Every finding on record at Villas at Sunny Acres, The

Based on record review and interviews, the facility failed to prevent misappropriation of property for one (#7) of three residents reviewed for misappropriation of personal property out of 18 sample residents.Specifically, the facility failed to prevent the theft of Resident #7's narcotic medication card containing 89 pills.Findings include:I. Facility policy and procedureThe Abuse Prevention and Reporting policy, reviewed March 2026, was provided by the nursing home administrator (NHA) on 4/7/26 at 1:00 p.m. It revealed in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Exploitation-any occurrence involving misappropriation of a resident's property (deliberately misplacing, exploiting, or wrongfully using, either temporarily or permanently, a resident's belongings or money without the resident's consent).The Drug Diversion Reporting and Response policy and procedure, revised 3/16/24, was provided by the NHA on 4/8/26 at 3:15 p.m. It revealed in pertinent part, Drug diversion is using or taking possession of a prescription medication or medical gas from residents' prescriptions and E-Kit (emergency kit for medication) intentionally and without proper authorization. Suspicion of drug diversion may arise from a variety of circumstances, including, but not limited to the following: suspicious activity identified during routine monitoring and/or proactive surveillance, and self-disclosure of drug diversion by an individual.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included muscle wasting and atrophy, age-related osteoporosis, wedge compression fracture T11-T12 (thoracic) vertebra (back bone) and muscle weakness. The 3/31/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed Resident #7 experienced pain on occasion and had as needed (PRN) pain medication ordered. B. Resident interviewResident #7 was interviewed on 4/7/26 at 10:05 a.m. Resident #7 said he experienced daily pain that was managed by daily scheduled pain medication. He said when the pain was worse, he would ask for his PRN oxycodone (opioid medication for moderate to severe pain). Resident #7 said he had not had any issues receiving this medication when he asked for it. However, he said he remembered a time when he asked for it and was told there was not any in the building for him, which he said he thought was strange because he did not take it very often. C Record ReviewReview of Resident #7's April 2026 CPO revealed the following physician's order: Oxycodone HCL oral tablet 5 milligrams (mg) by mouth every 8 hours as needed for pain three times a day PRN, ordered on 12/24/24. Review of Resident #7's December 2025 medication administration record (MAR) revealed the resident had requested oxycodone on 12/29/25 for a pain rating level of 7 out of 10. The December 2025 MAR documented the resident had received the PRN oxycodone on 12/29/25. The facility's drug diversion investigation, dated 12/31/25, was provided by the NHA on 4/7/26 at approximately 2:00 p.m. The investigation included written statements from the involved staff members, the incident write up by the NHA, and a written narrative of a meeting, dated 1/2/26, between the NHA, the director of nursing (DON), the human resources representative and licensed practical nurse (LPN) #4. Documents from the investigation revealed (LPN) #4 had been in the facility on 12/26/25, her day off, and had looked up two residents in the facility's electronic charting system who were on oxycodone, including Resident #7.Registered nurse (RN) #5's written statement, dated 1/2/26, documented that RN #5, as the offgoing shift nurse on 12/26/25, completed the medication narcotic count with LPN #4, even though LPN # 4 was not the oncoming shift nurse on 12/26/25. RN #5 documented on the narcotic count sheet that there were 24 narcotic cards in the medication cart.The 12/26/25 written statement by LPN #3, the oncoming shift nurse on 12/26/25, documented she counted the narcotic cards by herself and identified a discrepancy between the narcotic card count and the number on the narcotic count sheet from the morning of 12/26/25. LPN #3's statement indicated she changed the number on the narcotic count sheet to match the narcotic card count.LPN #4's written statement, dated 12/29/25, documented that she had been in the building on 12/26/25 and counted with the offgoing shift nurse, RN #5, in order to relieve RN #5 early and then LPN #4 gave the keys to the medication cart to LPN #3. The investigation revealed LPN #3 worked again on 12/29/25 when Resident #7 asked for his PRN oxycodone pain medication. LPN #3 could not find Resident #7's narcotic card in the medication cart. LPN #3's written statement, dated 12/26/25, documented when LPN #3 counted the narcotic cards on 12/21/25, there had been an oxycodone medication card for Resident #7 in the medication cart. On 1/2/26 the NHA, the DON, the human resources representative and LPN #4 met. The human resources representative's written statement, dated 1/2/26, documented that LPN #4 admitted to taking Resident #7's oxycodone medication card from the medication cart on 12/26/25. LPN #4 was relieved of her duties and escorted off the premises at that time. III. Staff interviewsThe assistant director of nursing (ADON) and the NHA were interviewed together on 4/7/26 at approximately 5:10 p.m. The ADON said the missing card of Resident #7's oxycodone pain medication was not discovered until 12/29/25, when Resident #7 requested a dose of PRN oxycodone for his pain. The ADON said the medication nurse, LPN #3, was aware that Resident #7 had a card of oxycodone in the medication cart but could not find it when the resident requested a dose on 12/29/25. The ADON said LPN #3 notified the DON at that point. The ADON said nurses should not count the medications on the cart alone. The ADON said the professional standard of practice for narcotics counting was for the oncoming/offgoing shift nurses to complete the narcotics count together and sign off on the narcotic count sheet. She said if there was a discrepancy in the narcotic count, the nurse in charge or the DON would be notified immediately. The ADON said there would be documentation if a narcotic card had been used up or discontinued. She said there was no documentation for Resident #7's oxycodone card to be missing. LPN #3 was interviewed on 4/8/26 at 9:40 a.m. LPN #3 said she was the oncoming shift nurse on 12/26/25. She said a nurse manager, LPN #4, provided her with the keys to the medication cart but did not count the narcotics with her. LPN #3 said she counted by herself and noticed a discrepancy between the written number of narcotic cards and the actual count for the narcotic cards and changed the number on the narcotic sheet so the counts would match. She said she did not notify anyone of the discrepancy at the time she discovered it. LPN #3 said on 12/29/25, Resident #7 asked for a PRN dose of oxycodone and she knew he had a medication card for oxycodone, but she could not find it on 12/29/25. She said she went to the emergency medication supply to pull an oxycodone to give to Resident #7. She said she notified the DON of the discrepancy on 12/29/25. LPN #3 said the nurses were not to leave the medication cart without counting the narcotic medications with the oncoming shift nurse. She said both nurses were supposed to sign the narcotic count sheet and if there was a discrepancy in the narcotics count, then the DON should be notified immediately. RN #5 was interviewed on 4/8/26 at 4:04 p.m. RN #5 said she was the offgoing nurse on 12/26/25. She said LPN #4 had come to the building to relieve her early, although LPN #4 was not on duty that day. RN #5 said she counted the narcotics with LPN #4, who was her supervisor, and signed the narcotic count sheet, however; LPN #4 did not sign the narcotic count sheet. LPN #4 was interviewed at 4:12 p.m. LPN #4 said she did enter the building early on 12/26/25 even though it was her day off. She said she did count the narcotics with the offgoing shift nurse (RN #5), but did not sign the narcotic count sheet. LPN #4 said she took Resident #7's oxycodone medication card from the medication cart the morning of 12/26/25. LPN #4 said she admitted to taking Resident #7's oxycodone medication from the medication cart that day (12/26/25) to the NHA and the DON on 1/2/26.

Based on observations and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include: I. Facility policy and procedure The Palatable Food policy and procedure, revised October 2021, was provided by the food and nutrition resource (FNR) on 4/4/25 at 1:45 p.m. It read in pertinent part, The facility will prepare and serve food that were palatable, attractive and at a safe and appetizing temperature. The facility will prepare food by methods that conserve nutritive value, flavor, and appearance. The facility will utilize pre-written menus. II. Observations On 4/3/25 at 11:31 a.m., the daily lunch menu was observed on the wall next to the entrance of the Longs Peak dining room. It revealed the menu was vegetable soup, house salad with dressing, orange-glazed chicken, Hawaiian rice, sugar snap peas, bread or roll with butter, chocolate cake and a choice of beverage. A test tray for a regular diet was evaluated by five surveyors immediately after the last resident had been served their meal for lunch on 4/3/25 at 12:47 p.m. The test tray consisted of an orange glazed chicken, green peas, Hawaiian rice, roll, pureed vegetable soup, and chocolate cake. - The chicken was dry and flavorless; and, - The Hawaiian rice tasted like plain rice and did not contain pineapple (see record review below). -The posted menu indicated snap peas were to be served, the test tray consisted of green peas. III. Resident interviews Resident #100 was interviewed on 3/31/25 at 4:39 p.m. He said he did not like the food because he thought it was the same items all the time. Resident #111 was interviewed on 3/31/25 at 1:48 p.m. She said she wanted more variety in the meals. Resident #105 was interviewed on 3/31/25 at 12:21 p.m. She said the food was either too salty or tasteless. Resident #76 was interviewed on 4/1/25 at 9:47 a.m. He said the food was not as good as it used to be, and the food was too spicy. Resident #58 was interviewed on 3/31/25 at 1:42 p.m. She said she did not like the food. She said the dietary manager (DM) did not understand the residents wanted better quality, more variety and more options. Resident #53 was interviewed on 3/31/25 at 3:53 p.m. She said the food was cold and the food did not look appetizing. IV. Record review The recipe for the Hawaiian rice and the orange-glazed chicken breast was provided by the DM on 4/3/25 at 6:23 p.m. The Hawaiian rice recipe indicated the ingredients included: white rice, water, green bell peppers, margarine and pineapple tidbits. The orange glazed chicken breast recipe indicated the ingredients included: chicken breasts, margarine, brown sugar, ground allspice, dry mustard, salt, all purpose flour and orange juice. The November 2024 resident council meeting minutes revealed Resident #29 said her food was still served cold. Resident #73 said she wanted more vegetables. The December 2024 resident council meeting minutes revealed the residents wanted more variety in ice cream. V. Staff interviews Cook (CK) #1 was interviewed on 4/3/25 at 11:32 a.m. She said the Hawaiian rice consisted of rice, butter, bell peppers and onions. -However, according to the recipe, CK #1 should have put pineapple tidbits in the rice (see record review above). CK #2 was interviewed on 4/3/25 at 12:36 p.m. He said he cooked additional chicken because they ran out of chicken. He said he used the chicken breasts that were used for items on the always available menu. He said the orange-glazed chicken that was prepared before lunch service was cooked with chicken thighs. CK #1 was interviewed again on 4/3/25 at 12:39 p.m. She said the sauce she used for the additional chicken breast cooked during meal service consisted of brown sugar, honey and an orange. -However, according to the recipe CK #1 should have included ground allspice, dry mustard, salt and flour (see record review above). The DM, the FNR and the nursing home administrator (NHA) were interviewed on 4/3/25 at 5:35 p.m. The DM and the NHA said they tasted the food daily. The DM said she tasted the chicken at lunch today and the NHA had breakfast. The FNR said she tasted the lunch meal before lunch meal service started. The FNR said the lunch meal tasted good. The DM said the chicken tasted drier than it should have tasted. The DM said they ran out of chicken thighs midway through meal service, so they used chicken breasts. The DM said chicken thighs would have tasted better with the orange glaze than chicken breasts. The FNR said she tasted the chicken thighs and the DM said she tasted the chicken breasts. The DM said she did not serve sugar snap peas because they had an issue with their distributor. The DM said they could have modified their posted menu. The DM said the pureed soup could be salty once it was modified. The DM said the Hawaiian rice was not the same as what would be served at a restaurant based on the residents' dietary restrictions. She said that usually, Hawaiian rice was saucy. The DM said the Hawaiian rice should have had peppers, onions, and pineapple. The DM said she was not aware that there was no pineapple in the Hawaiian rice.

Based on record review and interviews, the facility failed to inform the resident's representative of the change in condition for one (#176) out of five residents reviewed out of 49 sample residents. Specifically, the facility failed to timely notify Resident #176's representative of a fall, the need for medical imaging (Xray) of her left hip, new orders for pain medication and an appointment for a diagnostic imaging procedure to show detailed internal images (CT) scan in a timely manner. Findings include: I. Facility policy and procedure The Change of Condition Reporting policy, revised October 2020, was provided by the nursing home administrator (NHA) on 4/3/25 at 10:30 a.m. The policy read in pertinent part, The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. II. Resident #176 A. Resident's status Resident #176, age 89, was admitted to the facility on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included heart rhythm disorder (A-Fib), heart failure, history of transient ischemic attack (TIA) and cognitive communication deficit. The 1/23/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. B. Representative interviews Resident #176's daughter-in-law was interviewed on 4/3/25 at 3:43 p.m. She said the resident's representative (Resident #176's son) was at the facility the morning of 2/11/25 to discuss discharging Resident #176 to the resident's home. The resident's representative was told by an unidentified case manager the resident had more insurance days and the team would discuss the discharge and call him back. The resident's representative spoke to a case manager later in the day and was only then notified there had been a change of condition due to a fall the night before (2/10/25) and the resident's condition had deteriorated. Resident #176's daughter-in-law said during the next several days they saw Resident #176 getting weaker and lying in bed. The daughter-in-law said the resident was not acting like herself because of the pain medication. Resident #176's daughter-in-law said prior to 2/10/25 there was a meeting with the family, resident, staff members including the case manager to discuss the passing of Resident #176's daughter and now the primary contact would be the resident's representative, her son. Resident #176's representative was interviewed on 4/3/25 at 5:11 p.m. He said he visited Resident #176 the morning of 2/11/25 and spoke to an unidentified case manager about discharging Resident #176 to her home that day. Resident #176's representative was told she still had insurance coverage and the team would discuss the discharge and call him back. He said there was no communication about the fall while he was there in the morning, He said Resident #176 was complaining of pain the morning of 2/11/25, which was new for her. He said he talked to a case manager later in the afternoon and was advised, because of Resident #176's change of condition, discharge was not recommended. He said he was then notified of the 2/10/25 fall and of the Xrays that were taken on 2/11/25. He said he had no prior notification from the facility regarding the fall or Xrays. He said he was told that the facility tried to call Resident's #176's daughter. He said the facility was aware that she passed away. He said there was a meeting for Resident #176 which included the case manager regarding the passing of the resident's daughter. He said he was listed as the first contact. He said he noticed a change in the resident and she was sleeping more, not getting out of bed and was told she was on pain medications after the medication was started. Resident #176's representative said he was not notified of the 2/20/25 CT scan appointment until the morning of 2/20/25 when he went to visit his mother and she was not at the facility. Resident #176's representative was then advised of the appointment. He said had been visiting sometimes up to three times a day prior to her rehospitalization . C. Record Review The nursing facility's face sheet listed Resident #176's representative, her son, as first emergency contact. There was no one listed as the resident's power of attorney (POA). There was only one contact listed. A progress note, dated 2/10/25 at 10:45 p.m., documented in pertinent part, the family member or representative was notified on 2/11/25 at 6:00 a.m. -The note did not specify which family member/representative was notified. A progress note, dated 2/10/25 at 11:03 p.m., documented in pertinent part, the nurse practitioner (NP), on-call nurse and POA were notified of the resident's fall. A progress note, dated 2/11/25 at 5:48 a.m., documented the writer attempted to call Resident #176's daughter and POA twice to notify her of the resident's fall. The phone went immediately to voicemail and the writer was unable to leave a message due to the mailbox being full. This was passed on to the dayshift nurse to try and contact the daughter again. -However, the facility was notified Resident #176's daughter passed away prior to 2/10/25, see interviews above. Resident's #176 daughter was not listed on the face sheet. A progress note, dated 2/11/25 at 12:26 p.m., documented an Xray of the left hip was completed due to a fall and were negative for a fracture. The Xray results were received and communicated to the physician. Review of the February 2025 CPO revealed the following physician's orders: Tramadol 50 milligram (mg) one tablet by mouth every six hours as needed for moderate and severe pain, ordered 2/11/25; and, Tylenol 1000 mg by mouth every eight hours as needed for pain, ordered 2/11/25. -Review of Resident #176's electronic medical record (EMR) failed to show the resident's representative (Resident #176's son) was notified of the 2/10/25 fall, the ordered Xrays or the addition of pain medication at the time when it occurred. D. Staff interviews The director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on 4/2/25 at 5:15 p.m. The DON said the expectation was for the responsible party to be notified after a fall. Primary care physician (PCP) #1 was interviewed 4/3/25 at 2:50 p.m. PCP #1 said she had no contact with the family regarding the resident's fall or plan of care. PCP #1 said she asked the resident if she wanted to go to the hospital for tests or stay at the facility for Xrays. PCP #1 said the resident chose to stay at the facility. She said it was the facility's responsibility to contact the responsible party after a fall. III. Facility follow-up The NHA provided additional information on 4/4/25 at 12:43 p.m., after the exit. The NHA sent a screen shot of a phone and said it belonged to social worker's (SW) #1's phone. The screen shot revealed SW #1 called the resident's representative (son) phone on 2/11/25 at 2:43 p.m., lasting 34 seconds. Another screen shot revealed an incoming call from the resident's representative's phone number on 2/11/25 at 3:09 p.m. The NHA said SW #1 provided notification of the fall and Xray results at that time. -However, Resident #176 fell on [DATE] at approximately 10:15 p.m. and the resident's representative was not notified until 2/11/25 at 3:09 p.m., approximately 17 hours after the fall occurred, after Xrays were taken and medications were ordered. The NHA provided a written statement from SW #1 on 4/4/25 at 12:43 p.m. The 4/4/25 statement read in pertinent part, SW #1 notified the resident's representative of the fall and Xray results during the phone conversation on 2/11/25 at 3:09 p.m.

Based on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADL's) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (#326 and #8) of five residents out of 49 sample residents. Specifically the facility failed to -Offer repositioning to Resident #326 and Resident #8, who were dependent residents; and, -Provide assistance with toileting for Resident #326. Findings include: I. Observations During a continuous observation on 4/1/25, beginning at 8:38 a.m. and ending at 12:39 p.m., the following was observed: At 8:39 a.m. Resident #326 was lying in bed with her eyes opened. She was leaning to the right side of her bed. Resident #8, who resided in the same room, was sleeping in her wheelchair. At 9:15 a.m. Resident #326 was lying in bed with her eyes closed leaning to the right side. Resident #8 was sitting in her wheelchair sleeping. The room smelled of urine. At 10:30 a.m. Resident #326 was lying in bed with her eyes open leaning to the right side. Resident #8 was sitting in her wheelchair next to her bed. The room continued to smell of urine. At 11:01 a.m. Resident #8 was in her room. An unidentified staff member asked Resident #8 if she wanted to put pants on. Resident #8 declined. The unidentified staff member did not reposition or provide care to Resident #8. At 11:24 a.m. Resident #326 was lying in bed leaning to the right side. Resident #8 was sitting in her wheelchair in her room. At 11:48 a.m. certified nurse aide (CNA) #2 and CNA #3 provided incontinence care to Resident #326. The CNAs changed the resident's brief. The resident's brief was saturated with urine. There was a blue line on the outside of the brief that indicated the brief was wet. At 12:39 p.m. Resident #326 was lying in bed with her eyes closed leaning to the left side. Resident #8 was sitting in a wheelchair sleeping. -Resident #326 was not provided incontinence care or repositioning for over three hours, from 8:38 a.m. until 11:48 a.m -Resident #8 was not repositioned for four hours, from 8:38 a.m. until 12:39 p.m. II. Resident #326 A. Resident status Resident #326, age 87, was admitted on [DATE] and passed away on 4/2/25 at the facility. According to the April 2025 computerized physician orders (CPO), diagnoses include muscle weakness, limitation of activities due to disabilities and urinary tract infection. The 3/3/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required substantial/ maximal assistance of two people with toileting hygiene and personal hygiene. B. Record review The ADL care plan, revised 10/19/20, revealed Resident #326 had an ADL self care performance deficit initiated on 10/1/19 . Pertinent interventions indicated the resident required staff assistance for toileting. -However, observations revealed staff failed to offer or provide assistance with toileting (see observations above). The oxygen care plan, revised 10/22/22, revealed Resident #326 had oxygen therapy related to ineffective gas exchange initiated on 10/3/19. Pertinent interventions included changing the residents position every two hours to facilitate lung secretion movement and drainage. -However, observations revealed the staff failed to offer or provide assistance with repositioning (see observations above). III. Resident #8 A. Resident status Resident #8 age 85, was admitted on [DATE]. According to the April 2025 CPO diagnoses included dementia, lack of coordination and difficulty walking. The 2/28/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required maximum assistance from two staff members for transfers, toileting and showering. B. Record review The ADL care plan, initiated on 11/9/19 and revised on 11/12/19, revealed Resident #8 had a self-care performance deficit. Pertinent interventions included the resident required staff assistance for repositioning -However, observations revealed staff failed to offer or provide Resident #8 with repositioning for four hours (see observations above). IV. Staff interviews CNA #3 was interviewed on 4/1/25 at 11:35 a.m. CNA #3 said Resident #326 and Resident #8 needed help to go to the bathroom. CNA #3 said Resident #326 and Resident #8 needed to be checked every two hours for repositioning and incontinence care. Registered nurse (RN) #1 was interviewed on 4/1/25 at 1:08 p.m. RN #1 said Resident #326 and Resident #8 needed to be repositioned every two hours to check if they need to be cleaned to prevent skin breakdown and for comfort. Licenced practical nurse (LPN) #2 was interviewed on 4/2/25 at 1:40 p.m. LPN #2 said if any of the residents needed staff assistance then they should be checked at least every two hours. LPN #2 said checking for incontinence every two hours was important to prevent skin breakdown and to ensure the residents were clean and dry. The DON and the regional clinical resource (RCR) were interviewed together on 4/3/25 at 5:58 p.m. The DON said any resident that was dependent on staff for toileting should be checked every two hours. The DON said that was the standard of care that should be done. The DON said the nurses and the CNAs were trained to check Resident #326 and Resident #8 every two hours. The RCR said Resident #326 had an air mattress as an intervention for skin breakdown but the CNAs and the nurses needed to provide repositioning and offer incontinent care at least every two hours. The RCR said any resident whose care plan indicated they needed assistance with repositioning should be offered repositioning every two hours to prevent skin breakdown. The DON said it was important to provide timely repositioning and incontinence care to maintain skin integrity by offloading any bony areas and to maintain the residents comfort.

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record one (#376) of five residents reviewed for advance directives out of 49 sample residents. Specifically, the facility failed to ensure: -Resident #376 had a physician's order for their cardiopulmonary resuscitation (CPR) wishes in the resident's electronic medical record (EMR); and, -Resident #376's care plan included the resident's CPR wishes. Findings include: I. Facility policy and procedure The Advanced Directive policy, reviewed February 2025, was provided by the nursing home administrator (NHA) on [DATE] at 10:20 a.m. It read in pertinent part, Documentation shall be maintained in each resident's record. The facility will have a system for staff to identify the code status of each resident. II. Resident #376 A. Resident status Resident #376, age 73, was admitted on [DATE]. According to the [DATE] computerized physician's orders (CPO), diagnoses included esophageal obstruction, lobar pneumonia (a type of pneumonia that affects one or more lobes of the lung) and asthma. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 13 out of 15. B. Record review Review of the [DATE] CPO did not reveal a physician's order indicating the resident's CPR wishes. -On [DATE] (during the survey), a physician's order was entered into Resident #376's EMR for the resident's CPR wishes. Review of the resident's comprehensive care plan did not reveal documentation indicating the resident's CPR wishes. A review of the resident's EMR did not reveal documentation indicating the resident's medical orders for scope of treatment (MOST) form was scanned into the EMR and was not available for review. Registered nurse (RN) #3 could not locate Resident's #376's MOST form in the Advanced Directive binder, which was kept at the nurse's station.t have a copy of Resident #376's MOST form for review. On [DATE] at 5:25 the resident's MOST form was provided by social worker (SW) #2. The MOST form was signed on [DATE] (during the survey) by the resident's physician. The MOST form was scanned into the resident's EMR on [DATE] (during the survey). III. Staff interviews SW #2 and RN #3 were interviewed together on [DATE] at 5:15 p.m. RN #3 and SW #2 said on admission, the admitting nurse filled out the MOST form and confirmed the order in the EMR. They said a copy of the MOST form was put into the Advanced Directive binder and the original MOST form was placed in a folder for the provider to sign. They said once the original was signed this replaced the copy in the binder and the form was scanned into the EMR. SW #2 said she located Resident #376's MOST form in the folder that was waiting to be signed by the physician. SW #2 said the MOST form was signed by Resident #376 on [DATE]. SW #2 said Resident #376's MOST form had not been signed by the physician.

Based on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to prevent an elopement from the secured unit building for Resident #276. Findings include: I. Facility policy and procedure The Elopement/Unsafe Wandering policy and procedure, revised June 2024, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, To provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed or nongoal directed/aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization and or any necessary supervision to do so. Residents with capabilities of ambulation and/or mobility in wheelchairs will have an elopement/wandering evaluation completed to determine the risks for elopement and unsafe wandering on admission. Residents with high risk factors identified on the elopement/wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wandering behavior. These interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering. If a resident is missing, it is a facility-wide emergency. Missing resident procedures will be initiated. Determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, institute a search of the premises. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify the administrator, the director of nursing (DON), the resident's legal representative, the attending physician and law enforcement officials. When the resident returns to the facility, an assessment of the resident will be completed to determine if medical attention is required, provide interventions as indicated, notify search teams that the resident has been located, attending physician and resident representative will be notified of the resident's return, document relevant information in the resident's medical record. An elopement evaluation will be completed post-elopement with follow up documentation for a minimum of 72 hours following the incident. A review of the elopement incident by the interdisciplinary team (IDT) will include an investigation to determine the safety of the environment and probable causal factors leading to the elopement. The care plan will be updated and include interventions to address the possible need for increased level of supervision, staff will be educated on proper identification, assessment, and treatment of residents with elopement risks. Education will be provided on orientation and annually thereafter. II. Facility investigation of Resident #276's elopement on 3/31/25 The facility's investigation timeline of Resident #276's elopement was provided by the NHA on 4/2/25 at 12:19 p.m. The investigation revealed that at approximately 1:44 a.m. on 1/31/25 Resident #276 was seen on his unit. At 2:00 a.m. the unit nurse was on another unit with a different resident and the certified nurse aide (CNA) assigned to Resident #276's unit was on break. When the unit nurse returned to Resident #276's unit, the unit nurse noted that Resident #276 was not on the unit. The unit nurse and a CNA conducted a search and were able to find Resident #276 outside close to the entry of the facility's property. The staff were able to escort Resident #276 back into the facility. At 2:50 a.m. the registered nurse (RN) assessed Resident #276 for injuries. At 6:00 a.m. the unit nurse was verbally educated on ensuring that staff breaks were spaced appropriately so the unit was not unattended and ensuring that doors were properly latched when people entered and exited. At 7:00 a.m. Resident #276 was placed on frequent checks. At 8:45 a.m. the maintenance director (MTD) completed an environmental check to ensure that the doors were functioning and ensure that the doors latched properly. The MTD confirmed that everything was functioning and latching properly. At 6:18 p.m. the nurse practitioner documented a medication review for Resident #276. At 9:21 p.m. the psychiatric nurse practitioner documented completion of an evaluation of Resident #276. The investigation further documented that through facility determination, Resident #276 went over two desks at the nurse's station and activated the delayed egress door. The investigation included a timeline of the events of 3/31/25, root cause analysis and education to staff on the secure unit. The education included coordinating break times to ensure one staff member was always present on the unit. -However, the care plan did not address Resident #276's wandering behavior until during the survey process, even though the elopement/wandering assessment documented he was high risk. -Additionally, the care plan was not updated for elopement/wandering by social services until 4/3/25 (during the survey). III. Resident #276 A. Resident status Resident #276, age 83, was admitted on [DATE]. According to the April 2025 computerized physician order (CPO), diagnoses included dementia, type 2 diabetes and insomnia. The 3/24/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because Resident #276 was rarely or never understood. The staff assessment for mental status revealed that Resident #276 had short-term and long-term memory problems and his daily decision-making skills were severely impaired. The assessment indicated that Resident #276 required partial to moderate assistance with the majority of his activities of daily living (ADL). The assessment indicated that Resident #276 wandered. B. Resident representative interview Resident #276's representative was interviewed on 4/1/25 at 11:45 a.m. The representative said Resident #276 was recently diagnosed with dementia. She said a month ago he was able to drive himself to his appointments. She said he was adjusting to a new environment and it was all a new experience to him and to their family. The representative said she was aware of Resident #276's elopement on 3/31/25, she said the facility staff notified her, but she did not understand how a resident could elope from the secure unit. She said Resident #276's wishes were for safety and comfort and this was supposed to be the focus of his care. C. Observations On 4/2/25 at 1:50 p.m. an unidentified maintenance staff member was observed testing the doors to the middle secure unit to make sure that the doors locked properly. On 4/2/25 at 2:00 p.m. the door to the middle secure unit was observed to be slightly open. The door was able to be pushed fully open and allow a person to walk through the door and enter the middle secure unit without using a key card to unlock the door. On 4/2/25 at 2:31 p.m. the door to the middle secure unit was again able to be opened, without using a key card, in order to exit the middle secure unit. The light on the key pad where staff swiped their key cards was blinking from red to green, indicating that the door was not locked. D. Record review Review of Resident #276's mood/behavior care plan, initiated 3/27/25 and revised 4/2/25 (during the survey), revealed Resident #276 had mood/behavior problems due to his diagnosis of dementia with behaviors. The care plan documented that Resident #276 had had some agitation/aggression since admission and he liked to move furniture around and was at times difficult to redirect. The care plan documented Resident #276 would urinate in trash cans and on the floor. The care plan further revealed Resident #276 had a history of wandering without intent. Interventions included offering coffee, snacks, walks outside, going on outings, redirecting the resident to do a craft, offering a fidget lock box or pretend tool set, offering listening to Korean music and watching Korean television (TV). Review of Resident #276's secure unit placement care plan, initiated 4/3/25 (during the survey) revealed Resident #276 was a wanderer and elopement risk. Interventions included distracting the resident from wandering by offering a fidget lock box, fishing games, Korean music and TV, offering snacks and coffee and documenting the resident's wandering behaviors and attempted diversional interventions. The 3/20/25 elopement/wandering evaluation documented that Resident #276 was at high risk for wandering and elopement. The 3/20/25 medication administration note documented that Resident #276 was having behaviors of wandering, pacing the unit, touching other resident's hands, picking up the trashcan and moving it and then trying to sit on it and trying to sit on furniture that was already occupied. The note further documented that Resident #276 was pushing on the doors and causing the alarms to go off. The note documented that staff continued to redirect the resident but it was unsuccessful most of the time. The 3/21/25 behavior note documented that Resident #276 was pacing, restless and hitting the alarmed doors multiple times. The note documented that a drink and snack were given to Resident #276 and Resident #276 was able to make his needs known by asking or showing staff what he wanted. The 3/21/25 social services note documented that Resident #276's wandering behaviors continued. The 3/23/25 medication administration note documented that Resident #276 continued to wander and needed constant supervision. The 3/24/25 behavior note documented that Resident #276 continued to try to open doors and he was observed trying to open the back doors with a fork. The note further documented Resident #276 continued to wander into other residents' rooms. The 3/25/25 medication administration note documented Resident #276 continued to wander and exit seek. The 3/27/25 behavior note documented Resident #276 was restless and exit seeking by hitting the doors multiple times and causing the alarms to go off. The note documented that staff was able to redirect him by offering snacks and TV and staff would anticipate Resident #276's needs. The 3/28/25 behavior note documented Resident #276 was restless, pacing nonstop, wandering into other residents' rooms and causing the alarms to go off by hitting the doors. The note documented that staff redirected him by offering snacks, coloring and light activities, but Resident #276 continued to be restless. An incident note, dated 3/31/25, documented that Resident #276 had an unwitnessed fall around 2:50 a.m. As the RN was coming to the unit to do a fall assessment, Resident #276 was observed sitting in a wheelchair in the common area. The unit nurse had notified RN that Resident #276 jumped over the nurse's station wall and was able to leave the unit through the doors of the neighboring unit and out of the building. The note documented that the unit nurse told the RN that she was on a different unit and the CNA was on her break during the time that Resident #276 left the building. The unit nurse and a CNA drove around the building and were able to locate Resident #276 outside of the building but still on the facility campus. Resident #276 was observed to have a quarter-sized laceration on his right front forehead and a laceration on his left foot on the tarsal area of the big toe, and a minor laceration on the right knee from the fall outside of the facility. The unit nurse was to complete the fall and elopement interventions. The 3/31/25 nursing note documented that the nurse returned to the unit from the other two units to find that Resident #276 was missing. After searching each room, the nurse and CNA went outside to find Resident #276 near the entrance of the facility grounds, which was close to a very busy street. The note documented that Resident #276 was trying to go home and the unit nurse notified the RN of the incident and to come and perform an assessment on the resident. The same injuries were listed as in the incident note above. IV. Staff interviews The assistant nursing home administrator (ANHA) was interviewed on 4/2/25 at 10:03 a.m. The ANHA said Resident #276 eloped from the secured unit by jumping over the nurse's station to the other unit and pushed on the door by the hallway furthest from the nurse's station, which was a fire door that opened after a delayed period. She said the resident did not exit the building but he did leave the unit. The NHA was interviewed on 4/2/25 at approximately 11:15 a.m. The NHA said he did not recall all the details, but said he would ask the director of nursing (DON) to provide a timeline and walk through the events of 3/31/25. The DON was interviewed on 4/2/25 at 1:20 p.m. The DON said Resident #276 walked from his bedroom to the nurse's station around 2:00 a.m. and crawled over the nurse's station and went over the nurse's station through the neighboring unit. She said he was able to exit through that unit because the door was not fully latched closed. She said Resident #276 then found his way to the main exit. She said the doors were locked from the outside from 8:00 p.m. until 6:00 a.m. She said you could push the main doors of the secure unit open and it would not alarm but if someone left, they could not get back in. The DON said Resident #276 was found outside in the parking lot close to the entrance of the facility property. Social worker (SW) #3 was interviewed on 4/2/25 at 1:42 p.m. SW #3 said that social services did not have a specific schedule that they used when going on breaks but that the nursing staff did because there had to be someone on the floor at all times. CNA #1 was interviewed on 4/2/25 at 1:58 p.m. CNA #1 said when CNAs went on their breaks, they told each other they were going on break and they could only go one at a time so that way everyone could shift units and ensure there was always someone covering the floor. She said there was supposed to be someone on the floor at all times. CNA #5 was interviewed on 4/2/25 at 2:34 p.m. CNA #5 said that staff rotated when they went on their breaks to ensure the floor was always covered. She said if the light on the door was blinking then that meant the door was locked. CNA #6 was interviewed on 4/2/25 at 2:43 p.m. CNA #6 said that nurses would help cover the floor when the CNAs went on break. He said that if staff saw that a door was open then they should go and look to see why the door was open. He said that if there were any residents that were on elopement precautions then he would check the Kardex. He said that staff got elopement and dementia training during all-staff meetings. Licensed practical nurse (LPN) #5 was interviewed on 4/2/25 at 2:57 p.m. LPN #5 said CNAs were rotated for their breaks and nurses went when they found the time to go on their breaks. She said there was always someone on the floor. She said the doors that went to the outside of the unit had a light that blinked by the lock, which indicated they were locked. SW #3 was interviewed again on 4/2/25 at 2:01 p.m. She said new interventions that were put in place for him were the fidget lock box, fake tools and art supplies. SW #3 was interviewed a third time on 4/3/25 at 5:36 p.m. SW #3 said the facility staff believe Resident #276 was able to elope due to the lock not properly locking in the other unit's door. The MTD was interviewed on 4/3/25 at 5:45 p.m. The MTD said he identified a problem with the double door on the secure unit that was not latching appropriately. He said since it was noted, the door was guarded by staff members to ensure no residents left the unit. He said the door was fixed and functioning appropriately as of this afternoon 4/3/25. The MTD said he checked all the doors on the secure unit monthly to ensure they were functioning properly, however, he said this problem was not noted until recently.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#116) of two residents reviewed for dialysis out of 49 sample residents. Specifically, the facility failed to: -Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center; and, -Ensure thorough documentation was completed for Resident #116 dialysis treatments. I. Facility policy and procedure The Renal Dialysis, Care of Resident, Hemodialysis Access Site policy and procedure, revised December 2020, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, It is the policy of the facility to provide standards in the care of the residents on renal dialysis and the care of the vascular access site for hemodialysis. The facility licensed nurse will complete the baseline information, pre- and post-dialysis section of the nurse dialysis communication record. The dialysis center licensed nurse will complete the dialysis center section of the nurse dialysis communication record. II. Resident #116 A. Resident status Resident #116, age 80, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included end-stage renal disease, acquired absence of the kidney, malignant neoplasm of the right kidney, dementia, Melkersson's syndrome (a neurological disorder that caused facial swelling or paralysis) and the need for renal dialysis. The 1/26/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) of eight out of 15. She required substantial assistance with toileting, showering, and dressing. She required supervision with personal hygiene and set up for oral hygiene and eating. The MDS assessment indicated the resident received dialysis treatments. B. Resident interview and observations Resident #116 was interviewed on 3/31/25 at 2:57 p.m. Resident #116 said she did not know what day of the week she went to dialysis. She said there was a sign above her bed that indicated she attended dialysis on Tuesday, Thursday and Saturday. C. Record review Review of Resident #116's dialysis care plan, initiated 1/24/25, revealed the resident received dialysis on Tuesdays, Thursdays and Saturdays at 7:10 a.m. Interventions included checking arteriovenous fistula (a surgical connection between a vein and artery used for dialysis) as ordered, not drawing blood or taking blood pressing in arm with graft, encouraging the resident to go to scheduled dialysis appointments, monitoring labs and reporting to the doctor as needed, monitoring, documenting and reporting to doctor as needed any signs and symptoms of infection to access site and nutritionist to consult. -However, the care plan did not indicate to monitor vital signs and weights pre- and post-dialysis treatment. Review of Resident #116's April 2025 CPO revealed the following physician's order related to dialysis: Dialysis on Tuesday, Thursday and Saturday, ordered 1/28/25. Check vital signs upon return from dialysis, ordered 1/26/25. Monitor port site for signs and symptoms of infection every shift, ordered 1/23/25. Prostat AWC (a liquid protein supplement), 30 milliliters (ml) twice a day for dialysis and to optimize nutrition, may mix with juice, ordered 2/13/25. Nepro (oral nutritional supplement), provide three times a day for malnourishment and to optimize nutrition, ordered 1/24/25. Review of the February 2025 (2/1/25 to 2/28/25) medication administration record (MAR) revealed the following: -Dialysis was left blank on 2/1/25, 2/6/25, 2/8/25 and 2/22/25. -Review of the resident's electronic medical record (EMR) did not indicate why the MAR was left blank on 2/1/25, 2/6/25, 2/8/25 and 2/22/25. Review of the March 2025 MAR revealed the following: -Dialysis was left blank on 3/20/25 and 3/27/25. -Review of the resident's EMR did not indicate why the MAR was left blank on 3/20/25 and 3/27/25. Resident #116's dialysis binder was provided by licensed practical nurse (LPN) #4 on 4/3/25 at 1:43 p.m. Each log had three sections on one sheet of paper, which revealed the following: The first section was to be filled in by the facility before dialysis with the date and the resident's vital signs, which included temperature, pulse, respirations, blood pressure, weight and oxygen saturation levels. The section indicated to document the resident's weight, the resident's prescribed diet and if the resident's access site was intact. The section also prompted the nurses to document if the resident was COVID-19 positive, if the facility had a resident who was COVID-19 positive and if the resident was exposed to COVID in the past 14 days. The second section was the post-dialysis section was to be filled out by the facility with the resident's vital signs and if the access site was intact. A nurse's signature was required to validate that the information was completed. The third section of the communication form was to be filled out by the dialysis center staff. The documentation included the resident's vital signs, the resident's weight pre- and post-dialysis, the diet, if the access to the site was intact, and any recommendations or comments. A provider's signature and a date were required to validate that the information was completed. -However, Resident #116's dialysis binder included two communication forms. Resident #116's dialysis communication logs from 2/13/25 to 3/29/25 were provided by the NHA on 4/3/25. -The facility was unable to provide dialysis communication forms for 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25 and 2/11/25. -Review of the resident's EMR did not indicate if the resident missed dialysis on 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25 and 2/11/25. Review of the communication forms that the facility provided documented the following: The pre-dialysis section had the diet section left blank on the following dates: 2/20/25, 2/27/25, 3/20/25, 3/25/25 and 3/27/25 The pre-dialysis section had the weight left blank on 2/13/25, 3/11/25 and 3/29/25 The pre-dialysis section had the access site intact section blank on 3/22/25. The dialysis center section was left blank on the following dates: 2/18/25, 3/8/25, 3/15/25, 3/20/25, and 3/27/25 III. Staff interviews LPN #4 was interviewed on 4/3/25 at 6:10 p.m. He said when a resident went to dialysis, the facility nurse was responsible for obtaining the resident's pre-dialysis vital signs, weight and making sure the dialysis access site was intact. He said he documented the information on the dialysis communication sheet. He said the dialysis communication sheet went with the resident to dialysis in a binder. LPN #4 said the dialysis staff completed the dialysis center information on the communication sheet. LPN #4 said when the resident returned from the dialysis center, the resident's vital signs were obtained. He said the facility nurse entered the post-dialysis vital signs either on the dialysis communication sheet or on the MAR. He said he was not sure why some of the communication sheets were not completed in their entirety for Resident #116. Assistant director of nursing (ADON) #1 and the director of nursing (DON) were interviewed on 4/3/25 at 4:22 p.m. ADON #1 said when a resident was admitted to the facility and was receiving dialysis, the facility would make sure they knew the days, time, and location when the resident went to dialysis. ADON #1 said the nurse monitored the port or fistula site for signs and symptoms of infection each shift. ADON #1 said if the resident had a fistula, the nurse would remove the dressing as indicated per the dialysis center, which generally was the day after dialysis. ADON #1 said the days the resident had dialysis, the nurse completed vital signs and obtained the resident's weight. ADON #1 said the nurse documented the vital signs and the resident's weight on the communication form. ADON #1 said the communication form was placed in a binder that also had the resident's face sheet, the resident's preferences for life sustaining measures and a list of the resident's medication. ADON #1 and the DON said they did not know information was missing from the dialysis communication form for Resident #116. They said they did not know Resident #116's MAR was missing information.

