Every finding on record at Vista Grande Rehabilitation and Healthcare Center

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service.Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24),4, retrieved on 6/9/26, Food employees shall clean their hands and exposed portions of their arms immediately as specified under S 2-301.12 before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (Chapter 2-301.14)II. Facility policy and procedureThe Handwashing/Hand Hygiene policy, revised December 2025, was provided by the nursing home administrator (NHA) on 6/3/26 at 12:22 p.m. The policy read in pertinent part, Hand hygiene is the primary means for preventing healthcare-associated infections (HAs) and the transmission of multidrug-resistant organisms (MDROs). This facility requires strict adherence to evidence-based hand hygiene practices for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers, and students. Hand hygiene is indicated before touching a resident; before preparing or handling food, medications, or parenteral solutions; before clean or aseptic procedures; before moving from work on a soiled body site to a clean body site on the same resident; after exposure to blood, body fluids, excretions, or contaminated surfaces; after touching a resident; after touching the resident's environment or belongings; after glove removal; and whenever hands are visibly soiled. The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed.III. Observations1. Kitchen meal serviceDuring a continuous observation of the lunch meal service in the kitchen 6/2/26, beginning at 10:50 p.m. and ending at 12:37 p.m., the following was observed:At 11:25 a.m. cook #1 removed her gloves, placed a container in the refrigerator. She donned (put on) new gloves and proceeded to plate resident meals. [NAME] #1 did not wash her hands after touching the refrigerator door handle and donning new gloves to plate meals. At 11:34 a.m. dietary aide (#1) used her gloved hands to open the cabinet door, she then removed a hamburger patty from a bag and placed it directly on the grill. She did not change her gloves or perform hand hygiene after touching the cabinet handle and before directly touching the food. Dietary aide #1 then removed her gloves and performed hand hygiene.At 11:36 a.m. dietary aide #1 opened the refrigerator and retrieved a bag of hot dogs and donned new gloves. She did not perform hand hygiene before placing new gloves on.At 11:38 a.m. dietary aide #1 removed a hot dog from the bag and placed it into the microwave, touching the microwave handle with her gloved hand. She then placed the remaining hot dogs back in the refrigerator opening and closing the door.At 11:40 a.m. dietary aide #1 used the same gloved hands to touch lettuce, a sliced onion and a tomato and place the items on a plate. At 11:43 a.m. dietary aide #1 used her gloved hands to open and close the refrigerator. She placed a hamburger patty in a bun on a plate, touching the bun with her gloved hands. 2. Assisted diningDuring a continuous observation of the lunch meal service in the dining room on 5/31/26 beginning 4:00 p.m. and ending at 4:45 p.m., the following was observed:Resident assistant #1 and an unidentified certified nursing aide (CNA) were providing meal assistance for two residents at table A, one resident at table B and one resident at table C. The unidentified CNA and resident assistant #1 went from table to table, positioning the residents at the tables, touching the resident's wheelchairs, touching each resident's utensils and beverage cups while providing meals assistance to each of the four residents without performing hand hygiene. IV. Staff interviewsCook #1 was interviewed on 6/2/26 at 12:20 p.m. cook #1 said hand hygiene should be conducted frequently when preparing and serving meals and when touching anything that could contaminate the food. She said hand hygiene should have been done every time gloves were put on and taken off. Dietary aide #1 was interviewed on 6/2/26 at 12:28 p.m. Dietary aide #1 said hand hygiene should be performed every time a staff member returned from a break, touched anything potentially contaminated and when putting on new gloves. The dietary manager (DM) was interviewed on 6/3/26 at 11:09 a.m. The DM said hand hygiene should be conducted before touching food related equipment and before and after glove use to prevent potential cross-contamination.The DM said hand hygiene should be done every time staff returns from a break, touches anything potentially contaminated and when putting on new gloves. She said her staff have been trained on hand hygiene and she would continue to remind them. The director of nursing (DON) was interviewed on 6/3/26 at 5:15 p.m. The DON said she was the infection preventionist for the facility. The DON said she did not educate the kitchen staff or spot check them in the kitchen for appropriate infection control practices. The DON said she would watch the dining room staff to check on hand hygiene in the dining room for residents and staff in the dining room. She said the DM was responsible for ensuring infection control practices were conducted during meal preparation and meal service for the kitchen staff.The NHA was interviewed on 6/3/26 at approximately 6:40 p.m. She said the facility mainly focused on resident hand hygiene, but based on the observations, they would continue to work with staff on hand hygiene.

Based on record review and interviews, the facility failed to provide a rationale to act upon the pharmacist's recommendations in a timely manner for three (#2, #3 and #4) of five residents out of 36 sample residents. Specifically, the facility failed to provide a rationale for not acting upon the pharmacist's recommendations for Resident #2, Resident #3 and Resident #4. Findings include: I. Facility policy and procedure The Medication Regimen Reviews policy and procedure, revised February 2025, was provided by the nursing home administrator (NHA) on 6/3/26 at 7:17 p.m. It revealed in pertinent part, Upon receiving the medication recommendation report (MRR) from the pharmacist, the physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what actions were taken to address them. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies (dementia with protein clumping built up in the brain causing problems with thinking, moving, and sleep), epilepsy, chronic kidney disease stage 3, transient ischemic attack (TIA - a mini-stroke), cerebral infarction (a stroke), atherosclerotic heart disease of native coronary artery (plaque builds up inside the arteries supplying blood to the heart restricting blood flow and oxygen to the heart muscle), atrial fibrillation (heart arrhythmia), essential hypertension (high blood pressure), type 2 diabetes mellitus, post-traumatic stress disorder, major depressive disorder, insomnia and hallucinations. According to the 3/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental status (BIMS) score of 14 out of 15. She used a walker and wheelchair. She required set up assistance with eating and supervision with oral hygiene, showering, and personal hygiene. She required partial assistance with toileting. The assessment revealed Resident #2 had an anxiety disorder. She took an antipsychotic medication and an antidepressant medication. The assessment revealed she took antipsychotic medications on a routine basis and a gradual dose reduction (GDR) was not attempted. The physician documented a GDR was clinically contraindicated on 1/21/26. The assessment revealed the section asking if the complete drug regimen review identified potential clinically significant medications was not completed, and the section asking if the facility contacted the physician by 12:00 a.m. of the next calendar day and completed prescribed recommended actions in response to the identified potential clinically significant medication issues was not completed. B. Record review Review of Resident #2's June 2026 CPO revealed the following physician's orders: Aripiprazole (an antipsychotic medication) 5 milligram (mg) tablet. Take one tablet by mouth one time a day for post traumatic stress disorder, ordered 3/16/26. Benadryl (antihistamine medication) 25 mg tablet. Take one tablet by mouth at bedtime for pruritus (an uncomfortable irritation of the skin that causes itching and scratching), ordered 3/15/26. Benadryl 25 mg tablet. Take one tablet by mouth as needed for itching, ordered 3/15/26. Calcitriol 0.25 microgram (mcg) capsule. Take one capsule by mouth one time a day, ordered 3/28/26. Cetirizine (antihistamine medication)10 mg. Take one tablet by mouth at bedtime for allergies, ordered 3/15/26. Duloxetine (an antidepressant medication) 30 mg capsule. Take one capsule by mouth one time a day for major depressive disorder, ordered 3/16/26. Duloxetine 60 mg capsule. Take one capsule by mouth one time a day for major depressive disorder, ordered 3/16/26. Insulin 100 units/milliliter (ml). Inject 20 units subcutaneously at bedtime for type 2 diabetes mellitus, ordered 3/15/26. Trazodone (an antianxiety medication) 50 mg. Take one tablet by mouth at bedtime for insomnia, ordered 3/15/26. Humalog 100 units/ml. Inject 8 units subcutaneously three times a day for type 2 diabetes mellitus, ordered 3/15/26. Gvoke kit (medication used to treat extremely low blood sugar) subcutaneous solution 1 mg/0.2 ml. Inject 1 mg subcutaneously as needed if the resident is unable to swallow, ordered 3/15/26. Sitagliptin (medication used to lower blood sugar) 50 mg tablet. Take one tablet by mouth one time a day for type 2 diabetes mellitus, ordered 3/16/26. Famotidine (medication used to treat stomach acid) 40 mg. Take one tablet by mouth at bedtime for indigestion, ordered 3/15/26. Review of the medication regimen review (MRR) forms provided by the facility revealed there were two sections on the form. The first section was completed by the pharmacist and provided a recommendation. The second section was the physician's response section. The physician's response section had three options for the physician to check; agree, disagree or other. If the physician marked disagree, the form instructed the physician to document a clinical rationale at the bottom of the form. Review of Resident #2's MRR forms, from 2/21/26 to 5/21/26, revealed the following: Renal dose adjustment on 2/21/26: Consider the following medication renal dose adjustments: cetirizine 5 mg once daily and Sitagliptin 25 mg once daily. The physician's response section was marked disagree. -However, the physician did not document a clinical rationale to explain the reason for not decreasing the cetirizine and Sitagliptin, as was recommended by the pharmacist. -Additionally, review of Resident #2's electronic medical record (EMR) did not reveal a rationale for why the pharmacist's recommendations for the decrease of cetirizine and Sitagliptin were not addressed. Benadryl 25 mg reviewed on 3/21/26: Please add dosing frequency or daily dose maximum warning to as needed order: Benadryl 25 mg. Take one tablet by mouth as needed for itching. Resident also has a scheduled order for 25 mg daily. The physician's response section was marked disagree. -However, the physician did not document a clinical rationale to explain the reason for not adding the dosing frequency or daily dose maximum for the Benadryl, as was recommended by the pharmacist. -Additionally, review of Resident #2's EMR did not reveal a rationale for why the pharmacist's recommendation for adding the dosing frequency or daily dose maximum for Benadryl was not addressed. Dulextine renal dose adjustment on 4/23/26: The current Dulextine dose is 90 mg daily, would you like to reduce it to 60 mg daily. Package insert dosing recommends avoiding use, some experts use up to 60 mg daily and monitored closely for adverse effects. The physician's response section was marked disagree. Sitagliptin renal dose adjustment on 4/23/26: Would you like to reduce the dose to 25 mg daily. The physician's response was marked disagree. Zytrec renal dose adjustment on 4/23/26: Current dose 10 mg once daily. Would you like to reduce to 5 mg daily. The physician's response was marked disagree. Famotidine renal dose adjustment on 4/23/26. Current dose 40 mg once daily. Would you like to reduce to 20 mg once daily. The physician's response was marked disagree. -However, the physician did not document a clinical rationale to explain the reason not to decrease the dosages of duloxetine, Sitagliptin, Zyrtec and famotidine, as was recommended by the pharmacist. -Additionally, review of Resident #2's EMR did not reveal a rationale for why the pharmacist's recommendations for the decrease of duloxetine, Sitagliptin, Zyrtec and famotidine were not addressed. Diabetes management basal titration on 5/21/26: Diabetes regimen of insulin glargine 20 units daily, Humalog 8 units three times a day and Sitagliptin 50 mg daily. The resident's blood glucose has been elevated, averaging above 200 milligrams per deciliter (mg/dl). Can we titrate basal insulin up at this time? Package insert titration recommendation: Lantus increase by 2 to 4 units every two to three days. The physician's response was to disagree and document that the resident requested for the current regimen. -However, there was no documentation in Resident #2's EMR to indicate that the pharmacist's recommendations for increasing the insulin dosage reviewed with Resident #2. III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included non-Alzheimer's dementia, anxiety, depression and diabetes. The 4/8/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She required partial assistance with activities of daily living (ADL). According to the MDS assessment, the resident did not have delusions, hallucinations or other behaviors exhibited during the assessment look-back period. The assessment documented Resident #3 received antipsychotic, anti-anxiety, and antidepressant high risk medications. The assessment revealed she took antipsychotic medications on a routine basis and a gradual dose reduction (GDR) was not attempted. The assessment revealed the section asking if the complete drug regimen review identified potential clinically significant medications was not completed, and the section asking if the facility contacted the physician by 12:00 a.m. of the next calendar day and completed prescribed recommended actions in response to the identified potential clinically significant medication issues was not completed. B. Record review Review of Resident #3's MRR, dated 3/23/26, revealed the pharmacist recommended a review of the resident's mirtazapine 15mg every night due to the resident's recent fall. The physician's response section indicated the resident's fall was unrelated to the above medications and medications warranted at this time. -However, the physician did not document a clinical rationale to explain the reason for not decreasing the resident's mirtazapine, as was recommended by the pharmacist. IV. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2026 CPO, diagnoses included heart failure, atrial fibrillation (abnormal heart rhythm), dementia, unspecified severity with behavioral disturbance, delusional disorder and chronic kidney disease stage 3. The 5/25/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. According to the MDS assessment, the resident did not have delusions, hallucinations or other behaviors exhibited during the assessment look-back period. The assessment documented Resident #4 received antipsychotic, anti-anxiety, and antidepressant high risk medications. The assessment revealed she took antipsychotic medications on a routine basis and a gradual dose reduction (GDR) was not attempted. The physician documented a GDR was clinically contraindicated on 1/21/26 The assessment revealed the section asking if the complete drug regimen review identified potential clinically significant medications was not completed, and the section asking if the facility contacted the physician by 12:00 a.m. of the next calendar day and completed prescribed recommended actions in response to the identified potential clinically significant medication issues was not completed. B. Record review The 1/29/26 MRR report documented Resident #4 had a physician's order for metoprolol succinate ER oral tablet extended release 24 Hour 25 mg tablet every other day and Metoprolol Succinate ER oral tablet extended release 24 Hour 50 mg tablet every other day. The pharmacist recommended decreasing Resident #4's metoprolol antihypertensive regimen dose to 25 mg due to the resident's low blood pressure. The pharmacist documented the resident's blood pressure had been consistently below 120 mmHg (millimeters of mercury) with occasional episodes of her blood pressure being less than 100 mmHg. The MRR report physician's response section was marked disagree. -However, the physician did not document a clinical rationale to explain the reason for not decreasing the resident's metoprolol dosage, as was recommended by the pharmacist. -Additionally, review of Resident #4's EMR did not reveal a rationale for why the pharmacist's recommendation for the decrease of metoprolol was not addressed. The 4/23/26 MRR report documented the pharmacist requested a physician's review of Resident #4's blood pressure medications, metoprolol succinate ER oral tablet extended release 24 Hour 25 mg tablets to be administered one tablet by mouth one time a day every other day for heart failure and metoprolol succinate ER oral tablet extended release 24 Hour 50 mg tablets to be administered one tablet by mouth one time a day every other day for heart failure. The pharmacist recommended decreasing Resident #4's metoprolol dose to 25 mg and 37.5 mg due to the resident's low blood pressure. The pharmacist documented the resident's blood pressure had been consistently below 120 mmHg with occasional episodes of her blood pressure being less than 100 mmHg. The resident's metoprolol medication had been frequently held due to her blood pressure being under 90 mmHg SBP (systolic blood pressure). The MRR report physician's response section was marked disagree. -However, the physician did not document a clinical rationale to explain the reason for not decreasing the resident's metoprolol dosage, as was recommended by the pharmacist. -Review of Resident #4's EMR did not reveal a rationale for why the pharmacist's recommendation for the decrease of metoprolol was not addressed. -Additionally, the pharmacist had previously recommended a decrease in the resident's metoprolol dosage in January 2026 (three months prior), which the physician marked as disagree and did not document a rationale for (see 1/29/26 pharmacist's recommendation above). V. Staff interviews The medical director (MD) was interviewed on 6/3/26 at 2:06 p.m. The MD said he had worked with the pharmacist for years and said the pharmacist knew what his (the MD's) recommendations for medications were, but the pharmacist kept asking him. He said the pharmacist could make medication changes based on best practices. He said the facility talked about each resident at the quarterly meetings. He said he signed the pharmacist's recommendations for residents' medications at this meeting with one signature for the entire packet of all residents' medication recommendations. He said he did not make many medication changes because the residents' families did not want any medication changes made. The director of nursing (DON) was interviewed on 6/3/26 at 3:18 p.m. The DON said the purpose of the pharmacist reviewing resident's medications monthly was to have an outside person review a resident's medication regimen to provide recommendations for labs and protocols that nursing and the physician may overlook. The DON said the physician was responsible for reviewing the pharmacist's medication recommendations. The DON said the physician reviewed the recommendations within a week of when the pharmacist made the recommendation. The DON said a pharmacist reviewed a resident's medications monthly and within ten days from when a resident was admitted to the facility. The DON said if the physician did not agree with the pharmacist's recommendation, the physician should document the rationale on the recommendation form. The DON said she was familiar with the recommendations for Resident #2, Resident #3 and Resident #4. She said she knew the physician disagreed with the pharmacist's recommendations for the residents; medications; however, there was no documentation on why he disagreed with the recommendations. Pharmacist #1 was interviewed on 6/3/26 at 5:11 p.m. Pharmacist #1 said a pharmacist reviewed a resident's medication on a monthly basis. He said if there was a new resident, the medications were reviewed within 10 days of the resident's admission to the facility. Pharmacist #1 said there were three types of recommendations he made. He said there were physician's recommendations, no recommendations and a DON recommendation. Pharmacist #1 said recommendations should be reviewed within a month from when the pharmacist made a recommendation. He said he documented the facility's response to a recommendation. Pharmacist #1 said if a physician disagreed with the pharmacist's recommendation, the physician should document the rationale for why he disagreed. He said it was important for a resident's medications to be reviewed because some residents were not able to advocate for themselves and some residents did not have family or friends who could advocate for them. He said it was important medications were given for the best optimization. Pharmacist #1 said he was familiar with Resident #2, Resident #3 and Resident #4. He said he did not always do the monthly reviews, but he said if the physician disagreed with the recommendations for the residents, there should have been documentation on why he disagreed. Pharmacist #1 said the physician was not always consistent with documenting the rationale.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease.Specifically, the facility failed to:-Ensure nursing staff disinfected blood pressure cuffs and sit-to-stand mechanical lifts in between residents;-Ensure nursing staff performed appropriate hand hygiene in between assisting residents; and, -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms.Findings include:I. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 6/9/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings.II. Facility policy and procedureThe Hand Washing Hand Hygiene policy, revised December 2025, was received by the nursing home administrator (NHA) on 6/3/26 at 6:53 p.m. It read in pertinent part, Hand hygiene is indicated: before touching a resident, before moving from work on a soiled body site to a clean body site on the same resident, after exposure to contaminated surfaces, after touching a resident, after touching the resident's environment or belongings (after glove removal) and whenever hands are visibly soiled.The Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised September 2022, was received by the NHA on 6/3/26 at 6:53 p.m. It read in pertinent part, The resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the occupational safety and healthcare administration (OSHA) bloodborne pathogens standard. The [NAME] Classification System is used to distinguish the levels of sterilization disinfection necessary for items used in resident care: Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs and crutches. Non-critical environmental surfaces include bed rails, bedside tables. Critical and semi-critical items are sterilized and disinfected in a central processing location and stored appropriately until use. Reusable items are cleaned and disinfected or sterilized between residents (durable medical equipment). Reusable resident care equipment is decontaminated and or sterilized between residents according to manufacturers' instructions. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident.III. Failed to disinfect blood pressure cuffs and mechanical lifts and perform appropriate hand hygiene between residentsA. Observations On 6/1/26 at 3:25 p.m. certified nurse aide (CNA) #1 and CNA #2, along with the NHA, transferred four unidentified residents out of the recliner chairs in the common area with one sit-to-stand mechanical lift. CNA #1, CNA #2 and the NHA went between the four residents, one after the other, to transfer them into their wheelchairs. The residents held onto the mechanical lift bar during the transfer. The staff members touched the residents' clothing and assisted the residents with placing their hands on the lift bar while being transferred out of the recliner chairs and into their wheelchairs. -CNA #1, CNA #2 and the NHA failed to disinfect the mechanical lift in between using it to transfer each resident.-Additionally, the staff members failed to perform appropriate hand hygiene after touching each resident. On 6/2/26 at 9:52 a.m. certified nurse aide with medication authority (CNA-Med) #2 took the blood pressure cuff from the top of his medication cart and placed it on an unidentified resident's arm to obtain the resident's blood pressure. After obtaining the resident's blood pressure, CNA-Med #2 put the blood pressure cuff back on top of his medication cart without disinfecting it. On 6/2/26 at 1:50 p.m. CNA-Med #3 took the blood pressure cuff out of her medication cart and the cuff on an unidentified resident's arm to obtain the resident's blood pressure. After obtaining the resident's blood pressure, CNA-Med #3 put the blood pressure cuff back into the medication cart without disinfecting it. -CNA-Med #2 and CNA-Med #3 failed to disinfect the blood pressure cuffs after obtaining residents' blood pressures.B. Staff interview CNA #4 was interviewed on 6/3/26 at 10:39 a.m. CNA #4 said hand hygiene was completed after assisting residents, going in and out of residents' rooms and before meals. She said she washed her hands when they were soiled or when a resident had an infection which required staff to wear personal protective equipment (PPE). She said she did not clean the mechanical lifts after each use or between residents.The director of nursing (DON), who was the facility's infection preventionist was interviewed on 6/3/26 at 5:30 p.m. The DON said hand hygiene should be performed frequently, including after resident care, going to the bathroom, during wound care, before and after eating and before and after touching equipment. She said the night shift cleaned and disinfected the wheelchairs and the medical equipment such as the mechanical lifts, as well as the blood pressure tower machines. The DON said staff did not generally clean the lifts or blood pressure equipment at any other time, unless the equipment was visibly soiled. She said the blood pressure cuffs were not cleaned in between residents because they generally touched clothing and not the skin of a resident. She said infection control education was completed on the computer annually and when it was needed because of a concern. IV. Failed to ensure housekeeping staff performed appropriate hand hygiene while cleaning residents' rooms A. ObservationsOn 6/2/26 at 9:22 a.m. housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER], which was a double-occupancy room. HK #1 donned (put on) gloves, sprayed the counters and sinks with a disinfectant spray, emptied the trash can and used a rag to wipe around the trash can before doffing (taking off) her gloves. She donned another pair of gloves without performing hand hygiene and swept the residents' room. After sweeping the resident's room, HK #1 doffed her gloves again and without performing hand hygiene, donned another pair of gloves and sprayed furniture polish onto a rag, wiped down the wood surfaces and repeated the procedure for both sides of the residents' room. She then took off her gloves, exited room [ROOM NUMBER] and walked across the hallway into another resident's room to get a box of gloves without completing hand hygiene. She said she ran out of gloves and did not have time to go get a box from the housekeeping closet. HK #1 re-entered room [ROOM NUMBER], donned another pair of gloves without performing hand hygiene and used a clean rag to wipe down the counters and the sink in room [ROOM NUMBER]. After wiping the counters and sink, she doffed her gloves, donned another pair of gloves and sprayed a rag with disinfectant to clean the high touch surfaces of the room and mopped the floor. Once she finished mopping the floor, HK #1 doffed her gloves, exited room [ROOM NUMBER] and pushed her housekeeping cart to resident room [ROOM NUMBER].Without performing hand hygiene, HK #1 donned another pair of gloves and proceeded to begin cleaning the second resident room. -HK #1 failed to perform hand hygiene before donning and after doffing her gloves during the duration of the entire room cleaning process.B. Staff interviewsHK #1 was interviewed on 6/2/26 at 9:35 a.m., immediately after the above observation. HK #1 said she completed training on how to clean a resident room when she started working at the facility. She said she did not know how often the facility provided additional room cleaning education. She said she performed hand hygiene when she was done cleaning the residents' rooms.The environmental director was interviewed on 6/3/26 at 5:45 p.m. The environmental director said he completed hand hygiene education with the housekeeping staff and the laundry services department. He said he completed one-on-one training with staff when needed. He said hand hygiene should be performed after disinfecting residents' rooms and in between putting on and taking off each pair of gloves.

Based on interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#2) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to protect Resident #2 from sexual abuse by Resident #73 on 12/11/25.Findings include: I. Facility policy and procedureThe Resident Right to Freedom from Abuse, Neglect and Exploitation policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/31/26 at 2:55 p.m. It read in pertinent part, The facility shall have and implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. The facility shall monitor the resident including the identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as sexually aggressive behavior such as saying sexual things and inappropriate touching and grabbing. Identify, correct and intervene in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur.II. Incident of sexual abuse of Resident #2 by Resident #73 on 12/11/25 A. Facility investigation The 12/11/25 summary of investigation revealed the allegation was substantiated. The summary documented that video surveillance revealed Resident #73 summoned Resident #2 over. Resident #2 went to Resident #73 and they held hands at the table. Resident #2 talked to Resident #73. Resident #73's response was mumbled and Resident #2 could not understand what he said. Resident #73 stroked Resident #2's sweater and her breast on top of her clothing. Resident #73 did not grab Resident #2. Resident #2 grabbed Resident #73's hand and moved it back to the table. Resident #2 held Resident #73's hand for a few more seconds and then moved to another table to eat her breakfast. Resident #2 reported the incident to a nurse after breakfast. There were two staff members in the dining room and they saw Resident #2 and Resident #73 holding hands but neither saw Resident #73 touching Resident #2's breast. The 12/11/25 facility report revealed the brief summary of the allegation was Resident #2 reported to registered nurse (RN) #2 at approximately 8:30 a.m. that Resident #73 touched her breast while they were in the dining room. The immediate intervention was to separate the residents and 15 minute checks were implemented for Resident #73. Resident #2's statement was completed on 12/11/25. It revealed Resident #2 went to the kitchen and Resident #73 waved Resident #2 to come over. Resident #2 went over and Resident #73 put his hands out. Resident #2 put her hands on his hands. Resident #73 was rubbing Resident #2's hands. Resident #73 took and looked at her hands. Resident #73 touched Resident #2's sweater and put his hand and rubbed down on her. Resident #2 shook her hand no and left. Resident #2 went down to the table to sit at the table. Dietary aide #1 brought Resident #2 her food. Resident #2 told dietary aide #1 thank you for getting me out of the situation. Resident #2 ate her breakfast and left the dining room and talked to RN #2. Dietary aide #1's witness statement was completed on 12/11/25. Dietary aide #1 said she was in the dishroom when Resident #2 went into the kitchen. Dietary aide #1 came out of the dishroom and she saw Resident #2 and Resident #73 holding hands. The residents were not talking. Dietary aide #1 said Resident #73 tried to pull her closer but the table was in the way. Dietary aide #1 asked Resident #2 what she wanted to eat and if she wanted to sit with Resident #73 or at another table she normally sat at. Resident #2 said No, I want to sit over there. Dietary aide #1 walked away into the kitchen to prepare Resident #2's food. When dietary aide #1 came back out, Resident #2 was sitting at the other table. Dietary aide #1 served Resident #2's food and Resident #2 said thank you.Dietary aide #2's witness statement was completed on 12/11/25. Dietary aide #2 said Resident #2 went into the dining room and went straight to the table Resident #73 was at and asked Can I sit by you? Dietary aide #2 went to deliver food to another resident. When dietary aide #2 walked back, she saw Resident #73 put his hands out toward Resident #2 and she placed her hands in his hands. Resident #73 leaned forward and grabbed her sweater. Dietary aide #2 said she went to the window for more food, turned around to deliver food and Resident #2 was heading to the other table. Dietary aide #2's staff interview was completed on 12/11/25. It revealed she witnessed a resident being touched inappropriately by another resident. Dietary aide #2 said she saw Resident #73 reach out and grab Resident #2's hand. Resident #73 touched Resident #2's breast outside of her sweater. The investigation documented that Resident #2's care plan was not updated following the incident. Resident #73's care plan was updated to include new medication orders, staff were to attempt to redirect Resident #73, encourage Resident #73 to participate in activities, offer non-judgmental support to the resident and to remind Resident #73 to keep hands to himself due to him not understanding some people did not like to be touched. B. Resident #2 - victim 1. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies (dementia with protein clumping built up in the brain causing problems with thinking, moving, and sleep), epilepsy, chronic kidney disease stage 3, transient ischemic attack (TIA - a mini-stroke), cerebral infarction (a stroke), atherosclerotic heart disease of native coronary artery (plaque builds up inside the arteries supplying blood to the heart restricting blood flow and oxygen to the heart muscle), atrial fibrillation (heart arrhythmia), essential hypertension (high blood pressure), type 2 diabetes mellitus, post-traumatic stress disorder, major depressive disorder, insomnia and hallucinations. According to the 3/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental status (BIMS) score of 14 out of 15. She used a walker and wheelchair. She required set up assistance with eating and supervision with oral hygiene, showering, and personal hygiene. She required partial assistance with toileting.The assessment revealed Resident #2 did not exhibit any behaviors. 2. Resident interview Resident #2 was interviewed on 6/2/26 at 9:10 a.m. Resident #2 said she was in the dining room when Resident #73 touched her arms and went up her arm to touch her breast. She said it made her feel horrible. Resident #2 said Resident #73 touched her breast over her clothes. Resident #2 said staff told her Resident #73 had a stroke and had dementia. Resident #2 said staff told her to roll with the punches. Resident #2 said it did not happen again.3. Record review -Review of Resident #2's comprehensive care plan revealed there was no care plan focus or interventions implemented to protect Resident #2 from further incidents with Resident #73 following the incident on 12/11/25. -Review of Resident #2's electronic medical record (EMR) revealed there was no documentation to indicate that Resident #2 was monitored after the incident with Resident #73 to ensure there were no changes to Resident #2's baseline. - Review of Resident #2's EMR revealed there were no progress notes related to the 12/11/25 incident with Resident #73. C. Resident #73 - assailant 1. Resident status Resident #73, age [AGE], was admitted on [DATE] and passed away in the facility on 2/19/26. According to the February 2026 CPO, diagnoses included hypertension, insomnia, cerebrovascular disease affecting right dominant side, unspecified dementia, behavior disturbance, sexual dysfunction, atrial fibrillation, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (chest pain), TIA, ischemic cardiomyopathy (heart disease when the heart muscle weakens and becomes unable to pump blood effectively) and peripheral vascular disease (a slow progressive circulation disorder).According to the 12/8/25 MDS assessment, the resident was moderately cognitively impaired with a BIMS score of nine out of 15. He required set up assistance with eating and substantial assistance with oral hygiene and toileting. He was dependent on showering.The assessment revealed the resident did not exhibit behaviors towards others. 2. Record review The attention-seeking care plan, initiated 3/15/23 and revised 2/13/26, revealed Resident #73 had behaviors of inappropriately touching others. Interventions included if he tried to hold hands with others, staff were to remind him to keep his hands to himself; administering medication per physician's orders, approaching him in a calm manner to avoid frustration and behavior escalation, attempting to redirect the resident when he was exhibiting behaviors, encouraging the resident to participate in activities, giving non-judgmental support, monitoring and documenting episodes of inappropriate behaviors and providing a structured schedule for daily care when possible.The 12/11/25 change in condition nurse progress note revealed staff reported Resident #73 inappropriately touched another resident (Resident #2). The physician was notified and gave new orders for finasteride and medroxyprogesterone (medications that are sometimes used to decrease hypersexual behavior). The resident's representative was notified and verbal consent was provided for the medications. The director of nursing (DON) and the NHA were made aware of the incident. III. Staff interviewCertified nurse aide with medication authority (CNA-Med) #2 was interviewed on 6/2/26 at 3:17 p.m. CNA-Med #2 said he reported abuse to the nurse on duty and management including the NHA and the DON. He said when he saw abuse, he separated the residents and made sure the residents were safe before reporting the abuse allegation to the nurse. CNA-Med #2 said he told the nurse and the nurse started the investigation. CNA-Med #2 said the incident was documented as a progress note and as behavior monitoring in the residents' medication administration records (MAR). He said a plan of action was made right away and was documented in the residents' charts to include what interventions were put in place. He said some interventions were keeping residents separated, offering activities they liked to do and monitoring for pain. CNA-Med #2 said interventions were documented in shift report, a communications book, and alert charting.CNA-Med #2 said he knew what escalated a resident's sexual behavior by getting to know them when they were first admitted . He said when behaviors were observed, he told the nurse and charted. CNA-Med #2 said he knew what de-escalated a resident's sexual behavior by finding the right staff member to care for the resident and educating the resident not to do it because it was not appropriate. He said some residents were always flirty, so he charted and staff knew the behavior. CNA-Med #2 said he knew if a resident had sexual behaviors because it was in the care plan, the progress note and the MAR. CNA-Med #2 said there were residents who had sexual behaviors. He said he was familiar with Resident #73. He said he never saw him exhibit any sexual behaviors with other residents, including Resident #2. RN #1 was interviewed on 6/2/26 at 3:46 p.m. RN #1 said she reported abuse to the DON and the NHA. She said if she saw abuse, she separated the residents, entered a progress note, notified the physician and the resident's representative. She said a progress note indicated what interventions were in place and said 15-minute checks were one intervention. RN #1 said residents were monitored post-incident for 24 hours. RN #1 said she knew what escalated a resident's sexual behavior based on the resident's diagnoses. She said some residents had dementia and when they sundowned (a state of late day confusion, anxiety and agitation related to dementia) they exhibited behaviors. RN #1 said residents did not understand and did not have awareness of the behaviors, so it was important to explain why they could not do what they wanted to do. RN #1 said interventions to de-escalate a resident's behavior was documented as a health status note. RN #1 said she was familiar with Resident #73 and said 15-minute checks and medications were added to decrease his sexual behavior. She said redirection and telling him not to do the behavior were interventions to prevent the sexual behavior. RN #1 said she was the nurse who Resident #2 reported the sexual abuse from Resident #73. She said the residents were both in the dining room and Resident #2 approached Resident #73. RN #1 said Resident #73 touched her arm and then went up to brush her breast. RN #1 said the event scared Resident #2. The NHA, the DON and the social services director (SSD) were interviewed together on 6/2/26 at 5:05 p.m. The NHA said she was the abuse coordinator for the facility. The NHA said the abuse investigations were divided between the NHA and the DON. The NHA said the SSD was training to be a NHA and she talked to the family during an investigation. The NHA said when abuse was reported, she obtained the details on what happened and determined if it needed to be reported. The NHA said the nurses reported abuse and she also reviewed camera footage following an incident. The NHA said she and the DON interviewed the staff and residents following an incident. The NHA said if a resident was unable to communicate, nursing staff monitored their behavior to see if there was a change in their baseline for 72 hours to seven days following an incident, depending on the circumstances. She said the monitoring was documented as alert charting and a progress note. The NHA said she determined what residents to interview by interviewing residents who were alert and oriented, who resided in the same unit or were in the same vicinity of where the incident occurred. The NHA said nurses, the DON and she determined what immediate interventions to put in place when investigating the allegation.-However, there was no documentation in Resident #2's EMR to indicate the resident was monitored for changes to her baseline following the incident with Resident #73 on 12/11/25 (see record review above). The NHA, the DON and the SSD were interviewed together a second time on 6/3/26 at 5:14 p.m. The NHA, the DON and the SSD said they were familiar with the 12/11/25 incident between Resident #2 and Resident #73. The DON said she did not know if anyone asked how Resident #2 felt after the incident. The NHA said they did not put interventions in place for Resident #2 because the resident did not want to be near Resident #73 and she did not think there needed to be interventions in place. The NHA said the facility knew Resident #73 had sexual behavior prior to the 12/11/25 incident and the interventions in place were not effective in preventing the 12/11/25 incident with Resident #2.

