular staff member would get the information. She said it was then expected the staff member working at that time would communicate information to the oncoming shifts. Restorative CNA #2 was interviewed on 1/29/18 at 11:44 a.m. She said she had been working at the facility for eight months and usually worked day shift. She said in November or the first of December she had received specialized training for gait belt use with transfers. She said prior to the recent training, she had not received any training on the sit-to-stand or Hoyer lift transfers. c. Administration interviews The DON was interviewed on 1/24/18 at 12:53 p.m. She said the staff development coordinator (SDC) had provided an in-service on 9/29/17 with gait belt use and transfer demonstration with the gait belt, as follow up to the Resident #21 and #44's falls on 9/28/17. The SDC was interviewed on 1/29/18 at 11:54 p.m. She said she had been working at the facility for four months. She said in late November 2017, she provided a transfer training in-service with CNA staff. -She said the in-service involved use of gait belts with transfers but did not include other safety issues such as locking the bed or wheelchair prior to transfers. She said the facility did not provide any training on transfer with sit-to-stand or Hoyer lifts with transfers. She said she was in the process of setting up an in-service training with those vendors to educate the licensed staff on proper use and safety. She said they had since added the training as a part of CNA orientation. - She said she did not know who was responsible for ensuring the licensed staff were current on competencies prior to working the floor. She said she was unable to provide any competencies other than gait belt use, influenza, perineal care, nurse to resident communication and hand hygiene. -She said she had contacted five staffing agencies that the facility used regularly, and requested education they had received on resident care. She said a couple agencies had responded back with written competencies and she needed to review them; however, other agencies said they relied on the CNA training and certification as competency. She said the facility used an internal program system to provide competencies and it would be available to the facility staff the following month. The DON was interviewed on 1/29/18 at 12:37 p.m. She said the facility's previous owner had one SDC and one infection control nurse to provide CNA training and education to three different facilities including their facility. She said the previous SDC was responsible for ensuring the CNA staff were trained on their competencies. 3. Failure to ensure resident transfer status was reliably communicated to all staff CNA #3, interviewed on 1/24/18 at 3:24 p.m., said she identified residents' transfer status by report from the off-going CNA. She said if she was unsure how a resident transferred, one option was to check the resident's care plan. However, she said she was unable to demonstrate how to access the care plan as she had never been shown how to access the care plan or the kardex. CNA #7, interviewed on 1/24/18 at 6:28 p.m., said she received the residents' transfer status in report from the off-going CNA. She said if she were not sure of the status, she could verify it with the nurse or she would check the resident's care plan. However, a few minutes later she said she did not know how to access the resident's care plan and kardex. CNA #10, interviewed on 1/25/18 at 11:09 a.m. said she did not know how to access a resident's transfer status from the resident's kardex. The physical therapist was interviewed on 1/25/18 4:10 p.m. She said a resident's transfer status was communicated to the nursing staff by word of mouth. -She said after a therapy evaluation or therapy screen was complete, the therapist would notify nursing verbally what the resident's transfer status was. She said the director of rehab attended the IDT morning meetings and that changes in resident transfer status were discussed in that meeting and occasionally, the therapist wrote a computerized physician order [REDACTED]. -She felt there could have been a better system to communicate a resident's transfer status, such as the use of a white board in the resident's room. She said when a resident had a change in their transfer status their care plan was updated; however, she felt the CNAs did not know how to access the information. 4. The nursing home administrator (NHA), corporate nurse consultant (CNC), and DON were interviewed on 1/25/18 at 3:18 p.m. The CNC said the facility identified concerns with falls on 9/29/17. -He said the facility had completed a full audit of residents transfer status, and the information was updated into PCC (internal electronic system). -He said the CNA staff knew how to access the kardex to obtain a resident's transfer status. He said during the in-service held on 9/29/17, the residents' transfer status was discussed and CNA staff were provided education of how to access the kardex, and how to use the sit-to-stand and Hoyer lifts; however, he was unable to provide documentation of education beyond gait belt use. The NHA said he felt that the facility had identified the breakdown in communication of identifying resident's transfer status, and follow up fall investigations and had since provided education and corrective action. D. Facility follow up 1. On 1/25/18 at 4:51 p.m., the NHA provided documentation of nurse aide training. He said moving forward, he planned to have all staff trained. The staff training included that CNAs will be able to identify the resident's transfer status utilizing the kardex, that staff would be trained on gait belt use, sit-to-stand lift, and Hoyer lift transfers and that staff would be trained on communication of resident decline. 2. The DON was interviewed on 1/29/18 at 12:57 p.m. She said moving forward, the SDC would monitor CNA competencies through the facility's internal electronic system. II. Environmental hazard Resident #18, age 88, was admitted on [DATE]. According to the January 2018 computerized physician orders [REDACTED]. According to the 11/9/17 minimum data set (MDS) assessment, the resident had short and long term memory impairments. He had severely impaired cognition and decision making capabilities. He was totally dependent on staff for transfers and bed mobility. A. Observations On 1/23/18 at 4:10 p.m., 1/24/18 at 10:00 a.m. and 1/29/18 at 11:03 a.m., the resident was observed lying in bed with a mat on the floor next to the bed. A high back wheelchair was placed on top of the mat and positioned against the head of the resident's bed. B. Record review A care plan dated 11/2/17 and updated 1/2/17 indicated the resident was at risk for falls due to unsteady gait, dementia and [MEDICAL CONDITION], and at risk for fractures related to [MEDICAL CONDITION] and vitamin D deficiency. Interventions included to anticipate and meet the resident's needs and to have a safety mat beside his bed at all times. C. Staff interviews CNA #11 was interviewed on 1/25/18 at 9:07 a.m. She said the fall mat was beside the resident's bed because he was at high risk to fall. She said whoever helped him to bed was responsible for putting the fall mat on the floor beside the bed. She said the staff member should ensure the mat was clear of clutter, including the wheelchair. CNA #2 was interviewed on 1/25/18 at 3:49 p.m. She said the resident had a fall mat on the side of his bed for safety. She said he used to fall out of bed by either rolling or crawling out. She said it was the responsibility of the CNAs to put the mat down and ensure the mat was clear of clutter, including the wheelchair. She said they had not received training on the placement of the fall mat or been told to make sure the wheelchair was clear of the mat, but CNAs should know that leaving the wheelchair on the mat might cause the resident to get hurt if he fell out of bed. LPN #2 was interviewed on 1/29/18 at 11:03 a.m. She observed the wheelchair sitting on top of the mat at the head end of the resident's bed was a safety risk. She said the resident was not able to get into his wheelchair himself but he used to try to crawl out of bed. -She said there should not be any tables or chairs on the mat so he would not hit the furniture if he tried to crawl or roll out of bed. She removed the wheelchair immediately. -She said the resident needed the fall mat, not to stop him from falling, but to prevent a bad injury or fracture if he did crawl out of bed. She said it had been a long time since he crawled out of bed but they still kept the mat there for his safety. - She said the SDC usually provided training to nurses and CNAs regarding safety devices in the facility. The SDC was interviewed on 1/29/18 11:18 a.m. She said the resident had not had a fall from his bed in a year but due to his history and circumstances, she thought it was necessary the mat remained at his bedside for safety. She said she usually trained staff on safety equipment, such as gait belts and mechanical lift transfers. She said she did not have specific training for the placement of fall mats; she said keeping the fall mats clear of objects was common sense. The DON was interviewed on 1/29/18 at 11:23 a.m. She said it was her expectation that fall mats were free from objects and all staff should know this. She said there was not a specific training on the placements of the fall mats because it was common knowledge the mats must be free of objects.

Based on observation, record review and resident and staff interviews, the facility failed to ensure three of 38 sample residents (#107, #28 and #8) received the care and services necessary to attain and/or maintain their highest practicable physical, mental and psychosocial level of well being. Cross reference F250 (medically-related social services) Specifically: -Resident #107, who was admitted to the facility with a known history of [MEDICAL CONDITIONS], personality disorder and depression, expressed and took steps to act upon suicidal thoughts through risk-taking behaviors. The facility failed to (1) initiate suicide precautions and evaluate the resident's lethality risk, (2) recognize, document and comprehensively respond to the resident's pattern of potentially self-harming behaviors and (3) communicate among caregivers (facility and agency staff) the resident's mental health history and risk-taking behaviors in order that staff could identify and coordinate responses in a manner that promoted the resident's mental, physical and psychosocial well-being and reduced her risk of self-harm. These facility's failures contributed to the resident's repeated expressions of suicidal thought and self-harmful actions which created a situation of immediate jeopardy for serious harm. -Resident #8's pain was not adequately assessed, monitored, and managed. Record review revealed two instances in July 2014 when resident #8 did not receive adequate pain management to reduce her chronic pain to a level below "severe/horrible" pain level of 7/10 based on the pain scale employed by the facility. -Resident #28's ordered treatments to address his leg wounds were not consistently implemented and the facility failed to timely assess and seek treatment for [REDACTED].#28's left leg. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy A review of resident #107's record revealed on 3/29/14, the resident attempted a suicidal gesture by parking her wheelchair in the street "to get hit by a car and die." On 4/15/14, the resident used a dinner plate to cut out her urinary catheter. On 5/25/14, the resident expressed [MEDICAL CONDITION] through pictures. Other risk taking behaviors by the resident included attempting to elope (5/25/14, 5/29/14 and 6/10/14), engaging in a resident to resident altercation (6/19/14) and refusing to re-enter the facility (for an indeterminant amount of time) late in the evening 7/9/14. The facility failed to address the resident's potentially self-harming behaviors in a manner to promote the resident's mental, physical and psychosocial well-being and to reduce her risk of self-harm. Specifically, the facility failed to initiate suicide precautions and evaluate the resident's lethality risk, recognize, document and comprehensively respond to the resident's pattern of potentially self-harming behaviors and communicate among caregivers (facility and agency staff) the resident's mental health history and risk-taking behaviors in order that staff could identify and coordinate responses in a manner that promoted the resident's mental, physical and psychosocial well-being and reduced her risk of self-harm. B. Imposition of Immediate Jeopardy On 7/15/14 at 3:20 p.m. the Nursing Home Administrator (NHA), the regional corporate vice president (RCVP) and corporate consultant (CC) were notified by the Health Facilities and Emergency Medical Service Division (HFEMSD) of the Colorado Department of Public Health and Environment that the facility's failure to provide care and services to address resident #107's repeated behaviors of self-harm, repeated expressions of suicidal ideation and repeated complaints of depression created a situation of Immediate Jeopardy for serious potential harm. An initial plan to abate the Immediate Jeopardy was presented by the facility at 5:58 p.m. on 7/15/14. This plan was determined to be incomplete and a second plan was presented at 6:57 p.m. by the RCVP and a CC. This plan read: "Plan to Remove Immediate Jeopardy The following is a plan of abatement for (the facility), dated 7/15/14 regarding alleged Immediate Jeopardy F-309 involving resident #107 and how the facility will safeguard the resident. Below is a summary of action items the facility has taken or will take to abate the Immediate Jeopardy: 1. Immediate Correction: Resident #107 is being sent out to the hospital for evaluation and admission for suicidal ideation. 2. Should the resident return, the resident will be assessed and offered a room change closer to the nurse's station and ensure there is adequate lighting in whatever room the resident resides in. Room (resident #107's current room), or other appropriate room, will be considered for a move should the resident return to the facility or other available and appropriate. (sic) If the resident returns, she will be admitted on 1:1 supervision for 72 hours and IDT (interdisciplinary team) will review at that time if she is appropriate to come off of the 1:1. - Resident #107 will be assessed at the hospital for mental health/[MEDICAL CONDITION], should she return, a referral to (city) Mental Health will be made for obtaining psych services outside of the facility. - Should the resident return, the NHA will attempt to identify a point of contact within the facility to act as a liaison and a person for the resident to trust to discuss concerns. - Should the resident return, a (named) consultant pharmacist and primary medical provider will conduct a medication review to ensure appropriateness. - Resident #107 will have a care plan developed that is specific to her history of suicidal ideation and her history of sexual assault related to [MEDICAL CONDITIONS] and in consideration of Foley catheter changes, and elopement risk 3. All residents with a history of suicidal ideation identified through an audit of the social services assessments, PASRRs (preadmission screening and resident review) and care plans will be assessed by nursing/social services for signs and symptoms of [MEDICAL CONDITION]. The audit will be completed by 7/16/14. Any identified residents will have their care plans reviewed and updated as needed. Staff will be educated to any specific and individualized needs related to resident [MEDICAL CONDITION] if needed. 