Every finding on record at Valley Manor Care Center

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on two of four units. Specifically, the facility failed to:-Ensure staff used personal protective equipment (PPE) when performing care for residents who were on enhanced barrier precautions (EBP); and, -Ensure staff wore PPE when handling dirty linen. Findings include: I. EBP failures A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 4/14/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant toantibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings. B. Facility policy and procedure The EBP policy, undated, was received from the infection preventionist (IP) on 4/9/25 at 1:20 p.m. The policy read in pertinent part, The policy of the facility on Enhanced Barrier Precautions, in addition to standard and contact precautions will be implemented during the high - contact resident care activities when caring for residents have an increase risk for an acquired a multi-drug resistant organisms (MDRO) such as a resident with a wound, an indwelling medical device or a resident with an infection. EBP refers to an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The purpose of EBP was to prevent opportunities to transfer MDROs to employees hands and clothing during care beyond the situation in which staff anticipate exposure to blood or body fluids. Personal protective equipment was required for all staff providing high content resident care to include gown and gloves with: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: of a central line, urinary catheter, feeding tube or tracheostomy and wound care of any skin opening requiring a dressing. C. Observations On 4/7/26 at 3:30 p.m. CNA #7 and CNA #8 entered Resident #74's room. Resident #74's door had a sign on the door to indicate Resident #74 required EBP with high contact care. CNA #7 and CNA #8 did not don a gown upon entering the room. CNA #7 and CNA #8 transferred Resident #74 to wheelchair including moving Resident #74's indwelling urinary catheter tubing and collection bag to the wheelchair. CNA #7 assisted Resident #47 out of their room while CNA #8 Resident #74's personal items out to a transport van. On 4/8/26 at 4:11 p.m. CNA #7 and CNA #8 entered Resident #8's room. Resident #8's door had a sign on the door to indicate Resident #8 required EBP with high contact care. CNA #7 and CNA #8 transferred Resident #8 with a Hoyer lift. CNA #7 and CNA #8 did not don a gown while transferring Resident #8 via hoyer lift; including the handling of Resident #8's indwelling urinary catheter and collection bag. On 4/8/26 at 4:12 p.m. RN #2 responded to the call light for Resident #48. Resident #48's door had a sign on the door to indicate Resident #48 required EBP with high contact care. RN #2 did not don a gown while assisting Resident #48 in the bathroom. On 4/9/26 at 9:33 a.m. CNA #1 and CNA #2 entered Resident #8's room. Resident #8's door had a sign on the door to indicate Resident #8 required EBP with high contact care. CNA #1 and CNA #2 did not don a gown while transferring Resident #8 from his recliner to his wheelchair via Hoyer lift; including the handling of Resident #8's indwelling urinary catheter and collection bag. D. Staff interview CNA #1 was interviewed on 4/9/26 at 9:43 a.m. CNA #1 said she completed video education on the computer as well as inservice training on EBP guidelines. CNA #1 said the amount of PPE she wore depended on the task the resident required. CNA #1 said she always wore a gown and gloves when emptying the catheter of a resident on EBP precautions. CNA #1 said she always wore gloves, but not a gown when completing transfers, incontinence cares, or bathing residents. E. Additional observations On 4/7/26 at 4:15 p.m. certified nurse aide (CNA) #4 was assisting Resident #45 in his room. CNA #4 assisted the resident in changing his brief while the resident lifted his bottom off the bed. CNA #4 did not don (put on) gloves or a gown. There was a sign hung on the door of the room that indicated the resident was on EBP. EBPs. F. Additional staff interviews CNA #4 was interviewed on 4/7/26 at 6:14 p.m. CNA #4 said Resident #45 needed assistance to change his brief, but the resident just lifted his bottom up so he could exchange the soiled brief with a clean brief. He said he usually only wore gloves and he wore a gown and gloves when he assisted him into the shower. He said he knew EBP precautions were put in place when someone needed an extra layer of protection from an infection or a disease. The IP was interviewed on 4/9/26 at 12:05 p.m. She said the facility's EBP policy stated to wear gown and gloves with high contact care such as bathing, changing, linen transfers, indwelling catheters and wounds. She said a sign was placed on the resident's door to alert the staff on what to wear. She said she had not had a formal education class with the staff yet and was in the process of setting up walking rounds with staff to show them how to don and doff (take off) for EBP precautions. II. Laundry failures A. Facility policy and procedure The Handling Linens to Prevent and Control Infection policy, undated, was received from theIP on 4/9/25 at 1:20 p.m. It read in pertinent part, It was the policy of the facility, linens (laundry) would be handled, stored, processed, and transported in a manner to prevent the spread of infection. All potentially contaminated linen to be handled with appropriate measures to prevent cross-transmission. All staff should follow standard precautions when handling all used linen which was potentially contaminated (gloves, gown when sorting and rinsing). B. Observations On 4/8/26 at 1:40 p.m. laundry assistant #2 was loading dirty linen into the washing machine. She wore one glove on her right hand, which did not cover her entire hand. She used her right hand to handle the linens from a laundry bin. She pushed the linen into the machine which touched her wrist, forearms and left ungloved hand. C. Staff interviews Laundry assistant #1 was interviewed on 4/8/26 at 1:48 p.m. Laundry assistant #1 said soiled linen was brought into the laundry room in a sugar bag (dissolvable bag), which was put right into the washing machine. She said PPE was used with soiled linen. She reached high into a cabinet and pulled down a container of gowns. She said there was a reusable gown on the back of the door in the soiled linen room. The IP was interviewed on 4/9/26 at 12:05 p.m. The IP said PPE was worn when handling visibly soiled linens. She said it was standard of practice to wear gloves when handling soiled linens. She said there was a risk of cross contamination without PPE.

Based on observations, interviews and record review, the facility failed to keep medical information confidential for one (#20) of one resident out of 36 sample residents.Specifically, the facility failed to ensure Resident #20's medical information was not located in the state survey findings binder in the front lobby of the facility where the public had access to it. Findings include:1. Facility policy and procedureThe Resident Rights policy, revised 4/25/25, was provided by the assistant director of nursing (ADON) on 4/9/26 at 5:55 p.m. It read in pertinent part, Resident rights include, but are not limited to the following categories, each of which is addressed in separate organizational policies: Right to be informed of and participate in treatment, right to choose attending physician, right to be treated with respect and dignity, right to self-determination, right to information and communication, right to privacy and confidentiality, right to a safe environment, right to voice grievances, right to protection from abuse, neglect, and exploitation, discharge, transfer, and appeal rights, financial rights and responsibilities.II. ObservationsOn 4/8/26 at 1:58 p.m. Resident #20's face sheet (a sheet including personal medical information including diagnoses) and medication list were found in the facility's state survey results binder in the front lobby of the facility. Resident #20's face sheet and medication list were behind the most recent survey results, dated 12/10/25.III. Staff interviewsThe nursing home administrator (NHA) was interviewed on 4/8/26 at 2:12 p.m. The NHA said she was surprised Resident #20's face sheet and medication list were found in the state survey findings binder. The NHA said only three staff members updated the state survey findings binder; the regional quality assurance coordinator, the director of nursing (DON) and herself. The NHA said the last time she remembered reviewing or updating the binder herself was May 2025. The NHA said she thought the last person to update the binder was the regional quality assurance coordinator with the new results in December 2025. The NHA said the face sheet and medication list for Resident #20 must have been sitting on the printer when the regional quality assurance coordinator printed the survey results. The NHA said must have not have noticed she grabbed both the survey results and Resident #20's documents and added both to the binder. The NHA said she removed Resident #20's face sheet and mediation list from the state survey findings binder. The NHA said she planned to review the rest of the binder to make sure no other residents personal health information was included in the binder. The NHA said she also planned to talk with the DON and the regional quality assurance coordinator to find out why Resident #20's personal health information was accidentally placed in the binder. The NHA said the face sheet and medication list in the front lobby was a possible Health Insurance Portability and Accountability Act (HIPAA) violation, and a resident's private information cannot be shared with anyone the resident did not consent to share information with.The NHA and the DON were interviewed together on 4/9/26 at 3:41 p.m. The NHA said she called the regional quality assurance coordinator and she confirmed that she likely accidentally included Resident #20's face sheet and medication list when updating the binder in December 2025. The DON said she spoke with the NHA about the situation on 4/8/26. The DON said they planned to change the procedure by having only the NHA and the DON update the binder and for updates to be reviewed by each of them prior to placing the state survey results binder back in the lobby to ensure no other residents personal health information was accidentally included in the binder.

Based on observations, record review and interviews, the facility failed to provide care to each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for four (#3, #6, #55, #61) of eight residents reviewed of 36 sample residents.Specifically, the facility failed to respond to call lights in a timely manner to provide care with dignity for Resident #3, Resident #6, Resident #55 and Resident #61. Findings include:I. Facility policy and procedureThe Call Light, Use of Resident Call System policy, revised October 2021, was provided by the assistant director of nursing (ADON) on 4/9/26 at 5:55 p.m. It read in pertinent part, All facility personnel must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. For bedside call lights, a light and a sound will appear and be heard over the door of the resident's room and on the board at the nursing station. For emergency call lights in bathrooms, shower and tub rooms, a light and a continuous sound will appear over the door of the room and on the board at the nursing station. Answer call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the Room. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. Quality assurance and assessment program to check the call light system at regular intervals per the manufacturer's recommendations.II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebral infarction affecting the left non-dominant side, hemiplegia and hemiparesis (weakness and loss of function of one side of the body), unspecified convulsions, chronic pain, muscle weakness, depression, dysphagia, carpal tunnel syndrome, paresthesia of the skin (pins and needles) and hypertension.The 3/18/26 minimum data set (MDS) assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #3 was dependent on staff for putting on footwear, toileting, oral hygiene and bathing. Resident #3 required substantial assistance with personal hygiene, upper and lower body dressing. Resident #3 had functional limitations to range of motion to the left upper and lower extremities.B. Resident interviewResident #3 was interviewed on 4/6/26 at 2:56 p.m. Resident #3 said it usually took a while for staff to respond to call lights. He said he did not even expect a response for at least 10 to 15 minutes. He said he frequently waited more than 20 or 30 minutes for assistance. Resident #3 said he sometimes had to yell for help. Resident #3 said he was not typically incontinent of bowel. He said one time he waited so long for someone to respond to his call light, he was incontinent of bowel in his bed. Resident #3 said he felt frustrated and embarrassed when he could see his bathroom from his bed, but needed to be cleaned up because no one could help him in time. Resident #3 said he observed the same thing happen to his previous roommate.III. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included coronary artery disease, hypertension, diabetes, non-alzheimer's dementia, depression, asthma, carpal tunnel syndrome and dysphagia.The 3/6/26 MDS assessment revealed Resident #6 was cognitively intact with a BIMS score of 14 out of 15. Resident #6 required substantial assistance with toileting and moderate assistance with bathing. Resident #6 required set up assistance with footwear, upper and lower body dressing and personal hygiene. Resident #6 ambulated with a walker or wheelchair.B. Resident interviewResident #6 was interviewed on 4/6/26 at 4:14 p.m. Resident #6 said she frequently waited over 20 minutes for assistance after pressing her call light. Resident #6 said both her and her roommate have had to wait up to a half an hour for assistance in the bathroom, sometimes having to yell for help. Resident #6 said having to wait so long felt very frustrating, and long wait times seemed to happen frequently at any time of the day.IV. Resident #55A. Resident statusResident #55, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included orthostatic hypotension, protein-calorie malnutrition, depression, anxiety, dysphagia, restless leg syndrome, insomnia and Gastro-esophageal reflux disease (GERD) .The 2/5/26 MDS assessment revealed Resident #6 was cognitively intact with a BIMS score of 15 out of 15. Resident #55 was dependent on staff for all transfers, bathing, toileting, personal hygiene, footwear, upper and lower body dressing. Resident #6 used a wheelchair for mobilityB. Resident interviewResident # 55 was interviewed on 4/7/26 at 9:45 a.m. Resident #55 said when she first moved into the facility, it felt like twice as many staff worked on the unit. Resident #55 said she frequently waited 20 to 30 minutes for assistance after pressing her call light. Resident #55 said the staff forgot to give her a shower last Sunday(4/5/26). Resident #55 said a certified nurse aide (CNA) offered her the choice to complete a bath before or after breakfast. Resident #55 said she told the CNA she preferred after breakfast, but the CNA never came back. Resident #55 said when she asked later in the day, the staff told her they did not have time any more. Resident #55 said she felt bad for the staff, she said she felt the staff were asked to do twice as much with only half the help. V. Resident #61A. Resident statusResident #61, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included hypertension, non-alzheimer's dementia, depression, sleep apnea, atrial fibrillation, abnormal gait and history of falls.The 1/23/26 MDS assessment revealed Resident #6 had moderate cognitive impairment with a BIMS score of nine out of 15. Resident #6 required supervision or touching assistance with toileting and bathing. Resident #6 was independent with all other activities of daily living. B. Resident interviewResident #61 was interviewed on 4/8/26 at 9:57 a.m. Resident #61 said she experienced long call light wait times. Resident #61 said she had to wait over twenty minutes for assistance after using the call light multiple times. Resident #61 said it could happen at any time, but seemed to happen most often during the night. Resident #61 said sometimes staff would enter to turn off the light at a reasonable time, but then leave and not come back to assist with what she called for in over an hour. Resident #61 said she remembered an instance where she had to scream for help from the toilet. VI. ObservationsOn 4/6/26 at 12:07 p.m. the call light for room [ROOM NUMBER] was activated, staff did not respond to the call light for 18 minutes. On 4/7/26 at 9:22 a.m. the call light for room [ROOM NUMBER] was activated, staff did not respond to the call light for 26 minutes.VII. Record reviewAn audit of call light response times from 3/25/26 through 4/8/26 was provided by the social services director (SSD) on 4/8/26 at 6:36 p.m. Review of the call light response log from 3/25/26 to 4/8/26 revealed the following call light response times:The call light was activated and not answered for 15 to 20 minutes 71 timesThe call light was activated and not answered for 20 to 30 minutes 59 times.The call light was activated and not answered for 30 to 40 minutes 13 times.The call light was activated and not answered for 40 to 50 minutes six times.The call light was activated and not answered for 50 minutes or longer seven times.The majority of call light response times 15 minutes or longer occurred from the hours of 12:00 a.m. to 12:00 p.m., establishing a pattern of prolonged call light response time during the morning hours.A grievance form related to long call light wait times, dated 12/15/25, was provided by the SSD on 4/9/26 at 5:44 p.m. A grievance was filed by a discharged resident and Resident #30 related to long call light wait times over the previous weekend. The grievance form revealed an audit of call light response times was completed and acknowledged call light wait times of 20 to 40 minutes. The grievance form documented staff were provided in-person education on the call light policy and procedure as correction action resulting from the grievance. VIII. Staff interviewsCNA #1 and CNA #2 were interviewed together on 4/9/26 at 10:04 a.m. CNA #1 said they usually had two CNAs for each hall, but if someone called off they would move a CNA from the rehabilitation unit to one of the other units to cover. CNA #1 said the facility used to have a CNA who was dedicated to giving residents baths. CNA #1 said she did not know why but the position went away and was not replaced. CNA #1 and CNA #2 both said they were responsible for answering the call lights as well as providing baths to all residents who have a bath scheduled that day for their hall. CNA #2 said they decided between them who wants to provide baths for which residents, and do their best to meet each resident's preferred bath time. CNA #1 said it was difficult to answer all of the call lights in a timely manner when one CNA is off the floor bathing a resident. CNA #2 said sometimes residents had been frustrated due to long wait times baths or around meal times, but the residents usually understood that they may need to wait during busy times of the day.The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 4/9/26 at 3:41 p.m. The NHA said when they first received the call light system with the ability to audit call light response times, they would perform routine audits regularly, but she had not completed a full audit recently. The DON said the call light response time did not describe why the resident was calling or what the circumstances were during the time of the call light. The DON said she knew sometimes the CNA would leave the light one because they needed additional assistance from the floor nurse. The NHA and the DON said they would not want a resident to wait longer than 15 minutes for assistance unless unexpected circumstances occurred requiring staff to respond, like a fall or change in condition. The NHA said they were not aware of any grievances related to call light response time so far this year, but residents previously filed occasional complaints. The DON said sometimes they would audit call light response times after receiving a complaint from a family member, reporting they were on the phone with the resident while the resident pressed their call light and waited over an hour for a response. The NHA said with each complaint, they would complete an audit of the reported time frame to confirm the call light response time and provide corrective education if needed, or ensure the residents call light functioned correctly. The NHA said she was able to briefly review the call light audit requested during the survey. The NHA said she saw an increased wait time during the busiest times of the day. However, the NHA and DON said they were not aware that instances of call light response times over 30 minutes were occurring almost every day. The DON and the NHA said they were also not aware of the pattern of prolonged call light response times; primarily in one hall in the morning until the time of the interview. The NHA said they planned to complete an in depth investigation to identify the root cause for prolonged response times. The SSD was interviewed on 4/9/26 at 5:41 p.m. The SSD said she attended all resident council meetings to take notes as well as assist residents with filing grievances or addressing concerns mentioned in the meeting. The SSD said she remembered a previous resident wanted to file a grievance related to long call light response times during the December 2025 resident council meeting. The SSD said the previous resident reported long wait times up to 30 minutes and reported watching several staff on their phone while residents waited for assistance. The SSD said when the previous resident expressed her concern, Resident #30 voiced the same concerns. The SSD said She reviewed a call light audit with the NHA to investigate the grievance. The SSD said she found call light response times ranging from 20 to 40 minutes at various times on each unit during the weekend. The SSD said the NHA was aware of the grievance and call light audit. The SSD said she also reviewed the call light audit requested during the survey and saw each hall continued to have call light wait times over 20 minutes.

Based on observations, record review and interviews, the facility failed to ensure residents were kept free from physical abuse for one (#7) of four residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #70; and,-Protect Resident #7 from physical abuse by Resident #64. Findings include:I. Facility policy and procedure The At-Risk Adult Mistreatment Reporting, Investigation and Response policy, dated 3/2/26, was provided by the assistant director of nursing (ADON) on 4/9/26 at 5:35 p.m. The policy read in pertinent part, The policy establishes the commitment to protect the safety, dignity, and well-being of at-risk adults by defining requirements to identify, report, investigate, and respond to suspected mistreatment in accordance with Colorado regulations. To ensure compliance with the mandated report obligations, promotes prompt protective actions, and outlines procedures for internal investigation, administrative follow-up, and staff responsibilities to support resident or participants safety and quality of care. The policy addresses both the organizational report responsibilities of the facility's programs and the individual obligations of staff as mandated reporters under state law. Ensuring resident or participant safety. Upon awareness of a suspected maltreatment, staff will immediately take all necessary actions to protect the resident or participant from further harm.This includes the removal of the alleged perpetrator from contact with the resident or participant when appropriate, provide necessary medical care, ensure supervision, and address any environmental or systemic risks that may pose immediate jeopardy.II. Incident of physical abuse by Resident #70 towards Resident #7 on 2/17/26A. Facility investigation The 2/17/26 facility investigation was provided by the director of nursing (DON) on 4/8/26 at 11:00 a.m.The investigation revealed Resident #70 came up behind Resident #7, grabbed her neck, pushed and slapped her, which caused a superficial wound to the jawline. The staff members who witnessed the event were interviewed and confirmed Resident #70 had ambushed Resident #7 from behind. The nurse on duty was not in the unit at the time. Other residents were interviewed but none observed the incident. The facility determined the behavior was new for Resident #70 and implemented one-to-one monitoring as an intervention. The investigation documented it was recommended to keep the residents separated by at least six feet as much as possible.The investigation documented the residents were unable to provide information regarding the incident due to their cognitive status. The investigation documented monitoring was completed for both residents. The residents' physicians and responsible parties were notified. The investigation documented the facility substantiated the physical abuse.B. Resident #7 (victim)1. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included Lewy body dementia with mood disturbance, anxiety and depression. The 1/26/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. She required maximum assistance with activities of daily living (ADL).2. Record review The vulnerability care plan, dated 8/18/25, revealed Resident #7 was at risk for abuse as she had dementia and communication deficits. Interventions included observing the resident to minimize and prevent re-occurrence. The skin assessment, dated 2/19/26, revealed Resident #7 sustained a superficial scratch to the right side of the jaw line less than one inch in size from the 2/17/26 incident.C. Resident #70 (assailant) 1. Resident statusResident #70, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dementia with severe agitation and behavioral disturbances, and depression. The 3/19/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. She required maximum assistance with ADLs. The assessment documented the resident displayed verbal and physical behaviors towards others 2. Record reviewThe behavior care plan, dated 10/7/24, documented Resident #70 had behavior problems with verbal and physical aggression towards staff and other residents, to include tendencies to ambush residents. Interventions included keeping the resident six feet away from Resident #7 as much as possible. A progress note, dated 2/19/26, documented Resident #70 attempted to grab Resident #7 by the back of her neck and slapped her on the side of her face. A superficial scratch was noted to Resident #7's jawline less than one inch in size.The residents were separated as soon as the incident occurred.III. Incident of physical abuse by Resident #64 towards Resident #7 on 4/7/26A. ObservationsOn 4/7/26 at 4:05 p.m. Resident #64 was in the common area. Resident #64 was sitting in a recliner and had her walker in front of her, yelled and moved her walker away from Resident #7, who was standing over her. Certified nurse aide (CNA) #5 and an activity assistant (AA) intervened and separated the residents immediately. B. Facility investigationThe 4/7/26 initial investigation was provided by the DON on 4/9/26 at 11:30 a.m. The investigation revealed Resident #7 attempted to take a blanket from Resident #64. In response, Resident #64 slapped Resident #7's hand. Resident #7 attempted to retaliate physically, however the staff promptly intervened and prevented further escalation of the incident. The investigation documented no physical injuries or emotional distress were noted. Both residents were safely redirected away from one another by staff and were currently under close observation by staff and would continue to be kept separated. C. Resident #7 (victim)1. Record reviewA progress note, dated 4/7/26, documented there was a resident-to-resident altercation on 4/7/26. The note documented Resident #7 was evaluated for injuries. The medical director, family and appropriate staff were notified. The skin assessment, dated 4/7/26, revealed no skin injuries from the 4/7/26 incident. D. Resident #64 (assailant)1. Resident status Resident #64, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included dementia without behaviors, anxiety, and depression. The 1/29/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. She required maximum assistance with ADLs. The assessment indicated the resident had no behaviors. 2. Record review A progress note, dated 4/7/26, documented there was a resident-to-resident altercation on 4/7/26. The note documented Resident #64 was evaluated for injuries. The medical director, family and appropriate staff were notified. The vulnerability abuse prevention care plan, dated 10/23/25, documented Resident #64 wandered into other residents' rooms. The care plan documented when the resident displayed persistent or inappropriate behaviors, staff should remove the resident to an area away from others.IV. Staff interviewsThe activity assistant (AA) was interviewed on 4/7/26 at 6:00 p.m. The AA said she redirected the resident away from each other when they were too close together. The AA said Resident #7 touched other residents' things and she had to redirect the resident away from others often. CNA #4 was interviewed on 4/7/26 at 6:14 p.m. CNA #4 said Resident #7 fiddled with and moved items around the facility. CNA #4 said Resident #7 went into other residents' rooms and spaces. He said he kept an eye on all the residents to keep them safe from a possible altercation. CNA #5 was interviewed on 4/8/26 at 3:30 p.m. CNA #5 said the residents who resided in the memory care unit were hard to redirect. She said Resident #7 wandered around the unit most of the day, getting into other residents' things. She said she tried to keep an eye on Resident #7. She said she often found herself in between residents to stop them from hitting each other. Licensed practical nurse (LPN) #1 was interviewed on 4/8/26 at 3:46 p.m. LPN #1 said when residents had an altercation, they were separated, a skin check was completed and the DON was notified. She said the staff would monitor the resident and keep an eye on them so they did not touch each other. The DON was interviewed on 4/8/26 at 4:30 p.m. The DON said allegations of abuse were reported when they occurred and a full investigation was started. The DON said the staff monitored the residents closely and redirected them when needed. She said Resident #70 ambushed Resident #7 from behind on 2/17/26. She said the staff intervened right away and a one-to-one caregiver was assigned to Resident #70. The DON said the staff were educated to have line of sight for residents when they were in the common area. The DON said the interventions for the victim of the alleged abuse were not usually updated. She said she recently started looking at placing interventions for both residents involved in altercations.The DON said since the incident of abuse between Resident #7 and Resident #64 on 4/7/26, the interdisciplinary team (IDT) had discussions about new interventions for Resident #7 because of her risk of wandering. She said as of today (4/8/26), Resident #7's care plan was updated to have her not sit by Resident #64. The DON said education had been completed with new approaches in the memory care unit after the second incident on 4/7/26.

Based on record review and interviews, the facility failed to ensure two (#21 and #44) of five residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 36 sample residents. Specifically, the facility failed to follow up on the pharmacist's recommendations for a gradual dose reduction recommendations (GDR) for Resident #21 and Resident #44 for two months. Findings include:I. Facility policy and procedureThe Unnecessary Medication, Psychotropic Medication and Gradual Dose Reduction policy was provided by the director of nursing (DON) On 4/9/26 at 5:35 p.m. The policy read in pertinent part, The purpose of this policy is to ensure that all medications prescribed and administered withinthe long-term care and skilled nursing facilities are clinically appropriate, evidence-based, and aligned with each resident's individualized needs, preferences, and goals of care. The policy outlines expectations for identifying and preventing unnecessary medication use, ensuring the safe and appropriate use of psychotropic medications, and implementing gradual dose reduction strategies when clinically indicated. Residents who use psychotropic drugs will receive a GDR and behavioral interventions, to be managed at lower doses or to discontinue these drugs. Within one year of a resident's admission on a psychotropic medication or after a practitioner has initiated a psychotropic medication, the facility will attempt a GDR in two separate quarters with at least one month between attempts, unless clinically contraindicated. After the first year, a GDR will be attempted annually, unless clinically contraindicated. Opportunities during the care process to consider whether the medication should be continued, reduced, or discontinued, or otherwise modified include: during the monthly drug regimen review by the pharmacist, when the physician or prescribing practitioner evaluates the resident's progress and during the quarterly MDS (minimum data set) review by the interdisciplinary team. GDRs will be documented in the resident's medical record in accordance with facility protocols.II. Resident #21 A. Resident statusResident #21, age greater than 65, was readmitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), anxiety and dysphagia. The 3/12/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required maximum assistance with her activities of daily living (ADL). B. Record reviewThe psychotropic medication care plan, dated 11/29/21, revealed Resident #21 was seen by behavioral health services. Pertinent interventions included evaluating the resident for changes in behavior, mood or anxiety level prior to use of or dose change for psychoactive medication.The pharmacy consultant recommendation, dated 12/9/25, documented the pharmacist recommended to attempt a GDR to 30 milligrams (mg) one time a day for the medication duloxetine (antidepressant) or complete a clinical contraindication. Review of Resident #21's February 2026 CPO revealed the following physician's order:Duloxetine 60 milligrams, one tablet by mouth two times a day, ordered on 6/17/24 and discontinued on 2/10/26.Review of Resident #21's April 2026 CPO revealed the following physician's order:Duloxetine 30 milligrams, one tablet by mouth one time a day, ordered on 2/10/26. -Review of Resident #21's electronic medical record (EMR) revealed the facility failed to address the pharmacist's recommendation (from 12/9/25) for approximately two months.III. Resident #44A. Resident status Resident #44, age [AGE], was readmitted on [DATE]. According to the April 2026 CPO, diagnoses included chronic obstruction pulmonary disease (COPD), dementia and depression. The 2/9/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a BIMS score of one out of 15. She required maximum assistance with her ADLs. B. Record review The psychotropic medication care plan, dated 4/6/23, revealed Resident #44 had anxiety with mood disturbances,visual hallucinations, restlessness and agitation. Pertinent interventions included notifying the medical director of recommendations for dose reduction trials or other pharmacist findings. The pharmacy consultant recommendation, dated 12/9/25, documented the pharmacist recommended to attempt a GDR to 30 mg one time a day for the medication duloxetine or complete a clinical contraindication. Review of Resident #44's February 2026 CPO revealed the following physician's order:Duloxetine 60 milligrams, one tablet by mouth at bedtime, ordered on 6/12/25 and discontinued on 2/6/26.Review of Resident #44's April 2026 CPO revealed the following physician's order:Duloxetine 30 milligrams, one tablet by mouth one time a day, ordered on 2/6/26. -Review of Resident #44's EMR revealed the facility failed to address the pharmacist's (from 12/9/25) recommendation for approximately two months.IV. Staff interviews The DON was interviewed on 4/9/26 at 4:30 p.m. The DON said the pharmacist made recommendations for residents' medications monthly. She said she then reviewed the recommendations and contacted the medical director to make the changes. She said most responses from the provider were within 30 days, but she had made several attempts to contact certain providers for the recommendations. She said she had difficulties ensuring Resident #21 and Resident #44's provider responded timely to pharmacy requests. V. Facility follow-upAn email was received by the DON on 4/10/26 at 3:49 p.m. The email revealed a fax confirmation showing the provider was first notified on 12/17/25 at 2:44 p.m. and 5:09 p.m.-The fax confirmation did not indicate which resident the provider was notified about. The email documented a second request was made on 2/6/26 at 8:25 a.m. for Resident #21's GDR review. -However, there was no documentation to show specific requests for medication modification for the GDR recommendations for Resident #44.