Based on observations, record review and interviews, the facility failed to ensure residents who were diagnosed with dementia received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #276. Findings include: I. Facility policy and procedure The Specialized Dementia and Behavioral Care Program policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, The Specialized Dementia and Behavioral Care Program includes a secured unit (SU) designed to meet the needs and ensure the safety of individuals with Alzheimer's, dementia/delirium, psychiatric/behavioral diagnoses, and other diagnoses deemed appropriate for the secured unit by the admissions assessment. To respond to the needs of both family and resident, the therapeutic milieu includes such services as individualized assessments and plan of care based on the needs of the resident. These services are designed to provide an understanding of the resident's specific requirements and skilled approach in the management of health, safety, and an emotional support of residents and family. The primary objective of the SU is to provide therapeutic setting that will maximize the resident's functioning for as long as possible and help ease the burden for families. The SU will maintain resident safety by being locked and/ or alarmed at all entry and exit doors. Through resident care planning, each resident will be cared for by an interdisciplinary team (IDT) of professionals working cooperatively and collaboratively to provide individualized care. II. Resident #276 A. Resident status Resident #276, age 83, was admitted on [DATE]. According to the April 2025 computerized physician order (CPO), diagnoses included dementia, type 2 diabetes and insomnia. The 3/24/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because Resident #276 was rarely or never understood. The staff assessment for mental status revealed that Resident #276 had short-term and long-term memory problems and his daily decision-making skills were severely impaired. The assessment indicated that Resident #276 required partial to moderate assistance with the majority of his activities of daily living (ADL). The assessment indicated Resident #276 found listening to music he enjoyed, group activities, participating in his favorite activities, going outside and participating in his religious activities were very important to him. The assessment indicated that Resident #276 wandered but did not exhibit any other behaviors. B. Observations During a continuous observation on 3/31/25, beginning at 11:40 a.m. and ending at 12:55 p.m., the following was observed: At approximately 12:00 p.m. Resident #276 was eating in the dining area, he was standing then sitting, then standing staff was assisting him and trying to redirect him to sit while eating. At 12:04 p.m. staff brought Resident #276 more food, he ate some but did not finish. At approximately 12:10 p.m. Resident #276 was grabbing books from the community book shelf and carried them around the unit. -Staff on the unit did not attempt to redirect the resident by offering a different meaningful activity to the resident At 12:13 p.m. an unknown male resident told Resident #276 to put the books back, however, Resident #276 did not put the books back. The unknown male resident then hit the back of the books that Resident #276 was holding. Staff did not observe the interaction or intervene. At 12:38 p.m. Resident #276 unplugged the computer from the wall and staff redirected him by telling him that the church group was coming up. -However, staff did not attempt to take the resident to the middle secure unit where the church group would be held. At 12:40 p.m. Resident #276 wandered into another resident's room. Staff did not see Resident #276 in the other residents' room until he came out of the room. Staff again told Resident #276 about the church group. -However, staff again did not attempt to take the resident to where the church group would be held. At 12:55 p.m. staff was taking other residents over to the middle unit for the church group activity. -However, staff did not take Resident #276 to the church group, despite having told the resident two times that the church group activity was coming up. During a continuous observation on 3/31/25, beginning at 3:36 p.m. and ending at 4:09 p.m., the following was observed: At 3:46 p.m. Resident #276 was in the common area sleeping in a rocking chair At 3:53 p.m Resident #276 woke up and began to push the entertainment center that was underneath the TV towards an unknown female resident. Resident #276 stopped right before he pushed it into the unknown female resident's foot. -However, staff did not intervene and attempt to offer the resident any meaningful activities to distract him from moving the furniture. Resident #276 walked into another resident's room and began to take his pants down to urinate in the other resident's bathroom. Staff was heard telling him not to use that bathroom and to use his own bathroom. -However, staff did not attempt to take the resident to his room to see if he needed to use the bathroom. At 3:57 p.m. staff moved the entertainment center back to where it had come from. At 4:09 p.m. Resident #276 was trying to remove an unknown female resident from the recliner she was sitting in. Staff continued to intervene by telling him no and that someone was already sitting in the chair. -However, staff did not attempt to offer the resident any meaningful activities to redirect the resident. C. Record review The impaired cognitive function care plan, revised 3/21/25, revealed Resident #276 had dementia with behaviors. Interventions included administering medications as ordered, communicating with family and care givers regarding capabilities and needs and keeping the resident's routine consistent. The trauma care plan, revised 3/27/25 revealed Resident #276 was at risk for re-traumatization due to his history of wartime trauma and experiences with racism. Interventions included anticipating and meeting the resident's needs, approaching the resident in a calm manner, ensuring the resident had opportunities to connect with religious/spiritual groups, ensuring the resident had opportunities to go outside and providing sensory activities to ground the resident when he was anxious. Review of Resident #276's mood/behavior care plan, initiated 3/27/25 and revised 4/2/25 (during the survey) revealed Resident #276 had mood/behavior problems due to his diagnosis of dementia with behaviors. The care plan documented that Resident #276 had had some agitation/aggression since admission and he liked to move furniture around and was at times difficult to redirect. The care plan documented Resident #276 would urinate in trash cans and on the floor. The care plan further revealed Resident #276 had a history of wandering without intent. Interventions listed included offering coffee, snacks, walks outside, going on outings, redirecting the resident to do a craft, offering a fidget lock box or pretend tool set and offering listening to Korean music and Korean television. The 3/20/25 medication administration note documented that Resident #276 was having behaviors of wandering, pacing the unit, touching other resident's hands, picking up the trashcan and moving it and then trying to sit on it and trying to sit on furniture that was already occupied. The note further documented Resident #276 became aggressive with staff when staff offered assistance. The note documented that staff continued to redirect the resident, but it was unsuccessful most of the time. -However, the note failed to document what interventions, if any, staff attempted to use to redirect the resident. The 3/21/25 behavior note documented that Resident #276 was easily upset when putting chairs on the table while other residents were still eating. Resident #276 got upset when he was told no and he did not like it when he was approached with medication and he slapped the nurse on the wrist and said No. He did eventually take his medication. The 3/23/25 at 12:35 a.m.behavior note documented Resident #276 was having behaviors of hitting, kicking and attempting to bite staff while staff was trying to provide care. -However, the note failed to document if staff attempted to use interventions to distract the resident from his behaviors. The 3/23/25 at 5:33 a.m. behavior note documented Resident #276 continued trying to bite staff and kick and hit staff anytime care was attempted. Resident #276 was talking in Korean only and getting easily agitated. Resident #276 was cleaned and changed only to be seen shortly after with his pants on his head, tearing up his brief and randomly urinating around the unit. An unsteady gait was noted. Resident #276 was assisted to his room, only to find he had torn up his bed and the bedding and mattress were on the floor, as well as other belongings scattered around the room. Staff cleaned the room, and the resident was encouraged to lay down, but he refused. Resident #276 was reminded that he could not be nude in the common area, but Resident #276 was ignoring staff and attempting to urinate on the floor again. Staff would continue to monitor. -However, the note failed to document that staff attempted to offer the resident meaningful activities to redirect his behaviors. The 3/24/25 nursing note documented that Resident #276's representative said he preferred to sleep on the floor and on the carpet at home while he was watching TV. The note documented this was a behavior he had done for years. -However, the facility failed to document the resident's preferred behavior of sleeping on the floor as a potential intervention for the behavior observed in the 3/23/25 nursing note (see note and care plan above). The 3/25/25 behavior note documented Resident #276 was very restless. He was pacing, hitting alarm doors and flipping tables and chairs multiple times. Staff was to redirect as needed. -However, the note failed to document what interventions, if any, staff attempted to use to redirect the resident. The 3/27/25 behavior notes documented Resident #276 was urinating in inappropriate places and had hit a CNA really hard on the ear. -However, the note failed to document what interventions, if any, staff attempted to use to redirect the resident. The 3/28/25 behavior note documented that Resident #276 had been awake for most of the night shift pacing, restless, wandering the unit and rearranging furniture. The resident refused to stay in bed. Resident #276 became agitated when staff redirected him from entering other resident's rooms. The resident attempted to unplug the TV and cords from the wall. Staff tried to redirect him with watching TV and coloring. The redirection only lasted a few minutes before Resident #276 continued with his behaviors. -However, the note failed to document if staff attempted to use to redirect the resident with other care planned interventions, such as offering the resident coffee or snacks (see care plan above). III. Staff interviews Social worker (SW) #3 was interviewed on 4/2/25 at 1:42 p.m. SW #3 said staff did dementia training through an online training program and the facility was trying to get a specialized training set up again to have staff trained yearly. SW #3 was interviewed a second time on 4/2/25 at 2:01 p.m. SW #3 said new interventions that were put into place recently for Resident #276 were a fidget lock box, fake tools and art supplies. SW #3 was interviewed a third time on 4/3/25 at 5:36 p.m. SW #3 said the facility recently found out about Resident #276's trauma history of wartime Korea and experiences with racism from his family. She said the family member informed the facility that Resident #276 was very busy and was always moving and doing something. SW #3 said the family member said he liked to fix things, so the facility got him some fake tools and he liked to fish so the facility tried some fishing games with him. SW #3 said none of those interventions seemed to help. -However, observations during the survey did not reveal that staff had offered those interventions to the resident to redirect him (see observations above). SW #3 said the facility was collaborating with Resident #276's family on determining effective interventions for him. She said the resident's dementia decline had been rapid, according to the family. SW #3 said facility staff reviewed all the new residents' charts before they were admitted to the unit. She said the facility staff had noticed that Resident #276 had not been sleeping which staff thought could be a contributing factor to his behaviors. SW #3 said facility staff had the resident on standard monitoring at night. She said he was exhibiting behaviors as soon as he was admitted to the facility. SW #3 said, as soon as facility staff knew about an effective intervention that worked with a resident, the resident's care plan was updated. She said the resident had recently started on Haldol (an antipsychotic medication) and the staff thought the medication was helping with the resident's behavior stabilization.

Based on observations, record review, and interviews, the facility failed to ensure all drugs and biologics were properly stored and labeled for one (#101) of two residents reviewed out of 49 sample residents. Specifically, the facility failed to ensure medications that were not administered were not left unsecured at Resident #101's bedside. Findings include: I. Facility policy and procedure The Medication Access and Storage policy and procedure, revised August 2019, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. It read in pertinent part, The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. II. Resident #101 A. Observation and resident interview On 3/31/25 at 3:20 p.m., during an interview with Resident #101, a white rectangular box labeled lidocaine hydrochloride (hcl) 3% cream (topical pain medication) was on the resident's bedside table. Inside the box was a used tube labeled lidocaine hcl 3% cream. Resident #101 said the staff applied the cream when providing personal care. On 4/2/25 at 11:24 a.m. registered nurse (RN) #2 was interviewed in Resident #101's room. RN #2 said the lidocaine HCl 3% cream and diclofenac 3% gel (topical pain medication) were on the resident's bedside table. RN #2 said the resident went to a program of all-inclusive care for the elderly daily and they could have sent her back with a prescription. RN #2 went to the medication cart. He said he was unable to locate either medication in his cart. RN #2 said he reviewed the resident's computerized physician orders (CPO) in the resident's electronic medical record (EMR) and he did not see an order for the lidocaine HCl 3% cream or for the diclofenac 3% gel. B. Record review A review of Resident #101's EMR did not reveal documentation that the resident was able to self-administer medications. A review of Resident #101's EMR revealed the resident did not have a physician's order for the lidocaine HCl 3% cream or for the diclofenac 3% gel. C. Staff interviews RN #2 was interviewed on 4/2/25 at 11:24 a.m. RN #2 said medications should never be left at a resident's bedside. RN #2 said the only time a medication could be left with a resident was if the resident had an assessment indicating the resident was able to self-administer medication. RN #2 said he only worked the unit Resident #101 resided on and there was only one resident who could self-administer medications. RN #2 said Resident #101 could not self-administer because a self-administered assessment was not completed for her. RN #2 said he never administered either medication and he would ask the resident when she returned from PACE to see who administered the medications. RN #2 was interviewed again on 4/2/25 at 5:35 p.m. He said he talked to Resident #101. He said Resident #101 said the staff applied both medications and she did not specify which staff member used the medication. RN #2 said he told the director of nursing (DON). The DON was interviewed on 4/2/25 at 5:51 p.m. The DON said medications could not be left with residents. She said the only time medications could be left with a resident was if the resident had an assessment indicating the resident was able to self-administer medications. The DON said Resident #101 could not self-administer medications because an assessment was not completed. The DON said it was important not to leave medications at the bedside because other residents could have found the medication and an accident could have occurred. III. Facility follow-up The NHA provided the following information on 4/4/25 at 11:30 a.m. An action plan titled the Over-the-Counter (OTC) Medications Process Improvement Plan revealed that OTC medications were found at the bedside. The facility conducted an audit to identify other residents who have medication at their bedside. No additional residents were identified with medications at the bedside. Education was initiated for nursing staff that treatments could not be left at the bedside.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of seven units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #326 and #95, who were both on enhanced barrier precautions (EBP) for pressure wounds. Findings include: I. Failed to ensure staff wore the appropriate PPE for Resident #326 and #95, who were both on EBP for pressure wounds A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 4/3/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. II. Facility policy and procedure The Infection Prevention and Control Program policy, revised October 2022, was received from the director of nursing (DON) on 4/1/25 at 1:30 p.m. The policy read in pertinent part, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goals: -Decrease the risk of infection to residents and personnel; -Recognize infection control practices while providing care; -Identify and correct problems relating to infection control; -Ensure compliance with state and federal regulations related to infection control; -Promote individual resident's rights and well-being while trying to prevent and control the spread of infection; and, -Monitor personnel health and safety. The infection prevention and control program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel. 'Personnel' covers staff, volunteers, visitors, and other individuals providing services under a contractual agreement. III. Resident #326 A. Observations On 4/1/25 at 11:32 a.m. a sign on Resident #26's door indicated the resident was on EBP. Resident #326 had pressure wounds on his thigh and coccyx. The sign on the resident's door indicated gloves and gowns must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. PPE was hanging on the back of Resident #326's door. On 4/1/25 at 11:48 a.m. certified nurse aide (CNA) #2 and CNA #3 were providing incontinence care to Resident #326. The CNAs changed the resident's brief. Both CNAs wore gloves while the incontinence care was provided. -However, CNA #2 and CNA #3 failed to put on protective gowns prior to providing incontinence care to Resident #326. IV. Resident #95 A. Observations On 4/2/25 at 1:34 p.m. a sign on Resident #95's door indicated the resident was on EBP. Resident #95 had pressure wounds on both of his heels. The sign indicated gloves and gowns must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. PPE was hanging on the back of Resident #95 door. On 4/3/25 at 11:15 a.m. CNA #1 was observed providing incontinence care to Resident #95. CNA #1 took Resident #95 to the bathroom, assisted the resident to a standing position, removed the resident's soiled pants and brief and assisted the resident onto the toilet. CNA #1 put on gloves prior to providing incontinence care to the resident. -However, CNA #1 failed to put on a protective gown prior to providing incontinence care to Resident #95. V. Staff interviews CNA #3 was interviewed on 4/1/25 at 11:35 a.m. CNA #3 said if a resident was on EBP, the room would have PPE available. She said EBP meant staff were to wear a gown when providing residents' care. CNA #3 said she was unsure if Resident #326 was on EBP she was and not sure why there was a sign on the resident's door. Registered nurse (RN) #1 was interviewed on 4/1/25 at 1:08 p.m. RN #1 said she would check the medical record dashboard to see if a resident was on EBP and also get a verbal report from the nurse going off shift. In addition, RN #1 said she would look for the signs on the doors which indicated a resident was on EBP. RN #1 said there should be PPE behind the doors in the residents' rooms if they were on EBP. RN #1 said the nurses and the CNAs should put on a gown and gloves for direct contact resident care, such as toileting, wound care, dressing and transferring to prevent a resident from getting an infection. RN #1 said she was unsure of how many residents she currently had on EBP in her unit. Licenced practical nurse (LPN) #2 was interviewed on 4/2/25 at 1:40 p.m. LPN #2 said when a resident was on EBP, the nurses and the CNAs were supposed to wear gloves and gowns when taking them to the bathroom, getting them dressed or changing the wound dressings to avoid spreading infections. CNA #1 was interviewed on 4/3/25 at 11:22 a.m. CNA #1 said if a resident was on EBP, she needed to put on gloves and a gown when providing resident care, such as toileting and dressing. She said she forgot to put on a gown when she took Resident #95 to the bathroom. CNA #1 said it was important to maintain EBP to prevent the residents from getting any infections or spreading infections. The DON, the regional clinical resource (RCR) and the infection preventionist (IP) were interviewed together on 4/3/25 at 1:46 p.m. The DON and the IP said CNAs and nurses were to wear gloves and a gown when providing foley care, incontinence care, wound care, dressing and transfers if a resident was on EBP. The IP said it was important to wear the appropriate PPE for the safety of the residents and staff and to prevent the potential spread of infections.

Based on observations, record review and interviews, the facility failed to ensure the resident's environment was free from accident hazards for three (#95, #12 and #19) of eight residents reviewed for falls out of 53 sample residents. Resident #95, who had a previous history of falls at the facility and was identified to be at high risk for falling, experienced a fall on 1/9/24 which resulted in a left hip fracture that required hospitalization and a left partial hip replacement. The facility failed to ensure effective and timely interventions were in place after 11/27/23 to prevent Resident #95 from sustaining a fall on 1/9/24 which resulted in a left hip fracture. The facility failed to ensure effective interventions to prevent additional falls on 2/6/24 and 3/1/24. The facility failed to timely assess and notify providers of the fall on 1/9/24 until two hours after Resident #95 began complaining of left lower extremity pain, when pain medication and a hip x-ray was ordered. The facility failed to notify the provider for further orders when the x-ray was not completed until 12 hours after the - ray was initially ordered and 14 hours after Resident #95 began complaining of left lower extremity pain. The facility's failures to implement effective and timely fall interventions resulted in Resident #95 sustaining a fall resulting in a left hip fracture. Due to the facility's failure to follow-up timely with the provider after the resident's fall and complaints of pain, Resident #95's left hip fracture was not identified and treated in a timely manner. Resident #12 was admitted on [DATE] with a known history of repeated falls and fall with major injury. Resident #12 sustained a fall on 11/13/23 which resulted in an abrasion to the resident's back. The facility implemented a fall intervention for Resident #12's bed to be in the lowest position when she was in bed following the 11/13/23 fall, however, facility staff failed to implement the intervention or report the resident refused to allow her bed to be in the lowest postion. Resident #12 sustained a second fall on 1/20/24 which resulted in the resident being transferred to the hospital and receiving 12 staples for a laceration to the back of her head. The facility again failed to update Resident #12's care plan with additional interventions or reassess the resident's fall interventions to determine their effectiveness. Due to the facility's failure to implement and monitor the effectiveness of fall interventions, Resident #12 sustained a fall resulting in a laceration to the back of her head which required staples. Additionally, the facility failed to: -Ensure staff were implementing the fall interventions identified on Resident #19's care plan; and, -Ensure staff knew what person-centered fall interventions were to be implemented for Resident #19 and where to locate what interventions were to be implemented for the resident. Findings include: I. Facility policy and procedure The Fall Management System policy and procedure, reviewed December 2023, was provided by the nursing home administrator (NHA) on 3/7/24 at 1:20 p.m. It read in pertinent part, It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan intervention will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. II. Resident #95 A. Resident status Resident #95, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included left femur fracture, vulvar cancer and dementia. The 1/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision/touch assistance with transfers and toileting, set up assistance for eating and was independent with personal hygiene and bed mobility. The assessment documented the resident did not have any falls since the prior assessment or admission. B. Observations and resident interview On 3/5/24 at 1:26 p.m., Resident #95 was sitting in a wheelchair wearing non-skid socks. Resident #95's bed mattress was observed to have raised edges. -There was no bedside floor mat observed in the room and no signage to remind the resident to call for assistance was observed in the room. On 3/6/24 at 1:00 p.m., Resident #95 was lying in bed on a raised edge mattress. The resident's bed was in a low position. -There was no floor mat observed on the floor next to the resident's bed and no signage to remind the resident to use her call light for assistance was observed in the room. On 3/7/24 at 1:00 p.m., signage was observed taped to the wall at the foot of Resident #95's bed underneath the television. Resident #95 was interviewed on 3/7/24 at 1:00 p.m. She said the night she broke her hip she fell on the floor next to the bathroom. She said when they returned her to bed it hurt a lot. She said it took them a long time to call the doctor and finally call an ambulance to take her to the hospital. She said she did not know what hipsters were and she was not currently wearing them. C. Record review The fall care plan, initiated 10/13/21 revised 3/8/23, indicated Resident #95 had experienced a fall. Interventions included signage to remind the resident to call for help, therapy to focus on safety with turning and sitting safely in chairs, bed bolsters in bed, bed in lowest position, non-skid socks, needed items within reach and neurological checks. The actual fall care plan, initiated on 1/11/24, indicated Resident #95 had experienced an actual fall with a left hip fracture. Interventions included bed in lowest position, encourage resident to share feelings with staff and engage in meaningful activities, evaluate height of chair and assess for super hemi chair versus leg rests, floor mat when resident was in bed, monitor and report to physician for pain, bruises, change in mental status, offer and encourage resident to wear hipsters for protection and therapy consult. A comprehensive review of the care plan interventions included to ensure staff applied non-skid socks was added after an unwitnessed fall out of her wheelchair on 11/27/23. A comprehensive review of the care plan interventions revealed bed placed in lowest position on 1/11/24, floor mat when resident was in bed and hipsters on 1/18/24 after the resident experienced a fall with hip fracture on 1/9/24. -However, observations revealed there was no floor mat next to the resident's bed when she was in bed and the resident said she did not know what hipsters were and was not wearing any (see observations and resident interview above). A comprehensive review of the care plan interventions revealed bed bolsters applied on 2/6/24 after the resident experienced a fall rolling out of bed on 2/6/24. A comprehensive review of the care plan intervention revealed evaluation of wheelchair height and assess for hemi chair versus leg rests on 3/4/24 after the resident experienced a fall transferring from her wheelchair to the bed. The 11/27/23 nursing progress note revealed Resident #95 had an unwitnessed fall out of her wheelchair. The resident was combative and had an elevated blood pressure and pulse during the assessment. The resident was observed wearing fuzzy non gripping socks. The resident was sent to the emergency department for further evaluation for a change in behaviors. The 11/28/23 fall committee interdisciplinary team (IDT) progress notes documented interventions initiated ensuring staff encouraged the use of non-slip socks at all times and occupational therapy upon the resident's return from the hospital. The 12/14/23 fall risk assessment indicated Resident #95 was at high risk for falls. The 1/9/24 at 9:30 p.m. nursing progress notes documented a fall, witnessed by a certified nurse aide (CNA), while the resident was ambulating in the room. There was no visible injury upon assessment by the registered nurse (RN) and the staff assisted the resident into a wheelchair. -A comprehensive review of Resident #95's electronic medical record (EMR) failed to reveal documentation of a pain assessment before the resident was moved to the wheelchair. -There was no documentation of notification of the provider, director of nursing (DON) or family members immediately after the fall. The 1/9/24 at 10:30 p.m. nursing progress notes documented the resident was complaining of left lower extremity pain. The RN assessment indicated there was no swelling or bruising. The RN explained to the resident she did not have pain medication ordered. -There was no documentation to indicate the RN notified the provider or the fall at the time the resident was complaining of left lower extremity pain to obtain orders for pain medication or an x-ray. The 1/10/24 at 12:22 a.m. physician's order revealed Ibuprofen 400 milligrams (mg) one time only for pain. -The physician's order for pain medication was not obtained until two hours after Resident #95 began complaining of left lower extremity pain. The 1/10/24 at 12:23 a.m. nursing progress notes documented the resident was complaining of left lower extremity pain and was moving the leg minimally. No injury was noted. A left hip x-ray was ordered. -The order for the x-ray was not obtained until two hours after Resident #95 began complaining of left lower extremity pain. The 1/10/24 at 1:49 p.m. nursing progress notes documented an x-ray of the resident's left hip was obtained at 12:30 p.m. and results of a fractured hip was reported to the facility. Resident #95 was sent to the hospital via ambulance at 1:40 p.m. -The left hip x-ray was not obtained until 12 hours after it was ordered (14 hours after Resident #95 began complaining of left lower extremity pain). -The EMR failed to reveal documentation that the facility had notified the provider for further orders when the left hip x-ray was not completed in a timely manner. The 1/10/24 fall investigation documented a witnessed fall. The resident was ambulating in her room on 1/9/24 at 9:30 p.m. and fell on the floor onto her left side and did not hit her head. She had initially complained of right hip pain but later complained of left hip pain. She was assessed by two RN's. Orders were received for pain medication and a left hip x-ray. Resident #95 was sent to the hospital on 1/10/24 at 1:30 p.m. It documented the physician was notified at 1:25 pm. Family member was notified on 1/10/24 at 3:40 p.m. (Two hours after the resident was sent to the hospital). The 1/16/24 hospital records documented the resident was admitted on [DATE] with a closed fracture of the left hip. The resident underwent surgery for a partial left hip replacement. -A comprehensive review of Resident #95's EMR failed to reveal an IDT note post fall on 1/10/24. The 1/16/24 fall risk assessment indicated Resident #95 was at high risk for falls. The 2/6/24 nursing progress notes documented a witnessed fall when the resident rolled out of bed and fell on to her right side but did not hit her head. A physical assessment was performed and the resident had no obvious injuries and denied pain. She was assisted back to bed. The 2/6/24 fall IDT progress notes documented a fall with no injuries. Interventions added were bolsters to the bed. The 2/6/24 fall investigation documented a witnessed fall of the resident rolling out of bed and landing on her right side. It documented there was no physical injury on assessment and the resident denied pain. The resident was assisted back to bed and the bed was left in lowest position with call light in reach. -A review of the EMR did not reveal if the bed mat was in place during the 2/6/24 fall. The 3/1/24 nursing progress notes documented an unwitnessed fall when the resident was self transferring to the bed from the wheelchair. Resident was assisted to bed, bed lowered to the floor, bed mat in place and educated to use call light. Resident had no injuries, no pain, vital signs and neurological assessments were stable. Provider, DON and family were notified. The 3/1/24 fall risk assessment indicated Resident #95 was at medium risk for falls. The 3/4/24 IDT progress notes documented an unwitnessed fall with no injuries. Interventions added were occupational therapy to assess wheelchair. The 3/4/24 occupational therapy (OT) notes documented the resident had low safety awareness. Interventions included were increasing functional ability to use walker, education to lock brakes on wheelchair before standing. Resident required verbal and tactile cues. The CNA documentation for fall prevention devices (low bed, mats on floor, hipsters, visual checks, bolster pillow/concave mattress) in place from 2/7/24 to 3/6/24 revealed: -On 2/7/24 there was no documentation of bed mats on the floor or bolster pillow/concave mattress in place; -On 2/8/24 there was no documentation of hipsters in place; -On 2/9/24 there was no documentation of bed mats on the floor or hipsters; -On 2/10/24 there was no documentation of bed mats on the floor or hipsters; -On 2/11/24 there was no documentation of bed mats on the floor, hipsters or non-skid socks; -On 2/13/24 there was no documentation of bed mats on the floor; -On 2/14/24 there was no documentation of bed mats on the floor; -On 2/15/24 there was no documentation of bed mats on the floor; -On 2/16/24 there was no documentation of bed mats or non-skid socks; -On 2/17/24 there was no documentation of bed mats, hipsters or non-skid socks; -On 2/18/24 there was no documentation of low bed; -On 2/19/24 there was no documentation of bed mats on the floor or hipsters; -On 2/21/24 there was no documentation of bed mats on the floor; -On 2/22/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/23/24 there was no documentation of bed mats on the floor, non-skid socks, and visual checks by staff; -On 2/24/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/25/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/26/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/27/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/29/24 there was no documentation of bed mats on the floor or non-skid socks; -On 3/1/24 there was no documentation of bed mats on the floor or non-skid socks; -On 3/2/24 there was no documentation of bed mats on the floor or non-skid socks; -On 3/3/24 there was no documentation of bed mats on the floor; -On 3/4/24 there was no documentation of non-skid socks; -On 3/5/24 there was no documentation of bed mats on the floor or non-skid socks; and, -On 3/6/24 there was no documentation of bed mats on the floor. The visual bedside kardex report (a tool utilized by CNAs to provide consistent care) indicated safety interventions included signage to remind the resident to call for help, added 10/22/21, bed bolsters, bed in lowest position, monitor for increased fall risk with position changes, needed items within reach, hipsters applied daily as tolerated and resident was independent with transfers. D. Staff interviews CNA #4 was interviewed on 3/7/24 at 12:45 p.m. CNA #4 said residents at high risk for falls should have a low bed and call light in reach. She said CNAs accessed the point of care (POC) task section to find out what fall interventions were in place for the resident. She said Resident #95 required a low bed and a call light in reach and one person assistance to transfer from wheelchair to the bed but she was getting to the point where she could transfer herself. She said she did not know of any other interventions. She said she did not know the frequency to check on Resident #95 but they would check on her every so often. Licensed practical nurse (LPN) #1 was interviewed on 3/7/24 at 12:50 p.m. LPN #1 said fall interventions were populated in the treatment administration record (TAR). She said residents at high risk for falls should have interventions to include a call light in reach and a specialty bed. She said she did not know the specific fall interventions for Resident #95 but she said the resident should not be transferring herself from the wheelchair to the bed. After consulting with the DON on how to access the care planned interventions, LPN #1 said Resident #95's interventions included a low bed, call light in reach, fall risk assessments, signage in room to call for help, a walker to ambulate, therapy to work with resident and bed mats in place while in bed. The DON was interviewed on 3/11/24 at 9:32 a.m. The DON said when a fall occurred the fall was reported to the RN and the RN would conduct an assessment before the resident was removed from the floor. She said the provider, family and DON would be notified. She said risk management would be notified and a post fall IDT committee would meet the following day. She said the IDT committee did a root cause analysis with staff input for what interventions to put into place to help prevent further falls and minimize injury. The DON said interventions were care planned and placed on the Kardex for CNAs. She said CNAs did a shift end report to discuss what fall interventions were in place for residents at high risk for falls. She said CNAs accessed the Kardex for the current fall interventions and the POC task tab was for documentation. The DON said nurses accessed the care plan, progress notes and reviewed IDT post fall notes to get the most current information on fall interventions. She said nurses did not access fall interventions on the TAR. The DON said standard fall interventions included call light in reach, bed in low position, floor mats, reminder signs, work around preferences to avoid self transfers, medication reviews, and frequent rounding every two hours. Increased rounding occurred with staff input for frequently falling residents. Frequent rounding was care planned and documented. She said frequent round documentation was on a separate form that was carried with the nurses. The DON said Resident #95 had bed mats after returning from her hospitalization in January 2024, however, she said the floor mats had been removed as an intervention on 3/7/24 (during the survey) because it was a tripping hazard. She said when an intervention was removed it would be documented on the care plan. The DON said Resident #95 would remove the signage to call for assistance. She said Resident #95 had not been cleared by therapy to self transfer. She said failure to implement or monitor fall interventions could result in additional falls or injury. 47151 III. Resident #12 A. Resident status Resident #12, age 85, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included chronic respiratory failure, cognitive communication deficit, lack of coordination, compression fracture of the first lumbar (lower back) vertebrae and repeated falls. The 1/27/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required substantial assistance for bathing and transferring in and out of the shower; moderate assistance with dressing and personal hygiene, and bed/chair to chair transfers; and supervision or touching assistance with mobility and moving from a sit to stand position. The MDS assessment revealed the resident had a history of a fall with a major injury. B. Resident observations On 3/7/24 at 7:59 a.m., Resident #12 was lying in bed in her room with the lights off. Resident #12's bed was not in a low position and a wheelchair, walker and bedside table were next to the bed. On 3/7/24 at 8:54 a.m., Resident #12 was lying in bed awake and reading. -Resident #12's bed was not in a low position and a wheelchair, walker and bedside table were next to the bed. -A review of the Fall Prevention Devices task response history revealed the low bed task was marked completed at 8:51 a.m. on 3/7/24 (see below). On 3/10/24 at 7:50 a.m., Resident #12 was in her bed with the lights off. -Resident #12's bed was not in a low position. C. Record review Resident #12's electronic medical record (EMR) documented Resident #12 had two falls at the facility on 11/13/23 and 1/22/24. The 11/13/23 nursing progress notes documented at 6:20 p.m. a staff member heard Resident #12 yelling for help from her room. Upon entering the resident's room, Resident #12 was lying on her back with her walker standing upright at her feet. Her feet were facing the window and her head was facing the door. Resident #12 said she was at her sink and when she turned to walk back to her chair, her right knee gave out. A RN was called to assess the resident. The RN assessment indicated Resident #12 told the nurse that her arthritic right knee gave way and she fell on the floor, landing on her back. Resident #12 said she bumped her head. The 11/13/23 fall committee interdisciplinary team (IDT) note documented Resident #12 had an unwitnessed fall in her room resulting in a small abrasion to her back. -The IDT note did not include any interventions put into place except for placing the bed in the low position, which was initiated on 7/25/23, and a therapy evaluation, which was not new to the resident's comprehensive care plan. The 1/20/24 nursing progress note documented at 7:30 a.m. a nurse heard a loud sound and someone yell for help while administering medications. The nurse ran to Resident #12's room and found Resident #12 on the floor in a supine position (on her back) in front of the bathroom. Resident #12 said she was trying to go to the bathroom while using her walker and fell . Resident #12 denied pain and dizziness. A physical assessment was conducted on Resident #12 which revealed the resident was bleeding from the back of her head, with blood observed on the floor. The nurse applied compression at the site of bleeding and shouted for help. Vital signs were taken and neurological observations began. Resident #12 appeared disoriented with time. Facility staff called 911 and and Resident #12 was transferred to a local hospital at 8:00 a.m. The physician, DON and Resident #12's family were notified. The 1/22/24 fall committee IDT note documented Resident #12 had an unwitnessed fall in her room that resulted in a posterior (back of) scalp laceration. Resident #12 was subsequently sent to the emergency room where she received staples for a head laceration. -The IDT note did not include any additional interventions put into place besides putting the bed in the low position, which had already been in place since 7/25/23, therapy evaluation (put into place since the previous fall) and a pharmacy consult. -The facility continued to fail to put effective interventions into place to prevent further falls with injuries after the knowledge of the resident's history falls and actual recent falls. A 3/2/24 nurse practitioner (NP) note documented Resident #12 had a past medical history of recurrent falls, and was at high risk for falls due to her poor safety awareness and generalized weakness. Resident #12's Fall Prevention Devices task response history was reviewed from 2/11/24 to 3/10/24. A low bed was listed as a fall prevention device, however a clear pathway was not listed. The low bed was marked completed at least once per day during the review period, and there were no documented refusals by Resident #12 recorded by facility staff during the dates reviewed. Resident #12's kardex (electronic care summary) was reviewed. Resident #12's kardex did not list the intervention of a clear pathway on her kardex, which was used by the CNAs to ensure fall interventions were in place (see interview below). Resident #12's fall care plan, initiated on 7/25/23, documented Resident #12 was at risk for further falls related to medication side effects, a wedge compression fracture of lumbar (lower back region) and multiple falls. Resident #12 had additional post fall care plans initiated 11/13/23 and 1/22/24. The 1/22/24 fall care plan revealed she had a fall with injury requiring staples to her head. Pertinent fall care plan interventions included: -Be sure the call light was within reach and encourage the resident to use it to call for assistance as needed, initiated 7/25/23; -Maintain a clear pathway free of obstacles, initiated 7/25/23; -Resident needed a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in a low position at night; side rails as ordered, handrails on walls, and personal items within reach, initiated 7/25/23; -Bed in lowest position, initiated 11/13/23; and -Bed in low position, initiated 1/22/24. -However, observations on 3/7/24 and 3/10/24 revealed interventions, such as the bed in the lowest position and an uncluttered pathway, were not being implemented (see below) and the investigation revealed Resident #12's refusal of interventions was not documented nor her care plan updated. D. Staff Interviews The DON was interviewed on 3/11/24 at 10:19 a.m. The DON said a clear pathway meant Resident #12's room should be cleared of items so the resident was able to ambulate safely in her room. The DON said the resident should have a clear space next to her bed so the resident could safely get to her wheelchair and walker to use them if needed. The DON said the bed in low position meant the bed should be in the lowest position while the resident was in the bed. CNA #1 and CNA #2 were interviewed on 3/11/24 at 1:20 p.m. CNA #1 said she used the kardex to see a resident's fall interventions. CNA #1 said Resident #12 should have a low bed when the resident was in bed, but Resident #12 did not like her bed low or her wheelchair and walker moved out of her reach. CNA #1 said Resident #12 was able to use the remote control for her bed and move her bed higher herself. CNA #1 said she had not reported Resident #12 refused to have her bed low to the nurse. CNA #1 said she was unsure if she was able to document in the resident's medical record her refusal of a fall intervention. CNA #2 said when Resident #12 refused to have her bed put in a low position, she would provide education to the resident on the importance of her bed being in a low position. CNA #2 said Resident #12 did not like her bed in a low position and Resident #12 used the remote to move her bed higher herself. CNA #2 said she was unsure if she was able to document Resident #12's refusal of fall interventions in the resident's electronic medical record. -However, there was no documentation in Resident #12's medical record that she did not like or refused to have her bed in a low position or assessments completed of the effectiveness of the fall interventions on Resident #12's comprehensive care plan. The assistant director of nursing (ADON) #1 was interviewed on 3/11/24 at 1:30 p.m. The ADON #1 said if a staff member marked the low bed task complete, her expectation was that the bed was in a low position. ADON #1 said Resident #12 was able to adjust the height of her bed herself, however that was not included in the comprehensive care plan and had not been evaluated during the IDT fall reviews for effectiveness. The DON was interviewed again on 3/11/24 at 1:54 p.m. The DON said she was not aware Resident #12 refused to have her bed in the low position and she expected the staff to mark the refusal in the fall prevention devices task history. The DON said Resident #12's comprehensive care plan should have been updated to include her refusals of fall interventions. The DON acknowledged that the resident's comprehensive care plan and medical record lacked the documentation to show the facility had evaluated the effectiveness of the current interventions to prevent further falls with injuries. E. Facility follow up The facility provided additional information regarding Resident #12 on 3/12/24 at 5:21 p.m. The facility provided a general statement regarding fall interventions. The statement documented, At the time of the fall or incident the nurse is to put an intervention in place and document that intervention they determine may keep the resident safe: the next business morning when the IDT reviews the risk management they may determine the intervention one nurse put in place with limited information was not appropriate, and discontinue, change or add to that intervention. -However, Resident #12's comprehensive care plan documented three separate fall care plans that included fall interventions with the intervention of a low bed initiated on 7/25/23 at the time of her admission to the facility, and added after Resident #12's falls on 11/12/23 and 1/20/24. -The facility failed to provide documentation the fall interventions, specifically that of a low bed and clear pathway, were implemented and the effectiveness of these interventions were monitored to modify the care plan as necessary and discontinue or change the intervention. Further documentation provided by the facility revealed in a note signed by the director of rehabilitation (DOR), Resident #12 was interviewed on 3/12/14 after the survey exit. The note documented Resident #12 reported she wanted the bed at mid height and did not want the bed in a low position. -There was no documentation provided that the fall intervention of a low bed implemented on 7/25/23, and added on 11/12/23 and 1/20/24 was effective, or that the facility staff followed up with Resident #12 on her refusals of the fall intervention prior to 3/12/24, after the survey exit. The facility also provided physical therapy progress notes for Resident #12. The physical therapy progress notes documented dates of service as 12/29/23 to 1/22/24. -The physical therapy notes did not provide documentation regarding the implementation or effectiveness of the fall intervention for Resident #12's low bed. The facility provided an undated care plan document that revealed no changes had been made to the care plan since the last care plan review (1/22/24). -The documentation failed to provide updated information to Resident #12's refusals, the effectiveness of her low bed fall intervention, or effectiveness of maintaining a clear pathway in Resident #12's room. 46849 IV. Resident #19 A. Resident status Resident #19, age 71, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included stroke with paralysis of the left side, mild cognitive impairment and cognitive communication deficit. The 1/11/24 MDS assessment documented the resident had a moderate cognitive impairment with a BIMS score of twelve out of 15. She required a wheelchair for mobility and had functional impairments to her upper extremities on one side. The resident was unable to walk and required one-person limited assistance with locomotion. She required maximal assistance with showering, dressing, toileting, transfers and bed mobility. The assessment documented the resident had not had a history of falls and had not fallen in the six months prior to admission. B. Observations On 3/5/24 at 2:48 p.m., Resident #19 was sleeping in her bed. -The call light was hanging on the floor out of the resident's reach [TRUNCATED]