4. The facility will be educated on: - The suicide precautions procedure - Initiation of the use of the Suicide Lethality Evaluation - The initiation of a safety plan - Notification to: the primary medical provider, any current mental health provider and social services. 5. All licensed clinical and social services staff available today 7/15/14 will be educated by the Nurse Practice Educator on the above. All nursing and social services staff unavailable on 7/15/14 will be educated regarding suicide lethality and managing suicidal ideation before being able to work on their next shift. Education will also include notification of [MEDICAL CONDITION] to the primary medical provider, any current mental health provider and social services for further evaluation. C. Removal of Immediate Jeopardy On 7/16/14 at 11:48 a.m., the NHA was informed that the Immediate Jeopardy had been lifted. Interview with the facility medical director and the NHA on 7/15/14 at revealed the resident had been transferred out of the facility to the hospital for evaluation of her suicidal thoughts at 7:00 p.m. on 7/15/14. However, based on review of the resident's medical record, resident and staff interviews and observations, deficient practice remained at a G level, actual harm that is isolated. II. Failure to Recognize and Respond to Resident #107's Mental, Physical, and Psychosocial Needs. A. Facility Policy A review of the facility suicide precautions policy (effective date 6/1/1996 and revised on 1/2/2014) read in part: - Evaluate all patients with actual/potential suicidal tendencies or who express a wish to die. - Immediately report behaviors to supervisor and attending physician. - Limit restrict mobility throughout the center - Remove all sharp items from the resident's room - Use disposable dinnerware and utensils The facility also utilized the corporation's form titled "Suicide Lethality Evaluation." -The form had a total of six bullet points. The points included: Taking the threat seriously, ask the resident for a specific plan, is the plan realistic or attainable. -If the above two questions are answered yes, then the threat is high. -The sixth bullet point read to ensure the resident's safety; encourage the resident to sit in a public area, place on 15 minute checks and inform charge nurse for appropriate medical interventions. B. Resident #107 Resident #107, age 56, was admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet dated 3/30/14 documented mental health admission [DIAGNOSES REDACTED]. 1. Resident Status According to the 5/14/14 quarterly Minimum Data Set (MDS), the resident had no cognitive deficits as evidenced by a score of 15/15 on the brief mental status testing. Section D - Mood documented that the resident felt down, depressed or hopeless, had little energy and felt bad about herself at least 7 to 11 days of the 14 day look back assessment period. Section E0200 indicated that the resident had not rejected cares and had displayed no behaviors. The computerized physician orders [REDACTED]. -[MEDICATION NAME] (antidepressant) 100 mg nightly - [MEDICAL CONDITION], start date 5/15/14; -[MEDICATION NAME] (anti-anxiety) 0.5 mg every 8 hours - as needed for anxiety, start date 5/15/14; -[MEDICATION NAME] (anti-psychotic) 150 mg daily - depressive order, start date 5/15/14. The resident had ancillary orders for a Foley catheter and/or straight urinary catherization (ordered 2/15/14 and again 5/23/14) every night shift by midnight. (A straight urinary catherization is the temporary insertion of a urinary catheter into the resident's urinary tract when a resident cannot urinate or to release residual urine. A Foley catheter remains in the urinary tract for an extended period of time). A review of the resident's elopement/wander evaluation form completed by facility nursing staff on 3/4/14, 3/27/14 and 4/1/14, indicated the resident was not at risk for elopement. 2. Preadmission Assessment Resident Review (PASRR) A review of the PASRR level 2 dated 9/10/13 and present in the resident's medical record, indicated that the resident had a primary [DIAGNOSES REDACTED]. (The resident also had a history of [REDACTED]. The PASRR indicated the resident needed mental health therapy sessions three times weekly. Another intervention documented in the level 2 indicated that the resident's therapist was to discuss the resident's progress with the facility. The section of the PASRR Level 2 titled 'behavior monitoring and management' had three interventions/recommendations regarding the ongoing cares the facility should implement in cares for the resident. These interventions included: - The first intervention was that the resident should be approached in a sensitive, comforting manner regarding her [MEDICAL CONDITION] perhaps by the facility social worker, to discuss triggers that can be avoided during cares by staff. In light of the resident's repeated sexual assaults the staff may want to utilize caution when providing hands on care. -The second intervention documented included assisting the resident in coordinating follow up appointments and transportation to all mental health appointments and providers. The resident was an open client with the county mental health center and the facility should assist in getting the resident to appointments with psychiatry. The document read "please see recommendations above" in mental health specialized services section. -The third and final intervention documented that if there was any concern about suicidal ideation the nursing facility would need to follow the facility protocol to maintain her safety per level of risk of safety assessment. Monitor and report any concerns to the psychiatric provider and the facility primary provider. review of the resident's medical record revealed [REDACTED]. Review of the resident's care plan on 7/15/14 revealed the resident was not care planned for depression or [MEDICAL CONDITION]. This included no instruction to staff on how the resident should be approached, what "triggers" could be avoided by staff during cares, as well as directions to staff to use caution when providing hands on care. (See PASRR recommendations above) However, the resident was care planned 1/7/14 (target date of 6/4/14) for suicidal ideation. -The care plan goal was that the resident would remain safe and free from suicidal ideation (SI) through the next review (6/4/14). -Interventions included: Encourage resident to meet with contract mental health counselors, initiate SI protocol when SI are made and notify PCP (primary care physician) and mental health counselors of any change in mood or behavior. No updates had been made to the suicidal ideation care plan since the original care plan date of 1/7/14 despite repeat expressions of suicidal ideation and risk-taking behavior (see below). 3. Resident Expressions of Suicidal Ideation and Risk-taking Behaviors - Facility response - Failures in Facility response Record review revealed the resident expressed suicidal ideation and exhibited risk-taking behaviors several times from 3/29/14 - 7/9/14. Record review, including change of condition forms, nursing progress notes (3/29/14 - 7/9/14), mental health notes (3/15/14 - 6/27/14), physician progress notes [REDACTED]. risk following her suicidal gestures and risk-taking behavior; (2) failed to recognize, document and comprehensively respond to the resident's pattern of potentially self-harming behaviors; and (3) failed to communicate among caregivers (facility and agency staff) the resident's mental health history and risk-taking behaviors in order that staff could identify and coordinate responses in a manner that promoted the resident's mental, physical and psychosocial well-being and reduced the resident's risk for self-harm. a. 3/29/14 On 3/29/14, the facility physician orders [REDACTED]." On 7/15/14 at approximately 9:40 a.m., interview with the resident revealed the resident parked her wheelchair in a road by the facility. She said, "I was going to get hit by a car and die." Review of nursing progress notes for 3/29/14 revealed: -No documentation of the resident verbalizing suicidal ideation to facility staff and physically acting on her suicidal threat by "parking her wheelchair in a road "in order to "get hit by a car and die." -No documentation that the resident's therapist was notified of the incident. -No documentation of a suicidal lethality assessment as expected per facility policy and the resident's PASRR. -No review/revision of the resident's suicidal ideation care plan to alert staff of the resident's risk-taking behavior. Review of social service progress notes revealed no note on 3/29/14 about the resident's suicidal ideation and risk-taking behavior. A late entry was made on 4/14/14, 16 days after the 3/29/14 incident; it read the resident was sent to the hospital after being found in the street with [MEDICAL CONDITION], the mental health suicide hotline number was provided to the resident." Review of mental health progress notes by the LSW revealed no documentation from mental health services regarding the resident's statements on 3/29/14 of suicidal ideation and her plan "to get hit by a car and die." The most contemporaneous documentation found in the mental health notes was dated 4/4/14. It read that the resident would benefit immensely from learning self soothing techniques while at the facility. Review of the medical provider progress notes revealed no notes regarding the events on 3/29/14. The next provider visit was 4/2/14 and it did not reference the resident's suicidal ideation and plan on 3/29/14. b. 4/15/14 On 4/15/14 a facility change of condition form was initiated by staff nurse #25 at 10:15 p.m. The documentation indicated that the reason for the change of condition was "resident cut urinary catheter out with broken glass." Review of nursing progress notes revealed: -A note dated 4/15/14 at 8:30 p.m., authored by facility nurse #26, documenting the resident stated she found a broken plate in the dining room and cut her catheter out of her vaginal area using the broken plate. Half of the plate had been located and the other half was not found. The other half of the urinary catheter was removed by staff nurse #26 and all pieces of the urinary catheter were recovered. The progress note on the change of condition indicated the medical doctor had been notified of the incident and the resident's behavior at 10:15 p.m. There was no documentation mental health was notified. -A review of the nursing notes dated 4/15/14 at 9:30 p.m. following the 8:30 p.m. note, documented the resident had requested a pair of scissors from staff nurse #25. The nurse replied to the resident "no you cannot cut it out." The night nurse went to speak with resident. -A review of the nursing notes dated 4/16/14 at 6:00 a.m. documented by staff nurse #26 read that the resident had used pieces of a plate to cut her urinary catheter and removed the catheter herself. The nurse documented that she had found two pieces of catheter on the floor in her room. None of the nursing notes above revealed documentation of an assessment of the resident for physical or mental trauma as a result of the actions she had taken, no documentation of increased supervision of the resident following the incident, no documentation of steps to ensure sharp objects were removed from the resident and her room, no documentation mental health was notified or assessed the resident's status, and no documentation of suicidal lethality questioning. Review of the resident's care plan revealed no revisions to alert staff of the resident's behavior or to guide staff in addressing her cares. Review of social service notes revealed no notes regarding the 4/15/14 events and no discussion with the resident whether the catheter or other cares triggered [MEDICAL CONDITION] symptoms as recommended in the resident's PASRR (see above). However, a social service assessment completed on 5/14/14 indicated the resident had no major emotional changes within the last quarter, notwithstanding the events on 3/29 and 4/15/14. Review of mental health notes by the LSW revealed the resident was seen on 4/25/14, ten days after she had cut her urinary catheter out with a facility dinner plate. The mental health worker did not document anything about the resident's behavior on 4/15/14 with her catheter. Review of the medical provider progress notes dated 4/16/14 revealed documentation the resident had a fall on (4/15/14) and pulled her Foley (catheter) out. There was no reference to how the catheter had been removed or reference to the resident's mental and psychosocial state. c. 5/25/14 On 5/25/14 the facility form change of condition was initiated by staff nurse #25 at 3:45 a.m. The documentation indicated that the reason for the change of condition was "suicidal ideation." Review of nursing notes attached to the change of condition form and authored by facility nurse #28, indicated that the resident had been found by staff at the nurses' station, crying. The resident had drawn multiple pictures and some included drawings of the resident killing herself with pills. There were numerous degrading and negative statements related to the resident's emotions. The entire packet of pictures and writings was four pages in length. Observation of the pictures drawn by the resident (located in the medical record) revealed the resident depicted graphic pictures of herself being sexually assaulted as a child, being harassed because of body image, and killing herself with her medications. -Review of nursing notes on 5/25/14 at 1:00 p.m., indicated the resident had suicidal issues this shift and will continue to monitor the resident. This notation was made 10 hours after the resident was found at the nurses' station with the pictures. -The next entry in the nursing notes was made at 9:00 p.m. It read the resident remained on 1:1 supervision 'for behavior.' The progress note further indicated the resident had attempted to elope from the facility once when supervision staff was on their lunch break. -None of the nursing notes documented an assessment of the resident's suicide risk or ongoing assessment of her mental health status. Review of the resident's care plan revealed no review/revision of the resident's suicidal ideation care plan about the resident's drawings, her distress at the nurses' station or how to assist the resident, as well as keep her safe from self-harm. Review of social service notes revealed no documentation was available in the resident's medical record under the tab social services to reflect the events of the resident's plan of suicide on 5/25/14. An entry made on 5/27/14 by the social worker discussed a missing notebook resident #107 was accused of taking. There was no reference to the resident's