REHABILITATION CENTER AT SANDALWOOD, THE

A licensure survey was completed on 4/22/24 to 4/26/24. Two deficiencies were cited.

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Based on interviews and record review, the facility failed to provide timely and effective interventions to prevent weight loss for one (#41) of four residents reviewed for weight loss out of 35 sample residents. Resident #41 was admitted to the facility for long term care on 1/14/23 and readmitted on 9/14/23 with diagnoses of hyper-IgE syndrome (a rare immunodeficiency syndrome), anemia (low blood count) and dementia. Resident #41 had multiple food allergies, including soy protein, brussels sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. On 10/1/23, Resident #41 weighed 139 pounds (lbs). On 10/15/23, Resident #41 weighed 119.2 lbs, which indicated the resident had lost 19.8 lbs. The registered dietitian (RD) requested the resident to be reweighed on 10/16/23, 10/19/23, 10/24/23 and 10/26/23. The resident was not reweighed until 10/26/23, 10 days after the initial reweigh was requested, where she weighed 116.5 lbs. The resident had lost 16.2% (22.5 lbs) in 25 days, which was considered severe. The facility did not implement a nutritional intervention to address the resident's severe weight loss until 11/7/23 when a nutritional orange juice supplement was added three times a day. The physician had ordered the resident's weight to be obtained weekly beginning 11/11/23 and ending on 1/15/24. During this time the facility failed to follow physician orders and weigh the resident consistently on a weekly basis to closely monitor the resident's weight loss. On 2/8/24, Resident #41 weighed 110.3 lbs. The resident had lost an additional 6.2 lbs from 11/6/23 to 2/8/24. Despite the resident losing an additional 6.2 lbs from 11/6/23 to 2/8/24, the facility did not implement additional nutritional interventions. On 3/15/24, Resident #41 weighed 103 lbs. On 3/19/24, 3/20/24, 3/22/24 and 3/26/24 the RD requested the resident to be reweighed. The facility did not reweigh the resident until 4/1/24 where she weighed 100.5 lbs. The resident sustained a 6.6% (7.3 lbs) weight loss, which was considered severe from 2/8/24 to 3/15/24 in one month. The facility implemented fortified mashed potatoes on 3/31/24, 16 days after the resident sustained a severe weight loss. On 4/1/24 the resident triggered for severe weight loss of 27.7% (38.5 lbs) in six months from 10/1/23 to 4/1/24. The facility did not reassess and implement further nutritional interventions to address the resident's severe weight loss. Due to the facility's failures to closely monitor the resident's weight, obtain timely reweighs and implement timely nutritional interventions, Resident #41 sustained a 27.7% (35.8 lbs) weight loss in six months, which was considered severe. Findings include:I. Facility policy and procedureThe Weight and Height Management policy and procedure, revised on 12/6/18, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m. It read in pertinent part, "Residents will be weighed a minimum of monthly by nursing, unless otherwise ordered by the physician. Upon admission, residents will be weighed weekly for four weeks unless contraindicated (resident preference, pain, end of life)."The registered dietitian (RD) will evaluate weekly admission body mass index (BMI), baseline weights and weight trends to recommend weight frequency. "The physician will be notified of significant weight loss. "If a weight change as noted above is accurate the direct care nurse or RD should review and evaluate recent acute temporary care plan to identify possible reasons for the weight change. "The RD/designee will review weights and make recommendations, based on potential weight gain or loss trends."II. Resident #41A. Resident statusResident #41, age 77, was admitted on 1/14/23 readmitted on 9/14/23. According to the April 2024 computerized physician orders (CPO), diagnoses included hyper-IgE syndrome, anemia and dementia. The 3/19/24 facility assessment revealed the resident had moderate cognitive impairment with a briefinterview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for toileting. She required substantial/maximal assistance with personal hygiene, bed mobility, transfers and required supervision with touch assistance and cueing with eating. The assessment documented the resident was 63 inches (five foot, three inches) tall and weighed 103 lbs. The resident had a weight loss of 5% or more in one month or a weight loss of 10% in six months that was not physician prescribed. B. Record reviewThe nutrition care plan, initiated on 9/28/23 and revised on 4/3/24, revealed Resident #41 had significant unplanned weight loss. The resident had a history of significant unplanned weight loss. The care plan documented the 3/27/24 nutrition assessment of the resident's current oral intake and the supplement of six ounces (oz) nutritional white grape juice three times a day was determined to be not sufficient to meet the resident's assessed caloric needs. The resident had pneumonia on 3/8/24. The interventions included encouraging high protein foods, monitoring weights, providing a gluten restricted diet, providing her meals in her room without assistance, providing cueing and encouragement, encouraging the resident to eat and drink throughout day, monitoring the amount of food and fluid intake at meals, providing six oz of nutritional white grape juice three times a day and offering four oz of fortified mashed potatoes with gravy at lunch.