Based on record review and interviews, the facility failed to timely report an allegation of abuse involving three (#43, #39 and #76) of five residents reviewed for abuse out of 36 sample residents.Specifically, the facility failed to-Timely report allegations of abuse by licensed practical nurse (LPN) #3 towards Resident #43;-Report allegations of abuse by LPN #3 towards Resident #39; and, -Report allegations of abuse by the occupational therapist (OT) towards Resident #76. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, initiated 3/2/26, was provided by the nursing home administrator (NHA) on 4/9/26 at 5:35 p.m. It read in pertinent part, This policy establishes (the facility's) commitment to protecting the safety, dignity, and well-being of at-risk adults by defining requirements for identifying, reporting, investigating, and responding to suspected mistreatment in accordance with Colorado regulations. (The facility) will ensure that all suspected mistreatment of at-risk adults is reported, investigated, and responded to in accordance with this policy, federal requirements, and Colorado regulations. All staff are required to report suspected mistreatment, cooperate with investigative processes, and support actions that protect resident/participant safety, without fear of retaliation. Any (facility) employee or volunteer who has reason to believe that an at-risk adult has been mistreated or is at imminent risk of mistreatment will immediately report this concern to their supervisor, Administrator/Executive Director, or designee. II. Allegation of verbal and physical abuse by LPN #3 towards Resident #43 A. Resident #43 (alleged victim)1. Resident statusResident #43, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included adult failure to thrive, chronic atrial fibrillation unspecified and kidney disease stage three. According to the 4/7/26 minimum data set (MDS) assessment, Resident #43 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out 15. The MDS assessment indicated Resident #43 used a walker for mobility and required partial to moderate assistance for dressing. According to the MDS assessment, Resident #43 did not have physical or behavioral systems directed to others. 2. Resident interview Resident #43 was interviewed on 4/7/26 at 9:15 a.m. Resident #43 said a few nights ago (4/3/26), over the weekend, he asked the nurse (LPN #3) what pills he was taking. He said LPN #3 told him that if he did not want to take his (expletive) pills then he did not have to. According to Resident #43, LPN #3 slammed the pills down on the table and left. He said he felt bad about the interaction with the nurse, so he had to lay down and relax. He said he did not know what to say afterwards and felt very frustrated. He said he was always told that it was his right to ask what medication he received. He said he wanted to find out what the problem was, so he went to the hallway to talk to her. He said since it was night time, he was wearing a shirt and underwear at the time because that was what he slept in. He said he did not feel he should have to get fully dressed again to ask her a question. Resident #43 said LPN #3 yelled at him again because he came out to the hall without pants over his underwear. He said she grabbed him by the arm and pushed him through his room doorway. He said the nurse was very, very upset and he was shocked. He said he could not figure out what he did wrong and she just blew up at him. He said he reported the incident the next morning (4/4/26) to someone in the front office. Resident #43 said he believed someone must have spoken to the nurse (LPN #3) because the next day she was his nurse again but was very nice and explained his pills to him. He said the staff all knew about the incident and he filled out a report (see 4/6/26 grievance form below). He said the way the LPN #3 treated him was abusive, was not professional and lacked nurse character. He said he did not want LPN #3 to be his nurse again. He said he did not understand why she was so mad at him. He said his roommate (Resident #12)was also in the room during the incident. 3. Additional resident interviewResident #12 (Resident #43's roommate) was interviewed on 4/7/26 at 9:20 a.m. Resident #12 said the nurse (LPN #3) was mad at Resident #43 and slammed his pills on the table. He said the pills went everywhere. He said a staff member later looked for the pills under the dresser with a flashlight. He said after LPN #3 slammed the pills on the table, she stayed outside of the room with her cart and he heard her slamming things around. Resident #12 said he was interviewed by staff and he filled out a report (grievance form). 4. Record reviewThe 4/6/26 grievance form for Resident #43 was provided by the NHA on 4/8/26 at 6:35 p.m. The grievance form documented that on 4/3/26, Resident #43 felt the nurse on the overnight shift did not like him asking about his pills and threw his pills on the floor. Resident #43 was told that if he did not want the pills he did not have to take them. The grievance form documented Resident #43 walked outside of his room to talk to someone but the nurse (LPN #3) shoved him back into his room.Review of the State Agency portal revealed the facility reported the incident on 4/9/26 at 10:36 a.m., six days after the incident occurred, five days after Resident #43 reported the incident to the front office employee and three days after the resident filed a grievance form regarding the incident. Cross reference F610: failure to thoroughly investigate an allegation of abuse.5. Staff interviewsCertified nurse aide (CNA) #9 was interviewed on 4/7/26 on 4:48 p.m. CNA #9 said she saw Resident #43 was very upset over the weekend and reported an incident between him and LPN #3 to the staffing coordinator and possibly another nurse. She said the social services director (SSD) was aware of the incident. She said Resident #12 told her the night nurse was very nasty to Resident #43. The SSD was interviewed on 4/7/26 at 4:53 p.m. The SSD said she was called by staff on Saturday (4/4/26) about an incident that happened at night on 4/3/26. She said she was not at the facility at the time but notified the NHA and the director of nursing (DON). -However, the facility failed to report the allegation of abuse until 4/9/26.The SSD said she met with Resident #43 on 4/6/26. She said Resident #43 said he thought some of his medications were discontinued and he asked the nurse (LPN #3) what medication he received. The SSD said he told her that LPN #3 became upset with him, was very rude to him and was kind of aggressive in her tone and meanness. She said he told her that the nurse was pretty mad when he asked about the medication and slammed the medication on the bedside table. She said he thought some of the medication rolled onto the floor. The SSD said Resident #43 told her that LPN #3 told him he could not be out in the hall without his clothes on and led him by his arm back to his room. The SSD said Resident #43 was still distressed about the 4/3/26 incident on Monday 4/6/26 when she interviewed him. The SSD said she interviewed Resident #43's roommate, Resident #12, on 4/6/26. She said Resident #12 saw the incident and reported the LPN #3 was not at all nice to Resident #43. She said both Resident #43 and Resident #12 filled out a grievance form on 4/6/26 with another staff member regarding the 4/3/26 incident. The SSD said allegations, such as the one reported by Resident #43 would usually be reported to the State Agency and investigated. Cross reference F610: failure to thoroughly investigate an allegation of abuse.The SSD said when there were allegations of potential abuse with a staff member, the facility reported the incident and investigated it. She said she was told by the DON that Resident #43 and LPN #3 had worked it all out on Sunday (4/5/26) and there was no malintent. The NHA and the DON were interviewed together on 4/8/26 at 4:58 p.m. The NHA said when a grievance was submitted by a resident, it was first triaged to the appropriate department and the SSD would let her know if something needed to be addressed right away, such as if it was a reportable incident or if it was an immediate nursing concern. The DON said Resident #43 was upset Friday night (4/3/26) because he was not going home on 4/3/26 and was confused about his medication changes. The DON said Resident #43 reported to staff that his nurse (LPN #3) was rude to him on 4/3/26. The DON said she spoke to LPN #3 and was told by the nurse that Resident #43 asked what medications he was getting. The DON said the nurse reported that she told Resident #43 that she would have to check on the computer, which upset him. The DON said LPN #3 should have already known what he was getting so she could tell him. The DON said the following day (4/4/26), Resident #43 was still upset and wanted to have a meeting about the incident. The NHA said she received Resident #43 and Resident #12's grievances on 4/6/26 regarding the 4/3/26 concerns. The NHA said she felt the incident was already looked at, felt Resident #43 was not at risk and the grievances did not meet reporting criteria. The NHA said at first she thought Resident #43's concerns were possibly a verbal abuse allegation but there was no intent to cause harm and there was not a negative outcome. She said she did not feel Resident #43's concern was physical abuse because there was no harm. The NHA said Resident #43 did not have an injury related to the incident, he did not indicate that he was fearful and there was no physical outcome. The NHA said she felt the grievance was in a grey area and there was nothing that the resident said that indicated possible abuse or that he was emotionally harmed. The NHA said the words Resident #43 used, such as shoved and slammed, in the grievance would need to be clarified but felt they had an understanding of what had happened. The NHA said she did not know if anyone asked Resident #43 if he felt the situation was abuse. She said the resident never expressed that the incident was that serious in level. The NHA and the DON were interviewed together a second time on 4/9/26 at 2:20 p.m. The NHA said she reported Resident #43's allegation of abuse on 4/8/26 (five days after the incident occurred), after it was identified that he felt that was abused by LPN #3. The NHA said she was aware of Resident #43's grievance but she had not had a chance to talk to him yet. The DON said she became aware of Resident #43's medication concern and that LPN #3 was rude after an employee texted her on 4/4/26. She said she thought the issue was resolved over the weekend. She said she had not talked to Resident #43 before he reported the incident to staff. The DON said the determination that the issue was resolved was based on her conversation with LPN #3. The NHA said the incident was not reported to the State Agency on 4/4/26 or 4/6/25 because she did not know Resident #43 felt the incident was abuse. The NHA said it was not a clear allegation of abuse at the time. The NHA said they just had bits and pieces of what happened. The NHA said if they had the full story, then they would have been able to better determine if the incident needed to be reported and investigated earlier.The DON said an allegation of abuse was not on the radar at the time the incident was reported to her on 4/4/26. The staff coordinator was interviewed on 4/9/26 at 4:52 p.m. The staff coordinator said she was working on 4/4/26 when Resident #43 came to her and said he wanted to meet with upper management right away. She said he was tearful and really upset. She said she was told that the night nurse was short with him. The staff coordinator said she told Resident #43 that management might not be able to meet right away on 4/4/26 but they would talk to him at least by Monday (4/6/26).III. Allegation of abuse by LPN #3 towards Resident #39 A. Resident #39 (alleged victim)1. Resident statusResident #39, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dysphagia, pharyngoesophageal phase, age related osteoporosis, cognitive communication deficits and anxiety. According to the 4/7/26 MDS assessment, Resident #39 was cognitively intact with a BIMS score of 15 out 15. The MDS assessment indicated Resident #39 used a wheelchair for mobility dependent on staff for most of her activities of daily living (ADL). 2. Resident interview Resident #39 was interviewed on 4/6/26 at 4:02 p.m. Resident #29 said she woke up with LPN #3 putting pills in her mouth and checking her body for patches about a week ago She said she was upset about it and reported her concern and filled out a grievance form. 3. Record reviewReview of the State Agency portal revealed the facility did not report an allegation of abuse by LPN #3 to the State Agency.Review of Resident #39's progress notes did not document Resident #39's concerns about nursing care.A 4/6/26 grievance form was provided by the NHA on 4/8/26 at 6:35 p.m. The grievance form documented Resident #39 stated she was asleep on the night nurse LPN #3 came into her room and shoved pills down her throat. The nurse told the resident that she also had to check to see if she had a patch on after the resident told her the prior staff member took the patches off. According to the grievance form, Resident #39 was concerned because she did not want to choke on pills and did not want to be woken up with pills being shoved in her mouth. The grievance summary section of the grievance form documented Resident #39's medication administration record (MAR) identified the resident had two medications before bed and the lidocaine patches were removed at bedtime. The grievance or finding of conclusion section of the grievance form documented the nurse, LPN #3, was a new traveling nurse and did not know that Resident #39 did not take her medications lying down. The nurse was educated on the resident's preference. LPN #3 said she needed to confirm that the resident's patches were off of her. The grievance conclusion documented the grievance was partially confirmed and LPN #3 was educated on the resident's preference.-However, the facility failed to report the allegation of abuse to the State Agency.An interview and observation with Resident #39, conducted by the DON on 4/8/26, was provided by the NHA on 4/9/26 at 3:38 p.m. According to the DON's interview and observation, there was no observed concerns when LPN #3 provided medication to Resident #39 on 4/8/26. The interviewed documented Resident #39 felt she was comfortable with LPN #3 and they had made amends.An interview with Resident #39, dated 4/9/26 and documented by the assistant director of nursing (ADON), was provided by the NHA on 4/9/26 at 3:38 p.m. According to the interview, Resident #39 told the ADON that she and LPN #3 had a truce and she no longer had concerns. 4. Staff interviewsThe SSD was interviewed on 4/8/26 at 4:09 p.m. The SSD said she processed and followed up with all the grievances submitted to her. She said she logged the concern and then asked the resident to clarify the information on the grievance form. She said she made a copy of the grievance and then gave the grievance form to the pertaining/appropriate department manager who would address the concern and action. The SSD said she usually would follow up to determine if the concern was resolved. The SSD said Resident #39 was very mad about the incident and was upset regarding how she was treated by LPN #3. The SSD said she took two whole pills at night and was worried she could have choked. She said the 4/3/26 incident with LPN #3 was not reported to her until 4/6/26. The SSD said the word shoved would have triggered her to report the allegation and investigate it. She said she confirmed with Resident #39 that the resident felt the nurse shoved her pills down her throat and took the grievance to the NHA and the DON. She said they said they would talk to LPN #3 and sort it out. The SSD said she would have reported and investigated when Resident #43 and Resident #39 used triggering word such as shoved during interactions with LPN #3 and the word slammed used by Resident #43. She said that was why she asked the NHA and the DON to review the grievances. The NHA and the DON were interviewed together on 4/8/26 at 4:58 p.m. The DON said LPN #3 was new to Resident #39. The DON said Resident #39 reported that LPN #3 checked her pain patches and shoved pills down her throat while the resident was laying down. The DON said there was no investigation or reporting, other than the grievance form, because Resident #39 said she was okay after LPN #3 later talked to her. The DON said LPN #3 was educated on how Resident #39 preferred to take her medication. The DON said she did not feel the concerns Resident #39 had with LPN #3 were the same as the concerns that Resident #43 had with LPN #3 on 4/3/26. IV. Incident between Resident #76 and the occupational therapist (OT) A. Resident #76 1. Resident statusResident #76, age greater than 65, was admitted on [DATE] and discharged on 12/31/25. According to the December 2025 CPO, diagnoses included a displaced fracture of the greater trochanter of the left femur, subsequent encounter for closed fracture with routine healing and diabetes mellitus. According to the electronic medical record (EMR), the resident had abnormalities of gait and mobility.The 12/5/25 MDS assessment identified Resident #76 was cognitively intact with a BIMS score of 14 out 15. The MDS assessment indicated Resident #76 had impairment to one side of his upper and lower extremities. He was dependent on staff to sit to stand and to transfer from surface to surface. According to the MDS assessment, the resident used a wheelchair for mobility. The MDS assessment indicated Resident #76 did not have physical or verbal behaviors or behavioral symptoms directed towards himself or others. 2. Representative interviewResident #76's representative was interviewed on 4/8/26 at 1:03 p.m. The representative said Resident #76 was admitted to the facility for therapy but felt the therapists were borderline abusive. She said Resident #76's other representative would often attend the therapy sessions with Resident #76. She said one of the therapists yelled at Resident #76 and kicked his foot to move it. She said the therapist said he was not going to work with him anymore. She said the other representative reported the kick from the therapist to Resident #76 to the staff. She said she discharged Resident #76 shortly after the incident because she was unhappy with the care and wanted him to go somewhere that he would get more therapy.3. Record reviewA 12/22/25 email was reviewed with the SSD on 4/9/26 at approximately 3:30 p.m. The email identified the SSD reported concerns of potential abuse to the NHA. According to the email, Resident #76's representative felt she had observed the OT kick Resident #76 during a therapy session. A 12/22/25 occupational therapy note was provided by the NHA on 4/9/26 at 7:57 a.m. The note documented Resident #76 yelled and told the OT don't push me around like that during the 12/22/25 occupational therapy session. The note documented the OT did not feel safe continuing to practice transfers if Resident #76 was going to be verbally aggressive and not pay attention to verbal cues. According to the note, the OT told the resident he did not feel comfortable continuing the session and he assisted Resident #76 back to his room in his wheelchair. -However, review of the State Agency portal did not reveal the facility reported the allegation of abuse. 4. Staff interviewsThe director of rehabilitation, the DON and the nurse manager were interviewed together on 4/9/26 at 1:06 p.m. The director of rehabilitation said Resident #76 had physical therapy three times a week and occupational therapy twice a week. The DON said Resident #76 reported that he was kicked by a therapist. The DON said they reviewed the situation and spoke with the OT. -However, the facility failed to report the allegation of physical abuse to the State Agency. The director of rehabilitation said Resident #76's left foot had to be lifted related to his history of a stroke. She said when the therapists would move his foot with their foot, it could have been misconstrued as a kick. The director of rehabilitation said the way Resident #76 would want to move was not safe and he did not have good safety judgement. She said sometimes he did not understand what the therapists were trying to do. The nurse manager and the director of rehabilitation said they spoke to the OT about the kicking concern. The nurse manager said she held a care conference about it. The director of rehabilitation said she did not think she was in the facility at the time of the care conference.The NHA was interviewed on 4/9/26 at 2:14 p.m. The NHA said she was aware of the kicking incident reported by Resident #76's representative on 12/22/26. The NHA said it was quickly determined that the OT was lifting up the resident's foot to move it. The SSD was interviewed on 4/9/26 at 3:21 p.m. The SSD said Resident #76's representative mentioned in a care conference that she observed the OT kick Resident #76 in the foot. The SSD said she asked either the director of rehabilitation or the OT to speak to the representative. The SSD said as far as she knew, the concern was not resolved. The NHA was interviewed a second time on 4/9/26 at 5:01 p.m. The NHA said the incident between Resident #76 and the OT was not reported or investigated for alleged abuse. She said she felt the representative's concern regarding the kicking of his foot was handled and resolved. She said Resident #76 was later discharged . The NHA said she was not aware of the 12/22/25 OT note that documented that Resident #76 told the OT not to push him around.

Based on record review and interviews, the facility failed to thoroughly and timely investigate an allegation of abuse involving two (#43 and #76) of five residents reviewed for abuse out of 36 sample residents.Specifically, the facility failed to:-Thoroughly investigate an allegation of abuse by licensed practical nurse (LPN) #3 towards Resident #43; and,-Thoroughly investigate an allegation of abuse by the occupational therapist (OT) towards Resident #76. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, initiated 3/2/26, was provided by the nursing home administrator (NHA) on 4/9/26 at 5:35 p.m. It read in pertinent part, This policy establishes (the facility's) commitment to protecting the safety, dignity, and well-being of at-risk adults by defining requirements for identifying, reporting, investigating, and responding to suspected mistreatment in accordance with Colorado regulations. Any (facility) employee or volunteer who has reason to believe that an at-risk adult has been mistreated or is at imminent risk of mistreatment will immediately report this concern to their supervisor, Administrator/Executive Director, or designee. Upon receipt of a report of suspected mistreatment of an at-risk adult, the facility or program will initiate an internal investigation to determine whether the alleged incident occurred and to ensure appropriate protective and corrective actions are taken. The investigation will be thorough, impartial, and timely, and will be coordinated by the appropriate designated operational and clinical personnel in collaboration with Quality and Compliance as needed.II. Allegation of physical and verbal abuse by LPN #3 towards Resident #43 A. Facility investigation A request was made for the investigation regarding the allegation of physical abuse verbal abuse on 4/8/26 at approximately 5:00 p.m. The NHA said the facility did not have a full investigation of the allegation incident (see interviews below). B. Resident #43 (alleged victim)1. Resident statusResident #43, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included adult failure to thrive, chronic atrial fibrillation unspecified and kidney disease stage three. According to the 4/7/26 minimum data set (MDS) assessment Resident #43 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out 15. The MDS assessment indicated Resident #43 used a walker for mobility and required partial to moderate assistance for dressing. According to the MDS assessment, Resident #43 did not have physical or behavioral systems directed to others. 2. Resident interview Resident #43 was interviewed on 4/7/26 at 9:15 a.m. Resident #43 said a few nights ago (4/3/26), over the weekend, he asked the nurse (LPN #3) what pills he was taking. He said LPN #3 told him that if he did not want to take his (expletive) pills then he did not have to. According to Resident #43, LPN #3 slammed the pills down on the table and left. He said he felt bad about the interaction with the nurse, so he had to lay down and relax. He said he did not know what to say afterwards and felt very frustrated. He said he was always told that it was his right to ask what medication he received. He said he wanted to find out what the problem was, so he went to the hallway to talk to her. He said since it was night time, he was wearing a shirt and underwear at the time because that was what he slept in. He said he did not feel he should have to get fully dressed again to ask her a question. Resident #43 said LPN #3 yelled at him again because he came out to the hall without pants over his underwear. He said she grabbed him by the arm and pushed him through his room doorway. He said the nurse was very, very upset and he was shocked. He said he could not figure out what he did wrong and she just blew up at him. He said he reported the incident the next morning (4/4/26) to someone in the front office. Resident #43 said he believed someone must have spoken to the nurse (LPN #3) because the next day she was his nurse again but was very nice and explained his pills to him. He said the staff all knew about the incident and he filled out a report (see 4/6/26 grievance form below). He said the way the LPN #3 treated him was abusive, was not professional and lacked nurse character. He said he did not want LPN #3 to be his nurse again. He said he did not understand why she was so mad at him. He said his roommate (Resident #12)was also in the room during the incident. 3. Additional resident interviewResident #12 (Resident #43's roommate) was interviewed on 4/7/26 at 9:20 a.m. Resident #12 said the nurse (LPN #3) was mad at Resident #43 and slammed his pills on the table. He said the pills went everywhere. He said a staff member later looked for the pills under the dresser with a flashlight. He said after LPN #3 slammed the pills on the table, she stayed outside of the room with her cart and he heard her slamming things around. Resident #12 said he was interviewed by staff and he filled out a report (grievance form).4. Record reviewThe 4/6/26 grievance form for Resident #43 was provided by the NHA on 4/8/26 at 6:35 p.m. The grievance form documented that on 4/3/26, Resident #43 felt the nurse on the overnight shift did not like him asking about his pills and threw his pills on the floor. Resident #43 was told that if he did not want the pills he did not have to take them. The grievance form documented Resident #43 walked outside of his room to talk to someone but the nurse (LPN #3) shoved him back into his room.The summary of the grievance, documented by the social service director (SSD) on 4/6/26, read Resident #43 was under the impression that his medication was discontinued. He asked the nurse what the pills were and was told they were the pills he always took. According to the summary of the grievance, the nurse slammed the pills down on the bedside table. The pills spilled and the nurse told the resident to take them or do not take them. The summary documented Resident #43 later walked to the nurse to talk to her and she told him he could not be without pants on and took him by the arm and walked him back to his room and told him to go back to bed. The grievance form summary of steps taken to investigate the grievance and the findings/conclusion, dated 4/7/26, identified the director of nursing (DON) documented she spoke with the nurse (LPN #3) on 4/4/26 about the medication concerns prior to receiving the grievance form. According to the grievance findings/conclusion, LPN #3 had already spoken to Resident #43 and went over the medication changes and explained the current medications. The findings/conclusion documented there was no confirmation of spilled medication. The grievance form documented the grievance was partially confirmed due to questions of medications and the nurse was re-educated regarding knowing what a resident's medications were before giving them to a resident. According to the grievance form, Resident #43 was discharged on 4/7/26 and he did not work with LPN #3 after the 4/3/26 overnight shift. The 4/6/26 grievance form for Resident #12 (roommate of Resident #43) was provided by the NHA on 4/9/26 at 9:36 a.m. The grievance form documented Resident #12 witnessed LPN #3 being very rude to Resident #43 on 4/3/26. He said the nurse made him very angry and she was not a good nurse to Resident #43. According to the grievance, Resident #12 said it was a very upsetting situation.The summary of the grievance, documented by the SSD on 4/6/26, identified the SSD confirmed Resident #12's grievance statements. The grievance form summary of steps taken to investigate the grievance and the findings/conclusion, dated 4/6/26, documented Resident #12 was unable to give details about what occurred and said he agreed with what his roommate said. According to the grievance, Resident #12 was concerned about the situation for his roommate but not concerned about himself or interacting with LPN #3.An undated statement, signed by the DON, was provided by the NHA on 4/8/26 at 6:35 p.m. The statement documented the DON asked LPN #3 on 4/4/26 to describe her interactions with Resident #43 on 4/3/26. The statement documented Resident #43 was frustrated and upset with LPN #3 because she could not identify all the medication she was giving him. The statement documented LPN #3 told the DON that later on the night of 4/3/26, Resident #43 came out of his room in his underwear and she mentioned that he should probably not be in the hallway with just his underwear on and she walked him back to his room. According to the statement, the DON commented that LPN #3 should have known what medications were being given to residents and should provide an explanation/information to the residents going forward. The statement indicated LPN #3 brought her computer down to Resident #43 on 4/4/26 and explained all his medication to him, and she felt their interaction with each other was good and Resident #43 was joking around with her. LPN #3's statement regarding the incident on 4/3/26, dated 4/7/26, was provided by the NHA on 4/8/26 on 6:35 p.m The statement documented that LPN #3 introduced herself to Resident #43 and asked him his name. She provided him his medication in a medication cup between 7:00 p.m. and 8:00 p.m. while he sat on the side of the bed with his bedside table in front of him. The statement documented the resident asked what medication he was receiving and she named off what she could remember and told him that she could look up the rest for him. She said Resident #43 became frustrated and angry and said some not nice things. According to the statement, LPN #3 told Resident #43 that he did not have to take the medication but he took the medication and she left his room. The statement documented LPN #3 said Resident #43 walked out of his room in his underwear and told her he wanted to talk to her. The statement documented LPN #3 told him he should not be out of his room in his underwear and they could walk and talk down to his room. The statement documented that Resident #43 said it was his right to know his medication and he wanted a meeting with someone on the following day (4/4/26). She said she apologized for not knowing how things were done at the facility. The statement documented that she reviewed his medication with him on the night of 4/4/26, he took his medication and there were no other concerns. The statement documented she only had verbal interactions with Resident #43 and did not put her hands on him. A 4/9/26 statement, signed by the NHA and the DON, was provided by the NHA on 4/9/26 at 5:35 p.m. The 4/9/26 statement documented the NHA and the DON contacted Resident #43's representative. According to the statement, Resident #43 was sleeping at the time of the call and the representative was not aware of any concerns or problems he had at the facility. The statement documented Resident #43 was asked to call her back when he could. Review of Resident #43's progress notes did not document the 4/3/26 incident or allegation between Resident #43 and LPN #3.5. Staff interviewsCertified nurse aide (CNA) #9 was interviewed on 4/7/26 at 4:48 p.m. CNA #9 said she saw Resident #43 was very upset over the weekend (4/3/26) and reported an incident between himself and LPN #3 to the staffing coordinator and possibly another nurse. She said the SSD was aware of the incident. She said Resident #12 told her the night nurse was very nasty to Resident #43. The SSD was interviewed on 4/7/26 at 4:53 p.m. The SSD said she was called by staff on Saturday (4/4/26) about an incident that happened at night on 4/3/26. She said she was not at the facility at the time but notified the NHA and the DON. The SSD said she met with Resident #43 on 4/6/26. She said Resident #43 said he thought some of his medications were discontinued and he asked the nurse (LPN #3) what medication he received. The SSD said he told her that LPN #3 became upset with him, was very rude to him and was kind of aggressive in her tone and meanness. She said he told her that the nurse was pretty mad when he asked about the medication and slammed the medication on the bedside table. She said he thought some of the medication rolled onto the floor. The SSD said Resident #43 told her that LPN #3 told him he could not be out in the hall without his clothes on and led him by his arm back to his room. The SSD said Resident #43 was still distressed about the 4/3/26 incident on Monday 4/6/26 when she interviewed him. The SSD said she interviewed Resident #43's roommate, Resident #12, on 4/6/26. She said Resident #12 saw the incident and reported the LPN #3 was not at all nice to Resident #43. She said both Resident #43 and Resident #12 filled out a grievance form on 4/6/26 with another staff member regarding the 4/3/26 incident.The SSD said allegations, such as the one reported by Resident #43 would usually be reported to the State Agency and investigated. She said she was often the lead in abuse allegations but she was not involved in the 4/3/26 investigation other than interviewing Resident #43 and Resident #12 related to their grievances. She said she was the grievance coordinator for the facility. The SSD said the incident between LPN #3 and Resident #43was not discussed with the interdisciplinary team (IDT). She said she was told by the DON that Resident #43 and LPN #3 had worked it all out on Sunday (4/5/26) and there was no malintent. Cross reference F609: failure to report an allegation of abuse to the State Agency.The SSD said when there were allegations of potential abuse with a staff member, the facility would report the incident and investigate it. She said the investigation would include interviewing the resident and other residents that may have witnessed the incident or had similar experiences with the same staff member. She said the staff members involved in the allegation and other staff members would be interviewed. She said the facility then would make a determination on if the allegation was substantiated. The SSD said she was not sure why the 4/3/26 was handled differently. The NHA and the DON were interviewed together on 4/8/26 at 4:58 p.m. The NHA said when a grievance was submitted by a resident it was first triaged to the appropriate department and the SSD would let her know if something needed to be addressed right away such as if it was a reportable incident or if it was an immediate nursing concern. The DON said Resident #43 was upset Friday night (4/3/26) because he was not going home on 4/3/26 and was confused about his medication changes. The DON said Resident #43 reported to staff that his nurse (LPN #3) on 4/3/26 was rude to him. The DON said she spoke to LPN #3 and was told by the nurse that Resident #43 asked what medications he was getting. The DON said the nurse reported that she told Resident #43 that she would have to check on the computer, which upset him. The DON said LPN #3 should have already known what the resident was getting so she could tell him. The DON said the following day, Resident #43 was still upset and wanted to have a meeting about the incident on 4/4/26. The DON said LPN #3 reviewed all his medications with him and he chose which ones he wanted to take. She said LPN #3 told her that she did leave the medications in his room but did not say anything about slamming them down. The DON said LPN #3 told her that she did not grab his arm and purposely take him to his room. She said LPN #3 reported that she might have accidentally touched the resident's arm but she did not remember. The NHA and the DON said they felt like a mini-investigation was already done when the DON had a conversation with LPN #3 over the weekend and was fact finding before the grievance was written on 4/6/26. The DON said she did a verbal education over the phone with LPN #3 regarding medications. The DON said LPN #3 provided a written statement on what happened on 4/3/26 and LPN #3 told Resident #43 that he could have another nurse if he wanted one but the resident said he was okay. The DON said if she knew Resident #43 was really upset over the weekend about the incident, she would have come in to talk to him. The NHA said she received Resident #43 and Resident #12's grievances on 4/6/26 regarding the 4/3/26 concerns. The NHA said she felt the incident was already looked at, felt that Resident #43 was not at risk and the grievances did not meet reporting criteria. The NHA said at first she thought Resident #43's concerns were possibly a verbal abuse allegation but there was no intent to cause harm and there was not a negative outcome. She said she did not feel the resident's concern was physical abuse because there was no harm. The NHA said Resident #43 did not have an injury related to the incident, he did not indicate that he was fearful and there was no physical outcome. The NHA said she felt the grievance was in a grey area and there was nothing that the resident said that indicated possible abuse or that he was emotionally harmed. The NHA said the words he used, such as shoved and slammed in the grievance would need to be clarified but felt they had an understanding on what happened. The NHA said she did not know if anyone asked Resident #43 if he felt the situation was abuse. She said he never expressed the incident was that serious in level. The NHA said the nurse probably could have used a better approach. The DON said the SSD interviewed Resident #12 on 4/6/26 about the incident. She said Resident #12 reported that he agreed with what Resident #43 said. The DON said Resident #12 was a poor historian and not able to give details at a later date on specifics. The DON said no other residents were interviewed about LPN #3 or about abuse other than Resident #39. The DON said Resident #39 was interviewed because she submitted a grievance form (see below).The NHA and the DON were interviewed together a second time on 4/9/26 at 2:20 p.m. The NHA said she reported Resident #43's the allegation of abuse on 4/8/26 after it was identified that he felt that was abused by LPN #3. She said the facility started a full investigation. The NHA said Resident #12 was interviewed. She said Resident #43 discharged on 4/7/26 and she tried to call him but he was not available. She said she spoke to his representative and she was not aware of any incidents. The NHA said she did not know if the incident was reported to the representative when it was reported to the facility on 4/4/26. The DON said she was just aware of Resident #43's medication concern and that the nurse was rude after an employee texted her on 4/4/26. She said she thought the issue was resolved over the weekend. She said she did not talk to Resident #43 after he reported the incident to staff. The DON said the determination that the issue was resolved was based on her conversation with LPN #3. The NHA said she did not know if the SSD asked Resident #43 if he felt he was abused. The NHA said she was aware of Resident #43's grievance but she had not had a chance to talk to him yet. The NHA said the facility had an abuse investigation packet they used that included abuse questions. She said the packet was used when the residents reported abuse concerns. She said if someone had asked him directly if he felt he was abused then that might have prompted an abuse investigation and she would have reported earlier to the State Agency. The NHA said it was not a clear allegation of abuse at the time of the incident. The NHA said they just had bits and pieces of what happened. She said they were now finding out a lot of staff had some information pertaining to the incident. The NHA said if they had the full story, then they would have been able to better determine if the incident needed to be reported and investigated earlier.The DON said an allegation of abuse was not on the radar at the time it was reported to her on 4/4/26. She said she knew Resident #43 was upset about the medications and that he felt the nurse was rude to him. The DON said it would have required more interviews with Resident #43 to understand what he meant by rude. The DON said rudeness was not always abuse. The DON said someone should have come in and gotten to the bottom of the incident. The staff coordinator was interviewed on 4/9/26 at 4:52 p.m. The staff coordinator said she was working on 4/4/26 when Resident #43 came to her and said he wanted to meet with upper management right away. She said he was tearful and really upset. She said he told her that the night nurse was short with him. The staff coordinator said she told Resident #43 that management might not be able to meet right away on 4/4/26 but they would talk to him at least by Monday (4/6/26).III. Allegation of physical abuse by the OT towards Resident #76A. Facility investigationA request for the facility's investigation regarding the allegation of physical abuse by the OT towards Resident #76 was requested on 4/8/26 at approximately 5:00 p.m. The NHA said they did not have a documented investigation of the incident(see record review below).A. Resident #76 1. Resident statusResident #76, age greater than 65, was admitted on [DATE] and discharged on 12/31/25. According to the December 2025 CPO, diagnoses included a displaced fracture of the greater trochanter of the left femur, subsequent encounter for closed fracture with routine healing and diabetes mellitus. According to the electronic medical record (EMR), the resident had abnormalities of gait and mobility.The 12/5/25 MDS assessment identified Resident #76 was cognitively intact with a BIMS score of 14 out 15. The MDS assessment indicated Resident #76 had impairment to one side of his upper and lower extremities. He was dependent on staff to sit to stand and to transfer from surface to surface. According to the MDS assessment, the resident used a wheelchair for mobility. The MDS assessment indicated Resident #76 did not have physical or verbal behaviors or behavioral symptoms directed towards himself or others. 2. Resident #76's representative interviewResident #76's representative was interviewed on 4/8/26 at 1:03 p.m. The representative said Resident #76 was admitted to the facility for therapy but felt the therapists were borderline abusive. She said Resident #76's other representative would often attend the therapy sessions with Resident #76. She said one of the therapists yelled at Resident #76 and kicked his foot to move it. She said the therapist said he was not going to work with him anymore. She said the other representative reported the kick from the therapist to Resident #76 to the staff. She said she discharged Resident #76 shortly after the incident because she was unhappy with the care and wanted him to go somewhere that he would get more therapy.3. Record reviewA 12/22/25 email was reviewed with the SSD on 4/9/26 at approximately 3:30 p.m. The email identified the SSD reported concerns of potential abuse to the NHA. According to the email, Resident #76's representative felt she had observed the OT kick Resident #76 during a therapy session. A 12/22/25 occupational therapy note was provided by the NHA on 4/9/26 at 7:57 a.m. The note documented Resident #76 yelled and told the OT don't push me around like that during the 12/22/25 occupational therapy session. The note documented the OT did not feel safe continuing to practice transfers if Resident #76 was going to be verbally aggressive and not pay attention to verbal cues. According to the note, the OT told the resident he did not feel comfortable continuing the session and he assisted Resident #76 back to his room in his wheelchair. -However, the facility failed to investigate the allegation of physical abuse. 4. Staff interviewThe director of rehabilitation, the DON and the nurse manager were interviewed together on 4/9/26 at 1:06 p.m. The director of rehabilitation said Resident #76 had physical therapy three times a week and occupational therapy twice a week. The director of rehabilitation said Resident #76 had behaviors during the therapy sessions. She said Resident #76 had difficulty processing information and would be impulsive or argumentative at times. The nurse manager said Resident #76 reported to his representative that he was not going to therapy, so the representative started observing sessions to show he was attending. The DON said Resident #76 reported that he was kicked by a therapist. The DON said they reviewed the situation and spoke with the OT. The director of rehabilitation said Resident #76's left foot had to be lifted related to his history of a stroke. She said when the therapists would move his foot with their foot, it could have been misconstrued as a kick. The director of rehabilitation said the way Resident #76 would want to move was not safe and he did not have good safety judgement. She said sometimes he did not understand what the therapists were trying to do. The nurse manager and the director of rehabilitation said they spoke to the OT about the kicking concern. The nurse manager said she held a care conference about it. The director of rehabilitation said she did not think she was in the facility at the time of the care conference.The NHA was interviewed on 4/9/26 at 2:14 p.m. The NHA said she was aware of the kicking incident reported by Resident #76's representative on 12/22/25. The NHA said it was quickly determined that the OT was lifting up the resident's foot to move it. She said she was not sure when they talked to Resident #76's representative but there was a 12/22/25 email.The SSD was interviewed on 4/9/26 at 3:21 p.m. She said Resident #76's representative mentioned in a care conference that she observed the occupational therapist kick Resident #76 in the foot. The SSD said she asked the OT what happened during the therapy session and he explained to the SSD that he was sliding Resident #76's foot. The SSD said she spoke to Resident #76's representative and told her about the foot sliding technique. She said the representative was more upset about the incident then Resident #76 was. The SSD said the representative said it was possible that it looked rougher than it was, but she would advocate for Resident #76 and wanted to contact the frequent facility visitor. The SSD said the representative felt that the OT should have explained to Resident #76 what he wanted the resident to do, then it would not have been as physical. The SSD said she did not see the 12/22/25 care conference documented in his progress notes. She said the 12/22/25 email that she sent the NHA was the only documentation to follow up on the concerns that she was aware of. The SSD said she asked either the director of rehabilitation or the OT to speak to the representative. The SSD said as far as she knew, the concern was not resolved. The NHA was interviewed a second time on 4/9/26 at 5:01 p.m. The NHA said the incident between Resident #76 and the OT was not investigated for alleged abuse. She said she felt the representative's concern regarding the kicking of his foot was handled and resolved. She said Resident #76 was later discharged . The NHA said she was not aware of the 12/22/25 OT note that documented that Resident #76 told the OT not to push him around.

Based on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (#3) of three residents out of 36 sample residents. Specifically, the facility failed to: -Ensure Resident #3's brace was consistently implemented; and, -Ensure range of motion exercises were consistently completed for Resident #3's contracture. Findings include:I. Facility policy and procedureThe Rehabilitative Services policy and procedure, revised 7/10/19, was provided by the assistant director of nursing (ADON) on 4/9/26 at 5:55 p.m. It read in pertinent part, The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Range of motion (ROM means the full movement potential of a joint. Active ROM means the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint. Active Assisted ROM means the use of the muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment (such as a strap). Based upon the assessment, the care plan interventions must include the provision of necessaryequipment and/or services necessary, adapting the environment to meet the needs of the resident, the use of equipment for bed mobility, walkers, canes, splints, braces or other rehabilitative equipment as prescribed by the attending practitioner and/or as allowed by state law, and PT/OT (physical therapy/occupational therapy). Examples of interventions may include treatments such as active, passive, and/or active-assisted ROM, muscle strengthening and stretching exercises, land and/or water based activities, and/or specific physical and/or occupational therapies.II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebral infarction affecting the left non-dominant side, hemiplegia and hemiparesis (weakness and loss of function of one side of the body), unspecified convulsions, chronic pain, muscle weakness, depression, dysphagia, carpal tunnel syndrome, paresthesia of the skin (pins and needles) and hypertension.The 3/18/26 minimum data set (MDS) assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #3 was dependent on staff for putting on footwear, toileting, oral hygiene and bathing. Resident #3 required substantial assistance with personal hygiene, upper and lower body dressing. Resident #3 had functional limitations to range of motion to the left upper and lower extremities.B. Resident interviewResident #3 was interviewed on 4/09/26 at 9:11 a.m. Resident #3 said his left arm did not listen to him any more and he had carpal tunnel in his right hand. Resident #3 said he used to have a blue brace for his left arm and a smaller white brace for his right hand. Resident #3 said he wore the blue brace a couple of times, but then it went missing a long time ago. He said he did not know where it was. Resident #3 said if the braces were available he would want to wear it at least some of the day to keep his hand in a comfortable position. Resident #3 said he did not remember any staff completing ROM exercises with him other than when he was doingPT with the facility over a year ago.C. ObservationsOn 4/6/26 at 3:07 p.m. Resident #3 did not have a brace on either hand. Resident #3's left arm was flaccid and his hand rested in a closed position, making a fist. Resident #3 was able to reposition his left arm using his right hand. Resident #3 was able to open the fingers of his left hand with his right hand. On 4/8/26 at 10:00 a.m. Resident #3 was in the group interview without a brace for either hand.On 4/9/26 at 9:54 a.m. Resident #3 did not have a brace on either hand. Certified nurse aide (CNA) #1 and CNA #2 looked in Resident #3's room including all of Resident #3's personal storage areas, but were unable to locate braces for Resident #3. C. Record reviewResident #3's care plan, revised 4/2/26, revealed a care plan focus for the restorative nursing program. The care plan directed staff to assist Resident #20 with ROM twice a day to move through his tolerated range with supporting joints through five repetitions each on the following motions: shoulder flexion, abduction/adducation, interntal/external rotation, elbow flexion and extension, forearm supination and pronation, wrist flexion, extension and rotation, finger flexion and extension. Additional interventions included providing a splint to Resident #20's left hand and forearm after doing passive ROM in the evening and before putting on in the morning.Review of Resident #3's CNA restorative program tasks revealed the following in pertinent part,CNA task for passive range of motion (PROM) to Resident #3's left upper extremity; assist to move through the tolerated range, support the joints about and below the shoulder with abduction and adduction, as well as internal and external rotation. Assist to move through the tolerated range, support the joints with flexion and extension of the elbow; and with supination and pronation of the forearm. Complete five repetitions to each area, twice a day.CNA task for splinting program: apply splint to left hand after completing PROM to wrist, hand and fingers. Apply the brace at bedtime and remove it in the morning.-However, observations revealed the resident did not have a splint in place (see observations above).Review of the CNA task for PROM of Resident #3's left upper extremity documented Resident #3 received PROM 12 out of the last 30 days.Review of the CNA task for splinting of Resident #3's left hand documented Resident #3 had a brace applied twice out of the last 30 days. III. Staff interviewsCNA #1 was interviewed on 4/9/26 at 9:43 a.m. CNA #1 said she knew Resident #3 previously had a brace for his left arm because she used to work the evening shift approximately a year ago. She said she would assist with ROM and placement of the brace when assisting Resident #3 before bed. CNA #1 said she now worked the morning shift, and she had not seen the brace recently. She said she assumed the brace was still in Resident #3's room and was still being applied every evening. CNA #1 said she completed ROM with Resident #3 by asking Resident #3 to move the extremities he was able to control while assisting Resident #3 with getting dressed followed by CNA #1 assisting Resident #3 to open his left hand. CNA #1 said the way she assisted with ROM was more active ROM than passive ROM. CNA #1 said she was not sure if the task was to provide Resident #3 with active ROM or passive ROM. CNA #1 and CNA #2 were interviewed together on 4/9/26 at 10:04 a.m. CNA #1 said it was possible that Resident #3's roommate had taken Resident #3's brace. CNA #2 said they did not look through any of Resident #3's roommate's storage when looking through his room to prevent Resident #3's roommate from getting upset. CNA #2 said Resident #3's roommate had a history of rummaging through and taking other people's objects, then becoming upset when staff try to give the items back to Resident #3. The director of rehabilitation and the director of nursing (DON) were interviewed together on 4/9/26 at 1:06 p.m. The director of rehabilitation said she had not seen Resident #3 for physical therapy (PT) or occupational therapy (OT) in over a year.The DON said she did not remember Resident #3 participating in PT or OT for a couple of years. The director of rehabilitation said she did not have any documentation from the last time Resident #3 received physical therapy because the charting system changed since the last time Resident #3 received PT or OT. The director of rehabilitation said a splint as described in the restorative nursing task was not accurate and it was more likely that it was recommended for Resident #3 to have a brace to prevent contracture. The DON said typically a brace was considered a treatment and Resident #3 should have also had an order for the brace. The director of rehabilitation said the nursing staff were responsible for implementing the tasks designated in a resident's restorative care plan, and she would provide oversight and education. The director of rehabilitation said she could not say if the restorative interventions for Resident #3 were still appropriate without re-assessing Resident #3.