Based on record review and interviews, the facility failed to report allegations of abuse in accordance with state law for two of two allegations of abuse.Specifically, the facility failed to: -Report an allegation of sexual abuse by Resident #73 towards Resident #2 on 12/11/25 to the ombudsman; and, -Report an allegation of sexual abuse by Resident #18 towards Resident #48 on 5/15/26 to the State Agency and the ombudsman.Findings include: I. Facility policy and procedureThe Resident Right to Freedom from Abuse, Neglect and Exploitation policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/31/26 at 2:55 p.m. It read in pertinent part, When the facility has identified abuse, the facility will increase enforcement action, including reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations.II. Allegation of sexual abuse by Resident #73 towards Resident #2 on 12/11/25The facility investigation for the sexual abuse by Resident #73 towards Resident #2 on 12/11/25 was provided by the NHA on 6/2/26 at 5:25 p.m. The investigation documented the following: The sexual abuse between Resident #73 and Resident #2 occurred on 12/11/25 at 7:23 a.m. -However, there was no documentation the ombudsman was notified of the incident (see interview below). III. Allegation of sexual abuse by Resident #18 towards Resident #48 on 5/15/26A. Resident #48 -victim1. Resident status Resident #48, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included transient ischemic attack (TIA - a mini stroke), cerebral infarction (a stroke), dementia, anxiety, depression and chronic respiratory failure with hypoxia. The 5/25/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She had an impairment on one lower extremity and used a wheelchair. She required setup assistance with eating and partial assistance with oral hygiene, toileting, showering and personal hygiene. She did not exhibit any behaviors. B. Resident #18 - alleged assailant 1. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included chronic obstructive pulmonary disease (emphysema - a progressive lung disease restricting airflow), hypertension (high blood pressure), intracranial injury with loss of consciousness, osteoarthritis and dementia with agitation.The 3/24/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He had an impairment on one lower extremity and used a wheelchair. He required set up assistance with eating. He required supervision with oral hygiene and moderate assistance with toileting, showering, and personal hygiene. The assessment revealed he did not exhibit any behaviors. 2. Record review The 5/15/26 nurse behavior note revealed Resident #18 was taken to smoke and became verbally sexually abusive to a female certified nurse aide (CNA) and again to another female resident (Resident #48). The nurse spoke to Resident #18 and he just laughed.-There was no further documentation regarding the incident.Cross-reference F610 for failure to investigate and alleged violation. -On 6/2/26 at 5:25 p.m., the facility was unable to provide documentation that the 5/15/26 allegation of sexual abuse was reported to the State Agency and the ombudsman. IV. Frequent visitor interview A frequent visitor, with knowledge of the facility, was interviewed on 6/2/26 at 4:10 p.m. The frequent visitor said the facility was required to report all allegations of abuse to the ombudsman. She said she was not aware of any abuse allegations made to the ombudsman for the past 12 months. She said there had been an ombudsman assigned to the facility for the past 12 months. V. Staff interviews The NHA, the director of nursing (DON), and the social services director (SSD) were interviewed together on 6/2/26 at 5:05 p.m. The NHA said staff should report potential abuse immediately to the DON or the NHA. The NHA said she was the abuse coordinator for the facility . The NHA said she reported abuse to the State Agency. The NHA said the initial incident report should be submitted to the State Agency within two hours if the resident experienced injury or harm. The NHA said she did not report abuse to the ombudsman. The NHA said she did not know allegations of abuse needed to be reported to the ombudsman. The NHA and the SSD said there had not been an ombudsman assigned to the facility until the past six months to a year.-However, according to the frequent visitor, there had been an ombudsman assigned to the facility for the past 12 months (see interview above).

Based on record review and interviews, the facility failed to investigate an allegation of sexual abuse for one (#48) of two residents of 36 sample residents. Specifically, the facility failed to investigate an allegation of sexual comments made by Resident #18 towards Resident #48 on 5/15/26.Findings include: I. Facility policy and procedureThe Resident Right to Freedom from Abuse, Neglect and Exploitation policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/31/26 at 2:55 p.m. It read in pertinent part, When the facility identifies abuse, it will take all appropriate steps to immediately remediate the noncompliance and protect residents from further abuse. The facility will conduct a thorough investigation of the alleged violation, and implement appropriate corrective actions. In addition, the facility will revise the resident's care plan when the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.II. Incident involving Resident #18 and Resident #48 on 5/15/26 A. Facility investigationA request was made for an investigation regarding the allegations of sexual comments by Resident #18 towards Resident #48 on 5/15/26. -However, the facility was unable to provide documentation to indicate an investigation was completed (see interviews below).B. Resident #18 - alleged assailant 1. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (emphysema - a progressive lung disease restricting airflow), hypertension (high blood pressure), intracranial injury with loss of consciousness, osteoarthritis and dementia with agitation.The 3/24/26 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 had an impairment on one lower extremity and used a wheelchair. He required set up assistance with eating. He required supervision with oral hygiene and moderate assistance with toileting, showering, and personal hygiene. The assessment revealed he did not exhibit any behaviors. 2. Record reviewThe behavior care plan, initiated 10/18/24 and revised 2/13/26, revealed Resident #18 had behaviors related to inappropriate touching of other residents and agitation toward staff, accusations toward staff, inappropriate and unwanted lewd and sexual comments to staff and others. Interventions included administering medications per physician orders, approaching the resident calmly to avoid frustration and behavior escalation, attempting to redirect the resident when exhibiting behaviors, encouraging Resident #18 to ask questions to reduce anxiety, giving non-judgmental support and monitoring and documenting episodes of inappropriate behaviors. The 5/15/26 nurse behavior note revealed Resident #18 was taken to smoke and became verbally sexually abusive to a female certified nurse aide (CNA) and again to another female resident (Resident #48). The nurse spoke to Resident #18 and he just laughed.-There was no further documentation regarding the incident. C. Resident #48 - alleged victim 1. Resident status Resident #48, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included transient ischemic attack (TIA - a mini stroke), cerebral infarction (a stroke), dementia, anxiety, depression and chronic respiratory failure with hypoxia. The 5/25/26 MDS assessment revealed the resident was cognitively impaired with a BIMS score of five out of 15. She had an impairment on one lower extremity and used a wheelchair. She required setup assistance with eating and partial assistance with oral hygiene, toileting, showering and personal hygiene. She did not exhibit any behaviors. III. Staff interviews The NHA, the director of nursing (DON), and the social services director (SSD) were interviewed together on 6/2/26 at 5:05 p.m. The NHA said she reviewed the nurse progress note in Resident #18's electronic medical record (EMR) from 5/15/26. She said the progress note described what happened between the CNA who took Resident #18 out to smoke and not to another resident. The NHA said she did not know why the nurse wrote that a resident was involved. The NHA said the nurse who wrote the note no longer worked at the facility and the CNA worked per diem (as needed) and was unavailable to be interviewed. The NHA, the DON and the SSD were interviewed together a second time on 6/2/26 at 6:05 p.m. The NHA said she contacted the nurse who wrote the 5/15/26 progress note in Resident #18's EMR and the nurse said it was not just the CNA who Resident #18 made sexual comments to, but he additionally made comments to Resident #48. The NHA said she did not ask what the exact comment made towards Resident #48 was. The NHA said the facility's investigation was ongoing. -However, the incident was not investigated until 6/2/26, 18 days after staff were aware of the alleged sexual abuse allegation. The NHA, the DON and the SSD were interviewed together a third time on 6/3/26 at 6:45 p.m. The NHA said if a resident did not like how they were spoken to, the resident should report the incident to management so the facility could investigate. The NHA said residents had a right regarding how they were spoken to, including the right not to be spoken to in a sexual way. The NHA said the facility was aware that Resident #18 had a history of making sexual comments towards residents.Cross-reference F742 for failure to provide treatment/services for mental/psychosocial concerns.

Based on record review and interviews, the facility failed to provide a rationale to act upon a third party guarantee of payment to the facility for one (#3) of one resident out of 36 sample residents. Specifically, the facility failed to ensure they did not violate federal guidelines for placing a [NAME] on Resident #3's property for $28,000.Findings include:I. Professional referenceAccording to Justice In Aging's Nursing Home Debt Collection Practices Put Residents' Family And Friends At Risk (11/1/24), retrieved on 6/15/26 from https://justiceinaging.org/nursing-home-debt-collection-practices/#post-50332-footnote-1, Federal law prohibits a nursing home from conditioning a nursing home resident's admission or continued stay on a third party's personal guarantee to be financially responsible for the resident's bills. Despite this prohibition, nursing homes still attempt various stratagems, through contracting and otherwise, to force financial liability upon residents' family members, friends, and other third parties. These practices impose significant and unnecessary financial strain on family members and other third parties, including lawsuits seeking hundreds of thousands of dollars. This pressure frequently compels adult children and others to pay alleged debts out of their own pockets to protect the nursing home resident.In response to this problem, the Consumer Financial Protection Bureau (CFPB) conducted a public hearing and released an issue spotlight on problematic nursing home collection practices in September 2022. The CFPB also issued a joint letter with the Centers for Medicare and Medicaid Services (CMS) directed to the nursing home industry and collection lawyers to remind them of their responsibilities under the Nursing Home Reform Act (NHRA), Fair Debt Collection Practices Act (FDCPA), and Fair Credit Reporting Act (FCRA).Despite the work of CMS and the CFPB, abusive nursing home debt collection actions against third parties continue to be filed.According to CFPB and CMS joint letter addressing Nursing Facility Debt Collection Practices (9/8/22), retrieved on 6/15/26 from https://files.consumerfinance.gov/f/documents/cfpb_nursing-home-debt-collection_joint-letter_2022-09.pdf, The Consumer Financial Protection Bureau (CFPB) and the Centers for Medicare & Medicaid Services (CMS) remind you of your responsibilities under the Nursing Home Reform Act (NHRA), Fair Debt Collections Practices Act (FDCPA), and Fair Credit Reporting Act (FCRA). The NHRA prohibits nursing facilities from requesting or requiring that a third party personally guarantee payment to the facility as a condition of a resident's admission or continued stay in the facility. Contract terms that conflict with the NHRA are unlawful, and alleged debts resulting from such unlawful contract terms are invalid and unenforceable. Some nursing facilities have attempted to evade this prohibition by creating admission contracts that attempt to hold third parties liable for a resident's debt. When a nursing facility claims that a non-resident is personally financially responsible for a resident's bill and engages a third-party debt collector to collect the debt, the debt collector may violate the FDCPA by attempting to collect debts that are invalid under the NHRA. They may also violate the FCRA by furnishing information regarding such invalid debts to consumer reporting agencies. Nursing facilities that violate the NHRA's requirements may be subject to enforcement action by state agencies and by CMS. Debt collectors who violate the FDCPA and FCRA may be subject to enforcement actions by the CFPB and other federal and state government agencies, as well as to private actions brought by consumers. We urge nursing facilities and their debt collectors to examine their practices to ensure that they comply with the NHRA, FDCPA, and FCRA. II. Promissory Note The Promissory Note secured by Deed of Trust, dated 2/3/26, for Resident #3, documented the following:For value received, the undersigned family representative and Resident #3 promise to pay the facility the principal sum of $28, 201.00, together with all future advances, with interest at the rate of eight percent per annum. Principal and interest shall be payable at the facility or at such place as the note holder may designate. The entire principal amount outstanding and accrued interest thereon shall be due upon the sale of any of the subject properties, Resident #3, undivided one third interest in the sub lot. Payments received for application to the note shall be applied first to the payment of any late charges, if any, second to the payment of accrued interest at the rate specified, if any, and the balance applied in reduction of the principal amount hereof. Any payment made more than 15 days after the due date thereof shall be assessed a 10 percent late penalty. If any payment required by this note is not paid when due, or if any default under any deed of trust securing this notes occurs, interest shall immediately begin to accrue at the default rate of 18 percent per annum until paid, and the entire principal amount outstanding and accrued interest thereon shall at once become due and payable. Interest on [NAME] disbursements shall be eight percent per annum. The note holder shall be entitled to collect all reasonable costs and expenses of collection and or suit, including, but not limited to reasonable attorney's fees. Borrower may prepay the principal amount outstanding under this note at any time, in whole or in part without penalty. Borrower waives presentation, notice of dishonor and protest. Any notice to borrower provided for in this note shall be in writing and shall be given and be effective upon mailing such notice by first class mail, addressed to borrower at the borrowers address stated below, or to such other address as borrower may designated by notice to the note holder. Any notice to the note holder shall be in writing and shall be given and be effective upon delivery to note holder at the address stated in the first paragraph of this note, or such other address as note holder may designate by notice to borrower. The indebtedness evidenced by this note secured by a deed of trust dated or even dated herewith, and until released, said deed of trust contains additional rights of the note holder. Such rights may cause acceleration of the indebtedness evidenced by this note. Reference is made to said deed of trust for such additional terms. Such deed of trust grants rights in the following described property. Resident #3, undivided one third interest in the sub lot. Signed by the power of attorney for Resident #3.III. Resident #3A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included non Alzheimer's dementia, anxiety, depression and diabetes. The 4/8/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She required partial assistance with activities of daily living (ADL). B. Resident's representative interview Resident #3's representative was interviewed on 6/1/26 at 8:45 a.m. The representative said the facility put a [NAME] on the shared property she had with Resident #3 for back payment that was due to the facility, which Medicaid did not pay. She said the facility approached her with the [NAME] information. Resident #3's representative was interviewed a second time on 6/3/26 at 2:35 p.m. The representative said the facility asked her to put a [NAME] on the property. She said she was paying the facility privately when Resident #3 admitted to the facility, but she eventually applied for Medicaid. She said the Medicaid application took a while to get approved because Medicaid kept requesting more information from her to proceed with the application. She said the [NAME] was completed after Medicaid had reimbursed the facility, but did not cover all of the resident's stay while the application was in process. She said she did not deal with Medicaid. She said the social services director (SSD) and the corporate business office manager assisted her with the Medicaid application. She said Medicaid kept asking for one more item to complete the application, which delayed the Medicaid approval for Resident #3. She said the facility told her she owed the facility for costs that were not reimbursed by Medicaid once the funding was approved. She said this amounted to approximately $28,000 for the three month period, about $9000 per month, which was a nightmare for her. She said she was not sure how much the facility received from Medicaid IV. Staff interviewsThe SSD was interviewed on 6/3/26 at 3:13 p.m. She said when a resident moved into the facility, the referral was followed by the hospital either under Medicare payment, long term care payment or respite. She sat down with families to explain the admission process. When a resident was off Medicare after 20 days and the resident chose to stay either they paid privately or she assisted in filling out the Medicaid paperwork for payment. She said the facility worked with all residents and payor sources giving families resources and working with Medicaid. She said families would give her the information needed and she would send this information to the state for approval. She said the usual time for Medicaid approval was within 45 days and most residents were a good criteria for approval. The SSD sometimes Medicaid had been denied for residents because of date discrepancies and families were then set up on payment plans, pending the Medicaid approval. She said if a family had a life insurance policy and the funeral was not prepaid out of the life insurance, Medicaid would deny payment. The SSD said this happened for Resident #3 and the resident's representative completed an appeal for Medicaid. The SSD said the [NAME] was completed on Resident #3's property because Medicaid denied approval for the resident due to date discrepancies. She said Resident #3's Medicaid application was super extensive because of multiple life insurance policies and Medicaid would not cover $28,000 dollars owed to the facility for the resident's care. She said the corporate business office manager completed the [NAME] on Resident #3's property and she (the SSD) had the representative sign with her (the SSD) notarizing the [NAME] and she (the SSD) then filed the [NAME] with the state. She said the facility received payment from Resident #3's monthly social security payments and the resident's representative also paid privately, in addition to Resident #3 being funded by Medicaid. The nursing home administrator (NHA) was interviewed on 6/3/26 at 5:55 p.m. The NHA said she understood liens would help cover backpay when discrepancies happened with Medicaid applications. She said she was not aware of the [NAME] on Resident #3's property.The director of operations was interviewed on 6/3/26 at 6:00 p.m. The director of operations said he was aware of the [NAME] on Resident #3's property. He said there were date discrepancies which had delayed the resident's application for Medicaid and in the meantime, a [NAME] was placed on Resident #3's property with the approval of the resident's representative. He said he had spoken with the corporate business office manager, who reported the resident's representative was worried about back payment and the representative voluntarily signed the [NAME] for the property. He said the company, as a whole, had three or four residents with liens on their properties. -However, according to the joint letter from CFPB and CMS, the facility was not authorized by federal law to place a [NAME] on a resident's home who received Medicaid benefits (see professional reference above).

Based on observations, record review and interviews, the facility failed to to ensure residents received treatment and care in accordance with professional standards of practice for one (#7) of six residents out of 36 sample residents.Specifically, the facility failed to ensure a registered nurse (RN) completed a head-to-toe assessment after a fall resulting in a hip fracture for Resident #7.Findings include:I. Professional referenceAccording to Nurse Journal's Licensed Practical Nurses (LPN) Versus Registered Nurses (RN) (9/8/25), retrieved on 6/11/26 from https://nursejournal.org/resources/lpn-vs-rn-roles/, LPNs and RNs both monitor patients, administer medications, perform wound care, help patients with basic tasks like bathing and feeding, and often educate and support patients and their loved ones. However, there are differences in the education requirements and scope of practice between RNs and LPNs. LPNs and RNs share many duties and have significant flexibility and job security. RNs, however, typically have more professional autonomy, with LPNs often unable to take certain actions without approval from an RN, physician, or other appropriate member of the care team. LPNs perform vital work in collaboration with RNs, physicians and other healthcare professionals. LPNs work alongside or under the supervision of RNs to deliver care and support to patients. Compared to LPNs, RNs generally operate independently. In certain settings, they may delegate some tasks to LPNs. RNs use their specialized judgment, skills, and knowledge to provide direct patient care in various settings. RNs and LPNs share many nursing tasks, but their scope of practice differs depending on their state. In all situations, RNs have a broader scope of practice than LPNs.Generally speaking, only RNs provide initial assessments. Therefore, an RN must perform all tasks that require close monitoring and frequent assessment, such as initiating blood products, the first round of antibiotics and initial patient assessments.II. Facility policy and procedureII. Facility policy and procedureThe Accidents and Incidents Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/3/26 at 6:39 p.m. It documented in pertinent part, All accidents or incidents involving residents, employees, visitors, vendors occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor or charge nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The Assessing Falls and Their Causes policy, revised March 2018, was provided by the NHA on 6/3/26 at 6:39 p.m. It documented in pertinent part, The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone.III. Resident #7 A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included respiratory failure, dementia, osteoporosis and a history of falls with fractures. The 3/26/26 minimum data set (MDS) assessment revealed Resident #7 was severely cognitive impaired with a brief interview for mental status (BIMS) score of 99 out of 15. She was dependent on staff assistance with activities of daily living (ADL). The assessment indicated the resident had had a fall with injury. B. Record reviewThe nurse progress note, dated 3/19/26 at 7:15 p.m. and written by LPN #1, documented the nurse heard a loud commotion as another resident called for help for Resident #7. Resident 37 was found lying on her left side with her knees slightly bent towards her chest. A full physical and neurological assessment was completed and neurological checks were initiated.The resident showed no signs or symptoms of injury or impairment. The resident was alert and oriented to self and was not able to give a description of the fall. The certified nurse aides (CNA) had already scooted the resident back into her chair one other time prior to the fall. The resident was wearing non-slip slippers and silk pajamas. She had a chucks pad (smooth padding) under her bottom. The resident was put into the recliner chair at the nurses' station by the CNAs for observation following the fall. The resident shook her head no when asked if she was feeling any pain. -However, LPN #1 completed the assessment for Resident #7 immediately following the fall. -There was no documentation to indicate a RN completed a head-to-toe assessment for the resident immediately after the fall, prior to the staff placing the resident in the recliner at the nurses' station. The nurse progress note, dated 3/19/26 at 11:07 p.m. and written by LPN #1, documented Resident #7 continued on neurological checks for a fall that evening. The resident showed no signs or symptoms of skin impairment, shortening of the leg, rotation of the legs or fracture post-fall. The resident was placed in the recliner chair for observation. The resident fell asleep for over one hour and when the nurse tried to get her up to take her to her bed and the toilet, the resident pulled back and moaned with a facial grimaced expression. The resident stated hurts and terrible. The resident was alert and oriented to herself but normally did not speak. The nurse, while waiting for the resident's representative to call back, notified the director of nursing (DON) and the physician to explain what happened. The DON observed the cameras, which revealed the resident was holding her left hip and was not able to put any weight on her hip with two CNAs helping her to stand. The resident was placed back in the recliner chair for comfort. Emergency medical services (EMS) were notified for transport of the resident to the hospital. The resident's representative called back and was notified the resident was sent to the hospital for further evaluation.-However, the DON, who was a RN, did not provide a visual assessment of Resident #7 until almost four hours after the resident initially fell and was transferred to from the floor to the recliner after being assessed by LPN #1 (see above). The progress note, dated 3/20/26 at 2:24 a.m. and written by LPN #1, documented Resident #7 had returned from the hospital via EMS and laid in bed. Resident #7's family accompanied her to the facility. The resident was given pain medication at the hospital and EMS handed the nurse a bottle of pain medications to be administered every four to six hours as needed for pain. The resident's diagnosis was a fracture of the left femoral neck (hip). The family had declined surgery for the resident. The resident had no bruising at the hip, slight swelling was noted and the area was tender to the touch.The interdisciplinary team (IDT) note, dated 3/20/26, documented video surveillance revealed Resident #7 was restless and self-propelling herself around the nurses' station multiple times in her wheelchair (on 3/19/26). The resident was seen repositioning herself in the wheelchair by scooting herself back. The resident was noted to be wearing silk pajamas, causing the resident to slide down in her wheelchair. The resident attempted to scoot herself back by grabbing onto the nurses' station and partially standing to scoot herself back. The force of the scoot caused the resident's wheelchair to roll back and the resident fell to the floor landing on her left side.Review of the hospital records, dated 3/19/26, revealed Resident #7 sustained a fracture of her left femoral neck (hip) with displacement. IV. Staff interviews Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 6/3/26 at 8:45 a.m. CNA-Med #1 said when a resident fell, the nurse had to do an assessment. She said she could not do resident assessments. She said she stayed with the resident until the nurse was there for support. CNA #1 was interviewed on 6/3/26 at 1:20 p.m. CNA #1 said when a resident had a fall, she notified the nurse. She said the CNA-Meds would also get the nurse to look at the resident. The DON and the NHA were interviewed together on 6/3/26 at 4:45 p.m. The DON and the NHA said the first step when a resident fell was to notify the nurse to complete an assessment. The NHA said the LPN completed the assessment and notified the DON. The DON said Resident #7 had a fall (on 3/19/26 and she was notified via phone by the LPN. She said she reviewed the video footage of the fall and guided the LPN from there but did not go to the facility after hours. She said the RN did not have to go in for the assessment. She said Resident #7 was sent to the hospital for further evaluation.-However, there was no documentation in Resident #7's EMR to indicate the DON was notified by LPN #1 until almost four hours after the resident initially fell and LPN #1 and the CNAs transferred the resident from the floor to the recliner, prior to obtaining a RN assessment and guidance from the DON (see record review above).

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care for one (#7) resident reviewed for hearing problems out of 36 sample residents. Specifically, the facility failed to consistently ensure Resident #7`s hearing aids were working and placed in the resident's ears.Findings include: I. Facility policy and procedure The Hearing Impaired Resident, Care of policy, revised February 2018, was provided by the nursing home administrator (NHA) on 6/3/26 at 6: 53 p.m. It read in pertinent part, Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. This facility does not provide comprehensive audiological evaluations or devices to assist with hearing, such as hearing aids and amplifiers. Staff will assist residents with care and maintenance of hearing devices. When interacting with the hearing impaired or deaf resident, staff will: Evaluate the resident's preferred method of communication with staff and other residents. Determine the resident's awareness of and adaptation to hearing loss. Evaluate and address avoidable obstacles to effective communication. Regularly engage the resident in conversation using whatevercommunication method he or she prefers. Encourage the resident to participate in activities that he or she enjoys. Directly face the resident when speaking so he/she can follow facial expressions and lip read, if possible. When speaking, enunciate clearly, slowly, and in a normal tone. Provide pencil and paper or tablet to communicate in writing, if the resident is able. Provide a sign language translator and written material to explain care and treatment information, as appropriate. Evaluate resident's adaptive needs and progress at regular intervals.II. Resident #7A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included respiratory failure, dementia, osteoporosis and a history of falls with fractures. The 3/26/26 minimum data set (MDS) assessment revealed Resident #7 was severely cognitive impaired with a brief interview for mental status (BIMS) score of 99 out of 15. She was dependent on staff assistance with activities of daily living (ADL). The assessment indicated the resident wore a hearing device daily. B. Resident's representative interviewResident #7s representative was interviewed on 5/31/26 at 3:56 p.m. The representative said she had to put Resident #7's hearing aids in every time she came into the facility to see her. She said she had requested the facility to please make sure the resident wore her hearing aids daily.C. ObservationsOn 6/2/26 at 3:15 p.m. Resident #7 was sitting in her wheelchair in the common area. She did not have her hearing aids in her ears. On 6/3/26 at 8:45 a.m. Resident #7 was sitting in her wheelchair in her room. She did not have hearing aids in her ears. An attempt to interview her, but the resident did not respond when spoken to. On 6/3/26 at 11:00 a.m. Resident #7 was sitting in her wheelchair in the dining room. She did not have her hearing aids in her ears. On 6/3/26 at 1:15 p.m. Resident #7 was laying in her bed and she did not have her hearing aids in her ears. D. Record reviewThe impaired communication care plan, revised 6/4/25, revealed Resident #7 had impaired communication related to dementia. Interventions included allowing the resident ample time to comprehend what was being said and allowing time for the resident to respond, applying the resident's hearing aids in the morning and removing them at bedtime and audiology referrals as neededIII. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/3/26 at 1:20 p.m. CNA #1 said there were a few residents in the facility who wore hearing aids. She said the hearing aids were important so the residents could hear what staff were saying in order to help them. She said Resident #7's representative helped her with her hearing aids. Certified nurse aide with medication authority (CNA-Med) #3 was interviewed on 6/3/26 at 1:30 p.m. CNA-Med #3 said residents wore hearing aids and the staff assisted to put the hearing aids in and take them out at night. She said some residents stored the hearing aids in the nurses' cart so as to not lose them. CNA-MEd #3 said Resident #7 wore hearing aids and was assisted by staff to put them in. The director of nursing (DON) was interviewed on 6/3/26 at 5:10 p.m. The DON said the CNAs or the CNA-Meds assisted the residents to put in their hearing aids when they got them up in the morning. She said Resident #7 wore hearing aids and the staff should assist the resident to put them in daily.