Based on observation, record review and interviews, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#130) of three residents reviewed for colostomy care out of 53 sample residents. Resident #130 was admitted to the facility on [DATE] with diagnoses of cognitive-communication deficit, anxiety disorder and with toxic megacolon (swelling and inflammation of the colon) that required a colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). Resident #130 required extensive assistance from staff for toileting and had a severe cognitive impairment according to the brief interview for mental status assessment. The facility failed to consistently assist Resident #130 with the care of the colostomy. The facility failed to ensure she was provided with proper education to continue to independently care for the colostomy based on her assistance and cognitive functioning. The facility failed to have a personalized care plan for Resident #130 ' s colostomy to include education to be provided or the goal of becoming independent with the care of her colostomy. Due to the facility's failures, Resident #130 was not provided with consistent care for her colostomy, which resulted in her bag often being full and smelling bad which embarrassed her and made her feel subhuman. The colostomy site was not consistently cleaned by staff and Resident #130 was not shown how to properly care for the site which caused it to be inflamed (red). Findings include: I. Professional reference The National Library of Medicine Colostomy Care, updated on 5/28/23 and retrieved on 3/13/24 from: https://www.ncbi.nlm.nih.gov/books/NBK560503/ revealed in pertinent part, The purpose of colostomy care was for skin protection and care for patient acceptance and to prevent stoma related complications. This activity outlines colostomy creation and care and highlights the role of the interprofessional team in evaluating and treating patients with this condition. Managing a colostomy is generally done by a nurse or an entero-stomal therapist, but providers should be aware of the stoma's condition in case intervention may be required. The 2-piece system consists of a base-plate with a removable ostomy bag attached to the skin. Although it is very durable and long-lasting, it requires an amount of skill to use, has a weaker adhesive, and does not fit very well. Before starting the procedure, all supplies should be arranged, and handwashing and donning of gloves should be done. The used stoma bag should be first emptied of all content, and then the flange removed by gentle traction on the bag or flange towards the stoma with counter-traction on the skin. An adhesive remover may also be used. The stoma and parastomal area should be gently cleaned with water and dabbed rather than scrubbed without using soap. The stoma should be assessed and must be moist, above skin level, and pink to red in color, and the peristomal skin should be normal. The surgeon should be notified of any deviation from this. The stoma should be measured, or the previous measurement remembered, and the size should not be more than 1/16-1/8. The peristomal skin should be dried appropriately to allow good seal formation. Adhesive pastes or powders may also be applied peristomally. The paper cover on the back of the flange is then removed with the border tape in place. It is then placed around the stoma and held for 1 to 2 minutes to create an adequate seal. If it is a 2-piece bag, it is clipped onto the flange. A belt may be applied around the abdomen and clipped to the sides of the flange to hold it in place. After this, safe disposal of the stoma bag, handwashing, and procedure documentation must be done. II. Resident #130 A. Resident status Resident #130, age 77, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included toxic megacolon (swelling and inflammation of the colon), cognitive-communication deficit and anxiety disorder. According to the 12/14/23 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She required extensive assistance from staff for toileting and supervision/touching assistance for personal hygiene. The resident had an ostomy. B. Observations and resident interview Resident #130 was interviewed on 3/7/24 at 9:28 a.m. The resident said she was required to change her colostomy bag. The resident said she did not always have the supplies to do the task. The resident said she would go days with her colostomy bag full and it would smell bad and was embarrassing. The resident said it made her feel subhuman. The resident said the nurses would not let her change the bag until it tore. The resident said she had cleaning supplies but was never shown how to use them. The resident said she would clean the site with a wet wipe or toilet paper. The resident said the staff showed her once but had never looked at the site after that. The resident said her skin around the stoma site was cherry red. The resident said she had been asking to change her bag since 10:30 p.m. the night before and they did not provide her with a bag until 9:20 a.m. The resident's clothing, which she wore to bed, had leakage from the stoma site on them. The trash can in the bathroom had the used colostomy bag with fecal matter, toilet paper and wet wipes. C. Record review According to a 12/8/23 surgical discharge summary documented the resident had a total abdominal colectomy and ostomy. According to the cognitive care plan dated 12/8/23 documented the resident had short-term memory loss. Interventions included the following: Use simple directive sentences. Give step-by-step instructions one at a time as needed to support cognitive function. The resident required supervision/assistance with all decision-making. According to the colostomy care plan dated 12/11/23 documented the resident had a colostomy. Interventions included the following: staff should encourage good nutrition and hydration to promote healthier skin. Follow facility protocols for injury treatment. Keep the resident ' s skin clean and dry. Use a pressure-relieving/reducing mattress to protect the skin while in bed. The resident should avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -However, the care plan did not include the education procedure for the resident or the goal of becoming independent with the care of her colostomy. According to the medication administration note dated 1/20/24 documented the resident was not available for education and assistance with learning to care for colostomy. According to social services dated 1/23/24 documented if the resident moved in with her husband, she would need to be educated on emptying and placing back the colostomy bag. III Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/12/24 at 9:00 a.m. CNA #3 said the resident needed help with colostomy care. CNA #3 said the resident was not discharged due to her inability to perform colostomy care independently. Licensed practical nurse (LPN) #1 was interviewed on 3/11/24 at 10:37 a.m. She said the resident performed her colostomy care by herself. LPN #1 said the nursing staff educated the resident on proper colostomy care. LPN #1 said the nursing staff did not have a standard way to perform education or return demonstration. LPN #1 said the tasks in the treatment administration record were reminders for staff to ask the resident if she had performed the tasks. The director of nursing (DON) was interviewed on 3/11/24 at 3:14 p.m. The DON said individuals who perform colostomy care should be assessed to ensure the resident performed the task safely. The DON said nurses performed the colostomy care because the certified nurse aides (CNAs) were not qualified to accomplish the task. The DON said the nurse staff should continue to oversee the colostomy care. The DON said the nursing staff did not have a standard education plan for educating residents about colostomy care. The DON said the resident needed to be able to perform colostomy care to be discharged safely. The DON said the resident should not use toilet paper to clean her stoma site. The DON said the resident was able to communicate her needs clearly and accurately. The DON said the colostomy bag should be emptied when it was full. The DON said the staff should bring the resident supplies when the resident asked for them. The DON said there would be no leakage if the bag was placed properly. IV. Facility follow-up The NHA provided the following information post survey on 3/12/24 at 5:29 p.m. It read in pertinent part, According to the interdisciplinary team (IDT) care plan review team meeting, dated 3/8/24, the resident said she could perform colostomy care; however the IDT team said the resident continued to require oversight from staff. -The IDT meeting confirmed that the resident continued to require oversight from staff. In addition, according to the MDS assessment (see above) she required extensive assistance from staff. According to the BIMS assessment dated [DATE], the resident scored 15 out of 15. -The facility changed the residents BIMS score from a six (severe cognitive impairment) out of 15 to a score of 15 (cognitively intact) out of 15 after the survey. A signed document dated 3/12/24 from Resident #131 outlining the steps required to perform colostomy care and the resident acknowledged that she understood and could perform these steps. -However, this had not been completed prior to the survey and the document did not include a demonstration back from the resident. A progress note dated 3/12/24 documented the resident was able to complete the return demonstration of colostomy care. -However, there was no documentation during or prior to the survey that the resident was able to complete colostomy care with return demonstration.

Based on observations, record review and interviews, the facility failed to ensure one (#26) of three out of 53 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #26 displayed slurred speech, confusion, and left sided weakness resulting in an admission to the hospital on 1/17/24. It was concluded he had suffered from a stroke and was readmitted to the facility on [DATE]. On 1/21/24, the resident weighed 161.9 pounds (lbs). On 2/19/24, a month later, Resident #26 weighed 143.3 lbs. which was a 11.49% weight loss and a difference of 18.6 lbs. On his next weight on 3/7/24 (during the survey), the resident weighed 137.6 lbs. which was a 3.98% loss and a difference of an additional 5.7 lbs with a total of 18.6 lbs and 15.02% weight loss. According to the change of condition minimum data set (MDS) assessment dated [DATE], the resident required maximum assistance with eating. The MDS revealed the resident relied on the staff for more than 50% of the task of eating. The resident was participating in speech and occupational therapy to improve his oral intake and functional ability to eat. Education was provided to the staff caring for him on techniques and risks for the resident to improve his oral intake. Based on observations and interviews, it was determined the staff were not consistently providing the resident the level of assistance required according to his functional limitations and this contributed to his significant weight loss. Findings include: I. Resident #26 A. Resident status Resident #26, age 82, was admitted to the facility on [DATE]. According to the March 2024 computerized physician's orders (CPO), diagnoses included diabetes mellitus type II, dementia, and heart disease. The 1/24/24 MDS assessment showed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of twelve out of 15. The resident required maximum assistance with personal hygiene and eating. The resident required total assistance with bed mobility, toileting, dressing, showering, and transfers. The resident had an impairment to one side of his body causing functional limitations. The resident had a swallowing disorder with loss of liquids/solids from his mouth when eating, coughing and choking during meals, and complaints of pain or difficulty with swallowing. B. Resident observations The resident was observed on 3/5/24 at 12:25 p.m. in the dining room of the secured unit. Certified nurse aide (CNA) #11 provided the resident with a mechanically altered meal. The plate was placed in front of the resident but no staff members sat down with the resident. The resident was able to lift a regular cup of fluids and drink after a lot of effort with his right hand. The occupational therapist (OT) sat down with the resident at 12:33 p.m. and adjusted his clothing protector. She left the table at 12:34 p.m. to locate a cup of ice cream for Resident #26. The resident kept trying to get the attention of the staff by saying excuse me several times. CNA #8 sat down with the resident at 12:36 p.m. and assisted him one spoon of his lunch. The OT returned at 12:37 p.m. and provided the resident with a cup of ice cream. The resident displayed left sided weakness when trying to lift the ice cream cup in front of him. He was able to feed himself ice cream with his right hand and hold the cup with his left hand while OT provided encouragement and cues to the resident. The OT left the table at 12:38 p.m. CNA #11 sat down at the resident's table at 12:38 p.m. and assisted the other resident sitting at the table with his meal. The speech therapist (ST) came at 12:41 p.m. and was providing instruction to the staff to remind the resident to clear his throat when eating and take sips of fluids in between bites of food. ST left at 12:46 p.m. During the continuous observations, the resident coughed three times while eating his ice cream. The staff did not respond when the resident coughed. CNA #8 came at 12:28 p.m. and asked the resident if he was done with his lunch. The CNA took the plate away and scrapped it in the trash. He was then taken to the common area at 12:49 p.m. During the meal, the resident was observed to have drank three cups of fluids, ate one bite of his lunch plate, and completed one cup of ice cream. Resident #26 was observed on 3/6/24 at 12:33 p.m. in the dining room of the secured unit. The meal was placed in front of the resident at 12:40 p.m. The resident attempted to lift his right arm to the plate and struggled when he got his arm caught under the table. The resident called out to CNA #5 stating I need help at 12:40 p.m. The CNA walked past the resident and did not acknowledge him. At 12:43 p.m. Resident #26 called out to CNA #5 again for assistance and CNA #5 sat down with the resident. The resident was able to get his arm from under the table and the CNA provided the resident with a cup of ice cream. Once the resident began eating the ice cream independently, CNA #5 left the table at 12:44 p.m. At 12:49 p.m the resident was able to get one spoon of food from his meal plate into his mouth after several attempts. The resident still had fluids in his mouth he had not swallowed when he put the food into his mouth. At 12:53 p.m., the resident saw CNA #5 and requested assistance. CNA #5 sat down and assisted the resident. The resident was cooperative and when he wanted another bite, he opened his mouth freely. Twice CNA #5 tried to put food into the resident's mouth while he was still chewing and CNA #5 was looking away. Both times, the resident put his hand up to prevent the CNA from putting food into his mouth. The CNA did not speak to the resident, provide encouragement or cueing during the meal. The CNA assisted the resident three spoons of food between 12:53 p.m. and 12:58 p.m. After the resident put his hand up the second time, the CNA stopped feeding him. The CNA left the table at 12:58 p.m. At 1:00 p.m., CNA #8 took the resident's plate and scraped it in the trash. C. Record review The ADL comprehensive care plan revised on 9/16/19 revealed the resident had self care deficits related to a history of falls, dementia, and physical limitations. Interventions initiated on 3/7/24 (during survey) included cueing and one-on-one assistance for eating. The nutrition care plan initiated 1/21/24 revealed the resident had a nutrition problem related to a new stroke and dysphagia (difficulty swallowing). The resident had triggered a significant weight loss and required a mechanically altered diet related to chewing/swallowing difficulties. The resident had difficulty feeding himself at times related to a stroke affecting his non-dominant left side. Interventions initiated 3/7/24 (during survey) included to provide vanilla ice cream and mildly thick liquids during meals and occasionally assist/cue with eating. -The care plan did not indicate the resident refused meals or had unavoidable weight loss. The March 2024 CPO revealed the following physician orders: Speech therapy (ST) evaluate and treat- ordered on 1/20/24; Occupational therapy (OT) evaluate and treat- ordered on 1/20/24; Physical therapy (PT) evaluate and treat- ordered on 1/20/24; Regular diet, minced and moist, mildly thick with vanilla ice cream at all meals- ordered 3/7/24 (during survey); and Boost (supplement drink) high calorie- three times a day- ordered 3/8/24 (during survey) - this was the only nutritional supplement ordered for the resident while he was experiencing significant weight loss since his readmission back to the facility. A review of progress notes dated 2/12/24 to 3/11/24 revealed: NP progress note dated 2/12/24 revealed the resident had a recent stroke 1/17/24. The resident was at weight loss/malnutrition risk. He was being followed by the registered dietitian (RD) for nutritional supplement recommendations. The resident had a diagnosis of dysphagia and staff were to monitor for difficulty swallowing and signs of aspiration. NP progress note dated 2/19/24 revealed the resident was on a diabetic diet, minced and moist with mildly thick liquids. The NP documented weight loss was likely expected and unavoidable due to the disease progression, multiple comorbidities, and sporadic intakes (eating). If weight loss continued, it was suggested to consider a hospice evaluation and referral. -However, according to the NP interview (see below), the NP was not aware the nutritional interventions for his weight loss were being consistently provided. NP progress note dated 2/28/24 revealed the resident had failed to thrive since the stroke. Oral intakes were less than 25% and to consider hospice if weight loss continued. NP progress note dated 3/4/24 revealed the resident continued with poor oral intakes and nutritional guidance was provided by the RD. It was suggested to consider hospice for the resident. -NP notes failed to reveal the NP was aware the level of assistance required for intakes was not being consistently provided to mitigate weight loss and failure to thrive. Resident weights reviewed from 1/21/24 to 3/7/24 revealed: 1/21/24 161.9 lbs. was the resident's weight immediately after the stroke. 1/29/24 156.2 lbs. which was a 3.52 % loss. 2/7/24 150.0 lbs. which was a 3.97 % loss. 2/12/24 143.8 lbs. which was a 4.13 % loss. 2/19/24 143.3 lbs. which was a 0.35 % loss. 3/7/24 137.2 lbs. which was a 3.98 % loss. From Resident #26's readmission to the facility on [DATE] to 3/7/34 (during the survey process), the resident lost a total of 18.6 lbs and 15.02% weight loss. Nutrition assessment dated [DATE] revealed the resident would be trialed on a scoop plate. Intake was 0-50% and the resident required assistance with meals. -It did not include any other nutritional interventions to prevent further loss of weight. A review of the resident's medical record did not reveal any additional nutritional assessments since his continued significant weight loss. Daily skilled progress notes dated 3/6/24 revealed the resident had active symptoms of dysphagia and complaints of difficulty or pain with swallowing. He held food in his mouth/cheeks or residual food in mouth after meals. He coughed or choked during meals or when swallowing medication. Nutritional approaches include mechanically altered diet and thickened liquids. -Condition follow up progress note dated 3/6/23 revealed current conditions: resident not eating 50% of meal, or not drinking 50%. Physical therapy notes dated 1/22/24 revealed the resident had been referred post stroke. His prior level of ADL functioning was independent and currently was maximum assistance for ADLs. A review of occupational therapy notes dated 1/23/24 to 3/11/24 revealed: Occupational therapy notes dated 1/22/24 revealed the occupational therapist (OT) provided the resident with assistance for self-eating tasks. The RN was provided education by OT to provide the resident with one-on-one staff assistance with eating tasks at all times. Occupational therapy notes dated 1/23/24 revealed the resident required one-on-one staff assistance for self feeding. Occupational therapy notes dated 1/24/24 revealed the resident required moderate assistance to complete self-eating and drinking tasks. Education was provided to the RN on techniques to promote the use of the left upper extremities (arm/hand) as able with increased cues. Occupational therapy notes dated 1/25/24 revealed the resident completed the self feeding task with OT assistance with initiation of positioning of left upper extremity and hand over hand to initiate grasp on the cup while using utensils in right upper extremity. The resident required verbal, visual, and tactile cues. Education was provided to the RN and CNA staff via a visual demonstration on techniques. The staff verbalized understanding of the education. Occupational therapy notes dated 1/31/24 revealed the resident completed the self feeding and drinking task with verbal, visual, and tactile cues for continuum of task. RN and CNA staff were educated to incorporate left upper extremity throughout tasks via facilitating grasp onto plates and cups as well as having left upper extremity positioned into immediate midline (chest area) positioning with tasks. Occupational therapy notes dated 2/1/24 revealed the resident completed the self feeding and drinking task with overall moderate assistance. Education was provided to staff on proper wheelchair positioning and set up of bilateral upper extremities with a focus on grasping cups, plates, and bowls with his left hand. Occupational therapy notes dated 2/12/24 revealed the resident was noted with increased oral intake of food and completed the self feeding and drinking task with minimal assistance. Education was provided to the RN and CNA staff on positioning modifications and setup for self feeding and drinking throughout the meal. Occupational therapy notes dated 2/13/24 revealed the resident required minimal assistance with maximum verbal cues for self pacing during eating and drinking tasks. The resident tended to eat and drink with increased speed and overall decreased safety awareness. The RN was present and aware of intermediate coughing and recommendations for one-on-one staff assistance with alternating the residents food and liquid intake at a slower pace. Occupational therapy notes dated 2/15/24 revealed the resident completed self feeding and drinking tasks with minimal assistance and maximum assistance for verbal, visual, and tactile cues for sequencing and self safe pacing throughout. Occupational therapy notes dated 2/29/24 revealed the resident was able to complete the self feeding tasks while sitting in his wheelchair at the tabletop. The resident was able to scoop and transport food to his mouth with verbal and visual cueing to initiate the task and the resident was able to attend self feeding task following cueing to improve self eating and nutrition. Occupational therapy notes dated 3/5/24 (during survey) revealed the resident completed the self feeding and drinking task with multiple trials. Overall minimal assistance provided with hand over hand to initiate grasp onto bowl with hand left hand to complete task with right upper extremity for feeding. Increase time required for cueing for attention to task and safe sequencing. Occupational therapy notes dated 3/7/24 (during survey) revealed education was completed with RN, CNA, and memory care staff with training on recommendations for one-on-one staff assistance with meals for cueing. The staff were educated on the resident's ability to physically complete self feeding tasks with use of his right upper extremity with recommendations to incorporate/facilitate grasp of left upper extremity onto plates and bowls throughout the meal. It was recommended by OT for staff to encourage the resident to complete eating independently as he is able to. However, if the resident is fatigued and not able to complete the task on his own, staff are to provide assistance. The staff are to encourage the resident to eat at a slower pace with smaller bites while checking occasionally for pocketing (storing food inside mouth and not swallowing.) The staff verbalized understanding of education with visual demonstration provided. A review of speech therapy notes dated 1/23/24 to 3/11/24 revealed: Speech therapy notes dated 1/23/24 revealed the resident had been started on minced and most texture food with mildly thick liquids. For meal tasks, the resident successfully responded 55% of the time with therapeutic attempts and 75% of the time if given tactile cues and visual aides during meal. Speech therapy notes dated 1/26/24 revealed the resident required moderate to maximum cueing to remain attentive to meal tasks. The resident ate rapidly using large bites and talked with food in his mouth. Exhibited coughing after swallowing 50%-60% of the time. Speech therapy notes dated 2/13/24 revealed the resident would leave his drinking cup tipped at his mouth for several seconds and required maximum cueing to complete follow through of the drinking task. There had been a positive impact on drinking when a spouted cup (a cup with a lid and a spout to drink out of to decrease fluid flow) was presented. Speech therapy notes dated 2/14/24 revealed the resident completed more efficient swallowing of mildly thick liquid drinking tasks when intake was provided by on-one-on staff in a quiet environment. Speech therapy notes dated 2/21/24 revealed the nurse had reported to the ST the resident had episodes of choking on his own saliva when taking medications. Speech therapy notes dated 2/26/24 revealed ST was to begin trialing a spouted cup. Speech therapy notes dated 3/4/24 revealed the resident benefited when an adaptive cup with straw was used to assist with drinking Speech therapy notes dated 3/11/24 revealed ST was working with the resident on identifying food items to add to the resident's diet to promote adequate nutrition. III. Staff interviews CNA #10 was interviewed on 3/6/24 at 9:16 a.m. She said Resident #26 needed staff to sit with him, prompt him and assist him to eat. CNA #8 was interviewed on 3/6/24 at 9:36 a.m. She said Resident #26 needed staff to sit with him and prompt him to eat meals. He would feed himself independently sometimes but staff had to sit with him, cue, and prompt him. She said if the staff put a plate of food in front of him and walked away, he would not eat. CNA #11 was interviewed on 3/6/24 at 9:51 a.m. She said Resident #26 required total assistance to include assistance from staff to eat his meals. She said he was not able to eat independently. The registered dietitian (RD) was interviewed on 3/6/24 at 9:57 a.m. She said Resident #26 had a stroke recently and had swallowing difficulties. He required thickened liquids and had decreased intakes. The resident required a lot of help with eating to include cueing, prompting and assistance at times. The OT had tried a scoop plate and a cup and a lid to assist the resident with eating. She said in order to monitor the effectiveness of feeding interventions, staff needed to weigh the resident weekly. The RD said she did not know why weekly weights were stopped 2/19/24. The RD said she put a boost supplement into place, however did not have any other documented nutritional interventions. The ST and OT were interviewed on 3/6/24 at 10:10 a.m. The ST said she had been working with the resident to advance his diet from the current texture for resident preference. The resident had swallowing difficulties, was at risk for aspiration and weight loss. The OT said she had instructed staff to put items in the resident's left hand for stability and to encourage him to use his right hand to utilize the utensils to feed himself. He currently needed one-on-one supervision for meals to include at minimum prompting to eat. The resident did not eat independently. She had provided education to the CNAs several times on how to provide the resident adequate eating assistance. Based on her assessment of the resident, he could benefit from therapy. Hospice was intended for residents who could not benefit or participate in therapy. The OT said to determine if a resident could no longer benefit from therapy, the facility needed to exhaust all interventions. To exhaust all interventions, the interventions needed to be tried as intended and on a consistent basis. The director of nursing (DON) was interviewed on 3/7/24 at 10:52 a.m. She said Resident #26 had decreased oral intake since his stroke in January 2024. The DON had considered referring the resident for hospice but wanted to exhaust all possible interventions before referring them. The CNAs provided assistance to the resident during meals by encouraging, cueing or physically assisting him with a spoon. The DON said according to the staff, sometimes the resident would feed himself if the staff put his meal plate in front of him. The DON had not observed the resident during meals. The resident was weighed weekly and the DON was not aware the resident had not been weighed since 2/19/24. Speech therapy had been working with the resident on intake and swallowing difficulty but the DON did not know the interventions therapy had recommended for eating assistance. She did not know what interventions therapy had instructed the CNAs to use with the resident and if the CNAs had been consistently using the interventions. The physician had recommended hospice for the resident but the DON said she did not know if the physician knew the eating assistance interventions were not being followed consistently. The NP was interviewed on 3/11/24 at 11:18 a.m. He said resident #26 recently had a stroke and had begun losing weight related to a failure to thrive. He said he was not aware there were eating assistance interventions that were not being used with the resident consistently. The NP said he had never observed the resident eating or drinking but had just assumed the staff were doing all available interventions. He said he thought the resident was receiving the care and services required and still losing weight, however that was not the case based on the observations throughout the survey. IV. Facility follow-up On 3/13/24 at 3:32 p.m. an updated care plan was provided by the NHA. The documents were as follows: The nutrition care plan revised 3/13/24 (after survey) revealed the resident had a nutrition problem related to a new stroke and dysphagia. The resident meet criteria for significant weight loss. Unavoidable noted due to comorbidities. Multiple interventions will still be attempted and in place. -The facility identified the resident's significant weight loss as unavoidable, however based on the observations during the survey process, Resident #26 did not receive the care and services required to meet his nutritional needs. The facility failed to identify that the resident was not receiving the eating assistance he required while he continued to lose a significant amount of weight. The facility failed to put significant nutritional interventions into place, failed to conduct regular nutritional assessments and observations of the resident during meals and address his continued significant weight loss. -No new interventions were put into place in the care plan.

Based on observations, record review and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies and advocacy groups. Specifically, the group interview revealed the residents were not aware of where the State Agency phone numbers were posted in the facility. Findings include: I. Resident group interview A resident group interview, which included four cognitively intact residents according to facility assessment, was conducted on 3/6/24 at 1:00 p.m. Resident #80, #92, #128 and #302 said they did not know where the State Agency and ombudsman information were posted in the facility. They said they had not been informed of this information during resident council meetings. Resident #128 said he was not informed of how to make a formal complaint or how to contact the state agency. II. Observations Observations conducted throughout the facility on 3/5/24 at 3:00 p.m. revealed the facility failed to ensure the posting of names, addresses (mailing and email) and telephone numbers of pertinent state agencies, such as the state survey agency and the state licensure office, and adult protective services. Observations conducted with the nursing home administrator (NHA) on 3/6/24 at 2:45 p.m. on the facility's four nursing units revealed the NHA was unable to locate the posting of names, addresses (mailing and email) and telephone numbers of pertinent State Agencies, such as the State Survey Agency and the State licensure office, and Adult Protective Services. III. Record review The nursing home administrator (NHA) provided an untitled audit dated January 2024. It documented: A chart titled infection control documented the following: Check for notification signs to report complaints and recent survey results updated was marked as met. -However, according to the observations, conducted during the survey process, showed the facility failed to post the State Agency contact information. -The audit did not provide any additional information regarding where the notification signs were posted and verified as present. IV. Staff interviews The NHA was interviewed on 3/6/24 at 2:30 p.m. The NHA said the facility did not have postings regarding information of pertinent State Agencies. He said there had been a posting in the past, but it must have been removed. The NHA said a corporate clinical consultant was tasked with performing a quarterly audit to verify the required information was posted, however he was unable to locate the postings. V. Facility follow-up On 3/6/24 at 3:20 p.m, during the survey process, the NHA provided a copy of a list of names, addresses (mailing and email) telephone numbers of all pertinent State Agencies and advocacy groups. Observations conducted on 3/6/24 at 4:00 p.m. revealed the list was posted in the four units of the facility, after it was brought to the attention of the NHA.