Based on record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#44) of four residents reviewed for accident hazards out of 36 sample residents. Specifically, the facility failed to protect Resident #44 from possible ingestion of medications left unattended on the medication cart. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 4/6/26 to 4/9/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/31/26. I. Facility plan of correctionThe corrective action plan was implemented immediately by the facility in response to Resident #44 alleged ingestion of medications. The facility implemented medication cart audits, education and monitoring. The contract nurse was terminated during the investigation. The four medication carts in the facility were audited on 3/16/26 for any discontinued medications and items left on top of the cart. The medication carts were audited again for any discontinued medication or items left on top of the cart at random times on 3/17/26, 3/18/26, 3/20/26, 3/21/26, 3/24/26 and 3/3/26. The current memory care environment safety audit had been increased from weekly to daily. To include all private and public rooms to be inspected and free from any unsafe items. The audit was completed on 3/4/26, daily from 3/9/26 to 3/25/26, 3/28/26 and 3/31/26. Nurse education was completed on 3/18/26 by the DON on the seven rights of safe medication administration. How to store medication safely behind lock and key, disposition of discontinued medications and the process when medication cart was left unattended. Included in the email were the medication cart audits completed at random times and dates which revealed how medications were secured and stored.The memory care staff were reeducated on the on-going supervision or additional help when other staff provided cares to residents. The facility would keep resident safe from further ingestion of medications left on the medication cart.The facility would be in compliance by the end of March 2026.II. Facility policy and procedureThe Medication Error Identification, Reporting and Management policy, dated 8/19/25, was provided by the director of nursing (DON) on 4/6/26 at 6:49 p.m. The policy read in pertinent part, The policy established the requirements for the timely identification, reporting, investigation, and management of actual and potential medication errors in the facilities healthcare programs which reflects the commitment to safeguarding residents or participants safety, high-quality care, regulatory compliance and fostering a culture of accountability, learning, and continuous improvement. The facility will ensure all actual and potential medication errors, including near misses, were promptly reported, thoroughly investigated, and addressed in accordance with the policy. Staff will take immediate action to protect the health and safety of residents or participants,implement provider-directed interventions, and document events in compliance with the policy. Medication errors include:- Wrong Patient. Administering a medication to the wrong resident or participation. -Wrong Medication. Administering a medication not ordered for that resident/participant.- Wrong Dose. Administering too much (overdose) or too little(underdose) of the ordered medication (including duplicate administration).II. Resident #44A. Resident statusResident #44, age [AGE], was readmitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnosis included chronic obstructive pulmonary disease (COPD), dementia and depression. The 2/9/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. She required maximum assistance with activities of daily living (ADL). B. Facility investigationThe 3/13/26 facility investigation was provided by the director of nursing (DON) on 4/9/26 at 9:30 a.m. The investigation revealed Resident #44 allegedly consumed liquid Citalopram (antidepressant) left on the medication cart, which was unattended for 10 to 15 minutes. The investigation documented the resident was unable to describe where and how she obtained the medication. The investigation documented the bottle potentially had 150 milliliters (ml) of medication in it, which the resident may have consumed. The medication was prescribed to another resident. The medication had been discontinued, but not removed from the cart immediately for destruction. The investigation documented the facility attempted to interview RN #2, who was an agency staff member, however the nurse refused to write a statement and gave vague responses when asked questions. The investigation documented due to the lack of participation from the agency nurse, it was unclear how the medication came to be on top of the cart. RN #2 was trained on the facility's policy and procedure of safe medication administration and storage. The investigation documented the attending provider sent orders to monitor the residents pulse and temperature every thirty minutes until 10:00 p.m. that night. Per the facility's policy, obtaining resident's full vital signs were obtained every four hours and level of cognition was monitored. No harm came to the resident, and the resident did not have any reaction to the potential ingestion. Two additional head to toe assessments were completed on 3/17/26 and 3/17/26 and revealed no changes to residents' level of consciousness from baseline. The investigation documented the consulting pharmacist was interviewed by the facility and stated there could be an interaction with the resident's current medication duloxetine (antidepressant) as it was a duplicate therapy order and could carry a small risk of a serotonin effect. The pharmacist also stated the medication citalopram overdose often had mild to moderate symptoms, particularly with ingestion under 600 milligrams.The investigation's conclusion was RN #2 attempted to audit the medication cart. She started the process of medication destruction and was pulled away from the cart without returning the medication inside the cart before leaving the unit. The facility determined RN #2 most likely abandoned the medication on top of the cart and the resident grabbed the medication off the top of the cart when the nurse was not present.C. Record reviewA progress note, dated 3/13/26 at 11:53 a.m., documented the nurse was alerted of an incident in the memory care unit at 10:30 a.m. Resident #44 was found in her wheelchair in the common area of the unit. The note documented the resident had consumed liquid medication. The note documented the resident was alert at baseline with no distress and with no level of conscious change. The resident denied pain and self-ambulated in her wheelchair. She was not able to describe where and how she obtained the medication. The note documented the resident had consumed liquid citalopram that had been left on the medication cart. The note documented the bottle contained 50 ml, but it was unknown how much medication remained in the bottle before the resident took it. The agency nurse notified the provider and received orders to monitor the residents pulse and temperature every thirty minutes until 10:00 p.m. and obtain resident's full vital signs (blood pressure, temperature, pulse and respirations) every four hours and monitor the residents level of consciousness. The agency nurse contacted the family and all other pertinent parties of the incident.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/8/26 at 4:38 p.m. LPN #1 said the medication cart was locked at all times and nothing was stored on top of the cart. She said she had recent education on medication storage and destruction. The DON was interviewed on 4/9/26 at 12:45 p.m. The DON said said a full investigation was completed after it was alleged Resident #44 ingested medications not prescribed to him. The DON said the facility assumed the resident had picked up the medication off the cart because the nurse left it unattended and left the unit. She said the nurse was terminated from the facility. She said the facility started medication audits and completed education to the nurses and the memory care staff which included keeping eyes on the residents at all times. The DON said the facility hired an additional activity assistant person and expanded the safety audits from weekly to daily. She said the medication should not have been left on the cart unattended.

Based on observations, record review and interviews, the facility failed to ensure accurate assessments, informed risks, and ongoing monitoring was in place for one (#74) of three residents with bed rails out of 36 sample residents.Specifically, the facility failed to:-Ensure a bed rail safety assessment was completed prior to the bed rail placement on Resident #74's bed; and, -Ensure less restrictive measures were attempted prior to the use of bed rails for Resident #74. Findings include:I. Resident #74A. Resident statusResident #74, age greater than 65, was admitted on [DATE] and discharged [DATE]. According to the April 2026 computerized physician's orders (CPO), diagnoses included restless leg syndrome, osteoporosis, macular degeneration, chronic kidney disease, atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD), presence of urogenital implant, generalized anxiety disorder and chronic pain. The baseline care plan for Resident #74 revealed Resident #74 was dependent on staff for toileting, bathing, and transfer. Resident #74 required substantial assistance with footwear, upper and lower body dressing. B. Resident interview and observationsResident #74 was interviewed on 4/7/26 at 11:21 a.m. Resident #74 said she was staying at the facility on a respite stay, and planned to discharge home soon. Resident #74 said she had contractures to her left hand and fingers, but she was able to loop her hand around the quarter bedrail at her wrist and use the bed rail to reposition in bed. Resident #74 said a staff member installed the quarter bed rail a few days after she arrived at the facility on 4/1/26. Resident #74 said a staff member made sure the quarter bed rail was safe for use, but she did not remember which staff. Resident #74 said she would have liked another quarter bed rail on her right side to assist with repositioning in bed. Resident #74 said she was worried she could roll out of the bed when she turned toward the right without something to hold on to. During the interview, the bed rail was in place on the left side of the bed. C. Record reviewReview of Resident #74's CPO revealed the following orderLeft assist bar on bed for turning assistance, ordered 4/1/26. The 4/2/26 physical device data collection evaluation indicated the resident did not have any assistive devices. -However, per the director of nursing (DON) interview the bed rail was placed on the resident's bed on 4/3/26 and a new assessment was not completed (see interviews below). D. Staff interviewsThe nursing home administrator (NHA) and the DON were interviewed together on 4/9/26 at 3:41 p.m. The NHA said they identified the restorative program as an area for improvement prior to the survey. The NHA said they recently hired an ADON and one of the areas they planned for the ADON to manage once she was trained was the restorative program. The NHA said she reviewed the facility's internal messaging program and the it appeared the quarter bed rail for Resident #74's bed was installed on 4/3/26, after the assessment. The DON said once the assistive device was installed, a new assessment should have been completed by the nursing staff to ensure Resident #74 could use the device safely.

Based on observations, record review and interviews, the facility to ensure residents were free from accidents or hazards for one (#1) of three residents reviewed for accidents out of three sample residents. Specifically, the facility failed to implement interventions to prevent an elopement for Resident #1, despite identifying the resident at high risk for elopement.Findings include:I. Facility policy and procedureThe Wandering and Elopement Policy and Procedure revised November 2016, was provided by the nursing home administrator (NHA) on 10/30/25 at 12:05 p.m. It revealed in pertinent part, This facility promotes the least restrictive environment for all residents while recognizing the potential of residents wandering. This facility will utilize monitoring and alarm systems; sign in and out books on all units and maintain pictures of all residents on their units. This facility will maintain a response plan for implementation in the event of a missing resident. Social services or designee will complete an admission Assessment and an Elopement Risk Assessment prior to admission to the secured unit, and prior to placement of a wander guard. Elopement Risk Assessments will also be completed annually, with significant changes and as needed. Wandering or elopement risk will be identified pre-admission or on admission and on going. II. Incident of elopement for Resident #1 on 8/31/25A. Facility investigationThe NHA provided the facility investigation of the 8/31/25 elopement event on 10/30/25 at approximately 10:40 a.m. The investigation revealed the following: The investigation summary documented that on 8/31/25 at approximately 3:15 p.m. Resident #1 was found in a supermarket parking lot approximately 0.2 miles from the facility by certified nurse aide (CNA) #4. The investigation summary documented Resident #1 was last known to be in the facility at approximately 2:00 p.m. The facility was not aware Resident #1 had eloped from the facility until CNA #4 found Resident #1 while the CNA was on break. When CNA #4 found Resident #1, he was talking with two unidentified citizens who were on the phone with the police to report a missing person. CNA #4 called the facility from the supermarket parking lot to inform them of the elopement. CNA #4 stayed with Resident #1 until the police arrived and provided escort back to the facility. The investigation summary documented Resident #1 was assessed to be at his baseline cognition and without injury after the event. The investigation summary documented Resident #1 was placed on one-to-one observation in the short term to keep Resident #1 safe. The facility investigation documented the interventions implemented after the event included audits of the alarm system to ensure door alarms were functioning properly as well as education to nursing staff. The investigation summary documented the resident eloped from the front door of the facility and it was missed because no staff member was present to monitor the front door at the time of the resident's elopement. The investigation documented an interview with CNA #4 on 8/31/25 at 3:45 p.m. CNA #4 said she was driving to the gas station on her break when she spotted a familiar face in the supermarket parking lot. CNA #4 said Resident #1 was talking with a gentleman in the parking lot who was on the phone. When CNA #4 introduced herself, the gentleman told her he was talking with the police dispatcher and the dispatcher wanted to talk with her. CNA #4 said she gave her the information she had and the dispatcher told her to stay with Resident #1 until the police arrived. CNA #4 said she called the facility to inform them about Resident #1 immediately after talking with the dispatcher. When Resident #1 and CNA #4 returned to the facility, CNA #2 assisted with returning Resident #1 to his room so CNA #4 could talk to the nurse assigned to his unit. The investigation documented the last time Resident #1 was seen in the facility prior to the elopement event was by CNA #3 at approximately 1:50 p.m. The investigation documented an interview with CNA #3 on 8/31/25. CNA #3 said she briefly saw Resident #1 in the hallway while approaching the kitchen to pick up a lunch order for the memory care unit. CNA #3 said she did not remember anything unusual about the interaction, she only remembered briefly seeing him in the hallway. The investigation documented CNA #2 was the CNA assigned to Resident #1's hall on the day the elopement event occurred (8/31/25). The facility investigation documented an interview with CNA #2 on 8/31/25. CNA #2 said she remembered she was bathing a resident at the time of Resident #1's elopement. CNA #2 said when the bath was complete, she found out Resident #1 was missing and possibly at the theater next to the local supermarket. CNA #2 said she walked out of the facility to walk to the supermarket when she saw Resident #1 and CNA #4 walking back to the facility with a police officer. The facility investigation did not include a written statement or documented interview with the nurse assigned to Resident #1's hall on the day the elopement event occurred. B. Resident #11. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbances, macular degeneration, hearing loss to the right ear, obesity and recurrent pneumonia. The 10/9/25 minimum data set (MDS) assessment revealed Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #1 required set up assistance with dressing, footwear, and hygiene. Resident #1 required moderate assistance with bathing. Resident #1 had behaviors of wandering with exit seeking and intruding into the space of others on one to three days during the assessment look-back period. Resident #1 required cues with ambulation and used a wheelchair independently for mobility. The MDS assessment revealed the resident was at risk of endangering himself or intruding on others' personal space and exhibited wandering behaviors on one to three days during the assessment look-back period.2. ObservationsOn 10/30/25, from 11:36 a.m. until 12:10 p.m., during a walkthrough of the facility's alarm system with the maintenance director (MTD), the audio alarm to a door in the dining room was noted to be deactivated. The NHA approached the MTD and told him she deactivated the alarm a few minutes ago because a family was visiting a resident and the family was frequently going outside to eat in the courtyard next to the dining room (setting off the alarm). The NHA said she planned to reactivate the alarm when the visit was over. During the walkthrough, the alarm system also sent pager alerts to the floor nurses when a door was opened. However, the pager system only alerted staff the front door was opened instead of paging the nurse with which specific door was opened. The MTD contacted the alarm company at the end of the walkthrough in order to have a representative fix the pager system. On 10/30/25 at 12:57 p.m. the alarm to the door in the dining area was checked The audio alarm remained deactivated and no staff members responded when the door was opened. No visiting family members were in the dining room or courtyard, but the alarm had not been reactivated. On 10/30/25 at 1:27 p.m. the alarm to the door in the dining area was checked again. The audio alarm remained deactivated and no staff members responded when the door was opened. On 10/30/25 at 2:21 p.m. the alarm to the door in the dining room was checked a third time. The audio alarm had been reactivated and was functioning at that time. 3. Record reviewResident #1's comprehensive care plan, revised 9/22/25, documented a care plan focus for behaviors related to dementia, including making racial comments towards staff and physical and verbal aggression toward staff. However, the interventions documented in the care plan did not address Resident #1's exit-seeking behavior.The elopement risk assessment, dated 8/1/25, documented Resident #1 was at risk for elopement. The assessment documented Resident #1 had wandering and exit seeking behaviors with increased confusion in the afternoon. The elopement risk assessment documented a wandering and elopement care plan was initiated with the assessment. Interventions included engaging Resident #1 in simple, structured activities that avoided overly demanding tasks, if Resident #1 was exit-seeking or showing signs/verbalizations of wanting to leave the facility, staff were to provide redirection to another meaningful activity.-However, review of Resident #1's comprehensive care plan did not reveal a care plan focus for elopement risk.The hospice interdisciplinary team (IDT) note, dated 8/20/25, revealed documentation acknowledging Resident #1 had exit-seeking behaviors prior to the elopement event on 8/31/25. The IDT note documented the resident was frequently looking for his spouse and for his car. The progress note, dated 9/15/25, documented Resident #1 continued to have exit-seeking behaviors and making statements about finding his car or wanting to leave the facility to go home. The progress note documented Resident #1 saw the facility's nurse practitioner to rule out medical causes for increased agitation and exit-seeking and none were found. The progress note documented a physician's order was given for Resident #1's placement on the secure memory care unit after consent was received from the resident's representative. III. Staff interviewsCNA #5 was interviewed on 10/30/25 at 11:32 a.m. CNA #5 said Resident #1 was in her hall assignment for a short time before he was moved to the secured unit. She said Resident #1 would often go to activities, sit in the common area to visit and go to the front area and sit near the front door. She said staff on another hall would either bring him back to his hall or radio her and his other CNAs to bring him back to his hall. CNA #5 said the resident frequently wandered but his wandering would increase in the afternoons after 2:00 p.m. She said Resident #1's representative would visit him three to four times a week. CNA #5 said his behaviors would increase after the representative left. CNA #5 said the front door was alarmed from 7:00 a.m. to 7:00 p.m. and all the other doors were alarmed 24 hours a day.The receptionist was interviewed on 10/30/25 at 11:50 a.m. The receptionist said she worked weekdays from 8:00 p.m. to 5:00 p.m. She said the only time she left the front desk was to deliver messages for staff on lunch break. She said the front desk was covered by another staff member when she went on break. She said she made sure she notified the night nurse when she left the facility at 5:00 p.m. She said the front doors automatically locked at 7:00 p.m. The receptionist said she had a list of residents who could sit outside in front of the building. She said she could not see the outside area near the bench in front of the building but would check on the residents every 15 minutes. She said she would be able to see a resident start to go down the sidewalk from her position. The MTD was interviewed on 10/30/25 at 12:10 p.m. The MTD said each door besides the front door to the facility was armed with both an audio alarm and a pager alarm system 24 hours a day. The MTD said the front door had a pager alarm 24 hours a day but only used an audio alarm from 7:00 p.m. to 7:00 a.m. The MTD said the facility was contacting companies to install a wanderguard system but had not accepted a bid from an installation company yet. The MTD said the purpose of the pager system was to alert the floor nurses as to which door was opened. The MTD said because the pager system had always alarmed front door during the testing walkthrough (on 10/30/25), the nurse would not know which door to check. The MTD said he was not sure how long the pager alarm system was not sending accurate messages, but he planned to contact the current alarm company immediately to have the pager alarm system fixed. Licensed practical nurse (LPN) #1 was interviewed on 10/30/25 at 12:10 p.m. LPN #1 said she was new to the facility and had only worked at the facility for approximately three weeks. LPN #1 said since she started at the facility, the pager system had only ever said front door and she had not seen other locations come through the pager. LPN #1 said she typically ignored the pager because it only said front door and she assumed the staff member at the front desk would be there. CNA #1 was interviewed on 10/30/25 at 12:53 p.m. CNA #1 said she was assisting residents with eating in the dining room on the day of Resident #1's elopement. CNA #1 said nobody informed her of the audio alarm for the door from the dining room to the courtyard outside. CNA #1 said she was able to see the door from where she was seated, so she could see if someone walked out the door, but if her back was turned because she was helping another resident, she would not have the cue from the audio alarm to inform her someone left.The NHA was interviewed on 10/30/25 at 2:21 p.m. The NHA said the audio alarm to the door in the dining room was only deactivated for approximately ten minutes on 10/30/25. The NHA said she told the MTD to reactivate the alarm at approximately 12:30 p.m.The MTD was interviewed again on 10/30/25 at 3:45 p.m. The MTD said he did not recall that the NHA requested he reactivate the audio alarm to the door in the dining room. The MTD said he remembered he did reactivate the alarm, but it was when the employee from the alarm system company arrived at the facility between 1:30 p.m and 2:00 p.m.The receptionist was interviewed a second time on 10/30/25 at 2:50 p.m. The receptionist said she had heard that Resident #1 went out the front door but it was on a Sunday when she was not working. She said there was another receptionist who worked on weekends until 1:00 p.m. The NHA was interviewed a second time on 11/3/25 at 11:11 a.m. She said after Resident #1 eloped, she increased facility education and frequently checked on Resident #1. She said the facility was in the process of updating their elopement policy and waiting for a final approval from their corporate office to install a wander guard system. The NHA said the main focus to prevent the recurrence of another elopement was increasing staff education, assessing resident's risk and knowing where the residents were at all times. She said the staff needed to know where their residents were and not just rely on the paging system connected to the doors. She said the facility had four pagers in circulation with two more available if needed. The NHA said a nurse or a designee should go to the door if their pager went off to make sure a resident was not going out the door without staff knowledge. She said a CNA or an activities assistant could also check the doors. She said the facility had enough pagers to make sure the designated person on each hall had a pager. The NHA said Resident #1 left the facility without someone noticing because no one responded to the door when the pager went off. She said she felt the situation was isolated. She said since Resident #1's elopement, the facility was much better at identifying a resident's risk, paying more attention to when the pagers signaled an alert and understanding the importance of checking the doors. The NHA said the facility's investigation of Resident #1's 8/31/25 elopement incident identified a need for more oversight at the front door due to gaps in the schedule when no one was at the front desk when the elopement occurred. The NHA said the front door locked at 7:00 p.m. She said there was no one at the front desk from 5:00 p.m. to 7:00 p.m. on weeknights and from 1:00 p.m. to 7:00 p.m. on weekends. She said since Resident #1's elopement, she had encouraged the weekend receptionist to stay until 3:00 p.m. She said there was usually a manager or the nurse practitioner working near the front desk from 5:00 p.m. to 7:00 p.m. but not someone directly watching the front door. The NHA said that was what the pager system was for. The NHA said when a resident was admitted to the facility, the nurses reviewed the resident's risk for elopement and then reported the risk to the social services director (SSD). She said the SSD would complete the risk assessment and create an elopement risk care plan. The SSD was interviewed on 11/3/25 at 11:50 a.m. The SSD said if a resident was determined to be at risk for elopement, she would be informed in the morning interdisciplinary team (IDT) meeting. She said she would complete the risk assessment and create an elopement risk care plan. The SSD said when Resident #1 was admitted , his BIMs identified he had moderate impairment with dementia, attended activities, expressed no desire to leave the facility and did not have wandering behavior. The SSD said over the course of a couple weeks at the facility, Resident #1's behaviors worsened and he became more confused. She said the resident started to exit-seek. The SSD said he would look for his car and/or his wife. She said there was not much documentation identifying the behavior, but it was reported to her so she did a new elopement risk assessment. The SSD said she discussed her concerns of Resident #1's increased behaviors with IDT about moving to another room further away from the front door on another hall and encouraged him to participate in more activities. She said she created a care plan on 8/1/25 for his increased risk for wandering/elopement but there was a glitch in the computer system. The SSD said the care plan she created was marked resolved by mistake and it did not show in the system as an active care plan. The SSD said Resident #1's wandering behaviors would increase after the resident's representative would leave the facility after visiting him. She said she spoke to the resident's representative about moving him to another hall further away from the front door on 8/13/25 and she agreed. She said hospice was also working with the resident's representative to identify other interventions that could improve his behaviors. The SSD said the resident's medications were reviewed by hospice but not increased until 9/15/25 by the nurse practitioner (NP).The SSD said she created another elopement risk care plan on 9/2/25 but it was resolved once Resident #1 went to the memory care unit on 9/16/25 and a new care plan for the secured unit was created. The SSD said Resident #1 was exit-seeking and yelling when he was first placed on the memory care unit but his behaviors had since improved and he had been easier to redirect in a smaller environment. The regional consultant was interviewed on 11/3/25 at approximately 12:20 p.m. The regional consultant said the facility was in the process of creating a risk assessment for elopement that would better identify a resident's risk for elopement. The regional consultant said there were no current residents in the facility that were at high risk for elopement other than residents already on the memory care unit. She said behaviors however could change so the facility would continue to evaluate residents' risks.

Based on record review and interviews, the facility failed to ensure two (#17 and #39) of five residents out of 38 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. Resident #17 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure and severe protein-calorie malnutrition. On [DATE], the resident weighed 137 pounds (lbs). On [DATE] the resident sustained a 5.8% (percent) (7.88 lbs) weight loss in 21 days, which was considered severe. After the resident sustained the weight loss the facility failed to implement additional nutritional interventions to address the resident's weight loss. The resident sustained an additional 8.5% (11.8 lbs) weight loss from [DATE] to [DATE], which was considered significant. The facility failed to implement additional nutritional interventions to address the resident's continued severe weight loss. On [DATE] a physician's order was entered into the resident's electronic medical record (EMR) which indicated to weigh the resident weekly on Wednesdays. The facility failed to consistently monitor the resident's weight. On [DATE], the resident weighed 111 lbs. The resident sustained 19% (26 lbs) weight loss from [DATE] to [DATE], which was considered severe. The only nutrition intervention that was implemented was a nutritional supplement in [DATE], prior to the resident sustaining severe weight loss. The facility failed to provide the supplement as ordered and consistently document the amount the resident consumed when the oral nutritional supplement was offered. Additionally, the facility failed to monitor and track Resident #39's weight loss and implement person-centered nutritional interventions to address the resident's weight loss. Findings include: I. Facility policy and procedure The Comprehensive Medical Nutrition Therapy Assessment policy, revised 2021, was provided by the nursing home administrator (NHA) on [DATE] at 1:18 p.m. It read in pertinent part, The registered dietician gathers information for the comprehensive assessment from the medical records, individual observations, and nutrition-focused physical assessment. Nursing staff provides details about the individual's nutrition intake, daily routines, food preferences, and vital signs. The registered dietician will develop the specification of the nutritional concern or nutritional diagnosis which is a clear statement that provides the basis for individual-specific interventions. For example, inadequate oral food and fluid intake related to oral intake less than 50% as evidenced by greater than or equal to 5% unintended weight loss in the past 30 days. The Dehydration policy, revised 2021, was provided by the NHA on [DATE] at 1:18 p.m. It documented in pertinent part, Each individual will receive sufficient amounts of fluid based on individual need and personal preference to prevent dehydration and maintain health. The High Calorie/High Protein Supplements policy, revised 2021, was provided by the NHA on [DATE] at 1:18 p.m. It documented in pertinent part, Individuals needing supplemental nutrition will be served a suitable high calorie/high protein supplement between meals or as part of a medication pass-supplement program. The food and nutrition services department will prepare supplements and deliver them to nursing staff at the appropriate time. Nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record, meal intake reporting records, and/or the medication administration record. II. Resident #17 A. Resident status Resident #17, over the age of 65, was admitted to the facility on [DATE]. According to the [DATE] computerized physician's orders (CPO), diagnoses included COPD, chronic respiratory failure and severe protein-calorie malnutrition. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was independent with eating, required moderate assistance with oral hygiene.He was dependent on staff for bathing, toileting transfers and dressing. The assessment documented the resident was 70 inches (5 foot, 10 inches) tall and weighed 107 pounds. It indicated the resident had a weight loss of 5% or more and the resident was not on a prescribed weight loss regimen. B. Resident interview Resident #17 was interviewed on [DATE] at 9:26 a.m. Resident #17 said he did not eat any breakfast today. The resident said that he usually did not eat a large breakfast. He said he was actually a little hungry this morning ([DATE]). The resident said he had not been offered breakfast by nursing staff today and his nutritional supplement had not been given to him. The resident said a staff member came into his room and took his lunch order for the day. The resident said the nursing staff did not monitor how much he drank of the nutritional shakes. The resident said he did not get the nutritional shake every day like he was supposed to. C. Record review The nutrition care plan, revised on [DATE], revealed the resident had a diagnosis of malnutrition. The care plan documented interventions including educating the resident on food groups, monitoring laboratory values for nutritional well-being, observing signs and symptoms of depression and offering the resident foods high in protein and calories that will promote weight gain. -A review of the comprehensive care plan revealed the care plan was not updated with person-centered nutrition interventions after the resident sustained weight loss on [DATE], [DATE] or [DATE]. Resident #17's weights were documented in the resident's electronic medical record (EMR) as follows: -On [DATE], the resident weighed 137 lbs; -On [DATE], the resident weighed 136 lbs; -On [DATE], the resident weighed 135 lbs;-On [DATE], the resident weighed 137 lbs; -On [DATE], the resident weighed 137 lbs; -On [DATE], the resident weighed 129.12 lbs; -On [DATE], the resident weighed 118.04 lbs; -On [DATE], the resident weighed 116 lbs; -On [DATE], the resident weighed 119 lbs -On [DATE], the resident weighed 111 lbs; and, -On [DATE], the resident weighed 108.4 lbs. -The resident lost 7.88 lbs (5.8%) from [DATE] to [DATE] in 21 days, which was considered severe. -The resident lost 11.08 lbs (8.5%) from [DATE] to [DATE] in one month, which was considered severe. -The resident lost 26 lbs (19%) from [DATE] to [DATE] in four months, which was considered severe. The [DATE] CPO revealed Resident #17 was to be weighed weekly on Wednesdays, initiated on [DATE]. -Reident #17 was not weighed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] as ordered. The [DATE] dietary nutrition data collection assessment documented Resident #17 had lost approximately 40 lbs in the last six months related to poor oral intake. The progress note documented the goal was for the resident to lose weight. -However, there was no documentation from a physician indicating the weight loss was desired. The [DATE] dietary nutrition data collection assessment documented Resident #17 required 1500 milliliters (mL) of fluid per day. A dietary progress note, dated [DATE], documented that the resident had lost ten percent of his body weight in the last six months. The progress note documented that the resident had requested meat sandwiches in the past but these were often not eaten and instead were being thrown away by the kitchen when they expired. The progress note documented the resident had advanced COPD which was the reason he had poor oral intake. The progress note documented that the dietary staff expected the resident to continue to lose weight. -However, a review of the electronic medical record (EMR) did not reveal the facility had implemented person-centered nutritional interventions after the resident sustained weight loss or had documentation for a physician regarding unavoidable weight loss. A review of the resident's EMR revealed the resident had a physician's order to receive a house shake supplement one time a day for nutritional supplementation, ordered [DATE]. The snack shake list (from [DATE] to [DATE]) was provided by the RD on [DATE] at 11:28 a.m. It documented Resident #17 was offered a nutritional supplement on 13 out of 29 days. -The facility failed to offer a nutritional supplement to Resident #17 for 16 of the 29 days between [DATE] and [DATE]. A review of the certified nurse aide (CNA) task response history (from [DATE] to [DATE]) revealed Resident #17 had a task that specified to offer the resident snacks or supplements. -The task sheet did not differentiate between offering the resident a nutritional supplement or a snack. The task sheet only had documentation that he was provided a snack or supplement on 19 of the 30 days. A review of the CNA task response history (from [DATE] to [DATE]) revealed staff had documented the amount the resident had eaten for 85 out of 90 meals during the review period. It was documented the resident ate less than 50% of his meals for 32 of 85 documented meals. A review of the CNA task response history (from [DATE] to [DATE]) revealed staff had documented the resident had consumed less than 1500 ml of fluids on 16 of 30 days and consumed less than 100 ml on five of the 30 days. -The facility failed to ensure documentation revealed the resident consumed the recommended amount of fluids to maintain hydration in 16 of 30 days between [DATE] and [DATE]. III. Resident #39 A. Resident status Resident #39, over the age of 65, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses included dementia, cardiomegaly (an enlarged heart) and chronic kidney disease. The [DATE] MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. The resident required supervision or touching assistance with eating. She was dependent on staff for oral hygiene, dressing, toileting and personal hygiene. The assessment documented the resident was 63 inches (5 foot, 3 inches) tall and weighed 132 pounds. It indicated the resident had not had any significant weight loss or weight gain. B. Record review The nutrition care plan, initiated on [DATE] and revised on [DATE], revealed the resident had unintentional weight loss related to dementia on [DATE]. The care plan documented the resident enjoyed eating snacks and coffee between meals. The interventions included having snacks available to the resident, providing handled cups at meals, offering the resident preferred foods, and monitoring the resident's intake. -The facility failed to document new interventions in the comprehensive care plan after significant weight loss was documented on [DATE], [DATE], and [DATE]. The [DATE] CPO revealed Resident #17 was to be weighed weekly on Wednesday evenings, initiated on [DATE]. Resident #39's weights were documented in the EMR as follows: -On [DATE], the resident weighed 146 lbs; -On [DATE], the resident weighed 143 lbs; -On [DATE], the resident weighed 142 lbs; -On [DATE], the resident weighed 141 lbs; -On [DATE], the resident weighed 146 lbs; -On [DATE], the resident weighed 135.92 lbs; -On [DATE], the resident weighed 139 lbs; -On [DATE], the resident weighed 130 lbs; -On [DATE], the resident weighed 135 lbs; -On [DATE], the resident weighed 125 lbs; -On [DATE], the resident weighed 133 lbs; and, -On [DATE], the resident weighed 129.96 lbs. -The resident lost 9.04 lbs (6.7%) from [DATE] to [DATE] in three months. The [DATE] dietary nutrition data collection assessment documented the resident was eating ,d+[DATE]% of her meals. -No interventions for the focus area of nutrition were identified. The assessment documented the resident's weight had been stable for the last six months. The [DATE] dietary nutrition data collection assessment documented the resident was eating ,d+[DATE]% of her meals. The assessment documented the resident had sustained significant weight loss of greater than 5% in the last month or a loss of 10% or more in the last six months and was not on a prescribed weight loss regimen. The assessment documented Resident #39 required an estimated 1800 mL of fluids per day. The assessment documented the facility had been having problems with the scales in the facility. The RD questioned the accuracy of weights taken on [DATE] and [DATE]. -The facility failed to implement person-centered nutritional interventions after it was identified the resident had sustained significant weight loss. -The facility did not reweigh the resident after it was identified there was an issue with the scale. -The assessment did not identify any additional interventions to prevent further significant weight loss for Resident #39. The [DATE] interdisciplinary care conference progress note documented the resident's spouse was in attendance. The progress note documented the facility was monitoring Resident #39 for weight loss. The resident had been eating less than 50%of her meals on average. A review of the CNA task response history (from [DATE] to [DATE]) revealed staff had documented the amount the resident had eaten for 72 out of 90 meals during the review period. It was documented the resident ate less than 50% of her meals for 17 of 72 documented meals. Nutrition and fluids documentation was reviewed in the EMR for 30 days between [DATE] and [DATE]. Resident #39 was documented to have consumed less than 1800 mL of fluids on 30 of those 30 days of opportunities. The resident was documented to have consumed less than 1000mL of fluids on 11 of those 30 days. -The facility failed to ensure Resident #39 consumed the estimated required amount of fluids to maintain physical function on 30 of 30 days between [DATE] and [DATE]. IV. Staff interviews CNA #2 was interviewed on [DATE] at 1:28 p.m. CNA #2 said Resident #39 required set-up assistance for eating. She said the resident usually drank fluids without assistance. CNA #2 said Resident #39 sometimes needed to be prompted to drink fluids or to ask if the resident had enough. CNA #2 said Resident #39 usually ate his meals in the dining room. CNA #2 said the CNAs and the nurses were responsible for documenting the amount of food consumed at meals in the EMR. Registered nurse (RN) #4 was interviewed on [DATE] at 1:34 p.m. RN #4 said Resident #17 preferred to eat his meals in his room. RN #4 said the dietary aides were responsible for passing out nutritional supplements to the residents. She said the CNAs and RNs delivered meal trays to the residents who preferred to eat in their rooms. RN #4 said whoever picked up a resident's meal tray when they were finished eating should document how much they ate and drank in the EMR under task documentation. The registered dietitian (RD) was interviewed on [DATE] at 11:12 a.m. The RD said when a resident sustained significant weight loss it was documented under the dietary progress notes. The RD said the comprehensive care plan should be updated when a resident experienced significant weight loss to include new person-centered nutritional interventions to help prevent further weight loss. She said the snack shake list documented if the resident was offered a nutritional supplement, but did not document how much of the nutritional supplement was consumed. The RD said she did not know whose responsibility it was to see how much of the nutritional supplement the resident was consuming. The RD said her process for assessing the effectiveness of the nutritional shake was to ask the resident if they were enjoying the nutritional supplement. The RD said she had concerns about how this assessment process would work for residents with cognitive impairment. The RD said staff doid not measure the amount of nutritional supplement remaining after resident consumption. The RD said she used nursing staff documentation regarding what residents had consumed at meals to help make informed nutritional recommendations. The RD said she believed some of the documentation was inaccurate. The RD said she did not know how much of the nutritional supplement Resident #17 had been consuming. The RD said she was not receiving complete information regarding the resident's meal intakes to base her nutritional recommendations on for residents in the facility. The RD said it was important to know exactly how much of a nutritional supplement the residents consumed so she could make good resident-centered recommendations. The maintenance director (MA) was interviewed on [DATE] at 3:13 p.m. The MA said the scale was calibrated on [DATE]. The MA said all of the scales were properly functioning and were routinely calibrated.The MA said he was not notified that a particular scale was having an issue with weight accuracy. The director of nursing (DON) was interviewed on [DATE] at 7:27 p.m. The DON said the facility should assess and address significant weight loss.The DON said person-centered nutritional interventions should be implemented after the assessment was completed. She said the nutritional interventions should be included on the resident's comprehensive care plan. The DON said the amount consumed of a nutritional supplement should be documented by nursing staff. The DON said the facility recently changed who was responsible for documenting the amount of supplements a resident had consumed recently. The DON said she was worried the nursing staff did not have time to correctly documented how much of a nutritional supplement the resident had consumed.The DON said she the documentation for Resident #17 and Resident #39's nutritional supplements did not include how much the residents had consumed. The DON said both Resident #17 and Resident #39 did not drink enough fluids. The DON said the facility needed to improve on documentation and provide education to improve resident record accuracy.

