Every finding on record at Yampa Valley Healthcare Center

Based on record review and interviews, the facility failed to ensure residents were kept free from accidents or hazards for one (#3) of two residents out of six sample residents.Resident #3, was admitted on [DATE] with diagnoses of cerebral vascular disease (CVA), and diabetes. Resident #3 was dependent on staff assistance for transfers using a Hoyer lift (mechanical lift). On 10/28/25, the staff were transferring Resident #3 from her bed to the shower chair using the Hoyer lift. The Hoyer lift sling came unhooked from the Hoyer lift during the transfer, which resulted in Resident #3 falling to the floor. The resident hit her head when she fell and was transferred to the hospital for evaluation. At the hospital, the resident was diagnosed with an acute parafalcine subdural hematoma (blood accumulation on the brain).Specifically, the facility failed to transfer Resident #3 safely, which resulted in the resident sustaining a brain injury. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/6/26 to 5/7/26, resulting in the deficiency being cited as past non-compliance with a correction date of 10/30/25.I. Incident on 10/28/25On 10/28/25, staff were transferring Resident #3 using the Hoyer lift. The staff failed to use the Hoyer lift properly, resulting in the lift sling coming unhooked. Resident #3 fell to the floor and sustained an acute parafalcine subdural hematoma. II. Facility plan of correctionThe plan of correction the facility implemented in response to Resident #3's fall on 10/28/25 was provided by the director of nursing (DON) on 5/6/26 at 3:45 p.m. The plan of correction documented the following. A. Immediate action to correct the deficient practice On 10/29/25, the facility conducted an investigation of Resident #3's fall. The facility interviewed all staff who were on duty when the resident fell and all staff who were involved in care for the resident on the day of the fall and a few days prior to the fall.On 10/29/25, the facility completed an inspection of the mechanical lift and determined the lift worked correctly with no imperfections.On 10/29/25, the facility interviewed staff and all staff reported the mechanical lift was functioning well.B. Identification of other residentsOn 10/29/25, the facility completed an audit and identified one other resident in the building who used the mechanical lift and was at risk for falls. C. Systemic changesOn 10/28/25 audits were initiated to verify the mechanical lift and the slings to have no defects for fall prevention interventions.On 10/29/25 and 10/30/25, nursing leadership re-educated all nursing staff in regards to reviewing the residents' care plans and Kardex's (staff directive tool), as well as the importance of following and implementing interventions outlined in these documents in an effort to reducethe risk of falls for facility residents. The DON completed competencies for the certified nurse aide (CNA) #4 and CNA #5 from the incident on 10/29/25.D. MonitoringThe DON and or designee was responsible for spot checking care staff during resident transfers who used the mechanical lift monthly.The maintenance director completed an audit of the mechanical lift monthly. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place.III. Facility policy and procedureThe Accident and Incident Investigating and Reporting policy, dated July 2017, was provided by the DON on 5/7/26 at 11:10 a.m. It read in pertinent part, All accidents or incidents involving residents, employees, visitors, and vendors occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor or charge nurse shall promptly initiate and document investigation of the accident or incident. The following data as applicable shall be included on the Report of Incident/Accident form. The date and time the accident or incident took place, the nature of the injury, the circumstance surrounding the accident, where the accident took place, the name of witness (s), the injured person account of the accident, the time the injured person's physician was notified and the family, the condition of the injury and disposition of the injured. Any corrective action taken place after the incident with follow up and any other pertinent information.The Lifting Machine, using a Mechanical Lift Policy, dated July 2017, was provided by the DON on 5/7/26 at 11:10 a.m. It read in pertinent part, At least two nursing assistants are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that require: lifting a resident off the floor or transferring a resident from bed to chair. Lift design and operation vary across manufactures. Staff must be trained and demonstrate competency using the specific machines or devices in the facility.IV. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included subdural hematoma (buildup of blood on the surface of the brain or brain injury), cerebral vascular disease (CVA) and diabetes. The 2/4/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was dependent on staff assistance for activities of daily living (ADL) and a mechanical lift was required for transfers. B. Record reviewThe nurse note, dated 10/28/26 at 10:31 a.m., revealed Resident #3 fell from the Hoyer lift during a staff-assisted transfer. The note documented the resident sustained visible injuries to her face and left arm. The nurse called for emergency transport and the resident left the facility via ambulance at 10:07 a.m.The fall investigation report, dated 10/28/25 at 9:36 a.m., revealed Resident #3 was being transferred in the Hoyer lift from the bed to the shower chair when one of the straps on the Hoyer lift sling came off of the Hoyer lift hook and the resident fell to the floor of her room. The resident sustained a laceration to her forehead. Emergency medical services (EMS) were called to have the resident transported and assessed at the emergency room (ER). At 2:20 p.m. the facility was notified the resident had an acute subdural hematoma along a portion of the falx cerebri (part of the brain).The hospital records, dated 10/28/25, revealed Resident #3 presented to the hospital via helicopter after a fall out of a mechanical lift on 10/28/25. Initial imaging on 10/28/25 revealed an acute parafalcine subdural hematoma. The documentation revealed neurosurgery was consulted and the resident was admitted to the hospital for monitoring. The hospital records, dated 10/29/25, revealed a repeat CAT scan (computed axial tomography - image of the brain) was completed on 10/29/25 which showed improvement and the resident could be discharged back to the facility. The risk for falls related to a cerebral vascular disease care plan, revised on 11/16/25, revealed Resident #3 was at risk for falls. Pertinent interventions included educating the resident, family and caregivers about safety reminders and what to do when a fall occurred. The ADL self care performance care plan, revised 11/16/25, documented the resident required a Hoyer lift (with two-person assistance for transfers. V. Staff interviewsCNA #1 was interviewed on 5/6/26 at 3:45 p.m. CNA #1 said Resident #3 used the mechanical Hoyer lift for transfers. He said he was recently provided education on how to transfer residents with the lift safely.CNA #2 was interviewed on 5/6/26 at 2:30 p.m. CNA #2 said Resident #3 required the use of the Hoyer lift for transfers. She said when transferring a resident with a Hoyer lift, two caregivers were needed. She said Resident #3 fell out of the lift last year (2025). She said the facility had all the caregivers read a packet on how to transfer residents. She said they talked about the fall in a staff meeting as well. Registered nurse (RN) #1 was interviewed on 5/7/26 at 9:10 a.m. RN #1 said Resident #3 fell out of the mechanical lift last year (2025). She said she was the nurse present during the fall and completed the assessment. She said the lift sling hook fell out the hook (holster) when the CNAs moved the resident to try and position her into the shower chair. RN #1 said the resident fell onto the floor and hit her head. She said she called EMS and sent Resident #3 to the hospital to be assessed further. She said she was part of educating the CNAs on transferring residents with the Hoyer lift and completed the training before the resident came back from the hospital a few days later. The maintenance director was interviewed on 5/7/26 at 9:50 a.m. The maintenance director said when Resident #3 fell on [DATE] he examined the mechanical lift immediately and found the lift to be working correctly. The DON was interviewed on 5/7/26 at 11:50 p.m. The DON said Resident #3 fell from the mechanical lift when the CNAs shifted the resident in the sling for positioning into the shower chair. She said the loop of the sling came off the hook which caused the resident to tip and fall to the ground. The DON said the resident was sent to the hospital. She said she immediately started an investigation and found the lift was working correctly and the sling had no rips or deformities. She said she educated the care staff within the next two days (10/29/25 and 10/30/25) on transferring with the Hoyer lift and watched the two CNAs who were present when Resident #3 fell do a transfer while she observed them. She said the facility continued to audit the Hoyer lift. She said she regularly looked for any rips or deformities with lift slings. She said she completed spot checks for transferring residents. She said Resident #3 sustained a brain injury from the incident. She said she continued to educate the staff and work with staff to ensure care planned interventions were being followed for the residents' safety.

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for three (#2, #5 and #3) of eight residents reviewed out of eight sample residents. Specifically, the facility failed to:-Implement interventions to prevent an elopement for Resident #2 and;-Implement fall interventions for Resident #5 and Resident #3.Finding include: I. Elopement failures A. Facility policy and procedure The Wandering and Elopement policy, revised March 2019, was provided by the director of nursing (DON) on 9/30/25 at 3:26 p.m. It revealed in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. B. Resident #2 1. Resident status Resident #2, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician's orders (CPO), diagnoses included unspecified sequelae of cerebral infarction (complications from a stoke), epilepsy, type 2 diabetes mellitus without complication, unspecified dementia with unspecified severity, major depression depressive disorder, lack of coordination, abnormalities of the gait and mobility, personal history of a transient ischemic attack (TIA) and cerebral infarction (stoke) without residual deficit. The 8/4/25 minimum data set (MDS) assessment identified Resident #2 had a short and long term memory problem with a staff assessment for mental status and had some difficulty with new situations per staff assessment. The MDS assessment indicated Resident #2 had wandering behaviors and verbal behavioral symptoms directed at others. According to the assessment, Resident #2 was independent in mobility with use of his wheelchair. 2. Resident observations and interview Resident #2 was smoking in the outside courtyard on 2/29/25 at 2:35 p.m. Resident #2 did not have a wanderguard attached to his wheelchair or wore a wanderguard bracelet. He said he had no concerns with the facility and was not planning on leaving. 3. Record review Review of Resident #2's comprehensive care plan did not identify he was at high risk for elopement and had an actual elopement. The care plan did not include interventions to prevent a recurrence of an elopement. The cognition care plan, revised 5/2/25, documented Resident #2 had impaired cognitive function or impaired thought processes related to dementia. The smoking care plan, revised 8/11/25, documented Resident #2 was an unsupervised smoker. The intervention, revised 5/8/25, directed staff to supervise the resident when smoking. -The smoking care plan documented the resident was both an unsupervised and a supervised smoker. The care plan did not clearly identify the level of supervision needed after smoking supervision was identified as a safety intervention due to the resident's 7/8/25 elopement. The 6/10/25 quarterly risk for elopement/wandering assessment documented Resident #2 was a low risk for elopement. The 7/8/25 missing person report documented Resident #2 had poor safety awareness, had difficulty making his needs known, a diagnosis of dementia and mobilized wheelchair independently. The report documented Resident #2 was missing from the facility for 45 minutes. He left the facility out the front door and wheeled himself to his representative's place of employment, three blocks away. The report indicated the wanderguard bracelet was placed on the resident wheelchair and he was put on supervised smoking. The 7/8/25 behavior note documented Resident #2 left the facility without staff knowledge and went to his representative's business. The resident was brought back to the facility by the POA. According to the behavior note, the resident was assessed and had no injuries as a result of the elopement. The note identified he was using inappropriate language and striking out at the representative and staff when he was returned to the facility. The resident's physician was notified and placed an order for Hadol (antipsychotic medication) to calm Resident #2. The note documented a wanderguard was put in place for his safety. The facility investigation for Resident #2's 7/8/25 elopement was provided by the DON on 9/29/25 at approximately 2:50 p.m. The investigation documented Resident #2 was last seen at the facility on 7/8/25 at 11:00 a.m. and brought back to the facility by his representative at 11:45 a.m. The representative informed the facility that Resident #2 had self propelled himself to her place of business and she had to assist him back to the facility in his wheelchair. The investigation documented Resident #2 said he went out the front door because he was upset at his representative and wanted the representative to take him home. Review of the July 2025 CPO revealed a wanderguard/alert device for underneath Resident #2's wheelchair, start date 7/8/25, identified the resident's wanderguard was discontinued on 7/25/25. The September 2025 treatment administration record (TAR) did not identify Resident #3 was monitored for behaviors of elopement, exit seeking or wandering. The 9/10/25 quarterly risk for elopement/wandering assessment documented Resident #2 was at a high risk for elopement related to leaving the facility unsupervised, cognition, diagnosis, impaired vision, hearing and/or communication, an expressed desire to go home, and the responsible party expressed concern of the resident leaving the facility. Review of the 9/10/25 quarterly assessment identified Resident #2 had an increased risk for elopement compared to the June 2025 elopement assessment indicating the resident was at a low risk for elopement. 4. Staff interviews Certified nurse aide (CNA) #4 was interviewed 10/30/25 at approximately 10:10 a.m. She said for residents with a wanderguard who were too close to the door, she would encourage them to move away from the door. She said if the residents left the facility, she would follow them. She said she usually worked on another unit and was not aware of who had elopement precautions off the memory care unit. CNA #3 was interviewed on 9/30/25 at 10:20 a.m. CNA #3 said if Resident #2 was seen by the front door, she would redirect him. She said Resident #2 did not have a wanderguard. CNA #1 was interviewed on 9/30/25 at 10:25 a.m. She said she had residents that were at risk for elopement wore a wanderguard on their ankle or wheelchair. She said if a wanderguard triggered the door alarm, she would check the door and redirect the resident. She said there were a few residents that would say they want to go home but they were not a risk for elopement but checked in on them. Licensed practical nurse (LPN) #2 was interviewed on 9/30/25 at 10:34 a.m. LPN #2 said when residents were expressing an interest to leave the facility, she would make sure their needs were met and try to decrease their escalated behaviors. She said residents' interventions were identified in the care plan and tracked in the treatment administration record. She said residents that were at risk for elopement wore a wanderguard. She said she was not concerned about any other residents attempting to elope that did not have a wanderguard. LPN #2 said she did not Resident #2 would try to elope again because he has been happy. She said she had heard Resident #3 wanted to leave the facility but she did not think he had the physical ability. She said the staff tried to make him comfortable and de-escalate his behavior. The DON was interviewed on 9/30/25 at approximately 11:00 a.m. She said when residents were admitted to the facility they were assessed for elopement risk. She said residents were reassessed when they start showing signs of exiting seeking, packing or other related behaviors. She said the facility then evaluates if the resident needs to be placed on the secured memory unit or have a wanderguard. She said a wanderguard was often placed resident when the resident was exiting seeking and not redirectable and/or eloped. The DON said Resident #2 no longer has a wanderguard because the staff spoke to him and his representative. The DON said Resident #2 agreed to not leave the facility again. She said he has not attempted to leave the facility again since his July 2025 elopement. She said in the past when he was upset he tended to go to the front door and was difficult to redirect. She said he used to have a wanderguard around the time he first admitted when he had prior elopement attempts. She said just before the 7/8/25 elopement, he seemed to be more calm in his behavior. The DON said he still would get angry but he was not going to the door like he did before. The DON said after his 7/8/25 elopement, the facility had not made changes to his care plan other than unsupervised smoking. She said the staff have not recently noticed him exit seeking when he was upset. The DON said Resident #2 was not exit seeking just before his elopement but would spend time near the front door. The DON said they would start him on 15-minute checks to make sure the situation did not happen again. She said a couple years back he had a wanderguard in place for a while because he was very angry and had difficulty adjusting to the facility. She said prior to his elopement in July 2025, he was calm but then became upset with his representative and went to her work. CNA #2 was interviewed on 9/30/24 at 4:32 p.m. CNA #2 said Resident #2 was independent with smoking and does not require supervision outside. She said he had left the facility a couple times. She said Resident #2 did not tell anyone he was planning on leaving but just left. CNA #2 said he was upset with his POA because she had not brought his snacks to him. She said it was routine for him to become upset with his POA and staff. She said he had not left the facility since July 2025 but will still get angry. She said so she tries to watch him closer when he is upset so he does not go out the door CNA #2 said he had a wanderguard after he elopement in July 2025. She said the wander guard was temporary and she did not know why it was discontinued. LPN #1 was interviewed on 9/30/25 at 4:26 p.m. LPN #1 said Resident #2 had a temporary wanderguard but had since been discontinued because he had a verbal agreement with the facility not to elope again. He said the staff monitors where he was but not with formal documentation. The activity director (AD) was interviewed on 9/30/25 at 4:42 p.m. The AD said Resident #2 was an unsupervised smoker. The social service director (SSD) was interviewed on 9/30/25 at 4:04 p.m. She said she was aware that Resident #2 was not on a wanderguard because he verbally agreed not to leave the facility again. She said she was not involved with the details of the verbal agreement. She said she was more involved with the team on trialing him with unsupervised smoking in the courtyard. She said Resident #2 and his representative have been informed that if Resident #2 tried to leave the facility again without staff acknowledgement, then he would be placed on supervised smoking. She said she was not concerned that he would try to leave the courtyard because he left out the front door in July 2025 and the courtyard had a lock on the gate that he could not reach. II. Fall prevention failures A. Facility policy and procedure The Falls - Clinical Protocol policy, revised September 2012, was provided by the DON on 9/30/25 at 3:26 p.m. It revealed in pertinent part, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). B. Resident #5 1. Resident status Resident #5, age greater than 65, was admitted on [DATE] and discharged [DATE]. According to the September 2025 CPO, diagnoses included end stage heart failure, schizophrenia, chronic obstructive pulmonary disorder (COPD), pulmonary embolism and generalized muscle weakness. Resident #5's referral document, completed 9/22/25 documented Resident #5 had intermittent and increasing confusion, increased weakness and falls at home prior to admission to the facility. The referral documented the resident had baseline supplemental oxygen needs of 1-2 liters per minute via nasal cannula for air hunger. The referral documented the resident was a high fall risk. 2. Resident representative interview Resident #5's representative was interviewed on 9/30/25 at 9:09 a.m. The representative said Resident #5 was admitted to the facility because he fell multiple times at home and needed more supervision. She said she visited him most days he was at the facility and she felt he was not checked on frequently for safety even though he was a high fall risk. She said Resident #5 was confused, impulsive and did not use his call light for help. The representative said she received a phone call from the facility nursing home administrator (NHA) sometime in the afternoon on 9/24/25. She said she was told Resident #5 pulled out his own foley catheter and hit his head on the nightstand. She said she went to visit him and a staff member told her Resident #5 fell after he slipped in his urine when he pulled his foley catheter out. The representative said she also found Resident #5 on the floor on 9/26/25 at approximately 10:00 p.m. She said she went to visit him and had to alert staff that he fell again and was on the floor. The representative said after the second fall on Friday she asked the facility to put the fall mat in place, however the fall mat was leaning against the wall the next morning on 9/27/25. She said on the morning of 9/27/25, Resident #5 was no longer responding to her voice and was rocking back and forth. The representative said she requested Resident #5 go to the hospital. She said Resident #5 passed away in the hospital on 9/28/25. 3. Record review The progress note, dated 9/23/25 at 9:35 p.m., documented Resident #5 had impulsive behavior and dizziness. The progress note documented Resident #5 insisted on leaving or getting up but was unable to state why or where he was going. The progress note documented Resident #5 was at high risk for falls. The progress note, dated 9/24/25 at 6:00 p.m., documented the resident was admitted under comfort care and the facility was still completing baseline assessment. The progress note documented Resident #5 was not cooperative in keeping the nasal cannula in his nose for proper oxygenation and did not use the call light. The progress note documented if Resident #5 did not receive his as needed (PRN) morphine, then Resident #5 experienced air hunger and increased anxiety which caused him to try and ambulate unassisted, increasing the risk of falls. The progress note documented earlier in the afternoon, the day nurse reported Resident #5 was very agitated and ripped out his own Foley catheter because he needed to pee. The progress note documented a catheter was placed, PRN medication was administered and seemed to be effective on the follow up assessment. The progress note documented the nurse spoke to the resident representative about giving the morphine more consistently, but the resident representative did not want it given unless absolutely necessary because she wants him more alert so he's able to eat more and socialize. On 9/30/25 at approximately 10:00 a.m., two internal fall reports regarding Resident #5 were provided by the DON. They revealed in pertinent part, The fall report, dated 9/24/25 at 12:30 p.m., documented Resident #5 was found in bed with a new skin tear to his forehead. The fall report documented the resident was alert and oriented to person, place and situation, but disoriented to time. The fall report documented Resident #5 told staff he got up to go somewhere but could not recall where and fell backward onto the bed, hitting his head on the footboard of the bed. The fall report documented multiple predisposing factors contributing to the fall including confusion, gait imbalance, changes in cognition, recent illness and changes in medication. The fall report documented if Resident #5 did not receive PRN Morphine, then Resident #5 would have increased air hunger and anxiety causing Resident #5 to ambulate without assistance. -However, the fall report did not document if Resident #5 was wearing supplemental oxygen at the time of the fall, and review of vital signs and neurological checks completed after the fall do not include documentation of oxygen saturation. The fall report, dated 9/26/25 at 8:00 p.m., documented Resident #5 was found on the floor of his room by his resident representative. The fall report documented Resident #5 was unable to recall how the fall occurred. The fall report documented Resident #5 had no new injuries on assessment, but appeared anxious and confused. The fall report documented the resident was lethargic, disoriented to time, place, and situation. -However, the fall report did not document if Resident #5 was wearing supplemental oxygen at the time of the fall and review of vital signs, and neurological checks completed after the fall do not include documentation of oxygen saturation. Review of Resident #5's care plan, initiated 9/23/25 and revised on 9/24/25, revealed Resident #5 had a focus on risk for falls due to his decreased mobility and terminal illness. Interventions included anticipating resident needs, ensuring the resident was wearing appropriate footwear when ambulating, education to resident, family, and caregivers about safety reminders, ensuring the call light was within reach and providing a safe environment free from spills or clutter with personal items within reach. Review of Resident #5's September 2025 CPO revealed no orders for supplemental oxygen. Additionally, review of daily vital signs for Resident #5 revealed missing documentation of oxygen saturation on 9/26/25. 4. Staff interviews CNA #1 was interviewed on 9/30/25 at 2:05 p.m. CNA #1 said she took care of Resident #5 while he resided at the facility, but could not recall the dates. CNA #1 said Resident #5 was confused, agitated and unable to follow directions. CNA #1 said she knew Resident #5 was on hospice, but was not aware Resident #5 had multiple falls in the facility and did not remember any specific fall interventions for Resident #5. CNA #1 said she was not aware Resident #3 expressed any desire to leave the facility and she was not aware Resident #3 was at risk for elopement. LPN #1 was interviewed on 9/30/25 at 1:57 p.m. LPN #1 said he took care of Resident #5 the night shift of 9/24/25. LPN #1 said he was aware Resident #5 fell earlier in the day but did not remember if Resident #5 had any injuries from the fall or from pulling out his own catheter. LPN #1 said he did remember Resident #5 wore supplemental oxygen via nasal cannula, but LPN #1 said he did not remember how much oxygen and he did not remember if Resident #5 had orders for oxygen. LPN #2 was interviewed on 9/30/25 at 3:37 p.m. in Resident #3's room. LPN #2 confirmed no sign to remind Resident #3 to call for assistance was hanging in Resident #3's room. LPN #2 said she remembered seeing the sign in his room previously. LPN #2 said Resident #3 changed rooms recently and she thought the sign was not put back up in the new room. LPN #2 said she planned to print out and hang a new sign for Resident #3. The DON was interviewed on 9/30/25 at 2:26 p.m. The DON said she met with Resident #5's representative almost daily while Resident #5 was at the facility. The DON said they rushed the referral process for Resident #5. She said Resident #5 wanted to leave the hospital and return home despite multiple falls and hospitalizations when he lived at home. The DON said Resident #5 was confused and agitated upon admission. The DON said Resident #5 required convincing to stay in the facility on the first day. The DON said they had a fall mat in place for small period of time after the first fall, but during IDT review on 9/25/30, they felt it was not a good intervention since Resident #5 refused to wear shoes or non slip socks. She said the floor mat would be an obstacle. The DON said she thought Resident #5 wore 3 L of supplemental oxygen, but she did not know why no oxygen order was entered into the CPO. The DON said air hunger increased Resident #5's anxiety and restlessness. The DON said she was not sure why there was no documentation of oxygen saturation on 9/26/25, the day the second fall occurred. The DON confirmed that the paper documentation of vital signs and neurological checks completed after each of his falls did not include a space to document oxygen saturation. The DON said she planned to change the paper form to include documentation of all vital signs. The DON was interviewed again on 9/30/25 at 5:15 p.m. The DON said Resident #3's ability to transfer independently fluctuated daily and most days he was able to transfer himself safely. The DON said the reminder sign placed in Resident #3's room in March 2025 was probably lost when he moved closer to the nurses' station. The DON said she planned to review with risk for falls care plan and ensure all of the interventions were in place. C. Resident #3 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the September 2025 CPO, diagnoses included Huntington's disease (a progressive disorder that causes involuntary movements, cognitive decline, and psychiatric symptoms), major depressive disorder, shortness of breath, chronic obstructive pulmonary disease with acute exacerbation, generalized muscle weakness, lack of coordination, unspecified abnormalities of the gait and mobility, essential tremor and unspecified dementia with unspecified severity. The 7/24/25 MDS assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. According to the MDS assessment, Resident #3 used a wheelchair for mobility and required partial to moderate assistance to transfer from surface to surface. The MDS assessment identified the resident has had multiple falls since his admission to the facility. The assessment did not identify he had rejections of care behaviors. 2. Observations and resident interview On 9/30/25 at 9:05 a.m. Resident #3 propelled his wheelchair with his feet to his room from the dining room. -Resident #3 was not escorted to his room as indicated in his care plan (see below). At 9:13 a.m. Resident #3 self-transferred himself from his wheelchair to his bed. Resident #3 did not push his call light on to request for help or lock his wheelchair breaks before he transferred. He said he usually transferred himself to bed. -Resident #3 was not escorted to his room as indicated in his care plan. At 11:56 a.m. Resident #3's room was observed and there was not a sign in his room reminding him to call staff for assistance prior to self-transferring. 3. Record review The fall care plan, revised 3/27/25, identified Resident #3 was at risk for falls related to Huntington's disease, weakness and decreased mobility. According the care plan, Resident #3 had a history of falls. The care plan revealed he had four unwitnessed falls between January 2025 and March 2025. Pertinent interventions included staff to anticipate and meet Resident #3's needs (7/23/19), staff was educated to provide Resident #3 contact guard during ambulation and transferring into chairs (5/2/19), Resident #3 used a wheelchair and directed staff to escort Resident #3 to and from meals for safety related to his unsteadiness and Huntington's disease for his safety (9/23/24); directed staff to place a sign in his room to remind him to call for staff assistance with increased unsteadiness (10/2/24) and staff to replace a visual cue/sign in the resident's room to help remind him to call for assistance (initiated 1/13/25 and revised 3/27/25). -There was no evidence indicating the facility reviewed the resident's fall care plan to ensure current interventions remained appropriate after Resident #3's 8/14/25 fall. The 8/15/25 health status note documented Resident #3 fell on the previous shift (8/14/25) without injury. The 8/14/25 fall investigation was provided by the director of nursing (DON) on 9/30/25 at approximately 10:00 a.m. The investigation identified Resident #3 had an unwitnessed fall on 8/14/25 at 4:15 p.m. He was found in his room sitting on the wet floor. The investigation indicated Resident #3 said he was incontinent and sat down on the floor to change. The investigation identified incontinence and self ambulating without assistance were factors of the fall. According to the investigation, Resident #3 did not use his call light when he tried to ambulate to the bathroom. -Review of the provided fall documentation did not identify the resident's fall interventions were reviewed to ensure the interventions remained appropriate after Resident #3's 8/14/25 fall. 4. Staff interviews The DON was interviewed on 9/30/25 at approximately 11:00 a.m. The DON said Resident #3 last fall was related to urine on the floor. She said he should be monitored for taking himself to the bathroom. She said staff were now going into his room to check on him which had decreased his fall risk.

Received treatment and care in accordance with professional standards or practice out of eight sample residents.Specifically, the facility failed to:-Complete a wander risk assessment after Resident #1 had a change of condition and left the building;-Obtain physician's orders for the use of Resident #1's wanderguard; and, -Ensure Resident #1's care plan was updated with the use of a wander guard. Findings include:I. Facility policy and procedureThe Wandering and Elopement policy, revised March 2019, was provided by the director of nursing (DON) on 9/30/25 at 3:26 p.m. It revealed in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included diabetes type I, epilepsy (seizure disorder), history of infection of the central nervous system, unspecified mood disorder, Parkinson's disease (causes tremors) and abnormal gait and movement.The 8/11/25 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 required moderate assistance with bathing and required set up assistance with lower body dressing, oral hygiene, personal hygiene and toileting. Resident #1 was able to ambulate independently. B. Facility investigationThe DON provided the facility investigation of the 9/14/25 elopement event on 9/29/25 at approximately 2:50 p.m. It revealed in pertinent part,The investigation summary documented on 9/14/25 at approximately 2:40 p.m. Resident #1 was found on the sidewalk approximately 0.5 miles from the facility by licensed practical nurse (LPN) #3, who was on break when she spotted Resident #1 outside of the facility. LPN #3 drove back to the facility to confirm Resident #1 was missing. The facility staff searched the premises to confirm that Resident #1 had eloped from the facility when they found his empty wheelchair in the front lobby. The facility was not aware Resident #1 eloped from the facility until altered by LPN #3. LPN #3 and another staff member drove back to the street where LPN #3 saw Resident #1. When attempting to assist Resident #1 into a vehicle, Resident #1 collapsed. The facility contacted emergency medical services (EMS). Per the EMS report, Resident #1 had altered mental status and a blood glucose reading of 129 milligrams per deciliter (mg/dL). EMS transported Resident #1 to the local hospital for additional evaluation. Resident #1 returned to baseline cognition in the emergency room and was transported back to the facility on 9/14/25. Upon return to the facility, Resident #1 agreed to wear a wanderguard to prevent further elopements. The investigation documented the wanderguard was applied to the resident.The investigation documented a written statement by LPN #3 on 9/14/25. LPN #3 wrote she last saw Resident #1 at 1:30 p.m. to administer a scheduled medication. LPN #3 wrote she went on break and saw Resident #1 walking down the street. LPN #3 wrote she drove back to the facility to get another staff member to help her. LPN #3 wrote they drove back to where she saw Resident #1. LPN #3 documented she attempted to assist Resident #1 to stand, but Resident #1 lost consciousness. LPN #3 documented she lowered him safely back to the ground. LPN #3 wrote she then called 911 and the assistant director of nursing (ADON). LPN #3 wrote she stayed with Resident #1 until the ambulance arrived within 10 minutes from the time she called. C. Resident interview and observationsResident #1 was interviewed on 9/29/25 at 1:50 p.m. Resident #1 said he remembered the events around his elopement from the facility a few weeks prior to the interview. He said he could not remember why, but that he got up from his chair and began walking. He said he did not know why he was confused at the time and did not know why he decided to leave the facility. He said he did not remember how, but he was found by a staff member from the facility sitting next to a post down the street. Resident #1 said he remembered the facility staff shaking him to get him to wake up. Resident #1 said the staff member tried to help him stand up but he was too weak. Resident #1 said an ambulance arrived to help him up and he went to the hospital. Resident #1 said when he was first found and aroused by the staff member he was not able to answer any questions but he was able to speak normally in the emergency room. He said the emergency room doctor told Resident #1 it appeared he had a seizure. Resident #1 said since returning to the facility, the facility put a wanderguard bracelet in case he became confused and began to wander again. Resident #1 said he approved of the intervention since he still did not know what caused the change in behavior and did not want to get injured if he was confused. Resident #1 said he thought staff checked to make sure the bracelet worked correctly but did not know when or how they checked it. During the interview, Resident #1 was observed to have a wanderguard on.D. Record reviewA wandering/elopement assessment was completed on 9/12/25 at 12:46 p.m. The assessment documented Resident #1 did not have a history of elopement behaviors and was at a low risk for elopement.-Review of Resident #1's electronic medical record (EMR) did not reveal documentation that the facility completed a new wandering/elopement assessment after Resident #1 had a change of condition and left the faciity on 9/14/25.Residents #1's care plan, initiated on 8/23/23 and revised 8/24/25, revealed there were no changes made to address changes in mental status or risk for wandering/elopement after the elopement incident on 9/14/25.Review of Resident #1's September 2025 CPO on 9/30/25 revealed no physician's orders for a wanderguard bracelet and no treatment orders to monitor Resident #1's bracelet to ensure the device was functioning properly.Review of Resident #1's EMR did not reveal an assessment for the use of the wanderguard prior to the implementation of the wanderguard.Review of Resident #1's progress notes revealed no documentation related to the change of condition on 9/14/25. E. Staff interviewsLPN #1 was interviewed on 9/30/25 at 1:57 p.m. LPN #1 said the facility had a device to test the wanderguard to ensure the bracelet was working. LPN #1 said each resident wearing a wanderguard bracelet should have a physician's order for it to be checked for placement and function each shift. LPN #1 said any nurse at the facility was able to enter the wanderguard order, but typically the nurse who placed the wanderguard bracelet on the resident should have obtained and entered the order. LPN #1 said he was aware Resident #1 was wearing a wanderguard bracelet but he was not aware Resident #1 did not have an order in place. LPN #1 said he planned to enter the order after the interview to ensure Resident #1's wanderguard was checked each shift going forward. The DON was interviewed on 9/30/25 at 5:15 p.m. The DON said she was not sure why Resident #1 did not have orders for his wanderguard bracelet and did not have an updated care plan or an updated elopement risk assessment after the elopement event occurred. The DON said she planned to ensure those items were in place and planned to discuss with the social services coordinator and the MDS coordinator as to why these updates were not completed.

Based on record review and interviews, the facility failed to honor resident choices for six (#4, #10, #11, #14, #15 and #18) of 10 residents reviewed out of 18 sample residents.Specifically, the facility failed to offer Resident #4, Resident #10 and Resident #11, Resident #14, Resident #15 and Resident #18's preferred community activities outside of the facility. Findings include:I. Resident #4A. Resident statuResident #4, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included acquired absence of the left leg (above the knee), neuromuscular dysfunction of the bladder, Spina Bifida and Osteochondrodysplasia (a genetic disorder affecting the legs). The 3/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with repositioning, transfers, toileting, dressing and showering.B. Resident interviewResident #4 was interviewed on 8/5/25 at 9:15 a.m. Resident #4 said the bus the facility used to transport residents broke down around August last year (2024). Resident #4 said the bus was not replaced and the facility did not provide a community activity outside of the facility until June 2025. Resident #4 said she attended resident council meetings to complain about the lack of activities and filed a grievance with the facility. Resident #4 said the facility used to offer multiple trips to the store each month and activities at a local lake. She said the facility offered a group stroll and roll activity to a park down the road, but it was not the same since staff can only push so many wheelchairs and it was too far for most residents to walk independently. Resident #4 said she would like to be able to go into town for events or to the store again. C. Record reviewResident #4's care plan, initiated on 5/20/24 and last revised on 1/29/25, indicated Resident #4 was dependent on staff meeting the emotional, intellectual, and social needs of Resident #4 due to their physical limitations. Pertinent interventions included assistance with arranging community activities and arranging transportation. II. Resident #10A. Resident statusResident #10, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included left sided hemiplegia (loss of function of one side of the body), lupus (autoimmune disease) and rheumatoid arthritis. The 4/29/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #10 required touching assistance with transferring to and from the shower/tub and was independent with all other activities of daily living (ADL).B. Resident interviewResident #10 was interviewed on 8/5/25 at 09:38 a.m. Resident #10 said the facility had not offered her any community activities outside of the facility since her admission. Resident #10 said until they recently hired the new staff for activities, the facility was only offering Bingo. Resident #10 said she would like to be able to go to the store and activities in town. III. Resident #11A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), Bipolar disorder (mental illness), anxiety and vitamin D deficiency. The 7/21/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15Resident #11 required moderate assistance with bathing, and required set up and clean up assistance with eating, oral hygiene, and personal hygiene. Resident #11 ambulated independently. B. Resident interviewResident #11 was interviewed on 8/5/25 at 2:38 p.m. Resident #11 said he used to go all over the community for outings and really enjoyed going out. He said the facility stopped the outings on the bus, which added to his feelings of being trapped. He said there was a roll and stroll sheet to sign up but then they took the sign up sheet down. He said he would like more opportunities to spend time outside the facility on outings.C. Record reviewResident #11's care plan, initiated on 4/20/22 and last revised on 2/14/25, indicated Resident #11 preferred activities included going outside and walking around when the weather permitted. Interventions included inviting Resident #11 to group activities providing activities suited to his interest and to read, listen to music, or go outside if Resident #11 did not want to participate in the group activity in order to provide social and sensory stimulation. IV. Resident #14A. Resident statusResident #14, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included COPD, cerebral infarction (stroke), Bipolar disorder, anxiety and post-traumatic stress disorder (PTSD). The 6/6/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15.Resident #14 required moderate assistance with bathing and toileting; and required set up and clean up assistance with eating, dressing, oral hygiene, and personal hygiene. Resident #14 was able to ambulate small distances with moderate assistance and able to use a wheelchair to wheel herself independently at least 50 feet, but less than 150 feet. B. Resident interviewResident #14 was interviewed on 8/5/25 at 02:42 p.m. Resident #14 said she recently became the resident council president and heard from the other residents previous requests for a vehicle to go on resident outings. Resident #14 said she participated in the stroll and roll event, but she was not sure all residents would be able to participate and Resident #14 said she would like variety in the outings provided by the facility.V. Resident #15A. Resident statusResident #15, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included coronary artery disease, chronic venous insufficiency, muscle weakness, impaired gait, and vitamin D deficiency. The 6/9/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15.Resident #15 required assistance with bathing, dressing, hygiene, toileting, and transfers. Resident #15 used a wheelchair and were able to wheel themselves independently over 150 feet. B. Resident interviewResident #15 was interviewed on 8/5/25 at 3:08 p.m. Resident #15 said she was the resident council president until recently. Resident #15 said she lived at the facility for years and the facility used to provide a variety of outings including trips to the dollar store or fishing down at the local river. Resident #15 said the bus broke down last August and the facility stopped providing outings. Resident #15 said she brought up the lack of outings or the request for a new bus every month at the resident council meeting but nothing changed. VI. Resident #18A. Resident status Resident #18, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included cerebral infarction (stroke), epilepsy (seizure disorder), abnormal gait and mobility and depression. The 5/5/25 MDS assessment revealed the resident had impaired speech, but was usually understood and able to understand others per staff assessmentResident #15 required assistance with bathing, hygiene, toileting, and transfers. Resident #15 used a wheelchair and were able to wheel themselves independently over 150 feet. B. Resident interviewResident #18 was interviewed on 8/5/25 at 5:41 p.m. Resident #18 said he had not gone on any outings since admission to the facility. Resident #18 said he wanted to go to the store when offered different options of possible outings. VII. Record reviewThe nursing home administrator (NHA) provided the resident council meeting minutes on 8/4/25 at 1:50 p.m. The minutes revealed the following:The resident council meeting minutes, dated 5/20/25, documented the residents requested to go on outings. The facility documented response was hiring a new activities director and the addition of stroll and roll activities. The resident council meeting minutes, dated 6/17/25, documented a repeated request for a bus to go on outings. The resident council meeting minutes, dated 7/15/25, documented another repeated request for a bus to go on outings. The meeting minutes documented the next stroll and roll activity planned 7/15/25.The director of nursing (DON) provided a grievance filed by Resident #4 on 8/5/25 at 2:12 p.m. The grievance, dated 7/1/25, documented Resident #4 complained that the facility felt like a prison, the facility was not providing activities other than bingo and did not have an activity director. The resolution of the grievance was the facility hired a new activities director and was in the process of hiring a new activities associate. VIII. Staff interviews The activities assistant was interviewed on 8/5/25 at 3:31 p.m. The activity assistant said she started at the facility approximately three weeks ago. She said the facility also recently hired an activities director but they took leave shortly after starting and have not returned. She said she had coordinated resident activities since she started including the most recent stroll and roll event. She said she was aware the facility used to have a bus for resident outing, but to her knowledge there were no current plans to replace the bus. She said she used the van to take residents to appointments, but the van could only accommodate one resident in a wheelchair. She said she would be able to drive the bus for resident outings if the facility acquired a new one. She said the stroll and roll events were not a full replacement for resident outings since most residents can not ambulate far enough independently to walk to the park, limiting the number who can participate by the number of wheelchairs and staff available to leave the facility to push them. She said outings involving other people in the community would greatly improve the quality of life of the residents in the facility. The maintenance director (MTD) was interviewed on 8/5/25 at 12:21 p.m. The MTD said the facility bus broke down before he started working at the facility, but to his knowledge, there were no plans to replace the bus after it broke despite multiple requests from residents and staff members. The MTD said the city offers a bus for senior activities to the independent living facilities in the area. The MTD said the van used for appointments was not an adequate replacement for the bus because the van can only accommodate one resident. The NHA and the DON were interviewed together on 8/5/25 at 5:51 p.m. The DON said the bus broke down on the interstate last August (2024). The DON said after it was evaluated by a mechanic, the bus could not be repaired and the bus was sent to a salvage yard. The DON said the requests for a bus were brought up to her management but a new bus purchase was not approved by the time of the interview. The DON said due to the remote location of the facility and the lack of sister facilities in the area, the facility had not been able to find an affordable replacement. The DON said she was aware of the multiple requests for resident outings, but felt not all residents who expressed interest in previous outings attended them when offered.