mental and psychosocial status or attempt to elope. Review of physician orders [REDACTED]. However, a nursing progress note dated 5/25/14 at 11:00 p.m., indicated that the facility provider requested the resident's 1:1 supervision be discontinued as it was unnecessary. Review of mental health notes revealed the next note was dated 6/6/14 with no reference to the drawings on 5/25/14 depicting suicide by pills or to the resident's elopement attempt. Review of the medical provider progress notes 5/29/14 read, "resident followed up for supposed suicidal ideation. Patient stated that she drew the pictures because staff would not listen to her. Resident was keeping to herself to avoid interaction with others." d. Additional risk-taking behaviors (1) 5/29/14 A review of the nursing progress notes dated 5/29/14 at 9:30 p.m., revealed the resident attempted to elope from the facility. -No documentation was found in the progress notes that the resident's repeated elopement attempt (see note above on 5/25/14) was reported to her mental health counselor, the facility social service department or her medical provider. Review of mental health notes 6/6/14 revealed no reference to the resident's elopement attempts. (2) 6/10/14 Review of the nursing progress notes dated 6/10/14 timed 2-10 shift and authored by staff nurse #25, documented the resident attempted again to elope from the facility. The progress notes indicated that social services department was notified. Review of social service notes revealed on 6/10/14 the social service associate (SSA) spoke with resident after the resident attempted to elope. There was no documentation of a discussion, including why the resident eloped and how to address the need exhibited by the elopement. Review of mental health notes revealed documentation 6/13/14 three days after the resident's second elopement attempt. There was no documentation addressing the elopement. Review of the most contemporaneous medical provider progress note was dated 6/16/14 six days after the resident attempted to elope from the facility. There was no documentation addressing the elopement. Further review of the resident's record revealed no reassessment of the resident's elopement risk after her third elopement attempt, even though she had previously not been assessed to be at risk for elopement. There was no evidence in the resident's record that this behavior, repeated and per prior assessments new, was discussed by the facility interdisciplinary team or with the resident's mental health worker. (3) 6/19/14 Review of the nursing progress notes dated 6/19/14 indicated the resident was involved in a verbal confrontation with another resident. The residents were separated and the house supervisor was notified of the incident. There was no indication the facility informed the resident's therapist of the incident although this, like the resident's elopements, represented a new behavior. On the same date at approximately 10:00 p.m., the resident was documented by nurse #25 to be outside of the facility, unsupervised and refusing to come inside. The resident was brought inside by the night nurse and the resident was upset and unwilling to talk. Review of the most contemporaneous mental health notes were dated 6/27/14 and documented the resident's mood seemed positive. The plan was to continue treatment three times monthly to stabilize and process feelings. There was no documentation about the resident's elopements or verbal altercation with another facility resident. Review of the medical provider progress notes dated 6/19/14 documented that the resident continued to have ongoing psych issues. (4) 7/9/14 Review of nursing notes dated 7/9/14 and timed at 9:50 p.m., revealed the resident was refusing to come inside to take medications and unwilling to talk to nurses and was withdrawn. Resident continued to sit outside of the north side door and the night shift nurse was aware. -The next entry in the nursing progress notes was made at 2:00 p.m., the next day on 7/10/14. There was no documentation to show whether or how frequently the resident was monitored by the facility night nursing staff and when the resident may have re-entered the building. Review of the medical provider progress notes dated 7/10/14 revealed the resident reported to the provider that she had felt depressed over the weekend (7/9 and 7/10/14). The resident stated that she was picked on specifically on the weekends. 4. Staff and Provider Interviews a. The Director of Nursing (DON) was interviewed on 7/15/14 at approximately 10:30 a.m. The interview revealed: -She was responsible for staff education and problem solving for the nursing staff. She said the last training she held about a resident being depressed and who to report it to was in January 2014. She further stated that the last time she was educated about what to do if a resident reported self harm was January 2014 when she reviewed the policies. - The facility protocol for a resident who is depressed and or expresses [MEDICAL CONDITION] is to make sure the resident is immediately safe, notify family physician (and) anyone who could be involved, limit risk, 1:1 supervision, sending out to evaluation, removing sharps and anything potentially harmful. The DON stated that no facility residents were on a specialized behavior program (PASRR Level 2 recommendations) from a nursing standpoint. The DON said the facility has mental health counselors who come in and work with different clients and after they see a resident they put a note in the residents' charts. The DON said social services would be tracking the documentation to see if there needs to be any adjustments and with the residents plan of care or medications. b. The facility Nursing Home Administrator, regional consultant, vice president of operations, social worker and director of nursing (DON) were interviewed on 7/15/14 at approximately 3:20 p.m. -They confirmed there had never been any suicide lethality assessments done when, as set forth above, the resident verbalized and took steps to carry out [MEDICAL CONDITION]. -They acknowledged, after three requests for documentation, that the facility was not monitoring the resident's behaviors relating to suicidal ideation, elopement, or altercation to evaluate frequency, intensity, or effectiveness of interventions. c. The facility's social worker and two contract social workers (CSS#1) and interim social service assistant (CSS #2) were interviewed on 7/15/14 at 11:30 a.m. and approximately 2:30 p.m. and 7/21/14 at approximately 2:00 p.m. Review of all the resident's social service progress notes from 9/13/13 until 6/11/14 (the last entry made by the facility social service department) revealed no documentation of any communication with the agency overseeing PASRR evaluations regarding the resident's multiple suicide attempts, facility elopements and behaviors in the resident ' s medical record. Interview with the social service staff revealed the facility had been without a social service director since 9/2013. CSS #1 had been hired to help the social worker with whatever needed to be done. -The social worker said the social service department is responsible for providing mental health care by making sure there is follow up on any recommendations on the PASRR. -The social worker said that she had been trained to respond to a resident who expresses self- harm and to report it to the house supervisor and the resident ' s mental health contact and also ask the resident if they had a plan. If the resident states that they will kill themselves, she would try to build trust with the resident. -The social worker said it is the role of everyone in the facility to monitor and evaluate if a resident is having a bad day and how bad it is and what to do about it. The social worker said social service staffs monitor residents' physical, mental and psychosocial status by reviewing significant change of condition forms. Once a significant change form is observed, the care plan is updated. -The social worker said if a resident is displaying behavioral symptoms and depression, she would go by and say hi, especially in the dining room when residents are all there, in one place. -The social worker said she was not currently aware of any resident on a specialized behavior program (PASRR Level 2 recommendations) or any residents that have active suicide ideations or plans. -CSS #1 said resident #107 has a [DIAGNOSES REDACTED]. CSS #1 said she has told the resident staff can't sit with her all the time the way she would like them to. "We can't always hold the resident's hands the way the resident wants us to." -CSS #1 confirmed there had been no ongoing depression screens done after the resident's [MEDICAL CONDITION], elopements, and verbal altercation with another resident. -CSS #1 said the mental health worker had not sent the resident's quarterly assessment to the facility; therefore, it was not available to facility staff for follow up on recommendations. d. The resident's contract mental health LSW (NSW #1) responsible for overseeing the resident ' s mental health progress provided at the facility, was interviewed on 7/16/14 at approximately 10:00 a.m. The mental health provider, who worked with the resident's therapist, said she knew the resident well. She said she did not receive information that the resident had been having straight catheterizations preformed nightly by the facility nursing staff. She stated that if the facility would have passed this information on to the resident's therapist, the therapist could have better understood the resident's responses around vaginal issues during her therapy sessions. The mental health provider was unaware the resident had cut her catheter out with a facility dinner plate. She stated that the facility had not communicated this event to the mental health therapist that worked with the resident. She stated that the information would have been helpful in addressing the resident's [MEDICAL CONDITION] and sexual abuse issues. The mental health provider said the resident could successfully carry out her suicidal plans whether it was purposeful or not, and the facility should evalu

Based on record review and interviews with staff and resident, the facility failed to provide medically-related social services to attain and maintain the highest practicable mental and psychosocial well-being for one of 38 sample residents (#107). Cross reference F309. Specifically: Resident #107 was admitted to the facility with a known history of post traumatic stress disorder (PTSD), personality disorder and depression. The facility social service department failed to ensure a comprehensive psychological assessment was completed on admission, failed to follow state Level 2 Preadmission Screen and Resident Review (PASRR) recommendations, and failed to promote communication with mental health providers about the resident's mental and psychosocial status to promote the resident's mental and psychosocial well-being. These failures contributed to repeated suicidal expressions and gestures by resident #107 and to the resident feeling 'dumb, stupid, bad and worse.' Findings include: Resident #107, age 56, was admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet dated 3/30/14 documented mental health admission [DIAGNOSES REDACTED]. 1. Resident Status Review of the 5/14/14 quarterly Minimum Data Set (MDS), revealed the resident had no cognitive deficits as evidenced by a score of 15/15 on the brief mental status testing. Section D - Mood, documented the resident felt down, depressed or hopeless, had little energy and felt bad about herself at least 7 to 11 days of the 14 day look back assessment period. Section E0200 indicated that the resident had not rejected cares and had displayed no behaviors. The computerized physician orders [REDACTED]. -Elavil (antidepressant) 100 mg nightly - neuropathy, start date 5/15/14; -Ativan (anti-anxiety) 0.5 mg every 8 hours - as needed for anxiety, start date 5/15/14; -Seroquel (anti-psychotic) 150 mg daily - depressive order, start date 5/15/14. review of the resident's medical record revealed [REDACTED]. 2. Psychological history and suicidal ideation and high risk behaviors after readmission. a. 3/29/14 A review of the resident's record revealed that on 3/29/14, the facility physician ordered the resident sent to the emergency room to evaluate the "resident wanting to kill herself by sitting in the street." b. 4/15/14 A review of the resident's medical record dated 4/15/14 indicated that a facility change of condition form was initiated by staff nurse #25 at 10:15 p.m. The documentation indicated that the reason for the change of condition was "resident cut urinary catheter out with broken glass." (The resident had ancillary orders for a Foley catheter and/or straight urinary catherization (ordered 2/15/14 and again 5/23/14) every night shift by midnight.) c. 5/25/14 A review of a 5/25/15 facility change of condition form was initiated by staff nurse #25 at 3:45 a.m. It documented the reason for the change of condition was "suicidal ideation." -Review of nursing notes attached to the change of condition indicated the resident had been found by staff at the nurses' station, crying. The resident had drawn multiple pictures and some included drawings of the resident killing herself with pills. The entire packet of pictures and writings was four pages in length. -Observation of the pictures drawn by the resident (located in the medical record) revealed the resident depicted graphic pictures of herself being sexually assaulted as a child, being harassed because of body image and killing herself with her medications. Later that same day, the resident attempted to elope from the facility. d. 5/29/14 A review of the nursing progress notes dated 5/29/14 at 9:30 p.m., revealed the resident attempted to elope from the facility. e. 6/10/14 Review of the nursing progress notes dated 6/10/14 timed 2-10 shift and authored by staff nurse #25, documented the resident attempted again to elope from the facility. f. 6/19/14 A review of the nursing progress notes dated 6/19/14 indicated the resident was involved in a verbal confrontation with another resident. On the same date at approximately 10:00 p.m., the resident was documented by nurse #25 to be outside of the facility, unsupervised and refusing to come inside. The resident was brought inside by the night nurse and the resident was upset and unwilling to talk. g. 7/9/14 A review of nursing notes dated 7/9/14 and timed at 9:50 p.m., revealed the resident was refusing to come inside to take medications and unwilling to talk to nurses and was withdrawn. Resident continued to sit outside of the north side door and the night shift nurse was aware. 