Based on resident and staff interviews and record review, the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to effectively address, resolve and maintain a systematic approach to ongoing resident concerns of staff treatment towards residents that were brought up during resident council. Findings include: I. Facility policy and procedure The following policies were provided by the director of nursing (DON) on [DATE] at 6:06 p.m. The Resident Council policy, revised [DATE], identified the facility must consider the views of the resident council and must respond promptly to the grievances and recommendations of the council. The policy directed to the facility to follow the grievance process. The Grievance/Concern policy, last revised [DATE], read in pertinent part, Grievances will be routed and tracked by the grievance officer/social service or designee. They (grievances) will be given to the appropriate department manager for follow-up, according to the nature of the grievance. Grievances will be responded to within 7 days for non-emergency concerns. The facility will notify the complainant to provide updates on resolution for the complaint. Additionally, complainants have the right to a written decision regarding the grievance. The manager responsible for investigating and resolving the grievance will complete the grievance/concern form including a plan for resolution. Grievance decisions will include: the date of the grievance was received, the summary of the resident's grievance, steps taken to investigate the grievance, summary of finding/conclusion regarding the grievance, statement is whether the grievance was confirmed or not confirmed, corrective action taken by the facility as a result of the grievance, and the date the written grievance was issued Tracking system will be used for quality assurance, identifying any trends, systematic problems, and Improvement efforts. II. Resident council minutes The resident council minutes and a sheet identified as resident council follow-up were provided by the DON on [DATE] at 5:05 p.m. The review of the resident council minutes identified residents indicated concerns with staff treatment during care. The minutes did not identify follow-up and/or a sustainable plan for resolution. The concerns were not resolved according to resident interviews (see below interviews). The [DATE] resident council minutes read a resident had problems with the certified nursing aides (CNAs) being rough with her and careless. Two other residents agreed and commented that the CNAs did a lot of jerking and pulling. According to the minutes, the concerns would be addressed by the DON and CNAs would be educated on bedside care. A [DATE] follow-up notation was attached to the minutes regarding the CNAs were rough. The notation read the resident who identified the staff was rough was followed up with after the council meeting. She said did not feel abused but felt the CNA's were rushing her when she needed assistance with her care and were always in a hurry to go to the next resident. The resident felt the CNAs needed to take their time when providing more care. The [DATE] through [DATE] grievance/concern tracking resolution log was provided by the corporate consultant (CC) at approximately 6:15 p.m. The [DATE] log did not identify residents expressed rough or rushed care. The February 2024 resident council minutes identified three residents still felt the CNAs rushed too much and were not taking their time with provided care. The minutes did not identify a plan to address the continued and unresolved concern of CNAs rushing during care. The February 2024 grievance/concern tracking resolution log did not identify residents in resident council and continued to express feelings of rushed care by CNAs. The [DATE] resident council minutes indicated reeducation to nursing would be completed related to staff rushing during care. The minutes did not identify when staff would be reeducated as identified in the [DATE] and February 2024 minutes. The minutes did not identify the residents felt their concerns with rushing were resolved. The [DATE] resident council minutes read a resident was concerned about CNAs and nurses stating they would be back or the staff would not return to the resident. Other residents indicated they also had that as a concern and wanted an explanation on why the CNAs were not attending to them. Another resident said she was not happy that the staff left her on the toilet for a while. The minutes identified residents felt staff were giving the residents attitudes and reprimanding them for asking for help. According to the minutes, the former NHA told the residents that everyone needed to go to the bathroom after meals so receiving assistance may take longer at that time. The minutes did not identify how the facility was going to address the concerns of staff not returning to the resident; staff attitudes; feelings of being reprimanded; and a resident concerned she was left on the toilet for a while. The minutes did not identify whether the residents felt their concerns with staff rushing with care were resolved from the [DATE] and February 2024 resident council meetings. The [DATE] grievance/concern resolution tracking log identified a resident not included in resident council meetings and not part of the below resident interviews, felt a CNA was rude. According to the log the identified CNA's contract expired as the resolution. The [DATE] log did not include residents from resident council who felt the staff had attitudes and felt they were reprimanded for asking for help. The [DATE] healthy workplace meeting minutes were provided by the CC on [DATE] at approximately 6:15 p.m. The workplace minutes identified the meeting was attended by seven members of the interdisciplinary team (IDT). The workplace minutes read the staff needed to be reminded at all staff meetings not to rush with residents and take their time as part of good customer service. A customer service sheet defining the traits of good customer service with a handwritten notation that read [DATE] all staff meeting was provided by the CC on [DATE] at approximately 6:15 p.m. The sheet did not identify who attended the all staff meeting and the sheet did not identify not rushing with care was addressed in the inservice as identified as a concern with residents in resident council. The sheet did not instruct staff to make sure the resident's needs were addressed before the staff left the room. According to the sheet, staff should maintain a positive attitude. The resident council follow up sheet, dated [DATE], read follow up items from resident council since [DATE]. The follow up form listed multiple concerns brought in resident council including water temperature, shower schedule, hearing aids, missing laundry, television on at night and staff rough/rushing. The follow-up sheet did not identify when the concerns were addressed other than on [DATE]. According to the follow up sheet, all the concerns were resolved or improved, other than Resident #24 still felt there was one CNA who still had issues with the rushing. However, this was contrary to resident interviews below, identifying other residents also identified concerns with rushing staff. The [DATE] follow up said the identified CNA would no longer provide care to the resident for the time being. The [DATE] resident council minutes did not identify if the residents felt their concerns of staff rushing, staff attitudes and staff reprimanding them when asking for help, left on the toilet, and staff telling residents they would be back and not return were resolved. The [DATE] grievance/concern resolution tracking log identified additional residents had concerns with staff treatment towards them. On [DATE] and again on [DATE], two different residents expressed concerns with rude staff. The [DATE] response was the nurse's contract expired. The [DATE] response was staff agreed to be careful. The residents were not part of the resident council meeting or resident interviews The [DATE] resident council follow up sheet did not identify the [DATE] resident council concern of staff attitudes and feelings of being reprimanded which was still identified as a concern during the [DATE] through [DATE] interviews (see below). An undated quality assurance and performance improvement (QAPI) discussion form was provided by the CC on [DATE] at approximately 6:15 p.m. According to the form there had been a decrease in concerns and grievances which was unusual. The form identified between [DATE] and [DATE] there were grievances logged without follow up. The form identified resident council minutes were reviewed for the past three months and there were alot of concerns but most of the concerns were from one resident. The form identified action was to start generating concerns/grievances from resident council and log the concerns and leadership should plan to attend the meeting. The interdisciplinary (IDT) morning meeting would review all grievances and discuss until resolution. -QAPI discussion form read most of the resident council concerns were from one resident however a review of the council minutes identified multiple residents expressed concerns with staff care. III. Resident interviews A. Resident individual interviews Resident #4 was interviewed on [DATE] at 4:10 p.m. Resident #4 said the staff had an attitude in the way they spoke to her when she answered her call light or if she took a while in the bathroom. Resident #31 was interviewed on [DATE] at 4:31 p.m. Resident #31 said his main concern was staff would come in to help him but they would be very quick in the process with whatever he needed and then leave before he was able to get all the assistance he wanted such as help put on his jacket. He said he would like the staff not to rush so much and take the time to make sure he did not need more assistance. He said some things were very hard for him to do on his own. Resident #16 was interviewed on [DATE] at 4:36 p.m. Resident #16 said some of the staff were rude and had an attitude during care and they spoke to her. She said she had to ask one staff member not to come into her room because she was very rude. Resident #45 was interviewed on [DATE] at 10:20 a.m. Resident #45 said when the CNAs answered her call light, they did not stay long enough in her room to finish helping her. She said sometimes she just needed something small like getting her earrings for her but the CNAs leave too fast to help with the request. B. Resident group interview Five residents (#4, #22, #45, #51 and #53), who were identified as interviewable by the facility and assessment, were interviewed on [DATE] at 10:30 a.m. Resident #45 said one problem that she and everyone had continued to have was that staff rushed in the room and did not take the time to listen to what the residents asked and needed from them. She said when the staff were rushed could cause miscommunication between staff and the residents. She said the staff leave and assume all the needs were met without asking the residents. Resident #4 agreed. Resident #4 said the staff dashed in and out of her room. Resident #4 said had reported her concerns repeatedly but staff continued to rush during care. Resident #4 said when the staff helped her dress the CNAs took her shirt off so fast it hurt her ears. Resident #4 and Resident #51 said when staff helped transfer them, they moved so fast it made them feel dizzy. Resident #51 said he has asked staff not to assist him anymore and he does most things by himself. Resident #51 said that when he told staff he had a problem or need, the staff did not pay attention. Resident #22 said there was a nurse that would do that to her. Resident #53 said staff would complete the first thing he asked them to do but would then leave the room without making sure she did not need anything else. She said she would then have to push the call light on again to have them come back. She said the CNAs seemed so happy to leave the room before the resident could ask for items such as her water and her chapstick. She said the staff had too many people to take care of at one time and told her they were short staffed. Resident #4 said she had the same concerns and had told the nurses and the social service director (SSD). The group said staff treated them with dignity but the CNAs had an attitude and rushed care because they were so busy. Resident #22 said the staff was pushy when they gave her instructions. Resident #53 said CNA's tell her she was confused and talk to each other and not her when she asked for something. Resident #51 said he would tell the nurses his concerns but they would just raise their eyes up and talk over the top of him to other staff which made him feel frustrated. Resident #45 said she was worried and felt she was a burden to staff so she tried to do as much as she could by herself. Resident #22 and Resident #53 agreed. Resident #53 said she would try to give the CNAs all of her requests at one time because their time was short with her but still would do only one of the tasks. Resident #51 staff just needed to pay more attention. Resident #4 said she has bumped the bathroom wall because the CNAs rushed to put her on the toilet. She said the CNA would leave her on the toilet and tell her they needed to help another resident and would come back later. She said they would leave her there for a while. She said it was not comfortable to have to remain on the toilet for extended times. She said she did not have a clock in the bathroom so she could not say how long she was left there. She said it made her feel annoyed when she was left there. Resident #22 said she had been left on the toilet for over 15 minutes. IV. Staff interviews The DON, the corporate consultant (CC) and the SSD was interviewed on [DATE] at 5:57 p.m. The SSD said the activity director used to be the one responsible for notifying staff of concerns addressed in resident council. The SSD said the resident council meetings were on Mondays every month but she did not work at the facility on Mondays. The SSD said she was present for the resident council in [DATE] and [DATE]. The DON said the SSD changed her schedule so she could help lead and be present for the meetings. The SSD said grievance cards also known as blue cards were created after resident council meetings if the residents expressed concerns. The SSD said every open/not resolved concern was reviewed in the morning meetings. The CC said during a [DATE] mock survey (survey preparation review) it was identified not all of the grievances were followed up on but there was a decrease in grievance cards generated. The CC said in [DATE] the facility started working on a process to address the grievances. She said the facility logged the grievances but the grievances cards for staff to follow-up on got lost in piles. The SSD said she was the one responsible for tracking unresolved or open concerns until the concern was addressed and resolved. She said on [DATE] she started writing down all the concerns in [DATE] and [DATE] because they needed to be addressed The SSD said she reviewed the recent resident concerns. She said Resident #4 had a concern with toileting in [DATE] regarding being left on a bed pan. She said no other resident had expressed concerns of being left too long on a toilet or a voiding device. The SSD said she checked in with Resident #4 and she did not say anything about being left too long on the toilet. The SSD reviewed the grievance tracking log and said nothing was reported in [DATE] and she was not aware of the concern. The SSD said she reviewed the [DATE] resident council minutes and said there was a concern regarding toileting care. She said she did not receive a grievance form and was not provided the [DATE] resident council minutes from the activity director. The CC said the resident council minutes should be reviewed in the quality assurance performance improvement (QAPI) meeting. The CC said starting next week the resident council minutes would be reviewed in QAPI. The SSD said regarding staff attitudes, a resident on [DATE] submitted a grievance that a nurse was rude to him. The SSD said the resident council said they would prefer to have a conversation with CNA's but the CNAs were too much in a hurry to talk to them. She said the staff sometimes were too fast in resident rooms and the residents felt the staff was rushing with the care and not communicating enough with the resident. The SSD said the follow-up of the concern should have been documented in council minutes and addressed on a grievance form. The SSD said the regarding staff rushing through resident care was not followed up using the grievance form process but she was made aware of the concern when the activity director told her about the concern after a meeting. The SSD said Resident #4 still felt there were concerns with an identified CNA and the CNA was removed for her care this week ([DATE]-[DATE]). The CC said the facility addressed customer service with staff during an [DATE] staff meeting. -However, the facility was unable to provide documentation which demonstrated that not rushing residents or asking residents if they needed anything else before the staff member left the room was included in the inservice. The CC said it was important for the residents to feel important and heard. The CC said there needed to be more oversight in the grievance process. The CC said they identified the concerns with lack of grievance follow-up in February 2024 but plans to improve the process did not start till the week on [DATE] (during the survey process). The CC said the activity director who was originally responsible for the grievance cards after resident council was educated in [DATE] but there were still identified concerns but lack of follow through. The DON said the former NHA was responsible for overseeing the process but he was no longer at the facility. The SSD said in the QAPI meeting they had identified a slow down in grievance cards but there was not a follow-up plan. The DON the quality assurance nurse (QAN) led QAPI. The CC said the facility reminded staff not to rush with care but the facility could evidence that they addressed the concern with staff. -However, the CC could not provide dates when reminders were provided to staff. The SSD said moving forward she would regularly attend the resident council meeting, document staff education and concerns on a grievance form. She said the facility would provide timely follow-up of the concerns within a week of the concern and follow up with the resident to make sure the resident felt the concern was addressed and resolved. The QAN, DON and the SSD were interviewed together on [DATE] at 8:01 p.m. The QAN said during QAPI each department gave an update on what the facility needed to address, if there was anything reportable, and if there was anything we needed to discuss as a team. The QAN said if there were concerns in the resident council the activity director addressed the concerns in QAPI and the QAPI members would then review each concern. The SSD said starting this week she was ultimately responsible for the grievance follow-up in the resident council. The DON said the facility was to go over the concerns they knew they already had and there were more concerns they did not know about. She said she would review the concerns with the QAN and create a performance action plan to make sure all concerns are put on the grievance forms. The DON said there was a gap when not all of the concerns were addressed in QAPI.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of three dining rooms and one of one kitchenette. Specifically, the facility failed to: -Ensure hand hygiene was offered and provided to residents during meal times; -Ensure staff plating ready-to-eat food used hand hygiene after touching potentially contaminated surfaces; and, -Ensure staff used hand hygiene before donning gloves to serve ready-to-eat food. Findings include: I. Facility policy The Infection Prevention and Control Program policy, revised 2/25/19, was provided by the director of nursing (DON) on 5/20/24 at 2:00 p.m. It read in pertinent part, The Infection Prevention and Control Program will utilize the policies and procedures within the Infection Control Manual. The program includes employee health, management of residents with infectious diseases, hand hygiene for staff, residents and visitors; cleaning and disinfection procedures including appropriate surfaces and equipment, food safety and linen handling. Staff education is provided at orientation, yearly, during outbreaks and as needed includes handwashing. -The Hand Washing policy, dated 2021, was provided by the corporate consultant (CC) on 5/23/24 at 3:53 p.m. The policy identified staff should perform hand hygiene when entering the kitchen, immediately before engaging in food preparation, before donning disposable gloves before and after working with food and after engaging in other activities that would contaminate the hands. According to the policy, staff should be educated and reminded of the importance of hand washing. -The Hand Hygiene policy and procedure, dated 8/21/23, was provided by the CC on 5/23/24 at 3:53 p.m. It read in pertinent part, The hands of the conduits for almost every transfer of potential pathogen from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. To protect patients from healthcare associated infection, hand hygiene must be performed routinely and thoroughly. Clean and healthy hands with intact skin, short fingernails, and no rings minimize the risk of contamination. The Centers of Disease Control (CDC) recommends that patients perform hand hygiene with soap and water or alcohol-based hand sanitizer before and after eating food, before touching the eyes, nose, or mouth, after using the restroom, after blowing the nose, coughing, or sneezing and after touching any surfaces in healthcare facility, such as the bed rail or remote control, to decrease the spread of infection. The Bare Hand Contact with Food and Use of Plastic Gloves policy, dated 2021, was provided by the CC on 5/23/24 at 3:53 p.m. It read in pertinent part, Single-use gloves will be worn when handling food directly with hands to ensure that bacteria was not transferred from the food handlers hands to the food product being served. Bare hand contact with food is prohibited. Hands are to be washed when entering the kitchen and before putting on single-use gloves and after removing single-use gloves. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched the gloves must be changed, and the hands must be washed. II. Observations The main dining room was observed continuously on 5/20/24, beginning at 11:23 a.m. and ending at 12:55 p.m. Observations identified the following: -19 residents were not offered hand hygiene before they were served their meal of fish, rice and zucchini or a hamburger and chips or sandwich. -Three residents self propelled their wheelchairs into the dining room by using their hands on the wheels of the wheelchair. Staff did not offer or encourage the residents to use hand hygiene before they ate their meal in the dining room. -Hand hygiene supplies were not passed out in the dining room or provided on the dining room tables. The memory care unit dining room was observed during a continuous observation on 5/20/24, beginning at 11:00 a.m. and ending at 12:07 p.m. Observations identified the following: On 5/20/24 at 11:00 a.m. 10 residents were in the memory care dining room. -The residents were not offered hand hygiene. -A male resident and a female resident entered the dining room using their walkers, The residents were not not offered hand hygiene before lunch after touching the handles of their walkers. At 11:04 a.m. a male resident self-propelled his wheelchair by placing his hands on the wheels of his wheelchair into the dining room. -The male resident was not offered hand hygiene. Between 11:36 a.m. and 12:07 p.m. four residents were served hand held food which included a grilled cheese sandwich, an egg salad sandwich, a fried egg sandwich or a peanut butter and jelly sandwich. The remainder of the residents were serviced cod, chips, asparagus, and angel food cake. The memory care unit dining room was observed during a continuous observation on 5/22/24, beginning at 11:42 a.m. and ending at 12:36 p.m. Observations identified the following: On 5/22/24 at 11:42 a.m. six residents were in the dining room. -At 11:43 a.m., four residents were brought into the dining room and not offered hand hygiene. -At 11:45 a.m. another resident was brought into the dining room and was not offered hand hygiene. -At 11:46 a.m. three tables were observed with hand sanitizer placed on them while nine tables were without hand sanitizer. -At 11:47 a.m. a male resident walked into the dining room and a female resident entered the dining room with staff, neither of the residents were offered hand hygiene. -At 11:48 a.m. a female resident wrapped tissue around her finger and stuck her finger up her nostril to clean out her nose. The resident then grabbed a lemon, with the finger that was in her nose, and squeezed it on her fish. -At 11:52 a.m. two residents were brought into the dining room and were not offered hand hygiene. -At 11:57 a.m. a female resident was assisted to the dining room and was not offered hand hygiene. -At 11:58 a.m. a male resident was assisted to the dining room and was not offered hand hygiene. At 12:00 p.m. two residents at the assistance table were offered hand hygiene. -At 12:04 p.m. a male resident was brought into the dining room and not offered hand hygiene. -At 12:07 p.m. a female resident was brought to the dining room and was not offered hand hygiene but the staff completed hand hygiene after she placed the resident at the table. -At 12:13 p.m. two more residents at another assistance table were offered hand hygiene. -At 12:15 p.m. a female resident who was not offered hand hygiene, ate her fish and cake with her hands. At 12:24 p.m. a male resident struggled to put condiments on his hamburger. His tablemate took his hamburger and buns, applied condiments and sat them back on the table cloth. The resident took his burger back from his table mate and assembled his burger. The resident ate his hamburger. -Neither resident was offered hand hygiene. -At 12:28 p.m. a female resident was eating a cookie with her hands. She was not offered hand hygiene and licked chocolate off her fingers. -At 12:36 p.m. two female residents were wiping their nose with their hands and proceeded to eat the fish with their hands. The memory care unit dining room was observed during a continuous observation on 5/22/24, beginning at 4:00 p.m. and ending at 5:13 p.m. Observations identified the following: -At 4:00 p.m. residents were being brought into the dining room by staff for the dinner meal. Hand sanitizer or hand wipes were not readily available on the tables. -At 4:13 p.m. 11 residents were seated at the dining room tables and none of the residents were offered hand hygiene. -At 4:15 p.m. a male resident walked into the dining room using his walker, he was not offered hand hygiene. At 4:48 p.m. cook #3 arrived at the unit with the meal cart. He grabbed the door handle to enter into the memory care unit. -Cook #3 did not perform hand hygiene when he entered the kitchenette after touching the door. At 4:53 p.m. cook #3 exited the memory care unit kitchenette and went to the main kitchen. -At 4:57 p.m. cook #3 returned to the memory care unit. He grabbed the door handle to the memory care unit and failed to perform hand hygiene when he entered the kitchenette. [NAME] #3 added food to the steam table and retrieved clean dishes. He touched the center of the clean plates with his thumb. -At 4:59 p.m. cook #3 wiped his right hand on his right thigh then put a glove on his left hand. He failed to wash his hands before applying the glove and cutting the residents ' sandwiches. -At 5:02 p.m. cook #3 removed the glove. He failed to wash his hands and proceeded to plate the main entree. He touched serving utensils, meal tickets and the surface of clean dishes. -At 5:09 p.m. cook #3 put on one glove without performing hand hygiene to cut an uncrustable peanut butter and jelly sandwich in half. He removed the glove and did not wash his hands. At 5:13 p.m. cook #3 broke down the steam table and left the unit. -Cook #3 again failed to wash his hands. III. Record Review The following trainings were provided by the registered dietitian (RD) on 5/23/24 at 1:19 p.m.: A 1/16/24 memory care unit staff training identified hand hygiene during meals was reviewed with the certified nurse aides (CNA) and nurses who worked on the memory care unit. -The training did not identify dietary staff who served on the memory care unit received the hand hygiene training. -A 1/18/24 dietary meeting did not identify hand hygiene was reviewed with the two cooks and the dietary assistant who attended the meeting. Glove use was reviewed during the meeting. -A 3/27/24 dietary meeting identified hand hygiene and glove use was reviewed with four dietary assistants and two cooks. The signature sheet identified cook #3 attended the meeting. The undated online food handling training documented the goal of food safety was to prevent the hazards that cause foodborne illness. To prevent foodborne safety hazards from affecting food, staff must understand the relationship between their actions and potential risk of foodborne illness. According to the online training, the most important thing that anyone can do to prevent foodborne illness was to wash their hands. The training identified that, during food preparation, staff should perform hand hygiene as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. Hand hygiene should be performed before eating food. III. Staff interviews The RD) was interviewed on 5/23/24 at 9:49 a.m. The RD said staff was trained on hygiene during the facility ' s annual skills fair and online training. The RD said the dietary staff received additional hand hygiene and infection control training with the dietary manager (DM). The DM was interviewed on 5/23/24 at 1:17 p.m. The DM said she reviewed hand hygiene with her staff. She said she reviewed how often and how long staff should clean their hands and proper glove use. She said the nursing department was responsible for training the nurses and CNAs. The DM said staff serving meals to the residents should perform hand hygiene between passing each plate, between helping each resident with their meal, when donning and doffing gloves and after touching any high touch surface area such as a door. She said hand hygiene helped prevent the spread of germs and bacteria. Observations of the memory care unit during meal service were shared with the DM. She said staff should have performed hand hygiene every time they stepped away and returned to the service line. She said touching a door or any high touch surface and then plating resident meals without hand hygiene increased the risk of spreading germs to the residents ' food. The regional infection preventionist (RIP) was interviewed on 5/23/24 at 2:29 p.m. The RIP said staff should perform hand hygiene before and after resident cares and entering resident rooms and anytime after touching their face or high contact surfaces. He said residents should be offered hand hygiene after toileting, before food, and anytime as needed. He said staff should use alcohol based hand rub (ABHR) before handling anything resident food related and in between residents during meal service. He said residents should be offered hand hygiene just before they eat at the table so the resident would have clean hands while they ate and decrease the risks of consuming germs and/or bacteria. The RIP said if a resident was propelling themselves to the dining room table, staff should make sure to encourage residents to use ABHR near the entrance of the dining room. He said staff should offer hand wipes at the dining room tables before the residents received their meal. The RIP said residents should not touch another resident ' s food. He said staff should intervene and redirect the resident to their own food. He said if food contact occurred by another resident, staff should offer to replace the touched food to avoid potential cross contamination. The RIP said the facility had not set up a hand hygiene process before meals other than encouraging residents to use hand hygiene. He said the facility had not set up a process or procedure to make sure hand hygiene was offered to residents before meals. He said staff were educated on the importance of hand hygiene a couple of times a year. CNA #4 was interviewed on 5/23/24 at 7:44 p.m. CNA #4 said she offered hand hygiene before residents went to the dining room. She said the rehab dining room did not have hand wipes to clean the residents ' hands. CNA #2 was interviewed on 5/23/24 at 7:45 p.m. CNA #2 said she used hand hygiene before she entered and left each residents ' room. She said she washed with soap and water after three uses of hand sanitizer or using the restroom. She said she offered the residents hand hygiene before meals and after they used the bathroom. She said she offered and provided residents hand hygiene in their rooms because she typically took them to the restroom before meals then offered it again in the dining room. She said if residents refused, she would still offer hand hygiene at meals and sometimes she would place ABHR in her hands and ask the residents how they were while she would rub the ABHR into their hands. CNA #7 was interviewed on 5/23/24 at 7:48 a.m. CNA #7 said most residents washed their hands at the sink in their room or she offered hand wipes to them before they ate. The quality assurance nurse (QAN) was interviewed on 5/23/24 at 8:01 p.m. The QAN said, during a January 2024 and February 2024 quality and assurance performance improvement (QAPI) meeting, the interdisciplinary team (IDT) discussed the facility ' s dining room process. She said in January 2024 the facility identified the residents refused to wash their hands. She said staff needed to stay on top of hand hygiene in the dining room and in resident rooms. She said the staff needed to encourage the residents to perform hand hygiene before meals in the dining room and offer hand wipes when residents received meal room trays. She said the IDT discussed how they could have residents practice hand hygiene more often and how to make it more appealing for the residents. The QAN said the dietary staff was provided hand hygiene education and the DM encouraged her staff to use hand hygiene. She said the staff providing the meals had tried hand wipe sanitizer packets on the meal trays and helped residents use the wipes. She said if the residents did not like the wipes, staff should offer the residents ABHR. Observations were reviewed with the QAN. She said the facility would start conducting more hand hygiene education with staff and complete audits of hand hygiene practices.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#50) of three residents out of 38 sample residents Specifically, the facility failed to ensure staff used a gait belt appropriately for assistance and not to restrain a resident from getting out of her wheelchair. Findings include: I. Facility policy The Physical Devices and Bedrails policy, revised 3/15/23, was provided by the director of nursing (DON) on 5/22/24 at 6:51 p.m. It read in pertinent part, In accordance with Federal and State laws, this company has a very stringent policy regarding the use of physical devices on residents, as a restraint. Our philosophy of providing residents with the highest possible quality of care and life, is reflective of our belief that it is essential for our residents to maintain their dignity and independence by being permitted to take the normal risks of everyday life. Devices used in an attempt to remove these normal risks of living, violate the rights of residents, greatly reduce their quality of life and present significant physical and psychological risks. For these reasons, and in accordance with Federal and State laws, devices used in our facility will only be considered to treat a medical symptom or condition that endangers the physical safety of the resident or other residents, and under the following conditions: -To improve the resident's mobility and independent function; -To treat residents'medical symptoms; -To restrict movement to protect the resident during treatment and diagnostic procedures; -As a last resort measure, after less restrictive measures have been taken and proven unsuccessful; -To prevent the resident from injuring himself or others; -With a physician's order; -With the consent of the resident or responsible party; and, -When the benefits of the device outweigh the identified risks. II. Observations During a continuous observation on 5/22/24, beginning at 3:00 p.m. and ending at 5:28 p.m., the following was observed: At 3:00 p.m. Resident #50 was observed continuously standing up and sitting down. She walked a couple of steps and pulled her wheelchair behind her. Resident #50 had a gait belt on and the staff with her used it to provide the resident with assistance because she was unsteady on her feet. At 3:44 p.m. registered nurse (RN) #2 switched out with certified nurse aide (CNA) #5 and took over providing oversight of Resident #50. Resident #50 continued to stand up and sit down. Resident #50 continued to walk a few steps as she pulled her wheelchair behind her. At 3:47 p.m. Resident #50 attempted to stand up and RN #2 used the resident's gait belt to pull her back into the seat of her wheelchair. Resident #50 stood up and walked a couple of steps. RN #2 pulled Resident #50's gait belt backward and pushed the resident's wheelchair forward and Resident #50 sat back down. At 3:49 p.m. Resident #50 attempted to stand up and RN #2 pulled the resident's gait belt. RN #2 held the gait belt to the back of the wheelchair when the resident sat back down so the resident was unable to stand up. At 3:50 p.m. Resident #50 stood up and RN #2 pulled the gait belt as she used her right knee to push the wheelchair under the resident. At 3:52 p.m. Resident #50 was trying to stand up and walk with her wheelchair. The resident said please, please, please as RN #2 pulled the wheelchair backward and prevented the resident from moving forward. At 3:53 p.m. Resident #50 stood up and RN #2 used her right hand to grab the resident's right shoulder and pushed the resident back into her wheelchair. CNA #5 saw what happened and told RN #2 that Resident #50 was strong. At 3:55 p.m. Resident #50 stood up and RN #2 pulled the resident by her gait belt and made her sit back in her wheelchair. At 3:57 p.m. CNA #5 switched with RN #2 and began providing oversight of Resident #50. Resident #50 stood up and walked a few steps while she pulled her wheelchair behind her and then sat down in her wheelchair. CNA #5 walked with Resident #50 as she walked. CNA #5 assisted Resident #50 to her bedroom to use the bathroom. At 4:07 p.m. RN #2 switched out with CNA #5 again and began providing oversight of Resident #50. The activity director (AD) entered the memory care unit and RN #2 let Resident #50 walk without pulling the gait belt. When the AD left the unit RN #2 pulled Resident #50's gait belt and sat her back in her wheelchair. At 4:08 p.m. Resident #50 stood up and said give it to me. RN #2 said not right now and used both hands to pull the resident back into her wheelchair by her gait belt. At 4:09 p.m. Resident #50 stood up and pulled her wheelchair forward while RN #2 pulled the wheelchair backwards. The resident and the nurse pulled on the wheelchair so hard that the wheels stopped moving. RN #2 tried getting Resident #50 to sit in her wheelchair but the resident wanted to walk. Resident #50 made a sstt-sstt-sstt sound but when RN #2 prevented the resident from walking, the noise was more frequent. At 4:11 p.m. RN #2 let Resident #50 walk a little bit but she got too close to another resident and RN #2 pulled her gait belt and sat her back in her wheelchair. At 4:12 p.m. Resident #50 sat in her wheelchair and RN #2 pushed down on the gait belt so the resident was not able to stand. Resident #50 stood up and said hurry, come on, hurry, come on as she tried to walk. RN #2 pulled her gait belt backward and she sat back in her wheelchair. At 4:14 p.m. Resident #50 tried walking again and RN #2 pulled her back into her wheelchair with the resident's gait belt. Resident #50 said please, please, please and appeared upset. At 4:15 p.m. Resident #50 stood up and sat down numerous times. Each time Resident #50 stood up RN #2 pulled her back down with her gait belt. This occurred five times in a row. At 4:16 p.m. Resident #50 stood up and walked approximately five steps before RN #2 used her gait belt to pull her back into her wheelchair. When Resident #50 was sitting in the wheelchair, RN #2 pushed down on the gait belt which prevented the resident from standing. At 4:17 p.m. Resident #50 stood up and pulled her wheelchair for approximately 10 steps. RN #2 pulled the gait belt and the resident pulled her wheelchair. The wheelchair slid sideways and the nurse had to straighten the wheelchair out before she had the resident sit down. At 4:18 p.m. the AD entered the unit again and RN #2 let Resident #50 walk a few steps. When the AD looked at RN #2, the nurse pulled Resident #50's gait belt as she used her right knee to push the wheelchair under the resident and made her sit down. The AD saw the incident, however, the AD did not speak to RN #2 and left the unit. At 4:19 p.m. Resident #50 stood up and tried walking forward. As she pulled her wheelchair forward, RN #2 pulled the wheelchair backward which prevented the resident from walking. At 4:44 p.m. CNA #5 switched out with RN #2 and began providing oversight of Resident #50. Resident #50 walked around as she pulled her wheelchair behind her and stopped making the sstt-sstt-sstt noise as much as she was when she was prevented from walking by RN #2. III. Record review Resident #50's dementia care plan, initiated on 7/21/21, documented the resident had unspecified dementia without behavioral disturbances. Interventions included approaching the resident in a calm, slow manner and re-approaching at a later time as needed, keeping daily routines consistent with the same repetition to promote memory cueing and cueing and reorienting the resident as needed. Resident #50's fall care plan, revised 10/11/23, documented the resident was at high risk for falls with a Morse fall risk score of 55. Interventions included keeping the bed in the lowest position while the resident was in bed, placing a fall mat at bedside while the resident was in bed, providing stand-by assistance when the resident was ambulating, hourly rounding for the 4P's (personal items, pain, personal needs and positioning), being sure the call light was in place in room and bathroom and reminding the resident to use the call light when assistance was needed and keeping needed items in reach of the resident. -However, the facility failed to include interventions to address what to do when the resident was constantly up and down and interventions to address what to do when the resident pulled her wheelchair behind her as she walked. IV. Staff interviews CNA #5 was interviewed on 5/22/24 at 4:25 p.m. CNA #5 said she covered any unit the facility assigned her. She said Resident #50 paced and was constantly standing and sitting. CNA #5 said when Resident #50 was walking, the staff pulled the wheelchair behind the resident in case she needed to sit down. CNA #5 said Resident #50 started pulling her wheelchair behind her while she walked on 5/22/24. CNA #5 said the resident probably pulled her wheelchair the way therapy pulled it behind residents to prevent falls. CNA #5 said Resident #50 was a fall risk but she was unaware of what fall interventions were in place for the resident. CNA #5 said staff were supposed to hold the gait belt in a supportive way and did not really touch the gait belt. She said staff just kept their hand under the gait belt in case the resident sat down unexpectedly. CNA #5 said she had Resident #50 walk because she was determined to get up and there was no reason to stop her. CNA #5 said she had seen other staff pull on the resident's gait belt and try to keep the resident in her wheelchair but CNA #5 was uncomfortable with that practice and did not tell anyone or speak to the staff who pulled the gait belt. CNA #9 was interviewed on 5/22/24 at 4:30 p.m. CNA #9 said she worked the memory care unit a lot and Resident #50 paced every day. CNA #9 said she felt Resident #50 had been standing and sitting constantly and walking with her wheelchair for quite some time. CNA #9 said she kept her hand by Resident #50's gait belt to support the resident as she walked. CNA #9 said she saw other staff pull on Resident #50's gait belt to make her sit down but the facility never allowed for the staff to pull on gait belts. CNA #9 said she let Resident #50 walk around and pace and hoped it would help with her behaviors. CNA #9 said she was taught if a resident wanted to walk the staff needed to let them walk safely. CNA #9 said staff were not supposed to restrain residents. CNA #9 said Resident #50 was a fall risk but she was unaware of any fall interventions in place. CNA #9 said she had not told anyone that some staff were pulling on the resident's gait belt in order to keep the resident from standing up. Activity aide (AA) #1 was interviewed on 5/22/24 at 4:35 p.m. AA #1 said she was assigned to the unit for activities. AA #1 said Resident #50 was always up and down. AA #1 said Resident #50 was a fall risk but she was unaware of any fall interventions in place because she was not allowed to provide resident care. AA #1 said she observed some staff pull the resident's gait belt to make her sit back in her wheelchair. AA #1 said she knew the staff were not allowed to pull on the gait belt but had not told anyone it was occurring. RN #2 was interviewed on 5/22/24 at 4:38 p.m. RN #2 said she was the nurse assigned to the memory care unit and she worked the unit all the time. She said Resident #50 started wandering within the past few weeks. RN #2 said Resident #50 was a fall risk and her fall interventions were that she needed one-to-one supervision. RN #2 said staff were not allowed to pull on the gait belt but the staff held the gait belt if they felt she was going to fall. RN #2 said she sometimes let Resident #50 walk but it depended on how her balance was at that moment. RN #2 said she pulled on Resident #50's gait belt if the resident was too far forward. RN #2 said she felt she was not pulling on the gait belt and she was concerned the resident was going to fall. The director of nursing (DON) and the corporate consultant (CC) were interviewed on 5/22/24 at 7:08 p.m. The DON said a gait belt was used to transfer residents and it was not okay to be used as a restraint or to put a resident in their wheelchair. The CC said some residents received restorative therapy and the staff needed to keep their hand under the bottom of the gait belt, not on top of the gait belt to be pulled. The DON said she was opening an investigation and was investigating abuse and restraints. The CC said the investigation started as abuse for the night. The CC said the facility was a restraint-free facility. The DON said she knew RN #2 and felt the nurse was probably more concerned about Resident #50's safety than trying to restrain her to her wheelchair. The DON said RN #2 probably did not realize she was hurting Resident #50 or potentially causing injuries and probably did not know she was using the gait belt as a restraint. The memory care coordinator (MCC) was interviewed on 5/23/24 at 10:30 a.m. The MCC said Resident #50 recently started walking. The MCC said the resident had a change in her condition a while back which prevented her from walking and staff used a lift for transfers. The MCC said RN #2 was not supposed to pull on the gait belt or prevent Resident #50 from getting out of her wheelchair. The MCC said she requested Resident #50's hospice team to complete an assessment because the MCC worried the resident was experiencing end-of-life agitation and restlessness. The MCC said she provided education to the staff who worked the unit on 5/23/24 and the DON was helping with the education to the rest of the facility. The MCC said all staff were required to complete a six-hour dementia computer course by 6/1/24 and felt it would help. The MCC said if activities occurred the way the residents needed, it prevented a lot of incidents which included potential staff burnout. The MCC said it was unacceptable for RN #2 to pull on Resident #50's gait belt, push the wheelchair into the resident, or prevent the resident from walking. The DON was interviewed again on 5/23/24 at 2:11 p.m. The DON said RN #2 was suspended and the investigation was ongoing. The DON said every shift was provided education in-person on the proper use of a gait belt. The DON said the facility assigned all staff online training for gait belts and restraints. The DON said all staff were required to complete a six-hour dementia training by 6/1/24 and she monitored everyone's progress to ensure it was being completed. The DON said dementia capable care training was going to be completed by all staff by the end of July 2024. The DON said the facility wanted the MCC to have an AA who was managed by the MCC so the AA was consistent for the unit and was able to provide the residents with the activities they needed. The DON said it was important not to pull on a gait belt to prevent injuries and pain. The DON said a lot of residents were admitted to the memory care unit at the same time which overwhelmed the unit and increased the tension. The DON said RN #2 was probably burnt out from Resident #50 and providing one-on-one supervision alone. The DON said she walked with Resident #50 and saw it was difficult to provide assistance to the resident with just one staff member. The DON said Resident #50's interventions were updated and if the resident wanted to walk she needed two staff members to provide assistance. The rehabilitation therapy director (RTD) was interviewed on 5/23/24 at 4:52 p.m. The RTD said gait belts should be used for assistance and not used to restrain residents. RN #1 was interviewed on 5/23/24 at 4:49 p.m. RN #1 said she was the rehabilitation nurse and said the gait belts were used to assist residents with transfers and ambulation. RN #1 said gait belts were not to be used as restraints. CNA #6 was interviewed on 5/23/24 at 6:21 p.m. CNA #6 said gait belts were used to walk with residents who were a fall risk. CNA #6 said gait belts kept the residents safe and prevented falls. CNA #6 said she had not seen staff restrain residents with a gait belt. CNA #4 was interviewed on 5/23/24 at 6:23 p.m. CNA #4 said gait belts were used to safely walk with residents. CNA #4 said she did not think staff were allowed to pull on the gait belt. CNA #4 said gait belts should not be used to restrain residents at any time. RN #3 was interviewed on 5/23/24 at 6:31 p.m. RN #3 said gait belts were used to safely transfer residents. RN #3 said staff were not allowed to pull on the gait unless staff were preventing a fall. RN #3 said gait belts were not used to restrain residents. V. Facility follow-up The DON provided a follow-up report on 5/29/24 at 3:08 p.m. The DON said RN #2 was no longer assigned to the memory care unit. She said RN #2 was required to complete gait belt and restraint training. The DON said RN #2 was assigned to work under the direct supervision of the evening nurse supervisor and was assigned the same schedule as the supervisor. The DON said RN #2's supervision level would be re-evaluated in six months.