Based on observations, record review and interviews, the facility failed to ensure two (#26 and #5) of six residents out of 16 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #26 was admitted to the facility for long term care on 1/4/23 with diagnoses of dementia, hypotension (low blood pressure), hypokalemia (low potassium), hypothyroidism (low thyroid function) and depression. Upon admission on 1/4/23, Resident #26 weighed 152 pounds (lbs) and she reported she liked to eat eggs, coffee and sweets. Resident #26 had gradual weight gain until 4/12/24 when she weighed 190 lbs. At this time, the resident started gradually losing weight. On 9/4/24 the resident weighed 182 lbs. The resident sustained 12 lbs (6.5%) weight loss in one month, from 9/4/24 to 10/3/24, which was considered severe. The facility failed to implement effective person-centered nutrition interventions to address the resident's decreased oral intake and severe weight loss. On 9/27/24, Resident #26 weighed 174 lbs, which indicated the resident had lost eight lbs in 20 days. The registered dietitian (RD) recommended implementing a house nutrition supplement, however, the facility failed to obtain a physician's order for the house supplement and track the resident's acceptance of the intervention. Due to the facility's failures, Resident #26 continued to lose weight and weighed 168 lbs on 11/4/24, which indicated the resident lost 22 lbs (11.6%) in six months. Additionally, Resident #5 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety, anemia (low red blood cell count) and dysphagia. Resident #5 sustained a weight loss of 12.8% (24 lbs) from admission on 8/5/24 through 11/4/24, which was considered severe. According to Resident #5's nutrition care plan, pertinent interventions were initiated on 8/28/24 which included a house shake once a day. The facility failed to implement additional person-centered effective nutritional interventions for Resident #5 and meet the resident's dietary preferences to prevent significant weight loss. Review of the physician progress notes revealed no documentation of Resident #5's significant weight loss and poor nutritional status. There was no documentation on expected or unplanned weight loss, or updated care plan goals and appropriate interventions to improve resident's nutritional status. Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy, revised March 2022, was provided by the nursing home administrator (NHA) on 11/7/24 at 10:00 a.m. It read in pertinent part, Any weight change of five pounds or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria one month - five % weight loss is significant; greater than five % is severe. Three months - 7.5% weight loss is significant; greater than 7.5% is severe. Six months - 10% weight loss is significant; greater than 10% is severe. II. Resident #26 A. Resident status Resident #26, over the age of 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included dementia, hypotension , hypokalemia, hypothyroidism and depression. The 10/1/24 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not conducted because the resident was rarely or never understood. She experienced hallucinations and wandering and required setup and clean up assistance with eating. The assessment documented the resident was 70 inches (five foot, ten inches) tall and weighed 174 lbs. It indicated the resident had weight loss and was not on a physician prescribed weight loss program. B. Observations During a continuous observation of the lunch meal service on 11/5/24, beginning at 12:01 p.m. and ending at 1:24 p.m., the following was observed: Resident #26 was served lunch consisting of the regular menu which consisted of grilled fish, parmesan noodles, sliced zucchini, wheat bread and a chilled fruit cup and ate approximately 50% of the meal. When the resident finished eating, she stood up from the table and walked to her room. -The resident was not encouraged by staff to continue eating or offered any additional snacks or food items. C. Record review The nutrition care plan, initiated on 1/18/23 and revised on 9/22/24, revealed Resident #26 had a potential nutritional problem related to hypothyroidism (low thyroid function), dementia and depression. The interventions included administering medications as ordered, (1/18/23), observing/documenting/reporting as needed any signs of dysphagia such as pocketing, chocking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals (1/18/23), providing and serving diet as ordered and recording intake (1/18/23), providing daily menu assistance with making menu choices (1/18/23), RD to evaluate and make diet change recommendations as needed (1/18/23) and weighing the resident per facility protocol (1/18/23). -Review of the resident's comprehensive care plan did not reveal the facility implemented new person centered nutritional interventions after Resident #26 had sustained significant weight loss on 10/3/24 and on 1/4/24. Resident #26's weights were documented in the resident's electronic medical record (EMR) as follows: -On 4/12/24, the resident weighed 190 lbs; -On 4/16/24, the resident weighed 188 lbs; -On 5/7/24, the resident weighed 188 lbs -On 6/4/24, the resident weighed 186 lbs; -On 7/1/24, the resident weighed 186 lbs; -On 8/5/24, the resident weighed 188 lbs; -On 9/4/24, the resident weighed 182 lbs; -On 9/24/24, the resident weighed 174 lbs; -On 10/3/24, the resident weighed 170 lbs; -On 10/15/24, the resident weighed 169 lbs; -On 10/22/24, the resident weighed 168 lbs; -On 10/28/24, the resident weighed 167 lbs; and, -On 11/4/24, the resident weighed 168 lbs. -The resident lost 22 lbs from 8/5/24 to 11/4/24, in three months, which was considered severe. -The resident lost 12 lbs from 9/4/24 to 10/3/24, in one month, which was considered severe. -The resident lost 23 lbs from 4/12/24 to 11/4/24, in six months, which was considered severe. The 5/4/24 mini nutritional assessment (MNA) documented Resident #26 had no decrease in food intake or weight loss over the past three months. -However, Resident #26 had lost two lbs during the past three months. The 7/15/24 RD assessment documented Resident #26 was eating a regular diet and more than 75% of her meals. The recommendation was to continue with the current plan of care. A nutrition progress note, dated 9/20/24, documented the resident was discussed at the nutrition at risk (NAR) meeting because the resident had weight loss, however, her intake was adequate but due to her wandering during the day she needed to be encouraged to eat. Weekly weights were initiated. A nutrition progress note, dated 9/27/24, documented the resident was discussed at the NAR meeting because she had lost eight lbs. The note revealed she was sleeping more, pale and laboratory (lab) testing had been ordered. It was recommended to add house supplements to her diet once the lab results were obtained. -Review of the November 2024 CPO did not reveal a physician's order was implemented for a house supplement. The 9/28/24 progress note documented Resident #26 tested positive for COVID-19. -However, Resident #26 had already lost eight lbs prior to a COVID-19 diagnosis. The 10/4/24 RD assessment documented Resident #26 had a recent significant weight loss due to COVID-19 and poor intake while she was sick. The recommendation was for RD to monitor the resident as needed. -However, the facility failed to implement interventions to combat the residents' decreased intake while she had COVID-19. The 10/15/24 progress note documented Resident #26 was moved to the secured unit. The 10/21/24 certified dietary manager (CDM) nutritional assessment documented Resident #26's weight was trending down and that the resident liked to eat almost everything. -After the CDM identified the resident's weight was trending down, the facility failed to implement person-centered effective nutritional interventions to meet the resident's dietary preferences after the resident sustained a 11.6% (22 lbs) weight loss in six months, from 4/12/24 to 11/4/24, to address the resident's significant weight loss and decline in oral intake. D. Staff interviews NA #1 was interviewed on 11/5/24 at 1:26 p.m. NA #1 said it was difficult to get the residents on the secure unit to eat if they did not want to. She said the residents consumed more food if they were able to hold the food and walk around the unit. -However, observations did not reveal residents were given finger foods to walk around the unit with (see observations above). The NHA was interviewed on 11/6/24 at 2:27 p.m. The NHA said she had been watching over the kitchen for the past two months since the dietary manager left. She said the facility had been trying to hire someone to fill the position but it had been difficult since it was a small town. She said the RD visited the facility about twice a month. Cross reference: F801 failure to employ a full time dietitian or a qualified dietary manager. The RD was interviewed on 11/6/24 at 2:30 p.m. The RD said residents' preferences and nutrition interventions were not included in the care plan because she was directed not to include detailed information like that by another consultant. She said the nurse notified the physician and the residents' representatives of any weight loss. She said food preferences were communicated to the staff on the residents' food cards. She said she did not like the current form the facility was using to obtain the residents' preferences because it focused on the residents' dislikes and not their preferences. She said she would like to change it. The RD said when a resident was admitted to the facility, the admissions clerk collected the food preference information and if the resident was not able to identify likes and dislikes, she contacted the family for the information. She said the house supplements should only be given at meal times if the resident continued to eat the meal. She said if the resident started eating less at meal times, the supplement should be given outside of meal times. The RD said Resident #26 sustained significant weight loss since she had COVID-19. 31229 III. Resident #5 A. Resident status Resident #5, age 83, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety, anemia (low red blood cell count) and dysphagia (difficulty swallowing). The 8/12/24 MDS assessment revealed the resident was cognitively intact with a BIMS score 14 out of 15. She required supervision with eating, and substantial/maximal assistance with transfers and ADLs. The MDS assessment documented the resident was 64 inches (five foot, four inches) tall and weighed 188 lbs. The resident did not have any swallowing disorders. The MDS assessment documented the resident had not had any recent significant weight loss or weight gain or nutritional approaches were documented. The MDS assessment documented Resident #5 was prescribed an anticoagulant, antibiotic, diuretic, opioid and hypoglycemic medication. B. Resident interview and observation Resident #5 was interviewed on 11/4/24 at 4:45 p.m. Resident #5 said she did not like the food that was served most of the time. She said I wish I had soup (cream of potato) every evening. She said she did not like rice. She said she liked potatoes. She said she was not aware of foods that were always available in case she did not like what was served. During the interview, the cook (CK) approached Resident #5 and said the kitchen did not have soup in the kitchen to serve to residents. C. Record review The nutrition care plan, dated 8/8/24 revealed the resident was at risk for weight loss because of poor food intake at meals which was on average 25% to 50%. Interventions included eight oz of house shake once a day (8/28/24) and her food preferences included soups. -Despite the resident's food preferences, she was not served soup (see observation above). Resident #5's weights were documented in the resident's EMR as follows: -On 8/6/24, the resident weighed 188 lbs; -On 8/12/24, the resident weighed 186 lbs; -On 9/4/24, the resident weighed 176 lbs; -On 10/9/24, the resident weighed 170 lbs; and, -On 11/4/24, the resident weighed 164 lbs. -The resident lost 12 lbs (6.4%) from 8/6/24 to 9/4/24, in one month, which was considered severe. -The resident lost 24 lbs (12.8%) from 8/6/24 to 11/4/24, in three months, which was considered severe. A review of the November 2024 CPO revealed the following physician's orders related to nutrition: House shake 8 oz in the morning, one time a day with breakfast for decreased meal intake, ordered on 8/28/24. Spironolactone oral tablet 25 mg (diuretic medication), give 25 milligrams (mg) by mouth in the morning for edema, ordered on 9/5/24. Torsemide oral tablet 20 mg (diuretic medication), give one tablet by mouth two times a day related to unspecified diastolic (congestive) heart failure, ordered on 8/27/24. On 8/8/24, the RD documented the resident was new to the facility. The RD would monitor the resident's weights while she adjusted to the facility. The resident had one plus (1+) edema to her bilateral lower extremities. The resident's weight may fluctuate. The resident's current weight was 188 lbs. The resident was at increased nutritional risk related to COPD, chronic kidney disease, diabetes and gastro esophageal reflux disease (GERD). On 8/27/24 the RD documented, the resident was at increased nutritional risk for weight loss as evidence by poor meal intake. She had recently gained weight related to edema. The RD documented the resident's weights may fluctuate related to diuretic use. The resident was recently started on a house shake eight oz one time a day. The RD documented the resident's recent weight gain was related to edema to her lower extremities. The RD tried to contact the physician several times. The RD documented she would continue to monitor. -However, the resident had lost two lbs from 8/6/24 to 8/12/24. On 9/5/24 the RD documented, the resident had lost weight. The resident had edema and was on diuretics. She was not eating well. The resident was at increased nutritional risk related to COPD, dementia, chronic kidney disease, diabetes and GERD. The resident's meal intake was poor. -However, review of the resident's EMR did not indicate changes in the resident's 1+ edema to her bilateral lower extremities. On 11/5/24 the RD documented, Resident #5 had 1+ edema to her bilateral lower extremities. The resident was on diuretics. She has been losing weight since admission, which could be related to fluid loss. The resident was receiving a house supplement with breakfast. The resident was at risk for weight loss as evidenced by poor intake at meals. The resident was consuming an average of 25% to 50% of her meals. The resident's weight had been trending down related to edema and diuretic use. The resident liked soup. The resident was encouraged to ask for an alternate meal option if she did not like what was being served. The RD documented she would continue to monitor as needed. -A review of Resident #5's EMR did not reveal physician notes related to the resident's nutritional status and weight loss. D. Staff interviews The RD was interviewed on 11/6/24 at 3:45 p.m. The RD said she did not observe Resident #5 eating her meals as she was not in the facility often. She said she participated in the NAR meetings remotely. E. Facility follow-up The facility provided documentation on 11/8/24 indicating Resident #5 was on two diuretics, she was reviewed weekly in the NAR meeting and interventions were in place. -However, review of Resident #5's EMR did not reveal documentation indicating the resident's edema had worsened or improved from 1+ on her bilateral lower extremities and did not include efficient supplementation to improve nutritional status.

Based on observations, record review and interviews, the facility failed to designate a person to serve as the director of food and nutrition services who was a qualified dietitian, certified dietary manager (DM), or a certified food service manager. Specifically, the facility failed to employ a qualified DM or have a full time registered dietitian (RD). Findings include: I. Observations The 11/4/24 at 11:37 a.m. kitchen tour revealed there was no dietary manager (DM) currently employed at the facility. II. Record review -The facility was unable to provide documentation that indicated there was an individual that was employed by the facility that was a qualified dietary manager. II. Staff interviews The nursing home administrator (NHA) was interviewed on 11/4/24 at 12:04 p.m. The NHA said the facility did not have a DM. She said the facility was advertising this open position, however at that moment there were no candidates that had applied for the job. She said the registered dietitian (RD) was on a consultant basis and came to the facility two times a month. The cook (CK) and the dietary aide (DA) were interviewed on 11/4/24 at 1:00 p.m. The CK and the DA said the last DM left more than a month ago and currently the facility did not have a qualified DM. The RD was interviewed on 11/5/24 at 12:00 p.m. The RD said she was not employed full or part time in the facility. She said she was on a consultant basis, coming to the facility two times a month and when needed. She said she helped with food ordering. She said the NHA ordered the food.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure housekeeping staff followed proper infection control procedures for cleaning resident rooms. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 11/7/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. According to the Fabuloso Original Orange with Baking Soda Safety Data Sheet (SDS) (6/14/24), retrieved on 11/19/24 from blob:https://sdsportal.ext.colpal.cloud/d49f16ab-af24-4b78-81f0-3a9cdf800118, Recommended use: all-purpose cleaner for household use. -The SDS did not indicate the cleaning product was approved for disinfection purposes in healthcare settings. II. Facility policy and procedure The Cleaning and Disinfecting of Environmental Surfaces policy and procedure, revised August 2019, was received from the nursing home administrator (NHA) on 11/6/24 at 3:40 p.m. It read in pertinent part, Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled. Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Perform hand hygiene after removing gloves. Floors shall be maintained in a clean, safe, and sanitary manner. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures. Mop heads shall be washed with a disinfectant and rinsed well after each use. Clean mop heads must be applied when changing areas of mopping and when used in isolation rooms. Procedures for the cleaning of mop heads are maintained by the director of housekeeping services. III. Manufacturer's guidelines The manufacturer's guidelines for the Virex II 256 disinfectant used by the facility were retrieved on 11/15/24 from https://1source.diversey.com/see3/PSS064-VirexII256-LTR-env3-HRNC.pdf. It read in pertinent part, Virex II 256 is a one-step, quaternary disinfectant cleaner and deodorant to clean and disinfect hard surfaces. To disinfect, all surfaces must remain wet for 10 minutes. IV. Observations On 11/5/24 from 10:27 a.m. until 10:42 a.m. housekeeper (HSK) #1 and HSK #2 were cleaning the secure unit. The two were working together to sweep and mop the floors of the unit. HSK #1 was sweeping resident rooms and HSK #2 was mopping the rooms. HSK #2 mopped three rooms (rooms #27, #30 and #32), the living room and the dining room with the same mop head and mop water. At 10:42 a.m. HSK #2 exited the secure unit and emptied the mop bucket. -HSK #2 did not change the mop water or the mop head in between cleaning each resident room, the living or the dining room, despite using a non-healthcare approved cleaning product, which was not a disinfectant, in her mop bucket water (see Fabuloso Orange SDS Sheet above and interviews below). On 11/6/24 at 8:31 a.m. HSK #2 was cleaning room [ROOM NUMBER]. HSK #2 put on gloves and entered the resident's room. -HSK #2 did not perform hand hygiene prior to putting on the gloves and beginning cleaning the room. HSK #2 entered the resident's bathroom and sprayed the toilet, grab bars, towel bar, sink and cabinet with Virex II 256 disinfectant. She immediately wiped the grab bars, towel bar, toilet and sink. -HSK #2 did not allow the disinfectant to remain wet on the surfaces in the bathroom for the manufacturer's recommended amount of time (see manufacturer's guidelines above). Using the same rag she used to wipe down the toilet and other surfaces in the bathroom, HSK #2 went into the resident's bedroom and wiped down the resident's two dressers. -HSK #2 did not change her gloves or perform hand hygiene after cleaning the toilet and bathroom before wiping the resident's dressers. -HSK #2 did not change rags after cleaning the toilet and bathroom before wiping the resident's dressers. -HSK #2 did not spray disinfectant on the dressers. At 8:39 a.m. HSK #2 returned to her cart and placed the Virex disinfectant on the cart. She disposed of the first rag and got a new rag. HSK #2 returned to the resident's room and wiped down the overbed table and both nightstands. -HSK #2 did not change her gloves or perform hand hygiene prior to returning to the room to wipe down the overbed table and nightstands. -HSK #2 did not spray disinfectant on the overbed table and nightstands. HSK #2 returned to the cart and removed her gloves and put on new ones before returning to the resident's bathroom to clean the toilet with the toilet brush. -HSK #2 did not perform hand hygiene after removing her gloves prior to returning to the bathroom to clean the toilet. HSK #2 put Fabuloso Original Orange with Baking Soda in the toilet and cleaned the toilet. She returned the toilet brush to the cart and got a rag then went back to the resident's bathroom and wiped down the outside of the toilet. -HSK #2 did not change her gloves or perform hand hygiene prior to returning to the bathroom and wiping down the outside of the toilet. -HSK #2 did not clean the toilet bowl with a disinfectant or spray disinfectant on the outside of the toilet. At 8:45 a.m. HSK #2 went back to the cart, removed her gloves and used hand sanitizer. She put on new gloves and went back to the resident's room and picked up the floor and removed the trash. She placed a water bottle that was sitting on the floor on the dresser she had previously cleaned. -HSK #2 did not disinfect the bottom of the water bottle prior to placing it on the dresser. At 8:49 a.m. HSK #2 swept the bathroom floor into the resident's room and continued sweeping the pile to the doorway of the resident's room where she swept it into the debris container. At 8:54 a.m. HSK #2 went to room [ROOM NUMBER], a double occupancy room, where HSK #1 had been cleaning. HSK #2 began mopping the floor in room [ROOM NUMBER]. She mopped one side of the room and most of the other side of the room before returning to the cart to change mop pads. -HSK did not change mop pads in between cleaning each side of the residents' room. HSK #2 mopped the remaining portion of room [ROOM NUMBER] and returned to the cart. HSK #2 changed her gloves and used hand sanitizer before returning to room [ROOM NUMBER]. At 8:55 a.m. HSK #2 got a new mop pad and began mopping the bathroom floor in room [ROOM NUMBER]. She continued mopping half of the resident's room then returned to the cart and replaced the mop pad before mopping the other half of the resident's room. -HSK #2 did not change mop pads after mopping the bathroom floor before mopping the first half of the resident's room. At 8:59 a.m. HSK #2 knocked the resident's oxygen nasal cannula off of the bed and onto the floor. She picked up the nasal cannula, placed it back on the resident's bed and continued to mop the floor where the nasal cannula had fallen. -HSK #2 did not sanitize the resident's oxygen nasal cannula prior to putting it back on the resident's bed. HSK #2 completed cleaning the room at 9:00 a.m. V. Staff interviews HSK #2 was interviewed on 11/5/24 at 10:39 a.m. HSK #2 said she began working for the facility as a housekeeper three days ago (11/2/24). She said HSK #1 trained her. HSK #2 said she used Fabuloso Original Orange with Baking Soda in the mop water. HSK #1 was interviewed on 11/6/24 at 8:30 a.m. HSK #1 said she had been in the position of housekeeper for one month. She said she used Virex II 256 disinfectant in the wet rag bucket, Virex II 256 disinfectant spray in the spray bottles and Fabuloso Original Orange with Baking Soda in the mop water. She said no one trained her on how to clean the facility when she started, so she just did her own thing when cleaning. The NHA was interviewed on 11/6/24 at 9:39 a.m. The NHA said the previous housekeeper quit without notice over a month ago and HSK #1 took over the housekeeping position to help out. She said housekeepers should change mop pads between the bathroom and different resident areas of the residents' rooms. She said cleaning rags should be changed between the same areas to prevent the spread of germs which could increase infections in the facility. The NHA said there was no reason for the housekeepers to use an unapproved residential cleaning agent such as Fabuloso Original Orange with Baking Soda because the facility had the appropriate healthcare-approved cleaning/disinfecting products available for use. The clinical nurse consultant (CNC) was interviewed on 11/6/24 at 3:06 p.m. The CNC said it was important to follow specific instructions when cleaning residents' rooms so as not to spread germs or infections. She said it was not appropriate to use a rag that was used to clean a residents' bathroom to clean any other areas in the residents' rooms, such as the dresser.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerator. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 11/6/24 at 3:40 p.m. It read in pertinent part, Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. II. Observations On 11/5/24 at 11:09 a.m., the medication refrigerator was observed with licensed practical nurse (LPN) #1. Two vials of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) were in a plastic container on the shelf. -The Ativan was not in a permanently affixed locked compartment inside of the refrigerator. III. Staff interviews LPN #1 was interviewed on 11/5/24 at 11:09 p.m. LPN #1 said the plastic container on the shelf in the refrigerator contained two vials of liquid Ativan two milligrams (mg), which was provided by the pharmacy for emergency use. She said anyone with access to the refrigerator could just take the Ativan out of the refrigerator because it was not locked in a separate compartment. The clinical nurse consultant (CNC) was interviewed on 11/6/24 at 3:11 p.m. The CNC said controlled medications should always be kept in secure compartments and double-locked. She said when controlled medications were not secured they could be taken by unauthorized persons. The director of nursing (DON) was interviewed on 11/6/24 at 3:15 p.m. The DON said she was not aware that the controlled medications should be in a permanently affixed locked container inside the refrigerator. She said she would speak with her maintenance supervisor and make sure it was fixed as soon as possible.

Based on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for three (#1, #2 and #3) of six residents reviewed for abuse out of six sample residents. Resident #1, who had a diagnosis of Alzheimer's disease and a tendency to wander, had a plan of care which documented the resident had impaired safety awareness and wandered aimlessly. The interventions were to offer Resident #1 pleasant diversions, structured activities, food, conversation, television and card games. On 2/28/24 Resident #1 wandered into Resident #2's room. Resident #2 told Resident #1 he was in the wrong room and told him to leave. Resident #1 refused to leave the room which caused Resident #2 to push Resident #1 to the floor. A staff member, who was informed that Resident #1 went to the wrong room, rushed to the room but she was unable to open the door. Resident #1 was on the floor in front of the door and was moaning in pain. The staff member eventually opened the door. Resident #1 and Resident #2's roommate informed the staff member that Resident #2 pushed Resident #1. Resident #1 was sent to the hospital and was diagnosed with a fracture to his right femoral neck (the thigh bone below the hip joint). Resident #1 was admitted to the hospital and required surgical repair to heal the fracture. On 3/8/24 Resident #1 readmitted to the facility. The resident was placed on 15-minute checks for supervision related to Resident #1 being non-weight bearing when he returned to the facility. On 7/9/24 Resident #1, who remained on 15-minute safety checks, went into Resident #3's room. Resident #3 and his roommate asked Resident #1 to leave the room. Resident #1 refused and Resident #3 attempted to push Resident #1's wheelchair out of the room. Resident #1 hit Resident #3 in the face and pulled Resident #3's hair. A staff member intervened and removed Resident #1 from the room after the altercation occurred. Due to the facility's failure to prevent Resident #1 from wandering into another resident's room, Resident #1 was involved in a resident to resident altercation with Resident #2, which resulted in Resident #1 sustaining a right hip fracture and being sent to the hospital for surgical repair of his hip. Additionally, after the resident to resident altercation with Resident #2, the facility again failed to implement person-centered interventions to prevent Resident #1 from wandering into other resident's rooms, which resulted in a resident to resident altercation between Resident #1 and Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 3:00 p.m. It read in pertinent part, Residents have the right to be free from abuse. The resident abuse prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: -Identify and investigate all possible incident of abuse; -Investigate and report any allegations within timeframes required by federal requirements; -Protect residents from any further harm during investigations; -Establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse; and, -Involved the resident council in monitoring and evaluating the facility's abuse prevention program. The Abuse and Neglect Clinical protocol, revised March 2018, was provided by the NHA on 8/6/24 at 3:00 p.m. It read in pertinent part, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will order measures required to address the consequence of an abuse situation. The physician and staff will address appropriately causes of problematic resident behavior where possible. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. The medical director will advise facility management and staff about ways to ensure that basic medical, functional and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process. II. Incident of physical abuse between Resident #1 and Resident #2 on 2/28/24 The facility abuse investigation documented that on 2/28/24 at 7:08 p.m. a resident informed the nurse that Resident #1 wandered into Resident #2's room. Resident #2 and his roommate asked Resident #1 to leave the room. Resident #1 refused to leave the room. Resident #2 got out of his recliner, walked over to Resident #1 and pushed Resident #1 to the floor. When staff arrived to the room, Resident #1 was on the floor in front of the room door moaning in pain. Resident #2 said Resident #1 fell . Resident #2's roommate and Resident #1 motioned that Resident #2 pushed Resident #1. The summary of the incident documented Resident #1 had a history of wandering and wandered into Resident #2's room and refused to leave. Resident #1 was sent to the hospital via an emergency ambulance. Resident #1 sustained a right femur fracture and required surgery to repair the injury. Upon Resident #1's return to the facility on [DATE], 15-minute safety checks were implemented for Resident #1. The facility substantiated the incident. III. Incident of physical abuse between Resident #1 and Resident #3 on 7/9/24 The 7/29/24 facility abuse investigation documented Resident #1 ambulated via his wheelchair into Resident #3's room. Resident #3 and his roommate told Resident #1 he was in the wrong room, but Resident #1 refused to leave. Resident #3 attempted to push Resident #1's wheelchair backwards out the door. Resident #1 swung at Resident #3 with his hands and hit Resident #3 in the face. Resident #1 then pulled Resident #3's hair. Resident #3 yelled out and staff entered Resident #3's room. Resident #1 was sitting in his wheelchair with his head down and Resident #3 was standing next to Resident #1. Both residents were assessed and no injuries were noted. Resident #1 did not answer questions about the incident. Resident #3 and his roommate were interviewed on 7/29/24 and said Resident #1 wandered into their room and refused to leave. Resident #3 and his roommate said Resident #1 hit Resident #3 and pulled Resident #3's hair before staff entered the room. The investigation documented the previous interventions included Resident #1 was on 15-minute safety checks. The investigation documented no new recommendations or interventions were implemented. -The facility failed to implement a new effective person-centered intervention to prevent Resident #1 from wandering into other resident's rooms in order to prevent an additional resident to resident altercation. The facility did not substantiate this allegation because it was not identified as abuse. -However, physical abuse occurred due to Resident #1 willfully hitting and pulling Resident #3's hair. IV. Observations During a continuous observation on 8/7/24, beginning at 10:50 a.m. and ending at 11:15 a.m. The following was observed: At 10:50 a.m., Resident #1 was laying on his bed with his head under a blanket. At 10:52 a.m., licensed practical nurse (LPN) #1 walked down one of the two hallways and completed 15-minute checks on other residents. LPN #1 failed to go down the hallway where Resident #1's room was located to complete a 15-minute check for the resident. At 11:00 a.m., Resident #1 was laying on his bed with his head under a blanket. At 11:05 a.m. LPN #1 assisted a resident and passed by Resident #1's room but did not look in Resident #1's room. At 11:15 a.m., Resident #1 was laying on his bed with his head under a blanket. Staff did not complete a 15-minute check. -The facility failed to complete a 15-minute check on Resident #1 from 10:50 a.m. to 11:15 a.m. V. Resident #1 A. Resident status Resident #1, age 89, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnosis included Alzheimer's disease. The 6/19/24 minimum data set (MDS) assessment revealed Resident #1 was unable to complete a brief interview for mental status (BIMS). A staff assessment for mental status revealed the resident was rarely understood, had moderate cognitive impairments, and was unable to identify the current season, the location of his room and staff names or faces. B. Resident #1's representative interview Resident #1's representative was interviewed on 8/7/24 at 11:58 a.m. The resident's representative said he understood the facility was not able to provide one on one attention to each resident but he felt Resident #1 needed a little more supervision. He said Resident #1 worked his entire life and did not like to sit still. The resident's representative said Resident #1 needed fulfilling activities such as being helpful instead of arts, crafts or games. The resident's representative said when he visited Resident #1 he took the resident outside on walks and it helped with limiting the resident from attempting to self-transfer. The resident's representative said he felt the supervision the facility provided for the resident could have been better. He said he was not sure what the facility did for Resident #1 when he was not at the facility visiting regarding care, activities and supervision. The resident's representative said he did not see staff complete 15- minute checks when he visited the facility. He said he felt Resident #1 did not get enough activities that he enjoyed or to keep him busy. C. Record review The elopement care plan, revised 2/5/24, revealed Resident #1 was an elopement risk and wandered. The intervention included Resident #1 had a wander guard for safety. -The facility failed to update Resident #1's care plan to include an intervention to keep Resident #1 from wandering into other residents' rooms after the resident to resident altercations on 2/28/24 and 7/29/24. The behavior care plan, revised 7/25/24, revealed the resident had behavioral issues that were due to his diagnosis of dementia, aggression and exit seeking behaviors. Interventions included the following: administering medications as ordered (7/26/21), anticipating and meeting the resident's needs (7/26/24), being aware of the resident's triggers and which of his behaviors triggered other residents (5/9/22), providing the opportunity for positive interactions and attention (8/18/22), explaining all procedures to the resident before starting cares and allowing him a few minutes to adjust to changes (7/26/21), intervening as necessary to protect the rights and safety of others (7/26/21), monitoring behavior episodes and attempting to determine an underlying cause (7/26/21) and providing an activities program that was of interest and accommodated the resident's status. -However, the facility failed to implement new interventions following the resident to resident altercations on 2/28/24 and 7/9/24. The care plan last had new interventions implemented on 6/18/22. The intervention documented on 7/25/24 had was already been implemented on 6/18/22. The 2/28/24 progress note documented the NHA was notified of an incident and arrived at the facility to start an investigation. The 2/29/24 progress note documented the staff were directed to a resident's room that Resident #1 had entered. Resident #1 was on the floor in front of the room door and was yelling out in pain. The staff opened the door and Resident #2's roommate pointed at Resident #2 and motioned that the resident pushed Resident #1. Resident #1 said Resident #2 pushed him to the floor. Resident #2 denied pushing Resident #1. The staff called 911 and Resident #1 was transferred to the emergency room for medical treatment. The 2/29/24 progress note documented the hospital notified the facility that Resident #1 had fractured his right hip and the resident was being admitted to the hospital. The 3/8/24 progress note documented the resident was admitted back to the facility. VI. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged to a hospital on 4/14/24. According to the April 2024 CPO, diagnoses included heart failure and dementia. The 4/15/24 MDS assessment documented, based on staff assessment, the resident had a memory problem, experienced inattention and disorganized thinking. The assessment documented Resident #2 had physical behaviors directed towards others and verbal behaviors directed at others. B. Record review Resident #2's cognitive care plan, revised 3/5/24, revealed he was at risk for impaired thought process due to dementia. Interventions included asking yes or no questions to determine the resident's needs, communicating with the resident and his family regarding his capabilities and needs and monitoring for changes in his cognitive function. Resident #2's behavioral care plan, revised 3/5/24, revealed the resident displayed conflictual and difficult behaviors with other residents due to adjusting to his living situation and his diagnosis of dementia. Interventions included intervening when the resident demonstrated inappropriate behaviors, helping the resident identify his stressors which led to behaviors and referring to counseling as needed. -The facility failed to update Resident #2's care plan after the resident to resident incident occurred on 2/28/24 and failed to inform staff the resident had a problem with other residents wandering into his room. A review of Resident #2's electronic medical record (EMR) did not reveal documentation regarding the resident to resident altercation with Resident #1 on 2/28/24. VII. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included Huntington's disease (neurological disorder that causes nerve cells in the brain to break down), muscle weakness and abnormalities of gait and mobility. According to the 7/18/24 MDS assessment, Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record review Resident #3's communication care plan, revised 7/12/19, documented he had a communication problem due to Huntington's disease and was slow to find his words. Interventions included anticipating and meeting the resident's needs, being conscious of the resident's position when in groups to promote proper communication with others, discussing the resident's concerns or feelings regarding his communication difficulty and validating Resident #3's message by repeating what he said out loud. Resident #3's cognitive care plan, revised 7/12/19, documented he had an impaired thought process due to Huntington's disease. Interventions included administering medications as ordered, asking yes or no questions in order to determine the resident's needs and presenting just one thought at a time. Resident #3's neurological care plan, revised 7/16/19, documented he had an alteration in his neurological status due to Huntington's disease. Interventions included completing assessments for side effects of psychotropic medications, cueing and reorienting the resident as needed, giving medications as ordered and obtaining and monitoring lab or diagnostic work as ordered. -A review of Resident #3's EMR did not reveal documentation regarding the resident to resident altercation with Resident #1 on 7/9/24. VIII. Staff interviews The NHA was interviewed on 8/7/24 at 10:00 a.m. The NHA said Resident #1 constantly wandered. She said Resident #1 wandered into the storage closet in the NHA's office when Resident #1 had to use the restroom. The NHA said she wondered if Resident #1 wandered into other rooms when he needed to use the restroom. The NHA said Resident #1 was placed on 15-minute checks when he returned from the hospital on 3/8/24. She said the facility felt 15-minute checks were a good intervention for Resident #1's wandering and because he was a high fall risk because it provided increased rounding and supervision for the resident. The activity director (AD) was interviewed on 8/7/24 at 1:43 p.m. The AD said she updated the activity calendar for each month and scheduled four to five group activities each day. She said she updated the activity care plans but she was pretty far behind. The AD said she reviewed the residents' diagnoses and cognitive levels to determine if a resident was independent or dependent upon staff of activities. The AD said Resident #1 was dependent upon staff to meet his emotional, intellectual, physical and social needs. The AD said she had not updated Resident #1's care plan. The AD said she was not aware Resident #1 enjoyed working. She said she planned to update his preferred activities to job-like activities. She said Resident #1 enjoyed participating in the ball toss groups but other activities did not interest him. The director of nursing (DON) and the NHA were interviewed together on 8/7/24 at 1:59 p.m. The DON said if a resident sustained several falls the facility implemented 15-minute safety checks. The DON said Resident #1 was a high fall risk and wandered which was why he was placed on an enhanced supervision level. The DON said the nurses and the CNAs completed the 15-minute checks. She said all of the staff were aware of the supervision levels for each resident and which residents were on 15-minute safety checks. The DON said the staff included Resident #1 in as many activities as possible and Resident #1 enjoyed walking. She said the staff were told if Resident #1 started walking then staff needed to follow behind him with his wheelchair. The DON said she was not aware Resident #1's care plan was not updated. The NHA said Resident #1 understood English but preferred speaking Spanish. The NHA said the facility had quite a few staff members who were fluent in Spanish and it helped when communicating with Resident #1. She said Resident #1 did not respond well to female staff whether the female staff spoke Spanish or not. She said Resident #1 usually only spoke to male staff who spoke Spanish. The NHA said she was not aware the staff who did not speak Spanish did not attempt to communicate with Resident #1 at all and just asked the male staff to translate for them. She said all staff needed to attempt to communicate with the resident. The NHA said she did not think to add the resident's preferred communication and staff to the resident's care plan. The DON said she was not aware the staff signed off on the 15-minute checks without looking at the residents each time. The NHA said she was not aware the staff signed off on the15-minute checks without looking at the residents each time.

