Every finding on record at University Park Care Center

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of four units.Specifically, the facility failed to:-Ensure resident rooms were cleaned in a hygienic manner; -Ensure staff wore appropriate personal protective equipment (PPE) when providing care to a Resident #14, who was on enhanced barrier precautions (EBP); and, -Ensure staff performed hand hygiene while assisting residents with meals. Findings include: I. Failed to ensure resident rooms were cleaned in a hygienic manner. A. Professional references According to the Clorox Company, 2026, retrieved on 9/1/26 from https://www.clorox.com/products/clorox-clean-up-cleaner. It read in pertinent part, To Clean and Disinfect Hard, nonporous Surfaces Spray four to six inches from surface and allow product to penetrate tough stains and messes. Treated surface must remain wet for 30 seconds. According to the Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, revised July 2021, retrieved on 9/1/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) retrieved on 9/1/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It revealed in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. B. Facility policy and procedure The Daily Room Cleaning procedure was provided by the housekeeping supervisor on 8/26/26 at 3:50 p.m. It read in pertinent part, -Clean from high to low; -Remove gloves and sanitize; -Take orange rag and wipe down counter top then sink; and, -Put gloves on and get the broom. B. Observations On 8/25/26 at 10:28 a.m. housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER], a double occupancy room with one resident currently residing in it. HK #1 applied gloves and entered the resident's room carrying the Clorox multipurpose spray cleaner and a dry rag from the cleaning cart. He sprayed the sink and counter area with the Clorox multipurpose spray cleaner. After waiting more than 30 seconds, he wet the rag from the sink faucet and he began wiping down the sink bowl rim, then the bottom of the sink bowl, and then moved to wiping the sink counter. Using the same rag used to clean the sink and counter, HK #1 wiped down the resident's cupboards next to the counter from top to bottom, and then back to the top of the cupboard. HK #1 used the same rag and wiped down the top of the resident's bedside table. HK #1 left the resident room and removed his gloves. He did not perform hand hygiene after removing his gloves. Without applying a new pair of gloves, HK #1 picked up the broom from the cleaning cart and entered the resident's room carrying the broom. He swept the resident's room and without gloves, touched the resident's bedside table and moved the table. HK #1 exited the room and said he had completed cleaning the resident's room. C. Staff interviews HK #1 was interviewed on 8/25/26 at 10:28 a.m. HK #1 said he had been trained by a floor technician, who was a member of the housekeeping staff, and a housekeeper from station three about four months ago when he was hired. He said he participated in training with the housekeeping supervisor about a month ago, but did not say if this included hand hygiene and the use of gloves during the cleaning of residents' rooms. The housekeeping supervisor was interviewed on 8/26/26 at 3:50 p.m. The housekeeping supervisor said it was important for housekeeping staff to use hand hygiene and gloves when cleaning residents' rooms. She said the use of hand hygiene and gloves was in the instructions for resident room cleaning found on the Daily Room Cleaning procedure. The housekeeping supervisor said it was important to practice the use of hand hygiene and gloves every time a resident's room was cleaned in order to prevent the transmission of illnesses in the facility. The housekeeping supervisor said housekeeping staff should follow the housekeeping process to keep a hygienic practice and use a clean to dirty, high to low approach when cleaning residents' rooms. The housekeeping supervisor said housekeepers should not wipe a dirty area and then use the same rag to wipe another surface. She said the hygienic practice was important to prevent the spread of infections in the facility. The infection preventionist (IP) was interviewed on 8/26/26 at 3:04 p.m. The IP said housekeeping staff needed to use hand hygiene and gloves when cleaning residents' rooms in order to prevent the spread of disease. The IP said training on hand hygiene and the use of gloves should follow the CDC's guidelines. II. Failed to ensure staff followed EBP procedures when providing care to Resident #14 A. Professional reference The CDC's, Frequently Asked Questions About Enhanced Barrier Precautions in Nursing Homes (revised 6/28/24) was retrieved on 9/1/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html. It revealed in pertinent part, Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). Enhanced Barrier Precautions 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 (residents with wounds or indwelling medical devices). B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised 6/5/26, was provided by the NHA on 8/28/26 at 4:45 p.m. It read in pertinent part, The facility should use enhanced barrier precautions (EBP) as an additional multi-drug resistant organism (MDRO) mitigation strategy for residents that meet the following criteria, during high-contact resident care activities; EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. High contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, medical device care or use, and wound care. C. Observations On 8/26/26 at 1:45 p.m. Resident #14 was lying in his bed with a continuous tube feeding connected. Resident #14 required a percutaneous endoscopic gastrostomy (PEG) device (a medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications when a patient cannot swallow or eat safely) to provide feeding and nutrition. An EBP sign was placed next to the door of Resident #14's room directing staff to use a gown and gloves when providing high contact care for the resident, including tube feeding. Registered nurse (RN) #2 performed hand hygiene, donned gloves and entered the resident's room to stop the tube feeding and disconnect the feeding tube from the resident's PEG device. -However, RN #2 failed to put on a gown when entering Resident #14's room, as was directed by the EBP sign at the door. D. Staff interviews RN #2 was interviewed on 8/26/26 at 2:08 p.m. RN #2 said she did not think a gown was required to disconnect a tube feeding from a resident who was on EBP. RN #2 was interviewed a second time on 8/26/26 at 2:10 p.m. RN #2 said she consulted with RN #3 regarding the use of a gown to disconnect the tube feeding in Resident #14's room. She said RN #3 said she would check with the DON. RN #3 was interviewed on 8/26/26 at 2:20 p.m. RN #3 said the DON confirmed that staff must wear a gown and gloves to disconnect Resident #14's tube feeding. The IP was interviewed on 8/26/26 at 3:04 p.m. The IP said nursing staff should follow EBP requirements and use a gown and gloves when providing high contact care to a resident with tube feedings. The director of nursing (DON) was interviewed on 8/26/26 at 2:35 p.m. The DON confirmed the EBP sign by Resident #14's door and confirmed staff were required to wear a gown and gloves when providing high contact resident care for Resident #14, including tube feeding care. The DON said it was important to follow EBP when providing tube feeding care to Resident #14 in order to prevent infection to a vulnerable resident or spread infection to other residents. III. Failed to ensure hand hygiene was performed while providing feeding assistance between Resident #12 and Resident #67. A. Observation On 8/24/26 at 7:29 a.m. certified nurse aide (CNA) #9 was providing feeding assistance to Resident #12 and Resident #67. CNA #9's hand covered Resident #12's hand as she assisted the resident to eat eggs with a fork. CNA #9 then picked up Resident #67's fork and assisted her with a bite of eggs. -CNA #9 failed to perform hand hygiene after making contact with Resident #12's hand and before touching Resident #67's fork. B. Staff interviews CNA #6 was interviewed on 8/27/26 at 11:53 a.m. CNA #6 said the first step in providing feeding assistance to a resident was to perform hand hygiene. She said there were hand hygiene wipes that were used for the residents' hands in the dining room. She said while she provided feeding assistance, she would engage with the resident, give them a clothing protector, explain what they were eating and offer fluids throughout the meal. CNA #6 said hand hygiene should be performed by the staff member providing feeding assistance frequently between residents if they were providing feeding assistance to multiple residents at the same time. She said it was not okay if a staff member made contact with someone's hand and then continued to provide feeding assistance without performing hand hygiene between the residents. CNA #6 said the potential negative outcome of not performing hand hygiene between residents was spreading germs. The DON was interviewed on 8/27/26 at 2:21 p.m. The DON said both staff and residents should perform hand hygiene before meals. She said if the staff member performing feeding assistance switched residents they were assisting during the meal, they needed to sanitize their hands. She said if the staff member made contact with the resident's hand and then touched another resident's fork, they should have sanitized their hands. The DON said it was important to perform hand hygiene between residents to prevent cross contamination between residents.

Based on record review and interviews, the facility failed to ensure one (#86) of four residents was free from abuse out of 47 sample residents.Specifically, the facility failed to ensure Resident #86 was free from sexual abuse from Resident #54. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised 4/1/26, was provided by the nursing home administrator (NHA) on 8/25/26 at 12:04 p.m. It read in pertinent part, This facility will establish policies and protocols for preventing sexual abuse, such as identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded. The facility will identify, assess, care plan for appropriate interventions and monitor residents with needs and behaviors which might lead to conflict, such as sexually aggressive behavior. II. Incident of sexual abuse by Resident #54 towards Resident #86 on 7/7/26 A. Facility investigation The 7/7/26 facility investigation was provided by the NHA on 8/26/26 at 1:45 p.m. The investigation documented that on 7/7/26 at 6:20 p.m. certified nurse aide (CNA) #2 was walking down the hall when she noticed two residents talking. As she got closer, she heard Resident #54 state a sexually inappropriate comment then reach out and touch the breast of Resident #86. CNA #2 separated them immediately. CNA #2 said Resident #86 did not appear to be fearful or scared and just raised her eyebrow. No injury or change in behavior was noted. The investigation revealed that on 7/8/26 at 7:30 a.m., the social services director (SSD) documented that she was informed by the assistant director of nursing (ADON) that Resident #54 was sexually inappropriate with Resident #86 at change of shift. The director of nursing (DON) interviewed CNA #2 in front of the SSD and the ADON. CNA #2 said that Resident #86 was in the hallway across from Resident #54's room when Resident #54 came into the hallway and whispered something to Resident #86. CNA #2 said she did not hear what was whispered, but as she approached the residents, she overheard Resident #54 tell Resident #86 I want to suck the (explicit language) out of your titty, and Lets find a place to go (explicit language). Resident #54 then grabbed Resident #86's breast and squeezed. CNA #2 said that she told Resident #54 that was not appropriate and to leave. CNA #2 reenacted the interaction and squeezed her right breast with a full hand. The investigation documented that immediate interventions included separating the residents, monitoring Resident #86 until she went to sleep and moving Resident #86's room to a different hallway within one hour. Both residents were interviewed on 7/8/26 between 8:15 a.m. and 8:25 a.m., respectively, and neither resident recalled the incident. The facility also interviewed and documented the responses of 14 residents, 14 staff members and ten family members of residents who resided at the facility. The investigation revealed that Resident #54 had a history of behaviors and had been involved in a physical abuse allegation in the last 12 months, while Resident #86 had not been involved in any previous occurrences. The investigation concluded that the interdisciplinary team (IDT) reviewed this allegation and determined that Resident #54 reached out and grabbed the breast of Resident #86. B. Resident #86 (victim) 1. Resident status Resident #86, age [AGE], was admitted to the facility on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, and chronic pain. The 8/26/26 minimum data set (MDS) assessment revealed Resident #86 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident used a manual wheelchair for mobility. The MDS assessment indicated Resident #86 did not have physical or verbal behavioral symptoms directed toward others. 2. Resident representative interview Resident #86's representative was interviewed on 8/26/26 at 8:13 a.m. Resident #86's representative said Resident #86 had dementia and was not able to talk about or remember the event of 7/7/26 where a male resident (Resident #54) had approached her and made inappropriate sexual comments and then grabbed her breast. Resident #86's representative said before Resident #86 had dementia, she would have been upset about inappropriate sexual comments made to her. She said Resident #86 probably would have hit a person for making inappropriate sexual comments towards her or when grabbing her breast. 3. Record review Resident #86's dementia care plan focus, revised on 4/20/26, revealed the resident had impaired cognitive ability and impaired thought processes related to dementia and Alzheimer's disease, and interventions included to allow extra time for Resident #86 to respond to questions and instructions, and to face and speak clearly when communicating with the resident. Resident #86's progress note, dated 7/10/2026 at 5:01 p.m., revealed an interdisciplinary team (IDT) meeting to review the incident on 7/7/26 overheard by CNA #2 where Resident #54 had approached Resident #86 in a hallway and made inappropriate sexual comments and appeared to touch her breast. An IDT intervention included Resident #86 had been moved to a different hall away from Resident #54 (the alleged assailant). C. Resident #54 (assailant) 1. Resident status Resident #54, age [AGE], was admitted on [DATE]. According to the August 2026 CPO, diagnoses included Alzheimer's disease, dementia and depression. The 6/15/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. He required substantial/maximal assistance with showering, partial/moderate assistance with toileting and personal hygiene, and supervision/touching assistance with other activities of daily living (ADL). The assessment documented the resident did not have verbal or sexual behaviors toward others. 2. Record review Resident #54's sexual behavior care plan, initiated 7/9/26 and revised 7/14/26, documented the resident had exhibited inappropriate sexual behaviors. Pertinent interventions, revised 7/10/26, included assisting Resident #54 to develop more appropriate methods of coping and interacting with staff and residents; encouraging the resident to express feelings appropriately to staff; offering the resident Pepsi, Coke or favorite snacks when experiencing difficulty with coping; educating the resident/family/caregivers on successful coping and interaction strategies such as redirection and removing the resident from the situation; reinforcing why the behavior was inappropriate and/or unacceptable to the resident; and, intervening as necessary to protect the rights and safety of others. -The behavior care plan and interventions were not initiated after Resident #54's documented sexual behavior towards staff and residents on 4/15/26 (see progress note below). A 4/15/26 alert note documented Resident #54 presented with sexually inappropriate behaviors towards staff and fellow residents this shift. Staff attempted to redirect the resident back to his room. A 7/8/26 behavior note documented Resident #54 did not sleep at all and might request a sleeping medication. Earlier, a CNA had reported that the resident made sexual comments and inappropriate touch to Resident #86. Staff would monitor the situation. A 7/8/26 event note documented Resident #54 came out from his room and approached Resident #86 and said, Lets find a room so I could suck the (explicit language) out of your titties. Resident #54 also told Resident #86 that he wanted to (explicit language) the (explicit language) out of her. The nurses separated the residents and kept Resident #86 close to the medication cart. The physician, family and administration were notified. A 7/10/26 event note documented that an IDT meeting was held for the resident-to-resident incident on 7/7/26. With clarification from the nurse, Resident #54 remained in the hall propelling himself up and down the hall until he laid down for the night. No other residents were out at that time, and Resident #54 had no other interactions with other residents for the remainder of the night. Interventions included requesting a medication review from the psychiatric physician and receiving a new medication recommendation; and, initiating a sexual behaviors care plan with interventions such as removing from the situation and offering Pepsi and favorite snacks such as cookies/sweets. III. Staff interviews CNA #2 was interviewed on 8/25/26 at 5:40 p.m. CNA #2 said she witnessed the resident-to-resident interaction between Resident #86 and Resident #54. She said Resident #54 was self-propelling in his wheelchair out of his room while mumbling to himself under his breath. She said Resident #54 then looked up, made eye contact with Resident #86 and started to make sexual comments about her, then reached out and grabbed her breast. CNA #2 said she immediately intervened, separated the residents, and notified administration. She said she did not witness any sexual behaviors by Resident #54 prior to this incident. She said she thought Resident #54's behaviors had been better controlled after he started a new medication. The ADON was interviewed on 8/26/26 at 4:39 p.m. The ADON said she performed the assessment on Resident #54 following the alleged sexual abuse incident. She said there were no findings on his assessment, and she could not recall the resident demonstrating sexual behaviors prior to this incident. The DON was interviewed on 8/27/26 at 2:21 p.m. The DON said she recently moved into the role of DON, but she was previously the facility's MDS coordinator. She said the types of abuse included physical, sexual, verbal, nonverbal, financial, neglect and misappropriation of property. She said the abuse coordinator was the NHA. The DON said when abuse was suspected, staff were to first make sure the resident was safe then notify the DON immediately. She said she would then notify the NHA of the allegation. She said the last staff meeting that discussed abuse training was in July 2026. The DON said she was aware of the incident between Resident #86 and Resident #54. She said Resident #54 said some explicit statements to Resident #86 and then he grabbed her breast. She said since the incident, staff had been educated on timely abuse reporting, timely notifications, the interventions for the residents to be separated, and ensuring Resident #86 did not go down the hallway that Resident #54 resided on. The DON said she was not aware of any previous sexual behaviors by Resident #54. After she reviewed the electronic medical record (EMR), the DON said there was sexual behavior documented on 4/15/26. She said she was not the DON at that time and was unaware of the incident. The DON reviewed Resident #54's care plan and said the behavior care plan and interventions were not initiated until 7/10/26. She said based on the progress note from 4/15/26, the care plan should have been initiated after the incident in April 2026 because the resident had already exhibited inappropriate behaviors. She said there was potential for negative outcomes as a result of sexual abuse because Resident #86 was unable to consent to the unwanted touching. IV. Additional staff interview The DON was interviewed on 8/27/26 at 2:23 p.m. The DON said Resident #86 had dementia, therefore she could not consent to unwanted touching. The DON said Resident #86 should have been moved sooner to a room closer to the nurses' station for closer monitoring in order to prevent the incident that occurred with Resident #54 on 7/7/26.