Based on record review and interviews, the facility failed to ensure the resident's legal representative was provided an opportunity to exercise a right on behalf of the resident for one (#30) of five residents reviewed for resident rights out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #30's Medical Orders for Scope of Treatment (MOST) form was signed by the resident's medical durable power of attorney (MDPOA) instead of a family member who was not the resident's legal representative. Findings include: I. Facility policy The Advanced Directive and Health Care Directive policy, revised [DATE], was provided by the social services director (SSD) on [DATE] at 7:15 p.m. It read in pertinent part, It is the policy of the facility to honor their residents'advanced directives. The facility will provide orientation and training programs to educate staff on advance directives. A health care power of attorney or medical durable power of attorney delegating authority for an agent to make health care decisions in the case the individual delegating that authority subsequently becomes incapacitated. The legal representative, agent, attorney in face, proxy, substitute decision-maker, or surrogate decision-maker is a person designated and authorized by an advanced directive or by State law to make a treatment decision for another person in the event the other person becomes unable to make necessary health care decisions. II. Resident status Resident #30, age 87, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and dementia (impaired ability to remember, think and make decisions). The [DATE] minimum data set (MDS) assessment documented Resident #30 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. III. Record review Resident #30's MDPOA document, signed and effective [DATE], was provided by the director of nursing (DON) on [DATE] at 3:25 p.m. It documented that the resident legally granted two of his family members the power to act in his place, for his benefit, to the same extent he could have acted for himself with regard to all medical matters. The document identified, by name, the two family members (first MDPOA and second MDPOA) the resident wished to have act on his behalf when he could not. The second MDPOA would act on his behalf if the first MDPOA was no longer able to fill that role. The document was signed by the resident and both MDPOAs on [DATE]. Resident #30's MOST form was reviewed on [DATE]. The MOST form documented that Resident #30 wished for no cardiopulmonary resuscitation (CPR), he wanted selective treatment without burdensome measures and no artificial nutrition by tube. The MOST form documented the discussion and the form was completed by one of Resident #30's family members. -However, the facility failed to ensure the family member who signed the MOST form was Resident #30's first MDPOA or the second MDPOA, who were legally appointed as the resident's representatives. IV. Staff interviews Registered nurse (RN) #1 was interviewed on [DATE] at 4:25 p.m. RN #1 said she completed MOST forms when residents were admitted to the short-term rehabilitation hall. She said she checked the electronic medical record (EMR) to find out who the MDPOA was for the resident. She said she was unsure how to confirm the MDPOA listed was actually the resident's MDPOA. The social services director (SSD) was interviewed on [DATE] at 7:10 p.m. The SSD said the nurse assigned to the hall the resident was admitted to was responsible for getting the resident's MOST form completed. She said she confirmed the MDPOA as she checked the paperwork received from the last placement of the resident. She said the rehabilitation residents MOST forms were reviewed during admission and at care conferences and the long-term care residents were reviewed quarterly. The SSD said if it was discovered a MOST form was signed by someone other than the resident or the MDPOA, the form was inaccurate and a new form needed to be completed. The SSD said the MOST forms were not reviewed by social services except during care conferences. The director of nursing (DON) was interviewed on [DATE] at 7:27 p.m. The DON said the floor nurses were responsible for completing the MOST forms during admission. She said she did not know how the nurses confirmed the MDPOA was accurate. She said there was not a process but the facility worked with the residents and their families to get a guardianship going if that was needed.

Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for two (#66 and #6) of five residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to: -Prevent Resident #6 from physically abusing Resident #66; -Update Resident #66 and Resident #6's care plans with effective interventions to prevent abuse; and, -Identify patterns or causes of resident-to-resident abuse. Findings include: I. Facility policy The Resident or Client Protection Freedom from Abuse, Neglect and Misappropriation policy, revised 11/3/22, was provided by the director of nursing (DON) on 5/20/24 at 10:00 a.m. It read in pertinent part, It is the policy of this facility that all residents are free from abuse and neglect. Each individual has the right to be free from verbal, sexual, physical and mental abuse, including injuries of unknown source, misappropriation of resident property, corporal punishment, mistreatment, neglect and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, other residents. The objectives of this resident protection plan are to protect individuals cared for at our facility from maltreatment, to describe the policies and procedures adopted and implemented by our facility to protect the individuals, to comply with and exceed the protection required by law, facilitate the process of reporting suspected maltreatment and review the resident protection plan on an annual basis or more frequently if needed. II. Resident-to-resident incident between Resident #66 and Resident #6 on 5/6/24 The incident notes for the 5/6/24 physical abuse incident were provided by the DON on 5/22/24 at 5:53 p.m. The victim, Resident #6, was documented as being severely impaired cognitively and had a history of behaviors that included agitation, outbursts, crying, restlessness, sadness, throwing items, yelling, hallucinations and paranoia. The alleged assailant, Resident #66, was documented as being severely impaired cognitively and had a history of behaviors that included hallucinations, restlessness, wandering into other residents'rooms, exit-seeking, yelling out at people who were not there and believing people were stealing her money. On 5/6/24 Resident #66 was trying to enter a room to use the bathroom as Resident #6 was leaving the room. Resident #66 asked Resident #6 to excuse her because she needed to use the bathroom. Resident #6 grabbed Resident #66 by the arm and slapped her across the face. Resident #66 was upset and yelled that she was going to bash her head in and referred to Resident #6. Resident #6 did not hear what Resident #66 said. Resident #6 yelled, They (Resident #66) do not want me in their room. The residents were separated. The incident was witnessed by a housekeeping staff member. The residents were assessed for injuries the following day 5/7/24. The investigation began on 5/7/24 because the incident was not reported timely by the staff. Resident #66 had a bruise on the back of her right hand and it was documented as a bruise that was healing from the resident hitting her hand on the bathroom door. Resident #6 had no new injuries documented. -However, the facility failed to assess the residents immediately after the incident to ensure temporary injuries were not present and to confirm the source of Resident #66's injury. III. Resident #66 A. Resident status Resident #66, age 78, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dislocation of the right shoulder, dementia with other behavioral disturbances and adjustment disorder with depressed mood. The 4/3/24 minimum data set (MDS) assessment documented Resident #66 had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. Resident #66 experienced hallucinations, physical behavioral symptoms, verbal behavioral symptoms and behavioral symptoms not directed toward other people, including wandering. Resident #66 put herself and other residents at significant risk for physical injury, her behaviors interfered with the resident's care, interfered with the resident's participation in activities or social interactions and potentially put Resident #66 at risk for wandering into a dangerous area or situation. B. Record review Resident #66's dementia care plan, initiated 3/7/24, documented the resident had dementia, unspecified severity of dementia with other behavioral disturbances. Interventions included keeping a daily routine consistent with the same repetition to promote memory cueing, keeping the resident's environment constant and items in reach, providing activities or recreation of the resident's choice and praising efforts when tasks were completed. Resident #66's behavioral care plan, initiated 3/11/24, documented the resident's target behaviors included agitation, angry outbursts, crying, restlessness, sadness, throwing items, yelling, hallucinations and paranoia. Interventions included providing one-on-one activities such as crafts, keeping the resident separated from Resident #6 as much as possible with direct staff supervision if they were in the common area together, offering coffee and soda to the resident as well as sweet snacks, redirecting the resident and reapproaching the resident after a few moments, removing the resident from a high-stress area or common area, taking the resident outside to calm her down, turning on sports on the television (TV) as she enjoyed golf and softball, approaching the resident in a calm manner, not arguing with the resident, documenting behaviors and the resident's response to interventions and talking with the resident in a calm voice when behavior was disruptive. Resident #66's vulnerability care plan, revised 4/18/23, documented the resident was on an individual abuse prevention plan because she had behaviors and low cognition. Interventions included if the resident was displaying persistent or inappropriate behaviors, staff was to remove the resident to an area away from others, observing and implementing interventions to minimize and prevent reoccurrence and providing a safe environment for the individual and others and ensuring the safety of others. -However, the facility failed to revise Resident #66's care plans with personalized effective interventions to prevent resident-to-resident abuse following the physical altercation with Resident #6 on 5/6/24 (see physical altercation above). Cross-reference F744: failure to provide treatment/services for dementia care. IV. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnosis included mild dementia. The 3/6/24 MDS assessment documented Resident #6 had a severe cognitive impairment with a BIMS score of one out of 15. Resident #6 experienced hallucinations, delusions, physical behavioral symptoms and behavioral symptoms not directed at others, including wandering. B. Record review Resident #6's behavioral care plan, revised 8/22/23, documented the resident had a severe cognitive loss. Interventions included keeping the resident separated from Resident #66 as much as possible with direct staff supervision if they were in the common area together, offering crafts and one-on-one time, offering crafts and religious shows on TV, offering to go outside when she was agitated, offering her to read her bible and coloring, offering sweet treats, tea, juice, water and soda, approaching the resident in a calm manner and documenting behaviors and resident's response to interventions. Resident #6's mood care plan, revised 6/26/23, documented the resident experienced an alteration in feelings of well-being and hallucinations that altered her mood. Interventions included approaching the resident warmly and positively, identifying the resident's interests and involving the resident in meaningful activities. Resident #6's dementia care plan, revised 4/4/23, documented she had mild dementia without behavioral disturbances. Interventions included approaching the resident in a calm, slow manner and reapproaching at a later time as needed, keeping daily routines consistent with the same repetition to promote memory cueing, keeping the environment constant and items in reach and providing activities or recreation of resident's choice and praising efforts when tasks were completed. -However, the facility failed to update Resident #6's care plans with effective personalized interventions to prevent resident-to-resident abuse following the physical altercation with Resident #66 on 5/6/24 (see physical altercation above) -Resident #6's care plan failed to document a vulnerability care plan and an individual abuse prevention plan. Cross-reference F744: failure to provide treatment/services for dementia care. V. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 5/22/24 at 4:25 p.m. CNA #5 said the memory care unit had a lot of resident-to-resident abuse because most of the residents had dementia. She said sometimes the staff were fast enough to prevent contact from being made and sometimes the staff were not fast enough. CNA #9 was interviewed on 5/22/24 at 4:30 p.m. CNA #9 said the resident-to-resident incidents occurred but it depended on the day and which residents had behaviors. She said sometimes there were a lot of incidents on the unit. Activity aide (AA) #1 was interviewed on 5/22/24 at 4:35 p.m. AA #1 said the residents sometimes got into arguments or fights with each other but it was because of their dementia. Registered nurse (RN) #2 was interviewed on 5/22/24 at 4:38 p.m. RN #2 said if the staff kept the residents separated it helped prevent resident-to-resident incidents. She said it was a memory care unit so the residents had incidents but she was unsure if she would call the interactions abuse. The memory care coordinator (MCC) was interviewed on 5/23/24 at 11:05 a.m. The MCC said patterns of resident-to-resident incidents had not been identified but she noticed the incidents occurred in the evenings or when she was not there. The MCC said she thought the incidents were because of sundowning (behaviors that occurred in people with Alzheimer's or dementia in the afternoon or evening). Cross-reference F744: failure to provide treatment/services for dementia care. The MCC said she wondered if staff provided the residents with activities in the evening and was worried the lack of activities caused the residents to become more restless and agitated. The MCC said she planned to change her hours to provide the evening shift with more supervision. She said the memory care unit needed an activity aide who worked well on the unit and helped with activities. The MCC said if activities occurred like the residents needed, then the unit would have decreased behaviors and resident-to-resident altercations. The DON was interviewed on 5/23/24 at 2:11 p.m. The DON said a handful of residents were admitted ded to the memory care unit very quickly and overwhelmed the unit. The DON said she was unaware staff failed to provide activities on the evening shift. She said the MCC needed to have her own AA for the unit because the current AAs rotated each week as to who worked the memory care unit. She said the AA who covered the unit was supposed to work more of an 11:00 a.m. to 7:00 p.m. or 12:00 p.m. to 8:00 p.m. shift. She said she was not aware the AA worked from 2:00 p.m. to 10:00 p.m. and was not consistently providing activities like the residents needed.

Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure the residents'food was palatable in taste, texture, appearance and temperature. Findings included: I. Resident interviews Resident #23 was interviewed on 5/20/24 at 3:02 p.m. Resident #23 said some of the meals she had been served were cold. Resident #16 was interviewed on 5/20/24 at 4:54 p.m. She said the beef was often tough. Resident #54 was interviewed on 5/21/24 at 8:58 a.m. He said the facility was a lost cause when it comes to food and tried to eat as little of the food provided by the facility as possible. He said he bought most of his own food. He said the food was frequently served cold. Resident #46 was interviewed on 5/21/24 at 9:06 a.m. She said the food was served cold and had limited seasoning. Resident #45 was interviewed on 5/21/24 at 10:25 a.m. She said the vegetables were usually overcooked. Resident #4 was interviewed on 5/21/24 at 12:49 p.m. She said the food was often over cooked and the cooked vegetables squirted water out of them when she tried to eat them. She said the food was usually cold even though the plate it was served on was warm. Resident #53 was interviewed in the dining room on 5/22/24 at 12:55 p.m. after her meal. She said her meal was served cold. II. Observations During a continuous observation on 5/22/24 beginning at 3:40 p.m. and ending at 6:01 p.m. the following was observed during the dinner meal preparation and service in the main kitchen: At 4:25 p.m. cook #2 took the temperature of the cooked carrots and mixed vegetables. The cooked carrots and mixed vegetables sat in covered containers with water. The temperature of the first container of carrots was 200 degrees F. The second container of carrots were 185 degrees F. The last container of carrots was 179 degrees F. The mixed vegetables were 200 degrees F. -At 4:29 p.m. cook #2 tested how soft the carrots were with a fork and said some of the carrots had bounced back and some were easily mashed with a fork. -At 4:49 p.m. cook #2 placed the containers in the steam table. -At 4:54 p.m. cook #2 took the temperatures of the food that was in the steam table. The mashed potatoes were 125 degrees F. The pureed carrots were 136 degrees F. The hamburger patties were 122 degrees F. The DM said the hamburger patties needed to be above 135 holding temperature. She said she would reheat the hamburger patties to 165 degrees F. because the meat fell into the danger zone. -At 5:03 p.m. meal service began in the main dining room. -At 5:31 p.m. the dining room service was completed and cook #2 started plating the room trays to load onto a hot holding cart. Two test trays were evaluated immediately after the last resident had been served their room tray for dinner on 5/22/24 by three surveyors. The regular diet test tray consisted of salisbury steak with gravy, mashed potatoes and carrots. -The temperature of the salisbury steak covered in gravy was 120 degrees F. Portions of the steak that were not covered in gravy and were 111 degrees F. The steak was lukewarm. -The mashed potatoes and gravy were 136.8 degrees F. -The carrots were 100.5 degrees F. The carrots were lukewarm, watery in taste and over cooked texture. The pureed diet test tray consisted of salisbury steak with gravy and pureed carrots. -The salisbury steak was 111 degrees F. -The pureed carrots were 121 degrees F. III. Record review The January 2024 resident council minutes indicated concerns with the cooked vegetables identifying the vegetables tasted like wall paper paste. -The resident council minutes did not identify a plan to correct the vegetables after residents identified a concern (cross-reference F565 grievances of a group). The February 2024 resident council minutes read the vegetables were too watery. One resident said she felt the dietary staff did not love food. Another resident said she no longer loved food after living at the facility. The March 2024 resident council minutes read a resident said her vegetables were mushy. According to the minutes, the other residents agreed. The March 2024 food committee minutes read the pasta salad and the tuna salad needed to be less watery and the overcooked broccoli was gross. The May 2024 resident council minutes read the meat was too tough, the quality of the soup had declined and the broth and chicken tasted bad, the food had been cold and the vegetables were mushy. According to the minutes, the quality of the food was worse later in the week. The May 2024 food committee read the dietary department was working on ways to improve food temperatures. IV. Staff interview The dietary manager (DM) was interviewed on 5/23/24 at 1:17 p.m. The DM said she was aware there were resident concerns with food temperatures for the last couple of months. The DM said some of the cooks did not turn the steam table on prior to the meal services. She said she also had identified that the staff were plating the meals too early and the meals were sitting too long before the staff delivered the meals to the residents. She said she has retrained all of the staff on timing and on 5/20/24 she changed the order of delivery service. She said the dining room was now served first and the room trays were served last in hopes to improve the meal temperatures. The DM said the residents had expressed concerns with the taste of the food. She said some of the residents felt the food was too salty or too tough to chew. The DM said she observed the weekend cook and identified some food preparation concerns. She provided additional training to the weekend cook. The DM said other concerns that had been identified were the overcooking and taste of the vegetables. The DM said the steamer had ongoing concerns with not working correctly and had been reviewed by the facility maintenance department and the equipment service vendor. The DM said the steamer helped the dietary department maintain food temperatures and helped prevent the overcooking and undercooking of the vegetables. She said a new part was ordered on 5/15/23 for the steamer but it had not arrived at the facility yet. The DM said she identified concerns with the cooks preparing the meals. She said the cooks were leaving the vegetables in the streamer for too long. She said this caused the vegetables to get overcooked. She said the cooks were also not setting the steamer at the correct temperature. She said she started seeing concerns with overcooking since the beginning of the year. The DM said she felt it was a combination of the cooks error and a need for new equipment. The DM said the steamer not working correctly had been an ongoing concern over the last couple of years. She said the steamer has had parts replaced and fixed but still was not working correctly. She said she was currently waiting on invoices and then would present her concerns to the nursing home administrator (NHA). The DM said she has tried to train the cooks on different methods of cooking to improve palatability and make sure the vegetables were not mushy in taste and texture. She said she was at the facility for two and a half days a week to provide kitchen and cooking oversight. She said the charge cook was here five days a week for three meals a day. The DM said there was an overlap between her schedule and the charge cook which caused the kitchen to not have a supervisor for two days a week. She said the limited oversight of the food could have been part of the palatability concerns and not using proper cooking techniques. The DM said when she was not at the facility, the charge cook was the one to ensure cooks were cooking the food properly, however, the charge cook needed to be retained on proper cooking methods too. The DM said she had scheduled to retrain the charge cook on 5/28/24. The DM said she had provided training to the charge cook off and on since March 2024 but was still identifying concerns. She said one possible reason was a language barrier. She said she acquired training handouts in Spanish on 5/17/24 but had not handed the training material out yet to the staff who primarily spoke Spanish. The DM said she tried to communicate with the charge cook by using a translating hot line but there was still communication barriers. She said the charge cook was responsible for oversight of the other cooks for three of the cooks only spoke English which could also be a breakdown in communication. The SSD was interviewed on 5/23/24 at 5:57 p.m. She said she frequently received grievances on food concerns. The quality assurance nurse (QAN) was interviewed on 5/23/24 8:01 p.m. The QAN said resident food palatability had been discussed in the quality assurance and improvement (QAPI) meetings after residents had grievances about food temperatures being off or food being mushy. The QAN said the DM and registered dietitian (RD) were working on correcting the concerns. The QAN said the following resident council meeting there were no further concerns and the grievance was resolved. The QAN was informed of ongoing resident concerns and test tray observations. The QAN said the facility would look at opportunities for improvement and needed to get a better oversight on the issues.

Based on interviews and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for two (#30 and #21) of five residents reviewed for medications out of 38 sample residents. Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #30 and Resident #21. Findings include: I. Facility policy and procedure The Psychoactive medication use policy, revised 8/14/23, was provided by the nursing home administrator (NHA) on 5/23/24 at 7:34 p.m. It read in pertinent part, PRN orders for psychotropic medications are limited to 14 days, but orders may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. II. Resident #30 A. Resident status Resident #30, age 87, was admitted on [DATE]. According to the May 2024 computerized physician order (CPO), diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and dementia (impaired ability to remember, think and make decisions). The 4/26/24 minimum data set (MDS) assessment documented Resident #30 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. B. Record review A review of the September 2023 CPO revealed the resident had a physician's order Lorazepam oral concentrate (anti-anxiety medication) 0.5 milliliter (ml) every four hours PRN for anxiety or agitation related to dementia for 90 days, ordered on 6/13/23 and discontinued on 9/11/23. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's electronic medical record (EMR) did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. A review of the January 2024 CPO revealed the resident had a physician's order w for Lorazepam oral concentrate 0.5 ml every four hours PRN for anxiety or agitation related to dementia for 90 days, ordered on 10/31/23 and discontinued on 1/29/24. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. A review of the May 2024 CPO revealed the resident had a physician's order for Lorazepam oral concentrate 0.5 ml every four hours PRN for anxiety or agitation related to dementia, ordered on 2/14/24 and discontinued on 5/14/24. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. A review of the May 2024 CPO revealed the resident had a physician's order for Lorazepam oral tablet 1 milligram (mg) every four hours PRN for anxiety or agitation related to dementia for 60 days, ordered on 5/16/24 and was scheduled to be discontinued on 7/15/24. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. 50314 III. Resident #21 A. Resident Status Resident #21, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included dementia, cerebrovascular disease (disease affecting the blood vessels) and insomnia (difficulty sleeping). The 4/17/24 MD) assessment revealed the resident was severely cognitively impaired with a BIMS assessment score of three out of 15. She required substantial or maximal assistance with eating, oral hygiene, and personal hygiene.She was dependent on staff for bathing, dressing, and toileting. B. Record review A review of the CPO revealed the resident had a physician's order for Seroquel (antipsychotic medication) 400 milligrams (mg) orally at bedtime for agitation and give 100 mg orally every 12 hours as needed for agitation, ordered on 8/8/23 and was discontinued on 9/11/23. -The antipsychotic medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. Further review of the May 2024 CPO revealed a physician's order for Lorazepam oral tablet 1 mg every 6 hours for anxiety/agitation and give one tablet by mouth every four hours as needed for anxiety/agitation for 90 days, ordered on 8/16/23 and discontinued on 9/21/23. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's electronic medical record (EMR) did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. IV. Staff interviews The pharmacist (PH) was interviewed on 5/23/24 at 4:44 p.m. The PH said psychotropic medications can only be ordered for more than 14 days if there was a documented reason by the physician. The PH said she did not have a documented reason why Resident #21's PRN Lorazepam or Seroquel was ordered for more than 14 days. The director of nursing (DON), nursing home administrator (NHA) and the corporate consultant (CC) were interviewed together on 5/34/24 at 7:27 p.m. The DON said PRN psychotropic medications could only be ordered for more than 14 days if there was a documented reason by the physician, up to a maximum of 90 days. The DON and the CC said there was not a documented reason why Resident #21 was prescribed Lorazepam and Seroquel for more than 14 days. The CC said it was against the regulation to have PRN psychotropic medications ordered without a reason for more than 14 days.