Based on observations, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 25 sample residents. Resident #11 was at nutritional risk with diagnoses of gastroesophageal reflux disease, muscle weakness and dementia. The registered dietitian (RD) implemented measures for the resident's nutrition risk and weight. Observations during the survey revealed the resident was not provided finger foods or fortified foods at meals, a brightly colored plate and alternatives offered when Resident #11's intake was poor. The facility failed to implement nutritional recommendations at mealtimes. Furthermore, the nutritional recommendations were for the interdisciplinary (IDT) team to follow up with the physician regarding her weight loss on multiple occasions and a reweight when Resident #11 lost weight and those recommendations were not followed up on. Due to the facility's failure to implement the nutritional recommendations, Resident #11 sustained a weight loss of eight pounds between 11/3/23 and 11/17/23, 6.8% which was considered significant weight loss. In addition, the resident continued to lose weight in total of 14 pounds in two months, 11.9% which was considered significant weight loss. Findings include: I. Facility policies The Weight Assessment and Intervention policy, revised March 2022, was provided by the nursing home administrator (NHA) on 2/8/24 at 8:57 a.m. It documented in pertinent part, Any weight change of 5% or more since the last weight assessed is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The Nutrition/unplanned Weight Loss policy, revised September 2017, was provided by the NHA on 2/8/24 at 8:57 a.m. It documented in pertinent part, The staff will report to the physician significant weight losses or any abrupt or persistent change from baseline appetite or food. The physician will review medical causes of anorexia and weight loss before ordering interventions. The staff and physician will identify pertinent interventions based on identified causes and resident conditions. The physician and staff will monitor nutritional status and response to interventions. II. Resident #11 A. Resident status Resident #11, age 89, was admitted on [DATE]. According to the February 2024 computerized physician orders, diagnoses included glaucoma (eyesight problem), gastro-esophageal reflux disease (backflow of stomach acid into to the esophagus), muscle weakness, vascular dementia (impaired blood flow to brain causing problems with memory, reasoning, judgment and planning) and psychotic and mood disturbances. The minimum data set (MDS) from 1/10/24 documented Resident #11 was rarely/never understood. The MDS showed the resident required substantial/maximal assistance with activities of daily living (ADLs), which included eating, dressing, toileting and mobility. The resident was 68 inches tall (five foot eight inches) and weighed 108 pounds. B. Observation Resident #11 was observed continuously on 2/5/24 from 4:40 p.m. to 6:30 p.m. The observations were as follows: -At 4:55 p.m. the resident was assisted to the dining room table. -At 5:30 p.m. the resident received her meal. The food was served on white plates and not on bright colored plates (see care plan below). The meal consisted of a vegetable soup, cottage cheese with fruit and dessert. There was no supplement or cranberry juice served with the meal. There were no finger foods or fortified foods that she was supposed to be served (see record review below). -At 5:40 p.m. an unidentified certified nurse aide (CNA) assisted the resident with her meal. She took two bites of her dinner. She then took two bites of her dessert. -There were no other food choices offered to the resident for having eaten less than 50% of her meal. Resident #11 was observed continuously on 2/6/24 from 11:30 a.m. to 1:15 p.m. The observations were as follows: -At 12:24 p.m. the resident received her meal. The food was served on white plates and there was no cranberry juice served with the meal. The meal consisted of mashed potatoes, broccoli, a pork chop and slice of cake. There were no finger foods or fortified foods served to her. -At 12:30 p.m. an unidentified CNA assisted Resident #11 with her eating her meal. -The resident ate one bite of food and pushed the plate away from her. -There was no other food offered to this resident. -The interventions from the care plan were not followed based on these observations (see below). B. Facility assessment of resident's nutritional status on admission The care plan, updated on 11/21/23, identified that this resident had a nutritional problem related to dementia. Pertinent interventions included encouraging the resident to have snacks in the dining room, provide fortified foods, drinks and desserts, bright colored plates used to encourage intake and cranberry juice served at meals. The RD assessed this resident on 12/20/24. She assessed the resident's weight was trending downwards. She documented the resident's low intake of meals at 55%. C. Resident's weight record Resident #11's weight record showed the resident lost eight pounds which occurred between 11/3/23 and 11/17/23, 6.8% which was considered significant. The resident's weight on 11/3/23 was 118 pounds and the weight recorded on 11/17/23 was 110 pounds. The wheelchair scale was used in each weight. -There was no reweigh documented for confirmation of a loss the following day (as indicated by the RD assessment). The next weight entered was 108 pounds on 11/30/23. The resident's current weight was 104 pounds on 1/30/24. The resident lost 14 pounds over a two month period, 11.9% which was considered sginficant weight loss. D. Registered dietitian recommendations The registered dietitian (RD) recommended the resident was offered fortified foods and desserts, offered a supplement twice daily, had meals served on brightly colored plates, had meal assistance from nursing staff, was offered a sweet snack between meals (ice cream, cookies), was offered cranberry juice at meals and was brought out of her room for snacks and activities. This RD note was documented on 11/17/23. The progress note from nutrition/dietary services dated 11/17/23 documented this resident had a 12 pound weight loss in two weeks and meal intake was low at 52%. A reweigh was requested. The nursing team was going to discuss it with the physician. The nursing team was to continue with the recommendations (see above) from the RD. -However, the reweigh was not documented. -There was no documentation that the nursing staff had this discussion with the physician in the medical record. The nutrition/dietary services progress note dated on 12/15/23 showed nursing staff was to inform the physician of additional weight loss and to discuss appetite-stimulating medications. The nutrition/dietary services progress note on 12/22/23 documented nursing staff was to follow up with the physician on appetite stimulants. The nutrition/dietary services progress note on 1/5/24 documented the nursing staff was to discuss the resident with the physician. -There was no documentation in the medical record the nursing staff had discussions with the physician. III. Staff interviews The cook was interviewed on 2/6/24 at 12:30 p.m. The cook said that the tray line did not have any food which contained fortified food (powder protein). -An observation of the puree vegetable during the interview revealed there was no protein added to the pureed vegetables when they were supposed to be fortified. The dietary manager (DM) was interviewed on 2/6/24 at 12:40 p.m. The DM said the whey protein powder was added to the resident's meal (who consumed fortified foods) after the meal was served. The corporate registered dietitian (CRD) was interviewed on 2/8/24 at 9:50 a.m. She said residents with weight loss were reviewed weekly in nutrition risk meetings by a registered dietitian (RD). She said the RD was onsite typically for one day each month. She said she did not know Resident #11's nutrition plan of care. The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said there was an offsite dietitian who completed the weekly nutrition assessment report (NAR) for at-risk residents. She said it was the dietary manager's responsibility to follow up and ensure the fortified foods were in place for the appropriate residents. She said every resident should always be offered an alternative to their meal if they ate less than 50%. She said nurses were to enter progress notes of when and what they have communicated with physicians about.

Based on observations, interviews and record review, the facility failed to ensure five (#3, #13, #20, #10 and #9) of six residents reviewed for activities of daily living (ADLs) out of 25 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Residents #33, #13, #20, #10 and #9, who were dependent on staff for bathing care, were provided bathing consistently with their plan of care. Findings include: I. Resident #3 A. Resident status Resident #3, under age 65, was admitted on [DATE]. According to the February 2024 computerized orders (CPO), diagnoses included chronic pain, hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) that affected her left side. The 11/4/23 minimum data (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required total assistance of two with activities of daily living which included showers. She had no behaviors or refusal of care. B. Resident interview Resident #3 was interviewed on 2/8/24 at 9:00 a.m. Resident #3 said she wanted to receive two showers each week, however, she received only one a week and sometimes less than that. She said her family had never showered her (as indicated by the record, see below). C. Record review The care plan, initiated 8/14/23, identified the resident had an ADL self-care performance deficit related to activity intolerance, impaired balance, and chronic pain. Pertinent interventions included the resident required extensive assistance for bathing/showering and was to receive two showers/baths a week and as needed. The bathing record from 1/9/24 to 2/5/24 showed the resident received only two showers out of eight opportunities. The shower record showed the activity of bathing did not occur or family and/or non-licensed facility staff provided care 100% of the time for the missed opportunities. II. Resident #13 A. Resident status Resident #13, over age 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included muscle weakness, lack of coordination and unspecified abnormalities of gait (walking) and mobility. The 1/2/24 MDS assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required substantial/maximal assistance with bathing and showering. She had no behaviors or refusal of care. B. Resident interview Resident #13 was interviewed on 2/6/24 at 1:35 p.m. She said she had showers scheduled twice weekly in the morning. She said she was not offered showers that frequently. She said she preferred to take showers in the morning when she was not tired. Instead, the nursing staff only offered showers to her late afternoon or during the evening. The resident said her family had never showered her in this facility (as indicated by the record, see below). C. Record review The bathing record from 1/9/23 to 2/5/24 showed the resident received only one shower out of eight opportunities. The shower record showed the activity itself did not occur or family and/or non-licensed facility staff provided care 100% of the time for the missed opportunities. 20287 III. Resident #20 A. Resident status Resident #20, age 76, was admitted on [DATE]. According to the February 2024 CPO diagnoses included chronic pulmonary embolism and chronic obstructive pulmonary disease. The 12/5/23 MDS assessment documented the resident had moderate cognitive impairment with a score of nine out of 15. The MDS coded the resident as requiring partial to moderate assistance with activities of daily living which included bathing. She had no behaviors. B. Resident interview The resident was interviewed on 2/5/24 at 3:00 p.m. The resident said there was not enough staff and she did not receive her showers as scheduled. She said she would prefer to have three showers a week. The resident's palms of her hands had dark substance on them, from wheeling her wheelchair. C. Record review The care plan, updated on 10/26/23, identified the resident had activities of daily living (ADL) self care performance related to dementia, confusion. Pertinent interventions included the resident required a one person assist with bathing/showering two times a week and as necessary. The bathing record from 1/9/24 to 2/5/24 showed the resident received only three showers out of eight opportunities. 50314 IV. Resident #10 A. Resident status Resident #10, age 95, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), anxiety and generalized muscle weakness. The 2/1/24 minimum data set (MDS) assessment revealed the resident had no noted cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavior symptoms were noted. She required assistance for transfers, personal hygiene and toilet use, medications, and had no rejection of care. She was rarely incontinent of bowel or bladder. B. Resident interview Resident #10 was interviewed on 2/6/24 at 10:51 a.m. Resident #10 said she would like to have three showers per week, but would consider two showers per week acceptable. Resident #10 said she personally informed the nursing home administrator (NHA) that on one occasion she was not bathed for three weeks. Resident #10 recounts that it took another week after that conversation to receive a shower. C. Record review The care plan dated 11/18/23 identified the resident was to receive one person assistance with showers. The bathing record from 1/9/24 to 2/5/24 showed the resident received only two showers out of 17 opportunities. V. Resident #9 A. Resident status Resident # 9, over the age of 65, was admitted on [DATE]. According to the Februray 2024 CPO, diagnoses included myasthenia gravis (chronic autoimmune disorder), heart disease, osteoarthritis, osteoporosis and generalized muscle weakness. The 12/16/22 minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She had no behaviors. She required assistance for transfers, and personal hygiene. B. Resident interview Resident #9 was interviewed on 2/5/24 at 4:10 p.m. Resident #9 said she was not getting regular showers. Resident #9 said she would like to be bathed three times per week, however would receive one bath per week. Resident #9 explained one time that staff was so short on one busy bath day, she told staff not to worry about her bath so someone else who needed it more could get it. Resident #9 explained she felt forgotten and unimportant when the promised twice a week showers did not happen. C. Record review The bathing record from 1/9/24 to 2/5/24 showed the resident received only four showers out of 19 opportunities. The care plan, dated 12/11/23, identified the resident was to receive one person assistance with showers, or a sponge bath if the resident cannot tolerate a shower. VI. Staff interviews A staff member who wished to stay anonymous was interviewed on 2/6/24.The staff member said showers were not provided to residents as there was not enough staff. Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 9:51 a.m. LPN #2 said regular care, such as showers and wound care for residents were not being done consistently. A staff member who wished to stay anonymous was interviewed on 2/7/24. The staff member said they had to skip showers because there was not enough staff. A staff member who wished to stay anonymous was interviewed on 2/8/24. The staff member said there was not enough staff to assist residents with showers. The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said residents were scheduled to receive showers two times a week, unless otherwise requested. She said the nursing staff used shower sheets that documented showers were completed. -When the shower sheets were requested for Residents #3, #13, #20, #10 and #9, the DON did not provide the documentation by the exit of the survey on 2/9/24.

Based on interviews, observations and record review, the facility failed to ensure three (#25, #3 and #10) of three out of 25 sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure oxygen concentrators had distilled water to humidify the oxygen concentrators for Resident #25, #3 and #10. Findings include: I. Professional reference According to the [NAME] Advantage for Basic Nursing handbook, third edition, retrieved from Treas, [NAME] S., et al. [NAME] Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. [NAME] Company, 2022., Key concepts of administering oxygen included, in relevant part, Attach the flow meter to the oxygen source. Attach the humidifier to the flow meter. The humidifier is a small plastic container containing normal saline. The humidifier adds moisture in with the oxygen, which can dry the nasal or oral cavity. II. Facility policy and procedure The Oxygen Administration policy and procedure, dated October 2010, was provided by the corporate nurse consultant (CNC) on 2/8/24 at 8:57 a.m., read in pertinent part, Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check water level in the humidification jar. Documentation includes how the resident tolerated the procedure. III. Resident #25 status Resident #25, age 92, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included COVID-19, weight loss, mild dementia, hypertension (high blood pressure), and anxiety. The 2/2/24 minimum data set (MDS) assessment documented that the resident was cognitively intact with no short-term or long-term memory impairment. A. Observation On 2/6/24 at 4:00 p.m., Resident #25 was observed sitting on her bed in her room receiving oxygen therapy. The oxygen concentrator indicated that the resident was receiving oxygen at 3 liters per minute (LPM) by nasal cannula. The concentrator had a jar connected to it for distilled water, which was empty. B. Record review The February 2024 CPO documented: -Oxygen by nasal cannula at 3 LPM continuously - ordered 1/22/24. A review of the resident's medical record did not indicate that a comprehensive care plan had been developed for the resident's use of oxygen therapy. IV. Resident #3 status Resident #3, under the age of 65, was admitted on [DATE]. According to the February 2024 CPOs, diagnoses included chronic pain, hemiplegia (paralysis to one side of the body), and hemiparesis (weakness to one side of the body) following a cerebral infarction (stroke) that affected her left side. The 11/2/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required total assistance of two people with all activities of daily living. A. Resident interview and observation Resident #3 was interviewed on 2/8/24 at 8:45 a.m. The resident said her nose felt dry and was hurting. She said the jar on her oxygen concentrator had been empty for a couple of days. Resident #3 had a nasal cannula in her nose and her oxygen concentrator was set to 2 LPM The oxygen concentrator had a jar for distilled water connected to it, however the jar was empty. B. Record review According to the February 2024 CPO, the resident's oxygen saturation was to be kept greater than 90% - ordered on 8/4/23. A review of Resident #3's medical record did not reveal documentation that a comprehensive care plan had been developed for the resident's use of oxygen therapy. V. Resident #10 status Resident #10, older than 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, obstructive sleep apnea (OSA), generalized muscle weakness, and hypertension (high blood pressure). The 2/1/24 MDS assessment revealed the resident did not have cognitive impairment with a brief interview for mental status score of 15 out of 15. She required one person assistance for transfers, personal hygiene and toileting. It indicated that the resident required continuous oxygen. A. Resident interview Resident #10 was interviewed on 2/6/24 at 10:51 a.m. Resident #10 said that her oxygen concentrator was always out of water. She said that her oxygen concentrator had been empty for a week or longer. B. Observations On 2/6/24 at 10:51 a.m., 2/7/24 at 2:58 p.m. and 2/8/24 at 8:12 a.m., Resident #10's oxygen concentrator was empty of distilled water. C. Record review The February 2024 medication administration record (MAR) documented that the resident required oxygen via nasal cannula at 3 LPM related to her diagnosis of COPD - ordered on 11/23/2018. VI. Staff interviews The director of nursing (DON) was interviewed on 2/6/24 at 4:30 p.m. She said the nurses and certified nursing aides (CNA) were responsible for refilling the jars with distilled water for the oxygen concentrators. She observed the empty jar in Resident #25s room. She took the empty jar to the nurse's station, refilled the jar with distilled water and then reattached it to the oxygen concentrator. She said the facility did not have a process in place to ensure oxygen concentrator jars remained full of distilled water. She said the facility had eight gallons of distilled water, which was kept at the nurse's station. She said all residents wearing oxygen received humidification through the oxygen concentrators. The DON said there was an empty jar of distilled water on Resident #3's oxygen concentrator. She refilled the jar and connected it to the concentrator. CNA #6 was interviewed on 2/7/24 at 3:55 p.m. She said that CNAs or nurses were able to refill oxygen concentrators. CNA #6 said the supply room had several bottles of unopened distilled water intended for oxygen humidification containers. She said she did not know whose responsibility it was to ensure the oxygen concentrators had distilled water. The DON was interviewed on 2/8/24 at 9:00 a.m. She acknolwedged the empty jar of distilled water on Resident #3's oxygen concentrator. She refilled the jar and connected it to the concentrator.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference citations: -F677 activities of daily living for dependent residents; and, -F689 accident hazards. Findings include: I. Resident care needs The facility census was 38 residents. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 10:30 a.m. LPN #2 said there were two residents who required a two person transfer using a mechanical Hoyer lift. She said there were five residents who required extensive assistance with eating. She said out of the 38 residents there were only five residents who required minimal assistance with activities of daily living. She said all 38 residents required supervision and assistance with showering. II. Staffing requirements for each station (east and west) The director of nurses (DON) was interviewed on 2/8/24 at 11:19 a.m. The DON said the facility had 38 residents. She said the staffing structure was two licensed nurses on the day shift and four certified nurse aides (CNAs) on the day shift. She said an extreme low would be three CNAs. Evening shift typically had two licensed nurses one of which was an registered nurse (RN) and three CNAs for the evening shift. The night shift one licensed nurse and one CNA. III. Resident council minutes The 11/21/23 resident council meeting documented the residents had concerns in regards to call lights taking too long to be answered and showers not being completed timely. IV. Resident interviews Resident #8 was interviewed on 2/5/24 at 3:00 p.m. Resident #8 said the facility did not have enough staff. He said he had to wait a long period of time for assistance. V. Resident group interview A resident group interview was conducted on 2/7/24 at 9:30 a.m. with six alert and oriented residents (#9, #10, #17, #20, #21 and #22). All residents in the group interview said there was not enough nursing staff. Some of the comments were as follows: -Showers, making beds, brushing teeth and washing their faces got skipped because there was not enough staff. -Answering call lights took 25 minutes and longer. -There were typically two CNAs during the day, two during the evening and one at night during the week, which was not enough to take care of them. -There were typically two nurses during the day, one during the evening and one at night during the week, which was not enough to take care of them. -Weekends had even less staff than listed above. -When they brought this concern to the administration, they were told there was a shortage of staff everywhere. -There was traveling nursing staff used in the past however, it was not used any longer. -Some of the residents have resorted to checking on one another when they have noticed call lights were on. VI. Observations On 2/7/24 at 8:15 a.m. there was a certified nurse aide (CNA) and the restorative aide working the floor for 38 residents. At 8:35 a.m., there was only one CNA assisting five residents with their meals. The DON was working the mediation cart. On 2/8/24 at 8:05 a.m. three CNAs and one RN were scheduled. The DON was working the medication cart. At 4:00 p.m. the DON was working the medication cart. She said she had a nurse on vacation and therefore had to work the medication cart. On 2/9/24 at 8:00 a.m., the nursing home administrator, who was a RN, was working the floor as a CNA. The DON was working the medication cart. VII. Interviews The facility staff who were interviewed wished to stay anonymous. Numerous staff said they were told not to discuss staffing issues or other concerns with the survey team. The interviews were as follows: Anonymous staff member #1 was interviewed on 2/6/24. The staff member said the facility was always short on staff. The staff member said it was difficult to get all showers for residents completed and to provide timely meal assistance to dependent residents. Anonymous staff member #2 was interviewed on 2/7/24. The staff member said the past weekend there was only one CNA assigned on the day shift. Anonymous staff member #3 was interviewed on 2/7/24. The staff member said call lights were not answered timely because not enough staff. Lunch and dinner breaks were not taken as there was not enough time. Showers were not completed as scheduled and incontinence care was not performed timely. The facility had staffed five CNAs during the survey inspection on 2/6/24 which was not a normal situation. Anonymous staff member #4 was interviewed on 2/8/24. The staff member said it was difficult to perform good care to residents as they did not have enough time. The staff member said there was no one they felt comfortable talking to the administration. The staff member said Hoyer lifts were completed with one staff member when they were supposed to have two staff. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 8:40 a.m. The LPN said the facility currently had two CNAs on the floor and the NHA was working the floor. She said she could not leave only two CNAs on the floor to take care of all the residents. She said they had three scheduled, however, one CNA called and quit. The DON was interviewed on 2/8/24 at 11:18 a.m. The DON said three CNAs scheduled during the day was considered an extreme minimum. The DON said she started her employment 12/13/23. She said she did identify areas in nursing care which needed to be addressed, however, she did not have enough time to put together plans to fix them. She said she had been addressing the showers not happening as scheduled. She said she was always available to help the CNAs with care but if they did not ask she could not help. She said she had been working the medication cart a lot this past week as she had a nurse on vacation. She said the facility was actively working on hiring staff. The DON did not respond when asked how the CNAs were able to get the resident cares and responsibilities done during meal times with two CNAs. The corporate nurse consultant (CNC) was interviewed on 2/9/24 at 8:50 a.m. The CNC said the facility was attempting to hire two RNs and currently had four NA in the certification program. 50314 50315

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#10 and #14) of two residents reviewed for medication errors out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #10 was administered her chronic obstructive pulmonary disease (COPD) medications ordered for nearly a week; and, -Resident #14 was administered his medication for Huntington's disease. Findings include: I. Facility policy and procedure The Medication Ordering and Receipt policy and procedure, dated 6/21/17, was provided by the director of nursing (DON) on 2/8/24 at 8:57 a.m. It documented in pertinent part, Non-dose bulk medications such as inhalers, liquids, creams, and patches must be reordered by the facility when there is no more than a four day supply of medication remaining. II Resident #10 A. Resident status Resident #10, age 95, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included COPD, anxiety, obstructive sleep apnea, generalized muscle weakness and hypertension (high blood pressure). The 2/1/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavior symptoms were noted. She required assistance for transfers, personal hygiene and toilet use, medications and had no rejection of care. B. Resident interview Resident #10 was interviewed on 2/6/24 at 10:51 a.m. Resident #10 said she did not receive her medication for COPD for a week. Resident #10 said she remembered that not receiving her medication affected her by making her very tired. She did not participate in any activities all week as she usually did. Resident #10 said she just ate breakfast, lunch and dinner and laid down in her bed as she was too weak and tired to do anything else. C. Record review The February 2024 CPO showed an order for Anoro Ellipta one inhalation. Inhale orally one time a day for COPD. Ordered 12/29/23. The January 2024 medication administration record (MAR) showed the Anoro Ellipta medication was not administered on 1/5/24, 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/11/24 and 1/12/24. -A review of the progress notes revealed the medication was not available from the pharmacy on each day. III. Resident #14 A. Resident status Resident #14, age 70, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included generalized weakness and Huntington's disease. The 1/26/24 MDS assessment showed the resident had no cognitive impairment with a score of 13 out of 15 on the BIMS assessment. The resident required partial to moderate assistance with activities of daily living. B. Record review The February 2024 CPO documented the following orders: -Gabapentin 600 mg three times a day for Huntington's disease, ordered 7/5/19. -Tetrabenazine 25 mg two times a day for Huntington's disease, ordered 8/12/19. -Austedo 12 mg twice a day for Huntington's disease, ordered 1/14/24. The January and February 2024 MAR and progress notes revealed: -Two doses of Gabapentin out of five ordered doses were administered between 1/13/23 to 1/14/23. -A review of the progress notes revealed Gabapentin was not available from the pharmacy on 1/13/24 and 1/14/24. -Tetrabenazine 25mg was not administered out of three medication administration opportunities between 1/13/24 and 1/14/24. -A review of the progress notes revealed Tetrabenazine was not available from the pharmacy on each day. -Austedo 12mg was missed for a total of 10 doses on 1/17/24, 1/18/24, 1/9/24, 2/4/24, 2/5/24, 2/6/24 and 2/7/24. -A review of the progress notes documented the Austedo was not available from the pharmacy on 1/17/24, 1/18/24, 1/19/24, 2/4/24, 2/5/24, 2/6/24 and 2/7/24. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 8:51 a.m. LPN #2 said bedside nursing staff were not responsible for ordering medications. LPN #2 said the facility administration ordered medications for residents. The pharmacist was interviewed on 2/7/24 at 12:21 p.m. The pharmacist said Resident #14 had two fill orders for his Austedo on 1/17/24 and 2/3/24, both of which were filled on those days. The pharmacist said orders were not sent to the pharmacy for Resident #14's Gabapentin or Tetrabenazine. The director of nursing (DON) was interviewed on 2/7/24 at 2:06 p.m. The DON said medication orders by the physician should always be followed. The DON said that if a resident with Huntington's disease did not receive their medication, the doctor to be notified, the resident's family to be notified, herself to be notified and an assessment of the resident should be conducted. The DON said the information should be documented in the resident's progress notes. The medical director (MD) was interviewed on 2/7/24 at 2:52 p.m. The MD said Resident #10's Anoro Ellipta was an important medication for chronic obstructive pulmonary disorder (COPD) management and keeping the resident out of the hospital. The MD said he had not been notified the resident did not get this medication for six days and said he should be notified if a resident could not receive their Anoro Ellipta medication.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include: I. Resident group interview A resident group interview was conducted on 2/7/24 at 9:30 a.m. with six cognitively intact residents (#9, #10, #17, #20, #21, and #22). All the residents in the group said the food was not palatable. Additional resident concerns and comments from the group interview included: -The food was not seasoned well, it was either not seasoned at all or very salty; -Residents had to bring their own seasoning to the dinner table; -The evening cook and weekend cook were inconsistent with the addition of seasoning and the food was worse on evenings and weekends; -One resident said she often bought her own ravioli and would ask for that for dinner if she did not like what was being served for dinner; -The food was always served cold; -The vegetables were cooked but served cold and there were always raw carrots in the mix of cooked vegetables; -Room trays did not always come with condiments; and, -Residents said they would like to have ice cream anytime rather than just on Saturdays. -The residents said they had been told for months by the food committee that they were working on the residents' complaints. II. Resident interviews Resident #8 was interviewed on 2/5/24 at 3:00 p.m. Resident #8 said that he had resided at the facility for a while. He said the food was not good. He said it was not seasoned and it was served cold. He said he purchased his own food so he could eat it if the meal was not palatable. Resident #19 was interviewed on 2/5/24 at approximately 3:30 p.m. Resident #19 said the food was served cold and the food did not have enough seasoning. III. Resident council minutes The 11/21/23 food committee minutes showed the residents had concerns with the vegetables being served cold and not fully cooked. The residents requested ice cream more often and not just on Saturdays. The 12/19/23 resident council minutes showed the residents had concerns with vegetables being served cold. Residents requested to be served ice cream more often. IV. Observation The evening meal was observed on 2/6/24 beginning at 5:15 p.m. in the dining room. The plates used to serve the residents' food were only slightly warm. The chocolate pie did not have any mechanism to keep it cold such as refrigeration or ice. On 2/6/24 at 5:35 p.m., the room trays arrived on the floor. There were nine trays on the cart. -There was no salt, pepper or other condiments provided with the room trays. V. Test tray A test tray, regular diet was evaluated on 2/6/23 at 5:50 p.m. The following observations were made: -The steak sandwich was 105.6 degrees fahrenheit (F) and was cold to the palate; -The mixed vegetables were 112.6 degrees F and were cold to the palate; and, -The chocolate pudding was 62.6 degrees F and was lukewarm to the palate. VI. Interview Cook (CK) #1 was interviewed on 2/6/24 at 12:30 p.m. CK #1 said the facility no longer ordered ice cream in the small ready to serve containers. She said she had been told ice cream was not to be served except on Saturdays. The dietary manager (DM) was interviewed on 2/7/24 at 2:00 p.m. The DM said the facility did not have the heating element which went with the thermal plate cover. She said the plate warmer was not working properly and therefore the food was not put onto hot plates. She said she was aware of the residents' food complaints. She said she had been working with the cooks on knife skills and cooking standards. She said the cart with the room trays had condiments on it and the server needed to offer the condiments to the residents when the trays were delivered. The social worker (SW) was interviewed on 2/8/24 at 10:26 a.m. The SW said she had heard the food needed some improvement. The nursing home administrator (NHA) was interviewed on 2/9/24 at 10:04 a.m. The NHA said the reason ice cream was not being served to residents other than Saturdays, was because the residents were not eating their meals and eating too much ice cream. She said the facility was going through a gallon of ice cream a day. The NHA said ice cream floats or other treats were served during activities. 50314 50315

Based on interviews and record review, the facility failed to protect one (#23) resident from abuse out of 25 sample residents. Specifically, the facility failed to: -Ensure Resident #23 was protected from physical abuse by Resident #24 on 11/25/23; and, -Conduct a thorough investigation of a resident to resident altercation, including documentation of staff interviewed, which resulted in the appropriate authorities not being notified of physical abuse of Resident #23. Findings include: I. Facility policy The Abuse and Neglect policy, revised March 2018, was received on 2/9/24 at 9:07 a.m by the corporate nurse consultant. The policy read in pertinent part, Abuse is defined as the willful infliction of injury. The nurse will report findings to the physician. The Abuse, Neglect, Exploitation and Misappropriation Prevention program, revised April 2021, was received on 2/9/24 at 9:07 a.m. by the corporate nurse consultant. The policy read in pertinent parts, the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives. Protect residents from abuse by anyone including facility staff, other residents. II. 11/25/23 incident between Resident #23 and Resident #24 A. Facility investigation The 11/25/23 investigation summary documented Resident #23 was in Resident #24's room going through his belongings. Resident #24 requested for the resident to leave the room. Resident #24 said he did not push the resident, but he placed his hand on her back and walked her out of his room. Once out of the room, Resident #23 was walking in the hallway going towards the nurses station stumbled and fell on to the floor. The summary documented after speaking with staff and residents it was determined that Resident #23 did fall in the hallway witnessed by a resident who stated Resident #24 was in his room when she fell . Interventions were to educate the resident on not entering other resident rooms and use handrails while walking down the hallway. Resident #23 had a small cut over left eye, a bump below right knee and a small abrasion on left. elbow. -However, according to staff interviews during the survey (see interviews below), Resident #24 admitted at the time of the incident on 11/25/23, he had pushed Resident #23 because she was in his room and would not leave. III. Resident #23 A. Resident status Resident #23, age 75, was admitted to the facility on [DATE] and discharged on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances and generalized anxiety. The 10/13/23 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a score of eight out of 15 on the brief interview for mental status (BIMS). The resident was independent in ambulation and showed no behaviors. B. Record review The care plan, initiated on 10/15/23, identified the resident was a high risk for elopement and wandering related to being disoriented to place. She had attempted to leave the facility unattended, wandered aimlessly and significantly intruded on the privacy of others by searching through and removing personal belongings. Pertinent interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, television and books and to monitor location every 15 minutes. The 10/24/23 progress note documented the resident had been confused all evening and trying to find her dog, she kept wandering into other residents' rooms. IV. Resident #24 A. Resident status Resident #24, age 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included schizophrenia and bipolar disorder. The 1/23/24 MDS assessment documented the resident had a score of 15 out of 15 for the BIMS. The resident was independent in activities of daily living. The resident had no behavior problems. B. Record review The 10/30/23 progress note documented the resident had an altercation with another resident. Both residents were redirected. The care plan, updated 11/30/23, identified the resident had behavior problems. The resident care plan documented his diagnosis put him at risk for abusing others and being abused by others. He became aggravated with loud noises. Pertinent interventions included, his behavior was deescalated by taking him to a quiet environment, encourage him to write poetry, go outside and listen to music. The progress note dated 1/22/24 documented the resident returned to the facility from the facility van, he was very manic and out of sorts related to having a roommate. The progress note dated 1/23/24 showed the resident was saying inappropriate statements to the roommate. Redirected the resident and moved the roommate to another room. V. Staff interviews The social worker (SW) was interviewed on 2/8/24 at 10:26 a.m. The SW said Resident #23 no longer resided in the facility. She said the resident had dementia and that she would wander throughout the building and exit seek. She said she was not involved with the investigation. She said Resident #24 did not like for other residents to enter his room. She said she had heard that it was a verbal altercation between the two residents and not physical. She said verbal altercations were to have a thorough investigation. Registered nurse (RN) #1 was interviewed on 2/8/24 at 1:52 p.m. RN #1 said he was the charge nurse when the resident to resident incident occurred. The RN said he heard screaming and saw Resident #23 laying on the floor in the hallway on her left side. Resident #24 was standing in the doorway and said he shoved Resident #23 because she was in his room and would not leave. He said the resident's injury on her knee showed force and the skin tear showed the direction she fell with force. A staff member, who wished to be anonymous, was interviewed on 2/7/24. The staff member said they had heard Resident #24 admit to pushing Resident #23 as she would not leave his room. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 11:00 a.m. LPN #2 said Resident #24 had a history of not getting along with other residents. She said he had a history of manic behavior. She said he did not like having a roommate or other residents entering his room and he would not get physical with the roommate but he would say mean and inappropriate things to the resident. The nursing home administrator (NHA) was interviewed on 2/9/24 at approximately 10:00 a.m. The NHA said she was notified of the incident. She said she came into the building and she asked Resident #24 if he pushed Resident #23 and he denied it. The NHA said she had spoken to the staff working, however, it was not included in the investigation. The NHA said she did not substantiate it as abuse. She said she viewed the cameras and did not see anything which indicated abuse. The NHA said she had no record of the video recordings.