Based on observations and interviews, the facility failed to ensure residents retained the rights to their personal belongings for two (#11 and #51) of five out of 53 sample residents. Specifically, the facility failed to obtain Resident #11 and Resident #51's permission prior to searching and confiscating items from their rooms. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, reviewed April 2023, was received from the nursing home administrator (NHA) on 3/11/24 at 4:21 p.m. It read in pertinent part, The resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. II. Resident #51 A. Resident status Resident #51, age 91, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), the diagnoses included heart disease, morbid obesity and chronic kidney disease. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required partial/moderate assistance with personal hygiene, toileting, supervision with transfers and was independent with eating and bed mobility. B. Observations and resident interview On 3/5/24 at 11:30 a.m. registered nurse (RN) #3, who was wearing street clothes, was observed entering and exiting multiple resident rooms. Resident #51 was interviewed on 3/5/24 at 2:09 p.m. She said a nursing staff member went through her drawers that morning without asking her permission. She said she did not know the nurse. She said she had mentholatum cream (cream used to soothe sore muscles and joints) at her bedside that she self administered. She said the nursing staff member made her feel like a criminal because she had the mentholatum cream at her bedside. She said the nurse did not ask her permission before removing the cream from her room. III. Resident #11 A. Resident status Resident #11, age 81 , was admitted on [DATE]. According to the March 2024 CPOs, the diagnoses included heart disease, type 2 diabetes mellitus (DM) and major depressive disorder. The 1/16/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with toileting, personal hygiene, transfers, set up assistance with eating and was independent with bed mobility. B. Resident interview Resident #11 was interviewed on 3/5/24 at 2:46 p.m. He said a nurse with blonde hair came into his room that morning and removed two tubes of athlete's fungal foot cream and a laxative pill that was lying on the counter. He said she went through his drawers without his permission. He said he knew his rights and she should have asked for permission before opening and going through his drawers. He said she removed the cream and pill without asking his permission. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/11/24 at 10:14 a.m. She said all staff needed to obtain a resident's permission before searching a resident's belongings or drawers. The director of nursing (DON) was interviewed on 3/11/24 at 3:10 p.m. She said RN #3 was the staff member who was going in and out of the resident's rooms on 3/5/24. She said consent should be obtained from the resident before any staff member was able to search resident belongings and drawers. She said resident's with medications at the bedside needed an order and an evaluation. She said she would provide education with RN #3 regarding her interactions with the residents and not going through resident belongings without permission.

Based on observations and interviews, the facility failed to ensure two (#6 and #56) of two residents reviewed for abuse out of 53 sample residents were free from abuse. Specially, the facility failed to prevent a resident to resident altercation between Resident #6 and Resident #56. Findings include: I. Facility policy The Abuse Prevention policy, dated 7/11/21, was received from the nursing home administrator (NHA) on 10/12/23. It read in pertinent part: The employees of the facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Assess, care plan, and monitor residents with history of aggressive behaviors, behaviors such as entering other residents' rooms, self-injurious behavior, communication disorders, totally dependent on staff. II. Resident to resident physical altercation between Residents #6 and #56. A. Observations of a resident to resident altercation on 3/5/24 between Resident #6 and Resident #56 Resident #6 was observed on 3/5/24 at 3:00 p.m. approaching Resident #56 who was coming out of a resident room. Resident #6 pushed Resident #56 in the shoulder and Resident #56 reached out and grabbed the wrist of Resident #6. The two residents yelled at each other but the words were unintelligible. Two unidentified staff members approached the residents and got in between them. The staff member (later identified as CNA #9) stood in front of Resident #6. While still looking at Resident #56, Resident #6 balled up his fists and held his hands up in a boxing pose. Another unidentified staff member (later identified as the activity assistant) redirected Resident #6 to another part of the unit and Resident #56 back to his room. B. Facility investigation Staff interviews provided by the facility on 3/6/24 at 10:45 a.m., revealed the activities assistant (AA) and certified nursing aide (CNA) #9 had been involved. In the AA's statement, she wrote she was providing a hand massage and then heard loud voices. She got up and saw Resident #6 and Resident #56 getting into it and she separated the two residents. She denied seeing contact made between the two residents. -The investigation failed to have the AA define what getting into it entailed. CNA #9's statement documented she did not witness any incident between Resident #56 and Resident #6, despite the observations of CNA #9 being involved and separating both residents. III. Resident #56 (victim) A. Resident status Resident #56, age 71, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included stroke, vascular dementia, alcohol dependence in remission, and macular degeneration. The 2/2/24 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with a brief interview of mental status (BIMS) score of ten out of 15.The resident used a wheelchair for mobility. He required maximum assistance from staff with personal hygiene, toileting, dressing, and showering. He required supervision with transfers. It indicated the resident did not exhibit any behaviors during the assessment period. B. Record review The cognitive care plan, revised 2/10/23, revealed the resident had impaired cognitive functioning, decision making, and thought processes related to dementia. Interventions included identifying self at every interaction, keeping the resident's routine consistent, and providing psychosocial support by social services. The behavior care plan, initiated on 3/6/24 (during the survey process), revealed the resident had the potential to demonstrate behaviors related to anger. Triggers for the resident were other residents expressing behaviors and getting too close to his personal space. Interventions included analyzing the circumstances for triggers and de-escalating, documenting behaviors and attempting interventions, and engaging the resident calmly when agitated. A social service progress note dated 3/5/24 revealed the social services director (SSD) followed up with Resident #56 post altercation. The resident said he had a bad day, Resident #6 had entered his personal space and he did not like that. A social services progress note dated 3/6/24 revealed Resident #56's roommate, Resident #6, had been moved to another room. Resident #56 told SSD he was sorry for the incident and he was only playing around. IV. Resident #6 (assailant) A. Resident status Resident #6, age 85, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included dementia, anxiety, and major depressive disorder. The 1/22/24 MDS assessment documented that the resident had short and long term memory deficits, severe impairment in decision making, and was only orientated to people and places. The resident used a wheelchair for mobility. He required maximum assistance from staff with toileting, dressing, and showering. He required supervision with transfers, personal hygiene, and eating. It indicated that the resident did not exhibit behaviors during the assessment period. B. Record review The cognitive care plan, revised 5/18/23, revealed the resident had episodes of delirium and confusion related to dementia. Interventions included identifying self at every interaction; observing environmental factors; and providing gentle redirection. The behavioral care plan, initiated 8/18/23, revealed the resident had the potential to demonstrate behaviors such as agitation, physical aggression, and delusions related to major depression disorder. Interventions included monitoring the resident for increased anger, labile mood, agitation, feeling threatened by others, thoughts of harming someone else, and possession of objects that could be used as weapons. Staff to document behaviors and interventions. The March 2024 CPO revealed the following physician orders: Behavior monitoring of episodes of agitation and delusions- ordered on 6/16/23. Behavior monitoring for episodes of self-isolation and irritability- ordered on 6/16/23. -The March 2024 medication administration record (MAR) indicated that the resident did not exhibit any behaviors, however staff indicated that Resident #6 had behavioral concerns (see interviews below). V. Staff interviews CNA #7 was interviewed on 3/5/24 at 3:45 p.m. She said Resident #6 and Resident #56 had a history of verbal altercations, however she was unaware of any physical altercations. CNA #9 was interviewed on 3/5/24 at 3:50 p.m. She said Resident #6 and Resident #56 always verbally fought with each other. Resident #56 did not like it when other residents got too close to him. CNA #9 said Resident #6 had a history of going around the secured unit pushing other residents and getting close to other residents' personal space. She said Resident #6's behavior caused issues for other residents. CNA #9 said she responded to the altercation on 3/5/24. She said did not witness Resident #6 push Resident #56 but did witness Resident #56 release Resident #6's wrist when she approached. She said she witnessed Resident #6 put his fists up. She said she re-directed both residents and prevented further escalation of the incident between the two residents. CNA #9 said she did not report to the nurse or the abuse coordinator regarding the incident because she had not witnessed either resident hit the other resident. Licensed practical nurse (LPN) #4 was interviewed on 3/5/24 at 3:54 p.m. She said she had not been notified by staff of an altercation between Resident #6 and Resident #56. She said Resident #6 had problematic behaviors toward other residents on the secured unit and said she was not surprised he had pushed Resident #56. The nursing home administrator (NHA) was interviewed on 3/5/24 at 4:20 p.m. He confirmed he had received a report from LPN #4 regarding a resident to resident altercation between Resident #6 and Resident #56. He said CNA #9 should have made the report immediately. The NHA was interviewed again on 3/6/24 at 10:30 a.m. He said the facility had started an investigation regarding the altercation between Resident #6 and Resident #56. Resident #6 had been moved to another room and the two residents were on frequent checks during the investigation. The NHA provided the occurrence number for the report made to the State Agency. During the survey, the AA was unavailable for interview. VI. Facility follow up On 3/12/24 at 4:45 p.m. documents were provided by the nursing home administrator (NHA) via email. The documents were as follows: Facility findings of physical abuse investigation. The facility concluded there was no abuse and unsubstantiated the incident. Through the internal investigation, staff interviewed denied witnessing physical contact between the two residents. -The facility unsubstantiated the incident between Resident #56 and Resident #6, even though it was witnessed and reported to the NHA (during the survey process) that Resident #6 pushed Resident #56, Resident #56 grabbed Resident #6's wrist, and the residents continued to verbally attack one another.

Based on record review, observations and interviews, the facility failed to ensure that one (#19) of six residents out of 53 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #19, residing on the secure locked unit, had the required documentation to justify such restrictions including documentation such as doctor orders, documentation reflecting secure/locked placement was the least restrictive approach possible and documentation the impact or reaction to the resident was assessed. Findings include: I. Facility policy The Secure Unit policy, revised March 2024, was provided by the nursing home administrator (NHA) on 3/8/24 at 10:37 a.m. It read in pertinent part: In order to place a resident into a secure environment, the facility shall ensure that all of the following requirements are met: An evaluation team finds, based on available evidence, that: a. The resident is a serious danger to self or others, or b. The resident habitually wanders or would wander out of buildings and is unable to find the way back, or c. The resident has a significant behavioral health issue that seriously disrupts the rights of other residents; and in all cases d. Less restrictive alternatives have been unsuccessful in preventing harm to self or others. A practitioner has authenticated the placement. Written findings and the factual basis for the placement are documented in the health information record. There shall be a designated team to evaluate placement of a resident in a secure environment. The team shall include, at a minimum, the director of nursing or designee, a social services staff member, the administrator or designee and an individual (with mental health or social work training as appropriate to the needs of the residents) who is not a facility staff member (independent reviewer). II. Resident #19 A. Resident status Resident #19, age 71, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included stroke with paralysis of the left side, mild cognitive impairment, cognitive communication deficit and anxiety. The 1/11/24 minimum data set (MDS) assessment documented the resident had a moderate cognitive impairment with a brief interview of mental status (BIMS) score of 12 out of 15. She had behaviors of verbal and physical aggression towards others. She did not have behaviors of wandering. She required a wheelchair for mobility and had functional impairments to her upper extremities on one side. The resident was unable to walk and required one-person limited assistance with locomotion. She required maximal assistance with showering, dressing, toileting, transfers and bed mobility. B. Resident interview Resident #19 was interviewed on 3/5/24 at 2:37 p.m. She said she did not like the unit she had been moved to because the staff did not allow her to have choices about when she ate, when she went to sleep or when she was able to take a shower. The unit doors did not open and the resident could not come and go to other parts of the building. She expressed feeling angry and confused as to why she had been moved to the unit she was on. C. Record review The comprehensive care plan, revised 1/8/24, revealed the resident had a self care deficit related to a stroke with one sided paralysis. The resident required assistance from staff to complete activities of daily living (ADL) to include one to two person staff assistance with toileting, transferring, bed mobility, and dressing. Interventions included evaluation and treatment from physical, occupational, and speech-language therapy. The resident had a diagnosis of depression with a history of sadness, decreased appetite, and increased fatigue. Interventions included to arrange for psychological consultation as indicated and encourage the resident to express her feelings. -The care plan did not include wandering or elopement behaviors or interventions attempted prior to a secure unit placement. The March 2024 CPO revealed the following physician orders: Admit to secure memory care unit effective 2/23/24-ordered on 3/7/24 (during the survey). -No physician orders were located for placement on the secure unit prior to the survey. No behavior tracking was located to monitor for wandering or exit seeking behaviors. An elopement evaluation dated 1/5/24 revealed the resident was physically immoble with intermittent confusion. She had no history of elopements and did not make statements regarding a desire to leave the facility. -No other elopement evaluations were located in the resident's medical record. A review of the hospital referral for placement dated 1/5/24 failed to reveal the resident had a history of elopements or wandering in the community. The resident had been living alone in the community with limited social support outside of a home health care agency. She suffered two falls at home and was admitted to the hospital. A St. Louis University Mental Status (SLUMS) examination assessment was done at the hospital and the resident had scored a six out of 30 indicating the probability of a diagnosis of dementia. She was oriented only to herself during the hospital stay. The hospital physician indicated a suspicion of dementia, however a neurological (the specialized field of diagnosing and treating disorders of the brain and nervous system) follow up was needed. The hospital referral included an evaluation of the resident including her condition at time of admission on 12/30/23. The nurses indicated the resident presented with poor hygiene and signs of diminished care as well as signs and behaviors of suspected dehydration. A SLUMS examination assessment for cognitive impairments was administered at the facility with the resident on 1/8/24. The resident could not recall date, complete mental subtraction, list multiple animals within a minute, count serial numbers backwards, correctly draw a clock with accurate time, identify shapes, or recall all the details of a story after a brief delay. She scored a ten out of 30 indicating the probability of a diagnosis of dementia. This score was an improvement from her previous SLUMS on 1/5/24. -This SLUMS assessment had been administered three days after the resident admitted to the facility after a hospitalization and was not repeated after the resident acclimated to the new living environment. A physician authorization for the special care unit dated 2/23/24 indicated the resident habitually wandered and would not be able to find her way back if she wandered out of the building and least restrictive alternatives had been unsuccessful in preventing harm to self or others. The authorization form indicated the resident was not a danger to herself or others and did not have serious behavior concerns disrupting the rights of other residents. The authorization form had not been signed by the physician. The preadmission secure unit evaluation and review form dated 2/23/24 revealed the resident had displayed exit seeking behaviors and wandering without intent. The section describing the least restrictive interventions attempted and why the attempts were unsuccessful only indicated the resident was wandering. The NHA, the social services director (SSD) and director of nursing (DON) had signed the form; however, the independent reviewer had not signed the form. Occupational therapy notes dated 2/29/24 revealed the resident stated to the therapist she wanted to return to where she came from (the prior unit). The resident displayed increased agitation and continued verbalizations of desiring to return to the long term care unit. A speech therapy (ST) evaluation and plan of treatment dated 3/4/24 revealed the resident was recently transferred to the secure memory care unit due to an increased risk of elopement. At the time of the evaluation, the resident could understand others and could make herself understood. She was able to follow one-step directions and was cooperative. A cognitive assessment revealed the resident had a moderate cognitive decline. An interpretation by the evaluator revealed the resident had decreased knowledge of current/recent events, reduced memory of personal history, and an inability to complete complex tasks. According to the interpretation, there was the possibility for the resident to retain the capacity for new learning with the use of visual aids and recognition of familiar people/places/and routines. The facility census of admissions and room moves was reviewed on 3/5/24 at 2:10 p.m. The resident was admitted on [DATE]. The resident was moved to a different room on 1/11/24. The resident was moved again to a different room on 1/18/24. The resident was then moved to the secure memory care unit on 2/23/24. Progress notes were reviewed from 1/5/24 to 3/11/24 revealed: A nurse practitioner (NP) progress note dated 1/8/24 revealed the resident admitted to the facility after a fall at home. The resident was admitted for medical management and rehabilitation. The resident had intermittent confusion and was alert to herself and situations. A social services summary progress note dated 1/12/14 revealed the resident exhibited short term memory loss as evidenced by disorientation of time and difficulty with recall abilities. Her BIMS score was a twelve out of 15. Her speech was clear and she was able to make her needs known to others. A daily skilled progress note dated 1/16/24 revealed the resident showed intermittent confusion but responded well to verbal commands. A social services progress note dated 2/23/24 revealed the social services staff contacted the resident's representative to consent to the resident being moved to the secure memory care unit temporarily for the resident's safety. A nursing progress note dated 2/25/24 revealed the resident was eating poorly due to not being able to pick and choose what she would like to eat. A behavior progress note dated 3/1/24 revealed during nurse rounds, the resident refused to use the restroom or have her brief changed. The resident grabbed the certified nurse aide (CNA) by the wrist and squeezed leaving a bruise. The resident displayed agitation and stated to the nurse she did not like the unit. She could not pick her own meals, she had to do what the staff told her to do, and verbalized hating being on the unit. The resident was redirected to an activity with assistance from another CNA. A NP progress note dated 3/2/24 revealed the resident was residing in the secure memory care unit due to the need for closer supervision and for safety. A social services progress note dated 3/7/24 (during survey) revealed the social services director (SSD) conducted a psychosocial check in with the resident. The resident told the SSD the unit was fine and nice. The resident did not voice any concerns. -No further progress notes were located demonstrating exit seeking behaviors or least restrictive alternatives attempted and failed. III. Staff interviews Registered nurse (RN) #2 was interviewed on 3/11/24 at 10:40 a.m. She said Resident #19 had behaviors of verbal aggression towards staff but no physical behaviors. The resident had not made attempts to elope from the secure unit since admitting. RN #2 knew the resident when she resided on the other unit of the facility. The resident had several room moves but RN #2 did not know why. The resident had confusion where her room was and had approached the double doors leading to the assisted living section of the facility but had not tried to exit. RN #2 said the resident frequently expressed feeling unhappy and restricted on the secure memory care unit. CNA #11 was interviewed on 3/11/24 at 10:52 a.m. Resident #19 has not made attempts to elope since coming to the secure unit. CNA #11 was told the resident had tried to leave when living on the other side of the facility in the long term care unit, but CNA #11 said she had only ever seen the resident approach the double doors but not attempt to leave them. The NP was interviewed on 3/11/24 at 11:18 a.m. He said Resident #19 would benefit from the programs and increased interaction on the secure unit. He did not know why she was initially moved over to the secure unit. The NP said he had not personally observed any exit seeking or wandering behaviors from the resident and said she would not be able to go very far in a wheelchair. The SSD and assistant nursing home administrator (ANHA) were interviewed on 3/11/24 at 1:01 p.m. The SSD said if a resident was determined to meet criteria for the secure memory care unit, a physician authorization form, a consent from the responsible party, and a physician's order for placement were obtained prior to the resident admitting to the secure unit. The facility worked with an external behavioral health agency to provide the independent reviewer for the evaluation process. The independent reviewer was part of the preadmission evaluation of the resident. The criteria for an existing resident to move to the secure memory care unit would be wandering into other resident's rooms, exit seeking behaviors, as well as behaviors disruptive to other residents. The SSD said she did monthly audits on the documents required for secure unit placement for all the residents residing on the unit. She did not have documentation of the audits. The SSD was aware the resident had initially moved from the rehabilitation part of the facility to the long term care side before moving to the memory care unit but did not know how many times she was moved total between 1/5/24 and 2/23/24. She was not aware if this impacted the resident's behaviors or cognition. The SSD said it was noted the resident had gone towards the exit doors leading from the long term care side to the assisted living part of the facility. This was the determination for movement to the secure memory care unit. She did not know what least restrictive interventions had been attempted before placement. The ANHA was not aware of the state or facility requirements for secure unit placement. She said preadmission evaluations needed to be signed by all managers involved and the independent reviewer. The physician authorization for placement was signed by the physician. These documents were signed within seven days of a resident's moving to the secure unit. The responsible party consent and physician order were in place before moving onto the secure unit. The DON was interviewed on 3/11/24 at 2:56 p.m. A physician order, responsible party consent, documentation of evidence of wandering, and a preadmission evaluation are in place prior to admission to the secure memory care unit. Least restrictive interventions should be attempted first and documented. Interventions included assessing the resident for intentions with wandering and for unmet needs provoking wandering or exit seeking behaviors. Administration had received an email documenting Resident #19 was observed near the double doors leading from the long term care unit to the assisted living area. The DON did not know if there was a wandering risk assessment completed or if there was documentation in the chart of wandering behaviors. The NHA was interviewed on 3/11/24 at 3:32 p.m. He provided an email dated 2/23/24 from the assistant director of therapy revealing the resident had been found trying to leave the double doors leading from the long term care unit to the assisted living area. He provided another email from the social services staff dated 2/23/24 revealing the resident was to be moved to the secure memory unit due to risk of elopement. The resident was moved immediately after this incident. The NHA did not know if additional or alternative interventions were tried prior to admitting to the secure unit. He did not know if the SSD or social services staff had assessed the resident to determine the motivation or intent, if there were unmet needs, or if the secure memory care unit was the only appropriate intervention available. IV. Facility follow up On 3/12/24 at 4:45 p.m. documents were provided by the NHA: The previously reviewed note from the referral packet from the hospital dated 1/2/24 indicating the resident had a SLUMS score of six out of 10. The previously reviewed facility SLUMS assessment dated [DATE] with a score of 10 out of 30. A care plan review dated 2/22/24 revealed the resident had short term memory loss and difficulty with memory recall. The resident had been having difficulty locating and identifying where her room was in the long term care unit. -The note did not reflect the census which showed the resident had three room changes between 1/5/24 and 1/18/24 on the long term care unit. A CNA alert charting note dated 2/22/24 at 10:00 a.m. documenting the resident had tried to leave the health care center (long term care side of building) double doors and the CNA and therapy staff redirected her. The preadmission secure unit placement evaluation form from 2/23/24 with a signature from the independent reviewer but the date remained 2/23/24. -The form reviewed during the survey was dated 2/23/24 without independent reviewer signature. A social services progress note dated 2/26/24 marked as a late entry revealing the SSD had reached out to the resident's son to advise him she would be the resident's new social worker on the secure memory care unit. The representative was agreeable to the move and had no concerns. -This note was not located in the progress notes when reviewed on 3/11/24 (during survey) and there was no date/time stamp for the late entry. A physician progress note dated 3/5/24 (during survey) marked as a late entry revealing the resident was more mobile in her wheelchair and rarely found in her room. She had been wandering to the outside of the facility at times and had been unable to find her way back. She had asked the provider during the visit where she was supposed to go, indicating to the provider she did not know where her room was. -As of 3/5/24, the resident had moved four times since admission on 1/5/24 and was already residing in the secure memory care unit. -This note was not located in the progress notes when reviewed on 3/11/24 (during survey) and there was no date/time stamp for the late entry. An interdisciplinary team progress note dated 3/12/24 revealing the resident was reviewed and continued to meet criteria for secure memory care unit placement. A behavior progress note created on 3/12/24 backdated 2/23/24 revealing the occupational therapist had redirected the resident away from the double doors leaving the long term care unit. She stated to the therapist she wanted to get out of here.

Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to one (#191) of three out of 53 sample residents to ensure a safe discharge from the facility. Specifically, the facility failed to provide evidence and documented confirmation that home health services were arranged upon Resident #191's discharge from the facility, per physician orders. Findings include: I. Facility policy and procedure The Discharge Planning Process policy and procedure, revised December 2023, was provided by the nursing home administrator (NHA) on 3/11/24 at 4:09 p.m. It read in pertinent part, The discharge process should effectively transition them to post-discharge care, and minimize clinical or other factors which are related to the possibility of a readmission. The facility's discharge planning process shall provide and document sufficient preparation. II. Resident #191 status Resident #191, age 73, was admitted on [DATE], and discharged on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included cellulitis (bacterial infection of skin) of right lower limb, type 2 diabetes mellitus, and acquired absence of left leg below the knee (amputation). The 2/4/24 discharge minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance with toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, and transfers lying to sit. She was dependent on the use of a manual wheelchair for mobility. A. Resident representative interview The resident's representative (RR) was interviewed on 3/12/24 at 1:37 p.m. She said that Resident #191 was discharged home alone on 2/4/24 without home health (HH) services in place. The RR said she was not aware that the HH company did not accepted the facility's referral until the day after Resident #191 had been discharged (2/5/24). The RR said on the day (2/4/24) of Resident #191's discharge, the nurses had advised her that home health services were not set up, only a physician's order. RR said she received an email from the social services assistant (SSA) that morning saying she had sent a referral to a home health agency for PT (physical therapy), OT (occupational therapy, and RN (Registered nurse). The RR said the SSA had failed to make personal contact with the home health company to confirm the resident had been accepted. The RR said the facility did not follow physician orders to provide home health services at discharge. She said the resident especially needed a home care nurse to provide wound care to the right calf. The RR said she had to perform the wound care even though she had no medical training or education from the facility. The RR said on Tuesday (2/6/24), two days after the resident discharged home, Resident #191 had a fall and sliced her right leg. The RR said that emergency services had taken Resident #191 to the emergency room where she had to have eight stitches. The RR said without home health care confirmed and in place, it was an unsafe discharge for Resident #191. The RR said the SSA did not ensure a safe discharge and placed Resident #191 in an extremely unsafe situation. The RR said she had to look for a home health agency on her own. She said that the agency started care on 2/19/24. The RR said Resident #191 was home without home healthcare for 15 days. B. Record review The discharge care plan, initiated 11/12/23, revealed the resident planned to return home where she lived alone in an apartment. The interventions included encouraging the resident to discuss feeling and concerns with an impending discharge; establishing a pre-discharge plan with the resident, family/caregivers; evaluating the progress and revising the discharge plan as needed; evaluating the resident's motivation to return to the community; evaluating and recording the resident's abilities and strength, with family/caregivers/IDT (interdisciplinary team); determining gaps in the resident's abilities which will affect discharge; making arrangements with required community resources to support independence post-discharge; and preparing and giving the resident, family member and caregiver contact numbers for all community referrals. A review of the CPOs dated 1/30/24 revealed Right posterior calf wound. Cleanse with wound cleanser, apply collagen powder to wound bed, cover with foam dressing; change three times per week. A review of the PT home evaluation note on 1/31/24 revealed, Reviewed with team patient's improved level of functional mobility but need for some home health services to optimize safety and carryover. A review of the OT home evaluation note on 1/31/23 revealed, Reviewed with team patient's improved level of functional mobility but need for home health services to ensure safety and carry over in the home. A review of the CPOs dated 2/1/24 revealed Discharge is scheduled for 2/4/24 to return home. Home health care will provide PT, OT, RN. Send with belongings. An email sent to the RR from the SSA on 2/4/24 at 9:07 a.m. documented, Referral sent to (company name) Home Health Care, will provide PT, OT, RN for home health care needs. -However there was no documentation provided that the home health company had received, accepted and was able to staff the referral. A review of a text message sent from the RR to assistant nursing home administrator (ANHA) on 2/4/24 at 9:58 a.m. revealed, Resident #191 is set to discharge at 1:30 p.m. today. Nurses have advised there is nothing set up for home health care only a Dr. (doctors) orders. A review of the facility's physician discharge summary, dated 2/4/24 at 9:23 a.m. revealed in pertinent part, Disposition: Discharge to home with home health. History of present illness: Patient discharged to SNF (skilled nursing facility) and then to home with wound vac. However home health care was not successfully arranged. Rehabilitation process: Resident #191 has achieved the desired rehabilitation goals and collectively deemed safe to transition home with health services. I certify that home health services are medically necessary as the patient is expected to be relatively homebound and any initial trips away from home will require considerable taxing efforts and subsequent office appointments with you or a specialist. Documentation was requested from NHA on 3/7/24 at 11:53 a.m. for the preferred home health referral from the facility (social services department), and confirmation response from the home health company for accepting the referral. -No documentation was provided. See NHA interview below. III. Staff interviews The NHA was interviewed on 3/11/24 at 9:28 a.m. He said the facility did not receive confirmation from the preferred home healthcare company that they were able to accept the referral for Resident #191. He said the facility discharged the resident without confirmation that home health services were arranged. The director of nursing (DON) was interviewed on 3/11/24 at 10:25 a.m. She said the discharge process was to receive a physician order to discharge, and the social services department opens up a discharge summary with IDT involvement. She said social services makes a plan that includes needs, goals, appointments, equipment, home healthcare or other ancillary needs. The DON said if there were not any home health companies that were available to take a referral, social services should inform the physician and the resident/responsible party. The DON said if the physician orders were not able to be followed for home healthcare services, they would reconsider the plan. The DON said communication between the home health company and the discharge planner was important to ensure a safe discharge. The DON said she would not have wanted Resident #191 discharged without home health services in place because Resident #191 at high risk of infection and hospitalization . The SSD, ANHA, and SSA were interviewed on 3/11/24 at 12:20 p.m. The SSD said the discharge process was to set up a care conference/IDT to see what was needed such as medical equipment, where going at discharge (i.e. home), home healthcare and other supportive services. The ANHA said a discharge date was then scheduled, and the physician would complete a discharge assessment. The SSA said if home health service were not available, she would offer outpatient therapy to the resident. The SSA said she was the case manager who arranged Resident #191's discharge home. She said Resident #191 was referred to a home health agency that the family preferred and that had cared for the resident in the past. The SSA said she sent the home health referral on Friday 2/2/24. She said the home health agency had accepted the referral. She said she did not have any documentation that the home health had received and accepted Resident #191's referral. The SSA said she found out on Monday 2/5/24 from the RR that the home health company did not accept the referral. The SSA said she did not follow up with the preferred home health company, nor offer to arrange alternate home health services. The referred home health company was contacted on 3/11/24 at 1:43 p.m. The home health referral coordinator (HHRC) said she received a fax referral from the facility for Resident #191 on 2/2/24. The HHRC said they did not receive a call from the facility to confirm or follow up. The HHRC said she called the facility to advise that the agency could not accept the referral because they did not have the staffing available. IV. Facility follow-up On 3/12/24 at 5:00 p.m., the NHA provided the following information via email: It revealed the INHA and SSA called the preferred home health provider following the survey on 3/12/24 to follow up on the home health care needs for Resident #191. The home health director of nursing (HHDON) responded in an email on 3/12/24 at 1:48 p.m. to the ANHA and revealed in pertinent part, Resident #191 was a client with (company name) home health for two years. In that time, she fired all clinicians and would constantly make complaints, which were unfounded. Since Resident #191 had declined all of our clinicians, we were unable to meet her needs to staff appropriately. Staffing was the reason why we could not take her back. Additionally, Resident #191 wrote a review about (company name) home health, rated very poorly, stating that we should, 'close our doors.' This was not a factor to decline the referral, only to give more details. When she would call about a complaint or issue, each time would end with her abruptly hanging up the phone until time passed and history would repeat itself. If you have any questions or would like more clarity, please let me know. - The documentation confirmed the preferred home health company declined the facility referral for Resident #191 due to staffing and the facility failed to follow up to ensure Resident #191 had a safe discharge and home health services at home per physician order and therapist recommendations.

Based on interviews and record review, the facility failed to assist one (#60) of two sample residents reviewed for vision/ancillary services out of 53 sample residents. Specifically, the facility failed to offer to arrange Resident #60 an appointment for optometry services. Findings include: I. Facility policy The Hearing and Vision Services policy and procedure, revised March 2023, was provided by the nursing home administrator (NHA) on 3/11/24 at 4:04 p.m. It revealed in pertinent part, The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. Employees should refer any identified need for hearing or vision services/appliances to the social worker/social service designee. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources (Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation. II Resident status Resident #60, age 84, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included Horner's disease (disrupted nerve pathway on one side of the brain to the face and eye) and acute respiratory failure. The 12/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance from two people with most of her daily activities. The resident required a corrective lens. III. Resident interview Resident #60 was interviewed on 3/5/24 at 2:56 p.m. She said she had asked staff for an optometry appointment since she was admitted . She could not see well and it was affecting her ability to do activities that she liked to do. Resident #60 said she thought she may have cataracts and wanted to see an eye doctor for a checkup. IV. Record review According to an activity note dated 10/25/23 the resident asked the activities staff about getting an optometrist appointment. The activities staff advised the resident to talk to social services. According to the vision care plan dated 11/17/23, the resident was at risk for impaired visual function due to a nuclear cataract (clouding that develops in the lens). Interventions included the following: Arrange a consultation with an eye care practitioner as required. Encourage the resident to wear visual appliances for safety and to promote independence. Monitor, document, and report signs of acute eye problems to the physician. Remind the resident to wear glasses when she is up. V. Staff interviews The social services director (SSD) was interviewed on 3/11/24 at 10:03 a.m. The SSD said the department was in charge of assisting with optometry appointments. The SSD said Resident #60 did require glasses. The SDD said the resident did not have insurance covering the in-house optometrist. The SDD said the social services department would assist with scheduling and transportation to an outside provider. The SSD said she could not obtain documentation showing the resident was offered optometry services. The director of nursing (DON) was interviewed on 3/11/24 at 3:27 p.m. The DON said the social services department assisted with ancillary care. The DON said when a resident had concerns with an optometry appointment they should inform the nursing staff and they would inform the appropriate person. The DON said Resident #60 should have had an optometry appointment when she told the staff.

Based on observations, record review and interviews, the facility failed to ensure one (#101) of three residents reviewed for oxygen therapy was provided respiratory care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Ensure Resident #101 received oxygen as ordered by the physician; and, -Ensure Resident #101's oxygen saturation level (amount of oxygen in the blood) was monitored appropriately. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, reviewed June 2023, was provided by the nursing home administrator (NHA) on 3/11/24 at 4:13 p.m. It read in pertinent part, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Document all appropriate information in medical record: oxygen therapy, respiratory assessment finding, method of oxygen delivery, flow rate, patency of cannula, resident's response and any adverse reactions or side effects. II. Resident #101 A. Resident status Resident #101, age 72 , was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease with acute exacerbation (COPD) and morbid obesity with hypoventilation (shallow breathing). The 1/23/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required substantial/maximal assistance with toileting, personal hygiene, transfers, set up assistance with eating and supervision with bed mobility. B. Observations and resident interview On 3/5/24 at 11:38 a.m., Resident #101 was lying flat in bed on room air with an oxygen nasal cannula lying on the bedside table. The oxygen concentrator was set at five liters per minute (LPM) of oxygen. On 3/6/24 at 12:57 p.m., Resident #101 was lying flat in bed on room air with an oxygen nasal cannula in a plastic bag hanging on the oxygen concentrator. The oxygen concentrator was set at five LPM. On 3/7/24 at 10:28 a.m., Resident #101 was lying flat in bed with an oxygen nasal cannula in his nose and the oxygen concentrator was set at five LPM. On 3/7/24 at 4:00 p.m., Resident #101 was lying in bed with an oxygen nasal cannula in his nose and the oxygen concentrator was set at five LPM. On 3/11/24 at 11:00 a.m., Resident #101 was lying in bed with an oxygen nasal cannula in his nose and the oxygen concentrator was set at five LPM. Resident #101 was interviewed on 3/6/24 at 10:40 a.m. Resident #101 said the nurse had taken him off of his oxygen this morning (3/6/24) and left it on the bedside table. He said the staff had been placing him on five LPM of oxygen. He said staff had not checked his oxygen saturation level that morning (3/6/24). C. Record review The oxygen therapy care plan, initiated 11/22/22, indicated Resident #101 required oxygen related to ineffective gas exchange. Interventions included assist with ambulation as indicated, give medications as ordered by physician, monitor for signs and symptoms of respiratory distress including pulse oximetry, oxygen setting at 4 (four) LPM via nasal cannula, promote lung expansion and improve air exchange by proper body positioning with head of bed at 45 degrees. -A review of the oxygen therapy care plan did not reveal any personalized interventions added after his readmission on 1/30/24. The 1/30/24 physician orders documented apply oxygen via nasal cannula up to 4 (four) liters of oxygen to keep oxygen saturations at or above 90 percent (%), titrate (adjust) as indicated. The order was discontinued on 3/6/24. The 3/6/24 physician orders documented apply oxygen via nasal cannula up to four liters of oxygen at night and as needed to keep oxygen saturation at or above 88%, titrate as indicated. The resident's oxygen saturations were documented as follows: -3/5/24 at 7:14 a.m. 89% on room air; -3/6/24 at 4:48 p.m. 97% at four liters per minute; -3/7/24 at 12:17 p.m. 98% on room air; -3/7/24 at 6:11 p.m. 90% on oxygen via nasal cannula. No flow rate was documented; -3/7/24 at 9:51 p.m. 90% on oxygen via nasal cannula. No flow rate was documented; -3/8/24 at 5:32 p.m. 96% on oxygen via nasal cannula. No flow rate was documented; -3/9/24 at 6:53 a.m. 95% on oxygen via nasal cannula. No flow rate was documented; -3/9/24 at 5:10 p.m. 93% on oxygen via nasal cannula. No flow rate was documented; -3/10/24 at 5:22 p.m. 95% on oxygen via nasal cannula. No flow rate was documented; and, -3/11/24 at 7:09 a.m. 93% on room air. A comprehensive review of the resident's oxygen saturations revealed it was documented only once on 3/5/24, 3/6/24, 3/8/24 and 3/10/24. A comprehensive review of the resident's oxygen saturations failed to reveal documented flow rates on 3/7/24, 3/8/24, 3/9/24, 3/10/24. -A comprehensive review of the resident's medical record failed to reveal physician ordered parameters on how often oxygen saturations should be checked. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/11/24 at 10:14 a.m. LPN #1 said oxygen flow rates along with parameters were ordered by the physician and were populated on the treatment administration record (TAR). She said, for any resident on oxygen therapy, if their oxygen saturation level fell below 90% on the prescribed oxygen flow rate and required more oxygen than the prescribed flow rate, the physician should be notified. She said residents on oxygen therapy required vital signs with oxygen saturations checked and documented every eight hours. She said it was the nurse's responsibility to ensure it was documented. LPN #1 said documentation included if the oxygen saturation was on room air or nasal cannula and the oxygen flow rate if oxygen was being used. She said Resident #101 was on four liters per nasal cannula at night and as needed to keep oxygen saturations at or above 88%. -However, observations revealed the resident's oxygen concentrator was set to five LPM (see observations above). The director of nursing (DON) was interviewed on 3/11/24 at 3:00 p.m. The DON said every resident on oxygen therapy should have a physician order for oxygen liter flow and parameters for titration and monitoring. She said oxygen therapy and the parameters were care planned and placed on the task assignments for the certified nurse aides (CNA). She said if a resident on oxygen therapy required more oxygen outside of the ordered parameters the physician should be notified. The DON said oxygen saturation monitoring depended on physician orders but typically it was done at least once a shift.