3. Failure to provide resident #107 the medically-related social services necessary to attain and maintain her highest practicable mental and psychosocial level of well-being. a. Failure to ensure a comprehensive psychological assessment was completed that identified social and psychological needs and strengths and included appropriate social service interventions upon admission. (1) Admission assessment A review of the social service document titled, 'Social services History/Admission Assessment,' (undated) revealed the document was authored by the previous social worker who has not been employed at the facility since 9/2013. This document was incomplete as it was missing pertinent assessment information, including in the sections of mental status and social/lifestyle. The social /lifestyle assessment indicated the resident had been previously residing in motels and the resident found the living situation stressful. The section of mental health documented that the resident was alert and oriented. The information above was the only documentation made by the facility social worker in the section pertinent to the resident's mental health even though the resident was admitted to the facility from the hospital where a level one PASRR for mental health had determined that the resident had a major mental illness of major depression and PTSD and would need mental interventions while residing at the facility. (2) First suicidal expression after admission A further review of the social service progress notes dated 9/13/13 at 1:00 p.m., less than three hours after admission, indicated that the resident contacted the social service department the day of her admission to the facility regarding suicidal ideations. -The progress note indicated that the resident wanted to return to the hospital because she missed her nurse. The note further stated the resident wanted to hurt herself. The resident would not share information with the social worker related to whether or not the resident had a plan with her verbalized suicidal ideations. -The social worker documented that the resident was tearful and wanted to "return home even though the resident did not have a home." The social worker documented that she left a message for the resident's mental health worker and there was no response at this time. -There was no documentation present in the resident's medical record that the resident was further interviewed by the social service staff to assess the resident's mental and psychosocial needs in order for the development of a comprehensive care plan to meet these needs and to direct staff in promoting the resident's psychosocial well-being. b. Failure to follow state PASRR level 2 recommendations (1) PASRR recommendations -A review of the PASRR Level 2 dated 9/10/13 and present in the resident's medical record, indicated that the resident had a primary [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. -A review of the PASRR Level 2 dated 9/10/13, indicated that the resident needed weekly mental health therapy sessions. Another intervention documented in the Level 2 indicated that the resident's therapist was to discuss the resident's progress with the facility. -A section of the PASRR Level 2 dated 9/10/13 titled 'Behavior Monitoring and Management,' had three interventions/recommendations regarding the ongoing cares that the facility should implement in cares for the resident. The first intervention was the resident should be approached in a sensitive comforting manner regarding her PTSD perhaps by the facility social worker, to discuss triggers that can be avoided during cares by staff. In light of the resident's repeated sexual assaults the staff may want to utilize caution when providing hands on care. The second intervention documented included assisting the resident in coordinating follow up appointments and transportation to all mental health appointments and providers. The resident was an open client with the county mental health center and the facility should assist in getting the resident to appointments with psychiatry. The document read "please see recommendations above in mental health specialized services section." The third intervention documented that if there was any concern about suicidal ideation the nursing facility would need to follow the facility protocol to maintain her safety per level of risk of safety assessment. Monitor and report any concerns to the psychiatric provider and the facility primary provider. (2) Failure to implement PASSR recommendations (a) Care planning Review of the resident's care plan on 7/15/14 revealed the resident was not care planned for depression or PTSD. This included no instruction to staff on how the resident should be approached, what "triggers" could be avoided by staff during cares, as well as directions to staff to use caution when providing hands on care. The resident was care planned 1/7/14 (target date of 6/4/14) for suicidal ideation that included the following interventions: Encourage resident to meet with contract mental health counselors, initiate suicidal ideation protocol when suicidal ideations are made and notify PCP (primary care physician) and mental health counselors of any change in mood or behavior. However, no updates had been made to the suicidal ideation care plan since the original care plan date of 1/7/14 despite repeat expressions of suicidal ideation and risk-taking behavior (see above). Moreover, when the resident began attempting to elope, there was no evidence a care plan was developed with the interdisciplinary team to address this risk-taking behavior. (b) Suicide protocol Review of the resident's change of condition forms, nursing progress notes (3/29/14 - 7/9/14), mental health notes (3/15/14 - 6/27/14), physician progress notes [REDACTED]. Facility protocol directed staff to take a resident's threat of self harm seriously, evaluate the threat, and ensure the resident's safety. (c) Social service support A review of social service notes from 9/13/13 until 6/11/14 (final social service entry as of survey exit 7/21/14) revealed the facility social services department failed to provide timely and effective social services to resident #107 when she expressed suicidal thoughts and exhibited risk-taking behaviors. -Review of social service progress notes revealed no note on 3/29/14 about the "resident wanting to kill herself by sitting in the street." A late entry was made on 4/14/14, 16 days after the 3/29/14 incident. It read that the resident was sent to the hospital after being found in the street with suicidal ideations, "the mental health suicide hotline number was provided to the resident." -Review of social service notes revealed no notes regarding the 4/15/14 events ("resident cut urinary catheter out with broken glass)" and no discussion with the resident whether the catheter or other cares triggered PTSD symptoms as recommended in the resident's PASRR (see above). Moreover, a social service assessment completed on 5/14/14 indicated the resident had no major emotional changes within the last quarter, notwithstanding the events on 3/29 and 4/15/14. -Review of social service notes revealed no documentation was available in the resident's medical record under the tab 'social services' to reflect the events of the resident's plan of suicide on 5/25/14 which included drawings depicting abuse and suicide by pills, followed by an elopement attempt. An entry made on 5/27/14 by the social worker discussed a missing notebook resident #107 was accused of taking. There was no reference to the resident's mental and psychosocial status or attempt to elope. -Review of social service notes revealed on 6/10/14 the social service associate (SSA) spoke with resident after the resident attempted to elope on 6/10/14. There was no documentation of a discussion, including why the resident eloped and how to address the need exhibited by the elopement. (d) Communication with mental health providers and state PASRR agency. A further review of all the resident's social service progress notes made by the facility social service department (9/13/13 - 6/11/14) indicated no documentation of any communication with the state agency responsible for PASRR evaluations regarding the resident's suicidal ideations and risk-taking behaviors. A review of mental health notes in and around the time of the resident's suicidal expression and risk taking behavior 3/29, 4/15, 5/25, 5/29, 6/10, 6/19 and 7/9/14 completed by the licensed social worker (LSW) failed to reflect the incidents detailed in the change of condition forms, nursing notes, and physician orders [REDACTED]. -Review of mental health progress notes by the LSW revealed no documentation from mental health services regarding the resident's statements on 3/29/14 of suicidal ideation and her plan "to get hit by a car and die." The most contemporaneous documentation found in the mental health notes was dated 4/4/14. It read that the resident would benefit immensely from learning self soothing techniques while at the facility. -Review of mental health notes by the LSW revealed the resident was seen on 4/25/14, ten days after she had cut her urinary catheter out with a facility dinner plate. The mental health worker did not document anything about the resident's behavior on 4/15/14 with her catheter. -Review of mental health notes revealed the next note was dated 6/6/14 with no reference to the drawings on 5/25/14 depicting suicide by pills or to the resident's elopement attempt. -Review of the most contemporaneous mental health notes following the resident's altercation with another resident and refusal to re-enter the facility on 6/19/14 were dated 6/27/14 and documented the resident's mood seemed positive. The plan was to continue treatment three times monthly to stabilize and process feelings. There was no documentation about the resident's elopements or verbal altercation with another facility resident. -Review of mental health notes further revealed no reference to the resident's elopement attempts 5/25, 5/29 and 6/10/14 and altercation with another resident 6/19/14. The resident's contract mental health LSW responsible for overseeing the resident's mental health progress provided at the facility, was interviewed on 7/16/14 at approximately 10:00 a.m. Her interview revealed: -She said she did not receive information that the resident had been having straight catheterizations preformed nightly by the facility nursing staff. She stated that if the facility would have passed this information on to the resident's therapist, the therapist could have better understood the resident's responses around vaginal issues during her therapy sessions. -She was unaware the resident had cut her catheter out with a facility dinner plate. She stated that the facility had not communicated this event to the mental health therapist that worked with the resident. She stated that the information would have been helpful in addressing the resident's PTSD and sexual abuse issues. -She stated the resident could successfully carry out her suicidal plans whether it was purposeful or not, and the facility should evaluate her lethality risk every time the resident makes suicidal statements and the information should be relayed to mental health that the resident is having a hard time. 4. Resident Interviews Resident #107 initially was interviewed on 7/15/14, beginning at 9:40 a.m. in her room. The interview revealed: -When she sits outside, the resident said she thinks a lot about how the road could meet heaven. She said she had tried to sit in traffic before and kill herself but nobody at the facility took her seriously; they don't think she will actually kill herself. She said her "favorite thing to do" is to sit outside looking at traffic. -Staff knew her history of sexual abuse but they didn't care when it came to the catheters and PTSD. -She doesn't trust anyone at the facility; they don't have time to listen to her and tell her to find something to do. The facility staff informs her she starts all the fights even though no one even talks to her. She said she goes away and sits by herself because no one will listen. -She wished she had not shared the pictures she drew (see 5/25/14 above) because nobody cares and everyone now knows how she feels. She feels dumb, stupid, bad and worse. -Staff make her roommate's bed nearly every day and then they leave the room and never come back and make hers. She said, "I feel like I am not even worth them making my bed. I have so much pain and it hurts badly." She said staff doesn't like to take care of her because she is obese. 5. Staff interviews a. The facility's two contract social workers (CSS #1) and interim social service assistant (CSS #2) and the facility social worker were interviewed on 7/15/14 at 11:30 a.m. approximately 2:30 p.m. and 7/21/14 at approximately 2:00 p.m. The interviews revealed: -Interview with the social service staff revealed the facility had been without a social service director since 9/2013. CSS #1 had been hired to help the social worker with whatever needed to be done. -The contract staff CSS #1 was here to help out with the reviews of all the facility's PASSRs. They are without a social service director (SSD) and needed help to catch up with the things that have gotten behind since the SSD quit. -CSS #1 said that upon her review of residents at the facility, she had found resident #107's information and submitted some paperwork to the state agency in charge of PASRR evaluations because the resident was no longer classified under major depression and had been switched to general depression. She said no paperwork had been submitted for awhile. -The social worker said the social service department is responsible for providing mental health care by making sure there is follow up on any recommendations on the PASRR. -The social worker said she was not currently aware of any resident on a specialized behavior program (PASRR Level 2 recommendations) or any residents that have active suicide ideations or plans. -CSS #2 indicated that the facility with limited staff and no social service staff monitor residents' progress and improvements including physical, mental and psychosocial functioning by using the change of condition form. However, once she sees a change of condition form, she updates the care plans for the change. -CSS #1 said resident #107 has a [DIAGNOSES REDACTED]. CSS #1 said she has told the resident staff can't sit with her all the time the way she would like them to. "We can't always hold the resident's hands the way the resident wants us to." -CSS #1 confirmed there had been no ongoing depression screens done for resident #107 after the resident's suicidal ideations, elopements, and verbal altercation with another resident. -CSS #1 said the mental health worker had not sent the resident's quarterly assessment to the facility; therefore, it was not available to facility staff for follow up on recommendations. b. The facility Nursing Home Administrator, regional consultant, vice president of operations, social worker and director of nursing (DON) were interviewed on 7/15/14 at approximately 3:20 p.m. -They confirmed there had never been any suicide lethality assessments done when, as set forth above, the resident verbalized and took steps to carry out suicidal ideations. -They acknowledged after three requests for documentation, that the facility was not monitoring the resident's behaviors relating to suicidal ideation, elopement, or altercation to evaluate frequency, intensity, or effectiveness of interventions. 6. Cross-reference F309 for further details on the resident's suicidal expressions and risk-taking behaviors and the facility's failure to comprehensively respond to address the resident's mental and psychosocial needs.