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#18 and #4) of four residents reviewed for pressure injuries out of 25 sample residents. Specifically, the facility failed to: -Consistently assess and document a pressure injury for Resident #18; -Obtain physician orders for the treatment of a pressure injury Resident #18; -Consistently assess and document a wound for Resident #4; -Obtain physician orders for the treatment of a wound for Resident #4; and, -Conduct weekly skin assessments for Resident #4. Findings include: I. Professional Reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/12/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage 2 should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility Policy The Pressure Ulcers/Skin Breakdown policy was obtained from the corporate nurse consultant (CNC) on 2/8/24 at 9:12 a.m. The policy documented in pertinent part: The Nurse shall describe and document pressure sore location, stage, length, width, depth, and presence of exudates or necrotic tissue; and, The physician will guide care when new wounds develop. III. Resident #18 A. Resident status Resident #18, age 80, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO) diagnoses included macular degeneration, legal blindness and displaced fracture of the greater trochanter (top of the femur). The 1/24/24 minimum data set (MDS) assessment showed the resident had cognitive impairments. The resident had both short and long term memory impairments and had moderate impairment for decision making. He required substantial assistance with activities of daily living. He was at risk for pressure injury. -The MDS failed to code that the resident had a pressure injury. B. Observations On 2/8/24 at 2:52 p.m., Resident #18 was observed to have a dressing in place over his lower medial spine. The dressing was dated 2/7/24. The resident had a gauze bandage on his right foot. C. Record review The care plan, revised on 1/31/24, identified the resident had a potential for pressure ulcer development. Pertinent interventions included administering treatments as ordered and monitoring for and informing the resident and his family and care givers of any new skin breakdown. Review of Resident #18's February 2024 CPO revealed the following physician's order for the resident's right heel: Cleanse with normal saline or soap and water and pat dry with gauze. Apply sure prep to peri wound area. Apply collagen to bed of wound and cover with foam dressing. Change dressing three days a week or if accidentally removed or soiled. The start date of the order was 1/22/24. -The February 2024 CPO failed to have an order for the treatment of the lower medial spine wound. The 2/2/24 skilled charting documentations showed the resident had a right heel pressure ulcer. -However there were no measurements documented for the wound. The 2/7/24 skilled charting documentation included a skin condition section, however, there was nothing documented regarding Resident #4's right heel wound or the medial spine wound. D. Director of nursing (DON) interview The DON was interviewed on 2/9/24 at 9:09 a.m. The DON said Resident #18 had a pressure injury on his right heel. She said the dressing was scheduled every three days and as needed. The DON reviewed the medical record and confirmed there were no recent skin assessments which documented the measurements or the assessment of the pressure ulcer. She said that the resident had not been seen by a wound physician. The DON said Resident #18 had a pressure injury on his medial spine. She said he had a foam padded dressing to help protect the wound. She said any type of wound treatments needed to have a physician's order. The DON confirmed there was no assessment in Resident #18's EMR about the pressure wound on his medial spine. The DON said she had documented the measurements of the wound on the resident's right heel, however, she said the documentation did not save in the EMR. 50314 IV. Resident #4 A. Resident Status Resident #4, age 80, was admitted to the facility on [DATE]. According to the February 2024 CPO, diagnoses included dementia, type 2 diabetes and glaucoma. The 7/12/23 MDS assessment revealed the resident was significantly cognitively impaired and unable to complete all aspects of the brief interview for mental status (BIMS). The resident required one person assistance with eating, hygiene, dressing, bathing, turning in bed and two person assistance with toileting and transfers. The assessment documented the resident had no pressure ulcer wounds on admission and required interventions to prevent pressure ulcers. B. Observation On 2/7/24 at 1:17 p.m., Resident #4's skin was observed with a staff member who wished to remain anonymous. The resident had an open wound on his medial scrotum. The wound was approximately 1.5 centimeters (cm) long by 1 cm wide by 0.1 cm deep. -There was no dressing covering the wound. C. Record review The Braden scale assessment (a tool utilized to predict pressure injury risk), completed on 1/3/24, showed the resident was at risk for developing a pressure injury. The care plan, initiated 12/7/23, identified the resident was at risk for pressure injury due to requiring assistance with turning and transfers. Pertinent interventions included assisting the resident with positioning and repositioning the resident in bed every two hours. A weekly skin check, dated 1/3/24, documented Resident #4's skin was warm, dry and intact. -Review of the resident's electronic medical record (EMR) failed to show any other weekly skin checks were completed after 1/3/24. -The February 2024 CPO failed to show Resident #4 had a physician's order for treatment for the pressure injury on the resident's medial scrotum. -Review of the resident's EMR contained no documentation to indicate the pressure injury was being monitored. D. Staff Interviews A staff member, who wished to remain anonymous, was interviewed on 2/7/24 at 9:51 a.m. The anonymous staff member said the resident had a wound on his scrotum. The staff member said the wound had been present for several weeks. The DON was interviewed on 2/8/24 at 1:21 p.m. The DON said she was personally involved in wound care for all residents in the facility. The DON said she had briefly assessed the skin of Resident #4 in January 2023 but the resident did not want her involved in his skin care and therefore she did not pursue further evaluations of his skin. She did not follow up with any other nurses to ensure they were assessing his skin consistently. The DON said weekly skin checks needed to be documented for all wounds. She said she preferred for one nurse to perform wound measurements. She said she was the nurse responsible for measuring all wounds currently. The DON said the nurses should document and monitor wounds and pressure injuries on a consistent basis. She confirmed weekly wound assessments with measurements were not completed for Resident #4. The DON was interviewed a second time on 2/9/24 at 9:09 a.m. The DON said the facility did not have a wound physician but could call for a consultation if a wound was not healing. The DON said all wound treatments needed to have a physician's order. The nursing home administrator (NHA) was interviewed on 2/9/24 at approximately 10:00 a.m. The NHA said the facility had no pressure injuries. -However, the DON said Resident #18 had two pressure injuries (see DON interview regarding Resident #18 above).

Based on observations, interviews and record review, the facility failed to provide an environment free from accident hazards for one (#3) out of 25 sample residents. Specifically, the facility failed to: -Investigate a fall Resident #3 on 1/17/24; -Properly secure Resident #3 in the facility van when going to an appointment on 1/24/24; -Ensure two staff assisted Resident #3 with a mechanical lift transfer. Findings include: I. Resident #3 Resident #3, under the age of 65, was admitted on [DATE]. According to the February 2024 computerized orders (CPO), diagnoses included chronic pain, hemiplegia (paralysis to one side of the body), and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) that affected her left side. The 11/4/23 minimum data (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required total assistance of two staff with activities of daily living (ADLs) which included showers, positioning and transfers. She had no behaviors or refusal of care. II. Failure investigation a fall and properly secure Resident #3 A. Resident interview Resident #3 was interviewed on 2/6/24 at 2:15 p.m. She said she suffered a fall on 1/17/24. She said two certified nursing aides (CNA) dropped her during a transfer and she fell on her left side. She said her left ankle was hurting and the director of nursing (DON) came in to assess her. Resident #3 said she was transported to a doctor's appointment via the facility van. She said during her van ride, she was not strapped in properly and there was an accident that occurred on 1/24/24. She said she suffered bruised ribs to her left side from the accident. B. Record review 1. 1/17/24 -Review of the medical record revealed there was no documentation regarding the fall on 1/17/24. The fall occurred according to the resident and staff interview (see interviews). -Fall records for Resident #3 on 1/17/24 were requested from the nursing home administrator (NHA) on 2/7/24 and the facility failed to provide them by exit of the survey on 2/9/24. 2. 1/24/24 Records for facility van maintenance were requested on 2/7/24 at 3:00 p.m. and were not received by the exit on 2/9/24. The 1/24/24 investigation summary report and police report were obtained from the NHA on 2/8/24 at 11:00 a.m. The investigation summary included the name of the facility, date the incident occurred, resident name, description of what happened, interventions and signature of NHA. -However, the investigation was not included in the medical record. C. Staff interview Hospitality aide (HA) #1 was interviewed on 2/7/24 at 2:30 p.m. She said it was her first time driving the facility's van and she received a five minute training on the van from the facility maintenance director. The facility maintenance director showed her how to turn the van on and strap in the wheels of the wheelchair to the van. She said she felt pressured into signing the training form given to her by the nursing home administrator (NHA). HA #1 said while she was driving Resident #3 to a doctor appointment, the van was side swiped and as a result the resident flipped out of the wheelchair since she was not properly secured. She said the seatbelt to go across the chest of the resident in the wheelchair was broken and it was not fixed. The maintenance director was interviewed on 2/7/24 at 2:45 p.m. He said there were two seatbelts for the wheels on the wheelchair and one seatbelt that strapped across the chest of a resident in a wheelchair. He said he did the training course for staff operating the van that included utilizing the three belts when transporting a resident. He said the broken seatbelt was fixed right away after the accident on 1/24/24. He demonstrated the three working seatbelts for the wheelchair. An anonymous staff member was interviewed on 2/8/24 at 9:00 a.m. She said she was assisting in the transfer with Resident #3 when she was dropped and suffered a fall on 1/17/24. The resident fell on her left side and was complaining of left ankle pain. The staff member told the DON right away and the DON came in to assess Resident #3. 50314 III. Failure to use two staff for a mechanical lift transfer A. Facility policy and procedure The Mechanical Lifting Machine policy and procedure, dated July 2017, was provided by the director of nursing (DON) on 2/9/24 at approximately 9:00 a.m. It documented in pertinent part, At least two nursing assistants are needed to safely move a resident with a mechanical lift. B. Observations On 2/8/24 at 4:15 p.m. certified nurse aide CNA #6 operated a Hoyer (mechanical) lift to transfer Resident #3. There was no other staff member in the resident's room assisting with the transfer. C. Record review The 8/14/23 ADL care plan documented the resident had a self care deficit related to activity intolerance, impaired balance and chronic pain. Pertinent interventions included the resident requiring one person extensive assistance with all transfers. -However, based on observations and interviews, she required a mechanical lift for transfer with two staff. D. Staff interviews CNA #4 was interviewed on 2/8/24 at 2:37 p.m. CNA #4 said she had heard of staff members using the Hoyer lift with one staff member instead of two as required. CNA #4 said she saw this with Resident #3 in the past. CNA #4 said she had seen the physical therapist transfer residents alone who required two person assistance. The physical therapist (PT) was interviewed on 2/8/24 at 5:10 p.m. The PT said staff should be using two staff members to transfer residents who require a mechanical lift.

Based on record review and interviews, the facility failed to provide appropriate pharmaceutical services to meet the needs of residents for one (#1) of three residents reviewed for pharmacy services out of 25 sample residents. Specifically, the facility failed to ensure medications were available to prevent missed doses of Prostat liquid (a protein supplement for wound healing) for Resident #1. Findings include: I. Facility policy and procedure The Medication Ordering and Receipt policy, revised June 2017, was received from the nursing home administrator (NHA) on 2/8/24 at 8:57 a.m. The policy documented in pertinent part, Routine (tab/capsule) medication orders will be cycle filled every 24 hours and delivered to the facility on a daily basis. Unit dose bulk medications (liquids, creams, patches, ophthalmic, inhalers) and controlled substances must be reordered by the facility when there is no more than a four day supply of medication remaining. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included muscles weakness, Parkinson's disease (progressive disorder affecting the nervous system and parts of the body controlled by the nervous system) with dyskinesia (abnormal movements), gait (walking) abnormalities, muscle wasting and cerebral infarction (stroke). The 1/19/24 minimum data set (MDS) assessment documented the resident was rarely/never understood. It documented that the resident required substantial/maximal assistance for activities of daily living (ADLs) which included bathing, toileting, dressing and mobility. B. Record review Review of the January 2024 CPO revealed Resident #1 had a physician's order for Prostat liquid 30 milliliters (ml) to be given twice daily. -The medication had an order date of 12/15/23 and was discontinued on 1/31/24. -Review of Resident #1's January 2024 medication administration record (MAR) revealed the resident did not receive the Prostat liquid protein nutritional supplement from 1/2/24 through 1/13/24, 1/15/24, 1/23/24, 1/24/24, 1/28/24 and 1/29/24. The administration code for the dates of the missed medication doses was documented as Other/See progress notes. The progress notes for the dates of the missed medication doses documented the following reasons for the missed doses: -Prostat liquid 30 ml two times a day for supplement was unavailable; -Waiting on order; -On order; -Waiting for medication from pharmacy; -Needs to be ordered; and, -Waiting on pharmacy. -There was no documentation in Resident #1's electronic medical record (EMR) to indicate the resident's family or physician was notified regarding the medication being unavailable and/or the resident missing several doses of medication. C. Staff interview The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said nurses were instructed to order medications in a timely fashion (two to three days before the medication ran out) so medication administration did not get missed. She said she was aware of Resident #1's missing Prostat. She said the Prostat was not ordered because the nursing staff was new and the nurse who used to order medications was no longer working at the facility. The DON said there was a gap in communication that was never closed on who was to reorder the medication. She said she did not know of a backup pharmacy the facility used when medications were unavailable. She said the bedside nurse should always notify the family of the resident and the physician when medications were not given.

Based on observation and interviews, the facility failed to ensure residents received notice orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Information of how to file a complaint with the State Agency; -Post local contact agency for information about returning to the community; -Post information on Medicaid fraud; and, -Post a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies in the facility. Findings include: I. Resident group interview The resident group interview was conducted on 2/7/24 at 9:30 a.m. The group consisted of six alert and oriented residents selected by the facility. All six residents (#9, #10, #17, #20, #21 and #22) said they did not know where the facility posted information in regard to State Agencies contact information. II. Observations Observations throughout the building on 2/7/24 at approximately 1:30 p.m. revealed there was no statement for how a resident could file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. There was no email address for the State Survey Agency included in the posting. The posting included a mailing address and phone number for the State Survey Agency and was in a glass compartment which was over six feet high in approximately a font of 12. The posting did include the phone number to the Center of Medicare and Medicaid. The posting failed to have the Adult Protective Services, where State law provides jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and Medicaid fraud unit and a statement that the resident may file a complaint with the State Survey agency concerning and suspected violation of State or Federal nursing facility regulations. III. Staff interview The social worker (SW) was interviewed on 2/7/24 at 2:00 p.m. The SW said she was unsure who originally made the posting on how to get in touch with the State Agencies because it was long before she had worked there. She said she was not aware of what specifically was required for the postings.

Based on observations, record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#20) of six residents reviewed for falls out of 24 sample residents. The facility failed to ensure Resident #20, who had nine falls within six months, had effective interventions, supervision and assistance in place to prevent further falls. Resident #20 suffered multiple falls with injuries including lacerations to his face and his head, including an emergency room visit where he received six stitches and he continued to fall. Findings include: I. Facility policy The Nursing Services Policy and Procedure Manual for Long-Term Care, revised April 2018, was provided on 6/15/23 at 3:07 p.m. by the nursing home administrator (NHA). It read in pertinent part, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. II. Resident #20 A. Resident status Resident #20, age 73, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic pain, muscle weakness, lack of coordination, unspecified abnormalities of gait and mobility, dementia and other abnormalities of gait and mobility. The 6/6/23 minimum data set (MDS) assessment showed that Resident #20 had severe cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment indicated Resident #20 required extensive assistance with transfers and toilet use and limited assistance from caregivers for walking around his room. His balance was unsteady and he needed assistance to balance himself. He used a walker or wheelchair for ambulation. Resident #20 was listed as having one fall since admission or most recent assessment. -However, Resident #20 had nine falls within a six-month period (see record review below). B. Resident interview Resident #20 was interviewed on 6/14/23 at 2:52 p.m. He stated he was supposed to use his call light when he wanted to get up. Resident #20 said the caregivers did not respond in a timely manner to call lights, especially when he had to use the restroom. I got to do what I got to do, so I would walk to the bathroom alone and fall. Resident #20 had signage around his room that documented, Please remember to use your wheelchair or walker at all times. He explained how previous falls led to his placement at the facility and he kept falling during his stay. He said staff kept his wheelchair out of reach so he would not use it without calling for assistance but he still got up anyway when he could not wait any longer to use the restroom. Resident #20 stated he used to have a walker but the facility did not want him to use it anymore due to falling a lot and removed it from his room. -The use of a wheelchair and no walker and keeping the wheelchair out of the resident's reach so he would ask for assistance was not included in the care plan (see below). C. Observations On 6/12/23 at 2:00 p.m., Resident #20 was observed walking out of his room into the hallway. A staff person approached and asked him why he was walking, then helped him back into his room and closed the door. During the resident interview on 6/14/23 at 2:52 p.m. (above), no walker was observed in his room. He was in bed and his wheelchair was at the foot of his bed facing away from him toward the wall. Resident #20 was observed throughout the survey, from 12:00 p.m. to 6:00 p.m. on 6/12/23 and from 8:30 a.m. to 6:00 p.m. on 6/13, 6/14 and 6/15/23. He spent most of his time in his room with his door closed, except for meals and going outside to smoke. He ambulated in his wheelchair independently [NAME] himself through the facility to the back door and received assistance from staff to exit the back door to the smoking area. D. Record review According to the fall risk care plan, initiated on 9/15/21 and most recently revised on 4/18/23, Resident #20 was listed as weight-bearing and he needed assistance from one staff member to ambulate. Resident #20 also needed limited assistance from one staff for when he walked around and as needed (PRN) in his wheelchair. Resident #20 was listed as a high fall risk due to a diagnosis of Parkinson's disease which would affect his coordination and gait. Interventions were the following: -Anticipate and meet the resident's needs (9/15/21). -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (9/15/21). -Resident #20 forgets to use his walker or wheelchair and needs reminders to use his call light and allow staff to assist with transfers (undated). -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (10/12/21). -Ensure proper positioning when in wheelchair (4/18/23). -Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair (9/15/21). -Follow facility fall protocol (9/15/21). - 'I like to get myself up and into my wheelchair, please make sure my wheelchair is within easy reach' (6/13/23, during the survey). -Offer frequent assistance to the bathroom, assist in keeping clean, dry, and comfortable (10/1/21 and 6/13/23). -Signage placed in room to remind resident to use his wheelchair and walker when ambulating (9/21/22). -Place signage around my room to remind me to use my call light and wait for assistance (11/15/22). -Place wheelchair wedge with support to help with falling (4/17/23). -Push wheelchair when outside (4/18/22). -The resident's actual falls with injury were not documented in his care plan. -There was no evidence of tracking and trending the times of day or night the resident had fallen, in order to develop more effective fall prevention measures. -The care plan did not define how frequently the resident should be offered assistance to the bathroom. -New interventions following each fall were not added to the care plan. -No wedge cushion was observed in the resident's wheelchair during the survey. -No signage was observed in the resident's room to remind him to use his call light for assistance. -The resident's wheelchair was not within his reach in keeping with the care plan, per observation and resident interview. Review of nursing progress notes and fall investigations for the previous six months revealed: 1. Unwitnessed fall on 1/17/23 Resident #20 had an unwitnessed fall on 1/17/23 at 1:49 a.m. He was found on the bed on his hands and knees, cursed at staff, and said he had fallen to the floor. No injuries were noted. -No fall investigation was provided. 2. Witnessed fall on 2/9/23 Resident #20 had a witnessed fall on 2/9/23 at 4:45 p.m., with an injury that led to an emergency room visit. He had a laceration to the right eyebrow and received six stitches in the hospital. He had been ambulating in the hall behind his wheelchair, tripped and fell , hitting the right side of his face. -The facility failed to correct how Resident #20 was utilizing his wheelchair which resulted in an injury. The facility failed to provide limited assistance with walking due to the resident being unsteady and supervision to ensure timely assistance to prevent falls with injury. 3. Unwitnessed fall on 2/17/23 Resident #20 had an unwitnessed fall on 2/17/23 at 5:15 p.m. (late entry documented at 9:28 p.m.) He came out of his room and told staff he fell while he was walking across the room. He had a laceration to the right side of his forehead, no bleeding or swelling and no other injuries. Witnessed fall, staff involved, on 3/16/23 Resident #20 had a witnessed fall on 3/16/23 at 6:57 p.m. Staff were pushing him in after smoking, his wheelchair caught on the door threshold, pitching him from the wheelchair to his knees. He had abrasions on both knees. 4. Unwitnessed fall on 3/27/23 Resident #20 had an unwitnessed fall on 3/27/23 at 9:33 p.m. according to nursing notes which documented no further details other than that neurological checks were initiated. No injuries were noted. 5. Witnessed fall on 4/13/23 Resident #20 had a witnessed fall on 4/13/23 at 9:35 p.m. He was outside in his wheelchair, hit a groove in the concrete causing him to fall. He hit his head and suffered a laceration above his right eye. The nurse cleaned, steri-stripped, provided an ice pack and initiated neurological checks. The resident later had swelling to the right side of his face. Review of the facility investigation revealed the interdisciplinary team (IDT) recommendation for a new intervention was education. The facility documented in the report they updated the care plan to reflect the recommendation. -However, the care plan was not updated regarding education. -The type of education to be provided and to whom was not documented in the investigation. -The care plan intervention to supervise the resident for safety when he was outside was not updated until 4/18/23, five days later. 6. Unwitnessed fall on 4/16/23 On 4/16/23 at 1:35 p.m., Resident #20 fell and sustained an abrasion to his hand. The fall investigation determined Resident #20 fell out of his chair onto his knees and scraped his hand. The previous intervention was listed as a wedge (cushion) for Resident #20's wheelchair. A new intervention was documented to ensure proper positioning in the wheelchair. The facility documented in the report they updated the care plan to reflect the recommendation. -The care plan was not updated until after the resident's second fall outside although the 4/16/23 fall was caused by staff. -The care plan was updated regarding the wedge cushion, but it was not observed in the resident's wheelchair (see observations above). 7. Unwitnessed fall on 5/17/23 On 5/17/23 at 12:42 a.m., Resident #20 was found sitting on the floor in front of his bed. The fall investigation determined he was getting up to go to the bathroom, slipped, and fell on to his buttocks. Previous interventions were documented as education and signage. A new recommendation was entered as a referral to physical therapy (PT). The facility documented in the report they did not update the care plan based on the new intervention. He suffered two skin tears on his right hand. -Although, the resident was going to the bathroom without assistance, the care plan was not updated with specific interventions about anticipating the resident's bathroom assistance needs and how often to provide the assistance. -He was already receiving PT at the time of this fall according to therapy notes. -The care plan was not updated after the 5/17/23 fall. 8. Unwitnessed fall on 6/8/23 On 6/8/23 at 9:28 p.m., Resident #20 was found sitting on the floor (with no noted injuries) in his room, holding his knees. The resident's roommate had to use his call light for assistance. The resident's wheelchair was four to five feet away from him. The fall investigation determined Resident #20 was headed to the bathroom when he slid down onto the floor off his bed. Previous interventions were documented as education and signage. A new recommendation was entered to maintain his wheelchair within easy reach of Resident #20. The facility documented in the report the care plan was updated with this recommendation. -However, observation and resident interview (above) revealed the resident's wheelchair was not consistently kept within his reach. -The care plan was not updated regarding timely bathroom assistance, although the resident fell attempting to go to the bathroom without assistance. -There was no recommendation for, or evidence of, PT or restorative services following this fall. Therapy notes revealed he was discharged from PT on 6/5/23, where he had been working on training in wheelchair propulsion and maneuvering within his environment. Resident #20's fall assessment completed 6/8/23 showed he had a fall risk score of 55, indicating high fall risk. -No further fall risk assessments were provided. -Review of the times Resident #20 fell revealed most of his falls happened late at night or early morning. However, there was no evidence the facility identified this trend to identify root causes, meet the resident's needs, and implement measures to meet those needs. Review of IDT notes on 6/13/23 revealed Resident #20 had many falls. Resident #20 utilized his wheelchair as a walker and agreed to utilize it how it was meant to be used. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/15/23 at 8:40 a.m. CNA #1 explained occasionally the facility was short staffed and they worked with what they had but it delayed the time it took to answer call lights. We manage the best way we can when we are understaffed. CNA #1 said Resident #20 fell a lot due to his Parkinson's disease and not waiting for the nursing staff to answer his call light. CNA #1 explained Resident #20's fall precautions were signs posted in his room and that staff needed to stop him if they saw him ambulating. Staff located fall precautions and care instructions in the care plan but CNA #1 did not know how to find care plans so she relied on signs posted in the residents' rooms. Nurse aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. NA #3 stated a lot of falls occurred because call lights were not answered in a timely manner and residents would get impatient waiting for a response. She stated the facility was usually understaffed therefore staff did not answer call lights. She explained Resident #20 would get up independently and staff constantly needed to remind him to use his call light and wheelchair. Resident #20 typically did not like to wait for staff to answer his call light so he would walk himself where he needed to go. He was on hourly checks and staff reminded him not to walk around on his own. NA #3 did not know how to look up care plans and relied on signs posted in the residents' rooms or asked other floor staff what each resident needed specifically. Physical therapy aide (PTA) #1 was interviewed on 6/15/23 at 3:30 p.m. regarding Resident #13's fall and recovery. PTA #1 stated Resident #20 had just been discharged from physical therapy (PT) in June 2023. He was still being treated by restorative therapy because he had reached his maximum physical capability due to his diagnosis of Parkinson's disease and there was nothing more to be done with PT. The nursing home administrator (NHA) was interviewed at 2:00 p.m. on 6/15/23 and Resident #20's fall investigations were requested. The NHA said it would be a huge stack of documentation since the resident had frequent falls. She did not say why the resident fell so frequently or what prevention measures the facility was taking. At 2:30 p.m. on 6/15/23 she provided only four fall investigations: for 4/13/23, 4/16/23, 5/17/23 and 6/8/23.

Based on observations, record review and staff interviews, the facility failed to ensure three (#4, #13 and #31) of five residents reviewed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 24 sample residents. Specifically, the facility failed to timely assess the residents at risk for nutrition to ensure interventions were appropriate and implemented to prevent significant weight loss, consistently review residents identified at a nutritional risk as an interdisciplinary team, and effectively determine the accuracy of residents' weights. Resident #31 had chronic kidney disease and nephrotic syndrome that caused fluid retention and fluid loss, creating fluctuation in her weight. The resident had little appetite. Towards the end of May 2023 and consistently in June 2023, the resident complained of nausea and vomiting. The resident was placed on comfort care on 6/14/23. Resident #31 was weighed daily between 4/17/23 and 5/30/23. On 5/15/23 Resident #31 weighed 154 lbs. The resident was admitted to the hospital on 5/19/23. The resident weighed 139 lbs on 5/20/23, indicating a 15 lb weight loss of 9.74%, which was severe. A 5/20/23 progress note identified the hospital did not remove excess fluid during her hospital stay. Record view identified Resident #31 was not reassessed after the significant weight loss to determine if additional interventions could be implemented. On 5/27/23, Resident #31 weighed 136 lbs. On 5/28/23 the resident weighed 118 lbs, identifying a weight loss of 18 lbs at 13.24%, which was severe. Progress notes identified the resident had periods of nausea and was prescribed medication to reduce the symptoms; however, record review identified the resident was not reassessed or reviewed to determine if nutritional interventions could be implemented. Resident #31 was weighed again on 5/29/23. The resident weighed 114 lbs, indicating an additional four lbs weight loss in a day and a two lb loss on 5/30/23 resulting in a weight of 112 lbs. The resident was weighed again on 6/2/23 and the resident gained back the two lbs. Between 6/2/23 and 6/13/23, the resident complained of nausea almost daily and had incidents of documented vomiting. The prescribed medication for the nausea was usually effective after administration. She reported little to no appetite. Even though the resident had a significant weight loss and had nausea, vomiting and loss of appetite, Resident #31 was no longer weighed daily and was not weighed again until 6/8/23 with a weight result of 100 lbs. The resident was not re-weighed to determine the weight's accuracy. According to the weight record the resident lost a total of 14 lbs in six days at 12.28% (considered severe) between 6/2/23 and 6/8/23. Resident #31 lost a total of 39 lbs with a 28.6% (considered severe) weight loss between 5/20/23 and 6/8/23. The resident was not reassessed or reviewed by the registered dietitian (RD) until 6/14/23, during the survey. New nutritional interventions to promote weight stabilization and appetite were not recommended from the RD until 6/14/23 and 6/15/23. Resident #13 experienced significant weight loss since her admission to the facility. The facility failed to ensure her weights were obtained timely. The resident admitted to the facility with a weight of 172 lbs. She sustained significant weight loss of 22 lbs in three months from 12/21/22 to 3/10/23. From 5/30/23 to 6/9/23 the resident sustained an additional 30 lbs weight loss. There were no additional measures implemented when the resident sustained an additional 30 lbs weight loss. For Resident #4, the facility failed to maintain adequate nutritional parameters by ensuring weights and weight loss/gain were accurately assessed, physician-ordered nutritional supplements were provided and documented when the resident refused meals and evaluate the care plan to determine if nutritional interventions were implemented and effective. Findings include: I. Facility policy and procedure The Nutrition Assessment policy, revised October 2017, was provided by the registered dietitian (RD) on 6/15/23. The policy read in pertinent part: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident on admission and as indicated by change of condition that places the resident at risk for impairment. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering interpreting data and using the data to help define meaningful interventions for the resident at risk for or with impaired nutrition .Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the residents risk for nutritional complications. Such interventions will be developed with the context of the resident's prognosis and personal preferences. The Weighing and Measuring the Resident policy, revised March 2011, was provided by the nursing home administrator (NHA) on 6/15/23 at 3:07 p.m. According to the policy, the facility needed to determine the resident's weight and height to provide an ongoing record of the resident's body weight as an indicator of nutritional status and medical condition of the resident and determine the ideal weight of the resident. The policy identified the following guidelines to to promote an accurate weight assessment every time the resident was weighed, when possible: -Weigh the resident at the same time of day; -Use the same scale; -Use the same amount of clothing as prior weighing: and, -Ensure the weight scale was calibrated. The weighing and measuring policy directed staff to report significant weight loss or gain to the nurse supervisor. The policy identified the threshold for significant, unplanned, and undesired weight loss based on the following criteria: -In one month, 5% weight loss was significant; greater than 5% in a month was severe. -In three months, 7.5% weight loss was significant; greater than 7.5% in three months was severe. -In six months, 10% weight loss was significant; greater than 10% was severe. II. Resident #31 A. Resident status Resident #31, age 70, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, stage 4 (severe), type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure (CHF), nephrotic syndrome with unspecified morphologic changes (severe swelling), pleural effusion (fluid build up in the chest and lung cavity), aplastic anemia (lack of production of blood cells, and acidosis (too much acid in the body fluids). The 5/16/23 minimum data set (MDS) assessment revealed Resident #31 had short term memory problems. The MDS assessment indicated the resident had modified independence in decision making regarding tasks of daily life. According to the MDS assessment, Resident #31 exhibited fluctuating disorganized thinking and a continuous altered level of consciousness. The resident had an acute change in mental status for her baseline. The MDS assessment indicated Resident #31 was independent with eating and weighed 154 pounds (lbs). She had no known weight loss of more than 5% in one month or 10% weight loss in six months. The resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. B. Record review The 2/24/23 weight and vital summary record read the resident's admission weight was 156 lbs. The 3/10/23 nutrition/dietary note read Resident #31 was followed at NAR (nutrition at risk) meeting for four weeks as a new resident to establish weight baseline. She was down 14 lbs in two weeks. According to the note, the resident had excess fluid that required draining at the hospital, every two weeks. The note indicated the facility expected weights to go up and down related to disease progression of nephrotic syndrome. The note read intakes were extremely variable with an average intake of 40% of meals. The note identified the staff would continue to monitor in NAR for weight fluctuations. The 3/10/23 NAR meeting minutes record identified the resident had a 9% weight loss since her admission on 2/24/23. The weight and vital summary record between 3/12/23 and 3/15/23 identified the resident's weight fluctuated between 150 lbs and 162 lbs. The nutrition at risk care plan, initiated 3/15/23, read Resident #31 was at a nutritional risk related to diagnosis of CHF, anemia, type 2 diabetes mellitus, vitamin D deficiency, hyperkalemia (increased blood potassium), chronic kidney disease, hypertension and reported lower appetite. According to the care plan, the resident was prescribed diuretic therapy which may cause fluctuations in weight. Interventions initiated on 3/15/23 included the following: -Administer medications as ordered by MD (medical doctor). Observe for and document any side effects. -Monitor and record labs as ordered. -Monitor and record weights per facility protocol or as ordered. -Offer snacks daily. -RD to evaluate and make recommendations PRN (as needed). -Serve diet as ordered. -The care plan did not identify additional nutritional interventions after the resident lost significant weight when the resident had a decrease in appetite related to nausea and vomiting (see below). The 3/16/23 nutrition/dietary note read Resident #31 was eating approximately 50% of her meals. The resident reported a low appetite. According to the note, the RD discussed a high calorie dietary supplement with the resident and she was receptive to the supplement. The nutrition note indicated staff would continue to monitor at the NAR meeting for weight fluctuations. The 3/16/23 NAR meeting record, provided by the facility on 5/15/23, read the resident was on a diet of no added salt (NAS) and controlled carbohydrates (CCHO). The NAR record indicated the resident was down a total of five lbs in 30 days. The resident was provided a supplement of choice once a day related to a low appetite, eating a variable amount of 50%. The 3/23/23 nutrition/dietary note identified the resident continued to be followed in the NAR meeting for weight fluctuations and had an intake of 50% at meals. Resident #31 continued to be receptive to her supplements and drank about half of it. -The 3/23/23 NAR record did not identify changes to the resident's weight or intake. The NAR meeting record under current weight was left blank. The 4/10/23 administration note identified the resident had an order to provide the resident with a supplement of choice, once a day for low appetite/intakes. The order directed staff to provide the resident the supplement as a p.m. snack. The 4/13/23 NAR record identified the resident's weight as of 4/13/23 was 150 lbs and she ate 50% to 75% of her meals. The 4/14/23 nutrition/dietary note read Resident #31 was followed in NAR with weight fluctuations related to fluid retention and weight drain at the hospital. According to the note, the resident accepted her supplement well and was on daily weights to monitor fluid retention. The note revealed the resident would be discontinued from NAR. -Review of the progress notes and assessments, identified Resident #31's nutritional status was not assessed or reviewed by the RD between 4/14/23 and 6/14/23 when she was having nausea, vomiting and weight loss (see below). The 4/22/23 health status note read the resident had complained of nausea and vomiting. Resident #31 was prescribed Zofran to help reduce the symptoms nausea and vomiting. The 5/15/23 weight and vital summary record identified she weighed 154 lbs. The 5/16/23 transfer to the hospital note read the resident was transferred to hospital related to low oxygen saturation levels, low resident response when spoken to and convulsions. The resident had three plus edema to bilateral lower extremities. The 5/19/23 admission summary note read the resident returned from the hospital after she had two blood transfusions. The note identified the hospital did not remove fluid from the resident. The 5/20/23 weight and vital summary record identified she weighed 139 lbs after her return from the hospital. -The record review identified the resident was not assessed by the RD after the change in condition and weight loss. The 5/21/23 health status note identified the resident's condition after hospitalization and blood transfusions. According to the note, the resident continued to sleep almost 20 hours a day. She had a despondent affect. The note identified the resident continued to drink water, tea and soda and had a fair appetite, eating 60% of her meals. The weight and vital summary record between 5/21/23 and 5/30/23 identified the resident was weighed daily. The 5/24/23 administration notes identified the resident vomited. She was provided with Zofran and it was effective. The resident's weight and vital summary record, by use of the wheelchair scale, identified weight fluctuation between 5/21/23 and 5/27/23: -137 lbs on 5/21/23 -126 lbs on 5/24/23 -136 lbs on 5/27/23 The weight and vital summary record on 5/28/23 indicated the resident weighed 118 lbs by use of the wheelchair scale, revealing an 18 lb loss in a day. The weight and vital summary record on 5/29/23 indicated the resident weighed 114 lbs by use of the wheelchair scale, revealing a 4 lb loss in a day. The weight and vital summary record on 5/30/23 indicated the resident was weighed and reweighed. Both weights on 5/30/23 indicated the resident weighed 112 lbs. -The weight record identified that the resident lost six lbs between 5/28/23 and 5/30/23. The weight and vital summary record identified the resident was weighed again on 6/2/23. The resident weighed 114 lbs. The 6/2/23 administration notes identified the resident vomited. She was provided Zofran which was effective. The 6/3/23 administration note identified the resident was nauseated and had dry heaves. She was provided Zofran which was ineffective. The 6/4/23 administration note read daily weights in the morning related to nephrotic syndrome with unspecified morphologic changes were no longer indicated. The 6/6/23 health status note read the resident complained of nausea. She was provided zofran. According to the note, the resident was educated on taking small sips of fluid. The note identified the resident had temporal wasting (loss of muscle mass around the temple caused by nutritional deficiency, weight loss). The 6/6/23, 6/7/23 and 6/8/23 administration notes read Zofran was effective for her nausea. The weight and vital summary record identified the resident was not weighed again until 6/8/23. The record identified the resident weighed 100 lbs, a loss of 14 lbs in a week, between 6/2/23 and 6/8/23. The review of the weight record between 6/8/23 and 6/15/23, did not identify the resident was reweighed after the identification of a 14 lb weight loss. The 6/9/23 health status note read the resident was not eating, slept 22 to 23 hours a day and had temporal wasting. According to the note, the physician spoke to the resident and she did not want hospice. The 6/10/23 administration notes read Zofran was effective for her nausea. The 6/11/23 administration notes read some emesis and bile and not eating. The resident was provided with Zofran but it was not effective. The 6/12/23 health status note read the resident continued to decline, not eating and barely drinking. The 6/13/23 administration note read the resident was provided Zofran which was effective. - The NAR record identified the resident was not reviewed in NAR between 4/14/23 and 6/13/23 after she had a significant weight loss, increase in nausea and vomiting and a decline in eating. -The resident was not reviewed in NAR until during the survey (see RD interview). Record review identified the resident was not assessed by the RD between 4/14/23 and 6/13/23 after the resident had a weight loss of 50 lbs at 33.33%. Resident #31 weighed 150 lbs on 4/17/23 after the last NAR meeting and she weighed 100 lbs on 6/8/23 during her last record weight. The 6/14/23 at 6:08 p.m. nutrition/dietary note read the RD conducted a follow up assessment for significant weight loss of 26.3% body weight in 30 days. Resident #31 had a weight of 100 lbs and a body mass index (BMI) of 14.8. According to the RD's assessment, she felt the weight on 6/8/23 was inaccurate. She requested a reweigh on 6/12/23 and again on 6/14/23. Resident #31 reported she did not have an appetite and did not want to eat. The RD observed the resident attempting to eat dinner and she became immediately nauseated. Resident #31 stated she liked ice cream. The RD discussed supplements and the resident's husband informed the RD that she stopped drinking them a few days ago because they make her vomit immediately after consumption. The resident's husband informed the RD they spoke to the physician and the loss of appetite was expected with kidney failure. The RD asked the resident if there were any foods she would eat or she was craving and she said no. According to the note, the RD made the following recommendations: -Monitor intakes and weights closely. -Contact physician regarding vomiting and loss of appetite. -Offer ice cream frequently as snacks or at meals. -Suggest meal alternatives daily and inquire about the resident's current cravings. -Liberalize diet. -RD to follow as needed. The 6/14/23 RD note identified additional nutritional interventions could be offered to the resident. The weight and vital summary record on 6/15/23 did not identify the resident was weighed as requested by the RD (as noted above) to determine the resident's current weight. The 6/15/23 NAR minutes record read the weight a month prior to 6/15/23 was 112 lbs, however, according to the weight and vital record, the resident weighed 156 lbs on 5/15/23 and 139 lbs on 5/20/23 after she returned from the hospital. The resident did not weigh 112 lbs until 5/30/23. -The resident's current weight was left blank on the NAR record. The review of the weight and vital summary record on 6/15/23 did not identify the resident was weighed as requested by the RD to determine the resident's current weight. The 6/15/23 physician note read Resident #31 reporting feeling tired and not well. She had been eating or drinking very little and did not have an appetite. According to the note, the physician discussed the transition to hospice care and she would like to have medications that helped her feel more comfortable. The nursing staff reported a worsening of overall condition and a decrease in food and fluid intake. The physician identified the resident was not in acute distress and had a frail appearance. The resident declined dialysis during hospitalization and in multiple conversations with the physician. The initial worsening of lower extremity edema was treated with diuretics with resolution. The diuretics were stopped at that time. The resident had progressively been eating very little. She continued to decline with worsening weight loss, decreased strength and activity. The note read the physician would discontinue unnecessary medications and follow up in a week. The 6/15/23 nutrition/dietary note read Resident #31 was followed at NAR for significant weight loss of (left blank). Resident #31 began comfort medications on 6/14/23. The resident's weight loss was related to diuresing (an increase in fluid loss through urine) and end stage renal failure. The resident was offered dialysis and had refused. The resident did not have an appetite and was often nauseated with food. The resident was currently refusing her supplement because it caused her to vomit. The resident was offered enteral nutrition by the physician but she was not interested. The note identified the RD recommended offering bland foods to help with nausea and offered soups at meals. -The note identified additional nutritional interventions could be offered to the resident. C. Staff and resident interviews The RD was interviewed on 6/14/23 at 4:26 p.m. The RD said she first assessed Resident #31 in March 2023 as a new admission. The RD said she was told the resident did not have an appetite. The RD said because the resident was a new admission and the RD was worried about potential weight loss she placed the resident on NAR to review her nutritional status. The RD said the resident was admitted to the facility on diuretic therapy which caused her to have some weight fluctuation. The RD said Resident #31 did not have concerns with nausea or vomiting during that time. The RD said after assessing the resident, she identified the resident had a lot of comorbidities (more than one disease or condition) including chronic kidney disease and type 2 diabetes. The interventions included providing diet orders, monitoring the resident's weight and intake, providing a supplement and follow up as needed. The RD said the last NAR meeting to review residents at risk was conducted on 4/13/23. She said the facility was going to meet in May 2023 but the meeting never took place. She said the NAR meeting usually occurred in the second or third week of the month. The RD said the June 2023 meeting had not been scheduled yet but it would probably happen next week. She said sometimes the residents' weights were not done timely before the NAR meeting, making it difficult to review the resident's current weight status. The NAR said she had to continue to check in with nursing staff to weigh the residents. The RD said she was not notified of Resident #31's weight loss on 5/28/23 (a loss of 21 lbs at a 15.11% between 5/20/23 and 5/28/23) and did not review her at that time. The RD said staff should notify her when residents had weight loss. She was not always notified of weight changes. She said normally she was at the facility for two to three days consecutively a month. She said when she was not at the facility, staff could email or call her. However, the RD said she had been at the facility on a regular basis for the past month but she had been assisting the dietary department and the interim dietary manager until the manager started her employment. She said she heard in passing last week that Resident #31 was not doing well so she asked nursing to weigh her and she was planning on seeing her this week (the week of the survey) to review what was going on. The RD said Resident #31's 18 lb weight loss (between 5/28/23 and 6/8/23) was potentially inaccurate and staff should have been reweighing residents anytime any weight looked out of normal. She said she would like residents to be reweighed when there was more than a two to three pound change. The RD reviewed the resident's record and said the resident's weight was down to 100 lbs. She said the resident lost quite a bit in six days. The RD said she asked the director of nursing (DON) to have the nursing staff weigh Resident #31 but she was not sure if the staff had weighed her yet. The RD said she did not see a record for the weight. She said Resident #31 should be weighed at least once a week because of her weight fluctuations. The RD said when residents were at risk for weight loss or had actual weight loss, the RD could help by recommending appropriate interventions. The RD said the weight record for Resident #31 showed she had a significant weight loss. She said significant weight loss was when a resident had a 5% weight loss in 30 days, a 7.5% weight loss in 90 days and 10% weight loss in 180 days. The RD said she would need to investigate Resident #31's nutritional status further because she had had little contact with the facility regarding Resident #31's weight changes. She said the first step was to observe and understand what the resident was eating and if there were food options the resident would consider trying. She said she would see if the resident liked the provided supplement. The RD reviewed the resident's intake records and said the resident took the supplement almost every day at 25%. She said the supplement amount provided could be double or triple its current provided dosage due to the resident's low meal intake and weight loss. She said she would need to investigate nutritional status and options more. She said she would talk with Resident #31's husband, observe a meal to see how she eats and see if the resident needed more assistance at meals. She said the resident may be interested in going to the dining room. The RD said she was responsible for updating the nutrition care plan and reiterated that she had been covering the kitchen since May 2023. She said it was important that all residents at nutritional risk were reviewed regularly to get ahead of concerns, make sure interventions were in place and make sure staff were all on the same page so interventions would have appropriate follow through. Resident #31 was interviewed with her husband (Resident #30) on 6/14/23 at 5:29 p.m. Resident #31 said she had not been eating very much lately because she did not have an appetite. Resident #30 said they met with the physician today (6/14/23) and he said Resident #31 had renal failure and prescribed Resident #31 new medications. -At 5:34 p.m. Resident #31 was with the RD. The resident was asked if she wanted anything else in addition or besides her meal. The resident stated she wanted an ice cream. The ice cream was provided. The RD was interviewed again on 6/15/23 at 9:50 a.m. She said on the evening of 6/14/23 she met with members of the interdisciplinary team and held a NAR meeting. The RD said the DON told her Resident #31 had been offered dialysis and enteral feeding but the resident refused. The RD said she met with Resident #31 to watch her eat her dinner meal on 6/14/23. The resident told the RD that she did not have an appetite and had little interest in food. The RD said the resident tried to eat her bread and she became nauseated. The RD said the resident said she liked ice cream. The RD said her plan moving forward was to monitor Resident 31's weights, offer ice cream at meals and snacks. She said the dietary staff would offer her the ice cream and daily, would ask her if there was anything else she would like to eat. The RD said she asked the resident about her supplement intake and the resident said it had been making her nauseated. The RD said the resident's most recent loss was severe. She said she would have wanted to be notified by the facility after the loss was identified. The RD said weights were monitored but they were inconsistent. She said Resident #31 still had not been weighed after her request. The RD said would continue to work with staff to have needed weights. The nursing home administrator (NHA) and the chief executive officer (CEO) were interviewed on 6/15/23 at 8:08 p.m. They said the facility identified a problem with communication between the RD and the nursing department. The CEO said the NAR meeting should be conducted weekly. He said it was the facility's opportunity to sit down together to review residents with a nutritional risk and add or adjust interventions. He said the facility was not having the NAR meeting as often as they should be. The CEO said management staff met with the RD on the need to increase the frequency of the NAR meeting. The NHA and CEO said staff should communicate with each other on a daily basis regarding residents presenting with nutrition concerns. The NHA and the CEO said the facility identified a concern with accuracy of weights. They said one staff member should primarily weigh the residents to help with weight consistency. They said having multiple people weighing a resident could cause weight fluctuations. They said the facility would focus on ensuring accuracy of weights, frequency of the NAR meetings and communication between the RD and nursing department. 48412 III. Resident #13 A. Resident status Resident #13, age 90, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included hypothyroidism, muscle weakness, a fractured tailbone with two other fractures in the pelvis, noninfective gastroenteritis and colitis, age-related osteoporosis and stage three chronic kidney disease. According to the 3/28/23 MDS assessment, Resident #13 had no cognitive impairment with a BIMS score of 15 out of 15. The MDS assessment indicated Resident #13 only needed assistance from staff for set up during meals. B. Record review A nutritional assessment was completed, upon admission, on 12/15/22. It documented Resident #13 was on a regular diet and not on any nutritional supplements. Meal intakes were marked at 70% with her current weight at 172 lbs. No concerns were noted for her weight. Her food preferences were listed as she liked gluten-free options, like oranges and tangerines and overall was not very picky. According to the resident's care plan initiated on 1/2/23, weight loss was not listed as a specific focus area with interventions in place. Resident #13 had an activity of daily living (ADL) self-care deficit referring to limited mobility from a fracture to the sacrum, sacral wing, and pubic ramus sustained on 1/7/23 from a fall in the facility. Interventions were entered for staff to provide milkshakes or liquid food supplements when the resident refused or had difficulty with solid food or provide nutritious foods that could be taken from a cup or mug where appropriate. The care plan documented the resident had osteoporosis and osteoarthritis. Interventions included to encourage adequate nutrition and hydration and encourage the resident to maintain weight in a normal range for her height. A review of Resident #13's weights since her admission, documented in the weights and vitals record revealed: 12/21/23, her first weight after being admitted was documented at 172 pounds (lbs). 1/23/23, after she returned to the facility from the hospital, Resident #13 had a weight of 172 lbs. Resident #13's weight was not obtained for February 2023. 3/10/23 Resident #13 had a weight of 150 lbs with a 12.8% weight loss within 90 days. Resident #13's weight was not obtained for April 2023. 5/22/23 Resident #13 weighed 152 lbs. 5/30/23 Resident #13 had a weight of 150 lbs. 6/9/23 Resident #13 had a weight of 120 lbs with a 20% weight loss within 30 days. -There was no evidence of a re-weight to determine if the weight loss was accurate. Resident #13 was added to the NAR meeting discussion on 3/10/23. Meeting minutes for 3/10/23 read, Resident #13 was reviewed at NAR for significant weight loss of 12.8% across 90 days. Resident was admitted with a weight of 172 lbs on 12/21 and now weighs 150 lbs. Resident is finally eating a bit better - previous weeks she had multiple fractures and was not eating much. Recommend interviewing the resident to understand if weight loss was intentional. Recommend weight maintenance. We will continue to follow at NAR for weight stability. NAR meeting minutes for 3/16/23 read, Resident #13 was reviewed at NAR for significant weight loss of 6.4% across 30 days. Resident is fixated on her weight. Resident is finally eating a bit better - previous weeks she had multiple fractures and was not eating much. Registered dietitian (RD) discussed weight loss with resident and she states she has not been wanting to eat as much because she had been laying around. Resident is getting out more and coming to activities so we expect to see intakes improve. Supplement initiated. Recommend weight maintenance. We will continue to follow at NAR for weight stability. A nutr[TRUNCATED]