Based on record review, observations, and interviews, the facility failed to ensure three (#19, #7 and #119) of seven residents reviewed out of 55 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to develop and implement person-centered care plans that identified the residents' fall risk; included effective fall reduction interventions; and implement and provide timely and consistent fall prevention interventions, for Residents #19, #7 and #119. Resident #19 was identified as a fall risk within the comprehensive care plan. The facility failed to provide sufficient supervision and training for caregivers to prevent falls and injuries. The fall risk care plan was put into place on 12/10/2020 which identified the resident as a fall risk. On 9/4/22, Resident #19 fell during a staff assisted transfer from the resident's wheelchair to a weight chair and sustained a fracture to the right tibia, a bone in the ankle. Documentation revealed the resident fell forward out of the chair onto the floor, landing on the knees, resulting in a fracture to the ankle. The resident was being assisted during the transfer by one staff. The resident was assessed by the facility nurse after the fall but was not sent to the emergency room for assessment and treatment of the sustained fracture until the following day when the resident complained of increasing pain and swelling of the right ankle. Following the resident fall on 9/4/22 the resident had four additional falls within a 76 day period of time, resulting in multiple bruises and a hematoma (pooling mass of mostly clotted blood formed under the skin) to the forehead. Resident #7 was admitted on [DATE], the facility's secure memory care unit. Upon admission the resident was assessed to be at risk for falls related to being a new admission, poor balance and medication side effects. The care plan documented the resident should have appropriate non-slip footwear when ambulating. On 11/26/22 the resident was walking outside while wearing flip flop footwear on the patio on an uneven surface and fell off the sidewalk. The cause of the fall was determined to be improper footwear. Resident #7 was continuing to wear non-skid socks with sandals and was observed during the survey on 11/28/22 and 11/30/22 to still be wearing slip-on sandals with no straps to secure the footwear onto the resident's feet. The facility's failure to ensure the resident was wearing appropriate footwear while walking on a pathway with uneven edges where the resident slipped off the path caused the resident to sustain a contusion (bruising and swelling) around his right eye and a laceration to the forehead, needing hospital assessment and treatment with sutures. Additionally the resident continued to be at risk for additional falls. Additionally, the facility failed to provide adequate supervision to a resident identified as high fall risk based upon the resident's assessment needs for Resident #119. Findings include: I. Facility policy The Fall Management policy and procedure, revised June 2018, was provided by the nursing home administrator (NHA) on 12/7/22 at 11:40 a.m. It revealed in pertinent part, It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. On admission, the fall risk evaluation will be completed to determine his/her risk for sustaining falls. Each resident is assisted through providing adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. The resident's care plan will be updated. The QAA (quality assurance) Committee will analyze trends related to falls and will determine if further intervention is needed. II. Resident #19 A. Resident status Resident #19, age 87, was admitted on [DATE] and readmitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included epilepsy, age-related macular degeneration (vision loss or blurry vision), osteoarthritis in the right hip, schizophrenia, and fracture of right tibia with routine healing. The 10/27/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident required extensive assistance with activities of daily living; including two plus staff physical assistance for transfers between surfaces; when moving from a sitting to standing from a chair/wheelchair or from the side of the bed; and when using the toilet. The resident needed one staff member to provide physical assistance for bed mobility, personal hygiene and dressing. The MDS revealed the resident had two or more falls without injury. -However, Resident #19 suffered a fall on 9/4/22 that resulted in a fracture which is considered a major injury. B. Observations During continuous observation on 11/30/22 from 8:46 a.m. to 10:29 a.m., Resident #19 was observed: -At 8:46 a.m., a certified nurse aide (CNA) got Resident #19 out of bed and into the wheelchair. The resident was reaching for items that may or may not have been present. The resident was seen leaning forward in the wheelchair reaching for an item on the floor. The resident was wearing a walking boot on the right foot. -At 9:20 a.m., the resident was seen leaving the room after breakfast self-propelling in a wheelchair with no supervision. -At 9:56 a.m., the resident was brought back to the room by the assistant director of nursing (ADON) #1. The resident stayed in the room sleeping in the wheelchair until 10:29 a.m. C. Record review The fall prevention care plan, initiated on 12/10/2020, revised on 12/15/21, documented the resident was a fall risk related to epilepsy, impared mobility, and weakness. The interventions included anticipating the resident's needs, keeping the call light within reach, and checking the brakes on the wheelchair. -The care plan did not document the resident's need for two staff to assist with safe transfers. The cognitive care plan, initiated on 1/3/2020 and revised on 5/9/22, documented the resident was at risk for cognitive function and thought processes related to disease process. The goal was for the resident to be able to communicate basic needs on a daily basis. Interventions included giving step by step instructions one at a time to support cognitive function, communicate by speaking face to face, reducing distractions and using direct simple sentences with necessary cues. The visual impairment care plan, initiated on 8/6/19 and revised on 5/6/2020, documented the resident was at risk for impared visual function related to macular degeneration. Interventions included monitoring for loss of mobility, double or tunnel vision, hazy or blurred vision. The activities of daily living (ADL) care plan, initiated on 12/10/2020, documented the resident had ADL self care deficits. Interventions included: transfers required participation of two staff members for moving from a sitting to a standing position; coming to a standing position from sitting in a chair/wheelchair or from the side of the bed, and when transferring from surface to surface. The bowel and bladder incontinence care plan initiated on 8/6/19 documented the resident had the potential for bowel and bladder incontinence. Interventions included: encouraging fluid to promote prompt voiding (urinating) response and monitoring for signs and symptoms of a urinary tract infection (UTI). The fall risk assessment dated [DATE], documented the resident had a history of three or more falls within the last 90 days; was disoriented; had poor eyesight; required use of an assistive device for balance; took three to four different medications and had predisposing factors that could lead to falls. The assessment revealed the resident was at a high risk level for falling and indicated interventions should be put promptly into place. D. Resident falls The resident medical record from 9/1/22 to 11/28/22 was reviewed; the record documented the resident had five falls in an approximate 76 day period of time; resulting in a fractured ankle, numerous bruises and a hematoma to the forehead (see below): 1. 9/4/22 fall occuring during staff assisted care Fall notes dated 9/4/22 at 8:22 p.m., documented that while receiving staff assistance to transfer from a wheelchair to the weight scale chair the resident slipped off the chair to the floor landing on both knees. The resident was unable to make the full transfer from one surface to the other; and CNA #1 who was assisting the resident with the transfer assisted the resident to the floor. The resident was assessed by the facility nurse to not be injured. -Only one staff member was present to assist the resident with the transfer from one chair to the other. The facility failed to assist and perform the resident transfer to meet the resident's needs as care planned (see above). Fall notes dated 9/5/22 at 2:20 p.m., documented the resident was assessed to have edema (swelling), bruising, and pain to the right ankle; and the resident was unable to bear weight on the right leg. The resident was placed on bed rest with the right lower leg elevated all shift. The physician was notified and an x-ray was ordered. A fall committee IDT (interdisciplinary team) note dated 9/7/22 documented the resident had a fall on 9/4/22, witnessed with injuries. The resident complained of right knee pain on 9/5/22 at 9:00 a.m., and was unable to put any weight on the right leg. An x-ray was ordered by the physician. The resident was sent out to the emergency room and returned to the facility on [DATE], with a diagnosed fracture of the right distal tibia (ankle). Hospital treatment notes dated 9/6/22 documented the resident was assessed to have a fractured ankle confirmed by x-ray. The hospital treated the resident's injury and provided the following treatment orders: a splint was placed on the right ankle. 2. 10/23/22 unwitnessed fall Nursing notes dated 10/23/22 documented that at 7:00 a.m. the resident was discovered sitting on the floor next to the bed. The resident said she rolled out of bed because the bed was wet with urine. The resident was reassured, assisted onto the wheelchair, and reeducated on safety awareness. The resident was not injured. A fall committee IDT note dated 10/24/22 documented the resident's fall on 10/23/22, and that it was expected that the resident would develop bruising after the fall. The new intervention to be added to the resident's care plan was for staff to offer help and assist the resident to get out of bed before 7:00 a.m. -There was no documentation for an intervention specific to offering the resident toileting assistance in the early morning hours. 3. 10/25/22 unwitnessed fall Nursing notes dated 10/25/22 at 1:19 p.m. documented that the resident was assessed for injuries because she was found on the floor at the bedside crawling towards her wheelchair. Nursing assessment revealed the resident had no apparent injuries; but was restless; had poor self awareness of physical ability; was acting spontaneously; and trying to ambulate without assistance. The nurse tried to educate the resident to use the call light for assistance but the resident was unable to reorient. Nursing was encouraging the resident to rest for periods between ADLs to help prevent fatigue. A fall committee IDT note dated 10/26/22 documented the resident was expected to develop bruising from the fall. New interventions included blood work and health review. 4. 10/27/22 unwitnessed fall Fall notes dated 10/27/22 documented the resident was found on the floor, in a sitting position, at bedside. The resident was very confused and unable to explain what happened. A registered nurse (RN) assessed the resident for injuries and none were found. Interventions included having a fall mat placed at bedside, with the bed in the low position, and the call light within the resident's reach. A fall committee IDT note dated 10/27/22 documented bruising was anticipated. Interventions included ordering a urinalysis assessment. 5. 11/20/22 unwitnessed fall Nursing notes dated 11/20/22 at 10:30 a.m. documented the resident was found sitting on the floor at bedside. The resident said she was sitting in her wheelchair and bent forward to pick her spilled food up off the floor and fell . The resident was assessed for injuries and found to have suffered a hematoma to the right side of the forehead. An ice pack was applied. The resident was assisted back to the wheelchair and was reminded to use the call light to call for assistance. A fall committee IDT note dated 11/21/22 documented the resident had a forehead hematoma with bruising that measured 4 centimeters (cm) by 3 cm. The new intervention was to encourage the resident to attend meals in the dining room. E. Staff interviews ADON #1 was interviewed on 11/30/22 at 10:22 a.m. ADON #1 said some residents fall frequently due to a history of falls and deficits. He said that staff were expected to keep an eye on residents who were assessed to be at high risk for falling to prevent falls. He said that fall history was documented in the resident's care plan and the information should be passed on in report (giving the information from nurse to nurse at shift change) and was accessible to nursing staff in the resident record. Licenced practical nurse (LPN) #1 was interviewed on 11/30/22 4:03 p.m. LPN #1 said that the staff were trying to get a weight on resident #19 on the night of 9/4/22 and the resident fell during the transfer and fractured her ankle. LPN #1 said the fracture was healed now, however the resident was unable to walk. The resident requires the use of a mechanical lift to get out of bed and for all transfers (from surface to surface). The resident was able to stand and pivot to transfer from surface to surface, but this required two staff for the task. RN #2 was interviewed on 12/1/22 1:01 p.m. RN #2 said that CNA #1 was transferring resident #19 (on 9/4/22) when the resident fell and broke her ankle. RN #2 said that Resident #19 was a two person assist for transfer and the CNA should have had another staff to assist with the resident transfer. The director of nursing (DON) was interviewed on 12/05/22 5:37 p.m.; the assistant nursing home administrator (ANHA) was present. The DON said that Resident #19 was being transferred to the weight chair and fell forward onto her knees. The DON said that when a resident required the assistance of two staff to complete a transfer, the CNA performing the transfers could ask the nurses for help if they could not find another CNA to assist. The DON said documentation did not reveal if there were two CNAs performing this task or who the CNAs or nurses were during the transfer of Resident #19 when she fell . The DON said the CNAs and nurses completed the same competencies and those were completed in June of 2022 or when a new employee was hired. The interventions were tailored to each resident the longer they stayed at the facility, if there was a concern, and when falls occurred. The DON said that all employees had completed the fall precaution training. 44949 III. Resident #7 A. Resident status Resident #7, age 83, was admitted on [DATE]. According to the December 2022 computerized physician orders, diagnoses included Alzheimer's disease, gout of right ankle and foot, and bilateral osteoarthritis of knee. The resident resided in the memory care unit. The 10/21/22 minimum data set assessment indicated the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. It indicated supervised one person assistance for locomotion on unit and extensive one person assistance for locomotion off unit. It indicated a wheelchair was coded for mobility devices. It indicated the resident did not wander. B. Resident representative interview The resident's representative was interviewed on 11/29/22 at 11:29 a.m. She said Resident #7 had a fall recently. She said he put on his coat and went outside because he wanted to leave. She said by the time staff found him he was around the building. She said the nurse was able to ask him to come back inside. She said while the nurse was walking with him he fell and hit his head. She said he had to be sent out to get stitches. She said she had brought him new slippers but she could not find them in his room. She said when she visited him one day he was wearing someone else's sweatpants and they were too long and a fall hazard. She said she had not seen any activities happening during her visits but activities would help keep the residents busy. C. Observations Resident #7 was observed on 11/28/22 at 10:12 a.m. ambulating around the unit. He was wearing non-skid socks with sandals that appeared to be made of plastic material. He asked if there was a back window he could look out in order to see if his truck was parked outside. Resident #7 was observed on 11/30/22 at 11:41 a.m. ambulating to lunch. He was wearing non-skid socks with sandals. Resident #7 was observed on 12/1/22 at 12:55 p.m. at a table in the dining room. He appeared to be asleep in a chair and was wearing non-skid socks with no shoes. D. Record review The fall investigation was provided by the nursing home administrator (NHA) on 11/30/22 at 4:00 p.m. It indicated the resident had a fall on 11/26/22 while outside. It indicated the predisposing situational factors were active exit seeker, wanderer, and improper footwear. It indicated the family had given him flip flops that may have caused him to trip. Progress notes for Resident #7 revealed the following: On 11/26/22 a progress note was completed and indicated Resident #7 was wearing his coat and went to the door to the patio. He went outside and the alarm was set off. A nurse went to the door and turned off the alarm and followed the resident. The resident had walked to a back corner of the patio. The nurse asked him to come back inside to eat lunch and the resident agreed. The resident had on flip flops over socks and stepped off the sidewalk edge. It indicated the nurse broke his fall but he bumped the right side of his forehead on the sidewalk edge. The resident had an open laceration and the nurse held pressure while emergency services were notified. On 11/26/22 a progress note was completed that indicated the resident returned from the hospital with sutures to his forehead and a contusion around his right eye. It indicated brain scans were identified as normal. The resident denied pain. On 11/28/22 a progress note was completed related to a fall committee meeting. It indicated injuries from the fall on 11/26/22 were a laceration to forehead with bruising anticipated. It indicated a new intervention as encouraging to wear appropriate footwear when ambulating. The fall care plan, revised 10/17/22, indicated Resident #7 was at risk for falls related to being a new admission, poor balance and medication side effects. Interventions included ensuring the resident was wearing appropriate footwear when ambulating or wheeling in a wheelchair, maintaining a clear pathway, avoiding rearranging furniture, and keeping needed items within reach. An additional fall care plan, revised 11/28/22, indicated Resident #7 had fallen on 10/31/22 and 11/26/22. Interventions included checking range of motion, ensuring proper footwear when ambulating, and neurological and vital checks as ordered. E. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 11/28/22 at 3:00 p.m. He said Resident #7 had a black eye and stitches because he fell recently. He said there were no other injuries. Certified nurse aide (CNA) #5 was interviewed on 11/30/22 at 10:28 a.m. She said Resident #7 had a fall recently but did not know if any new fall interventions were in place. She said when he left on 11/26/22 he got far out onto the patio before the nurse was able to redirect him. She said Resident #7 knew he could push on the door until it clicked and unlocked and the alarm went off. The activities director (AD) was interviewed on 12/5/22 at 11:11 a.m. She said she had not seen Resident #7 wander or elope. She said the resident was often looking for his car. She said he was a newer resident and staff was still learning what his interests were. The social services assistant (SSA) was interviewed on 12/5/22 at 11:36 a.m. She said Resident #7 wandered around the pod but had not tried to leave the facility. She said he liked to go out onto the courtyard. The assistant director of nursing (ADON) was interviewed on 12/5/22 at 11:59 a.m. She said Resident #7 was independent with walking and transfers. She said the back patio was fenced off and locked. She said Resident #7 was out walking around the patio when he misstepped and fell and hit his head on the concrete. She said she was unsure what footwear he was wearing at that time. She said the resident typically wore tennis shoes. She said sandals would not be the best footwear and a shoe with more of a sole would be appropriate. The director of nursing (DON) was interviewed on 12/5/22 at 3:56 p.m. She said on 11/26/22, Resident #7 pushed on the back patio door in the memory care unit. A nurse went over to the door and took him outside. She said they walked outside and when he turned to come in, he tripped and fell . She said appropriate shoes would include anything with a hard sole. She said if the resident had flip flops that were unsafe, staff should tell him not to wear them. 47351 IV. Resident #119 A. Resident status Resident #119, age 84, was admitted on [DATE]. According to the November 2022 computerized physician's orders (CPO) diagnoses included legal blindness, cognitive communication deficit, muscle wasting and weakness, abnormalities of gait and mobility, and repeated falls. The minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status with a (BIMS) score of five out of 15. The resident had severely impaired vision, adequate hearing, and did not reject care. The resident required extensive assistance from one staff member for toileting and personal hygiene. The resident needed limited assistance (guided maneuvering) with bed mobility and transfers. The resident used a manual wheelchair in the community and required supervision or assistance with moving from a sitting to standing position and transferring from surface to surface. The resident can walk 50 feet with supervision and staff assistance but was unable to maintain balance without staff support. The resident had a fall history admission to the facility and had one fall with minor injury (lacerations cuts/skin tears and bruising) since admission. B. Resident observations and interviews On 11/28/22 from 9:33 a.m. to 10:45 a.m. Resident #119 was observed. Resident #119 was sitting in a manual wheelchair at the bedside yelling out for staff to come into the room to talk with him. The resident had a call light in reach, but was unable to use it to call for staff assistance. Even when prompted to use the call light the resident was not able to activate the call light. Staff did not enter the room for the entire observation. At 10:47 a.m., Resident #119's roommate entered the hallway looking for staff; no staff were around. The roommate said Resident #119 had been calling out for staff assistance for sometime and no staff had come into help Resident #119. The roommate said Resident #119 had periods of confusion and had had numerous falls while living in the facility; so the facility recently moved Resident #119 into the room to be with another person. The roommate said he had been watching out for Resident #119 since he moved in. When he saw Resident #119 get up out of the wheelchair and head to the bathroom he went to help him get on the toilet because Resident #119 was not walking well. He said he was afraid Resident #119 would fall if he did not help and Resident #119 would not wait until he went for staff help. The roommate said Resident #119 was still on the toilet and needed staff to help him finish, get cleaned up and back to his wheelchair safely. I've done all I can do for him. -No staff were in the hall; the floor nurse, who was down the hall at the nurses desk was alerted that Resident #119's roommate helped Resident #119 to the bathroom and get on the toilet to go to the bathroom; and that Resident #119 needed staff assistance to finish using the toilet and get back to his wheelchair. On 12/5/22 at 8:53 a.m. Resident #119 was observed sitting in a manual wheelchair at bedside with a rolling over the bed table placed in front of him. Resident #119 was holding the call light in his hands but had not pressed the call light for staff assistance. The resident was observed standing up and walking forward pushing the bedside table with his body, as he walked. When asked where he was headed the resident responded to the bathroom. Verbal attempts to cue the resident to sit back down until staff could arrive to assist the resident to the bathroom were unsuccessful. The resident continued to walk forwards towards the bathroom while pushing the table forward with his lower body. The resident did not seem to realize the table was in the way and made no attempts to move the table from his walking path. The resident was very unbalanced and unsteady while walking and was reaching for objects that were not there in an apparent attempt to steady himself. The resident's roommate assisted in alerting staff to the resident's need for assistance; and a staff arrived to assist the resident to the bathroom. Resident #119's roommate was interviewed on 12/5/22 at 11:30 a.m. The roommate said Resident #119 was blind and seemed very confused. Resident #119 had lucid moments but mostly did not make sense in conversations. Resident #119 was particularly confused and night yelling out and talking with people who were not there. The roommate said he felt sorry for Resident #119 and felt he was responsible to watch out for Resident #119 to make sure he remained safe. C. Record review The comprehensive care plan initiated 9/14/22 and updated 12/6/22 documented a care focus for fall prevention and the goal for this care focus was the resident will resume usual activities without further incident. Interventions included the following: -Offer and encourage the resident to eat his meals in the dining room within line of sight. -Place a mattress on the floor (discontinued 12/6/22) -Place a mattress on the floor next to the bed, as a floor mat; -Offer assistance to get out of bed around 6:30 a.m., if awake; -Offer and encourage hip protectors and helmet (discontinued on 12/6/22 per resident choice); -Place a raised edge mattress on the resident's bed; -Continue interventions on the at-risk plan. Fall history in past 60 days Review of Resident #119's medical record revealed the resident had seven falls in the 60 days immediately following admission. The resident entered the facility being a known fall risk. The resident sustained minor injuries in each of the seven documented falls. Each fall required first aid treatment. Based on the nursing assessment the resident showed poor safety awareness and memory deficits which prevented the resident from being able to remember safe practices such as using the call light to ask for staff assistance when attempting transfers, walking and wanting to use the bathroom. Fall prevention intervention failed to provide the resident consistent assistance to prevent falls with injury (see post fall notes below). Post fall note dated 9/14/22 at 1:35 p.m. revealed: Resident #119 was found at his bedside on the floor. Staff heard a noise, entered the resident's room, and found Resident #119 at bedside on the floor with non-skid socks on; the call-light within reach. Resident #119 was unable to say how or why he fell . Resident #119 sustained an abrasion to the back of his head and right flank area. The resident was oriented to person and place (at baseline) and denied pain. LPN #4 encouraged Resident #119 to use his call light and wait for assistance prior to attempting ambulation (getting up and standing on his own). Resident #119 was agreeable, yet,was forgetful. LPN #4 recommended increased rounds to monitor safety. New interventions included: provide an edge raised mattress and increasing rounds to check on the resident. Post fall note dated 9/26/22 at 5:46 p.m. revealed: Resident #119 was found lying on the floor mat next to his bed. The resident sustained a left upper extremity skin tear 4.0 cm by 1.0 cm. The resident had on non-skid footwear; the bed was in the lowest position; the call light was in reach; and the floor mat was in place. Resident #119 said he was trying to go home and was unable to recall details of fall prevention education. New interventions included: continue to provide therapy to increase the resident's strength and endurance; evaluate the resident's room and bed, offer hipsters (cushioned hip protectors); offer a protective helmet; and place the mattress on the floor. Post fall note dated 9/26/22 at 6:49 a.m. revealed: Resident #119 was found on the floor on his knees next to the bed. The resident sustained a left upper arm skin tear measuring 2.5 centimeters (cm) by 1.0 cm and was incontinent of urine. The room was dark and the bedside table was within reach. The resident was assisted into his wheelchair, provided with non-skid socks, and a floor mat was placed next to the bed. New interventions included: providing the resident a floor mat at bedside and offering the resident assistance to get out of bed around 6:30 a.m. Post fall note dated 9/27/22 at 11:53 p.m. revealed: Resident #119 was found lying on the floor at the bedside face down position. The resident sustained a laceration to the left eyebrow measuring 3.0 cm by 1.0 cm and complained of a headache and generalized pain. Resident #119 was transported to the hospital emergency room for further evaluation. A computerized tomography examination (CT scan) and x-rays revealed no skull fracture, hemorrhage or fractures. Interventions included: continue to offer hipsters, helmet, and floor fall mat. Post fall noted dated 10/10/22 at 11:07 a.m. revealed Resident #119 was observed laying on the floor next to his wheelchair in the resident dining room. Resident #119 said he wanted to walk home. The resident was wearing shoes at the time of the fall and had been waiting for the meal to be served. The resident was assessed there were no injuries but the resident was found to have poor safety awareness and impaired memory. New interventions included: for the resident to not be left unattended when in the dining room at meal time and to provide the resident with continuous one to one assistance during meals. Post fall note dated 11/7/22 at 2:16 p.m. revealed Resident #119 was found on the floor with his lower body on the bed and head and upper body on the floor. The resident sustained a contusion (bruising) to his forehead and skin tear to the left forearm and elbow. The resident denied pain. Resident #119 told staff he was trying to get into bed. New interventions included: place the resident's bed in the lowest position; provide a wedge side mattress; continue to provide the floor fall mat, remove the bed frame and place the resident's bed mattress on the floor. Post fall noted dated 11//7/22 at 5:17 p.m. revealed Resident #119 was found laying flat on the floor. Resident #119 told staff he was trying to go to the bathroom and fell . The resident sustained redness, and swelling to the left side of his head with mild pain; and a skin tear with bleeding to the left forearm and elbow. Interventions included a reminder for the resident to call for staff assistance when he needed to use the

Based on record review and interviews, the facility failed to ensure the care and services provided met professional standards of practice to ensure the residents highest practicable level of well being for three (#3, #5, and #4) out of seven sample residents. Resident #3 was admitted to the facility with a history of falls, and contributing factors of [MEDICAL CONDITION], dementia with behaviors, and adult failure to thrive. Resident #3 had three falls within one week of admission to the facility. (cross-reference F689) The last fall, unwitnessed occurred on 6/3/2020. On 6/3/2020 Resident #3 fell backwards in his wheelchair (see summary of incident in nursing notes) and was found lying on his back next to his wheelchair, both of his knees were bent with his feet near his buttocks. The resident was unconscious and did not respond to verbal stimuli or sternal rub, his pupils were equal, widened at approximately eight centimeters and did not constrict to light and were directed down and to the right. Instead of Resident #3 being sent out to the hospital for evaluation and treatment, Resident #3 was put back into bed by staff and approximately 15 minutes after the initial assessment the resident was verbalizing, but unintelligible. The resident's MOST form, signed on 5/29/2020 indicated the resident was a do not resuscitate (DNR) with selective treatment with the goal of treating medical conditions while avoiding burdensome measures. The facilities failures to treat and identify change in conditions for Resident #3 who sustained a fall with head injury, loss of consciousness, and a decline from baseline contributed to a delay in emergent care for Resident #3. Furthermore, Resident #3 was documented to be sleeping when the nurse attempted to give medications hours after the residents fell . This opportunity was missed along with others to identify the emergent need to send the resident out the hospital for an evaluation and treatment. Moreover, the resident was documented by the hospital to have a loss of consciousness event that occurred over eight hours prior to admission to the hospital. He was intubated in the trauma bay for a coma score of six. Trauma workup included: chest x-ray, CT of head and neck, and CT of chest, abdomen, and pelvis. Trauma workup revealed a subdural hematoma and subarachnoid hemorrhage with herniation. In addition the patient had an occipital fracture and right intertrochanteric [MEDICAL CONDITION] that was not displaced. Additonally the facility failed to monitor and prevent decline in non-pressure skin conditions which led to infections for Residents #5 and #4. Findings include: I. Facility policy and procedure The monitoring for significant change in condition policy was provided electronically by the nursing home administrator on 10/28/2020 at 3:30 p.m. It read, in pertinent part: It is the policy of this facility to ensure each resident receives quality of care services to attain and maintain the highest practicable physical, mental, and psychosocial well being in accordance with the interdisciplinary comprehensive assessment and plan of care. If at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the Nurse Supervisor should be made aware of and he or she will monitor. The Falls Monitoring and Management policy, dated 4/2020, was provided by the director of nursing (DON) on 10/22/2020 at 12:00 p.m. It read, in pertinent part: For an individual who has fallen, the following interventions include, but are not limited to: -Document neurological assessments on the neurological assessment form. a. Complete initial neurological assessment then as follows: b. Every 15 minutes x four c. Every 30 minutes x four d. Every one hour x four e. Every four hours x four f. Every eight hours until 72 hours of observation is completed. II. Resident #3 A. Resident status Resident #3, age 76, was admitted on [DATE] and discharged to the hospital on [DATE] with a subdural hematoma and a subarachnoid hemorrhage with herniation. According to the June 2020 computerized physician orders (CPO), the [DIAGNOSES REDACTED]. The 6/3/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15. He exhibited inattention, disorganized thinking, and wandering. He required extensive assistance of one staff member with bed mobility and transfers, supervision with walking in the room, limited assistance walking in the hallway, and extensive assistance of two staff with toileting, personal hygiene and bathing. He used a walker and a wheelchair. He had a history of [REDACTED]. B. Record review On 6/3/2020 at 12:00 p.m. the nurse noted to hear a loud noise and a large ouch come from the resident's room. The nurse found the resident lying on the floor, by his wheelchair. He had apparently flipped the chair on its back and he was lying on his back with his eyes closed. The nurse noted it took the resident a long time to wake up and respond, a sternal rub eventually helped and he woke. He did appear to hit his head but had no broken skin and there was no bump or reddened area. The physician and family were notified. On 6/3/2020 at 12:05 p.m. an RN note read she was called to the unit to assess the resident on the floor. She noted the resident was lying on his back next to his wheelchair, both of his knees were bent with his feet near his buttocks. The resident appeared to be unconscious and did not respond to verbal stimuli or sternal rub, his pupils were equal, widened at approximately eight centimeters and did not constrict to light. His eyes were noted to be directed down and to the right. Approximately 30-45 seconds later the resident was responding to sternal rub with facial grimace and arm movements. Range of motion appeared within normal limits and no shortening or rotation was noted to lower extremities. The resident was assisted to his wheelchair, then to bed with two staff members for further evaluation. Approximately three to four minutes after the initial assessment, the residents pupils were reactive to light. Approximately 15 minutes after the initial assessment the resident was verbalizing, but unintelligible. On 6/3/2020 at 2:46 p.m. the resident's physician ordered stat (immediate) laboratory tests to be completed related to falls. -No further documentation was revealed to indicate the physician was given all the facts to make a sound informed decision of only ordering laboratory tests for Resident #3 in his current condition post fall with a head injury. On 6/3/2020 at 4:20 p.m. a daily skilled nursing note read the resident's motor response deviated from baseline. Grasps were decreased on both upper extremities and decreased movement to both lower extremities. The resident's pupil response deviated from baseline, abnormal pupil response on both right and left eyes, but slowly resolves. He was slow with his responses and he was mumbling. On 6/3/2020 at 10:46 p.m. a nursing note read at 7:00 p.m. the nurse writer attempted to give medications to the resident but he appeared to be sleeping so medications were not administered at that time. At 7:30 p.m. laboratory representatives came and obtained a blood sample for a stat lab. At 9:15 p.m. a certified nurse aide (CNA) alerted the nurse that the resident had blood coming out of his nose, the nurse went in and assessed the resident and was assisting staff on providing care, the resident was unresponsive verbally but was moving his feet. The nurse opened the resident's eyes and both pupils were not dilating, when the CNA went to adjust the head of the bed, the resident started to vomit copious amounts of blood. The nurse called the physician and obtained an order for [REDACTED]. The nursing staff failed to identify emergent negative effects for a resident post fall with a head injury as mentioned above the staff allowed the resident to possibly fall asleep. The resident's neurological checks for 6/3/2020 were reviewed and revealed the resident's neurological signs were poor but stable with pupil response sluggish in both eyes, strong upper extremities and weak lower extremities from 12:00 p.m. to 5:45 p.m., then recorded at 6:45 p.m. the residents pupils were documented to be wider and non-reactive, upper and lower extremities were weak, he was disoriented and unresponsive. -The nursing staff failed to identify the continued decline in Resident's #3 status even when the neurological check at 6:45 p.m. documented a further negative change in cognition. There were no additional neurological checks due to the resident's hospitalization . Limited hospital records were provided by the NHA on 10/20/2020 at 4:43 p.m. Upon review, the hospital records revealed the resident presented to the emergency department after he was found unresponsive by staff at the nursing facility. He had had several falls prior to admission including a nine minute loss of consciousness event that occurred over eight hours prior to admission. He was intubated in the trauma bay for a coma score of six. Trauma workup included: chest x-ray, CT of head and neck, and CT of chest, abdomen, and pelvis. Trauma workup revealed a subdural hematoma and subarachnoid hemorrhage with herniation. In addition the patient had an occipital fracture and right intertrochanteric [MEDICAL CONDITION] that was not displaced. The family was consulted and wished for the patient to remain a DNR and they did not wish for lifesaving measures or surgical interventions. C. Staff interviews A licensed practical nurse (LPN) #2 was interviewed on 10/21/2020 at 12:36 p.m. She stated if a resident had a change in neurological signs she would call an RN immediately to assess and call the resident's physician for orders. LPN #1 was interviewed on 10/21/2020 at 12:53 p.m. She stated if a resident had a change in condition or neurological status she would call an RN to assess immediately and would call the resident's physician immediately for further instructions. RN #1 was interviewed on 10/21/2020 at 4:04 p.m. He stated he was frequently called to assess residents who had fallen. He stated he assessed the resident for injury, neurological signs of a possible head injury and the situation surrounding the fall. He stated an RN needed to complete the assessment. He stated if a resident had a change in neurological signs after a fall, he called the resident's physician immediately for further instructions and if the resident should be sent out to the hospital. He stated if a resident had a bad fall with head involvement and unresponsiveness, he called the physician and explained the whole situation. He stated he documented the physician's response and any orders in the medical record. The director of nursing (DON) was interviewed on 10/21/2020 at 4:25 p.m. She stated the neurological checks should be completed and there should be no areas left blank or documentation that the resident was sleeping as a reason why neurological checks were not completed. She stated if the resident refused, there should be a note related to the refusal and an explanation of how the staff member knew the resident was ok. She stated if a resident had a change in neurological signs, the staff should immediately inform the physician. A neurological check education dated 7/10/2020 was provided by the DON electronically on 10/29/2020, it read: It is important when initiating neurological checks on a resident that all time of the neurological checks are completed fully. Neurological checks are initiated immediately when potential head injury is identified and spans 72 hours post incident. Full sets of vital signs as well as pupillary and neurological status needs to be documented on each of these checks. Sleeping is not an acceptable reason for not performing neurological checks. If a resident is being monitored for potential head injury, it would be crucial to assess their status if they appear to be sleeping. III. Resident #5 A. Resident status Resident #5, age 83, was admitted on [DATE]. According to the September 2020 CPO, the [DIAGNOSES REDACTED]. The 9/8/2020 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of seven out of 15 and she exhibited disorganized thinking. She required extensive assistance of one staff member with her mobility and ADLs. She required staff stabilization, did not walk, and had impairment on one side of her body. She experienced two or more falls with no injury, no falls with injury or major injury since her prior assessment. B. Record review On 9/18/2020 at 12:26 p.m. a nursing note read the resident was walking with staff assistance and came back from the restroom. Staff briefly let go of the resident with one hand while still holding her with the other hand to move the bedside table. The resident lost her balance and fell backward and to the right. Staff called for help. The resident was alert, pupils were equal and reactive to light, hand grasps at baseline. Noted the resident was bleeding from the right side of her head. Range of motion to all extremities at baseline and the resident showed no signs of pain. The resident was assisted up to her wheelchair, the area to the right side of her head was cleansed. Hematoma noted measuring four centimeters by three centimeters. Area no longer bleeding and no visible laceration noted. Ice applied to the area. Neurological checks were started according to facility policy. Physician and family were notified. Will continue to monitor, no new orders at this time. On 9/18/2020 at 2:45 p.m. a nursing note read the resident was in the shower room taking a shower and a hematoma was noted to the right parietal lobe, bleeding was controlled. Call was placed to the physician to inform about the hematoma. An order was received to send the resident to the emergency room for evaluation and treatment. The resident's family was informed about the transfer to the emergency room . On 9/18/2020 at 9:35 p.m. a nursing note read the resident returned to the facility with four staples to the right side of her parietal lobe at the site of the hematoma. The resident was alert to self and pleasantly confused. On 9/18/2020 at 11:22 p.m. a nursing note read the staff continued on follow up for the fall, the resident had a right head scalp laceration with four staples. The resident did not complain of pain or discomfort. Bed in the lowest position, fall mat in place, encouraged the resident to call for assistance, and the call light was safely within reach. On 9/19/2020 at 10:30 a.m. a nursing note read the resident denied pain or discomfort, denied headache, had no changes in mental status, and was up in her wheelchair. On 9/19/2020 at 9:08 p.m. a nursing note read the resident continued on fall follow up, right head scalp laceration with four staples, neurological assessment and range of motion were at baseline, and the resident denied pain or discomfort. On 9/20/2020 at 8:15 a.m. a nursing note read the resident was lying in bed and was restless. She denied headache, her respirations were shallow. Her speech was garbled and she was unable to answer simple questions but was able to follow simple commands. This was a change in her mental status. The physician and family were notified. On 9/20/2020 at 9:30 a.m. a nursing note read the resident's family decided to have the resident transfer to the emergency room for evaluation. Review of hospital records for the resident from 9/20/2020 to 9/23/2020 revealed the resident was diagnosed with [REDACTED]. The hospital course summary revealed the resident was admitted for concerns for [MEDICAL CONDITION] a scalp wound and scalp [MEDICAL CONDITION]. The resident fell and hit her head and went to the emergency department for laceration repair and had staples placed. A few days later there appeared to be purulent drainage around the staple site and the resident had increased right sided swelling in her face, elevated which count of 35 and [MEDICAL CONDITION] the low 100s. The staples were removed in the emergency department and she was started on intravenous antibiotics with rapid resolution of her symptoms. A head CT was performed at the hospital on [DATE] upon admission and revealed extensive right facial and right skull soft tissue swelling with fluid and gas. Review of the resident's treatment administration record (TAR) for September 2020 revealed an order was added on 9/20/2020 to monitor staples to head for signs of healing or infection until resolved every shift for 10 days. The TAR revealed the spaces for sign off for monitoring were blank. Additionally, the resident returned to the facility with the staples on 9/18/2020 and there were no orders for monitoring the site. There was no evidence in the resident record monitoring of the laceration site to her head occurred prior to her transfer to the hospital. C. Staff interviews The assistant director of nursing (ADON) was interviewed on 10/22/2020 at 3:29 p.m. She stated she also acts as the wound nurse for the facility. She stated she would expect there to be documentation of monitoring for the laceration and staple site for the resident. She stated she would have expected the resident to return from the emergency department on 9/18/2020 with orders to monitor the site and if there were no orders, the nursing staff should have been monitoring the site. She stated the resident fell on a Friday and did not return from the emergency department before she had left for the weekend. She stated the weekend supervisor should have been monitoring the site. She stated the facility charted by exception, so could assume the site was being monitored, though there were no issues. The ADON stated there was no documentation of signs or symptoms of infection other than the change in mental status. She further went on to imply the resident could have developed the symptoms described by the hospital on the way to the hospital or while waiting in the emergency department. The DON was interviewed on 10/22/2020 at 3:45 p.m. and stated she would expect for there to be detailed documentation of an injury site at least in the nursing notes if there was no physician order written [REDACTED]. IV. Resident #4 A. Resident status Resident #4, age 88, was admitted on [DATE] and discharged on [DATE]. According to the September 2020 computerized physician orders (CPO), the [DIAGNOSES REDACTED]. The 9/18/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required supervision of one staff member with his mobility and activities of daily living (ADLs). He had no skin injuries or impairments at the time of the assessment. B. Record review On 9/22/2020 at 6:45 p.m. an RN note read during the resident's skin assessment an open area was found to his right shin. The resident responded it comes and goes. The area was cleansed with wound cleanser and foam dressing was applied. The physician was in the building and saw the wound. Resident was his own power of attorney. Wound RN was notified. The resident denied pain. On 9/23/2020 at 6:09 a skin committee note read the resident was noted to have vascular wounds and weeping to his right shin after a shower. The resident had increased [MEDICAL CONDITION] to his right lower extremity. The resident stated he has had lower extremity wounds before. Treatment as ordered. Monitor for signs of healing and infection until resolved. Physician was notified and the resident was self responsible. Review of the resident's TAR revealed an order was written on 9/22/2020 to apply wound cleanser, xeroform and dry dressing to open areas to the right shin every day. The space for the nurse to sign off on 9/23/2020 to indicate the treatment was done was left blank. -No documentation was revealed in the residents chart to indicate the physician was notified of the change in wound status. The physician identified it on wound rounds, see following notation. On 9/27/2020 at 5:23 p.m. a physician note revealed the resident's wound appeared infected, lab tests were ordered and the antibiotic medication [MEDICATION NAME] was ordered. On 9/28/2020 at 9:53 a.m. a nursing discharge summary note revealed the resident did develop a wound to his right lower extremity that was very painful and limiting his mobility at times. The vascular wound measured 16 cm x 14.8 cm. On 9/29/2020 at 5:36 p.m. a skin committee note revealed the wound nurse spoke to the resident's daughter after wound rounds and informed her that the resident had increased [MEDICAL CONDITION] and an open area to his lower right leg. She informed the resident's daughter the physician had ordered ultrasound to his leg. The resident's daughter requested to speak to the physician related to the wound and home health care. The resident was discharged home on[DATE] with home health care and wound care. C. Staff interviews The DON was interviewed on 10/22/2020 at 3:45 p.m. She stated there should not be blank spaces left on the TAR because that is what is used to prove treatments were completed as ordered. She stated the staff will receive additional and updated training from her related to head injuries, monitoring injuries, and documentation. A staff in-service form for wounds and treatment orders dated 9/11/2020, was provided by the DON electronically on 10/29/2020. It read: For any resident with any type of open wound a treatment order must be started. If this is a new admission, check the hospital records for treatment orders. If you are unable to determine the hospital treatment orders, request orders from the provider. Ensure you are placing treatment orders and orders to monitor until resolved immediately.

