Every finding on record at Walbridge Memorial Convalescent Wing

Based on record review and interviews, the facility failed to provide a menu that offered a variety of food options. Specifically, the facility failed to ensure residents were not served a repetitive menu that offered a high quantity of chicken and pork. Findings include:I. Facility policy and procedureThe Menu Planning policy, revised September 2023, provided by the dietary manager (DM) on 12/11/25 at 5:35 p.m. According to the policy, a seven day restaurant style menu shall be used to accommodate general therapeutic diets that would include a variety of selections. II. Resident interviewResident #28 was interviewed on 12/8/25 at 4:23 p.m. Resident #28 said there was too much chicken served on the menu. She said she did not complain because she understood that the large amount of chicken was probably due to a need for cost effective protein. III. Resident group interview Four residents (#7, #26, #27 and #28) who were identified as alert and oriented through facility and assessment the were interviewed in a group setting on 12/9/25 at 12:52 p.m. The residents said they were served chicken almost everyday and were frequently served pork. The residents in the group said they were tired of all the chicken and pork on the menu. IV. Record reviewResident council minutes were provided by the nursing home administrator (NHA) on 12/8/25 at 1:59 p.m. The September 2025 through December 2025 resident council minutes were reviewed pertaining to food. The council minutes did not identify the expressed concerns of too much chicken as identified in the above and below interviews. The October 2025 resident council minutes identified the DM informed the residents that the facility had a new five week menu cycle and to let him know if they did not like something or something was not working, the dietary department could change it. The weekly menus starting on 10/26/25 and ending on 11/29/25 were provided by NHA on 12/11/25 at 9:33 a.m. The menu for the week of 10/26/25 identified chicken was on the menu five days that week. The only days chicken was not served to the residents was on Monday 10/27/25 and Wednesday 10/29/25. Review of the weekly menu identified pork was served three times that week. The menu for the week of 11/2/25 identified chicken was on the menu three days that week. The chicken was served three days in a row on 11/2/25, 11/3/25 and 11/4/25. Review of the weekly menu identified a meal consisting of or included pork was served five times that week. The menu identified pork was served twice on 11/6/25. The menu for the week of 11/9/25 identified chicken was on the menu three days that week and a meal consisting of pork was served five times. The menu for the week of 11/16/25 identified chicken was on the menu three days that week and a meal that consisted of or included pork was served seven times that week and twice on 11/19/25. The menu for the week of 11/23/25 identified chicken was on the menu three days that week and a meal that consisted of or included pork was served six times that week and twice on 11/27/25. The menu did not identify what the residents were served for lunch on 11/27/25. The weekly menus starting on 11/30/25 and ending on 12/27/25 were provided by dietary manager (DM) on 12/11/25 at 5:23 p.m. The menu for the week of 11/30/25 identified chicken was on the menu five days that week and a meal that consisted of or included pork was served five times and twice on 12/4/25. The menu for the week of 12/7/25 identified chicken was on the menu three days that week and a meal that consisted of or included pork was served four times that week and twice on 12/11/25. The menu for the week of 12/14/25 identified chicken was on the menu twice that week. Pork was on the menu five times and was scheduled for two of the three meals on both 12/14/25 and 12/18/25.The menu for the week of 12/21/25 identified chicken was on the menu for three meals and scheduled to be served twice in a row on 12/21/25 and again on 12/22/25. Review of the weekly menu identified a meal consisting of or included pork would be served seven times that week and for breakfast and dinner on 12/24/25 and 12/25/25. V. Staff interviewsThe DM was interviewed on 12/11/25 at 4:57 p.m. He said Resident #28 recently said they were served too much chicken during a recent resident council. -However, review of the resident council minutes did not reveal this concern was documented or addressed in the meeting (see record review above). The DM said Resident #28 did not like chicken. The DM said it was important to have a balanced menu for residents to ensure the dietary department was meeting the residents' nutritional needs in addition to their preferences. He said he would look at the menu and replace the chicken with another protein if needed. The DM was interviewed again on 12/11/25 at 5:40 p.m. The DM said that he had an opportunity to review the menus and agreed with residents that chicken served five days a week would be too much chicken. He said he would work on changing the menu to provide more variety in the meals. The NHA was interviewed on 12/11/25 at 6:33 p.m. She said the DM and the registered dietitian collaborated together to create menus for the residents. The NHA said too much chicken was brought by the resident council. The NHA said she reviewed the menus and saw there was repeating protein in a week, like chicken and pork.

Based on observations and interviews, the facility failed to ensure food was served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure dishes were properly sanitized. Findings include:I. Professional reference According to the Food and Drug Administration Food Code (2022), retrieved on 12/17/25, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160 degrees F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160 degrees). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160 degrees F. (4-302.13)II. Facility policy and procedureThe High Temperature Sanitation policy, dated July 2025, was provided by the dietary manager (DM) on 12/11/25 at 3:35 p.m. The policy read in pertinent part, High temperature sanitation is the process of using hot water to sanitize the wares. This occurs when the surface temperature of the wares reaches 160 degrees Fahrenheit (F). The 160 degrees F surface temperature is achieved by utilizing all aspects of the ware washing process. It is accumulated on dishes over a period of time on hot water sanitizing dish machines, not just a single high temperature final rinse. Therefore, each step of the warewashing process must be operating at its proper temperature. The hot water is crucial in achieving the proper surface temperature as it is much longer than the rinse cycle. The water cycle will bring the surface temperature up to a certain point so that it goes into the final rinse, minimum temperature of 180 degrees F rinse water will bring the service temperature of the wares to 160 degrees F to properly sanitize.II. Observations and interviews The dishwashing machine and dish cycle was observed on 12/10/25 at approximately 11:50 a.m.Dietary aide (DA) #1 said the dishwashing machine was a high temperature machine. DA #1 said the temperature gauges on the digital screen were frozen so they used a temperature disk to get the temperature. He laid the disk flat on a plastic tray, placed the tray in the dishwasher and ran the disk through the wash and final rinse dish cycles. DA #1 opened the dishwasher and the temperature disk read 146 degrees F. He said they have had problems with their dishwashing machine and parts of it were broken. Observations of the dishwashing cycle were conducted on 12/11/25 between 10:00 a.m. and 10:10 a.m. The DM placed the temperature disk flat on a plastic tray, placed the tray in the dishwasher and ran the disk through the wash and sanitize dish cycles. The DM ran the machine four different times, checking the temperature disk after the final rinse cycle. Three out four times the temperature on the disk did not read over 160, with temperatures indicating disk surfaces level of 146 degrees F, 158 degrees F, 165 degrees F and 155 degrees F.The dishwashing machine was observed again with the DM on 12/11/25 at approximately 3:35 p.m. after he learned how to place the temperature disk in the dishwashing machine and after the finial rinse digital sensor was reset. The DM placed the disk on the rack set up like a plate and ran the dishwasher machine. The digital final rinse sensor read 184.82 degree F and the disk temperature read 170 F. The DM said that frozen digital temperature gauges might have affected the actual water temperature and he would contact the vendor to check if that could be a reason for the lower temperature observations.IV. Staff interviewThe DM was interviewed on 12/11/25 at 10:13 a.m. The DM said it was important for the water in the dishwashing machine to be hot enough to kill germs and bacteria on the dishes for proper sanitation. He said the dishwashing machine usually ran temperatures of over 180 degrees F. The DM said he was surprised that the disk showed lower temperatures during the observations. He said the digital sensor gauge on the dishwashing machine had not been working for a while and their service vendor provided the kitchen with the temperature disk to check temperatures. He said the dishwasher was recently served by the vendor but the temperature sensor was not fixed. The DM said the dishwashing machine was old and he was working with the vendor to try to get a new one for the facility. The DM was interviewed a second time on 12/11/25 at 3:30 p.m. The DM said the wash cycle digital sensor on the washing machine was still broken but he was able to reset one of the sensors. The DM said he spoke to the dishwashing machine vendor and learned that he was setting up the temperature disk wrong. He said the disk should have been set in a rack like a plate and not flat to accurately read the surface level of the disk and ensure the temperature was high enough for sanitation. The DM said it was important for the kitchen staff to accurately take the temperature of the dishwashing machine to make sure there was no bacteria left on the plates after the final rinse cycle and ensure proper surface sanitation. He said the vendor would come back to the facility and fix all the gauges.The DM was interviewed again on 12/11/25 at approximately 4:45 p.m. The DM said he spoke to his dishwashing machine vendor who said a faulty sensor possibly could have affected the temperature levels of the water but that was not determined. The DM said new temperature gauges have been ordered so staff does not have to rely on the disk to check the sanitation surface levels of the dishes The nursing home administrator (NHA) was interviewed on 12/11/25 at 6:35 p.m. The NHA said the DM had brought up concerns about the dishwashing machine and wanted it replaced. The NHA said the facility was in the process of replacing the machine and a new machine was approved. She said she does not have an arrival date for the new dishwashing machine. V. Facility follow upThe dishwashing machine arrival date was provided by the NHA on 12/12/25 at 4:43 p.m. via email. According to the email, requests from the dishwashing machine vendor have been delayed but a new dishwashing machine was scheduled for delivery on 12/31/25 and the temperature gauges would be replaced as soon as possible and prior to the receipt of the new machine.

Based on observations, record review and interviews, the facility failed to ensure the residents' right to a safe, clean, comfortable and homelike environment for four (#13, #26, #27 and # 28) of seven residents out of 19 sample residents.Specifically, the facility failed to provide washcloths and hand towels in Resident #13, Resident #26, Resident #27 and Resident #28's rooms. Findings include:I. Resident #13A. Resident statusResident #13, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included atrial fibrillation, depression, anxiety, osteoporosis, heart failure and dementia without psychotic disturbance and anemia.The 11/18/25 minimum data set (MDS) assessment revealed Resident #13 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. Resident #13 required substantial assistance with bathing, footwear and lower body dressing. Resident #13 required moderate assistance with toileting and upper body dressing and required only set up and clean up assistance with personal hygiene.B. ObservationsOn 12/8/25 at 4:58 p.m. Resident #13's room had no hand towels or washcloths in her bathroom. Resident #13 had a paper towel dispenser but no linens in the room.On 12/10/25 at 3:47 p.m. Resident #13's room had one hand towel and no washcloths.C. Resident interviewResident #13 was interviewed on 12/8/25 at 4:58 p.m. Resident #13 said she frequently did not have any wash cloths or hand towels in her bathroom. Resident #13 said she thought the linens were available but the staff frequently forgot to stock the rooms. Resident #13 said staff provided hand towels and washcloths whenever she asked, but she felt like she was being a bother by having to ask for something so simple all of the time. II. Resident #26A. Resident statusResident #26, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), depression, hypertension and edema.The 10/22/25 MDS assessment revealed Resident #26 was cognitively intact with a BIMS score of 15 out of 15. Resident #26 was independent with eating, personal hygiene, upper and lower body dressing and toileting. Resident #26 required moderate assistance with bathing.B. Resident interviewResident #26 was interviewed on 12/9/25 at 12:52 p.m. Resident #26 said the facility was inconsistent when stocking her room with washcloths. Resident #26 said when she requested washcloths from staff, sometimes staff would look and tell her none were available. Resident #26 said the issue was brought up in resident council and the facility ordered more, but keeping washcloths in her room remained inconsistent. III. Resident #27A. Resident statusResident #27, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included chronic kidney disease, heart failure, polyneuropathy and depression.The 9/23/25 MDS assessment revealed Resident #27 was cognitively intact with a BIMS score of 14 out of 15. Resident #27 was independent with eating, personal hygiene, bathing and toileting. Resident #27 required moderate assistance with upper body dressing and substantial assistance with lower body dressing and footwear.B. Resident interviewResident #27 was interviewed on 12/9/25 at 12:52 p.m. Resident #27 said the facility did not consistently have washcloths and hand towels stocked in her room. Resident #27 said sometimes staff told her no more washcloths were available until the next laundry delivery. Resident #27 said sometimes she had to use the corner of a previously used washcloth or towel to wash her face. IV. Resident #28A. Resident statusResident #28, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included hypertension, spinal stenosis of the lumbar region, chronic pain syndrome, osteoporosis and frequent migraines.The 10/21/25 MDS assessment revealed Resident #28 was cognitively intact with a BIMS score of 15 out of 15. Resident #28 was independent with eating, personal hygiene, dressing and toileting. Resident #28 required minimal assistance with bathing. Resident #28 ambulated independently with a walkerB. Resident interviewResident #28 was interviewed on 12/9/25 at 12:52 p.m. Resident #28 said the facility did not always have wash cloths or hand towels available. Resident #28 said sometimes she had to use a large amount of paper towels to wash and dry her face and hands. V. Resident council meeting minutesThe resident council meeting minutes, dated 7/1/25, revealed a complaint from a resident that the unit was short on towels, washcloths and sheets. The minutes revealed the nursing home administrator (NHA) said she would follow up with laundry to ensure the facility was receiving adequate linen supplies. -However, the August 2025, September 2025, October 2025 and November 2025 resident council meeting minutes did not mention anything regarding follow-up for the lack of washcloths or hand towels.VI. Additional observationsOn 12/8/25 at 4:09 p.m. Resident #6's room had no washcloths or hand towels.On 12/9/25 at 8:48 a.m. Resident #16's room had no washcloths or hand towels.VII. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 12/9/25 at 9:08 a.m. CNA #3 said each residents' room should have washcloths and hand towels hanging on the towel rack in the bathroom. CNA #3 said the CNAs on each shift should be checking residents' rooms and restocking linens. CNA #3 said the reason no towels were in Resident #13's bathroom was probably because the night shift CNA used them and forgot to restock them. Licensed practical nurse (LPN) #2 was interviewed on 12/11/25 at 10:44 a.m. LPN #2 said she was aware the unit had frequent shortages of washcloths. LPN #2 said the facility's linen supply, including wash cloths and hand towels, was managed by the hospital laundry service attached to the unit. LPN #2 said each day, the unit CNAs went to each room and restocked the linens in the bathrooms and sometimes the CNAs let her know they ran out of linens. LPN #2 said the CNAs told her what room they were able to get to before running out of linens to restock. LPN #2 said when that happened, she would have to tell the night shift staff where to start restocking again when the next supply came back from the laundry. LPN #2 said she did not have a way to ensure the next shift followed through on restocking all of the remaining residents' rooms with washcloths and hand towels. LPN #2 said the facility did order more washcloths for the unit recently, but the availability or the linens could depend on the time the dirty linens were provided to laundry and the time the clean laundry arrived from the hospital. LPN #2 said the facility completed supply audits of certain items, but they currently did not audit washcloths or hand towels. LPN #2 said she planned to ask for these items to be added to the audit list to try to identify when linens were in short supply. The director of nursing (DON) was interviewed on 12/11/25 at 5:26 p.m. The DON said she remembered a lack of washcloths and towels was brought up in a resident council meeting a few months ago. The DON said she ordered more towels and washcloths for the units and had not heard any complaints since. The DON said she was not aware the CNAs were reporting they were running out of towels while trying to restock residents' rooms. The DON said paper towels were not adequate for a home-like environment because people would expect to be able to wash their face with linen washcloths or towels if they were in someone's home. The DON said staff were able to supply residents with washcloths upon request, but residents should not have to ask for them as they should be available in the bathroom. The DON said she planned to talk with her floor staff to find ways to track washcloths and ensure residents' rooms were adequately stocked with hand towels and washcloths.

Based on record review and interviews, the facility failed to timely investigate an allegation of abuse involving one (#26) of three residents reviewed for abuse out of 19 sample residents.Specifically, the facility failed to timely investigate and report an allegation of misappropriation of property for Resident #26.Findings include:I. Facility policy and procedureThe Abuse Prevention Program policy, revised September 2023, was provided by the nursing home administrator (NHA) on 12/8/25 at 1:20 p.m. It read in pertinent part, To maintain an abuse free environment and establish guidelines to address suspected occurrences involving resident abuse (mistreatment, exploitation, neglect or verbal, physical or sexual abuse, including injuries of unknown source and misappropriation of resident property). Reports of abuse are promptly and thoroughly investigated. An occurrence report will be filled out within 24 hours by the charge nurse.The abuse policy outlined how to complete an investigation regarding misappropriation of property. According to the policy, the facility would review the complaint report; interview the person or persons reporting the incident; interview any witnesses to the incident; review the resident's medical record if indicated; search the resident's room with the resident's permission; interview staff members that had contact with the resident during the relevant periods or shifts of the alleged incident; conduct interviews with the resident's roommate, family members and visitors; and, create a root cause analysis with the circumstances surrounding the incident.The Reporting Suspicion of a Crime policy, revised December 2025, was provided by the NHA on 12/11/25 at 9:58 a.m. The policy documented reports of a suspected crime, to include allegations of misappropriation of resident property, would be reported to the appropriate parties no later than 24 hours after the issue was reported. II. Resident statusA. Resident statusResident #26, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and depression, unspecified.The 10/22/25 minimum data set (MDS) assessment identified Resident #26 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment indicated Resident #26 used a walker for mobility and was independent with most of her activities of daily living (ADLs). The MDS assessment did not indicate she had inattention, disoriented thinking or behaviors directed towards herself or others. B. Resident interviewResident #26 was interviewed on 12/8/25 at 5:16 p.m. Resident #26 said she was missing a $50.00 bill. She said the money had been missing for a couple of months. She said she had placed the bill under her pillow but it was no longer there when she attempted to retrieve it later that afternoon in October 2025. Resident #26 said she had reported it when she realized it was gone. She said she had a volunteer help her look for the money in her room but they could not find it. She said had not heard anything back from the facility after she reported the money missing from her room. Resident #26 was interviewed a second time on 12/10/25 at 10:20 a.m. Resident #26 said the missing $50.00 bill was given to her in a card from a friend of hers. She said she was so happy to have received the money because she was going to use it to buy her grandson a gift. She said she looked all over her room but still could not find it. She said she did not know if the money was somewhere in her room or if someone took it. Resident #26 said she still hoped the money would turn up. She said if she did not get the money back, she hoped that if someone took it from her, they were able to put it to good use.C. Record reviewA request made on 12/10/25 with the director of nursing (DON) for an October 2025 facility investigation for an allegation of Resident #26's missing money was not provided (refer to staff interviews below). A summary of a 12/10/25 grievance investigation for Resident #26's missing money and related documents were provided by the NHA on 12/11/25 at 9:58 a.m. The grievance summary identified the investigation was not complete and was ongoing. The summary outlined some of the steps taken during implementation of the 12/10/25 investigation, to include an internal misappropriation investigation, staff education of misappropriation and reporting and confirmation that the allegation was reported to the State agency for possible misappropriation. According to the summary, all staff meetings agendas had been updated for misappropriation and reporting for additional review at all monthly staff meetings. The staff would be required to complete online training for protecting older adults on hire and annually. The volunteers would be re-educated on protecting older adults, reporting, and their role in any investigations, if applicable. The summary identified the topic of misappropriation, reporting and staff responsibility would be addressed during resident council. The summary indicated the video footage from the day of the event (10/30/25), on all persons entering/exiting the room, and those times had been reviewed and the facility administration planned to provide and implement personal lockboxes for residents' rooms if the residents agreed. The 12/10/25 grievance form identified Resident #26's grievance of missing money was documented as a grievance on 12/10/25 at 10:50 a.m. and submitted to the social services director (SSD). The grievance form documented the resident's account of the missing money. According to the grievance form, Resident #26 was provided $50.00 from the facility on 12/10/25 and she and her family were satisfied with the facility's response to her grievance. The grievance form indicated Resident #26 was offered a lock box to keep her money in, which she declined. The 12/10/25 misappropriation investigation documented the timeline of the allegation and the facility's response to the allegation regarding Resident #26's missing money. The investigation documented the money was last seen on 10/30/25 at 1:50 p.m. The money was reported missing on 10/30/25 at 4:06 p.m. to the DON. The allegation of the missing money was reported to the NHA and the risk manager on 12/10/25. The allegation of misappropriation was reported to the State agency and the ombudsman on 12/11/25. The investigation documented Resident #26 felt someone stole the money. III. Staff interviewsThe DON was interviewed on 12/10/2025 at 10:31 a.m. The DON said if a resident reported to her or staff that they were missing money, a grievance form and an incident report would be filled out, the NHA would be informed and an investigation would be conducted. The DON said Resident #26 reported to her that she was missing money from her room in October 2025. The DON said she was on the way out the door to an appointment and then was on leave for a week when it was initially reported to her. She said Resident #26 and a volunteer with the resident, had concerns about a newer staff member possibly taking the money. The DON said she informed licensed practical nurse (LPN) #2 of the missing money. The DON said the volunteer helped Resident #26 look for the money in her room. She said she did not know if an investigation on the missing money was completed or if the incident was reported. She said she did not inform the NHA of the resident's missing money in October 2025 or the days following the allegation. The DON said she should have checked on the status of the missing money when she came back from her leave. She said she had forgotten about it. She said she would report the missing money to the NHA, complete an incident report and grievance form and initiate an investigation (during the survey). The DON said the steps to follow up on the allegation of the missing money should have been started sooner. LPN #2 was interviewed on 12/10/25 at 10:54 a.m. LPN #2 said she was informed by the DON that Resident #26 had reported missing money from her room. She said the DON did not delegate any follow up responsibilities to her related to Resident #26's allegation of missing money. LPN #2 said she checked in with Resident #26 regarding the money on 12/8/25 and the resident said she might have lost the money herself. LPN #2 said she was not aware of any other residents reporting missing money in the facility. The DON was interviewed a second time on 12/10/25 at 4:59 p.m. The DON said she completed a grievance form for Resident #26 and the NHA started an investigation into the missing money. She said the incident was reported to the State agency. She said Resident #26 did not want the police to be called. The DON said Resident #26 was provided $50.00 from the facility to replace the missing money from October 2025. The NHA was interviewed on 12/10/2025 at 6:02 p.m. The NHA said an investigation into the missing money was now under way and the facility was in the process of interviewing staff and reviewed the video footage from 10/30/25, the day the money was reported missing. She said the video footage did not show any staff member alone in the resident's room on 10/30/25. The NHA said Resident #26 said she opened the card with the money in it and placed the money under the pillow because she was on her way to bingo. The NHA said when a resident reported missing money, the staff would conduct a search for it. She said the staff would notify the family when there was an accusation of missing money or suspicion of theft. She said it was not a usual practice to have a volunteer search the resident's room instead of staff. The NHA said the investigation into the missing money included reviewing the staff schedule to determine who was working at the time of the reported missing money and see if anyone witnessed suspicious activity. She said the facility would report the allegation to the State agency and the police if there was anything missing of monetary value. The NHA said Resident #26's allegation of missing $50.00 from her room on 10/30/25 should have been reported and investigated right after she reported it to staff. The NHA said staff should have then conducted a search for the money in her room after obtaining the resident's permission. The NHA said the staff searched for the money in Resident #26's room on the weekend following the 10/30/25 allegation. The NHA said she had not reported the missing money to the State agency but she was going to report it soon. She said would continue to educate staff to report any allegations of missing money and property to her as soon as they became aware of the allegation so it could be followed up with right away. The NHA said if an investigation was not conducted shortly after the allegation, then the facility was less likely to be able to correct the concern. The NHA was interviewed a second time on 12/11/25 at 6:33 p.m. The NHA said allegations of missing money in the facility were not a common event. She said another search in Resident #26's room was conducted, but the money was not found. She said the money was replaced and the incident had now been reported to the State agency.

Based on observations, record review and interviews, the facility failed to to ensure received treatment and care in accordance with professional standards of practice for one (#19) of six residents out of 19 sample residents.Specifically, the facility failed to: -Ensure residents' medications were not pre-poured; and,-Administer Resident #19's eye drops in accordance with professional standards.Findings include:I. Professional referencesAccording to the American Academy of Allergy, Asthma and Immunology, retrieved on 12/11/25 from https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/eye-drops, When administering multiple eye medications, wait five to 15 minutes before delivering the second medication to the same eye in order to prevent dilution.According to Fundamentals of Nursing 10th edition by [NAME] and [NAME] et. al, 2021 pp. 672, Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications. The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication.II. Resident #19A. Resident statusResident #19, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety, macular degeneration and legal blindness. The 11/6/25 minimum data set (MDS) assessment revealed Resident #19 had severe cognitive impairment with impaired short-term and long-term memory. Resident #19 required moderate assistance with eating, repositioning and oral hygiene. Resident #19 required substantial assistance with toileting, bathing, dressing, footwear and personal hygiene. Resident #19 required moderate assistance with use of a wheelchair for mobility. B. ObservationsOn 12/10/25 at 9:09 a.m. licensed practical nurse (LPN) #3 administered the following medications to Resident #19:Refresh Ophthalmic Solution 1.4-0.6 % (polyvinyl alcohol-Povidone). Instill one drop in both eyes.Prednisolone acetate ophthalmic suspension 1 % (prednisolone acetate). Instill one drop in the right eye.-However, LPN #3 waited only one minute and eight seconds between each ophthalmic medication administration, which was below the recommended minimum wait time of five minutes.III. Pre-pouring medication failureOn 12/9/25 at 2:18 p.m., during observation of the medication storage area, three pill cups were observed in the top drawer of the medication cart. Each cup had one pill in it. Each cup was labeled with an unidentified resident's initials and the time the medication was ordered to be given, but the cups were not labeled with which medication was in the cup. LPN #1 said at the time that he went to administer the scheduled medications to three residents but they were not on the unit during lunch time, so LPN #1 said he labeled each cup and put them in the medication cart to give them when the residents returned. IV. Staff interviewsLPN #3 was interviewed on 12/10/25 at 11:43 a.m. LPN #3 said she was aware she did not wait the appropriate time between administering Resident #19's ophthalmic medications. LPN #3 said normally she would administer Resident #19's first ophthalmic medication, then his oral medication and then his second ophthalmic medication. LPN #3 said Resident #19 was sleepy this morning and the observation of his medication administration was not his typical morning routine. LPN #3 said she planned to administer the resident's other medications between eye drops to ensure there was an appropriate wait time between ophthalmic medications.LPN #1 was interviewed on 12/9/25 at 3:20 p.m. LPN #1 said he normally did not keep residents' medications in cups in the cart. LPN #1 said he did not check to see if the three residents were on the unit prior to preparing the scheduled medications. LPN #1 said normally he was told which residents were leaving the facility for appointments in the morning, but he was not told these three residents were leaving the unit. The director of nursing (DON) was interviewed on 12/11/25 at 5:26 p.m. The DON said it was considered standard practice to wait after administering the first ophthalmic medication before giving the second ophthalmic medication. The DON said the reason to wait was to ensure the first medication was not washed out by the second medication. The DON said LPN #3 should have planned the medication administration to give Resident #19's oral medication between ophthalmic medication administrations to ensure each medication had time to absorb. The nursing home administrator (NHA) was interviewed on 12/11/25 at 6:52 p.m. The NHA said LPN #1 spoke with her about the medications kept in cups in the medication cart. The NHA said LPN #1 told her the residents who were off of the unit were at the group interview. The NHA said LPN #1 still should have checked to see if the residents were available before preparing the medication. The NHA said LPN #1 should have also disposed of the medications when he found out the residents were not available and prepared new medications when the residents returned instead of storing the medications in cups in the medication cart. The NHA said medications should not be stored in a cup in the cart because the medications could be forgotten or administered incorrectly.