Based on observations, record review and interviews, the facility failed to protect seven of seven residents (#19, #25, #10 and four residents who asked to remain anonymous) out of 29 sample residents, from resident-to-resident abuse that contributed to the residents experiencing emotional and psychological harm. This deficiency was cited previously during a recertification survey on 3/25/21. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Specifically, the facility failed to protect the residents from repeated instances of verbal and mental abuse by Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 toward other residents which contributed to residents feeling fearful, helpless, isolated, anxious, and stressed. Residents reported Resident #19's abusive behavior toward them triggered prior mental health conditions and a feeling that they needed to physically protect themselves against Resident #19. The facility's failure to recognize the harm created by Resident #19's abusive behavior toward the residents and its failure to develop and implement an effective response created an immediate jeopardy situation of further abuse and resident harm if steps were not taken to immediately correct the situation. Further, the facility's ineffective response contributed to resident distrust and fear of retaliation by both Resident #19 and staff if their concerns were made known. Cross-reference F742 Failure to provide behavioral/mental health services resulting in psychosocial harm. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Interviews revealed the facility failed to protect residents from repeated instances of verbal and mental abuse by Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 toward other residents which contributed to residents feeling fearful, helpless, isolated, stressed, and anxious. The Resident Council president, Resident #25, reported that Resident #19 called residents derogatory names (stupid, dumb, old man, thief, and obscenity, obscenity and obscenity, and repeatedly cursed at facility residents. Resident #25 said she was scared to death of Resident #19 and was fearful of physical harm. She said when Resident #19 yelled at her, she just wanted to hide in a corner. Resident #25 said, as the Resident Council president, she felt helpless and did not know what to do. Additional resident interviews confirmed Resident #19's abusive behaviors, including threats of physical harm, and their feelings of isolation and fear. The facility, despite knowledge of Resident #19's abusive behaviors, failed to develop effective preventive interventions, thereby subjecting the residents to on-going abuse. On [DATE] at 4:05 p.m., the nursing home administrator (NHA) and director of nursing (DON) were informed that the facility's failure to take steps to protect Residents #25, #10, four residents that asked to remain anonymous, as well as Resident #19, from known abusive behavior by Resident #19, created an immediate jeopardy situation that placed the residents at risk for serious harm if the failures were not immediately corrected. B. Interim plan to ensure resident safety On 4/20/22 at 5:25 p.m. the NHA implemented an interim plan to ensure the safety of all residents until a formal, final plan could be submitted on 4/21/22. The facility immediately initiated ongoing one-to-one supervision of Resident #19. C. Facility plan to remove immediate jeopardy On [DATE] at 4:44 p.m. the facility submitted its final plan to remove immediate jeopardy. The plan read: 1. Facility initiated one-on-one oversight of Resident #19 on 4/20/2022 at approximately 4:40 p.m. This will continue indefinitely. All staff will be educated prior to providing one-on-one care in the following areas: a. Safety of all residents, including Resident #19. b. Redirection options. c. De-escalation of verbal outbursts. 2. All staff will be educated by 4/22/2022 on specific redirection techniques, that include: a. Redirection away from the immediate area. b. If the resident refuses to leave the situation, offer activities of interest, such as smoking or coffee, provide opportunities for positive interaction and attention. c. If appropriate, staff will discuss the resident's behavior and remind the resident when inappropriate discussions occur, and ask the resident about her rock collection. 3. The facility has reached out to the quality improvement organization (QIO) for guidance. A meeting with several team members from the QIO have been scheduled for 4/22/2022 at noon. 4. Resident was visited by an outside mental health professional on 4/20/22 at approximately 7:20 p.m. without remark. Facility is waiting for documentation of the final report from this provider. 5. Behavior management education will be completed on all new hires and agency staff prior to working their first shift. 6. Facility has purchased cigarettes for Resident #19 and has initiated supervised smoking, per resident's request on 4/20/2022. Staff reports the resident enjoys smoking. 7. Resident 19's care plan was reviewed and updated on 4/21/22. Interventions currently in place include emphasizing positive aspects of compliance related to positive interactions with others, redirecting the resident when necessary, offering activities of choice, such as smoking/coffee. When the resident becomes agitated, attempt to intervene before escalation, and engage calmly in conversation. 8. The facility will complete a facility-wide audit to determine those negatively affected by Resident #19's actions. The facility will complete this facility-wide audit by 04/22/2022. This audit will be used to create the support-based group listed below and will include all residents who want to participate. 9. The facility will develop a support-based group compiled from facility-wide audits. Residents identified with reported trauma will be offered services outside the facility. D. Removal of immediate jeopardy On 4/21/22 at 5:20 p.m. the NHA and DON were notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, deficient practice remained at H level, a pattern of actual harm. II. Facility policy and procedures The Preventing Resident Abuse policy, initiated 11/1/17, was provided by the NHA on 4/21/22 at 5:52 p.m. The policy read in part: All residents have the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents symptoms. As part of Resident Abuse Prevention, the administration will protect our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . [Will] develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] [Will] require staff training orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident and behavior . identify and assess all possible incidents of abuse . [Will] establish and implement a QAPI (quality assurance plan of improvement) review and analysis of abuse incidences; [Will] implement changes to prevent future occurrences of abuse; and involve the resident council in monitoring and in evaluating the facility's abuse prevention program. The Resident Rights policy, revised August 2009, was provided by the NHA on 4/21/22 at 5:52 p.m. The policy read in part: Federal and state laws guarantee certain basic rights to all residents of this facility .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. III. Resident #19 A. Resident status Resident #19, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/8/22 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS identified the resident had inattention and disorganized thinking. Resident #19 required supervision for bed mobility, transfers, locomotion on and off the unit, personal hygiene, eating and toileting. The MDS indicated Resident #19 exhibited physical behaviors directed at others for one to three days during the MDS seven day look back period. According to the MDS, the resident also had verbal behaviors for four to six days out of the seven day look back period. The resident did not have rejections of care. B. Observation and interview 1. Prior to facility notice of immediate jeopardy On 4/18/22 at 5:55 p.m. during the evening meal service. Resident #19 was propelling herself in her wheelchair through the dining room. Resident #34 was yelling out in confusion for her dog. Resident #19 yelled back in a mocking tone, where's my dog, where's my dog. Resident #19 laughed and took herself outside to the courtyard. On 4/19/22 at 3:50 p.m., Resident #19 approached the surveyor in the hallway. The resident stated to the surveyor, Don't go in that room, he's a [vulgar term]. Licensed practical nurse (LPN) #3 looked at the resident and stated, that wasn't very nice. LPN #3 then said to the surveyor, This is what we have to deal with every day. On 4/20/22 at 4:17 p.m. Resident #19 was heard down the hallway yelling from her room, the words were not distinguishable. -At 4:18 p.m. Resident #19 exited her room and entered the dining room. Resident #19 stopped in the middle of an entrance point of the dining room. -At 4:19 p.m. Resident #10 attempted to navigate around Resident #19 to exit the dining room while in her wheelchair. Resident #10 accidentally bumped the foot peddle of Resident #19 because of the limited space available for her to pass. Resident #10 quickly apologized and backed up her wheelchair. Resident #19 told Resident #10, I wish you would stop running me over, you do it all the time. Resident #10 said she would go the other way and proceeded to propel herself to the other side of the dining room. Resident #19 said as she motioned to residents sitting at a dining table, You will probably just run over them, too. Resident #19 was interviewed on at 4/20/22 at 4:23 p.m. after she accused Resident #10 of running over her. She did not express interest in the interview or respond to questions. Resident #19 then focused her attention on the television show playing in the dining room. Resident #10 was interviewed on 4/20/22 at 5:01 p.m. Resident #10 said Resident #19 was always giving her a hard time. She said that was how Resident #19 was. She said sometimes it upset her but she was used to it. 2. After facility notice of immediate jeopardy On 4/21/22 at 9:48 a.m. the minimum data set coordinator (MDSC) sat in a chair across from the room of Resident #19. Resident #19's room door was closed. The MDSC said she was providing one-to-one supervision of Resident #19. On 4/21/22 at 3:40 p.m. Resident #19 was observed on 4/21/22 at 3:40 p.m. with the MDSC during her one-to-one supervision as she wheeled throughout the facility. Resident #19 was smiling, and talking to the MDSC. She was not focusing on other residents and seemed to enjoy the positive attention. IV. Resident interviews Although Resident #19 did not have any concerns with the facility, interviews with Residents #25, and four residents that asked to remain anonymous revealed they were frustrated, scared and fearful of Resident #19 and felt the facility did not know how to stop her verbal and physical aggression. A. Resident #19 was interviewed on 4/19/22 at 3:25 p.m. She said she had no concerns with the facility. B. Resident #25 was interviewed on 4/19/22 at 3:30 p.m. and again on 4/20/22 at 9:03 and 9:55 a.m. Record review revealed Resident #25, age 72, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her 2/12/22 MDS revealed the resident was cognitively intact with a BIMS of 15 out 15. Resident #25 identified herself as the Resident Council president. She said Resident #19 said rude things to residents in the facility and made fun of residents who could not defend themselves. Resident #25 said Resident #19 called her a obscenity and called others obscenity dumb, stupid and idiot. She said these were just some of words Resident #19 used against residents. Although she acknowledged this may affect residents differently, she said she had seen a resident cry because of Resident #19's behavior toward them. Resident #25 said she had to ask Resident #19 twice to leave a Resident Council meeting on 4/19/22. She said Resident #19 flipped her off and left, but returned to the meeting five minutes later, and called a resident and a housekeeper obscenities. Then, when lost and found clothes were brought before the residents for identification, Resident #19 called another resident a thief when he retrieved a clothing item. Resident #25 said she asked Resident #19 not to call the resident a thief and asked her, again, to leave the meeting. She said Resident #19 then said, You are all a bunch of obscenity. Resident #19 proceeded to call her an obscenity and left the meeting. Resident #25 said she was so flustered she couldn't continue reading the Resident Council minutes. She did not know what she should do. Resident #25 stated she was frantic and felt like she wanted to go into a corner and hide. Resident #25 said she got scared because she didn't know what to do if Resident #19 came after her. Resident #25 stated, It was bad enough to be called names, but Resident #19 threatens to beat people up. Resident #25 said about a year ago, Resident #19 had tried to hit her. She said she was backed in a corner and knew Resident #19 was coming directly for her. Resident #25 said she was trying to get out of Resident #19's way. She said her back was turned and then she heard another resident yell out to Resident #19 to stop. Resident #25 said that resident told her she saw Resident #19 raise her hand in an attempt to hit her. Resident #25 said she gets scared when people yell at her. She said it triggered an old trauma she had, stating that years ago, and had also experienced retaliation when she once reported a staff member. She stated she had [CONDITION(S)] from that incident and Resident #19 brought up those memories; she said she didn't want to experience retaliation again. Resident #25 said, again, that she was upset about Resident #19 attending the 4/19/22 Resident Council meeting. She said that even though the activity director (AD) and the activity assistant (AA) were at the Resident Council meeting, she was the one who had to tell Resident #19 to leave the meeting. Although the AD spoke to Resident #19, Resident #25 said she thought the AD really was not sure how to handle the situation because she was new to her position. Resident #25 said she thought she could handle the situation with Resident #19 until her behavior during the Resident Council meeting. She decided then that she'd had enough. She said the residents here were her family and Resident #19 was her family, too, but Resident #19 was out of control. Resident #25 said she was the Resident Council president and it frustrated her to no end that she could not control Resident #19's behavior in the meeting and could not protect the other residents in the meeting or at any time. Resident #25 said as the Resident Council president, she was supposed to be a resident advocate but she feels useless and does not know what to do about Resident #19's behaviors. She said it keeps occurring: Resident #19 acts out, she is told to leave and then she comes right back, even more angry, and then makes fun of everyone or continues to call them names. Resident #25 said Resident #19 was disruptive to others during the meals and bingo, too. She said staff remind the resident to not yell out obscenities but that was the only step staff took and it didn't seem to bother Resident #19 or change her behavior. Resident #25 said staff did not know what to do with Resident #19. Resident #25 said she has seen Resident #19 try to hit staff when asked to leave an area and she has seen staff rolling her backwards to her room as she swung at them. Resident #25 repeated that Resident #19 scared her. She said the resident constantly says she is going to beat someone up. Resident #25 said that, although she is a grown up, she still feels scared to death of Resident #19. She said when Resident #19's anger was directed at her, all she wanted to do was hide in a corner. She said it was really hard to have to feel that way all the time. Resident #25 said she told the DON on 4/19/22 that she felt scared and fearful of Resident #19. Resident #25 stated she told the DON about Resident #19 attending the 4/19/22 Resident Council meeting, what happened there, and how it made her feel. She stated the DON said, How come this only seems to come up when the State is here? Resident #25 said she told the DON that Resident #19 always calls people names, acts out in bingo, at meals used vulgar language and the certified nurse aides (CNAs) have to tell her that was not proper language. Resident #25 stated the DON asked her if she was afraid of Resident #19 and she said, Yes, I am scared of her. C. A resident that asked to remain anonymous was interviewed on 4/20/22 at 10:41 a.m. The resident stated s/he had numerous verbal altercations with Resident #19. S/he stated, She'll tell me she's going to beat me up and I'll tell her no you won't. The resident stated Resident #19 is always loud and cussing; the staff just tell her to lower her voice. The resident said it bothers her/him that Resident #19 is loud and yelling when her/his roommate is sleeping. The resident stated, but what can we do about it? What can you do about it? D. A resident that asked to remain anonymous was interviewed on 4/20/22 at 11:26 a.m. The resident stated Resident #19 had called her names. S/he stated, s/he just lets it roll off because that is just the way she is. E. Another resident was interviewed on 4/20/22 at 2:10 p.m. The resident requested to remain anonymous. The resident said s/he would like to know what was going to be done about Resident #19 who screamed and yelled all night. The resident said Resident #19 could be heard through the walls, yelling. S/he said Resident #19 screams and speaks nasty to people. The resident said s/he no longer talks to Resident #19 and said Resident #19 called her/him and everyone, names like obscenity. S/he said when family members hear the cursing, they do not want to come back to visit. The resident said her/his family was approached by Resident #19 when they were visiting the facility. Resident #19 came up to his/her family and said what the obscenity are you doing here. The resident said her/his family told her/him that the facility sounded like a crazy house. The resident said her/his family had not returned again to visit after that. The resident expressed s/he felt isolated, not having her/his family visit. The resident, referring to Resident #19, asked She won't find out, will she? She won't bother me, (if) she stays away. I'm not worried, I'm just saying somebody may tell her. S/he said Resident #19 was constantly talking about the residents' incontinent briefs and mocking them. Nobody would want to say anything, I guess they're scared or something. F. A resident was interviewed on 4/20/22 at 5:12 p.m. The resident requested to remain anonymous. The resident said the last time s/he spoke to the State, staff was upset with him/her. S/he said several staff would no longer even talk to her because s/he spoke to the State about facility concerns. The resident said s/he was scared to death that anything s/he said would have negative repercussions for her/him. The resident said the facility might try to kick her/him out of the facility. The resident said Resident #19 was very disruptive and destructive. The resident said s/he has seen Resident #19 knock items off the dining table when she was upset and she has been kicked out of bingo multiple times. The resident said staff do not know what to do with her; she is asked to leave the area and then she comes back minutes later. The resident said Resident #19 knew s/he had observed her aggression towards others and she has told her/him that s/he was next, putting her fisted hand into her other hand and re-creating a punching gesture. The resident said s/he had a cane that s/he would use to protect herself/himself against Resident #19, if necessary. The resident said s/he also has given a cane to another resident for protection against Resident #19. The resident said s/he had a bad heart and s/he felt the stress in the facility was going to kill her/him. V. Group Interview A resident group interview confirmed Resident #19 was confrontational, mean, cursed at them, tried to hit them and called them derogatory names. They indicated that the staff did not know how to handle the resident. They also feared retaliation by Resident #19 and staff. A resident group interview was conducted on 4/20/22 at 2:06 p.m. with five residents deemed interviewable by facility assessments. A. One of the residents said the council did not like the DON or NHA to be regularly involved in the council meetings because they (administration) might not like to hear what the residents have to say. She also did not want staff taking notes during the council meeting. She said residents have asked her not to share names when they complain in council about their concerns. The resident said she was concerned about staff getting mad at her for reporting grievances. She said she was concerned about staff retaliation because of a past trauma she endured when she reported a staff member years ago and he confronted her about the report. B. Another resident brought up the 4/19/22 Resident Council meeting. She confirmed that the activity director (AD) spoke to Resident #19 because she was cursing and very disruptive in the meeting, but Resident #19 continued the behavior after the AD spoke to her. The resident said she had a bigger voice than the AD so she told Resident #19 to get out. The resident said she did not know what else to do. C. All residents in the group interview expressed they were subject to direct confrontation with Resident #19, or had to hear her confront other residents. The residents in the group interview made the several statements regarding their feelings and interactions with Resident #19 and what it was like to have to live with her. Residents stated: - There are curse words included in every conversation with her. - She can be heard cursing at people in the hall. - She was out of control, calling people names and interrupting conversations. - She was everyone's pain. Sometimes she was nice, sometimes she was a b - When she calls me names, I just have to try to ignore it. - When she was being mean and calling people names, that was verbal abuse. The other residents agreed with the statement. - She felt frustrated, flustered and fearful because she had seen Resident #19 try to take hits at other people and she did not want to be in the midst of that. It's a worry about retaliation. from Resident #19. -Resident #19 will find out if we complain about her; my worry is that she will find out. VI. A frequent facility visitor interview confirmed Resident #19's abusive behavior toward other residents and residents' fear of her. A frequent facility visitor was interviewed on 4/20/22 at 3:15 p.m. She said Resident #19 wanted either good or bad attention from people. She said she had heard in the past of residents complaining about Resident #19's behavior and spoke to Resident #19, thinking her behavior could be reigned in. She said she had never seen her behavior first hand and when she did, it stunned her. The visitor explained she attended the recent Resident Council meeting when Resident #19 made a lot of noise. Resident #25 asked Resident #19 to remain respectful in the meeting and the AD spoke to Resident #19 twice, telling her if she continued to curse, she would have to leave. Resident #19 then called Resident #25 an obscenity. The resident left the meeting three times but continued to return. She flipped off Resident #25 and said I'm gonna kick somebody's obscenity. The visitor said the other residents handled the situation well. She said she thought the residents were afraid of Resident #19. She said to the best of her knowledge, Resident #19 had not hit anyone, but hearing the comments from the residents in the group interview (see above), maybe she had. The visitor said she was not aware until after hearing the residents' comments that Resident #19's behaviors also were at night, which could be quite disruptive. VII. Staff interview Staff interviews confirmed the facility was aware of Resident #19's aggressive behavior toward other residents but did not recognize the emotional and psychological harm residents felt as a result. Further, although staff were able to articulate interventions to address the resident's behavior, resident interviews (see above) and interview with the frequent facility visitor (see above) revealed these interventions were not effective in protecting the residents from Resident #19's abuse. A. The MDSC was interviewed on 4/20/22 at 11:31 a.m. The MDSC said all staff were responsible for checking in on residents when they were upset. She said she sometimes can hear Resident #19, loud and upset, from her office located outside of the dining room. She said when Resident #19 exhibits behaviors, staff try to keep residents safe by taking her out of the area, offering to sit and talk with her, offering to do her nails or redirecting her with coffee and by asking her what she needs. The MDSC said sometimes staff let her self-soothe but not when other residents were involved and at risk. B. The activity director (AD) was interviewed on 4/20/22 at 11:37 a.m. She said Resident #19 would blurt things out. The AD said on 4/19/22 during the Resident Council meeting, Resident #19 was loud and disruptive. The AD said she asked Resident #19 to leave the meeting and Resident #19 left but then came back moments later and called Resident #25 an obscenity. Resident #19 was asked to leave again but she returned and was again loud, rude and confrontational. The AD said Resident #19 called Resident #1 a thief. She said staff interventions to address Resident #19's behaviors were care planned. C. The social service director (SSD) was interviewed on 4/21/22 at 1:43 p.m. The SSD said part of her role was to provide emotional support for residents. The SSD said if residents were feeling down, she was always available to listen to them. She said she tried to get to know the residents. The SSD was asked about the plan to address Resident #19's behaviors. She said she has seen staff remove Resident #19 from the situation when her behaviors escalate. The staff try to give her space and explain to her that she can not call residents names, and walk her to her room. The SSD said they have tried offering Resident #19 mental health services but she has refused in the past. The SSD said they also make sure she does not have roommates. The SSD said residents have said Resident #19 yelled at them, but usually said it did not bother them. The SSD said she has asked the residents if they felt safe in the facility. She said no one has told her they did not feel safe and no one had mentioned they felt afraid. The SSD she said thought said residents were trying to cope with Resident #19. The SSD said that since (during the survey) the facility had learned the residents were expressing fear of Resident #19, the new plan moving forward was for Resident #19 to be assessed again by mental health services, to offer her medication to help her sleep better, and to give her smoking privileges back. Resident #19 would also be closely supervised for both her smoking and her interactions with other residents. She said Resident #19 has told her that she wants to be left alone and she wants to leave the facility. The SSD said the resident had been turned down for transfer by ten facilities in Colorado and because the resident had an interest in Texas, she would start looking at facilities there. The SSD said she would continue to communicate with residents and continue having residents complete abuse audit questionnaires. She said she routinely asked residents questions on abuse and would interview each resident at least quarterly. She said if she identified a concern, she would follow up with the DON. The SSD said if residents expressed concerns about a staff member, she would not share that information with the identified staff member but would refer it all the the DON. She said residents had completed abuse questionnaires between December 2021 and April 2022. According to the questionnaires, residents were interviewed regardless of their cognitive abilities. She said if residents expressed a concern but were not able to fully communicate their concern, she would ask staff if they were aware of any incidents and would monitor and track that resident's behavior, looking for changes. She said she would document the concern and findings. Review of abuse questionnaires revealed: -A 12/22/21 questionnaire was completed by Resident #25. The resident had said she did not feel safe and there was a lot of chaos. The SSD said Resident #25 did not share any more details. She said she did not follow up with the resident at a later time or have another staff member re-approach her. She said she did not document the concern other than in the questionnaire and was not aware if the resident was offered additional support related to her feelings of being unsafe. The SSD said it did not sound like it was an issue. -A 2/9/22 questionnaire was completed by Resident #26. According to the questionnaire, the resident was asked if she felt safe. Resident #26 said yes and no. The resident identified Resident #19, but the run ins have improved with the addition of another resident. Resident #26 was asked if she had feelings of being afraid. The resident responded she was weary of. The SSD said Resident #26 was weary of Resident #19's yelling. The SSD said Resident #26 mistrusted staff. She tended to stay in her room except to play bingo. She was paranoid and had a related diagnosis. The SSD said residents with paranoia can have their feelings heightened by the behaviors of others. The SSD said Resident #26 would have run ins with Resident #19. The SSD said she could not show she documented or followed up with Resident #26's feelings of weary of and feelings that she sometimes did not feel safe. D. Administrative assistant (ADM ) #1 was interviewed on 4/21/22

Based on record review, observations and interviews, the facility failed to ensure adequate nutrition and assistance to prevent weight loss for one (#20) of five residents reviewed out of 29 sample residents. Resident #20 lost seven pounds over an eight day period, and experienced significant weight loss. Resident #20 had a 5% weight loss from 2/7/22 to 2/21/22 and a 7.5% weight loss from 2/7/22 to 4/19/22. The facility failed to assess and implement timely interventions, including dining assistance, to prevent the resident's significant weight loss. Findings include: I. Resident status Resident #20, age 84, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/10/22 minimum data set (MDS) assessment revealed that a brief interview for mental status (BIMS) assessment was not completed as the resident was rarely understood. The MDS revealed the resident required set up help for eating (using utensils to bring food and liquid to the mouth and swallow food and liquid once the meal is placed in front of the resident) and did not indicate a weight loss. II. Observations On 4/19/22 at 8:52 a.m., the resident was in his room, slumped in his chair, with his bottom near the edge of the chair and his head was to the left side of the back of the chair. A breakfast plate was in front of him on his side table. The food appeared uneaten and the orange juice was full with plastic covering the top of the glass. At 12:20 p.m., the resident was observed in his room slumped in his chair with a lunch plate in front of him on his bedside table. The food plate was untouched and the beverage cups were still full. The nursing supervisor/registered nurse (NS) was observed going into the resident's room assisting him a bite of food. The resident did eat the bite; it was meat that looked like stew meat. The NS then left the resident's room. Ten minutes later at 12:30 p.m., the NS was observed going back into the resident's room and assisting him another bite of meat. The resident took that bite and ate the meat. The NS was observed leaving the room after that bite of meat. At 12:36 p.m. the resident was observed sitting in his room with his lunch plate about two feet in front of him on the bedside table. The resident's tray revealed only a few bites of food were eaten. The NS was observed walking into the resident's room. The resident told the NS he needed to use the restroom and after using the restroom, he would eat the rest of his lunch. The NS was observed asking a certified nurse aide (CNA) to take the resident to the restroom. At 12:53 p.m., the resident was observed in his chair drinking juice. There were a few more bites of food eaten. It appeared the resident ate about 25% of his meat and vegetables; the macaroni and cheese appeared untouched. On 4/20/22 at 8:52 a.m., the resident was in the dining room for breakfast. He was sitting in his wheelchair at a table. He had scrambled eggs, pancakes and bacon on his breakfast plate. The breakfast appeared uneaten. The NS was observed walking into the dining room and asked the resident, Are you going to eat? She then assisted the resident a bite of pancake. The NS was observed walking away to assist another resident and Resident #20 was observed sitting in his wheelchair not attempting to eat or drink. At 8:57 a.m., administrative assistant (ADM) #1 was observed walking out of her office and asked the resident if he wanted another bite. The resident shook his head. A CNA then removed the breakfast plate from in front of the resident and did not offer an alternative. III. Record review Upon record review of the resident's documented weights, the resident had a 5% weight loss from 2/7/22 to 2/21/22 and a 7.5% weight loss from 2/7/22 to 4/19/22. Upon record review, the resident weighed 124 pounds (lbs) on 2/7/22 and weighed 107 lbs on 4/12/22. The 2/322 physician ordered [MEDICATION(S)] 15 mg once a day, to stimulate appetite. The 2/3/22 physician ordered half size meal portions if the resident requests. The nutritional assessment dated [DATE] indicated the resident's weight was 124 lbs. The assessment indicated the resident was on a regular diet and meal intake was 25-50%. The recommendations were to cut down on portion sizes and add more ethnically appropriate foods. The nutritional progress note dated 2/17/22 at 1:34 p.m. indicated the resident was discussed at a weight meeting as a new admission. The resident lost 4 lbs in one week. There was a concern the portion sizes may have been too large for the resident. The nutritional progress note dated 3/3/22 at 1:18 p.m. revealed the resident was discussed at a weight meeting for a loss of 5% of the resident's body weight in one month. The note stated the resident ate poorly and consumed less than 50% of meals. The note stated the resident complained about large portions which made it hard for him to eat. The intervention of attempting ethnically appropriate food was documented in the nutritional progress note. -Although, the resident portion sizes were decreased, previous to 3/10/22 (see below) there was no additional supplementation or interventions added to provide the resident with additional calories and protein with his ongoing weight loss. The nutritional progress note dated 3/10/22 at 11:08 a.m. revealed the resident was discussed due to a 9.7% weight loss in one month. The note documented the resident ate 26-50% of meals. Interventions included giving the resident Ensure supplements twice a day and offering snacks frequently including at bedtime. On 3/10/22 the physician ordered Ensure three times a day after meals for nutritional supplementation. The nutritional progress note dated 3/17/22 at 11:29 a.m. revealed the resident was discussed at a weight meeting due to a 9.7% weight loss in one month. The note stated the resident received supplements three times per day. The note stated the resident only ate 75% of one meal and refused to eat any more food. The intervention was to offer supplements between meals. The nutritional progress note dated 3/28/22 at 11:56 a.m. indicated the resident was discussed at a weight meeting for a 6.9% weight loss over a month. The note stated the resident ate poorly but appeared to have been eating more. The note indicated the resident's weight seemed to have stabilized. The nutritional progress note dated 3/31/22 at 12:32 p.m. indicated the resident was discussed at a weight meeting due to a 7.5% weight loss over 90 days. The note stated he ate poorly but had been eating meals to completion more often. The note stated the resident refused ethic cuisine and needed cueing to eat. -When the resident refused ethnic cuisine, there were no additional measures to determine his food preferences and offer the resident food he liked. The nutritional progress note dated 4/8/22 at 3:31 p.m. revealed the resident was discussed at a weight meeting for a 5% weight gain in one month and an 8.1% weight loss over 90 days. The note stated the resident ate poorly but had been improving since the CNAs helped the resident set up to eat and assisted him his first bite of food. The nutritional progress note dated 4/14/22 at 11:33 a.m. indicated the resident was discussed at a weight meeting for a 10% weight loss over 90 days. The note stated the resident ate poorly, less than 50% of his meals. The resident received supplements three times per day, which the resident drank. Interventions included: thicker silverware and discussion the resident may have needed to assisted with meals. The resident's care plan, initiated on 3/24/22 and revised on 4/19/22 (during the survey), revealed the resident had experienced a significant weight loss of 9.7% in 90 days as of 4/19/22. The interventions included: monitor/record/report to physician any signs and symptoms of emaciation, significant weight loss of three lbs in one week; provided supplements as ordered; served diet as ordered and monitored intake and recorded meals eaten; resident had a preference for Hispanic foods, offered as able. The nutritional progress note dated 4/19/22 (during survey) at 2:30 p.m. revealed the resident was seen for a weight loss of 9.7% body weight in 90 days. The note indicated the resident's intake was 26-50% of meals and the supplement Ensure which was consumed 75% of the time. The recommendations were: continuing to honor resident preferences, providing supplements as ordered and offering light snacks. IV. Staff interviews The NS was interviewed on 4/19/22 at 12:20 p.m. She stated the resident was fully capable of feeding himself. She said he just needed a little cueing. She stated she would assist him a few bites of food, leave, and check on him every five minutes or so. She stated he could be stubborn at times. She said he had a choice of meals and if he did not like something, he would be verbal about that. She stated the cueing had been working, as he started gaining back some weight. The dietary manager (DM) and registered dietitian (RD) were interviewed on 4/21/22 at 11:01 a.m. The RD stated the resident had been improving, as upon admission he was not eating as much. The RD said the resident was given supplementation and had just started eating in the dining room. The DM stated the resident was a tough one and he would not speak to the DM or some of the staff. The DM said he had been trying to work with the resident to obtain the resident's food preferences. The DM said he had tried sending the resident ethnically appropriate foods and the resident did not like that. According to the DM, the resident stated he wanted smaller portions so the kitchen cut back on his portion size. The DM said the resident's family asked if they could have tried thicker silverware (which was not observed to be using) that would be easier for the resident to use, which the DM did provide to the resident. The DM stated they have tried several interventions such as having the resident eat in the dining room and providing the resident with the supplement Ensure three times a day, which the resident drank almost 100% of the time. The RD stated the resident was started on the medication [MEDICATION(S)] (an antidepressant) which helped with the resident's appetite. The RD stated the last nutritional assessment was completed on 4/19/22. The recommendations from the nutritional assessment were to promote snacks, supplementation, help the resident understand how important communication was, spend more time with the resident to help him progress forward with thicker silverware to help promote his own plate to mouth if he was willing. The DM stated he was unsure if the resident received snacks during the day. The DM stated he was willing to try and have a dedicated staff member assist the resident.