Based on record review and interviews the facility failed to ensure the resident environment was kept as free from accident hazards as possible and that residents received supervision and devices to prevent accidents for five (#3, #5, #2, #6, and #7) out of six residents reviewed for accidents out of seven sample residents. The facilities failures to ensure Resident #3 received adequate supervision to prevent three falls contributed to Resident #3's injuries. The last fall on 6/3/2020 was unwitnessed and Resident #3 sustained a head injury, loss of consciousness, and a decline from baseline requiring hospitalization . Resident #3, as documented by the hospital, sustained subdural hematoma and subarachnoid hemorrhage with herniation. Resident #3, in addition to, also had an occipital fracture and right intertrochantreic [MEDICAL CONDITION] that was not displaced. Additionally, the facility failed to ensure: -Resident #5 received supervision to prevent falls and proper ambulation assistance to prevent a fall with head injury; -Resident #2 received supervision to prevent multiple falls resulting in injuries; -Residents #6 and #7 received supervision to prevent falls with minor injury; and, -Relevant and effective interventions were implemented and monitored to prevent falls. Cross-reference F658 Professional Standards-ensure assessments were completed and F684 Quality of Care-prevent major injuries with falls. Findings include: I. Facility policy and procedure The Falls Monitoring and Management policy, dated April 2020, was provided by the director of nursing (DON) on 10/22/2020 at 12:00 p.m. It read, in pertinent part: It is the policy of the facility that: -Residents are assessed and evaluated to identify risks for injury due to falls; -Residents receive necessary treatment and monitoring after a fall; -Interventions are implemented to minimize risks for injury due to falls. The licensed nurse is responsible for assessing and evaluating the resident's fall risk on admission, quarterly, and with a significant change in condition. The Post Fall Assessment policy, revised August 2017, was provided by the nursing home administrator (NHA) on 10/21/2020 at 1:00 p.m. It read, in pertinent part: It is the policy of this facility that if a resident sustains a fall, an incident report is completed. A registered nurse will complete an initial assessment. A care plan or an update to an existing care plan will then be generated. A post fall assessment is done to identify possible causative factors that could have contributed to the fall. The information is then used to formulate a plan of care in an attempt to prevent further falls or incidents. If there is an existing plan of care in the resident's medical record pertaining to falls it should be updated to reflect newly identified risk factors and approaches The Falls Prevention policy, revised 8/2017, was provided by the NHA on 10/21/2020 at 1:00 p.m. It read, in pertinent part: The purpose of this policy is to: -Investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize the potential for injury; -Identify residents at risk for falls and determine appropriate interventions. -Care plans will be revised and /or updated to reflect changes in interventions. II. Resident #3 A. Resident status Resident #3, age 76, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the June 2020 computerized physician orders [REDACTED]. The 6/3/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15. He exhibited inattention, disorganized thinking, and wandering. He required extensive assistance of one staff member with bed mobility and transfers, supervision with walking in the room, limited assistance walking in the hallway, and extensive assistance of two staff with toileting, personal hygiene and bathing. He used a walker and a wheelchair. He had a history of [REDACTED]. B. Record review On 5/29/2020 an admission fall risk assessment was completed and identified the resident was a high fall risk. He was identified to be disoriented, had experienced one to two falls in the past three months, was regularly incontinent, had poor vision, required assistance devices for mobility, and had one to two [DIAGNOSES REDACTED]. On 5/30/2020 an admission history and physical was completed by the resident's physician. It read the resident was transferred from another nursing facility due to the need for a secure environment due to wandering. The resident had experienced multiple recent falls with injury related to unsteady gait and poor safety awareness. He required assistance with most of his activities of daily living (ADLs), was at elevated risk for falls and would require close monitoring. On 5/30/2020 a fall care plan was initiated, it read, The resident is at risk for falls related to confusion, gait and balance problems, incontinence, psychoactive drug use, unawareness of safety needs, and wandering. The goal read, Resident will not sustain serious injury through the next review. Interventions included: Avoid rearranging furniture; be sure the call light is within reach and encourage to use it and call for assistance as needed; bed in lowest position; ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair; keep needed items in reach; maintain a clear pathway free of obstacles; therapy evaluation and treatment per physician orders. There was no intervention in his fall risk care plan related to his need for increased supervision. On 6/1/2020 at 4:45 p.m. the resident experienced a witnessed fall where he walked out of his room into the hallway without assistance, fell straight backwards and hit his head. The resident was assessed by the registered nurse (RN) and was identified to have a quarter size blue bruise to the top back of his head, no other injuries were identified and he was assisted up to his wheelchair. The nurse indicated the resident became clammy after being assisted to his wheelchair. He was identified to have been wearing non-slip socks. Neurological checks were initiated and completed appropriately. The physician and family were notified. An actual fall care plan was initiated on 6/1/2020, it read the resident had an actual fall on 6/1/2020 with no injury. The goal was that the resident would resume usual activities without further incident. The interventions included: encourage fluids and dietary consult; check orthostatic blood pressure every shift for 72 hours; neurological checks as ordered; and continue on therapy. There was no intervention added to the actual fall care plan related to the resident's need for increased supervision. On 6/2/2020 at 10:45 a.m. the resident experienced another witnessed fall in the common area where he stood up out of his wheelchair, attempted to remove his shirt and fell backwards hitting his head. The resident was assessed by an RN and was identified to have an old healing laceration reopened with minimal bleeding noted. Neurological checks were initiated and were completed appropriately. The physician and family were notified. On 6/2/2020 at 11:27 an RN assessment note read the resident was assessed in the common area for a fall. The resident was noted to be lying on his back next to his wheelchair. His shirt bottom was pulled over his head, his non-skid socks were removed and lying on the floor next to the resident. The resident was noted with blood at the back of his head, which was a prior area of injury that had reopened with a slight amount of bleeding and a two by two area of bruising noted. The resident denied pain, range of motion normal, legs equal in length, no rotation noted, grasps equal and pupils equal and reactive. An update was made to the resident's actual fall care plan on 6/2/2020 and read the resident had an actual fall on 6/2/2020 with minor injury. Interventions added included: Medication review. There was no evidence in the resident record the intervention of medication review occurred. On 6/3/2020 at 12:17 a.m. a nursing note revealed the resident was on monitoring for fall. The resident was constantly attempting to get up out of his wheelchair, had an unsteady gait, and was noncompliant with isolation precautions. On 6/3/2020 at 12:00 p.m. the nurse noted to hear a loud noise and a large ouch came from the resident's room. The nurse found the resident lying on the floor, by his wheelchair. He had apparently flipped the chair on its back and he was lying on his back with his eyes closed. The nurse noted it took the resident a long time to wake up and respond, a sternal rub eventually helped and he woke. He did appear to hit his head but had no broken skin and there was no bump or reddened area. The physician and family were notified. On 6/3/2020 an RN note read she was called to the unit to assess the resident on the floor. She noted the resident was lying on his back next to his wheelchair, both of his knees were bent with his feet near his buttocks. The resident appeared to be unconscious and did not respond to verbal stimuli or sternal rub, his pupils were equal, widened at approximately eight centimeters and did not constrict to light. His eyes were noted to be directed down and to the right. Approximately 30 to 45 seconds later the resident was responding to sternal rub with facial grimace and arm movements. Range of motion appeared within normal limits and no shortening or rotation was noted to lower extremities. The resident was assisted to his wheelchair, then to bed with two staff members for further evaluation. Approximately three to four minutes after the initial assessment, the residents pupils were reactive to light. Approximately 15 minutes after the initial assessment the resident was verbalizing, but unintelligible. On 6/3/2020 at 2:46 p.m. the resident's physician ordered stat (immediate) laboratory tests to be completed related to falls. -No further documentation was revealed to indicate the physician was given all the facts to make a sound informed decision of only ordering laboratory tests for Resident #3 in his current condition post fall with a head injury. On 6/3/2020 at 4:20 p.m. a daily skilled nursing note read the resident's motor response deviated from baseline. Grasps were decreased on both upper extremities and decreased movement to both lower extremities. The resident's pupil response deviated from baseline, abnormal pupil response on both right and left eyes, but slowly resolved. He was slow with his responses and he was mumbling. On 6/3/2020 at 10:46 p.m. a nursing note read at 7:00 p.m. the nurse writer attempted to give medications to the resident but he appeared to be sleeping so medications were not administered at that time. At 7:30 p.m. laboratory representatives came and obtained a blood sample for a stat lab. At 9:15 p.m. a certified nurse aide (CNA) alerted the nurse that the resident had blood coming out of his nose, the nurse went in and assessed the resident and was assisting staff on providing care, the resident was unresponsive verbally but was moving his feet. The nurse opened the resident's eyes and both pupils were not dilating, when the CNA went to adjust the head of the bed, the resident started to vomit copious amounts of blood. The nurse called the physician and obtained an order for [REDACTED]. The resident's neurological checks for 6/3/2020 were reviewed and revealed the resident's neurological signs were poor but stable with pupil response sluggish in both eyes, strong upper extremities and weak lower extremities from 12:00 p.m. to 5:45 p.m., then recorded at 6:45 p.m. the residents pupils were documented to be wider and non-reactive, upper and lower extremities were weak, he was disoriented and unresponsive. There were no additional neurological checks due to the resident's hospitalization . An update was added to the resident's actual fall care plan on 6/3/2020 and read the resident had an actual fall on 6/3/2020 with major injury. Added interventions included: frequent checks for 72 hours upon return from the hospital. Limited hospital records were provided by the NHA on 10/20/2020 at 4:43 p.m. Upon review, the hospital records revealed the resident presented to the emergency department after he was found unresponsive by staff at the nursing facility. He had had several falls prior to admission including a nine minute loss of consciousness event that occurred over eight hours prior to admission. He was intubated in the trauma bay for a coma score of six. Trauma workup included: chest x-ray, CT of head and neck, and CT of chest, abdomen, and pelvis. Trauma workup revealed a subdural hematoma and subarachnoid hemorrhage with herniation. In addition the patient had an occipital fracture and right intertrochanteric [MEDICAL CONDITION] that was not displaced. The family was consulted and wished for the patient to remain a DNR and they did not wish for lifesaving measures or surgical interventions. III. Resident #5 A. Resident status Resident #5, age 83, was admitted on [DATE]. According to the September 2020 CPO, the [DIAGNOSES REDACTED]. The 9/8/2020 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of seven out of 15 and she exhibited disorganized thinking. She required extensive assistance of one staff member with her mobility and ADLs. She required staff stabilization, did not walk, and had impairment on one side of her body. She experienced two or more falls with no injury, no falls with injury or major injury since her prior assessment. B. Record review On 6/7/2020 at 11:23 a.m. a nursing note revealed the nurse walked past the resident's room and the resident was leaning on the side of her bed on the floor. She stated she was trying to go see her husband. She denied any pain or discomfort. The nurse immediately examined the resident, she had no injuries, she was transferred to her wheelchair. Staff members were checking on the resident frequently. Resident's family and physician were notified, her call light was in reach, and her shoes were on. Neurological assessments were initiated and staff continued to monitor the resident. On 6/7/2020 at 11:58 a.m. an RN assessment note read resident was received sitting in her wheelchair. The resident denied pain, neurological checks were started, and palpated the entire body without grimace or signs of pain. A fall risk assessment dated [DATE] revealed the resident was at high risk for falls. She was mildly disoriented, had experienced three or more falls in the past three months, was continent, had adequate vision, had a balance problem, a change in gait pattern when walking, and required the use of an assistive device when ambulating, and took three to four medications and had one to two predisposing conditions related to falls. The resident experienced additional falls on 6/16/2020, 7/11/2020, 7/19/2020, 8/5/2020, 8/8/2020, and 8/29/2020. These falls occurred in the resident's room and were often related to attempts to self transfer and toilet. Review of the above falls revealed no concerns with RN assessment or completion of neurological checks. A fall risk care plan was initiated on 6/12/2019 and revised on 7/7/2020 and read: Resident is at risk for falls related to immobility, incontinence, cognitive loss, medication side effects, and limited range of motion. The goal for the care plan was: the resident would be free of falls through the review date. Interventions included: call light in reach and encourage to use it to call for assistance; keep needed items in reach; maintain a clear pathway free of obstacles; therapy evaluation and treatment per physician orders; added 8/8/19: anticipate and meet needs; avoid rearranging furniture; and follow facility fall protocol. An actual fall care plan was revised on 8/31/2020 and read the resident had actual falls on 6/7/2020, 6/16/2020, 7/11/2020, 7/19/2020, 8/5/2020, 8/8/2020, and 8/29/2020 with no injury. The goal was to resume usual activities without further incident through the review date. Interventions included: 6/7/2020 bed bolsters; 6/16/2020 continue transfer program with restorative nursing, fall mat next to bed; 7/11/2020 body pillow for positioning; 7/19/2020 keep wheelchair positioned next to bed when resident is in bed, encourage hipsters; 8/5/2020 encourage resident to eat meals in dining room with proper social distancing; 8/8/2020 checklist placed in room for intervention reminders; and 8/29/2020 clip touch, call light to outer side of bed at all times. There were no interventions added related to increased supervision needed by the resident or interventions related to increased toileting or activities despite the multiple falls experienced by the resident. Review of the resident record did not show evidence of monitoring the interventions that were in place. On 9/18/2020 at 12:26 p.m. a nursing note read the resident was walking with staff assistance and came back from the restroom. Staff briefly let go of the resident with one hand while still holding her with the other hand to move the bedside table. The resident lost her balance and fell backward and to the right. Staff called for help. The resident was alert, pupils were equal and reactive to light, hand grasps at baseline. Noted the resident was bleeding from the right side of her head. Range of motion to all extremities at baseline and the resident showed no signs of pain. The resident was assisted up to her wheelchair, the area to the right side of her head was cleansed. Hematoma noted measuring four centimeters by three centimeters. Area no longer bleeding and no visible laceration noted. Ice applied to the area. Neurological checks were started according to facility policy. Physician and family were notified. Will continue to monitor, no new orders at this time. On 9/18/2020 at 2:45 p.m. a nursing note read the resident was in the shower room taking a shower and a hematoma was noted to the right parietal lobe, bleeding was controlled. Call was placed to the physician to inform them about the hematoma. An order was received to send the resident to the emergency room for evaluation and treatment. The resident's family was informed about the transfer to the emergency room . On 9/18/2020 at 9:35 p.m. a nursing note read the resident returned to the facility with four staples to the right side of her parietal lobe at the site of the hematoma. The resident was alert to self and pleasantly confused. On 9/18/2020 at 11:22 p.m. a nursing note read the staff continued on follow up for the fall, the resident had a right head scalp laceration with four staples. The resident did not complain of pain or discomfort. Bed in the lowest position, fall mat in place, encouraged the resident to call for assistance, and the call light was safely within reach. On 9/19/2020 at 10:30 a.m. a nursing note read the resident denied pain or discomfort, denied headache, had had no changes in mental status, and was up in her wheelchair. On 9/19/2020 at 9:08 p.m. a nursing note read the resident continued on fall follow up, right head scalp laceration with four staples, neurological assessment and range of motion were at baseline, and the resident denied pain or discomfort. On 9/20/2020 at 8:15 a.m. a nursing note read the resident was lying in bed and was restless. She denied headache, her respirations were shallow. Her speech was garbled and she was unable to answer simple questions but was able to follow simple commands. This was a change in her mental status. The physician and family were notified. On 9/20/2020 at 9:30 a.m. a nursing note read the resident's family decided to have the resident transfer to the emergency room for evaluation. -The resident did not return to the facility. Review of limited hospital records revealed the resident was admitted to the hospital with [REDACTED]. (cross reference F684) On 9/23/2020 a CNA received one to one education related to using a gait belt for all resident transfers and ambulation related to the resident's fall on 9/18/2020. The assistant director of nursing (ADON) was interviewed on 10/23/2020 at 4:23 p.m. she stated she was the acting DON at the time of the education and had provided the education to the CNA. She stated the education was for proper use of a gait belt and to not let go of a gait belt when ambulating a resident, not because she was not using a gait belt with the resident. IV. Resident #2 A. Resident status Resident #2, age 82, was admitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 8/4/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of three out of 15. She required extensive assistance of two staff members with mobility and activities of daily living (ADLs) she used a wheelchair for mobility. She had experienced two or more falls with no injury, two or more falls with minor injury, and no falls with major injury since her last assessment. B. Record review An actual fall care plan was initiated on 7/15/2019 the resident was a high fall risk and had multiple falls with no injury from 8/16/19 - 6/2/2020. The goal for the care plan was the resident would resume usual activities without further incident. The interventions included: therapy screens (multiple); body pillow; raised edge mattress; checklist in resident's room in Spanish reminding to use call light; night light; room move; frequent toileting approximately every two hours; non-slip material to wheelchair; keep needed items in reach; follow facility fall protocol; non-skid socks at bedtime; environmental checks; maintain a clear pathway; alternative footwear; bolsters to bed; staff education on current fall interventions; encourage resident snacks; fall intervention audit; floor mat; provide extra blanket at night; emotional support visits from family; medication review; assist to lay down after lunch; and therapy inform staff when sessions are complete. A fall risk assessment dated [DATE] revealed the resident was high risk for falls. She was disoriented, had three or more falls in the past three months, was regularly incontinent, had adequate vision, required the use of assistive devices for ambulation, took three to four medications and had one to two predisposing conditions related to falls. On 6/25/2020 at 9:18 a.m. an RN assessment note read the RN was called to the unit for a resident fall. The resident was lying on her back on the floor in the common area with her eyes closed. She opened her eyes easily to verbal stimuli, her pupils were equal and reactive to light. She indicated pain to the left side of her forehead. She had a small laceration to the outer edge of her left eyebrow approximately one centimeter in length, bleeding had subsided and staff had cleaned the blood from the resident. The resident denied pain to any other area. Her legs were equal in length with no rotation noted. Hand grasps were equal. The resident was assisted up to wheelchair with gait belt and two staff assistance. On 6/25/2020 at 10:44 a.m. the LPN wrote, the resident attempted to ambulate without assistance or wheelchair or walker. She was observed falling facedown and she hit the left side of her face. She had a laceration to the left side of her head above her eyebrow, area was cleansed and one steri-stip was applied after speaking to the nurse practitioner (NP). Her daughter was informed. On 6/25/2020 a daily skilled note revealed the resident required a lot of attention to avoid falls. On 6/26/2020 a new intervention of increased 1:1 visits with activities was added to the actual fall care plan. Neurological checks were reviewed and on 6/27/2020 at 9:00 p.m. and on 6/28/2020 at 5:00 a.m. the resident was noted to be sleeping so neurological checks were not completed. On 6/29/2020 at 8:45 a.m. a nursing note read the nurse was on the phone and heard a loud noise. The resident was noted to be lying on her left side in the dining room with a small pool of blood under her head. The RN was called to assess. The resident had an approximately 2.5 centimeter laceration to the right top back of her head. The resident reported pain to the site. The NP was notified and ordered to call dispatch to assess and treat the laceration. No other injuries were noted. The resident's daughter was notified and consented to dispatch treatment. The resident was alert and speaking normally, her mental status was at baseline. She had tried to stand up from her wheelchair when the fall occurred. She was wearing anti-slip socks. On 6/29/2020 at 8:50 the RN assessment note read the resident was noted to be lying on the floor in the dining area with blood on the floor around her head. She reported pain to the back of her head but nowhere else. Upon assessment the residents pupils were equal and reactive, hand grasps within normal limits and range of motion to upper and lower extremities was normal. [MEDICAL CONDITION] measured approximately 2.5 centimeters with a significant lump under the laceration area. Resident was assisted to a sitting position after assessment and was assisted to wheelchair with a gait belt and two staff members. On 6/29/2020 at 2:00 p.m. dispatch health arrived and treated the laceration with three staples. On 6/29/2020 a new intervention of medication review was added to the resident's actual fall care plan. There was no evidence in the resident record that a medication review occurred. Neurological checks were reviewed and were completed appropriately. On 7/4/2020 at 2:11 a.m. an eMar note read the resident was found in her room on the floor. The resident reported no pain and did not appear to have any injuries. The resident's daughter and NP were notified with no new orders. The resident continued to try and get out of bed and was brought to the nurses station to prevent further falls or injury. Upon review, there was no evidence of RN assessment, fall investigation, or updates to the care plan for the above incident. The neurological assessment log was reviewed and revealed the fall occurred on 7/3/2020 at 7:00 p.m. though only vital signs were recorded at 7:00 p.m., the sections of pupil size and reaction, extremity strength, consciousness, speech, and responses were left blank. Additionally, the resident was noted to be sleeping from 7:15 p.m. to 9:45 p.m. and refused until 9:45 a.m. on 7/4/2020. The neurological checks were completed from 7/4/2020 on night shift until 7/5/2020 on night shift when a new fall occurred. On 7/6/2020 at 10:25 a.m. a nursing note read the CNA alerted the nurse that the resident was on the floor. The resident was noted to be on her left side in the TV room. She was noted to have a small bruise on her right index finger, her neurological signs were within normal limits. The RN was called to assess the resident. The resident had anti-slip socks on, she was attempting to ambulate by herself. The resident was assisted by two staff members and a gait belt back to her wheelchair. The resident's family and NP were notified. On 7/9/2020 at 4:18 p.m. a late entry note for 7/6/2020 at 8:30 a.m. written by the former DON read the writer assessed the resident after a fall in the memory care unit. A small bruise was noted to her right index finger, no head injuries were noted, hand grasps were equal and range of motion at baseline. On 7/7/2020 interventions of medication review and therapy to evaluate the wheelchair were added to the resident's actual fall care plan. -There was no evidence a medication review or a wheelchair evaluation occurred for the resident. Neurological checks were reviewed for the above fall and were completed appropriately. On 7/14/2020 at 6:11 p.m. a nursing note read the resident had refused to get up for breakfast and when the CNA went to get her up later, she was found lying on her right side on her fall mat by the bed. She denied pain or injury. She was assisted to her feet and into her chair. She was alert and at her mental baseline. Her family and her daughter were informed. On 7/16/2020 a late entry note for 7/14/2020 at 9:50 a.m. was written by the RN supervisor and read, Was called to the unit for resident fall. Upon entering the room, the resident was noted lying on the floor next to her bed on the fall mat. Non-skid socks were in place. Resident denied injury and stated she slid off of the bed. No apparent injuries were noted. Pupils were equal and reactive, hand grasps were normal and range of motion was normal. No shortening or rotation was noted to the resident's lower extremities. No bumps, lumps, abrasions, bruises or lacerations noted. The resident was assisted to standing position with a gait belt and assistance of two staff members. On 7/15/2020 an intervention of therapy to evaluate bed for positioning was added to the resident's actual fall care plan. There was no evidence a bed positioning evaluation occurred. Review of the neurological check log for the above incident revealed the spaced for the upper and lower extremity tests were left blank from 7/14/2020 at 9:45 a.m. until 4:35 p.m. On 7/22/2020 at 3:00 p.m. a nursing note read the nurse witnessed the resident get up out of her chair and fall sideways on her left side. Upon examination a small lump was noted to the back of her scalp. DON did assessment and no other injuries or bruising was noted. The resident denied discomfort, neurological checks were initiated and were in range for the resident. Range of motion was normal to all extremities. Resident's family and NP were notified. On 7/22/2020 at 3:32 an RN assessment note from the former DON read the resident had an unwitnessed fall in the dining area. Hand grasps were equal, range of motion was at baseline. A small goose egg was noted to the back of the head on the left side. Skin was closed and intact and no other skin issues were noted. On 7/23/2020 an intervention of request hospice evaluation was added to the resident's actual fall care plan. On 7/23/2020 at 3:10 p.m. a call was initiated for a hospice evaluation with the NP and resident family member in agreement. Neurological checks were reviewed for the above incident and were completed appropriately. On 8/8/2020 at 5:33 p.m. a nursing note read the resident was found by staff on the floor next to her chair in the dining room. The resident had blood coming from a laceration next to her right orbit. The laceration was cleansed and two steri-strips were placed over the laceration. The RN did assess the resident and no other injuries or bruising was noted. Neurological checks were in range and range of motion was normal to all extremities. Pain medication was given for general discomfort. The resident's physician and family were notified. Upon review, there was no RN assessment note fo(TRUNCATED)

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents of seven sample residents remained free from falls. Specifically the facility: Failed to use foot pedals on a wheelchair while pushing Resident #1 after the resident was identified with increased weakness and low back pain. The resident fell forward out of the wheelchair when she could not hold her legs up. The resident was transferred to the hospital. This fall resulted in a fractured left hip and a laceration above her right eye. Failed to utilize two staff members to perform activities of daily living as ordered by the physician for Resident #1 resulting in a fall causing a nasal fracture and lacerations above her right eye and top of her head. The resident was transferred to the emergency room . Failed to provide adequate supervision for Resident #1 after the resident was identified with wandering and impulsive behaviors resulting in a fall causing a laceration under her right eye and another visit to the emergency room . Findings include: Facility policy and procedure The Falls Monitoring and Management policy and procedure, last revised 4/19, provided by the director of nursing (DON) on 7/23/19 at 4:30 p.m. revealed in pertinent part, The licensed nurse is responsible for assessing and evaluating the resident ' s fall risk on admission, quarterly, and with a significant change in condition. Document fall risk on the Fall Risk Assessment form. Implement plan of care for residents identified at a high risk for falls. The IDT (interdisciplinary team) will discuss: Predisposing factors, injuries and interventions. Resident #1 status Resident #1, age 91, was admitted on [DATE] and re-admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/26/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required extensive assist of one to two staff for her activities of daily living (ADL). The resident had a fall with a fracture in the last six months. Record review According to the admission Fall Risk Assessment done on 5/14/19, the resident was a moderate risk for falls with a score of eight. A score of 10 or higher would indicate the resident was a high risk for falls. Review of this document revealed it was inaccurate because the appropriate number of falls were not indicated, the resident received medications and had predisposing diseases not identified that increased her risk of falls. The addition of this information would reveal a higher score placing the resident in a high fall risk category. The care plan, initiated 5/14/19, revealed the resident was at risk for falls related to impaired balance, medication side effects, [MEDICAL CONDITION], depression, pain, wandering behavior and incontinence. Interventions included: -Avoid re-arranging furniture; -Be sure the call light is within reach and encourage to use it to call for assistance as needed; -Bed in lowest position; and -Keep needed items, such as water, in reach. According to the 6/11/19 Physical Therapy Discharge Summary, the resident was seen from 5/15/19-6/11/19. The resident was unable to meet her goals due to being severely limited by severe pain. She was unable to ambulate more than 10 feet and required minimal assist. The resident did improve her ability to complete transfers and bed mobility to contact guard assist with occasional stand by assist. She was discharged from skilled services due to insufficient progress. According to the 6/11/19 Occupational Therapy Discharge Summary, the resident was seen from 5/15/19-6/11/19. The therapist recommended the resident transition to long term care or 24/7 care at that time due to pain affecting her balance, standing tolerance and transfers. The resident was a high fall risk related to pain in her sacrum. According to a 6/17/19 incident note, the registered nurse (RN) was pushing the resident in her wheelchair to breakfast. The resident had her feet elevated (not on foot pedals) then suddenly dropped her feet causing her to fall forward out of her wheelchair onto the floor. The resident had a laceration above her right eye and was grabbing her right hip (left hip was identified in future documentation) screaming out in pain. The resident was sent to the emergency room . According to the 6/18/19 Fall Committee IDT (interdisciplinary team) progress note, the resident did not have foot pedals on her wheelchair as she propelled herself with her feet and arms. New interventions included: offer the use of foot pedals. Therapy to evaluate and treat upon return from the hospital. According to the 6/19/19 admission record, the resident was readmitted for rehab for left [MEDICAL CONDITION]. She was alert and oriented times one person. She was exit seeking, looking for her husband. The care plan was updated with the date of the fall and new interventions included: -Send to emergency department (ED) for evaluation; -Therapy to evaluate upon return; -Offer foot pedals for wheelchair; -Check range of motion; -For no apparent acute injury, determine and address causative factors of the fall; -Neurological checks as ordered; -Vital signs as ordered; and -Continue interventions on the at-risk care plan. According to the (MONTH) 2019 CPO, an order was received on 6/22/19 for care in pairs every shift. The care plan was updated with this intervention on 6/24/19. Review of the Daily Skilled Notes from 6/20/19-7/2/19 revealed the resident required two person assist with ADL ' s and transfers. According to the 6/27/19 Weekly Skilled Review, the resident was inconsistent with participation in therapy, demonstrating increased behaviors including combativeness and yelling. The resident had increased agitation which interfered with care and participation in therapy. She required extensive assist of two persons for bed mobility, transfers, toileting. She required frequent cues for sequencing and redirection. According to the 7/3/19 incident note, the RN was called to the resident ' s room to assess the resident after a fall. The CNA said she had the resident seated on the edge of the bed dressed and was starting to assist the resident to stand when the resident attempted to stand rapidly on her own and her legs gave out. The resident lunged forward landing head and face first on the base of the over the bed table. The resident had a large swollen area to her forehead with a laceration above her right eye and on the top of her head. The resident was sent to the emergency room . According to a 7/3/19 nursing progress note, the resident returned from the emergency room with sutures and a fracture to the nasal bone. According to the 7/3/19 Fall Committee IDT progress note, the resident had a witnessed fall in her room. New interventions included: -two persons assist with transfers however this had been ordered and care planned as care in pairs prior to this fall and was not followed; and -continue therapy. According to the 7/5/19 therapy progress note, therapy will continue with the plan of care to focus on decreasing risk for falls by improving balance and functional mobility. According to the (MONTH) 2019 CPO, the resident received the following orders on 7/5/19: 1. Low bed when in bed. 2. Use foot pedals when assisting resident with locomotion in chair (Does not need foot pedals if self-propelling). 3. Encourage two person assist when able, resident attempts to transfer self so if only one staff available, attempt to keep safe. 4. Encourage toileting every two hours while awake. The care plan was updated with the date of the fall and new interventions included: -Redo fall risk assessment to reflect resident high risk of falls; -Wait on medication review from physician for medication changes if indicated; Updated to every two hour toileting and encouraging related to incontinence with resident; -Continue with low bed; -Continue to encourage two person transfers, realizing that resident attempts to transfers self and two staff may not be there to assist in intervening. If that is the case one staff will attempt to redirect resident and keep safe to prevent falls; -Encourage foot pedals when resident is being assisted with locomotion. Resident does however also self-propel in wheelchair, if she is doing that it is okay to not have the foot pedals in place as we want the resident to be mobile; -Update Kardex (used to communicate resident care needs) to reflect safety measures for certified nurse aides (CNA); -Encourage one to one activities with the resident. Will encourage the resident to participate in activities to increase engagement and supervision. According to the 7/5/19 Daily Skilled Noted, the resident was alert and oriented to self and was exit seeking four times during the shift. Interventions such as repositioning, toileting, placing in a quiet room and medications were all ineffective. According to the 7/6/19 incident note, the RN found the resident in another resident ' s room. She was lying on her stomach with the wheelchair foot pedals under her abdomen. The resident had a laceration under her right eye. The resident was sent to the emergency room . According to the 7/8/19 Fall Committee IDT progress note for review of the fall on 7/6/19, the resident had an unwitnessed fall in another resident ' s room. New interventions included for social services to facilitate a sitter for the resident. The care plan was updated with this intervention on 7/8/19. According to the (MONTH) 2019 CPO, the resident was admitted to hospice services on 7/11/19. The resident received a Broda (a tilt-in-space positioning) chair on 7/13/19 and the staff started using the sit to stand lift to transfer the resident. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/18/19 at 3:35 p.m. She said the process for falls was if it was reported by a CNA, go to the resident, then call RN to assess. The RN performed range of motion and neurological checks. The resident was interviewed if cognitively able. Then the resident was assisted off the floor with the use of a gait belt or mechanical lift. The family and physician were notified and they would start 72 hour neurological checks and charting (4x15 min, 4x30 min, 4x1 hour, and every 8 hours up to 72 hours). LPN #2 was interviewed on 7/18/19 at 3:43 p.m. She said fall risk assessments were completed upon admission and quarterly. She said if the assessment indicated the resident was a high fall risk then interventions needed to be put into place and care planned to assist with fall prevention. RN #2 was interviewed on 7/18/19 at 3:50 p.m. She said when a resident fell , only an RN could assess the resident. She said we always assume they hit their head if the fall was unwitnessed. She said they would check for injury and move if able or call 911. She said the family and physician were notified. She said the nurse would initiate the risk management form and complete the objective findings. She said interventions put in place for a fall consisted of rounding, frequent toileting or check and change, low bed, call light within reach, fall mat and bolsters. LPN #3 was interviewed on 7/23/19 at 11:24 a.m. She said the order for care in pairs meant the resident was to have two people to provide care for her. She said it should be updated on the resident ' s care plan and the kardex. She said fall interventions were usually placed on the treatment sheets. She said foot pedals should be used on any resident that was dragging their feet when being pushed or when the resident ' s legs were short and hanging. She said the fall risk assessment was done on admission and then as indicated, usually with falls. She said physical and occupational therapy usually would assess the residents after a fall and recommend new interventions. She said some interventions included a low bed and fall mats. The director of rehabilitation was interviewed on 7/23/19 at 2:35 p.m. She said when a resident was admitted to the facility they were usually evaluated by therapy to determine their fall risk and what interventions needed to be implemented to prevent the resident from falling. She said the resident ' s fall risk was placed on the communication board in the computer for the nurses to see. She said Resident #1 was a moderate to maximum assist for her ADLs and it would be safer for the resident and the staff to have two persons in the room to assist her. The director on nursing (DON) was interviewed on 7/23/19 at 3:00 p.m. She said the care in pairs order was unique to Resident #1. It meant for care to be provided by two staff at all times but the resident was impulsive so if she tried to stand with only one staff member available they did the best they could to get a second person in to help. She said fall risk assessments were done upon admission, quarterly, with each fall and as needed. She said they are checked for accuracy by the IDT. Resident #1 ' s fall risk assessment was re-done when it was identified to be incorrect. She said if the fall risk assessment identified the resident to be a high fall risk, this information, along with interventions were communicated to the CNA ' s on the kardex and to the nurses on the communication board in the computer.