Based on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (#20 and #16) of four residents out of 19 sample residents. Specifically, the facility failed to:-Implement a recommended brace for Resident #20 to prevent a contracture; and,-Complete an occupational therapy assessment for Resident #16 to evaluate if an assistive device was necessary to prevent contracture, despite a documented decline in the resident's ability to feed herself.Findings include:I. Facility policy and procedureThe Rehabilitative Services policy and procedure, revised 11/1/23, was provided by the nursing home administrator (NHA) on 12/11/25 at 6:12 p.m. It read in pertinent part, We will provide restorative services while maintaining the highest possible level of activities of daily living (ADL). Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.II. Resident #20A. Resident statusResident #20, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included senile degeneration of the brain, thrombosis of the arteries of the upper extremities and age related physical disability. The 10/1/25 minimum data set (MDS) assessment revealed Resident #20 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. Resident #20 was dependent on staff for putting on footwear, required substantial assistance with toileting and bathing, required moderate assistance with dressing and supervision or cues with eating, personal and oral hygiene.B. Resident and resident's representative interviewOn 12/9/25 at 10:30 a.m., Resident #20 was sitting in her wheelchair with her representative son in the room. Both of Resident #20's hands rested in her lap in a closed position, making a fist. Resident #20 said her hands were always in this position because she had arthritis. Resident #20 said it was painful to open her hands, but denied having pain in them while they were at rest. Resident #20's representative said Resident #20 had a prescribed brace for her left hand. He said he had seen her wearing it before, but he said he could not find it in her room. C. ObservationsOn 12/10/25 at 7:44 a.m. Resident #20 was lying in bed. Resident #20 did not have the prescribed brace on her left hand or a washcloth in her hands to protect her skin. Resident #20 had a scant amount of blood around her right middle finger. On 12/10/25 at 9:17 p.m. Resident #20 was lying in bed with her hands closed without a brace on her left hand. Resident #20 said her hands felt numb, but not painful. D. Record reviewReview of Resident #20's December 2025 CPO revealed the following physician's order:Place a red foam device in the palm of left hand at bedtime for prevention of contractor, per physical therapy (PT), ordered 6/10/25.The physical therapy assessment, dated 5/15/25, revealed a physical therapy recommendation for orthosis (an external device like a brace or splint used to support, immobilize, correct, or improve the function of weak, injured, or deformed body parts) wear, including instructions to wear a thermoplastic splint (a custom medical device, molded from heat-softened plastic sheets, used for supporting, immobilizing, or mobilizing joints and limbs after injuries, surgeries, or for conditions like arthritis) in the left hand every night and as needed during the day.III. Resident #16A. Resident statusResident #16, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia without behavioral disturbance, depression, heart failure and malignant neoplasm of the left breast. The 10/8/25 MDS assessment revealed that the resident had significant cognitive impairment with short term and long term memory deficits with a BIMS score of zero out of 15. Resident #16 required substantial assistance with eating and oral hygiene and was dependent on staff for repositioning, toileting, bathing and dressing.B. ObservationsOn 12/9/25 at 9:11 a.m. Resident #16 was sitting in a recliner in her room being assisted with eating by certified nurse aide (CNA) #3. Resident #16's hands were resting on her lap in a closed position, with the pads of her fingers resting on her palms. Resident #16 had dried blood on her left hand and nails. Resident #16 was able to open her hands with assistance from CNA #3 to allow CNA #3 to clean the dried blood and Resident #16 did not appear to have any open wounds to her hands. C. Record reviewThe 7/14/25 MDS assessment revealed that during the review period, Resident #16 required only supervision and cues with eatingThe 4/29/25 MDS assessment revealed that during the review period, Resident #16 required only set up and clean up assistance.-Despite the quarterly MDS assessments showing a decline in Resident #16's ability to feed herself, no physical therapy or occupational therapy evaluation was completed to assess if Resident #16 could have fed herself with adaptive feeding utensils, or to assess if Resident #16 required a device to prevent contracture. IV. Staff interviewsCNA #3 was interviewed on 12/9/25 at 9:28 a.m. CNA #3 said the dried blood on Resident #16's hands was likely from Resident #16 picking at her skin, which she tended to do frequently. CNA #3 said Resident #16 used to be able to feed herself but had required assistance more often over the last few months. CNA #3 said she thought she saw Resident #16 using a large handled adaptive utensil a long time ago, but she could not remember for certain. CNA #3 said Resident #16 was able to open her hands, but unless Resident #16 was prompted to open her hands, she typically saw them resting in a closed position.CNA #4 was interviewed on 12/11/25 at 8:54 a.m. CNA #4 said Resident #16 only ate about 25% of her breakfast that morning and had needed complete assistance with eating. CNA #4 said when serving Resident #16 meals, she set up the food for the resident and she would attempt to let Resident #16 feed herself. CNA #4 said she would check back in with her after approximately ten minutes and if Resident #16 had not eaten, she would offer to assist her with eating. CNA #4 said she had heard of Resident #16 previously using an adaptive utensil, but she had never seen Resident #16 have any adaptive utensils on her meal tray or use them. CNA #4 said Resident #20 did not have a brace in her left hand this morning (12/11/25). CNA #4 said the night shift CNA told her she was not able to find it when assisting Resident #20 to bed the previous night. CNA #4 said if staff was not able to find the brace for Resident #20, they could at least place a washcloth in Resident #20's hand to protect the resident's skin. Licensed practical nurse (LPN) #3 was interviewed on 12/11/25 at 9:03 a.m. LPN #3 said Resident #16 usually required assistance with eating. LPN #3 said she had not seen Resident #16 use a brace or adaptive utensil before. LPN #3 said she had seen Resident #20 wearing a red foam brace before. LPN #3 said since she heard CNA #4 could not locate the brace this morning (12/11/25), she planned to search Resident #20's room and if she could not find it, she planned to contact the PT for a new brace. The director of nursing (DON) was interviewed on 12/11/25 at 5:26 p.m. The DON said she was not aware of the MDS assessments reflecting a decline in Resident #16's ability to feed herself. The DON said to her knowledge, Resident #16 has always required assistance with eating. The DON said the facility only recently hired their first MDS nurse, and the MDS assessments completed earlier in the year may not be accurate. The DON said she planned to refer Resident #16 for a physical therapy or occupational therapy assessment. The DON said she planned to follow up with LPN #3 to see if she was able to find the brace for Resident #20's left hand. She said if the brace was unable to be located, the facility would order a new brace. The DON said the reason a CNA might not have known to place a wash cloth in Resident #20's hand to protect her skin if they could not find the correct brace could be because many of the CNA staff were still new. The DON said she planned to complete in-service education on using a brace or wash cloth to protect the skin for residents who had contractures in their hands.

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#4) of two residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to implement effective fall interventions to prevent falls for Resident #4. Findings include:I. Facility policy and procedureThe Fall Management Program policy, revised February 2021, was provided by the nursing home administrator (NHA) on 12/11/25 at 6:12 p.m. It read in pertinent part, The facility operates in a culture of safety. Staff, residents and family members are encouraged to report any problems or potential problems. A falls management team is responsible for information gathering and developing a plan of action to deal with falls, near misses, and other safety concerns. Within seven days of a fall, the director of long term care or assistant director of long term care will do the following: Review TRIPS (tracking record for improving patient safety) and incident reports, ensuring concerns adequately addressed and that forms are properly filled out; incident reports will be forwarded to the risk manager. Gather data and bring it to the weekly interdisciplinary team (IDT) meeting for review, further problem solving, and monitoring of interventions. Findings and order requests will be forwarded to the attending physician as necessary via a physician communication form. Findings will be reviewed at the quarterly quality assurance and performance improvement (QAPI) meeting. The assistant director of long term care is responsible for initiating or updating care plans as needed for fall-related issues. The director of long term care and the assistant director of long term care are responsible for monitoring staff compliance and resident response to interventions.II. Resident #4Resident #4, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease (a disease causing shaking and affecting motor skills), depression, type 2 diabetes with polyneuropathy (tingling pain and numbness) and left rotator cuff tear.The 10/23/25 minimum data set (MDS) assessment revealed Resident #4 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #4 required supervision or cues when ambulating with a walker over 50 feet, required moderate assistance with bathing and toileting and required supervision or cues with dressing and footwear. The MDS assessment documented Resident #4 had zero falls during the review period.B. Resident interviewResident #4 was interviewed on 12/8/25 at 2:05 p.m. Resident #4 said she fell multiple times in the last few months including a fall overnight, early in the morning on 12/8/25. Resident #4 said her feet slid around in the non-slip socks and the side of the socks with the gripping material was not always touching the floor. Resident #4 said another thing contributing to her falls was that her incontinence brief frequently leaked when she walked and did not fit her well. Resident #4 said she changed her briefs herself. Resident #4 said in October 2025, she had a big fall and had to go to the emergency room and the fall left her with bruising for months. C. Record reviewResident #4's fall risk care plan, initiated 1/31/25 and revised 11/26/25, revealed Resident #4 was a high risk for falls related to Parkinson's disease, loss of balance, impaired decision making and impulsive behavior. Interventions included anticipating Resident #4's needs, ensuring the call light was within reach and encouraging Resident #4 to use the call light, non-slip floor grips at the bedside to assist Resident #4 when transferring out of bed, physical therapy evaluations and treatments as needed, ensuring Resident #4 wore proper footwear and for staff to review information on past falls and attempt to determine the cause of the falls, then alter or remove potential causes if possible.The occupational therapy (OT) evaluation, dated 7/21/25, documented Resident #4 was referred to OT due to a history of falls and safety concerns. The document revealed resident #4 had impaired cognition and limited safety awareness during transitional movements and activities of daily living (ADL) tasks. The document revealed Resident #4 was unable to demonstrate safe brake use with her four-wheeled walker during transitions. The document revealed an eight week therapy plan to increase resident stability, safety with four-wheeled walker use and reduce fall risk. The OT Discharge summary, dated [DATE], documented Resident #4 had inconsistent attendance to scheduled therapy appointments, but demonstrated improved endurance and activity tolerance. The document revealed the OT recommended Resident #4 had staff assistance with all out of bed transfers due to high fall risk and poor management of her walker. The document also revealed the OT recommended staff round as able to assess Resident #4's safety due to her lack of call light use and poor recall. The fall incident report, dated 10/26/25, documented Resident #4 had an unwitnessed fall. The document revealed Resident #4 got up from her bed using her walker to retrieve a card from a box sitting on the floor. Resident #4 leaned forward and lost her balance, falling forward and striking her face on the floor. The document revealed Resident #4 sustained a large hematoma (localized bleeding outside of blood vessels) to her forehead and bleeding from her nose. The progress note, dated 10/26/25, documented Resident #4 was transferred to the local emergency room for assessment after the unwitnessed fall. The progress note documented the resident had a hematoma to the forehead, facial bruising and bruising to the right knee. The fall care plan review form, dated 10/26/25 documented no changes to Resident #4's care plan.-There was no documentation in Resident #4's electronic medical record (EMR) to indicate the facility reviewed the resident's fall care plan and interventions to determine if the current fall interventions were effective or if new fall interventions were needed.The fall incident report, dated 11/25/25, documented Resident #4 had another unwitnessed fall. The document revealed Resident #4 was found sitting on the floor. The document revealed Resident #4 was ambulating back from the bathroom without her walker and without staff assistance. The document revealed Resident #4 said she got tired while walking back from the bathroom and tried to sit on her four-wheeled walker. The walker rolled away from her, causing her to fall. The document revealed staff education and reminders were provided to have Resident #4 call for assistance.-However, there was no documentation in Resident #4's EMR or the fall care plan review form to indicate the facility reviewed the resident's fall care plan and interventions to determine if the current fall interventions were effective or if new fall interventions were needed.The progress note, dated 12/8/25, documented Resident #4 refused to use the call light or ask for help. The progress note revealed Resident #4 removed her non-slip socks because they were wet due to an incontinence episode. The progress note revealed Resident #4 was checked on at 1:30 a.m. and fell at 2:00 a.m. The progress note revealed Resident #4 sustained a small red mark to her back.III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 12/10/25 at 1:57 p.m. CNA #6 said Resident #4 ambulated in her room without calling for assistance frequently because Resident #4 preferred to change her own brief. CNA #6 said Resident #4 frequently refused to allow staff to put on a gait belt when ambulating. CNA #6 said she was not aware of any additional fall prevention measures for Resident #4 beyond standard fall precautions. CNA #6 said she tried to check on all residents every two hours, but to her knowledge there was no plan to check on Resident #4 more frequently for safety. Licensed practical nurse (LPN) #2 was interviewed on 12/10/25 at 3:14 p.m. LPN #2 said Resident #4 frequently refused staff assistance with care and ambulation. LPN #2 said Resident #4 had the right to refuse assistance from staff and when she did, staff should try to reapproach her and remind Resident #4 that the interventions were for her safety. The director of nursing (DON) was interviewed on 12/11/25 at 5:26 p.m. The DON said the facility frequently reinforced education about allowing staff to use a gait belt and to call for assistance, but the majority of the fall prevention interventions for Resident #4 were implemented in the spring of 2025 and had not changed since she started falling frequently again the past few months. The DON said the facility had identified that most of the time, Resident #4 was falling while ambulating to or from the bathroom. The DON said she planned to complete another OT evaluation request to see if they could provide any recommendations, similar to the recommendation from the OT to place grip tape on the floor in front of Resident #4's bed, implemented in January 2025 in order to prevent Resident #4 from slipping out of bed.The NHA was interviewed on 12/11/25 at 6:52 p.m. The NHA said the facility frequently discussed how Resident #4 continued to fall and did not know what other interventions they could offer Resident #4. The NHA said some of the interventions the facility offered beyond the standard fall precautions were refused by Resident #4. The NHA said the facility planned to reach out to the medical director of another facility to see if the other facility had any fall intervention recommendations they had not previously offered to Resident #4. The NHA said each of Resident #4's falls were reviewed in an IDT meeting as well as the QAPI meetings.-However, the facility was unable to provide documentation of an IDT review or suggested interventions after the fall that occurred on 10/26/25.

Based on observations, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being one (#16) of five residents reviewed for unnecessary medications out of 19 sample residents. Specifically, the facility failed to discontinue or reevaluate a physician's order for Resident #16's as needed (PRN) Lorazepam (an antianxiety medication) after 14 days.Findings include:I. Resident #16A. Resident statusResident #16, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, depression, heart failure and malignant neoplasm of the left breast. The 10/8/25 minimum data set (MDS) assessment revealed that the resident had significant cognitive impairment with short term and long term memory deficits. The assessment revealed Resident #16 had no behavioral symptoms of yelling, kicking, hitting or refusal of care during the review period. Resident #16 required substantial assistance with eating and oral hygiene and was dependent on staff for repositioning, toileting, bathing and dressing. B. Record reviewReview of Resident #16's December 2025 CPO revealed the following physician's order:Lorazepam 2 milligrams (mg)/milliliter (ml) oral liquid. Give 0.25 ml by mouth every six hours as needed for terminal agitation, ordered 11/20/25 with no end dateReview of Resident #16's November 2025 and December 2025 medication administration record (MAR) revealed no PRN doses were administered during that timeframe.The November 2025 pharmacist's monthly medication review, dated 11/28/25, revealed the consulting pharmacist for the facility documented requests for a related diagnosis and end date for Resident #16's PRN Lorazepam order.-However, the medication had not been discontinued or re-evaluated at the time of the survey. -Review of Resident #16's electronic medical record (EMR) revealed there was no documentation from the physician indicating a justification for continuing the resident's PRN Lorazepam beyond the 14 days.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/9/25 at 3:05 p.m. LPN #1 confirmed Resident #16's PRN Lorazepam order did not have an end date. LPN #1 said he was not aware the regulation required all PRN anxiolytic (antianxiety medication) to have a 14-day end date or additional documentation from the physician to continue the order beyond 14 days. LPN #1 said now that he was aware of the regulation, he planned to contact the prescribing physician to discontinue the medication since Resident #16 had not required any doses of the medication. The director of nursing (DON) was interviewed on 12/11/25 at 5:26 p.m. The DON said she was aware PRN anxiolytic (antianxiety medication) medications required a 14-day end date or additional documentation from a physician to continue the order beyond 14 days. The DON said she was not sure why the nurse who entered the physician's order forgot to add an end date when entering the order. The DON said she planned to change the order form used to request PRN Lorazepam so it required an end date to complete the order.

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment.Specifically, the facility failed to implement enhanced barrier precautions for Resident #2 and Resident #8.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 12/19/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.II. ObservationsOn 12/11/25 at 9:51 a.m. Resident #2's room was observed. Resident #2 required a feeding tube (a soft flexible tube inserted directly into the stomach to deliver nutrition, fluids and medications when a person is unable to eat or swallow safely) and had an indwelling urinary catheter.-However, there was no personal protective equipment (PPE), including gowns, observed in or near Resident #2's room. On 12/11/25 at 9:58 a.m. Resident #8's room was observed. Resident #8 had an indwelling urinary catheter.-However, there was no PPE, including gowns, observed in or near Resident #8's room.III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 12/11/25 at 10:00 a.m. CNA #5 said she had been working at the facility for approximately 18 months. CNA #5 said the nurses cleaned the residents' catheters and it was the CNAs responsibility to empty each catheter every shift, then report the output to the treatment nurse to document. CNA #5 said she completed hand hygiene and wore gloves to empty the residents' catheters, but she did not wear a gown when draining a catheter. CNA #5 said she had not heard of or had any training on EBP. CNA #4 was interviewed on12/11/25 at 10:05 a.m. CNA #4 said she normally performed hand hygiene to empty the residents' catheters and used an alcohol swab to clean the catheter after emptying it. CNA #4 said she had not heard of or had any training on EBP. CNA #4 said she did not wear a gown when cleaning or emptying a resident's catheter. Licensed practical nurse (LPN) #2 was interviewed on 12/11/25 at 10:46 a.m. LPN #2 said she knew the facility had two residents with indwelling catheters and one resident with a tube feeding. LPN #2 said she wore sterile gloves when cleaning a catheter, but she did not wear a gown. LPN #2 said she had heard of EBP, but thought it was only for residents with compromised skin integrity. LPN #2 said she was not aware that all residents with a catheter should have EBP or that staff should wear a gown when providing care to residents on EBP. The infection preventionist (IP) was interviewed on 12/11/25 at 2:24 p.m. The IP said he started in his role as IP with the facility earlier this year (2025). The IP said he was new to EBP and was currently learning about the topic. The IP said he was not aware if any residents in the facility required EBP yet. The IP said he was aware of EBP for residents with wounds at risk for infection but he was not aware that residents with indwelling medical devices, including catheters and feeding tubes, also required EBP with direct care. The IP said he planned to review EBP guidance and audit residents in the facility to implement EBP for residents. The IP said currently, no residents in the facility had adequate EBP in place. The director of nursing (DON) was interviewed on 12/11/25 at 5:26 p.m. The DON said she had heard of EBP precautions a few years ago, but she was not aware that EBP had become a regulatory requirement. The DON said the facility did not have an EBP program in place yet. The DON said she planned to work with the IP to implement a program, including staff education regarding EBP. The nursing home administrator (NHA) and the risk manager were interviewed together on 12/11/25 at 6:52 p.m. The risk manager said EBP precautions were reviewed for residents with wounds at high risk for infection during the quarterly quality assurance and performance improvement (QAPI) meetings. The NHA and the risk manager said they had not previously discussed implementing EBP for residents with indwelling medical devices. The NHA said she planned to review the policy and work with the IP to implement EBP precautions for all identified residents who needed EBP.

Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for three (#19, #9 and #10) of four residents reviewed for mental health out of 29 sample residents. The facility failed to offer alternative mental health services when Resident #9 expressed wanting to die but refused counseling services. Resident #9 was admitted to the facility after a hip replacement and heart issues. Less than six months after she was admitted she was diagnosed with cancer. She did not have signs or symptoms of depression until she fell on [DATE] and broke her right arm. She lost her independence and said she felt disgusted with herself since she needed staff to help her with all activities of daily living (ADLs). During her interview, she was withdrawn and had been isolating herself in her room. She said she may never be able to use her right arm like she used to ever again and she was upset about it. She said every night she thought about dying and was ready to go. She did not understand why she had not died yet. The facility failed to identify, monitor and timely provide support to address the resident's newly developing depression, nor did the facility implement a person-centered care plan to include a timely referral for other types of mental health services after the resident refused formal therapy. Furthermore, the facility failed to evaluate Resident #10 on an ongoing basis and develop a comprehensive, person-centered plan of care to meet his psychosocial needs. The facility failed to make reasonable attempts to secure professional behavioral health services when a potential need was identified that Resident #10 was developing signs and symptoms of depression. The facility failed to assess, identify and implement person-centered interventions to maximize Resident #10 goals for care. Due to the facility's failures, the resident had several days of feeling down, depressed or hopeless according to the patient health questionnaire and expressed he was trying to exist and was bored with life. In addition, the facility failed to offer Resident #19 counseling services for her mental well-being. The facility failed to identify, monitor and timely provide support to address the resident's depression worsening after her family stopped visiting her, such as through the implementation of a person-centered care plan and timely referral for mental health services. Findings include: I. Facility policy The Behavioral Health Policy, effective [DATE], was provided by the director of nursing (DON) on [DATE] at 3:01 p.m. read in pertinent: Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, and/or accommodating a resident's distress or loss of abilities. Behavioral health care and services will: -Ensure that the necessary care and services are person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety, -Ensure that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being, -Provide meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents, and the community, -Provide an environment and atmosphere that is conducive to mental and psychosocial well-being, -Ensure that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated, -Identify individual resident responses to stressors and utilize person-centered interventions developed by the interdisciplinary team (IDT), -Ensure care plans address the individualized needs of the resident and contain individualized interventions based on the diagnoses; and -Ensure that the IDT, which includes the resident, the resident's family, and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered. II. Resident #9 A. Resident status Resident #9, age over 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO) diagnoses, included transient cerebral ischemic attack (stroke), squamous cell carcinoma (cancer) and heart disease. According to the [DATE] minim data set (MDS) assessment Resident #9 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS did not contain an assessment of the resident for depression. B. Resident interview Resident #9 was interviewed on [DATE] at 3:02 p.m. Resident #9 said she was getting on the bus to go out for the Fourth of July parade as a group activity and fell . She said she felt disgusted with herself and was angry that she fell . Resident #9 said she could only lift her arm about 90 degrees to her body and she may never get to lift it more. She said while she healed she could not participate in group activities. She said a physical therapist (PT) went to her room to work with her. She said activities were not offered to her in her bedroom. She said she was depressed and ready to die. Resident #9 said she was admitted to the hospital after the fall to treat her injuries but could not remember how long she was admitted for (record review showed she was admitted for 10 days). She said when she returned to the facility she was no longer independent and required staff assistance for almost everything. Resident #9 said she fell again on [DATE] when she tried to pick a card up off the floor and slid out of her wheelchair. Resident #9 said it was embarrassing and she scooted herself across the floor to get her call light for staff assistance. She said she was still depressed and was not sure if the facility offered her counseling services but she did not want to talk to someone. She said she did not know what else the facility could do to help her depression but every night she felt depressed and thought she was better off dead or was ready to die because of her age and she still could not walk or be independent. She said she felt like her bones were taking a long time to heal. C. Record review Resident #9's comprehensive care plan, revised [DATE], documented the resident had a decline in activity involvement due to her depression and her broken arm. An intervention for activities, revised on [DATE], was to explain to the resident the importance of social interaction and encourage the resident's participation by invitation and encouragement. It was also documented the resident had depression signs and symptoms due to her right broken humerus (arm) and subsequent decline in functional abilities. Interventions were documented as the following: -Discuss with the resident any concerns, fears, issues regarding health, or other subjects, -Monitor, document, and report any risk for harm to self as needed; and -Monitor, document, and report any signs or symptoms of depression. A progress note entered on [DATE] documented Resident #9's MDS assessment was completed. During the MDS assessment, the resident stated that had thoughts that she would be better off dead because her arm was not allowing her to do as much as she used to. She said she knew it was healing just not as fast as she wanted it to. The resident was asked if she wanted to speak to a therapist about her thoughts and she stated that she did not want to talk to anyone. The ADON and DON were notified of the findings and the ADON was going to talk to the resident.The resident was asked if she would like to attend her upcoming care plan meeting on [DATE]. The resident stated that she did not want to attend. A progress note entered on [DATE] documented the ADON spoke with Resident #9. The resident said that she had feelings of depression due to the fact that her arm still had not healed and she needed a lot of assistance from staff. The resident said at times she felt she would be better off not being here. The ADON asked the resident to further elaborate on what she meant and if she had thoughts of harming herself. The resident denied thoughts of harming herself but said she felt like she could not care for herself without so much help from staff that she may have been better off not making it through the fall that resulted in her arm injury. The ADON consoled the resident and said he understood her feelings and that it was okay for her to feel a little down about not being as independent as she was previous to her fall. The ADON told the resident he was concerned about her being too depressed or her depression worsening. The resident said she did not want to talk to anyone about the situation but she agreed to the ADON informing her physician to see if medication was needed for her depression. A care conference held on [DATE]. The notes documented Resident #9 had a positive outlook on life. She was not fond of being at the facility but was making the best of it. The note documented that the resident said it was hard getting old. Resident #9's patient health questionnaire (PHQ-9) was documented as a nine which indicated mild depression. Resident #9 said she did not want to talk to anyone at this time but agreed to the ADON informing her physician about possibly starting an antidepressant. The resident was having a hard time because she was not healing as fast as she wanted and was not independent like she used to be and it made her upset. A progress note entered on [DATE] documented the physician visited the resident on [DATE]. The physician said the resident's appetite was good and she still attended desired activities. The resident declined therapy and medications during the visit and would inform the staff if her depression symptoms worsened. The facility continued with therapy and the resident's current plan of care. A progress note entered on [DATE] documented Resident #9's lungs had crackles in the bases. The resident denied being uncomfortable and admitted to a non-productive cough. The resident told the nurse that she did not want to go to the hospital and declined all tests. She said that she was ready to go (die) when it was her time. She allowed the nurse to give her oxygen to keep her oxygen within normal limits. A progress note entered on [DATE] documented Resident #9's oxygen saturation decreased to 86% (normal limits 90% and above) on room air. The resident refused to wear oxygen. The resident stated that she did not want to go to the hospital and declined all tests. She said if it was her time to go then she was ready. The resident's physician said she would visit the resident for an assessment. A progress note entered on [DATE] documented the nurse notified the resident's medical durable power of attorney (MDPOA) of Resident #9 refusing to wear her oxygen. The resident's oxygen saturation was at 77% on room air. The resident's MDPOA said he was on his way to the facility. The nurse ended the phone call and reapproached the resident to offer oxygen and the resident agreed. A progress note entered on [DATE] documented the resident tested positive for rhinovirus (type of head cold) and began antibiotics. D. Staff interviews The ADON was interviewed on [DATE] at 2:30 p.m. He said before Resident #9's accident she was independent with all activities of daily living (ADLs). He said she was very private and did not want any interventions in place for her depression. The ADON said she did not want to die but if she died then she was okay with it. He said the resident declined activities because she did not want to be seen by other residents being wheeled by staff to activities. The staff encouraged the resident to participate in activities and that the other residents would not think less of her if she needed help from staff. The staff made her comfortable to participate in activities. He said the resident did not like when staff checked on her too much and would not let staff come in and sit with her. The ADON said the staff documented that they checked on her. -However, the facility failed to document consistently when they checked on Resident #9. The activity director (AD) was interviewed on [DATE] at 9:24 a.m. She said she knew the resident became more depressed after the accident because she was no longer independent. She said the fall affected Resident #9 physically however it affected her mentally and she became more withdrawn than she used to be. The AD said when the resident returned from the hospital the resident said she was giving up on life because of her injury. The AD said she would not be surprised if Resident #9 still felt this way but she did talk to her a lot and the resident seemed okay. She said the facility was not doing anything for Resident #9's depression that she was aware of. III. Resident #10 A. Resident status Resident #10, over the age of 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included traumatic subdural hemorrhage (bleeding in the brain post traumatic brain injury) with loss of consciousness status unknown, sequela (bleeding in the brain post traumatic brain injury), gastro-esophageal reflux disease without esophagitis, benign prostate hyperplasia without lower urinary tract symptoms (enlarged prostate gland that is not cancerous) and history of falling. According to the [DATE] MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He did not exhibit disorganized thinking or inattention. He did not have behaviors, including rejections of care. The MDS assessment identified Resident #10 had several days of feeling down, depressed or hopeless. B. Resident interview and observations Resident #10 was interviewed on [DATE] at 1:11 p.m. He said she had a stroke and he needed a new brain. He said he had been in his current condition for almost ten years. Resident #10 said he was having one hell of a time just trying to exist. The resident said he was bored and bored with life. Observations throughout the survey between [DATE] and [DATE] between the hours of 8:00 p.m. and 6:00 p.m. identified Resident #10 did not get out of bed. He ate his meals in his room. When the resident was not eating, he spent his time sleeping or watching sports channels. C. Friend of the resident interview A friend of Resident #10 was interviewed on [DATE] at 12:0 p.m. She said she tried to come see Resident #10 almost everyday around lunch time so he had some company. The resident's friend said the resident's family member had not been available to visit Resident #10 as often as he used to. She said she really did not see too many staff check in with Resident #10. He said he told her he just wanted to go to sleep and pass. The friend said she wished staff would try to encourage him to spend less time in his bed. D. Record review -The review of Resident #10's comprehensive care plan identified the facility failed to develop a person-centered psychosocial wellness care plan to maintain the resident's highest practicable level of physical, mental and psychosocial well being. The resident's care plan did not identify individualized approaches of care/interventions that were part of a supportive mental and psychosocial environment which was directed towards understanding, preventing, relieving, and/or accommodating the resident's distress or loss of abilities. The [DATE] social service assessment read Resident #10 walked with a walker with two person assist and a gait belt for short distances. He needed help with most ADLs such as transferring, bed assist, dressing, toileting and bathing. He could eat independently in his room with set up help. Resident #10 was aware of self, family, friends, years, month, day and his surroundings. The resident did not have behaviors and his mood was pleasant. According to the social service assessment under the category of psychosocial, Resident #10 had a family member that visited and the resident was developing a good relationship with the staff. He had tried to use headphones that connected to the television so he was able to hear better but the resident could not tolerate the headphones. -There was no additional information or needs provided under psychosocial when the resident was assessed with social services. The [DATE] physical therapy evaluation documented Resident #10 refused to participate during the physical therapy evaluation. According to the evaluation, the resident said I am just going to die here in this bed and I will lie here the rest of my life until I die. The [DATE] occupational therapy evaluation documented Resident #10 liked sports and the outdoors. He felt he could not stand or walk and declined occupational therapy or attempts to get out of bed during the therapy evaluation. According to the evaluation, the occupational therapist offered a trip outside, modified bowling in a seated position, and offered bingo. The occupation evaluation indicated the resident declined and said What is the point, I can't do it, I am just going to die here and I wish it would be sooner rather than later. I have too much blood in my head and no one can drain it, I don't just have a zipper up there. -The review of the [DATE] and the [DATE] treatment administration record (TAR) and progress notes did not identify Resident 10's mood and behavior was tracked and monitored after he made statements of wanting to die on [DATE]. A list of residents receiving counseling supportive services was provided on [DATE] by the facility. The list did not identify Resident #10 received counseling supportive services even though the resident identified he had several days of feeling down, depressed or hopeless as identified by the MDS assessment and feelings of wanting to lie in bed and die as identified in the [DATE] physical and occupational therapy evaluations. E. Staff interviews The activity director (AD) was interviewed on [DATE] at 9:53 a.m. The AD identified Resident #10 did not participate in group or individualized activities other than watching sports on television. The AD said when she had asked him to do an activity, he told her he just needed a new brain. The AD said the resident was not part of a one-to-one program offering additional opportunities for engagement and socialization (cross-reference F679 for activity programming). The social service director (SSD) was interviewed on [DATE] at 10:47 a.m. The SSD said she helped residents with emotional needs by connecting residents to counseling services and other volunteers who helped provide additional support. The SSD said she checked in with Resident #10 but had not documented her check ins. The SSD said Resident #10 had not told her he was bored with life. She said Resident #10 had said he felt he could not do what he used to do since his stroke, but he did not seem too upset by it. She said he would talk to her about his past job and sports. She said a family member that he was close to use to visit more but he has not visited Resident #10 as much lately. The SSD said counseling services might help Resident #10 break out of his shell and encourage him to come out of his room. She said she thought a physician referral for the counseling service was made for Resident #10 but she was not sure what the status was. The SSD was interviewed again on [DATE] at 12:40 p.m. The SSD said she was thinking of another resident when she said she thought Resident #10 already had a physician referral for counseling services. She said a referral for counseling service was not made with the physician for Resident #10. The SSD said she was not aware Resident #10 told therapy on [DATE] that he wanted to remain in bed and die. She said the documented resident comments should have been communicated to her so she could have followed up sooner. The assistant director of nursing (ADON) was interviewed on [DATE] at 2:26 p.m. The ADON said he just made a counseling referral for Resident #10's physician. The nursing home administrator (NHA) was interviewed on [DATE] at 2:41 p.m. The NHA said the facility had some options within the community for behavioral health services including counseling services with a local hospice provider and telehealth. The NHA said she would reach out to the licensed social workers on the hospital campus and she would research other available resources with mental health services outside the community. The NHA said the facility should have identified and communicated the expressed feelings from Resident #10 so the facility could have provided him additional support. IV. Resident #19 A. Resident status Resident #19, age over 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included dementia, recurrent major depressive disorder, left hip osteoarthritis, breast cancer and restless leg syndrome. According to the [DATE] MDS assessment Resident #19 had a severe cognitive impairment with a BIMS score of five out of 15. Her depression was not documented other than her diagnosis. B. Resident interview Resident #19 was interviewed on [DATE] at 11:53 a.m. She said she felt really depressed and the facility was not helping her with it. She said her family stopped visiting her but she did not know why. She said when her family did not visit it affected her mentally. Resident #19 said she was angry but did not know why. She said she knew she did not eat enough and had lost a lot of weight. During the interview, the resident was observed lying in her bed in the dark and she chewed on her nails constantly. C. Record review Review of the progress notes from [DATE] to [DATE] revealed the resident's depression signs and symptoms were not documented by the staff even though she had a diagnosis of major depression disorder and they discontinued her antidepressant on [DATE] and the facility restarted her antidepressant medication on [DATE] due to her losing weight. Resident #19's comprehensive care plan, revised [DATE], documented she was dependent on staff to meet her emotional, intellectual, physical, and social needs due to her cognitive deficits and physical limitations. The interventions for staff were to offer activities to Resident #19 and allow her to decline. She used Lexapro (antidepressant medication) for her depression. The interventions for the antidepressant were to monitor for negative side effects. She was documented as having a nutritional problem due to anorexia. The interventions documented were to monitor food intake and offer nutritional supplements when she refused to eat. -However, the facility failed to implement interventions for staff to provide support when the resident was depressed or guidance for staff to provide support for her major depressive disorder. D. Staff interviews The SSD was interviewed on [DATE] at 4:07 p.m. She said the facility had a few residents who had a hard time with depression and the facility worked with another organization to provide counseling services to the residents. She said the facility sent referrals if a resident needed counseling or therapy services and the organization provided the services once they accepted the referral. She said the facility completed pre-admission screening and resident review (PASRR) when residents were admitted . If the resident needed services the PASRR provided recommendations the facility followed. The SSD was interviewed again on [DATE] at 11:00 a.m. She said Resident #19 had a PASRR II completed and there were no recommendations needed for her major depressive disorder because dementia was her primary diagnosis. She said Resident #19 was not provided counseling services and she was not sure if the resident wanted to talk to anyone about her depression. Nurse aide (CNA) #1 was interviewed on [DATE] at 5:15 p.m. She said if a resident expressed depression or wanting to die she notified the nurse and made sure the resident did not have anything to harm themselves with. She said she would not leave the residents by themselves and used the call light to get help if possible. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 5:17 p.m. She said if a resident expressed depression or wanting to die she asked open-ended questions to get the resident to talk about what was going on and see if they were safe. She said she notified the resident's physician and the nurse supervisor. She said she did not experience a resident being depressed or heard of a resident saying they were ready to die. She said she checked the facility's policy to make sure she provided the correct amount of support to the resident and checked to see if the resident had anything to harm themselves. -The nursing staff interviewed had not worked at the facility for a long time and did not experience any residents showing signs of depression or expressing they wanted to die. 40467

Based on observations, record review, and staff interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Expired foods were disposed of in the activity refrigerator the residents used; -Foods were dated and sealed in the activity refrigerator; -Foods were dated and sealed in the cabinets of the activity kitchenette; and, -Kitchen staff practiced good hand hygiene and proper glove use while preparing and serving ready-to-eat foods to the residents. Findings include: I. Activity kitchenette A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved [DATE] from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Facility policy The Food Storage policy, revised [DATE], was provided by the dietary director (DD) on [DATE] at 12:40 p.m. and read in pertinent: All food shall be checked for spoilage. Food and nutrition products brought in by residents and families shall be evaluated by the resident's nurse for compatibility with the resident's therapeutic diet, shall be clearly labeled and dated, and shall be stored in a separate refrigerator using proper sanitation, temperature, light, moisture, ventilation, and security. C. Observations On [DATE] at 3:22 p.m., the activity refrigerator was observed to contain the following: -A partially eaten yogurt parfait, with an expiration date of [DATE]. -Six cherry tomatoes in a plastic zipped bag with a paper towel inside with no date. -Two orange slices wrapped in plastic cling wrap and were not dated. -Two orange slices in a white ramakin dish with plastic cling wrap without a date. The top orange slice had what looked like white mold growing on it. -An opened 32 ounce (oz) bag of shredded medium cheddar cheese with approximately one cup of cheese remaining and undated. -A bushel of green grapes in a plastic sandwich bag that was undated. Some of the grapes were brown and mushy and there was moisture or liquid in the bag. -A bowl of cucumber salad wrapped in plastic wrap with a date that was no longer visible. -A chunk of unidentifiable meat with a red sauce in a plastic bag that was initialed SS and dated [DATE]. -A piece of cake in a small bowl with plastic wrap that was undated. -A bowl of lima beans that was wrapped in plastic wrap and undated. -Two whole oranges and two whole cuties (small oranges) in an unlabeled and unsealed grocery bag. -Three whole apples in an unlabeled and unsealed grocery bag. -Half of a sliced brown and mushy apple in a sandwich bag that was undated. -A whole apple tied in a produce bag that was undated and unlabeled. -Two whole cuties in the produce drawer and were mushy. -A half-eaten container of spinach and artichoke dip in the refrigerator door that was undated and the name was illegible. -A small disposable condiment container that was yellow in color labeled SS and dated [DATE]. When the liquid moved there was a brown sediment on the bottom of the container. -A stick of butter that was cut with five tablespoons remaining that was unsealed and undated. -Approximately two tablespoons of butter in a sandwich bag that was undated. -Approximately eight ounces of shelled walnuts in a gallon-sized plastic bag that was undated and unlabeled. -A [NAME] jar of homemade apple butter dated ,d+[DATE]. -A [NAME] jar of homemade strawberry jam dated [DATE]. -A 16 oz container of buttercream frosting with one-third of the container remaining that was undated. At 3:30 p.m., the activity freezer was observed to contain the following: -One white dentistry hot and cold body pack was in the freezer. -Two purple pearl sports hot and cold body packs were in the freezer. -A white ramakin dish of what looked like chocolate ice cream was wrapped in plastic wrap and covered in freezer burn (ice crystals) without a name or date. At 3:40 p.m., the activity kitchenette cabinets were observed to contain the following: -The edges of three cabinet doors, under the coffee machine, were covered in spilled coffee that was dried up and sticky. -Opened zero-sugar wafer cookies were in a gallon plastic bag that was undated. -Hershey's kisses were in a sandwich bag that was undated. -A box of sugar ice cream cones was opened and undated. -A bag of opened marshmallows was opened and undated. -A bag of powdered sugar was opened and undated. -A packet of ranch dressing powder had the left corner torn off and it was unsealed and undated in the cabinet drawer by the ovens. -A four-quart Tupperware of what appeared to be sugar was unlabeled and undated and the scoop was inside the Tupperware on top of the item. -A box of Cinnamon Toast Crunch cereal had the bag opened and shoved back down into the box that was unsealed and undated. -A box of Rice Crisp Cereal was opened and the bag was shoved back down into the box and was unsealed and undated. -A plastic bag of brown sugar was undated. -An opened bag of white long-grain rice that was unsealed and undated. -An opened bag of monk fruit sweetener that was undated. -An opened bag of flour that had the opening of the bag folded over and was undated. -An opened bag of almond flour that was undated. -An opened bag of Splenda sweetener that was undated. -Two 24 fluid-ounce bottles of vegetable oil were opened and undated. -An opened bottle of sugar-free syrup was not dated in the cabinet. -An opened six-ounce bag of pecan chips was folded over itself and was not dated. -A baker's semi-sweet chocolate bar was opened and partially used had its wrapper folded over the bar and placed back in the box that was unsealed and undated. -A 64 oz container of old-fashioned oats that was almost empty and undated. -A 24-pack of two-bite assorted holiday cupcakes with four cupcakes remaining that were on the counter and undated. D. Staff interview The DD was interviewed on [DATE] at 3:16 p.m. He said he was unaware the activity kitchenette had undated and expired foods but he would ensure they got rid of the improperly sealed or expired food and was going to provide training to the floor staff. II. Resident water cups A. Professional reference According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (effective [DATE]) page 148, After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining and may not be cloth dried. B. Observations On [DATE] at 5:27 p.m. 26 normal-sized resident water cups were observed on the cart near the ice machine upside down and still wet. The cups were air drying but still wet on the cart when the cups were filled with ice water and served to the residents. On [DATE] at 9:46 a.m. 36 normal-sized resident water cups were observed on the cart near the ice machine upside down and still wet. The cups were air drying but still wet when the cups were filled with ice water and served to the residents. Two coffee mugs were placed in the activity kitchenette by an unidentified dietary aide (DA) and the mugs were not dried before going into the cabinet. At 3:45 p.m. 31 normal-sized resident water cups and one large resident water cup were observed on the cart near the ice machine. The cups were upside down and soaking wet. The cups were drying but still wet on the cart right before the cups were filled with ice water and served to the residents. C. Staff interviews The dietary manager (DM) was interviewed on [DATE] at 3:16 p.m. She said dishes, including cups needed to be completely air-dried before being used again. The DD was interviewed on [DATE] at 3:16 p.m. He said the water cups needed to be completely dried before they went to the floor to be used by the residents. He said he was going to provide training to the staff for air-drying the dishes correctly. III. Glove use and hand hygiene A. Professional reference According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (effective [DATE]) pages 47 to 48 Food employees shall clean their hands before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands. According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (effective [DATE]) page 74 If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Facility policies The Infection Prevention and Control for Nutritional Services policy, revised [DATE], was provided by the (DD on [DATE] at 12:40 p.m. and read in pertinent: All equipment shall be thoroughly cleaned after each use. Food handlers are required to perform hand hygiene prior to contact with or the preparation of food items and beverages. Food shall be served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact. Steam tables shall be kept in clean and sanitary condition through regular cleaning. Refrigerators shall be kept in clean and sanitary condition through regular cleaning and shall be used for food and food products only. All foods that have been prepared for service, but not shredded or chopped, shall be covered, dated, and discarded after three days if not used. Food preparation tables, work areas, cooking, serving utensils, and cutting boards shall be washed and sanitized before and after coming in contact with food. The Hand Hygiene policy, revised [DATE], was provided by the DD on [DATE] at 12:40 p.m. and read in pertinent: Gloves will be used per standard precautions whenever contact with blood, body fluid, or other potentially infectious matter is present, for contact with residents or residents' non-intact skin or as a part of transmission-based precautions and when using chemicals during cleaning activities. Gloves will be changed when moving from a dirty to a clean activity during resident care. Gloves will be removed after completing care for a resident or when leaving the work activity requiring the use of gloves. Gloves will not be worn for more than one resident. C. Observations Dinner observations on [DATE] at 4:30 p.m. Cook #1 wore gloves as she prepared plates for the residents. The meal was fried fish and chips (french fries), peas and onions, soup and ambrosia fruit salad. She started with plates that were different textures. She removed the breading from the fish and pulled the fish into smaller pieces with her gloved hands. She then pulled the french fries into smaller pieces. She scooped the peas and onions and covered the plate. After she touched the handles of the serving spoons, the plates, and meal tickets, she continued the same process of pulling the items to make smaller pieces with the same pair of gloves. When another batch of fish was completed in the fryer, cook #1 grabbed the thermometer from the container with a cleaning solution and took the temperature of the fish. She returned the thermometer to the container and continued tearing up fish with the same gloves. The DA wore gloves as he added the ambrosia fruit salad and drinks to the meal trays. He was observed to answer the phone with his gloves on and after he hung up he did not change his gloves. Cook #1 changed her gloves after she checked the temperature of the tater tots that came out of the fryer but grabbed another meal ticket with her new gloves and placed the cooked tater tots on the resident's plate. The DA took off his gloves to answer the kitchen phone but put his dirty gloves on a resident's meal tray. After he hung up the phone, he threw away the gloves but did not clean or replace the meal tray his gloves were on. Lunch observations on [DATE] at 11:40 a.m. Cook #2 prepared honey-roasted chicken thighs, macaroni and cheese, apple slices and brussel sprouts for lunch. She wore gloves while she prepared the meal. She used a knife to texture the chicken thighs but did not change her gloves after she chopped the meat and used her hands to put the chicken on the resident's plate. She used scissors to cut the brussel sprouts and laid them on the tray line when she was not using them. The tray line was covered in leftover scrambled eggs from breakfast that were not cleaned up after the meal was served. Cook #2 touched replaced her gloves twice during the meal, however she failed to perform hand hygiene inbetween changing her gloves and touched ready to eat foods with contaminated gloves. D. Staff interviews Cook #1 was interviewed on [DATE] at 4:30 p.m. She said she wore gloves while serving meals because it made it easier. She used the gloves to texture foods too because it was faster than a knife or scissors. She said she changed her gloves any time she touched non-food items. -However, based on observations (listed above) she changed her gloves sometimes after she touched non-food items. The DD was interviewed on [DATE] at 3:16 p.m. He said he had been reminding kitchen staff the gloves were not magic gloves and did not replace hand hygiene. IV. Facility follow-up The DD provided a copy of the daily huddles on [DATE] at 12:40 p.m. The huddles documented the DD talked about proper glove use with the kitchen staff on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. -Although the huddles were being held, observations above reveal improper glove use (see above). The DD provided a copy of a food and nutrition training on [DATE] at 3:16 p.m. He said he created training to provide the kitchen staff and planned on having everyone train by [DATE]. The training included: single-use gloves and bare-hand contact with ready-to-eat food.

Based on observations and interviews, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Cross-reference F679 for lack of meaningful activity programs Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) at www.nccap.org. retrieved on 12/18/23, identified an activity director must meet specific qualifications in education, certification and/or experience. The qualifications read in part: The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is; Licensed or registered, if applicable, by the State in which practicing is: -Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; -Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; -Is a qualified occupational therapist or occupational therapy assistant, or: -Has completed a training course approved by the State. An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. Directing the activity program includes scheduling of activities, both individual and groups, implementing and/or delegating the implementation of the programs, monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary. II. Facility policy The LTC (long-term care) Activity Program policy, dated 12/14/23, was provided by the director of nursing (DON) on 12/14/23 at 3:01 p.m. The policy read in part: The program will be managed by an activities director who is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. The director will do this by: -Scheduling activities, both individual and groups, implementing and/or delegating the implementation of the programs. -Monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident. -Making revisions as necessary. According to the activity program policy, the activities director will have one of the following qualifications: -An activity professional certified by the National Certification Council for activity professionals as an activity director certified or activity consultant certified. -In occupational therapist or occupational therapy assistant meeting the requirements for certification by the American Occupational Therapy Association and having at least one year of experience in providing activity programs in a long-term care facility. -A therapeutic recreation specialist (registered by the National Therapeutic Recreation Society) Having at least one year of experience in providing activity programming in a long-term care facility. -The person with a master's or bachelor's degree in the social or behavioral Sciences who has at least one year of experience in providing activity programming in a long-term care facility. -A person who has completed, within a year of employment, a training course for activity professionals in a credited state facility and who has at least two years experience in social or recreational program work, at least one year of which was full-time in an activities program in a healthcare setting. -A person with monthly consultation from a person meeting the qualifications set forth and subsections (1) through (5). The consultation shall be sufficient in amount to assist the activity staff members to meet resident needs. III. Record review The activity director (AD) job description, revised 2/10/22, was provided by the director of nursing (DON) on 12/14/23 at 3:11 p.m. The essential functions as an activity director as outlined in the job description were to: -Develop, plan, implement, and evaluate the (facility) activity programs. -Set goals with (residents) and establish steps to reach those goals. -Maintain thorough records of (resident) care plans and progress. -Collaborate, as appropriate and necessary, with other Healthcare professionals, both in and out of the (facility). -Actively participate in Resident care conferences as individual meetings with residents, families, and staff, as needed to plan and address concerns. -Other duties as assigned. The job description for the activity director outlined the education and experience needed for the position. According to the job description, the AD needed: -A bachelor's degree in Therapeutic recreation or related field; or 2 years experience in a social Recreation program within the last 5 years; or successful completion of a state-approved basic training course. -Must meet State requirements as an activity professional with one year of higher or transfer. -Previous working in a long-term care setting preferred. The resume and activity job offer for the current AD was provided by the nursing home administration (NHA) on 12/14/23 at 3:37 p.m. The AD job offer identified the AD started as the activity director on 11/8/22. -The resume identified the AD did not have direct activity experience or related education prior to her being hired as the facility activity director. IV. Staff interviews The activity director (AD) was interviewed on 12/14/23 at 9:53 a.m. The AD said her role as an activity director was to keep residents happy and engaged in activities of interest and provide opportunities to socialize. The AD said she had only been the facility AD for a year. She was not certified and she had not started classes to become certified. She said she was still learning her position and only received a week of training in activities before the former activity director retired. The AD said she did not have an activity consultant. She said if she had questions she would contact the former activity director. She said she attended some activity classes at a recent activity conference in October 2023. The nursing home administrator (NHA) was interviewed on 12/14/23 at 2:41 p.m. The NHA said the AD was hired a year ago as the activity director. The NHA said the AD did not have prior activity experience or related education in activities prior to her being hired as the activity director. The NHA said the facility would look into getting the AD an activity consultant. The director of nursing (DON) was interviewed on 12/14/23 at 3:04 p.m. She said the AD had taken an activity class in the fall and asked the former activity director questions when needed. The NHA and the DON were interviewed on 12/14/23 at approximately 4:00 p.m. The NHA with DON said the facility would work on getting a consultant for the AD. The NHA said the facility was not aware of concerns with the activity program or the required qualifications of an activity director.