Based on record review and interviews, the facility failed to ensure one (#19) of two out of 29 sample residents, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to implement effective interventions for Resident #19 to prevent and appropriately address Resident #19 abusive behaviors towards other residents. The facility failed to protect residents from continued verbal and mental abuse from Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 towards other residents, resulting in feelings of fear, helplessness, social isolation, humiliation, and extreme anxiety. The staff failed to document the all of Resident #19 behavior, creating a limited management awareness of the frequency of the behaviors towards residents. The facility provided staff education on behavior management but the trainings did not improve the hostile living environment that the residents were subjected to from Resident #19. Interviews identified a staff complacency of Resident #19 behaviors and ineffective interventions to intervene when problems occurred. Facility actions did not show effective results until after an immediate jeopardy situation was identified on 4/20/22 and the facility implemented ongoing one-on-one supervision of staff providing continued mitigation of her behaviors and consistent attention. The facility also allowed her to have smoking privileges again which was identified to calm her nerves. Cross-reference F600 failure to prevent resident to resident abuse that contributed to the resident experiencing emotional and psychological harm. Findings include: I. Facility policy and procedures The Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, was provided by the nursing home administrator (NHA) on 4/21/22 at 5:52 p.m. According to the policy, a behavior was a response of an individual to a variety of factors. The factors could include medical, physical, functional, psychosocial, emotional, psychiatric or environmental causes. The policy indicated behavior was influenced by past experiences, personality traits, environment, and interactions with other people. The policy identified behavior could always be a way for an individual in distress to communicate an unmet need, indicate discomfort, or express thoughts that could not be articulated. The policy read in part: As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: the residents usual pattern of cognition, mood and behavior; the residents usual method of communicating things like pain, hunger, thirst, and other physical discomfort; the residents typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; and the residents previous pattern of coping with stress anxiety and depression . new or changes in behavior will be documented regardless of degree of risk to the resident or others . The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risks to the residents, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress .Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strive to understand, prevent or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. II. Resident status Resident #19, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/8/22 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS identified the resident had inattention and disorganized thinking. Resident #19 required supervision for bed mobility, transfers, locomotion on and off the unit, personal hygiene, eating and toileting. The MDS indicated Resident #19 exhibited physical behaviors directed at others for one to three days during the MDS seven day look back period. According to the MDS, the resident also had verbal behaviors for four to six days out of the seven day look back period. The resident did not have rejections of care. III. Resident interviews Resident interviews conducted 4/19/22 and 4/20/22, identified residents felt they were verbally abused with her yelling and obscenities directed to them. They were fearful of the physical threats Resident #19 made towards them, so much so, several of the residents requested their names not to be identified, expressing worry that the resident would find out. The resident also revealed they saw her attempt to act on her physical aggression towards a resident and staff members. Additional resident concerns included helplessness, humiliation, triggers of post traumatic stress disorder ([CONDITION(S)]), and one resident stated the behaviors of Resident #19 prevented their family members from coming to visit them. Residents indicated staff's inaction to resolve the behaviors of Resident #19 reduced their confidence that the facility/management could and would be able to improve the abusive situation. According to the resident interviews, staff would talk to her reminding her that her behaviors were inappropriate and/or ask her to go to her room, she would leave but the resident would often return to the situation, even more upset, targeting specific residents. The residents identified a recent occurrence during the 4/19/22 Resident Council where she continued to call residents names and flipped off the Resident Council president and continued to return to the meeting with elevated aggression. Interviews identified staff did not know what to do when Resident #19's behaviors escalated. (Cross-reference F600, failure to prevent resident abuse.) IV. A frequent facility visitor interview confirmed Resident #19's abusive behavior toward other residents and residents' fear of her. A frequent facility visitor was interviewed on 4/20/22 at 3:15 p.m. She said Resident #19 wanted either good or bad attention from people. She said she had heard in the past of residents complaining about Resident #19's behavior and spoke to Resident #19, thinking her behavior could be reigned in. She said she had never seen her behavior first hand and when she did, it stunned her. The visitor explained she attended the recent Resident Council meeting when Resident #19 made a lot of noise. Resident #25 asked Resident #19 to remain respectful in the meeting and the AD spoke to Resident #19 twice, telling her if she continued to curse, she would have to leave. Resident #19 then called Resident #25 an obscenity. The resident left the meeting three times but continued to return. She flipped off Resident #25 and said I'm gonna kick somebody's obscenity. The visitor said the other residents handled the situation well. She said she thought the residents were afraid of Resident #19. She said to the best of her knowledge, Resident #19 had not hit anyone, but hearing the comments from the residents in the group interview (see above), maybe she had. The visitor said she was not aware until after hearing the residents' comments that Resident #19's behaviors also were at night, which could be quite disruptive. V. Observations On 4/18/22 at 5:55 p.m. during the evening meal service. Resident #19 was propelling herself with her wheelchair through the dining room. Resident #34 was yelling out in confusion for her dog. Resident #19 yelled back in a mocking tone, where's my dog, where's my dog. Resident #19 laughed and took herself outside to the courtyard. On 4/20/22 at 4:17 p.m. Resident #19 was heard down the hallway yelling from her room, the words were not distinguishable. -At 4:18 p.m. Resident #19 exited her room and entered the dining room. Resident #19 stopped in the middle of an entrance point of the dining room. -At 4:19 p.m. Resident #10 attempted to go navigate around Resident #19 and she tried to exit the dining room in her wheelchair. Resident #10 accidentally bumped the foot peddle of Resident #19 because of the limited space available for her to pass. Resident #10 quickly apologized and backed up her wheelchair. Resident #19 told Resident #10 I wish you would stop running me over, you do it all the time. Resident #10 said she would go the other way and proceeded to propel herself to the other side of the dining room. Resident #19 said as motioned to residents sitting at a dining table, You will probably just run over them too. On 4/21/22 at 9:48 a.m. the minimal data set coordinator (MDSC) sat in a chair across from the room of Resident #19. Resident #19's room door was closed. The MSDC identified she was providing one to one supervision of Resident #19. On 4/21/22 at 3:40 p.m. Resident #19 was observed on 4/21/22 at 3:40 p.m. with the MDSC during her one to one supervision as she wheeled throughout the facility. Resident #19 was smiling, and talking to the MDSC. She was not focusing on other residents and seemed to enjoy the positive attention. VI. Record review The April 2022 CPO for Resident #19 directed staff to monitor the behaviors of the resident. According to the CPO staff should look for signs of depression, crying, self isolation, feeling alone, restlessness, agitation, hitting, increased complaints, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [CONDITION(S)], refusal of care and verbal and physical aggression. The CPO also directed staff to document the behavior findings in the progress notes if identified. The April 2022 treatment administration record (TAR) indicated Resident #19 exhibited behaviors between 4/1/22 and 4/20/22. According to the TAR under behaviors, staff should document a Y if staff monitor the resident's behaviors and none of the behaviors of depression, crying, self isolation, feeling alone, restlessness, agitation, hitting, increased complaints, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [CONDITION(S)], refusal of care and verbal and physical aggression were observed. Staff should document a N if staff monitored the residents and observed any of the above behaviors. The TAR indicated Resident #19 had daily behaviors and on multiple shifts. Progress notes for Resident #19 identified showed limited behavior notes for Resident #19 and only two behavior notes for the month of April 2022, even though the CPO directed staff to document the behaviors in the progress notes which included an undocumented incident on 4/19/22 during Resident Council. On 4/19/22 a behavior note read Resident #19 was heard yelling down the hall. She was redirected to her room with no further incident. Additional notes were reviewed for the past few months. -The 10/15/21 behavior note read Resident #19 was teasing and making fun of other residents in the dining room. The resident became verbally abusive and was screaming loudly. According to the note, Resident #19 attempted to strike the nurse with her fists but was not able to make contact -The 12/5/21 behavior note read Resident #19 was rude and hateful, yelling at residents, telling them to shut up, and mocking other residents that needed assistance. According to the note, Resident #19 looked for weaker residents to pick on. -The 1/26/22 behavior note read the resident was yelling in the hallway. -The 4/3/22 behavior note read she was yelling and angry at residents for not allowing her to smoke with them. The review of the progress notes did not identify all the potentially abuse interactions as described by the as identified by resident and staff interviews,relating to Resident #19. The notes did identify the facility was aware of some of Resident #19's behaviors but allowed the behavior to continue to occur. The care plan for psychosocial well being, initiated on 3/5/19, identified Resident #19 had psychosocial difficulties related to lack of family support. The care plan indicated there were no new interventions to address her psychosocial difficulties since 3/5/19. The [CONDITION(S)] medication care plan, lasted revised 8/16/21, and the anti-anxiety medication care plan, lasted revised on 5/7/2020, identified Resident #19 was administered [CONDITION(S)] medications for her depression and anti-anxiety medication for her anxiety. The care plan indicated staff should monitor and record occurrences of targeted behavioral symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per protocol. The cognition care plan, last revised 3/5/19, indicated Resident #19 had an impaired cognitive function/impaired thought processes. According to the cognition care plan staff should: -Ask Resident #19 yes and no questions, presenting one thought, idea, question or command at a time. -Reminisce with the resident using photos of family and friends. However, according to the psychosocial care plan, the lack of family support contributed to her psychosocial difficulties. -The impaired cognition intervention, initiated on 3/13/22, identified staff should provide one to one visits, redirection, and change environment when she was agitated. The activities related psychosocial care plan, last revised on 5/27/21 identified Resident #19 was independent with her emotional, intellectual, physical needs. According to the care plan, the resident liked being part of group activities by watching from the sidelines. According to the care plan, staff should thank Resident #19 for her attendance in the activity function. The care plan did not address the resident's behaviors during the activity towards other residents or how staff should address her behaviors during the activity. The behavior care plan, initiated on 3/5/19, last revised on 3/29/22, read Resident #19, yelled, cursed and was verbally and physically aggressive. Interventions included: -The intervention, last revised on 3/13/2020, read staff to provide the resident with opportunities for positive interactions and attention. The care plan indicated staff should stop and talk to her as they passed her by. -The intervention, last revised on 3/13/2020, read staff should discuss the behavior with the resident, explaining and reinforcing why behaviors such as aggression, yelling and cursing, were unacceptable and inappropriate. -The intervention, last revised on 4/16/21, read staff should remind the resident of the unacceptability of verbal abuse. The behavior care plan, last revised on 4/16/21, read Resident #19 had a potential for poor impulse control. The care plan indicated all interventions were last initiated and revised on 4/16/21. Interventions included: -Analyze key times, places, circumstances, triggers, and what de-escalates the behavior. According to the care plan, the analysis should have been documented. -Assess and anticipate the resident's needs. -Assess the residents coping skills, support system and understanding of the situation. According to the care plan, staff should allow time for the resident to express herself and the feelings towards the situation. -Give the resident as many choices as possible about care and activities. -Intervene as needed to protect the rights and safety of others. According to the intervention, staff should approach the resident in a calm manner and divert her attention. Staff should remove the resident from the situation and take her to a different location as needed. -Assist Resident #19 with developing more appropriate methods of coping and interacting. According to the intervention, staff should encourage Resident #19 to verbalize appropriately and inform staff when she was upset. -Minimize the potential disruptive behaviors of resident #19 by offering a task which could divert her attention to positive interactions. -Maintain separate smoking times and activities between Resident #19 and other resident's to facilitate a safe environment for other residents when Resident #19's verbal aggression increases. -Monitor the behaviors of Resident #19 q (every) shift and prn (as needed). The care planned intervention directed staff to document the observed behavior and the attempted interventions. The review of the behavior care plan identified the behaviors of verbal abuse and physical aggression were not new behaviors of Resident #19. The behavior care plan identified there were no new interventions put in place since 4/16/21. -Despite Resident #19's behavior care plans in place, most of the interventions were over a year old and were either ineffective or not consistently implemented by staff. The safety care plan, initiated 10/1/21 indicated Resident #19 was a long-term smoker and enjoyed her smoke breaks to calm her nerves. However, interviews with staff identified the resident was no longer allowed to smoke because she exhibited unsafe behaviors. Interventions added on 4/21/22 after the facility was informed of an immediate jeopardy situation related to her behaviors. The interventions included: -Staff were to provide one to one supervision at all times to ensure interactions with staff and residents were appropriate. Staff was directed to intervene as needed to protect the rights and safety of others. -Maintain separate smoke times and activities between Resident #19 and other residents to facilitate a safe environment for others. -Provide opportunities for positive interactions and attention. -Redirect the resident as needed, removing her from escalating situations. According to the intervention, offer the resident fluids or smoking if she does not want to leave the activity. The smoking care plan short term goal, initiated on 4/21/22, read the facility would assist the resident with the development of appropriate methods to cope and interact with others. Facility education in-service training was provided on 4/21/22 by the director of nursing (DON). The education provided indicated staff had both behavior management training and aggressive resident training in the past four months. -A behavior management training was conducted on 12/17/21. According to the training, staff should: Reduce noise level and stimulation; give residents choices whenever possible; answer call lights promptly; report any signs of pain; and, use appropriate body language when speaking with the residents. -A aggressive resident training was conducted on 2/7/22. According to the training, staff should: Try to identify the cause of the aggressive behavior; use a calm voice; change the resident's environment; provide redirection and a one to one visit; and always make sure the resident and other residents were safe. VII. Staff interview Staff interviews confirmed the facility was aware of Resident #19's aggressive behavior toward other residents but did not recognize the emotional and psychological harm residents felt as a result. Further, although staff were able to articulate interventions to address the resident's behavior, resident interviews (see above) and interview with the frequent facility visitor (see above) revealed these interventions were not effective in protecting the residents from Resident #19's abuse. The MDSC was interviewed on 4/20/22 at 11:31 a.m. The MDSC said all staff were responsible for checking in on residents when they were upset. She said she sometimes can hear Resident #19, loud and upset, from her office located outside of the dining room. She said when Resident #19 exhibits behaviors, staff try to keep residents safe by taking her out of the area, offering to sit and talk with her, offering to do her nails or redirecting her with coffee and by asking her what she needs. The MDSC said sometimes staff let her self-soothe but not when other residents were involved and at risk. The activity director (AD) was interviewed on 4/20/22 at 11:37 a.m. She said Resident #19 would blurt things out. The AD said on 4/19/22 during the Resident Council meeting, Resident #19 was loud and disruptive. The AD said she asked Resident #19 to leave the meeting and Resident #19 left but then came back moments later and called Resident #25 an obscenity. Resident #19 was asked to leave again but she returned and was again loud, rude and confrontational. The AD said Resident #19 called Resident #1 a thief. She said staff interventions to address Resident #19's behaviors were care planned. The director of nursing (DON) was interviewed on 4/20/22 at 11:26 a.m. The DON said she initiated a verbal abuse investigation on 4/19/22, of Resident #19 based on comments made by Resident #25. The DON said the physicians have not given Resident #19 any kind of psychiatric diagnosis. The DON said the resident's physician has tried different medications but they have not seemed to make much of a difference. The DON said the facility has made multiple attempts without success to find alternate placement for Resident #19 around the state, including psychiatric facilities and facilities near her family. The DON said her family had very little contact with Resident #19 or little involvement in her care. The DON said the facility continued to do 15-minute checks on Resident #19, redirecting, taking her out of the situation, and taking her to her room. The DON said Resident #19 was a tough one. She was alert and oriented. She said her BIMS was 10/15 when assessed in March of 2021. She said it was definitely a behavior with Resident #19 and it almost was like attention-seeking. The DON said she noticed that Resident #19 takes her anger/behaviors out on the person that was reprimanding her, so they have encouraged residents not to say anything to her because she takes it out on them. The DON said she would rather Resident #19 curse at the staff than at the residents. She said she had been trying for a year to manage Resident #19's behavior. The DON said there have been some staff-witnessed behaviors. She said on 4/19/22, the AD and a frequent facility visitor were witnesses to Resident #19's behavior during the Resident Council meeting. She said no one reported the incident to her or the NHA at that time. She said she reviewed the charted behavior notes but was not informed by staff what had occurred. The DON reviewed Resident #19's behavior notes from the past year. She said in July 2021, the resident cursed at staff twice. In August 2021, her behavior again was directed towards staff. There was a behavior identified in October 2021. In December 2021, she was noted to be rude and hateful, yelling at other residents and she attempted to strike a nurse. The DON said there was also one other behavior in April 2022, when the resident was told by staff she could not go outside and smoke because she no longer smoked. The DON said Resident #19's family would not purchase her cigarettes after the resident was found smoking cigarette butts in her room. The DON said Resident #19 still would go outside but not to smoke. The DON said she thought the decrease in smoking could have contributed to her behavior. The DON said Resident #19 seemed to get more animated and louder when there were people in the building she did not know. She said when the facility had new floors put in, the DON said Resident #19 was very boisterous and loud, teasing them. The DON said there had also been more families coming in recently. She said she thought that may bother Resident #19 because she did not have visitors or friends at the facility because of her behavior. The DON said the resident was better in the evening and she would sit near the nursing station and talk to the facility's evening nurse who she liked. The DON said the facility had spoken to Resident #19 about her behavior but the resident said she was raised with older brothers and was rough with them. The DON said the resident also worked with all men as a dispatcher for a trucking company, so she thought her manner of speaking and her behavior was okay because it was the environment she was accustomed to. The DON said Resident #19 said she did not see anything wrong with how she spoke to residents or why it upset them. She said she has been spoken to the same way her whole life. The DON said the only way they have found to mitigate the situation when Resident #19 exhibited behaviors, she was to have her leave the situation. The DON said she asked the AD why she did not have Resident #19 leave the Resident Council meeting. She said the AD said she did not know she could have her leave because she was fairly new in her position and she thought it was Resident #19's right to be there. She said other staff members did not hear anything that the DON was aware of, referring to behaviors during the 4/19/22 Resident Council. The DON said she was still getting statements from staff regarding the incident in the Resident Council meeting. The DON said she notified the police, the ombudsman, the resident's physician and attempted to reach the family of Resident #19 but had not heard back from them. The DON said the social service director (SSD) was in the process of interviewing residents and the facility was actively investigating the residents' concerns. The maintenance assistant (MA) was interviewed on 4/21/22 at 9:45 a.m. He said he was assigned to provide one-to-one supervision of Resident #19 for part of the morning of 4/21/22. He said he had been asked to make sure Resident #19 was not alone if she went out to the resident common areas. He said it was not uncommon for Resident #19 to call him names. The MDSC was interviewed again on 4/21/22 at 9:50 a.m. She said she had been instructed to monitor the whereabouts of Resident #19 starting on 4/21/22. She said she had a good rapport with Resident #19. The MDSC said Resident #19 was always a smoker, and the MDSC would offer her cigarettes. The MSDC said the one-to-one supervision was to redirect and de-escate Resident #19 if she exhibited any behaviors towards others. She said the goal of the one-to-one supervision was for the safety of Resident #19 and other residents. The social service director (SSD) was interviewed on 4/21/22 at 1:43 p.m. The SSD said part of her role was to provide emotional support for residents. The SSD said if residents were feeling down, she was always available to listen to them. She said she tried to get to know the residents. The SSD was asked about the plan to address Resident #19's behaviors. She said she has seen staff remove Resident #19 from the situation when her behaviors escalate. The staff try to give her space and explain to her that she can not call residents names, and walk her to her room. The SSD said they have tried offering Resident #19 mental health services but she has refused in the past. The SSD said they also make sure she did not have roommates. The SSD said residents have said Resident #19 yelled at them, but usually said it did not bother them. The SSD said she has asked the residents if they felt safe in the facility. She said no one has told her they did not feel safe and no one had mentioned they felt afraid. The SSD she said thought said residents were trying to cope with Resident #19. The SSD said that since (during the survey) the facility had learned the residents were expressing fear of Resident #19, the new plan moving forward was for Resident #19 to be assessed again by mental health services, to offer her medication to help her sleep better, and to give her smoking privileges back. Resident #19 would also be closely supervised for both her smoking and her interactions with other residents. She said Resident #19 has told her that she wants to be left alone and she wants to leave the facility. The SSD said the resident had been turned down for transfer by ten facilities in Colorado and because the resident had an interest in Texas, she would start looking at facilities there. The SSD said she would continue to communicate with residents and continue having residents complete abuse audit questionnaires. She said she routinely asked residents questions on abuse and would interview each resident at least quarterly. She said if she identified a concern, she would follow up with the DON. The SSD said if residents expressed concerns about a staff member, she would not share that information with the identified staff member but would refer it all the DON. Registered nurse (RN) #1 was interviewed on 4/21/22 at 3:40 p.m. RN #1 said Resident #19 will sometimes not get up for the day until the afternoon and sometimes she would seclude herself in her room. But, when she was up, she was very attention seeking and would yell out constantly. The RN said she had heard her yelling in the dining room and would check on her, but usually she was just yelling at the television located in the dining room. She said she was aware of an incident between Resident #19 and Resident #22. She said both residents were yelling at each other and both residents were removed from the dining room. RN #1 said staff assigned to the dining room would usually be the ones to address the residents' behaviors in the dining room. RN #1 said she has heard Resident #19 call staff members obscenity but that was just how Resident #19 was. Administrative assistant (ADM ) #1 was interviewed on 4/21/22 at 4:20 p.m. She said Resident #19 had a strong and loud personality. ADM #1 said she usually will just yell at the television in the dining room which will escalate other residents. She said Resident #19 liked to get other people's goat and liked to irritate residents. She said Resident #19 has to be taken out of activities such as bingo. She said she has heard Resident #19 call another resident an obscenity. She said when that happens, the resident is asked to leave. ADM #1 said Resident #19 knows who she can irritate, such as Resident #25 and Resident #10, and will focus on irritating those residents. ADM #1 said Resident #19 was fully aware of what she was doing; she wanted a response and sought out attention whether it was good or bad. She said she knew Resident #19 well. She said Resident #19 can be redirected with Pepsi and coffee mixed with hot chocolate and creamers. ADM #1 said Resident #19 enjoyed television and sports. She said Resident #19 likes someone to talk to and someone to take her out for cigarettes. ADM #1 said she had worked at the facility for years and felt she was in tune with the residents. She said it would be good if staff had work groups again. She said before COVID, the facility held staff in-services. Staff used to be able to share information about residents on approaches that were working and a general conversation on what staff was seeing with the residents. ADM #1 said the facility has talked about having small group inservices but it was just in the brainstorming stage right now. She said it could be beneficial for all the new staff to be able to ask questions of the senior staff on how they work best with the residents. The ADM #1 said she had worked at the facility for years and felt she was intune with the residents. She said it would be good if staff had work groups again. She said befor[TRUNCATED]