Based on observations, interviews and record reviews, the facility failed to ensure one (#23) of three sample residents did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, the facility failed to timely assess a pressure area and timely implement precautions for the prevention and healing of pressure areas. The facility failures contributed to the worsening of an identified stage 2 coccyx pressure area, formation of new deep tissue injury and stage 2 pressure areas to the coccyx, and pain per resident interview. The findings included: A. Professional Reference The National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (February 2017), reveals the following pertinent information: - .International NPUAP-EPUAP Pressure Ulcer Definition-A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear . -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. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). -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 is removed, a Stage 3 or Stage 4 pressure injury will be revealed. - Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. B. Resident #23 1. Resident Status Resident #23, age 98, was admitted on [DATE]. According to the 2/17 computerized physician's orders [REDACTED]. The 12/12/16 admission minimum data set (MDS) comprehensive assessment demonstrated the resident had moderate cognitive impairment as evidenced by a brief interview for mental status score of 12 of 15. The resident had no behaviors that affected care and the resident did not exhibit rejection of care. The resident required extensive assistance from one staff for bed mobility and transfers. The resident was 59 inches tall and weighed 97 pounds. The resident did not have healed or unhealed pressure ulcers. The resident was at risk for pressure ulcers. The resident had pressure-relieving devices to the bed and chair. The resident was receiving hospice services. The 1/2/17 Braden Scale for predicting pressure ulcer risk demonstrated a score of 14, which signified moderate risk of skin breakdown. The Braden assessment indicated the resident was chairfast and the resident had very limited ability to change and control body position. The skin breakdown risk care plan, initiated on 12/6/16, identified the resident was at risk for skin breakdown related to risk for shearing and friction. The goal was for the resident to have no areas of impaired skin through the target date of 12/22/16. Approaches included: pressure-relieving cushion to wheelchair; protective cream after incontinence episodes; elevate heels off mattress; encourage weight-shifting exercises or assist to reposition frequently; lift with draw sheet; and observe skin daily with care and bathing. Report skin pain, redness, pressure areas and rashes to the nurse. 2. Discovery of a painful stage 2 pressure ulcer after admission - planned response a. Resident and Family Interview The resident was interviewed on 2/14/17 at 4:40 p.m. The resident said she had pain from an injury on her coccyx. According to the resident, she had a bed sore that formed while at the facility. The resident said she received a new mattress for her bed within the last day. The resident's son was interviewed on 2/15/17 at 3:39 p.m. The son said he had just learned of the resident's pressure ulcer. The son said the nurse informed him the wound had been there for a couple of days. The son said the resident had to stay in bed, rather than sitting in her recliner, as was her preference, while the wound healed. The son said the resident did not have a history of pressure wounds and was dissatisfied that one had formed. b. Record review and interview with the hospice registered nurse (HRN) Record review and interview with the hospice registered nurse (HRN) revealed the resident developed a stage 2 pressure ulcer to the coccyx that was identified by the HRN on 2/13/17. Review of the clinical record showed the resident's most recent weekly skin assessment was on 2/3/17. There was no injury to the coccyx on 2/3/17. Although the treatment administration record (TAR) showed a skin assessment was completed on 2/9/17, a corresponding weekly skin observation tool was not present in the electronic or paper record. There were no nursing progress notes that reflected completion of a skin assessment on 2/9/17; however, a hospice certified nurse aide (CNA) recap of services note on 2/9/17 showed the resident's skin was intact. Review of a hospice nurse's note dated 2/13/17 documented in part, Pt (patient) reports pain to the buttocks. Upon assessment I noted stage 2 to the coccyx. Contacted Dr. (name) and orders rec'd (received) for wound care to include [MEDICATION NAME]. Report given to (facility nurse) with changes. Also ordered air mattress and will encourage pt to lay in bed more than in recliner if possible. The HRN was interviewed by telephone on 2/16/17 at 5:26 p.m. The hospice nurse said she learned about the pressure area on the resident's coccyx when the resident reported pain. She said she assessed the painful area and recalled she found the resident's coccyx had one small, reddened area about the size of a dime (approximately 0.1 cm by (x) 0.1 cm) that had three tiny openings. The HRN said there was not any deep tissue pressure injury or any purple areas on the coccyx when she observed the wound on 2/13/17. The HRN said she reported the pressure area to the facility nurse, obtained orders to treat the wound and ordered an air mattress for the bed. The HRN said she reported the wound to the director of nursing (DON), who requested hospice provide a gel cushion, which she requisitioned from the medical goods supplier. The HRN said she believed the wound formed because the resident sat in her recliner most of the time, placing pressure on the coccyx. The HRN said she had not requested, nor was a request made of her, for a consultation with therapy to determine how to offload pressure when the resident was in the recliner. The HRN said she had not heard of using a gel cushion or other pressure relief device in a recliner. The HRN said she would look into getting a pressure-relieving device for use in the resident's recliner, but had not done so at the time of the call. The HRN said it was important to have proper settings in the low loss air mattress that the hospice supplied to the resident. The HRN said the pump should be set to a weight close to the resident's actual weight, but could be moved up or down a bit for comfort. The HRN agreed the resident weighed about 90 pounds. Regarding the air mattress, the HRN said positioning the resident on her back with the mattress at maximum (350 pounds) inflation could cause pressure rather than relieve it. She further said the resident should not be left in bed with the pump disconnected because the mattress would deflate resulting in the resident experiencing pressure rather than pressure relief. 4. Failure to timely assess a pressure area and timely implement precautions for the prevention and healing of pressure areas, contributing to the worsening of an identified stage 2 coccyx pressure area, formation of new deep tissue injury and stage 2 pressure areas to the coccyx, a. Observations Observations of the resident revealed the resident in bed, on her back, with the air mattress set on the firmest setting and with the air mattress deflated. The facility did not timely implement the new gel cushion requisitioned from hospice. Specifically: -The resident was observed on 2/14/17 at 4:40 p.m. The resident was positioned on her back, in bed. The resident had a specialty air mattress (MasonAir LS/AS 8800) in place. The mattress was set on 350 pounds (the firmest setting), with a 20 minute, alternating cycle. The head of the bed was elevated approximately 15 degrees. The mattress remained on the firmest setting when observed on 2/15/17 at 8:32 a.m., when the resident was out of bed and at breakfast. The mattress remained on the firmest setting when the resident was observed in bed, on her back on 2/15/17 at 9:33 a.m. No instructions as to setting were in place on the mattress pump/mattress controls. The air mattress pump alarm sounded on 2/15/17 at 9:35 a.m. Registered nurse (RN) #5 entered the room and looked at the bed. The RN agreed the power failure light was on. The RN said the pump was not working properly. The RN said she had reset the air mattress earlier and now it would not allow her to adjust the firmness to a more appropriate setting. The RN said the resident was less than 100 pounds and the mattress was set on 350 pounds, which was too firm. The RN said she would contact the maintenance staff to assist with the pump for the air mattress. At 9:39 a.m., a member of maintenance staff entered the resident's room; removed the pump from the airbed and carried it down the hall. The resident remained in the bed, on her back, after the pump removal. At 10:09 a.m., the resident remained in bed on her back with the pump from the air mattress not in place. The mattress was deflated. Slight pressure applied to the edge of the mattress resulted in the ability to feel the bed frame below. Maintenance returned to the room and re-installed the pump on the bed at 10:32 a.m. The resident remained in bed as the mattress was re-inflated. The resident, who had an existing pressure area, was in the bed without a pump in place for approximately one hour. During this time, staff did not reposition the resident or remove her from the deflated bed. A new gel cushion, still in its sealed plastic bag from the vendor, was in the resident's room on 2/15/17 at 3:39 p.m. The gel cushion was leaning on the backrest of the resident's wheelchair as the resident's son sat in the wheelchair visiting the resident. The gel cushion still in the bag was observed in the resident's guest chair (not her recliner) on 2/16/17 at 12:31 p.m. and again at 1:08 p.m. The resident's wounds and wound care were observed on 2/16/17 at 10:38 a.m. with RN #4, who was the facility wound nurse and the clinical manager (CM). Observation of the coccyx/sacral area revealed the resident's one stage 2 pressure ulcer on the coccyx identified 2/13/17 was now three stage 2 pressure ulcers and a deep tissue injury. -The CM checked the setting on the bed which was set for a firmness for a person weighing 170 pounds. The CM but did not adjust the bed settings. -The RN and the CM washed their hands, donned gloves and prepped wound care items using an aseptic technique. -The resident was positioned on her side and clothing items removed. The coccyx did not have a dressing in place, though the orders (see below) showed the wound should have had a border dressing. A white cream substance caked the wound. -The RN removed her gloves, washed her hands and donned new gloves. The RN cleansed the wound using normal saline and gauze. -The RN said there were three open areas on the coccyx/sacral region. The RN described each open area as a stage 2 pressure wound. The skin around the wounds was sloughing. Wound beds were pink, without drainage, eschar or slough. -The RN said the dark purple, non-blanching area to the right side of the coccyx was a deep tissue pressure injury. The deep tissue injury measured 3.2 cm length x 1.1 cm width. -The stage 2 pressure ulcer to the left side of the deep tissue injury measured 0.5 cm length x 0.6 cm width. -The stage 2 pressure ulcer on the right aspect of the sacral area measured 0.4 cm length x 0.3 cm width. -The stage 2 pressure ulcer distal of the coccyx measured 0.4 cm x 0.3 cm. -The RN applied zinc to the stage 2 ulcers and covered the entire coccyx with one 4 inch x 4 inch bordered dressing. There were no wounds on the resident's buttocks. The resident was observed on her back in bed with the firmness set at 170 pounds on 2/16/17 at 6:55 p.m. b. Record Review According to the record review, facility staff did not implement timely assessment and monitoring of the wound identified on 2/13/17. The resident did not have care planning in place to minimize risk related to the use of a recliner where she preferred to spend time. Documentation of the resident's wounds was untimely and inconsistent and finally, the record evidenced failure to obtain and communicate orders for use of a low loss air mattress and gel cushion. See care plan above; the care plan did not address offloading the resident when in her recliner. The care plan was not updated to reflect the presence of actual skin breakdown. The care plan did not reflect the use of a low-loss air mattress. The care plan did not address new measures to prevent additional skin breakdown. A review of the nurse's progress notes and skin/wound assessments in the clinical record for 2/13/17, 2/14/17, and 2/15/17 showed no assessment of the new pressure area identified and reported to the facility by the HRN on 2/13/17. Additionally, the resident was not assessed after being left in a malfunctioning airbed with the pump disconnected on 2/15/17 (see observation above). A review of the physician's orders [REDACTED]. A nurse's progress note dated 2/16/17 at 1:41 p.m. (following the wound observation above with RN #4 and the CM) read in part: -Resident seen for wound to sacral area. On distal sacrum stage 2 pressure injury noted measuring 0.5 x 0.6 x 0.1. Wound bed dark pink and blanches. No drainage noted. Wound edges poorly defined and slightly macerated. Dark purple unblanching DTI (deep tissue injury) noted to proximal sacral area. Area measures 1.1 x 3.2cm x 0 depth. Area closed with 0 drainage. Open area to proximal right aspect of sacrum measures 0.4 x 0.3 x 0.1cm. Wound bed dark pink and blanches. Wound edges defined, epidermis slightly peeled along edges. NO drainage noted. NO foul odor noted to sacral site . -The note did not include the measurement of the stage 2 pressure ulcer that abutted the left side of the deep tissue pressure injury. The measurement for the distal sacral pressure ulcer differed from the stated measurement made during observation with RN #4 earlier the same day. A late-entry hospice note dated 2/17/17 read, Wound to buttocks x3. Measure 0.1 cm x 0.1 cm x 0.1 on left buttock. 10% slough and 90% [MEDICATION NAME] tissue noted. Gel cushion ordered for wheelchair and recliner. -The note indicated the wound was on the left buttocks; however, the wound identified on 2/13/17 was on the coccyx area. -Additionally, the wound note on 2/13/17 indicated the wound was a stage 2 pressure ulcer. However, the presence of slough in a wound bed would suggest the wound was unstageable based on the National Pressure Ulcer Advisory Panel (NPUAP) definitions (see above). 5. Staff Interviews Staff interviews demonstrated a lack of awareness of the resident's coccyx pressure ulcer. Staff did not know about repositioning needs in the wheelchair and recliner. Staff did not know about settings for the resident's low loss air mattress. RN #5 was interviewed on 2/15/17 at 10:28 a.m. -When asked if the resident had one or more pressure ulcers, the RN reviewed her resident roster, which included information about resident care needs. The RN said the resident did not have any pressure injuries but at 4:12 p.m., she said she had learned the resident had a small area of shearing to the coccyx that may be a pressure area. The RN agreed she was unaware of the pressure ulcer at the time she stated the resident had no pressure ulcers. -The RN said the resident's clinical record did not have information about the resident's pressure ulcer. The RN said she did not see any report of the resident's pressure ulcer in the 24-hour report. CNA #11 was interviewed on 2/15/17 at 3:59 p.m. The CNA said she worked with the resident and today was her first day back working with the resident. -The CNA, who worked the evening shift and who had been on duty about two hours, said she last observed the resident's coccyx a few days ago, observing the resident's skin during perineal cares and during change of clothing; she said the resident was incontinent of bladder and bowel. She said when she'd last observed the resident's coccyx it was red and she had been putting cream on the red area. -The CNA said the resident spent most of her time in the recliner in her room, but came out for meals and bingo. The CNA said a hospice CNA, not a facility CNA, provided the resident's bathing. The CM, who was a RN was interviewed on 2/16/17 at 9:48 a.m. The CM said the resident had a new pressure area to her coccyx that had formed at the facility. -The CM reviewed the paper and electronic clinical record for the resident. The CM said she was unable to locate an assessment of the coccyx wound reported by the hospice nurse on 2/13/17. -The CM said the floor nurse caring for the resident on 2/13/17 should have assessed and documented on the wound. The CM said a complete assessment included wound measurements and descriptions of the wound bed, margins/edges, surrounding tissue, and drainage. -The CM said the only orders put in place upon discovery of the wound were treatment with [MEDICATION NAME], zinc and a border dressing daily and as needed. CNA #14 was interviewed on 2/16/17 at 1:08 p.m. The CNA said she had worked with the resident since the resident was admitted to the facility. -The CNA agreed there was a new gel cushion, in an unopened plastic bag, on the guest chair in the resident's room. The CNA said no one had informed her about the new cushion. The CNA said she thought the cushion might be a replacement for the wheelchair cushion. The CNA said the foam coccyx cushion on the resident's wheelchair was the cushion used by the resident since admission. -The CNA said the resident usually sat in her recliner, but now was to lie down in bed between meals. The CNA agreed there was not any pressure relief device in place in the resident's recliner. The CNA said she knew to help reposition the resident every two hours when in bed. The CNA did not identify a repositioning program for the wheelchair or recliner. Licensed practical nurse (LPN) #4 was interviewed on 2/16/17 at approximately 7:00 p.m. -The LPN said she did not know what settings the resident's low loss air mattress should be. The LPN observed the resident's mattress and said the setting currently was 170 pounds on a 10 minute alternating cycle. The LPN said the resident's current weight was about 90 pounds. The LPN consulted with RN #4, the DON and CM. The DON, CM, RN #4 and the LPN went to the resident's room. Upon return, the LPN said she had reset the resident's bed to a firmness for a person weighing 110 pounds but left the mattress on the ten minute alternating cycle. -The LPN said there was no guidance in the clinical record to direct how the resident's bed should be set; however, the 110 pound setting was the one closest to, without being lower than, the resident's current weight. The CM requested an interview on 2/17/17 at 7:56 a.m. The CM said the facility initiated an action plan related to the use of air mattresses on 2/10/17, prior to the date the resident had received her air mattress. The CM provided the action plan. -The action plan noted each resident with an air mattress should have a physician order [REDACTED]. -The action plan did not state the facility would audit to identify residents with air mattresses, presence of physician orders, and presence of monitoring. The action plan did not specify how, in an ongoing manner, mattresses provided from hospice would be identified so orders and monitoring could be implemented. -The CM said an audit was completed; however, the CM did not provide the audit for review. The CM agreed that orders and monitoring had not been in place for the resident's air mattress on 2/14/17, 2/15/17 and 2/16/17. The CM said the facility was waiting for the requested a copy of the user's manual for the resident's air mattress. The DON was interviewed on 2/17/17 at 4:32 p.m. The DON said when the HRN informed the facility nurse of the resident's wound, the facility nurse should have assessed and documented on the wound. The DON said the resident's coccyx was not assessed until the observation on 2/16/17 (see above). -The DON said a complete initial wound assessment was important to help determine if wounds were improving or worsening. The DON said the documentation of the wound should have included wound measurements and characteristics of the wound, like appearance of the wound bed, periwound, drainage, and odor. -The DON agreed that the resident's coccyx, as described by the HRN on 2/13/17, had worsened based on wound observations and documentation by the wound nurse on 2/16/17. The DON acknowledged the presence of multiple stage 2 pressure ulcers on the coccyx, but said she was not aware of the deep tissue pressure injury. -The DON said the resident's air mattress should not have been set to 350 pounds, which was the firmest setting. The DON said the resident's mattress was not appropriately set when it was on 170 pounds because the resident weighed 90 pounds. The DON said having the mattress set at too high a firmness could create pressure and would not provide the intended benefit of a properly set airbed. -The DON said the resident should not have been left in bed when the mattress was malfunctioning and when the pump was removed. The DON said staff should have assisted the resident to sit in her recliner or her wheelchair, as either would be preferable to being left in a malfunctioning bed. The DON said it was her expectation that staff assess the resident head-to-toe after being left in a deflated bed and agree this had not occurred. -The DON said the resident had not been assessed for positioning needs in the recliner or wheelchair. The DON said earlier in the day she had contacted the resident's medical provider and had obtained a referral for a single therapy visit to assess the resident's positioning needs in the wheelchair and in the recliner. The DON said the therapist could identify strategies and devices to help offload pressure to the resident's coccyx when in the wheelchair and the recliner. -The DON said the facility was in the process of re-establishing a weekly skin and weight meeting. In the meantime, she had consulted with the dietician about the resident's coccyx wounds. The DON said a protein supplement was ordered to promote healing.