Based on record review and staff interviews, the facility failed to provide necessary care and services for three of 12 sample residents (#1, #2, #3) to attain their highest practicable well-being. Specifically, 1. The facility failed to follow advance directive wishes established by residents #1 and #2. Resident #1 expired on [DATE]. Resident #2 expired on [DATE]. 2. The facility failed to assess hospice residents #2 and #3 for effectiveness when prn (as needed) medications were administered at end of life. The findings include: I. References: a. Advance Directives On [DATE], Center for Clinical Standards and Quality/Survey and Certification Group issued directives regarding Cardio [MEDICAL CONDITION] Resuscitation standards in a nursing home (S and C ,[DATE]-NH), "a resident of a skilled nursing facility or nursing facility has the "right to a dignified existence" and "Self determination" including the right to formulate an advance directive..the services provided by the facility "must meet professional standards of quality and that the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of the resident." Initiation of CPR - prior to the arrival of emergency medical services, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] in accordance with that resident's advance directives." b. Assessments, end of life and pain: According to the 4th edition of Mosby's Foundations of Nursing, p. 73, "The American Nurse Association defines assessment as a 'systemic, dynamic process by which the nurse, through interaction with the patient, collects and analyzes data about the patient. The nurse gathers information to identify the condition of the patient's health. Assessments are made on first contact with a patient and continuously throughout patient care.." According to the 4th edition of Mosby's Foundations of Nursing, p.1019, hospice/end of life care, "..The nurse's role is to focus on the effectiveness of the plan to ensure that the symptoms are being well controlled. The nurse must constantly assess and reassess the pain and symptoms to ensure that they are being managed." 1. Closed record review of sample resident #1, [AGE] years old, showed a re-admission date of [DATE]. The resident was admitted from the hospital after a [MEDICAL CONDITION] episode and had a history of [REDACTED]. Past medical history also included hypertension, DM, [MEDICAL CONDITIONS], aspiration pneumonia and failure to thrive. A feeding tube was placed. The resident was admitted for rehabilitation and therapy. Review of the Colorado medical Orders for scope of treatment (MOST), [DATE] indicated the resident requested 'YES' CPR. This instructed staff to attempt resuscitation. The MOST form was signed by the resident's Power of Attorney (POA). A [DATE] CPR care plan identified the resident desired CPR. Staff was directed to notify family if CPR was initated, verify absence of apical pulse, respirations, and/or blood pressure, initiate CPR, Call 911 and notify physician. On [DATE], there was a physician's orders [REDACTED]. Pt. does not want to return to hospital." On [DATE], the PA (physician's assistant) assessed the resident and noted the resident appeared to be failing. The family had denied hospice services. The resident did not wish to return to the hospital. There were no changes to the advance directives, he remained a Full COR. On [DATE] at 6:15 p.m., a nurse documented, "resident alert and oriented (times) x1. Complained of no pain or discomfort. Resident had no residual. Received 360 cc oral intake, 250 cc water bolus, 370 ml via [DEVICE] and 300 cc urine output from Foley. Urine clear, yellow and no blood. Resident lethargic but responding to verbal commands. VS ,[DATE], 17, 67, 98.8 and 98%." [DATE] --The resident was found without vital signs on [DATE] by his Licensed Practical Nurse for that evening/night shift. The LPN failed to initiate CPR, request a timely RN assessment (see interview below with RN that the LPN was looking around for something at the nursing station before alerting her of the resident's status), or call 911 for emergency support. The resident expired in the facility on [DATE]. On [DATE] at 7:00 a.m., the nurse documented, "VS ,[DATE] (blood pressure), 100' (temperature), 71 (pulse) and 18 (respirations). Oxygen saturations 91%. AAOx1, name only. Resident slept comfortably throughout the night. XL loose BM x1. [DEVICE] patent. Positive BS (bowel sounds) x4 quadrants), abd. Soft, NT, ND. Water given bolus as scheduled. T. 99.2 at 1:00 a.m., Resident quiet. Speaks when spoken to. PO intake - 100 cc - output = 450 cc. Denies pain or discomfort. [DEVICE] site c (clean)/dry. Scabbed over areas noted. Foley cath patent. Urine flow clear and yellow." There was no indication of what assessments or treatments occurred with the elevated temperature. No prn (as needed) Tylenol was administered for fever (as indicated on the night shift of [DATE] with temperature of 100 and 99.2 - MAR blank). There was an order for [REDACTED]. The next note, dated [DATE] at 2310 (should be [DATE] at 11:10 p.m.), "When I went in to resident's room at 7:40 p.m. to check the tube feeding machine I set it up about 30 minutes ago was working/running right or not, resident was found unresponsive and checked heart beat (pulse) wasn't present. Body was cold. There was no s/s (sign/symptom) of life. I called the Supervisor RN nurse at 7:41 p.m. and the nurse checked breathing and pulse. The RN called the Dr. and Dr. pronounced death at 7:43 p.m. Right after death was pronounced, catheter and [DEVICE] was taken off the body and family notified and body was cleaned. Called office of the coroner and faxed a form to use and faxed it back." Per the occurrence report filed with the health department on [DATE], the following events occurred on [DATE] (summary): LPN (licensed practical nurse) The LPN set up the tube feeding for the resident around 6:15 p.m. He then covered his dining room shift around 6:35 p.m. After dinner, he took his 30 minute break. After break, he went to check on the machine to make sure it was working, around 7:30 - 7:40 p.m. The machine was running, mouth of resident open. The resident was cold, checked pulse and no signs of life. The LPN responded at this state (cold and without pulse), it would be too late to start CPR. The LPN claimed CPR would be started when you see a resident become non-responsive. The nurse did not call STAT response. The nurse stated he called for the RN. The LPN was aware of the resident's COR status. The nurse was not sure if he told the RN the resident was a full COR. RN (registered nurse) At approximately 7:30 p.m., the RN stated she was working and talking with residents on her hall. She noted the LPN at the nursing station looking for something. When asked, the LPN stated he thought the resident had passed and was looking for a thermometer. The RN asked if the pulse was checked and he responded yes he checked but there was no pulse. The LPN had asked her to check the resident's status. She verified there was no pulse and the skin was cold to touch. The RN called the physician for a pronouncement of death. The RN stated the LPN did not say the resident was a full code. There was no nursing documentation of the RN's assessment. Both nurses were suspended pending the investigation. The LPN was terminated for not following the facility policy to initiate CPR. Facility response after [DATE]: Immediate re-education was started on [DATE] regarding the policy in following advance directives, checking advance directives, calling 911, obtaining the crash cart, and transferring care to EMS upon arrival. Education continued on subsequent days to ensure all staff was retrained. A mock drill was conducted with facility staff on [DATE] and is ongoing. Facility staff was tested on their understanding of a 'code response.' The facility conducted a full house audit of current residents to ensure advance directive information was in place. The facility continues to audit new admissions for advance directive information, MOST forms in place and signed, orders reflect advance directive wishes, care plan in place and face sheet (reviewed current audit tool on [DATE] at 10:02 a.m.). 2. On [DATE], the facility reported another occurrence regarding facility staff not following a resident's wishes for CPR. This occurred on [DATE], prior to the [DATE] event above. Sample resident #2, [AGE] years old, was admitted to the facility on [DATE]. According to the admission face sheet, the medical [DIAGNOSES REDACTED]. Review of the MOST form, dated [DATE], indicated the resident wanted CPR. The resident was admitted to hospice services on [DATE] due to [MEDICAL CONDITION]. The [DATE] physician's orders [REDACTED]. The [DATE] CPR care plan identified the resident desired CPR. The goal was to initiate CPR with the absence of no pulse, no blood pressure and/or no respirations. Staff was directed to call 911, initiate CPR, notify physician and verify the absence of apical pulse, and/or blood pressure. The [DATE] hospice care plan directed staff to evaluate for pain and medicate as ordered. The [DATE] pain care plan directed staff to administer pain medication as per physician's orders [REDACTED]. The resident had a witnessed fall out of the wheelchair on [DATE]. X-rays were negative for a fracture. Pain level was ,[DATE]. [DATE] On [DATE] at 6:50 a.m. (the last nursing assessment prior to death the next morning), the nurse documented, "97.6, 24, 100, ,[DATE]. Resident monitored for IFU (injury follow up). Res. had no complaints of pain or discomfort on night shift." This note was written by the night nurse ,[DATE] - ,[DATE]. There were no other assessments until the resident's expiration the next day at 8:29 a.m. Review of the March medication administration records (MARs) indicated the resident received prn (as needed) [MEDICATION NAME] .25 ml for pain at 3:30 a.m. and 9:00 a.m. There was no corresponding assessment by nursing in the nursing notes or MAR indicated [REDACTED] Staff was directed to monitor for pain every shift ([DATE]). On [DATE], the day shift assessment was blank. The evening shift documented zero pain and the night shift assessment was blank. [DATE] The resident was found without vital signs at 8:29 a.m. on [DATE] per nursing documentation on [DATE] at 8:57 a.m. There was no indication CPR was initiated according to the resident's advance directives. On [DATE] at 8:30 a.m., the nurse documented there were no signs of life at 8:29 a.m., No apical pulse, No blood pressure, No respirations. Physician notified. Hospice notified. Hospice was in to pronounce death. The advance directives were not followed. 3. Sample resident #3, [AGE] years old, was admitted to the facility on [DATE]. The resident was admitted under hospice care secondary to [MEDICAL CONDITION] with mets to lung and bone. The advance directives noted to withhold CPR. According to the [DATE] pain care plan, staff was directed to monitor pain, administer pain medications as ordered and note the effectiveness, document/report complaints and non-verbal signs of pain. [DATE] On [DATE] at 3:00 p.m., the nurse documented, "VS 96.4, P 101, R 24 BP ,[DATE], O2 92% on room air, lung sounds decreased, increase difficulty swallowing, Pt to eval, decrease intake, decrease output. Family with all day. C/O BLE (complained of bilateral lower extremity) disc (discomfort) PRN [MEDICATION NAME] at 10:45 schedule [MEDICATION NAME] given." [DATE] Although there were no assessments or nursing notes on [DATE], review of the April MARS revealed nursing administered the following prn medications without a corresponding assessment prior to administration or afterwards for effectiveness: On [DATE], staff administered [MEDICATION NAME] ([MEDICATION NAME] - antipsychotic medication ordered for restlessness) 1.0 ml (milliliter) at 1:00 a.m. and 10 p.m. There was no corresponding assessment. On [DATE], staff administered an [MEDICATION NAME] suppository at 1:00 a.m. The physician ordered this medication prn for temperatures over 101. There was no corresponding assessment. On [DATE], staff administered prn10 mg SL [MEDICATION NAME] (used for pain levels of ,[DATE]) at 1:00 a.m., 10:00 a.m., 2:00 p.m. and 9:20 p.m. There was no corresponding assessment. [DATE] The next entry, written on [DATE] at 9:30 a.m., "Hospice RN here - 99.4 - 103 - 18, 91% RA ,[DATE] eyes fixated, no verbal response, shallow breathing, medicated with SL at 0800." The next entry, written on [DATE] at 10:40 p.m., "At this time resident was non-responsive, no pulse or BP showed. Hospice company informed. RN manager arrived and processed. Pt. last breath noted at 10:40 p.m., MD pronounced at 11:45 p.m. Coroner notified via fax. Body released at 11:50 p.m." Interviews: On [DATE] at 3:38 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated nurses were retrained to always check the MOST form for advance directive information. The facility continues to conduct drills to ensure staff understanding. This was a very unfortunate event and the staff member no longer works here. -At 4:25 p.m., the NHA stated the nurse (for resident #1) did not follow the facility policy regarding advance directives and resident wishes. On [DATE] at 11:40 a.m., the NHA stated the facility has been in-servicing staff since the last survey regarding MOST forms and following resident wishes (last survey was in [DATE]). The LPN had attended those in-services. The NHA shared staff was in-serviced on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 8:22 a.m., the DON stated that with end of life, nursing would look at the whole resident, repositioning, comfort, oral cares and incontinent cares. She would expect charting by exception and for staff to chart any changes, liked increased discomfort. Staff should be assessing for effectiveness with prn medications and make notes in the MAR indicated [REDACTED]. With resident #2, the aide had discovered the resident had passed and got the nurse. The nurse stated she did not check the COR status as the patient was hospice and thought all hospice patients were a DNR. The nurse resigned. Staff was instructed to always check the MOST forms, even if they were on hospice.

Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that one of 50 sample residents (#119), received adequate supervision and assistive devices to prevent accidents. Specifically, the resident, known to have many fall risk factors (including recent hip fracture and surgery), fell in the bathroom while unsupervised. After a previous fall in this location, it had been determined the resident needed continuous monitoring while in the bathroom. Post-fall, the resident underwent [REDACTED]. The findings include: Resident #119, (closed record), age 80, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of aftercare for healing traumatic hip fracture, [DIAGNOSES REDACTED], abnormal gait, lack of coordination, dysphagia, cerebrovascular disease, [DIAGNOSES REDACTED], and kidney disorder. The 7/21/11 admission minimum data set (MDS) assessment documented the resident was able to make herself understood and understands others. She was independent with daily decision-making. The resident did not exhibit any behavioral symptoms. -The resident had unsteady balance and used a wheelchair for locomotion. She required extensive assistance by two staff members with transfers and toilet use and required extensive assistance by one staff member with bed mobility, locomotion, dressing, and personal hygiene. -The resident was occasionally incontinent of bowel and bladder. -The resident had a history of [REDACTED]. -The resident had frequent pain that limited her daily activities. She rated her pain as seven on a scale of one to ten. 2. Record Review a. Fall Risk The 7/14/11 admission nursing assessment documented the resident was unable to ambulate, used a wheelchair for locomotion, and required a two-person assist with transfers. She had a history of [REDACTED]. The 7/14/11 fall risk assessment documented the resident had fallen in the last 30 days, experienced a change in mobility, required assistance with transfers and ambulation, was incontinent, had recent changes in her medication, was experiencing pain, and used medications that could affect orthostatic blood pressure changes. The 7/14/11 device evaluation documented the resident was dependent for mobility, was dependent with transfers, had a recent left hip fracture, had impaired balance, and had fallen in the last 30 days. There were no interventions documented as attempted for fall prevention. The assessment documented, "No device indicated at this time." The 7/23/11 fall risk assessment documented the resident had fallen in the last 30 days, had experienced a change in mobility, required assistance with transfers and ambulation, was incontinent, wore glasses, and used medications that could affect her orthostatic blood pressure. b. Falls -7/22/11 - fall from wheelchair A 7/22/11 change of condition form documented the resident was found seated on the floor on her buttocks with a bump on her forehead. The resident had stood from her wheelchair independently. The resident's physician and responsible party were notified. The intervention implemented to prevent further falls was reminding the resident to use her call light. -7/25/11 - fall from bed A 7/25/11 change of condition form documented the resident was found on the floor seated on her buttocks. She had attempted to get out of bed independently. The resident was reminded to use her call light. The resident's physician and responsible party were notified at 7:00 a.m. on 7/25/11. A 7/25/11 interdisciplinary progress note documented the resident was reviewed during fall committee and the facility would "use safety devices (and) recommendations as needed." The nurse practitioner was evaluating the resident for interventions, "such as pressure pad for bed." A 7/25/11 interdisciplinary fall review documented the resident was encouraged to place items within close reach on her bedside table and was evaluated for and provided with a pressure alarm to her bed. A 7/25/11 physician's orders [REDACTED]. -7/28/11 - fall in bathroom A 7/28/11 change of condition form documented the resident was found on the floor in the bathroom. She had attempted to transfer independently from the toilet to the wheelchair. The resident required assistance by two staff members with transfers and continuous monitoring in the bathroom. The resident's physician and responsible party were notified. The intervention implemented to prevent further falls in the bathroom was reminding the resident to use her call light to request help. -8/12/11 - fall from wheelchair -An 8/12/11 change of condition form documented the resident was found lying on the floor in her room. She stated she was reaching for her call light and fell out of the wheelchair. The resident complained of pain to her left hip and x-rays were ordered. The x-ray was negative for fracture. The resident's physician and responsible party were notified. The interventions the facility implemented to prevent further falls from her wheelchair were moving the call light and reminding the resident to use it. Though this was the second fall the resident experienced out of her wheelchair, there were no new interventions implemented to prevent more falls from the wheelchair. -8/13/11 - fall in bathroom An 8/13/11 change of condition form documented the resident was heard screaming for help and was found on her back in the bathroom. The resident had attempted to stand from the toilet independently. The resident's husband was near her. The resident was counseled to use her call light at all times. The form documented a note, written 8/14/11, which read that the resident did not complain of pain or discomfort but was non-weight bearing on her left hip. Another note written on 8/14/11 at 9:00 p.m. documented the resident was unable to bear weight on her left hip and she was not able to move her left hip when in bed. There was no further documentation of assessment of the resident's left hip for possible injury. The intervention implemented to prevent further falls was reminding the resident to use her call light. An 8/16/11 nurse's note documented the resident went to a scheduled orthopedic appointment and was immediately admitted to the hospital for surgery to the left hip. The 8/16/11 hospital history and physical report documented the resident was admitted with "failure with the implanted hardware ...Her husband reports that she did sustain a fall about 4 days ago." The 8/21/11 hospital discharge summary documented the resident's hip pin was removed and a bipolar hip prosthesis was placed. An 8/23/11 nurse's note documented, "Resident readmitted from hospital on [DATE] after going to her (orthopedic appointment) and (physician) has stated a failure in her hardware to hip was shown to have gone through bone. Surgery was done and resident currently has a 24 (centimeter) long incision to (left) hip (with) 33 staples. Site is healing well. Resident also returned from hospital (with) a stage II pressure sore to the inside (right) leg (knee) ..." The facility's 8/26/11 re-admission MDS assessment documented the resident had frequent pain that made it hard for her to sleep and limited her daily activities. She rated her pain a nine on a scale of one to ten, indicating an increase in the resident's pain following the left hip injury and subsequent surgery. c. Failures: (1) Cross-reference F309; staff failed to adequately assess the resident's status following her fall in the bathroom 8/13/11. (2) Failure to provide adequate supervision and assistive devices for safety See above change of condition form 8/13/11; the resident was "found" in the bathroom on her back, following an attempt to stand independently. According to this documentation, the resident was not being supervised as directed on the 7/28/11 change of condition form. Further, review of the resident 8/5/11 care plan addressing the resident's risk for falls identified impaired balance, poor coordination, unstable health condition, unsteady gait, pain, history of multiple falls, generalized weakness, and decreased safety awareness. The approaches included: -keep commonly used articles within reach, -provide non-slip footwear, -remove all objects near the bed that could cause injury, -reinforce the need to use the call light to request assistance with transfers or ambulation, -place the call light within easy reach of the resident, and -"educate the resident on safety risks." The care plan did not address the need (as documented in the 7/28/11 change of condition form, above) to provide continuous monitoring of the resident while in the bathroom. Moreover, the care plan did not address the pressure alarm ordered 7/25/11, or include interventions for wheelchair safety. 3. Staff Interview On 10/12/11 at 1:30 p.m., the director of nursing (DON) stated the fall interventions implemented included a bed alarm on 7/25/11, and reminding the resident to use her call light to request help. She stated the facility did not have a specific policy on supervising residents in the bathroom who were at risk for falls, but the fall would be reviewed and interventions put in place to keep the resident safe while in the bathroom. The DON stated she did not know whether the fall in the bathroom on 7/28/11 was reviewed and interventions developed. The DON stated there were no further interventions implemented to prevent falls from the wheelchair or in the bathroom.

Based on record review and staff interviews, the facility failed to ensure one (#6) of seven sample residents received adequate supervision and assistive devices to prevent accidents. Specifically: Resident #6 was admitted to the facility following right (R) ankle surgery. On admission, the facility failed to clarify physician orders [REDACTED]. Resident #6 was transferred to the bathroom with the assistance of a licensed practical nurse (LPN), placing weight on her R foot. This contributed to "disruption" of the open reduction internal fixation (ORIF) surgical procedure, prompting transfer to the hospital and additional surgery. The findings include: Resident #6's closed record and hospital records were reviewed between 1/17/11 through 1/18/11. 1. Resident #6, [AGE] years old, was admitted to the facility from the hospital on [DATE], after a right (R) ankle open reduction internal fixation (ORIF) surgical procedure was performed at the hospital on [DATE]. The resident's medical [DIAGNOSES REDACTED]. Review of Hospital Discharge Physician Summary, dated 11/5/10, read in pertinent part, "DISCHARGE (primary) Diagnoses: [REDACTED]. . XXX[AGE] year-old female . . .sustained a right ankle fracture and underwent a open reduction and internal fixation for this fracture on October 31, 2010 ...without complications. The patient's postoperative course was unremarkable ...The patient is being discharged to a skilled facility for ongoing medical management 24-hour nursing care, as well physical therapy and occupational therapy following postsurgical course that has left the patient deconditioned and debilitated secondary to her ankle fracture ...The patient was seen by Orthopedics on the day of discharge and was deemed stable for discharge." 2. Facility Failures on Admission a. Failure to clarify safety precautions and transfer assistance needs. Review of Hospital Physician Discharge Orders, which were written on 11/2/10, read in pertinent part: "Primary Diagnosis: [REDACTED]." The discharge orders indicated elevation of the right leg. Review of the resident's chart revealed Physician admission orders Non-weight bearing." Under the section of "Other Treatments," only "Elevate legs" was transcribed. Review of the nurses' notes, written by the licensed practical nurse (LPN) for 11/5/10 (see further details below), read that the resident's medications were verified by the facility physician at 4:00 p.m. (1600) on 11/5/10, when per the note, the physician arrived. -There was no documentation that showed the physician assessed the resident's status and post-operative safety precautions. -There was no indication that the LPN sought clarification of the resident's weight bearing status, even though the physician was in the building 11/5/10. In an interview on 1/18/11 at 4:30 p.m., the Director of Nurses (DON) stated the resident's physician was out of the country and thus unavailable for an interview. b. Failure to complete an initial assessment of the resident's safety precautions and transfer assistance needs. (1) Record Review Review of nurses' notes for 11/5/10, revealed no initial assessment of the resident's medical condition or identification of transfer needs. Specifically: -Review of the nurses' notes for 11/5/10, written by the LPN on 11/5/10, revealed the notes were untimed and failed to identify when the resident was admitted . The note read, in pertinent part, that the resident was picked up from the hospital by facility staff and transported to the facility by the facility van. Interview with the van driver on 1/18/11 at 4:30 p.m. revealed the driver did not remember picking up resident #6, stating she picks up a lot of residents daily and doesn't keep track. In an interview with the LPN on 01/18/11 at 12:00 p.m., she said she was unsure about the resident's time of arrival. -Further review of the untimed nurses' notes for 11/5/10 revealed the notes read, in part: "Resident was admitted today from (Hospital name). She arrived via facility van in a w/c (wheelchair) accompanied by a staff member (facility staff). Resident has a dx (diagnosis) of blindness ...R ankle Fx r/t (related to) fall. Resident is A&O (alert and oriented) X3. She is on diabetic (medications), regular texture diet. She uses O2 (oxygen) at 2 L (2 liters via nasal cannula). . .She has a splint and ace bandage on R foot." There was no documentation of a nursing assessment of the resident's condition on admission, and no discussion of safety precautions and transfer needs, including whether the resident was to bear weight on her recent, surgically repaired R ankle. (2) Staff Interviews Interviews with both the RN and LPN indicated that neither the LPN nor RN performed timely initial assessment for the resident. The LPN who was responsible for the nurses' notes written on 11/5/10 was interviewed on 1/18/11 at 12:00 p.m. in the presence of the DON. The LPN said she did not admit or assess the resident on admission. She further stated the Registered Nurse (RN) admitted and assessed resident #6 after the resident arrived at the facility. The RN supervisor on duty 11/5/10 was interviewed on 1/18/11 at 4:00 p.m. in the presence of the DON. -The RN stated, "I did not do the admission (resident's admission) ...I cannot remember anything about (resident #6), I was not the primary nurse, the (LPN) was the primary nurse ...I was just verifying medication orders and putting them in the computer." The RN stated that he did not do the initial assessment for that resident. -The RN stated that on (11/5/10), he came in between 3-4 p.m., and that he was notified in report that there was a new admission (resident #6). -The RN stated, "I do not remember details but I verified her medications ...I did not do an assessment ...I do not remember the time she came in and I did not document on (resident #6)." On 1/18/11 at 4:30 p.m., the Director of Nurses (DON) was asked for clarification of the facility's admission process. The DON stated, "On admission, the nurse should do a quick head to toe assessment ...check the dressing ...assess the basic needs ...I did not see any limitations as far as transferring the resident (resident #6)." After the surveyor requested that the DON review the hospital physician discharge orders, the DON stated, "I see non-weight bearing now." The DON acknowledged that nursing staff failed to assess the resident's needs shortly after arrival. The DON acknowledged that there were no nurses' notes that indicated the time of arrival or medical condition of the resident's R ankle dressing. The DON stated that (resident #6) must have been at the facility by 4:00 p.m., because the physician came in and wrote orders. In this interview, the DON stated that the physician was unavailable for interview as she was out of the country. 