Based on record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for one (#118) of three residents out of 47 sample residents. Specifically, the facility failed to:-Provide Resident #118 adequate supervision when going outside; and, -Failed to complete a thorough elopement risk assessment. Findings include:I. Facility policy and procedureThe Elopement policy and procedure, reviewed 12/1/25, was provided by the nursing home administrator (NHA) on 8/26/26 at 3:30 p.m. It read in pertinent part, Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Upon completion of the other interdisciplinary team's (IDT) admission and readmission assessments, the IDT will review any additional unsafe wandering and/or elopement risk indicators and revise the resident's care plan as indicated. The IDT will review and revise the resident's unsafe wandering management care plan, if indicated, upon completion of each comprehensive, significant change and quarterly minimum data set (MDS) and upon an unsafe wandering or elopement event. Residents and/or family members will receive education on signing the resident in and out when leaving the facility at time of admission and as indicated thereafter. Residents and/or family members will receive education on the resident's unsafe wandering and elopement management care plan and provide opportunity for feedback. During admission and readmission process, a care plan will be initiated by the admitting nurse on any residents assessed with unsafe wandering or elopement behaviors. Associates will be provided unsafe wandering and elopements training upon hire, annually and as indicated by the Unsafe Wandering and Elopement Improvement Plans (PIPs). Elopement drill will be conducted at least quarterly.II. Facility investigation of Resident #118's elopement on 6/6/26The facility investigation was provided by the NHA on 8/26/26 at 4:02 p.m.The investigation, dated 6/6/26, revealed the NHA was called by receptionist #1 and was told that Resident #118 was down the road, around the corner. Receptionist #1 told the NHA that she was on the way to Resident #118. The NHA called the facility and requested that a certified nurse aide (CNA) meet her at the location of Resident #118. Resident #118 was then assisted into the van without incident and returned to the facility. Upon return to the facility, the investigation documented that the NHA verbally educated Resident #118 on the sign-out protocol and the safety of leaving the building and being outside. The NHA had Receptionist #1 place Resident #118's name in the elopement book until an assessment could be completed.The investigation documented that Receptionist #1 was interviewed. She said Resident #118 asked to go outside. She said he was not listed in the elopement book. She said five minutes after he had gone outside she was notified by a community member that a resident was down the road. She said she got into the car with the community member and they immediately drove to Resident #118. She said that she called the NHA from the inside the car while on the way to Resident #118. She said she stayed with Resident #118 until the NHA arrived. The investigation documented that education was completed with the receptionist, Resident #118 and staff regarding leaving the building. The investigation documented that nursing staff was looking for Resident #118 while the receptionist was with Resident #118 down the road. The investigation documented that no missing person's code was called and no other staff on duty was requested to search the facility/surrounding areas the Resident #118. It was documented that Resident #118 had severe cognitive impairment and did not have any prior attempts of elopement. Receptionist #2 stated Resident #118 had sat outside before and had never tried to leave. Receptionist #1 stated he was not in the elopement book and that was the first time he had gone outside for her. There was no injury documented in his chart regarding the event and it was documented that a CNA went to help and assist the resident with his return to the facility. The NHA documented that Resident #118 stated he wanted to go and see the neighborhood. Interventions implemented included staff education on elopement, the resident was placed in elopement book, and electric wheelchair safety evaluation. The facility investigation findings were the incident was not reportable as a search was not conducted for the missing resident and the health and safety of the resident was not at risk. Resident health, safety and welfare were not at risk as evidenced by Resident #118 asking to sit outside, Resident #118 was gone for five minutes per witness interview, Resident #118 was able to state needs and had no prior elopement concerns. -However, interviews during the survey revealed inconclusive times were reported regarding how long the resident was missing (see interviews below).III. Resident #118 A. Resident statusResident #118, age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician's order (CPO), diagnoses included multiple sclerosis and cognitive communication deficit. The 6/19/26 MDS assessment revealed Resident #118 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The assessment indicated that Resident #118 had lower body impairment and had no impairment with his upper body. The assessment did not indicate that Resident #118 wandered. B. Resident representative interviewResident #118's representative was interviewed on 8/24/26 at 1:38 p.m. Resident #118's representative said that the facility did not notify her that he had left the building until they had found him. She said the facility told her that Resident #118 was dehydrated when they found him. She said that she lived nearby and would have gone out and helped look for him. She said it was upsetting that they did not notify her earlier. She said that the facility he was in before allowed him to leave the facility grounds. C. Resident interviewResident #118 was interviewed on 8/24/26 at 2:12 p.m. Resident #118 said that he remembered when he left the building. He said that he was looking for a gas station and he got stuck. He said some people helped him. He said that since then he felt that the facility did not allow him the same freedoms he had as before. D. Community member interviewThe community member was interviewed on 8/27/26 at 10:16 a.m. The community member said she and her family were leaving their neighborhood and they saw Resident #118 in his motorized wheelchair in the middle of the street. She said they found Resident #118 approximately two miles away from the facility. She said when they stopped to see if he was okay, he was able to tell her that he was from a nearby facility but he could not remember the name. She said she was concerned because it was close to 100 degrees Fahrenheit (F) out that day. She said Resident #118 was visibly sweating and did not have any water or money with him. She said another person came up and was able to give Resident #118 some water, but left soon after. She said she called the police but no one showed up. She said she tried calling the closest facility but no one answered the phone. She said she then left Resident #118 with her husband under a tree in the shade and drove to the closest facility to see if they were missing anyone. She said when she got to the facility she tried the front door but the doors were locked. She said she then saw a woman in the parking lot and asked if she worked at the facility. She said she asked the woman if they were missing a resident. The employee told her yes and asked if she would take her to the resident. She said the entire ride back to the resident the employee was making calls to see if someone could get the facility van to pick up the resident. She said the employee did not give any indication of how long the resident was missing. She said the employee and Resident #118 started to walk back to the facility, which was around 4:45 p.m. E. Record reviewReview of Resident #118's elopement care plan, initiated 6/8/26, revealed he had a history of attempts to leave the facility unattended and wandered aimlessly. Interventions included adding Resident #118 to the elopement book, assessing for fall risk, complete elopement risk assessment, and encourage Resident #118 to participate in activities to divert from exit seeking behaviors. The 4/24/26 elopement risk evaluation documented that Resident #118 was not at risk for elopement. -However, the 6/8/26 elopement risk evaluation indicated the resident had a history of elopement at a previous living facility. The 6/8/26 elopement risk evaluation documented that Resident #118 had a history of elopement while at home/previous placement/previous facility, exhibited exit-seeking behavior(checking doors, windows, setting off alarms), history of leaving facility without supervision, or history of leaving facility without informing staff. The assessment did not initially indicate that Resident #118 wandered. However, the summary of the findings of the evaluation did indicate that he wandered and was at risk for elopement. -The 6/8/26 elopement risk evaluation contradicted itself.A late entry event note, dated 6/8/26 at 7:52 a.m., documented that the IDT meeting was held for an elopement that happened on 6/6/26. The note documented that Resident #118 left the facility and was observed down the road in his electric wheelchair. The note documented that the resident wanted to see the neighborhood. The note documented that education was given to the resident and staff on elopement. The resident's name was added to the elopement book and an electric wheelchair safety evaluation was done. The interventions were to be monitored for effectiveness. A late entry event note, dated 6/8/26 at 7:52 a.m., documented that at approximately 4:10 p.m. the nurse went to Resident #118's room to administer medication and listen to his lungs. Resident #118 was not in his room like he normally would be at that time. The nurse looked for Resident #118 throughout the facility asking other employees if they had seen Resident #118. None of the other employees could recall or report seeing him. The note documented that the nurse went to the front lobby and asked the receptionist if she had seen him or if family had forgotten to sign him out. The receptionist told the nurse that Resident #118 had gone outside to get some sun for a short while. The note documented the nurse went outside to find Resident #118. The note documented that the nurse circled the entire facility including the patios and parking lot and did not find Resident #118. The note documented that the nurse became concerned about Resident #118's welfare because the heat index was in the high 90's. The note documented that the nurse asked a male CNA who was working Resident #118's hall to drive out further to see if Resident #118 had gotten lost. The note documented that the assistant director of nursing (ADON) and the director of nursing (DON) were notified. A behavior note, dated 6/8/26 at 3:51 p.m., documented Resident #118 did not try and elope and went to an appointment. The note documented Resident #118 did not have any negative behaviors. A behavior note, dated 8/3/26 at 6:41 p.m., documented that Resident #118 had multiple behavioral episodes during the shift. The note documented Resident #118 was upset about something and was not making sense. Resident #118 was observed trying to get out of an exit door and stated he wanted to go out. The note documented Resident #118 was redirected without issues. Review of online maps revealed Resident #118 was found approximately one and half to two miles away from the facility based on the community members' reported location. IV. Staff interviewsCNA #8 was interviewed on 8/26/26 at 9:49 a.m. CNA #8 said that Resident #118 eloped before he started working at the facility. He said he started working at the facility in July 2026. He said he had not seen Resident #118 try to leave since he started working at the facility. CNA #4 was interviewed on 8/26/26 at 9:55 a.m. CNA #4 said she was not working the day that Resident #118 left the facility. She said he was not at risk for leaving prior to him leaving. She said he had not tried to leave the building since the event. She said that he would joke about leaving the facility but had never tried to leave the facility before. Receptionist #1 was interviewed on 8/27/26 at 11:49 a.m. Receptionist #1 said Resident #118 had asked to go outside and sit in the sun on 6/6/26. She said he was not an elopement risk prior to him leaving. She said that it was normal for him to go and sit outside. She said she would routinely check up on him when he was outside. She said her routine was to check on whoever was outside every ten minutes. She said he did end up leaving on 6/6/26. She said he later told her that he wanted to look around the area. She said someone had come and asked her if she was looking for a resident. She told them yes and asked if they could take her to him. She said he was close to a neighborhood. She said she had called the NHA and she had come with the van. She said that they got to them fairly quickly. She said he was probably gone for approximately 15 minutes. The DON was interviewed on 8/27/26 at 3:00 p.m. The DON said at the time that he left the building she was the MDS coordinator. She said that an elopement was when someone who needed supervision leaves facility grounds. She said someone who needed supervision was confused and/or unaware of their surroundings. She said she did not feel that when Resident #118 left the facility was considered elopement. She said she did not consider it elopement because he was alert and wanted to see what was around the facility. -However, Resident #118 was severely cognitively impaired.The DON said she did not feel he was in danger and he was not gone for a long period of time. The ADON was interviewed on 8/27/26 at 5:14 p.m. The ADON said Resident #118 had told receptionist #1 that he wanted to sit outside in the sun. She sad then someone came by and asked if we were missing a resident. She said he was gone for maybe five minutes. She said she was unsure of how far he was from the building. She said she did not think that he had eloped because he was not trying to run away or leave permanently. She said he was not cognitively impaired.-However, according to Resident #118's BIMS assessment, he had severe cognitive impairments. The ADON said he was just trying to look around the area. She said it was normal for him to sit out front and watch cars. She said they were unaware that he had left until the community came and asked if a resident was missing. The NHA was interviewed on 8/27/26 at 5:38 p.m. The NHA said she had gotten a phone call from receptionist #1 stating that Resident #118 was down the road and around the corner. The NHA said receptionist #1 said she was headed out to be with him. She said he was not an elopement risk prior to the event and would sit outside. She said he did not exit seek, wander, and was not confused. -However, according to Resident #118's BIMS assessment, he had severe cognitive impairments. The NHA said receptionist #1 told her that she had last seen Resident #118 eight to 10 minutes before the community member asked if they were missing a resident. She said she got to the facility soon after the phone call and was able to drive the van and take him back to the facility. She said he was not sweaty or anything and declined water when they got back to the facility. She said that Resident #118 did not pass any major highways and was exposed to the same amount of heat and cars as he would have been sitting in the front area. She said that nurses were looking for Resident #118 at the same time that the receptionist was with him. She said that education was given to Resident #118 about signing out and he has not had the behavior since. V. Facility follow upThe elopement performance improvement plan (PIP) was provided by the NHA on 8/28/26 at 4:45 p.m. (after the survey) The PIP documented the areas for improvement were the elopement books needed updated, all five of the elopement books needed to match, and that the secured unit residents needed to be added. The PIP documented that all of those areas were completed on 6/17/26. The plan of correction (POC) dated 6/17/26 was provided by the NHA on 8/28/26 at 4:45 p.m. (after the survey) The POC documented that a resident went off property after being let out by staff to sit in the front area. The resident was immediately assessed for injury and was educated on the pass-policy. The resident's elopement assessment and care plan were updated. Staff were educated on elopement evaluation, monitoring residents near exits, elopement books and the locations of the elopement books. The DON, social services director (SSD), NHA or designee to complete audits weekly for 12 weeks and reviewed through QAPI for three months.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one of three abuse allegations. Specifically, the facility failed to thoroughly investigate an allegation of physical abuse involving Resident #1 on 8/2/25 in order to prevent a second incident from occurring on 9/13/25.Findings include:I. Incident of alleged physical abuse between Resident #1 and his spouse on 8/2/2025A. Facility investigation The investigation of the alleged physical abuse incident between Resident #1 and his spouse was provided by the nursing home administrator (NHA) on 11/19/25 at 4:15 p.m. The facility investigation report revealed the witness stated Resident #1 was asking his spouse to leave so he could be alone. The spouse replied to be alone with her, pointing to the female one one-on-one staff member. Resident #1 and his spouse started arguing and the resident was getting closer to the spouse so the spouse put her hand up to stop Resident #1 from getting closer. The spouse's open hand made contact with the resident's chest and Resident #1 moved back slightly, not more than an inch. The witness stated the spouse's hand up was intended to create space but it was not a shove. The witness separated Resident #1 and his spouse and the spouse left the facility and Resident #1 remained with the witness. The alleged assailant (the spouse) was interviewed by the social services director (SSD) and the alleged assailant said Resident #1 wanted to be alone with his girls so she was getting ready to leave and he came up to her and she put her hand up to stop him from getting any closer. -The investigation failed to reveal documentation to indicate the date the interview occurred with the alleged assailant or what questions were asked of the alleged assailant, Resident #1's spouse.-The investigation failed to reveal that a statement was completed by the registered dietitian (RD) who witnessed the 8/2/25 incident to determine what the RD specifically saw related to the alleged pushing of Resident #1 by his spouse. The facility investigation report revealed the resident was kept safe during the investigation by separating Resident #1 and his spouse and the spouse left the facility. The investigation documented that there was education provided to the spouse about safety and de-escalation techniques and to let the facility staff handle the resident when he was agitated. Resident #1 was on one-on-one supervision for an unrelated incident. Resident #1 remained on one-on-one supervision for safety. -However, the investigation failed to reveal documentation that the alleged assailant was unable to enter the facility during the investigation process. -The investigation report failed to reveal documentation regarding when the education was provided to the alleged assailant. The 8/2/25 nurse event note revealed Resident #1's sitter reported the resident was pushed on the chest by his spouse, no fall occurred and the resident was noted to become agitated. Tylenol was given for pain and the resident declined a skin assessment. Resident #1 became combative. There was no visible skin tear or bruising noted at the time of the incident. Staff would continue to monitor the resident for safety. The 8/3/25 nurse behavior note revealed Resident #1's spouse arrived to the unit to take the resident out of the facility. The one-on-one staff member walked off when the spouse asked the resident if he was going to behave the way he did yesterday. Resident #1 appeared anxious but eventually left the facility with the spouse. Resident #1 returned from the outing with his spouse agitated and pacing. A report gathered from the family indicated the resident was not comfortable and wanted to get out of the car. Staff tried to calm the resident after medications and meals and the resident slept for an hour. Resident #1 eventually was back at his baseline. Staff would continue to monitor the resident for safety. The 8/21/25 SSD progress note revealed the SSD spoke with Resident #1's daughter regarding a family meeting with all of Resident #1's children and the spouse. The daughter was receptive to a family meeting regarding Resident #1's care and his spouse's difficulty with adjusting to the situation. The daughter would call the SSD back to schedule a meeting date and time. The 9/5/25 SSD progress note revealed the SSD and the assistant director of nursing (ADON) spoke with Resident #1's spouse. The spouse was encouraged to allow staff to assist Resident #1 when he needed care or assistance. Four staff members were interviewed on 8/3/25. The interview questions were as follows: did you witness the altercation yesterday (8/2/25), if yes what did you see and have you ever witnessed a family member be aggressive with any resident, if yes, what did you see. -However, the questions for the staff interviews failed to ask if they had any knowledge of any prior incidents between Resident #1 and his spouse. B. Alleged assailant interview The alleged assailant, Resident #1's spouse, was interviewed on 11/19/25 at 1:17 p.m. The spouse said she used to visit Resident #1 every day and then the facility restricted her visits. Resident #1's spouse said the facility told her to stay home so she did not interrupt Resident #1's schedule. She said she married him when she was [AGE] years old, had been married for 56 years and she had never been by herself. She said she was learning to be by herself and to keep herself busy. Resident #1's spouse said Resident #1 had declined in his health status since he was admitted to the facility and she said he did not realize she was there and he did not want to do anything when she visited him. She said since Resident #1 has been in the facility she felt like she was not needed. She said when she visited him lately, he slept most of the time and she liked to visit when he was awake and alert. She said Resident #1's sleeping did not do either of them any good. She said she hated going home and being alone. She said she joined a dementia support group and started going to the senior center to meet new people. She said it was hard to adjust; she spent ten years caring for Resident #1 after one of his kidneys was removed and now she was not needed.Resident #1's spouse said there was a meeting on 11/18/25 with the facility, the ombudsman and her children. She said the facility told her she pushed Resident #1 a couple of months ago. She said what happened was she was sitting next to Resident #1 when he was napping for three to four hours. She said he woke up and he told her it was time for her to go and the girls would take care of him. The spouse said the facility said she put her hand on his chest and since two to three staff members said it happened, they decided what happened. She said she did not push Resident #1. She said it did not take much common sense to know that if she was going to hurt Resident #1, she would have hurt him a long time ago. She said a couple of weeks after that visit, there was another time when she visited him and she was told she pushed him. She said the SSD said she would call in three to five days on what she needed to do. She said she did not hear from the SSD until the scheduling of the 11/18/25 meeting. Resident #1's spouse said there was another time she took him out of the facility and Resident #1 was upset with her because he heard he was going to their house and they were going to have company. Resident #1's spouse said he did not want anyone going to their house so she had to pull over because he was trying to get out of the car. She said she was able to call her son-in-law who helped drive him back to the facility (see investigation below). III. Incident of alleged physical abuse between Resident #1 and his spouse on 9/13/25A. Facility investigationThe 9/15/25 event note revealed there was an interdisciplinary team (IDT) meeting held for the aggression Resident #1 received on 9/13/25 when the resident's spouse became agitated when she was attempting to place shoes and glasses on the resident. The intervention was to have the spouse leave the building until further notice. The 9/13/25 event note revealed that at approximately 1:45 p.m., Resident #1 received physical aggression from the wife visiting. There were two witness statements taken on paper and submitted to the SSD. The resident was immediately removed from the situation, fully assessed for injury, skin and pain. The resident was crying and grabbing and hugging the staff saying I'm so sorry honey, I didn't mean to, I'm so sorry. The resident was visibly upset after the event. Bruising on the arm was noted. The pain signs and symptoms score was a 3 out of 10, on a pain scale of 1-10. B. Witness interview Certified nurse aide (CNA) #4 was interviewed on 11/20/25 at 12:43 p.m. CNA #4 said she was familiar with Resident #1 and his spouse. CNA #4 said Resident #1's spouse was allowed to visit and she was controlling about what Resident #1 could do. CNA #4 said Resident #1's spouse's demeanor was mad and aggressive. CNA #4 said Resident #1's spouse would tell him he needed to sit down and say things that upset him and made him cry. CNA #4 said there was one time Resident #1's spouse brought new shoes for the resident and she did not like the way he walked in the new shoes and she was aggravated. CNA #4 said she offered the spouse help and she said she did not need help so CNA #4 left Resident #1's room. CNA #4 said she could hear the spouse yelling at Resident #1. CNA #4 said on the same day, they were putting his shoes on and his glasses fell and he stepped on them. CNA #4 said Resident #1's spouse pushed him out of the way and said Look at what you did. CNA #4 said she told the spouse she had the resident and the spouse did not need to push him. CNA #4 said she walked with Resident #1 up and down the hallway in the unit. CNA #4 said Resident #1 was apologizing and crying. CNA #4 said since then she saw Resident #1 have moments of crying but she did not know what it was from and Resident #1 did not tell her why he was crying. CNA #4 said there were times Resident #1 and his spouse were in his room with the door closed and CNA #4 said she could hear the spouse yelling. CNA #4 said she saw the spouse visit and ask Resident #1 if she could sit with him and if she did not like what Resident #1 said she said fine, stay with your girlfriends and she would leave. CNA #4 said the girlfriend term started when there was one particular CNA who provided one-on-one supervision for the resident. CNA #4 said Resident #1 would converse with the CNA and not with the spouse and that would upset the spouse. CNA #4 said when the spouse was mean to Resident #1, he was agitated after her visits and it was hard to provide care to the resident. CNA #4 said since there were supervised visits, it was easier to feed him, assist him with showers and dress him. CNA #4 said he ate everything since supervised visits and he gained weight. CNA #4 said the resident had slept better since starting supervised visits. IV. Resident #1A. Resident status B. Resident #1's representative interviewResident #1's representative was interviewed on 11/19/25 at 12:26 p.m. The representative said the alleged assailant, Resident #1's spouse, had a hard time accepting Resident #1's dementia and his limitations. She said Resident #1's spouse's whole life had been taking care of Resident #1 and she was mentally struggling since Resident #1 was placed in a nursing facility. She said Resident #1's spouse had a hard time visiting Resident #1 because he liked to walk up and down the hallway and she was unable to walk with him because of her physical limitations. Resident #1's representative said there was a time Resident #1 wanted to walk and his spouse was tired so she made him sit in his wheelchair and made him stay sitting while she visited him. Resident #1's representative said that it was not okay to keep him in his wheelchair if he wanted to walk. Resident #1's representative said it was a relief the spouse's visits were now supervised because of how Resident #1 and his spouse could react towards each other. Resident #1's representative said the restriction of supervised visits once a week for an hour seemed excessive and she was glad the facility agreed to increase the number of visits to twice a week for two hours. C. Record review The weekly visit care plan, initiated 11/19/25, revealed Resident #1 would have two weekly visits with his spouse in the secured unit dining room. Interventions included the spouse could bring snacks and drinks for the resident and the spouse could bring activities to enjoy with the resident during the visit. The resistance to care care plan, initiated 7/1/25 and revised 8/8/25, revealed Resident #1 was resistant to care, an elopement risk, had the potential to invade others' space and was unaware of boundaries, including physical contact related to dementia. Interventions initiated after the 8/2/25 alleged abuse incident included continuing with supervised visits for safety even when the spouse was present and having one-on-one supervision by staff, and educating the resident, the family and caregivers of ways to deescalate situations, initiated 8/4/25. Interventions after the 9/13/25 incident included if the resident or the spouse became agitated, end supervised visitation immediately, initiated 9/15/25 and Resident #1's spouse was not to visit when Resident #1 or his spouse was agitated or aggressive, initiated 9/15/25. Additional interventions included a staff member or another family member must be present with the spouse at all times, and discouraging the resident's spouse from providing any care to the resident, initiated 9/25/25. The aggression care plan, initiated 9/18/25, revealed Resident #1 had the potential to have increased aggression related to dementia. Interventions included discouraging the resident's spouse from providing any care to the resident. The verbal aggressive care plan, initiated 11/18/25, revealed Resident #1 had the potential to be verbally aggressive related to dementia. -However, there were no interventions listed in the care plan on what to do if Resident #1 was verbally aggressive. The 9/18/25 SSD progress note revealed the SSD called to speak with Resident #1's spouse and daughter to explain the new visitation schedule. The spouse was to call the SSD each week before Friday to schedule an hour visit between the hours of 10:00 a.m. and 2:00 p.m. The visit would happen for one hour in the secured unit supervised by a manager or designee. The resident and his spouse would not be left alone during the visitation. The spouse was to come to the front of the building and sign in. The SSD would be called when she arrived to escort the spouse to the secured unit. If there was any agitation that occurred during the visit with the resident or his spouse, the visit would end immediately and the visitation schedule would be evaluated. The SSD asked for one of the children to accompany the spouse for at least the first three visits. Both the spouse and daughter understood. The 9/25/25 behavior note revealed that on 9/17/25 a plan was in place to remove the one-on-one supervision from the resident. The facility would attempt to have the one-on-one sitter removed from the resident. By pulling back, one-on-one supervision would still be there but would be more of a line of sight for one week and monitor the resident's behavior and interaction with other residents and family. The facility would watch for signs of behaviors such as threatening comments, clenching fists, kicking others, pushing others, entering other residents' rooms and personal space, anxiousness and restlessness towards residents and staff. If after one week the resident showed no aggression, the facility would discontinue and remove the one-on-one supervision. Staff were educated on the plan. A psychiatrist appointment was offered to the spouse on 8/25/25 to see if they would be able to manage the resident's behaviors. The spouse agreed with the plan and the referral was placed. The psychiatry office was six weeks behind on referrals at that time. The scheduler was to follow up. A new education was provided to staff in the secured unit on 9/24/25 detailing the resident's specific likes and wants. It explained the ways to redirect the resident if he became agitated or became irritated, such as speaking slowly, providing a quiet environment, and providing a brownie or milk. The facility spoke with Resident #1's physician and explained why the resident was placed on a one-on-one sitter, what was done while he was on one-on-one supervision, the changes in the resident, and that the facility was planning on removing the one-on-one supervision. The physician was in agreement with removing the one-on-one supervision and the . one-on-one supervision was removed during the day on 9/25/25. The facility would follow up with the family as issues arose. At that time, Resident #1 would continue on behavior charting and monitoring and the facility would address any issues as they arose. Social services was aware of the removal of the one-on-one supervision.The 11/5/25 SSD progress note revealed the SSD had a conversation with Resident #1's daughter after both of them spoke with the ombudsman. The daughter wanted to have the visits increased between her parents to two times weekly. The SSD suggested one of the children join the visits to observe them. The spouse continued to ask multiple questions to the resident during the visit and refused to walk with him due to her back problems. The SSD continued to educate the spouse regarding Resident #1's ability to understand multiple questions and if he wanted to walk during the visit, the spouse should walk with him. The daughter understood and said the spouse had the same behaviors when they had family outings and her siblings continued to educate her regarding the same topics. The SSD and the daughter scheduled a meeting with all of the children, the spouse and the ombudsman on 11/18/25. The 11/18/25 SSD progress note revealed a family meeting was held on 11/18/25 with Resident #1's spouse, three children, the ombudsman, a nurse and the SSD. The meeting was held to discuss the spouse being able to receive more visitation time with Resident #1. The spouse received supervised visits due to aggressive behavior with Resident #1. The spouse pushed Resident #1 on two separate occasions and was limited to one hour per week of supervised visits. The visitation schedule had occurred for the last two months. The spouse did well with supervised visitation. It was agreed to allow the spouse to visit two times weekly for two-hour visits. The visits were to occur in the secured unit dining room between 1:00 p.m. and 3:00 p.m. Staff would be educated on the visitation schedule. The spouse was educated that she could not provide any personal care for Resident #1. If the spouse wanted to walk during that time, the spouse was encouraged to walk with him. The spouse was able to bring snacks during the visit. All who were in attendance at the meeting were in agreement with the new visitation schedule and the schedule would be evaluated again after the first of the year. V. Staff Interviews CNA #1 was interviewed on 11/19/25 at 3:21 p.m. CNA #1 said she was familiar with Resident #1. CNA #1 said Resident #1 would strike out and refuse care, such as refusing to shower. She said he exhibited certain behaviors when staff were pushy, demanding, and did not let him have his own space, especially when there were too many people around him and forced him to sit down. CNA #1 said giving him space and distance helped de-escalate his behavior. CNA #1 said Resident #1 did not have the behaviors as often and he was easier to help because his spouse's visits were limited. CNA #1 said there was a time the spouse was aggressive and made Resident #1 sit when he did not want to sit. CNA #1 said she saw the spouse upset and she said it seemed like the spouse was jealous of the caregivers. CNA #1 said she heard the spouse be passive-aggressive to the resident and say Do you want to stay with your girlfriends? CNA #2 was interviewed on 11/20/25 at 10:03 a.m. CNA #2 said she was familiar with Resident #1. CNA #2 said Resident #1 was angry, combative and would strike out at staff. She said Resident #1 had escalated behaviors when staff told him what to do or if staff asked him questions. CNA #2 said the resident would get angry and combative. She said if the staff left him alone and let him walk, his behaviors went away. CNA #2 said Resident #1 had been mellow and quiet lately. She said Resident #1 had other visitors besides his spouse. CNA #2 said she saw him cry after his visitors left the facility. CNA #2 said there was a CNA who was scared of Resident #1's spouse and she no longer worked at the facility. CNA #2 said she saw Resident #1's spouse get upset with the resident. CNA #2 said the spouse closed Resident #1's door and she could hear the spouse yelling at Resident #1. CNA #2 said she heard the spouse yell at the resident not to do that and slammed the door on CNA #4. CNA #2 said before Resident #1's spouse's visits were restricted, his spouse came every day. CNA #2 said she saw the spouse in her car in the parking lot at 6:30 a.m. and she waited until 9:00 a.m. to go into the facility. CNA #2 said she saw the spouse ask Resident #1 if he wanted to speak to her and if he did not answer her, she started to cry and left the building. CNA #2 said she thought Resident #1's spouse was abusive because she heard the spouse yelling at the resident in his room. CNA #2 said every time the spouse visited, Resident #1 cried. CNA #2 said the spouse caused a scene, she was intimidating, and she escalated Resident #1's behavior after she left. CNA #2 said Resident #1 tried to swing and hit the staff. CNA #2 said they tried to redirect the resident when he was escalated. CNA #2 said there was a time the RD provided one-on-one care and Resident #1 asked his spouse to leave. CNA #2 said the spouse was upset and said, Do you want me to leave so you can be with your girlfriends? CNA #2 said she never saw the spouse push the resident but she heard about the day the spouse pushed the resident because he broke his glasses. CNA #3 was interviewed on 11/20/25 at 10:34 a.m. CNA #3 said she was familiar with Resident #1. CNA #3 said Resident #1's spouse showed physical and verbal aggression to Resident #1 about a month or two ago (August/September 2025). CNA #3 said the spouse was upset and angry. CNA #3 said the spouse took Resident #1's hand and yelled at him to just sit down and then he cried. CNA #3 said the spouse accused the resident of having a girlfriend. CNA #3 said the spouse thought all the staff who cared for Resident #1 were his girlfriends. CNA #3 said she did not think the spouse understood Resident #1's dementia and thought the staff would steal Resident #1 from her. CNA #3 said when she saw the spouse upset, the staff intervened by walking with the resident. CNA #3 said the spouse caused a scene by stomping her feet and slamming the resident's room door. CNA #3 said after the spouse visited, Resident #1 had behaviors, such as trying to hit the staff when they provided personal care. CNA #3 said the spouse was what escalated Resident #1's behavior because of her outbursts and she was high-strung. CNA #3 said since the spouse's visits were limited, Resident #1 hardly ever had behaviors.CNA #5 was interviewed on 11/19/25 at 3:19 p.m. CNA #5 said she was familiar with Resident #1. CNA #5 said Resident #1's spouse showed verbal aggression to Resident #1. CNA #5 said the spouse forced Resident #1 in a chair once or twice and would say things like looks like you want me here. CNA #5 said he hit and kicked staff, wandered into other residents' rooms, and urinated on the floor. CNA #5 said since the spouse's visits were limited, Resident #1's behaviors were a lot better and the interventions used were effective. The SSD and the NHA were interviewed together on 11/20/25 at 1:02 p.m. The SSD said she was responsible for meeting with the NHA and the DON to discuss abuse allegations. The SSD said she was responsible for interviewing any residents and staff. The SSD said she documented interviews in a paper notebook. The SSD said she had social service assistants (SSA) who also helped her investigate the abuse allegation. The SSD said for the 8/2/25 incident, her SSA interviewed the alleged assailant because the incident occurred over the weekend. The SSD said she did not talk to the assailant until Monday or Tuesday. The SSD said the interview should have been in the incident file. The SSD said she was not sure who provided education to the spouse after the 8/2/25 incident. The SSD said she reviewed her notes and she saw she talked to the spouse about transportation and how visits should go (see follow-up below). The SSD said she most likely was the one who provided education, but she was unable to find documentation of when she educated the wife. The SSD said for staff interviews, there was a question specific to the resident in the incident. The SSD said for the 8/2/25 incident, the SSA completed the interviews and he did not include a question about Resident #1. VI. Facility follow-up The NHA provided the following documents on 11/21/25 at 7:51 p.m., after the survey exit. The 8/2/25 incident witness statement revealed the RD was asked to perform a repeat demonstration of the RD's witnessed events regarding Resident #1's spouse and Resident #1. Resident #1's spouse was upset Resident #1 did not want to sit and visit with her as he had a tendency to pace the hallways frequently at that time during one-on-one sessions. The spouse became upset and asked the resident if he wanted her to leave and he could spend time with his girls, referring to the female staff members, such as CNAs and nursing staff. A majority of the one-on-one staff members were females as opposed to males. Resident #1 had a tendency to get into others' personal space and he did this with his spouse during the conversation in which his spouse placed her hands on his chest and applied pressure to create distance of approximately three to six inches. The shove was not hard, in the RD's opinion based on her witness testimony, and was not meant to be aggressive or abuse, but was meant to create distance between the two of them. The RD separated the resident and the spouse. The spouse left the facility and the RD spoke with the ADON, the SSD and the NHA. The SSA handled the investigation as he was the associate working in social services the day the incident occurred. The repeat demonstration included the RD to verbally describe the situation and what occurred along with physically showing the team the forcefulness or lack of forcefulness regarding the above situation. The DON described the return demonstration as the RD said the spouse was asked to leave so the resident could be with the girls. The spouse and the resident exchanged words. The resident started to walk towards his spouse. The RD said the spouse pushed the resident to create space between the two of them. The RD said it was a shove but the resident barely moved. The RD said multiple times that the spouse was trying to create space between the spouse and the resident. The RD was asked to complete a return demonstration with the SSD acting as the resident. The RD stood in front of the SSD with feet slightly apart. The RD's arms were straight out and her palms towards the SSD. The RD asked the SSD to walk towards the RD and the SSD walked forward directly into the RD's hands. The RD palms were on her upper chest and shoulder. The SSD was not pushed by the RD. The 8/4/25 SSD note revealed she spoke with the spouse. The SSD asked the spouse about the 8/2/25 incident. The spouse denied pushing the resident and denied doing anything considered aggressive. The spouse said she was frustrated with the resident and told him to stop coming towards her. The spouse said she did not understand why she was asked to leave the facility. The SSD informed the spouse the facility took physical abuse allegations seriously and explained the investigation procedure. The spouse said she understood the procedure. The SSD requested to call the spouse along with her three children to let them know the outcome of the investigation. The spouse agreed and agreed to refrain from visits until the investigation was concluded. The 8/6/25 SSD note revealed she spoke with the spouse and the resident's three children on a conference call. The SSD explained that due to the incident that occurred on 8/2/25, the spouse was to allow the CNAs to provide care and a one-on-one sitter would be in the room at all times with the resident, even when the spouse visited. The SSD encouraged the spouse to walk away or possibly take a drive if she became overwhelmed or frustrated with the resident during visitation. The SSD explained that all transportation for appointments for the resident could be provided by the facility and if the family wanted to transport the resident that one of the children, son-in-law or grandchildren needed to accompany them in the vehicle. All parties stated they understood the education and only wished to keep the resident safe. The SSD explained the facility had the resident's safety and well being as their priority as well as their other residents in the unit.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#42) of two residents out of 50 sample residents reviewed for pressure ulcers. Resident #42, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, developed a stage 3 pressure injury on 5/20/24 at the facility. The resident's care plan for skin breakdown failed to include interventions for repositioning the resident frequently to avoid potential pressure injuries. Observations during the survey revealed staff were not repositioning Resident #42 frequently in order to keep the resident from developing further pressure injuries. Additionally, the resident did not have the physician ordered wound treatment in place when the wound care physician (WCP) came to assess the resident's wound. Furthermore, the facility failed to accurately and consistently document the location of the resident's stage 3 pressure injury. Due to the facility's failures to ensure the resident's plan of care included appropriate pressure injury prevention interventions and ensure the resident was frequently repositioned by the staff, Resident #42 developed a stage 3 pressure injury to her left gluteal fold. 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 from https://www.internationalguideline.com/guideline on 6/12/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy and procedure, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. It read in the pertinent part, Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society). A risk assessment tool (Braden Scale) determines the resident's risk for pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form. A resident's risk may increase due to an acute illness or condition change (for example,upper respiratory infection, pneumonia, or exacerbation of underlying congestive heart failure) and may require additional evaluation. The frequency of assessment should be based upon each resident's specific needs. Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum a pressure redistribution surface (Group 1 mattress) is in use with turning and repositioning as needed with ADL care/assistance, incontinent care if needed to include skin barriers application as needed, preventative wheel chair cushion if indicated. Minimize injury due to shear and friction through proper positioning, transfers, and turning schedules (if indicated). Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care. Reposition at least every 2-4 (two to four) hours as consistent with overall patient goal and medical condition. Utilize positioning devices to keep bony prominences from direct contact. When positioned in a wheelchair, the resident is to be placed on a pressure reduction device and repositioned. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. III. Resident #42 A. Resident status Resident #42, over the age of 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia, prediabetes, muscle weakness and anxiety. The 5/9/24 minimum data set (MDS) assessment documented the resident was rarely/never understood and the brief interview for mental status (BIMS) should not be performed. She had short and long term memory problems and her cognitive skills were severely impaired based on the staff assessment for mental status. She was dependent on staff for all care and mobility. The assessment indicated the resident did not reject care. B. Observations During a continuous observation on 6/6/24, beginning at 9:26 a.m. and ending at 11:35 a.m., the following was observed: At 9:26 a.m. Resident #42 was lying in bed on her back with her eyes closed. At 11:35 a.m. Resident #42 remained in bed on her back. -Staff did not enter the resident's room to reposition the resident during the continuous observation. During a continuous observation on 6/6/24, beginning at 1:07 p.m. and ending at 2:59 p.m., the following was observed: At 1:07 p.m Resident #42 was in bed on her back with her eyes closed. At 2:59 p.m., Resident #42 remained in bed on her back with her eyes closed. -Staff did not enter the resident's room to reposition the resident during the continuous observation. During a continuous observation on 6/11/24, beginning at 9:16 a.m. and ending at 11:51 a.m., the following was observed: At 9:16 a.m., Resident #42 was lying in bed on her back with her eyes closed. At 11:20 a.m., certified nurse aide (CNA) #7 entered the resident's room to provide incontinence care prior to the wound team's arrival. At 11:30 a.m. the wound team arrived to provide treatment to the resident's stage 3 pressure injury. -Staff did not enter the resident's room to reposition the resident during the continuous observation until just before the wound team's arrival. On 6/11/24 at 11:30 a.m. Resident #42's skin was observed with the wound care physician (WCP) and the assistant director of nursing (ADON). When the resident's brief was removed and she was rolled to the side, the physician ordered treatment was not on the wound. There was a small, open reddened area to the left gluteal fold. C. Record review Resident #42's skin integrity care plan, updated on 9/17/19, documented the resident was at risk for breaks in skin integrity due to limited mobility, weakness and incontinence. The interventions included keeping the skin clean and dry and performing weekly skin checks. -The care plan did not address the resident's risk for pressure injury or document the resident had a stage 3 pressure injury. -The care plan failed to include an intervention for repositioning and turning of the resident. The weekly skin check completed on 5/10/24 documented Resident #42 had no skin issues. The Braden Scale assessment completed on 5/17/24 documented Resident #42 was at high risk for developing pressure ulcers with a score of 11 out of 18. A late entry progress note dated 5/17/24 documented an area to the right gluteal fold with redness and a small open area. A referral was made to the in house WCP and notifications were made to the resident's provider and the DON. -The progress note documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and WCP note below). -The weekly skin check completed on 5/18/24 documented the skin check was not performed due to the resident sleeping. A progress note dated 5/21/24 documented the resident was seen by the wound care team regarding the left gluteal fold. The weekly skin check completed on 5/25/24 documented an issue with the right gluteal fold. -The weekly skin check documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and wound tracker note below). The wound observation tool completed on 5/28/24 documented the resident had a stage 3 pressure injury that was facility acquired on 5/20/24 to the left gluteal fold. Treatment included an air mattress and washing the wound with wound wash, and apply substance P (a wound healing treatment, honey and foam daily. The weekly skin check completed on 6/1/24 documented an ongoing issue with the right gluteal fold. -The weekly skin check documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and wound tracker note below) A review of the June 2024 CPO documented the following physician's orders: Cleanse area to right gluteal fold every day and as needed for soiling with wound wash, pat dry, apply medihoney and cover with foam dressing until resolved, ordered 5/28/24. -The physician's order, started on 5/28/24, documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and wound tracker note below) The wound tracker documentation on 5/28/24 identified a stage 3 pressure wound to the left gluteal fold, measuring 1.2 centimeters (cm) by 1.4 cm by 0 cm, with minimal serous drainage (drainage that forms as a clear, thin and watery fluid). The plan of care recommendations indicated the wound was to be washed with wound wash, and apply substance P, honey and foam daily. E. Staff interviews The WCP was interviewed on 6/11/24 at 11:38 a.m. The WCP said Resident #42's wound was a stage 3 pressure injury most likely caused by the edge of the incontinence brief on the resident. He said the resident should not have developed the wound. The WCP said he wanted the staff to reposition the resident frequently and offload when in bed. The ADON was interviewed on 6/11/24 at 11:38 a.m. The ADON said Resident #42 had a pressure injury and she was surprised it had developed. She said the staff should be repositioning the resident frequently and offloading the resident when she was in bed. CNA #4 was interviewed on 6/11/24 at 4:00 p.m. CNA #4 said residents with pressure injuries or who were at risk for pressure injuries should be repositioned every two hours to prevent further injuries and assist with healing. The director of nursing (DON) was interviewed on 6/11/24 at 4:00 p.m. The DON said all residents with pressure injuries or who were at risk of developing pressure injuries should be repositioned every two hours to prevent and help heal pressure injuries.