Based on observations, record review and interviews, the facility failed to ensure menus met the needs of the residents and were followed. Specifically, the facility failed to ensure: -Menu items were not omitted; -Provide accurate portions; -Follow menu extensions; and, -Serve residents their food textured according to their diet orders. Findings include: I. Dinner observations on 12/13/23 at 4:30 p.m. The menu documented the residents received two-thirds of a cup of soup, three ounces of fish and chips, a half cup of peas and onions and a half cup of ambrosia jello salad. However, cook #1 served the residents the following: Resident #13 received a half portion of the meal, approximately one ounce of protein, three french fries, and a tiny scoop of peas and onions and the texture was minced and moist. The soup was omitted. -However, the computer physician orders (CPO) documented she needed a regular diet, minced and moist texture, and regular consistency. Resident #19 received a half portion of the meal, approximately one ounce of protein, seven french fries, a tiny scoop of peas and onions and was textured as bite-sized. The soup was omitted. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #3 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions and was textured as bite-sized. The soup was omitted. -However, the CPO documented she needed a regular diet, mechanic soft texture and regular consistency. Resident #10 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions and was textured as bite-sized. The soup was omitted. -However, the CPO documented he needed a regular diet, texture and consistency. Resident #4 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions and was textured as bite-sized. The soup was omitted. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #14 received a half portion of the meal, approximately one ounce of fish, seven french fries, and a tiny scoop of peas and onions and was textured as bite-sized and the meal was placed in a high-sided dish. The soup was omitted. -However, the CPO documented he needed a regular diet, chopped meat texture and regular consistency and only used weighted silverware. Resident #5 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions and was textured as bite-sized. The soup was omitted. -However, the CPO documented he needed a modified diabetic diet, chopped meat texture and regular consistency. Resident #7 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions and was textured as finger food. The soup was omitted. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #11 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions The soup was omitted. -However, the CPO documented she needed a regular diet, texture, and consistency. Resident #24 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, texture, and consistency. Resident #9 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, texture, and consistency. Resident #12 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #6 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #22 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #20 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #21 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #26 received a half portion of the meal, approximately one ounce of fish, seven french fries and a tiny scoop of peas and onions -However, the CPO documented she needed a modified diabetic diet, texture and consistency. Resident #28 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #25 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #17 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #2 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #16 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented he needed a regular diet, texture and consistency. Resident #30 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #29 received a regular portion of the meal but was served the same seven french fries as the residents who received a half portion. The soup was omitted. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #18 received two full scoops of peas and onions, a regular half-cup portion of the ambrosia jello salad and a two-thirds cup of soup. The fish and french fries were omitted. -However, the CPO documented she needed a regular diet, texture and consistency. II. Lunch observations on 12/14/23 at 11:40 p.m. The menu documented the residents received three ounces of honey-roasted chicken thigh, a half cup of macaroni and cheese, a half cup of apple slices, a half cup of bacon brussels sprouts, and a piece of baked s'more. However, cook #2 served the residents the following: Resident #21 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese and three brussel sprouts. -However, the CPO showed she needed a regular diet, texture and consistency. Resident #10 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts and his food was textured as mechanical soft. -However, the CPO documented he needed a regular diet, texture and consistency. Resident #19 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts and her food was textured as mechanical soft. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #13 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts and her food was textured as mechanical soft. -However, the CPO documented she needed a regular diet, minced and moist texture, and consistency. Resident #3 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts and her food was textured as mechanical soft. -However, the CPO documented she needed a regular diet, mechanic soft texture and regular consistency. Resident #20 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts but her food was textured as mechanical soft. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #9 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese and three brussel sprouts. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #11 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts that was textured as mechanical soft and placed in a high-sided dish. -However, the CPO documented she needed a regular diet, texture and consistency and she used a regular plate. Resident #24 received a regular portion of the meal that was textured as mechanical soft and placed in a high-sided dish. -However, the CPO documented she needed a regular diet, texture and consistency and she used a regular plate. Resident #1 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts and the chicken was textured as mechanical soft. -However, the CPO documented she needed a regular diet, chopped meat texture and regular consistency. Resident #22 received a half portion of the meal, approximately one and a half ounces of chicken, a small scoop of macaroni and cheese, three brussel sprouts that were textured as mechanical soft. -However, the CPO documented she needed a regular diet, texture and consistency. Resident #18 received two whole chicken thighs and the sides were omitted. -However, the CPO documented she needed a regular diet, texture and consistency. III. Staff interviews The registered dietitian (RD) was interviewed on 12/13/23 at 12:02 p.m. She said the residents' food preferences were honored and if the resident refused a meal then an alternative was offered. Cook #1 was interviewed on 12/13/23 at 4:30 p.m. She said she textured the residents ' food based on what floor staff told her to do or if she knew the residents had a choking incident. She said the meal tickets automatically printed off the residents ' textures and portions. She said the portions were printed as small or half portions because the residents wasted too much food and the facility wanted to cut back on food waste. Dietary aide (DA) #1 was interviewed on 12/13/23 at 5:00 p.m. He said he hand-wrote the half portion on the meal tickets if it was printed on the meal ticket so the cook could see it easier and the cook able to quickly get the meals plated. The dietary director (DD) and dietary manager (DM) were interviewed on 12/14/23 at 12:05 p.m. The DD said the staff should not omit any items on the menus unless the residents requested them to do so. The DM said the RD entered the residents ' diets, portions, and textures into their meal system and the kitchen staff printed the tickets and then followed them for the meal. The DD said half portion should only be written on the meal ticket when the residents requested a smaller portion. The DD said he would fix the meal tickets to show regular portions and if a resident requested a half portion the staff could write it on the ticket. He said the facility did not provide half portions because the residents wasted too much food and would provide training to all staff. He said he was unaware the kitchen staff textured residents ' foods who did not need it and would address the issue immediately. The DM said if staff omitted items or gave the incorrect portions the residents did not receive the correct meal to meet their nutritional needs. The RD was interviewed again on 12/14/23 at 12:51 p.m. She said she did not enter information into the facility's meal system for any residents. She said she had not entered half portions to automatically print on the meal tickets. She said the residents' meal tickets documented regular portions and if the resident requested a half portion the staff wrote it on the meal tickets for the kitchen to see.

Based on observation, staff interviews and record review, the facility failed to ensure one (#15) of six sample residents reviewed for assistance with activities of daily living (ADL) out of 29 sample residents Specifically, the facility failed to ensure: -Resident #15 received timely incontinence care; and, -Resident #15 failed to receive timely repositioning. Findings include: I. Facility policy and procedure The Bladder Incontinence policy, effective 11/1/23, read in pertinent part, Prompted voiding contact the resident every two hours during the day, focus the resident attention on voiding by asking whether he or she is wet or dry. Check the resident for wetness and give feedback on whether the resident's self report was correct or incorrect. II Resident status Resident #15, age older than 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbances, chronic pain and hypertension. The 9/10/23 minimum data set (MDS) assessment showed the resident had both short and long term memory impairments, and was moderately impaired in decision making. The resident required substantial to maximum assistance with activities of daily living. The assessment showed the resident was not on a toileting program and was frequently incontinent of urine. III. Observations 12/11/23 -At 10:20 a.m. the resident was sleeping in the recliner in the common area. -At 11:00 a.m. the resident remained in the same position. -At 12:19 p.m. the resident was transferred from the recliner to the wheelchair with no gait belt. She was assisted immediately to the dining room table. She was not offered to go to the bathroom or checked and changed for incontinence care. 12/13/23- the resident was observed continuously from 9:00 a.m. to 1:10 p.m. -At 8:45 a.m. certified nurse aide(CNA) #1 was assisting the resident from bed. -At 9:00 a.m. the resident was at the dining room table. CNA #2 was assisting the resident to eat. -At 11:00 a.m. to 12:12 p.m. the resident attended a group activity. -At 12:12 p.m. the resident was back at the dining room table. The unidentified CNA did not offer the resident to the bathroom and she was not offered or assisted to reposition off of her bottom. The resident was served her meal. -At 12:55 p.m. the resident was assisted to the bathroom. The resident did void in the toilet. IV. Record review The care plan, updated 11/16/23, identified the resident had mixed bladder incontinence related to dementia. Pertinent approaches were the resident benefits from staff to encourage the resident to go to the bathroom. The care plan documented the resident had the potential for pressure ulcer development related to immobility. Pertinent approaches were to follow facility policies and procedures to prevent skin breakdown. The resident needs assistance to turn/reposition at least every two hours, more often as needed or requested. -The care plan was incorrectly documented, the resident had a pressure ulcer. The most recent skin assessment dated [DATE] showed her skin was intact. The 12/14/23 Braden scale documented the resident was at risk for skin breakdown. V. Staff interview CNA #5 was interviewed on 12/13/23 at 2:43 p.m. The CNA said Resident #15 had no behavior problems and was always cooperative. She said that she was dependent on staff for toileting and repostining and offloading her bottom. She said the resident was not able to move from side to side. She was able to move her legs but not her bottom. She said she did not toilet the resident before the noon meal. She said when she did toilet the resident, she would assist her to sit on the toilet. The resident was continent at times but she needed to be offered toileting since the resident did not ask to go to the bathroom due to cognitive impairment. Licensed practical nurse (LPN) #1 was interviewed on 12/14/23 at 9:30 a.m. The LPN said the resident was unable to offload her bottom. She said she needed to be repositioned or stood up at least every two hours. The director of nursing (DON) was interviewed on 12/14/23 at approximately 3:00 p.m. The DON said Resident #15 was dependent on staff for personal care which included both positioning and toileting. She said the resident had a history of a pressure ulcer on her coccyx (tailbone). Although the pressure ulcer was healed, the resident was to be repositioned every two hours. She said the resident was to be offered and assisted with toileting before and after meals, at least every two hours and as needed.

Based on observation, interviews and record review, the facility failed to provide person-centered, individualized recreational activities to meet the psychosocial needs of two (#3 and #10) of five residents reviewed for activities of 29 sample residents. Specifically, the facility failed to ensure: -Create a program of activities either individuality or through group participation which promoted Resident #10's sense of well-being and supported his physical, cognitive, social and emotional health; -Develop an person-centered care plan with interventions to address Resident #10's activity and past leisure interests, to include his activity and socialization needs and overall psychosocial well-being approaches; -Implement the identified activity plan for Resident #10 and evaluate the response to the identified interventions; -Reevaluate and create new interventions when needed to continue to address Resident #10's activity and psychosocial needs; -Track and monitor Resident #10's participation in group and individual activity participation and/ or attempts to include and engage Resident #10 in opportunities to socialize and participate in group or individual activities; and, -Encourage and provide activities for Resident #3 based on her activity interests. Findings include: I. Facility policy The LTC (long-term care) Activity Program policy, dated 12/14/23, was provided by the director of nursing (DON) on 12/14/23 at 3:01 p.m. The policy defined activities as: Any Endeavor, other than routine ADLs (activities of daily living), in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. According to the policy the facility would offer a resident centered activities program that incorporates the resident's interest, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. The activity policy directed staff to: -Interview the resident, the resident family and or the residents representative regarding their likes (activity preferences) hobbies and dislikes. -Set up an appropriate plan of activities post interview. -Reassess the resident quarterly and as needed for a change of condition and update the activities plan as needed. -Provide activities that are broad enough to stimulate participation of all residents, including residents with mental and emotional impairments, but no resident shall be compelled to participate in any activity. -Develop programs to encourage community contact, including use of community volunteers inside the facility and activities for residents outside the facility. -Provide daily activities. -Retain activity attendance records. The activity program policy read: The program will be managed by an activities director who is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. The director will do this by: -Scheduling activities, both individual and groups, implementing and / or delegating the implementation of the programs. -Monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assess needs of the resident. -Making revisions as necessary. The LTC Behavioral Health policy, dated 8/3/23, was provided by the facility on 12/14/23. According to policy, the facility was to create and maintain a system to meet resident requirements for behavioral health to ensure the highest practical physical, mental, and psychosocial well-being of each resident. The policy directed staff to provide meaningful activities which promoted engagement, and positive meaningful relationships between residents and staff, families, and the community. II. Resident #10 Resident #10, over the age of 65, was admitted on [DATE] . According to the computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage (bleeding in the brain post traumatic brain injury) with loss of consciousness status unknown, sequela (bleeding in the brain post traumatic brain injury), gastro-esophageal reflux disease without esophagitis, benign prostate hyperplasia without lower urinary tract symptoms (enlarged prostate gland that is not cancerous) and history of falling. According to the 10/29/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He did not exhibit disorganized thinking or inattention. He did not have behaviors, including rejections of care. The MDS assessment identified Resident #10 had several days of feeling down, depressed or hopeless. According to MDS assessment, it was very important for Resident #10 to listen to music he liked. The assessment identified Resident #10 felt it was somewhat important for him to be around animals and pets, go outside, and participate in his favorite activities. The MDS assessment did not identify the resident's functional ability and goals. The 10/18/23 functional ability/restorative review form identified Resident #10 required extensive assistance with transfers, dressing, and toileting. He needed extensive assistance with his front wheeled walker for mobility. B. Resident interview and observations Resident #10 was interviewed on 12/11/23 at 1:11 p.m. He said she had a stroke and he needed a new brain. He said he had been in his current condition for almost ten years. Resident #10 said he was having one hell of a time just trying to exist. The resident said he was bored and bored with life. Resident #10 said he liked football and basketball. The resident was observed watching football highlights on his television. He said he just spent his time watching sports on television (TV). He said he could not walk and did not know what else he could do. Observations throughout the survey between 12/11/23 and 12/14/23 between the hours of 8:00 a.m. and 6:00 p.m. identified Resident #10 did not get out of bed. He ate his meals in his room. When the resident was not eating, he spent his time sleeping or watching sports channels. C. Friend of the resident interview A friend of Resident #10 was interviewed on 12/13/23 at 12:40 p.m. She said she tried to come see Resident #10 almost everyday around lunch time so he had some company. The resident's friend said the resident's family member had not been available to visit Resident #10 as often as he used to. She said she really did not see too many staff check in with Resident #10. He said he told her he just wanted to go to sleep and pass. The friend said she wished staff would try to encourage him to spend less time in his bed. D. Record review The review of Resident #10's care plan identified the facility failed to develop a person-centered activities care plan based on the resident's goals, individual activity interests, strengths and needs, past leisure pursuits and staff's knowledge of the resident as an individual. The review of Resident #10's care plan identified the facility failed to develop a person-centered psychosocial wellness care plan to maintain the resident's highest practicable level of physical, mental and psychosocial well being. The resident's care plan did not identify individualized approaches of care/interventions that were part of a supportive mental and psychosocial environment which was directed towards understanding, preventing, relieving, and/or accommodating the resident's distress or loss of abilities. The undated activity assessment read Resident #10 identified his past employment, where he spent most of his life, and he enjoyed TV, ice skating, skiing and high school and college track. The 11/3/23 activities initial review evaluation read the team (the facility/staff) would like to keep Resident #10 as active and engaged as he was willing and able to be. The activity evaluation identified the resident wanted one-to-one visits with staff. According to the activity review, Resident #10 enjoyed ice skating, skiing, and track during his younger years. Currently he enjoyed watching TV. The resident required modified activities to accommodate his cognitive and hearing deficit. He needed assistance to go to activities provided outside of his room. The activity review read Resident #10 would need to sit near (the activity) leader to hear. He might need verbal reminders. At this time he does not wish to attend activities. The review read staff were to offer word searches, and puzzles. The 11/7/23 physical therapy evaluation documented physical therapy recommended staff to continue to encourage Resident #10 in the participation of activities, getting up in the recliner, going outside with staff and seated exercise classes. The 11/7/23 occupational therapy evaluation documented Resident #10 liked sports and the outdoors. He felt he could not stand or walk and declined occupational therapy or attempts to get out of bed doing the therapy evaluation. According to the evaluation, the occupational therapist offered a trip outside, modified bowling in a seated position, and offered bingo. The occupation evaluation indicated the resident declined and said What is the point, I can't do it, I am just going to die here and I wish it would be sooner rather than later. I have too much blood in my head and no one can drain it, I don't just have a zipper up there. The occupational therapy evaluation recommended staff to continue to encourage participation in social/leisure activities for maintaining strength / current function as well as ADLs to promote improved hygiene and decrease risk of pressure sores. According to the evaluation, staff were educated on continuing to offer activities and encourage socialization and out of bed activity and continue to trial modified leisure activities such as seated bowling or exercise class. The 11/13/23 nurse note read physical therapy evaluated Resident #10 on 11/7/23.He did not qualify for occupational therapy. Staff were to continue to encourage participation in ADLs and leisure activities. The activity participation records for October 2023, November 2023 and December 2023 were requested from the facility. The review of the records identified an activity participation record was not created for Resident #10 for October 2023 and November 2023. The December 2023 activity participation records identify the resident watching television or movies daily and received frequent visitors. The record did not identify the resident was offered room or out room activities such as music, going outside, pet/animal visits, word searches, puzzles, sports related activities, exercise or one to one visits as identified as an interest and/or recommended by the above assessments/evaluations and notes. E. Staff interview The activity director (AD) was interviewed on 12/14/23 at 9:53 a.m. The AD said Resident #10 was not really active and liked to stay in his room. He got a visitor almost every day and watched TV. The AD said when asked him to do an activity, he told her he just needed a new brain. She said she has offered puzzles and word searches a couple of times but he declined the offer. The AD said she tried to get to know him but it took her a while. She said she knew he was a track star who broke track records. The AD said she offered a one-to-one activity program for residents who do not come out of their room and socialize. She said she was not sure why Resident #10 was not offered a one-to-one program but he would be reviewed again at his upcoming quarterly review. The AD said her role as an activity director was to keep residents happy and engaged in activities of interest and provide opportunities to socialize. The AD said he would be appropriate for a one-to-one program. She said she could visit with him offering support and conversation and just just be there for him. The AD said she could try in room activities such as aromatherapy or try an activity of portental interest such as shooting [NAME] in the portable basketball hoop. The AD said completed Resident #10's activity admission assessment but the form did not have enough questions to really target his interests. The AD said she did not complete a participation record in October 2023 and November 2023 for Resident #10. She said she had been slacking on completing documentation because she was having to do all the activities and resident documentation. The AD said she had limited training, education and experience in activities and as an activity director. (Cross-reference F680, qualifications of an activity director.) The AD said she had an activity assistant to help with activities but he left in September 2023. She said she did not have enough time in the day to do everything she needed to do. The AD said she felt like she was running all the time to try to keep everyone happy. She said she just needed time to think so she could come up with person centered activities. The AD said she felt overwhelmed trying to do group activities and all the one-to-one program activities. The AD said she felt her activity program needed improvement and she still needed to build/revamp the volunteer program. She said she needed more help because she was feeling like she was drowning with all she had to do. The AD said the facility was trying to fill the open activity assistant position. The AD said she felt she could do more residents that remained in their room like Resident #10 if she had more time. The social service director was interviewed on 12/14/23 at 10:47 a.m. The SSD said she helped residents with emotional needs by connecting residents to counseling services and other volunteers that helped provide additional support. The SSD said she checked in with Resident #10 but has not documented her check ins. The SSD said he had not told her he was bored with life (Cross-reference F740 behavioral health services). She said Resident #10 has said could not do what he used to do since his stroke, but he did not seem too upset by it. She said he would talk to her about his past job and sports. She said a family member that he was close to used to visit more but he had not visited Resident #10 as much lately. The certified occupational therapist assistant (COTA) was interviewed on 12/14/23 at 12:00 p.m. The COTA said she provided occupational therapy and assisted with residents' restorative maintenance plan. The COTA said Resident #10 refused therapy and Resident #10 was not on a restorative plan. She said she helped residents with some activities. The COTA said she could try to encourage Resident #10 to spend time outside of his room and potentially attend some activities. The nursing home administrator (NHA) was interviewed on 12/14/23 at 2:41 p.m. The NHA said the activity assistant position was posted but there was a limited pool of potential staff in the community. The NHA said the AD would start taking classes toward her activity director certification soon. She said the AD had reached out to the Colorado Activity Professional Association (CAPA) for guidance. The NHA said the AD was hired a year ago as the activity director. The NHA said the AD did not have prior activity experience or related education in activities prior to her being hired as the activity director. The NHA said the facility would look into getting the AD an activity consultant. The director of nursing (DON) was interviewed on 12/14/23 at 3:04 p.m. She said the AD had taken an activity class in the fall and asked the former activity director questions when needed. The NHA and the DON were interviewed on 12/14/23 at approximately 4:00 p.m. The NHA with DON said the facility was working on a consultant for the AD, was in process of building a volunteer program, and the COTA was able to help with resident activities. The NHA said the facility was not aware of concerns with the activity program or the required qualifications of an activity director. The NHA said the facility needed to find people to assist with the activity program. 48412 III. Resident #3 A. Resident status Resident #3, age over 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included muscle weakness, chronic pain, and polyosteoarthritis (joint pain and stiffness). According to the 11/7/23 minimum data set (MDS) assessment Resident #3 had a mild cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. B. Observations and resident interview On 12/11/23 at 1:00 p.m. there was a reading group by the fireplace listening to a story. At 2:05 p.m. Resident #3 came out of her room in her motorized wheelchair and asked if there were activities going on. At 2:10 p.m. Resident #3 came out of her room in her motorized wheelchair and asked what was going on for activities. At 2:14 p.m. Resident #3 came out of her room in her motorized wheelchair and asked what was going on for activities. She said she was bored and had nothing to do. On 12/13/23 at 11:39 a.m. Resident #3 came down the hallway in her motorized wheelchair. She asked what was happening down the hall because she heard people talking and laughing and was not invited. A balloon game was occurring in a group activity. Resident #3 participated in the balloon game until it ended at 11:45 a.m. She smiled as she hit the balloon with a pool noodle. She was disappointed when the activity ended since she was only there for a few minutes. C. Record review Resident #3 had an activity assessment completed on 11/8/23. It documented Resident #3 attended all desired activities with reminders and invitations. Resident #3 was able to participate independently with modifications for her hearing impairment. Resident #3 attended about half of the organized activities. Resident #3 loved bingo, reading, word searches and attending exercise groups. Resident #3's care plan, revised 11/16/23, indicated the resident was dependent upon staff for meeting emotional, intellectual, physical, and social needs referring to the disease process, being elderly and frail, vision and hearing deficit, cognitive decline, and physical limitations. Interventions were documented in the care plan as: -Ensure that the activities the resident attended were compatible with physical and mental capabilities, known interests and preferences, adapted as needed for her vision and hearing deficit, and age-appropriate, -Invite the resident to scheduled activities, -Provide a program of activities that were of interest and empowered the resident by encouraging or allowing choice, self-expression, and responsibility, -Provide the resident with an activities calendar and notify the resident of any changes to the calendar, -Thank the resident for attendance at the activity function; and, -The resident's preferred activities were bingo, exercise, meals, and coming out for snacks. D. Staff interviews The activity director (AD) was interviewed on 12/14/23 at 9:04 a.m. She said Resident #3 was hard-of-hearing. She said she tried to get the resident to participate in other activities besides bingo. She said Resident #3 never participated in reading groups because of her hearing deficit and would sometimes watch other residents participate in group activities. The AD said she did not provide alternative activities if Resident #3 did not want to participate in the group activities. She said she had a few residents with a one-on-one activity care plan but did not have an actual one-on-one activity program for the residents. Resident #3 did not have her activity participation documented before December 2023. The activity participation record for December 2023 documented the resident participated in exercise, personal hygiene, individual games, canteen, ADL work, library, socials and staff assistance. The AD said she did not have a key explaining what each activity was considered or counted as. The AD was unable to explain what canteen and staff assistance meant on the activity participation although it was documented for the resident. -However, personal hygiene and ADL work did not count as an activity. Licensed practical nurse (LPN) #1 was interviewed on 12/14/23 at 5:17 p.m. She said Resident #3 sometimes asked what activities were going on. She said every morning she worked she checked in on Resident #3 and told her what was planned on the activity calendar. LPN #1 said if Resident #3 asked about what was going on the staff took her to the activity if one was ongoing and encouraged the residents to be active. She said she was unaware of alternative activities if the resident did not want to participate in the ongoing activity.