Based on record review and interviews, the facility failed to ensure residents diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment to attain the highest practicable mental and psychosocial well being for two (#2 and #18) of two residents out of 36 sample residents. Specifically, the facility failed to: -Consistently monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs for Resident #2; and, -Identify and implement effective interventions for Resident #18's sexual behaviors.Findings include: I. Facility policy and procedureThe Behavioral Health Services policy, revised February 2019, was provided by the nursing home administrator (NHA) on [DATE] at 7:17 p.m. It read in pertinent part, Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorders will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable.II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies (dementia with protein clumping built up in the brain causing problems with thinking, moving, and sleep), epilepsy, chronic kidney disease stage 3, transient ischemic attack (TIA - a mini-stroke), cerebral infarction (a stroke), atherosclerotic heart disease of native coronary artery (plaque builds up inside the arteries supplying blood to the heart restricting blood flow and oxygen to the heart muscle), atrial fibrillation (heart arrhythmia), essential hypertension (high blood pressure), type 2 diabetes mellitus, post-traumatic stress disorder (PTSD), major depressive disorder, insomnia and hallucinations. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental status (BIMS) score of 14 out of 15. She used a walker and wheelchair. She required set up assistance with eating and supervision with oral hygiene, showering and personal hygiene. She required partial assistance with toileting.The assessment revealed the resident scored a 13 out of 27 on the Patient Health Questionnaire 9 (PHQ-9 - a tool used to determine depression) assessment, indicating the resident had moderate depression. During the 14-day assessment look-back period, the resident reported she had little interest in doing things on seven to 11 days, felt down on seven to 11 days, had trouble falling asleep or staying asleep on seven to 11 days, had poor appetite or overeating on seven to 11 days, had trouble concentrating on things on two to six days, and was moving or speaking slowly on seven to 11 days. B. Record review The psycho-social well being care plan, initiated [DATE] and revised [DATE], revealed Resident #2 was at risk for alteration in psychosocial well being related to her loss of independence, insomnia, PTSD and dementia. Interventions included administering medications per physician's orders, monitoring for psychosocial changes and offering psychologist and psychiatrist services as needed. The impaired psychiatric mood care plan, initiated [DATE] and revised [DATE], revealed Resident #2 had an impaired psychiatric and mood status related to loss of independence, depression, insomnia, PTSD and dementia. Interventions included administering medications and treatments as indicated, assisting the resident to cope by discussing possible solutions, behavioral health consults as needed, monitoring and reporting to the physician any signs or symptoms of acute psychosis or changes from her baseline, monitoring for signs of mood changes or distress and monitoring mood to determine if problems seemed to be related to external causes. The psychotropic medication care plan, initiated [DATE] and revised [DATE], revealed Resident #2 took aripiprazole, duloxetine and trazodone related to depression, Lewy body dementia and insomnia. Interventions included monitoring PHQ-9 assessment scores for indications of worsening signs and symptoms of depression. The [DATE] social services assessment revealed Resident #2's PHQ-9 assessment revealed she felt down, depressed or hopeless on two to six days in a 14-day assessment look-back period. The [DATE] social services assessment revealed the residents' PHQ-9 assessment was completed. The resident reported she had little interest in doing things on two to six days in a 14-day assessment look-back period. She felt down depressed, or hopeless on two to six days in a 14-day assessment look-back period. The [DATE] MDS assessment's PHQ-9 assessment score was one out of 27, indicating minimal or no depression. The [DATE] MDS assessment's PHQ-9 assessment score was 13 out of 27, indicating moderate depression. -A review of Resident #2's electronic medical record (EMR) did not reveal any documentation that addressed the resident's PHQ-9 scores and what follow up, interventions or services were offered to the resident. Review of Resident #2's [DATE] CPO revealed the following physician's orders: Aripiprazole (an antipsychotic medication) 5 milligram (mg) tablet. Take one tablet by mouth for PTSD, ordered [DATE]. Donepezil 10 mg tablet. Take one tablet by mouth at bedtime for dementia, ordered [DATE]. Duloxetine (an antidepressant medication) 30 mg capsule. Take one capsule by mouth one time a day for major depressive disorder, ordered [DATE]. Duloxetine 60 mg capsule. Take one capsule by mouth one time a day for major depressive disorder, ordered [DATE]. Trazodone 50 mg tablet. Take one tablet by mouth at bedtime for insomnia, ordered [DATE]. Behavior monitoring for duloxetine. Monitor for the following behavior: attention seeking, ordered [DATE]. Behavior monitoring for aripiprazole. Monitor for the following behavior: hallucinations of deceased husband, ordered [DATE]. Behavior monitoring for trazodone. Monitor for the following behavior: inability to sleep, ordered [DATE]. Monitor hours of sleep per shift, ordered [DATE]. Offer non-pharmacological behavior interventions for any behavior noted. Interventions included positive reassurance, active listening, calm environment and recliner in room, ordered [DATE]. -However, a review of Resident #2's medication administration records (MAR) and treatment administration records (TAR), from [DATE] to [DATE], revealed the resident exhibited behaviors and interventions that were not consistently offered and there was no documentation to indicate if interventions that were offered were effective. III. Resident #18 A. Resident statusResident #18, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic obstructive pulmonary disease (COPD - a progressive lung disease restricting airflow), hypertension (high blood pressure), intracranial injury with loss of consciousness, osteoarthritis and dementia with agitation.The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He had an impairment on one lower extremity and used a wheelchair. He required set up assistance with eating. He required supervision with oral hygiene and moderate assistance with toileting, showering, and personal hygiene. The assessment revealed the resident did not exhibit any behaviors. B. Resident group interviewFive residents (#8, #17, #35, #49 and #50), who were deemed interviewable by the facility and assessment, were interviewed on [DATE] at 2:40 p.m. All five residents said Resident #18 would flirt with women to get money from them for alcohol or cigarettes. Resident #49 said she could not describe the flirting but it was unwelcomed and she would have to tell him no. Resident #49 said Resident #18 had cognitive problems so she would not make a big deal of it. She said the staff were aware of his behaviors and there were video cameras everywhere that could watch him.C. Record review The behavior care plan, initiated [DATE] and revised [DATE], revealed Resident #18 had behaviors related to inappropriate touching of other residents and agitation toward staff, accusations toward staff, inappropriate and unwanted lewd and sexual comments to staff and others. Interventions included administering medications per physician's orders, approaching the resident calmly to avoid frustration and behavior escalation, attempting to redirect the resident when exhibiting behaviors, encouraging Resident #18 to ask questions to reduce anxiety, giving non-judgmental support and monitoring and documenting episodes of inappropriate behaviors. The [DATE] behavioral contract revealed Resident #18 signed a contract due to inappropriate, unwanted lewd and sexual comments made to staff and others. Review of a grievance, submitted by Resident #50 on [DATE], revealed Resident #50 reported Resident #18 pretended to jump at her, trying to get a reaction out of her. Resident #50 said she was afraid she would lose her balance and fall. The NHA and the director of nursing (DON) spoke to Resident #18 and asked him not to do it anymore. The NHA said there were female residents who had fragile bones and if they fell, they could seriously hurt themselves. Resident #18 verbalized understanding and said he would not bother Resident #50. Review of Resident #18's [DATE] CPO revealed the following physician's orders: Escitalopram (an antidepressant medication) 20 mg tablet. Take one tablet by mouth one time a day, ordered [DATE]. Behavior monitoring for escitalopram. Monitor for the following behavior: agitation towards staff and accusations towards staff, ordered [DATE]. Behavior monitoring for inappropriate, lewd, sexual unwanted comments to staff and others, ordered [DATE]. Behavior monitoring for inappropriate touching of other residents, ordered [DATE]. Offer non-pharmacological interventions for any behaviors noted. Interventions include redirection, remind the resident he can convey wants and needs without verbal aggression, remind him of the current time, ordered [DATE]. The [DATE] health status note revealed Resident #18 made inappropriate remarks to another resident's daughter who was leaving the facility. Residents were redirected not to make inappropriate statements to visitors. A female resident then began going to her room, and Resident #18 continued with a loud voice at the female resident stating, there goes another one, look at her. The resident was redirected again to quit making remarks to female guests and residents. Resident #18 chose to go to his room. The [DATE] social services note revealed the prior week, Resident #18 had made inappropriate remarks to a female visitor and a female resident. The [DATE] health status note revealed Resident #18 was being inappropriate about a wheelchair wash. The resident said Just so you know, there is semen on there. The resident's behavior would be passed along to the oncoming nurse. The [DATE] nurse assessment revealed most of the time, Resident #18 was cheerful. The resident was currently experiencing unwanted behavior. There was chronic disruptive behavior noted. He was easily upset when he had to wait to go out and smoke. When this happened, he became loud and angry and swore at everyone. He required reminders daily to be patient. The [DATE] behavior nurse note revealed Resident #18 was taken to smoke and became verbally sexually abusive to the female certified nurse aide (CNA) and to another female resident. The nurse spoke to the resident and he laughed. The [DATE] nurse note revealed Resident #18 was upset no one was available to take him for a supervised smoke break. The nurse told the resident that the CNA and the nurse explained why no one was available and instead of agreeing or accepting, he began to get loud. As the nurse walked away, he pretended to kick her and held his fists up in anger. The [DATE] behavior note revealed Resident #18 wanted to go out to smoke with another resident without staff present. Staff explained he had to have a staff member present and no one was available at the time. The resident was upset with the nurse. -A review of Resident #18's EMR, from [DATE] to [DATE], revealed the resident exhibited behaviors and interventions that were not consistently offered and/or documented if interventions were effective. IV. Staff interviews Certified nurse aide with medication authority (CNA-Med) #2 was interviewed on [DATE] at 3:17 p.m. CNA-Med #2 said he knew if a resident had a behavior to monitor based on getting to know the resident when they were first admitted to the facility. He said once he saw a behavior as a CNA, he would tell the nurse or CNA-Med so the behavior could be charted in the MAR or a progress note. CNA-Med #2 said he was familiar with Resident #18. CNA-Med #2 said Resident #18 had sexually aggressive behavior. He said Resident #18 would tell dirty jokes or be crude to others. CNA-Med #2 said he had not seen Resident #18 display any of the behaviors for a while. He said an intervention to help Resident #18 to not say dirty jokes around female residents was to have him be around men who liked to joke around amongst each other. CNA-Med #2 said he told Resident #18 in the past to not talk in a sexual manner around female residents and Resident #18 would say he would not do it. Registered nurse (RN) #1 said she knew what escalated a resident's sexual behavior based on the resident's diagnoses. She said some residents had dementia and when they sundowned (a state of late day confusion, anxiety and agitation related to dementia), they exhibited behaviors. RN #1 said residents did not understand and did not have awareness of the behaviors, so it was important to explain why they could not do what they wanted to do. RN #1 said interventions to de-escalate a resident's behavior was documented as a health status note.RN #1 said she was familiar with Resident #18. RN #1 said he had sexually aggressive behavior and she had not seen him have that behavior in awhile. She said Resident #18 cackled (a loud harsh nervous laughter) at a female visitor and he rubbed arms with young female staff. RN #1 said she redirected him and he was responsive to the redirection. RN #1 said redirection was educating Resident #18 on how to speak and suggesting the resident go to a new location in the building. RN #1 said she saw Resident #18 make inappropriate remarks towards other residents but she did not remember the specifics. The social services director (SSD) and the NHA were interviewed together on [DATE] at 1:03 p.m. The SSD said she had been the SSD at the facility for almost three years. She said she had monthly meetings with a licensed clinical social worker to provide guidance and oversight for social services needs. The SSD said nursing staff was responsible for determining what behaviors needed to be monitored. The SSD said a social services assessment was completed at admission, quarterly and as needed.The NHA said the interdisciplinary team (IDT) discussed resident behaviors in the morning meeting. The NHA said hospitals commonly left out behaviors in the referral paperwork. The NHA said if the referral paperwork from hospitals included behaviors, the NHA and the DON reviewed the behaviors to communicate with nursing. The SSD said she visited the resident when she knew the resident had a behavior to determine what triggered the behavior and what helped the resident. The NHA and the SSD said the behaviors were documented as a progress note and on the resident's care plan. The SSD said she did not review if interventions were effective for identified behaviors. The SSD said she was responsible for completing the social services section, including the PHQ-9 assessment, for the MDS assessment. She said the PHQ-9 assessment was used to measure the level of depression for a resident. The SSD said the PHQ-9 assessment was reviewed at admission, quarterly and as needed. The SSD said the IDT did not review PHQ-9 assessment scores. The SSD said she told the nurses if the score was elevating and the nurses notified the physician so the resident could be seen by the physician. She said she documented the conversation when the PHQ-9 assessment score was elevated and high as a progress note. The SSD said she was familiar with Resident #2. She said she had completed the PHQ-9 assessment for Resident #2 in [DATE], when her score increased. The SSD said she did not provide additional information related to the increasing PHQ-9 score. The NHA said the resident scored high because of the health changes she experienced. The SSD said she did not know if there was any referrals made to behavioral health services for Resident #2. The director of nursing (DON), the SSD and the NHA were interviewed together on [DATE] at 5:14 p.m. The DON said the IDT discussed as a group to determine what behaviors to monitor. She said when a resident was first admitted to the facility, the staff learned the resident's behaviors by observing the resident and asking the family why the resident was on a psychotropic medication and what interventions helped the resident. The DON said nursing staff documented the conversations and observations as behavior monitoring notes and as an admission note. The DON said she knew if interventions were effective because behaviors were monitored on the MARs. The DON said the MAR documented what a resident's behavior was, what interventions were used and if the interventions were effective. The DON said sometimes it was documented as a behavior note as well.-However, review of Resident #2 and Resident #18's MARs revealed documentation of the residents' behaviors and effectiveness of interventions was inconsistent (see above). The DON, the SSD and the NHA said they were familiar with Resident #18. The DON, the SSD and the NHA said he had sexual behaviors that were shown verbally to female staff, visitors and residents. The NHA said the interventions were to tell him that the behavior was not appropriate and to stop saying sexual comments. The NHA said the facility needed to figure out better interventions for Resident #18 so residents felt comfortable in their own home.The DON said the interventions were not effective for Resident #18 because he continued to make sexual comments.

Based on record review and interviews, the facility failed to meet all the requirements for the provisions of hospice care for two (#67 and #41) of two residents reviewed for hospice care services out of 36 sample residents. Specifically, the facility failed to: -Ensure hospice notes were readily available in Resident #67 and Resident #41's electronic medical records (EMR); -Ensure Resident #67 and Resident #41's comprehensive care plans were developed with a delineation of care responsibilities between the facility staff and the hospice care services team; and, -Ensure there was a designated hospice care services coordinator for the facility.Findings include: I. Facility policy and procedure The Hospice policy and procedure, revised July 2017, was provided by the nursing home administrator (NHA) on 6/3/26 at 7:12 p.m. It read in pertinent part, The facility has designated someone to coordinate care provided to the resident by our facility staff and the hospice staff. This person is responsible for ensuring information is obtained from hospice names and contact information for hospice personnel involved in hospice care of each resident. II. Resident #67 A. Resident status Resident #67, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - emphysema, an inflammatory lung disease that blocks airflow making it difficult to breathe), adult failure to thrive, severe protein malnutrition and a pressure ulcer. The 5/22/26 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. He required partial assistance with activities of daily living (ADL). B. Resident interview Resident #67 was interviewed on 6/3/26 at 10:15 a.m. Resident #67 said the hospice nurses changed the dressings to the wound on his bottom. He said the facility staff did not look at the wound or help with the dressing, only the hospice team did. He said he had been on hospice care services for approximately a year before admitting to the facility. He said hospice wanted him at the facility to help him gain weight, build strength and to help his wound to heal. He said the facility helped him with his indwelling Foley catheter and flushed the catheter daily. He said he had gained weight and he felt stronger since being in the facility. He said he wished the facility would help him with his wound care. He said the hospice nurse was coming in today (6/3/26) to look at his wound. C. Wound care observation and interview with hospice nurse On 6/3/26 at 12:40 p.m. the hospice registered nurse (RN) was observed during wound care for Resident #67. The hospice RN packed the resident's wound with sterile packing material and medihoney (wound healing cream). The hospice RN said she saw Resident #67's wound a few weeks ago and it appeared to be larger in size now, but she said the wound measurements were smaller. She said the hospice nurse that covered her when she was gone started to pack the wound due to the wound tunneling (narrow passageways or channels form underneath the skin's surface). She said this was a change from when she was there last. She said she was Resident #67s main hospice nurse and wanted him to move to the facility in order to help him gain strength, gain weight and to help his wound heal. She said his wound developed at home and progressed to a stage 4 pressure wound in a couple of weeks because of his inability to get up and move around on his own. The hospice RN said the main area of concern for Resident #67 was his wound. She said the hospice team used their standing physician orders for wound care, but now the wound had tunneled and started having an odor. She said she was hoping the facility's medical director (MD) would help guide them on wound care. She said she could not remember who, but someone from the facility had told her that hospice had to manage the resident's wound because he was only at the facility for a respite stay. She said she did not coordinate with anyone specific in the facility regarding the resident's care. The hospice RN said Resident #67 had an air mattress on his bed and a cushion on the wheelchair. She said he was able to move himself around more because he had increased his strength and he was able to ask for help when he needed it. She said the hospice admission nurse coordinated with the facility prior to the resident moving in, sent over wound care orders and the potential care plan for repositioning the resident and his diet with supplements. She said she completed a nurse progress note for each visit, but she had not left a copy with the facility. She said she verbally discussed her visits with the facility. D. Record review Review of Resident #67's June 2026 CPO revealed the following physician's orders: Monitor wound site to coccyx every shift. Monitor wound and document yes or no for issues.If issues noted, notify the medical director, ordered 5/22/26. Wound care to coccyx. Cleanse with wound cleanser, cover with dressing as needed when dressing is loose or soiled, ordered 5/25/26. -However, the orders did not indicate that hospice was responsible for providing the wound care. -There were no physician's orders for hospice care services. -Review of Resident #67's care plan revealed there was no care plan focus for hospice care services and no hospice interventions. The social services assessment note, dated 5/22/26, revealed Resident #67 was admitted to the facility for a respite stay. He was a do not resuscitate (DNR - no cardiopulmonary resuscitation). He had services with hospice and his admitting diagnosis was pressure ulcer, unstageable. The admission summary note, dated 5/22/26, revealed Resident #67 was admitted to the facility from home that morning via facility transport. Resident #67 was on hospice care services and admitted for respite with a diagnosis of a pressure ulcer to his sacral region, unstageable. E. Staff interviews Registered nurse (RN) #1 was interviewed on 6/3/26 at 9:00 a.m. RN #1 said the hospice nurses took care of the wound care for Resident #67. She said they came to the facility two times a week and when the facility staff called them. She said the facility nurses did not look at the wound or do wound care for the resident because he was on a respite stay with hospice care services. She said she had to talk to the medical director to at least get an as needed order for wound care in case the dressing fell off before the hospice team could be there. She said all other wound care orders were written by the hospice team. She said the hospice nurses gave the facility staff a verbal update when they were at the facility to see the resident, but she had not seen any progress notes from them. Certified nurse aide (CNA) #4 was interviewed on 6/3/26 at 10:39 a.m. CNA #4 said the hospice staff was responsible for Resident #67's showers. She said the facility CNAs just helped the resident get out of bed for meals and emptied his Foley catheter bag. She said otherwise, the hospice staff came in to help him. She said the resident was pretty independent and turned himself in bed III. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included congestive heart failure (CHF), vascular dementia, chronic obstructive pulmonary disease (COPD, spondylosis (age-related wear and tear affecting the spinal disks, joints, and bones), depression and anxiety. The 5/21/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. The assessment's functional status section was not completed. The assessment revealed the resident did not receive hospice services. B. Record review The hospice care plan, initiated and revised on 5/19/26, revealed Resident #41 had a terminal prognosis with hospice related to end of life diagnoses of congestive heart failure, COPD and vascular dementia. -A review of Resident #41's June 2026 CPO revealed there were no physician's orders for hospice services. -A review of Resident #41's hospice care plan, revealed Resident #41 was receiving hospice care service; however, it failed to include a delineation of care services between the facility and the hospice care services team. -A review of Resident #41's electronic medical record (EMR) revealed the resident's hospice care services notes were not available in the facility's electronic medical system. C. Staff interviews RN #2 was interviewed on 6/2/26 at 3:33 p.m. RN #2 said she knew a resident had hospice care services because when a resident was admitted to hospice care services, the hospice nurse came to the nurses' station to introduce themselves. She said hospice was documented in the admission note by the nurse, the 72-hour charting was done in the first three days the resident was admitted to the facility and as a physician's order. She said there was also a banner in the resident's chart that said the name of the hospice care services agency and their phone number. RN #2 said she knew when hospice staff were in the facility because hospice staff gave a schedule verbally and on the CNA clipboard. RN #2 said she was familiar with Resident #41. She said the resident was receiving hospice care services. RN #2 said she did not know when the hospice nurse was coming this week (the week of the survey). She said the hospice CNA came in this morning and the nurse came last week. RN #2 said she did not know how often the hospice nurse or the hospice CNA came into the facility per week. IV. Additional staff interviews The director of nursing (DON) was interviewed on 6/3/26 at 3:18 p.m. The DON said the hospice care services coordinator was either the social services director (SSD) or the charge nurse. The DON said the hospice care services coordinator was based on what was needed for the resident. The DON said staff knew a resident was receiving hospice care services because it was charted as a banner in the resident's chart. The DON said staff did not know the schedule for the hospice staff visits. The DON said the hospice nurses did not provide a schedule when they visited. The DON, the SSD and the NHA were interviewed together on 6/3/26 at 6:45 p.m. The NHA said the facility did not have a hospice care services coordinator and she did not know they were supposed to have a designated hospice care services coordinator. The DON and the NHA said there should be a hospice order provided by the hospice physician. The NHA said the facility had two residents who were receiving hospice care, Resident #67 and Resident #41. The NHA said there should have been a physician's order for hospice. The NHA said the residents' hospice progress notes should be available for the staff to know what the hospice care team was providing for the residents and a way for the staff to know when hospice staff made visits to the residents. The NHA said the facility did not use hospice care services until recently and they would make sure staff knew when hospice staff visited.

Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#1) of three residents reviewed for pressure injuries out of five sample residents. Specifically, the facility failed to implement interventions to prevent the development of a pressure injury for Resident #1. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com on 4/17/25, Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. The Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss. Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss. Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcer can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar tan, brown or black) on the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth,and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injuries Overview policy, revised April 2020 was provided by the nursing home administrator (NHA) on 4/10/25 at 5:59 p.m. The policy read in pertinent part, Pressure ulcer/injury refers to localized damage to the skin and or underlining soft tissue, usually over a bony promise or related to a medical or other device. A pressure injury will present as intact skin and maybe painful. A pressure injury will present as an open ulcer, the appearance of which will vary depending on the stage and it may be painful. Pressure injuries occur as a result of intense and or prolonged pressure or pressure combined with a shear. The Prevention of Pressure Injuries policy, revised April 2020, was provided by the NHA on 4/10/25 at 5:59 p.m. According to the policy, staff should review the resident's care plan, identify the pressure injury risk factors and interventions designed to reduce or eliminate the risk factors. The policy read in pertinent part, Assess the resident on admission for existing pressure injury factors. Repeat the risk assessment weekly and upon any changes of condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. Check the skin on a daily basis when performing or assisting with personal care or activities of daily living. Identify any signs of developing pressure injuries, including non-blanchable erythema (redness). Inspect pressure points, including sacrum, heels, buttocks, coccyx, elbows, ischium (base of pelvis) and trochanter (upper thigh). Reposition resident as indicated on the care plan. Do not rub or otherwise cause friction on skin that is at risk for injuries. Select appropriate support surfaces based on the resident's risk factors in accordance with the current clinical practice. Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. III. Resident #1 A. Resident status Resident #1, age greater than age 65, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE] to home with hospice services. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus without complications, muscle weakness, muscle wasting and atrophy, personal history of transientischemic attack (TIA) and cerebral infarction without residual deficits (stroke). The 3/9/25 minimum data set (MDS) assessment revealed Resident #1's cognition was moderately impaired and she exhibited a memory problem. The resident was dependent on staff for her activities of daily living (ADL) and used a wheelchair for mobility. According to the MDS assessment, the resident was at risk for developing pressure ulcers and had an unhealed pressure ulcer. The MDS assessment revealed the resident had an unstageable pressure ulcer. B. Record review The care plan for skin, initiated 3/23/23, indicated Resident #1 was at risk for impaired skin integrity related to muscle wasting, atrophy and moisture associated skin damage. The care plan interventions directed staff to provide a redistribution mattress to the resident's bed, provide a non-irritating service to reduce friction or shearing forces, assist the resident with turning and repositioning as needed, encourage her to reposition herself if able, complete a wound evaluation to monitor the progress of her skin, encourage the resident to comply to the interventions/treatments to minimize further skin impairment, complete a skin inspection every seven to 10 days and as needed, notify the physician/nurse practitioner (NP) of noted worsening skin or any new areas of skin breakdown and notify the nurse of any new areas of skin breakdown noted during bathing or daily care, including redness, blisters, bruises and skin discoloration. The 12/2/24 quarterly nursing evaluation was provided by the NHA on 4/10/25 at 11:56 a.m. The evaluation identified Resident #1's factors of risk to pressure injury. The nursing evaluation identified Resident #1's ability to respond to pressure related discomfort was slightly limited, she could not always communicate discomfort or had some sensory impairment which limited her ability to feel pain, her skin was occasionally exposed to moisture, she was chairfast, her ability to change and control her body position was very limited, her usual food intake pattern was probably inadequate and she had a skin friction and sheering potential problem. The 2/25/25 skin care plan intervention directed staff to provide pressure reducing boots to Resident #1's bilateral feet as tolerated with an option to remove during care. The 3/10/25 skin care plan intervention directed staff to elevate Resident #1's heels off the mattress as needed and tolerated. Review of the electronic medical record (EMR) identified Resident #1 was diagnosed with adult failure to thrive on 12/13/24, indicating the resident had a decline in her health (see interview below). Review of Resident #1's March 2025 CPO revealed the following physician's physician's orders: Pressure relieving mattress, protective footwear/heel protectors while in bed and decubitis (pressure ulcer/injury) precautions as needed, ordered 2/12/23. Mighty shake (high calorie supplement) three times a day for risk of malnutrition, ordered 12/3/24. Heel protectors to bilateral heels at all times for every shift, ordered 2/6/25. Air mattress overlay to be placed on the bed due to poor skin integrity, ordered 3/8/25. -However, review of the physician's orders revealed the resident had a physician's order for a pressure relieving mattress and heel protectors in bed ordered on 2/12/23 (see above). Review of Resident #1's December 2024, January 2025 and February 2025 medication administration records (MAR) and treatment administration records (TAR) did not identify that a pressure redistribution mattress was being utilized for the resident. Further review of Resident #1's December 2024 and January 2025 MAR and TAR did not identify heel protectors were being used for the resident. Review of Resident #1's February 2025 MAR documented heel protectors were used beginning on 2/6/25. From 2/1/25 through 2/5/25 there was no documentation the resident was using heel protectors. -However, according to the March 2025 CPO, the resident had a physician's order for a pressure relieving mattress and heel protector to be available for the resident's use, ordered on 2/12/23 (see physician's orders above). The 2/6/25 Braden Scale assessment (a tool for predicting pressure ulcer risk) was provided by the NHA on 4/10/25 at 11:33 a.m. The Braden Scale assessment identified Resident #1 was at risk for pressure ulcer development. The 2/6/25 change of condition note identified a certified nurse aide (CNA) notified the nurse of a discoloration to Resident #1's right heel. A physical assessment documented the discoloration to her right heel measured 2 centimeters (cm) by 2 cm by 2 cm and was non-blanchable (skin discoloration, usually redness, that doesn't turn lighter or disappear when pressed upon). The 2/6/25 wound evaluation was provided by the NHA on 4/10/25 at 11:33 a.m. The evaluation identified the new right heel wound was facility-acquired. The physician and the resident's representative were notified. According to the wound evaluation, the intervention was to encourage Resident #1 to reposition herself and use a pressure redistribution mattress on her bed. The evaluation documented the wound was evaluated by licensed practical nurse (LPN) #1. -However, according to the physician's orders, Resident #1 already had a physician's order for a pressure redistribution mattress which was ordered on 2/12/23 (see physician's orders above). -The wound evaluation did not identify the source of pressure to the resident's right heel. A 2/6/25 skin impairment incident report documented Resident #1 had been on a steady decline. The 2/13/25 wound evaluation was provided by the NHA on 4/10/25 at 11:33 a.m. The wound evaluation documented Resident #1 had discoloration to her right heel measuring 2 cm by 2 cm and was improving. The evaluation did not identify the determining factors of the improvement. According to the evaluation, the wound was evaluated by registered nurse (RN) #1. -The evaluation did not identify if the wound was evaluated by a physician/nurse practitioner or wound care specialist. -The evaluation did not identify the determining factors of the improvement. The 2/20/25 wound evaluation was provided by the NHA on 4/10/25 at 11:33 a.m. The wound evaluation documented Resident #1 had discoloration to her right heel measuring 2 cm by 2 cm and was improving. According to the evaluation, the wound was evaluated by registered nurse (RN) #1. -The evaluation did not identify if the wound was evaluated by a physician/nurse practitioner (NP) or wound care specialist. -The evaluation did not identify the determining factors of the improvement. A 2/24/25 skin inspection form completed by LPN #1 documented there were no new skin injuries. -The skin inspection form did not identify the condition of Resident #1's right heel wound. The 2/27/25 Braden Scale assessment was provided by the NHA on 4/10/25 at 11:33 a.m. The 2/27/25 Braden Scale assessment identified Resident #1 was at moderate risk for pressure ulcer development. The 2/28/25 change in condition evaluation identified Resident #1 would open her eyes but not respond vocally. The evaluation documented the resident was seen by the NP on 2/25/25 due to her recent decline. The evaluation did not identify the NP evaluated or saw Resident #1's right heel wound. A 2/28/25 health status note identified Resident #1's family took the resident to the emergency department at the hospital. Hospital records between 2/28/25 and 3/7/25 documented Resident #1 was admitted to the hospital and was treated for pneumonia symptoms with complications and was provided wound care to her right heel. The hospital records identified the resident's wound on her heel as a pre-existing right heel unstageable pressure injury that was present from the facility. A wound consultation conducted at the hospital documented Resident #1's right heel injury was identified as the pressure injury unstageable and measured 2 cm by 3 cm with unknown depth. The right heel pressure injury had semifirm eschar (a hardened, dry, black or brown dead tissue) and peeling of the epidermis (outer layer of skin). The unstageable pressure injury was not open and there was no drainage and no erythema. The resident's heel was painted with Betadine, a border dressing was applied and both her heels were offloaded with pillows. The hospital discharge orders directed caregivers to float Resident #1's heels, apply Betadine and keep a padded dressing on her right heel. The 3/7/25 admission summary note identified Resident #1 was admitted back to the facility on [DATE]. The 3/7/25 wound report identified the NP saw the Resident #1's pressure injury on 3/7/25. According to the wound report, the NP documented the measurements of the right heel wound on 3/7/25 as 4.5 cm by 4 cm by 0.1 cm. The NP documented the wound as a stage 2 pressure injury. The wound report directed staff to continue Bedadine daily and have the residents wear heel protectors at all times. The 3/7/25 Braden Scale assessment was provided by the NHA on 4/10/25 at 11:33 a.m. The Braden Scale assessment identified Resident #1 was at risk for pressure ulcer development. IV. Staff interviews The NHA, the director of nursing (DON) and RN #1 were interviewed together on 4/10/25 at 1:53 p.m. RN #1 identified herself as the facility's wound nurse. She said she was not wound care certified and the NP would assess wounds that were stage 2 or greater. She said if a wound was identified, the facility nurses would start standing wound physician's orders and then RN #1 and the NP would look at the wound on the following Monday. The DON said on 2/6/25, LPN #1 identified Resident #1 had a reddened area on her right heel. RN #1 said LPN #1 initiated a change of condition, requested the physician's order for heel protectors and notified RN #1 and the NP of the discoloration to Resident #1's heel. RN #1 said she saw Resident #1's heels on 2/10/25 but did not document it. She said she assessed Resident #1's heel on 2/13/25. She said the resident's heel was non-blanchable with discoloration and the wound was not open. RN #1 said the immediate intervention was to relieve the pressure from Resident #1's right heel so a heel protector was implemented on 2/6/25. She said there were no changes in her interventions because the heel did not worsen. She said the coloring started to improve and a blister was not formed. RN #1 said Resident #1 had been declining since December 2024. She said the resident had been losing weight and was less active. She said Resident #1 was at risk for pressure injuries. She said the resident's condition continued to decline. RN #1 said the more the resident declined in condition, the more she was at risk for pressure injury development. She said Resident #1 wore tennis shoes on her feet until 2/6/25 when the heel protectors were implemented. The NHA said a pressure relieving mattress was not implemented after Resident #1 was identified as being at risk for pressure injuries or after discoloration was identified on her right heel on 2/6/25. The NHA said the resident was at high risk for falls and used a scoop mattress instead to help decrease the risk of her falling. She said the resident was turned every couple hours when in bed, as standard practice. RN #1 said the NP saw Resident #1 on 2/25/25 but did not look at the resident's right heel. She said the NP reviewed the resident's overall decline and swallowing concerns. RN #1 said she did not assess Resident #1's for any changes to her heel after 2/20/25 and before she went to the hospital on 2/28/25. She said the resident's skin was looked at by the floor nurse (on 2/24/25), but only to identify if there were new wounds. She said the floor nurse did not assess the condition of the resident's right heel. RN #1 said Resident #1's heel was not seen by the NP until the resident returned from the hospital on 3/7/25. She said the NP saw the resident and implemented a pressure relieving air mattress when she returned from the hospital. RN #1 was interviewed again on 4/10/25 at 6:48 p.m. RN #1 said the facility needed to do a better job at identifying the root cause of pressure injuries. RN #1 said she thought Resident #1's shoes and leg rests caused the pressure to the resident's right heel when Resident #1 was in a declining condition, had weight loss and was moving less.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents. Resident #2 admitted to the facility on [DATE] with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1's electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1's falls. Findings include: I. Facility policy and procedure The Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator. The policy identified the following steps that should be taken after the initial data was collected: The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing (DON) services within 24 hours of the incident or accident. The DON shall ensure that the administrator receives a copy of the incident/accident form on each occurrence. The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia, history of falling, generalized muscle weakness, abnormalities of the gate and mobility, need for assistance with personal care, cognitive communication deficit, difficulty walking and unspecified dementia, severe, without behavioral disturbance. The 2/19/25 minimum data set (MDS) assessment documented Resident #2 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #2 required substantial/maximal assistance from a sit to stand position and was dependent on staff for a toilet transfer. She used a wheelchair for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment identified Resident #2 had a history of falls. According to the MDS assessment, Resident #2 had two falls without injury and one fall with a major injury since her admission or in the past six months and one fall without injury since her last assessment. B. Record review The fall care plan, initiated 11/20/24 and revised 12/10/24, identified Resident #2 was at risk for falls related to bladder and/or bowel incontinence, generalized weakness, history of falls and needing assistance with activities of daily (ADL). The fall interventions, initiated on 11/20/24, directed staff to implement preventative fall interventions/devices, ensure call light was in reach and needed items were within reach, educate the resident how to use the call light and monitor her for changes in mobility. The fall interventions, initiated on 12/10/24, directed staff to provide Resident #2 with non-skid footwear, conduct physical therapy (PT)/occupational therapy (OT) and speech therapy evaluations, educate the resident and her family to call for assistance before transferring and provide food and drinks within reach. The fall interventions, initiated on 12/12/24, indicated Resident #2 was impulsive, over estimated her abilities and needed to be kept within line of sight. The 12/12/24 fall intervention directed staff to place her in a recliner. The 12/12/24 fall intervention, revised on 1/22/25, directed staff to place anti-roll backs on her wheelchair. The fall intervention, initiated on 1/7/25, identified Resident #2 was placed on a toileting program. -The facility failed to implement timely interventions after Resident #2 sustained a fall on 11/21/24, 11/29/24 and 1/23/25. 1. Fall on 11/21/24 - unwitnessed The fall occurrence note, dated 11/21/24, identified Resident #2 was found on the floor in her room by a certified nurse aide (CNA). According to the note, Resident #2 was found on her back between the foot of the bed and the bathroom. The resident was toileted and brought to the nurse's station to keep within sight. The note documented the nurse completed a physical assessment to include range of motion. The resident was not able to move her right arm related to the presence of a right arm sling after a fall prior to her admission. The note documented the resident had a bump on the crown of her head but it was not known if the bump occurred at the time of the 11/21/24 fall or if the resident had the bump prior to her admission to the facility (11/20/24) from a fall at home. The note indicated the resident was not able to tell staff what happened other than she fell . Factors of the fall were identified as poor lighting and confusion. The 11/26/24 interdisciplinary team (IDT) meeting note identified Resident #2 was last toileted at 4:00 a.m. and checked at 4:45 a.m. The call light was in reach, her bed was in a low position, her wall light was on, she was incontinent at the time of the fall and was wearing socks. According to the note, the resident complained of shoulder and head pain. No other injuries were noted at the time of the incident. The nursing recommendation was to place the resident in a recliner in the line of sight. -The note did not identify if the socks the resident was wearing were non-skid or not. -The IDT note did not identify if the bump on her head occurred at the time of the 11/21/24 fall or if she had the bump from her last fall at home. -The review of the care plan did not identify new interventions were updated on the fall care plan until 12/12/24, three weeks after the 11/21/24 fall. 2. Fall on 11/29/24 - witnessed The 11/29/24 fall occurrence note identified Resident #2 had a fall. According to the note, a CNA observed Resident #2 attempting to transfer herself from her wheelchair to the recliner in the living room and she sat on the floor between two recliners. The resident had non-slip shoes on and her wheelchair was in front of her. The note indicated there were no injuries and she was placed in a recliner near the nurse's station. -The fall occurrence note identified Resident #2 was not placed in a recliner by staff as recommended in the 11/21/24 IDT note. The 12/3/24 IDT meeting note identified the recommendation after the fall was to implement a restorative program. -The restorative program for Resident #1 was not implemented until 12/13/24, two weeks after the fall (see interview below). -The review of the care plan did not identify that the restorative program was implemented as recommended on 12/3/24 by the IDT. 3. Fall on 1/4/25 - witnessed The 1/4/25 fall occurrence note identified Resident #2 was observed sliding from the recliner, down to the floor before staff could intervene. There were no injuries identified. According to the note, the resident stated she was going to the restroom. The 1/7/25 IDT note documented a video surveillance recording identified Resident #2 scooted herself over the edge of the recliner, walked around the foot rest, lost her balance and landed on her buttocks on the recliner foot rest which caused the recliner to tip forward. The resident slid down the foot rest and landed on the left side of her body. According to the note, there were no injuries and she denied any new or increased pain. The note indicated the resident did not ask to go to the restroom or was able to remember to ask for help. The nursing recommendations were to place the resident on a bowel and bladder toileting program. 4. Fall on 1/23/25 - unwitnessed The 1/23/25 fall occurrence note identified Resident #2 was found in a shower room on the floor at 7:45 a.m. The shower room door was propped open by a stool and unlocked. Resident #2 was laying on the floor on her right side with her pants pulled down below her knees. Her wheelchair was to the left of the resident and the brakes were unlocked. She was wearing non-slip shoes at the time of the fall. According to the note, during the nurse's physical assessment, the resident grabbed her right lower extremity in pain. Resident #2 had redness and light colored bruising to her right hip and a skin tear measuring 3 centimeters (cm) by 3 cm on her right knee. The note indicated the resident was sent to the hospital for an evaluation and treatment. The note documented the resident was last checked on at 7:40 a.m. Resident #2 was forgetful and overestimated her limitations. The bathing rooms were immediately locked. The 1/23/25 change in condition note identified Resident #2 returned to the facility with a diagnosis of a right femoral head fracture. Her family declined surgery. The note indicated the resident was on comfort-focused care. The note indicated the resident was attempting to crawl out of bed after returning from the hospital. The resident was placed in a recliner in view of the nurse's station due to her high fall risk. The 1/28/25 IDT meeting note identified staff were educated to keep doors locked for safety concerns as the nursing recommendation. -The fall care plan did not identify new care plan interventions were added after Resident #2 had another fall during a self-transfer that resulted in a broken hip (see care plan above). C. Education The 1/23/25 staff education sheet was provided by the NHA on 3/6/25 at 6:17 p.m. The education sheet identified 75 staff members were educated to keep all of the doors in the hallways locked, except for the resident's rooms. It indicated doors could not be propped open or left unlocked for staff convenience. According to the provided education, leaving the doors open was extremely dangerous. Staff was expected to frequently check all the doors on the hallways to ensure the hallway doors were properly closed and locked. The education indicated that disciplinary action would be taken if the doors were not secured. The 1/28/25 staff education participation record on reporting was provided by the NHA on 3/6/25 at 6:02 p.m. According to the education record, 71 staff members were informed/reminded to report changes, loss of balance (without a fall), falls, slips, trips, physical contact, choking, behaviors or any change of condition in a resident to the nurse. The education record documented it was the nurse's responsibility to document and assess once it was reported to the nurse. III. Staff interviews The DON was interviewed on 3/6/25 at 4:14 p.m. The DON said after a fall she conducted a fall investigation. She said during a fall investigation, she would look for any injuries/skin issues and review prior skin checks. She said if there were new injuries, she would look at the resident's environment to see if there was anything that the resident could have bumped into. The DON said staff documented the details of each fall in the risk management incident report and a fall occurrence note. She said she and the IDT reviewed who found the resident and at what time, how the resident was found, including the position of the resident, what the resident was wearing on their feet at the time of the fall, what was the lighting in the fall location, when was the resident last checked on and last toileted, was the resident continent at the time of the fall, was the resident wearing oxygen if they had a physician's order, was the call light in reach at the time of the fall, was it witnessed, was there a head injury and who was notified after the fall. The DON said Resident #2's fall on 11/29/24 was witnessed by a CNA. The resident was self transferring to a recliner in the living room. When Resident #2 was last checked on, she was continent. She was wearing non-skid shoes and the lighting was dim. The DON said the intervention was to continue to work with restorative nursing. She said Resident #2 started on a restorative nursing program on 12/13/24 after her November 2024 falls. The DON said the fall on 1/4/25 happened at the nurse's station. The resident landed on her left side of her body. The DON said the nurse was alerted when she heard a noise. The DON said it was not documented if Resident #2 was continent at the time of the fall, when she was last toileted or when she was last checked on. She said it was not documented what the resident was wearing on her feet at the time of the fall. The DON said the resident was able to say she was trying to go to the bathroom at the time of the fall. She said a bowel and bladder program was added to Resident #2's care plan and the CNA communication sheet/Kardex on 1/7/25. The DON said Resident #2's fall on 1/23/25 resulted in a hip fracture. She said the resident was found in the shower room lying on her right side. The DON said it was not documented what time the resident was last toileted other than it was on the night shift. She said the resident was last checked on at 7:40 a.m. She said she did not check if the resident was asked to use the toilet at 7:40 a.m. The DON said the resident normally needed assistance to use the toilet. She said she did not know who last checked on the resident before she fell . The DON said the resident was not able to say what happened or why she was in the shower/tub room but she assumed the resident was attempting to use the toilet because her pants were down and she was near the toilet. The DON said the door to the shower/tub room was propped open, allowing Resident #2 to enter the room. The DON said she did not know why the door was propped open and the light was on. The DON said the day staff said it was open when they arrived on shift. The DON said she questioned the night staff but no one could tell her why the door was left open. The DON said after reviewing the fall investigations, she felt she needed to ask more questions to get a better idea of all the fall details and what all happened. She said she saw areas where she could work on improving with her fall investigations. The NHA was interviewed again on 3/6/25 at 5:28 p.m. The NHA said Resident #2's fall on 1/23/25, which resulted in a hip fracture was because she self transferred herself to the toilet in the shower room. The NHA said Resident #2 used the toilet and then fell . The NHA said the door to the shower room should not have been left open for her to be able to enter. The NHA said the staff were educated to close and lock the doors. The NHA said falls were reviewed with the IDT and the new fall interventions were updated by the DON in the care plan within a week of the fall. CNA #4 was interviewed on 3/6/25 at 6:49 p.m. She said she worked with Resident #2 at night and would help other CNAs toilet her. She said she was not aware of a bowel and bladder toileting schedule for her, but she said Resident #2 was toileted every two hours, which was standard for any resident who needed assistance. The DON was interviewed again on 3/6/25 at 6:55 p.m. The DON said Resident #2 would try to get up and go to the bathroom by herself and not tell anyone. She said the care planned intervention bowel and bladder program for Resident #2 after her 1/4/25 fall meant she would be toileted every two hours. The DON said all residents were checked on every two hours.

Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#1) of two residents out of three sample residents. Specifically, the facility failed to timely report an injury of unknown origin for Resident #1 to the State Agency. Findings include: A. Facility policy and procedure The Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. The Unusual Occurrence Reporting policy, revised December 2007, was provided by the NHA on 3/6/25 at 6:02 p.m. The policy read in pertinent part, As required by the federal or state regulations, our facility reports unusual currencies or other reportable events which affect the health, safety, or welfare of residents, employees or visitors. According to the policy, unusual occurrences would be reported to the appropriate agencies as required by current law and or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event would be sent or delivered to the State Agency within 48 hours of reporting the event as required. The policy identified allegations of abuse, neglect and misappropriation of resident property and any other occurrences that interfered with facility operations and had effects on the welfare, safety, or health of residents, employees and visitors would be reported to the appropriate agency. B. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 12/29/24. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified osteoarthritis, edema, pain in the and left knee, history of falling, type 2 diabetes without complications, muscle weakness, acute embolism and thrombosis of unspecified deep vein of left lower extremity, unspecified dementia on specificity with psychotic disturbance, anxiety disorder and chronic pain syndrome. The 12/16/24 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments per staff assessment for mental status and presented with long term and short term memory loss. The resident required partial to moderate assistance with most of her activities of daily living (ADL). She used a walker for mobility. According to the MDS assessment, Resident #1 had hallucinations and delusions. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment did not identify the resident had a fall at the facility since her admission to the facility. C. Facility reported incident The State Agency reporting portal identified an allegation of neglect was reported for Resident #1 on 1/23/25, regarding an incident that occurred on 12/29/24. -The facility reported the incident to the State Agency 24 days after the reporting requirements. D. Record review Review of Resident #1's electronic medical record (EMR) revealed Resident #1's last known fall at the facility was on 2/8/24. The 12/26/24 skin assessments did not identify any skin concerns or injuries. The 12/29/24 health status note documented by licensed practical nurse (LPN) #1, identified a CNA attempted to move Resident #1 and she started to complain of severe pain. The CNA reported the pain to LPN #1. The resident cried out in pain when her hips were moved slightly. Resident #1 was diaphoretic, her oxygen saturation levels were at 55% and her blood sugar was at 340 milligrams/deciliter (mg/dl). According to the note, the resident's oxygen was set at 2 lpm (liters per minute) with a face mask. Her oxygen was increased to 3 lpm and her saturation levels rose to 77%. Resident #1 was full code and 911 was called. The note identified the resident in pain and cried out when paramedics transferred her from the bed to a gurney. The note identified Resident #1 was her own responsible party and she was aware she was going to the hospital. The note indicated the medical director (MD) was notified. The pain log identified Resident #1 last pain level check was on 12/29/24 at 12:10 a.m. The resident's documented pain level was at zero out of 10. The facility investigation summary was provided by the NHA on 3/4/25 at approximately 4:30 p.m. The summary identified the facility was notified that Resident #1 had right and left hip fractures. The hospital contacted registered nurse (RN) #1 on 12/29/24 and notified the RN of a bruise/hematoma on her left proximal thigh. The summary indicated the facility staff was asked about the bruise and none of the staff saw a bruise. -However, the facility failed to report the fractures, which were of unknown origin, until 1/23/25. The 12/29/24 hospital #1 emergency department physician note documented Resident #1 was in significant pain and a computed tomography (CT) scan identified bilateral fractures and an ortho-surgeon was contacted. The resident had a large left-sided proximal thigh hematoma with a suspicion of compartment syndrome. According to the note, Resident #1 was transferred to hospital #2 for higher level care. The 12/29/24 hospital #1 radiology report documented Resident #1 had intra-articular subcapital impacted right hip fracture, probably subacute and a subacute intertrochanteric left hip fracture, pathological fracture based on the CT scan. The resident had osteoarthritis, osteopenia and degenerative changes in the lower spine with multiple wedge deformities The 12/29/24 hospital #2 emergency department (ED) records documented Resident #1 was transported to hospital #2 for multiple concerns including bilateral femur fractures. She was admitted to hospital #2 for possible surgical repair of her fractures. The ED notes identified Resident #1 was not able to move her hips due to the broken femurs. She had a left hip hematoma that was determined not to be compartment syndrome. She had T-spine fractures and sepsis related to a urinary tract infection (UTI). According to the notes the resident would have a right hemiarthroplasty (a half joint hip replacement procedure). The resident had a fracture of her left femur, right femur and a fracture of multiple thoracic vertebrae E. Education The 1/28/25 staff education participation record on reporting was provided by the NHA on 3/6/24 at 6:02 p.m. According to the 1/28/25 education record, 71 staff were informed/reminded to report changes, loss of balance (without a fall), falls slips, trips, physical contact, choking, behaviors or any change of condition in a resident to the nurse. The education record documented it was the nurse's responsibility to document and assess once it was reported to the nurse. F. Staff interviews The NHA was interviewed on 3/5/25 at 4:05 p.m. She said after the 12/29/24 incident with Resident #1, she started an investigation by reviewing the hallway video and interviewing staff. She said she did not save the interview notes and the video only saved for two weeks. She said she reported the injury of unknown origin late on 1/23/25 because she did not know it was reportable. Cross-reference F610, failure to thoroughly investigate an injury of unknown origin. The NHA said on 12/30/24 an ED nurse contacted the facility and asked about a bruise on Resident #1's left outer hip. The NHA said the staff did not see the bruise when she was assessed by the RN. She said she did not believe the bruise was caused at the facility. She said the bruise could have occurred at the hospital or when the paramedics put her on a gurney. The NHA said she did not believe Resident #1 could have fallen at the facility to break her hip because she would not have been able to pick herself off the floor with a broken hip and put herself back to bed. The director of nursing (DON) was interviewed on 3/5/25 at 5:45 p.m. The DON said LPN #1 notified her to inform her that Resident #1 was sent to the hospital because she was screaming in pain. The DON said the resident was diagnosed with fractures to both of her hips. The DON said she did not know how the fractures occurred when it was reported to her. LPN #1 was interviewed on 3/6/25 at 10:53 a.m. LPN #1 said Resident #1 was fine on the evening of 12/28/24. She said the resident had no reports of pain and she walked normally down to her room. She said the CNAs checked on her every two hours. She said when the staff went to get her up to get dressed, she started crying in pain. LPN #1 said she tried to get her up to see if she could bear weight but she could not stand. She said she assessed Resident #1 with range of motion and hip palpitations (touch). She said she was able to look at the resident's skin a little bit but did not see any concerns. LPN #1 was interviewed on 3/6/25 again at 11:06 a.m. She said she did not see a bruise on the resident's hip or leg but just remembered she saw a small lump on Resident #1's forehead about nickel-sized with some coloring to the skin. She said she did not think the lump was new because new bruising was usually bright purple. She said she did not document or report the lump on her forehead. The DON was interviewed on 3/6/25 at 4:14 p.m. The DON said unexplained injuries, such as what happened to Resident #1, should have been reported within 24 hours and it was not reported timely.

Based on record review and interviews, the facility failed to thoroughly investigate an allegation of abuse and neglect for one (#1) of one resident out of three sample residents. Specifically, the facility failed to complete a thorough investigation when Resident #1 sustained an injury of unknown origin. Findings include: I. Facility policy and procedure The Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, All accidents or incidents involving residents, employees, visitors, and vendors occurring on premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and or the department director or supervisor shall promptly initiate a document investigation of the accident or incident. The policy identified the following data should be reported on a report of incident/accident form: The date and the time the accident or incident took place; the nature of the injury/illness; the circumstances surrounding the accident or incident; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured persons attending physician was notified, as well as the time of the physician's response and his or her instructions; the date and time the injured person's family was notified and by whom; the condition of the injured person including his or her vital signs; the disposition of the injured; any corrective actions taken; follow up information; other pertinent data is necessary or required; and the signature and title the person completing the report. The policy identified the following steps that should be taken after the initial data was collected: The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. The director of nursing (DON) shall ensure that the administrator receives a copy of the incident/accident form on each occurrence. The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 12/29/24. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified osteoarthritis, edema, pain in the left knee, history of falling, type 2 diabetes without complications, muscle weakness, acute embolism and thrombosis of unspecified deep vein of left lower extremity, unspecified dementia on specificity with psychotic disturbance, anxiety disorder and chronic pain syndrome. The 12/16/24 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments, per staff assessment, for mental status and presented with long term and short term memory loss. The resident required partial to moderate assistance with most of her activities of daily living (ADL). She used a walker for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment did not identify the resident had a fall at the facility since her admission to the facility. B. Facility investigation An investigation packet for Resident #1 was provided by the NHA on 3/4/25 at approximately 4:30 p.m. The packet included a summary of the events that occurred on 12/29/24, a police report, an emergency department physician report from hospital #1, a radiology report from hospital #1 and progress notes from the facility. The 12/29/24 summary of events documented on the night of 12/28/24, Resident #1 was sitting in the recliner in the common area, she was then toileted in the shower room by certified nursing assistant (CNA) #1 and CNA #2. The resident was then assisted to her room and to bed. The resident was sleeping and her brief was dry until 12/29/24 at 4:30 a.m. According to the summary, Resident #1 was incontinent of bowel, which was unusual for her, and she was soaking wet with sweat. The CNAs began to turn her on her side and she started to scream and scratch at them. The resident was diaphoretic (sweating) and licensed practical nurse (LPN) #1 was notified. LPN #1 assessed the resident and she hollered out when her hips were palpated (touched). The resident was hypoxic (low oxygen). The staff finished cleaning her up and the paramedics were called to transport the resident to the hospital. The summary identified the facility was notified that Resident #1 had right and left hip fractures. The hospital contacted registered nurse (RN) #1 on 12/29/24 and notified the RN of a bruise/hematoma on her left proximal thigh. The summary indicated the facility staff was asked about the bruise and none of the staff saw a bruise. The skin assessments on 12/5/24, 12/12/24, 12/19/24 and 12/26/24 did not identify a bruise. The 12/29/24 hospital #1 emergency department physician note documented Resident #1 was in significant pain and a computed tomography (CT) scan identified bilateral hip fractures and an orthopedic-surgeon was contacted. The resident had a large left-sided proximal thigh hematoma with a suspicion of compartment syndrome (build up of pressure in the body). According to the note, Resident #1 would be transferred to hospital #2 for higher level care. The 12/29/24 hospital #1 radiology report documented Resident #1 had an intra-articular subcapital impacted right hip fracture, probably subacute and a subacute intertrochanteric left hip fracture, pathological fracture based on the CT scan. The resident had osteoarthritis, osteopenia and degenerative changes in the lower spine with multiple wedge deformities. A 1/25/25 police report documented hospital #1 identified Resident #1 had hip and spinal fractures. The resident had both old and new fractures. According to the report, the medical team at hospital #2 was suspicious that Resident #1 went to bed and woke up with hip fractures without a fall. The report identified the resident's hospice nurse reported Resident #1 passed away on 1/23/25. The report documented the hospice nurse felt the injuries were suspicious because no one knew what happened to cause the injuries. A 1/30/25 police report documented the coroners office was contacted on 1/28/25 and Resident #1's death was ruled an accident. According to the police report, the coroner felt there were no signs of a fall. The fractures to her bones were from use and not injury. -The review of the provided facility investigation did not include staff or resident interviews after the 12/29/24 incident. C. Record review Review of Resident #1's electronic medical record (EMR) revealed Resident #1's last known fall at the facility was on 2/8/24. The 12/29/24 health status note documented by licensed practical nurse (LPN) #1, identified a CNA attempted to move Resident #1 and she started to complain of severe pain. The CNA reported the pain to LPN #1. The resident cried out in pain when her hips were moved slightly. Resident #1 was diaphoretic, her oxygen saturation levels were at 55% and her blood sugar was at 340 milligrams/deciliter (mg/dl). According to the note, the resident's oxygen was set at 2 lpm (liters per minute) and was applied with a face mask. Her oxygen was increased to 3 lpm and her saturation levels rose to 77%. Resident #1 was a full code and 911 was called. The note identified the resident was in pain and cried out when paramedics transferred her from the bed to the gurney. The note identified Resident #1 was her own responsible party and she was aware she was going to the hospital. The note indicated the medical director (MD) was notified. The pain log identified Resident #1 last pain level check was on 12/29/24 at 12:10 a.m. The resident's documented pain level was at zero out of 10. The 12/29/24 hospital #2 emergency department (ED) notes documented Resident #1 was transported to hospital #2 for multiple concerns, including bilateral femur fractures. She was admitted to hospital #2 for possible surgical repair of her (femur) fractures. The ED notes identified Resident #1 was not able to move her hips due to the broken femurs. She had a left hip hematoma that was determined not to be compartment syndrome. She had T-spine (thoracic spine) fractures and sepsis (infection of the blood) related to a urinary tract infection (UTI). According to the notes, the resident would have a right hemiarthroplasty (a half joint hip replacement procedure). The resident had a fracture of her left and right femur and multiple thoracic vertebrae fractures. According to the ED notes, the fractures were chronic, identifying the bone fractures were not healed properly. IV. Staff interviews The NHA was interviewed on 3/5/25 at 4:05 p.m. The NHA said after the 12/29/24 incident with Resident #1, she started an investigation by reviewing the hallway video and interviewing staff. She said she did not save the interview notes and the video only saved for two weeks. The NHA said on 12/30/24, the video surveillance revealed the resident was assisted back to her room by CNA #1 and CNA #2 between 6:15 p.m. and 6:30 p.m. Resident #1 did not have visitors or other residents enter her room after she went to bed. She said the resident reported pain while laying in bed when the staff tried to change her on the overnight shift. LPN #1 assessed the resident and sent her to the ED related to pain with movement and low oxygen saturation levels. The NHA said an ED nurse contacted the facility and asked about a bruise on the resident's left outer hip. The NHA said the staff did not see the bruise when she was assessed by LPN #1. She said she did not believe the bruise was caused at the facility. She said the bruise could have occurred at the hospital or when the paramedics put her on a gurney. The NHA said she did not believe Resident #1 fell at the facility to break her hip because she would not have been able to get off of the floor with a broken hip and put herself back to bed. The director of nursing (DON) was interviewed on 3/5/25 at 5:45 p.m. The DON said LPN #1 notified her to inform her that Resident #1 was sent to the hospital because she was screaming in pain. The resident was diagnosed with fractures to both of her hips. The DON said CNA #1 and CNA #2 were her CNAs at the time of the incident. CNA #2 was shadowing CNA #1 at the time because she only worked periodically and needed to learn the residents on the hall. The DON said she was told by the staff that Resident #1 had no indications of pain or concerns the day before the incident. She said the resident mostly sat in the lounge in the living room all day and told jokes. The DON said she interviewed all the day shift staff. She said she did not remember when Resident #1 was last toileted or if she had asked staff when the resident was last toileted. She said she hand wrote all her notes and had given them to the NHA. She said in the report, it was noted the resident was toileted every two hours, so she would have been checked on every two hours. Resident #1 was dry the last time they checked on her before the incident. The DON said Resident #1 would usually take her own brief off and throw it on the floor if it was wet. She said the next time she was checked on, she had a bowel movement. The DON said staff tried to change the resident but that was when she started to scream in severe pain. She said the resident's vital signs were taken and Resident #1's blood sugar level was 340 mg/dl, which was high for her. She said her oxygen saturation levels were at 55%, which could be life threatening. Resident #1 did not normally need to wear oxygen. She said LPN #1 placed 3 liters per minute (lpm) of oxygen via nasal cannula on the resident and her saturation levels went up to 77%. The DON said by the time the paramedics arrived, she was at 80%. The DON said the resident went to the ED around 4:45 a.m. on 12/29/24. She said the physician was contacted and he gave consent for the surgery. The DON said the police were contacted because adult protective services (APS) was notified of the incident. She said a son the facility was not aware of was also asking questions about the incident. CNA #3 was interviewed on 3/5/25 at 6:05 p.m. CNA #3 said she was working on a different hall than Resident #1 resided on, on the night of 12/29/24. She said CNA #1 told her she was checking on Resident #1's roommate when she identified a bowel movement odor from Resident #1 which was not normal because Resident #1 would take herself to the bathroom when she needed to use the toilet and she would also change her own brief if it was soiled. CNA #3 said CNA #1 asked her for her assistance because she was not able to get Resident #1 up from the bed. CNA #3 said CNA #1, CNA #2 and RN #1 were already with the resident and trying to change her when she entered Resident #1's room. She said the resident would moan when they tried to turn her, but she was not yelling. CNA #3 said the biggest concern she saw was the resident was sweating profusely and was very out of breath. She said Resident #1 was not screaming out when they rolled her to change her brief. She said the resident just got very tense when she was moved. CNA #3 said Resident #1 was normally able to talk and say what she needed. CNA #3 said the NHA asked her some questions a week after the incident. She said after the resident was taken to the hospital, the four of them (CNA #1, CNA #2, LPN #1 and CNA #3) just spoke to each other about what happened. CNA #3 said Resident #1 took herself to bed that night. -However, according to the facility's 12/29/24 summary of events (see above), Resident #1 was toileted in the shower room by CNA #1 and CNA #2 and then assisted to her room and to bed on the evening of 12/28/24. The NHA was interviewed on 3/5/25 at 6:44 p.m. The NHA said CNA #1 had her competency training completed to include transfer training on 11/21/24. The NHA said CNA #2 did not have her competencies completed because she worked at the facility sporadically. CNA #1 was interviewed on 3/6/25 at 10:22 a.m. CNA #1 said Resident #1 took herself to the bathroom but she would sometimes need reminders. She said on the evening of 12/28/24 she walked Resident #1 to her room to go to bed. She said she noticed it took Resident #1 a little longer to walk than usual. She said the resident complained of some leg and hip pain. CNA #1 said Resident #1 was toileted around 8:00 p.m. She said at 10:00 p.m., she checked on her and reminded her to try to go to sleep. She said on 12/29/24 at 12:00 a.m. Resident #1 was sound asleep and her brief was dry. She said at 2:00 a.m the resident was making some noise so the CNAs encouraged her to get up to use the bathroom. CNA #1 said on 12/29/24 at 4:00 a.m. she entered the room to check on Resident #1's roommate and noticed Resident #1 needed to be changed. She said CNA #2 tried to move Resident #1's legs so she could to get up to use the bathroom but the resident screamed, which was not normal for Resident #1, so she went to get LPN #1. CNA #1 said she tried to swing the resident's legs off the bed and tried to stand her but she was dead weight so they laid her back down. She said Resident #1 started screaming again when they changed her brief in bed. She said the resident was drenched in sweat and her oxygen saturation levels were low. She said CNA #3 brought in the oxygen and a second nurse, LPN #2 also came in to the room to help them with Resident #1. CNA #1 said she gave a verbal report of what happened to the NHA on the 12/29/24 night shift. She said she asked LPN #1 if there were any bruises she saw and she said no. CNA #1 said the staff was in shock because they never had seen Resident #1 in that condition. LPN #1 was interviewed on 3/6/25 at 10:53 a.m. LPN #1 said Resident #1 was fine on the evening of 12/28/24. LPN #1 said there were no reports of pain and she walked normally down to her room. She said the CNAs checked on her every two hours. She said when the staff went to get her up to get dressed, she started crying in pain. LPN #1 said she tried to get her up to see if she could bear weight but she could not stand. She said she assessed Resident #1 with range of motion and hip palpitations. She said she was able to look at the resident's skin a little bit but did not see any concerns. LPN #1 was interviewed again on 3/6/25 at 11:06 a.m. She said she did not see a bruise on her hip or leg but just remembered she saw a small lump on Resident #1's forehead that was about the size of a nickel with some bruise that was similar in coloring to her skin. She said she did not think the lump was new because a new bruise was usually bright purple. She said she did not document the lump on her forehead. RN #1 was interviewed on 3/6/25 at 1:42 p.m. She said the hospital ED called her and asked about a bruise on Resident #1 but she said she did not know anything about a bruise. She said she asked LPN #1 about the bruise and if anything happened before Resident #1 was sent to the hospital. RN #1 said nothing happened to cause the injuries that she was aware of. RN #1 said all the staff were surprised that Resident #1 had fractures and a bruise. RN #1 said Resident #1 would spend most of the day in a recliner in the living room or walk to her room or shower room to use the bathroom. She said no staff or residents reported any concerns to her. The NHA was interviewed again on 3/6/25 at 1:58 p.m. The NHA said she still thought Resident #1 did not fall and she ruled out abuse, because she watched the hall surveillance video and talked to staff. She said she did not interview other residents. Medical director (MD) #1 was interviewed on 3/6/25 at 3:47 p.m. MD #1 said the staff notified him that Resident #1 was sent to the hospital because she was in pain. MD #1 said the ED determined Resident #1 had bilateral hip fractures. MD #1 said he did not recall if Resident #1 had bruising along with the fractures but with that type of her injury, he would not be surprised if she had bruising. He said if one of the fractures was identified as a subacute fracture, it could indicate a fracture was potentially in the healing process. He said fractures could have easily occurred at Resident #1's age. The DON was interviewed on 3/6/25 at 4:14 p.m. The DON said she learned of the bruise on Resident #1's leg on the following morning (12/29/24) after the ED contacted the facility. She said she did not know which leg the bruise was found on or the size of the bruise. She said she was not aware of a lump on Resident #1's head or any other incidents that would have caused a lump on her head. The DON said she and the interdisciplinary (IDT) reviewed a resident when they sustained a change of condition, such as weight loss, falls and skin concerns. The DON said she did not conduct a fall investigation after Resident #1's 12/29/24 incident. She said she did not feel Resident #1 fell but she did not know what happened to cause the injuries. She said she did not think Resident #1 could have fallen because she was found in bed and did not think she would have been able to get up and in bed after a fall. She said she did not know how or when the resident acquired the bruise. She said normally when there was a bruise of unknown origin, she would conduct an investigation. She said for bruise investigations she would look how the resident transferred, check if the resident was on blood thinners, look at furniture or equipment that could have caused the bruise and check past skin assessments. The DON said the staff were good about documenting and they did not see or document a bruise for Resident #1 before she was sent to the hospital so she was not aware of the bruise to the leg until the ED notified the facility. She said she did not conduct a bruise of unknown origin investigation after she was notified of the bruise on her thigh from the ED. The DON said a bruise may not always show up right away after a resident was injured. She said that was why they continued to monitor the resident and check for skin injuries 24 hours after a fall. The DON said she was not aware of a nickel-sized lump on Resident #1's forehead. She said nothing was reported to her or documented. The DON said she reviewed skin assessments prior to 12/29/24 and nothing indicated that the resident had a lump on her head or bruising. She said Resident #1 was sent out to the hospital because of pain, not because of an unknown injury. She said she needed to get more details about the incident by asking more questions and making sure staff documented any skin related concerns. The DON said the resident had weak bones and the fractures could have happened before 12/29/24, according to a coroner report conducted in January 2025. The NHA was interviewed a third time on 3/6/25 at 5:28 p.m. She said a fall investigation was not done after Resident #1's 1/23/25 incident because the facility did not feel there was a fall. She said a bruise of unknown origin was not investigated because the staff did not see the bruise and felt it did not happen at the facility. She said she checked to see if the resident was on blood thinners but she was not. She said she did not do a full abuse investigation because there was no indication of abuse. The NHA said she never figured out why the resident had an oxygen saturation level of 55% because she did not have respiratory problems. The NHA said she was not aware of Resident #1's lump on her forehead with slight coloring until the LPN #1 contacted her today (3/6/25). She said she would have conducted a fall investigation to see what had happened if she would have known about the lump on the forehead earlier. She said the lump could have been caused by a fall, however, she still felt Resident #1 did not fall. She said nothing was documented about the lump on her head. The NHA said a staff education regarding falls was conducted on 1/28/25 and 1/29/25, just in case Resident #1 injuries were a result of an undocumented fall that was not reported.

Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents/hazards as possible prevent falls for two residents (#3 and #58) of four residents reviewed for falls out of 41 sample residents. Resident #3, who had a history of falling, was admitted on [DATE] and readmitted on [DATE]. Resident #3's fall care plan, dated 4/5/23, documented the resident was to wear non-skid socks as a fall intervention. On 4/16/23 Resident #3 sustained an unwitnessed fall. There were no new fall interventions added to the resident's care plan until 6/16/23, when an intervention for a scheduled toileting program was implemented. However, the care plan did not specify when the resident was to be toileted. Between 7/1/23 and 1/19/24, Resident #3 sustained six more falls. Several of the falls during that time frame occurred while the resident was attempting to take himself to the bathroom, however, the facility failed to ensure staff was following a toileting schedule for the resident as had been care planned on 6/16/23. Additionally, the facility failed to ensure other care planned interventions were in place at the time of several of the falls, including the intervention for the resident to wear non-skid socks. The facility identified for the resident's falls on 7/1/23 and 7/14/23 that the resident's oxygen levels in his blood were low which potentially was a factor for the falls, however, the facility failed to implement a fall intervention in regards to the resident's use of his oxygen. The facility failed to implement new fall interventions after the resident's falls on 7/1/23, 7/14/23, two falls on 8/2/23 and 8/14/23. On 1/29/24, Resident #3 sustained an unwitnessed fall. At the time of the fall, the care planned intervention of the resident wearing non-skid socks was not followed and the resident's blood oxygen level was again low. The fall resulted in a hip fracture which required the resident to be transferred to the hospital for surgical repair of the fracture. Resident #3 was readmitted to the facility on [DATE]. The facility failed to implement any new fall interventions after the resident returned to the facility following repair of the fracture. On 4/17/24, Resident #3 sustained another fall when he was not wearing non-skid socks. The facility again failed to implement any new fall interventions until 5/7/24 (during the survey). Due to the facility's failures to ensure staff were consistently following care planned fall interventions for Resident #3 and the failure to implement new fall interventions after each fall, Resident #3 sustained a fall which resulted in a major injury. Additionally, the facility failed to consistently identify, implement, review and update Resident #58's fall care plan with effective interventions to prevent further falls from recurring Findings include: I. Facility policy The Falls Clinical Protocol policy, revised March 2018, was provided by the corporate consultant (CC) on 5/9/24 at 1:58 p.m. According to the policy, many falls were isolated to individual incidents, however, a few residents fell repeatedly. Those residents often had an identifiable underlying cause.The nurse should assess and document the precipitating factors and details on how the fall occurred. The staff and the physician should identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of the falls. The policy outlined the need and process for the fall cause identification, treatment and management, and monitoring and follow up. The policy read in pertinent part: For an individual who has fallen, the staff and the practitioner will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and the physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has been resolved by addressing the underlying cause. If the individual continues to fall, the staff and the physician will reevaluate the situation and consider possible reasoning for the resident's falling (instead of, or in addition to those that have been identified) and also reconsider the current interventions. II. Resident #3 A. Resident status Resident #3, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, history of falling, other abnormalities of the gait and mobility, generalized muscle weakness, age related osteoporosis, chronic obstructive pulmonary disease, hypoxemia, dependence on supplemental oxygen, neurocognitive disorder with Lewy bodies, unspecified intellectual disabilities, cognitive communication deficit and Parkinson's disease with dyskinesia (impairment in voluntary muscle movements). According to the 3/21/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment did not identify the resident had any falls or fractures since his last assessment. According to the assessment, the resident was occasionally incontinent of urine. The MDS assessment marked the resident was not on a bowel and bladder toileting program. The resident had no behavioral symptoms or rejections of care. The assessment read the resident did not have alarms in place which monitored the residents movement and alerted staff when movement was detected. B. Observations Resident #3 was assisted out of the dining room by the environmental service director (ESD) on 5/6/24 at 12:03 p.m. He was reminded to use his call light. The resident had a low bed and a fall mat in front of his bed. The ESD left the resident's room. At 12:05 p.m. Resident #3 started to propel himself in his wheelchair into the bathroom. A certified nurse aide (CNA) walking passed the room saw the resident and quickly entered the room asking him to wait for her. The CNA assisted the resident in the bathroom. At 12:12 p.m. the CNA assisted the resident out of his room and into the living room. The resident was not transferred to a recliner (see interview below). Resident #3 was observed in the dining room on 5/7/24 at 2:29 p.m. during a bingo activity. He stood up from his wheelchair. The activity assistant (AA) #1 did not notice the resident standing up. The AA was alerted and assisted him back down to his wheelchair and offered him a tissue/napkin. She locked the resident's right brake and continued with the activity. At 2:37 p.m. Resident #3 stood up from his wheelchair again while he attempted to pull his pants slightly up from the back and sat back down. On 5/8/24 at 2:12 p.m. Resident #3 sat in the living room in a regular upright chair. The resident did not sit in a recliner and he was not wearing his oxygen. On 5/9/24 at 8:35 a.m. Resident #3 attempted to self transfer from his wheelchair to a couch in the front lobby. The resident had one hand on the arm of the wheelchair as he stood. His wheelchair was at an angle and not directly behind him. The resident's arms and legs shook. He was not able to complete the pivot towards the couch. Staff was not present as he attempted to transfer. The resident was not in view of staff or the hallway. The business office manager (BOM) was alerted to the fall risk as she walked down the hallway. The BOM assisted the resident to the couch and notified other staff. C. Record review The fall care plan, dated 4/5/23, read Resident #3 was at risk for falls related to neurocognitive disorder with Lewy bodies, Parkinson's disease, history of falling, and unsteadiness on feet. The care plan goal was to minimize Resident #3's risk for falls and injuries. Care planned interventions initiated on 4/5/23 directed staff to: -Educate the resident and family to call for assistance before transferring; -Ensure food and fluids were within reach; -Implement preventative fall interventions/devices; -Ensure his call light was within reach and educate the resident how to use call light; -Ensure needed items were within reach; -Ensure the resident wore non-skid footwear; and, -Have physical therapy, occupational therapy, evaluate the resident. The activity of daily living (ADL) care plan, initiated 4/5/23, identified Resident #3 had a self-care performance deficit related to unspecified intellectual disabilities, neurocognitive disorder with Lewy bodies, and Parkinson's disease. 1. Fall #1 The 4/16/23 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 4/16/23 at 5:00 p.m. The CNA was notified by Resident #3's roommate of the fall. The CNA entered the room and observed the resident in his recliner. The resident had a red mark on his right upper back. The resident said he was walking to the bathroom and fell on his buttocks and his back hit the window sill or his recliner. The resident said he slipped out of his wheelchair. The evaluation read the resident was incontinent of his bladder and was unaware of his limitations. -Review of the above care plan did not identify new interventions that were put in place after the 4/16/23 fall. New fall care planned interventions were not initiated until 6/16/23 (two months after the fall). According to the 6/16/24 care plan, a toileting schedule was created for Resident #3. -The care plan did not identify when the resident was scheduled to be toileted. Additional interventions included: -Place the bed against the wall; -Place the wheelchair within reach; and; -The use of a low bed and fall mat. 2. Fall #2 The 7/1/23 fall occurrence evaluation identified Resident #3 had a witnessed fall on 7/1/23 at 5:15 a.m. The resident was not injured. The nurse saw the resident try to walk to the bathroom. Resident #3 lost his balance and fell to the floor on his buttocks. The bed was in a low position at the time of the fall and his call light was within reach. The resident did not attempt to push his call light. The lights were off at the time of the fall. The resident had socks on at the time but the socks were not the non-skid socks. -The evaluation did not identify why the resident was not wearing non-skid socks as was care planned. The resident could not explain why he fell . The evaluation did not identify if the resident was wearing oxygen at the time of his fall. The evaluation read Resident #3's most recent oxygen saturation levels were 79% on room air and 95% on four liters per minute (lpm) of oxygen. -Review of the above care plan did not identify new fall interventions that were put into place after the 7/1/23 fall to the bathroom. 3. Fall #3 The 7/14/23 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 7/14/23 at 1:30 p.m. No injuries were observed. The resident was observed on the floor in his room laying on his left side in front of his wheelchair and recliner. The wheelchair brakes were locked and the call light was attached to his recliner. The evaluation identified non compliance with transfers, the recliner, the two end tables and a dresser were potential contributing factors to the fall. The resident said he was going to the bathroom when he fell . The evaluation did not identify when the resident was last toileted, despite the care plan documenting that a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. -The evaluation did not identify what type of footwear the resident had on at the time of his fall. The resident's most recent oxygen saturation levels were 82% on room air. The evaluation read the resident declined to wear his oxygen. The 7/25/23 long term care evaluation read on 7/14/23 the housekeeper found Resident #3 on the floor after she heard a noise from his room. A 7/26/23 health status note identified Resident #3 was injured during the 7/14/23 fall. According to the note, he had fading bruises to his left hip and left shoulder from his previous fall. The review of the above fall care plan did not identify new fall interventions that were put into place after the 7/14/23 fall while attempting to go to the bathroom, including reviewing for new placement of the resident's furniture. -The fall care plan did not include the resident's oxygen use or his refusal to wear oxygen, increasing his fall risk. 4. Fall #4 The 8/2/23 health status note read the resident was shuffling when ambulating to the bathroom. The 8/2/23 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 8/2/23 at 6:45 p.m. The resident was not injured. The resident was observed sitting on the floor on the side of his wheelchair in front of his recliner. The wheelchair brakes were not locked. His call light was within reach. Resident #3's pants were around his legs as he laid on his right side. The resident said he needed to go to the bathroom. -The evaluation did not identify when the resident was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. Contributing factors included a cluttered room and the resident forgot to use the call light. -The review of the above care plan did not identify new fall interventions were care planned, including ensuring the room was clutter free/free of obstacles. 5. Fall #5 The 8/2/23 fall occurrence evaluation identified Resident #3 had a second fall on 8/2/23. The second fall occurred at 8:00 p.m. in his room. The fall was not witnessed. The evaluation read no injuries were observed. The resident was observed sitting on the floor next to his bed. His call light was in reach. -The resident was not wearing non-skid socks, despite the care plan documenting that non-skid socks were implemented as a fall intervention on 4/5/23. The resident said he was going to the bathroom. -The evaluation did not identify when the resident was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. -The review of the above care plan did not identify new fall interventions were care planned after the two falls on 8/2/23. The 8/3/24 incident note read Resident #3 had a 1 centimeter (cm) by 1 cm bruise on his left buttocks due to his recent fall. The 8/3/23 wound evaluation note read the resident had new treatment orders for scattered bruising due to his recent falls. According to the wound evaluation his right buttocks had a 2 cm by 2.2 cm bruise, a 5.5 cm by 10.5 cm bruise on his left upper arm, a 0.5 cm by 4 cm bruise on his chest, and two bruises to his left shoulder measuring 3 cm by 4.3 cm and 2 cm by 3.5 cm. 6. Fall #6 The 8/14/23 fall occurrence evaluation identified Resident #3 had a witnessed fall on 8/14/23 at 2:00 p.m. The resident was not observed to be injured. He was observed by a staff member to walk unassisted. The resident lost his balance and was lowered to the floor onto his buttocks.The resident was continent of bowel and bladder and was attempting to go into the bathroom. The resident said he needed to go to the bathroom. -The evaluation did not identify when the resident was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. -The evaluation did not identify what footwear the resident was wearing at the time. -The evaluation did not identify if the resident was wearing his oxygen at the time of the fall. According to the evaluation, the resident refused to use his walker and would not call for assistance. -The review of the above fall care plan did not identify new fall interventions were care planned after the 8/14/23 fall. -The fall care plan did not identify the resident refused to use his walker. -The care plan did not identify an intervention for frequent monitoring of the resident related to his lack of call light use. The 8/15/23 interdisciplinary (IDT) note read the IDT team reviewed his falls. The nursing recommendations were a bowel and bladder program. The note read most of the falls were due to the resident needing to go to the bathroom. He was placed on a bowel and bladder program so staff would take him to the bathroom at least every two hours. According to the IDT note, the resident continued to attempt to use the bathroom without asking for assistance. Resident #3 was very focused on the task of going to the bathroom and not having an accident. He did not remember to ask for help. The note read the behavior was a usual behavior for the resident for many years, however, he had become more weak. He had tremors and had impaired coordination with his movements. The resident was working with restorative nursing for strengthening. The restorative program would start incorporating call light use prior to the bathroom in attempts to teach him to use the call light. The review of the incontinence care plan, initiated 4/5/23, read Resident #3 had episodes of bowel and bladder incontinence related to cognitive impairment, generalized weakness, pain and Parkinson's disease. The care plan intervention, dated 8/23/23, directed staff to assist Resident #3 with toileting every 2 hours and as needed. The fall care plan identified an added fall intervention on 12/18/23 of wheelchair anti-roll back breaks. 7. Fall #7 The 1/19/24 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 1/19/24 at 9:05 a.m. The evaluation read there were no injuries observed. The nurse was notified Resident #3 was on the floor in his room. The resident was observed sitting on the floor in front of his recliner. The resident was assisted back into his recliner. The resident said he slid out of his chair. The resident was educated and encouraged to use his call light. -The evaluation did not identify the foot wear the resident wore at the time of the fall. The evaluation read the resident's most saturation levels were at 90% on room air. The evaluation did not identify if the resident had his oxygen on at time of the fall. The evaluation did not identify if the resident had to use the bathroom or was incontinent at the time of the fall. The evaluation did not include if the recliner was reclined back at the time of the fall. The evaluation did not identify the resident's recliner was assessed for safety. The review of the fall care plan identified wheelchair brake extenders were added to the care plan on 1/19/24 as a fall intervention after the 1/19/24 fall. -However, according to the fall evaluation, Resident #3 fell out of his recliner, not his wheelchair, therefore the wheelchair brake extenders were not an appropriate intervention for the resident's fall from his recliner. -The care plan did not identify new interventions pertaining to the resident's recliner. The 1/22/24 IDT note read the IDT reviewed the 1/19/24 fall. The resident frequently self transferred and had been reminded to ask for assistance with transferring. According to the note, his previous interventions were brake extenders, anti-roll back and anti-tip brakes to his wheelchair. The new intervention would be to add a chair alarm to his wheelchair to notify staff to help the resident transfer one he initiated. -However, according to the fall evaluation, Resident #3 fell out of his recliner, not his wheelchair. -The review of the care plan identified the alarm was not placed on the resident's care plan until after his 1/29/24 fall with major injury. 8. Fall #8 The 1/29/24 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 1/29/24 at 8:45 p.m. The evaluation read the resident was assessed for injuries and assisted into bed by three staff members. The resident was unable to explain what happened. -The resident was not using oxygen, not calling for assistance and did not have non-skid/slip socks on at the time of the fall, despite the care plan documenting that non-skid socks were implemented as a fall intervention on 4/5/23. The resident's most recent oxygen saturation levels were 86% on room air. The evaluation read there were no injuries observed. The evaluation did not identify if the resident fell from his wheelchair, his recliner, or his bed. -The evaluation did not include when the resident was last checked on or when he was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. The evaluation did not identify if the resident was incontinent at the time of the fall or if he had to use the bathroom. The evaluation did not identify if the resident's pull alarm was sounding at the time of the fall (see below). The 1/29/24 change in condition note read the resident had several complaints of upper thigh pain. The provider was notified on 1/29/24 at 10:17 p.m. The 1/29/24 health status note read Resident #3 left the facility by ambulance at 10:30 p.m. to the hospital emergency room for an evaluation. The 1/30/24 IDT note read Resident #3 was admitted to the hospital with a left hip fracture. He was expected to have surgery. The resident's safety interventions included anti-roll back and anti-tip brakes to his wheelchair and a pull tab alarm. According to the note, the IDT would re-evaluate his interventions once he returned back to the facility. The IDT note did not include additional fall investigation information that was not already included in the fall occurrence evaluation. The 1/30/24 health status note read the facility contacted the intensive care unit (ICU) and was informed the resident would probably have surgery on 1/30/24. The 2/2/24 health status note read Resident #3 was readmitted to the facility on [DATE] from the hospital. The resident was admitted with a diagnosis of a displaced intertrochanteric fracture of left femur. The resident had a large amount of bruising covering his entire left leg. The 2/2/24 hospital discharge instructions read the resident had a left hip fracture and a closed intertrochanteric fracture of the left femur. The review of the fall care plan identified an alarm was added on 1/29/24. -The care plan did not identify the type or where the alarm was placed. The fall care plan did not have additional new fall interventions added to the care plan until 3/11/24, over a month after the resident returned to the facility after a major fall with injury. According to the fall care plan, staff should monitor the resident for changes in his mobility. The ADL care plan interventions, initiated 3/11/24, read the resident required two person assistance for bed mobility, transfers and toileting. The 3/14/24 health status note read the resident had new recommendations from occupational therapy (OT) regarding the resident's wheelchair. A low back wheelchair was recommended for positioning and mobility. According to the note, the resident no longer used a high back wheelchair so his anti tip backs were no longer helpful to him. Therapy discontinued the resident's wheelchair alarm and offered to let him rest in the recliner, which he agreed to. 9. Fall #9 The 4/17/24 fall occurrence evaluation read Resident #3 fell on [DATE] at 9:15 p.m. The fall was unwitnessed. Resident #3 was observed sitting on the floor leaning against the bed. -Resident #3 had regular socks on, despite the care plan documenting that non-skid socks were implemented as a fall intervention on 4/5/23 . Resident #3 did not use the call light prior to getting up. His oxygen was removed. The resident was assisted to bed and his oxygen was placed back on him. The resident did not have injuries observed. The resident said he was trying to get to the bathroom. According to the evaluation, the contributing factors of the fall were poor lighting, wearing of regular socks (not non-skid), and failure to use the call light. He was incontinent but continued to get to the toilet. The fall care plan after the 4/16/24 fall identified the care plan intervention to mark the residents low bed and fall mat, implemented on 6/16/23 as a fall intervention, was revised on 4/18/24. The 4/18/24 IDT note read staff would add a low bed and a fall mat. -However the care plan identified a fall mat and low bed was already in place as of 6/16/23. The review of the progress notes identified the resident had a low bed as of 3/26/23. -The fall care plan identified no new interventions were put into place until 5/7/24 during the survey period. The care plan read non skid strips were initiated on 5/7/24. -The care plan did not identify where the non-skid strips were added. A 5/7/24 health status note read the resident had a new order for grip tape to the bathroom floor noted due to previous falls. D. Staff interviews The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 5/9/24 at 11:23 a.m. The fall investigations were reviewed with the DON and the NHA. The DON said fall investigations should be conducted after each fall. She said she would want a clear investigation so staff could determine what happened to help with the prevention of future falls. Resident #3's 1/29/24 fall with major injury was reviewed with the NHA and DON. The NHA said the resident was found on his hands and knees on the floor. He did not have pain initially and was assisted to bed. The resident was reassessed after later complaints of pain and was sent to the hospital for an evaluation. The NHA said she did not know who found the resident after he had fallen. The NHA said the fall report did not identify when the resident was last checked on or when he was last toileted. She said staff were to do rounds every two hours on the resident. She said when a CNA would start their shift at 6:00 p.m.,after a report was given, the CNA would start rounding every two hours on all residents on their designated hall. The DON and the NHA said the fall documentation did not identify if the resident was incontinent at the time of the fall or if he needed to use the bathroom when he was found. The NHA said the documentation did not identify environmental factors in his room such as lighting. The documentation did not identify where the resident was found in his room such as in front of his wheelchair or bed. The documentation did not identify what the resident was doing before he fell . The NHA said staff interviews pertaining to the fall were not collected. The NHA said the resident was usually able to say what happened or what he was trying to do at the time of fall. The NHA said the fall documentation read that the resident was not able to explain what happened. The NHA and DON said the fall documentation identified the resident did not have his oxygen on or non-skid socks and there were no other fall-related factors documented. The NHA said she did not know why the resident did not have non-skid socks on, other than the possibility he did not want to wear them. She said he was very routine. -However, the resident was not care planned for refusing to wear non-skid socks. The NHA said the resident had low oxygen saturation levels at the time of the fall. The staff had to remind him to wear his oxygen all the time. The DON said Resident #3 needed to wear oxygen for COPD. She said when he did not wear his oxygen, he was at an increased risk for falls (cross reference F695, respiratory care). The DON said the care plan should include oxygen interventions when he refused. The NHA said the resident preferred to sit in a recliner. She said after the fall the staff started to encourage him to sit in the recliner in the living room for extra supervision. The NHA confirmed the recliner was not care planned as an intervention. She said all interventions should be care planned so staff was aware of the interventions. -Observations during the survey period did not identify the resident sitting in a recliner in the living room. Observations did identify the resident sitting in the living room in a regular chair or his wheelchair without his oxygen on (see observations above). The DON said the 1/29/24 fall investigation should have included staff interviews regarding when the resident was last checked on. She said the investigation should include what the situation was at the time of the fall and what his environment looked like at the time. The DON said staff should document if the interventions were in place when he fell and who found the resident. She said she would want to know why the resident could not express what happened. The NHA said the resident may have had confusion at the time because his oxygen saturation levels were down to 70% at the time. The NHA said most of the time after a fall, new interventions were put in place except when staff felt they tried all interventions and could not think of what else to do. The NHA said most of the resident's falls were due to him getting up to go to the bathroom. She felt Resident #3's attempts to toilet himself was a behavior. She said the behavior was not tracked. The NHA said she did not know why the resident did not want to wear oxygen. The DON said she would look at opportunities to reinforce positive behavior and would observe and ask the resident questions such as why he did not want to wear his oxygen. The DON and the NHA said, moving forward, they would start to look at Resident #3's individual toileting routines to help determine when the resident was mostly needing to void. The DON said all residents were checked on every two hours. She said Resident #3 was on a bowel and bladder toileting program/plan which would have the staff specifically ask the resident if he had to use the bathroom or encourage him to use the bathroom every couple of hours. CNA #1 was interviewed on 5/9/24 at 3:05 p.m. CNA #1 said she worked full time with twelve hour shifts on Resident #3's hall. She said Resident #3 needed assistance to go to the bathroom but he did not use the call light to inform staff when he needed to go. She said she reminded him not to stand up by himself and to use the call light. She said when she saw him head to his room, she would place him on the toilet when she could but then he would not use the call light when he was done. She said she did not think the resident could remember to wait and use the call light. She said she had found him attempting to walk with his pants down. CNA #1 said the resident had a low bed and tried to get up at night. She said she toileted him routinely before and after meals, however, she saidResident #3 was not on a toileting/bowel and bladder plan. She said residents who were on a toileting plan were to be toileted every two hours. CNA #1 said no residents on her hall, including Resident #1, was on a toileting/bowel and bladder plan. 50314 III. Resident #58 A. Resident status Resident #58, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included cerebral infarction