Based on observations, interviews and record review, the facility failed to ensure residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being for two (#6 and #66) of six residents reviewed for dementia care out of 38 sample residents. Specifically, the facility failed to: -Effectively implement a meaningful activity program for Resident #6 and Resident #66 to prevent resident-to-resident abuse; and, -Implement person-centered interventions for Resident #6's and Resident #66's behaviors. Findings include: I. Facility policy The Guidelines for Memory Support Programs and Services, revised February 2015, was provided by the director or nursing (DON) on 5/22/24 at 5:53 p.m. It read in pertinent part, The facility's memory support program or services operates under a person-centered model, with emphasis on the whole person. This model recognizes that all persons have physical, social, emotional, intellectual, occupational and spiritual needs, regardless of their level of cognitive function. Activity-focused living recognizes that all aspects of the residents'- anything they do or are involved with - are their activity at that moment. Activities, either individual or in groups, create a purposeful use of time and are adapted from tasks the residents would be doing if they did not have dementia. Memory support programs engage residents in cognitive, physical and psychosocial activities that focus on abilities, not limitations. The Activities Programs policy, revised 8/2/23, was provided by the corporate consultant (CC) on 5/23/24 at 3:53 p.m. It read in pertinent part, Varied activities will be planned and routinely scheduled. Activities will focus on the following: -To stimulate socialization and encourage fell owship; -To help maintain muscle tone and coordination; -To encourage and provide opportunities for mental functioning; -To provide sensory stimulation; -To reduce isolation, build self-esteem and strengthen coping capabilities and identity; -To provide entertainment; and, -To strengthen existing spiritual tenets and to provide an opportunity to express individual beliefs. II. Observations On 5/20/24 at 10:00 a.m. an informational video about bees was being played in the common area of the memory care unit. There were five residents in the common area during the activity and Resident #66 was sitting hunched over the counter by the common area. -However, four of the residents were asleep in recliners during the activity and Resident #66 was asleep at the counter. A continuous observation was conducted on 5/22/24, beginning at 3:00 p.m. and ending at 5:28 p.m. The following observations were made: At 3:00 p.m. six residents were observed in recliners in the common area with a movie playing on the television (TV). Resident #6 and Resident #66 were sitting in the dining room without staff interaction. At 3:30 p.m. Resident #66 and Resident #6 were still not being interacted with by the staff. Activity aide (AA) #1 sat in the common area watching the movie. Resident #66 was hunched over the kitchen counter and Resident #6 was looking for her money. At 3:42 p.m. AA #1 offered to paint a female resident's fingernails. AA #1 did not interact with the other residents. A resident was having some difficulty and Resident #6 was becoming agitated and concerned for the other resident. -Certified nurse aide (CNA) #5 told Resident #6 the female resident was okay but no one offered Resident #6 an activity or redirection. At 4:00 p.m. the residents were being moved to the dining room for dinner. At 4:35 p.m. CNA #5 said dinner was usually late and the residents were restless by the time the meal arrived on the unit. At 4:48 p.m. the meal cart arrived at the unit. Two male residents had left the dining room and went to their bedrooms because dinner was taking too long to arrive. Resident #6 was becoming agitated while waiting for dinner and said someone stole my money. At 4:59 p.m. cook #3 started serving meals after returning from the main kitchen. The unit staff tried to keep the residents at the tables for dinner. On 5/23/24 at 10:30 a.m. Resident #66 was sitting in the dining room, four residents were asleep in the recliners in the common area and one resident was watching the movie playing on the TV. Staff interactions were not provided because there were only two staff members on the unit at the time. III. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included mild dementia. The 3/6/24 minimum date set (MDS) assessment documented Resident #6 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. Resident #6 experienced hallucinations, delusions, physical behavioral symptoms and behavioral symptoms not directed at others including wandering. B. Record review Resident #6's behavioral care plan, revised 8/22/23, documented the resident had a severe cognitive loss. Interventions included keeping the resident separated from Resident #66 as much as possible with direct staff supervision if they were in the common area together, offering crafts and one-on-one time, offering crafts and religious shows on TV, offering to go outside when she was agitated, offering her to read her bible and coloring, offering sweet treats, tea, juice, water and soda, approaching the resident in a calm manner and documenting behaviors and resident's response to interventions. Resident #6's mood care plan, revised 6/26/23, documented the resident experienced an alteration in feelings of well-being and hallucinations that altered her mood. Interventions included approaching the resident warmly and positively, identifying the resident's interests and involving the resident in meaningful activities. Resident #6's dementia care plan, revised 4/4/23, documented she had mild dementia without behavioral disturbances. Interventions included approaching the resident in a calm, slow manner and reapproaching at a later time as needed, keeping daily routines consistent with the same repetition to promote memory cueing, keeping the environment constant and items in reach and providing activities or recreation of resident's choice and praising efforts when tasks were completed. Resident #6's activity and life enrichment care plan, revised 9/19/23, documented the resident had interests and preferences in activities that she wished to continue for as long as possible. Interventions included 7 Day Adventist, Bible study was important to the resident and, incorporating this into her plan providing the resident with her interests which included books and magazines, country music, movies, sitting in the day room, her own room and spending time outdoors, familiarizing the resident with the facility environment and activity programs regularly and providing the resident with independent activities of reading, writing and computer use, assisting only as needed. -However, the facility failed to update Resident #6's care plan with effective interventions to prevent resident-to-resident abuse and behaviors following a resident to resident altercation with Resident #66 on 5/6/24. (Cross-referenced F600: failure to prevent abuse) -Additionally, the facility failed to provide Resident #6 with meaningful activities as care planned (see observations above). IV. Resident #66 A. Resident status Resident #66, age 78, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included dislocation of the right shoulder, dementia with other behavioral disturbances and adjustment disorder with depressed mood. The 4/3/24 MDS assessment documented Resident #66 had a servere cognitive impairment with a BIMS score of two out of 15. Resident #66 experienced hallucinations, physical behavioral symptoms, verbal behavioral symptoms and behavioral symptoms not directed toward other people including wandering. Resident #66 put herself and other residents at significant risk for physician injury, her behaviors interfered with the resident's care, interfered with the resident's participation in activities or social interactions and potentially put Resident #66 at risk for wandering into a dangerous area or situation. B. Record review Resident #66's dementia care plan, initiated 3/7/24, documented the resident had dementia, unspecified severity of dementia with other behavioral disturbances. Interventions included keeping a daily routine consistent with the same repetition to promote memory cueing, keeping the resident's environment constant and items in reach, providing activities or recreation of the resident's choice and praising efforts when tasks were completed. Resident #66's behavioral care plan, initiated 3/11/24, documented the resident's target behaviors included agitation, angry outbursts, crying, restlessness, sadness, throwing items, yelling, hallucinations and paranoia. Interventions included providing one-on-one activities such as crafts, keeping the resident separated from Resident #6 as much as possible with direct staff supervision if they were in the common area together, offering coffee and soda to the resident as well as sweet snacks, redirecting the resident and reapproaching the resident after a few moments, removing the resident from a high-stress area or common area, taking the resident outside to calm her down, turning on sports on the television (TV) as she enjoyed golf and softball, approaching the resident in a calm manner, not arguing with the resident, documenting behaviors and the resident's response to interventions and talking with the resident in a calm voice when behavior was disruptive. Resident #66's activity and life enrichment care plan, revised 3/12/24, documented the resident had interests and preferences in activities that she wished to continue for as long as possible. Resident #66 was prone to behaviors of hitting and being disruptive during the day. Interventions included during behaviors resident will be taken to a quiet area and redirected to decrease behaviors, giving the resident the opportunity to express opinions of activities attended, giving the resident verbal reminders of activity before the commencement of activity, posting personal activity schedules in the resident's room, providing the resident with group activities and transporting the resident to activities. -However, the facility failed to update Resident #66's care plan with effective interventions to prevent resident-to-resident abuse and behaviors following a resident-to-resident altercation with Resident #6 on 5/6/24. (Cross-reference F600: failure to prevent abuse) -Additionally, the facility failed to provide Resident #66 with meaningful activities as care planned (see observations above). (Cross-reference F600: failure to prevent abuse) V. Staff interviews CNA #5 was interviewed on 5/23/24 at 4:25 p.m. CNA #5 said the staff provided activities but some days were crazier than other days. CNA #5 said with a resident constantly up and down the staff relied on the activity aide (AA) scheduled on the unit. CNA #9 was interviewed on 5/23/24 at 4:30 p.m. CNA #9 said staff tried to provide activities but right before and after dinner it was hard to complete activities. AA #1 was interviewed on 5/23/24 at 4:35 p.m. AA #1 said she was assigned to the memory care unit as the unit's AA. She said most of the residents slept during the movie so she waited around until there was an activity to do and that was why she offered to paint a female resident's nails. AA #1 said after she painted the resident's nails she waited for dinner to be served. Registered nurse (RN) #2 was interviewed on 5/23/24 at 4:38 p.m. RN #2 said the AAs provided activities to the residents and it was the AAs responsibility. RN #2 said that was the reason an AA was assigned to the unit. The memory care coordinator (MCC) was interviewed on 5/23/24 at 11:05 a.m. The MCC said the nursing staff needed to provide activities to the residents, not just the AAs. The MCC said during the day when she worked on the unit the staff provided a lot of activities. The MCC said she wondered if the evening shift provided activities when she was not there. The MCC said she needed to provide more supervision to the evening shift because she noticed residents had more behaviors, falls and resident-to-resident interactions in the late afternoon to early evening. The MCC said a lack of activities for the residents with dementia led to more problematic behaviors because they had nothing to do. The MCC said she was planning on working with the activity director (AD) to get some tailored activities for the memory care unit. The AD was interviewed on 5/23/24 at 1:44 p.m. The AD said she planned the activities on the memory care unit but received input from the MCC. The AD said the AA assigned to the unit was supposed to provide activities all day long, whether it was one-on-one or group activities. The AD said she was unaware the residents were not offered activities and were just left to sleep in the recliners. The AD said not interacting with the residents was not okay and she was going to discuss it with AA #1. The DON was interviewed on 5/23/24 at 2:11 p.m. The DON said the facility's management team was trying to approve an AA position on the memory care unit that worked directly under the MCC. The DON said the AAs rotated who covered the memory care unit so they did not know the residents as well as an AA who was permanently assigned to the unit. The DON said the memory care unit and residents needed an AA who worked well on the unit and management was hoping to find someone.

Based on record review and interviews, the facility failed to provide adequate respiratory care for one (#1) of three sample residents. Resident #1 used a noninvasive positive-pressure ventilation system to improve oxygenation when he moved into the facility on the afternoon of 5/14/23. However, the facility failed to ensure Resident #1's noninvasive positive-pressure ventilation was applied, his oxygen concentrator was operating properly and his vital signs were checked. As a result, on the morning of 5/15/23, nursing assessment revealed Resident #1's oxygen saturation levels were reduced to 74% and Resident #1 had difficulty breathing, requiring treatment at the local hospital emergency room . The resident was in distress when arriving at the hospital and for two hours after his arrival at the hospital. Facility failures to monitor vital signs, ensure the resident's physician-ordered respiratory equipment was applied and his oxygen concentrator was properly functioning contributed to the resident's need for emergency room treatment. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/8/23, resulting in the deficiency being cited as past noncompliance with a correction date of 5/19/23. I. Facility policies The Noninvasive Positive-Pressure Ventilation (NIPPV), Respiratory Therapy policy, dated 11/28/22, provided by the corporate nurse on 6/8/23 at 5:15 p.m. included: The NIPPV provides ventilatory support without an invasive endotracheal airway. The main goals of NIPPV are to improve oxygenation, decrease the work of the respiratory muscles, and relieve dyspnea while avoiding endotracheal tube insertion. Patients who may benefit from NIPPV include those with exacerbation of chronic obstructive pulmonary disease, heart failure, pulmonary edema, acute hypoxemic respiratory failure, or obstructive sleep apnea as well as patients with respiratory distress who are immunocompromised. The Bilevel Positive Airway Pressure (BiPAP) Use policy dated 11/28/22 included: BiPAP is a noninvasive positive-pressure ventilation mode that delivers inspiratory and expiratory positive airway pressure as the patient breathes. Used to improve oxygenation or ventilation or to prevent airway obstruction during sleep. II. Resident status Resident #1, age 68, was admitted on [DATE] with diagnoses including acute and chronic respiratory failure and emphysema. He was discharged home on 6/3/23. No minimum data set (MDS) assessment was available due to Resident #1's short stay in the facility. III. Facility investigation regarding failure to provide respiratory care started on 5/15/23 Review of the facility investigation revealed Resident #1 went to the emergency roiagnom on [DATE] to be evaluated for shortness of breath and low oxygen saturation the morning after he was admitted . It was discovered he did not wear his BiPAP the night before as licensed practical nurse (LPN) #1 forgot to put it on the resident. No vital signs were taken on night shift prior to change of shift and the event leading up to the ER visit. The resident during interview by the facility stated he did not wear the BiPAP during the night and that the night nurse (LPN #1) said he would come back in to put it on resident when he was ready for bed but that the nurse never came back in to put it on. LPN #1 during an interview by the facility said he spoke with the resident about wearing the BiPAP and the resident wanted to wait until about 1:00 a.m. to put it on because he wanted to stay up and watch a hockey game on television. The nurse said he forgot to go back in to put the BiPAP on. The nurse stated that every four hour vital signs were not done on this new resident per facility policy but did not realize they were not done by the certified nurse aide (CNA) until he was completing his charting at the end of his shift. The nurse (LPN #2) assigned to Resident #1 for the following day shift was interviewed by the facility and said: At 6:50 a.m. it was reported to her by the CNA caring for the resident that the resident said he had a hard night and it was difficult for him to breathe. Oxygen saturation levels were at 74% (normal range 95-100%), nebulizer treatment was given, the head of the resident's bed was elevated and the resident's condition was reported to the unit manager registered nurse. The registered nurse unit manager (UM) received report from LPN #2 that Resident #1 was in respiratory distress, nebulizer treatment was given and the head of his bed was elevated. After the nebulizer treatment, Resident #1's oxygen saturation went up to 90% and then started to decline. The BiPAP was removed and Resident #1 was placed on a non-rebreather mask with increased oxygen liter flow which increased his oxygen saturations to 88%. Emergency medical services (EMS) was called and the resident was transported to the emergency room for evaluation. Documentation review revealed Resident #1's vital signs were not documented every four hours for the first 24 hours per facility policies and procedures for newly admitted residents. Physician orders for Resident #1 to wear his BiPAP while sleeping were not followed. The resident returned to baseline respiratory status while in the ER. The facility investigation further revealed the oxygen concentrator in use for Resident #1 was not working properly. A respiratory therapist from the oxygen company used by the facility helped problem-solve the desaturation of the resident's oxygen while on the BiPAP and found that the BiPAP mask had a tear and that the oxygen concentrator needed to be serviced as it was putting out a lower amount of oxygen than what it was set for. There was an alert on the oxygen machine that indicated service was needed. The facility's conclusion was the resident's ER visit quite likely was due to the fact that the oxygen concentrator was not functioning correctly. Facility actions after the investigation were documented as follows: A new BiPAP mask was obtained along with a secondary mask in the event of mask failure on 5/15/23. The resident wore a pulse oximeter overnight to show oxygen saturation at all times with an alarm that would sound if oxygen saturation went below a pre-set percentage so staff could intervene immediately. The nurse was suspended 5/15/23 during the investigation and re-educated and given a corrective action on 5/19/23 for not following a physician order and for not following facility policy and procedures. The oxygen concentrator and BiPAP mask were replaced. All nurses were educated on use of the BiPAP and mask for Resident #1 specifically. Re-education regarding facility protocol on every-four-hour vital signs on all new admissions for the first 24 hours. Education to all nursing staff on alerts indicating service needed on the oxygen concentrators in use in the facility and to change them out promptly if service was indicated as of 5/19/23. LPN #1 was suspended during the facility investigation and given a written warning on 5/19/23 regarding failure to perform assigned duties in an appropriate manner or at assigned times, and poor work quality or productivity. Supervisory comments documented LPN #1 failed to closely monitor a newly admitted resident on the rehabilitation hall who was admitted with respiratory concerns and did not follow physician orders for supportive respiratory interventions. Corrective action for LPN #1 included monitor all new residents to the facility assigned to his care in a timely manner and according to (facility) policies and procedures as well as what is expected within the scope of practice for his nursing license. He will make sure all vital signs are completed per protocol and will make sure all supportive equipment to maintain respiratory status are utilized per physician orders. Failure to do so will lead to further corrective action up to and including termination of employment. LPN #1 and the director of nursing (DON) signed the corrective action worksheet on 5/19/23. IV. Record review Resident #1's care plan, initiated 5/14/23 and revised 5/23/23, identified alteration in respiratory maintenance and required NIV (non-invasive ventilation) therapy for optimal saturation during 4-6 hours of sleep. The respiratory therapist was responsible for NIV settings: non-invasive ventilation, and the RT's (respiratory therapy) office and cell phone numbers were listed. Approaches were: NIV care every shift, NIV disinfecting per infection control policy, 02 (oxygen) at 6 LPM (liters per minute) with use of NIV when asleep 4-6, while awake titrate 02 sat with goal of 88-92%, resident wears nasal cannula with oxygen between 4-6 liters with NIV mask with foam edges over nose and mouth, ensure tight seal with NIV, ensure that NIV does have water in humidifier and that heater is on, the RN (registered nurse) or LPN is responsible for placing the resident on the NIV at bedtime per the MD/NP (medical doctor/nurse practitioner) order. Physician orders dated 5/14/23 documented oxygen at 6 liters per minute with use of trilogy (NIV) when asleep 4-6 liters while awake to titrate oxygen saturation with goal of 88-92% every shift. Nursing progress notes on 5/14/23 at 3:30 p.m. revealed Resident #1 was admitted from an acute care hospital after treatment for COPD exacerbation. He was alert and oriented times four (to person, place, time and event). He used a BiPAP at night, 4-6 liters of oxygen per minute and try to maintain oxygen saturation levels at 88-92%. He does not have a lot of lung tissue left. Works hard to breathe. On 5/15/23 at 10:24 a.m., a change of condition note documented the resident was sent to the ER after assessment revealed low oxygen saturation of 74% on 6 liters of oxygen. His breathing was labored, cyanosis present, accessory muscle use and difficulty speaking more than two words. The hospital emergency room report dated 5/15/23 at 7:50 a.m. documented Resident #1 arrived by ambulance with dyspnea (difficult, labored breathing) and history of COPD. This started last night and is still present. The dyspnea is described as moderate and is worsened by exertion. The patient was discharged from the hospital yesterday to the facility, and was supposed to be on BiPAP and was not put on it last night. He was found to be hypoxemic this morning. The physician documented it was very self-explanatory that he required more oxygen than he got last night. The (nurse) said she is not sure if the 02 machine is working properly. On x-ray he does have a possible atelectasis (partial collapse of a lung) versus infiltrate in the left base. He will be treated for COPD exacerbation with azithromycin (antibiotic), Lasix (diuretic to treat edema) and DuoNeb (nebulizer treatment). The hospital plan of care documented Resident #1 was given Azithromycin 500 mg, Lasix IVP (intravenously) 40 mg over two minutes, Solu-Medro IVP 125 mg over three minutes, DuoNeb nebulizer treatment 1 unit dose given. After treatment the patient's distress was still present but improving, and documented as calm and resting quietly his oxygen saturation level was 92% on a nasal cannula at 4 liters per minute with no pain at 10:00 a.m. (two hours after his admission to the ER). Facility nursing progress notes revealed Resident #1 returned to the facility from the ER later on 5/15/23 although the exact time was not documented. He was encouraged by nursing staff to call the nurse before taking naps or falling asleep so nurse can place machine on resident. Resident #1 was discharged to his home with his family and medical equipment on 6/3/23. V. Interviews and facility follow-up Interviews with the nursing home administrator (NHA) and director of nursing (DON) between 2:30 p.m. to 4:30 p.m. on 6/8/23 revealed the quality assurance and process improvement committee had not met yet that month and they would review the incident and the facility's response in their upcoming meeting to avoid recurrence.The DON said there was only one current resident in the facility who had similar respiratory equipment, a BiPAP, which she administered herself and used independently. Follow-up interview with Resident #2 on the afternoon of 6/8/23 revealed she used her BiPAP independently and had done so for the past seven or eight years, since she had moved into the facility. She had no concerns. The RN/unit manager was interviewed on 6/8/23 at 4:00 p.m. She reiterated what had occurred with Resident #1 as documented above on 5/15/23. She said the respiratory therapist came in after Resident #1 returned from the hospital and assisted the facility with training the nurses on the rehabilitation unit. She said they involved the CNAs in the training so they would be aware, although they would not touch the BiPAP/NIV machines. They were told if the machine alarmed, to get the nurse immediately. She said the DON gave LPN #1 the training one-on-one at the same time. LPN #1 was not working at the time of the survey and was not interviewed. The director of nursing (DON) was interviewed on 6/8/23 at 4:30 p.m. She said Resident #1's respiratory equipment was called a non-invasive ventilator, which works the same way as a BiPAP or CPAP (continuous positive airway pressure). She said the respiratory therapist did the changing of filters and settings, all maintenance and care. The DON said the oxygen concentrator may have contributed to Resident #1's respiratory concerns and the nurses were educated on checking for warning lights and alarms. She said she had reported and investigated the incident with Resident #1 as neglect. She said they did not substantiate that LPN #1's treatment of Resident #1 was neglectful, but that LPN #1 had not followed physician orders, facility policy and nursing standards of practice. She reiterated the details of the investigation above, stating the facility suspended LPN #1 pending investigation, provided follow-up training for LPN #1 and the nurses and CNAs on the rehabilitation unit and LPN #1 received corrective action and training.

Based on observations, record review and interviews, the facility failed to ensure effective preventive interventions to prevent pressure injuries for one (#13) of four residents reviewed for pressure injuries out of 23 sample residents. Resident #13 admitted to the facility with diagnosis of hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) and was identified by assessment to be at high risk for developing pressure injuries. The resident required extensive two-person assistance with bed mobility, transfers, toileting, and bathing. The facility failed to ensure preventative interventions were implemented which resulted in the resident sustaining a facility acquired unstageable pressure ulcer to Resident #13's foot. These failures led to the resident experiencing tenderness and pain in his left foot. Findings include: I. Professional reference The NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel, was retrieved on 11/28/22 at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility policy and procedure The Prevention and Treatment of Skin Breakdown policy, revised July 2018, provided by the health information manager (HIM) on 11/17/22 at 5:44 p.m. read in pertinent part, It is the policy of (facility corporation) to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventive measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. III. Resident #13 A. Resident status Resident #13, age 79, was admitted on [DATE]. The November 2022 computerized physician orders (CPO) included diagnoses of epilepsy, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and iron deficiency. According to the 7/13/22 minimum data set (MDS) assessment the resident scored a 12 out of 15 on the brief interview for mental status exam indicating the resident's cognition was moderately impared. The resident required extensive two-person assistance with bed mobility, transfers, toileting, and bathing. The resident utilized a wheelchair for mobility. The resident was at risk for pressure ulcers and the resident's skin was intact. According to the 10/12/22 MDS the resident was at risk for pressure ulcers and had an unstageable pressure ulcer with applications of dressings to the residents feet. B. Resident interview Resident #13 was interviewed on 11/16/22 at 9:25 a.m. He said the wounds to his feet did not currently cause him pain. He was unsure of how he got them. (The resident was a poor historian.) IV. Record review The skin care plan, initiated 12/16/19 and listed as revised with no date, identified the resident was at risk for skin breakdown due to dry skin and high braden score (an assessment indicating pressure ulcer risk). The resident was identified with current unstageable pressure injuries to the plantar surface of the left foot. Interventions included, but not limited to: -Position resident's body with pillows/support devices, protect bony prominences (initiated 11/14/22); -Elevate heels off the bed to maintain pressure relief (initiated 11/14/22); and -Lift do not slide resident/use assistive devices to decrease skin friction (initiated 11/14/22). -The care plan interventions related to pressure relief of the resident's foot were not initiated until 11/14/22 (during survey). Physical therapy (PT) notes showed Resident #13 was on PT service from 7/27-8/5/22. The resident was noted to have increased trunk weakness and a flexed posture in the current wheelchair with inability to correct posture at times without assistance, making it more difficult for the resident to feed himself, swallow, or participate in activities of choice. Resident goals were to improve posture and comfort in wheelchair for resting and allowing resident to participate in activities with less pain and fatigue. There were no specific notes related to changes made to the resident's wheelchair positioning. A nurse's note dated 8/18/22 at 6:22 p.m. showed the resident was experiencing increased 3-4+ edema (water retention) bilaterally to his lower extremities. The on call provider was notified and a follow up appointment was recommended at the clinic the following morning per the resident's preference. A provider note (nurse practitioner) dated 8/19/22 showed the resident was seen in the clinic for increased edema and foot pain. It was noted the resident was complaining of pain to his right foot on the bottom described as constant and dull. He was wearing shoes that were not fitting him given his foot swelling. A weekly nursing skin check dated 9/13/22 showed the resident had no identified skin issues. An incident review dated 9/20/22 at 10:20 a.m. showed the certified nurse aide (CNA) had notified the nurse of a newly identified skin condition. The nursing narrative and assessment read, noted to balls of bilateral feet were darkened areas purple in color. Resident complains of pain while sitting up in the wheelchair with shoes on and feet in pedals. Increased pressure on bottom of feet due to pedals being shortened by therapy to promote better positioning may be cause of the discoloration to sites. The resident was noted to have 3+ pitting edema to the lower extremities. A nurses weekly wound documentation form dated 9/21/22 showed the initial data collection for newly in house acquired pressure injuries. A suspected deep tissue pressure injury was identified to the ball of the left foot measuring 2.0 x 1.8 centimeters (cm) (no depth available). A narrative description of the documentation read in part: Lateral edge of ball of left foot, deep purple in color with ridge of induration surrounding. Also noted is a lighter purple discoloration to the middle ball of foot measuring 2.8 cm x 1.6 cm. This looks more like bruising than a pressure area, however could turn out to be pressure as well. Resident wears tennis shoes that fit well while up in wheelchair but shoes/feet are longer than the footrest on the wheelchair at about the position of the discolored areas. Right foot also has some discoloration versus light bruising. Resident states the left foot is tender on palpation but denies pain or discomfort to the right foot. Therapy recently did an evaluation for wheelchair positioning as resident was leaning forward (hunched over) in wheelchair due to poor trunk control making it difficult for him to sit comfortably in the wheelchair and be able to sit up at the dining room table to eat or join in activities. Per therapy, the wheelchair leg rests and pedals were shortened to tilt hips back and help with trunk positioning to lean resident back instead of being hunched over. This may be an unintended consequence of the repositioning as it has increased the pressure to the bottom of resident's feet due to having the wheelchair pedals shorter. Resident to be up in wheelchair for meals and short activities only, with rest in between in his recliner. Resident is ok with new plan of care to be spending more time in the recliner than in wheelchair. -Weekly wound nurse assessments were completed weekly through time of survey. A nurses note on 10/18/22 showed the facility applied new devices for the resident to ensure less pressure on the feet. The resident stated that it seemed like they helped and hurt less, but still was having some pain and he asked to go to bed early to rest. The first mention of the foam pressure reducing devices was in a wound progress note on 10/19/22. -The resident had Prevalon boots implemented prior to 10/18/22, which were ineffective at healing the foot wound (see staff interviews below). The most recent weekly wound documentation dated 11/16/22 (during survey) showed the progression of the resident's wound. The wound was identified as an unstageable pressure injury to the ball of the resident's left foot measuring 1.0 x 1.0 centimeters. A narrative description of the area read: Suspected deep tissue injury now converted to an unstageable pressure wound that is located on the plantar surface of the left foot. This wound is noted at the medial aspect of the foot. This wound is noted to have stable eschar (dark scab, dead skin) that is flush with the surface of the foot, not raised. Wound is now noted to be soft underneath with light palpitation, the peri wound and surrounding tissue now soft to palpation. There is no noted warmth to the wound nor surrounding tissue, no drainage or signs/symptoms of infection. Wound painted with skin prep in two layers, and then left open to air. Foam pressure reduction devices are in place when in wheelchair. There is pressure sufficient pressure reduction. Resident is noted with 1+ edema in bilateral lower extremities. Historically therapy did an evaluation for wheelchair positioning as the resident was leaning forward in wheelchair due to poor trunk control making it difficult for him to sit comfortably in wheelchair and be able to sit up at dining room table to eat or join activities. Per therapy the wheelchair leg rests and pedals were shortened to tilt hips back to help with trunk positioning to lean resident back instead of being hunched over. This may be an unintended consequence of the repositioning as it increased the pressure to the bottom of resident feet due to having the wheelchair pedals shorter. V. Observation Resident #13's wound was observed on 11/16/22 at 9:25 a.m. The wound was intact with stable eschar to the surface. There were no signs or symptoms of infection. The resident denied pain with wound care. The wound was noted to be an unstageable pressure injury to the plantar surface of the foot. VI. Interviews CNA) #18 was interviewed on 11/16/22 at 10:19 a.m. She said she had worked Resident #13's hall for a long time and was familiar with the resident. She said his feet had swelled up bad to the point his shoes were not fitting him. She said when that happened they had some sort of pressure relieving boots on his feet so they were not directly against the metal pedals of the wheelchair, but when the wounds appeared they began using the foam pressure relieving boots he was using currently. CNA #10 was interviewed on 11/16/22 at 2:07 p.m. She said Resident #13 was in regular shoes when his feet were so swollen and he had compression stockings on at that time. She said his feet were just ballooning up and they had to take off the compression stockings. She said when the facility identified the skin breakdown they put him in some air boots at first, but the air boots were not working for him so that was why he was put in the foam boots (applied 10/18/22). Licensed practical nurse (LPN) #8 was interviewed on 11/17/22 at 11:40 a.m. She said there had been some changes to his care since his feet swelled up as he used to just wear tennis shoes. She said she thought because of the edema, the tight fitting shoes, and the wheelchair pedals being shortened was what caused his skin breakdown. Nurse manager (NM) #3 was interviewed on 11/16/22 at 4:05 p.m. She said Resident #13 had 4+ edema to his feet prior to the wounds, which they sent the resident to the provider's office to be treated. She said his shoes were not able to fit at that time. She said the increased edema, weight, and repositioning of the foot pedals due to his poor trunk control was the perfect storm scenario that caused the skin breakdown. NM #1 was interviewed on 11/16/22 at 4:05 p.m. She said the Prevlon air boots they had the resident in when his feet were swollen were not sufficient for the weight of his feet with all the edema as they were bottoming out. She said they tried other interventions such as not using a footrest in his wheelchair but Resident #13 kept sliding down in the wheelchair. She said they finally ordered the foam boots (applied 10/18/22) he was using now, and there was a request to have the resident fitted for a custom wheelchair. The director of nursing (DON) was interviewed on 11/16/22 at 4:05 p.m. She said increased edema causes more skin breakdown and the increased weight did not help. She said she thought due to the resident's increased foot weight with edema, the pedals being shortened for positioning, and the Prevalon air boots to be the cause of the skin breakdown. She said he was doing better with the foam boots he was in now. The therapy director (TD) was interviewed on 11/17/22 at 12:12 p.m. She said she was seeing Resident #13 for poor trunk control and wheelchair positioning due to increased weakness of the resident. She said she had made some changes to his wheelchair, but it was three weeks after that when his feet swelled up. There were no adverse changes from the wheelchair positioning prior to his feet swelling up, and she attributed the wounds to the increased weight from the edema.

Based on interviews and record review, the facility failed to ensure six (#8, #111, #53, #52, #25 and #51) of eight residents reviewed were free from abuse, neglect and mistreatment out of 23 sample residents. Specifically, the facility failed to ensure: -Resident #8, who was dependent on staff assistance, was free from mistreatment involving rough transfers, and verbal/mental abuse after reporting mistreatment; -Resident #111, who was dependent on staff assistance, was free from neglect when requesting assistance from staff who refused to provide the assistance; -Resident #53, who was dependent on staff assistance, was free from verbal/mental abuse during dining; -Resident #52, who was dependent on staff assistance, was free from physical resident to resident altercations; -Resident #25, who was dependent on staff assistance, was free from physical resident to resident altercations/abuse; and, -Resident #51, who was dependent on staff assistance, was free from physical resident to resident altercations/abuse. Facility failures to ensure residents were free from abuse/neglect contributed to Resident #8 feeling that she was flung around like a rag doll during transfers which caused her severe pain; and Resident #111 experiencing incontinence, and feeling that staff did not care for her and that she was treated like an animal. Findings include: I. Facility policy The Resident/Client Protection Freedom from Abuse, Neglect, and Misappropriation policy, revised 11/3/22, was provided on 11/17/22 at 3:00 p.m. by the director of nursing (DON). The policy provided in pertinent part: Each individual has the right to be free from verbal, physical and mental abuse, mistreatment and neglect. It is the responsibility of everyone to prevent abuse: -Provide residents with information about how and to whom to report concerns; -Create an atmosphere of reporting without fear of retribution; -Give feedback regarding complaints and concerns following concern and problem resolution policy (if a complaint is made, going back and asking resident if the situation is resolved). II. Resident #8: mistreatment and verbal/mental abuse A. Resident status Resident #8, under age 70, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), pertinent diagnoses included convulsions, acute and chronic respiratory failure with hypoxia, muscle weakness, hemiplegia (paralysis following stroke) affecting left dominant side, dyspnea (difficult or labored breathing), and history of falling. The 9/14/22 minimum data set (MDS) assessment documented Resident #8 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15, with no behavioral symptoms or rejection of care. Her mood severity score was eight out of 27, indicating mild depression. She needed extensive two-plus-person assistance with bed mobility, transfers, dressing and toilet use. She had occasional bladder incontinence and was continent of bowel, with no toileting program. She was transferred with a mechanical (sit-to-stand) lift and used a wheelchair for ambulation. Resident #8's care plan had no evidence of false allegations against staff. However, the care plan documented she was vulnerable because of her diagnoses and extensive care needs. B. Resident interview Resident #8 was interviewed on 11/14/22 at 11:45 a.m. She said certified nurse aide (CNA) #9 was sometimes abrupt, rough and rushed when assisting her with care, particularly during transfers. Resident #8 said CNA #9 would respond to her call light, come into her room and say, What do you want? Resident #8 said that when CNA #9 assisted her during transfers she felt like she was being tugged like a rag doll. She said, I can't move very well and they have to put me in the sit to stand lift. They hook me up so fast and they're talking to each other and flinging my shoulders forward and my oxygen is pulling my nose and it's a little fast for me. I feel like I have no control. It's kind of rough. I want to say stop, slow up. Resident #8 said she had a cyst in her back and if staff were not careful using the sit-to-stand lift, it yanks my back and legs and that hurts, and sometimes caused her severe pain. She said she had once asked CNA #9 if they could settle down with her and she kind of rolled her eyes at her partner CNA (#23). Resident #8 said she did not want CNA #9 to know she reported her because she'll get mad again and be rude or whatever. Resident #8 said she had spoken to her family about these concerns, and they had reported it to staff once or twice but did not recall who, and were going to report the concerns to management, but then the survey started. She said she wanted to continue working with CNA #9, but only if she would be gentle and respectful with her. C. Staff interviews Resident #8's concerns regarding rough treatment during transfers were reported to the nursing home administrator (NHA) and DON on 11/14/22 at 3:30 p.m. They said they were previously unaware and would suspend CNA #9, report to the State Agency and investigate. The DON was interviewed a second time on 11/14/22 at 5:50 p.m. She said she had interviewed Resident #8 who repeated some of the same concerns to her. CNA #9 had been suspended pending investigation. D. Failure to prevent verbal/mental abuse and retaliatory treatment Resident #8 was interviewed a second time on 11/15/22 at 10:12 a.m. She said CNA #3, who worked the evening shift, was hooking her up to the sit to stand lift on the afternoon of 11/14/22 and asked her why she had reported them. She said CNA #3 asked her, Did you talk to State about the way we transfer people or something? Resident #8 told her she had reported a particular person but it did not have anything to do with her. Resident #8 said she felt like CNA #3 asked her point blank and put her on the spot, with an attitude like Why did you do it? We know you did it so don't tell us you didn't. Resident #8 said she was shocked and felt like she was put in a bad position, which felt almost retaliatory. The NHA and DON were interviewed on 11/15/22 at 1:22 p.m. They said nobody except them and the social services director (SSD) knew of Resident #8's allegation of abuse the previous day and it was unacceptable for CNA #3 to have any information about that report, or to confront Resident #8. The DON said CNA #3's actions were totally inappropriate, she wished she had not said it, and she would follow up. CNA #3 was suspended that afternoon. E. Facility follow-up The DON was interviewed on 11/17/22 at 1:22 p.m., and reviewed supporting documentation of the facility investigation. She said they had investigated and returned CNA #9 to day shift duty after counseling and training, under the supervision of nurse manager (NM) #1. She said she talked with Resident #8 who said she wanted CNA #9 to continue providing care for her. The facility management team were conducting retraining on safe mechanical lift use and techniques and communication during care for all nursing staff related to Resident #8 and all residents who needed mechanical lifts for transfers. The DON told Resident #8 she would check in with her the following week, see how things were going, and if she was still comfortable with CNA #9. Regarding CNA #3, who was retaliatory with Resident #8, the DON said she was suspended pending investigation. The DON said at this point looking back at the previous verbal abuse incident (see Resident #53 findings below), verbal/mental abuse was implied and was still not acceptable, so she would more than likely be terminated. It's so soon after the last incident and it's the same implication, making a resident feel like a burden or they're doing something wrong, which is never okay. III. Resident #111: abuse/neglect A. Resident status Resident #111, under age 70, was admitted on [DATE]. According to the November 2022 CPO, pertinent admitting diagnoses included healing fractures to both legs, pressure ulcers to both heels, and epilepsy. The 10/3/22 MDS assessment documented Resident #111 was cognitively intact with a BIMS score of 14 out of 15, and no behavioral symptoms or care rejection. She needed two-plus-person assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She needed a mechanical (Hoyer) lift for transfers and used a wheelchair for ambulation. She was frequently incontinent of bladder and always incontinent of bowel. The care plan, initiated 11/14/22 (during the survey), identified trauma as a focus area due to risk for psychosocial disruption and resident reports that previous stays in a nursing home were traumatic for her. The care plan initiated 11/9/22 also identified vulnerability and various concerns voiced during her stay at the facility, with approaches including: Observe to minimize and prevent reoccurrences. B. Resident interview Resident #111 was interviewed on 11/14/22 at 2:00 p.m. She said CNA #4 had been abusive to her, that it had been happening since Friday (11/11/22), most recently the night before (11/13/22). She said the CNA responded when she rang her call light by saying, What do you want? Resident #111 said she asked for help to the bathroom and the CNA said they were busy and would come back later. Resident #111 said the CNA did not return, so she rang her call light again and the CNA told her, I'm going to lunch. The resident said the CNA did not ensure she received assistance to the bathroom, and she was incontinent as a result. C. Staff interview Resident #111's abuse/neglect allegation was reported to the NHA and DON on 11/14/22 at 3:30 p.m. The DON said they would report, and suspend the staff involved pending investigation. D. Facility follow-up The DON was interviewed on 11/17/22 at 1:22 p.m. She said CNA #4 had been suspended since Resident #111 reported how she was treated by her. The DON said they had some additional work to do but based on Resident #111's interview and CNA #4's interview, they had some additional work to do, and CNA #4 would be terminated. Review of the facility's investigative report revealed Resident #111 reported the allegation as in her interview above, and said because CNA #4 did not assist her, she ended up using the bathroom in her brief and then needed to be changed. Resident #111 reported to the DON that she felt she was treated like an animal. IV. Resident #53: verbal/mental abuse A. Resident status Resident #53, under age 70, was admitted on [DATE]. According to the November 2022 CPO, diagnoses included multiple sclerosis, dysphagia (difficulty or discomfort in swallowing), and functional quadriplegia. The 10/19/22 MDS assessment documented Resident #53 had severe cognitive impairment with a BIMS score of three out of 15. She had no behavioral symptoms or rejection of care. She needed extensive two-plus-person assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She needed extensive assistance with eating. B. Record review Review of nursing notes and a facility investigative report revealed a verbal/mental abuse incident involving Resident #53. A facility staff person had observed CNA #4 telling Resident #53, while assisting her to eat dinner, You need to hurry up. I don't have time for this. CNA #4 received written corrective action as a result. C. Staff interview The DON was interviewed on 11/17/22 at 1:22 p.m. She said CNA #4 was the same CNA who had made verbally/mentally abusive and retaliatory comments to Resident #8 (see Resident #8 findings above). She said CNA #4 received written corrective action after the incident on 10/24/22, and was currently under suspension. V. Facility follow-up The DON confirmed via email on 11/22/22 at 8:00 p.m. that CNA #9 was re-trained/re-educated and supervised, CNAs #3 and #4 had been terminated and no longer worked for the facility, and the State Board of Nursing would be notified as appropriate to each incident. 40467 VI. Resident to resident physical altercation on 9/12/22 A. Resident #52 1. Resident status Resident #52, age 71, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease with late onset, anxiety disorder and major depressive disorder. According to the 11/3/22 minimum data set (MDS) assessment, the resident's cognition was severely impaired. The staff assessment for a mental status indicated Resident #52 had a short and long term memory problem. She exhibited inattention and disorganized thinking. Resident #52 required staff supervision with walking and locomotion on and off the unit. She needed extensive staff assistance from one person for eating. The MDS assessment identified the resident had physical behavioral symptoms directed at others. 2. Record review The 9/12/22 post incident note read Resident #52 had an individual to individual altercation on 9/12/22 at 5:30 p.m. The 9/14/22 interdisciplinary (IDT) post investigation note read the root cause of the resident altercation was because Resident #52 was upset and aggressive towards others. The note did not identify what caused the resident to become upset. The behavior care plan, initiated on 8/23/22, read Resident #52 had escalating behaviors that could be triggered by loud noises and being touched. The care plan directed staff to allow the resident time when upset and approach later. According to the care plan, staff should allow the resident to sit away from the group when over stimulated during activities and meal time. The care plan identified the resident should be approached in a calm manner/calm voice when behavior is disruptive. The vulnerability care plan, initiated on 12/9/21, read Resident #52's staff would remove the resident from potentially abusive situations. According to the care plan, staff should observe for and implement interventions to minimize and prevent reoccurance (of potentially abusive situations.) -Review of Resident #52's care plan did not identify she was involved in a resident to resident altercation or identify new interventions after the 9/12/22 to prevent the recurrence of a resident to resident altercation. B. Resident #25 1. Resident status Resident #25, age over 65, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized anxiety disorder and adjustment disorder with other symptoms. According to the 8/31/22 minimum data set (MDS) assessment, the resident's cognition was severely impaired with a brief interview for a mental status score of five out of 15. Resident #25 required staff supervision with eating, walking and locomotion on and off the unit. The MDS assessment identified the resident did not have behavioral symptoms directed at others. 2. Record review The vulnerability care plan, initiated on 8/31/22, read Resident #25's safety would be protected through staff interventions. According to interventions, staff would remove the resident from potentially abusive situations and implement interventions to minimize and prevent reoccurance (of potentially abusive situations.) -Review of Resident #25's care plan did not identify she was involved in a resident to resident altercation or identify new interventions after the 9/12/22 to prevent the recurrence of a resident to resident altercation. C. Resident #51 1. Resident status Resident #51, age 79, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, serve with agitation, generalized anxiety disorder and major depressive disorder. According to the 10/12/22 minimum data set (MDS) assessment, the resident's cognition was severely impaired. The staff assessment for a mental status indicated Resident #52 had a short and long term memory problem. He exhibited inattention and disorganized thinking. Resident #52 required staff supervision with walking and locomotion on and off the unit. The MDS assessment identified the resident had behavioral symptoms not directed at others. 2. Record review The behavior care plan, initiated 9/8/21, identified Resident #51 could be aggressive and threatening to others. The vulnerability care plan, initiated on 1/6/22, read Resident #51's safety would be protected through staff interventions. According to interventions, initiated on 9/17/21, staff would remove the resident from potentially abusive situations and implement interventions to minimize and prevent reoccurance (of potentially abusive situations.) -Review of Resident #51's care plan did not identify he was involved in a resident to resident altercation or identify new interventions after the 9/12/22 to prevent the recurrence of a resident to resident altercation. D. Facility abuse investigation for the 9/12/22 resident to resident physical altercation allegations of abuse and investigation. The review on the abuse investigation packet, provided by the facility on 11/14/22, identified a physical altercation occurred on 9/12/22 between three residents. The investigation indicated Resident #52 was the assailant in the 9/12/22 altercation and Resident #25 and Resident #51 were the victims. According to witness statements, a certified nurse aide (CNA) was attempting to have Resident #52 sit down and the resident refused. Resident #52 then attempted to take Resident #25's plate of cake. The CNA step in the middle of the two residents and Resident #52 became angry and pushed the CNA. Resident #52 proceeded to hit Resident #25 in the face. Resident #52 continued to push the CNA. According to the statements, Resident #52 remained upset 10 minutes after the hitting Resident #25 and threw a napkin at Resident #51 and hit his arm. The investigation packet indicated Resident #52 was separated immediately from the residents. Her care plan would be updated and staff would be trained to redirect Resident #52 from other residents' personal space and items when upset and offer a quiet/calm space for the resident. Additional interventions included a pharmacy review of her medications. The investigation packet included a staff training form. The training identified the above interventions including staff to monitor what was in the reach of Resident #52 when she was upset so she would not throw items at others. E. Staff interview The director of nursing (DON) was interviewed on 11/17/22 at 11:21 a.m. She said the facility did not substantiate physical abuse regarding the 9/12/22 resident to resident altercation because it did not meet State criteria, the residents were not fearful. The DON said the facility investigated the incident and a physical altercation between the residents occurred on 9/12/22. The DON said she understood the Federal guidelines on what was considered physical abuse (due to the Resident #52's willful actions towards the other two victims). Nurse manager (NM) #2 was interviewed on 11/17/22 at 2:20 p.m. She said she was new to the facility and was unit manager for the memory care unit for the past month. She said she was not aware of a physical resident to resident altercation between Resident #52, Resident #25 and Resident #51. She said wished she was aware of the September 2022 altercation so she would know what behaviors to watch for and what interventions to implement/monitor. NM #2 said she would want to know why the altercation occurred and what were the underlying factors. The NM said she was only aware that there was sometimes frustration between Resident #52 and Resident #51 and Resident #52 sometimes pinched staff during cares. The NM said when Resident #52 became upset, she redirected her with coloring, snacks, and one-to-one attention. She said Resident #52 was receptive to hugs.