Based on observations, interviews and record review, the facility failed to provide person-centered dementia care to five (#33, #14, #15, #29 and #91) of five residents reviewed out of 13 residents who resided on the dementia care secured unit (SCU). Resident #33 had dementia with lewy bodies and behavioral symptoms including repetitive verbalizations that affected her well-being and that of others around her. She had delusions and hallucinations, and talked loudly and often cursed to herself, causing other residents' anxiety to escalate. Resident #16, who was typically very quiet, walked by Resident #33 when she was cursing, yelled at her to shut the (obscenity)! and charged toward her. He would have possibly injured Resident #33 had a staff person not stepped between them and redirected him, apologizing and explaining that Resident #33 was not talking to him. The facility failed to address Resident #33's behavioral symptoms in a manner that effectively calmed and soothed her, and prevented psychosocial harm to herself and others. She was given antianxiety and antidepressant medications. Resident #15 had Alzheimer's disease, spoke Spanish only, and spent most of his time in his room alone, or sitting at a table in the SCU common area looking out the window or sleeping with his head on his arms. Only one staff person was observed speaking a few phrases of Spanish to him during meal service. Resident #15 was not provided with meaningful activities, music, or opportunities to go outside when the weather was nice. He was given antipsychotic medication. Resident #14 had dementia with behavioral disturbance and spent most of her days pacing in the hallway and common/dining area, carrying a baby doll, grimacing, moaning and whimpering. She did not like to sit at the dining room table to eat, and staff did not offer her finger foods and drinks that she could carry with her. She was observed taking food and drinks from other residents' tables and walking away with them. She was not provided with meaningful activities, one-to-one activities, tactile or sensory objects to manipulate. She was given antipsychotic and antidepressant medications. Resident #29 had dementia, [CONDITION(S)] and mood symptoms and spent most of her days pacing to and from her room and into the common dining area, asking staff where she should go, what she should do, and what was next. She had purple, blue and red bruising and swelling to her face and eyes from a previous fall (cross-reference F689, falls/accidents). She was not provided with meaningful activities, one-to-one activities, pet visits or opportunities to go outside although the weather was nice. She was given antipsychotic and antidepressant medications. Resident #91 had Alzheimer's disease and depression. He was observed spending most of his time in his room, the television/dayroom and the common/dining area. He was admitted after a psychiatric hospital stay for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility contacted a mental health professional who visited and assessed him, but not until after his statement was reported during the survey. Resident #91 was not provided with meaningful activities or opportunities to go outside, other than for supervised smoke breaks. Resident #91 was given antipsychotic medication. The facility's failures to provide adequate dementia care services contributed to Resident #33's behavioral symptoms worsening and negatively affecting others, putting her at risk for verbal abuse and injury. The facility failure to provide dementia care and a homelike SCU negatively affected residents' quality of life and prevented residents from reaching their highest practicable psychosocial well-being. Cross-reference F758, unnecessary antipsychotic medications. Findings include: I. Facility policies The Dementia-Clinical Protocol policy, revised November 2018, was provided by the director of nursing (DON) on the afternoon of 4/21/22. The policy required in pertinent part the following: For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. -Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. -The facility will strive to optimize familiarity through consistent staff-resident assignments. -Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes and therapeutic and recreational activities will be supervised and supported throughout the day as needed. -The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. -Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). -Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. -The physician will help define potential benefits and risks of medical interventions (including cholinesterase inhibitors and other medications used to enhance or stabilize cognition) based on individual risk factors, current conditions, history and details of current symptoms. -The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. -Medications will be targeted to specific symptoms and will be used in the lowest possible doses for the shortest possible time, unless a clinical rationale for higher doses or longer-term use is documented. -If a psychiatric consultant is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress. -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. -The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. -The physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated. II. SCU environment observations The SCU environment had a lingering urine odor, noticeable from the entryway. The environment was not homelike, welcoming or conducive to spontaneous activities. A long hallway led to a television/day room and lounge chairs, but residents rarely entered the room and were not encouraged by staff to do so. The dining/common area was filled with square four-top dining tables. Several residents tended to gather near a table at the doorway where staff typically sat. There were no magazines, newspapers, puzzles, art supplies or tactile items to invite spontaneous activities or to promote a homelike environment. There was no private cordless phone. When residents received or made a call, staff removed the phone from the cabinet above the kitchen countertop area, and seated the resident next to the kitchen counter in the middle of the common area. There was no privacy for phone calls, and the room was typically loud, with hard floors and table tops echoing the sounds of residents and staff talking. There was no independent access to the outdoor secure courtyard. The only door to the outside was a fire door that sounded an alarm if opened. The window looked out onto a sidewalk that was deeply cracked, uneven, and surrounded by landscape rocks, creating an unwelcoming and unsafe environment (cross-reference F689, accident hazards). The SCU was typically staffed with two certified nurse aides (CNAs). There was no consistent social services or activity programming to promote highest practicable well-being and quality of life for the residents. The nurse entered the SCU only when requested by the CNAs or to give medications. The activity director entered the SCU occasionally to conduct a brief group activity, and then left the SCU. Review of the facility's resident roster matrix revealed that out of 13 residents who resided on the SCU, 12 residents were given antipsychotic medications and seven had experienced falls. Review of resident care plans revealed more of a focus on medications than individualized assessments and responses to root causes and unmet needs. III. Resident #33 A. Resident status Resident #33, under age 70, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/18/22 minimum data set (MDS) assessment documented severe cognitive impairment per staff assessment. Resident #33 was unable to complete the brief interview for mental status (BIMS). She had [CONDITION(S)] symptoms of hallucinations and delusions, trouble concentrating and poor appetite. She had behaviors that affected others but no care rejection. She had wandering behavior but it was not documented how it affected her or others, or if her behavior put her at risk. Resident #33 required limited physical assistance with transfers, ambulation, eating and personal hygiene; and extensive assistance with dressing and toilet use. She had unsteady balance and gait. Her fall history was blank. She took antianxiety and antidepressant medications daily. Her preferences were not documented on the above quarterly MDS assessment, but her 6/15/21 annual MDS documented it was very important to her to have snacks between meals and family involvement. It was somewhat important to her to keep up with the news, do things with groups, go outside in good weather, and participate in religious services. B. Observations An initial tour of the SCU on 4/18/22 at 1:15 p.m. revealed Resident #33 was standing in the common area, looking at the floor, talking loudly in a two-way conversation with herself. Nearby, a female resident with a walker was pacing up and down the hallway, circling the common area, talking loudly and disrupting other residents. Certified nurse aide (CNA) #1 was encouraging her to sit down because she had been standing for a long time. A male resident paced in the hallway and common area, walking toward another resident's room until a CNA redirected him back into the hall. Resident #90, who was sitting in a chair in the common area near Resident #33, said, Communication is hard and I don't want to be here. He said he was looking for a phone book and a pencil. (Resident #90 was moved to a room on the open unit at 4:00 p.m. that day.) CNA #1 said the SCU was typically staffed with two CNAs, which they needed, and the nurse covered the West hall and the SCU. Observations of the SCU and Resident #33 were conducted throughout the survey on the afternoon of 4/18/22, and throughout the day on 4/19, 4/20 and 4/21/22, and included the following of note: On 4/18/22 at 5:00 p.m., Resident #33 was being fed her dinner by a CNA. On 4/19/22 at 8:21 a.m., Resident #33 was being fed her breakfast by staff. A few minutes later she was saying to herself, You have to eat, honey, you do, as a CNA was scraping off her plate into the trash. Throughout the day on 4/19/22, Resident #33 remained in the common area, sitting or standing, looking down, constantly talking to herself. On 4/19/22 at 4:35 p.m., Resident #33 was talking loudly to herself. Resident #13, who was sitting nearby, loudly told her to Stop! On 4/19/22 at 4:59 p.m., Resident #33 was talking and cursing loudly and approaching other residents aggressively, including Resident #13 who was talking loudly near her. CNA #3 intervened to protect other residents who were standing or sitting nearby. On 4/19/22 at 5:11 p.m., Resident #33 was still talking loudly and as dinner was served, her voice and her cursing grew even louder. Resident #16, who was walking out of the dining room, yelled in Resident #33's face, Shut the (obscenity! and charged toward Resident #33. CNA #3 stepped between them, apologized to Resident #16 and reassured him, saying, She wasn't talking to you. CNA #3 redirected Resident #16 into the hallway as he said, She was looking right at me! On 4/19/22 at 5:13 p.m. several residents were eating dinner but Resident #33 was standing up near the dining room entry door, talking loudly to herself. Resident #13 was yelling at Resident #33 to stop it, oh my god! CNA #3 reassured Resident #13 that she would take Resident #33 to her room in a minute. At 5:16 p.m. CNA #3 tried to walk Resident #33 down to her room to eat but she refused, locking her feet and legs firmly in place, looking down at the floor and talking loudly. At 5:19 p.m., she was walking around the dining room, looking down at the floor and talking and cursing loudly to herself while other residents were trying to eat. Resident #13 said to her, Oh, knock it off! CNA #3 continued to separate Resident #33 from other residents who were walking by her while CNA #12 was assisting other residents in their rooms. At 5:23 p.m., Resident #33 was still standing up looking at the floor, talking to herself but more quietly. Resident #13 was watching her, and was not eating. At 5:31 p.m., Resident #33 continued to stand up and talk to herself. Her dinner was in her room where staff had tried to redirect her, and she had not eaten. At 5:32 p.m., CNA #12 asked the residents if they were finished with dinner, and if it was good. One resident responded that it was not very good, and she replied, I'm sorry, hopefully it will be better tomorrow. On 4/20/22 at 8:45 a.m., Resident #33 and other residents had finished breakfast. Resident #33 had her head down and was talking softly to herself, sitting at a table across from a staff person. Her glass of water was still full and her cranberry juice was two-thirds full. At 8:53 a.m., CNA #10 turned on some music. This was the first time music was observed playing in the common area on the SCU. As the music played, Resident #33 started talking louder. On 4/21/22 at 10:00 a.m., Resident #33 was standing up in the common area, talking to herself loudly, and very close to other residents and staff. A group of residents was standing around, no activities were happening. A third CNA was coming on duty and getting report from another CNA. She said it was good to have three CNAs. Resident #33 was observed during the survey from 4/18 through 4/21/22 spending most of her time in the common area, unengaged, standing or sitting with her head down, talking to herself. When she was not visiting with her husband, she talked to herself and looked miserable, either grimacing or with a flat affect. The facility failed to provide adequate dementia care services to help Resident #33 reach her highest practicable level of well-being, and negatively affected the well-being of other residents near her. C. Staff interviews On 4/20/22 at 10:30 a.m., Resident #33 was not in the common area. CNA #12 was interviewed and said Resident #33 was in her room, and her husband would be visiting her soon. Regarding the altercation with Residents #33 and #16 the previous day, she said Resident #16 was typically quiet but he responded aggressively to Resident #33 about once every week or two. She said Resident #16's anger toward Resident #33 was easily triggered, but also easily diffused. She said Resident #13 got escalated with Resident #33 and would usually say hey, stop it! but usually did not get agitated. Resident #6 would often yell at Resident #33 to shut the hell up! CNA #12 said the staff response to Resident #33's behaviors depended on their training. She said Resident #33 could be redirected by taking her to her room to calm her down with nobody else around, as well as telling other residents she was not directing her words at them. When she was not redirectable and being loud, CNA #12 said she would take other residents into the other common area. She said when Resident #33 was yelling and cursing loudly, she could intervene by taking her for a walk or calling her husband and letting her talk with him. She said Resident #33's husband visited her daily between 10:00 and 11:00 a.m., and he called her twice a day, and told them he was available if they needed him to talk with Resident #33. CNA #12 said she was used to working on the SCU with just two CNAs but some staff get very frustrated. She said it was a tough situation when staff did not have the correct training to deal with the situations. I usually respond with redirection and then report it to the nurse. CNA #12 said she knew Resident #33 got [MEDICATION(S)] (an antianxiety medication) and that does calm her down. She said Resident #33's visits and phone calls from her husband really do help her a lot. Regarding Resident #33's behavior, CNA #12 said, I do think it overstimulates the other residents and brings a lot of anxiety to have that constant yelling and not knowing if it's directed toward you or not. It can definitely seem like it sometimes. She said Resident #33's behaviors were typically intermittent throughout the day. On 4/19/22 at 11:15 a.m., Resident #33 was observed sitting in her room next to her husband, who was visiting, and quietly talking with him and not to herself. The director of nursing (DON) was interviewed on 4/20/22 at 11:30 a.m. She said the incident with Residents #33 and #16 was not reported to her by staff on 4/19/22. She said Resident #33's behaviors had been worse the last month and a half, and she was now on liquid [MEDICATION(S)]. She said she had noticed Resident #33 was talking angrily and cursing to herself more, but no staff had told her it was upsetting anybody else. She said the CNAs had good luck with redirecting her if they could get her to a quieter area, like the TV area or down the hall, separated from others so she was not hearing other people, the television, the reading activities or other people talking. When separated and more quiet, she does tend to calm. She's a totally different person when her husband is here. She will sit and converse with him. She doesn't talk to herself when he's here. The DON said Resident #33 probably had more psychiatric issues than she had ever been diagnosed with, but it was hard to say because her husband did not observe her behaviors. Her whole personality changes when he's here. She said Resident #33's husband visited daily and called often, which definitely helped to calm her. The social services director (SSD) was interviewed on 4/21/22 at 3:05 p.m. She said for residents on the SCU, she addressed dental, vision, hearing, mental health or behavioral needs, basically doing everything outside the realm of psychotropics and activities. She said residents would let them know if there were things they needed. She said she thought staff were very observant and met the SCU residents' needs accordingly. She thought residents were kept clean and well taken care of, and said they sent housekeeping back there, and more often than not there were no behavior issues that affected others. She said she had never noticed anyone really had an issue with Resident #33's behavior. She's not very cognitive, and she's having some delusions and things of that nature. I don't see residents react to things she says and she's never directed it at anyone. You have folks back there humming consistently, and they don't react really to other residents' behaviors. D. Record review Record review over the past six months revealed Resident #33 had experienced falls and weight fluctuations, behavioral symptoms and psychoactive medications. Resident #33's SCU placement care plan, initiated 8/6/2020 and not revised, identified dementia with lewy bodies, wandering, requires low stimuli, exit seeking. The goal was to remain safe within the facility and decreases in behavioral issues. Interventions were: ensure environment is free of hazards; maintain daily routine as much as possible, avoid unfamiliar situations and caregivers as much as possible; activities outside of the unit with appropriate supervision, assess for over-stimulation; redirect as possible to activities or change topic if behaviors evident; evaluate need for SCU placement per facility protocol and as needed; administer medications as ordered; assess/record/report adverse effects/ineffective outcomes to physician; educate and provide family support; pharmacy consult to review medications per facility protocol; report significant changes to physician/family/nurse; assess/record/report behaviors/interventions/outcomes to nurse/physician every shift and as needed. Resident #33's social needs care plan, initiated on 7/15/2020 and revised on 4/30/21, identified she was dependent on staff for meeting her emotional, intellectual, physical and social needs. The goal was participation in activities of choice one to three times weekly. Interventions included: enjoys listening to late 50s and early 60s music, visiting with her spouse and spending time on the phone talking with him; riddles and jokes both through books and handouts and spontaneous will be shared; access to telephone at her convenience; converse with resident during care; assist with arranging community activities, arrange transportation; assist/escort to activity functions; one-to-one as needed/requested; activities which do not involve overly demanding cognitive tasks; engage in simple, structured activities; encourage ongoing family involvement; invite her family to attend special events, activities, meals; establish and record prior level of activity involvement and interests by talking with her, caregivers, family on admission and as necessary; introduce to residents with similar background, interests and encourage/facilitate interaction; provide a program of activities that is of interest and empowers resident by encouraging/allowing choice, self-expression and responsibility; provide with a variety of snacks/beverages; provide the opportunity to participate in outdoor activities as weather permits; provide opportunity to participate in religious services; review activities needs with the family; and thank resident for attending activity functions. Resident #33's behavior problem care plan, initiated 7/20/2020 and revised 4/30/21, identified verbal aggression, yelling, impulsive behavior, wandering, resistive to care, throwing self on ground. Interventions included: one-to-one staff redirection, enjoys talking to husband often; administer medications as ordered; intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations; document behavior and potential causes; provide a program of activities that is of interest and accommodates resident's status. Resident #33's cognitive function/dementia care plan, initiated 7/20/2020 and not revised, included these interventions: administer medications as ordered; communicate with resident and husband regarding capabilities and needs; reduce any distractions: turn off TV, radio, close door etc. Resident understands consistent, simple, directive sentences. Provide her with necessary cues-stop and return if agitated. Keep routine consistent with consistent caregivers to decrease confusion. Reminisce with Resident #33 using photos of family and friends. Review of Resident #33's interdisciplinary team (IDT) progress notes for the past six months revealed minimal documentation regarding her behavioral symptoms, dementia care needs, and supervision/engagement. The following pertinent notes were documented: -12/13/21, Resident is active and independent, she has the right to choose which activity she wants to participate in. She participates in 1-3 activities weekly. -12/16/21 at 7:00 a.m., Resident very agitated and kept pulling her clothes off, pulled pants down and took a step before CNA could get to her she fell landing on buttocks, fall witnessed by CNA. Resident did not hit head, no apparent injury noted at this time. -1/16/22 at 1:58 p.m., Resident is very combative. She is refusing to take medication, throwing them on the floor, and spitting them out. She is being physically aggressive. She is cussing and screaming while wandering around the unit. -1/18/22 at 10:36 a.m., Resident continues to act aggressively to staff. Continues to pace, scream, cuss, and yell at staff and other residents. She is refusing to take medication most of the time. She will not redirect. Recommendation: change in medications. -2/3/22 at 9:59 a.m., Resident doesn't participate much in group activities anymore but we are able to still do one on ones with her at this time. -2/17/22 at 1:22 p.m., Food is used with her as a behavioral calming method. -There was no documentation of Resident #33's verbal behaviors, other residents' response to it, or the verbal altercation with Resident #16 on 4/19/22 (see observations above). Behavior documentation on the April 2022 treatment administration record (TAR) revealed the resident was monitored for the following behaviors: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [CONDITION(S)], aggression, refusing care every shift for [MEDICATION(S)] (antipsychotic), start date 11/10/2020. -However, the resident was taking [MEDICATION(S)], an antianxiety medication, not [MEDICATION(S)]. Nonetheless, the behaviors were not specified or resident-centered. Nursing staff marked Yes for behaviors 17 times on the day shift, seven times on evening shift, and none on the night shift. -No non-pharmacological interventions were documented on the TAR prior to administering as-needed [MEDICATION(S)]. IV. Resident #14 A. Resident status Resident #14, age 82, was admitted on [DATE]. According to the April 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to her 2/3/22 MDS assessment, she had severe cognitive impairment; [CONDITION(S)] symptoms including inattention, disorganized thinking and delusions; behavioral symptoms not directed toward others such as pacing, rummaging and disruptive sounds, but no rejection of care. Her balance was unsteady and she required extensive assistance for dressing, toilet use, hygiene; set up help, supervision, oversight, encouragement and cueing for eating; and supervision, oversight, cueing and physical assistance with ambulating in the corridor. She was frequently incontinent and needed extensive assistance with dressing, toilet use and personal hygiene. She took antipsychotic and antidepressant medications. The preferences that were important to her included caring for her personal belongings, snacks between meals, family involvement, use of the phone in private, reading books/newspapers/magazines, listening to music, being around animals, and spending time away from the nursing home. B. Family interview Resident #14's family member was interviewed on 4/20/22 at 9:25 a.m. Regarding the SCU environment, she said she was concerned about Resident #14's roommate (Resident #33) who seemed to be kind of upset and was yelling all the time, more like talking to herself. She said it was disturbing to her because she is my mother's roommate and that's got to be a little tough. My mom won't sleep in her bed anymore. She said she slept on one of the lounge chairs in the dining room/common area. They kind of let her sleep where she wants to, and I don't know if it has anything to do with the roommate either. I got a glimpse of mom's old personality about a month and half ago when that lady was yelling, not yelling at anybody, just herself or an imaginary person. My mom just looked at me and rolled her eyes. I don't think there's anything to be done about it, I think it's the disease of that lady. She said she was concerned about the antipsychotic medication Resident #14 was taking, and would like to see her off other than pain meds and her antidepressant; I'd like to see how she does off of all of it because I have heard that there are dangers with that stuff and dementia. Regarding activities, she said Resident #14 was not really interested in anything anymore other than walking. She used to like to just sit outside when she was in the assisted living. My understanding is they have a courtyard so I'll see if she'll sit out there with me. She pretty much doesn't really participate in activities. She used to. She said she suggested to the facility that Resident #14 might like a doll to carry around, because she did that at her previous assisted living facility. The family member said Resident #14 started moaning and crying at her previous facility. She had chronic back pain and her knees are like bone on bone. She used to get cortisone shots in her knees but that's not possible anymore. She said the doctors put her on [MEDICATION(S)] and she was initially concerned about opioids but, if that's what it takes for her to have a pain free existence, so be it. She said Resident #14 needed finger foods because she's not one to sit and eat a meal, but needs something she can carry around and [NAME] on. The family member said when she visited Resident #14 in the facility, she still paced but did not moan and cry, possibly because she spoke with her, walked around with her and engaged her. C. Observations Observations of Resident #14 were conducted throughout the survey on the afternoon of 4/18/22, and throughout the day on 4/19, 4/20 and 4/21/22, and included the following of note: On 4/18/22 at 5:00 p.m., the residents on the SCU had been served their dinner. Resident #14 was sitting at a dining room table moaning, holding a cookie and trying to eat spaghetti with her fingers at the same time, while also holding her baby doll. She had a glass of strawberry supplement near her plate. At 5:05 p.m. she was not eating. At 5:06 p.m. she stood up from the table and CNA #1 helped her sit back down and encouraged her to eat. At 5:08 p.m. Resident #14 had finished her strawberry drink but had not eaten anything. At 5:15 p.m. she was moaning and crying, backing her chair away from the table, and had not eaten anything more. At 5:20 p.m. she was walking around the dining room. She had eaten her cookie and drank her supplement but nothing else, and she was not offered finger foods or a different entree. Her spaghetti and sliced zucchini were left on her plate and a few minutes later were scraped into the trash can. At 5:24 p.m. Resident #14 was walking throughout the common area and hallway, moaning and crying, unengaged by staff. On 4/19/22 at 8:21 a.m. breakfast had been served on the SCU. At 8:32 a.m., Resident #14 was sitting at the table asleep with her arms crossed in front of her, not eating. A CNA asked her if she would like to eat some breakfast, and if she would like some help. She fed Resident #14 a bite of her eggs with sausage, which were cold by that time. Resident #14 wrinkled

Based on resident and staff interviews and record review, the facility failed to ensure three (#10, #14 and #4) of 10 residents reviewed out of 20 sample residents were free from verbal and physical abuse by Resident #36. Interviews with Resident #10 revealed she was subjected for several months to ongoing verbal and mental abuse, name calling and threats by Resident #36. Resident #10 said she felt hurt, bullied and fearful of verbal and physical retaliation as a result. Nursing staff were aware but did not appropriately intervene and protect Resident #10, treated the verbal abuse as a behavioral symptom of Resident #36, and failed to report the abuse to the nursing home administrator (NHA) or director of nursing (DON) for investigation and intervention. Record review revealed Resident #36 also was physically abusive towards Resident #14, slapping her on the face, and Resident #4, punching him in the chest and legs during an altercation that escalated from verbal to physical. Record review further revealed Resident #36 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failures subjected Residents #10, #4, #14, and multiple unnamed residents to repeated incidents of abuse by Resident #36, generating fear for safety and fear of Resident #36 retaliating and escalating her abusive behaviors. Cross-reference F609, failure to report alleged violations and F610, failure to investigate alleged violations. Findings include: I. Facility policy and procedures The Abuse Prevention Program, revised December 2016, provided by the director of nursing (DON) on the afternoon of 3/24/21, documented residents had the right to be free from abuse, including verbal abuse and intimidation inflicted by anyone, including other residents. The Resident-to-Resident Altercations policy, revised December 2016, was provided by the DON on the afternoon of 3/24/21. The policy statement documented, All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Policy interpretation and implementation included: Facility staff will monitor residents for aggressive/ inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported (to the parties named above). If two residents are involved in an altercation, staff will: -Separate the residents and institute measures to calm the situation; -Identify what happened including what led to aggressive conduct; -Notify each resident's representative and attending physician of the incident; -Review the events with the nursing supervisor and DON; -Consult with the attending physician to identify treatable conditions such as acute [CONDITION(S)] that may have caused or contributed to the problem; -Make any necessary changes in the care plan approaches to any or all of the involved individuals; -Document in the resident's clinical record all interventions and their effectiveness; -Consult psychiatric services as needed; -Complete a Report of Incident/Accident form and document the incident and any corrective measures taken in the resident's medical record; -Inquiries concerning resident-to-resident altercations should be referred to the DON or to the administrator. II. Resident status A. Resident #10 Resident #10, age 76, was admitted on [DATE]. According to the March 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided on the West hall. According to the 1/20/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident felt down, depressed or hopeless once, and felt tired or had little energy several days during the review period. No behavioral symptoms were documented. She needed extensive assistance with transfers, dressing and toilet use. She used a wheelchair and required extensive assist with ambulation/ locomotion off the unit. She received antidepressant medication daily. B. Resident #36 Resident #36, age 71, was admitted on [DATE]. According to the March 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided on the East hall. According to the 3/17/21 MDS assessment, she had moderate cognitive impairment with a BIMS score of 10 out of 15. No symptoms of [CONDITION(S)] or mood were documented. Rejection of care, one to three days during the review period, was the only behavioral symptom documented. The resident was independent for activities of daily living but needed supervision and assistance for locomotion off the unit. She used a wheelchair for ambulation. She received antidepressant medication daily. III. Resident interviews and observations A. Resident #10 Resident #10 was interviewed on 3/23/21 at 10:15 a.m. in her room. She said she had experienced verbal abuse from a resident here that I run into too often, who called her names like big ass, ugly, poor. She said, It hurts, but there's all kinds of people in the world and you have to put up with it. She's just foul mouthed. She reiterated that she ran into the resident too often when she was outside smoking, and thought she lived on the same hall, but I'm not a hall walker. The resident said she had not reported this to anyone, It's just like school, you don't tell on a bully. She's got friends and friends of friends who are very influential. She sits where she looks at me and wears at me all the time, like a little kid fighting on the playground. I suck it up, try to ignore it, turn my back on it. There are staff here who are friends with her who don't like me. She said she could tell by their stiffness, tone of voice and how they carried themselves in her presence. She was unable to name staff who were involved, but said what she thought the resident's name sounded like. B. Additional interviews and observations Resident #18, who had a BIMS score of 15 out of 15 (cognitively intact), was interviewed on 3/23/21 at 5:20 p.m. When discussing abuse and resident-to-resident interactions, she named Resident #36 and described her as just mean. She did not elaborate further. On the morning of 3/23/21 during an interview with another resident, loud screaming was overheard with unintelligible words from the opposite end of the hallway. A staff person was observed hurrying into Resident #36's room, where the door was open, and the screaming stopped. Resident #10 was observed on 3/22, 3/23, 3/24 and 3/25/21 spending most of her time in her room sitting in her wheelchair watching television. She received staff assistance to go outside for smoke breaks, and was observed sitting with two other socially-distanced residents and a staff person who assisted and supervised. The resident was not observed in the smoking area or common area with Resident #36. IV. Report to NHA/DON and facility follow-up A. Interviews Resident #10's allegation (see above interview) was reported to the nursing home administrator (NHA) and DON at 12:15 p.m. on 3/23/21. They said they were unaware. The DON said she was the abuse investigation officer. The NHA, who had just started two weeks before, asked the DON if Resident #10 had any history of false reports or accusations, and the DON responded, She does not. They said they would investigate and provide their findings. On 3/23/21 at approximately 3:00 p.m., the NHA reported that they had interviewed Resident #10, who reiterated to them her allegation and said she was fearful of retaliation from Resident #36. Resident #10 told them her last verbal abuse from Resident #36 was several months ago, and more recently she just glared at her. The NHA said they had reported the allegation to the State agency and their protocol was to call police, but they were afraid of Resident #36 getting loud, cursing, and escalating. She said one-to-one supervision would just escalate her more, and she will retaliate. After discussion she acknowledged and affirmed they needed to protect Resident #10 and other residents, and said they would call the police and ensure residents were protected. Resident #10 was interviewed a second time on 3/23/21 at 4:49 p.m. She said she was feeling better after talking with staff, and was glad to know that Resident #36 would not be out in the smoking area with her any more. On 3/23/21 at 4:59 p.m., the NHA reported that they called the police who said they would not come to the facility due to their Covid-19 protocol, but they would take the facility's report. The NHA said they interviewed Resident #36, who denied the allegation, and interviewed seven other residents who said they had no issues with other residents. They had not yet interviewed staff who observed/supervised smoking, but would do so, and they had not followed up regarding Resident #10's allegation that some staff treated her differently, siding with Resident #36. She said they would continue to investigate and share what they learned. Their current safety plan was every-15-minute checks for Resident #36, keeping her in line of sight in hallways and common areas, staggering supervised smoking times so Residents #10 and #36 were not in the smoking area at the same time, and checking in with Resident #10 periodically to ensure she felt safe. She said both residents were supervised smokers. B. Investigative summary report The NHA/DON provided the facility's investigation summary report of the Resident #10's allegation on the afternoon of 3/24/21 and said it was still in process. The report included the following: -Details of surveyor report of Resident #10's abuse allegation on 3/23/21 at 12:15 p.m. -Resident #10 had not previously reported this to any staff members at the facility. The NHA and DON documented they interviewed Resident #10 on 3/23/21 at approximately 12:45 p.m. and she reported the same concerns that she had reported to the surveyor. Resident #10 made the following comments: she uses the f-word a lot, she is still here, I don't know her name, she calls me fat ass and poor, I know she got in trouble before for calling me names because she told me, we both smoke, it's out there when she says things to me, she glares at me all the time, it happened a couple of months ago, I have never told anyone about this, I just turn my back on her, she has never tried to hit or touch me. -When asked if Resident #36 had ever threatened her, Resident #10 replied, She said that I shouldn't use my walker, that I should walk a mile because I have a fat ass. And she said that someone should take me out and shoot me. That was a long time ago. On 3/23/21 at 4:35 p.m., the social services director (SSD) and registered nurse (RN) #1 interviewed Resident #36, who stated that she only swears at people if they swear at her first. When asked if she put her hands on anyone, she replied, 'No, I'm never trying to hurt anyone.' -Staff informed (Resident #36) that there is an allegation that she was swearing and intimidating other residents. She replied, 'I will just stay away from everyone. I want nothing to do with anybody.' -(Resident #10) was interviewed at 5:00 p.m. When asked if she was afraid of retaliation, she replied, 'She might get physical. She doesn't get that close to me anymore, but still calls me fat ass when she goes by when we go smoke. I think maybe some of the staff are siding with (Resident #36).' -(Resident #10) denies being fearful of any staff member. -(Local) police were notified, case number obtained. -Ombudsman notified. -7 other cognitively intact residents were interviewed on 3/23/21 (including 2 residents who are supervised smokers) and none reported experiencing any abuse. -Initial report of verbal abuse made to the state. -Interventions put in place: Residents will be taken out at separate times to smoke. Documented 15 minute visual checks on (Resident #36). Staff educated to keep (Resident #36) within line of sight when she is out of her room. Review of the supporting documents revealed the following additional information from Resident #10's interview with the NHA/DON: (Resident #36) got into a fight with one of the staff, maybe (RN #1 who was) trying to put her in her room and she was fighting her. She was grabbing at (RN #1). -When asked if she felt safe around Resident #36, Resident #10 responded, No. I don't know if she would slap or not. -When asked if anyone overheard Resident #36 talk to her that way, Resident #10 said, Yes. It was really loud. Staff. If they are in the building they can hear her. She is not afraid to fight. -Asked if she was afraid of Resident #36, she said, She is very physical. Asked if Resident #36 had ever threatened her, Resident #10 said, Yes. Usually goes with the F-word . She will bite. I saw her try to bite someone. Saw bite marks on someone (did not know when). -Asked if it would be better if she were taken out at different times than Resident #36 to smoke, Resident #10 said, Yes. Twenty-one residents were interviewed without documented dates, times or interviewer names, and all denied abuse from anyone, or concerns with any other residents. No staff interviews were provided. A handwritten note stuck to the report documented, Investigation continues. Final report due 3/29/21. V. Record review A. Resident #10 Resident #10's care plan was not updated as of 3/24/21 regarding abuse from Resident #36. Likewise, no prior applicable care plan interventions had been developed, other than a psychosocial well-being care plan, initiated 4/4/19 and revised 2/26/2020, with the intervention: When conflict arises, remove (Resident #10) to a calm safe environment and allow to vent/share feelings. Review of nursing and interdisciplinary team meeting notes for the previous year revealed no documentation of abuse from Resident #36 directed toward Resident #10. However, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She reports that her daughter in law called her the 'C' word. There is a resident that uses foul language regularly. Nurses report that if anyone looks at her, she thinks they are going to attack her. There were no other physician or therapist notes regarding verbal abuse mentioned by or directed toward Resident #10. B. Resident #36 Resident #36's care plan was not updated as of 3/24/21 regarding abuse directed towards other residents. A care plan, initiated on 3/5/19 and revised on 3/13/2020, identified a behavior problem related to yelling, cursing, impulsive, refusing to use call light, physical aggression. The goal was fewer episodes of behaviors. Interventions were: -15-minute checks for safety (3/13/2020) -Administer medications as ordered, monitor for side effects and effectiveness (3/5/19) -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by (3/5/19) -Continue re-education related to language and communication skills (3/13/2020) -If reasonable, discuss resident's behavior, explain and reinforce why behavior is inappropriate and unacceptable to her related to cursing, yelling, aggressive behaviors (3/13/2020) -Provide a program of activities that is of interest and accommodates resident's status (3/5/19) Resident #36's psychosocial well-being care plan, initiated 3/5/19 and revised 10/17/2020, listed the intervention: When conflict arises, remove (Resident #36) to a calm safe environment and allow to vent/share feelings (3/7/19). The resident's nursing and IDT progress notes, reviewed for the previous year, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -4/15/2020 at 12:58 p.m. - Resident has been yelling, cursing this am, telling staff and other residents 'I hate you,' 'you are all b----es,' no physical aggression at this time. -4/18/2020 at 8:31 p.m. - Yells out and cusses all the time. -4/19/2020 at 1:34 p.m. - Resident is yelling and cussing in the hallway. She is cussing because she wants to go out smoking. She was told that it was not time yet. Resident went back to her room yelling. Yelling stopped this afternoon. -4/20/2020 at 6:52 a.m. - Resident is yelling and cussing, waving her arms around as she comes out of her room early for the smoke break that the f-----s went off and left her, continues to rant even after she was informed she was early. -5/2/2020 at 1:28 p.m. - Cursing yelling. -5/6/2020 at 1:22 p.m. - Swearing, cursing, yelling at other residents. Increased agitation about smoking schedule. -5/7/2020 at 1:35 p.m. - Yelling cursing. -5/9/2020 at 1:13 p.m. - Yelling cursing. -5/9/2020 at 8:56 p.m. - Yelling, cussing at others. -5/9/2020 at 8:58 p.m. - Yelling, cussing, verbal aggression. -5/12/2020 at 8:54 p.m. - Yelling, cussing, threatening roommate. Resident has been agitated, verbally abusive to other residents, talking to self. -5/14/2020 at 7:41 a.m. and 12:31 p.m. - Yelling, cursing, verbal aggression, scream, yell, cuss, threaten. -5/17/2020 at 1:32 p.m. - Screaming, yelling and calling staff and other residents bad names. -5/21/2020 at 1:31 p.m. - Yelling cursing. -5/23/2020 at 3:01 p.m. - Resident in a verbal altercation with (Resident #14) which ended in (resident) slapping (Resident #14) across the face. I was able to separate the residents and the situation dissipated. (Charted by RN #2. Resident #14 had severe cognitive impairment with a BIMS of two out of 15.) -5/27/2020 at 1:42 p.m. - Yelling cursing. -5/30/2020 at 9:17 p.m. - Yelling. Swearing at staff. -6/1/2020 at 2:10 p.m. - Yelling cursing. -6/5/2020 at 2:00 p.m. - Yelling cursing. -6/14/2020 at 7:18 p.m. - Yelling, cursing, refusing care, aggression. -6/23/2020 at 2:27 p.m. - Cursing at roommate. -6/28/2020 at 10:36 p.m. - Yelling out, verbal aggression, name calling. -7/3/2020 at 2:13 p.m. - Yelling, cussing others, hyper fixated on smoking. -7/8/2020 at 2:35 p.m. - Yelling and cursing at other resident in isolation as well as CNA (certified nurse aide). No physical aggression. Talking to (resident) was effective to calm behavior. (Charted by RN #2) -7/17/2020 at 6:31 a.m. - Resident yelling cussing because she wasn't woken up to go smoke. -7/19/2020 at 7:43 a.m. - Yelling shut the f--- up you frigging idiot to resident who was banging on the wall and other similar things. -8/2/2020 at 6:25 a.m. - Resident yelling at another resident threatening to knock her the f--- out telling her come on b---- you f---ing wh--- I'll knock you out. Staff intervene to separate residents. -8/4/2020 at 10:22 a.m. - The SSD documented in a quarterly note the resident can become verbally aggressive, screaming out profanities when agitated on a daily basis. 1:1 (one-to-one) redirection when agitated. -8/6/2020 at 1:34 p.m. - Cursing and yelling at staff and residents. -8/8/2020 at 10:43 a.m. - Loud noise heard, this resident and male resident arguing yelling and cursing at each other in the hallway. Male resident ran his wheelchair right up next to this female resident and she then struck him in chest and legs four or five times. This nurse got in between them both and after yelling and cursing finally separated into their rooms. This resident denies any injury or fear for safety. (Three staff members witnessed the incident: two RNs and a nurse aide.) -8/8/2020 at 9:19 p.m. - Yelling, cussing. -8/9/2020 at 1:32 p.m. - Cursing, yelling. -8/13/2020 at 8:44 p.m. - Yelling, cussing. -8/14/2020 at 4:18 a.m. - Being rude to other residents, mocking them and flipping them off. -8/14/2020 at 2:13 p.m. - Yelling, cussing. -8/16/2020 at 6:51 a.m. - Resident is cussing other residents and mocking another that is singing and minding his own business. -8/16/2020 at 2:27 p.m. - Yelling, cursing. -8/17/2020 at 2:46 p.m. - Yelling out, cursing. -8/19/2020 at 3:09 a.m. - Cussing at other residents, telling another resident to shut the f--- up and mocking him as he sings. -8/23/2020 at 8:43 p.m. - Cussing, yelling, calling names. -8/24/2020 at 6:49 a.m. - Yelling and cussing stating she's going to hurt somebody. -8/24/2020 at 2:23 p.m. - Yelling. -8/25/2020 at 6:35 a.m. - Resident having a verbal argument with resident in room [ROOM NUMBER]B. Prior resident was in DR (dining room) yelling and cussing with no one present. -8/26/2020 at 11:04 a.m. - (SSD) spoke to (resident) regarding smoking policy . only 2 smokers could be out at a time and they had to be 6 feet apart. (Resident) then began to curse this staff out telling staff 'I hate your f---ing guts.' This staff informed resident to be kind to other resident during smoking and to please follow smoking policy . -8/27/2020 at 6:36 a.m. - Very irritable and angry and rude to everyone. -8/28/2020 at 1:44 p.m. - Cursing and yelling. -9/3/2020 at 3:58 a.m. - Yelling, cussing, mocking others, rude, inappropriate. -9/3/2020 at 2:01 p.m. - Resident cursing, yelling, talking about other residents loudly. -9/4/2020 at 3:06 p.m. - Yelling, hitting, cussing. -9/5/2020 at 3:56 a.m. - Yelling, cussing, rude, demanding. -9/8/2020 at 2:00 p.m. - Yelling, cursing. -9/11/2020 at 3:08 a.m. - Yelling, cussing, mocking others, yelling I hate you to staff, calling other residents sons of b----es or f---ers. -9/11/2020 at 4:56 a.m. - Yelling, cussing, being loud and rude, mocking others. -9/13/2020 at 1:55 p.m. - Yelling, cussing, threatening to hit another resident. -9/17/2020 at 6:47 a.m. - Yell, cuss, mock other. -9/20/2020 at 1:43 p.m. - Cursing, yelling at staff and other residents. -10/11/2020 at 1:22 p.m. - Resident is verbally abusive towards other residents. Starts argument and calls others names. Having to watch resident when around others. -10/21/2020 at 3:21 a.m. - Cussing, yelling. -10/26/2020 at 2:39 p.m. - Extremely agitated with negative vocalizations to staff and other residents. -10/31/2020 at 7:27 a.m. - Scream, cuss, sit in doorway pressing doorbell over and over. -11/15/2020 at 3:40 a.m. - An SSD quarterly note documented, can become verbally aggressive, screaming out profanities when agitated on a daily basis. -11/30/2020 at 1:31 p.m. - Yelling, cursing. -12/1/2020 at 1:21 p.m. - Yelling, cursing. -12/15/2020 at 2:26 p.m. - Cursing down hall. -1/4/21 at 1:39 p.m. - Increase in complaints, cussing, yelling. -1/4/21 at 9:36 p.m. - Yelling, cussing. -1/7/21 at 1:23 p.m. - Resident yelling down hall and cursing. -1/17/21 at 1:31 p.m. - Cussing, yelling, verbal aggression. -1/18/21 at 2:10 p.m. - Yelling, cussing. -1/25/21 at 2:50 p.m. - Resident very verbally inappropriate all shift. Yelling and cursing at both other residents and staff. -1/26/21 at 1:18 p.m. - Yelling, cursing, verbally abusive to staff. -1/26/21 at 8:55 p.m. - Yelling at others, calling them names, cussing. -2/1/21 at 1:22 p.m. - Resident continues to scream and yell and call staff and other residents names. Resident hits staff. Redirection unsuccessful. -2/1/21 at 8:22 p.m. - Yelling and cursing. -2/4/21 at 1:18 p.m. - Yelling out, cursing. -2/11/21 at 3:37 a.m. - Yelling because she came out early for smoke break and had to wait for the time allotted to go out. -2/12/21 at 3:28 a.m. - Hollering and calling people names. -2/13/21 at 2:14 p.m. - Cussing, demanding of wants, yelling. -2/14/21 at 11:45 a.m. - Resident was kicking and hitting this nurse. This nurse tried to remove self from resident and resident clawed this nurse face. Resident continues screaming and calling staff derogatory names. Resident charging other aides with wheelchair, kicking staff. Resident is unable to be redirected. Resident sitting by her door screaming derogatory statements. Other residents are agitated by her behavior. -2/18/21 at 1:56 p.m. - Cursing down halls. -2/22/21 at 9:02 p.m. - Yelling, cussing. -2/23/21 at 1:56 p.m. - Cursing, yelling. -2/24/21 at 1:41 p.m. - Cussing, yelling out. Yelling at other residents. -3/3/21 at 4:10 p.m. - Calling people names, cussing. -3/5/21 at 6:32 a.m. - Yelling at staff, yelling at other residents, being rude and very loud. -3/9/21 at 6:39 a.m. - Resident was wanting to go out to smoke at 3:30 a.m. At the same time there was an urgent matter in the SCU and only one staff member on the floor. Resident went down the hall slamming doors and yelling. She came out of her room angry yelling that she wanted to go out to smoke. RN let her know that there was an emergency and that she would need to wait a bit. Resident yelled 'I don't give a f--- about your emergency.' Resident was taken out to smoke about 4:15 when staff was able to return to the floor. -3/13/21 at 1:06 p.m. - Verbal aggression. -3/21/21 at 2:40 p.m. - Cussing, calling names. -3/22/21 at 8:24 p.m. - Cussing at others, increased complaints. C. Record review revealed the facility failed to take steps to prevent repeated abuse by Resident #36 toward other residents. 1. The facility failed to follow its abuse policy (see above) From 4/15/20 to 3/22/21, there were at least 20 incidents of verbal abuse and two incidents of physical abuse directed at residents by Resident #36. However, only one incident was investigated. On the morning of 3/24/21, investigative reports generated by Resident #36's verbal and physical abuse against other facility residents were requested. Only one investigative report was provided, regarding the 8/8/2020 incident with Residents #36 and #4. This investigation by a previous NHA was not followed up with a report to the state or otherwise as both residents said they didn't care. The other abuse incidents directed toward other residents were not specifically documented, reported or investigated. (Cross-reference F609 reporting of alleged violations and F610 investigation of alleged violations of abuse.) 2. There was no documentation in physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. There was no documentation in nurses' notes that nursing staff notified the physician or the DON/NHA of the abuse documented in the progress notes, except for the one incident during August 2020. 4. See Resident #36's care plans above. Resident #36's care plans failed to include detailed information on the resident's abusive behavior, identify potential targets of her behavior and, critically, include specific interventions to prevent repeated abusive incidents; Resident #36's psychosocial care plan included the same intervention as Resident #10's psychosocial care plan. Further, the care plans failed to include revisions as her abusive behaviors continued. Finally, neither Resident #36 nor Resident #10's care plan had been updated with staff directives to ensure the residents did not go out to smoke at the same time. VI. Staff interviews Staff interviews confirmed the facility had failed to protect residents from abuse by Resident #36. Staff interviews indicated everyone was aware of Resident #36's behavior, viewing Resident #36's abuse as just her behavior and not reporting it as expected per facility policy (see above), contributing to Resident #36's continued and unaddressed abuse of Resident #10 and others. CNA #1 was interviewed on 3/24/21 at 2:00 p.m. She had just taken Resident #10 out to smoke and left her with another CNA and two male residents. -She said she did not typically take the smokers out, but she had been informed that Residents #10 and #36 were not to be taken out to smoke at the same time. She said she had not seen Resident #36 go after Resident #10 because Resident #10 was so quiet. However, she had seen Resident #36 go off in the hallways and during smoke breaks, yelling, calling people f---ing b----. They try to redirect her, tell her she can't say those things, wheel her away from others, and ask her to go back to her room. It's just her behavior. -She said she did not report these incidents to anyone because, Everyone's aware, they've all seen it and heard it. (Resident #36 is) very loud. She said they had not had an abuse prevention or behavioral intervention training in about a year, since the pandemic, and she would welcome the training. The social services director (SSD) was interviewed on 3/25/21 at 10:30 a.m. She said she had talked with Resident #10 about this several times since they became aware during the survey that Resident #10 had been verbally abused by Resident #36. -She did an inservice with all the staff (during the survey) and told them Residents #10 and #36 were not to go out on smoke breaks at the same time. She did not ask the staff if they had observed this behavior from Resident #36 directed toward Resident #10. She said she had not seen it herself. She said she conducted abuse training quarterly, and since the pandemic staff had to read and signed off the abuse training documents. -She acknowledged staff might consider Resident #36's abusiveness her behaviors. She said abuse/neglect training was important to her, as she did not want the residents to ever be abused or retaliated against. -She said she believed all the incidents involving Resident #36 directed toward residents were reported and investigated. When she talked with Resident #10, Resident #10 told her the most recent incident with Resident #36 was the previous day, but she was confused at the time. She said either way, Resident #10 told her she thought the most recent abuse from Resident #36 was very recent. Registered nurse (RN) #12 was interviewed on 3/25/21 at 11:15 a.m. She said she spent a lot of time with Resident #36 because she was very vocal with some of her behaviors. -She said she had talked with Resident #36 (as followup to the investigation initiated during the survey) and told her people were not appreciative of the way she was talking to them. She told her it was making a lot of other residents uncomfortable and making them not feel safe, and they would call the police if they had to. I don't think I've heard her say a single word to anybody since. If I see a situation with her and a resident where I think the situation could escalate, I redirect her to something to read or take her to her room and ask her about pictures, and start an entirely different conversation. She could not recall any recent behavioral intervention training, but thought they had received some abuse/neglect training. -She said as of 3/23/21, Residents #10 and #36 were not to be within each other's visual range at all, and were not going out to smoke together; however, neither of these directives had been placed on the two residents' care plans (see above). If I see them coming towards the same situation I'm going to intervene. (Resident #36) has 15-minute checks. If she's out of her room she's in someone's line of sight. CNA #4 was interviewed on 3/25/21 at 11:40 a.m. She said she had taken Residents #10 and #36 out to smoke together a couple of months ago. Resident #36 was not mean to Resident #10 that morning. -She said, with Resident #36 it comes in spurts. She picks different people. I tell her you should be nice, and she responds, 'I don't have to.' Sometimes she'll listen to me, sometimes she won't. I've found if you don't play into it as much she just kind of tones down. She's a little different every day. -She and (Resident #4) have elevated (argued heatedl[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure five of 24 sample residents (#22, #46, #48, #50, #68) received care and services in a manner to promote dignity and respect. Specifically, the facility failed to: - Answer call lights in a timely manner; - Provide dignified dining, bathing, grooming, and incontinence care. - Ensure residents' incontinence pads were not visible from the hallway; These failures contributed to residents feeling, as they stated in interviews, "upset" and "helpless" when staff did not answer their call lights in a timely manner. The findings included: 1. Expectations: Policy Review: The policy entitled "Quality of Life - Dignity" dated 2001 and revised 8/09, provided in pertinent part: "Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth ... Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures." Professional Reference: According to "Dementia Beyond Drugs", copyright 2010, page 137, it stated in pertinent part, "A person with dementia tends to have very strong antennae; she can feel when we are distracted, or not fully present for a connection ...each person has taught me ...the importance of relaxing into being in the present moment." 2. Call Light Response: On 7/2/14 at 3:42 p.m., resident #68 was interviewed. The admission minimum data set (MDS) assessment dated [DATE] documented that this resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she was cognitively intact. The resident was asked if she felt that the facility had enough staff and she stated, "I do have concerns that they are short staffed. I have waited a long time to go to the bathroom; I don't know if it was an hour or an hour and a half. The thing is, they came in and put me on the toilet, because with (resident #50), they left her on the toilet for 45 minutes one day. They always say they will come back, but then they just don't come back. They will come in and shut the (call) light off and then they don't come back again." The resident was asked how long she normally had to wait for help when her call light was pushed, and she said, "Sometimes it is 15-30 minutes, but they are the exceptions. Normally it is shorter than that." She stated, "It upsets me that you can't reach someone to have someone come in and help you. It makes you feel helpless." On 7/2/14 at 3:46 p.m., resident #50 was interviewed. The quarterly MDS assessment dated [DATE] documented that this resident had a BIMS score of 15, which indicated that she was cognitively intact. She explained that she was placed on the toilet and "had my call light on and they just didn't come back in." She said, "It has been a couple weeks" since the incident happened. She stated, "They just finally showed up and helped me. I waited and waited. It makes me feel helpless." The resident was asked if she felt the facility was short staffed, and she said, "I do. I don't think they have enough people to answer call lights because they say they are going to come in and help you and then they never come back. I didn't like it that they tell me they will help me and then not come back. Makes you feel lied to. It's one thing to wait; it's another thing to be lied to." 3. Dignified Incontinence Care: Resident #48, age 74, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. He was occasionally incontinent of urine and bowel. Resident #48's son said, "He (resident #48) has bathroom issues, and every time I take him out, he uses the bathroom in his pants ... One time I took him out three or four months ago and when I brought him back he was messy, and I told the nurse who is no longer there, that he needed to be cleaned up, and she said, 'What did you do? Poop your pants? Come on back and I'll get you cleaned up.' But I could tell dad was embarrassed and mortified. She took him back and she changed him, but when they came back out, I told her, 'That won't happen again. Do not use that language again. He needs to keep his dignity.' My dad doesn't realize he messes his pants. I don't think they check him enough." 4. Dining Experience: The main dining room was observed on 6/30/14 at 5:00 p.m. Two CNAs were sitting with four residents at a table for residents who needed assistance with their meals. The two CNAs were conversing with each other, but not with the residents, from 5:00 p.m. to 5:11 p.m. At 5:11 p.m., one of the CNAs asked a resident if they were getting hungry, but not before 11 minutes passing with no verbal or physical interactions with any of the residents seated at the table. 5. Transportation to shower room: A. An unidentified female resident was observed being escorted by a CNA down to the bath house on the morning of 7/1/14. The resident was wrapped in a bath blanket and was being taken down in a bath chair. The resident's buttocks were uncovered and visible to the public. B. Resident #46 (see below) was observed on 7/3/14 at 11:15 a.m. She was being transported from her room down to the shower room in a shower chair. She was nude and draped in a bath blanket. Her legs were dangling and were uncovered from the knees down. 6. Visible Incontinence Pads: A facility-wide inspection of residents' rooms was conducted on 7/3/14 from 9:30 a.m. through 9:45 a.m. The rooms of the following three residents included the following observations: A. Resident #68: Resident #68 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE] stated that this resident was independent with set-up for eating. She required extensive assistance of one for bed mobility, transfers, dressing, toileting, and personal hygiene. She was totally dependent of one for ambulating with her wheelchair or walker and for bathing. Section H of this MDS stated that this resident was occasionally incontinent of urine. On 7/3/14 between 9:30 a.m. and 9:45 a.m., an incontinence pad was observed from the hallway on the resident's recliner. The resident was not in their room at the time. On 7/3/14 at 1:00 p.m., a second observation was made of resident #68's incontinence pad being visible from the hallway. During this observation, the resident was not present in the room. B. Resident #46: Resident #46 was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] stated that this resident was independent for bed mobility, transfers, and ambulating with either her crutches for short distances or with her wheelchair for longer distances. She was independent with set-up for dressing, eating, toileting, and personal hygiene. She was totally dependent of one for bathing. Section H of this MDS stated that this resident was frequently incontinent of urine. On 7/3/14 between 9:30 a.m. and 9:45 a.m., an incontinence pad on the resident's recliner was observed from the hallway. Resident #46 was sitting on the pad at the time, but the pad remained visible. On 7/3/14 at 1:02 p.m., a second observation was made of resident #46's incontinence pad being visible from the hallway. During this observation, the resident was again, sitting on the pad, which was still observable from the hallway. C. Resident #22: Resident #22 was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual MDS dated [DATE] stated that this resident had a BIMS score of 2, which meant she was severely impaired with daily decision making. This resident was totally dependent of one for bed mobility, transfers, ambulating with her wheelchair, dressing, eating, personal hygiene, and bathing. She was totally dependent of two+ for toileting. Section H of this MDS stated that this resident was occasionally incontinent of urine. On 7/3/14 between 9:30 a.m. and 9:45 a.m., an incontinence pad on the resident's recliner was observed from the hallway. Resident #22 was sitting on the pad at the time, but the pad remained visible. On 7/3/14 at 1:04 p.m., a second observation was made of resident #22's incontinence pad being visible from the hallway. During this observation, the resident was again, sitting on the pad, which was still observable from the hallway. 7. Staff Interviews: Cross-refer to F311, F312 activities of daily living, and F353 insufficient nursing staffing, for additional staff interviews. Certified nursing assistant (CNA) #16 was interviewed on 7/3/14 at 9:58 a.m. She stated that she did consider incontinence pads in visible sight as a dignity issue. She then asked this surveyor what the facility could do about it. A registered nurse (RN) was interviewed on7/3/14 at 9:59 a.m. She stated, "I don't think we should ever see their (the resident's) briefs or pads." When asked what she did when she saw visible incontinence pads, she stated, "If I see that, I will try to fix it." CNA #21 was interviewed on 7/3/14 at 10:02 a.m. She stated that she did feel that visible incontinence pads were a dignity issue for residents. When she was asked what actions should be taken when she observed exposed pads, she stated, "We should cover them up." CNA #22 was interviewed on 7/3/14 at 10:05 a.m. She stated that exposed incontinence pads were a dignity issue and stated, if seen, she should "cover them up or pull the privacy curtain." The social services director was interviewed on 7/3/14 at 10:10 a.m. She was asked if she felt that CNAs ignoring residents during dining was a dignity issue, she initially stated she did not feel it was a dignity issue per se, but the behavior was not okay. When the scenario was elaborated upon and the SSD learned that approximately 10 minutes passed during which time the CNAs were observed to be conversing with each other and not speaking to the residents at all, she changed her mind, stating, "That's certainly not how they are trained." The SSD then shared that she was scheduled to do an in-service in the next few months related to dignity issues and would make sure that dignity in the dining room would be covered in this in-service. The corporate nursing consultant was interviewed briefly on 7/3/14 at approximately 11:00 a.m. She stated that ignoring residents during their dining experience was not acceptable and that having residents escorted to the bath house with anatomy exposed or dangling legs was also an issue of concern that would be addressed.