-The care plan did not document how frequently the resident was to be weighed. The April 2024 CPO revealed an order for weekly weights due to significant weight loss, ordered 11/11/23 and discontinued 1/15/24. The April 2024 CPO revealed an additional order for monthly weights on the first weekend of every month, ordered 1/15/24.-A review of the resident's medical record revealed the resident's weekly weight was not obtained on 11/18/23, 11/25/23, 12/2/23, 12/16/23, 12/23/23, 1/6/24 and 1/13/24. -A review of the resident's electronic medical record (EMR) revealed the resident's weight was not obtained in January 2024. The resident's weights were documented in the resident's EMR as follows:-On 10/1/23, the resident weighed 139 lbs;-On 10/15/23, the resident weighed 119.2 lbs;-On 10/26/23, the resident weighed 116.5 lbs;-On 10/31/23, the resident weighed 116.0 lbs;-On 11/6/23, the resident weighed 116.5 lbs;-On 12/7/23, the resident weighed 115.5 lbs;-On 12/28/23, the resident weighed 114.0 lbs;-On 2/8/24, the resident weighed 110.3 lbs;-On 3/15/24, the resident weighed 103 lbs; and,-On 4/1/24, the resident weighed 100.5 lbs. The resident sustained a 16% (22.5 lbs) weight loss, which was considered severe, from 10/1/23 to 10/26/23 in less than one month. The resident sustained a 6.6% (7.3 lbs) weight loss, which was considered severe, from 2/8/24 to 3/15/24 in one month. The resident sustained a 11.9% (13.5 lbs) weight loss, which was considered severe, from 12/28/23 to 4/1/24 in three months. The resident sustained a 27.7% (38.5 lbs) weight loss, which was considered severe, from 10/1/23 to 4/1/24 in six months. The April 2024 CPO revealed the following diet and nutritional supplementation orders:-Gluten restricted diet, regular texture, regular/thin consistency, ordered 9/26/23;-Magic cup once a day, ordered 10/4/23 discontinued 11/7/23; and,-HS (bedtime) snack, ordered 9/14/23. The 9/28/23 nutrition assessment documented the resident was independent with eating. Her weight was 140.5 lbs. She was on a gluten restricted diet with multiple food allergies, which included soy protein, brussel sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. The 9/28/23 nutrition assessment further documented the resident's current oral intake at meals was not sufficient to meet her assessed calories and protein needs. The interventions included encouraging the resident to consume high protein foods, continuing four oz Magic cup ice cream (frozen nutritional supplement) every day and continuing to monitor and follow up as needed. The 10/16/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested.-However, the facility failed to obtain the reweigh when it was requested. The 10/19/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from the previous weight of 139 lbs. A reweigh was requested.-However, the facility again failed to obtain the reweigh when it was requested. The 10/24/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested.-However, the facility again failed to obtain the reweigh when it was requested. The 10/26/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested.-However, Resident #41 was not reweighed until 10/26/23, 10 days after the RD initially requested the resident to be reweighed. -When the reweigh was obtained, Resident #41 weighed 116.5 lbs and had sustained a 16.2% (22.5 lbs) weight loss in 25 days, which was considered severe, from 10/1/23 to 10/26/23. The 11/7/23 nutrition progress note documented the resident's weight loss was due to insufficient oral intake at meals. The resident's preferences were reviewed and the Magic cup was discontinued per the resident's request. The current interventions included weekly weights. The RD reviewed with the resident to eat high protein foods and recommended starting a nutritional orange juice three times a day. The progress note documented the resident fed herself and received assistance and cueing as needed.-The resident sustained a 16.2% (22.5 lbs) weight loss, which was considered severe from 10/1/23 to 10/26/23 in less than one month. The facility did not implement a new nutritional intervention to prevent further weight loss until 11/7/23. The 12/31/23 nutrition progress note documented the resident's weight was down to 114 lbs on 12/28/23. Her average oral intakes at meals were 50% and, along with the current intervention of the nutritional orange juice, were insufficient to meet current caloric and protein needs. Other current interventions included continue with encouraging high protein foods, nutritional juice and the goal of increasing oral meal intakes of equal or more than 50%.The 12/31/23 quarterly nutrition assessment progress note documented the resident had significant unplanned weight loss. The resident was on a gluten restricted diet with multiple food allergies and was able to feed herself in her room with assistance, cueing and encouragement. Her average oral intake was 58% at meals. The progress note documented the Magic cup was not sufficient to meet her assessed caloric and protein needs so six oz of nutritional orange juice three times a day was implemented to help meet nutritional needs.