Based on record review and interviews, the facility failed to ensure each residents had the right to formulate an advance directive for three (#36, #37 and #57) of five residents reviewed for advance directives out of 41 sample residents. Specifically, the facility failed to: -Provide written advance directive forms or discussions to Resident #36, #37 and #57; -Re-evaluate Resident #36, #37 and #57 for their decision-making capacity periodically; and -Re-evaluate Resident #36, #37 and #57 periodically to determine if their advance directives were still in line with their wishes. Findings include: I. Facility policy and procedure The Advance Directives policy, revised September 2022, was provided by the corporate consultant (CC) on 5/9/24 at 12:00 p.m. It read in pertinent part, Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The interdisciplinary team conducts ongoing review of the residents decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. Changes are documented in the care plan and medical record. If the resident does not have an advance directive, the resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. II. Resident #36 A. Resident status Resident #36, over the age of 65, was admitted on [DATE]. According to the May 2024 computerized physician order (CPO), diagnoses included cerebral palsy, osteoarthritis, and generalized muscle weakness. According to the 3/9/24 minimum data set (MDS) assessment, Resident #36 was moderately cognitively impaired with a BIMS score of nine out of 15. -The assessment revealed Resident #36 was unable to answer what the correct year or month was and could not recall one of three words during the assessment. B. Resident interview Resident #36 was interviewed on 5/6/24 at 2:24 p.m. Resident #36 said he did not know what an advance directive was and he was unsure if he had one. Resident #36 said he liked to make medical decisions with his family when possible but he was unsure when he last asked them for advice or help in medical decisions. Resident #36 said he had not discussed medical decision-making or advance directives since he arrived at the facility (June 2021) C. Record review A physician's visit progress note, dated 3/26/24, documented the resident had cognitive impairment and that the resident was alert and oriented times three. -However, the resident was unable to recall what an advance directive was or if he had one (see resident interview above). A Medical Orders for Scope and Treatment (MOST) form was completed on 5/1/21 and was signed by Resident #36. The comprehensive care plan dated 3/20/23 identified the resident had impaired neurological status. Pertinent interventions included monitoring and reporting to the provider any changes in cognitive function. The care plan dated 3/16/23 identified an activities of daily living (ADL) self-performance deficit related to cognitive impairment. The multidisciplinary care conference progress note, dated 3/14/24, documented Resident #36 was alert and oriented and able to make needs known. -However the resident was unable to recall what an advance directive was or if he had one (see resident interview above). -No medical-durable power of attorney (MDPOA) was documented in Resident #36's electronic medical record (EMR). -There was no written advance directive documented in Resident #36's EMR to indicate an advance directive discussion had been had with Resident #36 or his MDPOA. III. Resident #37 A. Resident status Resident #37, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 CPO, diagnoses included dementia, altered mental status, and metabolic encephalopathy (a problem in the brain resulting from blood imbalances). The 3/22/24 MDS assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. -The assessment revealed Resident #37 was unable to recall the month or day of the week and required cueing to recall words during the assessment. B. Record review A MOST form was completed on 5/7/21 and was signed by Resident #37. A progress note, dated 12/13/23, documented Resident #37's POA verbally consented to the Covid SpikeVac booster. A progress note, dated 1/10/24, documented Resident #37's POA gave consent for the respiratory syncytial virus (RSV) vaccination. A progress note, dated 2/3/24, documented nursing staff requested permission from the resident's POA to send the resident to the emergency room . A progress note, dated 2/13/24, documented a discussion between nursing staff and the POA regarding a new medication order for the resident. The documentation included decisions made by the POA regarding medications for Resident #37. A progress note, dated 3/4/24, documented POA notification by nursing staff for newly identified hip and back pain. A progress note, dated 3/15/24, documented Resident #37's POA signed consent at admission for the resident to receive the Prevnar 20 vaccination. A progress note, dated 3/21/24, documented a nursing staff member called Resident #37's family. The progress note documented the POA understood the appointment and he would be accompanying the resident to her next appointment. A progress note, dated 3/27/24, documented nursing staff membercalled the resident's power of attorney (POA) and reminded him of upcoming appointments for the resident. -There was no medical durable power of attorney (MDPOA) identified or documented in Resident #37's EMR. -Despite multiple progress notes indicating the facility called Resident #37's POA for consents and appointments, there was no documentation to indicate the POA had been notified to discuss the resident's advance directives. IV. Resident #57 A. Resident status Resident #57, over the age of 65, was admitted on [DATE]. According to the May 2024 computerized physician order (CPO), diagnoses included dementia, chronic obstructive pulmonary disease (COPD), and high blood pressure (hypertension). According to the 4/20/24 MDS assessment, Resident #57 was cognitively intact with a BIMS score of 13 out of 15. B. Record review A MOST form was documented in Resident #57's EMR and signed by a family member identified as the MDPOA. The date the form was signed was unreadable. -However, there was no MDPOA form documented in the EMR. -There was no written advance directive documented in Resident #57's EMR to indicate an advance directive discussion was had with Resident #57, who had a BIMS score of 13 out of 15 C. Resident Interview Resident #57 was interviewed on 5/6/24 at 9:58 a.m. Resident #57 said he received help from his family about medical decisions when he wanted to involve them, but usually made his decisions himself. Resident #57 was aware of the MDPOA identified on his Colorado MOST form, and agreed the identified family member helped him with medical decisions occasionally. Resident #57 could not recall if the facility ever asked him about his advance directive wishes, or if the facility ever helped him complete advance directives. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 5/8/24 at 8:57 a.m. The NHA said Resident #36, Resident #37 and Resident #57 did not have any advance directives on file. The NHA said there was no documentation of advance directive discussions offered to Resident #36, Resident #37 or Resident #57. The social services director (SSD) was interviewed on 5/9/24 at 12:24 p.m. The SSD said there was no MDPOA documentation completed for Resident #36, Resident #37 or Resident #57. The SSD said there was no documentation of advance directive discussions with Resident #36, Resident #37 or Resident #57. The SSD said she interviewed residents about their existing advance directives and offered to complete a MOST form on admission. The SSD said residents who had advance directives needed to make their advance directive needs known to hold an advance directives discussion or complete advance directives. The SSD agreed residents should be re-evaluated for updates to their advance directives. The SSD said Resident #36, Resident #37 and Resident #57 had not been revisited for advance directive discussions. The SSD said she did not know how to approach situations where residents were already moderately cognitively impaired with no written advance directive. The SSD said she would seek more education about how to establish a surrogate decision-maker legally in those situations in the future. The SSD said she did not know if discussions regarding advance directives should be documented. The director of nursing (DON) and the NHA were interviewed on 5/9/24 at 1:48 p.m. The DON said there was an advance directive discussion with residents upon admission but it was not documented. The DON said it was important for cognitively impaired residents to have an identified decision maker so the care team could honor resident wishes if they were unable to make their own decisions. The NHA said admission advance directive discussions included asking the resident if they had an advance directive and offering to complete the MOST form. The NHA said residents with cognitive impairment should have an identified decision maker. The DON and the NHA said advance directive discussions should be re-offered to residents. The DON and the NHA reviewed the EMR for Resident #36, Resident #37 and Resident #57. The DON and the NHA said no advance directives were in the EMR for Resident #36, Resident #37 or Resident #57. The DON and the NHA said there was no documentation of advance directive discussions being held, or advance directives completion being offered to Resident #36, Resident #37 or Resident #57.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure Resident #22, #24, #16, #29, #47, #53 and #58 were tested for COVID-19 when presenting signs and symptoms of an upper respiratory infection; and, -Ensure Resident #58, #164 and #165 received the COVID-19 vaccination after consenting for it. -Ensure the facility used preventative measures to help reduce the potential risk of COVID-19. Findings include: II. Professional reference Interim for Infection Prevention and Control Recommendations for Healthcare Professional during COVID disease 2019 (COVID-19) pandemic updated 3/18/24, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 5/20/24. According to the Center of Disease Control and Prevention (CDC), The recommendations in the following guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. The update reflected the high levels of vaccine of infection induced immunity and the availability of effective treatments and prevention tools. The policy read in pertinent part, Encourage everyone to remain up to date with all recommended COVID-19 vaccination doses. Healthcare professionals, patients, and visitors should be offered resources and canceled about the importance of receiving the COVID-19 vaccine. Establish the process to make everyone entering the city aware of recommended actions to prevent transmission to others if they have any of the following three criteria: positive viral test for SARS-CoV-2; symptoms of COVID-19, or close contact with someone with infection. Anyone with even mild symptoms of covid-19 regardless of vaccination status should receive a viral test for SARS-CoV-2, as soon as possible. The CDC's Stay Up to Date with COVID-19 Vaccines, updated 5/14/24 was retrieved on 5/20/24 from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html and read in pertinent part, The CDC recommends the 2023-2024 updated COVID-19 vaccines. Everyone aged five years and older should get one dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. People aged 65 and older who received one dose of any updated 2023-2024 COVID-19 vaccination should receive one additional dose of updated covid-19 vaccine at least 4 months after the previous updated dose. 1. Facility policy The Infection Control Program policy, undated, was provided by the facility on 5/6/24. The policy identified the intention of the policy and the infection control program. The policy read in pertinent part, To provide and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and help prevent the development of transmission of disease and infection. The elements of infection control program included but was not limited to: -Investigates, controls, and prevents infections in the facility; -Decides what procedures, such as isolation, should be applied for individual resident; -Maintains a record of incidences and corrective actions related to infections. The director of nursing (DON) would serve as the coordinator of the infection control prevention and control program. The program coordination would include process and outcome infection control surveillance, monitoring and data analysis and documentation. The COVID-19 policy, undated, was provided by the facility on 5/6/24. The policy read in pertinent part, It is the policy of this facility to utilize precautions (and) prevention measures that apply to resident care, regardless of suspected or confirmed infection status of the residents, in any setting where healthcare is being delivered. Precautions are utilized to prevent and control transmission of infectious organisms through direct and indirect contact. This evidence-based practice is designed to protect healthcare staff and residents by preventing the spread of infections among residents and ensuring staff do not carry infectious pathogens on their hands or via equipment during resident care. The Vaccination of Residents policy was provided by the corporate consultant (CC) on 5/9/24 at 3:01 p.m. The policy read in pertinent part, According to the policy all residents would be offered vaccines that aid in the prevention of infectious diseases unless the vaccine was medically contraindicated or the resident had already been vaccinated. The facility COVID Vaccination Immunization Requirements for residents and staff, dated 5/13/21, was provided by the CC on 5/9/24 at 3:01 p.m. The policy read in pertinent part, When the COVID-19 vaccine is available to the facility, the facility shall offer each resident and staff the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized. III. Upper respiratory infections A. Resident status The following residents were identified with upper respiratory infections between March 2024 and May 2024: Resident #22, over the age of 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD) and acute upper respiratory infection. Resident #24, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included hypoxemia, personal history of COVID-19 and acute upper respiratory infection. Resident #16, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included hypertensive heart and chronic kidney disease without heart failure, shortness of breath, pneumonia, personal history of COVID-19 and acute upper respiratory infection. Resident #29, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included chronic respiratory failure with hypoxia, hypoxemia and acute upper respiratory infection. Resident #53, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included Alzheimer's disease, personal history of COVID-19 and acute upper respiratory infection. Resident #58, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included Alzheimer's disease, chronic kidney disease stage three, hypoxia, and upper respiratory infection. Resident #47, over the age of 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, personal history of COVID-19 and acute upper respiratory infection. B. Record review The March 2024, April 2024 and May 2024 surveillance mapping for infection was reviewed with the director of nursing (DON) on 5/9/24 at 10:00 a.m. The March 2024 surveillance mapping identified three resident had signs and symptoms of an upper respiratory infections: -Resident #22 was identified with a new upper respiratory infection on 3/25/24. The resident was treated with antibiotics. -Resident #24 was identified with a new upper respiratory infection on 3/25/24. The resident was treated with antibiotics. -Resident #16 was identified with a new upper respiratory infection on 3/25/24. The resident was treated with antibiotics. The review of the electronic medical records (EMR) of Resident #22, #24, and #16 did not document the residents were tested for COVID-19 after exhibiting signs and symptoms of an upper respiratory infection. The April 2024 surveillance mapping for infection in April 2024 identified four resident were identified with a new upper respiratory infection: -Resident #29 was identified with a new respiratory infection on 4/8/24. The resident was treated with antibiotics. -Resident #53 was identified with a new respiratory infection on 4/8/24. The resident was treated with antibiotics. -Resident #58 was identified with a new respiratory infection on 4/26/24. The resident was treated with antibiotics. Resident #58 was not provided the COVID-19 vaccination prior to his diagnosis of an upper respiratory infection (see below). -Resident #47 was identified with a new respiratory infection on 4/30/24. The resident was treated with antibiotics. The review of the EMR for Resident #29, #47, #53 and # 58 did not document the residents were tested for COVID-19 after exhibiting signs and symptoms of an upper respiratory infection. The May 2024 surveillance mapping for infection in May 2024 identified no new upper respiratory infections as 5/8/24. IV. Failure to offer the COVID-19 vaccine after consent A. Resident #58 1. Resident status Resident #58, over the age of 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease stage three, hypoxia, and upper respiratory infection. The 4/11/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of three out of 15. 2. Record review The immunization record and immunization report for Resident #58 was provided by the CC 5/9/24 at 2:47 p.m. The immunization record identified the resident's responsible party consented and signed for Resident #58 to receive to COVID-19 vaccination on 3/19/24. The immunization report documented his last COVID-19 booster vaccination was on 8/4/22. The report identified Resident #58 was not provided the vaccination since his admission on 3/19/24. B. Resident #164 1. Resident status Resident #164, over the age of 65, was admitted on [DATE]. According to the 4/25/24 MDS assessment, diagnoses included hypertension, depression, peripheral vascular or peripheral arterial disease. The assessment indicated the resident had severe cognitive impairment with a BIMS score of seven of 15. 2. Record review The immunization record and immunization report for Resident #164 was provided by the CC 5/9/24 at 2:47 p.m. The immunization record identified the resident's responsible party consented and signed for Resident #164 to receive to COVID-19 vaccination on 4/19/24. The record read the resident had not received a COVID-19 prior to her admission to the facility. The immunization report documented Resident #164 was not provided the vaccination since her admission on 4/19/24. C. Resident #165 1. Resident status Resident #165, over the age of 65, was admitted on [DATE]. The May 2024 CPO did not document her current diagnosis. The staff assessment for mental status identified she had a memory and had moderately impaired decision making skills. 2. Record review The immunization record and immunization report for Resident #164 was provided by the CC 5/9/24 at 2:47 p.m. The immunization record identified the resident's responsible party consented and signed for Resident #165 to receive to COVID-19 vaccination on 4/11/24. The immunization report documented Resident #165 was not provided the vaccination since her admission on 4/11/24. V. Staff interviews The DON, the NHA and the CC were interviewed on 5/9/24 at 10:00 a.m. The DON said the facility's last outbreak was in November 2023. The DON said the residents who had signs and symptoms and had upper respiratory infections on the March 2024 April 2024 and May 2024 surveillance mapping for infection were all treated for antibiotics. The DON said the surveillance mapping did not identify a specific type of upper respiratory infection and the residents were not tested for COVID-19. The DON said the facility would have tested the residents if a staff member had reported positive COVID or if local facilities had cases of a COVID-19 outbreak and the physician recommended testing of COVID-19. The CC said the facility should test every resident with signs and symptoms of a respiratory infection because COVID-19 could mimic the signs of an upper respiratory infection. The CC said it would be appropriate for all residents with an identified upper respiratory infection to be tested to rule out COVID-19. The DON said residents with upper respiratory infections were not placed on droplet precautions because there were no precautions recommended by the providers (physician and the nurse practitioner). The DON said she did not follow-up to ask the provider if precautions were needed and nothing was documented for precautions. The DON said when Resident #58 admitted and family signed his consent on 3/19/24, the resident was not feeling well because he was recovering from a cerebrovascular accident (CVA). The resident was offered the COVID-19 but his family wanted to wait. The resident remained at the facility and was not offered the vaccination again. The NHA said the facility was going to offer the vaccine at the next vaccination clinic. She said the clinic was not scheduled yet but staff were looking to set up the clinic the week after the survey. She said the resident did not have to wait for a vaccination clinic to get the vaccine. She said the resident was last vaccinated on 8/4/22 for COVID-19 but he had not received the latest vaccination booster. The DON said currently the facility did not have the latest vaccination booster to offer. The CC said the facility was able to get the vaccine shipped to the facility in a day and could be available to Resident #1. The DON said when residents admitted to the facility, the residents should be offered vaccinations. The CC said the facility should follow the CDC recommendations. The CC said Resident #58 would be offered the COVID-19 vaccination and she would show the DON how to order the vaccine. The DON said Resident #58 developed signs and symptoms of an upper respiratory infection. He had crackling in his lungs and a productive cough beginning on 4/26/24. Resident #58 was placed on antibiotics and by 5/5/24 he no longer had a cough. The resident was not tested for COVID-19 and droplet precautions were not but in place. The CC said the facility should follow the CDC recommendations to offer COVID-19 vaccinations to all residents and test for COVID-19 when residents present an upper respiratory infection. The DON said the facility would start to review all vaccinations and consents at the morning meeting and start a tracking form to ensure all needed components were in place and residents who consented for the vaccinations were not missed. The CC said she would educate nursing staff to test residents with upper respiratory infection symptoms for COVID-19. The CC was interviewed again on 5/9/24 at 2:10 p.m. The CC said Resident #164, Resident #165 and Resident #58 consented for the COVID-19 vaccine and did not receive the vaccine. The CC she would have Resident #58, Resident #164 and Resident #165 set up to receive the vaccinations, create an action plan and audit all COVID-19 vaccinations and provide nursing staff education to ensure all residents who wanted to be vaccinated were vaccinated. The CC said an admission checklist would also be put in place to ensure vaccinations were offered the vaccine shortly after the resident consented. The CC said she would also conduct an education with the DON and the nursing home administrator (NHA) regarding expectations of COVID-19 testing so any signs and symptoms of COVID-19 could be ruled out. VI. Facility follow up The following facility education was provided by the CC on 5/9/24 at 2:47 p.m. The CC said she was beginning the education on the afternoon of 5/9/24. The CDC COVID-19 Testing: What You Need Know brochure, updated 5/2/24, and the staff education for steps to take when residents were exhibiting signs or symptoms of covid identified the staff would be educated on the CDC list for COVID symptoms and to test for COVID when a resident had potential signs or symptoms for COVID. The education form read: -A PCR (polymerase chain reaction) COVID test needed to be completed and signed out on the MAR (medication administration record) via the PRN (as needed) COVID swab (kit). -If the PCR test is positive, implement isolation and set out PPE (personal protective equipment). -If the test is either positive or negative, notify the provider of assessment and results. -A change of condition needs to be completed. The CDC brochure read in pertinent part: Covid-19 testing can help you know if you have covid-19 so you can decide what to do next, like getting treatment to reduce your risk of severe illness and take steps to lower your chances of spreading the virus to others. The staff education for vaccinations read: -Upon admission or when updated guidance comes out consent will be obtained or refused for all vaccinations for resident choice. -The admitting nurse will get the consent and verify with the resident If they would like to get the musician immediately via Walgreens, Walmart or if they would want to wait until the next batch clinic of COVID boosters. -The nurse will document the resident's response. -The nurse will update immunization under immunization tab to keep the resident's EMR (electronic health record) up-to-date .

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for five out of five staff reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #2, #4, #5 and #6 and certified nurse aide with medication authority (CNA-Med) #1 received 12 hours of continuing education annually in all required training topic areas, including dementia management training and resident abuse prevention training. Findings include: I. Training record review Five randomly selected CNA training records were reviewed on 5/8/24. Of the five employees reviewed, four of the CNAs (#2, #4, #5 and #6) and CNA-Med #1 did not receive a full 12 hours of annual training. A. CNA #2 -CNA #2, hired on 11/13/21, had participated in only six hours of training during the annual training year and had no record of completing abuse, neglect or exploitation training. B. CNA #4 -CNA #4, hired on 6/27/19, had participated in only six hours of training during the annual training year and had no record of completing dementia management training and resident abuse prevention training. C. CNA #5 -CNA #5, hired on 5/3/22, had participated in only eight hours of training during the annual training year. D. CNA #6 -CNA #6, hired on 8/19/21, had participated in only 10 hours of training during the annual training year and had no record of completing dementia management training. E. CNA-Med #1 CNA-Med #1, hired on 11/30/17, had participated in only nine hours of training during the annual training year and had no record of completing dementia management training. II. Staff interviews The nursing home administrator (NHA) and business office manager (BOM) were interviewed together on 5/8/24 at 1:27 p.m. The BOM said she did not know the facility needed to track the number of training hours CNAs completed annually to ensure they received at least 12 hours of training. The NHA said the facility was approved to get a computerized training system within the next six months and tracking training was going to be easier and more consistent. The BOM said until they implemented the computerized system she would make a tracking system that would keep the training material, post-test results, dates, times, who completed the training and who missed the training. The NHA said the staff were informed when their training was scheduled and offered to be paid to complete the training on their days off. She said they had offered for staff to leave the floor to complete the required training but she felt she was unable to make the staff complete the training if they did not want to. The director of nursing (DON), the corporate consultant (CC) and the NHA were interviewed together on 5/9/24 at 4:00 p.m. The DON said she was responsible for training all of the nursing staff. The DON said she did not know how many hours of training the CNAs needed each year. The CC said CNAs needed to complete 12 hours of training each year. The NHA said if staff missed the training, management provided them with the training material and a quiz at a later date. She said training was offered on two different days in the afternoon so it was easier for everyone to attend. The NHA said the staff were encouraged to clock in and be paid for the training but the facility was unable to track the training process consistently and the BOM was coming up with a new process.

Based on observations, record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for three (#1, #23 and #38) of nine residents reviewed for dignity out of 41 sample residents. Specifically, the facility failed to: -Ensure staff treated Resident #1 with respect and dignity by acknowledging and responding to the resident when she spoke to them; -Ensure Resident #23 was treated with respect and dignity during meals; and, -Ensure Resident #38 was not yelled at or moved hastily when he got stuck on another resident' s chair in the dining room. Findings include I. Facility policy The Dignity policy, revised February 2021, was provided by the corporate consultant (CC) on 5/9/24 at 12: 00 p.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. When assisting with care, residents are supported in exercising their rights. For example residents are allowed to choose when to sleep, eat and conduct activities of daily living (ADLs) and are provided with a dignified dining experience. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included anoxic brain damage (caused when the brain was deprived of oxygen), other specified depressive episodes, attention and concentration deficit, a disorder of adult personality and behavior, cognitive communication deficit and impulse disorder. The 3/9/24 minimum data set (MDS) assessment documented Resident #1 was unable to complete a brief interview for mental status (BIMS) because she was rarely or never understood. The staff interview documented Resident #1 had a memory problem and could not recall the current season, the location of her own room, staff names and faces or that she was admitted to a nursing home. Resident #1' s cognitive skills for decision-making were severely impaired. B. Resident interview Resident #1 was interviewed on 5/6/24 at 11:42 a.m. Resident #1 was able to answer yes and no questions and make basic needs known if staff listened closely. Resident #1 was interviewed again on 5/9/24 at 3:45 p.m. Resident #1 said the dietary staff never asked what she wanted for meals and she wanted someone to take her order. C. Observations On 5/6/24 at 3:51 p.m. Resident #1 stood in the B hall without her walker. Certified nurse aide with medication authority (CNA-Med) #1 brought Resident #1 her walker. Resident #1 attempted to talk with CNA-Med #1 but he grabbed the front bar of her walker and pulled her from Hall B past the nurses' station to a recliner on the opposite side of Hall B. Resident #1 held onto the handles of her walker and was trying to keep up with CNA-Med #1 as he pulled her walker. Resident #1 had her arms fully extended in front of her with the top half of her body bent at approximately a 90-degree angle. Resident #1 had a hard time walking. She attempted to communicate with CNA-Med #1 but he did not listen to her and pulled her walker until he had her sit in a recliner. On 5/7/24 at 11:50 a.m. an unidentified staff member brought Resident #1' s tablemate her lunch. The staff member looked at Resident #1 and said Do not touch as she placed the plate in front of the other resident. At 11:54 a.m. an unidentified staff member brought Resident #1 her second plate of food. Resident #1 was excited and told the staff thank you three times but the staff walked away without responding to her. At 5:36 p.m. dietary aide (DA) #1 provided Resident #1 with a drink. Resident #1 said thank you and DA #1 walked away without acknowledging her. At 6:06 p.m. the environmental services director (ESD) brought Resident #1 a cup of juice. Resident #1 said thank you three times but the ESD did not respond to her and walked away. On 5/9/24 at 7:23 a.m. Resident #1 received her breakfast. She said thank you to DA #2 who walked away without responding. At 7:46 a.m. an unidentified staff member brought Resident #1' s tablemate her breakfast. Resident #1 said hi and the staff member did not acknowledge her. At 7:47 a.m. the unidentified staff member returned to give Resident #1' s tablemate water and silverware. Resident #1 again said hi and the staff member did not acknowledge her. At 7:50 a.m. Resident #1 said she did not get enough to eat and was still hungry. She asked for a soda to drink as well. Cook (CK) #2 was serving meals in the dining room and went to get a second plate of food for the resident. Resident #1 began eating her spilled food off of the floor while waiting for her second plate of food. -No staff attempted to redirect the resident from eating food off the floor. At 7:52 a.m. CK #2 brought Resident #1 more breakfast and a soda. Resident #1 laughed excitedly and told CK #2 thank you three times but CK #2 did not respond and walked away. D. Record review Resident #1' s communication care plan, revised on 6/14/23, documented she had impaired communication related to her cognitive impairment. The interventions included allowing ample time for the resident to comprehend what was said and allow time for a response, encouraging conversations in calm, quiet locations with minimal background noise, maintaining eye contact and approaching the resident from the front and paying attention to the resident' s body language and facial expressions. Resident #1' s psychiatric and mood care plan, revised on 6/14/23, documented she had an impaired psychiatric and mood status related to her history of anoxic brain damage and cognitive communication deficit. The pertinent interventions included administering medications and treatments as indicated by the physician's orders, assisting the resident in coping by discussing the possible solutions to conflict, monitoring for signs of mood changes or distress, monitoring the resident' s mood to determine if the problem was related to external causes, offering the resident encouragement, assistance and support to maintain as much independence and control as possible, offering the resident choices whenever possible in order to promote a feeling of self-worth and control over the environment and providing the resident with quality listening time and encourage expression of feeling. Resident #1' s behavioral care plan, revised on 9/12/23, documented she had behaviors which included depressive episodes, a disorder of adult personality and behavior, sexual disorders, an eating disorder where she ate non-food items, attention and concentration deficit and an impulse disorder. The pertinent interventions included offering Resident #1 assistance, encouragement and support to identify problems that were out of her control, offering Resident #1 choices whenever possible to promote a feeling of self-worth and control over the environment and care delivery and providing positive feedback to the resident when her behavior was appropriate and emphasize the positive aspects of compliance. E. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 5/8/24 at 1:36 p.m. CNA #3 said she worked with Resident #1 and they had a good relationship. She said the resident was not cognitively impaired to the extent other staff thought. CNA #3 said the staff did not always take the time to listen to Resident #1 when she communicated or they did not know how to listen to Resident #1. The nursing home administrator (NHA) was interviewed on 5/8/24 at 1:27 p.m. The NHA said Resident #1 had cognitive impairments. DA #1 was interviewed on 5/8/24 at 5:58 p.m. DA #1 said she was unsure how to communicate with Resident #1. She said she relied on staff who knew the resident well to help her know what the resident preferred. DA #1 said when she interacted with Resident #1 she laughed with or smiled at the resident and walked away for each interaction. DA #1 said it was hard to understand what Resident #1 said. The ESD was interviewed on 5/8/24 at 6:06 p.m. The ESD said he was able to communicate with Resident #1. He said the staff needed to take their time to communicate with the resident. CNA #3 was interviewed again on 5/9/24 at 11:13 a.m. She said staff needed to talk to Resident #1 the way they talked to the other residents because she truly understood, however she could not express herself to show she understood what someone said. She said staff thought Resident #1 had severe cognitive impairment because she had difficulties communicating. CNA #3 said Resident #1 was an intelligent woman and was able to communicate if staff took the time to listen to her. Restorative aide (RA) #1 was interviewed on 5/9/24 at 3:42 p.m. RA #1 said staff should guide Resident #1 when she was walking instead of pulling on the resident's walker. CNA #2 was interviewed on 5/9/24 at 3:47 p.m. She said she communicated with Resident #1 by giving her options and taking her time communicating with her. CNA #2 said she understood Resident #1, but it was hard at times. She said when Resident #1 was provided with time she was able to express herself and make her needs known. Registered nurse (RN) #1 was interviewed on 5/9/24 at 3:49 p.m. She said she communicated with Resident #1 by giving her time and being patient. She said Resident #1 was able to say the word or phrase of what she needed and that Resident #1 understood RN #1. DA #2 was interviewed on 5/9/24 at 3:55 p.m. DA #2 said she never took Resident #1' s orders for meals because she was not able to understand the resident. She said she wrote the resident' s name on a meal ticket and had the kitchen staff decide what to make her. The director of nursing (DON) was interviewed on 5/9/24 at 4:00 p.m. The DON said the staff were not supposed to pull on a resident' s walker when assisting them. She said if the staff were concerned about the resident falling they needed to walk next to the resident while utilizing a gait belt. The DON said she would conduct an in-service reminder to the staff to prompt the resident to walk instead of holding onto her walker. III. Resident group interview The resident group was interviewed on 5/8/24 at 9:00 a.m. The group consisted of five residents (#19, #28, #14, #56 and #24), which included the resident council president. The residents were identified by the facility and assessment as interviewable. Resident #56 said the staff yelled at residents during breakfast if they fell asleep while they were eating their food. He said a lot of the yelling was wake up, eat your breakfast, or sit down and eat your food. Resident #56 said he kept quiet during breakfast so the staff did not yell at him. Resident #28 said staff yelled at or raised their voices at her when they wanted her to eat her food faster. Resident #28 said she did not like the staff yelling at residents and she told the staff how she did not like it. IV. Additional resident interview Resident #50 was interviewed on 5/6/24 at 3:32 p.m. Resident #50 said during meals staff members yelled at residents in the dining room. She said the staff yelled sit down, eat your food, or wake up. She said if the resident was hard of hearing the staff yelled louder. She said 5/6/24 was the quietest her meal had been during breakfast and lunch since she was admitted and that it was nice. Resident #50 said she was a survivor of domestic violence and it scared her when the staff yelled. She said sometimes she had to eat in her room because the yelling triggered her post-traumatic stress disorder (PTSD) and it was overwhelming. V. Failure to treat Resident #38 and #23 with respect and dignity During a continuous observation during the breakfast meal on 5/9/24, beginning at 7:25 a.m. and ending at 8:00 a.m., the following was observed: At 7:25 a.m. Resident #38 was self-propelling his wheelchair between some tables in the dining room. He bumped into an unidentified resident' s chair by accident. Restorative aide (RA) #1 yelled Resident #38 you are bumping into another resident who is trying to eat his breakfast and he cannot enjoy it with you bumping him! Resident #38 did not respond to RA #1 and kept self-propelling. RA #1 grabbed Resident #38' s wheelchair and turned his chair and pushed him away from the resident he bumped into. RA #1 shook her head in frustration and walked away from Resident #38. At 7:30 a.m. Resident #23 fell asleep as she sat in front of her breakfast. RA #1 tapped the resident three times on her right arm and yelled wake up, eat your food! Approximately 30 seconds later, RA #1 tapped Resident #23' s right arm again and yelled wake up honey! At 7:34 a.m. the nursing home administrator (NHA) entered the dining room. While the NHA was in the dining room RA #1 did not yell at any residents. At 7:40 a.m. the NHA left the dining room. At 7:41 a.m. RA #1 attempted to wake up Resident #23 again and yelled Resident #23 wake up! Resident #38 was self-propelling in the wrong direction and RA #1 yelled Resident #38! You are going the wrong direction! Go in a different direction! Resident #38 did not respond to RA #1. RA #1 then grabbed his wheelchair and rotated him in the correct direction. RA #1 shook her head and rolled her eyes as she walked away from Resident #38. At 7:43 a.m. RA #1 sat a table away from Resident #23 and yelled at her if you are not going to eat you can go back to your room. VI. Staff interviews RA #1 was interviewed on 5/9/24 at 3:42 p.m. RA #1 said she had worked for the facility for many years. RA #1 said she assisted with breakfast every day and helped the residents who needed assistance with eating. She said if she felt the resident was not safe falling asleep in the dining room she tried to encourage them to wake up and eat. She said after three attempts at waking up the resident she asked another staff member to take the resident back to their room so they could sleep. She said she did not feel like she was yelling at the residents during breakfast on 5/9/24. She said some residents were hard of hearing and needed staff to increase their voices so the residents heard what was being said. She said it took a lot of encouragement and patience to support the residents during breakfast and sometimes staff needed to make their voices stern but she was not yelling. The NHA was interviewed on 5/9/24 at 4:00 p.m. The NHA said some of the staff were stern with the residents and it was often because of the staff' s misconception that residents had to eat their meals no matter the circumstances. The NHA said some of the staff felt it was in the residents' best interest to eat and drink at each meal so the staff continued to encourage the residents repeatedly. The NHA said she reminded the staff that the residents had the right to refuse breakfast and go back to bed. The NHA said she told the staff it was their job to encourage them politely and if the residents refused then let them leave the dining room. The NHA said the facility had some residents with weight loss and the staff did not want that to continue so they encouraged the residents to wake up and eat their food. Certified nurse aide (CNA) #3 was interviewed on 5/9/24 at 11:13 a.m. She said some staff yelled at residents in the dining room and it really only happened during breakfast. She said the staff yelled at the residents who fell asleep while eating or if they were hard of hearing then the staff raised their voices or yelled at them.