3. Transfer with front wheel walker. a. Family Interview Although attempts to reach the resident were unsuccessful, the resident's daughter reported the resident, assessed as alert and oriented on admission by the LPN (see above), shared information with her daughter regarding her stay at the facility. On 1/18/11 at 11:30 a.m., the resident's daughter was interviewed. -According to the resident, after she was brought to the facility, the resident told a nurse that she needed to use the bathroom and that she needed help with the transfer. -According to the resident, the nurse tried to help the resident to stand up and the resident could not do it. The nurse (LPN) wheeled the resident to the bathroom and told the resident to get up and use the bathroom. However, the toilet and the wheelchair were not at the same level and the resident did not have enough strength to transfer from the wheelchair to the toilet. -According to the resident, the nurse (LPN) told the resident that she (LPN) would try holding her (resident #6) and try to help resident #6 to get up from the wheelchair; resident #6 was to turn around and sit onto the toilet. -According to the resident, the daughter stated, "At this time she was not able to hold herself up; she (resident #6) was trying to stretch out on the bars. She could not grab onto the bars ...she ended up putting pressure on that right foot ...she was supposed to be NWB (non-weight bear) . . .(Resident #6) had to put weight on it (right lower extremity), the (LPN) was not able to hold (resident #6) up ...when she put pressure on that R foot, she dropped onto to the toilet real hard, not on the ground." -According to the resident, the daughter stated, "(Resident #6) used the bathroom . . . The (LPN) then helped her up with the use of a walker (front wheeled walker) to the wheelchair, then wheeled (resident #6) out of the bathroom." The resident's daughter further stated, "When my brother came in and looked at her (resident #6), she had blood on the dressing ...My brother called for someone and a male nurse came in and said they had to cut the bandage off ...when the bandage was cut off, the wound was bleeding and (resident #6) was in a puddle of blood." The daughter further stated that the ambulance was called and resident #6 was transferred back to the hospital where she underwent surgery. The daughter stated that prior to transferring the resident to the facility, she called the facility and faxed the resident's physician's orders [REDACTED]. She was not to bear weight at all on her right foot ..." b. LPN interview On 1/18/11 at 12:00 p.m., the LPN was interviewed in the presence of the DON about the resident's transfer to the bathroom. -The LPN stated that she responded to resident #6's call light. The LPN stated that the resident requested to use the bathroom. The LPN stated that at that time, everybody (other staff) was in the dining room. The LPN stated that at that time, the resident's physician orders [REDACTED]. -The LPN acknowledged that without clarification of physician orders [REDACTED]. -The LPN stated that the resident said she could use a walker and without clarification of physician transfer orders, the LPN stated that she brought a front wheel walker (FWW) for the resident. The LPN further stated, "I pushed her in a wheelchair into the bathroom. She (resident) said she could use a walker; I put a FWW in front of her and I tried to help her by pulling her up onto the FWW but I could not. ...I took away the walker (FWW) ...and while the resident was still sitting in the wheelchair, I (LPN) said to her (resident) to hold onto the bars (bilateral grab bars in the bathroom)." -The LPN said, "...I stood to the R side of the resident ...I (LPN) gave her (resident) a lift ...she was able to stand on one foot ...she pivoted while I was holding her under her armpit on the right side ...I told her to turn ...she turned then held both arms onto the left bar, she turned all the way, she 'staggered' ...I kind of gave her support under her R arm ...She turned all the way around and sat herself on the toilet." In that same interview of 1/18/11 at 12:00 p.m., the LPN stated that she left the room until the resident called to be transferred off the toilet. The LPN returned and assisted the resident off the commode, again, without verification of NWB transfer orders. The LPN stated, "I was able to get her up with a little bit of support. Again she pivoted and put herself in the wheelchair." The LPN stated that she did not know what time all the events took place but probably between 5:00 p.m. and 5:30 p.m., as everyone was at dinner at that time. Although it was unclear if NWB precautions were maintained through all those processes, see record review and family interview above; sometime later, the resident stated to the LPN that she put weight on that right foot when the LPN assisted her with transfer from the wheelchair to the toilet. c. Record Review Review of the resident's records and facility records revealed no documentation of the resident's transfer to the bathroom. However, the nurses' notes for 11/5/10 documented in pertinent part, "At around 20:00 (8:00 p.m.), resident's son came to nurse and said there was blood on her foot. Resident's R foot assessed at 8:00 p.m., moderate amount of blood soaked through the ace wrap, resident also complained of mild pain. She (resident) stated, 'I think I put weight on my R leg when I used the toilet (assisted to toilet by LPN) earlier'. . . "The NP (Nurse Practitioner) on call was notified. Orders received to send resident back to (hospital name) ...She (resident) was picked up by two paramedics at 2030 (8:30 p.m.)." Other than documenting the resident's transfer to the hospital, there was no documentation provided by the facility that the events on 11/5/10 were investigated or that staff were educated on assessments, orders, and safety precautions related to post surgical procedures. 4. Hospital History and Physical Report Hospital Admission physician notes, dated 11/6/10, indicated history of the present history in pertinent part: "This is a [AGE] year old lady with a history of ...blindness ...who was readmitted from the nursing home after she was discharged on [DATE]. Upon arrival in the nursing home, the patient had another fall that disrupted the internal fixation of her right ankle fracture. The patient (resident) presented to the emergency room (ER) with the sutures open and evidence of disruption of the hardware and a fracture. The patient (resident #6) was therefore taken to the OR (operation room) by Orthopedic Surgery and had a revision of the internal fixation of the fracture." Hospital Attending Physician Discharge Summary, dated 11/6/10 through 11/12/10, read in pertinent part: "This is a very pleasant [AGE] year old female who initially underwent open reduction internal fixation for a bimalleolar fracture on October 31, 2010 without complications. She was discharged to a skilled nursing home facility for which on the first day (11/5/10), the patient sustained a fall disrupting the hardware of the right ankle and suffering an open complex fracture that needed further surgical intervention, specifically refixation of the ankle fracture with a wound VAC (vacuum) on the medial side for trimalleolar fracture, for which she underwent on 11/8/10." 5. Administrative Interviews On 1/18/11 at 10:50 a.m., the Nursing Home Administrator (NHA) was interviewed. -The NHA stated, "There was no fall...when the nurse left the resident, she was sitting on the toilet ...resident had call light in the bathroom ...the LPN transferred her back into the wheelchair ...she (resident #6) was still sitting in wheelchair when the (LPN) left ...She did not report that she (resident) fell ." "She (resident #6) did not report that she fell ... (But see LPN interview and record review above - indicating the resident "staggered" onto the toilet and put weight on her R ankle)." -The NHA again stated, "We sent her directly to the hospital ...We would have done an investigation if she had come back ...We followed up with the nurse (LPN) there was no fall ...I will go look for the note." On 1/18/11 at 11:00 a.m., in subsequent interview with the NHA, he stated that there were no notes regarding the event or follow-up with the LPN. The NHA stated, "We determined there was no fall, no investigation was initiated."

Based on observation, record review, resident, family and staff interviews, the facility failed to provide necessary services to attain the highest practicable well-being for two of 10 sample residents (#1, #2). Specifically, the facility failed to monitor and timely reassess skin issues for both residents; which contributed to continued itching and redness. Staff also reported at times, sample resident #1 could draw blood due to the scratching. The findings include: A concern was filed with the health department regarding skin care and safety. An onsite investigation was conducted in the facility. I. Facility Expectations: According to the skin care and pressure ulcer management program facility policy (read in pertinent part), "The skin care and pressure ulcer management practice guideline describes the interdisciplinary approach..and uses 'APIE' approach to caregiving. Assess, Plan, Implement and Evaluate. Assessing moisture and its impact. Residents face many challenges because both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to break down. Prolonged exposure to urine and feces may cause irritation or maceration (softening of the skin), which can then hasten skin breakdown. It may be difficult to differentiate [MEDICAL CONDITION] (skin inflammation) related to incontinence from partial thickness skin loss (pressure ulcer). This differentiation should be based on clinical evidence and a review of presenting risk factors..[MEDICAL CONDITION] may occur in the area where the incontinence brief or under pad has been used. Also, the [MEDICAL CONDITION]/rash more typically present as intense [DIAGNOSES REDACTED], scaling, itching, papules, weeping and eruptions ...Based on the resident's assessment, the interdisciplinary team develops an individualized care plan to prevent or treat skin breakdown. This will include interventions specific to the risk factors identified through the assessment process.. In preparing a plan, the interdisciplinary team tries to meet the resident's individualized needs and updates the Nursing Assistant Care Record with this information..A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record. If skin integrity is compromised, the process moves into the wound management phase, the physician/responsible party is notified, and the care plan is updated with the appropriate interventions.." On 10/28/10 at 4:10 p.m., the Director of Nursing (DON) provided the above policy and stated the facility had a skin program. The DON stated she would expect the resident to be reassessed at least every two weeks for treatments and monitor to see if current treatments were effective. A. Closed record review of sample resident #1 showed an admitted to the facility on [DATE]. The resident was [AGE] years old. According to the admission record, the medical [DIAGNOSES REDACTED]. According to the 3/19/10 Minimum Data Set (MDS) assessment, the resident had short-term memory impairments and required extensive assistance with Activities of Daily Living (ADL). Staff noted the resident portrayed behaviors of repetitive verbalizations and questions. A rash was identified under skin problems. There were no further assessments (in the state MDS computer system) after this date. -Review of the resident's care plan (multiple dates of problems) revealed staff was directed to conduct weekly skin audits and daily skin audits during ADL cares. Staff were to report any signs and symptoms of breakdown or redness. -The 5/28/10 self care deficit care plan directed staff to adjust level of care according to individual needs, and to assist with showers and nail care per schedule and as needed. -The 5/12/10 behavioral care plan identified the resident had anxiety as evidenced by repeating questions and continuous crying. -There was no care plan related to the rash, scratching or itching. Alternative nursing interventions were not identified to show how the facility addressed the scratching/itching. 1. Through interviews with staff and family, sample resident #1 portrayed a history of scratching herself repeatedly, at times drawing blood. Review of the medical record showed nursing staff failed to timely reassess the cause of the scratching and to seek alternative medical treatments or determine the cause. There was a lack of skin assessments performed to keep a current description of the resident's skin to monitor treatments or need for revisions to the treatment plan: [REDACTED] -The family transferred the resident to another facility on 9/16/10 due to care concerns. On 9/22/10 at 10:59 a.m. and again on 9/30/10 at 11:00 a.m., one family member was interviewed about skin care, nail care, hygiene/grooming, lack of showers and scratching. The family member stated they were aware the resident scratched and had concerns about the location of her scratches. One area noted by the family members was on the resident's mid back; they questioned how the resident could reach that particular area. The family alerted the facility about their care concerns. The family member shared he was concerned about the lack of coordination/oversight of nursing care and physician communication. -On 9/30/10 at 8:55 a.m., the resident was interviewed and observed at her new facility, 14 days after leaving the former facility. The resident was in bed. She stated she had dry skin (even on her back) and it itched. The resident replied she scratched her skin because it itched. The resident's nails were approximately 0.2-0.3 centimeters long with pointed ridges. Dried blood and brown material were noted around nail bed and underneath the nails. Dried bloody spots were noted on the linen. The resident had small linear scratch marks scattered around her shins down to her feet, left hip area, mid back and upper torso. The resident stated she scratched her back. On 10/6/10 at 11:25 a.m. at the former facility, the director of nursing (DON) stated it looked like the resident had on/off issues with scratching. The DON stated when she observed the resident's skin condition, she recalled observing scratch marks on her shoulders but there was no broken skin. The DON stated if there were areas of suspicious scratch marks, she would expect an incident report to rule out abuse, but did not find one for this resident. Also, staff should have been attempting to determine the cause of her itching and checking her nails. The DON stated nursing staff was responsible for nail care. The DON recalled when she observed the resident, the nails were trimmed (cross-reference tag 312 lack of ADL assistance). The DON continued; the weekly skin assessments were not being done for this resident (or in the facility) and she developed an action plan to address this issue. The DON stated when the family member brought up concerns, she performed a skin assessment (but not documented). The DON reported no sores. On 10/19/10 at 3:50 p.m., a Licensed Practical Nurse (LPN - familiar with the resident) stated the resident required total care for grooming needs and always scratched. Initially, the LPN stated the physician ordered topical cream for treatment and then changed to as needed application. The LPN stated whenever they noticed the scratching, she applied cream. The LPN stated the resident scratched her buttock area, hips/thighs, arms and stomach. The LPN stated the resident had dry skin and was always scratching. The surveyor asked the LPN how the resident sustained [REDACTED]. The LPN responded the aides performed nail care, but she could not recall the status of her nails. The LPN was aware of old marks on her skin but did not observe her skin before her discharge from the facility. On 10/19/10 at 4:40 p.m., one Certified Nurse Aide (CNA - familiar with the resident) stated the resident was incontinent and required total care. The CNA stated the resident could dig, scratch and draw blood. The CNA stated she scratched her bottom, lateral thighs and low back. The CNA recalled the resident's nails were not long but long enough to scratch. The CNA stated the resident had special creams and she would notify the nurse. On 10/19/10 at 4:52 p.m., another CNA stated the resident scratched all the time, wherever she could reach. The CNA stated the nurse was responsible for applying the lotions. On 10/19/10 at 5:04 p.m., the unit manager (UM) stated the following comments about this resident. The resident's condition declined and there were medication changes including an increase in her anti-anxiety medications. The unit manager recalled the resident scratched and dug into her skin; at times drawing blood. The resident required re-direction. The dermatologist did not have a diagnosis, but recommended creams to offset the scratching. There was no change in the topical creams. Anxiety medications were increased to address the scratching. The unit manager stated the nails were trimmed when possible. The UM recalled the facility treatments included lotion, dermatology appointments and increased anxiety medication. When asked how the facility reassessed the resident's needs to address the itching/scratching, the UM was unsure. 