Based on resident and staff interviews and record review, the facility failed to ensure dignified, respectful care for two (#8 and #14) of eight residents reviewed out of 23 sample residents. Resident #14 said she did not receive timely assistance from staff for bathing and other care needs, and as a result she felt lonely and disrespected, wanted to go home, and cried a lot. Resident #8 said she sometimes did not receive dignified, respectful care, and as a result experienced bowel incontinence and felt ashamed, embarrassed, mad and aggravated. Findings include: I. Facility policy The Resident's Bill of Rights and Dignity Policy, revised 10/24/22, was provided by the director of nursing (DON) on 11/17/22 at 3:00 p.m. The policy included: The facility must enforce and ensure resident rights are enforced, including the resident has the right to a dignified existence, self-determination, and The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. II. Resident #14 A. Resident status Resident #14, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included spinal stenosis, lumbar region without neurogenic claudication (narrowing of the spinal canal in the lower back), chronic pain, pain in the right hip, anxiety disorder and major depressive disorder, single episode. According to the 10/13/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. The MDS assessment identified the resident required extensive physical assistance of more than two staff with bed mobility, transfers, dressing and toileting. The MDS assessment indicated the resident had periods of feeling down, depressed or hopeless. According to the MDS assessment, the resident had verbal behavior symptoms directed at others. B. Resident interview Resident #14 was interviewed on 11/14/22 at 1:16 p.m. She said she felt disrespected by staff. She said she felt some of the agency staff and some of the regular staff did not treat her with respect and dignity. The resident said she did not feel comfortable revealing the names of the staff. Resident #14 said on days she refused a bath or wanted to reschedule her bathing for another day, some of the staff got pushy telling her she stinks. The resident said staff did not tell her she stinks all the time but often enough for her to remember it. Resident #14 said she often had to wait longer than other residents to receive activities of daily (ADL) care. She said she had been told by staff that they hated coming into her room because once they came into her room, they could not leave. She said she needed a lot of help with her ADL care, positioning, and meal setup. She said she should not be made to wait longer for assistance. She said staff told her she had to be patient. She said it was a horrible feeling to feel lonely and disrespected. She said she wanted to go home and she cried a lot. She said the staff knows about her concerns. (Cross-reference F609, reporting an allegation of abuse.) C. Record review The 10/8/22 nurses note read Resident #14 said I don't want to be here anymore. The note read the nurse reported issues to the resident's cart nurse. The 10/20/22 behavior and mood note read Resident #14 had a behavior of urinating in her brief. According the note Resident #14 soiled her brief because the certified nurse aide (CNA) would not assist her up. The note read the CNA informed the nurse Resident #14 wanted to get up. The nurse finished her lunch and CNA and the nurse entered her room but the resident appeared to sleep. The note read the nurse re-entered the room a short time later to ask why the resident wanted to get up and the resident responded she had to pee but it's too late now. The note read the resident started to yell and continued to be rude to the CNA and the nurse said to the resident that she needed to stop blaming the CNA as we both went back in. According to the note in the resident response to the incident, the resident allowed her brief to be changed and was sulking at this time. D. Staff interviews The social service director (SSD) was interviewed on 11/17/22 at 3:04 p.m. with the social service consultant (SSC). The SSD reviewed the above 10/20/22 behavior note. She said the staff should not have scolded Resident #14 when the resident voiced her concerns. The SSD said residents should be treated respectfully. She said staff should treat residents how they (staff) would want to be treated and how they would want a loved one to be treated. The director of nursing (DON) was interviewed on 11/17/22 at 4:24 p.m. She said all staff were trained to treat residents with respect and dignity. She said all residents should feel they were treated with respect and dignity. The DON said the resident was their customer and the customer was never wrong. The DON said she was not aware of the resident's concerns identified in the 10/20/22 note. She said staff should never blame or chastise a resident. The DON said staff should help meet the resident's needs. The DON said a resident should not feel they did something wrong. The DON said she would be following up with Resident #14's concerns and provide additional education with staff. III. Resident #8 A. Resident status Resident #8, under age 70, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), pertinent diagnoses included convulsions, acute and chronic respiratory failure with hypoxia, muscle weakness, hemiplegia (paralysis following stroke) affecting left dominant side, dyspnea (difficult or labored breathing), and history of falling. The 9/14/22 minimum data set (MDS) assessment documented Resident #8 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15, with no behavioral symptoms or rejection of care. Her mood severity score was eight out of 27, indicating mild depression. She needed extensive two-plus-person assistance with bed mobility, transfers, dressing and toilet use. She had occasional bladder incontinence and was continent of bowel, with no toileting program. She was transferred with a mechanical (sit-to-stand) lift and used a wheelchair for ambulation. B. Resident interview Resident #8 was interviewed on 11/15/22 at 9:45 a.m. and on 11/17/22 at 9:35 a.m. She said she sometimes did not receive dignified, respectful treatment from staff, and mentioned the following concerns: Resident #8 said they woke her up too early in the morning, sometimes as early as 6:00 a.m., and breakfast was not served until 8:00 a.m. She had to sit in her wheelchair for two hours waiting for breakfast, and coffee was not served until 7:30 a.m. And I'm a coffee drinker. She said they told her the kitchen did not have the coffee ready until 7:30 a.m. After breakfast she was tired, and had to try to wheel herself back to her room. She said that sometimes when she needed the bathroom they could not assist her in a timely manner, so she had to sit and wait. She said there were often five or six call lights going off at the same time on her hall, and she sometimes had to wait 30 minutes to an hour for bathroom/incontinence assistance because staff were unable to help her in time. She said she had been incontinent of bowel as a result, and had felt ashamed. She said staff had actually said to her that if they could not get back to her in time, she could just use her brief. It felt really bad to me. I just had to sit in my recliner and make a really big mess. It's bad enough to have to wear a brief as it is. She said it felt especially bad when she had to sit in feces and it got on her clothes and went up her back. If I could've got to the bathroom in time I would have gone in the toilet and wouldn't have messed my clothes. It's hard, it's embarrassing. She said sometimes staff turned their backs on her and walked away from her when she was in the middle of a sentence, which made her think, I guess I wasn't supposed to say anything, they're not interested. Some just turn around and walk out with their back to you. Resident #8 said she also felt mad and aggravated with the treatment she sometimes received from staff. (Cross-reference F600 abuse/neglect). Resident #8 said she had discussed her concerns with her family, who had reported to nursing staff a couple of times, but she did not know which staff her family had spoken to. C. Record review The resident's care plan, initiated 9/14/22, identified vulnerability, preferences and altered continence status. However, there were no person-centered approaches regarding the resident's specific needs in those particular focus areas. There was no evidence of false accusations about staff. Review of the resident's medical record revealed frequent notes documenting that Resident #8's emotional status was appropriate with pleasant demeanor, but she was discouraged that she had an increase in incontinence but feels that she is making improvement in therapy. An activities note on 9/17/22 documented in part, Resident has been quieter than usual this week. She would look away when I would try to talk to her. Today, I went to help in the dining hall. She refused to eat, wouldn't really look at me and didn't want to do anything but go to sleep. -This was out of character for the resident but there was no documentation of staff follow-up with the resident. Nursing notes continued to document that the resident was concerned about episodes of incontinence of bladder, that she was mostly continent of bowel, and the resident said she thought therapy was helping. However, a nursing note on 10/18/22 documented in part, Resident stated that she feels therapy is helping her to decrease incontinence, but she continues to have functional incontinence because she cannot get to bathroom in time because she has to wait for lift. -There was no documentation of staff follow-up to address this concern. D. Staff interview The director of nursing (DON) was interviewed on 11/17/22 at 1:30 p.m. She said residents should be treated with dignity and respect, and their needs and requests should be honored in a timely manner, according to their preferences. She said all nursing staff had walkie-talkies and certified nurse aides (CNAs) were expected to call for assistance from nurses and nurse managers if they could not respond to multiple call lights, and/or could not address resident needs in a timely manner. She said she would investigate Resident #8's concerns and conduct more follow-up training for staff regarding dignity/respect and customer service. 40467

Based on observation, record review, family interview and staff interview, the facility failed to provide sufficient fluid intake to maintain proper hydration and health for one of two residents reviewed for hydration issues (#4) out of 43 sample residents. Specifically, the facility failed to provide proper hydration which contributed to resident #4 being hospitalized for [REDACTED]. According to the integrated progress notes, the first evidence that resident #4 may be dehydrated occurred with her urinalysis on [DATE], showing "possible dehydration." Seventeen days passed before the facility notified the physician and sent resident #4 to the hospital for treatment, upon request by the resident's family. Hospital records showed the resident had become dehydrated, resulting in [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. The care plan was not revised until two weeks after the resident returned from the hospital, and did not identify that the resident was cognitively unable to ask for fluids when she was thirsty. The care plan did not specify how often to offer the resident additional fluids, or the resident's favorite types of drinks and fluids. After the resident returned from the hospital, the facility staff was not observed to be offering resident #4 extra fluids and during most room observations, the resident's water pitcher was out of her reach. Some staff members were not aware of what consistency of fluids the resident was currently ordered. The findings included: A. Professional Reference regarding Hydration According to Mayo Clinic Staff, "Diseases and Conditions: Dehydration", [DATE], <http://www.mayocliniclorg/diseases-condtions/dehydration/basics/defination/con- 056> ([DATE]), "Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated ...Anyone may become dehydrated, but young children, older adults and people with chronic illnesses are most at risk. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. The safest approach is preventing dehydration in the first place ...Anyone can become dehydrated if they lose too many fluids. But certain people are at greater risk, including: ...older adults. As you age, you become more susceptible to dehydration for several reasons: Your body's ability to conserve water is reduced, your thirst sense becomes less acute, and you're less able to respond to changes in temperature. What's more, older adults, especially people in nursing homes or living alone, tend to eat less than younger people do and sometimes may forget to eat or drink altogether. Disability or neglect also may prevent them from being well nourished. These problems are compounded by chronic illnesses such as diabetes, dementia, and by the use of certain medications ...Dehydration can lead to serious complications, including: ...kidney failure. This potentially life-threatening problem occurs when your kidneys are no longer able to remove excess fluids and waste from your blood. Coma and death: When not treated promptly and appropriately, severe dehydration can be fatal ...Treating severe dehydration: Children and adults who are severely dehydrated should be treated by emergency personnel arriving in an ambulance or in a hospital emergency room , where they can receive salts and fluids through a vein (intravenously) rather than by mouth. Intravenous hydration provides the body with water and essential nutrients much more quickly than oral solutions do - something that's essential in life-threatening situations. To prevent dehydration, drink plenty of fluids and eat foods high in water such as fruits and vegetables ...Fluids can be obtained not just from water but also from other beverages and foods." B. Facility Policies regarding Hydration The facility policy #300 entitled "Hydration," dated 2010, noted in pertinent part the following: "Policy: Individuals at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to maintain proper hydration and health. Procedure: Assure that each individual receives sufficient amounts of fluids based on individual need to prevent dehydration and maintain health. 1. Risk factors for dehydration will be identified through continual nursing assessment. Risk factors for dehydration are as follows: Coma/decreased sensorium ... Functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs (e.g. aphagia, dysphagia) ... 2. Clinical signs of possible insufficient fluid intake are assessed through continual nursing assessment: Dry skin and mucous membranes, cracked lips, dry/coated tongue ... thirst and dry mouth, concentrated urine, laboratory values (elevated hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], transferrin, BUN, or urine specific gravity), elevated temperature, and headache ... 4. Fluids may include milk, juice, water, milkshakes, popsicles, ice cream, sherbet, gelatin, etc." Policy #302 entitled "Resource: Additional Recommendations for Promoting Adequate Hydration," dated 2010, noted in pertinent part the following: "1. TAPS: Turn, Align, Position, and Sips (of fluid). When an individual is turned every two hours, offer and encourage fluids at that time. 2. Serve special fluids such as punch, juice, [MEDICATION NAME] beverages, and other special drinks. Assist individuals to drink fluids with and in between meals. 3. Offer fluid with every interaction. 4. Offer additional fluids during medication pass (,[DATE] ounces). 5. Consider a special identifying hydration bracelet for high risk individuals. 6. Place a bright napkin on the individual's tray to identify the need for increased fluid...Get creative. Offer a variety of fluids such as: soft drinks, soup broths, ices popsicles, gelatin, gelatin fingers, milkshakes, etc." Policy #303 entitled "Fluids at the Bedside," dated 2010, noted in pertinent part: "Policy: All individuals will be provided with a fresh supply of water at the bedside unless otherwise medically contraindicated. Those who are unable to request or independently consume drinking water will be offered fluids by the nursing staff at every medication administration, individual contact for care, regularly scheduled snack passes and other times throughout the day ... by nursing and other eligible facility staff unless medically contraindicated as determined by the physician." Policy #304 entitled "Encourage Fluids Order," dated 2010, noted in pertinent part: "1. When the physician orders [REDACTED]. 2. The individual is then placed on "Intake and Output" monitoring so an accurate record can be kept. 3. If the physician orders [REDACTED]. The physician may then order a specific amount of fluid per day. 4. "Encourage fluids" can also be a nursing measure, and the above policy should be followed. 5. The food service department will provide a minimum of 1440 mls fluid on meal trays daily (16 ounces per meal). 6. Water will be provided at the bedside. 7. Nursing will provide additional fluids at medication pass, HS (hour of sleep), and other times throughout the day as needed." C. Resident #4 Resident #4, a [AGE] year-old female, was admitted to the facility on [DATE] and most recently re-admitted on [DATE] following a hospital stay for altered mental status due to severe dehydration and acute [MEDICAL CONDITION]. According to the face sheet, her [DIAGNOSES REDACTED]. Resident Status: According to the quarterly minimum data set ((MDS) dated [DATE], the resident had a BIMS (cognition) score of 1, indicating severe cognitive impairment. -The significant change MDS dated [DATE] noted the resident required extensive assistance of one for eating; extensive assistance of one to two-plus for ambulating in her wheelchair, bed mobility, transfers, dressing, and toileting; and total dependence for bathing. She had a swallowing disorder, including "coughing or choking during meals or when swallowing medications" and "complains of difficulty or pain with swallowing." She received a mechanically altered and therapeutic diet. The Colorado Medical Orders for Scope of Treatment (MOST) form dated [DATE] stated that the resident's niece/medical durable power of attorney requested no CPR (cardiopulmonary resuscitation), and limited additional interventions: "Use medical treatment, IV fluids and cardiac monitor as indicated." Under the section entitled "Artificially Administered Nutrition and Hydration," it stated, "Defined trial period of artificial nutrition/hydration by tube. (Length of trial: one month)." The care plan dated [DATE], identified, "Hydration: risk for dehydration r/t (related to) [DIAGNOSES REDACTED]." The interventions included: "Observe for signs and symptoms of dehydration: Skin turgor, dry mucous membranes, UTI (urinary tract infection), urine out-put, changes in mental status, fever and constipation. Notify physician if signs and symptoms. Provide and encourage fluids at all meals, activities, med passes, and at bedside as allowed per physician. Resident to be reviewed by weight and skin team as needed." The care plan dated [DATE], identified, "Potential for dysphagia, r/t past choking episodes." The interventions included: "Cue resident to lower head when swallowing. Assist her with feeding as needed, r/t [DIAGNOSES REDACTED] of BUE (bilateral upper extremities) on occasion, but allow as much independence as possible within her function eating skills, each meal, daily." The Speech Therapy Evaluation and Plan of treatment for [REDACTED]. It further recommended, "Upright during meals, liquids from a straw, double swallow, alternate liquids/solids, SMALL bites and sips." The resident had no care plan for hydration prior to her hospitalization on [DATE], although her risk factors were essentially the same. Her care plans were not updated until two weeks after her return from the hospital. Although the resident had swallowing problems (see MDS above), there was no evidence a speech therapy evaluation was done until after her hospitalization and treatment for [REDACTED]. Hospital Record Review: The local hospital's emergency department report, dated [DATE], showed that the following tests had abnormal lab values when the resident was first admitted : - Blood urea nitrogen was high at 50 (normal range was ,[DATE]) - Serum creatinine level was dangerously high at 1.40 (normal range was 0XXX,[DATE].99) - Glomerular filtration rate was low at 37 (normal range was >60) - Serum sodium level was critically high at 160 (normal range was ,[DATE]) - Serum potassium level was low at 3.4 (normal range was 3.5 - 5.0) - Serum chloride level was high at 113 (normal range was ,[DATE]) The General Summary Report from the hospital stay of ,[DATE] through [DATE] revealed continuing abnormal lab values as follows: - On [DATE], the glomerular filtration rate was still low at 40, the sodium was still critically high at 159, the potassium was still low at 3.3, the chloride was still high at 117, the BUN was still high at 50, creatinine was still dangerously high at 1.40, and the calcium was still high at 10.3 (normal range was 8.4 - 10.2). - On [DATE], the BUN was still high at 43, the creatinine was still high at 1.10, the glomerular filtration rate was still low at 49, the sodium was still critically high at 156, the potassium was still low at 3.4, and the chloride was still high at 115. - On [DATE], the [MEDICATION NAME] was still low at 3.2. - On [DATE], the creatinine was still low at 0.50. The admission history and physical, dated [DATE], stated in pertinent part, "Chief Complaint: Altered mental status. History of present illness: The patient is a [AGE] year-old female resident of a nursing home, who has been declining over the last several days. She has been less verbally responsive and has had more fatigue ...she was noted to have some urinary symptoms and urinary tract infection was diagnosed ...In the weeks prior to this, she has had some choking episodes that have improved with change in her diet texture. She has been eating and drinking a normal amount as the staff reports ...Her niece noted her to be not speaking at meals today and that she had a tear in her eye. She had last seen her about two weeks ago and at that point was speaking and responding normally, though she had difficulty speaking related to her severe Parkinson disease. The one thing the patient was able to communicate to her niece was that she was somewhat thirsty ...She has a pureed texture and nectar thick liquid diet ...Database: ...Sodium 160, potassium 3.4, BUN 60, creatinine 1.4, and [MEDICATION NAME] 4.6... -Assessment and Plan: ...1. Altered mental status, likely secondary to urinary infection, [MEDICAL CONDITION], dehydration, acute [MEDICAL CONDITION], acute coronary syndrome, and [MEDICAL CONDITION] 2. Urinary tract infection...3. Severe [MEDICAL CONDITION]. Her sodium is 160. This calculates to a 5.3 liter water deficit. We will try to resolve her [MEDICAL CONDITION] to normal sodium of 140 over the next 48 hours. We will give her D5 water at 112 ml/hour. We will check a BMP in six hours to ensure that we are correcting, but not over-correcting her sodium... 4. Acute [MEDICAL CONDITION]. I suspect the patient is dry... 5. Dehydration. She is very dehydrated. I suspect this is secondary to her Parkinson disease, her recent change to nectar thick liquid with dysphagia diet, as well as her inability to make her needs known to drink water. We will hydrate the patient gently and follow her labs closely... 8. Parkinson disease. She has progressive severe Parkinson disease. This is contributing to her altered mental status, as well as her dehydration. This contributes to her poor prognosis. I have discussed this with the family." The hospital progress note dated [DATE] stated in pertinent part, "Sodium 156, potassium 3.4, chloride 115, BUN 43, creatinine 1.1. Assessment and Plan: 1. Altered mental status. This is not significantly improved. Her sodium is not improved enough that I would expect her altered mental status to be normal. If her altered mental status is driven mostly by her urinary infection, I would expect to be improving by now. We will reassess this in the morning... 3. Severe [MEDICAL CONDITION]. Her sodium is down to 156. She is improving slowly, which is just what we want to see. We will continue our current care and reassess her metabolic panel in the morning. 4. Acute [MEDICAL CONDITION]. This is improving. 5. Dehydration. She continues to be dehydrated. We are giving her fluids and she is slowly improving... 8. Parkinson disease. She has severe Parkinson disease. We will see if she recovers from her current insult." The hospital progress note dated [DATE] stated in pertinent part, "The patient is responding better. She is verbalizing some and she is more awake. She is sitting up in a chair... Assessment and Plan: 1. Altered mental status: This is improving. The patient is close to her baseline... 2. [MEDICAL CONDITION] secondary to inability to take in adequate water: This has improved and her sodium is now normal... 4. Acute [MEDICAL CONDITION]: Her creatinine has normalized. 5. Dehydration: This has normalized with fluid resuscitation... She has severe trouble swallowing, and I think this is one of the reasons why she became dehydrated. She is on thickened liquids and these are unpalatable. Perhaps that is why she became dehydrated because they do not taste good. It is also possible she is not being offered sufficient fluids. We can certainly make sure that the nursing office offers her more fluids and perhaps we will take the risk of aspiration and offer her thin liquids so that her beverages are more palatable." The minutes from the discharge meeting conducted [DATE], conducted at the hospital before resident #4 returned to the facility, noted in pertinent part: "Pre-admit Discharge Planning Visit: ...(Niece/medical durable power of attorney's name) expressed concerns about (resident's) condition including dehydration, positioning... Discussed (previous primary care physician's) medical plan of care to treat (resident) at the facility first, evaluate response before sending her to the hospital... Addressed with (current primary care physician) and he accepted as primary care physician... Positioning. Physical therapy did teaching to nursing staff for use of new wheelchair for positioning. Transfer with mechanical lift two person assist with bed pan, bed mobility and repositioning in wheelchair... Dehydration/Food Intake. (Primary care physician) will discuss Advance Care Planning for nutrition/hydration with (resident's niece). (Resident's niece) will now make the decision for (resident) rather than allow (resident) to decide as choking contributed to (resident's) decline and hospitalization . Current diet menu is puree and thickened fluids. (Resident does not like fluids thickened and will not drink them, but she chokes/aspirates on thin liquids.)" The Inter-facility Transfer Form from the local hospital, dated [DATE], included an order for [REDACTED]. Facility Record Review: The Meal Intakes and Fluids in CC documentation form was reviewed from [DATE] through [DATE];1200 ml/day was recommended per the facility's dietitian (1 milliliter = 1 cubic centimeter). The resident consumed less than the daily recommended amount of fluids on the following days. The fluid intake during meals was the first number listed and the second number listed was the "fluid intake other than meal times (i.e. water pitcher, snack, between meals)." [DATE]: 720+470=1190 [DATE]: 820+240=1060 [DATE]: 530+15=545 [DATE]:760+420=1180 [DATE]:920+240=1160 [DATE]:820+340=1160 [DATE]: 420+340=760 [DATE]:720+360=1080 [DATE]:640+440=1080 [DATE]: 740+400=1140 [DATE]: 120+490=610 [DATE]: 120+540=660 [DATE]: 300+350=650 [DATE]: 120+100=220 (The day the resident was hospitalized ) [DATE]:120+1040=1160 (The day the resident was readmitted from the hospital) [DATE]: 860+280=1140 [DATE]: 760+300=1030 [DATE]: 780+290=1070 [DATE]: 720+220=940 [DATE]: 360+300=660 [DATE]: 920+240=1160 [DATE]: 540+580=1120 [DATE]: 260+300=560 [DATE]: 420+330=750 [DATE]: 360+360=720 [DATE]: 700+360=1060 [DATE]: 820+120=940 [DATE]: 560+540=1100 [DATE]: 520+410=930 [DATE]; 0+310=310 [DATE]: 220+500=720 [DATE]: 0+220=220 Out of the 66 days that were reviewed, this resident was documented to consume less than the recommended daily amount of >1200 ml of fluids on 32 days, or 48% of the time. Out of the 32 days that resident #4 consumed less than the recommended daily amount, she consumed less than 50% of the daily recommended amount on five days, or 16% of the time. Since her return from the hospital, the resident consumed less than the daily recommended amount of fluids on 18 out of 23 days, or 78% of the time. Facility Response to the resident's condition change/dehydration: The integrated progress notes, reviewed from [DATE] through [DATE], documented in pertinent part: - On [DATE], "CNA reported they obtained urine in bedpan for UA (urinalysis) dip, however denies providing proper peri-care and clean bedpan for dip. This nurse dipped urine anyway - results were within normal limits, however positive for [MEDICATION NAME] and possible dehydration. Fluid encouraged and noted by this nurse that resident drank 480 cc of fluids when up in wheelchair this morning." - On [DATE],"Resident has very limited verbal communication this shift. Can shake her head yes and no. Resident spoke a handful of words to nurse at lunch time, but not to any other staff all shift. Resident indicates that she is tired... CNAs report that resident has been less verbal since yesterday." - On [DATE], "Resident states she has a headache at lunch time." - On [DATE], "Resident too tired to sip water, po med (oral medications) held." - On [DATE], "Oral fluids: intake at meals <=120 ml; offered 240 ml fluids every shift." - On [DATE], "Staff report that resident is starting to pocket food and needed assistance with eating. Resident had to be fed her meal over the weekend." - On [DATE] at 11:06 p.m., "Resident had temperatures of 100.8, 101.7 at 1530 (3:30 p.m.), then 99.1 at 1700 (5 p.m.) taken tempanic. Resident was gotten up for supper and taken down to the dining room. Ate very little and did drink some fluid. Resident slept most of the evening and did not arouse at all when antibiotic shot was administered." - On [DATE] at 1:11 a.m., "Resident appears to be lethargic. Slow to respond to questions/commands." - On [DATE] at 2:59 p.m., "Resident's niece (name), came in today during lunch and is very concerned about resident not verbally communicating with her. Nurse spoke with niece about changes in resident's condition...Very little fluid intake, roughly 100 cc all shift per this nurse and CNAs. Nurse called (Dr.'s name) at 1335 (1:35 p.m.) and received a telephone order to send resident to the emergency room , per family request." - On [DATE], it was noted resident #4 was readmitted to the facility at 2:00 p.m. and upon arrival back to the facility, "...Lips: Dry or cracked. Saliva: thick... Other Risk Factors: Poor skin turgor." - On [DATE], "Resident is admitted on [DATE] to (facility). She has stable weight of 176 today and that is down from 183 when we sent her to the hospital. She did have a stable weight when she was sent, with her weight between 186 and 183 for the last 45 days... She is being reviewed per (dietary consultant) for her nutrition... She has a follow up with speech therapy for her swallowing. She is being assisted with her meals and she takes a bite and then is offered water that she sips through a straw. She did have one slight choking episode in the dining room, but she was able to clear it herself without intervention." - On [DATE], "She has a puree diet and a thin liquid, as she is a choking risk at this time. She did choke prior to her last hospital stay. She is having no signs of dehydration at this time. She is taking her fluids through a straw." - On [DATE], "Fluids encouraged with intake of 300 cc this shift. Output is 150 cc." - On [DATE] at 9:59 p.m., "Resident had positive dip UA (urinalysis) today... Verbal order received [MEDICATION NAME](antibiotic), 250 mg po BID x 5 days." - On [DATE], "Resident declined getting up for breakfast this morning. She is on Hospice for comfort care and continues her declining condition. Restorative dining will be discontinued, but whenever she desires to get up for breakfast, she will be welcome to attend and be assisted by the restorative nurse." On [DATE] at approximately 9:30 a.m., all laboratory values since [DATE] were requested from medical records. The facility's records were void of any laboratory values related to the evaluation of hydration, such as electrolytes, [MEDICATION NAME], creatinine, or blood urea nitrogen (BUN) since that date. On [DATE] at 11:00 a.m., the director of nursing (DON) stated that the resident had an order written [REDACTED]." -However, when reviewing the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for December of 2014, the documentation did not include that order. -The order on the November MAR/TAR stated, "Administer 240 ml of fluid of choice every shift for Prevention." The order was noted on the MAR indicated [REDACTED] -When asked, the DON stated that the order was discontinued given that the resident was now on hospice care. Family Interview: The resident's family member/POA was interviewed on [DATE] at 10:09 a.m. She said resident #4 had lived in the facility since 2003. She stated that approximately three weeks ago, she went on a trip for seven days. During that time, she had a cousin visit resident #4 on a daily basis in her absence. When the family returned, she said resident #4 was "just staring at me, staring out the window, and had a tear coming from her right eye." The family stated that she asked a staff nurse what was happening with the resident and the nurse stated the resident had been tested for a bladder infection and received a shot of something. The family member said she told the nurse that something serious was wrong and demanded that resident #4 be transported to the local emergency room . The family stated that the nurse told her that there was nothing that could be done further. The family continued to insist on hospitalization , which did occur. The family stated that the hospital records diagnosed a severe bladder infection and dehydration and stated that the resident was in severe pain. She stated that while the resident was hospitalized , she called a discharge planning meeting at the hospital and requested at that time for her family member's primary care physician be changed to the facility's medical director, who did accept the resident under his care. The niece said she was concerned that it took the facility so long to get the resident to the hospital. -During a follow-up interview on [DATE] at 1:55 p.m., the family member said, "I just wish I would have come back earlier ... and insisted that she go to the hospital sooner and maybe it would not be so bad now." Resident Observations: - During the initial observation of resident #4, on [DATE] at 9:22 a.m., the resident's skin appeared dry and her lips were somewhat chapped. - On [DATE], during the lunch service in the main dining room, it was observed that CNA #2 was serving thickened water and thickened apple juice to resident #4 even though she currently had an order for [REDACTED]. - On [DATE] at 4:55 p.m., resident #4 was sitting in the main dining room at the assist table in her wheelchair. Her body was leaning to the right. There were no drinks in front of her. - On [DATE] at 12:36 p.m., the resident was finishing her lunch. She had some apple juice in a sippy cup with a straw. She had drank approximately ,[DATE] or 80 cc's of the apple juice. A certified nurse aide (CNA) arrived at 12:40 p.m. to assist her with her apple juice and at that time, the resident drank quite a bit of juice at once. The CNA stated, "Were you thirsty, (resident's name)?" The CNA offered the resident another drink of juice at 12:43 p.m., but the resident refused at this time. Resident #4 was escorted back to her room by the CNA at 12:45 p.m., after consuming less than half of her cup of juice. The resident was not observed to take the remainder of her juice to her room with her. - On [DATE] at 2:12 p.m., it was observed that the resident's water pitcher in her room was mostly full, the water was lukewarm, and the pitcher was located approximately five feet from the resident's bed and out of her reach. - On [DATE] at 5:00 p.m., the resident's water pitcher remained out of reach of the resident. - On [DATE] at 10:15 a.m., the resident's water pitcher was on the rolling bedside table, which was approximately ten feet from the resident's reach. - On [DATE] at 10:20 a.m., CNA #7 was observed to be passing fresh water to residents' rooms. When interviewed, she said she just delivered water to resident #4, and did not offer the resident a sip. She stated that she had not seen the resident drinking anything that morning, but after repositioning the resident and trying to get her up for lunch, she would offer her some water. - On [DATE] at 12:05 p.m., the resident's water pitcher remained on the rolling table and was approximately 2 ? feet from the resident's reach. - There were no observations of CNAs or other staff passing the resident's room and offering the resident hydration. Staff Interviews: On [DATE] at 9:07 a.m., CNA #6 was interviewed. She stated that the CNAs were told to offer liquids to resident #4 every 15 minutes while the resident was awake. She said she was under the impression that this resident was still being ordered thickened liquids. The CNA said the resident had good and bad days. On [DATE] at approximately 10:30 a.m., CNA #2 was interviewed. She stated that if staff walked by resident #4's room, they were to offer and encourage fluids. She stated that during the day shift, they passed water at 10 a.m. daily. She stated that the evening shift passed water usually between 2:30 p.m. and 3:00 p.m. She said the resident had thin liquids with a straw ordered, and that the thickened liquids she originally served the resident yesterday was a kitchen error. CNA #7 was interviewed on [DATE] at 11:45 a.m. The CNA stated that resident #4 would still ask for water on occasion. She stated that the CNAs passed water at 10:00 a.m. and 2:00 p.m. She said that this resident's oral fluid intake varied from day to day. She stated that the resident would also usually bring the drinks that she did not finish during meals back to her room to finish. She stated that she stopped in the resident's room every few hours to encourage and offer fluids. She said that since the resident went on hospice, she was on thin liquids. Licensed practical nurse (LPN) #3 was interviewed on [DATE] at 10:50 a.m. She stated that every resident has a water cup in their room, but that resident #4 could not reach hers because of the decreased range of motion in her upper extremities. She stated that every time she was in resident #4's room to provide cares, she offered the resident a drink. She stated that during meals, the resident was offered one teaspoon of food, then the staff alternated this with a sip of fluid. She stated that when the resident was having one of her "tougher days," she would crush the resident's meds in applesauce as opposed to pudding, as it seemed to help dissolve the medications better. She stated that she, personally, had never seen any staff member trying something like milkshakes or popsicles to help increase this resident's fluid intake. The LPN stated that the resident had been refusing all food and medications both the day before and this date. She stated that on this date, the resident had taken nothing orally during her day shift. On [DATE] at 11:00 a.m., CNA #5 was interviewed. She stated that she was trained to offer residents who were at risk for dehydration sips of water during their cares. When asked if she had passed or seen anyone passing alternative forms of hydration to resident #4, such as popsicles or milkshakes, she stated that she had not. On [DATE] at 12:38 p.m., Restorative Nurse (#19) stated that the sippy cups held 240 cc of fluid. CNA #13 was interviewed on [DATE] at 2:37 p.m. and stated that resident #4 was on every 15 minute check, and that she was trained to go into the room during those checks and offer the resident water, and to see if she needed anything else. The CNA said she was aware that resident #4 was now on thin liquids. She was asked if that were the case and if this resident was on thin liquids, if the resident's water pitcher should be within the resident's reach. She acknowledged t