Based on observations, record review and interviews, the facility failed to ensure effective fall prevention interventions for one (#51) of seven residents reviewed for falls of 30 sample residents. Specifically, the facility failed to: -Accurately assess Resident #51 for fall risk after a fall outside of the facility; -Implement immediate actions to prevent further falls/incidents after Resident #51 reported a fall; -Reassess Resident #51's risk for falls after the resident reported a possible fall; -Conduct a timely investigation after Resident #51 reported a fall; -Ensure Resident #51's call light was within reach; and -Ensure adequate supervision to prevent unsafe resident self-transfers. Record review showed the resident was evaluated for increasing weakness concerns by nursing staff, and a risk for falls after a fall outside of the facility. Interviews with the director of nursing showed the resident was declining prior to his fall with injury; however, there were no new interventions implemented at that time to prevent falls. These failures resulted in the resident experiencing one self-reported fall and three unobserved falls, one of which resulted in a [MEDICAL CONDITION] requiring hospitalization with surgical intervention of the fracture. Findings include: I. Facility policies and procedures The Preventing Falls policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 1/23/2020 at 10:00 a.m., documented identifying residents at high risk and planning appropriate care and keeping necessary items within reach can reduce the risk for falls. Residents at high risk for falls were those with a history of falls, those who use assistive devices, and those with changes in health status. The facility shall investigate cause of accidents as per facility accident/incident protocol, monitor the residents response to the accident, develop and implement an individualized plan as part of the care plan, and evaluate and revise the plan as needed. Preventing falls was the responsibility of all staff members and the resident, the staff must be sure the environment was safe, health needs were met, and the residents had the necessary information to promote their own safety. The Accident/Incident Report policy, no date of inception or revision, provided by the NHA on 1/23/2020 at 9:12 a.m., documented the accident/incident report was completed for all unexplained bruises or abrasions, all accidents or incidents where there was injury or the potential to result in injury: allegations of theft and abuse reported by residents, visitors, or others; and resident to resident altercations. An investigation would be initiated within 24 hours of the discovery of a resident with an injury of suspicious or unknown origin, or receipt of an allegation of abuse. Investigation and findings must be documented and submitted to the long term care facilities medical staff for review. II. Resident #51 A. Resident status Resident #51, age 84, was admitted [DATE]. According to the January 2020 computerized physician orders [REDACTED]. According to the 9/10/19 minimum data set assessment (MDS), the resident was moderately imparied cognitively with a brief interview for mental status (BIMS) score of eight of 15. The resident did not reject evaluation of care including activities of daily living. The resident required limited one person physical assistance with transfers and bed mobility, toilet use, and personal hygiene. The resident was not steady but able to stabilize without human assistance with walking, turning, moving on and off the toilet, and moving from a seated to standing position. The resident used a walker, exhibited shortness of breath with exertion such as walking, and was occasionally incontinent of urine. B. Resident interview Resident #51 was interviewed on 1/20/2020 at 3:41 p.m. The resident said he fell a few weeks back trying to go to the bathroom and hurt his leg. He said it hurt him, but the facility gave him some medicine which helped. III. Record review A. Resident care plan The resident's care plan, problem onset 3/13/13 and revised 3/10/18, showed the resident had a potential for alteration in skin integrity related to dependency on staff/family for assistance with ADLs and cares with occasional incontinence. The resident problem of [DIAGNOSES REDACTED]. The resident's problem onset for potential for injuries/falls as he was ambulatory and has a portable oxygen tank that he keeps on his walker was initiated 3/15/13 and revised 3/1/18. Approaches to this problem were to ensure the room was kept free of clutter and safety hazards, and keep call light and frequently used items were within easy reach. B. Resident falls 1. Fall number one a. Resident accident/incident report A resident accident/incident report, completed 9/10/19, showed the resident experienced a fall outside of the facility while out on pass. The Resident stated he fell on the concrete and hit only his right hand. A bruise was noted to the right hand of the resident. The incident was not reported immediately by the resident or the group that took the resident out on pass. Immediate post incident action was to encourage residents to notify staff when a fall occurs so that the staff could take immediate care of the resident. A narrative of the investigation, completed by the director of nursing (DON), on 9/10/19 read, Resident reports that while he was out on pass with (local community group), he fell on the sidewalk. Resident states that he wasn't paying attention, and just fell . Resident's disease has progressed, and after discussion with PT (Physical therapy) and management, will have the resident use a wheelchair when going out on pass. Neuros were started as per protocol once staff were notified of the fall, all neuros and vital signs have been within normal limits. No other injuries noted other than the bruise to hand. b. Fall risk assessments 1) September 2019 assessment A fall risk assessment completed 9/19/19 (nine days after incident report) showed: Type of fall assessment: Monthly Mental Status: Score 0 as resident was assessed to be alert and oriented x 3, or comatose Falls in past three months: Score 0 as resident was assessed to have had no falls in last three months. Ambulation/Elimination status: Score 0 as resident was ambulatory and continent Vision status: Score 0 as resident vision was assessed as adequate with or without glasses. Gait Balance: Score 1 as resident required use of assistive devices such as walker. Systolic Blood pressure: Score 0 no drop between lying and standing, or not done. medications: [REDACTED]. Predisposing diseases: Score 2 as resident had 1-2 predisoposing conditions. Total score of 5, 10 or above deems high risk for falls and should be monitored closely for fall precautions. 2) October 2019 assessment The October 2019 fall risk assessment was the same selections and score as the September 2019 assessment. Fall risk assessments were requested for up to current January 2020; however, only up to October 2019 were provided. c. Occupational therapy notes An occupational therapy daily treatment note, completed 9/19/19, showed the resident was having more difficulty with walking when on outings and was in need of a wheelchair. An occupation therapy plan of care evaluation, completed more than a month later on 11/2/19, showed the reason for referral was due to increased weakness noted. Orders received to upgrade his restorative program. The resident had been at the long term care facility since 3/2013 and had been mobile around the facility with a four wheeled walker, but nursing stated that recently he had seemed less steady and more fatigued after returning from outings. Therapy precautions in place were oxygen, falls, tremors, and [DIAGNOSES REDACTED]. d. Facility failure The facility selected on both the September and October 2019 fall risk assessments the resident had no previous falls in the last three months. However, the incident report, dated 9/10/19, showed the resident experienced a fall while outside of the facility on pass and suffered a bruise to his right hand. This section of the fall risk assessment should have been selected as score 2 as the resident experienced 1-2 falls in the past three months. Under the section of ambulation/elimination, the facility selected the resident was ambulatory and continent. However, according to the resident's MDS assessment and care plan, the resident experienced episodes of incontinence. The facility should have selected score 4 ambulatory and incontinent, which would have increased the resident's total fall risk score to 11 making the resident at risk for falls. 2. Fall number two a. Accident/incident report An accident/incident report, dated 12/18/19 at 7:30 p.m., completed due to bruises of unknown origin, documented an unobserved fall with head bump/injury in the resident room. Staff observation notes showed the right side of the resident's face was swollen, hard, warm, and bruises under chin. The resident reported, I hit something going to the bathroom. Actions taken were noted to be neuro checks, offered ice packs but patient declined. There were no interventions documented under the the section actions taken to prevent further accident/incidents. b. Record review A nurse's note dated 12/18/19 at 7:30 p.m. read, Certified nurse aide (CNA) reported to this nurse that the resident's right cheek was swollen. The nurse assessed it, cheek was warm to touch. Resident denied pain. CNA after getting vital signs noticed when resident laid down that there was bruising under the chin, upon reassessing and interviewing the resident, neuros were started. Resident stated he hit his cheek on something while going to the bathroom. This nurse questioned resident as to if he fell . The resident did not answer the question directly but did say he may have put himself on the bathroom floor. There was bruising, two large one small, under chin and redness throughout. There was a hard spot in the middle of cheek on the right side of the face, vital signs within normal limits, temp was a low grade fever in the 99's. Resident resting, call light within reach, resident refused ice pack. A nurse's note on 12/19/19 at 12:00 p.m. documented the resident had increased swelling, redness, and warmth to the right ear and neck area. The resident was started on antibiotic therapy for suspected [MEDICAL CONDITION]. The follow up investigation from the reported fall from the resident, completed by the director of nursing (DON) and dated 12/20/19 no time stamp (more than 24 hours after resident self-reported possible fall), documented, Resident reports he thinks he fell out of bed causing the injury to his ear. However, resident did not call for help to get up before fall or report the fall until staff noticed ear. Resident has a scratch to his right ear, believed to be caused by resident himself, as resident has been seen on several occasions sitting in his recliner scratching at neck, face, mostly due to his Parkinson tremors. Suspected that the resident scratched self, causing wound then infection. If resident did fall, the resident would not have the ability to get up off the floor on his own and would need assistance. Since the resident did report a fall, routine neuros started per protocol and antibiotics started for wound/[MEDICAL CONDITION]. There was no fall risk assessment provided after the resident self-reported fall. Further nursing notes and the December 2019 Medication Administration Record [REDACTED]. c. DON interview The DON was interviewed on 1/23/2020 at 9:48 a.m. The DON said when a resident reported a fall they would make sure they are safe. If they determined the resident was OK to keep in house they would start vital signs, neuro checks, and monitor the resident. They would immediately start an investigation to determine the cause of the fall. She said investigations of falls were completed by her, and depending on when the fall happened it could impact the investigation. If it were to happen on the weekend when she was not there, she would conduct it when she returned to the building. She said even if the resident was not alert and oriented she would still ask the resident to see if they could recall the accident. She said she sometimes would start the investigation right away, but not get to the report for a couple days. She said the investigations and actions to be put in place were documented on the accident/incident reports. She said the resident's self-reported fall on 12/18/19 looked like classic [MEDICAL CONDITION] from a scratch, but the resident said he must have fallen and since he reported a fall they started their fall protocol on the resident. The DON said she was unsure of why the staff member did not document any actions to prevent further incidents on the investigation incident form, and the delay on the follow up investigation not being dated until 12/20/19 could have been because she didn't get to the report until that day. She said they honestly did not feel like the resident fell so no changes were made to his care plan in relation to falls, only to the skin issues at the time. She said the bruising was caused by the shingles rash. She said it was determined the resident could not have gotten up off the floor because they felt he was physically unable to due to needed physical assistance to do almost all things. d. Facility failure The facility failed to implement immediate actions to prevent further incidents after Resident #51 self-reported a possible fall. An investigation into the resident's fall was delayed, and not completed in a timely manner. No changes were made to the resident's care plan in relation to falls or new interventions or precautions put in place to prevent further falls. Therapy documentation showed the resident was referred for increasing weakness by nursing, and fall precautions were part of the therapy plan. Interventions after the first fall outside of the facility were to encourage the resident to report falls so staff could take care of the resident. The resident reported a possible fall; however, no further interventions were noted. e. Nursing notes A nursing note dated 12/26/19 at 3:00 p.m., showed Resident #51 was on intravenous therapy without complaints of dizziness on that shift. The resident was reminded to call for assistance with transfer. A nursing note, same date 12/26/19 no time stamp, showed the resident was more tired than baseline and fluids were encouraged. 3. Fall number three a. Accident/incident report An accident/incident report, completed 12/26/19 at 8:25 p.m. provided by the facility, showed the resident experienced an unobserved fall without head injury in the resident's room. The staff observation of accident documented a certified nurse aide (CNA) was walking down the hall and saw Resident #51 on his knees by his bed. Actions taken were documented, the RN was notified, an assessment completed, and vital signs and neuro checks were completed. Actions taken to prevent further accident/incidents were noted to remind the resident to use his call light when needing assistance. b. Nurse's note The registered nurse's note from 12/26/19 at 8:30 p.m. revealed the resident was found on the floor by a CNA, when the nurse arrived the resident was sitting on the bed. Neuro checks and vitals were within normal limits. The resident at that time denied pain, and the family and facility administration were notified of the fall at 8:43 p.m. The resident stated he reached for the TV remote and fell on the floor but he was not very descriptive about the incident. Resident then received intravenous (IV) medication which at the end of the treatment the IV infiltrated, the resident still denied pain from the fall at that time. The nurse reported she was helping the resident stand and the resident was not able to bear weight and complained of right knee pain. The physician was notified of the change in condition and the resident was transported to the local emergency department. The nurse noted the x-ray from the hospital showed a right [MEDICAL CONDITION], and he was reported to have abnormal labs (unrelated to fall) and would be kept inpatient. A follow up nursing note dated 12/27/2019 at 4:25 a.m. documented the hospital had called the facility relaying the resident's family decided on surgery and Resident #51 was transported to a larger medical center in a nearby city. c. Hospital inpatient records Hospital records from Resident #51's inpatient stay, admitted [DATE], showed the resident required surgical intervention with a right hip nail for a right osteoporotic intertrochanteric fracture status [REDACTED]. 4. Readmission and fall number 4 a. Resident #51's face sheet and progress notes showed he was readmitted to the facility on [DATE]. b. Accident/incident report An accident/incident report dated 1/4/2020 at 5:30 p.m., showed the resident was found on the floor near his wheelchair on his knees while going to or from the bathroom alone. Immediate actions taken were noted to include vital signs and neuro checks, and an assessment of his range of motion with lower and upper extremities which were within normal limits. Further post-incident actions were noted the resident was placed near the nurses station. c. Investigation A follow up investigation, dated 1/6/2020 at 6:12 p.m., completed by the DON, documented the resident reported he did remember falling onto his knees, but he could not recall what made him fall or how he fell . The resident stated he had been on some different medications, and maybe that was the cause. The resident had recently returned from the hospital after [MEDICAL CONDITION] and forgot to call and ask for help with transfers; no new injuries were noted from the fall or new medications. 5. Fall number 5 a. Accident/incident report According to the accident/incident report dated 1/8/2020 at 1:45 p.m., the resident was found on the floor after the hall CNA and MDS nurse heard a loud noise. The resident's window was broken. Immediate actions taken were neuro checks, the resident was removed from the area of broken glass, vital signs and range of motion assessed. The resident was toileted and showered to ensure all broken glass was off the resident. Other immediate post-incident actions were noted to encourage the resident to ask for help and use his call light, and to remind the resident he has to get assistance now since returning home from the hospital after having surgery from his [MEDICAL CONDITION]. b. Investigation An investigation, completed by the DON on 1/8/2020, revealed the resident reported he was getting up to go to the bathroom before he went in his pants. The resident apologized several times for falling and breaking the window. The DON was present at the time of the incident and assisted with the assessment. The resident forgets he recently had a [MEDICAL CONDITION] and surgery for [REDACTED]. Re-education and reminders to resident. No injuries noted from fall. Resident was taken to bathroom and toileted after assessment and determined to be stable. The resident's IV pole was determined to be the cause for the glass breaking as the investigations showed the resident grabbed the IV pole as he was falling and the pole hit the window. IV. Observations On 1/20/2020 at 3:27 p.m., Resident #51 was observed in his room self transfering from his recliner to his wheelchair. The resident appeared to be unsteady and shaking due to his disease process. CNA #7 was observed rushing to the resident's room and was overheard telling the resident he was not supposed to get up by himself. At 3:46 p.m. after CNA #7 toileted the resident and returned him to his recliner, the CNA left the room with the call light out of reach of the resident. An unknown maintenance staff member was also observed entering the resident's room to help the resident with his television remote, and after the maintenance staff left, the call light was still out of reach of the resident. On 1/21/2020 at 8:43 a.m. Resident #51 was observed in the resident common area self transferring from a recliner to his wheelchair. The resident was having difficulty pivoting to the wheelchair and was up for several seconds before the activities director noticed him and came over to help him. On 1/21/2020 at 11:55 a.m. CNA #7 was observed exiting Resident #51's room after assisting the resident with toileting. The call light was observed to be over on the resident's bed out of reach while he was in the recliner. On 1/22/2020 at 4:38 p.m. Resident #51 was observed standing in his room, hunched over and shaking while unsteadily holding on to his wheelchair, attempting to pivot. There were no staff around. His call light was attached to his recliner and not within reach. V. Staff interviews CNA #1 was interviewed on 1/22/2020 at 1:04 p.m. She said Resident #51 required extensive assistance with cares after his recent hip injury. She said he used to require limited assistance with his walker, but now they had to toilet, dress, and help him with almost everything. She said he was not supposed to self transfer, but he loved to try. Because of that he was one they had to watch all the time. She said they tried to keep him up front by everyone and staff, so they could keep an eye on him. She said they don't take him back to his room by himself because he would just try to get up by himself. She said Resident #51 did not like to use his call light, but instead he liked to verbally ask for his needs. However, she said with reminding he would sometimes use the call light. She said prior to the fall he wasn't a fall risk and he did not have many falls. She said he was walking with a regular walker with wheels prior to the injury. After the fall she said they could not leave him alone anymore. She said he did not refuse care and was very nice, and he was very alert and oriented and able to make his needs known. She said prior to leaving a room all staff should ensure residents' beds were in the lowest position if they were in bed, and their water and call light were within reach. RN #1, also the facility charge nurse, was interviewed on 1/22/2020 at 2:00 p.m. She said she had been working at the facility for a year and was familiar with Resident #51's cares. She said Resident #51 required pretty extensive assistance with everything, but he could feed himself. She said he was not supposed to self-transfer and they tried to keep a close eye on him. She said prior to the fall with his injury, he was very mobile with a walker. She said they were trying to keep Resident #51 up front so they could see him, but when in his room they really tried to encourage him to ask for assistance and use his call light. She said prior to his fall he was not a fall risk, but interventions in place were assistance with using the restroom and using his call light. She said most of the time he was alert and oriented and able to make his needs known, but sometimes he could be disoriented to time. She said there were a lot of times the resident would use his call light as he was already transfering himself. She said the resident's mobility had decreased and assistance needs increased since the fall with the injury, but he had not really complained of pain. She said staff should ensure residents' call lights were within reach, beds in the lowest position, and water or anything they needed were within reach prior to leaving a resident's room. The DON was interviewed on 1/23/2020 at 9:48 a.m. She said all staff, not just nursing, should make sure residents' needs had been met, call light within reach, and anything they needed like water were within reach prior to exiting a resident's room. She said Resident #51 was not as alert and oriented as he used to be, and some days were better than others. She said he was not always able to make his needs known. She said he almost always needed full assist with cares now, but even prior to the fall with injury he needed more assistance due to a slow decline. She said he had a lot of shaking and tremors and required lots of assistance because of that prior to his fall. After the fall she said mostly an increased need with transfers was required due being more cautious with his hip. She said he would use his call light as he was transferring and lacked the cognition to wait for assistance from staff. She said the call light was not appropriate for the resident, and a lot of the time he would yell at them to ask for help especially before the fall. Now, he was using the call light just as he transferred. She said he had not been a fall risk prior to the fall, but he was placed on IV therapy prior to the fall. She was unsure if IV therapy increased the risk for falls. She said Resident #51 was not supposed to self transfer, and they were working on that as much as they could. She said interventions after the fall were trying to help as much as possible not to transfer alone, and keeping the resident in activities so he could be supervised, as well as working with therapy. She said Resident #51 had fallen again since the fall with the [MEDICAL CONDITION], and they were trying with the resident. She said every time he fell they tried to keep him out of his room as much as possible without neglecting his wants to be in his room. They were trying to respect his wishes at the same time.

Based on observation, record review and staff interview, the facility failed to ensure that one (#85) of three residents reviewed for catheter use, out of 42 sample residents, who entered the facility without an indwelling catheter, was not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The facility failed to assess and document the reasons for initiating and continuing the use of an indwelling Foley catheter, failed to request or acquire a urology consult, and failed to provide care and services to restore as much normal bladder function as possible for the resident. These failures contributed to extended catheter use, discomfort, pain, urinary tract infections and bleeding. The findings: I. Expectations According to the "Guideline for prevention of catheter-associated urinary tract infections 2009" by the Healthcare Infection Control Practices Advisory Committee page 11, undated, " ...Example of inappropriate uses of indwelling catheters: as a substitute for nursing care of the patient or resident with incontinence." According to the 2007 "Fundamentals of Nursing-Caring and Clinical Judgment" 3rd edition, page 777; "Because of the high incidence of infection, an indwelling catheter should be removed as soon as possible..." According to the 2004 "Primary Care of the Older Adult: A Multidisciplinary Approach" 2nd edition, page 487; "Indwelling Foley catheters should be the treatment of [REDACTED]. A policy for "Urinary Catheter Care" number 2-12.48 was provided on 09/24/14 which outlined the following "Catheter care is performed appropriately to prevent complications caused by the presence of an indwelling catheter." The policy did not outline indications for use of a catheter. II. Resident #85 Resident #85, age 82, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident's brief interview for mental status (BIMS) score was 7 indicating severe cognitive impairment. Behavior was not exhibited for physical, verbal, or other behavioral symptoms. This resident did not exhibit behavior for rejection of care or wandering. For toilet use, the resident required extensive assist with one person physical assist. She had use of an indwelling catheter with no urinary toileting program trialed. She was frequently incontinent of bowel with no rating for urinary incontinence due to the catheter use. She had a [DIAGNOSES REDACTED]. Resident Status: (1) The resident's care plan, last revised on 09/09/14, identified the problem, "Resident has potential for alteration in skin integrity related to being incontinent of bowel and bladder and being dependent on staff/ family for assistance with mobility with history of UTI." -The goals included, "Resident will have no reddened or open areas next 90 days." -The interventions included "Encourage/assist resident to change position every 2 hours and PRN (as needed) ...provide incontinence care with soap and water past each episode of incontinence. Ensure clothing is clean and dry and sheets are wrinkle free ..." (2) The resident's care plan, last revised on 08/21/14, identified the problem, "Resident has potential for urinary tract infection due to indwelling catheter." -The goals included, "Resident will remain free of UTI over next 90 days." -The interventions included, "Encourage fluid intake every shift, maintain closed drainage system. Use aseptic technique when emptying bag, peri-care to include: cleanse urinary opening with soap and water per protocol, monitor for signs and symptoms of UTI: foul/cloudy urine, elevated temperature, low back pain, or burning/ frequency upon voiding. Alert charge nurse for notification of physician as needed, change Foley catheter every month and prn, change Foley drainage bag every week and prn, offer cranberry juice and/or water every shift, monitor and record I/O (intake and output) every shift, administer [MEDICATION NAME] (antibiotic) as ordered by physician for UTI." There was no current order for an antibiotic. A. Observations: -On 09/23/14 at 6:00 p.m., the resident was observed to have been sleeping in the recliner in the main living area. Her catheter bag was full of dark yellow urine. -On 09/24/14 at 11:20 a.m., the resident was observed to have been sleeping in the recliner in the main living area. Her catheter was full of thick, dark yellow urine. B. Record Review According to the Medication Administration Record [REDACTED]." This was marked as last completed on September 10, 2014. According to the most recent H&P (history and physical) dated on 08/04/14, " ...She presented with vaginal bleeding with clots ... has history of hysterectomy with removal of cervix due to [MEDICAL CONDITION] ... has indwelling Foley catheter due to constant urge to urinate ... family concerned about mass/tumor, compression on bladder, bleeding ..." The resident was discharged back to the facility the same day in stable condition. The CT (computed tomography) imaging of the abdomen and pelvis, dated 08/04/14, revealed no pelvic mass and no bowel obstruction. According to the H&P dated 02/05/14, the resident was "found to have a UTI and was started on an antibiotic to end on 02/06/14 ... The patient did experience some [MEDICAL CONDITION] early in her hospitalization , but did not require Foley catheter and once she was more mobile she has been able to void adequately ..." There were no urologist recommendations or visits documented in the medical record. Urology records were requested during the survey and had not been received as of 10/02/14. According to the departmental notes: -On 02/07/14, " ...resident slipped off side of bed and onto floor mat..." -On 02/10/14, " ...resident attempting to get out of bed ..." -On 02/11/14, " ...resident continues to get out of wheelchair without assistance ..." -On 02/13/14, " ...physical therapy told family that resident was doing 'worse.' Family said that their goal is for her to return home at some point ..." -On 02/13/14, " ...resident keeps trying to transfer self ... constantly wanting to go to room or bed, but when she is in bed she does not stay there, she crawls out of bed to fall mat ..." -On 02/17/14, " ...resident continues to attempt to get out of bed multiple more times throughout the night ..." -On 02/18/14, " ...after breakfast, she participated with therapies then wanted to go back to room ...she kept shouting to go to bed ..." -On 02/23/14, " ...resident has been very whiny and needy this shift ..." -On 02/26/14, " ...was called to room by CNA to find resident on floor next to chair, no injuries noted ..." -On 02/28/14, " ...continues to request to go to the bathroom frequently ..." -On 03/08/14, " ...wanting to go to the bathroom frequently ... order written for UA ... family states they preferred not to have her catheterized ..." -On 03/16/14, " ...will begin restorative bladder retraining program tomorrow 03/17/14 ..." -On 03/19/14, " ...requested to go to the bathroom every 5 to 10 minutes ..." -On 03/25/14, " ...continues bladder training program without success ..." -On 04/02/14, " ...continues to ask to go to the toilet frequently even after being toileted ..." -On 04/04/14, " ...very confused, fixated on the toilet, it is noted that she is having increase in what appears to be vaginal discharge that is brownish in color and has a foul smell ..." -On 04/05/14, " ...continues to want to be taken to the toilet very frequently ...continues to have vaginal discharge ... she has a history of [MEDICAL CONDITION] when she was younger and family wanting to know if that could be something to worry about ..." -On 04/10/14, " ...resident found on floor ... one side of lap buddy off ..." -On 04/11/14, " ...resident has been discontinued from bladder training due to non-compliance ..." -On 04/12/14, " ...order to place Foley ..." -On 04/12/14 at 12:42 p.m.," ...noted that urine in catheter tubing is blood tinged ... she tried to get out of bed last night and pulled out her catheter and it had to be replaced ... resident does complain of pain in that area when sitting down from standing up ... readjusted catheter ..." At 3:08 p.m., "resident continues to pull at lap buddy on wheelchair and can remove it at times ... urine noted dark amber with red tinged color ... resident has pulled on catheter once this shift ... behavior continues of wanting to be toileted, catheter explained and then a bowel movement is needed. She has requested the toilet 42 times this shift. At 1520 (3:20 p.m.), was given Tylenol for mild pain in her vagina effective at this time ..." -On 04/13/14, " ...at this time, catheter has not been effective but it does remain patent continues to drain dark amber urine with slight blood tinge color ..." -On 04/14/14, " ...this morning, resident was very lethargic, did not want to eat morning meal. She kept saying that she is very sick, wanting to know what is wrong with her ...there is blood in her catheter tubing and she did complain of pain ..." -On 04/15/14, " ...continues to want to go to the toilet frequently when she is told she has a Foley catheter, then she stated that she has to have a bowel movement ...she was found sitting on the toilet when she had taken her lap buddy off ...she is very anxious, states she is not feeling well ..." -On 04/19/14, " ...resident began (1) [MEDICATION NAME] (antibiotic) for UTI ...noted also started on [MEDICATION NAME] (urinary tract [MEDICATION NAME]-pain killer) ..." -On 04/28/14, " ...resident was asleep this morning and staff found her catheter had been pulled out, new Foley as re-inserted ..." -On 04/30/14, " ...resident was observed dragging the bag from her wheelchair, and bag repositioned ...has completed [MEDICATION NAME] for UTI ..." -On 05/01/14, " ...Urine amber with a pink tint ..." -On 05/08/14, "POA (power of attorney) would like to consider hospice if resident could get a terminal [DIAGNOSES REDACTED]. -On 05/19/14, " ...resident continues to verbally request to go to the bathroom to urinate or to have a bowel movement ..." -On 05/28/14, " ...started on (2) [MEDICATION NAME] (antibiotic) for UTI ..." -On 06/02/14, "At 2:19 a.m., resident had pulled out Foley catheter, re-inserted ...reddish colored urine ...At 6:50 a.m., resident had pulled out catheter ...resident was upset that the nurse had put another catheter back in ...resident started kicking, hitting, throwing things, pushing, and making rude remarks ...trying to pull out her catheter again ..." -On 06/04/14, "resident continues to have repetitive requests to go to the bathroom, she is given [MEDICATION NAME] with fair results. Resident color remains poor, having increased shortness of breath, increased swelling ..." -On 07/27/14, " ...wanting to go to the toilet frequently to urinate ...gross hematuria (blood in urine) ...behavior improved after her Foley was replaced ..." -On 07/30/14, " ...resident is started on (3) [MEDICATION NAME] (antibiotic) for UTI ..." -On 08/04/14, " ...she is having bright blood dripping into the toilet, did not appear to be coming out of the rectum, it appeared to be coming from her vagina ...transported to ER (emergency room ) ..." -On 08/05/14, "continues to have moderate amount of blood that appears to be coming from her vaginal area, blood is now more watery ..." -On 08/08/14, " ...resident received last dose of [MEDICATION NAME] for UTI ..." -On 08/14/14, "At 10:19 a.m., resident pulled out her Foley catheter this morning. Foley replaced ...At 9:21 p.m., resident had disconnected her bedside bag from her Foley catheter ..." -On 08/21/14, "At 4:03 p.m., continues to request to go to the bathroom and urine currently has a pink tint to it ...At 11:51 p.m., started on (4) [MEDICATION NAME] (antibiotic) IM (intramuscular) for UTI ..." -On 08/28/14, " ...completed [MEDICATION NAME] IM on 08/27 ..." -On 09/20/14, " ...resident is asking staff to take her to the bathroom. When staff reminds her that she has a catheter, she calls them names and rolls away ..." According to the physician notes: -On 04/11/14, "Will insert a Foley catheter and see how much of this fixation on needing to urinate is real ..." -On 04/18/14, "A Foley catheter was placed as patient was constantly saying she needed to urinate. The presence of the catheter did not change this behavior ...Seems the real issue is she doesn't like the lap buddy and she wants if off and the only way to get it off is to say she has to go to the bathroom ..." -On 05/02/14, "Patient with obsession and delusions around toileting is reportedly out of control. She has a Foley catheter in and she's come to realize now that she doesn't have to urinate so she's changed to saying she has to have a bowel movement. Will try having patient supervised in a merri-walker for an hour a day and see if being able to stand up and not be restrained in the wheelchair makes a difference ...seems that a lot of her behaviors are geared towards getting out of the wheelchair ..." -On 05/23/14, "She is doing better on the increased [MEDICATION NAME] but she still has moments when she gets fixated on something and won't let it go ..." -On 07/30/14, "Based on urinary changes with cloudy urine that was foul smelling, her urine was sent for evaluation ...Urine culture: E. Coli, resistant to most antibiotics ...we will treat with oral antibiotic the organism is most sensitive to." Physician notes and departmental notes were reviewed and void of any documentation related to monthly re-evaluation of the need for a Foley catheter. C. Staff Interviews A certified nurse aide (CNA #16) was interviewed on 09/24/14 at 3:05 p.m. and she stated that this resident had a catheter and, "That's part of the wanting to go to the bathroom. It pulls on her and makes her want to go to the bathroom." When asked why this resident had a catheter, she stated that she didn't know and that initially it was because of her frequent urination. Medication aide #13 was interviewed on 09/24/14 at 3:22 p.m. She stated that this resident had a catheter due to her behavior issues of asking for the bathroom repeatedly. She said she thought it helped the resident feel more secure. A licensed practical nurse (LPN #11) was interviewed on 09/24/14 at 3:37 p.m. She stated that this resident had a catheter due to behaviors. She said she thought initially the catheter was for her bladder not emptying all the way, but now it was for behaviors. The director of nurses (DON) was interviewed on 09/25/14 at 8:09 a.m. She stated that this resident had a catheter due to her always asking to go to the bathroom and that it "doesn't help." The medical director/resident primary care physician was interviewed by phone on 09/25/14 at approximately 1:40 p.m. He stated that this resident was receiving a catheter because of her incontinence, "part incontinence and part behaviors." He stated that the family also requested the catheter. When asked if that was an appropriate reason for catheter use, he stated "absolutely." He stated that it was more effective than when she did not have it.