2. Record review (references to skin) identified inconsistent monitoring of the resident's skin condition, reassessing current interventions or ensuring timely dermatology consults were completed. Also, there was a lack of discussion with the psychologist services and possible behavioral components with the resident's scratching: -At the time of admission, on 3/13/10, the admission assessment showed no skin issues. -The resident took daily [MEDICATION NAME] for allergies [REDACTED]. -On 3/26/10, the physician documented, "periodic pruritis (an itch or a sensation that makes a person want to scratch)/itching/scratching of arms, upper chest.." -On 4/19/10, the physician documented, "..ongoing pruritis or chest and back, has had mild relief from [MEDICATION NAME].. stop [MEDICATION NAME], start [MEDICATION NAME]." -On 4/19/10, there was an order for [REDACTED]. -On 4/19/10 physician order [REDACTED]." The physician ordered the above treatment. -On 7/4/10 at 10:00 p.m., the nurse documented, "left message for physician regarding resident's eye condition. Also that resident has a lot of marks on her legs, arms, shoulders from scratching applied [MEDICATION NAME] as ordered." No further entries were recorded until six days later. -On 7/5/10, there was an order for [REDACTED]. -On 7/10/10 (no time), the nurse documented, "..son furious about mother's condition..MD paged stat..wants MD to see resident on 7/12/10 and discover why she is breaking out, doesn't want mom to have [MEDICATION NAME] Monday when she is seen my MD." The resident was being treated for [REDACTED]. -On 7/11/10 at 2:00 p.m., the nurse documented, "..rash on back.." The resident was seen by the physician on 7/6/10 and then on 7/19/10. -On 7/19/10, the physician's assistant documented, "..has recurrent pruritis, dermatology consult ordered, pending. No current rash. SKIN: rash - warm and dry, no rash seen, multiple excoriated regions of arms." -On 7/24/10 at 11:30 a.m., a documented entry read, "..dermatology consult set up related to complaints of itching, res. cont. c/o itching but has no visible rashes, redness or skin irritation, received lotion to skin qd (daily) and prn (as needed) without relief from itching. Also spoke with NP (nurse practitioner) and MD re. itching and she states it may be behavioral in nature but okay to send dermatology consult." One month later, on 8/16/10, the dermatologist saw the resident and noted the following information, "..female who presents for an approximately six-week history of itching on the hands, arms and chest. She is here today with a CNA, but unfortunately, they forgot to bring the patient's medication list, however, they do not believe that any new medications have been added to her regimen in the last couple of months. She has no history of [MEDICAL CONDITION] or [MEDICAL CONDITION]..her medications are unknown..her skin is very xerotic (dry) on the arms, legs, back and abdomen. She has numerous linear excoriations on the hands, arms, and lower extremities. Some [MEDICAL CONDITION] papules are seen on the right forearm, but this is really the only primary lesion of note. Clinical Impression/Plan: Nonspecific [MEDICAL CONDITION], right arm with numerous excoriations and severe xerosis in the background. I would like to review the patient's medication list, and I asked the CNA to fax it to my office tomorrow. In the meantime, I recommended [MEDICATION NAME] 0.1% cream bid to arms, legs, and trunk for two weeks, then tapering to once daily on a prn basis. I also recommended head-to-toe [MEDICATION NAME] once daily for moisturization. Follow-up will be in two months to assess her improvement. They should also clip the patient's fingernails as they are quite long and are essentially personal weapons that she is using to excoriate herself." -There was no indication the nursing staff provided nail care (cross-reference tag 312 lack of ADL assistance) per the dermatologist recommendations or sent the medication sheet for a review. -On 8/20/10, the physician assistant documented, "patient seen by dermatology on 8/16/10 for ongoing pruritis - dry skin and given treatment for [REDACTED]. -On 8/22/10 at 9:30 p.m., the nurse documented, "no scratching.." -On 8/26/10 at 6:15 a.m., the nurse documented, "[MEDICATION NAME] 0.25 mg TID (three times a day) Dx. (diagnosis) anxiety.." -On 8/31/10 at 9:00 p.m., the Director of Nursing documented, " ...met with son..condition of her skin - the scratches on her back and the treatment.." -On 9/1/10, the interdisciplinary team met to discuss the resident and documented, "..constant scratching of self.." There were no changes to the care plan. -On 9/11/10 at 10:00 p.m., the nurse documented, "..topical cream applied to body as ordered.." -On 9/10/10, a different physician's group saw the resident and noted excoriation was evident on both lower extremities. Under the assessment section the following was documented, "[MEDICAL CONDITION] - currently using [MEDICATION NAME] and [MEDICATION NAME], these appear to be long term, will reassess as we get to know (resident name). a. Review of treatment records showed repetitive use of the [MEDICATION NAME] or [MEDICATION NAME] creams since her admission to the facility, specifically: In July, staff was applying [MEDICATION NAME] cream twice a day as needed per the physician's orders [REDACTED]. Review of the August 2010 medication and treatment records showed a handwritten note, "[MEDICATION NAME] cream USP 1% BID prn, apply to affected area for pruritis. According to the records, nursing staff applied cream on 8/7, 8/8, 8/6, 8/14 and 8/15. Review of the September 2010 medication and treatment records showed the physician prescribed [MEDICATION NAME] topical ointment to be applied daily to all of the skin (ordered 8/16/10). Another topical ointment was prescribed by the physician on 8/16/10 to be applied twice a day; [MEDICATION NAME]. The original order read as follows, "[MEDICATION NAME] 0.1% topical (external) bid (twice a day) everyday to arms, legs and back for two weeks then daily as needed to affected areas." Although, the order read to apply twice daily for two weeks, staff still recorded treatments being done through her discharge from the facility. 3. Behaviors: Psychotherapy visits ceased on 8/6/10. Review of records did not show how continuous scratching was addressed as a possible behavioral issue or how the facility coordinated care/behavioral strategies to address the resident's needs. Staff was tracking the following behaviors: calling out, yelling at others and refusal of cares. On 8/25/10, the resident was reviewed in the [MEDICAL CONDITION] committee meeting which indicated the resident received [MEDICATION NAME] three times a day. There was no information provided on what was discussed or how the facility was addressing scratching as a possible behavior. On 9/10/10, the physician increased [MEDICATION NAME] to four times a day for anxiety. 4. Shower records (2010) reviewed from May through September indicated the resident did not receive showers as scheduled (twice a week according to the DON in tag 514): Review of the shower book showed the resident only received one shower in September (before leaving) on 9/5/10. The staff member noted the resident had scratches on her back. Three showers documented in May and four showers were documented in June. Two showers were documented in July. Seven showers were documented in August; documentation noted the bottom area was red, or no skin issues. 5. Facility response to surveyor questions about skin and scratching: On 10/28/10 at 4:10 p.m., the surveyor asked the DON and nursing home administrator what actions the facility took to address the resident's ongoing scratching. On 11/3/10 at 2:03 p.m., the DON stated there was no further information regarding this resident's skin issues or facility interventions. The facility provided an outline of the resident's skin issues. Specifically, -According to a staff outline of the resident's skin issues and facility actions the physician ordered [MEDICATION NAME] cream to itchy regions twice a day as needed on 3/18/10. Family reported the resident was scratching and with no indication in nurse's notes. One month later, the [MEDICATION NAME] was discontinued and [MEDICATION NAME] continued (4/11/10). The resident was seen by psychologist for depression and isolation through 8/10. On 4/19/10, the physician ordered a dermatology consult and ordered [MEDICATION NAME] cream twice a day for fourteen days. On 4/30/10, the psychologist documented the resident could be delusional. On 6/4/10, the psychologist documented the resident could be 'somatic'. On 6/4/10, [MEDICATION NAME] cream was restarted and applied as needed. On 7/19/10, physician ordered a dermatologist appointment and questioned if medications might be contributing to ongoing pruritis. On 8/16/10, dermatologist consult with recommendation for [MEDICATION NAME] twice a day and daily [MEDICATION NAME] for moisture. As noted above, the resident experienced ongoing issues with scratching/itching from admission through discharge, six months. Although staff documented creams were applied, there was no clear indication of how the facility identified potential causes to thoroughly address the resident's needs. There was a delay in obtaining dermatology referrals, recommendations and re-assessing the source of the resident's continuous itching. B. Sample resident #2, [AGE] years old, was admitted to the facility on [DATE]. According to the admission record, the medical [DIAGNOSES REDACTED]. According to the 6/18/10 MDS, the resident had short and long term memory impairments and required extensive assistance with ADLs. No skin impairments were noted except for skin tears. The resident was continent of bowel and bladder. There were no further MDS assessments in the state system. -Several different copies of a care plan were reviewed noting different dates and additions. Review of the 5/26/10 skin breakdown care plan identified the resident had the potential for skin break down related to cognitive impairment, ADL impairments and bladder and bowel incontinence. Staff was directed to perform weekly skin assessments and report signs/symptoms of redness to the physician. A. 5/26/10 skin tear care plan noted the resident had problems with redness and shearing on the buttock. Staff was directed to provide treatments as ordered. 1. For a period of five months, the resident continued to experience redness to her peri-area and buttock region (onset 7/20/10 and treatment was initiated): From 7/20/10 through 9/1/10, the daily treatment remained the same to the above area with persistent redness to the area. On 8/30/10, the physician ordered triple antibiotic ointment and Allevyn to address a new open area on the right buttock due to shearing (the redness to the buttock area and peri-area remained). On 9/2/10, the facility contacted the son about the redness and new open area and staff noted the son was upset about how long this had been going on. As of 9/3/10, nursing staff did not have the Allevyn dressing and the physician was contacted, a delay of four days. The resident received a treatment on 9/3/10. On 8/31/10, the facility contacted the physician about the ongoing redness to the buttock and peri-area, five weeks after onset. On 9/1/10, the physician ordered a different treatment to address the skin issue. From 9/1/10 through 10/15/10, the same treatment continued for addressing the redness/buttock region. Although staff documented gradual and slow healing in September, the redness remained. There was no documented communication with the physician regarding the resident's continued skin condition until 10/12/10, six weeks later. On 10/15/10, the physician changed the treatment order during his visit and wanted staff to contact him within a week about the progress of this new treatment. On 10/15/10 the physician documented, "..she continues to have a red rash in the perineal area despite use of [MEDICATION NAME] cream, and more recently with the addition of [MEDICATION NAME] also. She says it itches sometimes. She is incontinent, and wears diapers, but nurse says the diapers are only underneath her at night, not fastened around her legs (observations below revealed staff was fastening the garments)..skin - diffuse [DIAGNOSES REDACTED]tous blanching rash with fairly well defined border over buttocks and peri-area; no ulcerations or satellite [MEDICAL CONDITION]. Plan - stop [MEDICATION NAME] and continue [MEDICATION NAME] 0.1% ointment bid for another week; staff to report on progress then, if not improved, would consider alternative antifungal cream." Ten days later, nursing staff contacted the physician on 10/25/10 around 1:00 p.m. and a new treatment order was received on 10/25/10. The new treatment order was not implemented into the computer system or treatment record until the next day, 10/26/10. The new cream was not available until 10/27/10. Review of the October treatment records showed the resident did not receive any treatments 10/23/10 until 10/27/10 due to the delay in contacting the physician and obtaining the new ointment. 2. Observations revealed the resident's briefs were fastened in bed and the area was red: On 10/24/10 at 2:43 p.m., the surveyor observed the resident's skin area with the weekend supervisor (resident verbalized permission to observe skin). The resident was in bed on her back. An incontinent brief was applied and fastened. After removal of the incontinent brief (minimally wet), there was a bright red ring present that ranged approximately 5-6 inches around. The ring was present continuously from the front private area down between the legs ending around the coccyx region (inner thighs, vaginal area, and coccyx area). The area was blanchable. The resident slept on a regular mattress. On 10/27/10 at 5:50 a.m., the surveyor observed the resident's skin area with the night nurse and resident permission. The resident had been partially dressed by staff that morning and had her pants and brief on (fastened). The nurse unfastened the brief and the area was still red and circular in nature (as noted above). The nurse stated the physician ordered a new cream which should start today. 3. According to a 10/14/10 bowel and bladder continence evaluation, the assessment was incomplete. There was no pattern to establish if the resident's incontinence needs had changed. The 10/25/10 monthly summary indicated the resident was incontinent. 4. Interviews: On 10/19/10 at 1:05 p.m., a family member stated the resident has had ongoing skin issues for the past six weeks. On 10/24/10 at 2:43 p.m., the resident stated the area was chapped from lying in urine too long and having wet briefs. The resident did state the lotions helped. On 10/28/10 at 4:10 p.m., the surveyor questioned why the area remained red for this long. The DON stated the resident's skin would improve and then decline, but never completely healed. The skin color would fluctuate between red and pink. The DON thought the briefs could be on but not fastened (open to air). The facility utilized briefs with the 'wick' system, which was supposed to wick the urine away from the skin. The DON stated treatments should be re-assessed at least every two week to see if current treatments were effective. II. Interviews regarding skin management and oversight: On 10/6/10 at 8:04 a.m., the newly appointed DON stated staff had not been conducting weekly skin assessments, and they were not being done before July. The DON stated she developed an action plan and nursing staff had been in-serviced regarding expectations and documentation. On 10/27/10 at 9:00 a.m., the DON stated residents, with medical or other issues, were discussed in the morning meeting with the interdisciplinary team. The DON stated staff had been re-inserviced on completing skin assessments and documenting findings on the back of the treatment sheet. The unit managers were now responsible for completing weekly skin assessments on residents with identified pressures. On 11/18/10 at 10:00 a.m., social services stated care coordination, education and communication between outside mental service providers and the facility would be helpful; strategies, interventions and/or techniques to meet behavioral components of resident care.