-The Magic cup was discontinued on 11/7/24 when the nutritional orange juice was ordered. -The resident weighed 114 lbs on 12/28/24. The facility did not implement additional nutritional interventions to prevent further severe weight loss, despite the resident's continued downward trend of weight loss. The 1/31/24 nutrition progress note documented the RD requested a weight to be taken in January.-However, there was no weight documented in the resident's weight section of the EMR for January 2024 (see resident's weights above). The 2/1/24 nutrition progress note documented the resident weighed 108.5 lbs. The resident had a decrease of more than five lbs from her previous weight. A reweigh was requested.-Review of the resident's EMR did not reveal when the resident's weight of 108.5 was obtained. The 2/5/24 nutrition progress note documented a reweigh requested. On 2/8/24 the resident weight was documented as 110.3 lbs, which continued to show a downward trend in weight loss.-However, the facility failed to add any additional nutritional interventions to prevent further weight loss. The 2/29/24 nutrition progress note documented Resident #41 ate in her room, was able to feed herself and received assistance and cueing. Her oral intakes at meals were 42% on average. The current nutrition interventions included nutritional orange juice. The 2/29/24 progress note further documented the resident's current oral intake and nutritional orange juice three times a day was not sufficient to meet nutritional needs. Resident #41 requested chocolate milkshakes.-However, review of the resident's EMR did not reveal the chocolate milkshakes were initiated per the residents request. The 2/29/24 nutrition progress note additionally documented Mighty shake (nutritional supplement) and Lyons Ready Care shakes (nutritional supplement) contained soy and the resident had a soy allergy. The nutritional orange juice three times a day was changed to nutritional white grape juice. -The RD documented the resident's oral intake and nutritional interventions were not sufficient to meet the resident's nutritional needs. However, the RD did not increase nutritional supplementation to help meet the resident nutritional needs after she had sustained further weight loss or explore other nutritional interventions or supplementation that would accommodate Resident #41's multiple food allergies. The 3/19/24 nutrition progress note documented the resident weighed 103 lbs, which was down from her previous weight of 110 lbs on 2/8/24. The RD requested for the resident to be reweighed.-However, the facility failed to obtain the reweigh when it was requested. The 3/20/24 nutrition progress note documented the RD requested the resident to be reweighed.-However, the facility again failed to obtain the reweigh when it was requested. The 3/22/24 nutrition progress note documented the RD requested the resident to be reweighed.-However, the facility again failed to obtain the reweigh when it was requested. The 3/26/24 nutrition progress note documented the RD requested the resident to be reweighed.-However, the facility again failed to obtain the reweigh when it was requested.-However, Resident #41 was not weighed until 4/1/24, 13 days after the RD initially requested the resident to be reweighed. -When the reweigh was obtained, Resident #41 weighed 100.5 lbs and had sustained a 6.6% (7.3 lbs) weight loss in one month, which was considered severe, from 2/18/24 to 3/15/24. -In the time between when the reweigh was requested and the time it was obtained, from 3/15/24 to 4/1/24, Resident #41 lost an additional 2.4% (2.5 lbs), which was not significant, but continued to demonstrate the continued downward trend of weight loss. The 3/31/24 nutrition quarterly assessment documented Resident #41 had weight loss. The note documented the resident's current oral meal intake and nutritional white grape juice three times a day was not sufficient to meet her assessed nutrition needs. The resident had a history of pneumonia on 3/8/24. The interventions included a goal of consuming 50% or greater for meals, gaining one to two lbs per week and offering four oz fortified mashed potatoes with gravy for lunch. The February 2024 medication and treatment administration record (MAR/TAR) documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days.-However, the February 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. The March 2024 MAR/TAR documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days.-However, the March 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. The April 2024 MAR/TAR documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days.-However, the April 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. A review of the April 2024 CPO and the medical record failed to reveal documentation of an interdisciplinary team (IDT) meeting regarding Resident #41's weight loss. A review of the meal intakes for Resident #41 from 3/25/24 to 4/22/24 revealed the following:-Out of 29 opportunities for breakfast, the resident ate 50% or less 11 times and 25% or less five times;-Out of 29 opportunities for lunch, the resident ate 50% or less nine times, 25% or less three times and the meal was not documented one time; and,-Out of 29 opportunities for dinner, the resident ate 50% or less seven times, 25% or less four times, refused one time and the meal was not documented three times. A review of snack intakes for Resident #41 from 3/27/24 to 4/22/24 documented the resident did not take a snack on 3/27/24, 4/7/24, 4/9/24, 4/12/24 and 4/16/24.