Based on observation, interview and record review, the facility failed to ensure two (#15 and #7) of four residents reviewed for dementia care out of 29 sample residents addressed their dementia care needs to maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #15 and Resident #17. Finding include: I. Facility policy The Managing Resident Behaviors policy, effective 11/1/23, was received on 12/14/23 at 4:09 p.m. by the director of nurses (DON). The policy read in pertinent part, The purpose to provide a guidelines for appropriately assessing, intervening and documenting resident behaviors.For the resident who exhibits behavior that require a less stimulating environment to discontinue behavior not welcome by others sharing their social space: -Offering activities in which the resident can succeed, that are broken into simple steps, that involve small groups or are one to one activities such as using the computer, that are short and repetitive. -Involving in familiar occupation-related activities. -Involving in physical activities such as walking, games, music, physically resistive activities such as kneading clay, hammering, scrubbing, sanding or using stretch bands. -Slow exercise. The DON was interviewed on 12/14/23 at approximately 4:09 p.m. The DON said the facility did not have a dementia program policy. She said the closest policy was the Managing Resident Behaviors policy. II. Resident #7 A Resident status Resident #7, age over [AGE] years, was admitted on [DATE]. According to the December 2023 computer physician orders (CPO), diagnoses included unspecified dementia with agitation and Parkinson's disease. The 9/25/23 minimum data set (MDS) assessment showed the resident had both short and long term memory impairment and was severely impaired in decision making. The resident required substantial to maximum assistance with activities of daily living. The assessment showed the resident did not have any behaviors, however had delusions. B. Observations 12/11/23 At 9:42 a.m. the resident was in bed with no activity and no television (TV) or radio playing. At 2:26 p.m. the resident was in bed with no activity and no TV or radio playing. At 3:46 p.m. the resident was sleeping in a recliner in room. There was no activity, television or radio playing. 12/12/23 At 10:10 a.m. the resident was sleeping in her recliner, in her room. There was no activity, TV or radio playing. At 2:13 p.m. the resident was in bed sleeping. At 4:23 p.m. the resident was in bed with no activity, TV or radio playing. 12/13/23 -At 10:00 a.m. the resident was in the dining room sitting at the table. There was no meaningful activty. She sat at the table and looked around. There was music playing in the dining room however the resident was not engaged since it was not 1940s music (as indicated on her care plan). -At 10:30 a.m. she remained in the same position at the table with no meaningful activity. -At 11:17 a.m. the resident continued to sit at the dining room table with no meaningful activity . The resident was not encouraged to attend the small group to do exercises. -At 11:28 a.m. the resident continued to sit at the dining room table with no meaningful activity. The music playing in the dining room, however not the resident was not engaged since it was not 1940s music. On 12/13/23 at approximately 4:00 p.m. the resident had her oxygen checked. Registered nurse (RN) #1 attempted to remove the cannula from the resident, however, the resident took hold of her hands. The resident was holding onto her hand and not letting it go. RN #1 asked a certified nurse aide (CNA) to assist, the resident took a hold of the CNA's hand and they were able to change the cannula, while the resident held the CNA's hand. -The resident did not haveany touch stimulation items, picture books or was able to listen to 1940s music as the care plan showed. C. Record review The care plan, revised on 11/16/23, identified the resident had impaired cognitive function related to dementia. Pertinent interventions were administering medications as ordered, engaging the resident in simple, structured activities that avoid demanding tasks, likes folding laundry and sorting silverware, reminiscing with the resident using photos of family and friends, she liked horses and 1940s music. The activity participation log for December 2023 (12/1/23 to 12/14/23) showed the resident attended music activities daily (the common area had continuous music playing). The participation log had marked as daily personal hygiene and canteen (sitting in the common area). -The participation log did not identify any touch stimulation was offered. D. Staff interview The activity director (AD) was interviewed on 12/14/23 at 9:10 a.m. The AD said the resident became agitated if she was in a common area with too many distractions. She said she did not do so well in group activities. She said she did not have any touch stimulation included in the activity programming. She said touch stimulation would be beneficial for the resident, as she always would grab the staff's hands to hold. She said the activity blanket was used on the table. The AD said she needed to review the activity calendar and look at adding more activities geared toward the lower functioning cognitively impaired residents. III. Resident #15 A. Resident status Resident #15, age older than 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included unspecified dementia with behavioral disturbances and chronic pain. The 9/10/23 MDS assessment showed the resident had both short and long term memory impairment and was moderately impaired in decision making. The resident required substantial to maximum assistance with activities of daily living. The assessment showed the resident did not have any behaviors. B. Observations 12/11/23 -At 10:20 a.m. the resident was lying in the common area in the recliner. She slept soundly. -At 11:00 a.m. the resident remained in the same position. -At 12:19 p.m. the resident was assisted to the dining room table for her noon meal. -At 12:23 p.m. CNA #2 sat with the resident to help assist her with eating. While the CNA sat next to the resident, she wore latex gloves and did not speak to the resident when assisting her. 12/12/23 -At 12:00 p.m. the resident was assisted to the table from the recliner. The clothing protector was placed on the resident, however, the CNA failed to tell the resident the clothing protector was being placed around her neck. -At approximately 12:15 p.m., the resident received her meal. CNA #2 wore latex gloves when she sat with the resident to assist the resident to eat. The CNA did not talk to the resident while she assisted the resident to eat. -At 4:01 p.m. the resident was assisted from the recliner to the dining room table. The resident sat at the table with no meaningful activity while she waited for her meal. -At 5:10 p.m. the resident received her dinner meal. The CNA was wore latex gloves while she assisted the resident to eat. She failed to communicate with the resident during her assistance. 12/13/23 -At 9:00 a.m. the resident was at the dining room table. CNA #2 was assisting the resident to eat. The CNA was wearing latex gloves while she assisted the resident with her meal. She did not communicate with the resident while she fed her breakfast. -At 9:20 a.m. the CNA left the table. The resident remained at the table, with no meaningful activity. -At 10:00 a.m. she remained at the table with no meaningful activity. -At 10:51 a.m. CNA #1 assisted the resident from the table and brought her to her room. She turned on the TV. The CNA scrolled through the channels to find something to watch. -At 10:58 a.m. the activity director invited the resident to the activity, she was then assisted to the common area to attend exercises. -At 11:17 a.m. the exercise class was happening, however, the resident was not participating during the arm exercises. She was not encouraged. -At 11:20 a.m. when the leg exercises started, she began to move her legs. She then participated in hitting the balloon with a foam noodle. -At 12:12 p.m. the resident was back at the dining room table. The unidentified CNA placed a clothing protector around her neck without talking to her. -At 12:55 p.m. the resident was assisted to her room, a mechanical lift was used to help with the transfer. CNA #1 did not communicate with the resident when she placed the sling around her waist or when the mechanical lift was going to start to lift her. C. Staff interview The AD was interviewed on 12/14/23 at 9:10 a.m. The AD said Resident #15 enjoyed bingo and exercises. She said the resident spent the majority of her time in the common area. She said the resident also enjoyed looking at picture books. She said the resident was not on any one-to-one program. She said when the resident was involved with activities, then encouragement should happen if the resident was not participating. The social service director (SSD) was interviewed on 12/14/23 at 10:00 a.m. The SSD said that she did not provide any resident specific education to the staff in regard to dementia care for either Resident #7 or Resident #15. The DON was interviewed on 12/14/23 at approximately 3:00 p.m. The DON said latex gloves should not be worn when assisting a resident to eat. She said that normally they did not wear them but the CNAs were nervous and thought it was best to wear the gloves during the survey. The DON said the staff should always communicate with the resident when care was provided and visit with the resident during meals. She said the facility showed specific videos on empathy and dignity to staff.

Based on observations, record review and interviews, the facility failed to ensure residents were free of unnecessary psychotropic medications for two (#15 and #7) of five residents out of 29 sample residents. Specifically, the facility failed to: -Attempt a gradual dose reduction (GDR) for psychotropic medications for Resident #15; and, -Appropriately identify and track individualized targeted behaviors for psychotropic medications for Resident #7. Findings include: I. Facility policy and procedure The Antipsychotic Use policy, undated, was received on 12/14/23 at approximately 12:00 p.m. from the nursing home administrator (NHA). The policy read in pertinent part, the purpose to ensure that the residents (name of facility) are not prescribed antipsychotics without appropriate assessment, non-medication based interventions, consent, monitoring, evaluation and consideration of gradual dose reduction. Behavioral interventions: individualized, non-pharmacological approaches provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical or psychosocial well being. Gradual dose reduction (GDR): Stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. II Resident #15 A. Resident status Resident #15, age older than 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbances, chronic pain and hypertension. The 9/10/23 minimum data set (MDS) assessment showed the resident had both short and long term memory impairment and was moderately impaired in decision making. The resident required substantial to maximum assistance with activities of daily living. The assessment showed the resident did not have any behaviors. B. Observations 12/11/23 -At 10:20 a.m. the resident was lying in the common area in the recliner. She slept soundly. -At 11:00 a.m. the resident remained in the same position. -At 12:19 p.m. the resident was assisted to the dining room table for her noon meal. -At 2:30 p.m. the resident continued to sleep in the recliner in the common area. 12/12/23 -At 5:10 p.m. the resident was assisted with eating her meal. The resident showed no behaviors. 12/13/23- the resident was observed continuously from 9:00 a.m. to 1:10 p.m. -At 8:45 a.m. the resident was assisted from bed. -At 9:00 a.m. the resident was at the dining room table. She was being assisted to eat. -At 11:00 a.m. to 12:12 p.m. the resident attended a group activity with no behaviors exhibited. -At 12:55 p.m. the resident was assisted to the bathroom. The resident was cooperative with the care. C. Record review The December 2023 CPO showed the resident had the following orders for the psychotropic medication Abilify 2 mg by mouth one time a day related to unspecified dementia with behavioral disturbances. The start date was 12/28/21. Review of the medical record showed the Abilify 2 mg one time a day was ordered on 3/31/2020 with the associated diagnosis of Alzheimer's with behavioral disturbances. The record showed the Abilify was discontinued on 12/17/19. -However, resumed on 1/20/2020. The risk benefit statement was requested by the pharmacist on 12/2/22 to perform a GDR. However, the physician declined the GDR with the following: Last attempt to wean resulted in excessive patient distress. The risk benefit was documented, I do not wish to change at this time and reevaluate at a future date and signed on 1/14/22. -The medical record failed to show any other attempts had been tried since 12/17/19 which was four years ago. Behavior records showed the following on the treatment records (TAR) to monitor paranoia and angry outbursts. From September 2023 to 12/14/23 the resident had no behaviors documented on the TAR. The care plan, revised on 11/16/23, identified the resident was prescribed Abilify for dementia. Pertinent approaches were: -Administer psychotropic medications as ordered by the physician; -Have pharmacy review medications and determine when a GDR was appropriate; -Monitor for withdrawal, rejection of care and decreased appetite. GDR attempted and failed. -The target behaviors on the care plan were not the same being monitored on the TAR. D. Staff interview CNA #1 was interviewed on 12/13/23 at 2:15 p.m. CNA #1 said the resident was cooperative with care. She said she did not have any issues with her refusing care, hitting or physical behaviors. She said the resident was not paranoid and did not have any angry outbursts. Licensed practical nurse (LPN) #1 was interviewed on 12/14/23 at 9:30 a.m. The LPN said that she had worked at the facility for about a month. She said the resident did not have any behaviors. She said the resident was prescribed Abilify for angry outbursts. The social service director (SSD) was interviewed on 12/14/23 at 10:00 a.m. The SSD said the resident was prescribed Seroquel. She said the resident had a drug dose reduction in 2019, however, her behaviors had returned. She confirmed no other attempts to reduce the medication had occurred. She said the resident was easily redirected. She said she could not remember what the returned behaviors were after the 2019 reduction, she just remembered agitation. The director of nurses (DON) was interviewed on 12/14/23 at approximately 3:00 p.m. The DON said the resident was on Abilify. She said the resident had a drug dose reduction in 2019, however, her behaviors had returned. She said there were no other attempts to reduce the medication had not occurred since. She said the dose reductions were recommended by the pharmacist and then the physician would agree or disagree. She said they did not want to attempt a gradual dose reduction, as she may have a return of the behaviors. She said the resident was easily redirected. The DON was interviewed a second time on 12/14/23 at 4:36 p.m. The DON said the risk benefit should be reviewed yearly and as needed in the event anything changed. III. Resident #7 A. Resident status Resident #7, age older than 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included unspecified dementia with agitation and Parkinson's disease. The 9/25/23 minimum data set (MDS) assessment showed the resident had both short and long term memory impairment and was severely impaired in decision making. The resident required substantial to maximum assistance with activities of daily living. The assessment showed the resident did not have any behaviors, however had delusions. B. Observations On 12/11/23 at 12:23 p.m. the resident was at the meal and being assisted. The resident took the food out of her mouth and dropped it on the floor. On 12/12/23 at 12:15 p.m. the resident received her meal and was assisted with a bite of food. The resident took the food out of her mouth and dropped it on the floor next to her. On 12/13/23 at approximately 4:00 p.m. the resident had her oxygen checked. Registered nurse (RN) #1 attempted to remove the cannula from the resident, however, the resident took hold of her hands. The resident was holding onto her hand and not letting it go. RN #1 asked a certified nurse aide (CNA) to assist, the resident took hold of the CNA's hand and they were able to change the cannula, while the resident held the CNA's hand. C. Record review The December 2023 CPO showed the resident had the following orders for the psychotropic medication Seroquel 25 mg by mouth twice a day with the associated diagnosis of unspecified dementia with behavioral disturbances. The start date was 9/23/23. Behavior records showed the following on the TARtarget behaviors of throwing food and anxiety related to the use of Seroquel. September 2023 -The resident had 11 days out of 30 with behaviors. The TAR showed the interventions were positive with the interventions of redirection and one-on-one. November 2023 -The resident had 20 days out of 30 with behaviors. The TAR showed the interventions were positive with the interventions of redirection and one-on-one. 12/1/23 to 12/14/23 -The resident had 11 days out of 14 with behaviors. The TAR showed the interventions were positive with the interventions of redirection and one-on-one. -The TAR did not document the exact behavior that the resident was exhibiting. The care plan, revised on 11/16/23, identified the resident had the potential to be physically aggressive related to dementia and overstimulation. Pertinent approaches were: -When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. -Document observed behavior and attempted interventions in behavior log. -Ensure the resident was wearing the oxygen cannula and it could exacerbate aggressive behavior. -When resident becomes agitated, guide away from the source of distress, engage calmly in conversation. -The care plan failed to show the same target behaviors being monitored as the TAR. D. Staff interview LPN #1 was interviewed on 12/14/23 at 9:30 a.m. The LPN said she had worked at the facility for about a month. She said the resident received the Seroquel for dementia with agitation. She said the resident threw food and it could be difficult for her to take her medications. She did well with redirection. She said the resident became overstimulated which caused her anxiety. The SSD was interviewed on 12/14/23 at 10:00 a.m. The SSD said the resident was on Seroquel medication because she had behaviors. The SSD said she threw food, sometimes hitting a staff member, agitation by grabbing staff. She said that the target behaviors were determined by the interdisciplinary team. The DON was interviewed on 12/14/23 at approximately 3:00 p.m. The DON said the resident was prescribed Seroquel. She said she the resident was on the medication because she threw food. The DON said she did not throw it at anyone and said the target behavior may not be the right target behavior because she had anxiety. She said in quality assurance it was discussed that she was not able to focus on eating. She said Mitrazpine (antidepressant medication) was tried but found that it was not beneficial. She said a better way to explain the resident's behavior was lack of ability to focus or relax to eat. She said they had questioned the use of an anti-anxiety but decision was the Seroquel. The DON said the target behaviors were discussed and decided upon by the interdisciplinary team.

Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#9) of two residents out of 29 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #9. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention, The Core Elements of Antibiotic Stewardship for Nursing Homes, updated 8/20/21, http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html included: Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. II. Facility policies A. The Management of Urinary Tract Infections policy, effective 7/1/23, was provided by the director of nursing (DON) on 12/14/23 at 1:40 p.m. read in pertinent: Policy: UTIs are the most common infection in nursing homes today. Therefore, residents exhibiting signs and symptoms of a UTI will be promptly screened and treated as necessary. Procedure: Monitor residents for signs and symptoms of UTIs, like a fever, urinary frequency or urgency, pain with urination, new flank (back) or suprapubic (bladder) tenderness, change in character of urine, onset of or increased confusion, tachycardia (rapid heart rate over 100 beats per minute), tachypnea (rapid breathing); increased or new: incontinence, functional decline, agitation, and lack or loss of appetite. If the resident has signs and symptoms of a UTI and is not acutely ill, then push fluids and monitor closely for up to three days. If the resident improves and symptoms resolve, no urinalysis is needed. If the resident does not improve or becomes acutely ill, the licensed nurse will complete the UTI screen. If two or more symptoms are present, the nurse will initiate a urinalysis and notify the physician. If one symptom is present, continue to monitor and push fluids. Consider other causes for the symptom. Notify the physician if needed. Obtain a urine sample. If the urine sample is positive for bacteria, obtain an order for a urine culture and sensitivity, if the resident does not have an as-needed (PRN) order. Upon receipt of the results, the nurse will notify the physician of the organism present and if it is resistant to any antibiotics. B. The Antimicrobial Stewardship policy, effective 9/1/23, was provided by the DON on 12/14/23 at 1:40 p.m. read in pertinent: The goal of this program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use for all residents. This policy has the potential to limit antibiotic resistance in the long-term care setting while improving treatment efficacy and resident safety, and reducing treatment-related costs. The facility will implement an infection-specific intervention to improve antibiotic use for UTIs and catheter-acquired UTIs (CAUTIs). Not ordering antibiotics until culture results are back for UTIs and CAUTIs. For residents with behavioral symptoms or cloudy, odiferous urine, institute close monitoring and encouraging fluids for three days before requesting an order for a urine culture, unless residents' condition requires faster action. Educational opportunities will be provided for clinical staff as well as residents and their families on appropriate use of antibiotics as needed. III. Resident status Resident #9, age over 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included transient cerebral ischemic attack (stroke), squamous cell carcinoma (cancer) and heart disease. According to the 11/1/23 minimum data set (MDS) assessment Resident #9 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #9 was continent of her bladder. IV. Record review A progress note was entered on 11/20/23 documented the off-going nurse reported the resident had an increased frequency of urination during sleeping hours. A urinary analysis was obtained and sent to the lab for testing. The resident's physician ordered Cephalexin (an antibiotic) 1 gram twice a day for seven days. The resident was informed and agreed to the plan of care and her medical durable power of attorney (MDPOA) was notified. A progress note was entered on 11/21/23 documented the resident took her first dose of Cephalexin without any problems. She denied pain, shortness of breath, nausea, and dizziness. She had an increase in urinary frequency and urgency and her urine appeared cloudy. Resident #9's intakes were good and the staff encouraged fluids. A progress note was entered on 11/27/23 documented the resident was taking an antibiotic for a UTI with no negative side effects. The resident denied any signs or symptoms of a UTI. A progress note was entered on 11/28/23 documented Resident #9 completed her course of antibiotics and had no signs or symptoms of a UTI or negative effects from the medication. An order note was entered on 12/2/23 for a new order of Cephalexin 1000mg twice a day for UTI and a voicemail was left for Resident #9's MDPOA. A progress note was entered on 12/2/23 documented Resident #9 started Cephalexin for a UTI with no negative effects. The resident admitted to mild UTI symptoms. She told the nurse that she was not sure she needed the antibiotic. She reluctantly took the medication after the nurse told her it was important and that she could get very sick if she did not take it. An order note was entered on 12/4/23 documented to check for the culture and sensitivity test from Resident #9's urine sample and report it to the medical director (MD). -The culture and sensitivity had no results at the time of the order. A progress note was entered on 12/6/23 documented Resident #9's culture and sensitivity test results were obtained and the MD was notified. The MD ordered the discontinuation of Cephalexin and started the resident on Ciprofloxacin 250mg twice a day for seven days. The resident was informed and denied painful urination or urgency. The staff encouraged fluid intake. Another progress note was entered on 12/6/23 documented the resident's Ciprofloxacin was delivered to the facility and the resident received her first dose with no adverse reactions. The resident denied pain or discomfort and fluids were encouraged. A progress note was entered on 12/8/23 documented the MD switched antibiotics from Cephalexin due to the urine culture and sensitivity results. The nurse told the resident and the resident verbalized her understanding. A progress note was entered on 12/12/23 documented that Resident #9 had no signs or symptoms of a UTI. Resident #9 was continent and only got up once to use the bathroom that night. -However, the facility did not complete a culture and sensitivity test on Resident #9's initial UTI symptoms before starting her on antibiotics on 11/20/23 and 12/2/23 per the facility's UTI policy. Non-pharmacological options were not documented as used or offered to Resident #9 before starting either round of antibiotics. An undated antibiotic care plan was uploaded to the chart for Resident #9. It documented the resident was ordered Cephalexin 1 gram twice a day for seven days by the MD. Interventions were documented as encouraging adequate fluid intake, giving antibiotic therapy as ordered and monitoring for signs or symptoms of a UTI. V. Staff interviews The DON was interviewed on 12/14/23 at 1:39 p.m. She said if a resident had symptoms of a UTI the staff watched the resident closely and increased their fluids. If they did not get better after three days the nurse obtained a urine sample and completed a urinalysis. If the urinalysis was positive, the MD was notified and the sample was sent for a culture and sensitivity test. If the culture and sensitivity test came back negative, the resident discontinued their ordered antibiotics otherwise the resident finished the course of antibiotics. Resident #9 had a positive culture and sensitivity test in November 2023 and started antibiotics. She finished her antibiotic and started another round due to symptoms of another UTI. -However, only one culture and sensitivity test was documented as completed for Resident #9 during the second round of antibiotics in December 2023.

Based on observation, record review and interviews, the facility failed to ensure one (#23) of two residents reviewed for skin and pressure injuries, out of 15 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Specifically, Resident #23 developed two facility acquired avoidable pressure ulcers on his back, one of which was unstageable. Resident #23 required assistance with staff for activities of daily living (ADLs) such as dressing but staff did not identify skin concerns on the resident's back until the resident had an unstageable pressure injury with 100% necrotic tissue. The resident was identified at risk for pressure ulcers but had limited pressure ulcer preventive measures in place. The resident also had a decline in condition, food intake and mobility. He was not on a routine turning schedule when he required assistance of staff with bed mobility. Resident #23 preferred to sleep on his back. Resident #23 was not offered an air mattress to relieve pressure and help reduce pressure ulcer development until 8/24/22, two days after the resident developed two facility acquired pressure ulcers. Findings include: I. Professional reference A. The NPUAP Pressure Injury Stages, The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility policy The Pressure Ulcer Prevention policy, revised 5/15/2020, was provided by the interim director of nursing (IDON) on 8/30/22 via email. The policy read in pertinent part: All residents will be assessed using the Braden scale upon admission, quarterly, and with significant change in condition. Findings will be documented in the resident's chart. Skin will be assessed during personal care and weekly skin checks. Any findings are to be communicated to the nurse orally or via the skin check record and documented by the nurse in the resident chart. Preventative measures will be instituted as soon as the resident is determined to be at risk for developing a pressure ulcer, or if a pressure ulcer is already present . Residents who cannot sufficiently turn themselves to relieve the pressure must be turned every two hours. If the resident does not tolerate turning due to confusion and combativeness, place the resident on a pressure relieving mattress and turn at least every 4 hours. Document in the nurse's notes. According to the policy the facility may use a pressure-reducing chair cushion or air mattress. Staff also should use a single layer pink pad over pressure relief cushions. The policy read the facility should maintain the resident's head of the bed at or below 30 degrees or at the lowest degree of elevation consistent with the resident's medical condition. Staff should reposition chair-bound residents every hour if they cannot perform pressure-relieving exercises every 15 minutes. Staff should use pillows, foam wedges, sheepskin and heel and elbow protectors to prevent bony prominences from rubbing together. The PUP (Pressure Ulcer Prevention) packet, undated, was provided by the IDON on 8/30/22 via email. The packet outlined facility procedures to prevent pressure ulcers. According to the PUP, staff should: -Complete a new Braden score assessment for high risk triggers and new pressure sores; -Place the resident on a Q (every) two hour turning log; -Provide the resident a pressure relieving mattress; -Notify the director of nursing (DON) and the assistant director of nursing (ADON). The DON or the ADON would notify registered dietician (RD) for nutritional consultation; and, -Complete the care plan and place it in the folder to be scanned into the chart; According to the PUP, if the pressure ulcer was a new wound. Staff would complete a wound assessment that included: -Wound picture; -Wound consult requested from the physician; and, -Request vitamin C and zinc orders from the physician. III. Resident status Resident #23, age 97, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/31/22 minimum data set (MDS) assessment indicated Resident #23 was moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident required limited assistance of one with bed mobility, dressing, personal hygiene, transfers, locomotion, and toileting. According to the MDS assessment, the resident was at risk for pressure ulcers. The MDS did not identify the resident had an actual pressure ulcer or interventions put in place to prevent the development of a pressure ulcer. IV. Observation and resident interview Resident #23 was sitting up in his lounge chair on 8/22/22 at 4:08 p.m. The resident was not observed to have a pressure relieving cushion or pad on his chair. He did not have a pressure relieving mattress or air mattress placed on his bed. He did not have positioning cushions or a wedge in place to assist the resident off his back. Resident #23 was observed in bed on 8/23/22 at 3:04 p.m. The resident was awake and laid flat on his back. He did not have a pressure relieving mattress or air mattress placed on his bed. He did not have positioning cushions or a wedge in place to assist the resident off his back. Resident #23 said he had some pain in his back. Resident #23 said he was not aware of any current wounds or injuries to his back. Resident #23 was observed sleeping flat on his back in bed on 8/24/22 at 10:24 a.m. The resident had a pillow/wedge positioned on his left side between him and the edge of the bed. The pillow/wedge did not provide the resident positioning support to relieve pressure off of the resident's back. A pressure relieving mattress or air mattress in place could not be determined at that time. -At 11:06 a.m. the resident was observed to be awake in bed. He had no changes to his position and continued to lay flat on his back. The resident said he was not in pain. -At 5:44 p.m. Resident #23 was observed sleeping in his bed. He did not have a positioning cushion, pillow or wedge in place and he laid flat on his back. Resident #23 was observed in bed sleeping 8/25/22 at 8:51 a.m. The resident laid flat on his back. He did not have a positioning device in place. -At 10:29 a.m. the resident remained sleeping in bed. There was no change in his position as he laid flat on his back. V. Record review The 11/14/19 CPO directed staff to conduct and skin check weekly and document the condition of skin every day shift every Monday. The 5/28/22 Braden scale for predicting pressure ulcer risk read Resident #22 was at moderate risk for pressure ulcer development. His sensory perception was very limited. His mobility was very limited but he walked occasionally. His skin was often moist. Resident #23 had probable inadequate food intake. The resident had a potential problem with friction and shearing. According to the Braden scale, the resident was able to move freely or required minimum assistance in movement. The 8/8/22 skin observation tool did not identify Resident #23 had skin concerns on his back. The 8/15/22 skin observation tool did not identify Resident #23 had skin concerns on his back. The 8/15/22 bath/skin check did not identify skin concerns. Review of Resident #23's medical record did not identify documented skin concerns prior to 8/22/22. The 8/22/22 Braden scale for predicting pressure ulcer risk read Resident #22 was at high risk for pressure ulcer development. His sensory perception was very limited. His mobility was very limited. Resident #23 had very poor food intake and had a problem with friction and shearing. According to the Braden scale, the resident required moderate to maximal assistance in moving. The 8/22/22 nurse note read Resident #23 was on alert charting for a pressure ulcer discovered on his back by the 8/22/22 day shift. According to the note, the wound nurse was scheduled to evaluate the resident on 8/23/22. The note read Resident #23 refused to lie on side despite encouragement. Pt. (patient) denies pain/needs, no s/sx (sign/symptoms) spreading infection at this time. Will continue to monitor. The 8/22/22 skin/wound note read Resident #23 was found to have two pressure wounds on his spine on the morning of 8/22/22. According to the note, the resident had a pressure ulcer on his lower spine that was 100% eschar (dead tissue). He had a second pressure ulcer on the middle of his spine that was non-blanchable [CONDITION(S)] (redness). The note indicated the physician, the (interim) director of nursing, and the resident's family were notified, and pictures of the pressure ulcers were taken and measurements were completed. The facility obtained orders from the physician. The note revealed the resident was started on a turning schedule. The note read if the resident was not receptive to turning/repositioning, the facility would implement an air mattress to be the next step. The resident was on nutrition intervention and vitamin C and zinc was implemented. The note identified the resident had a significant decline and had not been eating well, taking his supplements or getting up and moving as much. According to the wound note, Resident #23 sat and slept in the same position. Staff would be educated on the need for repositioning. The wound nurse was contacted and she would be available to see the resident on 8/24/22 for a wound consultation. The note read a new cushion for his back was requested from materials management (supply department). The 8/22/22 wound weekly observation tool read Resident #23's physician was contacted and responded to facility questions and requests. The 8/22/22 observation tool identified the pressure ulcer to the resident's lower spine was facility acquired and unstageable with necrotic tissue. The observation tool revealed the 8/22/22 observation was the first observation and did not have prior reference to refer to. The peri-tissue was red and the wound edges and shape were irregular. The unstageable pressure ulcer measured 15 millimeters (1.5 centimeters) in length and 25 milliliters (2.5 centimeters) in width. The tool indicated the presence of [CONDITION(S)]. The observation tool indicated a pad located on his chair had to be thrown away because it was soiled. The 8/22/22 CPO provided orders for wound care for pressure ulcer #1 on the resident's lower spine, and pressure ulcer #2 on the resident's mid spine. According to the orders, staff were to cleanse the pressure ulcers with [MEDICATION(S)] wound cleanser, skin prep to intact skin, and apply [MEDICATION(S)] every three days and prn (as needed). A second 8/22/22 CPO read the resident had orders for a wound consultation with the wound nurse. The 8/22/22 skin care plan read Resident #23 had a potential for pressure ulcer development related to immobility. According to the care plan, the resident should have intact skin, be free of redness, blisters or discoloration. The 8/22/22 care plan identified Resident #23 had a newly developed unstageable pressure sore on his back. Care plan interventions implemented on 8/22/22 included: -Administer treatments as ordered and monitor for effectiveness. -Educate the resident/family/caregivers on causations of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. -Inform the resident/family/caregivers of any new area of skin breakdown. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), and stage. -The resident required supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Care planned interventions added after 8/22/22 included: -Pressure relieving was added to the back of the resident's recliner as of 8/23/22. -Pressure relieving air mattress added to the resident's bed as of 8/24/22. -Attempt to reposition the resident every two hours as of 8/24/22. The care plan noted on 8/24/22, the resident was resistant to repositioning therefore an air mattress was implemented to the resident's plan of care. The 8/23/22 nurse note read Resident #23 was on focused charting for pressure ulcers on his back. According to the note, the wound nurse was to round and evaluate the resident on 8/24/22. The note identified Resident #23 requested to remain in his bed the majority of shift. He allowed staff to assist with toileting and repositioning. Pillows were placed for additional comfort/pressure relief which the resident was not tolerating well. Routine pain medication was administered per orders. The note indicated the resident spent some time up and out of bed and in his recliner with two person staff assistance and was offered fluids during his visit with his daughter. The 8/24/22 note read Resident #23 was on alert charting for pressure ulceration at his back. The note identified the resident had a stage 1 pressure ulcer (mid spine) and an unstageable pressure ulcer (lower spine). According to the note, he was encouraged to sleep on his side but wiggles until he is on his back again and will not sleep anywhere but on his back. The resident was compliant with all his cares, was afebrile with no signs and symptoms of a spreading infection, and is currently sleeping with deep/rhythmic breathing. The August 2022 visual/bedside kardex report (certified nurse aide communication care guide) as of 8/24/22, was reviewed. According to the kardex, the resident was able to move independently in his bed. -The kardex report did not direct staff to review Resident #23's skin during personal cares. The kardex did not direct staff to reposition the resident. VI. Staff interview The registered nurse clinical consultant (RNCC) was interviewed on 8/24/22 at 2:04 p.m. The RNCC said Resident #23 was at risk for pressure ulcer development but felt he was not on a pressure reducing mattress because he was on a turning schedule. She said there was no staff officially reviewing skin concerns prior to the IDON (interim director of nursing) who was placed in her position as of 8/22/22. The RNCC said a toileting schedule and a turning schedule could be one and the same. Registered nurse (RN) #1 was interviewed on 8/24/22 at 2:25 p.m. She said staff reviewed the resident's skin during baths/showers. The resident last was bathed on 8/15/22. The RNCC was interviewed on 8/24/22 at 5:31 p.m. She said a pressure relieving cushion was placed on the resident's chair as of 8/23/22. The RNCC said the facility was having difficulty with their air mattresses filling correctly with working air pumps. She said they have found an available air mattress and were in process of filling it and determining it was in good working order and holding air before placing it on the resident's bed. The RNCC said if the air mattress did not work, she assumed the IDON would order a new air mattress. She said she could not find a turning schedule for Resident #23. She said the IDON would hang a turning schedule in his room reminding staff to turn the resident every two hours. The RNCC said she could not find a wound consultant note so she would check if the wound nurse has seen the resident's pressure ulcer yet. Certified nurse aide (CNA) #1 was interviewed on 8/24/22 at 5:41 p.m. The CNA said staff were supposed to turn Resident #23 every two hours but he usually would not allow the staff to turn him because of his back and leg pain. CNA #2 was interviewed on 8/24/22 at 5:47 p.m. She said most residents should be turned every two hours if they were not able to turn themselves. She said she was not aware of having to do anything special for Resident #23. She said they would turn him more if he pushed his call light and requested. The IDON was interviewed with the RNCC on 8/25/22 at 5:21 p.m. They said the resident had a pressure relieving mattress on his bed as of 8/25/22. The RNCC said the wound nurse had not seen Resident #23 as ordered because she had a family emergency and did not inform the facility. The RNCC said the facility would work to improve communication with the wound nurse. She said the wound nurse would see the resident on the morning of 8/26/22. The IDON said she used to be wound care certified and would work on renewing her certification. The IDON said the resident's food intake has recently gone down. She said there was no documentation or reports that the staff had noticed concerns with Resident #23 before he was determined to have an unstageable pressure wound. Staff should be reviewing his skin weekly and then every time they perform cares such as dressing. The RNCC and the IDON said the resident has had a decline in condition and possibly at the end of life. They said they would inform staff during the new staff huddle to look at his skin daily. VII. Facility follow up The staff huddle minutes/agenda were provided by the IDON on 8/26/22 via email. According to the huddle minutes/agenda, the nurse practitioner saw Resident #23 on 8/26/22. He has had a significant change and was placed on comfort care as of 8/26/22. Resident #23 had a new turn/check/toilet log in place to have staff check off accordingly. The huddle minutes read staff were instructed to: -Turn Resident #23 every two hours and document on the turning log hung on the bathroom door. -Check his skin closely and make sure his dressing was intact and let the nurse know if his dressing was starting to come off his wound. The dressing should be changed every three days and as needed. -Monitor Resident #23 closely.