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 on two of four units. Specifically, the facility failed to ensure glucometers were cleaned in a sanitary manner. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Considerations for Blood Glucose Monitoring and Insulin Administration (2024), was retrieved on 6/18/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. It read in pertinent part, Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus, hepatitis C virus, human immunodeficiency virus (HIV) and other infections. Unsafe practices include: using fingerstick devices for more than one person, using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. II. Manufacturer' s guidelines The Assure Prism Blood Glucose Meter manufacturer cleaning and disinfecting guidelines. (April 2023), were retrieved on 6/17/24 from https://arkrayusa.com/diabetes-management/professional-healthcare-products/assure/assure-prism-multi/. It included the following recommendations in pertinent part, Each time the cleaning and disinfecting procedure is performed, two wipes are needed; one wipe to clean the meter and a second wipe to disinfect the meter. Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from meters. Meter surfaces must remain wet according to contact times listed on the wipe manufacturer' s instructions. Once complete, wipe the meter dry. The PDI Super Sani Cloth disinfecting wipes manufacturer guidelines (2024), were retrieved on 6/17/24 from https://pdihc.com/in-service/super-sani-cloth-disinfecting-wipes/. It included the following recommendations in pertinent part, Bactericidal, Tuberculocidal and Virucidal, effective for 30 microorganisms with a contact time of two minutes. III. Observations On 6/10/24 at 11:02 a.m. registered nurse (RN) #4 took an unlabeled glucometer out of medication cart #1. He was using the unlabeled glucometer to check Resident #64' s lunchtime blood glucose. He took the glucometer to the resident' s room and completed the blood glucose check. He returned the glucometer back to the medication cart and placed it into the drawer. -RN #4 did not clean or disinfect the glucometer. On 6/11/24 at 11:37 a.m. licensed practical nurse (LPN) #1 took an unlabeled glucometer out of medication cart #2 to check Resident #22' s lunchtime blood glucose. She took the glucometer to the resident' s room and completed the blood glucose check. She returned to the medication cart and used a PDI Sani Cloth disinfecting wipe and wiped off the glucometer. She then placed the glucometer in a cup to dry. -The glucometer was not visibly wet for two minutes. IV. Staff interviews LPN #1 was interviewed on 6/10/24 at 11:45 a.m. LPN #1 said glucometers must be cleaned after every use. She said the glucometers were wiped off with the PDI Sani Cloth wipes. She said after they were wiped off, glucometers needed to be allowed to dry for two minutes. The director of nursing (DON) was interviewed on 6/10/24 at 1:09 p.m. The DON said nursing staff had been following the [NAME] guidance (a nursing resource for nursing procedures) for cleaning and disinfection of glucometers. She said nursing staff should be cleaning and disinfecting glucometers after each use between residents. She said the [NAME] had recommended not wrapping glucometers with towelettes to keep the glucometer wet. She said glucometer manufacturer guidelines should be used for the cleaning and disinfection of the glucometer. She said the manufacturer guidelines should be used for contact disinfection times for PDI Sani Cloth disinfection wipes. She said she would provide education regarding the manufacturers' recommendations to RN #4 and LPN #1, as well as the day shift nursing staff and the oncoming nursing staff.

Based on interviews and record review, the facility failed to honor resident choices for two (#25 and #84) of two out of 50 sample residents. Specifically, the facility failed to ensure an effective system was established to honor and allow residents to make choices regarding their daily care. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, reviewed September 2023, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. It revealed, in pertinent part, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to reside and receive services in the facility with reasonable accommodation of resident and preferences except when to do so would endanger the health or safety of the resident or other residents. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. II. Resident #25 status Resident #25, age 79, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included vascular dementia, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body). The 3/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent upon staff for all activities of daily living (ADL). The assessment indicated that it was very important to him to choose what time he goes to bed. A. Resident interview Resident #25 was interviewed on 6/5/24 at 4:04 p.m. Resident #25 said all he ever did was lay in bed. He said the staff never asked him when he wanted to get up or go to bed, they just did everything when they wanted to. He said is it too much to ask for them to ask me what I want for a change. He said he would like to be up and out of bed before lunch. He said the facility staff always came into his room too early to get him up and when he would tell them no, they would not come back to ask him to get up later. He said the facility never set up a time schedule for him for his daily routine. He said he did not remember ever being asked about what time he would like to wake up, go to bed, or anything about his preferences for daily activities. B. Record review The ADL self-care deficit care plan, revised on 3/12/24, documented the resident had a self-care deficit due to left hemiplegia following a CVA (cerebral vascular accident), dementia/cognitive impairment, debility, limited mobility and weakness. It indicated that the resident required total assistance by staff members for ADLs. The interventions included encouraging the resident to participate to the fullest extent possible, encouraging the resident to use the call light for assistance, praising all efforts made by the resident, a physical therapy and occupational therapy evaluation and treatment as ordered and observing for any changes. -The comprehensive care plan did not indicate the resident's daily preferences. The 1/26/24 activities evaluation documented the resident varied with times he preferred to wake up and go to bed. The resident s Kardex (quick reference for the resident's care) did not indicate the resident's preferences for his daily care. II. Resident #84 A. Resident status Resident #84, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included fracture of the right femur and major depression. The 5/14/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. He was dependent upon staff for toileting, showering, dressing and required substantial assistance with personal hygiene. The resident exhibited daily episodes of physically and verbally aggressive behaviors directed at others. B. Record review The June 2024 CPO documented the following: -CPAP/BIPAP (continuous positive airway pressure / bilevel positive airway pressure) settings at 16/10 on 3 liters (L); CPAP/BIPAP on while sleeping and off while awake, ordered 2/29/24. The behavioral care plan, initiated on 5/14/24, documented the resident could become verbally and physically aggressive towards staff, as well as resistive to care. The interventions included anticipating and meeting the resident's needs, assessing the resident for triggers for his behavior, explaining all procedures to the resident before starting and allowing the resident a few minutes to adjust when placing the BIPAP on the resident, letting him know you are placing the BIPAP and if he refuses, contact the resident's responsible party to speak with him on the phone. The 5/22/24 nursing progress note documented at 5:19 a.m. revealed the resident wore his CPAP without any issues and slept through the night until 4:55 a.m. when he requested to be changed and wanted the mask removed. The staff said his representative wanted him to wear it longer, however he responded, I don' t care, I want it off. The 5/27/24 nursing progress note documented at 5:53 a.m. revealed it took several times to get the resident to put his CPAP on last night. He told staff, No, I' m still watching tv (television) and don' t want it yet. It indicated the resident would only put on the mask when he was ready. Upon telling the resident that they were notifying his representative, the resident responded, What the [expletive] you calling her for, I will put it on when I' m ready. On 5/27/24 at 10:41 p.m. the nursing progress note documented the certified nurse aide (CNA) entered the resident's room to ask him if he was ready to put the CPAP on and he responded, No, it's too early, I' m watching the game. On 5/28/24 at 1:37 a.m. the nursing progress note documented the nurse went in twice to put the CPAP mask on the resident, however he continued to refuse saying it was too early and he was not ready yet. However, when the CNA approached the resident later on, he was agreeable. The 6/9/24 nursing progress note documented at 10:53 p.m. revealed the resident continued to refuse to put on the CPAP machine after staff attempted several times. The resident took the mask and threw it to the foot of the bed. The nurse contacted the resident's responsible party who said she would come over to assist. -At 11:36 p.m. the nurse documented the resident allowed the placement of the CPAP machine after he was done watching television. -The facility failed to identify Resident #84 preferred to stay awake and watch television late into the night and early morning and would consistently refuse to wear the CPAP when he was approached too early. -By failing to identify the resident's preference and put together a schedule that was agreeable for the resident, he exhibited verbally and physically aggressive behavior because he did not want to don the CPAP until he was ready. III. Staff interviews Registered nurse (RN) #2 and RN #7 were interviewed on 6/11/24 at 2:30 p.m. RN #2 said she was not sure who asked the residents about their preferences for waking up and going to bed. RN #7 said she was not aware of a system the facility had in place to determine each resident's preferences. RN #2 said the CNAs were responsible for getting residents up in the morning and putting them to bed. RN #2 said there was not an established schedule. RN #2 said the CNAs did what worked best for them. RN #2 and RN #7 said they had both worked with Resident #84. RN #2 said he had a lot of behaviors which included trying to bite staff, yelling and screaming at staff and non-compliance. RN #7 said Resident #84 was particularly non-compliant with the use of the CPAP machine. RN #7 said he would yell at the CNAs or nurses, using foul language because he was not ready to put it on his face. RN #2 said she had not realized the trend that the resident liked to go to bed late at night and that he would become upset and yell about the CPAP when he was approached to go to bed earlier in the night. RN #7 said it would be helpful if the facility had a system to determine resident preferences and it could potentially have a positive effect on Resident #84's behavior of non-compliance and yelling at staff. CNA #7 was interviewed on 6/11/24 at 3:25 p.m. CNA #7 said the CNAs were responsible for assisting residents with getting up in the morning and putting them to bed at night. She said she did not follow a schedule, but usually went room by room to help residents the quickest. CNA #7 said she worked with Resident #25 often. She said she did not know what time he liked to get up in the morning or what time he liked to go to bed. She said she was not aware of a system at the facility that documented or indicated a resident preference in getting up and going to bed. CNA #7 said she often worked with Resident #84. She said she did not work with him at night, but had heard from other staff that the resident would become verbally and physically aggressive late at night because he did not want to wear the CPAP machine. She said she was not aware if the resident liked to get up at a certain time or go to bed at a certain time. She said that information was not documented on the Kardex. The activity director (AD) was interviewed on 6/11/24 at 4:50 p.m. The AD said she conducted an activity assessment upon each resident's admission and annually. She said within the activity assessment, there was a section that included the preferences of the resident to rise and go to sleep. She said the assessments were found in the resident's medical record and in a binder in the activity office. The AD said she was not aware if the nursing staff read her assessment. She said the facility did not have a process to take that information and ensure the CNAs and nurses were aware so the residents' preferences were followed. The NHA was interviewed on 6/11/24 at 5:32 p.m. The NHA said the activity staff were responsible for obtaining the resident preferences during their initial and annual assessment. She said the facility did not have a system in place to take that information and apply it to ensure the resident preferences were being honored.

Based on observations and staff interviews the facility failed to provide services for three (#24, #47, #157) of three residents out of 50 sample residents according to professional standards of practice. Specifically, the facility failed to: -Ensure safe medication administration practices were followed by administering medications immediately after preparation and not storing unadministered medications; and, -Ensure medications were not left at the bedside. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, page 606-607, retrieved on 6/12/24, It read in pertinent part, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. Odberg, K. R., [NAME], B. S., and Wangensteen, S. (April 2019). Medication administration in nursing homes: A qualitative study of the nurse role. National Library of Medicine, was retrieved on 6/13/24 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419124/. It read in pertinent part, The medication administration process consists of six stages: ordering and prescription, transcribing, dispensing, preparing, administering, and finally observing and documenting effects and side effects. Medication administration errors may occur anywhere along this chain and cause an adverse drug event. Many factors influence safe medication management. Some argue that nurses may have insufficient knowledge and skills to perform safe medication management, others point to normalization of risk inducing behavior and interruptions. II. Facility policy and procedure The Administration of Medications policy, dated 8/24/23, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. It read in pertinent part, Medication error means the observed or identified preparation or administration of medications or biological which is not in accordance with accepted professional standards and principles which apply to professionals providing services. Right drug. Compare the label on the drug to the information on the medication administration record three times including before removing the container from the drawer, as the drug is removed from the container and at the bedside before administering it to the resident. Do not prepare unmarked drug containers or illegible containers. Be sure to verify drugs at the patients' bedside with the MAR and two patient identifiers. III. Resident #24 A. Resident status Resident #24, age 74, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (a lung condition causing breathing problems), venous insufficiency (causing swelling in the legs), chronic pain and fibromyalgia (a disorder causing widespread pain). The 4/5/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15 and had no behaviors. She required supervision or touching assistance to perform bed mobility, transfers, toileting and bathing. B. Record review The June 2024 CPO revealed the following physician's orders: Torsemide 20 milligrams (mg), give one tablet by mouth one time per day for edema (swelling), ordered 4/16/24; and, Lidocaine External Patch 4%, apply to the upper back topically one time a day for pain, ordered 5/11/23. C. Observations During a continuous observation on 6/10/24 beginning at 7:51 a.m. and ending at 8:15 a.m. the following was observed: Licensed practical nurse (LPN) #1 was preparing and administering medications. LPN #1 retrieved the torsemide 20 mg from the medication cart and placed it in a medication cup. LPN #1 entered Resident #24's room to administer the medication. Resident #24 refused the torsemide medication during the administration. LPN #1 placed the cup with the torsemide in it, on the resident's table next to the bed, and then left the room. -LPN #1 left the medication in the resident's room unattended. -Additionally, LPN #1 removed a lidocaine patch 4% from the medication cart. She took it out of the packet, initialed and dated it, but did not place it on the resident. She put the lidocaine patch in the top drawer of the medication cart while she administered the rest of Resident #24's medications. D. Staff interviews LPN #1 was interviewed on 6/10/24 at 7:51 a.m. LPN #1 said Resident #24 often refused to take the torsemide medication. She said she put that medication in a separate cup so that if the resident declined it, she could waste the pill and mark it accordingly on the medication administration record (MAR). LPN #1 confirmed that after she had attempted to administer Resident #24's medications, she had left the torsemide in a cup at the resident's bedside. She said by leaving the medication at the resident's bedside, there was a risk of another resident entering the room and ingesting the medication. She said she would retrieve the medication immediately. LPN #1 said she typically waited until after Resident #24 took her shower before putting on the Lidocaine patch. She said she should have waited until after the resident showered before pulling the lidocaine patch to administer. She said medications should not be pre-pulled. Registered nurse (RN) #6 was interviewed on 6/10/24 at 9:00 a.m. RN #6 said medications should not be pre-pulled or pre-poured before administration. She said that was considered a safety issue. She said the lidocaine patch should not have been prepared beforehand and stored in the cart. She said this was a safety issue and medications that were pre-prepared could be confused between residents. The director of nursing (DON) was interviewed on 6/11/24 at 10:00 a.m. The DON said medications should not be left at the bedside. She said it was a safety concern for other residents potentially ingesting the medication. 47350 IV. Resident #47 A. Resident status Resident #47, age 77, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia, gait abnormalities and tremors. The 5/21/24 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. She required set-up assistance with toileting and was independent with eating, personal hygiene, bed mobility and transfers. B. Observations On 6/11/24 at 5:15 p.m., on medication cart #2, the following was observed with LPN #2: -A medication cup, unlabeled, with multiple tablets in it. V. Resident #157 A. Resident status Resident #157, age 73, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included anoxic brain damage (brain damage due to lack of oxygen) and heart disease. The 6/4/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial/maximal assistance with toileting, personal hygiene, partial/moderate assistance with bed mobility, transfers and was independent with eating. B. Observations On 6/11/24 at 5:23 p.m., on medication cart #3, the following was observed with RN #5: -A medication cup, unlabeled, with crushed medication mixed into chocolate pudding. C. Staff interviews LPN #2 was interviewed on 6/11/24 at 5:18 p.m. LPN #2 said she had been unable to administer Resident #47's medications because activities staff were with her. She said she was waiting for them to finish and had placed the medications in the medication cup in the medication cart. The director of nursing (DON) was interviewed on 6/11/24 at 5:20 p.m. The DON said if medications could not be immediately administered they must be destroyed in the drug disposal system. She said medications could not be stored once they had been removed from their original container. She said medications should not be prepared or stored before residents were able to take them. She said interruptions in the medication preparation and administration process may contribute to human error and contribute to avoidable potential medication errors by administering wrong drugs to wrong residents and at wrong times. She said she would provide education to LPN #2 and RN #5 regarding preparing, pulling and storing drugs before residents were able to take them. RN #5 was interviewed on 6/11/24 at 5:23 p.m. RN #5 said Resident #157 had refused to take his medications until dinner time. She said she did not dispose of his medication because it had to be crushed and she did not want to waste the medication.