-The documentation failed to reveal the type of snack offered and the amount consumed when the resident did accept a snack. The visual bedside Kardex report (a tool utilized by certified nurse aides (CNA) to provide personalized consistent care) indicated the resident needed to be encouraged to eat meals upright and remain upright for 30 minutes after eating. -It did not indicate Resident #41 needed supervision with touch assistance and cueing for meals. -It did not indicate the resident liked to eat her meals in her room and needed assistance when eating in her room. A review of the feeding assistance documentation for Resident #41 from 3/25/24 to 4/22/24 indicated Resident #42 received set up help only or no set up assistance from staff for meals on multiple occasions.-The feeding assistance documentation revealed Resident #41 received physical assistance with eating only one time during the 3/25/24 to 4/22/24 timeframe. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 1:50 p.m. LPN #1 said a print out was generated monthly on who needed to be monitored for weights. Residents who had trending or significant weight loss would be put on the weekly weight list. She said the RD communicated which residents needed to be weighed weekly with the nursing staff. She said Resident #41 was receiving nutritional juice three times a day with a bedtime snack. She said the resident usually ate in her room. She said she did not think Resident #41 was receiving assistance to eat while she was in her room. She said residents who had weight loss should be receiving supervision for meals. The RD was interviewed on 4/25/24 at 9:00 a.m. The RD said when residents triggered for weight loss they were put on weekly weights. The RD said if there was a change of five pounds or more from their previous weight they were reweighed to ensure the accuracy of the weight. She said she provided a list of residents that needed to be weighed to the assistant director of nursing (ADON). She said if the weights were not completed she would follow up with the ADON to ensure the weights were done. The RD said weights were monitored in addition to how well residents were doing with their supplement and their nutritional interventions. She said when residents' weights became stable they would be taken off of weekly weights and weighed monthly. She said residents who triggered for weight loss were discussed weekly at the IDT meeting. She said she did not know where the IDT discussions were documented. She said residents who needed additional assistance with meals were encouraged to eat in the dining room where staff was able to provide additional assistance and supervision or cueing if required. The RD said meal intakes were monitored for all meals and should be documented for all residents, including the residents who triggered for significant weight loss. The RD said Resident #41 triggered for weight loss on 10/15/23. She said she placed Resident #41 on weekly weights on 11/11/23 and was placed back on monthly weights on 1/15/24, because Resident #41's weight had stabilized. She said she monitored how Resident #41 did with her supplement and nutritional interventions. She said she knew the current order for Resident #41 said monthly weights but she was aware Resident #41 needed to be weighed weekly due to continued weight loss.-Despite the RD indicating in her interview that Resident #41 had been put back on monthly weights on 1/15/24, documentation of the resident's weights in the EMR revealed the resident's weight continued to trend downward consistently (see record review above).-Despite the RD indicating in her interview that she was aware the Resident #41 needed to be weighed weekly due to her continued weight loss, the facility did not put the resident back on weekly weights when she continued to lose weight (see record review above). The RD said Resident #41 had multiple food allergies and was on a gluten restricted diet with regular texture and thin liquids. She said she was placed on nutritional grape juice on 11/7/23.. She said nutritional juices contained additional calories and protein. She said Resident #41 seemed to like the nutritional grape juice better than the orange juice. She said she had added fortified mashed potatoes, which had additional butter and milk in them, to Resident #41's menu for lunch. She said the staff encouraged Resident #41 to eat in the assisted dining room but since the resident chose to eat in her room, CNAs should be providing additional supervision and cueing. CNA #3 was interviewed on 4/25/24 at 9:35 a.m. CNA #3 said residents that required assistance and supervision should ideally go to the restorative dining room for assistance. She said the Kardex would indicate if a resident needed assistance with their meals. She said Resident #41 ate in her room, however, she said she did not know if the resident required any additional assistance with meals. The NHA was interviewed on 4/25/24 at 9:30 a.m. The NHA said nutritional assessments were conducted on admission, yearly, quarterly and with a change of condition. He said he would try to locate where the nutritional IDT meetings were documented.-However, the nutritional IDT progress notes were not provided by the NHA prior to the survey exit on 4/26/24.