Based on observation, record review and staff interview, the facility failed to prevent pressure ulcers from developing for one of four residents reviewed for pressure ulcers (#117) out of 43 sample residents. Specifically: -The facility failed to prevent two pressure ulcers from developing for resident #117; -The facility failed to obtain and document wound measurements when the left heel pressure ulcer was first identified; -The facility failed to document weekly wound assessments to monitor the progress of the wound healing; and -The facility failed to ensure that proper technique was used to change the right buttock and left heel dressings. The findings included: A. Facility Policy On 12/9/14 at 1:09 p.m., the corporate nurse consultant provided the facility's policy and procedure titled, "Policy and procedure for the Prevention and treatment of [REDACTED]. "Policy: It is the policy of (corporation name) to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedure: 1. Prevention of Pressure Ulcers A. Braden Scale and Skin Risk Data Collection form (which includes a skin audit) will be done B. Turning and Repositioning Observation (tissue tolerance). Pressure is the primary cause of pressure ulcers. An effective turning and repositioning schedule can help reduce the risk of developing a pressure ulcer. Everyone's tissue tolerance (the ability of the skin and its supporting structures to endure the effects of pressure without breakdown), is different. Therefore, it is important to individualize each resident's turning and repositioning schedule. C. Nursing: Monitoring of Skin Integrity. Skin will be observed daily with cares by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse. Weekly skin audits on the bath/shower day will be performed by the Licensed Nurse. If a dressing is ordered, it will be monitored for appropriate placement on the resident ...The Nurse Manager or Wound Nurse will be notified upon identification of a wound. The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. D. Nutrition: The dietician will be notified. ...If a resident is admitted with or there is a new development of pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Initiate the GSMS (unknown abbreviation) Wound Care Protocols 2. Notify physician/nurse practitioner and family/designee 3. Notify supervisor/designee as assigned 4. Notify dietary for nutritional interventions 5. Notify therapy department for seating surface evaluation and possible treatment interventions and other interdisciplinary team members as appropriate. 6. Re-evaluate turning and repositioning intervals; initiate a new Turning and Repositioning Observation form. 7. Initiate Braden Scale and Skin Risk Data Collection form. 8. Re-evaluate interventions per risk factors identified ... 9. Update the care plan for skin integrity and nursing assistant care cards with any skin concern. Include appropriate risk factors, turning intervals and interventions as appropriate. 10. Initiate Weekly Wound Documentation Progress form in electronic health record which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial or full-thickness (arterial, venous, [MEDICAL CONDITION]/diabetic ulcers), length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling and/or pain ... 11. When a wound is present, daily wound monitoring should include: An evaluation of the wound, if no dressing is present. An evaluation of the status of the dressing, if present. The status of the area surrounding the ulcer/wound (that can be observed without removing the dressing). The presence of possible complications, such as signs of infections. Whether pain, if present, is being adequately controlled. Document on any changes or concerns in the nurse notes and re-evaluate prior steps 1-9 as appropriate. 12. Notify the physician/nurse practitioner, family and supervisor/designee if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate ..." B. Resident #117 Resident #117, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 10/29/14, included a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. She had adequate hearing, vision and clear speech, and there were no [MEDICAL CONDITION] or [MEDICAL CONDITION] behaviors or rejection of care. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She used a wheelchair for mobility. The resident was coded as "No risk of pressure ulcer," and there were pressure reducing devices for the chair and bed. She was occasionally incontinent of urine and always continent of bowel. She received [MEDICAL TREATMENT] three times each week. The resident's care plan dated 11/28/14 and last reviewed 12/2/14, identified the following problems, goals and interventions: "Resident has impaired skin integrity as evidenced by: small stage II open area to inner upper right buttock. Resident also has unstagable eschar area left heel ..." -The goal was that "Resident's open area will heal by 12/14/14. Unstagable area will resolve within next 14 days." -The interventions included: "Duoderm to small open area to right upper inner buttock until resolved. Replace with loosening/soiling until resolved. Fluff Kerlix to left heel and secure with Kerlix and float heels at all times while in bed. Elevate heels at all times when in chair or bed. Nutrition and hydration intervention to manage skin problems. Staff to place pillow between resident's knees and stand-pivot disc during transfers. Treatment as ordered by physician. Weight bearing as tolerated on right lower extremity. Weekly skin reports/documentation until area healed." 1. Left Heel Pressure Ulcer Observations: -On 12/2/14 at 2:53 p.m., the resident was observed sitting in her wheelchair in her room. She was wearing purple gripper socks on her feet, and her left foot was positioned flat and directly on the wheelchair foot pedal. It was not elevated or floated on a pillow. -On 12/3/14 at 9:22 a.m., the resident was observed sitting in her wheelchair in her room eating breakfast. She was wearing purple gripper socks and her right leg was in a splint and her foot was resting on a skate board. Her left foot was positioned flat and directly on the wheelchair foot pedal. It was not elevated or floated on a pillow. The resident stated, "I lay on my back for a month when I broke this leg," and she pointed to her right thigh. She said she chose to lie on her back at night, and the staff helped her to turn onto her side. She explained that she was unable to turn completely on her own, but some. She said that when she was in bed or in the recliner in her room, her left foot was elevated, but when she was sitting in her wheelchair; her foot normally sat directly on the foot pedal. -On 12/3/14 at 11:20 a.m., the resident was observed sitting in her wheelchair in her room. She was wearing purple gripper socks on her feet, and her left foot was still positioned flat and directly on the wheelchair foot pedal. It was not elevated or floated on a pillow. -On 12/5/14 at 9:07 a.m., the resident was observed sitting in her wheelchair in her room. She was wearing purple gripper socks on her feet, and her left foot was positioned flat and directly on the wheelchair foot pedal. It was not elevated or floated on a pillow. She explained that the nurse had changed her dressing earlier that morning. -On 12/8/14 at 12:12 p.m., the resident was observed sitting in her wheelchair in the rehabilitation dining room eating lunch. She was wearing purple gripper socks on her feet, and her left foot was positioned flat and directly on the wheelchair foot pedal. At 1:48 p.m., the resident was observed sitting in her wheelchair in her room watching television, and her left foot was still positioned flat and directly on the wheelchair foot pedal. Record Review: The Admission Data Collection note dated 10/23/14 included, "(Resident #117) was admitted to facility 10/23/14 ...for the reason of right femur fracture ...Body Audit completed ...Feet and toes bunions, heels clear ...Tissue Tolerance determines resident is not independent with bed mobility and resident is not independent with chair mobility. Current skin integrity inspection ...Coccyx: no concerns noted ...Heels: No concerns noted ...The resident will be repositioned while lying every (blank line, void of documentation) hours ..." The Braden Skin Risk Assessments were reviewed and documented the following: -10/23/14: Total score 14 = Moderate risk -10/30/14: Total score 17 = Mild risk -11/06/14: Total score 14 = Moderate risk -12/06/14: Total score 18 = Mild risk The electronic nurses' notes dated 11/3/14 included "Weekly Skin Check: (Resident #117) skin check completed by nurse today. See data form for further details." The "Bath Skin Check" form documented, "Weekly skin check, no areas of concern noted. [MEDICATION NAME] is intact with minimal drainage noted." The electronic nurses' notes dated 11/13/14 included, "Weekly Skin Check: (Resident #117) skin check completed by nurse today. See data form for further details." The "Bath Skin Check" form documented, "Resident with some light bruising where the top of her brace and ted hose ends on her right thigh. Resident with some old bruising to both of her hands. No other areas of concern noted at this time." The Medicare Skilled Nursing note dated 11/21/14 included, "Skin is warm, dry and pink. Ulcer to it. Heel healing, dressing changed and heel floated." The facility was unable to provide documentation that included the initial wound measurements, description, odor, staging or pain associated with the wound. The note was signed by a licensed practical nurse (LPN). The electronic nurses' notes dated 11/26/14 included, "Weekly Skin Check: (Resident #117) skin check completed by nurse today. See data form for further details." However, the facility was unable to provide documentation that the weekly skin check was completed. The Medicare Skilled Nursing note dated 11/30/14 included, "Changed dressing to heel. Minimal drainage noted." The note was signed by an LPN. The Weekly Wound Documentation form dated 12/2/14 documented that the left heel wound was first identified on 10/23/14. However, the physician and family were first notified of the wound on 12/2/14. The form documented that the wound was "Present on admission" and "per family statement she had this area in the hospital." The form documented that the wound measured 2 cm (centimeters) long by 2 cm width, zero depth, and was "Unstageable." The description included "dark area over heal not open and no drainage." The comments included "fluff dressing applied with sponge dressing to protect area. Pillows floated while in her room." The form was signed by RN #35. The Skin/Wound note dated 12/2/14 included, "Resolved left heel unstageable eschar ...Current treatment: Fluff Kerlix to left heel, float heels ..." The Medication Review Report included the following orders: -"Gauze fluff dressing on left heel. Float heels while in bed, every day and evening shift." The order was dated 12/2/14. -"Keep area clean and dry and wrap with gauze and soft foam dressing, one time a day." The order was dated 12/2/14, and did not specify the area or wound the dressing was to be applied to. The Medicare note dated 12/3/14 included, "Discussed with (daughter) who remarked that she thought the heel wound was there in the hospital and on admit on 10/23 as she was with me when I first noted the dark area on her heel. She now feels that she did not have it in the hospital and that the first time she saw it was with me on 11/21." The note was written by the rehabilitation nurse manager. The (local area hospital) notes were reviewed for resident #117's hospitalization that began on 10/13/14 and included, "Chief complaint: Fall with right femur fracture ...Dermatological review of symptoms: No other rashes/sores ...Skin-left upper extremity fistula unremarkable. Right lower extremity with traction splint in place, dressing over open fracture with oozing blood ..." There was no documentation that the resident's left heel ulcer was present at that time. The Orthopedic Trauma Service progress notes dated 10/14/14 were reviewed, and there was no documentation that the resident's left heel ulcer was present at that time. The discharge summary from the resident's hospitalization was requested from the facility, but as of 12/11/14, no additional documentation had been provided. Staff Interviews: On 12/2/14 at 4:55 p.m., the registered nurse (RN #40) manager for the East Hall, who was also the wound consultant, was interviewed. She explained that she had been wound care certified for "a couple years," and since that time, she and the rehabilitation nurse manager (RN #35) share the wound care responsibilities in the facility. She said, "I have been more of a consultant. Once they get me a job description, then I will take it over completely." She explained that sometimes she "will write something and there is not an agreement, and we meet with IDT (interdisciplinary team), QA (quality assurance), and that's when we come together as a team to assess. It is in transition and it is not totally consistent. Multiple nurses have been measuring (the wounds). I'm not doing any training, not doing any in-servicing." On 12/3/14 at 1:41 p.m., the director of nurses (DON) was interviewed and asked to clarify when the resident's left heel ulcer was first identified. She stated it was "Not identified on admission. Her heels were intact and clean. On 11/21/14, the nurse manager noted the wound, talked with the family, and the daughter said that it had been there since the hospital. So there is no weekly wound assessment other than what I have. That is not the expectation. The expectation is that it is identified immediately on admission and that the assessments are done weekly and properly." On 12/9/14 at 10:30 a.m., a certified nurse aide (CNA #11) who routinely worked with resident #117 was interviewed. She explained that when the resident was sitting up in her wheelchair, she made sure "she has her Rojo cushion on. She doesn't stay in (the wheelchair) very long." The CNA said that she made sure "the heel is not on anything," and checked the placement of her foot on the pedal "every time I walk by." On 12/9/14 at 9:35 a.m., LPN (#2) who routinely worked with resident #117, was interviewed. She explained that she expected "the heel to be floated up on pillows when she is in the wheelchair and in bed." She explained that the resident did not have special pillows designated for her foot, "they just use bed pillows." 2. Right Upper Buttocks Pressure Ulcer Record Review: The Admission Data Collection note dated 10/23/14 included, "(Resident #117) was admitted to facility 10/23/14 ...for the reason of right femur fracture ...Body Audit completed ... Tissue Tolerance determines resident is not independent with bed mobility and resident is not independent with chair mobility. Current skin integrity inspection ...Coccyx: no concerns noted ..." The Weekly Wound Documentation form dated 11/28/14 documented that the right buttock wound was first identified on 11/28/14 and was acquired in-house. The form documented that the wound measured 3 mm (millimeters) long by 3 cm wide by 0.01 (unit of measurement not documented) depth, and was a "Stage II." The description included, "Upper inner edge of right buttock near gluteal cleft ...80% slough ...20% [MEDICATION NAME] tissue ...slight peri-wound pinkness ...tender to touch. Resident had slid on transfer board at [MEDICAL TREATMENT] center last week, may be resultant of shearing over pressure point ...Orders requested for treatment. Resident continues to attend [MEDICAL TREATMENT] on routine basis. Will attempt to offload area slightly when up in chair to promote healing and offer comfort." The form was signed by RN #40. A progress note titled "Skin/Wound Note," dated 12/2/14 included "IDT Review: Stage II buttock resolved. No pain or discomfort per resident report..." The Medication Review Report included the following order: -"Stage II open area to right upper inner buttock. Cleanse with Saf-Clens. Pat dry. Place Duoderm spot to area. Secure dressing with [MEDICATION NAME]. Change every five days and PRN (as needed) loosening/soiling until resolved." The order was dated 11/28/14. The electronic note dated 12/6/14 included, "Her skin is very fragile and she has areas on her left heel and also on her coccyx. She did say that it happened at [MEDICAL TREATMENT] using the sliding board on 11/28/14. [MEDICAL TREATMENT] said they did use a sliding board but have no record of it happening there." Additional Observation: On 12/3/14 at 11:45 a.m., the East Hall nurse manager (RN #40) who was also the wound consultant, was observed to change the dressings on the resident's right upper buttock and left heel wounds. The resident was lying in bed and positioned on her right side. The following was observed: -At 11:48 a.m., the RN washed her hands and placed a disposable chux pad on the bedside table that overlapped onto the resident's bed. The RN placed a small note pad on top of the disposable pad, and then placed the clear wound measuring device directly on top of the note pad. -The RN was asked how the wound happened, and she explained that it might have happened while the resident was being transferred at [MEDICAL TREATMENT] while using a slide board. -At 11:50 a.m., the RN donned gloves and sprayed wound cleanser on the right upper buttock wound. The RN was then observed to use her left gloved hand to grasp her pen light and removed it from the lanyard around her neck, and shined the light toward the wound. The RN then placed the clear wound measuring device directly on the wound bed, measured the wound, and then discarded the device in the trash. She removed her glove and wrote, "1 cm L (length) x 0.5 cm W (width), 90% slough." Although the documentation (see above) noted that the buttock wound was resolved, observation revealed it was open. -The RN explained that there was "blanching around the perimeter" of the wound and she saw bruising to the lower portion of her buttocks. The resident said the area "was sore." -At 11:55 a.m., the RN used a pair of scissors and cut a piece of Duoderm dressing and applied it to the wound. She stated, "We may need an Equagel pad for her recliner." -At 11:56 a.m., the RN applied a clear [MEDICATION NAME] dressing over the Duoderm, and covered the resident up with blankets. -At 11:57 a.m., the RN removed the blankets covering the resident's left heel and reapplied a new pair of gloves. She did not wash her hands in between the two dressings. She removed the purple sock and dressing from the area and exposed a large, black, unstagable wound with a small amount of yellow slough around the inner edges of the wound. The skin surrounding the distal portion was blanchable and inflamed, and the RN stated that the proximal area surrounding the wound had "poor blanching." -At 12:00 p.m., the RN picked up a clear measuring device from her supply box and placed it directly on the wound bed. She said it measured 3 cm in length by 3 cm in width. -At 12:02 p.m., the RN removed the dirty gloves and replaced them with a new pair out of her supply box, and cut strips of tape and placed them on the bedside table. She then unrolled an absorbent padding and cut it with the same scissors that she had used to cut the duoderm for the right upper buttock dressing. She did not clean the scissors in between uses. The RN wrapped the wound in Kerlix and stated, "This is just a dry dressing. We don't ever pick on them if they are unstageable." -At 12:04 p.m., the RN dated the dressing change with the date "12/2/14" which was incorrect. Additional Interviews: On 11/9/14 at 11:26 a.m., the DON was interviewed again, and asked to explain the facility's wound care program. She said, "Everyone is trained to identify a wound. When it is identified, there is a protocol in place; request an order from the physician, (do a) Braden assessment, tissue tolerance assessment. It needs to be done at that time to show whether or not they can reposition themselves. We can put them on a turning program. Then the wound is looked at weekly. We have a wound certified nurse in-house who looks at these wounds." -The DON explained that the facility recently "did a QA program with (the wound nurse) to make the roles defined, so she knew her responsibilities for our building. Our goal is that when a wound is identified, all those things would happen. Then she would go in and look at the wound, get orders, work with the registered dietician and physician to heal the wound and not get worse." -The DON said the facility used a Weekly Wound Assessment that was required every week in order for the wound to be monitored. -The DON said the facility had a wound committee, and the wound nurse did weekly rounds "and then we meet two times a month to discuss weight and skin, and document it as an IDT and look to see what would be needed to heal the wound." -She explained that each nurse is responsible for monitoring and tracking the wounds, and they are overseen by the wound nurse. She stated, "But the unit managers are responsible for tracking it. We felt like it wasn't being watched closely enough. I wanted to make sure we had a closer eye on it with the improved QA action plan." She said when the wound nurse "does her weekly rounds, she measures them. All nurses are taught to measure. We like to have one nurse measuring." She explained that the facility was going to provide an all-staff training that day." -The DON was asked to explain what measures were put in place on admission to prevent resident #117 from developing pressure ulcers, and she said, "All of our beds are pressure reducing, so that is automatic. We don ' t have any that are not. Our therapists always put them on a pressure-reducing (wheelchair) cushion and that is a standard protocol in our building." -The DON said that she "would expect some kind of a pillow or cushion or her dressing in place. She should have something to protect her from the heel pedal that would not put pressure on it." Additional Documentation: On 12/9/14 at 1:37 p.m., the DON provided copies of the training that the facility was going to provide that day at their all-staff meeting. The presentation was titled "Pressure Ulcer Documentation, Staging and Treatments," and was presented by an RN who was an education specialist for their corporation. The training included proper staging of pressure ulcers, Weekly Wound Documentation form procedure, and a case study.

Based on observation; resident, family and staff interviews; and record review, the facility failed to have sufficient nursing staff to provide care and services for eight of 43 sample residents (#62, #30, #7, #9, #57, #19, #13, #4), to attain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failure to provide staffing contributed to residents experiencing incontinence which they stated was "embarrassing" and made them feel "uncomfortable" and "terrible." Cross reference F241 dignity, F242 bathing choices, F246 accommodation of needs, F312 eating and positioning assistance, F314 pressure ulcers, F315 urinary incontinence, F325 weight loss, F327 dehydration, F332 medication errors, F333 significant medication errors, and F362 sufficient dietary staff. The findings included: 1. Resident Census and Condition Report The facility Resident Census and Conditions of Residents report, signed by the director of nursing on 12/2/14, documented a census of 66 residents. The residents' functional, mental and psychosocial needs were described as follows: -33 residents needed assist of one or two staff for dressing, 38 residents needed assist of one or two staff for transferring, and 32 residents needed assist of one or two staff for toilet use. -22 residents were occasionally or frequently incontinent of bladder, seven residents had catheters, 16 residents were occasionally or frequently incontinent of bowel; 22 residents were on urinary toileting programs, and 16 residents were on bowel toileting programs. -43 residents were in a chair all or most of the time; 17 residents had contractures; two residents were bedfast all or most of the time; and ten residents ambulated with assistance or assistive devices. -27 residents had dementia or [MEDICAL CONDITION] and 37 residents had behavioral healthcare needs; 59 residents were on psychoactive medication; 17 residents were on antianxiety medications; 25 were on antidepressant medications; and five residents were on hypnotic medications. -66 residents were receiving preventative skin care, three residents had pressure ulcers, and 33 residents were receiving respiratory treatments. -Eight residents received hospice care, three residents were on [MEDICAL TREATMENT], and one resident received intravenous therapy. 2. Observations and interviews were conducted throughout the facility from 12/1 through 12/4/14 and 12/8 through 12/9/14. Administration and nursing staff were asked about the staffing schedules, resident activity, safety, and ability to meet the resident needs as outlined in their individual plans of care. Nursing staff were expected to help staff the dining room at mealtimes, to serve and assist with meals, and ensure resident needs were met. 3. Resident, Family and Visitor Interviews Resident #62 was interviewed on 12/2/14 at 11:30 a.m. She said there was not enough staff. Specifically, she stated,"When I wanted to go to the bathroom, one of the aides told me that they were short staffed. She told me if she had more hands like an octopus, she could make sure that I go. Since they are short staffed, they don't have anybody to take me." The resident said that "just yesterday" she was incontinent of urine. When asked how it made her feel, she stated, "It made me feel justified that I really did have to go." Resident #30 was interviewed on 12/2/14 at 11:04 a.m. She said, "They are cutting down on staff members. They need more help at night. Down my hall, there is usually one CNA. They need at least two on this hall at night. They are also short handed in the mornings. They're short all the way around on this hall. On the other hall, there can be four CNAs just standing around, and on this hall only two, working their heads off." The resident said both she and her roommate had had incontinence of both bowel and bladder while awaiting toileting assistance. She said her roommate had been incontinent of urine yesterday. When asked how it made her feel, she said, "Terrible." Resident #7 was interviewed on 12/2/14 at 2:28 p.m. She said, "Sometimes I don't think they have enough help. In fact, not too long ago I had an accident in my pants waiting for my call light to be answered. Sometimes you turn your light on and someone not qualified answers and turns off the light and you don't know it. It was embarrassing." On 12/3/14 at 11 a.m., resident #9's friend and former caregiver was interviewed. She said she thought the facility was short staffed. She said, "His eyes are often red, and I worry that he doesn't get his eye drops as needed." She was feeding the resident a bowl of ice cream, and it was observed that the resident's hands were dry and flaky, and needed lotion. On 12/3/14 at 2:52 p.m., resident #57 said, "They have the floating team now and we don't like it. They're not familiar with the patients' needs. They try but they don't know how to arrange our pillows or prop up our feet. Then you have to explain how you do this and how you do that. It works better if it's done your way. You get better care in a shorter time if you don't have to explain how to do this or how to do that. The float team is good for them maybe, but it's not so good for the patients. I just think I don't know her. You just feel kind of uncomfortable." On 12/3/14 at 3:12 p.m., resident #19 was interviewed. She said, "We have different bath aides, we never know who it's going to be. I don't like it. Everybody's quitting. I don't know what's going on, everybody's trying to get more hours. We do not have consistent staff. Different nurses, different CNAs, a lot of floaters. They do try." On 12/2/14 at 8:37 a.m., a family member of resident #13 was interviewed, and said, "Enough staff? No, I don't think so. If you push the (call) button, it is 20 to 30 minutes before somebody comes in, and I think that's too long. How often does that happen? It is regular. She wants to go to the bathroom, she has to go to the bathroom. Part of that is she has to have two people transfer her from the bed to the commode. So if someone does come in, they have to go get an assistant, and then she has to wait longer. I think it is too long just to wait for the response ... She just gets really anxious, and the anxiety... She used to be very active and now she has to wait on someone for help." On 12/2/14 at 10:09 a.m., a family member of resident #4 was interviewed. She said, "Every time I visit, call lights are going off, people are waiting to go to the bathroom. (Resident #4) needed a Hoyer lift and they often had to go find someone to get the Hoyer. Her wheelchair was smelling of urine and she was obviously incontinent. That's when they started using depends. I asked the nurse, 'What the heck is going on with my aunt?' She was complaining of back pain prior to her hospitalization ." (Cross-reference F327 dehydration) 4. Resident Council Meeting Minutes Minutes documented that ten to 13 residents were in attendance at each meeting, and brought up the following concerns: 9/14 - "Float team doesn't know how residents like care done ... (Response:) Float team reminded to check the kardex and ask residents how they want their care done. Resolved. ...(The director of nursing) talked about a nursing shortage in the area. There have been some traveling nurses brought in to help and (corporate) float team has been used. New CNAs have been hired and they continue to recruit for CNAs and nurses..." 10/14 - "Staff are getting changed out too often ... The staff are leaving the room before the residents can tell them everything they need ... (Response:) There is consistent staffing on the halls. Float team is used to fill the need and are required to work all the halls. Resolved." 11/14 - "Residents feel rushed when staff enter their room ... Residents feel that the residents who need assistance need a CNA to keep an eye on them in the dining room ... (Response:) Updates coming ... (The DON) talked about the assignment sheets that are being made for the CNAs ... the restorative nurse will only be working three days a week ... The nurse managers have changed their hours to 8-5 to assist the afternoon shift nurses." 5. Staff Interviews Staff members made the following comments during interviews conducted 12/1-12/4/14 and 12/8-12/9/14: -"They replace call-ins about 80% of the time." -"It would be nice to have bath aides. It would be better for the residents. Having consistency of a CNA makes it easier for the resident so they don't have to keep on saying how they like things done, especially with baths and with dressing." -"Some of the residents don't like to have floaters (new CNAs). The residents really like knowing who they're going to have." -"We have more residents refuse baths now than we ever did when we had (consistent staffing). Residents will say, 'I want so-and-so,' then find out she's off, and they'll wait until she gets back." -"We have staffing issues here. Sometimes we can't get people in here. The residents are the ones who it gets taken out on." -"A lot of the float team people don't know the residents' routines. That's why I work all the halls so I can get the residents' routines. I wouldn't say they're doing without, but sometimes it takes longer." The staffing manager was interviewed on the afternoon of 12/9/14. She said she was in charge of clinical staffing, for nurses and CNAs, throughout the building. -She said, "We generally staff based on census, and that means three to four aides per hall. The (secure unit) usually has two aides and a nurse, LTC would have three or four depending on census, and you'd have the same on the Rehab/Garden hall - three to four based on census. -Staffing is based on a census of 75, at 75 we'd have four on each hall. Our census this morning was 68. On the LTC hall there are three to four aides, but we always have a full time bath aide as well. -We don't always have a full residency on rehab hall. It's based on the amount of patients and their acuity." -When asked what she was learning from resident interviews, the staffing manager said, "I haven't heard any feedback on staffing from the residents." -When asked, she said she had had to tell CNAs to go home, but she said, "Census has stayed pretty steady for the last couple of weeks. There have been no issues with call-ins and not being able to replace staff." She said she talked to staff about going home early "after everybody's gone to bed at night. We're always fully staffed at mealtimes." -Asked what she had noticed in the dining room, she said, "I definitely saw some areas for improvement with meal service staffing." (Cross-reference F362 sufficient dietary staff) The nursing home administrator, interviewed late afternoon on 12/9/14, said staffing analysis was a current and ongoing project for the facility.

Based on record review and staff and family interview, the facility failed to ensure one (#3) of four sample residents received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to: -Implement fall prevention interventions that could have minimized falls for resident #3; -Update the falls care plan after the resident experienced falls; -Ensure non-slip socks were in place as per the care plan. These failures contributed to the resident experiencing falls with injury and treatment in the hospital emergency department. The findings included: Closed record review revealed that resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) The Significant Change of Condition MDS, dated [DATE], documented in part as follows: Resident #3 was coded to have had understanding-clear comprehension, had little interest or pleasure in doing things, feeling down, depressed, or hopeless, had behavioral symptoms, required extensive assistance of one person with bed mobility, transfers, dressing, toileting, not steady with moving from seated to standing position, walking, turning while walking, moving on/off toilet. The MDS, dated [DATE], documented no falls. Care Plan The care plan related to falls, dated 4/11/07 and revised on 12/6/10, documented in part as follows: Focus (Problem) - Resident at risk for injury related to falls secondary to [DIAGNOSES REDACTED]. Goals - Resident will be free from injury related to falls for the next 90 days. Interventions - Encourage the use of non-skid footwear, resident has episodes of forgetfulness, anticipate her needs, (per MDS and staff interview, resident #3 was cognitive to use her call light to call for assistance) monitor for safety issues when passing by her room, redirect/remind as needed, encourage resident to use call light when needs assistance, provide uncluttered environment, keep resident's furniture and personal items in same place so resident is able to find easily. -The care plan did not indicate how often to check on the resident in order to anticipate her needs. No toileting plan or schedule was included in the falls care plan, although the resident needed extensive assistance. The care plan included reminders to use the call light although the resident had periods of forgetfulness. -Although, resident #3 had falls with injuries on 6/28/11 and 7/18/11, there were no updates to the fall prevention care plan (see findings below). Record Review Review of nurses' notes revealed resident #3 had to be transported to the hospital emergency department twice, as a result of falls. After the 6/28/11 fall, the resident had to wear a splint on the small left finger that had edema. Resident #3 had to visit the hospital emergency department after a fall on 7/18/11 that resulted in stitches to the forehead. Review of the facility Post Fall Investigation revealed documentation in part as follows: -On 7/18/11, resident was discovered on the floor next to her bed at 4:45 a.m. Description of resident's cognitive and emotional status prior to fall was confused and lethargic as compared to resident's usual emotional status of anxious. Resident had bare feet at time of fall (no non-slip socks as per care plan), assistive devices in use at time of fall - none, resident was incontinent at time of fall - wet (resident wet even though documented that she had five minutes prior to fall been changed for incontinence), yes resident sustained [REDACTED]. Root cause of fall appears to be confusion and resident's lack of requesting assistance. Documentation in the Progress Notes, dated 6/28/11, read in part, resident did slip from bed on 6/28/11 at 9:45 a.m. with a bruise to the left little finger. Resident is declining, noted weight loss, skin concerns, pain management concerns, therapy looking at seating and positioning. The Fall Investigation Report, dated 6/28/11, documented the resident expressed she wanted to go to the bathroom, was last toileted 6/28/11 at 9:31 a.m. (just minutes prior to fall and need for toileting). Her mental status prior to fall was noted as crying, yelling, sleeping and her psychological status prior to the fall was fidgety/sleeping. Resident had gripper socks on. -The fall investigation form had a single line drawn through the documentation of crying, yelling and fidgety, although there were no staff initials or date of when/why the line was drawn through part of the documentation. Progress/Nurses Notes, dated 7/18/11, read in part, resident noted to be on the floor next to her bed at 4:45 a.m., resident noted to have scalp wound approximately 2.5 cm in length, a large skin tear on her left arm, resident sent to the hospital emergency room . Resident returned from hospital with stitches in her forehead laceration. After both falls, the fall investigation reports documented the resident said she was trying to go to the bathroom, although the facility documented she had just been toileted five minutes before. There was no evidence this was addressed as an anticipation of the resident's needs. Staff Interviews On 10/11/11, the Director of Nurses (DON) was interviewed related to resident #3 and her falls. The DON acknowledged that resident #3 did not have changes to the care plan. She said the resident did not have a low bed, a bed side floor mat, or bed alarms. The DON said the falls team had discussed the resident's falls and made a decision that a bedside mat would be more of a trip hazard, and bed alarms would scare the resident and that the resident was cognitive enough to use her call light to request help. She said a low bed was not initiated because the resident liked to sit up on the edge of her bed. However, no documentation of this IDT discussion could be found in the resident's medical record. There was no evidence of care plan interventions for frequent toileting or room checks on the resident to ensure her needs were met. Although the fall investigation report documented the resident was slightly more lethargic than baseline prior to her fall, there was no evidence of increased supervision. The resident's room was not close to the nurses' station, and there was no evidence the IDT team addressed ways in which to more closely monitor the resident for safety. On 10/11/11, multiple staff and one family member were interviewed as follows, including the DON, MDS Coordinator, and Physical/Occupational Therapy related to resident #3 and her condition. The staff expressed that resident #3 had chronic pain and the facility had tried multiple interventions. The staff expressed that pain issues contributed to the resident's overall health decline. The resident's family member was interviewed by phone at 9:20 a.m. on 10/25/11. She said the facility had provided multiple medications for resident #3 and the medications made the resident very sleepy and unable to use her call light most of the time. The medications she thought had contributed to weight loss, weakness, confusion and not being able to ambulate independently, and caused a fall risk. -The family member said the facility called her hours after the first fall on 6/28/11 and reported that the resident's fingers were swollen and her rings needed to be removed, and that the hospital emergency department had to cut the rings to get them off the resident's finger. The family member expressed the facility did not put interventions in place that might have decreased the risk for injury related to falls and the resident remained in the same room, and was not moved closer to the nurses' station. Summary While the facility furnished copies of staff education related to falls, the facility continued to lack interventions for fall prevention. Care plans were not updated to reflect the resident's fall risk or interventions to prevent further falls. There were no care plan interventions or other documentation related to monitoring the resident when she was calling out or moving about in the room during night time hours (see findings above). There was no documentation of a toileting schedule to anticipate the resident's needs and prevent falls.