Based on record review and staff interviews, the facility failed to implement an effective antibiotic stewardship program that included an effective system of identification of newly prescribed antibiotics, tracking prophylactic antibiotic use and tracking infections that were prescribed antibiotics for four (#103, #84, #73, #60) of four residents out of 50 sample residents. Specifically, the facility failed to: -Track and monitor the use of short-term antibiotics which were prescribed for Resident #103 and Resident #84; and, -Track and monitor the use of long-term/prophylactic antibiotics which were prescribed for Resident #73 and Resident #60. Findings include: I. Professional reference According to The Centers for Disease Control and Prevention (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes (3/19/24), retrieved on 6/17/24 from https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-b-508.pdf, Completeness of clinical assessment documentation at the time of the antibiotic prescription. Incomplete assessment and documentation of a resident's clinical status, physical exam or laboratory findings at the time a resident is evaluated for infection can lead to uncertainty about the rationale and/or appropriateness of an antibiotic. Completeness of antibiotic prescribing documentation. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing elements have been addressed and recorded. These elements include: dose (including route), duration (start date, end date and planned days of therapy), and indication (rationale and treatment site) for every course of antibiotics. II. Facility policy and procedure The Antibiotic Stewardship policy and procedure, reviewed 5/19/23, was provided by the nursing home administrator (NHA) on 6/11/24 at 3:00 p.m. It read in pertinent part, The antibiotic stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic resistant organisms and/or other adverse events. Antibiotic time out. At 72 hours after antibiotic initiation or first dose in the facility, each resident should be reassessed for consideration of antibiotic need. Interventions for syndrome specific antibiotic use and antibiotic prophylaxis. The AST (antibiotic stewardship team) will identify actions to directly impact inappropriate antibiotic use for specific syndromes and for prophylactic indications. Tracking. Process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of SBAR's (situation, background, assessment, recommendation) and other clinical documentation during clinical meetings and ongoing reviews of the completeness of prescribing documentation to include dose, route, duration and indication for use. III. Resident #103 A. Resident status Resident #103, age 67, was admitted on [DATE] readmitted [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation (irregular heart beat), type II diabetes mellitus and pulmonary nodule. B. Record review The June 2024 CPO documented the following physician's order: Amoxicillin (antibiotic) oral tablet 500 mg (milligrams), one tablet by mouth three times a day for a urinary tract infection (UTI) for 10 days, ordered 6/4/24 and discontinued 6/14/24. The 6/4/24 nursing progress notes documented Resident #103 was readmitted from the hospital with a diagnosis of UTI and dehydration after being transferred for confusion and blood in his urine catheter bag. It documented the resident had received antibiotics while at the hospital. It documented the resident was readmitted with a new order for Amoxicillin. The 6/4/24 facility antibiotic checklist indicated Resident #103 had been started on Amoxicillin for a diagnosis of UTI and the results of the laboratory work were at the hospital. -However, there was no documentation in the resident's electronic medical record (EMR) to indicate a urinalysis (UA) or cultures and sensitivity (C&S) (a laboratory test which identifies bacteria type and what antibiotics are best used to effectively treat the infection) were completed at the hospital. There was no documentation in the EMR to indicate the facility had followed up with the hospital in order to determine the appropriateness of the prescribed antibiotic to effectively treat the resident's UTI. -There was no infection surveillance line listing report provided for June 2024 that indicated the facility had monitored Resident #103's antibiotic use to ensure the resident's signs/symptoms of UTI, laboratory work or McGeer's criteria were met for the prescribed Amoxicillin. IV. Resident #84 A. Resident status Resident #84, age 82, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included right femur fracture, pulmonary embolism (blood clot) and Hodgkin's lymphoma (cancer). B. Record review The June 2024 documented the following physician's order: Keflex (antibiotic) oral capsule 500 mg four times a day for prophylaxis (prevention) for an infection due to a superficial venous thrombosis, ordered 6/7/24 and discontinued 6/14/24. The 6/7/24 nursing progress note documented Resident #84's sister had requested an antibiotic prescription for Keflex to be started as a prescription for the antibiotic had been sent to a local pharmacy. It documented a discussion by the facility with the emergency department (ED) regarding recommendations for the oral Keflex. The recommendations were discussed with the sister but she wanted the Keflex to be prescribed at the facility because a prescription had been sent to the pharmacy. The physician informed the sister/power of attorney (POA) the Keflex would be prescribed. -There was no documentation in Resident #84's EMR to indicate an antibiotic checklist for the Keflex had been completed. -There was no infection surveillance line listing report provided for June 2024 that indicated the facility had monitored Resident #84's antibiotic use to ensure the resident's signs/symptoms of infection, laboratory work or McGeer's criteria were met for the prescribed Keflex. V. Resident #73 A. Resident status Resident #73, age 66, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included Parkinson's disease (involuntary movement disorder) asthma and type II diabetes mellitus. B. Record review The June 2024 CPO documented the following physician's order: Nitrofurantoin (antibiotic) capsule 50 mg by mouth once a day for UTI prophylaxis, ordered 4/6/24. The 4/5/24 nursing progress/order note documented the Nitrofurantoin capsule 50 mg once a day for UTI prophylaxis failed a general dose range check based on drug and patient information provided. The drug dose needed to be adjusted based on renal function and manual screening was required. The 4/8/24 physician progress note documented Resident #73 was on Nitrofurantoin for urinary retention. -There was no documentation in Resident #73's EMR to indicate an antibiotic checklist for Nitrofurantoin had been completed. -The April 2024 infection surveillance line listing report documented Resident #73 was on Nitrofurantoin for prophylaxis and did not meet McGeer's criteria, which included a fever of 100.4 degree Fahrenheit, new or increased burning when urinating, urgency and frequency, new pain/tenderness in flank or suprapubic area, change in urine appearance, foul smell, blood in urine or a decline in mental or functional status. .-The May 2024 infection surveillance line listing report failed to document Resident #73 continued on Nitrofurantoin or if the resident's signs/symptoms of infection, laboratory work and McGeer's criteria were met (see criteria listed above). -The June 2024 infection surveillance line listing report failed to document Resident #73 continued on Nitrofurantoin or if the resident's signs/symptoms of infection, laboratory work and McGeer's criteria were met (see criteria above). VI. Resident #60 A. Resident status Resident #60, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included hemorrhagic cerebral vascular accident (stroke), dementia and hypertension (high blood pressure). B. Record review The June 2024 CPO documented the following physician's order: Nitrofurantoin oral capsule 50 mg by mouth once a day for recurrent UTI prophylaxis, ordered 3/4/23 and discontinued 5/2/24. The 4/24/24 UA report documented the resident was negative for nitrites (produced by bacteria in a UTI) and had white blood cells present (may indicate presence of an infection). It documented no further culture and sensitivity workup was required. The 5/2/24 urine C&S documented the resident had greater than 100,000 Escherichia Coli (a bacteria) that was resistant to Nitrofurantoin. -There was no documentation in Resident #60's EMR to indicate an antibiotic checklist for Nitrofurantoin had been completed. -The March 2024 infection surveillance line listing report failed to document Resident #60 was on Nitrofurantoin or if the resident's signs/symptoms of infection, laboratory work and McGeer's criteria, which included which included a fever of 100.4 degree Fahrenheit, new or increased burning when urinating, urgency and frequency, new pain/tenderness in flank or suprapubic area, change in urine appearance, foul smell, blood in urine or a decline in mental or functional status, were met. -The April 2024 infection surveillance line listing report failed to document Resident #60 continued on Nitrofurantoin or if the resident's signs/symptoms of infection, laboratory work and McGeer's criteria were met. -The May 2024 infection surveillance line listing report failed to document Resident #60 continued on Nitrofurantoin or if the resident's signs/symptoms of infection, laboratory work and McGeer's criteria were met. VII. Staff interviews The director of nursing (DON), who was the infection preventionist (IP), was interviewed on 6/11/24 at 9:03 a.m. The DON said the facility followed the McGeer's criteria for antibiotic stewardship. She said when an antibiotic was ordered, an antibiotic checklist was filled out by the nurse and turned into the IP, so it could be reviewed and input into the facility's infection surveillance computer portal. She said the portal was the facility's line item tracking system that documented the checklists regarding signs/symptoms, laboratory work, if the infection was reportable and whether it met the McGeer's criteria. The DON said if a resident was on an antibiotic for more than 30 days she did not track it. She said to track trends in infections and antibiotic use, she previously used a mapping system where she color coded the infection and antibiotics. She said she no longer used mapping to track trends, she just followed the infection surveillance line listing on the facility's computer portal. She said after it was identified that antibiotics were started without a checklist completed or received by the IP there was not accurate tracking of who was on antibiotics. She said the facility's current system in place was not a good system. Registered nurse (RN) #5 was interviewed on 6/11/24 at 11:15 a.m. RN #5 said when a new antibiotic was ordered it was placed on the alert log book and the IP, DON and assistant director of nursing (ADON) were notified. She said the log book was reviewed during morning meetings with staff and managers. She said she was not aware of an antibiotic checklist form that needed to be filled out and returned to the IP. She said when a resident presented with UTI or upper respiratory infection (URI) symptoms or any other infection, she notified the provider and followed their directions. Licensed practical nurse (LPN) #1 was interviewed on 6/11/24 at 11:20 a.m. LPN #1 said when a resident presented with symptoms of a UTI, URI or other possible infection she would call the provider. She said if an antibiotic was ordered, the antibiotic checklist with the McGeer's criteria was completed and turned into the IP to be reviewed. She said documentation of the symptoms and notification of the provider was documented in the EMR. The nursing home administrator (NHA) was interviewed on 6/11/24 at 5:32 p.m. The NHA said the facility's infection control program, which included antibiotic stewardship, was reviewed monthly during the facility quality assurance (QA) meeting. She said the percentage of infections for the month were reviewed and compared to previous months. The NHA said the DON had recently taken the position of DON, but had been the IP for a while. She said when the DON took over her new position, the facility hired an IP, who left the position abruptly in April 2024. The NHA said all antibiotic usage should meet the McGeer's criteria prior to the administration of the antibiotics and all antibiotic usage should be tracked and trended. She said she had seen the tracking of antibiotic usage in the past, but she thought that because the IP had left abruptly, the DON just did not have the time to follow through with the antibiotic stewardship program.

Based on observations, record review and interviews, the facility failed to ensure two (#26 and #25) of two residents with limited mobility reviewed for range of motion (ROM) out of 50 sample residents received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to: -Apply splints to ensure Resident #26 did not have a worsening contracture; and, -Ensure Resident #25 was placed on a restorative nursing program program, which was recommended by physical therapy. Findings include: I. Facility Policy The Splints and Braces policy and procedure, dated 1/16/24, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. The policy documented in pertinent part, The facility will provide splints and braces to upper extremities in accordance with professional standards of practice. The Restorative Nursing policy and procedure, reviewed 9/11/23, was provided by the NHA on 6/11/24 at 7:41 p.m. The policy documented in pertinent part, To promote the resident ' s optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident ' s assessments and indicators. Nursing assistants must be trained in the techniques that promote resident involvement in restorative activities. Restorative programs may be initiated by nursing and/or therapy. Procedure 1. Accurate and thorough assessment of the patient is fundamental in determining the patient ' s need for restorative services. 2. Restorative indicators are patient specific information that when alone or combined with other indicators establish the level of patient ' s restorative potential. 3. Restorative indicators may be identified by multiple disciplines utilizing various assessments, physician orders, progress notes, environmental factors, caregiver conversations, and any other means of communication. 4. Restorative Nursing Functions can be within one of the following categories: a. Range of Motion (Active and Passive) b. Splint or brace assistance c. Bed mobility d. Transfers e. Walking f. Dressing and/or grooming g. Eating and/or swallowing h. Amputation/prosthesis care i. Communication j. Toileting program k. Bladder retraining 5. Communicate the restorative care plan and care directives to other members of the interdisciplinary team. 6. Provide resident/caregiver teaching regarding the restorative care plan. 7. The trained CNA will document provided techniques per the restorative care plan in the medical record. 8. The licensed nurse will conduct an evaluation on a routine basis, to include progress towards goal and response to the program. Any changes will be documented in the medical record. The restorative care plan and care directive will be reviewed/revised as indicated. 9. Restorative Nursing does not require a physician order. It only requires a physician order when combined with therapy services or when it is a state specific requirement. 10. The Restorative Nursing Program is based on the RAI (resident assessment instrument) User ' s Manual. Individual states may apply more specific rules regarding implementation of the program and documentation requirements. Refer to your state specific requirements as indicated. II. Resident #26 A. Resident status Resident #26, over the age of 65, was admitted on [DATE]. According to the June 2024 computerized physicians orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (paralysis) following cerebral infarction (stroke) affecting right dominant side, contracture of the right elbow, contracture of unspecified joint and dementia. The 4/1/24 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) should not be conducted due to the resident rarely/never understanding. Resident #26 was identified with short and long term memory problems, cognitive skills that were severely impaired through staff assessment. The resident was dependent on staff for dressing, personal hygiene and transfers. The assessment indicated the resident had verbal behavioral symptoms directed towards others one to three days during the review that did not include rejection of care. B. Observations On 6/5/24 at 11:02 a.m. Resident #26 was sitting in his wheelchair with his right arm contracted to his chest. He was not wearing any contracture therapy devices on his right hand to protect his palm. His right hand was balled up with his fingers touching his palm. On 6/6/24 at 11:26 a.m. Resident #26 was sitting in his wheelchair with his right arm contracted to his chest. He was not wearing any contracture therapy devices on his right hand to protect his palm. His right hand was balled up with his fingers touching his palm. On 6/11/24 at 11:06 a.m., Resident #26 was sitting in his wheelchair with his right arm contracted to his chest. He was not wearing any contracture therapy devices on his right hand to protect his palm. His right hand was balled up with his fingers touching his palm. C. Record review A review of the care plan revised on 5/1/24 revealed a focus for an alteration in musculoskeletal status related to contractures to the right shoulder and hand. The care plan specified interventions included cleansing the right hand with soap and water, patting dry, folding a washcloth and placing the thumb, fingers and palm as he allowed. A review of Resident #26 ' s behavior tracking revealed the resident did not refuse care or have any behaviors on the days he was observed without the splint (6/5/24, 6/6/24 and 6/11/24). D. Staff interviews The director of nursing (DON) was interviewed on 6/11/24 at 1:20 p.m. The DON said the staff on the secured unit, particularly the nurse on shift, should be placing the washcloth on Resident #26 daily and she would provide the staff an inservice immediately. The MDS nurse was interviewed on 6/11/24 at 2:15 p.m. The MDS nurse said Resident #26 had used a brace in the past but he removed it, causing an increase in the severity of his contracture so they switched to the washcloth. The MDS nurse said Resident #26 continued to remove the washcloth at times and the only solution left for him was to have surgery. 38185 III. Resident #25 A. Resident status Resident #25, age 79, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included hemiplegia and hemiparesis. The 3/27/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent upon staff for all activities of daily living (ADL). B. Resident interview Resident #25 was interviewed on 6/5/24 at 4:04 p.m. He said all he ever did was lay in bed. He said the facility staff did not get him up or provide any range of motion exercises. He said all he wanted to do was to get up and move around. He said he had received physical therapy a couple of months prior, however he had not had any for a while. He said he was not placed on a range of motion (ROM) maintenance program after the physical therapy was discontinued. C. Record review The ADL self-care deficit care plan, revised on 3/12/24, documented Resident #25 had a self-care deficit due to left hemiplegia following a CVA (cerebral vascular accident), dementia/cognitive impairment, debility, limited mobility and weakness. It indicated the resident required total assistance by staff members for ADLs. The interventions included encouraging the resident to participate to the fullest extent possible, encouraging the resident to use the call light for assistance, praising all efforts made by the resident, a physical therapy and occupational therapy evaluation and treatment as ordered and observing for any changes. The therapy services care plan, initiated on 2/24/24, documented the resident required therapy services to maintain or attain his highest level of function. The interventions included assisting with mobility and ADLs as needed and providing therapy services as ordered. The 4/12/24 physical therapy discharge summary documented the resident was to be placed on a restorative program to include a restorative ROM program and a restorative bed mobility program. It indicated the restorative aide was trained to provide the recommended programs to Resident #25. D. Staff interviews The MDS nurse was interviewed on 6/11/24 at 2:21 p.m. The MDS nurse said she was responsible for overseeing the restorative program. She said each resident was assessed every quarter and placed on a restorative program for four weeks. She said the restorative program also placed residents on the restorative program from referrals by physical and occupational therapy. The MDS nurse said Resident #25 was placed on a restorative program on 6/7/24 (during the survey process). She said he was assessed because he was due for his quarterly assessment. She said she was aware he had received physical therapy in April 2024. She said she had no knowledge that the physical therapist had recommended the resident be placed on a restorative program at the completion of his therapy on 4/12/24. The MDS nurse was interviewed again on 6/11/24 at 2:45 p.m. The MDS nurse said she was unable to locate a referral from therapy to her to place Resident #25 on a restorative program. She said there must have been a breakdown in their system. She said all referrals were provided either via email or verbally.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not five percent (%) or greater. Specifically, the medication administration observation error rate was 5%, or two errors out of 40 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 6/12/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration policy, dated 8/24/23, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. It read in pertinent part, Staff who are responsible for medication administration will adhere to the Ten Rights of Medication Administration . right drug, dose, route, time and frequency, documentation, assessment, right to refuse, evaluation/response, education and information. Right Dose-Check the MAR (Medication Administration Record) and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering. III. Observations On 6/10/24 at 7:22 a.m. registered nurse (RN #4) was observed during medication administration for Resident #47. RN #4 checked Resident #47's order of Dorzolamide HCL Ophthalmic Solution 2%, one drop in the left eye, three times per day. RN #4 entered Resident #47's room and administered Dorzolamide HCL ophthalmic solution 2% to Resident #47. -RN #4 administered one drop of the Dorzolamide solution in both of the resident's eyes when the physician's order indicated to put one drop in the left eye. On 6/10/24 at 7:57 a.m. licensed practical nurse (LPN #1) was observed during medication administration for Resident #24. LPN #1 checked Resident #24's insulin order of Basaglar insulin 35 units. LPN #1 dialed up 35 units of Basaglar insulin into the KwikPen (insulin pen) and attempted to administer it to Resident #24. -LPN #1 did not prime (a process of drawing up two units of insulin and then dispensing an insulin pen plunger prior to drawing up an ordered amount of insulin) the pen first with two units of insulin, which was necessary to ensure any air was removed from the needle/cartridge and the resident received the entire dose of 35 units. V. Staff interviews LPN #1 was interviewed on 6/10/24 at 7:51 a.m. LPN #1 said insulin pens should be primed with two units of insulin prior to administering the insulin to ensure the resident was administered the full dose. She said she did not prime the insulin pen prior to attempting to administer the insulin. The director of nursing (DON) was interviewed on 6/11/24 at 10:00 a.m. She said insulin pens should be primed with at least two units of insulin before dialing up the dose of insulin to be administered. She said insulin pen priming was done to remove any air from the needle to ensure the correct dose of insulin was administered. The DON said she would provide education to the nurses on ensuring insulin pens were primed prior to administration. The DON was interviewed on 6/11/24 at 5:53 p.m. The DON said the nurses should follow the physician's orders as directed when administering medications. The DON said the eye drops for Resident #47 should have been administered with one drop in the left eye only, as directed by the physician.

Based on observations, record review and interviews, the facility failed to ensure one (#24) of five residents out of 50 total sample residents was free from a significant medication error. Specifically, the facility failed to ensure the insulin pen was primed prior to insulin administration for Resident #24. Findings include: I. Facility policy and procedure The Medication Administration policy, dated 8/24/23, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. It read in pertinent part, Staff who are responsible for medication administration will adhere to the Ten Rights of Medication Administration . right drug, dose, route, time and frequency, documentation, assessment, right to refuse, evaluation/response, education and information. Right Dose- Check the MAR (medication administration record) and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering. II. Manufacturer's guidelines According to [NAME] Lilly and Company (2022) Instructions for use Basaglar KwikPen, retrieved on 6/20/24 from https://pi.lilly.com/ca/basaglar-80u-ca-ifu-kp.pdf, guidelines for the Basaglar KwikPen state the following step should be taken prior to administering the medication: Prime before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. III. Resident #24 A. Resident status Resident #24, age 74, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included severe obesity and type II diabetes with neuropathy (nerve damage due to diabetes). The 1/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. B. Record review The June 2024 CPO documented the following physician's order: Basaglar KwikPen Subcutaneous solution pen-injector 100 units/ml (Insulin Glargine), inject 35 units subcutaneously (under the skin) two times a day for diabetes mellitus, ordered 6/27/23. C. Observation Licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #24 on 6/10/24 at 7:57 a.m. -LPN #1 dialed up 35 units of Basaglar insulin into the KwikPen for Resident #24 without first priming the pen with two units of insulin and attempted to administer the medication. IV. Staff interviews LPN #1 was interviewed on 6/10/24 at 7:51 a.m. LPN #1 said she should have primed the insulin pen prior to administration to ensure the resident received the entire dose. Registered nurse (RN) #6 was interviewed on 6/10/24 at 9:00 a.m. She said insulin pens should be primed with two units prior to dialing in the correct dose of insulin to be administered. She said this process was completed to ensure the resident received the correct dose of insulin. The director of nursing (DON) was interviewed on 6/11/24 at 10:00 a.m. She said insulin pens should be primed with at least two units of insulin before dialing up the dose of insulin to be administered. She said priming the insulin pen was done to remove air from the needle to ensure the correct dose of insulin was administered.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards on two of four units. Specifically, the facility failed to: -Ensure medications were stored in their original containers; and, -Ensure medications were stored in a sanitary manner, separately from food items. Findings include: I. Professional reference World Health Organization (WHO) (2023) Global burden of preventable medication-related harm in health care settings. Retrieved on 6/12/24, from https://iris.who.int/bitstream/handle/10665/376203/9789240088887-eng.pdf?sequence=1. It read in pertinent part, Medication errors are one of the leading causes of patient harm in health care, in additional therapeutic management, surgical procedures, healthcare related infections and diagnosis. Medication errors can occur throughout the use of medicines which usually includes the prescribing, dispensing, administration and monitoring stages. II. Facility policy and procedure The Storage and Expiration Dating of Medications and Biologicals policy and procedure, reviewed 8/7/23, was provided by the nursing home administrator (NHA) on 6/12/24 at 3:52 p.m. It read in pertinent part, Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. Facility should ensure that resident medication and biologicals for each resident are stored in the containers in which they were originally received. III. Observations On 6/11/24 at 5:04 p.m. unit medication cart #1 was observed with registered nurse (RN) #3. The following items were observed: -A plastic medication cup with five white tablets and the word sodium was written in black ink on the side of the medication cup. -Multiple unopened pudding cups were stored in a drawer with medications. On 6/11/24 at 5:15 p.m. unit medication cart #2 was observed with licensed practical nurse (LPN) #2. The following items were found: -Multiple unopened pudding cups were stored in a drawer with medications. IV. Staff interviews RN #3 was interviewed on 6/11/24 at 5:08 p.m. RN #3 said she did not have sodium tablets on her cart so she borrowed them from another cart and put them in a medication cup for later use for a resident. She said she was not aware this was not safe practice. She said she labeled them so she knew what they were. She said the pudding cups were for medication administration and they were stored in her medication cart for that purpose. LPN #2 was interviewed on 6/11/24 at 5:18 p.m. LPN #2 said the pudding cups were stored in the medication carts for use during medication administration. The director of nursing (DON) was interviewed on 6/11/24 at 5:20 p.m. The DON said all medications must be stored in the original labeled container with the medication name, strength and expiration date. She said this was important to prevent potential medication errors during medication administration. She said storing medications with food items was not a sanitary practice. She said she would provide education for RN #3 and LPN #2.

Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#1 and #4) of three residents reviewed for pain management out of four sample residents. The facility failed to ensure Resident #1 was administered pain medication as ordered. The resident admitted to the facility from the hospital on 8/30/23 with acute compression fractures of the spine and increased back pain. Resident #1 was prescribed Tramadol (pain medication to treat moderate to severe pain) on admission to the facility as needed for pain related to acute spinal fractures and pain. The facility failed to administer Resident #1's Tramadol from her time of admission on 8/30/23 until 9/2/23 and documented in nursing progress notes the Tramadol was not available. However, the Tramadol was available in the facility's emergency medication kit (see interviews below). The resident was administered Tylenol for pain levels up to 8 out of 10 (with 10 being the worst pain on the scale) from her admission on 8/30/23 until 9/2/23 when the Tramadol arrived from the pharmacy. There were no parameters for when to administer Tylenol versus Tramadol. The Tylenol was documented as not completely effective. Resident #1 complained on admission that the mattress was not comfortable. The facility failed to follow up on the resident's concern regarding her mattress for two days despite nursing note documentation that Resident #1 complained of the mattress being uncomfortable due to her multiple back fractures and lack of pain medication. A new mattress was ordered on the third day after the resident's admission. Furthermore, the resident had a care plan for pain which documented an intervention to administer pain medication and monitor effectiveness. The care plan had no further interventions, such as non-pharmacological interventions. In addition, the facility specifically failed to establish appropriate parameters for pain medications, ensure the appropriate pain medication was administered based on the resident's pain level and follow up consistently on the effectiveness of pain medications administered for Resident #4 who was readmitted to the facility on [DATE] following surgical repair of a hip fracture. Resident #4 was administered Tylenol for pain levels up to 8 out of 10 and Oxycodone (a pain medication to treat moderate to severe pain) for pain levels of 4 out of 10. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, revised 9/12/23, was received from the nursing home administrator (NHA) via email on 2/21/24 at 12:18 p.m. It read in pertinent part, Based on the assessment, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and or his or her representative, develops, implements, monitors and revises as necessary interventions to prevent or manage each individual resident's pain, beginning at admission. These interventions may be integrated into components of the comprehensive care plan, addressing conditions or situations that may be associated with pain, or may be included as a specific pain management need or goal. The facility will address/treat the underlying causes of the pain, to the extent possible. Developing and implementing both non-pharmacological and pharmacological interventions and approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both. II. Resident #1 A. Resident status Resident #1, age 82, was admitted on [DATE] and discharged home on 9/19/23. According to the September 2023 computerized physician order (CPO), diagnoses included collapse and fracture of the vertebrae with chronic back pain. The nursing admission assessment, dated 8/30/23, documented the resident was oriented to person, place, time and situation. The 9/18/23 minimum data set (MDS) assessment documented the resident required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. The assessment documented the resident was on scheduled and as needed (PRN) pain medication. B. Record review On 8/30/23, the admission nursing pain assessment documented Resident #1 had pain to her hips and upper extremities at a pain level of 6 on a scale of 1 to 10. The resident said an acceptable level of pain was a 4. The assessment documented the resident said sitting for too long and using her hands made the pain worse. Lying down and medications made her pain better. The assessment documented the resident said her sleep, rest and appetite were affected by the pain. Pharmacological treatment was documented as Tramadol 50 mg (milligrams) every six hours. The admission medication orders dated 8/30/23 documented the following physician orders: Tramadol 50 mg every six hours as needed for moderate pain. -The Tramadol order did not specify what pain level, on a scale of 1-10, moderate pain was. Acetaminophen (Tylenol) 325 mg two tablets every four hours as needed for pain. -There were no parameters for when to give the Tylenol or the Tramadol. Resident #1's August 2023 and September 2023 medication administration records (MAR) were reviewed. The August MAR documented the resident had pain levels of 2 to 8 out of 10 and was given Tylenol. Tylenol was documented as effective on the MAR. -However, the nursing notes documented that Tylenol was only somewhat effective and the Tramadol was not available (see progress notes below). The September 2023 MAR documented the resident began receiving Tramadol on 9/2/23 for pain levels of 3 to 7 out of 10. The resident took the tramadol one to two times daily once the facility obtained the medication from the pharmacy. -There was no Tramadol signed off on the MAR as being administered from admission 8/30/23 until 9/2/23 at 9:22 am for a pain level of 3 out of 10. Resident #1's nursing progress notes were reviewed from 8/30/23 through the resident's date of discharge on 9/19/23. On 8/30/23 at 4:00 p.m., the nursing notes documented the resident complained the mattress was too hard. The nursing notes documented they would get her an air mattress. On 8/30/23 at 9:41 p.m., the nursing progress notes documented the resident was given Tylenol for pain everywhere. At 11:48 p.m. the Tylenol was documented as only somewhat effective. On 8/31/23 at 1:51 a.m. the nursing notes documented the Tramadol was not available and the resident was given Tylenol for pain. On 8/31/23 at 4:45 a.m. the nursing notes documented the resident said the bed was horrible and she just can't stand it. -There was no follow up progress note to indicate a different mattress had been obtained for the resident. On 8/31/23 at 3:31 p.m. the nursing notes documented the resident again complained of the mattress being too firm. The nursing notes documented a new mattress had not been ordered because the resident had wanted to move to another facility but since her referral was denied the nurse would order an air mattress. -There was no follow up progress note to indicate a different mattress had been obtained for the resident. On 9/1/23 at 3:15 a.m. the nursing notes documented the resident was given Tylenol for pain and Tramadol was not available. The resident complained about the mattress again and said everything was uncomfortable. On 9/1/23 at 10:17 a.m. the nursing notes documented the Tramadol was not available and the on call provider was notified that a signed prescription was needed for the Tramadol. The progress note documented an air mattress had been ordered that morning. -There was no further documentation regarding the air mattress or when it arrived. -On 9/2/23, three days after admission for pain and fractures in her spine, Resident #1 began receiving Tramadol as ordered for pain management. The pain care plan, initiated 8/30/23, did not indicate the resident's location of pain. There two interventions listed included giving pain medication as ordered and evaluating the effectiveness of the pain interventions. -There were no non-pharmacological interventions for pain management documented on the care plan. III. Resident #4 A. Resident status Resident #4, age 87, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 CPO, diagnoses included dementia, right femur fracture and left femur fractures. The 12/14/23 MDS assessment revealed the resident had severe cognitive impairment and was unable to complete a BIMS assessment. Resident #4 had short and long term memory loss. She required substantial maximum assistance with transfers, toileting and bed mobility. Resident #4 was totally dependent on staff assistance for dressing and personal hygiene. The assessment documented the resident had a hip fracture and recent major surgery. B. Record review Resident #4's February 2024 CPO revealed the following physician orders for pain medications: Acetaminophen (Tylenol) 325 mg two tablets every twelve hours as needed for pain. The order date was 10/10/23. Oxycodone 5 mg every four hours as needed for moderate to severe pain. The order date was 1/10/24 (over one month after the resident was readmitted following the surgical repair of her hip fracture). -The Oxycodone order did not specify what pain level, on a scale of 1-10, moderate to severe pain was. Resident #4's January 2024 and February 2024 MARs were reviewed. The MARs revealed Resident #4 received Tylenol for pain levels documented up to an 8 out of 10 and Oxycodone for pain levels of 4 out of 10. The resident reported a pain level of 7 out of 10 on 1/20/24 at 9:59 a.m. and was given Tylenol. Over an hour later, at 11:04 a.m., the resident reported a pain level of 6 out 10 and was given Oxycodone. -Despite Resident #4 indicating her pain level was a 7 out of 10, the nurse administered Tylenol instead of Oxycodone which was ordered for moderate to severe pain. On 1/5/24 at 7:05 a.m., 1/10/24 at 7:57 a.m., 1/25/24 at 7:45 a.m. and 1/31/24 at 12:32 a.m., Resident #4 was given Oxycodone for pain levels of 6 to 8 out of 10. -However, the effectiveness of the pain medication was documented as unknown and there was no further follow up documented to determine if Resident #4's pain was managed appropriately. IV. Interviews Licensed practical nurse (LPN) #1 was interviewed on 2/21/24 at 9:59 a.m. She said if medications were not available on the medication cart she would call the pharmacy to obtain the medication. She said the facility had a machine with emergency medication in it. LPN #1 pulled out a list of medications in the machine. She said Tramadol was on the list of emergency medications available. LPN #1 said when multiple medications for pain were ordered such as a narcotic (Tramadol or Oxycodone) and Tylenol she started with the Tylenol, regardless of the resident's stated level of pain and rechecked the resident in an hour or so. She said if the Tylenol was not effective she would then administer the stronger pain medication. LPN #1 was not sure if pain medications had parameters for what levels of pain they should be given for. The director of rehabilitation (DOR) was interviewed on 2/21/24 at 10:39 a.m. She said she remembered Resident #1 and had treated her for physical therapy. She said she remembered the resident was in a lot of pain and could not be touched without complaints of pain, especially on her back. The social services director (SSD) was interviewed on 2/21/24 at 10:50 a.m. She said she had heard of recent residents who did not have medications available on admission. She said she knew the facility had an emergency medication machine if medications were unavailable but she did not have any further information regarding what medications were available from the emergency medication machine. The director of nursing (DON) was interviewed on 2/21/24 at 11:10 a.m. The DON said when a resident had multiple pain medications ordered the nurse should start with the lowest non-narcotic pain medication. However, the DON then said the facility should obtain pain level ranges for each pain medication. The DON said pain medication should be given according to ordered pain parameters. She said Tylenol should not be given first for pain levels of 8 out of 10. The DON said the nurse should follow the parameters and administer a narcotic medication as ordered and not wait to see if a non-narcotic medication worked first for a pain level of 8 out of 10. The DON said Resident #1 was admitted to the facility for physical therapy rehabilitation for multiple spinal compression fractures and increased pain in her back. She reviewed the nursing progress notes and said the resident was uncomfortable on her mattress and actions by the nurse should have been taken that day to switch out her mattress. She said the nursing staff should not have waited three days. The DON said the nurses documented multiple times that the Tramadol was not available but there was no documented follow up. The DON reviewed the medications available in the emergency medication machine and said Tramadol was available in the machine. She said she did not know why staff had not obtained the Tramadol from the emergency medication machine and administered it to Resident #1 instead of waiting for the medication to be delivered from the pharmacy. She said Resident #1 did not receive her first dose of Tramadol until 9/2/24 once the medication had been delivered to the facility. The DON said Resident #1's care plan did not have non-pharmacological interventions for pain. She said care plans for pain management should include non-pharmacological interventions. V. Facility follow up On 2/22/24 at 11:24 a.m., after the survey exit, the NHA emailed an inservice education dated 2/1/24. The education was titled Medication Management and IV (intravenous ) Medication Management. The inservice documented, If a medication is not found in the refrigerator or there is a question about the order, the nurse must contact the pharmacy and physician immediately to get medication clarification in a timely manner. -The inservice addressed medications in the refrigerator. It did not address obtaining and following parameters for pain medications or the medications available in the facility's emergency medication machine.

Based on interviews and record review, the facility failed to ensure residents retained the rights to their personal belongings for one (#1) of three residents out of four sample residents reviewed for personal belongings. Specifically, the facility failed to ensure Resident #1's right to have personal property when the resident's tape recorder was removed from her bedside and locked in a medication cart without the resident's permission. Findings include: I. Facility policy and procedure The Resident Belongings and Homelike Environment policy, dated 7/17/23, was received from the nursing home administrator (NHA) via email on 2/21/24 at 12:18 p.m. It documented in pertinent part, The facility will provide a safe, clean, comfortable, and homelike environment, which allows theresident to use his or her personal belongings to the extent possible. Residents' possessions, regardless of their apparent value to others, must be treated with respect. In a facility in which most residents come for a short-term stay, residents would not typically move his or her bedroom furniture into the room, but may desire to bring a television, chair or other personal belongings to have while staying in the facility. II. Resident status Resident #1, age 82, was admitted on [DATE] and discharged home on 9/19/23 . According to the September 2023 computerized physician orders (CPO), diagnoses included collapse and fracture of the vertebrae with chronic back pain. A nursing admission assessment, dated 8/30/23, documented the resident was oriented to person, place, time and situation. The 9/18/23 minimum data set (MDS) assessment documented the resident required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. III. Record review On 9/5/24 at 6:03 a.m., the nursing progress notes documented the resident had a tape recorder in her room next to her bed. The nurse on duty called the assistant director of nursing (ADON). According to the progress notes the ADON told the nurse to remove and lock up the tape recorder. The nurse told the resident she was unable to have a tape recorder and that it was illegal for her to have a tape recorder in her room. The progress notes documented the resident said she did not think that was fair to her. The progress note documented the nurse told the resident she was taking the tape recorder and would lock the tape recorder in her medication cart and give it to social services in the morning. -There was no further documentation in Resident #1's electronic medical record to indicate social services or nursing management followed up with the resident regarding the tape recorder after it was removed from her room and locked up. IV. Interviews Certified nurse aide (CNA) #1 was interviewed on 2/21/24 at 10:14 a.m. He said residents had the right to have their own belongings in their rooms. He said residents were allowed to have items like clothes or cell phones. The social service director (SSD) was interviewed on 2/21/24 at 10:50 a.m. The SSD said residents had the right to have personal items in their rooms such as pictures, clothing, phones and electronic tablets. She said the residents had the right to keep tape recorders. The SSD said she currently had a different resident that she bought a tape recorder for so she could record her thoughts and feelings as recommended by her psychologist. The SSD said the facility staff should not have removed Resident #1's tape recorder without her permission. She said she remembered Resident #1 but she was on vacation when the resident was admitted . The SSD said she was not aware the resident had a tape recorder which the staff had taken from her. She said the nursing staff should not have removed the tape recorder. The SSD said even if the staff thought Resident #1 was recording conversions with them the staff should not have taken her tape recorder. She said the staff should have explored why the resident was using the tape recorder and educated the resident not to tape record their conversations if that was their concern. The director of nursing (DON) was interviewed on 2/21/24 at 11:10 a.m. The DON said residents had the right to keep their own belongings when residing in the facility, including televisions, radios and jewelry. She said the residents could have a tape recorder. The DON said the nursing staff should not have removed the Resident #1's tape recorder from her room without her permission. The DON said the assistant director of nursing (ADON) and the DON at the time the tape recorder was removed were no longer working at the facility. The DON said Resident #1 had resided in a private room and there would have been no reason for her to not have a personal tape recorder for her own use. The DON said the resident may have been keeping a novel on the recorder or needed it for other reasons. She said the resident had pain in her back and upper extremities with the spinal compression fractures and it could have been difficult for her to write her thoughts. A frequent visitor (FV) was interviewed on 2/21/24 at 12:18 p.m. The FV said Resident #1's representative had called her and let her know the facility staff had taken away Resident #1's tape recorder. She said she had gone to the facility and told them to give the tape recorder back to the resident. The FV said she could not recall the date she received the phone call from Resident #1's representative or the date she spoke to the facility about returning the tape recorder and when it was returned to the resident

Based on interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for one (#1) of three residents reviewed for accident hazards out of three sample residents. Resident #1 had a diagnosis of dementia with wandering and resided in a secure unit. Resident #1 sustained nine falls from 9/17/23 to 11/27/23. The facility failed to ensure appropriate interventions and adequate supervision were implemented to prevent major injuries, including a fracture of the left and right hips, which were sustained in two separate falls. Due to the facility's failures to implement effective interventions and adequate supervision, Resident #1 sustained a fracture of the left hip from a fall on 10/7/23. The facility failed to implement effective interventions and supervision when Resident #1 returned from the hospital on 10/11/23. Following Resident #1's readmission to the facility, she sustained five more falls, obtaining a right hip fracture on 11/27/23. Additionally, the resident sustained a head laceration, a laceration above her right eye, skin tears and bruising to her upper and lower extremities from the multiple falls. Findings include: I. Facility policy The Fall Management policy, revised 4/7/22, was provided by the nursing home administrator (NHA) on 1/8/24 at 2:06 p.m. It documented in pertinent part, Avoidable accidents. This means that an accident occurred because the facility failed to identify environmental hazards and or assess individual resident risk of an accident, including the need for supervision and or assistive devices. Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards, risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Supervision or adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. The facility will assess the resident upon admission and readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment. During the admission and readmission process, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be at risk for falls. Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS (minimum data set assessment), upon a fall event and as needed thereafter. II. Resident #1 A. Resident status Resident #1, age 87, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included dementia, anxiety, wandering, right femur fracture, left femur fracture and a history of falls. The 12/14/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment and was unable to complete a brief interview for mental status (BIMS) assessment. Resident #1 had short and long term memory loss. She required substantial maximum assistance with transfers, toileting and bed mobility. Resident #1 was totally dependent on staff assistance for dressing and personal hygiene. The assessment documented the resident had a hip fracture and recent major surgery. B. Resident representative and frequent visitor interview A frequent visitor to the facility was interviewed on 1/8/23 at 12:40 p.m. She said she met with the facility after Resident #1 fell and broke her second hip on behalf of the resident's representative. The frequent visitor said she discussed with the facility putting a plan in place to prevent further falls and keep Resident #1 and other residents safe. The resident's representative was interviewed on 1/9/23 at 1:01 p.m. She said the resident had fallen and broken both hips and lacerated her head and eye while at the facility. She said therapy told her the resident needed to have a footboard or footrest on the wheelchair when she was in it, but the representative said they were never on. She said she paid one of her family members to go to the facility when she could not and stay with the resident during meals. The representative said the facility needed to have more eyes on Resident #1. The resident's representative said the staff appeared overwhelmed and short staffed. The resident's representative said the facility used wedges in the bed to keep the resident from getting up and the hospice provider had provided a new wheelchair. -There was no record of footrests or footboards in the progress notes or care plan (see below). C. Record review The fall care plan, initiated 11/18/22, documented the resident had a history of falls and was at risk for falls. The interventions were keep the call light in reach and orient to the room. -However, there were no additional fall interventions implemented with her known fall risk and history of falls. Interventions were not added to the care plan until after the resident had fallen multiple times (see below). 1. Fall on 9/17/23 On 9/17/23 at 12:25 a.m., the nursing progress notes documented the resident was walking backwards down the hall and fell . There was no injury. The fall care plan documented on 9/16/23 the staff were to encourage and assist Resident #1 to sit when she appeared unsteady. -However, there were no new interventions added to the care plan for the fall on 9/17/23. On 9/19/23 at 5:43 p.m. an interdisciplinary team (IDT) note documented the IDT met to review a recent event. There was no description of the event. The note documented the staff were educated to encourage the resident to sit when appearing unsteady and there were no new recommendations at that time. 2. Fall on 9/28/23 On 9/28/2 at 6:23 a.m. the nursing progress notes documented Resident #1 was found on the floor in her room when staff went into the room to check on her roommate. At 2:27 p.m. the nursing progress notes documented the family was notified of the fall and the resident would be evaluated by physical therapy (PT). The fall care plan included a PT evaluation on 9/28/23. 3. Fall 9/30/23 On 9/30/23 at 10:03 a.m. the nursing progress notes documented, witnessed fall, fading yellow green bruise to right knee and right elbow from previous fall. -It was unclear if this was a new fall or in reference to a previous fall. The only witnessed fall was on 9/17/23, prior to the unwitnessed fall 9/28/23. There was no further documentation in the nursing progress notes. -There were no changes to the care plan. On 10/4/23 at 3:12 p.m. a late entry documented the IDT met to review the recent event. The IDT note documented the resident had completed PT, no new interventions at this time, fall huddle complete. -It was unclear if this was related to the fall on 9/28/23 or 9/30/23. -The facility failed to implement new interventions and the resident continued to fall and fracture her left hip. 4. Fall on 10/7/23 with left hip fracture On 10/7/23 at 8:22 a.m. the risk management report documented the resident wandered into another resident's room and stumbled backwards attempting to sit in a chair. The resident had a wound to her left elbow and pain to her left leg. She was sent to the hospital. The report documented the resident had been having increased agitation since medication changes, wandered and ambulated without assistance. -There was no documentation of interventions for wandering into other resident rooms. The resident's antipsychotic medication Risperidone was discontinued on 9/30/23. The care plan was updated on 10/7/23 to encourage the resident to walk with a walker and PT to teach the resident to use a walker. -However, the resident was in the hospital with a hip fracture (see below). On 10/8/23 at 6:50 p.m. the nursing progress notes documented the hospital had called the facility to inform the facility the resident had surgery for the fracture in her left hip. On 10/10/23 at 6:44 p.m. Resident #1 returned to the facility from the hospital. On 10/11/23 at 12:55 p.m. the nursing progress notes documented the resident was working with PT and had a left hip fracture with surgical repair. The notes documented the resident frequently stood without assistance. -However, despite the residents' frequent standing without assistance, limited ineffective interventions were documented. The resident fell six more times and fractured her right hip (see below). On 10/12/23 at 3:31 p.m. an IDT progress note documented the incident was reviewed to include a discussion of new interventions. The progress note documented PT would work with the resident on ambulation with a walker and a medication review would be done by the pharmacy. -The specific incident that had been reviewed was not documented. On 10/12/23 the fall care plan was updated to include, anticipate the residents needs and encourage activities to promote exercise. On 10/17/23 at 10:42 a.m. the nursing progress notes again documented Resident #1 had dementia and would frequently stand without assistance. -However, limited interventions were provided for her impulsiveness. 5. Fall on 10/18/23 On 10/18/23 at 7:07 p.m. the risk management report documented the resident was sitting in a wheelchair near the nurse's station. The nurse noticed the wheelchair was empty and the resident was lying on the floor. The wheelchair brakes were not engaged. The resident had a 10 centimeter (cm) by 3 cm reddened area to her right shoulder and a raised area and bruising to the back of her head on the right side. The nurse documented therapy to assess for auto lock brakes on the wheelchair. The risk management report documented the resident was witnessed standing up and sitting down repeatedly. -There was no investigation as to why the resident was standing or what she may have needed. On 10/18/23 the care plan was updated to auto lock brakes to wheelchair. 6. Fall on 10/19/23 On 10/19/23 at 11:35 p.m. the nursing notes documented Resident #1 was lying on her back in front of her closet. The resident was advised to use her call light for assistance. -However, the resident had dementia with significant cognitive impairment according to her care plan. There was no investigation of what the resident may have been trying to do. On 10/19/23 at 11:45 p.m. the risk management report documented the resident was impulsive and repeatedly stood without assistance. On 10/19/23 the care plan documented a grab bar outside of the bathroom. Non skid strips in front of the closet. Mattress on floor next to bed. On 10/20/23 the care plan documented frequent checks for safety. Get the resident out of bed if she was restless and bring her in the common area. Offer a busy box for redirection and distraction. On 10/20/23 at 10:00 p.m. the nurse's notes documented the resident was on 15 minute checks and she had a fall mat next to her bed and wedge pillows in her bed. -There was no documentation the resident rolled out of bed. It was unclear what the wedge cushions in the bed were used for. After the sixth fall and fracture of the left hip, the facility implemented frequent safety checks. -However, the facility placed the resident in the dining room without supervision and she fell again resulting in a right hip fracture (see below). On 10/22/23 at 6:00 p.m. the skilled nursing progress notes documented the resident had COVID-19 and was more lethargic. The notes further documented the resident had dementia and would frequently stand without assistance. 7. Fall on 10/23/23 On 10/23/23 at 10:15 a.m. the risk management report documented the resident was in her room watching television at 10:00 a.m. and on the floor on the mat next to her bed at 10:15 a.m. There were no injuries documented. The report documented therapy would tilt her wheelchair and the resident was in isolation for COVID-19. The nursing notes further documented the provider was in and increased the resident's anti-anxiety medication. -However, there was no documentation the resident slid out of the wheelchair, only that she would stand without assistance as documented the previous day on 10/22/23. Tilting the wheelchair could prevent the resident from rising without assistance. -The care plan was reviewed. There was no new intervention on the care plan. Tilting the wheelchair was not on the care plan. On 10/23/23 at 4:42 p.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 10/24/23 at 1:46 p.m. the nursing progress notes again documented the resident would frequently stand without assistance. On 10/25/23 at 4:41 p.m. the IDT progress notes documented incident reviewed. The note listed the previous interventions implemented for falls. -There were no new interventions documented. On 10/25/23 at 6:03 p.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 10/30/23 at 10:36 a.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 10/31/23 at 9:36 a.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 11/6/23 at 10:17 a.m. the skilled nursing notes documented the resident would frequently stand without assistance. 8. Fall on 11/10/23 On 11/10/23 at 5:45 p.m. the risk management report documented the resident was sitting in the hall in her wheelchair. The resident fell and had moderate bleeding from the back of her head. The nursing notes documented she had a small laceration to the back of her head. The nursing note documented the resident's blood pressure began to drop she had smaller fixed pupils during the assessment and was not answering any questions or responding although she was awake and she was sent to the hospital. The report documented the resident had increased agitation and repeatedly tried to stand On 11/11/23 at 12:31 p.m. the nursing notes documented the resident returned from the hospital with no new orders and visible bruising to the back of the head. On 11/12/23 at 5:07 p.m. the nursing progress notes documented the resident was at the dining room table and continuously tried to get up. On 11/15/23 at 2:36 p.m., five days after the fall, the IDT notes documented a medication review had been done previously due to agitation. The IDT documented a weighted blanket would be used for comfort. -The weighted blanket did not indicate when she was supposed to have it on her for use as a fall intervention. -There were no additional interventions to determine if there was an unmet need that led to her impulsively getting up. 9. Fall on 11/27/23 On 11/27/23 11:35 a.m. the nursing notes documented the resident was in the dining room drinking fluids. The nursing staff wanted to obtain a urine analysis. The certified nurse aide (CNA) entered the dining room and observed the resident standing next to her wheelchair. The resident stepped to the right and fell . The resident had hit her right eyebrow on the floor causing a 0.5 cm laceration. The nurse documented the resident had a small laceration to the back of head. The resident had pain to her right thigh and was sent to the hospital at approximately 12:15 p.m. -The facility was aware the resident was impulsive and would stand up from her wheelchair in the dining room repeatedly. The investigation was unclear as to why she was left alone in the dining room. On 11/29/23 at 2:12 p.m. the IDT progress notes documented the resident would be taken to the dining room last and taken out first to monitor the resident. -There was no further investigation to determine if there was an unmet need and that was why she was trying to stand. On 12/1/23 at 9:00 a.m. the provider documented the resident readmitted to the facility from the hospital with a new diagnosis of fracture of the right hip. A hospice consult was ordered. The fall care plan was updated on 11/27/23 to take the resident to the dining room last when staff were present and monitor. The director of nurses (DON) provided a copy of the resident's activity notes for October to December 2023 on 1/8/24 at 2:00 p.m. She said the resident received supervision at activities. -The activity records were requested but not received for January 2024. -The activity records had multiple holes in the documentation. When activity was documented Resident #1 rarely participated passively, observed or actively participated. The October 2023 record revealed, other than meals or a snack the resident was at four activities for the month, twice in November 2023 and less than 10 times in December 2023. In three months, the resident participated in exercise twice in October 2023, none in November 2023 and three times in December. The DON provided a copy of psychiatric notes for October 2023 to December 2023 referencing the facility had been addressing the resident's anxiety as part of her falls. The notes documented in summary that the resident had been taken off her antipsychotic medication and was on a tapering up plan for anti-anxiety medication. She had dementia, depression, anxiety and a history of paranoia, sundowning (confusion in the late afternoon through the night) and agitation. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/8/23 at 10:54 a.m. She said she knew when a resident was a fall risk based on a report she received from the nurse. She said she did not know how else she would know if the resident was a fall risk. CNA #1 said for Resident #1 the staff tried to keep her call light in reach. She said she did not think this was a good intervention because of the resident's severe memory loss, she would not remember to use it. She said Resident #1 had fallen and broken both hips at the facility. CNA #1 said the last time she fell was in the dining room and she fell from her wheelchair. CNA #1 said she did not know what new interventions the facility had put in place to keep Resident #1 safe after her fall in the dining room. She said she tried to keep the resident in bed to keep her from falling because she had a lot of pain. The unit manager (UM) was interviewed on 1/8/23 at 11:03 a.m. She said when a resident [NAME] the nurse assessed the resident, notified the physician and family and started neurological checks. The UM said she was familiar with Resident #1. She said Resident #1 fractured her left hip when she tried to sit and missed a chair. She said she fractured her right hip when she stood up in the dining room without assistance and fell . She said the resident still tried to get up out of her wheelchair unassisted. The UM said currently the nursing staff had tried to keep her in bed between meals as a fall intervention. She said the family was present for most meals with her. The interim director of nursing (IDON), NHA and regional nurse consultant (RNC) were interviewed on 1/8/23 at 12:33 p.m. The NHA said the facility had reviewed the resident's falls, but said we can not supervise everyone, all the time. The NHA said the wedges on the resident's bed were being used for positioning not to keep the resident in bed. The RNC said the facility had a mock survey a few weeks ago and a lack of timely fall interventions implemented was identified in the mock survey. She said the facility had planned to complete training today on identifying the root cause of falls with nurse managers. She said the facility had written a performance improvement plan (PIP). The UM was interviewed again on 1/8/23 at 3:18 p.m. She said she wanted to revise her previous interview. She said the nursing staff tried to keep Resident #1 up out of bed, she would have so much agitation the staff would have to stay with her. IV. Facility follow up An undated document titled Plan of Correction (POC) for Adverse Events Packets, undated, was received from the NHA on 1/8/24 at 2:00 p.m. An email titled POC, dated 12/26/23 at 3:30 p.m. addressed to the NHA from the previous DON documented Here is the rough draft of the POC for adverse events. Let me know if you want me to add or change anything. The POC documented in pertinent part, Audits of incidents and adverse event packets weekly to ensure completion and accuracy. Education completed with the IDT team on completing assigned portions of adverse event packets in a timely manner. Fall Huddles to be completed in Grand Rounds every morning for falls recorded the previous day. Education on fall prevention and fall management completed at CNA Nurses meeting 11/28/23. Audit conducted on adverse event packets for the last three months to identify errors or incomplete. Those identified to be completed and corrected by the IDT team by 1/3/23. Daily audits of incident reports in morning meetings to identify possible Adverse event packets that are open will be discussed weekly by the IDT team to ensure accuracy and completion. Monthly quality assurance and performance improvement (QAPI) review. Education completed with nursing staff on 11/28/23 on fall prevention/management. Fall management education to be done at the monthly nursing meeting for a minimum of three months or until substantial compliance is met. Education with IDT team on adverse event packet 2/27/23. Weekly audits of adverse event packets, risk management, and incidents by IDT team. Weekly IDT meetings to ensure compliance with adverse event and event reporting. The POC addressed the accuracy and completion of adverse events including falls. -It did not address investigating the cause of falls or the appropriateness of interventions. On 1/8/23 at 2:03 p.m. the RNC provided an inservice sign in document titled, Mandatory CNA and Nursing Meeting, dated 11/28/23. Attached to the inservice sign in sheet was the Fall Management policy as documented above. -There was no further description of the meeting. -CNA #1, who was working with Resident #1, had not signed the inservice sheet. On 1/9/23 at 4:42 p.m. the NHA provided a timeline which documented the facility had provided occasional one-to-one care when the resident was agitated. The documentation revealed the intermittent one-to-one attention was when the staff redirected Resident #1 due to anxiety. This was no ongoing one-to-one supervision for safety.

Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of an injury of unknown source to the state survey agency for 1 (Resident #64) of 2 residents reviewed for abuse. Findings included: A review of the facility's policy titled, Area of Focus: Abuse and Neglect, reviewed 11/21/2022, revealed, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property are reported immediately but no later than 2 hours after the allegation is made. A review of the Admission Record for Resident #64 revealed the facility admitted the resident with diagnoses that included dementia, aphasia, and frontotemporal neurocognitive disorder. Review of Resident #64's annual Minimum Data Set (MDS), dated [DATE], revealed the facility did not complete a Brief Interview for Mental Status (BIMS) because the resident was rarely/never understood. The Staff Assessment for Mental Status indicated Resident #64 had severely impaired skills for daily decision making. The MDS indicated the resident had physical behavioral symptoms directed toward others on one to three days of the assessment period and had wandering behaviors daily. Review of Resident #64's Care Plan, revised on 11/03/2020, revealed the resident had impaired cognitive skills due to dementia and short-term and long-term memory deficits. A review of the Progress Notes for Resident #64 revealed an event note, dated 01/24/2023 at 8:11 PM and written by Registered Nurse (RN) #1. The note indicated Resident #64 lacked safety awareness and judgement with distances and was often observed to walk quickly and turn and bump into walls. The note indicated the resident had faint light purple bruising to the left eye lid and temple. The note further indicated the resident was non-verbal and no signs or symptoms of pain were noted. An observation on 01/31/2023 at 12:02 PM revealed Resident #64 was sitting in the dining room of the Alzheimer's unit. Resident #64 was wearing a soft helmet and had a purple/black discoloration around the left eye. In an interview on 02/01/2023 at 2:20 PM, Registered Nurse (RN) #1 revealed the facility's abuse protocol was see something, say something, and to report to the higher ups right away. RN #1 stated abuse needed to be reported to administrative staff within two hours so they could report it to other agencies. RN #1 stated Resident #64 had been a resident at the facility for about four years. RN #1 stated Resident #64 lacked impulse control, safety awareness, and spatial awareness, and that Resident #64 would pace back and forth on the unit and bump into things or open doors onto the resident. RN #1 said that on the morning of 01/24/2023, at around 7:30 AM, she provided medications to Resident #64 but did not notice any bruising or discoloration to the resident's eye at that time. RN #1 stated later that morning, Resident #64's family member (FM), FM #2, came for a visit and the family member and RN #1 observed bruising to the crease on the upper eyelid of Resident #64's left eye. RN #1 stated they never observed when or how the bruise may have occurred. RN #1 said she and other staff on the unit had observed the resident pacing in the room and bumping into things and they tried to redirect the resident at that time. It was sometime later when they realized there was a bruise on the residents left eye. RN #1 stated at that time, she initiated neurological (neuro) checks, and she reported the bruise to the Assistant Director of Nursing (ADON). RN #1 said she spoke to the ADON about the resident's behaviors, but she did not remember if she was asked if she observed when or how the bruise occurred. She said after that conversation, there was no further discussion about the bruise or the incident. RN #1 also stated this was the first time staff had observed an injury to Resident #64 and that due to Resident #64 being nonverbal, the resident was not able to tell anyone what happened. An interview on 02/01/2023 at 2:50 PM with the ADON revealed the facility's abuse protocol was to report concerns immediately and within two hours to the state or police. The ADON stated the Administrator, Director of Nursing (DON), and Social Services would initiate an investigation. The ADON stated Resident #64 could ambulate independently but walked very quickly and would run into things due to having no spatial awareness. The ADON stated RN #1 called her and reported the bruising immediately. The ADON stated Resident #64 had bruising to face and close to the left eye. The ADON said she spoke with the CNA staff along with RN #1 who informed her about the observations of Resident #64 walking into walls, or opening the doors on themselves but she stated neither staff ever reported when these observations were or when or where the bruise occurred. The ADON stated the bruise would not have appeared until sometime later, but staff were not able to pinpoint the exact moment or action that caused the bruise. The ADON stated she never specifically asked if staff observed when or where the bruise occurred. The ADON stated she did not think the bruise could have been caused by something other than Resident #64 bumping into something because staff kept a close eye on the resident and other residents did not bother Resident #64 anymore. The ADON stated she reported the bruise to the DON, but they did not think it was an injury of unknown origin since the staff were aware of behaviors that could have contributed to the bruise. The ADON stated staff never reported observations of these behaviors on the day of 01/24/2023 and only reported a history of those behaviors. The ADON stated she assumed the behaviors occurred that day, but she could not be certain and that was the first occasion she was aware in the last year that resulted in an injury to Resident #64. The ADON stated staff did not find the bruise concerning and it was not reported or investigated. The ADON stated staff kept an eye on the Resident but admitted there were times when resident was not being supervised. An interview on 02/01/2023 at 3:29 PM with the DON revealed the facility's protocol regarding abuse was see or hear, you report it. The DON stated staff should report immediately to their direct supervisor because the DON and Administrator only had a two-hour window for the facility to report to the state survey agency and initiate their investigation. The DON stated Resident #64 was ambulatory and walked back and forth between the nurse's station, the resident's room, and the dining room. The DON stated Resident #64 had poor spatial awareness, ran into other residents, and bumped into doors. The DON stated she had personally witnessed Resident #64 walk into another resident which resulted in the other resident smacking Resident #64 on the chin. The DON stated she became aware of the bruise on Resident #64's eye when RN #1 notified the ADON and herself that RN #1 was with the resident's family member in the resident's room when the bruising was observed to the inside crease of the resident's left eye. The DON stated an incident report was completed but they discussed it along with some CNA staff and they decided it was not abuse due to the resident's behavior. The DON admitted that the staff she spoke with that day could not say if the resident bumped into anything on 01/24/2023 or witnessed any interactions with other residents on that day. The DON agreed that the facility was not certain of when or how the injury occurred and that there were still a lot of unknowns and that it should have been reported to the state. An interview on 02/02/2023 at 9:08 AM with FM #2 revealed FM #2 was visiting Resident #64 on the morning of 01/24/2023, and at some point, when the resident was laying down, she could see a small bruise in the crease of the resident's left eye. FM #2 stated she asked staff about the bruise, but they informed her that none of them had ever noticed a bruise. FM #2 stated she was alone in the room and that no staff was with her when the bruise was observed, and she informed staff when it was identified. FM #2 stated staff had informed her that Resident #64 was off balance a lot and has issues with judging the distance of things. FM #2 stated she had noticed that Resident #64 was a little off balance at times and uncoordinated. FM #2 said staff told her they thought it might have been caused by Resident #64 bumping into things, but staff told her they never observed when it happened, and they could not be certain of what caused the bruise. An interview on 02/02/2023 at 12:20 PM with the Administrator revealed the incident was reported to the state survey agency for the first time on 02/01/2023. The Administrator stated he first became aware there was discoloration noted to Resident #64's left eye on 01/25/2023 after the ADON told him. He stated he asked staff how the resident got the bruise, and he was told staff had observed Resident #64 run into things frequently and pull the door into themself. The Administrator stated he was under the impression that staff knew when and how the bruise occurred. He stated he did not ask staff any questions to clarify that. The Administrator stated it should have been reported to the state survey agency on the day the bruise was observed. The Administrator agreed that the resident being nonverbal and having significant cognitive deficits made the resident more vulnerable and staff should never immediately assume any observed injury was a result of the resident bumping into something. The Administrator stated any injuries of unknown origin needed to be reported timely and stated he would be educating all staff and going forward he would make sure nothing like this happened again.

Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to have evidence that an injury of unknown source was investigated for 1 (Resident #64) of 2 residents reviewed for abuse. On 01/24/2023, staff observed Resident #64 to have a bruise on the left eye and the resident was unable to explain how the resident received the injury. Findings included: A review of the facility's policy titled, Area of Focus: Abuse and Neglect, reviewed 11/21/2022, revealed, In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: have evidence that all violations are thoroughly investigated. A review of the Admission Record for Resident #64 revealed the facility admitted the resident with diagnoses that included dementia, aphasia, and frontotemporal neurocognitive disorder. Review of Resident #64's annual Minimum Data Set (MDS), dated [DATE], revealed the facility did not complete a Brief Interview for Mental Status (BIMS) because the resident was rarely/never understood. The Staff Assessment for Mental Status indicated Resident #64 had severely impaired skills for daily decision making. The MDS indicated the resident had physical behavioral symptoms directed toward others on one to three days of the assessment period and had wandering behaviors daily. Review of Resident #64's Care Plan, revised on 11/03/2020, revealed the resident had impaired cognitive skills due to dementia and short-term and long-term memory deficits. A review of the Progress Notes for Resident #64 revealed an event note, dated 01/24/2023 at 8:11 PM and written by Registered Nurse (RN) #1. The note indicated Resident #64 lacked safety awareness and judgement with distances and was often observed to walk quickly and turn and bump into walls. The note indicated the resident had faint light purple bruising to the left eye lid and temple. The note further indicated the resident was non-verbal and no signs or symptoms of pain were noted. An observation on 01/31/2023 at 12:02 PM of Resident #64 revealed the resident was sitting in the dining room of the Alzheimer's unit. Resident #64 was wearing a soft helmet and had a purple/black discoloration around the left eye. An interview on 02/01/2023 at 2:20 PM with RN #1 revealed the facility's abuse protocol was see something, say something, and to report to management right away. RN #1 said on the morning of 01/24/2023, at around 7:30 AM, she provided medications to Resident #64 but did not notice any bruising or discoloration to the resident's eye at that time. RN #1 stated later in the morning, Resident #64's family member (FM), FM #2), came for a visit and the family member and RN #1 observed Resident #64 had bruising to the crease on the upper eye lid of the resident's left eye. RN #1 stated they never observed when or how the bruise may have occurred. RN #1 stated at that time, she initiated neurological checks, and she reported the bruise to the Assistant Director of Nursing (ADON). RN #1 said she spoke to the ADON about the resident's behaviors, but she did not remember if she was asked if she observed when or how the bruise occurred. She said after that conversation there was no further discussion about the bruise or the incident. RN #1 also stated this was the first time staff had observed an injury to Resident #64 and that due to Resident #64 being nonverbal, the resident was not able to tell anyone what happened. An interview on 02/01/2023 at 2:50 PM with the ADON revealed RN #1 called her and reported the bruising to Resident #64 immediately after the RN identified it. The ADON stated Resident #64 had bruising to the face, close to the left eye. The ADON said she spoke with the certified nursing assistant (CNA) staff along with RN #1 who informed her of observations of Resident #64 walking into walls or opening the doors on themselves, but she stated none of the staff ever reported when these observations were or when or where the bruise occurred. The ADON stated the bruise would not have appeared until sometime later, but staff were not able to pinpoint the exact moment or action that caused the bruise. The ADON stated she reported the bruise to the Director of Nursing (DON) but did not think it was an injury of unknown since the staff were aware of behaviors that could have contributed to the bruise. The ADON stated staff never reported observation of these behaviors on the day of 01/24/2023 and only reported a history of these behaviors. The ADON stated that staff did not find the bruise concerning and it was not reported or investigated. The ADON stated staff kept an eye on the resident but admitted there were times when the resident was not supervised. An interview on 02/01/2023 at 3:29 PM with the DON revealed the facility's protocol regarding abuse was if you see or hear you report it. The DON stated staff should report immediately to their direct supervisor because the DON and Administrator only had a 2-hour window for the facility to report to the state survey agency and initiate their investigation. The DON stated she became aware of the bruise on Resident #64's eye when RN #1 notified the ADON and the DON that RN #1 was with the resident's family member in the resident's room when the bruising was observed to the inside crease of the resident's left eye. The DON stated an incident report was completed and they all three discussed it with some CNA staff and they decided it was not abuse due to the resident's behavior. The DON admitted that the staff she spoke with that day could not say if the resident bumped into anything on the 01/24/2023 or witness any interactions with other residents on that day. The DON further stated that the facility was not certain of when or how the injury occurred and injury should have been investigated. An interview on 02/02/2023 at 9:08 AM with Family Member (FM) #2 revealed, she was visiting Resident #64 on the morning of 01/24/2023, and at some point, when the resident was laying down, she could see a small bruise in the crease of the resident's left eye. FM #2 stated she asked staff about the bruise, but they informed her that none of them ever noticed the bruise. FM #2 stated she was alone in the room and that no staff was with her when the bruise was observed, and she informed staff when it was identified. FM #2 stated staff had informed her that Resident #64 was off balance a lot and had issues with judging the distance of things. FM #2 stated she had noticed that Resident #64 was a little off balance at times and uncoordinated. FM #2 stated staff told her they thought it may have been caused by Resident #64 bumping into things, but staff told her they never observed when it happened, and they could not be certain of what caused the bruise. An interview on 02/02/2023 at 12:20 PM with the Administrator revealed the incident was reported to the state survey agency on 02/01/2023 and an investigation was initiated after the report was made. The Administrator stated he first became aware there was discoloration noted to Resident #64's left eye on 01/25/2023 after the ADON told him. He stated he asked staff how the resident got the bruise, and he was told staff had observed the resident running into things frequently and pulling the door into themself. The Administrator stated he was under the impression that staff knew when and how the bruise occurred and did not ask staff any questions to clarify that. The Administrator stated on the day the bruise was observed, an investigation should have been initiated at that time. The Administrator stated staff should never assume any observed injury was a result of the resident bumping into something. The Administrator stated any injuries of unknown origin needed to be investigated to ensure the safety of the resident.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff to ensure the residents receive the care and services they required in keeping with their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, -Six interview able Residents (#1, #3, #8, #9, #10, and #11) of 13 sample residents and one family members said the facility failed to provide sufficient staff which resulted in delayed and/or inadequate care; -Observations made during survey revealed care and services not being provided timely; and -Facility documentation of staffing revealed multiple call-ins of certified nurse aides (CNAs), CNA staff being shifted and time punches verifying CNAs were assigned alone on a single unit for up to four hours. Cross-reference F677 the facility failed to provide toileting to dependent residents in a timely manner. Findings include: A. Resident Census and Conditions The census and conditions of residents form, provided by the facility and dated 8/24/2020, revealed 106 residents resided in the facility. Care needs of the residents were documented as follows: -71 residents were dependent on staff for bathing and 35 residents needed the assistance of one or two staff to bath; -Zero residents were dependent on staff for dressing and 106 residents needed the assistance of one or two staff to dress; -14 residents were dependent on staff to transfer and 92 residents needed the assistance of one or two staff to transfer; -Seven residents were dependent on staff for toilet use and 99 residents needed the assistance of one or two staff to the toilet; -Zero residents were dependent on staff to eat and 105 residents needed the assistance of one or two staff to eat; -90 residents were frequently incontinent of bladder; -67 residents were frequently incontinent of bowel; -88 residents were in their wheelchairs all or most of the time; -67 residents had a [DIAGNOSES REDACTED].>-Three residents had current pressure injuries and 103 residents received preventive skin care; -4 residents received hospice services; -38 residents received respiratory care; -23 residents had contractures; and, -106 residents were on a pain management program. B. Resident interviews Residents, who per facility and assessment were interview able, made the following statements when asked if the facility provided sufficient nursing staffing: Resident #3 was interviewed on 8/24/2020 at 11:21a.m. She said she had to wait to get her call light answered on a daily basis. She said she had to wait anywhere from 20-30 minutes to get her call light answered. She said staff do not check on her on a regular basis. Resident #3 said, Yes, I can use my call light when I need assistance but it was their job to still check on me. She said staffing gets worse as the day progresses. She said staffing was okay during the morning shift but it got worse in the evening and graveyard shift. She said two weeks ago I was left on the toilet during shift change and the graveyard staff had to take me off of the toilet. Resident #11 was interviewed on 8/24/2020 at 9:02 a.m. He said it can take as long as 30-45 minutes to answer my call light. He said we have one certified nurse aide (CNA) for this hall and we require a lot of help on this hall. He said we have one light duty CNA who was unable to lift any residents ' so we have to wait. He said, I have called the corporate office on several occasions to express my concerns of lack of staff and the effect it had on our care, and my calls do not get returned. He said, I have had to wait an hour sitting in my own urine before I got any help. Resident #1's son was interviewed on 8/25/2020 at 10:10 a.m. He said approximately two weeks ago he had to call the facility to get his mother some help at approximately 7:00 p.m. He said, My mother said she needed to get toileted as no one was answering her call light. He said I called the facility and I finally got through to a gentleman who said he would go to the nursing station and tell them that his mother required assistance. He said staff did not provide any care for his mother until 10:15 p.m., and she reported she was still wet. He said he had received no follow up. Resident #8 was interviewed on 8/26/2020 at 2:00 p.m. She said they are having real problems with staffing. She said, I have been told that certified nursing aides CNAs are quitting and they are always calling off sick. She said, I will have to wait anywhere from 20-30 minutes to get help. She said sometimes CNA's would come in and turn the light off and never come back. Resident #9 was interviewed on 8/26/2020 at 2:19 p.m. She said the facility was short staffed. She said, I have to wait anywhere from 20-30 minutes to get my call light answered. She said a CNA just had a work injury so we for sure will be short staff this evening. She said we have even complained to the director of nursing (DON) and we still haven't heard any response from her. Resident #10 was interviewed on 8/26/2020 at 2:43 p.m. She said it does take a while to get my call light answered but the CNA ' s are busy. They have a lot of people to take care of. C. Record review 1. Daily staffing documentation The nursing daily staffing sheet schedules were reviewed from 8/1/2020 through 8/26/2020 census was 106. There were numerous entries of staff calling-in, being shifted to other facility units or to be determined of scheduling times (written in but not verified with time punch). An example of these entries were the staffing sheets of Sunday 8/2, 8/3, 8.6, 8/7, 8/8, 8/11, 8/12, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/22, 8/23, and 8/24/2020. The staffing sheet showed on 8/16/2020 they had a five no call no show and on one of the three units there was one CNA from 2:00 p.m.-6:00 p.m., and one CNA from 2:00 p.m.-10:00 p.m., on station three. On 8/16/2020 there was one CNA on night shift on one of the three units. On 8/18/2020 they had one CNA from 10:00 p.m. to 4:00 a.m. and one CNA on night shift on one of the three units (station three). On 8/21/2020 the staffing sheet showed one CNA was on station one, two and three for graveyard shift. The secured unit had two residents ' who were on 1:1 ' s (one-to-one) for various behaviors. Nurse log note dated 8/9/2020 at 11:13 pm. Resident #1 son had called about six times this evening about things his mother stated to him on the phone. He stated that the evening CNA left his mother without any clothes on and in an upright position in her bed. The residents son had told her earlier that he would be able to do the video calling. She got very upset about that. The CNA that was taking care of her told this RN that he has to use several packs of wipes during a care episode and she still felt that she was not cleaned well enough. When this RN went in to see how we could help she (the resident) just responded that I did not know what I was doing. She did have a gown on and had a blanket on however she had tossed the blanket on the floor. Her son called again and stated he was going to call again after a female CNA went to the room to attend to her needs. D. Staff interviews CNA #2 was interviewed on 8/25/2020 at 12:30 a.m. He said they were short staffed and it was affecting the care of residents. He said they often pulled a CNA from other halls to help on a wing and then that would make them short on that hall. He said, an example would be we have the nurse from the secured unit working both the secured unit and then hall E as well. CNA #1 was interviewed on 8/25/2020 at 12:35 a.m. She said there were supposed to be three CNA's at night but for the past two months they had been working with two CNA's. She said the facility had a lot of call offs. She said, I covered for another hall and I had 25 plus residents ' I needed to cover by myself. She said,this slows the response time for call lights, which in turn gets the resident upset because we are not answering the call lights in a timely manner. Licensed practical nurse (LPN) #2 was interviewed on 8/25/2020 at 12:40 a.m. She said, Yes we are short staffed. She said the facility could hire more nurses and more CNA's. She said, Each hall should have three CNA's, which we do not have. She said the short staff affected care in activities of daily living (ADL) and affected the quality and quantity of care each resident received. CNA #5 was interviewed on 8/25/19 at 12:44 a.m. She said she worked as needed (PRN). She said they had been calling her frequently to fill call offs. She said she had been filling shifts by herself and had had to cover a complete hall by herself. She said she could get the work done but the care was rushed which was not fair to the residents. She said this hall had quite a bit of residents who used the Hoyer lifts which adds to the delay of care when we are short. CNA #6 was interviewed on 8/25/2020 at 10:56 a.m. She said they had two CNA's on their hall. She said, most of the time it was hard to get everything done. She said she was unable to pass ice water and provide showers regularly to residents'. She said, This was the hardest hall to work at which affected time light response because we have such a high rate of residents who use the Hoyer lifts and two person transfers. She said We have to pull a CNA from other halls to help us and then this puts them short on the other halls. She said, The result has been we have had a lot of falls because we can't get to them fast enough. She said they don't get ice passed or showers done. The staffing coordinator was interviewed on 8/26/2020 at 9:04 a.m. She said the facility had a lot of call offs. She said almost on a daily basis. She said when we are short staffed we try to bring in PRN staff or ask staff to work a double shift. She said the staffing was getting better but it was still a daily issue. The director of nursing (DON) was interviewed on 8/26/19 at 12:51 p.m. She was told of the observations and interviews above. The DON said they staffed the facility based on their census, acuity and the need of their residents'. She said all managers helped on the floor during the day and they worked as a team. She said if they had call-ins they tried to find coverage. She said they used a lot of PRN staff. She said it was a challenge of staffing to monitor burnout and ensure staff were not working too many hours. She said a negative outcome would be lack of care for all of the residents in the facility.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 in two of six halls including an isolation room. Specifically, the facility; -Failed to offer face coverings for residents when entering rooms; -Failed to ensure face coverings were encouraged with residents when not in their personal rooms; and, -Failed to ensure resident equipment was cleaned between uses. Findings include: I. The Centers for Disease Control (CDC) recommended guidelines The CDC, Preparing for COVID-19 in Nursing Homes, updated June 25, 2020, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (8/18/2020). It read in pertinent part, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare personnel) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Implementing Social Distancing Measures. Implement aggressive social distancing measures (remaining at least 6 feet apart from others). Cancel communal dining and group activities, such as internal and external activities. Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene. Remind HCP to practice social distancing and wear a facemask (for source control) when in break rooms or common areas. The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (8/18/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update July 15, 2020) Implement Universal Source Control Measures. Patients may remove their cloth face covering when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room. II. Offer residents ' facial coverings when staff enter resident rooms A. Observations and interviews On 8/24/2020 at 9:00 a.m., certified nurse aide (CNA) #8 was observed entering room [ROOM NUMBER]. She asked the resident if that was all she wanted. She was observed approximately two feet away from the resident during this observation. She left the room at 9:05 a.m. On 8/24/2020 at 12:21 p.m. CNA #14 was observed in residents ' room providing perineal care (PERI). She was approximately three feet away from the resident as she was observed empting the urinal. The resident did not have a mask on while CNA was providing care. On 8/24/2020 at 1:06 p.m., CNA #12 was observed taking vitals of the residents. CNA #12 entered the room and placed the blood pressure cuff on the resident. She would not ask or offer the resident to put on a mask nor offer a Kleenex to the resident to cover her mouth. On 8/25/2020 at 9:36 a.m. housekeeping (HSKP) #1 was observed entering room [ROOM NUMBER]. She knocked on the door and entered the room. She did not ask the resident to cover her mouth with a mask or tissue. She finished cleaning the room at 9:42 and exited the resident ' s room. She said her training to enter a resident's room was to knock and announce herself and tell them what she was going to do. She said she had not received training to ask a resident to cover their face when she entered a room. Staff did not offer or ask residents ' to put on a mask or cover their nose and mouth with a kleenex while providing care. B. Interview CNA #8 was interviewed on 8/26/2020 at 8:56 a.m. She said residents are to wear their masks when they are outside their rooms. She said we were just told today that we are supposed to ask residents ' to put on a mask or cover their mouth with a Kleenex when we are providing care. The staff development coordinator was interviewed on 8/26/2020 at 9:23 a.m. She said residents are supposed to wear masks when they are out of their rooms and staff are to wear masks when they are providing care. She said it was her expectation that the staff would ask the residents to put on a mask or cover their nose with a Kleenex while care was being provided. She said a negative outcome would be the spread of infection and or disease. She said she would re-educate staff on offering face coverings and handwashing. The DON was interviewed on 8/26/2020 at 12:51 p.m. She said anytime a staff member broke the barrier of a room the expectation was for them to wash/sanitize their hands. She said she expected the staff to offer a face covering when entering the room. III. Failed to ensure residents had face covering while out of their rooms A. References The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (7/15/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. B. Observations On 8/24/2020 at 8:55 a.m., observation of the facility revealed three residents' sitting in their wheelchairs on B hall. All three residents did not have on any face masks. -At 12:24 p.m. a male resident was in his wheelchair sitting at the end of C hall. He did not have a mask on. CNA #2 did not encourage residents to put on a mask as she walked by the resident. -At 3:13 p.m. A female resident was sitting in her wheelchair next to the bird Avery. No staff were observed to encourage residents to put on a mask as they walked by the resident. On 8/25/2020 at 3:30 p.m. CNA was observed taking a male resident in his wheelchair to the shower room. The male resident did not have a mask on during this observation. The CNA did not encourage or ask the resident to put on a mask. -During the above observations staff did not encourage residents to wear their masks when out of their rooms. C. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 8/25/2020 at 9:29 a.m. He said all residents are supposed to wear masks when they are out of their rooms. He said if we see a resident without a mask we are supposed to encourage them to wear their masks or offer to get them a mask to wear. Licensed practical nurse (LPN) #1 was interviewed on 8/25/2020 at 10:16 a.m. She said, All the residents should have had their masks on while out of their rooms. CNA #9 was interviewed on 8/25/2020 at 10:29 a.m. She said, Some residents' would wear their masks and some residents wouldn't. The SDC was interviewed on 8/26/2020 at 9:23 a.m. She said all of the residents' should have a mask on while out of their room. She said staff get too comfortable with the residents they know who do not wear their masks. She said staff should encourage all residents when out of their rooms to wear a mask and they should encourage them to wear them. The DON was interviewed on 8/3/2020 at 1:00 p.m. The DON was informed of the observations above. She said all residents should be [MEDICATION NAME] safe social distancing. She said staff should ensure all residents; are six feet apart when they are in common areas. She said a negative outcome would be cross-contamination and spread of infections. IV. Failed to ensure resident equipment was cleaned between uses. The Centers for Disease Control (CDC) recommended guidelines The Center for Disease Control (2019) Guideline and Recommendations for Disinfection in Healthcare Facilities, accessed on 8/27/2020,retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection. It read in pertinent part; -Disinfect non-critical medical devices (like blood pressure cuffs) with an EPA-registered disinfectant using the label ' s safety precautions and use directions. Most EPA-registered disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of disinfectants against pathogens with a contact time of at least 1 minute. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient). -If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient (who is in isolation) before using this equipment on another patient. However, multiple scientific studies have demonstrated the efficacy of disinfectants against pathogens with a contact time of at least 1 minute. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient). -If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient (who is in isolation) before using this equipment on another patient. Sani-Cloth Bleach Germicidal Disposable Wipe Features and Benefits (2019), retrieved from: https://pdihc.com/products/environment-of-care/sani-cloth-bleach-germicidal-disposable-wipe. It read in pertinent part, Disinfection level: EPA-registered intermediate level disinfectant. Overall contact time: four minutes. Pre-moistened wipes are ready to use. Efficacy claims: 50 microorganisms, including [MEDICAL CONDITION], norovirus and 14 multidrug resistant organisms. Formulation: 1:10 (one to 10 ratio of bleach to dilution). Not for use on skin. According to manufacturer's information regarding Clorox Pro, germicidal bleach, updated 2020, retrieved from: https://www.cloroxpro.com/products/clorox/germicidal-bleach/ it read, Causes severe [MEDICAL CONDITION] serious eye damage. Dwell times ranged from 30 seconds to five minutes. A. Observations On 8/25/2020 at 8:25 a.m., CNA #12 was observed going room to room on D hall taking resident blood pressures. She would exit each room and enter the next room without sanitizing or cleaning the mobile monitoring blood pressure machine. -At 9:20 a.m., A CNA was observed exiting room [ROOM NUMBER]. The CNA had a bag of soiled linens in one hand and pushed the Hoyer lift with the other hand. She plugged the Hoyer lift into the outlet and moved it next to the wall. The CNA did not wipe or sanitize the Hoyer lift after use. -At 9:40 a.m. CNA #12 again was observed going in and out of the resident's room with the mobile blood pressure machine. She would not sanitize or clean the mobile monitoring blood pressure machine. -At 12:16 p.m. A CNA was observed exiting room [ROOM NUMBER]. The CNA had a bag of soiled linens in one hand and pushed the Hoyer lift with the other hand. She plugged the Hoyer lift into the outlet and moved it next to the wall. The CNA did not wipe or sanitize the Hoyer lift after use. -At 4:01 p.m. CNA #13 was observed to enter room [ROOM NUMBER], which was an isolation room. CNA #13 proceeded to take the resident ' s vitals. She exited the resident room and proceeded to enter room [ROOM NUMBER]. She proceeded to take the vital signs of both residents in room [ROOM NUMBER]. CNA #13 did not sanitize or wipe the mobile blood pressure monitoring machine. B. Staff interview RN #7 was interviewed on 8/25/2020 at 1:02 p.m. RN #7 said, staff were supposed to wipe and sanitize the blood pressure machine before entering the residents room and after exiting the residents room. She said this would include the sit to stand and Hoyer lifts. RN #5 said when a resident was on isolation precautions the resident would have their own equipment as it would not be shared with others. CNA #13 was interviewed on 8/25/2020 at 4:11 p.m. She was supposed to sanitize the blood pressure machine before we go into a resident ' s room and when we exit the room. She said, I did not wipe or sanitize the blood pressure machine before or after exiting the resident ' s rooms. She said she was not aware of the proper procedure of checking blood pressure in a room which was in isolation. The SDC was interviewed on 8/26/2020 at 9:23 a.m. She was informed of the observations from the previous day. She said all of the resident equipment should be sanitized before and after for each use with the residents. She said the sit- to-stand and Hoyer lifts should be sanitized in the same manner. She said when a resident was in isolation they should have their own medical equipment as it was not to be shared. She said a negative outcome would be the spread of infections and disease.

Based on observations, record review and interviews, the facility failed to provide an environment free of accidents and hazards for 25 residents residing on the D hall (residents #34, #40, #75, #95, #145 and residents A - T), seven residents residing on the G hall (resident #174 and residents U - Z) and 14 residents residing on the H hall (residents #22, #33, #60, #113, #126, #133, #138 and #147 and residents AA - FF). Specifically: - The facility failed to ensure appropriate egress (a means of going out) was available in case of fire or emergency on three halls; and - The facility failed to provide fall interventions for one (#85) out of 35 sampled residents. On 12/19/16 observations revealed three halls (H, G, and D) where residents resided were blocked and rendered unusable as a means of egress. When staff was questioned as to how they would evacuate residents in an emergency including fire, they were unaware of any secondary plan of evacuation. Both the H and D halls were observed to have large areas of construction directly outside of the door, consisting of a large hole and rebar where steps had been removed. The G hall was observed to have a plastic tarp securely fastened to the ceiling and walls and construction equipment on the bottom of the tarp holding it down. This resulted in residents in the area having no means of evacuation if a hazard was present at the interior end of the G hall. As a result of the facility's action, residents residing on halls H, G, and D did not have a safe exit from the building, which jeopardized the safety of these residents and created a situation of immediate jeopardy for serious harm. The findings included: I. Immediate Jeopardy (IJ) A. Imposition of IJ On 12/19/16 at 2:14 p.m. the nursing home administrator (NHA) was informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to provide appropriate egress to residents in case of an emergency left the facility residents vulnerable and created a situation of immediate jeopardy for serious harm. B. Facility Response to the IJ The abatement plan was accepted on 12/19/16 at 6:21 p.m. The IJ remained in effect until the H hall residents were evacuated, and the D hall had an appropriate egress of a ramp constructed and available for use. The tarp was removed on the G hall which provided immediate access. A revised copy of the abatement plan was received from the NHA on 12/20/16 at 3:11 p.m. which included the evacuation of residents from the H hall as they were not able to create an appropriate egress for that hall. The revised abatement plan read: December 20, 2016 The following is a plan of abatement dated December 20, 2016, regarding alleged immediate jeopardy F323, involving appropriate egress points on D Hall, G Hall, and H Hall and how the facility will safeguard all residents until the permanent life safety improvements (ramps) are completed. 1. G Hall repair work was completed and the egress point fully accessible by 3:30PM on 12/19/16. This repair work was done to extend the sprinkler head to meet code, and all egress obstacles subsequent to the extension installation were removed. The Executive Director/designee will ensure all future proposed work on egress points meet life safety standards before work begins. 2. A temporary metal ramp, appropriately supported and safe for resident use, will be installed outside the D Hall egress door on 12/20/16 to assure safe passage to the outside should it become necessary to evacuate in a life safety emergency until permanent life safety construction improvements are completed. The work will be completed by employees of (construction company) with oversight provided by the local foreman, (name), and the Executive Director, (name). 3. All residents on H Hall will be safely assisted on 12/20/16 to available rooms within the center. These residents will remain off H Hall and D Hall until permanent life safety construction improvements are completed on these halls. In addition, no new admissions will be placed on H hall or D Hall until the permanent life safety construction improvements are completed. The work will be completed by employees of (construction company) with oversight provided by the local foreman, (name), and the Executive director, (name). 4. As soon as all of the appropriate local and state permits have been approved, work will begin on the permanent egress ramps for both H Hall and D Hall. 5. All staff currently on duty on the evening shift on 12/19/16, will be inserviced immediately on the temporary revised D Hall evacuation plan. Training will be completed 12/19/16 by the SDC/designee and will specifically identify the installation of the new temporary ramp at the end of D Hall that will allow safe passage of residents through this egress point if necessary. 6. All remaining staff will be inserviced prior to the beginning of their shift in the building or no later than the beginning of the shift should telephonic or in person communication not be possible. 7. The actions leading up to this abatement plan will be reviewed by the center's Performance Improvement Committee at the next monthly meeting to look for ways to prevent recurrence. On 12/20/16 at 8:17 p.m. with the completion of the evacuation of the H hall, the reopening of the exit to the G hall, and the construction of a safe egress (a ramp) from the D hall, the NHA was informed the immediate jeopardy was lifted. However, deficient practice remained at an E level. C. Facility Policy The policy titled, Fire Procedures, noted in pertinent part: If you discover a fire: R. Remove anyone in the room while calling out Dr. Red, location . for assistance. Close the door to the fire room and any room connecting doors. A. Activate the fire alarm. C. Close all remaining doors and windows in the fire zone, placing residents into rooms. Note: Shut off room air conditioning/heating units as these doors and windows are being closed (does not apply to fire room). E. Evacuate remaining rooms in the smoke compartment, if directed to do so by the person in charge. 2. Order of the above steps is somewhat flexible. However, the evacuation of the room's occupant(s) and confinement of the fire shall be the top priority. D. Observations On 12/19/16 observations revealed three halls (H, G, and D) where residents resided were blocked and rendered unusable as a means of egress. When staff was questioned as to how they would evacuate residents in an emergency including fire, they were unaware of any secondary plan of evacuation. Both the H and D halls were observed to have large areas of construction directly outside of the door, consisting of a large hole and rebar where steps had been removed. The G hall was observed to have a plastic tarp securely fastened to the ceiling and walls, and construction equipment on the bottom of the tarp holding it down. This resulted in residents in the area having no means of evacuation if a hazard was present at the interior end of the G hall. E. Staff interviews The physical therapist (PT) was interviewed on 12/19/16 at 11:56 a.m. He said in the case of a fire emergency, he would close the residents in their bedrooms and wait for the fire marshal's instructions. The hallways had their own exits, and if instructed, he would assist the residents to the exits and outside of the building. There were three hallways with construction located at the emergency exits. He said he did not know what he would do for residents located on one of those hallways if there was an emergency. He had no recent education on evacuation plans. Certified nurse aide (CNA) #6 was interviewed on 12/19/16 at 12:02 p.m. She said when there was a fire emergency, the doors located towards the center of the building would automatically close and contain the fire. All resident bedrooms were required to be closed and checked for residents. She said construction inside of the building had been going on for over six months. She had not been educated on an evacuation plan in case of an emergency. She said, There would not be a way to get them (residents) out if we needed to evacuate. Licensed practical nurse (LPN) #3 was interviewed on 12/19/16 at 11:55 a.m. She said the residents would be evacuated in case of a fire. She stated if they could be taken out of the West door she would take them, but if they had to go through the North door (hall H) she would have to ask management for further instructions. Registered nurse unit care coordinator (RNUCC #1) was interviewed on 12/19/16 at 11:56 a.m. She stated if they could not get residents out of the emergency exit in case of a fire, they could go through the resident bedroom windows. She stated staff had not received education since the construction had started. The activities assistant (AA) was interviewed on 12/19/16 at 12:10 p.m. She said in the case of a fire, she would first locate the fire and then evacuate the residents by way of the nearest emergency exit. She said the emergency exits had been under construction for approximately two weeks and she had not received information on a new emergency plan for residents residing on the hallways with construction. She said residents would not be able to exit the hallways in the case of an emergency. A solution to the emergency exit concern would have been to relocate residents to empty rooms and above the construction areas. However, no residents had been relocated prior the start of construction. The director of maintenance (DOM) was interviewed on 12/19/16 at 12:45 p.m. He said he was unsure if Life Safety (surveyors) were notified of the construction on the emergency exits. A person was designated to make rounds and determine if a fire was present. The sprinklers were turned off during the day time. In the case of an emergency, the residents' windows could have been broken and the residents pulled out of the windows. The nursing home administrator (NHA) was interviewed on 12/19/16 at 1:00 p.m. He said the DOM and director of housekeeping (DOH) were responsible for the evacuation plan and staff education on the evacuation plan through a safety committee. -He said the construction process consisted of 20 phases, starting in 11/15 and continuing into the new year. When one area was obstructed, the safety committee would determine the best exit route. The NHA said he did not attend the safety committee meetings. -At 1:33 p.m. the NHA said the construction was in the mechanical stage of renovations. There was no documented plan for the construction phases kept by the facility. The facility met with the contractor through each phase of the project and logged their discussions. The log of discussions was not provided. At 1:35 p.m. the DOH said the engineers kept the contracts and the facility did not have a copy. At 1:36 p.m. the DOM said all discussions were logged, with information on safety and the work in progress. The log was not provided. The DOM was interviewed again on 12/19/16 at 1:39 p.m. He said education on phases of construction was provided to the staff, but education on an emergency plan for the construction on the exits did not occur. The three emergency exits under construction were barricaded off. He said there was no way a resident was able to cross the barriers and get outside. In the past, residents had been moved to hallways without construction for safety. However, he confirmed none of the residents on the three affected halls had been moved from the areas of construction. Monthly fire drills were completed, but the drills did not include the current construction areas. At 1:55 p.m. he said a temporary evacuation plan had not been created before or after the construction on the emergency exits had begun. The fire marshal was interviewed on 12/19/16 at 4:01 p.m. He said in the case of a fire, residents could be transported into the center of the building or through a broken window. He said a temporary ramp would be able to be built by tomorrow. He was not aware of a new evacuation plan or that staff education had not occurred since the construction had on the exits had begun. F. Record Review Review of the construction safety meeting notes revealed the following: -11/3/16: Removal of the stars at the D and H halls will occur next week to accommodate the start of the ADA ramp work . Demo for this work will start Monday. Staff will be trained regarding egress. Plates will also be provided for egress at the rear. No evidence of training was provided and all interviews revealed there were never 'plates' put in place. -12/8/16: Demo for the ramp work is complete. Support Piers are in place. Ramps installation will begin tomorrow. The first pour was delayed due to snow. -12/15/16: Ramps should be in place by Christmas. We are including a crush form slab liner under horizontal pavement as the slabs and walls are tied together. II. Failure to provide fall interventions A. Resident Status Resident #85, age 77, was admitted on [DATE]. According to the 1/16 computerized physician orders [REDACTED]. According to the 11/29/16 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. She was documented rejecting care one to three days out of the last seven. She required extensive assistance for bed mobility, transfers, dressing, and toilet use. She utilized a wheelchair for mobility. B. Record review: The care plan, initiated 11/25/13, identified the potential for injury or fall related to the [DIAGNOSES REDACTED]. Interventions included two person assist with toileting and a pressure alarm while in wheelchair. The care plan, initiated 9/20/14, identified incontinence from decreased mobility related to [DIAGNOSES REDACTED]. Interventions included to provide prompt peri-care as needed (PRN) for incontinent episodes between regularly scheduled toileting times. The signed 12/16 CPO documented transfers with the assist of two ordered 5/27/16 and pressure alarm while up in wheelchair due to poor safety awareness ordered 8/26/16. C, Observations: The resident was observed on 12/20/16 at 9:24 a.m. going to the restroom alone, transferring self to the toilet, and exiting the bathroom without assistance. The resident was observed on 12/21/16 at 8:30 a.m. She wheeled herself to the room, went into the restroom unassisted. When she was done, she sat in her doorway until a certified nurse aide (CNA) walked by and assisted her pulling up her pants. D. Interviews: CNA #1 was interviewed on 12/22/16 at 7:43 a.m. She said the resident did not have any transfer requirements. She said the resident was a little unsteady while standing. She said the resident goes to the restroom by herself even though she was not supposed to. She said the resident is a one person transfer. She said the resident was not on a specific toileting schedule. CNA #6 was interviewed on 12/22/16 at 7:47 a.m. She said she can transfer herself to the toilet and call when/if she needed assistance after she was done. She said the resident did not have any transfer requirements. She said the resident was not on a specific toileting schedule. Registered nurse unit care coordinator (RNUCC) #3 was interviewed on 12/22/16 at 8:50 a.m. She said the resident was a one person assist for transfers, and transferred herself to the toilet. She said she was not aware the CPO included the two person transfer order or the order for a chair alarm. She said the resident would disable or break the chair alarms on the chair. She said she would call the provider to relay the information. She said the resident will toilet herself if needed. The director of nursing (DON) was interviewed on 12/22/16 at 8:57 a.m. She said she would expect the nurses to follow physician orders. She said if the resident was a fall risk the CNA's needed to assist her. She said she did not know if the resident was on a toileting schedule, but she was aware the resident did disable/break chair alarms. She said the CNA's needed to assist her to the toilet to help prevent another fall. She said the staff needed to re-evaluate and discontinue the chair alarm.