Based on record review, observations and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for four (#1, #14, #15 and #23) residents out of seven residents reviewed for falls and accidents out of 15 sample residents. Specifically, the facility failed to implement timely interventions and create effective approaches to prevent the recurrence of falls. The facility failed to create and implement a structured fall management program to help mitigate falls and fall recurrences. Resident #23 fell 12 times from 1/17/22 to 8/15/22. Many of the falls resulted in minor injuries. The resident sustained a fracture on 7/24/22, which was his eleventh fall. There were limited new interventions put in place after each of the falls. Interventions primarily included the staff monitoring and the reminder to the resident to use his call light for assistance. Resident #23 had impaired cognitive status and did not recall his falls as identified in both the 7/24/22 emergency department report and during an 8/24/22 resident interview. Almost all of the resident's falls were related to his need to use the bathroom. The resident would use his walker and wore shoes or non-skid socks to get up and attempt to take himself to and from the bathroom independently. The fall reports completed by the facility identified the resident was often not toileted an hour before the falls or it was unknown if the resident was toileted an hour before the falls. His interventions did not identify the toileting pattern or put specific toileting interventions in place. Resident #1 fell five times from 3/8/22 to 8/12/22. Most of her falls resulted in minor injuries such as skin tears. On her fourth fall that occurred on 4/17/22, the resident hit her head and face on a dresser and sustained lacerations requiring sutures. The resident had limited interventions put in place after each fall to prevent the recurrence of the falls. Resident #15 fell out of a bathing chair because the chair track was not secured on 5/23/22. The resident sustained minor injuries. The bathing chair securement/functional operation was not part of routine preventive maintenance checks before or after the incident on 5/23/22 to help ensure the bath chair was safe for use. The facility could not provide evidence that staff were educated on proper use of the bathing chair and what to look for when operating the bathing chair to prevent recurrence. Interviews with certified nurse aides (CNAs) that were responsible for bathing residents identified they were not educated by the facility of the potential malfunctions and actions to take when operating the bathing chair with a resident. Resident #14 fell six times since his 3/8/22 admission to 8/19/22. Resident #14's last four falls all occurred from 7/4/22 to 8/19/22. The facility failed to update the care plan with new interventions and consistently implement interventions such as a fall mat at the resident's bed side. Findings include: I. Facility policy and procedure The Fall Management Program policy, revised February 2021, was provided by the facility on 8/25/22. According to the Fall Management Program policy, the facility was to incorporate a fall management program. The policy read in pertinent part: The (facility) operates in a culture of safety. Staff, residents and family members are encouraged to report any problems or potential problems. A fall management team is responsible for information gathering and developing a plan of action to deal with falls, near misses and other safety concerns. Any resident at risk for falling is entered into the fall management program. The policy directed staff to take the follow preventive measures when resident safety concerns were identified: -Increase toileting frequency of the resident by staff; -Increase staff supervision and assistance for residents during specific high-risk times; -Increase monitoring using alarms; -Provide proper pain management; -Ensure the resident was using safe footwear; -Add a fall mat; -Provide specific behavioral management. The policy indicated the facility would complete an initial care plan, a TRIPS Report and an incident report, to ensure concerns were adequately addressed after a fall. The policy identified the director of nursing (DON) and the assistant director of nursing (ADON) were responsible for monitoring staff compliance and response to interventions. According to the policy, the interdisciplinary team (IDT) in efforts to prevent fall recurrence, would elevate and intervene as needed with: -Resident urinary needs that could potentially cause unsafe transfers; -Adequacy of resident monitoring; -Bed safety; -Wheelchair seating; -Environment; and -Underlying medical conditions and chronic conditions. II. Resident #23 A. Resident status Resident #23, age 97, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included cardiomegaly, dementia without behavioral disturbances, fracture of unspecified part of the neck of the left femur. The 7/31/22 minimum data set (MDS) assessment indicated Resident #23 was moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident required limited assistance of one with bed mobility, dressing, personal hygiene, transfers, locomotion, and toileting. According to the MDS assessment, Resident #23 had two or more falls since his admission. He did not have rejections of care. B. Resident interview Resident #23 was interviewed on 8/24/22 at 11:06 a.m. He said he used his call bell regularly for assistance and they said staff answer the call light promptly. He said he did not remember if he had fallen or not. Resident #23 said he did not have current pain. C. Observations Resident #23 was sitting up in his lounge chair on 8/22/22 at 4:08 p.m. He said he was not in pain and did not have any concerns. His call light was placed near his reclining chair and was within reach. Resident #23 was observed in bed on 8/23/22 at 3:04 p.m. The resident was awake and laid flat on his back. Resident #23 said he had some pain in his back. Resident #23 said he was not aware of any current wounds or injuries. He did not have positioning cushions or a wedge between him and the edge of the bed. His bed was not in its lowest position. He did not have a fall mat next to his bed. His call light cord was next to him on his bed but the call button rested on the floor. Resident #23 was observed sleeping flat on his back in bed on 8/24/22 at 10:24 a.m. The resident had a pillow/wedge positioned on his left side between him and the edge of the bed. His call light was within reach. His bed was not in its lowest position. He did not have a fall mat next to his bed. -At 11:06 a.m. the resident had no changes to his position and continued to lay flat on his back. The resident still had a pillow/wedge positioned on his left side between him and the edge of the bed. His call light was still within reach. His bed was not in its lowest position. He did not have a fall mat next to his bed. -At 5:44 p.m. Resident #23 was observed sleeping in his bed. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. Resident #23 was observed in bed sleeping on 8/25/22 at 8:51 a.m. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. His bed was set at its lowest position. -At 10:29 a.m. the resident remained sleeping in bed. There was no change in his position. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. His bed was set at its lowest position. D. Record review Fall #1 The 1/17/22 incident report read Resident #23 found on the floor next to his recliner at 1:45 p.m The resident stated he tripped coming back from the bathroom. The incident report indicated the fall was unwitnessed and he was ambulating without assistance but used his walker. The resident sustained minor injuries. He had a bruise to left elbow, a skin tear to back right hand, and a reddened area to left iliac crest (top of the pelvis.) The paper tracking record for improving patient safety (TRIPS) report indicated the resident was wearing shoes at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. He did not place his call light on to request assistance. Report identified the interventions put in place after the fall was: -The resident was instructed to call for help. -Increase staff monitoring. Fall #2 The 1/19/22 TRIPS report read Resident #23 was found on his bedroom floor at 9:30 p.m. He wore non-skid socks at the time of the fall and used his walker. The fall was not witnessed. According to the report, it was unknown if the resident was toileted within an hour of the fall. He did not place his call light on to request for assistance. The resident sustained minor injuries of two skin tears. The report identified the intervention put in place after the fall was: -The resident was instructed to call for help. An incident report for the 1/19/22 fall was not provided. Fall #3 The 1/23/22 incident report read Resident #23 found on his bedroom floor at 6:25 p.m. Resident #23 said he was attempting to move over his bedside table from in front of him so he could go to the bathroom. The incident report indicated the fall was unwitnessed and he was ambulating without assistance but used his walker. The resident did not sustain injuries. According to the incident report, the resident agreed to use his call light. The call was provided and secured to his blanket. The incident report indicated a sign was placed at the resident's bedside, reminding him to call for staff assistance before ambulating. The 1/23/22 TRIPS report indicated the resident was wearing non-skid socks at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for help but the report did not clarify if he did not wait for staff assistance after placing his call light on. He did not place his call light on to request for assistance.The report identified the intervention put in place after the was: -The resident was instructed to call for help. Fall #4 The 1/29/22 incident report read Resident #23 was found sitting on the floor in front of his reclining chair at 5:15 p.m. Resident #23 said he was attempting to move his bedside table from in front of him so he could go to the bathroom. The incident report indicated the fall was unwitnessed. The resident did not sustain injuries. The 1/29/22 TRIPS report indicated the resident was wearing shoes at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the interventions put in place after the fall were: -The resident was instructed to call for help. -Use his walker. The care plan for falls, last revised on 2/23/22, read Resident #23 was at high risk for falls. Interventions initiated on 8/7/19 were: -Ensure the resident's call light was in reach. -Provide prompt response to all requests of assistance. -Follow the fall protocol. -The resident uses a walker to ambulate. Fall #5 The 3/2/22 incident report read Resident #23 was found sitting on his floor at 6:10 a.m. According to the incident report he tripped over his feet while walking to his recliner. The resident sustained a skin tear to his right elbow and skin tear to the back of his right hand as a result of the unwitnessed fall. The resident complained of chest pain. X-rays were conducted and there were no fractures found to his chest. He wore non-skid socks and used his walker at the time of the fall. The 3/2/22 TRIPS report indicated the resident was going either to or from the bathroom at the time of the fall which contradicted the incident report. He wore non-skid socks and used his walker at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help.The report identified the interventions put in place after the fall were: -The resident was instructed to call for help. -Increase staff monitoring. Fall #6 The 3/14/22 incident report read Resident #23 was found on the floor near his bed. His shoes were on and his walker was next to him. He was found laying on his right side with a blanket under his head. He denied pain, however he had an abrasion to his right shoulder and a bruise to his right thigh as a result of his unwitnessed fall. The resident stated that he came back from the bathroom and his knees went out from him. The 3/14/22 TRIPS report identified the resident was found on the floor at 9:15 p.m. The TRIPS indicated the resident wore shoes and used his walker at the time of the fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the intervention put in place after the fall was: -The resident was instructed to call for help. Fall #7 The 4/5/22 incident report read Resident #23 was found on the floor near his bed at 8:00 a.m. The resident said he lost his balance while he tried to get back in bed after using the bathroom. According to the report, Resident #23 was not toileted within an hour of the fall. The resident did not sustain injuries as a result of his unwitnessed fall. The 4/5/22 TRIPS report indicated the resident wore non-skid socks and used his walker at the time of the fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the interventions put in place after the fall were: -The resident was instructed to call for help. -Increase staff monitoring. Fall #8 The 4/30/22 incident report read Resident #23 was found on his bedroom floor. The resident said he lost his balance when he tried to get up from the toilet. He then crawled into his bedroom. The resident sustained a skin tear to his right elbow and a skin tear to his right upper arm as a result of his unwitnessed fall. The identified intervention was to remove a cane from his room and place the call light within his reach. The 4/30/22 TRIPS report identified the resident fell at 12:45 p.m. The TRIPS report read he wore non-skid socks and used a cane at the time of the fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for assistance. The report did not clarify he used his call light before or after his fall, to call for assistance. The report did not identify additional interventions. The fall care plan intervention initiated on 6/2/22, after the resident had eight falls in 2022, read: -Ensure the resident was wearing appropriate footwear when ambulating. According to the intervention, the resident wears black tennis shoes. The 6/22/22 minutes for the all-staff meeting were provided by the interim director of nursing (IDON) on 8/24/22 at 5:27 p.m. According to the minutes, staff were informed that they needed to be aware of the various interventions that have been established for the fall risk residents. The minutes read a fall subcommittee would be implemented in the near future to look carefully at the residents who were at risk for falls and had history of falls. The subcommittee would review and brainstorm to see if new interventions needed to be incorporated. The minutes identified that the former director of nursing would ask staff for their input on resident falls. Fall #9 The 6/23/22 incident report read Resident #23 was found on his bedroom floor. He was trying to go to the bathroom. The resident did not sustain injuries from his unwitnessed fall. The 6/23/22 TRIPS report identified the resident fell at 2:30 p.m. The TRIPS report read he wore shoes at the time of his fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for assistance. The report did not clarify he used his call light before or after his fall, to call for assistance. The report did not identify interventions put in place after the fall. Fall #10 The 7/8/22 incident report read Resident #23 was found on his bedroom floor laying supine in front of his bed. The call light was activated after he fell . He said he was coming from the bathroom and slipped. He was trying to go to the bathroom. The resident sustained a skin tear to his left elbow from his unwitnessed fall. According to the incident report, interventions included increased staff monitoring and education to use the call light when needing assistance and ambulating. The 7/8/22 TRIPS report identified the resident fell at 1:30 p.m. The TRIPS report read he wore shoes and used a walker at the time of his fall. According to the report, it was unknown if Resident #23 was toileted within an hour of the fall. The TRIPS report indicated an additional intervention of a physical and occupational therapy referral. The 7/8/22 Morse fall scale for Resident #23 was conducted. According to the Morse scale scoring key, a resident with a score of 45 or greater was at high risk for falling. Resident #23 was assessed to have a high fall risk score of 90. Fall #11 The 7/24/22 incident report read Resident #23 was found on his bedroom floor laying on his right side at 10:43 a.m. He said he was heading back from the bathroom when his feet came out from under him. The resident sustained a skin tear to his left hand and a bruise to his right elbow from his unwitnessed fall. The resident was able to move all of his extremities and denied pain. The incident report noted no other injuries were observed. The resident was assisted off the floor and placed in his recliner. The incident report indicated new orders for a chair alarm were put in place due to his frequent falls and refusal to use his call light. The 7/24/22 TRIPS report identified the resident fell at 1:30 p.m. The TRIPS report his feet were bare other than TED hose (compression stockings) but he used his walker at the time of his fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report did not indicate additional interventions were put in place other than the chair alarm. The 7/24/22 at 3:00 p.m. hospital emergency department (ED) report revealed Resident #23 was brought to the emergency room related to groin pain. According to the ED report, the resident fell the morning on 7/24/22, was assessed by the facility staff who identified skin tears but otherwise seemed fine. The ER report read the afternoon of 7/24/22, the resident started to complain of right side groin pain and was limping so he was brought to the ER for an evaluation. The ED report indicated the resident denied pain at the time of the ER evaluation and did not recall the fall. The 7/24/22 x-ray findings were provided by the facility on 8/25/22. The resident had images of his bilateral hips. The images did not reveal acute fractures or traumatic malalignment. The finding recommended the consideration of a computerized tomography (CT) scan for further evaluation. The 7/27/22 CT scan findings were provided by the facility on 8/25/22. The CT scan revealed the resident had subacute, partially healed fractures of his left pubic bone (forward-facing bone of the pelvic bones) and left inferior pubic ramus (part of the pelvis.) The CT finding also identified an acute, faintly visible nondisplaced fracture of the left inferior public ramus anterior (part of the pelvis) to the older fracture. The 8/10/22 minutes for the all-staff meeting were provided by the IDON on 8/24/22 at 5:27 p.m. According to the minutes, staff were presented with, and discussed, the fall reports for May 2022, June 2022 and July 2022. The 8/10/22 all staff meeting minutes indicated the former DON told the staff they would start a fall subcommittee so they could receive input from various staff members and the clinical quality director (CQD). The subcommittee would look at factors such as tracking, to identify if falls were happening more frequently at certain times. -The 8/10/22 minutes identified a fall subcommittee, discussed as a near future pursuit in fall management on 6/22/22, still was not implemented as of 8/10/22. Fall #12 The 8/15/22 incident report read Resident #23 was found on his bedroom floor by his recliner after taking himself to the bathroom. The resident did not sustain injuries. According to the incident report, the resident was toileted and his alarm was replaced. The 8/15/22 TRIPS report identified the resident fell at 8:45 p.m. His alarm did not sound to notify staff that he was standing up. The TRIPS report read he wore shoes and used a walker at the time of his fall. According to the report, the resident was toileted within an hour of the fall. The resident did not use the call light to request assistance prior to his fall. The TRIPS report indicated the resident was instructed to call for help. An 8/15/22 paper care plan labeled Care Plan Interventions to Manage Falls was provided by the facility on 8/24/22, which identified Resident #23 should have been on a toileting program and wore appropriate footwear. Other interventions for Resident #23, according to the paper care plan were to: -Monitor the resident for appropriate use of devices and appropriate footwear. -Discuss the reason for falls with caregivers. -Keep the resident in view during high risk times if possible, implementing hourly checks if more then one fall in 30 days -Trend of falls for the resident, including the reason for the fall and the location of the fall. The 8/22/22 fall care plan intervention, the one intervention added to the care plan after 6/2/22 and after the resident had four more falls and added the first day of survey, read Resident #23 had multiple falls causing fractures. The intervention read the resident had a tab alarm that acts as a call light since he often forgets to use the call light. E. Staff interview The IDON was interviewed with the registered nurse clinical consultant (RNCC), the chief nursing officer (CNO) and the CQD on 8/25/22 at 4:44 p.m. According to the RNCC, the staff identified a concern with his footwear. His shoes were not grippy on the floor surface. The resident had new shoes. Staff increased monitoring. According to the RNCC, the monitoring was neurological checks after each fall and increased foot traffic past his room. The RNCC said there was no documentation showing evidence of the increased foot traffic monitoring which was described as staff looking into the resident's room as they passed by. The RNCC acknowledged neurological checks after a fall was not a long term intervention to prevent future falls. She said the resident's falls were discussed in post fall huddles and through word of mouth. The RNCC said a fall mat intervention was not placed next to the resident because it would have been a tripping hazard because he was self ambulating out of bed. The IDON said the facility was checking alarms to ensure they were in working order. They have implemented management changes including the hiring of a new assistant director of nursing (ADON) in September 2022. The facility has posted a turning schedule in Resident #23's room. During the interview, it was identified Resident #23 has had a recent overall decline/change in condition and a fall mat would now be appropriate to place at the resident's bedside because he has had increased weakness and was no longer attempting to get up. The resident was placed on comfort measures as of 8/25/22. The IDON said the resident's multiple falls were a serious concern and the facility would conduct fall education with staff. A fall committee would be implemented within the next week. She said care plans would also be a focus to improve on. The CQD said the fall risk tool would be reassessed, identifying high fall risks, patterns, and hourly rounding. He said he would like all staff to help identify changes to fall management. III. Resident #1 A. Resident status Resident #1, age 91, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included dementia, pain in unspecified knee, cardiomegaly, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and anxiety. The 5/22/22 minimum data set (MDS) assessment identified a brief interview for mental status (BIMS) could not be completed. According to the MDS the resident's cognition was moderately impaired. She exhibited short and long term memory impairment. The MDS also indicated the resident had inattention and disorganized thinking. Resident #1 required extensive physical assistance of one person with locomotion, bed mobility, dressing, toileting, and personal hygiene. She needed extensive physical assistance from more than two persons for transfers. The resident did not have rejections of care behaviors. According to the MDS assessment, the resident had a fall with no injuries and a fall with major injuries. B. Observation Resident #1 was observed sleeping in bed on 8/23/22 at 2:08 p.m. The resident had a wedge or cushion between her at the edge of the bed. A fall mat was on the floor at the side of her bed. Her call light was within reach. Her bed was not in a low bed position. On 8/24/22 at 10:21 a.m. Resident #1 was observed sleeping. The resident had a wedge or cushion between her at the edge of the bed. A fall mat was on the floor at the side of her bed. Her call light was within reach. Her bed was not in a low bed position. -At 10:59 p.m. two certified nurse aides (CNAs) enter the resident's room with a hoyer (mechanical) lift to transfer out of bed. On 8/25/22 at 8:50 a.m. Resident #1 was in bed sleeping. The resident had a wedge or cushion between her at the edge of the bed. A fall mat was on the floor at the side of her bed. Her call light was within reach. Her bed was in a low bed position. C. Record review Fall #1 The 3/8/22 incident report read Resident #1 had an unwitnessed fall. She was found on the floor of the kitchenette at 8:15 p.m. The resident had two skin tears to her left elbow measuring 2 centimeters (cm) x 1 cm and 1 cm x cm. The resident wore non-skid socks and was noted to have soiled her pants. The resident told the staff to get her up when they were assessing her. The resident was returned to her wheelchair. The 3/8/22 TRIPS report identified the resident was believed to be reaching for something causing the fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident was toileted after the fall as the immediate intervention to prevent recurrence of falls. No other intervention was indicated. Fall #2 The 4/2/22 incident report read Resident #1 had an unwitnessed fall on 4/2/22 at 2:30 a.m. The resident was heard yelling to staff that she fell . Resident #1 was found on her fall mat by her bed, laying on her left side. According to the incident report the resident's bed was in a low position and her call light was within reach. She did not use her call light to alert staff. The report indeed the resident sustained a redden area to her mid back as a result of the fall. There were no other injuries noted. The 4/2/22 TRIPS report identified Resident #1 was attempting to get out of bed. She was toileted within an hour of the fall. She was found with bare feet. The intervention put in place after the 4/2/22 fall was to increase staff monitoring. No other intervention was indicated. Fall #3 The 4/9/22 incident report read Resident #1 had an unwitnessed fall on 4/9/22 at 6:45 a.m. The resident was found on the floor. She was using incoherent verbalizations when she was found and was not able to describe what happened. Resident #1 sustained a skin tear to her right forearm. The 4/9/22 TRIPS report identified Resident #1 was attempting to get out of bed. The report indicated it was unknown if the resident was toileted within an hour of the fall. She was found with bare feet. The intervention put in place after the 4/9/22 fall was to increase staff monitoring. No other intervention was indicated. Fall #4 The 4/17/22 incident report read Resident #1 had an unwitnessed fall on 4/17/22 at 11:30 a.m. The resident was found on the floor in her bedroom. She sustained a laceration to her left eyebrow and left side of head. The resident was transported to the emergency department (ED) at the hospital for an evaluation. The 4/17/22 TRIPS report identified Resident #1 was not toileted within an hour of the fall. Her call light was within reach and her bed was in the lowest position. The interventions put in place after the 4/17/22 fall were to: -Instruct the resident to call for help. -Move her dresser. The report did not identify why the dresser was moved or if the resident hit the dresser during the fall, resulting in the lacerations. The 4/17/22 ED hospital report read Resident #1 had a 3 cm gaping left eyebrow laceration and a 3 cm parietal laceration. The lacerations were sutured. According to the ED report, the staff heard a slumping noise from the resident's room. The resident did not have a loss of consciousness, nausea or vomiting. The resident was at end of life care and the resident's son requested she have minimal visits to the ED. The ED report read the resident had frequent falls in the past few months and past year. She was in bed at the time of the fall and apparently slipped and fell on to the nightstand next to her bed. The ED report indicated the fall was due to dementia. The 4/17/22 nurse note read the resident fell during the day shift resulting in lacerations and sutures. According to the note, the resident tried to stand on several occasions and was encouraged to stay in her wheelchair by staff. A second 4/17/22 nurse note read Resident #1 attempted to get out of bed, staff helped the resident back into bed and then went to get a lift to get the resident up for the day. According to the note staff returned to the resident less than five minutes later with the lift, the resident had fallen out of bed. She was observed lying on the floor in the bedroom. She had lacerations to her eyebrow and left side of head and a bruise to her head. She was treated with sutures at the ED but the family did not want scans conducted. The intervention identified was for one staff member to staff with the resident while the second staff member retrieves the lift. Fall #5 The 8/12/22 incident report read Resident #1 had an unwitnessed fall on 8/12/22 at 4:00 a.m. The resident was found on the floor in her bedroom on her fall mat when a CNA was passing water to residents. The resident did not sustain injuries. The resident was transferred back to bed. According to the incident report interventions included: -Placing a wedge pillow under the resident's left side to prevent her from rolling out of bed. -The bed was lowered to its lowest position. The 8/12/22 TRIPS report identified it was unknown if the resident was toileted. Her call light was in place and the bed was in the l[TRUNCATED]