A recertification survey with complaint #CO35671 was completed on 4/22/24 to 4/26/24. Nine deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/22/24 to 4/26/24. No deficiencies were cited.

Based on observations, interviews and record review, the facility failed to ensure one (#63) of one resident reviewed for activities of daily living out of 35 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to:-Provide Resident #63, who had difficulty with communication, with an appropriate communication tool to ensure the resident was able to effectively communicate his needs to staff; and,-Create a person-centered care plan for Resident #63 which addressed his communication deficits. Findings include: I. Facility policy and procedureThe Person-Directed Care Plans policy and procedure, reviewed 7/12/22, was provided by the nursing home administrator (NHA) on 4/25/24 at 1:50 p.m. It read in pertinent part, "The purpose of long term person-directed care plans is to tell a resident story. Care plans will be developed consistent with the resident's specific conditions, risks, needs, behaviors, preferences, and current standards of practice. Measurable goals and individualized interventions will be identified." II. Resident #63A. Resident statusResident #63, age 90, was admitted on 1/5/22, and readmitted on 1/9/23. According to the April 2024 computerized physician orders (CPO), diagnoses included atherosclerosis of coronary artery bypass graft (heart disease), depression, dysphagia (difficulty in swallowing) and cognitive communication deficit (difficulty with communicating including difficulty with understanding, producing language, and nonverbal communication skills such as gestures and facial expressions). The 1/23/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required substantial/maximal assistance with bed mobility, transfers, and upper body dressing. He was dependent on lower body dressing, toilet hygiene, wheelchair mobility and shower/bathing. He used a tube feeding for eating. The assessment documented the resident had a cognitive communication deficit diagnosis. The assessment documented the resident had adequate hearing and his speech clarity was clear with distinct intelligible words. He made himself understood with the ability to express ideas and wants considering both verbal and non-verbal expression. The assessment documented the resident had the ability to understand others with clear comprehension. The assessment documented the resident did not have a restorative nursing program for communication. The care area assessment (CAA) was not triggered for communication to be addressed in the care plan. B. Resident observation and interviewResident #63 was interviewed on 4/22/24 at 11:37 a.m. Resident #63 was seated in his wheelchair in his room. Resident #63 had a book and an iPad on his side table. Resident #63 was alert but did not respond to simple words such as hello or yes/no questions when asked. He did not make any sounds with his voice. -Attempts to communicate with and understand Resident #63 were not successful during the interview and there was nothing observed in the resident's room, such as signage with communication instructions, to indicate how to communicate effectively with the resident. Resident #63 was interviewed again on 4/23/24 at 10:13 a.m. Resident #63 was seated in his wheelchair, his bed was made, his television was on. Resident #63 was able to shake his head slightly to some yes and no questions. Resident #63 pointed to his mattress but it was unclear what he was attempting to communicate. -Attempts to effectively communicate and understand the resident were again unsuccessful during the interview and there was nothing observed in the resident's room, such as signage with communication instructions, to indicate how to communicate effectively with the residentC. Record review-Resident #63's comprehensive care plan, initiated 1/16/22, revealed there was no care plan related to his cognitive communication deficit and no interventions related to ensuring the resident was able to effectively communicate his care needs to staff. -The mood/antidepressant care plan, revised 2/2/23, documented an intervention to encourage the resident to express any feelings of anger, frustration and sadness.-However, the care plan did not reveal how the resident would be able to communicate and express his feelings. The cognitive care plan, revised 2/2/23, revealed the resident did not have a diagnosis of dementia but displayed episodes and moments of confusion. The interventions included using consistency when conversing/interacting with the resident.