Based on record review and interviews, the facility failed to ensure incidents of abuse, neglect and injuries of unknown origin involving 12 of 52 sample residents (#7, #69, #115, #18, #84, #98, #125, #124, #159, #197, #52 and #136) were thoroughly investigated and that measures were taken to protect residents from further incidents of abuse, neglect and injuries of unknown origin. On 5/17/12 the Colorado Department of Public Health and Environment (CDPHE) received a complaint of alleged physical abuse of residents #7 and #69 and failure to investigate injuries of unknown origin for residents in the secure unit. Record review and staff interviews confirmed resident #7 sustained fractures in her right forearm and review of a log in the secured unit revealed 73 incidents had been recorded, from 1/1/12 to 5/12/12, of bruising, skin tears, resident to resident altercations, un-witnessed falls, and resident collisions with objects in their environment. The facility lacked evidence that these incidents were thoroughly investigated, reported, and that steps were taken to prevent residents' from further harm. This created a situation of immediate jeopardy for serious resident harm. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY Record review revealed resident #7 sustained fractures in her right forearm and resident #69 sustained a fracture of her [MEDICATION NAME] spine. Although a cause for resident #69's fracture was identified (spontaneous due to [MEDICAL CONDITION]), resident #7's fractures of the right forearm were not thoroughly investigated and reported, and steps to protect the resident were not developed, even though, per care plan, the facility identified the resident had the potential to be abused and/neglected. Staff interviews and record review revealed the existence of a "Near Miss Investigation" log on the facility's secured unit. Review of the log revealed 73 documented incidents of bruises, resident to resident altercations and collisions with objects in the environment. The information in the log was not entered into the facility's system for identification, investigation and tracking. Further record review revealed none of these documented incidents, from 1/1/12 to 5/12/12, were investigated, even when repeated incidents were reported. There was no evidence that the facility took steps to prevent further resident injuries. On 5/17/12 at 3:25 p.m., the Nursing Home Administrator (NHA), the Director of Nurses (DON), Assistant Director of Nursing (ADON) and Clinical Nurse Consultant (CNC) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility failure to thoroughly investigate injuries of known and unknown origin created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY 1. Initial Verbal Plan 5/17/12 On 5/17/12 at 4:30 p.m., the DON and ADON said each resident would be given a head to toe skin check that day. Those residents with skin deformity would receive an immediate abuse investigation. All staff was getting education on abuse identification and reporting, as well as training in the use of mechanical lifts. On 5/17/12 at 4:40 p.m., the CNC confirmed at this time that the nursing staff was to write down issues (previously recorded only in the log) in the clinical record and on 24 hour report. 2. Initial Written Plan 5/18/12 at 8:25 a.m. On 5/18/12 at 8:25 a.m., the CNC presented a written plan to keep the residents safe from injuries of unknown origin. Included in the initial plan were status of skin checks and injury investigations of residents #7 and #69. All staff were to be educated on alleged abuse identification, and reporting to their direct supervisor. Nursing staff would be educated on the use of mechanical lifts for safe transfers. The facility's 1/18/12 plan was incomplete; it did not include any indication of clinical record documentation of incidents of potential causes of injury. It also did not address maintenance of an open communication without fear of reprisal to staff or others who report concerns. Therefore, the immediate jeopardy was not removed. 3. Additional Plans 5/18/12 The facility's additional proposed plans to remove immediate jeopardy, submitted on 5/18/12 at 9:58 a.m. and 11:15 a.m., were also rejected by CDPHE as incomplete. The plans failed to include evidence of on-going monitoring of staff performance of safe transfers, and education of as-needed (prn) staff as well as those with days off over the next few days. The immediate jeopardy was not removed. 4. Plan 5/18/12 The facility submitted another plan on 5/18/12 at 12:45 p.m. The plan read: "The following is a plan of abatement dated May 17, 2012, regarding alleged immediate jeopardy F225 involving two residents (names of resident #7 and #69), and how the facility will safeguard all other residents. 1. (Resident #7 room number, medical record number, and name): Unable to determine cause of alleged bruises 4/6/12. A head to toe assessment was completed 5/17/12 with slight reddened area on right middle finger from cast which was padded, excoriation under right breast with treatment ordered, and small approximately 1 millimeter (mm) circular scratch upper right forehead from that skin tag that was half off. This resident was interviewed on 5/17/12, and stated (she was) not afraid of anyone, (was) not treated rough, (had) never been mistreated and never been dropped or hurt during cares. Alert and oriented to self and able to make needs known to others. 2. (Resident #69 room number, medical record number, and name): The investigation into the cause of the [MEDICATION NAME] vertebra #12 (T12) fracture from x-ray report dated 5/4/12 has been initiated. This resident was interviewed on 5/17/12, and stated (she was) not afraid of anyone, (was) never treated rough by any one, (had) never been hurt when transferred by staff and never been dropped during cares. This resident is alert and oriented, does not remember season but knows where she is and able to make her needs known to others. Other alert and oriented residents will be interviewed on 5/17/12. Staff assigned to (the resident's nursing station and hallway) from the day shift May 2, 2012 through day shift on May 5, 2012 will be interviewed within 24 hours. Head to toe assessment was completed on 5/17/12 with no bruises, no rashes and no [MEDICAL CONDITION]. 3. All current in house residents will receive a head to toe assessment on 5/17/12. These assessments are documented on the Weekly Skin Integrity Data Collection form. Any resident with identified injuries of unknown origin will have an immediate investigation initiated to rule out abuse. 4. All staff currently on duty on evening shift on 5/17/12 will be inserviced on what is abuse, how to report alleged abuse and to report alleged abuse immediately to their direct supervisor. 5. Nursing staff currently on duty on evening shift on 5/17/12 will be inserviced on proper use of mechanical lifts/transfers including reporting immediately to their direct supervisor any malfunction of the equipment and any injury to the resident during the use of the mechanical lifts/transfers. All remaining nursing staff will be inserviced during their next shift on abuse, transfers and system change. 6. Staff on vacation and PRN staff will be contacted and inserviced on abuse, transfers and system change on near miss program prior to working their next shift. 7. All current working staff on 5/18/12 will be reassured that their (sic) will be no retaliation/retribution as evidenced by (name of management company) code of conduct policy. All other staff will be appraised prior to working their next shift. 8. Therapy/designee will observe residents requiring assist with transfers at least once on 5/18/12. Ongoing monitoring. 9. Maintenance department will check all lifts for proper function by end of day 5/18/12. Ongoing monitoring. 10. System change: On 5/18/12 the near miss program will be changed to assessment by licensed nurse, documented in chart by license nurse, and noted on 24-hour report on shift of occurrence and incident report as appropriate. On 5/18/12, staff in house will be inserviced on system change. On 5/18/12, Nursing Administration will review 24-hour report and all incident reports at the end of each shift to verify system utilized correctly. Any staff not working on 5/18/12 will be inserviced prior to working their next shift. All 24 hour reports and all incident reports will be reviewed daily during after morning stand-up." C. REMOVAL OF IMMEDIATE JEOPARDY On 5/18/12 at approximately 1:45 p.m., DON and CNC were informed that the facility's plan presented at 12:45 p.m. lifted immediate jeopardy of F225. However, observation, record review and interviews revealed deficient practice remained at an E level (pattern with more than minimal harm). II. FAILURE TO THOROUGHLY INVESTIGATE AND REPORT RESIDENT #7'S MULTIPLE FRACTURES A. Facility Policy The facility abuse policy provides that incidents or suspected incidents of resident abuse, neglect or injury of unknown origin be reported to the nursing home administrator and the director of nursing. The facility abuse policy stated that the federal requirements mandate that facilities must ensure all allegations of abuse are reported immediately to their state survey agency. The Nursing Home Administrator (NHA) will provide the person investigating the incident with any supporting documents. The resident abuse report form will be used during the interview process of the staff, family and visitors. B. Resident #7 1. Resident #7, age 82, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date documented admitting [DIAGNOSES REDACTED]. The computerized physician orders [REDACTED]. as needed - pain. The minimum data set (MDS), dated [DATE], documented the following: -The resident had some cognitive impairment and was coded in section B0800 as having difficulties understanding others but was able to comprehend conversations, wore glasses. She had moderate cognitive impairment scored a 5/15 on the brief interview of mental status (BIMS), was able to makes needs known, had clear speech and an amputation of the left leg. -In section G - Functional status - the resident was coded as needing physical help in bathing, bed mobility, transfers, locomotion on the unit and dressing. The resident was coded as using a wheelchair for mobility. 2. Observations On 5/14/12 at approximately 12:00 p.m., the resident was observed sitting in her wheelchair in her room. The resident had a pink cast on her right forearm area. She was watching television. The resident was interviewed at this time. The interview revealed that the resident had broken her arm, but did not remember how the accident had happened. She stated that her arm hurt after the injury but that she does not remember what happened to her arm. Resident was difficult to redirect with conversation about facts of the injury. On 5/15/12 at approximately 11:25 a.m., the resident was observed being assisted to the dining room for the lunch meal. The staff was observed providing full assist with locomotion of the resident's wheelchair. On 5/16/12 at approximately 10:30 a.m., the resident was observed receiving total assistance with hygiene needs from the facility staff. 3. Record Review - Fractures of Right Forearm 4/23/12 a. Documentation in the resident's medical record section titled 'nursing notes,' nursing documented the following: -On 4/17/12 - 9:30 p.m., the resident was pleasant and cooperative with cares, all needs were anticipated by staff, wheelchair for mobility, mechanical lift for transfers, and no skin issues addressed at this time. -On 4/23/12 - 10:00 a.m., "8cm x 7cm area of redness to right forearm just above the wrist. The resident did complain of mild tenderness to the area of her right forearm. Call placed to provider by nursing for an x-ray." -On 4/23/12 - 5:30 a.m., the certified nurse aide (CNA) reported possible bruising to right wrist; however, the area was documented as brown/discolored, warm to touch area appeared unapproximated and Assistant Director of Nurses (ADON) was notified to assess the area. The day shift registered nurse also was informed to follow up on the residents right arm discomfort, discoloration and deformity. -On 4/23/12 - 4:00 p.m., an x-ray of the right hand, wrist and forearm was done. The indication for the x-ray included decreased range of motion and increase in pain, swelling and bruising. -On 4/24/12 - 4:51 p.m., the x-ray results came back as positive for fractures of the right ulna, radius and styloid bones. The ADON and Nursing Home Administrator (NHA) were notified. -On 4/24/12 - 5:00 p.m., a gutter splint was placed on the resident's right arm. The arm was elevated and ice applied. An appointment at the orthopedic surgeon was scheduled for next day. -On 4/25/12 - 1:42 p.m., the resident returned from the orthopedic office with her right forearm in a cast. -On 4/26/12 - the interdisciplinary team (IDT) met and discussed the resident's right fractured wrist. The team stated that the resident had no knowledge of the injury. b. X-ray Report -A document titled 'final x-ray addendum,' dated 4/23/12, documented the following: The findings were discussed with facility physician. Additional radiographic imaging of the wrist may be considered for evaluation for acuity and identification of additional injuries or displacement. Examination of the forearm shows sub acute ventral [MEDICAL CONDITION] radius is present with articular surface extension. Mild ventral angulations are present on the x-ray. Osseous fragments are noted dorsal to the wrist and most likely representing the ulnar styloid fracture seen on the wrist examination. The acuity of the ulnar styloid process injury is unclear. 4. Record Review - Facility Investigation A document called 'Incident follow up and Recommendation', dated 4/24/12, documented the following: -The DON signed off on the incident on 4/24/12, the day of the injury. -The NHA signed off on the incident on 4/30/12, six days after the incident. -The facility medical director signed off on the incident on 5/2/12, eight days after the initial injury. -The fall assessment evaluation was not updated as a result of the incident. No significant change on the MDS was required (or completed) per the facility documentation. -The investigation concluded that three facility staff interviewed on the night of the injury; all documented in their employee statements that they were unaware of what had happened to the resident. Five additional staff stated that they were not sure of the origin of the resident's right forearm injury. Nursing documented that the resident was a two person transfer assist with a mechanical lift. -The investigation was completed on 5/2/12. It was concluded that the origin of the resident's three forearm fractures was not identified. Review of the facility's abuse report form revealed the origin of the resident's fractures remained unknown. 5. Record Review and Interview - Facility Response a. Review of the resident's care plan revealed a care plan, "Potential for abuse/ injuries of unknown origin," was initiated 4/24/12. -Approaches included that nursing and social services observe for signs of abuse and injuries of unknown origin when completing daily and weekly skin assessments. -The goal on the resident's care plan was that an investigation be conducted of any injury of unknown injury and or allegations of resident abuse, and the residents right forearm area be observed per each shift assessment. -The care plan continued to document that the resident would be free from abuse and any type of injuries. The resident was to be given pain medications after each daily nursing assessment of pain. 6. Failures in Facility Response - Failure to protect the resident from further abuse/mistreatment or injury The medical record contained no care plan for the potential/actual abuse prior to the incident on 4/24/12. The care plan developed after discovery of the resident's injury included no plans to protect the resident from further injury. There was no direction to staff regarding safe transfers or safe use of the lift. There was no plan to increase supervision, although the facility had identified the resident was at risk for abuse and injuries of unknown origin. Record review revealed no evidence that staff were monitored while transferring the resident and while providing care, in order to ensure the resident's safety. Record review revealed no evidence that the resident's injuries of unknown origin had been reported to the State as a potential allegation of abuse, neglect or mistreatment. Record review revealed no documentation to support staff education regarding the identifying and reporting potential/actual resident abuse. 7. Staff Interviews On 5/15/12 at approximately 10:00 a.m., the DON was interviewed about the investigation report of injury on 4/24/12, involving resident #7. The DON said she was aware of the injury. -The DON further stated she was aware of the facility abuse policy and the criteria for reporting injuries of unknown origin to the state survey agency. She said she did not feel that the resident's injuries met the recording criteria. -The DON said she felt like a complete investigation was done after the incident, even though the facility had been unable to determine the origin of the fractures in the resident's right forearm. On 5/15/12 at approximately 10:45 a.m., the NHA was interviewed about the investigation report of injury on 4/24/12, regarding resident #7. The NHA said he was notified of the incident but did not know the particulars of the incident. He was unaware that the resident had three separate areas of fractures to her right forearm. The NHA stated that he was sure that the facility abuse policy had been followed and proper notifications to the state were made. On 5/15/12 at approximately 11:00 a.m., the social service director (SSD) was interviewed about the investigation report of injury on 4/24/12, regarding resident #7. -The SSD said she was aware of the resident's injury of unknown origin. She said she had done the investigation of the injury and felt that it was complete. She acknowledged that there was no root cause identified as a contributing factor of the injury. -The SSD said the nurse on duty the night of the injury had been dismissed from the facility. The SSD stated that the employee was not compliant with the facility's expectations of writing telephone orders from physicians. -The SSD said she aware of the facility and state requirements for reporting abuse; she did not explain why the injuries had not been reported to the State. On 5/17/12 at approximately 9:00 a.m., the NHA was asked about the criteria for reporting abuse. He stated he was not sure where that criteria was located, but would have an employee find it. He stated he was aware of the current residents (see below) with injuries of unknown origin. On 5/17/12 at approximately 10:00 a.m., in an interview with the NHA, DON, the assistant DON (ADON), and the regional nursing consultant (RNC) regarding resident #7, the NHA offered no information regarding resident's #7 injuries of unknown origin. On 5/17/12 at approximately 10:10 a.m., the ADON stated that the facility had a no tolerance policy on any type of abuse. She further stated that it was her expectation that the facility staff report any occurrences of abuse according to the facility's abuse prohibition policy. III. FAILURE TO INVESTIGATE INJURIES ON THE SECURED UNIT A. Secured Unit Resident Characteristics According to the face sheets and most recent minimum data set (MDS) assessment information, 19 of 19 residents on the secure unit had a [DIAGNOSES REDACTED]. The facility's secured unit placement admission evaluation and authorization listed the following as being criteria for placement and remaining on the secured unit: -At risk for wandering away from a familiar setting with the inability to find his/her way home. -At risk for disturbing the rights of others related to disruptive behaviors. -At risk of danger to self or others. -Less restrictive alternatives have been unsuccessful in preventing harm to self or others. B. Pertinent Facility Policies and Practices 1. Abuse Reporting The facility policy on abuse reporting read in pertinent part: -All personnel will promptly report an incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. -All alleged or suspected violations of mistreatment, abuse, neglect, injuries of unknown origin (e.g., bruising and skin tears) will be promptly reported to the administrator and/or director of nursing. 2. Bruising The facility flow sheet on bruises (part of the abuse policy provided by the facility) read in pertinent part: For any bruise found on a resident, if of unknown etiology, the charge nurse was to: Interview the resident, do a full body skin assessment, notify medical doctor (MD) and family of bruise and of the investigation process, staff interviews and statements for possible cause, then notify administrator or Director of Nurses (DON) or Assistant DON (ADON), document known reason for bruise, size of bruise, color and location and completion of (incident) report and change of condition. C. Documentation of Incidents of Bruises, Skin Tears, Falls, and Resident to Resident Altercations, as well as Collisions with Objects in the Environment 1. On 5/17/12 at approximately 9:00 a.m., a clipboard in the secured unit nursing station was identified. This clipboard, upon observation, held documentation with a heading "Near Miss Investigation" at the top of each page. The documentation included dates, resident names and descriptions of "near miss" events. These events included falls, abrasions, bruises, skin tears, residents found on the floor, resident to resident altercations and resident to staff altercations. Some of the documentation indicated mechanism of injury; however, some of the documentation listed only the injury or altercation. Based on the documentation on the "Near Miss Investigation" log, a total of 73 incidents had been recorded, from 1/1/12 to 5/12/12. -Six of 19 residents currently on the secured unit had injuries of unknown origin. The facility did not provide investigations of these injuries. -Eight events documented occurred during activities of daily living (ADL). The events noted injury or possible bruising. All eight of the events were noted as having occurred with staff present. The facility did not provide investigations for these events. 2. Resident-specific events recorded on the "Near Miss Investigation" log included: a. Resident #115, age 83, with the [DIAGNOSES REDACTED]. -1/2/12- bruise noted to right hand -Nursing documentation provided did not indicate mechanism of injury. -1/11/12- bruise to left shin-Nursing documentation provided did not indicate mechanism of injury. -4/30/12- resident pushed other resident into rail-No nursing documentation, no investigation of incident to prevent reoccurrence. -5/11/12- resident resistive to care, resident may have bruising to arms and hands- No nursing documentation, and no investigation whether bruising was related to the resident's "resistance" and whether staff appropriately intervened. b. Resident #18, age 74, had [DIAGNOSES REDACTED]. -1/3/12- skin tear- Nursing documentation provided did not indicate mechanism of injury, no investigation to determine causation and rule out abuse and/or mistreatment. -1/17/12- bruise left inner thigh- Nursing documentation did not indicate mechanism of injury and no investigation to determine causation and rule out abuse and/or mistreatment. -2/4/12- self inflicted bruise on top of previous bruise left hand- No nursing documentation and no explanation of how it was determined the bruise was "self inflicted." -2/4/12- bruise top of left hand, bumped on door handle- No supporting nursing documentation. c. Resident #136, age 80, with the [DIAGNOSES REDACTED]. -2/3/12- other resident grabbed right breast- No nursing documentation, no investigation, no documentation of steps to ensure resident safety. -2/6/12- pushing other resident, ran over left foot, no nursing documentation in either resident's record. -4/30/12- resident pushed into rail by resident (#18)- No nursing documentation, no investigation, no documentation of steps to ensure resident safety. d. Resident #84, age 90, with the [DIAGNOSES REDACTED]. -1/11/12- bruise right forearm- Nursing documentation provided did not indicate mechanism of injury. No investigation to determine causation and rule out abuse and/or mistreatment. e. Resident #98 a [AGE] year old with the [DIAGNOSES REDACTED]. 1/11/12- bruise left elbow- Nursing documentation provided did not indicate mechanism of injury. No investigation to determine causation and rule out abuse and/or mistreatment. f. Resident #125, age 85, with the [DIAGNOSES REDACTED]. -1/15/12- smashed right hand- No nursing documentation provided. No explanation of how resident "smashed" hand, no documentation of steps to prevent reoccurrence. -1/16/12- bruise to nose- Nursing documentation provided did not indicate mechanism of injury. No investigation to determine causation and rule out abuse and/or mistreatment. g. Resident #159, age 87, with the [DIAGNOSES REDACTED]. -1/17/12- bruise to wrist- Nursing notes indicated resistance to care as mechanism of injury. No investigation whether to ensure staff appropriately intervened when the resident was "resistive." h. Resident #124, age 79, with the [DIAGNOSES REDACTED]. -2/4/12- self inflicted scratch to buttock- No nursing documentation. No explanation how the facility determined the scratch was "self inflicted." -2/12/12- purposefully hit other resident's meri-walker- No nursing documentation in either residents' medical record. No investigation to determine causation and no documentation of interventions to prevent reoccurrence. -3/5/12- scraped arm on shower chair- No nursing documentation. No investigation whether staff ensured the shower chair was in good working order. i. Resident #197, age 93, with the [DIAGNOSES REDACTED]. -2/26/12- crawling on floor- No nursing documentation. No explanation why the resident was on the floor. -3/3/12- fingers caught in other resident's assistive device- No nursing documentation. No documentation of interventions to prevent reoccurrence. -4/20/12- staff opened door and hit resident in left elbow- No nursing documentation. No investigation to determine causation and no documentation of interventions to prevent reoccurrence. j. Resident #52, age 83, with the [DIAGNOSES REDACTED]. -3/27/12- feet ran over by other resident- No nursing documentation. No documentation of interventions to prevent reoccurrence. The facility did not provide investigations (see interview below) for any of the events listed above. 3. Staff Interviews On 5/17/12 at approximately 10:00 a.m., the DON stated the facility reviewed falls, injuries and bruises each morning for the entire facility. On 5/17/12 at 3:43 p.m., a licensed practical nurse (LPN) on the secured unit stated that the "Near Miss Investigation" log was not to record incidents. She also stated the purpose of the log was to record potential issues that may become more serious. After reviewing the log, the LPN stated the events on the log, specifically the resident to resident altercations, bruises, cuts, and injuries of unknown origin and un-witnessed falls, should not have been recorded on the log. The LPN stated these events should have been considered incidents and should have been documented in the electronic medical record, and an investigation should have been initiated. On 5/21/12 at approximately 2:00 p.m., a request was made to the DON, for the facility investigations into 13 events (specific to bruises, injuries and resident to resident altercations - see above) that had occurred, from 1/1/12 to 5/12/12. The facility did not provide any investigations regarding the 13 events requested. (The facility did provide three investigations unrelated to the events documented on the "Near Miss Investigation" log.) On 5/21/12 at 3:15 p.m., an interview was conducted with the DON and the social services director (SSD). The DON and SSD stated the purpose of the facility secured unit was to provide residents that were at increased risk of injury to self or others with an increased level of supervision. -The DON also stated the "Near Miss Investigation" logs had been discontinued with the exception of the secured unit. She went on to say the purpose of this log was an informal form for reporting incidents that might have later needed a complete incident report. The DON further stated the secured unit manager should have reviewed the "Near Miss Investigation" log daily, and reported (if necessary) the findings to herself (the DON). She also stated she should have been notified if a resident had pushed another resident or an injury had been recorded and she was not aware of the injuries or resident to resident altercations documented on the "Near Miss Investigation" log. -The DON stated it was acceptable for a resident to be pushing another resident in a wheelchair on the secured unit; and she was not aware that there had been injuries recorded on the log due to this. The DON further stated it was not acceptable for staff to continue to provide ADL care to a resident when the care provided placed the resident at risk of injury. On 5/22/12 at 8:53 a.m., the DON confirmed the facility had provided all of the available investigations (three events that were not on the log - see above) for events on the secured unit. The DON further stated all of the available facility investigations (not just the 13 requested) had been provided for the time period of 1/1/12 to 5/12/12. On 5/23/12 at approximately 8:15 a.m., the DON said she was unaware the "Near Miss Investigation" log was still in use at the time it was discovered in the secured unit.