Based on observations, record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for nutrition/hydration, out of 15 sample residents, maintained acceptable parameters of nutritional status to avoid unintended weight loss. The facility failed to identify and implement timely interventions to maintain the resident's weight. The facility failed to timely respond to Resident #1's significant weight loss. Resident #1 lost 15 pounds (lbs) in one week, resulting in 11.6% total weight loss between 7/10/22 and 7/17/22. The facility did not timely consult with the registered dietitian (RD) after the resident lost 15 lbs. The facility did not incorporate new interventions in response to the weight loss. The resident lost an additional 7 lbs between 7/17/22 and 8/21/22, revealing a total weight loss of 22 lbs at 17.1%. The facility and RD did not attempt to identify the causation of the weight loss or follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the July 2022 and August 2022 meal intake records identified the resident frequently ate less than 25% of her meal, most prominently at breakfast. The facility did attempt to identify the potential root cause to her low meal intake. The facility failed to consistently document snacks and additional fluids to determine if the resident was receptive and receiving the snacks and fluids. The facility failed to create a care plan identifying Resident #1's risk for significant weight loss and provide care plan directive interventions in attempt to maintain the resident's weight, promote weight gain once the weight had become significant, and to prevent further weight loss. Findings include: I. Facility policy and procedure The Resident Nutrition and Weights policy, revised March 2021, was provided by the facility on 8/25/22. The policy identified the purpose of the nutrition policy was to establish a method of systematically monitoring the residents nutritional status, providing proper nutrition for residents and monitoring the effects of nutritional intake. The policy read in pertinent part: Those residents with significant weight changes will be discussed mostly during the Weight, Skin and Nutrition meeting. Residents with the following clinical conditions will be considered at risk for weight loss: Medication usage such as diuretics, laxatives or cardiovascular agents; also poor oral health status, depression, dementia, therapeutic are mechanically altered diet, lack access to culturally accepted foods, slow eating pace, cancer, refusal to eat, open wounds, [CONDITION(S)], [CONDITION(S)], kidney disease, [CONDITION(S)] (chronic obstructive pulmonary disease), altered bowel elimination and gastrointestinal surgery. According to the policy, weights will be obtained for scheduled order. If a resident weighing over 100 lbs has been identified to have a five pound weight change, the staff should reweigh the resident with charge nurse or assistant director (ADON). The charge nurse or the ADON would enter the weights in the resident's medical record and review for weight gain or loss. The policy identified weight changes at or above 5% in one month, 7.5% in three months, or 10% in six months were considered to be significant. According to the policy, if significant weight loss was identified, staff should complete the following actions within 48 hours of weight loss identification: -Order in an [MEDICATION(S)] in level as per standing order. -Consult the registered dietitian. -Notify the physician. The policy indicated all residents with significant weight change would have a care plan addressing the residents needs with measurable objectives to be done in the appropriate time frame. According to the policy, food percentage intakes were monitored by dietary and certified nurse aides (CNAs) and charted in the medical record by the CNAs. Documentation/charting should also include snack and supplement intake. II. Resident status Resident #1, age 91, was admitted on [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/22/22 minimum data set (MDS) assessment identified a brief interview for mental status (BIMS) could not be completed. According to the MDS the resident's cognition was moderately impaired. She exhibited short and long term memory impairment. The MDS also indicated the resident had inattention and disorganized thinking. Resident #1 required extensive physical assistance of one person with eating, bed mobility, dressing, toileting, and personal hygiene. She needed extensive physical assistance from more than two persons for transfers. The MDS assessment indicated Resident #1 did not have a weight loss of 5% or more in a month in the MDS look back period and did not have a 10% weight loss or more in the six months. The resident was not on a physician prescribed weight gain regimen. The resident did not have rejections of care behaviors. The MDS assessment identified the resident had possible signs and symptoms of swallowing difficulty with foods and liquids. There were no identified concerns with the resident's oral/dental status. III. Observations Resident #1 was observed in the dining room on 8/23/22 at 9:53 a.m. with her eyes closed. The resident was provided assistance with her breakfast. She accepted the assistance, opening her eyes for short periods at a time and making a small amount of incoherent verbalizations. Resident #1 was in the dining room on 8/24/22 at 5:47 p.m. drinking an Ensure with a straw. The resident was able to drink the Ensure independently. IV. Record review The weight record identified the following: -2/27/22, Resident #1 weighed 126 lbs; -5/1/22, Resident #1 weighed 133 lbs; -5/29/22, Resident #1 weighed 124.5 lbs; -6/26/22, resident #1 weighed 128 lbs; -7/10/22, Resident #1 weighed 129 lbs; -7/17/22, Resident #1 weighed 114 lbs; -7/25/22, Resident #1 weighed 112 lbs; -8/14/22, Resident #1 weighed 111.3 lbs; and, -8/21/22, Resident #1 weighed 107.2 lbs. The weight record identified Resident #1 lost 15 lbs in seven days, resulting in 11.6% total weight loss between 7/10/22 and 7/17/22, which was considered significant weight loss. The weight record identified Resident #1 lost 22 lbs between 7/10/22 and 8/21/22, revealing a total weight loss of 17.1%, which was considered significant weight loss. The CPO for Resident #1 was reviewed. The CPO indicated the last CPO intervention for weight loss was on 8/25/21. The CPO did not identify the resident had new orders or changes in her orders when the resident presented significant weight loss between 7/10/22 and 8/21/22. The CPO identified the following pertinent orders: -The 9/18/19 CPO read the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The 9/18/19 read the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The 9/18/19 CPO read the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The 12/11/19 CPO read the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -The 1/30/21 CPO read the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The 8/25/21 CPO read the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The review of the medical record did not identify the resident's [MEDICATION(S)] levels were checked as ordered when significant weight loss was identified in July 2022. The 4/13/22 mini nutritional assessment identified Resident #1 was malnourished. The 7/13/22 dehydration risk screener assessment read Resident #1 required extensive physical assistance with eating and was at risk for dehydration. The July 2022 weight review report, sent to the facility from the RD on 7/27/22, was provided by the facility on 8/25/22. The July 2022 weight report identified the resident weighed 112 lbs in July 2022. The report indicated Resident #1 lost 12.5% total weight within 30 days and 9.68% weight loss between 90 days of the review. -The report did not identify the day of the weight review or the dates for the 30 day and 90 day review. According to the July 2022 weight review report the resident had a liquid multi-vitamin started on 7/30/21, protein power and Juven (protein mix) added to her diet on 8/25/21. She consumed 50% of her Ensure and accepted a homemade shake 75% of the time. According to the report, the resident had progressive dementia and a history of refusing her adaptive sippy cup. -The weight report did not identify new interventions. The July 2022 intake record identified Resident #1 ate less than 25% of her meals on the following days in July: -7/1/22 for breakfast and lunch; -7/3/22 lunch; -7/5/22 lunch; -7/6/22 lunch; -7/8/22 dinner; -7/9/22 breakfast; -7/11/22 dinner; -7/12/22 dinner; -7/13/22 breakfast and lunch; -7/14/22 lunch; -7/16/22 dinner; -7/20/22 breakfast; -7/21/22 breakfast; -7/22/22 breakfast and dinner; -7/24/22 breakfast; -7/25/22 lunch; -7/27/22 breakfast; and, -7/28/22 breakfast. The record identified the resident only refused two meals in July 2022. The resident refused dinner on 7/14/22 and dinner on 7/20/22. The record showed the resident was not available for breakfast on 7/16/22. The record read Resident #1 meals were not applicable on: -7/4/22 for breakfast; -7/11/22 for breakfast; -7/27/22 for dinner; and, -7/30/22 for breakfast. -The intake record did not identify why the meals were not applicable to the resident. According to the July 2022 intake record, the resident only was offered and received snacks and additional fluids on 7/6/22 and 7/25/22. The August 2022 intake record identified Resident #1 ate less than 25% of her meals on the following days between 8/1/22 and 8/24/22: -8/3/22 dinner; -8/4/22 breakfast, lunch and dinner; -8/5/22 lunch; -8/7/22 breakfast; -8/9/22 dinner; -8/10/22 breakfast; -8/11/22 breakfast; -8/12/22 breakfast; -8/13/22 breakfast; -8/20/22 breakfast; -8/22/22 breakfast and lunch ; -8/23/22 breakfast; and, -8/24/22 breakfast. The record identified the resident refused four meals in August 2022. The resident refused breakfast on: -8/6/22; -8/8/22; -8/18/22; and -8/21/22. The record showed the resident was not available for breakfast on 8/2/22. The record for meal on 8/22/22 was left blank. According to the August 2022 intake record, the resident only was offered and received snacks and additional fluids on 8/2/22. The 8/30/19 activities of daily living (ADL) care plan identified the resident had a self-care performance deficit related to dementia. The intervention for eating, initiated 7/6/21, read Resident #1 required extensive assistance from one staff member to eat. -The August 2022 care plan did not document that Resident #1 was at risk for significant weight loss or had actual significant weight loss. The August 2022 care did not identify the resident had a nutritional care plan. The care did not identify interventions to maintain the resident's weight other than the type of assistance she needed to eat. The care plan did not identify interventions to prevent weight loss or interventions to take once significant weight loss was identified. The care plan identified there were no new interventions pertaining to the resident's nutritional needs. V. Staff interview The interim director of nursing (IDON) was interviewed with the registered nurse clinical consultant (RNCC) on 8/25/22 at 4:44 p.m. The IDON said she started in her position as the IDON on 8/22/22 and did not know the former director of nursing's weight loss processes. The IDON said she would have expected that after identification of significant weight loss, staff would look at what would have potentially caused the weight loss and contributing factors such as poor intake and reason for poor intake. The physician would be notified and the weight loss and interventions would be discussed in the monthly weight review meeting. The RNCC said the RD reviewed residents in her monthly weight review and emailed staff with her concerns. They said a weight review report was completed and passed to the former DON but she was not sure where it was placed. The IDON said the resident was already offered protein powder and Ensure and did not believe new interventions were implemented after the identification of significant weight loss. She said the resident liked the apple Ensure. The IDON said she was not aware the resident did not have a nutritional care plan but should have. The IDON and the RNCC said moving forward, the facility was now under new nursing management and she would make sure nurses notify her of weight changes. The IDON said Resident #1 weights would be checked weekly and a nutrition care plan would be added with new interventions. The RD was interviewed on 8/30/22 at 9:24 a.m. The RD said she was aware of Resident #1's significant weight loss as identified in the July 2022 weight review report but did not incorporate new interventions. She said she was not aware that resident dropped to 107 lbs in August 2022. She said the resident was already on a multivitamin, protein powder, and Ensure. She said it was normal protocol to try to incorporate new interventions and try different approaches to promote weight gain when a resident had experienced a significant loss in weight. She said she conducted a weight review in August 2022 with the former DON, also identifying significant weight loss, but did not incorporate new weight interventions. She said she provided her August 2022 weight report to the former DON but was not sure where the information went from there. The RD said she had not reviewed resident weights since her last review on 8/10/22. During the interview, the RD reviewed the 107 lbs weight for Resident #1. She said staff should have contacted her with the weight change and conducted a weight to determine it was accurate. The RD said as of 8/30/22, the resident's current weight is at 112 lbs, still indicating a significant weight loss. She said she was not sure why the resident had a significant weight loss in such a short time but believed it could be because the staff was not providing enough attention and assistance as a potential contributing factor. The RD said she was not aware Resident #1 did not have a nutrition care plan, providing staff directives and communication. The RD said she was not responsible for resident care plans. She said she has not observed the resident eat recently but according to her meal intake record, the resident ate 76% to 100% of her meals, 50% to 60% of the time. The RD said she had not requested the resident's labs or [MEDICATION(S)] to be checked to determine if there were other medically related contributing factors related to her weight loss. The RD said moving forward she would work with the facility to improve communication and instruct staff to increase attention and encouragement during meals. She said she would order Magic Cups (high calorie ice cream nutritional supplement) to have staff offer to the resident. VI. Facility follow up An 8/26/22 staff huddle update (conducted after survey exit) was provided by the IDON on 8/29/22 via email. According to the huddle, staff was instructed to offer Resident #1 ice cream and apple juice flavored Ensure. The huddle update indicated staff should document the additional food and fluid interventions under the snack (intake) record. The huddle update reminded staff to document snacks provided. A 8/29/22 email sent by the IDON read the IDON completed a weight review on 8/29/22 and would review the findings with staff on 8/30/22 during a staff huddle. The IDON said identified concerns would be directed to the RD and the physician as needed. A 8/29/22 handwritten nurse note identified as the weight review was provided by the IDON on 8/29/22 via email. The weight review for Resident #1 read she had a 10% weight loss within 180 days. The identified weights to determine the loss were 126 lbs to 112 lbs. The review did not identify the dates of the weights. The review identified the prior interventions of Juven, protein powder and Ensure between meals. The 8/29/22 did not identify new interventions. The 8/29/22 nutrition care plan was provided by the IDON on 8/30/22 via email. The care plan indicated the resident has nutritional problem(s) or potential nutritional problem(s) related to anorexia. The 8/29/22 intervention included: -Monitor, document and report as needed any signs and symptoms of dysphagia such a pocketing/holding food in mouth, choking, coughing, drooling, and making several attempts at swallowing. The care plan directed staff to document and report refusals to eat and any other concerns during meals. -Monitor, document and report to the physician and signs of of malnutrition, emaciation (cachexia),muscle wasting, and significant weight loss of 3 lbs in one week, 5% weight loss or greater in one month, 7.5% weight loss in three months, and 10% or greater in 6 months. -Obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. -Provide and serve supplements as ordered to include Ensure BID (twice a day), protein powder TID (three times daily.) -Provide, serve diet as ordered, monitor intake, and record quality of meal (intake). -RD to evaluate and make diet change recommendations PRN (as needed).

Based on observations, record review and interviews, the facility failed to ensure one (#17) of two residents reviewed for pressure ulcers out of 18 sample residents did not acquire an unstageable pressure ulcer. Resident #17, who was at risk for pressure ulcers and had no pressure ulcers as of 4/11/21, spent virtually all of his time lying in bed on his back. The facility failed to implement a turning and repositioning schedule, failed to implement a proper pressure relieving mattress to keep weight off the resident's heels, failed to acquire a timely wound nurse consultation, failed to revise the care plan to reflect actual skin breakdown, and failed to consistently document weekly wound assessments. These facility failures contributed to Resident #17 developing an unstageable pressure ulcer on 5/6/21 to his left heel which was Stage 4 on 5/17/21 when the wound had slough and necrotic tissue present. The left heel wounds became infected requiring two courses of antibiotic treatment. Findings include: I. Facility policies and procedures A. The Pressure Ulcer Prevention policy, provided by the assistant director of nursing (ADON) on the afternoon of 5/27/21, documented the purpose was to promote healthy, intact skin through risk assessment and preventative measures. Preventative measures were to be instituted as soon as the resident was determined to be at risk for developing a pressure ulcer, or if a pressure ulcer was present. -Residents who cannot sufficiently turn themselves to relieve pressure must be turned every two hours. If a resident did not tolerate turning due to confusion and combativeness, place the resident on an air mattress overlay and turn at least every four hours. Document in nurses' notes. -May use a pressure reducing air mattress; refer to the interdisciplinary team to order appropriate surfaces for beds. -Relieve pressure under heels by using heel elevating pillows or other devices. B. The Pressure Ulcer Management policy, provided by the ADON on the afternoon of 5/27/21, documented in part the following: -Preventative measures will be initiated if not already in place. Staff will be instructed to avoid positioning the resident on the pressure ulcer. -Ensure air mattress overlay in place, and institute turning every two hours if not already being done. The policies did not instruct the use of air overlays versus alternating air mattresses for pressure relief for residents at high risk. II. Professional reference regarding air mattresses According to Direct Supply (2018) Air Overlays vs. Mattresses, retrieved from https://www.directsupply.com/blog/air-overlays-vs-mattresses-which-is-best-for-my-resident: Most air overlays only measure three inches thick, and are not nearly large enough to prevent a typical resident bottoming out. When this happens, all benefits of immersion are lost as the body's peak points of pressure will rest on the surface underneath, providing the ideal condition for pressure ulcers. III. Resident status Resident #17, age 87, was admitted on [DATE]. According to the May 2021 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/11/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. No behavioral symptoms or care rejection were documented. He required extensive assistance with activities of daily living except eating. He had a suprapubic catheter and was occasionally incontinent of bowel. He was 72 inches tall and weighed 164 pounds. He had no pressure ulcers, but was at risk for pressure ulcers, and had moisture associated skin damage. IV. Resident interview and observations The resident was interviewed on 5/24/21 at 4:00 p.m. He said he had a pressure ulcer on his left heel, and that they changed his dressing every afternoon. He said he had previously had pain to his left heel but they changed medicines and it has a deadening effect. Observation revealed he had an plastic overlay mattress on his bed and a foam device to float his heels. He said he had sores on both heels but one had healed; however he thought the right one was coming back because it's sore. Further observations of Resident #17 on 5/24/21, and throughout the days of 5/25, 5/26 and 5/27/21, revealed he did not leave his room or sit up in his chair. He was on his back in bed during subsequent observations, and his heels were resting directly on his bed, not floated. On 5/25/21 he was observed lying diagonally in bed with his ankles crossed, putting pressure on both his heels. V. Record review A. Care plan The care plan, initiated 9/13/16 and revised 2/2/21, identified potential for pressure ulcer development related to disease process, diabetes, history of ulcers and immobility. The goal was for intact skin. Interventions included: -Air mattress overlay placed on resident's bed 2/2/21; -Follow facility policies for prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor nutritional status; -Resident had hard callous on right heel upon admission, no tenderness, skin intact 3/23/2020; -The resident requires pressure relieving/reducing device on bed/chair 3/23/2020. -The resident did not have a care plan for actual skin breakdown. B. Physician orders Pertinent May 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound care orders for left heel: cleanse with wound cleanser, apply barrier ointment or skin prep to protect intact peri-wound skin, apply [MEDICATION(S)], cover with gauze, wrap with [MEDICATION(S)] gauze daily. No Coban, use tape to secure, every day shift for pressure ulcer, ordered 5/6 and started 5/7/21. [MEDICATION(S)] (antibiotic) capsule, 500 mg, give two capsules four times a day for infection, left heel for 10 days, starting 5/24 and ending 6/3/21. Protein powder with meals three times daily, ordered 5/19/21. C. Nurses' notes and wound assessments On 5/6/21 at 1:44 p.m., the first nurses' note about the resident's pressure ulcer documented, Resident complaining of more increased pain to the left heel decubitus (pressure ulcer) . notifying (physician) of increased pain of description of wound. The physician ordered [MEDICATION(S)] for pain and [MEDICATION(S)] with vitamin C for healing. On 5/10/21 at 2:43 a.m., a nurse documented the resident had a non healing left heel wound. Left foot wrapped as ordered and floating as tolerated. Foul odor noted in room, becoming stronger at left heel. Denies any pain at this time. On 5/10/21 at 5:41 p.m., a nurse documented the wound has s/s (signs and symptoms) of infection. (Physician) ordered [MEDICATION(S)] (antibiotic) 500mg (by mouth four times daily for) 10 days. On 5/15/21 at 4:29 p.m., Resident continues on [MEDICATION(S)] for wound on heel. Heel appears to have developed a hard shell over wound. Discharge is not noted today but strong odor is still present. On 5/17/21 at 11:51 a.m., a weekly wound observation note (wound assessment) documented a stage 4 pressure ulcer to the resident's left heel with slough and necrotic tissue present. The extent of necrosis to the wound bed was 100%. A small amount of serosanguinous drainage was documented with foul odor present. The wound measures 4 mm long by 2 mm wide. The peri-wound tissue was pink and sloughy, edges are rolled, and infection was suspected due to drainage, foul odor and inflammation. Interventions were documented as leg pillow to keep heels off bed. On 5/21/21 at 2:03 p.m., Resident completed [MEDICATION(S)] today; he still has s/s of infection (odor, redness, tenderness, mod amt drainage). RN contacted (physician) and he ordered [MEDICATION(S)] (one by mouth twice daily for) 10 days. He requested a wound culture which was done and sent to the lab. He also asked (wound nurse) to eval - she is a wound nurse that works in surgery (at the hospital). On 5/22/21 at 4:20 p.m., Resident is on [MEDICATION(S)] . awaiting results of culture . He says that his left heel wound is tender to touch but doesn't require pain medication. On 5/24/21 at 7:24 a.m., This nurse made a phone call to surgery services to request resident left heel evaluation by (wound nurse); voice message left in her phone answer machine. -The wound assessment dated [DATE]was blank, indicating the most recent weekly assessment was not completed. On 5/25/21 at 6:41 p.m., Infection care plan has been done. On 5/27/21 at 8:24 a.m., nursing notes documented, Changed dressing on resident's heel this morning, wound continues to have a strong odor. Area was cleaned with wound cleanser, area has a soft green covering, eschar is noted. Santyl ointment applied, covered with gauze pad and curlex wrapped around foot. Resident slept through process. On 5/27/21 at 5:54 a.m., Wound care nurse came to resident and looked at his wound, and will get back with us on new wound care orders. D. Pain assessments Review of May 2021 medication administration records was reviewed for pain levels 1-10, it revealed the resident requested Acetaminophen on 5/5 and 5/6/21 for 6/10 pain, 5/9/21 for 5/10 pain, and twice on 5/16/21 and 7/10 and 9/10 pain. He requested [MEDICATION(S)] on 5/25/21 for 8/10 pain. VI. Wound observation On 5/27/21 at 11:10 a.m., Resident #17's wound care was observed with the wound registered nurse (RN), licensed practical nurse (LPN) #3 and RN #3 present. LPN #3 unwrapped the Kerlix dressing to the resident's left heel. There was no drainage observed on the small non-adhesive dressing which was over the wound. The wound was then exposed. The wound was measured by the wound nurse, and measured 2.5 cm x 3.5 cm. There was an area of necrotic (eschar) tissue within the wound bed. The remaining wound contained yellow slough. The peri-wound was intact with slight redness to the edges. The right heel was observed and there was no wound; the skin was intact with only a small hard callous in the middle. The wound nurse identified the left heel wound as unstageable. She recommended autolytic (medicated) debridement (no scalpel/sharp debridement at this time). VII. Staff interviews The registered dietitian (RD) was interviewed on 5/26/21 at 4:15 p.m. She said for wound healing, Resident #17 was getting a multivitamin, Ensure once or twice daily depending on acceptance, protein powder twice a day, which they were increasing to three times as of today, and as of today they would add Juven (supplement for wound healing) as well. He was also taking [MEDICATION(S)] and vitamin C. Following his blood glucose (BG) levels, they're in appropriate range, so I don't think his BG is contributing to his non-healing right now. The medical director was interviewed on the afternoon of 5/27/21. After discussing overlay versus alternating air mattresses (see professional reference above), she said she would order an alternating air mattress for Resident #17. The assistant director of nursing (ADON) was interviewed on 5/27/21 at 4:37 p.m. She said Resident #17's pressure ulcer was unstageable and she was surprised it was assessed as a Stage 4 on the 5/17/21 wound assessment. She said that during the COVID-19 outbreak Resident #17 was in his room, then became resistant to coming out of his room. She said he actively kicked off the heels up pillow the staff had been using for him for a long time. And because he was in his room a significant amount of time, his dietary and fluids decreased, his foot was always on the bed, and he was not taking in the appropriate amount of nutrition to help his body heal the pressure ulcer. The wound started as a blister and they started treating it right away, but no matter what treatment they used, he would not keep his feet off the bed (however, there was no documentation of the resident refused repositioning or heel floating) His feet are dependent and that makes it hard. He kicked off the foam heel cups, as well as pillows. -The facility failed to implement increase monitoring of his feet with the resident would not keep his feet off the bed nor was it care planned the resident would not keep his feet off the bed. The ADON said they had an overlay on his bed, added Ensure, [MEDICATION(S)], vitamin C, a multivitamin, protein powder, and the infection control nurse reviewed his wound regularly and gave direction. She said the resident's doctor looked at the wound numerous times, and just this week the facility had a wound nurse assess it. She said he was at risk before the pressure ulcer developed, and it would behoove them to have an alternating air mattress and he doesn't because we don't have one. She said she planned to pick one up herself that weekend. She said they could get one delivered but they were expensive and the former DON had declined to purchase one. The ADON said if only they had that professional reference (see above) three months ago, the resident's pressure ulcer might have been avoided. She said she agreed wholeheartedly that Resident #17 should have had an alternating air mattress.