Based on observation, record review and interviews, the facility failed to ensure two of 24 sample residents (#23 and #43) received care and services to maintain acceptable parameters of nutritional status. These failures contributed to both residents experiencing significant weight loss. The findings included: I. Expectations -According to the Nutrition Care of the Older Adult by the American Dietetic Association, 2nd edition 2004, page 104, "Nutrition assessment is a comprehensive approach completed by a dietetics professional, which defines nutritional status using medical, nutrition, and medication histories; physical examination; anthropometrics measurements; and laboratory data." -According to the Academy of Nutrition and Dietetics Nutrition Care Manual, 2014, "Frozen malts, yogurt, milk shakes, eggnog, nutritional supplements, ice cream, sherbet, plain regular or sugar-free gelatin or other foods that become thin liquid at body temperature are thin liquids." II. Facility Standards -According to the "Weight Assessment and Intervention" policy, revised on December 2008, "Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal confirmation must be confirmed in writing. The dietitian will respond within 24 hours of receipt of written notification." III. Resident Failures A. Resident #23 Resident #23, a [AGE] year old female, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Sheet (MDS) assessment dated [DATE], the Brief Interview for Mental Status (BIMS) score was not available. The resident had signs and symptoms of possible swallowing disorder with loss of liquids/solids from mouth when eating or drinking. 1. The resident's care plan last revised on 5/21/14 identified the problem, "High risk for aspiration, complications due to dysphagia related to [MEDICAL CONDITION]'s." -The goals included, "Resident will remain free of aspiration, injury and complications related to dysphagia and will be compliant with fluid consistency restrictions through next review date." -The interventions included, "Assess and record and report to MD: choking on food or liquids, coughing, respiratory distress, fever, [MEDICAL CONDITION] watery eyes, wheezing ...thickened liquids and pureed foods as ordered ...feed slowly. Watch for signs of choking ..." 2. The resident's care plan, last revised on 5/21/14, identified the problem, "Potential for complications related to [MEDICAL CONDITION]'s disease." -The goals included, "Resident will maintain optimal quality of life within limitations imposed by disease process..." -The interventions included, "Monitor, record, report to MD signs and symptoms of progression or complications ...decreased swallowing ability ...monitor nutritional status and serve diet as ordered. Monitor intake and record ..." 3. The resident's care plan, last revised on 5/21/14, identified the problem, "Resident potential for dehydration due to new environment, meds, cognitive status, disease progress, chewing and swallowing problems, dementia, [MEDICAL CONDITION]'s disease, shaking..." -The goals included, "Resident will show no signs and symptoms of dehydration through next review ..." -The interventions included, "Offer drinks and water at all meals, water pitcher in room, fresh water in the morning and evening, invite resident to all activities and offer drinks in between meals ...monitor weights and vital signs, monitor intake and output ...nectar thick liquids ...weekly weights ordered, resident refuses to eat or drink at meals ..." 4. The resident's care plan, last revised on 5/21/14, identified the problem, "Resident at risk for weight loss or nutritional decrease due to new environment, medication, cognitive status, disease progress of [MEDICAL CONDITION]'s, shaking, chewing, and swallowing problems, dementia, resistance to care, depression, activities of daily living (ADL) decline, difficulty making self understood, poor memory, disruptive behaviors..." -The goals included, "Resident will be free of signs and symptoms of weight loss or gain or nutritional decrease through next review ..." -The interventions included, "Encourage resident to eat 75% of all meals ...if significant weight loss/gain occurs, notify family and registered dietitians for suggestions and or supplement, monitor fluids and food intake at meals, offer periodic snacks, invite to activities and promote drinks and or snacks ...weekly weights ordered, resident refusing to eat most meals, provide diet as ordered ..." 5. The resident's care plan, last revised on 5/21/14, identified the problem, "Actual or potential nutritional problem risk due to new environment, meds, cognitive status, disease progress of [MEDICAL CONDITION]'s, chewing and swallowing problems..." -The goals included, "Resident will continue to eat foods of choice with minimal weight change through next review and not show loss of nutritional status with no signs/symptoms of malnutrition ..." -The interventions included, "Will have gradual weight gain/loss, provide diet as ordered of regular/pureed, observe, document, report to MD signs and symptoms of malnutrition cachexia, weight loss, muscle wasting, provide supplements when ordered, monitor weight as ordered ...monitor mouth pain, chewing or swallowing problems, offer assistance, cueing and encouragement ...weekly weights ordered, resident refusing to eat most meals ...give resident adequate amount of time to eat ..." 6. Observations: -On 06/30/14 from 1:00 p.m. through 6:00 p.m., this resident was observed to be in bed with no food noted at bedside or assisted to resident. No meal noted for dinner meal. (Meal intake records stated refused) -On 07/01/14 at 5 p.m., the resident was taken back to her room by 5:09 p.m. with the staff noted to have stated that she wasn't hungry. Only one bite was noted to have been attempted. Only two staff members were noted to have been in the secure unit dining room. -On 07/02/14 at 8:12 a.m., the resident was observed to have been fed with only a few bites consumed. The staff member stated that she just did not want to eat. -On 07/02/14 at 12:05 through 12:40 a.m., the resident was observed to have been sleeping in her chair at the beginning of the meal. She was observed to have coughed a couple of times during her meal. Meal service was interrupted several times with the staff cueing other residents and helping another resident into a chair. By 12:40 p.m., the resident was noted to have consumed most of her juice, most of her water, some applesauce, most of her barbeque meat with bread, most coleslaw and most potato salad. She was noted to have eaten well with continued assistance in the dining room. -On 07/03/14 at 8:15 a.m., the resident was observed to have eaten well with a particular staff member providing continued assistance. -On 07/03/14 at 12:30 p.m., the resident was observed to have eaten most of her food and fluids with the same staff member providing continued assistance. 7. Record Review According to the meal intake records: -For the month of June 2014: For 4 out of 86 meals; 75-100 percent consumed For 20 out of 86 meals; 25-50 percent consumed For 62 out of 86 meals; less than 25 percent consumed -For the month of May 2014: For 12 out of 89 meals; 75-100 percent consumed For 21 out of 89 meals: 25-50 percent consumed For 56 out of 89 meals: less than 25 percent consumed -For the month of April 2014: For 11 out of 87 meals; 75-100 percent consumed For 22 out of 87 meals: 25-50 percent consumed For 54 out of 87 meals: less than 25 percent consumed According to the weight records: -12/02/13: weight 105 pounds -03/09/14: weight 105 pounds -05/05/14: weight 102 pounds -05/12/14: weight 101 pounds -06/02/14: weight 96 pounds (5.9 percent significant weight loss x 1 month); (8.6 percent significant weight loss x 6 months) -06/15/14: weight 92 pounds (8.9 percent significant weight loss x 1 month); (12.4 percent significant weight loss x 3 months); (12.4 percent significant weight loss x 6 months). -06/22/14: weight 88 pounds -06/29/14: weight 86 pounds (6.5 percent further weight loss x 2 weeks) According to the "nutritional history" assessment in the chart dated 04/21/09, the dietary manager documented on the assessment form without inclusion of the registered dietitian evaluation and missing sections including clinical observations and medications. (No other nutritional assessments were available.) According to the most recent nutritional progress note, dated on 04/12/14, the dietary manager documented, "Weight team note - picked up resident for weekly weights. Resident has lost weight. Discontinue pudding and add ice cream at 2 and HS (night). Will continue to monitor." -On the nutritional progress note, dated on 03/14/14, the registered dietitian documented, "Reviewed dietary manager note for 02/13/14." (No current registered dietitian notes addressing the significant weight losses were available.) According to the Medication Administration Record [REDACTED] -Ice cream was provided orally twice daily in which 25-100 percent was documented as consumed nine out of 52 times. (Ice cream is a thin liquid.) According to the physician's orders [REDACTED]. (No nutritional supplement was ordered.) According to the interdisciplinary progress notes: -On 06/20/14: "Resident continues to refuse meds and food. Will take some fluids." -On 06/11/14: "Weight team meeting. Resident weight down to 96 pounds. Appetite poor. Will start weekly weights." -On 06/07/14: "...Resident did not get out of bed for noon or evening meals." -On 05/16/14: "Resident refused her evening meds and dinner." "Met for weight team. Weight stable, discontinue weekly weights." According to the "monthly summary" dated on 06/14/14, "Resident has been refusing food, some fluids and three-fourths of her meds for a few weeks. Doctor and family aware. Resident is end stage [MEDICAL CONDITION]'s." The chart was reviewed and was found void of any speech therapy (ST) documentation. B. Resident #43 Resident #43, a [AGE] year old male, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the BIMS score was not available. 1. The resident's care plan, last revised on 04/30/14, identified the problem, "Resident is an actual nutritional risk due to environment." -The goals included, "Resident will continue to eat foods of choice with minimal weight change through next review and not show loss of nutritional status without signs/ symptoms of malnutrition." -The interventions included, "Resident will have gradual weight loss/gain; provide diet as ordered of Regular/Regular, observe, document, report to MD signs/symptoms of malnutrition; provide supplements when ordered, monitor weight as ordered. Report to MD and registered dietitian, monitor labs and diagnostics work. Report to MD and registered dietitian, monitor for mouth pain chewing or swallowing problems, monitor intake of foods and liquids at meals ..." 2. The resident's care plan, last revised on 04/30/14, identified the problem, "Resident maybe at risk for weight loss or nutritional decrease due to environment." -The goals included, "Resident will be free of signs/symptoms of weight loss/gain or nutritional decrease through next review." -The interventions included, "Encourage resident to eat 75% of all meals, encourage family to bring in well liked foods and drinks ...if significant weight loss/gain occurs, notify family and registered dietitian for suggestions and/or supplements, monitor fluids and food intake at meals ...weigh as ordered." According to the comprehensive plan of care, dated 04/30/14, "Met for admission care conference. Daughter participated via phone ...weight is 192 pounds down 2%, good eater, no concerns ..." 3. Observations -On 07/01/14 at 5:10 p.m., the resident was observed to be fed the dinner meal. -On 07/02/14 at 8:12 a.m., the resident was observed to be fed the breakfast meal. -On 07/02/14 at 12:05 through 12:40 p.m., the resident was observed to be sleeping in a chair with some coughing noted with the meal. Some meal service interruption was noted when the two staff members stopped to assist another resident into a chair. The resident was observed to have consumed less than 25 percent of the meal and three-fourths of the applesauce. (Two staff members were observed to have helped assist all residents during the meal.) 4. Record Review According to the meal intake records: -For the month of June 2014: For 69 out of 86 meals; 75-100 percent consumed For 14 out of 86 meals; 25-50 percent consumed For 3 out of 86 meals; less than 25 percent consumed -For the month of May 2014: For 64 out of 88 meals; 75-100 percent consumed For 15 out of 88 meals: 25-50 percent consumed For 9 out of 88 meals: less than 25 percent consumed -For the month of April 2014: For 49 out of 82 meals; 75-100 percent consumed For 22 out of 82 meals: 25-50 percent consumed For 11 out of 82 meals: less than 25 percent consumed According to the weight records: -03/09/14: weight 202 pounds -03/24/14: weight 208 pounds -03/31/14: weight 201 pounds -04/07/14: weight 192 pounds (5 percent weight loss x 1 month) -04/26/14: weight 197 pounds (5.3 percent weight loss x 1 month) -05/05/14: weight 187 pounds -05/12/14: weight 186 pounds -06/02/14: weight 185 pounds -06/15/14: weight 183 pounds -06/22/14: weight 180 pounds -06/29/14: weight 179 pounds (10.9 percent significant weight loss x 3 months) According to the "nutritional evaluation" assessment in the chart, dated 02/23/14, the dietary manager documented on the assessment form without inclusion of the registered dietitian evaluation. Missing sections included: physical characteristics, clinical observations, clinical data, food preference/intolerances, source of information and overall nutritional summary. (No other nutritional assessments were available.) According to the most recent nutritional progress note, dated on 03/14/14, the registered dietitian documented, "Reviewed resident records. Calculated residents IBW (ideal body weight) range..." with inclusion of resident's estimated nutritional needs. (No current registered dietitian notes addressing the significant weight losses were available.) According to the physician's orders [REDACTED]. (No nutritional supplement was ordered.) The chart was reviewed and was found void of any speech therapy (ST) documentation. C. Staff Interviews -On 07/02/14 at 11:00 a.m., CNA #18 was interviewed. She stated that the only resident she was aware of having any weight loss was resident #23. She stated that this resident refused to eat but drank fluids well. She stated that she was not sure who was in charge of monitoring the weight losses in the facility. -On 07/02/14 at 11:00 a.m., CNA #27 was interviewed. She stated that the restorative CNA was usually the one who notified them of the residents with weight losses. She stated that resident #27 usually ate when food was provided to him. -On 07/02/14 at 11:00 a.m., RN #6 was interviewed. She stated that she looked at the weight book to see which residents had experienced weight loss. She also stated that the weight team meets monthly. She also stated that there wasn't a speech therapist in the building. -On 07/03/14 at 1:00 p.m., the dietary manager (DM) was interviewed and she stated that she calculated the weight changes. She stated that resident #23 ground her teeth a lot and that they were going to get her a dentist appointment. When asked if this resident was on a nutritional intervention, she stated that she was on thickened liquids. The DM stated that resident #43 ate really well when he first came in. "He still eats, but I'm not sure what is going on with him. I don't think he is on nutritional supplements." -On 07/02/14 at 3:00 p.m., the corporate nursing consultant, RN #4, and the director of nurses DON were interviewed. The corporate nursing consultant stated that the registered dietitian (RD) came to the weight meeting and that the DM calculated the weight losses. When asked if they were aware of weight losses associated with these residents, they stated that they would have to look at the report. They confirmed that there were no speech therapists in the county. When asked if they contacted the medical doctor (MD) when there were significant weight losses, they stated that they did if they were significant. -On 07/03/14 at 10:00 a.m., the medical director was interviewed. When asked if he expected residents who had experienced weight losses to have been assessed by the registered dietitian, he stated, "Yes. If that isn't how things are getting done, then we need to work on that." -On 07/03/14 at 10:00 a.m. through 12:00 p.m., four attempts were made to contact the registered dietitian with two messages left on her voicemail. No response was received from the registered dietitian. -On 07/03/14 at 1:24 p.m., the nursing home administrator (NHA) was interviewed and she stated that the weight meeting met monthly for review of any significant weight losses and weight gains. She stated that they hired a new RD with the resignation of the previous one.

Based on observations, resident interviews, staff interviews and record review, the facility failed to provide care and services to attain the highest practicable physical, mental and psychosocial well-being of each resident. These failures contributed to residents feeling, as they stated in interviews, "upset" and "helpless" when staff did not answer their call lights in a timely manner. Residents and family members further stated in interviews that residents were incontinent as a result of short staffing and the lack of timely assistance. The findings included: Cross-refer to F241 dignity, F311 and F312 activities of daily living, F314 pressure ulcers, F325 weight loss, and F441 infection control. A. Facility Policy and Procedure: On 7/2/14 at 5:00 p.m., the director of nurses (DON) provided the facility's policy and procedure titled, "Staffing," revised April 2007, which included: "Our facility provides adequate staffing to meet needed care and services for our resident population. 1. Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. 3. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are adequately staffed to ensure that resident needs are met. 4. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each shift during at least one (1) week of each quarter to appropriate state agencies as required. Such workweek is selected by the state survey agency. 5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee." B. Resident Care Needs: According to the Resident Census and Conditions of Residents report provided by the DON on 7/1/14, the facility census was 47. Resident needs were documented as follows: -For bathing, 35 residents needed assistance of one or two staff, and 12 were dependent; -For dressing, 39 residents needed assistance, and four were dependent; -For transferring, 29 residents needed assistance, and four were dependent; -For toilet use, 28 residents needed assistance, and four were dependent; -For eating, six residents needed assistance, and five were dependent. Regarding bowel/bladder status and mobility: 28 residents were occasionally or frequently incontinent of bladder; 24 residents were occasionally or frequently incontinent of bowel; 19 residents were in a chair all or most of the time; and 3 had contractures. Regarding mental status: 21 residents had behavioral healthcare needs and 26 residents had dementia. Regarding special care: 16 residents received respiratory treatments. C. Resident Interviews: On 7/2/14 at 3:42 p.m., resident #68 was interviewed. The admission minimum data set (MDS) assessment dated [DATE] documented that this resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she was cognitively intact. The resident was asked if she felt that the facility had enough staff and she stated, "I do have concerns that they are short staffed. I have waited a long time to go to the bathroom; I don't know if it was an hour or an hour and a half. The thing is, they came in and put me on the toilet, because with (resident #50), they left her on the toilet for 45 minutes one day. They always say they will come back, but then they just don't come back. They will come in and shut the (call) light off and then they don't come back again." The resident was asked how long she normally had to wait for help when her call light was pushed, and she said, "Sometimes it is 15-30 minutes, but they are the exceptions. Normally it is shorter than that." She stated, "It upsets me that you can't reach someone to have someone come in and help you. It makes you feel helpless." On 7/2/14 at 3:46 p.m., resident #50 was interviewed. The quarterly MDS assessment dated [DATE] documented that this resident had a BIMS score of 15, which indicated that she was cognitively intact. She explained that she was placed on the toilet and "had my call light on and they just didn't come back in." She said, "It has been a couple weeks" since the incident happened. She stated, "They just finally showed up and helped me. I waited and waited. It makes me feel helpless." The resident was asked if she felt the facility was short staffed, and she said, "I do. I don't think they have enough people to answer call lights because they say they are going to come in and help you and then they never come back. I didn't like it that they tell me they will help me and then not come back. Makes you feel lied to. It's one thing to wait; it's another thing to be lied to." On 7/3/14 at 1:57 p.m., resident #18 was interviewed. The quarterly MDS assessment dated [DATE] documented that this resident had a BIMS score of 15, which indicated that she was cognitively intact. She was asked if she felt the facility was short staffed, and she stated, "Truthfully, yes." She explained that she attends the resident council meetings, and during the last meeting a resident "talked about the fact that they waited two hours to go to get somebody to come in and take them to the potty. And by the time they had gotten help, it was too late and they had already soiled themselves." She explained that during the week of 5/26/14 she went for two days without any towels in her bathroom. She stated, "We never got any more for two days. I brought it up to (CNA #19). I had told her about how the CNAs hadn't brought in any towels or washcloths. At the same time it had happened, housekeeping never came in and my trash had piled up ...so that kind of thing goes on." She stated, "The girls will come in and you don't get your showers ...I know (resident #50), she says especially on weekends she doesn't get her bath. They always tell her that they are so busy that they can't give it to her. When things are running behind, that is one of the things that sort of gets slipped by." D. Family Interviews On 6/30/14 at 2:30 p.m., resident #54's daughter was interviewed. She said "staffing was bad," there were not "enough girls working on the floor, especially on the weekends and evenings." She said if her mom needed help with anything during meal times that she would have to wait, "nothing happens during meals" because the staff is in the dining room assisting residents with meals. She said there were no CNAs to help with toileting or putting people to bed during meal time. She said that fresh water gets passed twice per day, unless something out of the routine happens. She said that anytime something unusual happens, the regular routine does not happen. She said that on the weekends, "all bets are off for a regular routine because sometimes there is only one nurse and one CNA." -She said that her mom can be incontinent at times and if the staff came in frequently on a routine basis during the day, she would be continent. She said the staff have not toileted her mom on a frequent routine schedule and that her mom has often had incontinent accidents. -She said that there may have been some improvement with the new director of nurses, but that he had only been at the facility for a short time, and "there's been no change in the staff ratio." -She said her mom is cold all of the time, and that she does not like to bother the staff to ask for help. -She said it was so bad once that she felt like calling the police department because there was not enough staff to provide help for her mom or the other residents. She said she had talked to the previous director of nurses about the issue, but that she does not feel that the problem of the shortage of staff has been resolved yet. -She said that she had talked to the social services manager also, and had explained to her that she was going to talk to the people from the state about the facility's staffing shortage. -During a follow-up interview on the evening of 7/2/14, the resident's family member said another thing that bothers her is that the bed was not made up correctly. She said this is the second day in a row that she was here when the CNA came in to help her mom to bed and the bed did not have a top sheet or blanket. She said that the staff used the resident's personal quilts to cover her mom, but she feels the bed should be made up to include a top sheet and blanket and that her mom's quilts should just be extras due to her Mom getting so cold at times. On 7/1/14 at 9:29 a.m., resident #48's son was interviewed and asked if he felt the facility had enough staff, and he stated, "I don't think so. When I met with (the facility owner) that one time, I told him I thought there was a (State) law that they had to have so many staff members per resident. I feel like some of those girls are run ragged, and sometimes they reduce the staff numbers. I've seen it when bells are going off and bed alarms are going off, and you just become immune to it." He confirmed that he was at the facility almost daily to see his father. (Cross-Reference F312, activities of daily living.) On 7/3/14 at 9:30 a.m., resident #56's wife requested to speak to a surveyor and was interviewed at that time. She was asked if she felt the facility had enough staff, and she said she did not. She stated, "There has been a lot of stress and a lot of people quitting." She said her husband's "teeth don't always get brushed. Sometimes when they are short staffed, he will be incontinent and I change him myself." She explained that "usually every day" she finds her husband "soaked with urine. He uses adult diapers." She said she usually feeds her husband his meals, and "sometimes there is no one else to take care of the other two residents at the table. If they had more people to help serve, it would go faster. There are not always enough people to help feed in the dining room." She stated, "Sometimes residents are asking me to help them go to the bathroom and then they will wet themselves. I will push their (call) button and try to get help." She explained, "We have such a bunch of new CNAs here and they don't have time to sit and get to know the residents." She said that her husband does not refuse care, and said, "He doesn't use the call light; he can't." On 7/1/14 at 11:05 a.m., resident #49's son was interviewed and asked if the facility had enough staff. He stated, "They are trying to correct that now. There is only one person back there (in the secure unit)." He stated that there needed to be more training in the unit and said, "There needs to be more staffing in the unit for cares and during meals ...There is a high turnover with the nursing staff." E. Staff Interviews: On 7/3/14 in the afternoon, the previous director of nurses (and current MDS coordinator) was interviewed. She said that resident #54's daughter had voiced her complaint about staffing. She said on the day that they were short that the daughter said she was going to call the police (see above), there was a manager on call, and on the day of the daughter's concern, that on-call manager did come in to work. She said that she had followed up on concerns of the family member and had tried to resolve the issues. She said it was hard to hire and keep good CNAs. On 7/2/14 at 11:00 a.m., a registered nurse (RN #6) who had worked at the facility for one year was interviewed, and asked if she felt that the facility had enough staff. She stated, "No. I was the MDS Coordinator and talk about PPD (nursing hours allotted per day per resident) and with the amount of residents in the building. With the amount of two-person assists, it's not realistic. We need more nurses but I feel like the East hall is understaffed and needs two people at all times. One on each hall and a float is not enough." The RN was asked how this impacted resident care, and she said, "They don't get the care that they deserve. I feel like they can't take the time and people get missed. Like teeth not brushed or not shaved in the morning. The little stuff that makes a difference, like peri-care, including incontinence (care)." She gave the example that resident #56 "is not shaved." The RN was asked if she had to re-prioritize what gets done when they are short staffed, and she stated, "Yes, I have to stop what I am doing and find a CNA and take them to the room to brush teeth or wash their face." On 7/2/14 at 2:57 p.m., a licensed practical nurse (LPN, #3) who routinely worked the day shift was interviewed and asked if she felt the facility had enough staff. She stated, "Sometimes I feel like we need more CNAs on the floor. It doesn't matter what the budget is. Resident care should come first." She confirmed that she has heard complaints from residents who said that they feel rushed with their cares. The LPN was asked how tasks get re-prioritized when they are short staffed, and she said, "We've been where I feel like we were short, but according to standards we are not. But if I need to help do something to help get it done, that's what I do." The LPN was asked how this impacted the residents, and she stated, "They are not getting the correct care as far as the time that needs to be spent with them to make sure everything is done properly." On 7/1/14 at 3:21 p.m., a CNA (#17) who had worked at the facility for over two years was interviewed. She was asked if the facility had enough staff, and she stated, "No. We have a lot of residents who (require a) two-person assist. And when we don't have enough staff, we have to go grab someone else, and it can take a long time to go get someone else to help you." On 7/1/14 at 3:38 p.m., a CNA (#25) who had worked at the facility for one year was interviewed. She explained that she felt the staffing was adequate when there were two CNAs staffed in the secure unit and on the East and West hallways, and there was a float. She said, "Some days it's one and one and a float ...It's a little overwhelming." The CNA confirmed that she worked 40 hours per week, and was asked how often they work short staffed. She said, "I think five to eight days out of the month ...(The residents) don't feel like they are getting the quality care. They like to talk to us." She said when they are short staffed, "You bump up the speed a little bit." On 7/2/14 at 10:23 a.m., a CNA (#21) who had worked at the facility for almost one year was interviewed. She confirmed that she had answered call lights in the past and told residents she would get back to them, and stated, "Because usually if they are wanting something simple I can help. But if it is a two-person assist I would have to get back to them and get another CNA with me." She said there were approximately six residents on the west hall that required a transfer with the assistance of two people. She was asked if she felt the facility had enough staff and she stated, "Like the days that we get only three (CNAs) it is really rough on all the CNAs because we are always running back and forth." The CNA was asked how this impacted resident care, and she stated, "I'm not going to lie; I think we are rushing for giving them the right care that they need." On 7/2/14 at 11:00 a.m., a CNA (#18) who routinely worked in the secure unit was interviewed and asked if she felt the facility had enough staff. She stated, "I would have to say in the unit, we could use another CNA back here during the day and evening shift. Usually we have only two. More residents are needing more assistance ...The others get cued." The CNA was asked how being short staffed impacted resident care, and she explained, "There are a few two-person (assists) back here, and when (resident #53) is awake, we bring him in the hallway, so we can hear him when we are helping a (resident who requires a two-person lift). (Resident #53) is very one on one." On 7/2/14 at 2:40 p.m., a CNA (#24) who had been at the facility for eight years was interviewed and was asked if she felt that the facility had enough staff. She stated, "I feel like there is not enough staff sometimes to take care of the residents ...I think our staffing is good if (the newly hired staff) will stay, but it is a problem just getting them to stay. They are younger, and they just stay until they get their training and then they leave. The residents feel it. Sometimes it is too much change and too much stimulation, but there needs to be consistency and those same people need to be on the same halls because they know you. They know they are going to get their showers at the same time." On 7/2/14 at 3:00 p.m., a CNA (#23) who had worked at the facility for one month was interviewed, and she said she was a "[AGE] year CNA veteran." She said she has answered call lights in the past and then told a resident she would have to get back to them and stated, "Yes, if they are a two-person transfer and they need to go to the bathroom, I tell them it will be a minute but I have to go find my partner." The CNA was asked if she has ever heard a resident at the facility complain about feeling rushed during their care, and she said, "I have heard that a couple of times, especially with the ladies on the East (hall) who need a little more help. (Resident #68) asked me point blank,'You're not going to leave me if you hear a call light are you?' She was on the toilet. She asked me that even before I got her on the toilet. I told her that if I heard a bed alarm I would have to leave, but she told me that I would need to find someone else to sit with her. I ended up sitting with her for the whole time. It's not that she can't be left; it's that she doesn't want to be. I've heard through the grapevine that she had to wait a long time to get off the toilet ...The staffing is my main concern. It is the lack of help. The nurses do have their own jobs to do, not just answer call lights." She said, "It affects resident care in that there are a lot of two-person transfers here, so that means that person would have to wait longer to get help because we will have a float or we'll have to find someone from another hall to help, and a lot of times she's not readily available. It is really hard to answer call lights all at once." She explained, "I don't feel that all the time we have enough staff. I feel that there should be two CNAs on each of these halls, plus a float, but I feel that we need to be significantly better staffed." F. Record Review: The "Daily Nursing Schedule/Assignments" for the facility were reviewed from 4/1/14 through 7/1/14. The facility had a schedule for CNAs that included a day shift from 6:00 a.m. to 2:30 p.m., an evening shift from 2:00 p.m. to 10:30 p.m., and a night shift from 10:00 p.m. to 6:30 a.m. The documents showed that the facility was fully staffed on a daily basis. G. Additional Staff Interviews: On 7/3/14 at 12:25 p.m., the DON and corporate nurse consultant were interviewed, and the DON confirmed that he began working at the facility on 6/23/14. They were asked what their expectation was for how the staff are to answer call lights. The DON stated, "(The facility staff) were in-serviced on 6/23/14 and I let them know my expectations right off the bat ...I told staff I don't care who it is, but I expect you to answer call lights. You might not be able to do any patient care, but you can get nursing staff to help." They were informed of comments made by the facility staff that they are short staffed, and the nurse consultant stated, "With the staff, I would say that it is subjective." The DON stated, "We staff based on acuity, and the way that I've been staffing since 6/23/14, I have not heard any issues since then ...I have seven (CNAs) during the day, including the restorative aide, and I have five in the evening, and then three at night. And that is not including the nurses; that's just CNAs." The DON was asked how he assured that there are adequate staff to meet the needs of the residents, and he stated, "I'm making the schedule, so it is my responsibility, so I make sure there are enough staff working ...I oversee all of the staffing." The DON said, "I don't believe we are running short, but I'm going to get back to you on that. When we are really short, a nurse has to work the floor as a CNA." On 7/3/14 at 2:14 p.m., the DON, corporate nurse consultant and MDS coordinator were interviewed again. They explained that the MDS coordinator was the previous DON prior to 6/23/14. They were asked why there is a perception among residents, staff and family members that the facility is short staffed, and the MDS coordinator stated, "When I first started, our census was extremely low compared to what they are used to. Of course there are fewer workers in the building so they feel like they are short staffed because there are not as many of them. We are over on our numbers on some days. We have not ever been short staffed. I don't know how to change the perception." The corporate nurse consultant stated, "The perception is their reality." The DON explained that the facility is staffing above the minimum (State) PPD guidelines of 2.1, and stated, "Most of those days we were higher than the minimum."