Based on observations, record review and interviews, the facility failed to ensure that one (#29) of eight residents reviewed for nutritional risk, out of 42 sample residents, maintained acceptable parameters of nutritional status. Specifically: -The facility failed to offer resident #29 nutritional supplements as ordered; and -The facility failed to identify and address the resident's severe weight loss in a timely manner. The failures contributed to the resident experiencing severe weight loss of 12 pounds within two months. The findings included: A. Facility Policy The nursing home administrator (NHA) provided the facility's policy and procedure titled, "Nutrition at Risk," undated, which included in pertinent part: "Policy: Assessment identification of risk factors will be identified as such for clinical baseline data and/or investigation purposes based on the following criteria: 1. Residents with pressure ulcers 2. Residents with unplanned weight loss or gain in the following suggested parameters: 1 month: 5% significant loss, >5% severe loss ...3 months: 7.5% loss, >7.5% severe loss ...6 months: 10% significant loss, >10% severe loss ... 5. Residents who leave more than 50% of their meal food uneaten at most meals ... All weights will be reviewed by the Dietary Manager to determine weight variances. NAR (Nutrition at Risk) score assessment will be completed by DM upon admit and quarterly ..." B. Resident #29 Resident #29, age 83, was admitted to the facility originally on 7/9/14 and then readmitted on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score was 9, which indicated she was cognitively impaired. She had adequate hearing, speech and vision and was independent with eating. She had [MEDICAL CONDITION] signs and symptoms present that included inattention, and mood behaviors of feeling down, depressed or hopeless. She had feelings of tiredness and having little energy and trouble concentrating on things that occurred two to six days, and rejection of care that occurred one to three days. She required limited assistance with bed mobility, transfers and toilet use, and extensive assistance with dressing and personal hygiene. The resident had been transferred to a sister facility's secure unit for behavior management on 7/16/14, and returned to the facility on [DATE]. Record Review: The resident's care plan, dated 7/14/14 and last revised 9/19/14, identified the following problems, goals and approaches: "(Resident #29) admits with ideal body weight range-Potential for alteration in nutrition related to inadequate intake of meals, snacks, supplements to maintain nutritional stability, weight loss potential. Refuses meals, snacks, supplements. Will order/accept then eat 1-2 bites and state 'No,' leaves table. Can be very agitated. May be combative if pressured." -The goal was that "(Resident #29) will maintain nutritional stability without significant weight changes as evidenced by adequate intake of meals, snacks, supplements for 90 days." -The approaches included, "Provide (Resident #29) with meals of choice as enhanced dining allows. Offer alternate meal if intake is less than 50% Encourage (Resident #29) to eat meals, snacks, but do not 'force.' Provide supplement per order. Monitor/record intake every day. Monitor weight weekly and as needed for significant changes. Report to nursing should changes occur. If possible, serve no desserts, fruit juice, breads, potatoes or pastas." The resident's weights were reviewed from 7/9/14 through 9/5/14, which included the following: -07/09/14 = 137 pounds -07/14/14 = 132 pounds -08/27/14 = 132 pounds -09/05/14 = 125 pounds She had a 12 pound weight loss in two months, which calculated to 8.7 percent, which is a severe weight loss. Additionally, the eight days between 8/27/14 and 9/5/14, the resident had a seven pound weight loss, which calculated to 5.3 percent, and is also a severe weight loss. The computerized physician's orders [REDACTED]. -"Offer nutritional supplement every six hours as needed for meal intake less than 50 percent, and document percentage of amount consumed on supplement button in smart charting." The "Meal and Snack" intake records were reviewed for resident #29 from 7/10/14 through 9/25/14, which included: -July = Ate less than 50% of her meals 13 times out of the seven days she was in the facility. -August = Ate less than 50% of her meals eight times out of the six days she was in the facility. -September = Ate less than 50% of her meals 10 times out of the 25 days she was in the facility. The medication administration record (MAR) for July 2014 was reviewed. The order to "Offer nutritional supplement every six hours as needed for meal intake less than 50 percent and document percentage of amount consumed on supplement button in smart charting" was void of documentation, which indicated that it had not been given. According to her meal intake above, the resident should have been offered the nutritional supplement a total of 13 times, which was not done. The MAR for August 2014 was reviewed. The order to "Offer nutritional supplement every six hours as needed for meal intake less than 50 percent and document percentage of amount consumed on supplement button in smart charting" was void of documentation, which indicated that it had not been given. According to her meal intake above, the resident should have been offered the nutritional supplement a total of eight times, which was not done. The MAR for September 2014 was reviewed. The order to "Offer nutritional supplement every six hours as needed for meal intake less than 50 percent and document percentage of amount consumed on supplement button in smart charting" was void of documentation, which indicated that it had not been given. According to her meal intake above, the resident should have been offered the nutritional supplement a total of 10 times, which was not done. The physician's orders [REDACTED]. A progress note dated 7/16/14 written by the dietary manager included, "(Resident #29) is refusing to eat most meals, snacks, does not accept supplements. She will take a few bites, leave table, 'play' with food but not eat. She can become combative if she feels pressured. She is offered snacks, shakes. She may accept them but will not generally eat them. Will continue to offer." A "Nutritional Risk Initial Review" completed by the dietary manager on 9/4/14 included "Diet order: Regular. Percent intake: 41-65%. Comment: No fruit juice, bread, potatoes, pasta, desserts. Meal location: Dining room. Medications with nutritional implication: [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (insulin), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (antidiabetic)." The initial "Nutritional Progress Review" dated 9/4/14 included "Weight loss 5% or more in last 30 days; or 10% in last 180 days: No ...Nutritional Problem: Leaves 25% or more of foods uneaten at most meals ...Nutritional Approaches: None of the above." The section titled "Dietary Supplement between meals" was not check marked. "Food consumed-Average: 51-75%...Meal assistance needed: Independent." An additional comment at the bottom of the form included "(Resident #29) makes her own meal choices. Restrictions listed related to low sugar foods. Within ideal body weight range. Monitor for additional nutritional interventions as needed." This form was completed by the dietary manager on 9/4/14 and reviewed by the registered dietician on 9/11/14. A progress note dated 9/11/14 written by the registered dietician included "New resident familiar to me from sister facility ...Weights: 132 pounds (8/27/14), 125 pounds (9/5/14). BMI (body mass index) normal ...No labs to evaluate. Recommendations: 1) Monitor oral intakes, tolerance, labs as available, skin, weights, and care plan. 2) Will monitor weights closely." There were no recommendations for noted weight loss, and as of 9/25/14, there were no additional weights obtained on this resident. A progress note dated 9/25/14 written by the dietary manager included, "Visited with (Resident #25) at length at suppertime 9/24/14. She had requested numerous items for supper and other meals, but consumes small portions or eats ice cream. While visiting with her she stated 'I figured it out; it's me, not the food. I think I want something, then I don't want it when I get it.' I asked (Resident #29) if there is anything that 'sounds good' that we might try. She said 'No, it's just me. I can't think of anything.' When asked what her favorite meal at home was she stated 'beans and fried potatoes.' We have this on our menu as it is one of our most requested meals by other residents also. She then said, 'I know, but it's not like my mom made them.' I told her we would keep trying and if she thought of anything to please let dietary know." A review of the MAR for September 2014 documented that the resident's blood glucose results daily at 11:00 a.m. were 300 milligrams/deciliter (mg/dl) or greater on 19 days, and 400 mg/dl or greater on two days. According to the American Diabetes Association, the normal range for blood glucose is around 60 to 120 mg/dl, depending on when a person last ate. She was given Humalog insulin sliding scale coverage as needed, and staff was to notify the physician for blood sugars greater than 400. Observations: On 9/23/14 at 11:21 a.m., resident #29 was observed sitting at a table alone in the dining room. She pushed her lunch plate of food away from her, towards the center of the table. She'd eaten 100% of the pudding dessert and approximately one-third of the au gratin potatoes but did not appear to eat more than a few bites of the marinated Philly steak or the creamed peas. She asked the dietary staff for ice cream, which was provided to her. On 9/24/14 at 8:07 a.m., resident #29 was observed sitting at a table alone in the dining room. She'd eaten approximately half of a sausage patty, a few bites of scrambled eggs, and a few bites of hot cereal, and 100% of her chocolate pudding. The resident was asked how breakfast was, and she stated, "I don't like it." At 8:07 a.m., the resident propelled herself away from the table and out of the dining room independently. (Cross-Reference F364 Palatable Foods) On 9/25/14 at 8:12 a.m., resident #29 was observed propelling herself around in circles around the nurse's station multiple times. She appeared restless and kept asking staff what the date was. On 9/25/14 at 11:04 a.m., resident #29 was observed sitting at a table in the dining room, speaking to the social services director. There was a bowl of soup in front of her that had not been touched, and a package of crackers and a key lime pie. She had eaten approximately half of the key lime pie and half of one of the crackers. At 11:20 a.m., she'd eaten 100% of her dessert and the soup remained untouched. Resident Interview: On 9/24/14 at 12:32 p.m., resident #29 was interviewed and asked how lunch was that day. She stated, "Terrible. I was so constipated that I couldn't eat anything." She explained, "I also had some ice cream, and I've been filling up a lot lately on ice cream. I'm just trying to eat enough to keep it down. It seems like everything they have any more is just awful." She said that she had not previously spoken with the facility staff about how the food tasted. On 9/25/14 at 8:50 a.m., resident #29 was interviewed again and asked how breakfast was that morning. She stated, "Not very good. I just had a pancake. I'm so fed up with what's here, and I don't know what I want." Staff Interviews: On 9/25/14 at 9:35 a.m., the medication administration aid (MAA) #13 and the charge nurse #11, who routinely worked with resident #29 were interviewed. The MAA explained, "Normally I see her drinking lemonade or milk shakes all the time." She said that the resident will routinely go and get a house milk shake from the resident's refrigerator by herself and drink it, which makes her blood sugars high. The MAA was asked if the nutritional supplements for the month of September had been offered to the resident and documented on the MAR, and the MAR was void of documentation. The charge nurse stated, "Dietary is supposed to let nursing know if a supplement is supposed to be given. But I'm not going to lie to you, that doesn't always get done." On 9/25/14 at 10:00 a.m., the registered dietician was interviewed and was informed of the resident's severe weight loss, and she confirmed, "That's why she was triggered for me to see." She explained that she is not involved in the facility's weight and skin meeting, and stated, "(Dietary manager) obtains the information from the meeting and will call or email if someone needs to be seen right away." -At 11:58 a.m., after the registered dietician had evaluated resident #29, she stated, "She's on the perfect diabetic diet. I couldn't see any labs on her and would like to see an A1C (blood sugar measurement) on her to see where she is with that. She is on [MEDICATION NAME] and insulin. I don't know if it is just her refusal to eat sometimes, but I think maybe her insulin could be adjusted a little bit." She said that her "only recommendation is to check that one lab." She added, "She is a hard lady. She definitely refuses to eat sometimes. There are no new weights-there was still just the 9/5 weight so I want to monitor her and see what is going on." The dietician did not order any additional weights to be obtained. On 9/25/14 at 2:22 p.m., the dietary manager was interviewed and asked what challenges she faced with resident #29. She stated, "Getting her to eat!" She explained, "She just told me yesterday she had asked to try some of the macaroni and cheese and didn't want what we had for supper. So I went and got her a sample. She sat there and said 'You know, this is really good macaroni and cheese but I just don't want it.' I don't know if it's her taste; She's not one you are going to hold down and force it down her." -The dietary manager explained that she participates in the NAR (Nutrition at Risk) meetings, and that she was the person who collected the weight information. She confirmed that the team would be reviewing resident #29's weight loss at the meeting on 9/26/14 for the first time. She stated, "I was out of town for the last one. I could get my NAR book and look and see. She hasn't been significant at this point. We have been watching her, until we got the weight this week. I'm waiting on weights for this week, and we'll see if it is significant." -The dietary manager stated, "I don't know what else to do with her. I will go back and look and see what percentage she has lost." On 9/25/14 at 4:30 p.m., the director of nurses (DON) and nursing home administrator (NHA) were interviewed. They confirmed that the Nutrition at Risk committee met weekly, and is attended by the dietary manager, housekeeping director, DON, NHA, social services director, housekeeping director, therapy staff, MDS coordinator and the medical director. The NHA explained that the dietary manager, "Runs reports and determines how much weight they have lost; I don't know what percentage they go by, and then we will discuss it." She said, "We try to figure out what the cause is, and usually we will order a supplement." -They were asked if resident #29 had triggered as someone to look at in the NAR meeting, and the NHA stated, "No, because she has had a weight gain of seven pounds since her first admit in July." She explained that the facility did not conduct the NAR meeting on Friday, 9/19/14, because they were out of town at a conference, and said, "So tomorrow she will be on the list. We haven't met for two weeks." -They were informed of resident #29's severe weight loss, and the DON explained that she was not surprised, and said, "Her eating habits are a little erratic. She will eat (expletive) out of the snack baskets, like juice, puddings, milkshakes." She explained that recently the resident complained that she felt like her blood sugars were running low, so the DON checked her BG and, "It was in the 150s and I told her that was normal, and she ate chips and soda. Her dementia does play into it a lot." They were not aware that the resident had suffered a severe weight loss. -They were informed of the resident's elevated blood sugars, and the DON explained that the staff "Don't always notify me of those." She stated, "When they come here and they want to eat cakes and cookies, and that makes them happy, why not let them be happy? That's what insulin is for. I think taking it away is awfully cruel." She was not aware that the resident's BGs were routinely elevated. On 9/25/14 at 2:06 p.m., the resident's physician, who was also the facility's medical director, was interviewed. He confirmed that he was aware that the resident's blood sugars were elevated and explained that she had just recently been transferred back to the facility. He stated, "I know her BGs (blood glucose) haven't been as well controlled over at (facility name), and that is on my list of issues to address tomorrow." He was informed of the resident's severe weight loss, and confirmed that he had not been informed by the facility about it yet. He stated, "That makes sense that her weights are going down if her BGs are so high." On 10/8/14, a follow-up call was placed to the DON to ask if there were any more current weights for the resident after 9/5/14. She checked and said the resident's weight on 10/1/14 was 126, and that there had been no other weights in between. The DON said, when asked, that 9/5/14 was her last weight, and if residents were on regular monthly weights, there was no set day or date, but they would typically be weighed the first week of the month. Although the resident had experienced severe weight loss of 12 pounds in two months, the concerns and findings above regarding the resident's weight loss had been discussed with the facility team during the survey ending on 9/25/14, the RD said she would monitor the resident, and the NAR committee was planning to meet on 9/26/14, the resident was not re-weighed until six days after the survey ended.

Based on observation, resident and staff interviews and record review, the facility failed to have sufficient nursing staff to provide care and services for 11 out of 19 residents reviewed for staffing concerns, out of 42 sample residents, to attain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failure to provide sufficient staffing contributed to residents experiencing incontinence, being left on the toilet for extended periods, and feeling "embarrassed," "ashamed," "ignored" and "mad." Cross Reference F241, F253, F309, F312, F315, F323, and F325 The findings included: I. Resident Census and Condition Report Review of the facility Resident Census and Condition Report signed by the nursing home administrator (NHA) on 9/22/14 documented a census of 71 residents. The residents' functional, mental and psychosocial needs were described as follows: -47 residents were occasionally or frequently incontinent of bladder, 26 residents were occasionally or frequently incontinent of bowel; and zero residents on both urinary and bowel toileting programs. -64 residents were in a chair all or most of the time; 9 residents had contractures and zero residents were bedfast all or most of the time; and 6 residents ambulated with assistance or assistive devices. -22 residents had dementia or [MEDICAL CONDITION] and 7 residents had behavioral healthcare needs; 44 residents were on psychoactive medication; 11 residents were on antianxiety medications; 35 were on antidepressant medications; and 7 residents were on hypnotic medications. -71 residents were receiving preventative skin care and 26 residents were receiving respiratory treatments. II. Observations and interviews were conducted throughout the facility from 9/22/14 through 9/25/14. Administration and nursing staff were asked about the staffing schedules, resident activity, safety and ability to meet the resident needs as outlined in their individual plans of care. A. Facility Expectations The facility's policy and procedure titled, "Staffing Plan," which was undated, was reviewed. It included "Nursing services are organized to meet the nursing care needs of all residents. Nursing services are provided 24 hours a day, seven days a week. The facility must use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Sufficient personnel are assigned and on duty to assure safe, effective nursing care, including relief personnel during vacations, holidays, and sick leaves. Time schedules will be maintained and posted, indicating numbers and classification of nursing personnel." B. Resident Interviews Resident #100, during an interview on 9/24/14 at 2:00 p.m., said the facility did not have sufficient nursing staff. -"No, especially at night. We have one person that I see at night, and she covers a lot of ground. Then there is a young woman who comes in and she is very, very kind, but she's not a nurse. At night it is quite difficult to get help. You do have to wait quite a while at night. I can put myself in my wheelchair, but I'm not supposed to by myself." -She said at night she has waited the "longest is 30-35 minutes. Last week I had to wait twice for about that amount of time. And then they just apologize and apologize, but they are so short-handed. They say, 'I'm sorry. I was over on E-Hall and had to come from there and I was putting somebody down.' -"One night I messed all over the bed. They had given me a (laxative) for my bowel and I was so embarrassed. I think that happened to me twice. Last time it happened was maybe one month ago. I've been a very proud person all my life. My mother told me don't ever be ashamed of what you are ...But I was embarrassed ...I was just wilted. I'm not used to that kind of stuff." Resident #6, during an interview at 11:53 a.m. on 9/23/14, said the facility did not have sufficient nursing staff. -"I used to work as a nurse's aide for seven years, so I know what it takes to take care of people. We have a staffing problem, definitely. It's not that there is a problem with the staff who are here; there just aren't enough of them. Worse times are in the evenings and on the weekends. -Two or three weeks ago, I was left in the bathroom for 45 minutes after I was done. During that time someone came in and said they would be right back, but then didn't come back. It just happens. I know that they are busy and have so much to do and everything. I don't want to bother the girls. -In fact, I wet my pants several times within a reasonable time because I couldn't get to the bathroom. In fact, I had one girl who said to me, 'I had you on the bedpan an hour ago,' and I don't care if I was just on it ten minutes ago; when I have to go after they give me my [MEDICATION NAME] (diuretic), I have to go! And I've had six kids and my bladder and my muscles are weaker, so when you have to go, you have to go. As you get older, your muscles get weaker." Resident #29, during an interview on 9/22/14 at 3:24 p.m., said the facility did not have sufficient nursing staff. -"Because they are always in a hurry and don't have time to help you. They will say 'Come down here (to your room) and turn your light on,' but it will take 10-15 minutes waiting for someone to take you to the bathroom, and that's no good." Resident #87 was interviewed on 9/25/14 at 5:15 p.m. She stated that she felt like the facility still did not have enough staff. She stated that staffing was better, but still had a way to go and there were still delays in having her call lights answered. She stated that once she waited for over 30 minutes to have her call light answered and that she "dirtied my pants before I got there (waiting for assistance to get to her bathroom)." She was asked how that situation made her feel and she stated that it made her feel "very embarrassed." She stated that episodes of incontinence had happened to her on two or three different occasions. She stated, "It's lack of help, I think, because the girls who work here run ragged. They come in to help us and they are sweating and rushing through everything that they do." Resident #6 was interviewed on 9/25/14 at 5:30 p.m. She said, "I waited 45 minutes the other day, which was within the past week, for someone to answer my call light to get me off the toilet." When this resident was asked how that made her feel, she stated, "My bottom and legs were numb. It didn't feel good at all. Sometimes I feel ignored." She went on to state, "There's just not enough help. Most of the girls are willing and ready to help you, but there's not enough of them." Resident #70, interviewed at 9:30 a.m. on 9/23/14, said, "They could use more staff. Sometimes things have been late ... when I first got here I couldn't wipe myself. I was too stiff, and the brace I had hurt too bad, and I had to ask to go to the bathroom. If they knew I was in the bathroom or waiting for the bathroom, they'd stick their head in and ask if I could wait a minute. Stuff that's out of their control." Resident #17 was interviewed on 9/22/14 at 3:34 p.m. She stated that she had to wait up to an hour and 10 minutes for assistance. She stated that she had never had an accident but she knew of other residents who had accidents with the long wait. Resident #84 was interviewed on 9/22/14 at 2:51 p.m. She stated that about two months prior, she had been left in the bathroom on the toilet without further assistance. She stated she had to "scoot" herself out of the bathroom and that she had a broken hip. She stated that she was "mad" and "just didn't like it." Resident #87, during an interview on 9/23/14 at 11:09 a.m., said that in her opinion they could use more help. She said that she knows they get very busy at times. She said that a couple of times she had an accident while waiting for the staff to come help her to the bathroom. When asked how that had made her feel she said, "Well it did not make me feel good, but I know the girls are busy and they are working hard." She said she thought the facility could use more help/staff on the floor and less staff up in the offices. C. Family Interviews: A family member of resident #16, interviewed at 10 a.m. on 9/23/14, said, "I'm concerned. Staff has called and told me that my mom has fallen, hit the floor again, they applied restraints. She was telling me that she was trying to call for assistance and I guess she's just impatient. I think you have to anticipate, but she tells me she does push the button." -"Sometimes she claims that she stays in the cafeteria long after she's finished eating and she really wants to get back to the room, but the staff are putting other people back in their rooms." -"That was the only concern she had. Maybe it's related to not enough staff, I don't know." Resident #4's family member was interviewed on 9/25/14 at 11:30 a.m. and said: "I still feel they need more staff to help residents after dinner and before bed, which is Sundowner's time for residents and very mixed up. They tell us yesterday mom was in a recliner, very agitated, and I asked what happened. (The NHA) said she just doesn't feel good. You can only sit or lie so long. They don't get to walk - I think there's a lot more they could do for PT for these residents. And I looked yesterday and the wheelchairs were absolutely filthy ... To come in and find Mom crying and smelly (from incontinence) is not okay with me." On the morning of 9/24/14 family member #1 was interviewed. The family member said he/she did not think there was enough staff available to provide the care and services to residents without having to rush the residents. He/she said that his/her family member has had multiple bruises and skin tears probably caused from the staff not taking the extra time needed to properly care for the resident with fragile skin. He/she said that the resident also required help with meals, and on occasion he/she had dropped in to visit and found the resident sitting at the dining table without eating and no staff sitting at the dining table to provide assistance. On 9/25/14 at 11:40 a.m. family member #2 was interviewed. He/she said that the facility did not have enough staff, and that when visiting the resident, if he/she calls to ask for staff assistance, the resident often will have to wait for a while for help. He/she said the staff often mention that they are busy and will come back to provide assistance. He/she said that staff express to the family that they are short of staff. He/she said that one time one staff tried to transfer the resident alone using the mechanical lift and there should have been two staff to provide assistance with the mechanical lifting device. D. Record Review On 9/24/14 at 5:02 p.m., the NHA provided the facility's "Weekly Staffing Ratios" from 5/26/14 through 9/21/14. At 6:10 p.m., she explained that the "Hours Per Patient Day (PPD) reflected the total number of nursing staff who worked during that 24-hour period, and stated "We want it to be about 3.0." The weekly PPDs were less than 3.0 during the following weeks: -Week of 06/02/14 = 2 days -Week of 06/16/14 = 1 day -Week of 06/23/14 = 1 day -Week of 06/30/14 = 7 days -Week of 07/07/14 = 7 days -Week of 07/14/14 = 3 days -Week of 07/28/14 = 2 days -Week of 08/04/14 = 5 days -Week of 08/11/14 = 1 day -Week of 09/01/14 = 5 days -Week of 09/08/14 = 5 days -Week of 09/15/14 = 5 days (Cross-Reference F323, Falls/Accidents) E. Staff Interviews Certified nursing assistant #19 was interviewed on 9/25/14 at 12:16 p.m. She shared that resident #87 was found incontinent a few months ago and that the resident was very upset that she was not toileted in a timely manner and had an accident in her pants. Staff member #23 was interviewed on 9/25/14 at 2:15 p.m. She stated that she felt that the facility really did not have enough nursing staff. When asked why she felt this way, the staff member stated that some of the call lights do not get answered in a timely manner. She stated, "I can clean four to five rooms in some of the times I've observed the same call light going off." When she was asked how long that took, she stated "maybe 45 minutes to an hour." She stated that she observed this occurring just a few weeks ago. She was asked if any resident had been incontinent due to lengthy waits for call lights and she stated that one or two residents had been. She was asked if she could recall any specifics and she stated that those occurrences happened in the afternoons. CNA #16 was interviewed on 09/24/14 at 3:05 p.m. She stated that some days are short on staffing and that "it's hard when we are short." LPN #11 was interviewed on 09/24/14 at 3:37 p.m. She stated that there was not enough staffing at the facility. She said she didn't see the residents get the individualized care that they needed. "I know the CNAs don't have enough help. We have more falls and more behaviors with the lack of staffing." She stated there needed to be more nurses on the floor for a skilled nursing facility and more CNAs. She stated that the staff did a great job with ensuring the residents got toileted, bathed, and shaved but they "have to be cut short." CNA #10 made the following comments about staffing levels and how residents were affected: -"It's hard to work two halls at once because you have people who may not need help and then you have someone who is pretty much one-on-one, and constantly trying to check on (a resident) who's (at high risk for falls). You have to really keep an eye on her, and it's hard to do that when you have both halls to work on." -"(On) the (unassigned) hall where (resident care is distributed among the other aides); I felt like residents weren't being well cared for. Right now it's D hall; before, it was B hall." -"If you have a two-person lift you have to go find someone else ... Then another call light goes off ... Last week a (non-interviewable) resident was incontinent (because staff could not assist her on time). I knew she wanted to go to the bathroom, but by the time I got there the resident had already gone, so I had to lay her down and change her. Then she still had to go, so I took her to the bathroom..." -"I know dietary cut back on one dietary aide and I know in the afternoon (residents) don't get their afternoon snacks sometimes ... They let people go because we were low census. I don't know if we're back up where we need to be or not. I don't know about the average, how much you're supposed to have before adding more staff. We used to work with at least seven CNAs plus a floater to float around wherever needed, or if we're too busy that floater usually did bedding, vitals and stuff like that, but now the bedding is on housekeeping ... The floater used to do our vitals, be an extra assistant in the dining room, the rest of us would stay out and do call lights. Seven staffing was enough - that helped us pretty much. As of today after 2 p.m. we only have five (CNAs)." On 9/25/14 at 4:30 p.m., the NHA and director of nurses (DON) were interviewed, and asked if they felt the facility had enough staff available to make sure the residents get the care and assistance they need without having to wait a long time. They both answered "Yes," and the NHA confirmed that call light audits were performed at the facility and the results showed that call lights were being answered "within five minutes." -The NHA said she felt that there was enough oversight to prevent falls, "I think most of the time. Right now we have a few residents who demand an extreme amount of attention. But for the most part, we are staffed very well." -The NHA explained that the facility was able to provide enough baths for residents and stated, "Any time they ask for a bath, they can have one. They just don't ask. We have one resident who takes an hour and a half. We can't just leave her in there." -The NHA and DON were informed of the interviews with residents, staff members and family members who felt the facility did not have enough nursing staff, and the DON stated, "I think it's bull. I think we are adequately staffed. I think we tended to spoil our staff a few years ago when we were running with eight aides for 60 residents and they weren't having to work as hard. It wasn't necessarily that they were on the floor all the time. We had a lot of trainees come in and then they would transfer to another facility." -"Our staff also gets used to the student nurses and CNAs (certified nurse aides) who come through. I can tell you that most of the complaints happen right after dinner. All of their call lights come on at the same time; they all have to go potty and want to go to bed. We have a one-hour overlap with six CNAs from day shift and five CNAs from night shift here at the same time, all answering call lights. And, there are still people who have to wait and aren't happy. But when you have 60 to 70 residents who have to go to the bathroom at the same time, you aren't going to have enough staff to help them. So many families have unrealistic expectations and expect one-to-one care. That 'she' should never be left unattended. That's unrealistic." -The DON stated, "Even if there are two residents on every hall who had to (use the restroom) at the same time, there is only one CNA on each hall, so someone is always going to have to wait. For the most part, we can get things covered, or we will have someone from day shift stay over, and try to accommodate those situations. After dinner is a tense time. If they fell at home, they are going to fall here."