Based on observations, interviews and record review, the facility failed to consistently and thoroughly assess, manage and alleviate severe, constant pain for one (#10) of two residents reviewed out of 18 sample residents. Resident #10, who was diagnosed with end stage [CONDITION(S)] and multiple contractures, said in interviews on 5/24/21 and 5/25/21 that she experienced constant pain, at an 8/10 (eight out of 10) level, and that pain medications helped for a while but the pain returned as soon as her medications wore off. She said she had been in pain all her life, and palliative/hospice care had not been discussed with her. Nursing staff and the resident's physicians were aware and documented her pain was uncontrolled, that she requested comfort care and pain relief. Although pain medications were added and adjusted, the resident continued to experience severe breakthrough pain several times daily. Pain assessments prior to medication administration were frequently not documented, nor was the quality and location of pain, and effectiveness of pain medications after administration. The resident's pain contributed to loss of appetite, weight loss, depression, cognitive loss; and four Stage 2 pressure ulcers (three to her sacrum and one to her left heel) because movement, repositioning and bathing were too painful. Pain assessments revealed her pain interfered with her sleep and her daily life. Non-pharmacological methods for pain relief such as heat, cold packs, massage, physical therapy transcutaneous electrical nerve stimulation (TENS) treatments and aromatherapy had not been care planned or documented as recently attempted. The resident's inadequate pain management contributed to physical and psychosocial harm, as the resident regularly stated her pain was 8/10 and stated she wanted to fall asleep and not wake up anymore, and that she was tired of suffering and wanted to be kept comfortable at the end of her life. Although she opted for comfort care, said goodbye to her family, and began giving away her personal possessions, the facility failed to acknowledge the resident's end of life choices and provide adequate pain relief. Findings include: I. Facility policies and procedures A. The Pain Management policy, revised March 2021, was provided by the assistant director of nursing (ADON) on the afternoon of 5/25/21. The policy/procedure documented in pertinent part, that pain, both acute and chronic, has a significant effect on quality of life for long term care residents. In an effort to prevent negative outcomes related to pain, this policy outlines a systemic approach for addressing residents' pain. Each resident will receive a comprehensive pain assessment quarterly and for change in condition such as persistent or worsening pain. Interim assessments would be done by nursing staff each shift, and documented on the medication administration record (MAR) in the appropriate spot. For the cognitively intact resident, the nurse may use the numerical one-to-ten scale or visual scales such as the Faces scale or pain thermometer scale. The nurse may question the resident about their ability to perform activities of daily living (ADLs) and/or use clinical observations. The nurse will report pain to the attending physician if the pain has worsened from a previous screen despite treatment. If a resident has increased requests for pain medication, the nurse will report the change to the attending physician in a timely fashion. Urgent requests for pain management will be directed to the on-call physician if the attending physician is unavailable. Scheduled dosing will be used in an effort to consistently control pain. Non-pharmacological methods of pain control may be used first, with resident consent. Such methods may include, but are not limited to, TENS units, music, massage, heat/cold application, therapeutic activities, repositioning, distraction, cushions, aroma therapy, relaxation techniques, humor, and exercises. The nurse administering the medication will document date, time, medication, route given, pain rating, and type of pain. Within one hour of pain medication administration, nursing will follow up with the resident and document results. If the pain medication is unsuccessful, the nurse may add non-pharmacologic relief, or a different medication according to the resident's MAR, taking resident preference into account. Monitoring pain data will be part of the facility's ongoing quality improvement program. B. The Comfort Care policy, revised February 2021, was provided by the ADON on the afternoon of 5/25/21. The documented purpose was to provide comfort care measures for residents who have reached the final stage of their lives and their goal is a peaceful death with dignity. Appropriate care is provided to alleviate pain. When comfort care is desired, the resident's plan of care will outline measures to be implemented to ensure: the resident's right to die with dignity and respect; promotion of quality of life; conserving the resident's energy, preserving emotional and physical well-being and providing adequate pain relief. -The ADON said the facility did not have policies regarding palliative care or hospice, as requested, as these services were not offered by the facility due to lack of resources and funding. II. Resident status Resident #10, age 68, was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/9/21 minimum data set (MDS) assessment, the resident was her own decision maker. She had modified cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. There was no documentation of [CONDITION(S)] or behavioral symptoms, and no rejection of care. She was totally dependent for ADLs, and had range of motion impairments to her upper and lower extremities. She had an indwelling catheter and was always incontinent of bowel. She had medically complex conditions including MS, [CONDITION(S)] and depression. She had moderate pain during the assessment, almost constantly, and no numerical pain level was documented, although she was able to numerically rate her pain (see interview and pain assessment findings below). Her pain made it difficult to sleep at night and limited her day to day activities. She had weight loss, was 64 inches tall and weighed 100 pounds. She had one Stage 2 pressure ulcer. She took antidepressant and opioid medications daily and received oxygen therapy. She had a life expectancy of less than six months. -Review of the resident's 2/14/21 MDS assessment revealed she was cognitively intact with a BIMS score of 15 out of 15, three months earlier. II. Resident/staff interviews and observations Resident #10 was interviewed on 5/24/21 at 1:00 p.m. She said, I have pain all the time. She rated her pain at 8/10, and said the location was My butt. That's where it always is. There's not much they can do. She said she had been in pain all her life. The resident said she had lost weight, approximately eight or nine pounds, but said she was not concerned about that. The resident was observed lying on her right side in her bed, with her neck bent forward and her chin to her chest. Her neck was contracted and supported with pillows, but she was able to raise her head. She said she stayed in bed because it was more comfortable for her. She had an alternating air mattress on her bed. On 5/25/21 at approximately 8:30 a.m., the resident said her pain level was 8/10. Her registered nurse (RN) #1 said she had given her [MEDICATION(S)] but she could give her [MEDICATION(S)] which usually helps, and did so. On 5/25/21 after lunch, the resident again rated her pain at 8/10. RN #1 and licensed practical nurse (LPN) #3 were notified and LPN #3 said she had just given Resident #10 [MEDICATION(S)] 10 minutes ago, and it needed time to take effect. Review with RN #1 of Resident #10's medications revealed she had orders for [MEDICATION(S)], [MEDICATION(S)] Sulfate, and [MEDICATION(S)] patches. Upon checking back with Resident #10 approximately 30 minutes later, she said her pain was 8/10. Her pain medication ([MEDICATION(S)]) had been ineffective. RN #1 checked Resident #10's orders and said she was able to give her sublingual [MEDICATION(S)], and prepared it to administer to Resident #10. Upon checking back with RN #1 a few minutes later, she said Resident #10's pain was improved at 3/10. -Per interview with RN #1 and LPN #3, the facility had no palliative care or hospice available. They said they did not know why and LPN #3 said she wondered why palliative care was unavailable to residents at the facility. At 4:00 p.m., RN #1 said Resident #10 could have her regularly scheduled pain medications and she would prepare her medication and give them to her. She said Resident #10 always gives high numbers when describing her pain: 7, 8, 9 out of 10. On 5/25/21 at 4:58 p.m., the resident was sleeping, leaning forward in her bed, grimacing. On 5/25/21 at 6:15 p.m. Resident #10 said she was in pain, 8/10 and they had told her they could not give her anything else for pain. Her face was red and sweaty, and the front of her T-shirt was wet with drool. This was reported to a certified nurse aide (CNA) coming on duty, who said she would notify Resident #10's nurse. She said the nurses were in a shift change meeting and currently unavailable. On 5/26/21 at 8:02 a.m., the resident was sleeping, with her head down and her face not visible. Review of the resident's MAR on the morning of 5/26/21 revealed the resident was not given a pain medication until an hour and 45 minutes later and effectiveness was not documented (see below). There were no nursing notes to indicate why, or that the resident's pain level of 8/10 was reported on 5/25/21 at 6:15 p.m. On 5/26/21 at 10:22 a.m. Resident #10 was sleeping with her head down, grimacing. On 5/26/21 at 2:53 p.m., Resident #10 was asleep with her head down, grimacing. On 5/26/21 at 6:00 p.m., Resident #10 said she was okay, and her pain level was okay. III. Record review A. Care plans The resident's care plan, initiated 2/3/19 and revised 11/27/2020, identified chronic pain related to MS. The goal was adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included: -Pain is alleviated/relieved by [MEDICATION(S)] PRN (as needed) and [MEDICATION(S)] patch, scheduled [MEDICATION(S)], PRN compound suppositories, PRN [MEDICATION(S)] cream, PRN [MEDICATION(S)] for breakthrough pain. -Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. -Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain. The care plan further documented (under ADLs) that Resident #10 was exclusively staying in bed and requested the facility stop weekly weights, as being lifted in the Hoyer (mechanical) lift was very painful for her. She was placed on comfort care on 5/14/21 and all care was focused on her comfort. She received bed baths only as she could not tolerate sitting up in the shower chair. She was transferred via Hoyer lift only and requested that the Hoyer lift be used as little as possible. On 11/27/2020 she was not getting out of bed. Her physician declined gradual dose reduction of her [MEDICATION(S)] antidepressant in January 2020 due to increased signs and symptoms of depression. She had a lack of appetite identified on 3/23/2020, and was eating less than 25% of all meals, stating she just was not hungry. She was refusing all supplements, Ensure, protein shakes. On 3/7/21 she would drink Juven in water daily to supplement protein intake. She had a healing Stage 2 pressure ulcer on her coccyx on 3/7/21. She had an indwelling catheter due to a pressure ulcer on her coccyx on 11/27/2020. -The resident's care plan was not revised to include comfort care, current pain medications, non-pharmacological pain interventions, her reports of unrelieved pain, instructions to medicate for pain prior to care provision, or current skin breakdown. The resident had four Stage 2 pressure ulcers as of 5/27/21. B. Pain assessments Resident #10's most recent 3/21/21 Pain Interview assessment documented she had pain or hurting almost constantly over the last five days, which made it hard for her to sleep at night. Pain interference with daily activities was not assessed. Her numeric rating scale was 7/10. She had [MEDICATION(S)] patches, scheduled pain medication, PRN pain medication. Is effective for pain at patch change, when the patch is on 3rd day, requests more PRN pain medication. The assessment further documented, Resident does not ask for pain medication PRN, and has voiced effectiveness. -A status change pain assessment was not conducted when Resident #10 began requesting PRN pain medications and stated her pain medications were often ineffective (see observations/interviews above and pain level documentation below). C. Pain medication orders Review of May 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of May 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] XR tablet extended release 12 hour 100 mg (milligrams), 100 mg once daily for MS (started 11/17/19). -[MEDICATION(S)] tablet 200 mg, 200 mg twice daily for pain (started 11/16/19). -[MEDICATION(S)] Sulfate (concentrate) solution 100 mg/5ml (milliliters), give 8 mg by mouth every 4 hours for comfort care related to MS, hold medication if respirations under 12 (started 5/27/21). -Acetaminophen tablet 325 mg, give 2 tablets every 4 hours PRN for pain (no pain level parameters documented in order, started 2/28/21). -[MEDICATION(S)] Patch 72 hour 12 mcg/hr, apply 1 patch transdermally every 72 hours for pain with 50 mcg (micrograms) patch to equal 62mcg and remove per schedule (started 11/19/2020). -[MEDICATION(S)] Patch 72 hour 50 mcg/hr, apply 50 mcg transdermally every 72 hours for pain with 12 mcg to equal 62 mcg (started 11/19/2020). -[MEDICATION(S)]-Acetaminophen tablet 10-325 mg, give 1 tablet every 4 hours as needed for pain, APAP from all sources not to exceed 3 gm/24hr. (started 2/28/21) -[MEDICATION(S)] Sulfate (concentrate) solution 20 mg/ml, give 8 mg every 2 hours as needed for shortness of breath or pain related to MS. If respirations are below 12 hold medication (started 5/26/21). -Suppository blend pellet (suppository base), insert 1 suppository rectally every 12 hours as needed for pain: [MEDICATION(S)] 5mg, [MEDICATION(S)] 5mg, [MEDICATION(S)] 2mg. May be given vaginally (started 6/9/2020). D. Failure to adequately address pain levels of 7/10 and above Review of the resident's May 2021 MAR revealed her pain levels, when assessed prior to administration of PRN pain medications, were 7/10 or above (up to 9/10) several times per day, a total of 72 times from 5/1-5/26/21. Instead of numeric pain levels, check marks were often documented above nurses' initials. Effectiveness of the PRN medications were often not documented as assessed, and pain medications were often documented as ineffective. The location and quality/description of the resident's pain was rarely documented. On the night of 5/25/21, Resident #10 reported 8/10 pain at 6:15 p.m. (see interview above). However, review of the MAR on 5/26/21 revealed she did not receive anything for pain on 5/25/21 until her regularly scheduled dose of [MEDICATION(S)] Sulfate at 8:00 p.m., one hour and 45 minutes later, and after she had been told she could not have anything else for pain. Instead of a numerical pain level, the nurse documented a check mark. There were no nursing notes regarding this administration or its effectiveness. There was no documentation that the resident reported 8/10 pain at or before 6:15 p.m. that night and had been denied pain medication, or that the resident's pain was reported to the nurse (after this was reported to a CNA, see above). Nursing notes documented scheduled [MEDICATION(S)] Gel 1% was applied at 9:34 p.m. and [MEDICATION(S)] Sulfate PRN was given at 11:38 p.m. No numerical pain assessments were documented on the night of 5/25/21. No non-pharmacological pain interventions were documented, and physician notification was not documented. E. Interdisciplinary (IDT) and physician notes Review of IDT notes for the past six months revealed the documentation was predominantly related to Resident #10's pain, which was ongoing and typically at 8/10 to her buttocks, lower back and neck, when the location was assessed. IDT notes included the following pertinent documentation: -On 1/19/21 the resident's physician documented in a visit note Resident #10 was receiving transdermal 50mc/hr [MEDICATION(S)] patch for pain but without adequate control. Repositioning strategies have been discussed with the patient but she is uninterested due to comfort concerns . She expresses constant 8/10 pain in her buttocks that is poorly managed with her current regimen. She is interested in exploring other options to help get better pain control. She is not interested in anything else and has no interest in doing things other than watch TV (television) in her room. Her main goal is improved pain control. -On 1/28/21 a nutrition/dietary note documented in part, Patient with no new weight recorded since November (2020). Of note, patient has been refusing many things, including weight checks and nutrition interventions. Per report, she has developed a stage 2 to her coccyx. 17 lb weight loss noted in 4 months (from July-November 2020 weights). This is 16%, which is significant . -On 2/4/21 a medical director note documented in part, End stage MS and accompanying debility, immobility, contractures and chronic pain. Depressive disorder due to condition. Exacerbated by uncontrolled pain . Low back pain is not adequately controlled. She is amenable to increasing the frequency of [MEDICATION(S)]. (Primary care physician) and I have been discussing and considering other options including [MEDICATION(S)] or [MEDICATION(S)]. The liquid [MEDICATION(S)] concentration would be effective more rapidly than her [MEDICATION(S)]. Long acting [MEDICATION(S)] may be more effective than her [MEDICATION(S)] patches given that the latter are not well absorbed when people have low body fat . Pain into legs that is sometimes relieved with PRN [MEDICATION(S)]. Sometimes not. Does not like waiting for so many hours between doses of breakthrough medicine when she is having pain. Wonders about starting [MEDICATION(S)] instead. The medical director changed her [MEDICATION(S)] from 1 tablet every 6 hours PRN to 1 tablet every 4 hours PRN for 30 days due to pain in the coccyx as above. -On 2/5/21 at 2:47 a.m., a nurse documented, Pt (patient) yelling out HELP and CNA went to see what was wrong. Pt could not find call light and needed pain medication. [MEDICATION(S)] provided. At 3:27 a.m. the pain medication was documented as effective and the resident was sleeping. -On 2/10/21, the registered dietitian (RD) documented, Patient with new weight on 1/29 of 99.5#, has refused suppositories in the past. Weight loss of 5.2% in last 180 days. Stage 2 to coccyx reported. Juven was ordered. -On 2/18/21 a social services note documented, Significant pain. It has been reviewed numerous times by MD . She is bed bound . Healing stage 2 on her coccyx. -On 2/19/21 a medical director note documented in part, pain in the coccyx. We discussed potential switch to liquid [MEDICATION(S)] from her [MEDICATION(S)] patch, since she is likely not absorbing much of it due to lack of body fat . Contracture of multiple joints (muscle relaxer) not helpful . I wanted to talk to her about other pain med modalities/options as well. Her pain is sometimes overwhelming and meds don't work. Usually in her groin or pelvis. -On 2/19/21 a social services note documented in part, (Resident) is bent over far, she has been this way for years and is not under any stress at this time. She does not work with PT anymore because it causes too much pain for her. She states she does not have as much pain when she is bent over, that it relieves some of the pain. She can lift her head for a short amount of time . says she hasn't been sleeping as well due to pain. -On 4/8/21, the medical director documented, She has too much pain in her body to allow transfer to the shower or bath, so she gets only bed baths . She reports that her pain is at 5, which is good for her, she says. -On 4/14/21, a nurse note documented the resident's physician visited and was informed, she had refused to order breakfast or lunch today . staff reported resident has been declining food last few days. (Physician) reports resident saying she wanted to go to sleep and not wake up. Resident has been more withdrawn this last week. Will continue to monitor. -On 4/16/21 the medical director documented, Chronic neck pain from her MS and severe chronic deformity. Depressive disorder due to condition. Exacerbated by uncontrolled pain. Pain in the coccyx . Palliative care . (Resident) would like to be made as comfortable as possible. She understands that she has a poor prognosis. There is nothing in particular that motivates her to live longer. She does not want aggressive medical interventions to prolong her life. She does want pain control . Consider something stronger than [MEDICATION(S)] or [MEDICATION(S)] for her breakthrough pain . Once we have a reliable medicine for breakthrough pain I think it would be safer (from a pain point of view) to make plans to change her long acting med to [MEDICATION(S)] or something else . Will cont(inue) to discuss with (resident's physician) and RN. (Resident) has been saying that she just wants to sleep. She would rather sleep all day and not be aware of what is going on around her. She cannot bathe because of pain with movement and her deformities. Her pain is out of control with any movement . -On 5/4/21 at 8:11 p.m., a nurse documented in part, Resident continues to appear stuporous (lethargic) although does wake to request pain medications. [MEDICATION(S)] given PRN at 6:00 p.m. Effective results, resident asleep. -On 5/5/21 at 3:00 p.m. the resident's physician documented, Severe [CONDITION(S)] with sodium 120. Patient has requested end of life care: 'I want to fall asleep and not wake up anymore.' -On 5/5/21 at 3:28 p.m. a nurse documented, Resident also showed relief when I spoke to her about comfort measures. From this nurse's perspective, you could see a weight being released from resident on the new comfort measures. -On 5/8/21 at 12:36 a.m., a nurse documented, Resident continues on comfort measures. Reports pain during HS (hour of sleep) med pass. Offered PRN [MEDICATION(S)] as she had recently had [MEDICATION(S)] at (5:30 p.m.). Resident states that she doesn't want to take [MEDICATION(S)] until her sister visits. Explained that [MEDICATION(S)] was not ordered to end life, but to provide comfort for pain. Resident did not respond to this nurse. Resident requested [MEDICATION(S)] and APAP for pain. No further complaints of pain voiced. Resting comfortably. -On 5/8/21 at 4:43 a.m., Resident requested pain medication at (4:20 a.m.) [MEDICATION(S)] administered at (1:40 a.m.). [MEDICATION(S)]/APAP brought to resident's room. Explained what was being given. Resident asked why [MEDICATION(S)] wasn't brought. Reminded resident of earlier conversation. Resident reports that her sister did come (she did have visitors yesterday although this nurse not certain if sister present) and that she wanted [MEDICATION(S)]. Education provided again to resident. Explained that medication is provided for pain but that she still has other medications as previously ordered, that medication can cause sedation and can depress the respiratory system. Also explained that she is receiving a low dose at this time, that medication is not long acting and that as a PRN, she must request it. Resident states she understands and would like [MEDICATION(S)] dose at this time. [MEDICATION(S)] administered at 0.1ml/2mg at (4:30 a.m.). -On 5/8/21 at 5:57 p.m., a nurse documented, Resident spoke with (medical director) today and they agreed to having [MEDICATION(S)] scheduled and PRN. Resident is tired of 'suffering' and wants to be kept comfortable at end of life. She has requested comfort measures. [MEDICATION(S)] DCd (discontinued). Resident has had a lot of family members visit in the past week and she is telling them that she does not want to live anymore. (The resident's physician) was here on the 5th and he initiated comfort care orders. He discontinued weights, vitals, meds (medications) that aren't for comfort. -On 5/10/21 at 5:36 p.m., Resident requesting pain medication frequently. RN spoke with (resident's physician) and he increased [MEDICATION(S)] dose. Very poor PO (oral) intake today. Wound on sacral area is closed. -On 5/11/21 at 2:34 a.m., Resident was sleeping and she could not be woken up enough to take her (8:00 p.m.) medications. Gave [MEDICATION(S)] at (11:30 p.m.) for pain. VS (vital signs) at (11:40 p.m.) BP (blood pressure) 86/55, P (pulse) 67, 02 (oxygen saturation) 98. -On 5/13/21, a social services note documented, Resident is on comfort care. She is on scheduled [MEDICATION(S)] with a PRN order for breakthrough, and she also is able to take her oral pain medication and [MEDICATION(S)] patches . Has a stage 2 pressure sore that has healed and then re-opened . Not interested in anything except some music but refused to have music set up in her room . Would like to donate some of her glass figures to staff, with work with (family) for this. -On 5/19/21 at 3:20 a.m., a nurse documented, During routine cares new pressure area noted to (left) lateral heel and two new areas noted below chronic sacral wound. Skin assessment updated . Resident continues to call frequently asking for additional pain medications. Resident reports minimal relief after [MEDICATION(S)] administrations. -On 5/23/21 at 9:55 p.m., a nurse documented, Resident [MEDICATION(S)] has been increased in dose, no adverse effects, resident verbalizes she has pain all the time, at this time it is tolerable, verbalizes the [MEDICATION(S)] is effective at times. -On 5/25/21 at 1:31 p.m., a nurse documented giving a [MEDICATION(S)] tablet, which she documented as ineffective at 2:40 p.m., with the resident reporting 8/10 pain. At 2:44 p.m. she gave 8 mg of [MEDICATION(S)] which she noted at 3:30 p.m. was effective with a reported pain level of 2/10. No other pain medications were documented in nursing notes until 9:34 p.m. [MEDICATION(S)] gel and 11:38 p.m. scheduled [MEDICATION(S)]. The pain level and effectiveness were not documented. (See observation above where the resident reported 8/10 pain at 6:15 p.m. which was not addressed.) -On 5/26/21 at 2:25 p.m., the resident was given PRN [MEDICATION(S)] with no pain level or effectiveness documented until 7:23 a.m. when effectiveness was documented as unknown. The resident continued to report level 7/10 or 8/10 pain when she was awake, and was documented to have every two hour checks per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (See physician interviews below.) Review of the resident's every-two-hour check documentation revealed nursing staff were to document the date, time, their initials, Resident #10's pain level, and pain medication administered. The resident reported 8/10 pain on 5/26/21 at 1:30 p.m. and was given 8mg [MEDICATION(S)] and [MEDICATION(S)]. At 2:55 p.m. she had 7/10 pain and received PRN [MEDICATION(S)]. At 3:55 p.m. she had 4/10 pain and received no medication; at 4:15 p.m. she had 4/10 pain and received 8 mg [MEDICATION(S)]. At 6:00 p.m. she was sleeping, received no medication, and respirations were not counted. At 8:00 p.m. she had 8/10 pain and received [MEDICATION(S)]. At 10:00 p.m. she was sleeping and her respirations were 12. On 5/27/21 at 12:00 a.m. she was sleeping with 12 respirations. At 2:00 a.m. and 4:00 a.m. she was sleeping and unresponsive with 14 respirations. At 5:30 a.m. she had 7/10 pain, was given [MEDICATION(S)] and respirations were 14. At 6:32 a.m. her pain was 2/10 and no [MEDICATION(S)] was requested. At 7:30 a.m. she had 8/10 pain, was sleepy and reported pain but treatment postponed with no respiration count. At 7:35 a.m. and 8:00 a.m. she had 8/10 pain and was due for scheduled [MEDICATION(S)] but her meds were held because her respirations were eight and she was not able to swallow and lethargic. At 10:35 a.m. her pain was 2/10 and no [MEDICATION(S)] was requested. At 12:20 p.m. her medications were held because her respiration rate was 9, stupor, and no pain medication was given. At 1:00 p.m. she was very somnolent, non-responsive, cares given, resident responded at very end, and no pain level or medications were documented as given. At 2:35 p.m., her pain was 8/10, respiration was 8, she was unable to keep her head up, and gave no response when asked again, no medications were given. At 3:10 p.m. her respirations were 9, no medications were given and no pain level was documented. At 5:08 p.m., the medical director said to give [MEDICATION(S)] scheduled & [MEDICATION(S)]. Review of weights for the previous year revealed Resident #10 weighed 115 pounds on 4/16/2020 and her most current weight was 100 pounds. Her weight had been down to 88 pounds on 11/5/2020. -Nurses were not consistently documenting whether the resident was asleep or awake, number of respirations per minute, pain levels, or follow-up on pain medication requests per resident and physician request (see physician interviews below). IV. Failures in facility response to Resident #10's pain Review of IDT notes and MARs revealed the facility failed to develop a step-by-step protocol to assess and relieve Resident #10's pain. The medical record further revealed the resident did not receive pain medication as often as she could have them, and that nursing staff did not check with her often enough to assess her pain levels. Even when the resident requested pain medications and said her pain was 8/10 or higher, she frequently did not receive pain medications as requested and nurses did not consistently check back with the resident to ensure her pain medications were effective, to assess whether they needed to take further measures or notify the physicians if medications were ineffective. These failures continued until the medical director got involved and specifically directed nursing staff to honor the resident's wishes for pain relief and comfort. V. Staff interviews The assistant director of nursing (ADON) was interviewed on 5/25/21 at 4:30 p.m. She said she was concerned about Resident #10's pain, acknowledged it was severe, and said her tolerance was high and opioids were less effective for her. She also found Resident #10 was sleeping in between doses but she was ready to go. She said they had not sought a pain clinic consult, or discussed Resident #10 in quality assurance meetings. She said they had discussed comfort care with Resident #10, who really wanted them to help her go, but they could not do that. She said they did not have palliative or hospice care available at the facility, but the resident was now on comfort care. She acknowledged, however that Resident #10 was not comfortable. She said their medical director worked for a hospice agency in a city about two hours away, and planned to see Resident #10 on 5/27/21. She said she did not know what they would do if the opioids stopped working for Resident #10. She said the medical director had discussed initiating [MEDICATION(S)], but that would require weaning her from opioids and then starting [MEDICATION(S)] at the lowest dose. She doesn't have that long to live and she'd be in horrible pain. You wouldn't let an animal suffer in this much pain.