Based on observation, interview and record review, the facility failed to provide needed treatment and services for one of seven sample residents (#3). Specifically, the facility failed to provide CPR (cardiopulmonary resuscitation) for resident #3, although the MOST form/physician orders [REDACTED]. Findings include: A. Facility failures 1. Resident record review Review of resident #3's closed record revealed the resident was admitted on [DATE], readmitted on [DATE], with [DIAGNOSES REDACTED]. Post-admission [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE]. The resident's most recent MDS (minimum data set) assessment dated [DATE], revealed the resident was [AGE] years old. The MDS coded the resident to have short/long term memory problems, modified independence with daily decision making (some difficulty in new situations only); required extensive assistance with bed mobility, dressing, personal hygiene; total dependence with transfers, toilet use and bathing, and had one stage 2 pressure ulcer. The resident's MOST (medical orders for scope of treatment) form was not signed by the physician but signed by the medical power of attorney (MDPOA) on [DATE], designating CPR (yes, attempt resuscitation/CPR); discussed with patient and agent under MDPOA. Stickers on the front of the resident's record read, "Full Code" and "Pacemaker". The advance directives sticker read, "durable power of attorney". A form titled cardiopulmonary resuscitation (CPR) was signed by the resident on [DATE] indicating CPR should be initiated in case of extreme emergency. The medical durable power of attorney for health care decision form designated a MDPOA and a secondary MDPOA to follow living will procedures and was signed by the resident on [DATE]. The living will dated [DATE] provided instructions for medical or surgical treatment. Review of physician orders [REDACTED]. -[DATE] COR status: Full COR. -[DATE] Pronouncement of death at 9:23 a.m. Physician notes disclosed -[DATE] Returned from hospital, altered mental status, pneumonia. Cardiac catheterization done, echo and new stent (tube placed in the coronary arteries that supply the heart, to keep the arteries open). Non-compliant, [MEDICAL CONDITION], poor health, pacemakers, stents, cardiomegaly, [MEDICAL CONDITION] (continuous positive airway pressure/uses mild air pressure to keep airways open) at night and right lateral calf wound. -[DATE] COR full, stress test shows old infarction, hypokinesia, 2 healing ulcers buttocks, wound right lateral leg. -[DATE] High blood pressure stable, sleep apnea (on [MEDICAL CONDITION] therapy), history of complete heart block and has a permanent pacemaker in place, implanted in 2003 with generator change in 2010. Review of social service notes revealed: -[DATE] Quarterly assessment note-Remains full COR. Care conference summary notes disclosed: -[DATE] COR status reviewed, will remain full COR. -[DATE] COR status: Full COR. Care plans revealed: -[DATE] Alert and oriented x3, scored 15 out of 15 on the BIMS (brief interview of mental status). -[DATE] Requires extensive to total assistance with most ADLS. Uses a wheelchair for mobility, requires a mechanical lift for all transfers with assistance of ,[DATE] staff. Approaches included bariatric bed, upper ? side rails up only when repositioning in bed, Golvo lift for all transfers. -[DATE] At nutritional risk, height 73 inches and BMI (body mass index) 39.3. -[DATE] Potential for pressure ulcers, recurrent skin breakdown to buttocks related to incontinence and recurrent skin breakdown on feet due to [MEDICAL CONDITION], diabetes and [MEDICAL CONDITION]. Approaches included pressure reduction mattress on bed. -[DATE] Advance directive, niece is MDPOA. Approaches included Full COR, notify niece and physician of any changes in condition. Review of nurse's notes disclosed: -[DATE] 2:00 -10:00 p.m. BP (blood pressure) ,[DATE], pulse 70, respirations 22 and oxygen saturation (O2 sat) 96% on 4 liters per minute oxygen. On contact isolation for possible norovirus. Resident weak this shift, unable to help with turns. Physician notified. -[DATE] from 2:,[DATE]:00 a.m. Resident slept well through the night with [MEDICAL CONDITION] on. BP ,[DATE], pulse 68, respirations 22, O2 sat 94% on 4 liters per minute. -[DATE] at 8:45 a.m. Occupational therapist notified registered nurse (RN) that resident was not responding. Told CNA to get RN from (named unit which was next door). The RN assessed resident upon entering room. Resident was gray in color and cold to touch. No respirations, no pulse, no heartbeat. RN from other unit arrived in room. She assessed resident and stated that resident had expired. We discussed transfer resident for CPR. We came to conclusion that we could not safely transfer resident to floor. RN from other unit called physician and this RN called 911 for orders. Review of the weight record dated [DATE] revealed the resident weighed 292 pounds. Review of a resident transfer form completed by the facility on [DATE], disclosed, "was found blue/gray without pulse, respiration or response to painful stimuli". B Onsite review: 1. Observations On [DATE] beginning at around 10:45 a.m., during the initial tour, observation revealed all nursing units had a crash cart (wooden type cabinet) with a blue bariatric board attached. Observation of the nursing units revealed there were 4 nursing units (ruby crossing/long peak and rainbow road/mountain view) in the main building and three units in the memory care building. Ruby crossing/longs peak units were close to the front of the building and had a total of 31 resident rooms. The kitchen was located across from the ruby crossing/longs peak units. As one faced the ruby crossing hallway, longs peak was to the right. There was a middle lounge before entering the mountain view hallway. At the end of the mountain view hallway, there was a nursing station then to the right was the rainbow road hallway. The mountain view/rainbow unit held 31 resident rooms. The bed that resident #3 used while residing at the facility was observed on [DATE] at 4:55 p.m. The resident's bed was a Gendron maxi-rest bariatric bed. The base of the bed had metal rods across the base of the bed such that CPR could have been done on the bed. Observation of the mattress on [DATE] at around 10:00 a.m., revealed it was a Panacea mattress. The pressure mattress pump was viewed on [DATE] at 10:10 a.m. The pump was a Mason LS/AS 8800 pump without a CPR button. The mattress pump could have been turned off and the mattress deflated so CPR could have been performed. 2. Interviews: Interviews with 5 CNAs and 3 licensed nurses beginning on [DATE] at 9:40 a.m., revealed they all knew where the bariatric boards were located on each unit, could quickly locate the code (CPR) status for each resident and could answer basic questions about how CPR was done. 3. Document review: The initial occurrence report submitted by the facility to the health department on [DATE], revealed in pertinent part, "The occupational therapist (OT) entered the room of a male resident to provide therapy. She stated she had knocked on the door and called the resident's name but he did not respond. When she entered the room, she patted his arm, called his name and found him to be unresponsive. The OT summoned the RN (nurse #1) assigned to the resident. The resident was on a bariatric bed with a pressure reduction mattress. The resident was a full COR per his MOST form. The RN was aware that the resident was a full COR. The RN entered the room and checked for heart sounds with his stethoscope, respirations and no response. Finding no heart sounds, no respirations and no response, RN did not start CPR but summoned RN (nurse #2) from the next hallway. This RN also checked for heartbeat, respirations and responsiveness. This RN was also aware that the resident was a full COR, called the physician who said to call 911. RN (nurse #1) called 911. The fire department crew arrived approximately 15 minutes later and did perform CPR per their protocol without success. They notified the police because they believed that CPR should have been initiated prior to their arrival. Facility policy is that CPR be initiated on a resident identified as full COR. The two nurses were placed on administrative leave pending investigation. The police provided a case number. Both RNs (#1 and #2) were placed on administrative leave pending investigation and terminated on [DATE]. Reference checks and background checks were completed on both RNs and no problems identified. Description of circumstances: from Occurrence Report 8:45 a.m. The occupational therapist knocked on door and called resident's name. She did not receive a response so she completed gowning for contact precautions and went into the resident's room. She patted the resident on the arm, called his name and did not receive a response, she asked the environmental services manager (still in hallway) to get a nurse. Nurse #1 ran to the resident's room, entered the room, listened to the resident's heart with his stethoscope, heard no heart sounds, saw/heard no respirations and received no response. At 8:50 a.m. nurse #1 asked the therapist to get the other RN (nurse#2) from the other hallway. She (nurse #2) came to the room immediately, assessed the resident with a stethoscope, noted the absence of heartbeat, absence of respirations and response and stated the resident was "gone". The RNs discussed how they might lower the resident to floor to do CPR and decided it was not feasible. They left the room to call the physician and 911. At 9:03 a.m., the physician was called and at 9:06 a.m. the physician returned the call at the same time the RN (nurse #1) called 911. Approximately at 9:06 a.m., the nurse (#1) went to end of the hallway to direct the emergency team and the other RN (nurse #2) began to gather paperwork for a transfer. At 9:15 a.m. the emergency team arrived and administered CPR for approximately 18 minutes. Conclusion of the facility: RNs acted inappropriately by not initiating CPR. The resident was a full COR and both RNs knew this however they did not procure the emergency cart nor did they call for additional assistance. They delayed in calling 911. Were facility policies and procedures followed: No. It is the expectation of the facility that if a resident has signed a MOST form indicating that he/she wants CPR, that CPR be provided. Interventions put into place to prevent recurrence: Investigation initiated ,[DATE] and ended [DATE]; bariatric CPR boards ordered for each unit and placed on [DATE]; initial report to health department ,[DATE] and summary report on [DATE]; registered dietician evaluated and provided list of residents with BMI greater than 35 on [DATE]; In-service nursing staff on initiating CPR on full COR residents without exception including protocol for bariatric residents started ,[DATE] and completed [DATE]; follow up with therapy regarding therapist CPR certification; in-service nurses on how to initiate CPR for residents with BMI greater that 35 and full COR; resident services audit all charts (advance directives, completion signatures, corresponding orders, indicative sticker) on [DATE]; human resource audit nursing staff records (current CPR certification) on [DATE]; add COR status to CNA care sheets on [DATE]; request in-service by fire department on [DATE] and tentatively scheduled for [DATE]; QA review of event with medical director and IDT [DATE]; follow up report to board of nursing regarding occurrence [DATE]; NHA audit all expirations/deaths since [DATE] (there have been none/no date) for appropriate follow up on advance directives (this will be ongoing and reviewed monthly in QA/UR. All current nursing associates review and sign F155 CPR versus no CPR (no date); add to orientation packet for new hires to be reviewed and signed the F155 information (no date)". Random record review on [DATE] beginning at 11:00 a.m., revealed seventeen of 18 resident DNR/Full COR stickers, advance directive/COR status, MD order and social service notes matched. The NHA (administrator) was informed of the discrepancy in one record on [DATE] at around 4:00 p.m. On [DATE], the facility provided a thorough audit (see below under facility correction) completed on [DATE] to ensure all COR status documents in each resident record were consistent. On [DATE] at around 2:00 p.m., review of five employee records (hired in the last 4 months) revealed each had a current CPR card and had completed new hire orientation prior to working on the floor. On [DATE] at around 4:00 p.m., a CPR policy was requested from the NHA but was not provided prior to the end of survey. Review on [DATE] of an EMS (emergency medical system) report dated [DATE] read in pertinent part: -Alarm date and time [DATE] at 8:59 a.m. -Arrival date and time [DATE] at 9:06 a.m. -Priority response yes. -Action taken provide advanced life support -Clear date and time [DATE] at 10:07 a.m. -Narrative text " caller statement not breathing, no heartbeat " . -Narrative text " found unattended by staff, lying supine in bed in room. Initiated care on scene. C. Facility Correction 1. Review of facility documents as evidence of corrective action (in pertinent part) revealed the facility stated there were no identified concerns related to CPR/advance directives. Review on [DATE] of a social service audit dated [DATE] of resident records for consistency in COR status documentation. The NHA was informed of a discrepancy (see above) and on [DATE]. An updated audit dated [DATE] revealed records was reviewed for consistency in documentation. On [DATE], review of an invoice dated [DATE] revealed 4 bariatric boards (CPR bariboard 27x18) were ordered. On [DATE] at around 2:00 p.m., review of the human resource (HR) audit dated [DATE] of CPR card status for nursing staffs (RNs, LPNs and CNAs) disclosed the CPR cards were current. On [DATE] at 8:00 a.m., the facility was informed of a discrepancy with the facility list of employees, list of employees signing the in-service sign in sheet, employee list and the HR list. On [DATE], review of an updated CPR audit revealed CPR cards for all employees were current and no further issues identified. On [DATE], review of an advance directive audit dated [DATE] revealed there were 4 residents with BMI above or close to 35. The audit included names of 3 residents with DNR (do not resuscitate) but no MOST form and 2 with no MDPOA form. There was no written evidence these issues had been corrected. In addition, a handwritten notation at the bottom of the form read done next to names of 2 residents that needed the correct sticker on the sticker page (sticker reads full COR but resident had DNR status or no COR sticker). On [DATE] at around 8:00 a.m., the administrator (NHA) was informed of the need for written evidence the above issues were corrected. On [DATE], review of the updated BMI list/documentation disclosed the discrepancies (above) were corrected. In-service documents were compared to the employee list and the human resource list on [DATE]. There was a discrepancy in the list of names and on [DATE] at around [DATE] at 4:00 p.m., the NHA was informed of the discrepancy of who attended in-service training on CPR. She was informed that 14 staffs did not attend training. On [DATE], review of an updated list of all staff who attended in-service training, who was on leave during the training and agency staff that attended training. Review on [DATE] of the quality assurance (QA)/utilization review (UR) meeting held on [DATE] with the medical director and IDT (interdisciplinary team) to discuss the occurrence on [DATE]. The QA review meeting sign in sheet was included and the meeting notes revealed the resident ' s record was reviewed. The notes read " expired on [DATE], following hospitalization from ,[DATE] to [DATE]. It was found that nurse (#1) responsible for initiating resuscitation on this full COR resident consulted with social services and the registered dietician before calling the physician and told by the physician to call 911. It took 20 minutes for the 911 team to reach the facility and start resuscitation. It was reported that there was no ticking found from the resident's cardiac pacemaker. The fire department staff were also present at the facility during the process and interviewed and took statements of key staff members. The coroner investigator interviewed and the staff as well as the niece of the resident, who was notified by staff of her uncle's status. She arrived to the facility within an hour of being called. The fire department was contacted to give an in-service to staff on [DATE] on how to respond to the full COR situation in the facility. The Health information department was to request a copy of the death certificate. The medical director/attending physician stated he will need to wait for results of the coroners report to know definitively as to cause of death. He completed the physician discharge summary including diagnoses, an additional notation that the final [DIAGNOSES REDACTED]. The interim NHA stated procedures must be put into place to prevent this type of incident from occurring in the future and the best we will be able to do at the present. It was reported that there are 15 full COR residents in the facility. Social services conducted an audit on [DATE]. Her report was available for this meeting " . Review of a document on [DATE] with the board of nursing (BON) address, indicated a report was sent by certified mail on [DATE] with the certification number documented on the form regarding nurses #1 and #2. On [DATE], a BON complaint form for both nurses (#1 and #2) dated [DATE] was reviewed. A facility corrective action form dated [DATE] revealed both nurses were suspended from [DATE] to [DATE] then terminated on [DATE]. On [DATE] at around 3:00 p.m., the assistant director of nursing revealed the BON received the complaint forms on [DATE]. Review of personnel files with the human resource staff on [DATE] at around 2:00 p.m., revealed nurses #1 and #2 were terminated on [DATE]. Both nurses had current CPR cards; RN license verification revealed licenses were current with no actions against them and background/reference checks for both nurses were done prior to starting work on the floor. Each nursing unit "residents COR status sheet" was reviewed on [DATE]. The sheets were signed by nurses at the change of shift. On [DATE], COR status sheets were compared to the COR status audit completed by social services and revealed they were consistent. On [DATE], the facility revised their resident COR status documentation sheet. The facility provided documentation for the change which showed full COR residents on individual halls/areas on unit, resident name and number; provided instruction to nurses regarding how changes would be communicated and how to share updates made. The resident COR status verification signature sheet included signature blocks for each shift and at the bottom read "I acknowledge it is my responsibility to verify the advanced directive legal document in the resident's chart for their MOST up to date advanced care planning directive. These are located under the advance directive tab. I will also note any change on the 24 hour report". At the bottom of the form read "the nurse will sign to verify his/her hallway each shift on the resident COR status sheet. When a change is noted, the nurse initiating the change will note it on the sheet, notify the supervisor and place the change on the 24 hour report. When an update is made, the shift supervisor will print and distribute the updated COR sheet to each hallway". Review of an action plan dated [DATE] revealed the facility -suspended the licensed nurses involved in the incident on [DATE] at 1:00 p.m. -started an investigation of the incident on [DATE], completed the investigation on [DATE] and completed the review on [DATE]. -bariatric boards ordered for each unit on [DATE] and video training on use of the boards on [DATE]. -occurrence reported to the health department on [DATE] and summary report on [DATE]. -RD evaluated and provided list of residents with BMI above 35 on [DATE]. -resident services staff to flag records with BMI above 35 and full COR status on [DATE]. -in-service nursing staff on how to initiate CPR for residents with BMI greater than 35 who are full COR done [DATE]. -follow up with therapy department regarding therapist CPR certification/CPR class scheduled for [DATE]. -in-service nursing staff regarding initiating CPR on full COR without exception, including protocol for bariatric residents done [DATE]. -resident services to audit all charts for advance directive completion with signatures, corresponding MD order and indicative sticker done [DATE]. -human resources to audit nursing staff records regarding current CPR certification done [DATE]. -add COR status to CNA care sheets per their request done [DATE]. -requested in-service on initiating CPR on [DATE] by fire department and scheduled for [DATE], all staff to attend training. -QA review of event with medical director and IDT done [DATE]. -Follow up report to board of nursing regarding facts of occurrence (date completed not provided). -medical records to obtain coroner report regarding cause of death request done [DATE]. -NHA audited all expirations/deaths for appropriate follow up on advance directives. -all current nursing associates review and sign F155 CPR versus no CPR, add to orientation packet for new hires (reviewed and signed) and add to agency orientation packet done [DATE]. -quarterly mock CPR full code drill start ,[DATE].-CNA training regarding use of emergency buttons in resident rooms done [DATE]. -evaluate location/proximity to nurse's station for all full code residents done [DATE]. -masks on walls in full code rooms/other locations? Review with team on [DATE]. Review of the resident census and conditions dated [DATE] revealed 44 residents had advance directives. Review of CNA care sheets on [DATE] revealed resident's COR status had been added. On [DATE], a flyer disclosed CPR training for (rehabilitation) therapists scheduled for [DATE]. On [DATE], review of the [DATE] CNA meeting notes disclosed a CPR quiz was completed by each CNA. Answers were discussed and why some answers not correct. Areas reviewed-CPR situation, use of bariatric boards, use of masks, do CPR until 911 arrives, how to identify resident code status, COR status location and location of emergency carts. Discussion also included the mandatory safety fair will be held in April (no date). Review of job descriptions for RN, LPN and CNA on [DATE] revealed each job description required current CPR certification. Review of the CPR drill team documentation on [DATE] disclosed team meeting conducted on [DATE] with sign in sheet provided; the visual aide sheet revealed a brightly yellow and red colored document with graphics. Instructions included 1. Responsive? Can you hear me? Can you open your eyes? 2. Help. Calling for help brings responder #2 to the scene. 3. Call 911. Responder 32 call 911 and gets the crash cart. 4. 30 to 2. 30 compressions (2 inches deep) and 2 breaths. The center of the visual aide showed a human form saying call 911 and at the bottom of the visual aide read push hard and fast. On [DATE] review F155 and CPR versus no CPR document that staff were to sign disclosed printed F155 regulation and surveyor guidance; addressed state law about health care decisions and refusal of treatment and the facility perspective. The facility perspective read as follows "when a resident at (name of facility) has an advanced directive (generally the MOST form), the directions on the form are to be followed. If the advanced directive is Yes CPR attempt resuscitation/CPR and staff find a resident without pulse or breathing/ cardiopulmonary arrest, CPR is to be started immediately. The EMS (911) system is to be activated and CPR continued until the EMTs arrive and take over. Staff can relieve each other while doing CPR, but the CPR is never to be started and then stopped before EMTs arrive or until the physician is notified and gives an order to stop CPR. If the advanced directive is No CPR, do not resuscitate/DNR/allow natural death, CPR is not to be started. The physician and family/responsible party are to be notified. No matter what our personal opinions may be about CPR versus no CPR/DNR, we must honor the wishes of the individual. Even though the age of our residents is 90 and most of our residents are very frail, if they have chosen to receive CPR, we must honor their wishes. At the bottom of the form was a place for the staff date and sign. On [DATE], review of an undated document titled CPR initiation/expectation and emergency carts disclosed -licensed nurses are expected to know which of their patients are full COR and those who are DNR. -a resident can elect to change their CPR status at any time; therefore one must always refer to the MOST form in the front of the chart under advanced directive tab for the resident's most current wishes. The MOST form is not valid unless it is signed by the physician. -CPR must be carried out per the resident/family wishes that the facility has on file at the time of the event. -It is utmost importance to have crucial conversations with residents/families about advanced directives when they are not in a time of crisis. -labeling of charts for COR status delineates whether they are full COR or DNR. -CPR is to be initiated on any resident who is full COR in the event they become unresponsive, have no breathing/or no normal breathing (gasping), inability to find pulse in less than 10 seconds or are without pulse then activate emergency response. -Bariatric tips, guidance for safer handling during resuscitation, when CPR can be discontinued and emergency carts was also addressed. CPR training by the fire department EMS-rescheduled per the fire department request. The in-service documents were not available for review. Coroner's report pending per QA report and interview. Coroner's report was not available for review (see above). Systemic plan of correction completed by the IDT on [DATE], in pertinent part read: -residents affected by practice: licensed nurses suspended pending investigation, post investigation both nurses terminated and both nurses reported to the BON; investigation completed; critical event review, occurrence reported to the health department; obtain coroner's report regarding cause of death; -other residents with potential to be affected by this practice: RD evaluate/provide list of residents with BMI 35 or above; resident services to flag residents records with BMI above 35 who are full COR; resident services audited all charts to ensure charts labeled with correct COR sticker, social service notes match MD order and COR status; human resources audited all nursing staff records for current CPR certification; in-serviced all nurses/CNAs on how to initiated CPR for residents including those with BMI greater than 35 who are full COR; requested in-service on [DATE] by fire department on initiating CPR; ADON in-service staff regarding use of emergency button/emergency pull cord during emergency scenarios; bariatric boards for each unit/installed and video training of board use; Systematic changes to be implemented: - new hire staff and agency staff will be educated on F155 (COR status versus DNR), tips for bariatric residents and facility system of identifying full COR residents prior to working on the floor; all new hires receive F155 training on first day facility orientation prior to working the floor; all agency staff are required to provide current CPR certification information prior to working at the facility (coordinated between staffing coordinator and vendor contact); quarterly in-service of initiating CPR with all licensed nurses and CNAs; care sheets all CNA care sheets will be kept up to date with current COR status; all COR changes will be on COR status sheet, reported to supervisor and noted on 24 hour report, COR sheets will be updated by ADON/supervisor; list of all resident COR status will be stored in the front of the narcotic book; licensed nurses will sign each shift that COR status was verified, any changes will be added to 24 hour report and updated by the nursing supervisor/ADON; resident services to audit monthly for 3 months and quarterly thereafter to ensure MOST form, advance directive completion with signature, sticker, MD order and social services notes are matching, results reported to QA; NHA to audit all expirations and deaths to ensure proper follow up on advance directives; therapist not currently required to be CPR certified, class scheduled [DATE]; CPR full code drill [DATE] first drill, weekly thereafter for 4 weeks, monthly for 4 months and quarterly thereafter; [DATE] CPR drill at facility annual safety fair; CPR kits added to each unit (CPR mask and visual aide); results of drills to be reported to QA monthly; bariatric CPR boards ordered for each unit and installed; video training of board use; -QA: QA review of event with medical director and IDT; QA review monthly with following audits (CPR full code drills, resident services audit and NHA audit expirations/advanced directives). Interviews: On [DATE], nurse #1 was not available for interview. Nurse #2 was not available for interview on [DATE]. The director of nursing was not available during the abbreviated survey but the assistant director of nursing (ADON) was available for interview. The medical director was not available for interview. On [DATE] at around 2:50 p.m. a meeting was held with the NHA and the ADON. The NHA revealed: -After the event she notified the executive director. -Resident #3's room was located on the mountain view hallway, the first door closest to the middle lounge. Nurse #1 was responsible for the mountain view hallway and nurse #2 was on the rainbow road hallway (further away from the middle lounge). -Nurse #1 went into the dietary/kitchen area for assistance (near longs peak/rub crossing units) and asked for any clinical person. The dietician told nurse #1 to call 911 and the nurse went back to the unit. The nurse had to pass the middle lounge and the ruby crossing hallway to reach the kitchen area near the ruby crossing/longs peak units. -Nurse #2 was working on the transfer paperwork. -The social worker informed the NHA of the resident condition, said resident had expired awhile ago and nurses did not know they needed to call 911. -She said the DON was in CPR class that day and not available for assistance. -The investigation began after the paramedics left, beginning with interviews and both nurses were relieved of duty by 1:30 p.m. pending the investigation.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for residents who received coffee from at least three dining rooms, including one of 48 sample residents (#156). Specifically: -The temperature of coffee served to residents in one dining room was in excess of 170 degrees Fahrenheit (F) without appropriate monitoring of the temperature. -The temperature of coffee served in at least three of the facility's dining rooms was in excess of 160 degrees F. -Resident #156 sustained burns on both thighs from a coffee spill. The facility's failure to respond to the burns in a manner consistent with preventing further burns for residents by ensuring coffee was not available until it was 150 degrees F or less created a situation of immediate jeopardy for serious harm. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY 1. Record review in the afternoon on 9/17/12 of resident #156's physician's telephone orders, care plan and nurse's notes revealed the resident sustained [REDACTED]. 2. Observations The facility had one main kitchen with two dining rooms (main and East). There was a separate kitchen for the other building which supported the memory care unit (MCU). The MCU had three different dining rooms referred to as pods. East Dining Room: Observations on 9/17/12 during the noon meal in the east dining room revealed a resident was served a cup of hot coffee. The coffee was served without a lid. Steam was rising from the coffee cup. After meal service, a cup of coffee was poured from the same urn and the temperature was 162 degrees Fahrenheit (F). Observations in the east dining room on 9/18/12 during the morning meal beginning at 7:30 a.m., revealed coffee being served from the coffee urns. The temperature of the first cup of coffee was 158.0 degrees F. Approximately 3 cups of coffee were served out of the urn. -At approximately 7:45 a.m., the dietary server was observed to make a new pot of coffee. The coffee was brewed directly into the serving urn. The temperature of the coffee was not checked prior to being served. -A cup of coffee was served immediately after brewing (directly into the urn). The temperature was found to be 178 degrees F. When the server placed the cup of coffee (without a lid) in front of a resident, and told her to be careful because it was hot. The resident who received the hot coffee had constant movement from her disease process. The coffee continued to be served to residents without lids. No ice cubes were observed being placed into the coffee. Observations on 9/18/12 at 8:30 a.m., in the east dining room revealed another urn of coffee was made. The temperature of the coffee was 178.0 degrees F (as measured by the surveyor). The dietary server was interviewed on 9/18/12 at approximately 8:30 a.m. The server stated that she did not take the temperature of the coffee. She stated that it was hot and that she told the residents to be careful when they were served. Satellite Kitchen in Memory Care Building On 9/18/12 at 6:47 a.m., a dietary staff member working in the satellite kitchen in the Memory Care Building was interviewed. She stated she had just brewed the coffee and had poured the coffee in the thermal pots that she then takes to the three Pods for breakfast. When asked if she temps the coffee at any time, she stated, "No" and she asked if she should. She then poured a cup from the thermal pot and temped the coffee. The thermometer read 168 degrees F. 3. On 9/18/12 at 11:00 a.m., the Nursing Home Administrator (NHA), and the Director of Nursing (DON) and the Food Service Director (FSD) were notified by the Colorado Department of Public Health and Environment (CDPHE) that serving residents coffee in excess of 150 degrees F created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On 9/18/12 at 2:30 p.m., the NHA submitted a plan to remove immediate jeopardy to CDPHE. A revised plan was submitted at 4:00 p.m. The plan dated 9/18/12 read: "...This protocol supersedes all previous hot beverage delivery protocols. All coffee brewers in public areas have been disabled immediately. Completed 9/18/12 by 12:30 p.m. The commercial coffee brewers will be removed from public areas by the coffee vending company as soon as they are able to arrive at the facility. Scheduled for the afternoon of 9/18/12. Household coffee brewers used for staff coffee will be kept in a secure location and will NEVER be used to provide coffee to residents. Effective immediately, all coffee/hot beverages for resident consumption will be brewed/provided by the dining services department. Temperatures of each urn/airpot of coffee, hot beverages and soup will be taken and recorded in the kitchen prior to being sent to the units. No hot beverages will leave the kitchen unless they are at 150 degrees or below. Because all temperatures will be taken by dining services, thermometers will not routinely be placed in the dining areas to ensure good infection control and calibration processes. Record will include date, time, temperature, and signature of person taking the temperatures. Dining service manager/designee will audit the temp logs at least daily to ensure compliance; appropriate action - including disciplinary action - will be taken for any staff member who fails to follow this protocol. Dining Service manager/designee will spot check temperatures behind the assigned employee at each meal (3 times daily) for one week effective the evening of 9/18/12, then one meal per day randomly for 2 weeks. This will then be discussed in QA (Quality Assurance) for additional guidance, suggestions and follow up. Urns/airpots/cups with hot beverages will not leave the kitchen until the temperature is at 150? or below. Temped urns/airpots will be provided at each meal service. Additional urns/airpots will also be provided so that residents may have coffee between meal service. Staff can call dining services if additional hot beverages are needed. Coffee/hot beverages may then be served to residents with or without lid, depending on residents' preferences; noting that lids will keep beverage at temperature longer, but no beverages will be served hotter than 150?. Residents who prefer lids will be asked to sign an informed consent indicating understanding that the beverage will remain hotter longer and the risk for spills and burns. All residents may be at risk for spilling coffee due to weak upper body strength; tremors; Alzheimer's disease or other dementias; needing assistance with meals, including beverages; decreased eyesight, or a variety of other factors. All residents are encouraged to consume hot beverages in an area where staff circulate so they may be assisted as needed. Facility currently has 15 to 20 residents who prefer room trays. These residents, should they prefer to consume hot beverages in their room without supervision will be screened by therapy for ability to safely consume hot beverages - to the extent possible. The screening will be completed by the evening of 9/18/12. For those residents determined to require OT treatment, nursing staff will begin calling physicians for orders the evening of 9/18/12. Any new residents admitted will be screened for safety upon admission should they prefer to consume hot beverages in their rooms. Staff will fill the beverage cup 2/3 full of hot beverages to minimize the opportunity for spillage. This will begin the evening meal of 9/18/12. Staff will not microwave a beverage to make it hotter effective the evening of 9/18/12. No nursing or dining services staff member will be allowed to work until they have been educated on this protocol and sign understanding and acknowledgement. Dining services and nursing staff will be educated on this new protocol at the start of each shift effective the afternoon of 9/18/12, and at the beginning of each shift ongoing until all staff members have been educated. Completion of education will be dependent on return to duty following leave of absence or vacation. For any on call, prn staff, they will be e-mailed this protocol and they will have to acknowledge receipt and understanding prior to beginning a shift. Agency staff will be given a copy of this and will have to sign an acknowledgement and understanding prior to beginning their shift. New hires will receive education regarding this protocol during their first day orientation prior to participating in direct patient care. This protocol will be distributed to all other department managers for review with all their staff. Once it has been presented to these other staff members i.e. housekeeping, therapies, activities, etc. staff signatures will be obtained indicating acknowledgement and understanding. No staff member may provide a hot beverage to a resident until they have signed that they understand this protocol. Ongoing auditing for compliance once staff has been educated: Dining services will audit test trays, including beverages, for temperature and proper hot beverage levels daily for one week; five times a week for three weeks, and at least twice weekly thereafter or depending on the recommendations of the QA committee. Meal services will be audited by a supervisory staff member/designee each meal for one week; at least daily for three weeks, and least twice weekly thereafter or depending on the recommendations of the QA committee. Items being monitored include but are not limited to: -Ensuring fluid level of hot beverages is not above 2/3 full -Ensure staff are not using the microwave to heat resident food/beverages -Status and safety of residents eating or drinking hot liquids in their rooms -Ensuring staff provide hot beverages from approved prefilled, pre-temped beverage dispensers." An "IMPORTANT!!!" memo was provided that was addressed to: "ALL NURSING STAFF" and "ALL DINING SERVICES STAFF." The memo was not dated, and read: "To minimize the chance for spills and burns related to hot liquids, the following residents ARE NOT to be given hot beverages in their room until therapy has had a chance to evaluate them and determine safe interventions to prevent spills and potential burns. These residents may drink hot beverages in the dining room where staff are available to assist, but not in their room until we have therapy recommendations for safety. Please make sure that no hot beverages are taken to these residents in their rooms: (14 resident names were listed)." Evidence was provided of Informed Notification for Hot Liquids understanding hot liquids may be consumed in the dining room where staff would be available to assist until therapy evaluation and recommendation was completed for each of these residents. Evidence was provided of an occupational therapy screen with recommendation for coffee with or without lids for each of these residents. Documentation of the in-services was provided. C. REMOVAL OF IMMEDIATE JEOPARDY On 9/18/12 at 4:30 p.m., the NHA was notified that the facility's plan of correction had been accepted and immediate jeopardy had been removed. However, deficient practice remained at a G level (isolated actual harm). II. FAILURE TO ADEQUATELY RESPOND TO RISK POSED BY HOT COFFEE TEMPERATURES. A. PROFESSIONAL REFERENCES According to Brown and Diller, The Journal of the International Society for Burn Injuries, "Calculating The Optimum Temperature For Serving Hot Beverages," Volume 34, Issue 5, (2008), page 648: "Hot beverages such as tea, hot chocolate, and coffee are frequently served at temperatures between 160 degrees Fahrenheit (?F) ...and 185 (?F)...Brief exposures to liquids in this temperature range can cause significant scald burns...The analysis points to a reduction in the presently recommended serving temperature of coffee to achieve the combined result of reducing the scald burn hazard and improving customer satisfaction". According to the Consumer Protection Safety Commission, Tap Water Scalds, Document #5098, www.cpsc.gov/cpscpub/pubs/5098.html <http://www.cpsc.gov/cpscpub/pubs/5098.html>, (5/31/00): "Exposure to water temperature at 150 (?F) can cause third degree burns in 2 seconds. Third degree burns penetrate the entire thickness of skin and permanently destroy tissue." B. RESIDENT #156 Record review of the face sheet revealed the resident, age 91, was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The 8/3/12 significant change minimum data set (MDS) revealed resident #156 scored 9/15 on the brief interview for mental status (BIMS) indicating moderate impairment, displayed mood problems, demonstrated some behavioral symptoms, required limited to extensive physical assistance with most activities of daily living, and required only set-up with supervision for eating/drinking. The resident's 8/3/12 care plan revealed the resident had dementia, history of decreased socialization, repeated "terrible statements and verbalizations and is unpleasant at times," behavioral symptoms of disruptive behaviors, verbally and physically abusive at times, resistant to cares, yelled out loudly, swearing, swinging arms, hitting, slapping, pinching and picking at herself. The 8/3/12 care plan also revealed dementia with short-/long-term memory problems, difficulty with recall, poor endurance and generalized weakness, and unable to live independently or perform own cares. The Social Service Director (SSD) for the MCU was interviewed at approximately 5:20 p.m. on 9/17/12. She said resident #156 was admitted to a room in the Health Center and was transferred to the Memory Care Unit (MCU) on 8/16/12. 1. Burn to Thighs from Coffee The 8/14/12 nursing note for the 10 p.m. to 6 a.m. night shift (ending at 6 a.m. on 8/14/12) revealed the resident slept well through the night until approximately 5 a.m. when cares were provided and she was "Given cup of coffee (and) brought out to DR (dining room)." The 8/14/12 nursing note for the "6-2" day shift revealed the resident denied pain or discomfort and she worked with restorative therapy. There was no evening shift nursing note on 8/14/12. The nursing note for the night shift ending at 6 a.m. on 8/15/12 revealed when the resident was assisted for toileting, the nurse noted a red mark on the resident's right thigh "resident stated spilled coffee on herself, resident confused and unable to tell me when she spilled the coffee. Resident (with no) coffee this shift. On (left) thigh found 2 clear fluid-filled blisters measured by wound care nurse (name) at 7:30 (a.m.). Plan is to place suresite over blisters and monitor when open, rec(eived) new orders, resident also (with) red area (left) inner knee" per the wound care nurse. (Left) thigh area 12.0 x 2.0 - 2 fluid-filled blisters within area, upper blister 2.0 x 1.8 cm, lower blister 3.0 x 2.0, several satellite red areas above (left) knee 2.5 x 2.0 sm(all) fluid-filled blister (right) thigh 1.0 x 0.8 cm. Suresite applied to blisters, silvadine cream to red areas BID (twice a day). Dining room staff aware all lids on cups (with) hot liquids except for residents (with) waivers. Staff educated resident to drink coffee in common areas only. Resident denies pain to area, (no) s/s (signs/symptoms) verbal/non-verbal noted when area touched at 7:30 a.m. lying in bed, (no) distress noted. Continue (with) close supervision." Resident #156's 8/15/12 acute care plan revealed a red "mark R (right) thigh noted NOC (night) shift. Resident states spilled coffee on herself. Noted clear fluid-filled blister left thigh ... (left) thigh area 12.0 x 2.0 (cm) 2 fluid-filled blisters, within area upper blister 2.0 x 1.8 below blister 3.0 x 2.0 several satelite red areas on thigh and above (left) inner knee 0.2 x 5 x 2.0 small fluid-filled blister (right) thigh 1.0 x 0.8 (cm). The goal was "area will resolve x2 weeks." The interventions were to: *Ensure resident has lid on coffee, *Ensure resident supervised when drinking warm beverages at all times, *Suresite to blisters, and *Silvadene cream to red areas twice daily. The physician's telephone orders revealed an order on 8/15/12 to "clean burns on bilateral inner thighs with wound cleanser, apply over fluid-filled blister suresite and change prn (as needed). Check blisters daily. Apply Silvadene 1% cream to all red areas BID (twice daily)." The 8/15/12 day shift nursing note revealed "areas bilat thighs pink (with) serous filled blisters (left) thigh & small serous blister (right) thigh (with) opsite dressings clean, drsg (dressing) intact. No (increased) redness or (increased) inflammation noted. Resident is supervised @ all times with warm beverages (with) lid & tol(erated) well ... denies pain to areas (on) thighs." The 8/15/12 evening shift nursing note revealed the resident complained of "pain to left thigh, described it as a 'burning' feeling. Resident received Tylenol (with) positive effects. Resident denied pain at HS (bedtime)." The nursing note for the night shift ending at 6 a.m. on 8/16/12 revealed "small blister on (right) thigh opens & bottom blister on (left) thigh opened - resident has removed suresite. (Left) thigh (upper) blister tried to cover (with) suresite but resident removed. (No) s/s infection, drainage at this time." The 8/16/12 day shift nursing note revealed the "Resident to transfer to memory care unit (MCU) this am at about ten. Staff will transfer with personal belongings, medications & medical records." The 8/16/12 nursing note at 10:30 a.m. revealed the resident was "admitted to (MCU) facility on Copper Creek from Med Center accompanied by MC staff. Resident appears comfortable & content. Introduced to staff and various other residents. Oriented to room and unit. Provided a cup of coffee in dining room and she looked around and appeared content." The 8/17/12 physician's telephone order at 10 a.m. was for "Silvadene cream to open blisters (bilateral) inner thighs - apply adaptic gauze & 4x4's and secure with Mepilex tape. Change BID." The 8/17/12 nursing note at 3 p.m. revealed "New order obtained for blistered areas to (bilateral) inner thighs." The 8/18/12 nursing note at 9 p.m. revealed "dressing to bilat thighs changed. C/O (complained of) discomfort during dressing (change)." The nursing note for the night shift ending at 6 a.m. on 8/19/12 revealed "(No) C/O. Dressing done to (bilateral) inner thighs. (No) s/s infection. (No) behaviors." The 8/19/12 nursing note at 9:30 p.m. revealed "Resident has (no) C/O pain or discomfort. Resident refused vitals & refused dressing (change) to bilat legs." The 8/20/12 nursing note at 8 a.m. revealed "burn on (right) inner thigh measures 7.5 x 3.0 (cm), area red (with) center open area (with) thin layer of yellow slough. Burns on (left) thigh upper area 3.5 x 1.0 yellow slough present in wound bed. Lower area on (left) thigh measures 13.0 x 5.0, 25% yellow slough. Area above (left) knee red and measures 1.3 x 3.0, no blister present. Areas painful to touch otherwise resident denied pain or discomfort. No edema present or signs of infection noted." The 8/20/12 physician's telephone order at 1:45 p.m. was to "clean wounds bilateral inner thighs (with) wound cleanser. Apply Silvadene cream to all burn areas. Cover open areas (with) Adaptic, then ABD pads, secure (with) Hyperfix tape, (change) BID." The 8/26/12 nursing note at 8 a.m. revealed "Burned area on (left) lower thigh 4.0 x 2.0 (cm) wound bed beefy red no depth. Several satellite scabbed areas. (Right) inner thigh open area 1.0 x 1.5 wound bed pink no depth. Several scabbed satellite areas. Denies pain or discomfort. No s/s of pain noted." The 9/4/12 nursing note at 8 a.m. revealed "Treatment dc'd to bilateral inner thighs areas resolved." 2. Facility Investigation of Incident The Director of Nurses (DON) provided the facility's investigation of resident #156's burns in the morning on 9/18/12 and explained the information provided was the complete investigation. The injury investigation revealed the injury was "unwitnessed," with "poor safety awareness," the resident was "combative or resistive during care," and had an "unwitnessed fall" in the last 30 days. The injury investigation summary read, "when daughter (name) called this AM she stated when she was here about 1730 (5:30 p.m.) on 8/14/12 her mother had a towel on lap, when she took her to her room, she noted a coffee stain - dry on shirt changed her shirt, front of pants were damp - not changed - mother (with no) C/O at that time, client says spilled coffee." The witness statements read, "There were no direct witnesses to the spill. Interview of (registered nurse) - resident uses lidded coffee cup but she was not present that evening so she is uncertain if she had lidded cup for supper. She did have lidded cup for breakfast on 8/15/12" ... "CNAs (certified nurse aides) who cared for resident 8/14/12 day shift report resident without any redness or signs of injury" ... evening shift "CNAs interviewed and none observed resident spill hot coffee on herself evening of 8/14/12. (names) report (resident #156) uses lidded cup. (name) denies receiving any reports from resident or CNA staff regarding resident spilling coffee or any sort of redness/burns when undressed for bed." The resident interview read, "states spilled coffee on herself - can not say exactly when." Measures implemented to prevent similar injuries in the future: "Notify all staff resident must have lid on coffee be supervised when drinking." However, there was no evidence the facility implemented measures to protect all facility residents from hot coffee. 3. Staff Interview On 9/18/12 at 10:07 a.m., an interview was conducted with the Nursing Home Administrator (NHA), DON and the Food Service Director (FSD). -The DON said in the morning on 8/15/12 she got a call from a Health Center (HC) nurse about finding blisters on resident #156's thigh, fluid filled possibly from a burn. A nurse called the resident's daughter and the daughter said she noted coffee stains on the resident's shirt and her pants were wet. The daughter changed the resident's shirt, but not her pants. It was not reported at that time that anything was wrong and there were no witnesses. The DON said in the morning on 8/15/12, the staff called the resident's physician and got orders. -The NHA said they investigated with staff and the staff gave the resident coffee in a lidded cup. The NHA said the residents could refuse the lidded cup; staff were to add three ice cubes to the coffee if the resident refused the lid. -The NHA explained adding ice to unlidded coffee cups was a plan from about a year ago. The NHA said the dieticians (at the time) had tested the temperature of the coffee and found by putting three ice cubes in the coffee, it lowered the temperature to the appropriate temperature. The NHA explained, "If you want hotter coffee, you get a lid. We do not have a policy on hot coffee." The NHA said it was her understanding the dietary staff ensured the temperature was checked for what temp it went into the urn, but she did not know if it was tested on e time or on a daily basis. -The NHA, when asked what changes were made after resident #156's coffee burns were discovered, said, "We checked to see who uses lids and where she got her coffee from. Don't know where she got her coffee from, we're not really sure of the events. Daughter was in the night before and found coffee stain on towel. -The FSD said, "We temp every week and have a log. The managers do tray audits, staff never do it." When the FSD was asked when the coffee temperature tests were done, the FSD said with test trays and the coffee could've been in the urns for 30 minutes. The FSD said they contracted with a new coffee company about 10 days ago and they said the pot brewers had to be at 190 degrees F. The FSD said the serving temperature of coffee was appropriate at anything over 160, just like the soup. -The FSD said the facility protocol was to take the coffee temperature down to 140 before serving. When asked how staff know the coffee is at the appropriate temperature for serving, the FSD said the kitchen staff tested (assuming no variations in temperature) and found that adding three ice cubes to one cup of coffee took care of the high temp. -The FSD said she knew about hot coffee concerns last night; however, the coffee observations the next morning were still hot. The FSD said, "We just changed coffee companies and did not reassess temps since the switch (10 days). -The FSD said the nursing staff do not temp the coffee, so they do not know (the temperature) and do not have access to thermometers. The FSD said there were no concerns brought to her attention about hot coffee. The FSD said the two chefs and the RDs (registered dieticians) should all know the proper temperature. When asked what today's serving temperature of the coffee was, the DM did not know. -The FSD provided the most recent test tray evaluations. There were only six for the time period of 7/10/12 to 9/11/12, rather than the ten expected for that time frame (per weekly checks). The 7/10/12 lunch coffee temperature was 149 degrees. The 7/19/12 supper coffee temperature was not tested . The 8/8/12 lunch coffee temperature was 144 degrees. The 8/15/12 lunch coffee temperature was 147 degrees. The 8/27/12 supper coffee temperature was 152 degrees. The 9/11/12 lunch coffee temperature was 153 degrees. Per the DM interview, the coffee temperatures were obtained up to 30 minutes after the coffee was put in to urns, rather than the time the coffee was put in the urn or when the coffee was actually served/available to the residents. -The NHA, DON and FSD were asked if any in-services were provided after the resident's 8/14-15/12 burn, and they said there were no inservices after this burn. The DON said she was not aware of other residents being burned by hot coffee, but she would check to be sure. -The FSD stated the coffee was brewed at 190 degrees per the coffee brewer company. The FSD stated the facility wanted the temperature of the coffee to be about 160 F and if the temperatures were below that, then the residents might request the coffee to be re-heated. The FSD re-confirmed staff was to place ice cubes in the coffee if there was no lid. The FSD stated she did not observe staff putting ice cubes in the coffee yesterday (during her observations on 9/17/12). 4. Facility Protocol The facility clinical protocol was provided on 9/18/12 and was marked with an effective date on 5/10. The purpose was "To assure resident safety by minimizing the opportunity for spills and burns from hot beverages." -The General Information/Definitions were: "Because of the potential for decrease in skin sensitivity and/or reaction time, patients and residents in a skilled nursing facility are at risk for burns from hot liquids. These burns can be to the skin following a spill, or the oral mucosa from drinking large amounts of a hot liquid." -The Policy dated 5/10 was: "Hot beverages will be served in lidded cups. For those who refuse a lidded cup, the temperature of the hot beverage will be lowered to minimize the opportunity for a burn. Because this risk cannot be eliminated, residents who refuse a lid will have to sign an informed refusal." -The Procedure was: "(1) All residents will receive a lid on each hot beverage cup at meals and between meals. (2) Residents who refuse a lid on their hot beverage cup will receive education and if needed, the option of signing an informed refusal. (3) For those residents who refuse lids, staff members will add 3 ice cubes of approximately a 1" x 1" x 0.5" size to a 6 ounce hot beverage which has been tested to lower the beverage to approximately 140 (degrees) F (the lowermost limit for hot foods according to federal regulations). Residents will also be informed of this procedure prior to signing the informed refusal. (4) Family/Responsible party will be notified of resident preference. (5) If a resident is unable to understand and/or sign informed refusal, then his/her POA (power of attorney) will be educated and offered the option of signing an informed refusal. Informed refusal may be given over the phone, with documentation indicating the name of the POA, date, time, informed refusal was given, and the name of the staff member to whom the refusal was given. (6) Informed refusals will be assessed at least annually to ensure proper safety precautions are in place. OT evaluations will be ordered as needed if a resident is experiencing a decline in dining function or safety. (8) (there was no #7) Each dining room maintains an accessible list of those who refuse a lid on their hot beverage cup, (and therefore, will need 3 ice cubes added to their beverage). List will be updated as changes are made." C. FURTHER DINING ROOM OBSERVATIONS/INTERVIEWS The facility had one main kitchen with two dining rooms (main and east). There was a separate kitchen for the other building which supported the memory care unit (MCU). The MCU had three different dining rooms referred to as pods. 1. MCU The evening meal was observed on all three pods of the MCU on 9/17/12. At 5:11 p.m., in the Copper Creek dining room pod, no residents had coffee. At 5:14 p.m., in the Silverthorne dining room pod only one resident (#102) had coffee and the coffee was covered with a lid. A CNA was asked for a cup of coffee from each urn (with caffeine and decaffeinated) as if it were being provided to a resident. The CNA got the coffee and the temperatures were both 134 degrees F. At 5:17 p.m., in the Gold Rush dining room, the coffee in the two urns was 148 and 126 degrees. On 9/17/12 at 5:35 p.m., the MCU dietary staff member was interviewed. She explained the dietary staff pick up the coffee urns from each of the three MCU dining rooms in the mornings, before breakfast, take the urns downstairs (to the kitchen) to clean the thermoses and filled them with coffee, one "regular" and one "decaf" for each of the 3 pods. Then another round (of coffee) after breakfast "around 10:30 a.m. ... we brew it, we don't temp it." On 9/17/12 at 5:40 p.m., two MCU CNAs were interviewed. Both said they rarely served coffee to residents at supper because residents complained it kept them awake. They both said there was no thermometer for checking the temperature of food or fluids in this pod (Gold Rush). On 9/18/12 at 11:53 a.m., the SUS chef (assistant to the main chef) was interviewed in the Memory Care building. The coffee poured from the thermal pot at the time lunch was being served was 160 degrees F. She stated that she will instruct staff to open all lids of the thermal pot and then to remain open for the coffee to cool down and she would retemp the coffee before it would be served to ensure it would be at the correct temperature. 2. Main Dining Room The main kitchen brewed the coffee directly inside the kitchen and then transferred into the holding containers; which were then brought out to the main dining room. Coffee was directly served into the cups from this container. The east dining room had two coffee brewers functioning on a countertop. Residents had access to the hot water spicket. The coffee was brewed directly into the holding containers for service to the residents. a. 9/17/12 Observations: On 9/17/12 at 4:40 p.m., in the main dining room, there were two coffee pots already set up in the dining area. A staff member was pouring the coffee for a resident and steam was noted coming up from the coffee. Coffee lids were available in the dining area. Some residents received lids and others did not. Those who did not receive lids were not noted to receive ice in their cup of coffee. No residents were noted shaking or spilling beverage (main dining room). The Food Service Director (FSD) was asked how staff determined who received a lid for their coffee. The