-The care plan did not reveal how the resident would be able to communicate with the staff. A 10/12/23 speech-language pathologist (SLP) evaluation revealed Resident #63 was evaluated for treatment of speech, language, voice, communication and/or auditory processing. The resident was referred to SLP due to exacerbation of cognitive impairment, decreased safety awareness, increased need for assistance from others and decreased speech intelligibility. The treatment diagnosis was cognitive communication deficit. The overall treatment goal was to improve the resident's intelligibility of speech. The short term goal of SLP treatment was for the resident to demonstrate adequate vocal hygiene (proper breath support and maintaining adequate hydration) with greater than 75% of opportunities in order to improve vocal quality with communication of his basic wants/needs. The resident's baseline on 10/12/23 revealed he required maximum assistance and education related to the goal was provided. The long term goal of SLP treatment was for the resident to increase his ability to communicate using conversational responses/exchanges during structured communication exchanges with minimal cues in order to communicate his basic wants/needs and in order to participate in meaningful interactions. The resident's baseline on 10/12/23 revealed the resident required moderate cueing. Resident #63 was discharged from SLP services on 11/17/23 after a total of six visits due to the highest practical level achieved. At discharge on 11/17/23, the short term goal of SLP treatment was not met as the resident was 60% accurate (not 75%) and required moderate assistance. At discharge on 11/17/23, the long term goal of SLP treatment was not met and the resident continued to require moderate cueing. The SLP discharge recommendations revealed the resident appeared at baseline and was to continue with long term care and family support for the highest quality of life. -Although the resident continued to require moderate cueing and assistance with communication at discharge from SLP treatment, there was no evidence of continuity of care and follow up with the nursing staff and daily care team to prevent a decline and maintain Resident #63's communication abilities. D. Staff interviewThe director of rehabilitation (DOR) was interviewed on 4/25/24 at 11:46 a.m. The DOR said the therapy staff did not write care plans but there should have been verbal communication with the nursing staff to update the care plan after the SLP therapy ended. The DOR said she did not know how the caregivers for Resident #63 interacted with him. She said some of the caregivers knew him well and communicated with gestures and the resident could communicate some. The DOR said she would recommend signage or a communication board to be used with Resident #63 and she would let nursing staff know to put something in the care plan to follow through on communication with the resident. The DOR said physical therapy (PT) was currently seeing the resident due to a decline in transfers and they noted a decline in his communication as well. The DOR said the current SLP was out on vacation, but due to Resident #63's decline in communication, she would get an order for a new SLP evaluation so new recommendations for the resident's communication could be put in place from the SLP.The director of nursing (DON) was interviewed on 4/25/24 at 12:01 p.m. The DON said Resident #63 communicated in a low voice whisper. The DON said he would also nod his head and communicate with his daughter through an iPad. The DON said Resident #63 should have a communication care plan so new staff members or agency staff would know how to communicate with him and know his preferences. The DON said Resident #63 nodded in the morning when asked how he was doing. The DON was not sure how he was able to communicate needs such as his pain levels. During the interview with the DON, the DON asked an unnamed certified nurse aide (CNA) who was passing by in the hallway about Resident #63. The CNA said she communicated with the resident by asking him yes or no questions. She said she would show the resident two outfits and he would point to the one he wanted to wear for the day. The CNA said she gave Resident #63 extra time in order to communicate his needs to her. The DON said it would have been important to communicate the CNA's effective ways of communicating with the resident in a care plan so other caregivers would know the communication techniques. The DON said the purpose of a care plan was to understand how to take care of a resident but she did not see a communication care plan for Resident #63. The DON said she would have a discussion and get the resident's care plan updated so staff know how to communicate with and take care of Resident #63.

Based on observations, record review and interviews, the facility failed to ensure one (#17) of one resident out of 35 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents'choices. Specifically, the facility failed to ensure Resident #17 received a new CPAP (continuous positive airway pressure) mask timely. Finding include:I. Resident #17A. Resident Status Resident #17, age 89, was admitted on 6/19/23. According to the April 2024 computerized physician orders (CPO), diagnoses included obstructive sleep apnea (intermittent obstruction of the airway during sleep), chronic respiratory failure with hypoxia (decreased oxygen) and dependence on supplemental oxygen. The 3/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive assistance of one staff member with dressing and personal hygiene. B. Observations and resident interview Resident #17 was interviewed on 4/22/24 at 11:00 a.m. The resident had a reddened area across the bridge of his nose and reddened lines on either side of his nose. Resident #17 said his CPAP mask was not fitting well. The resident said he had recently received a new mask but it was still irritating the bridge of his nose. Resident #17 said the facility was doing nothing to prevent the irritation to his nose. On 4/22/24 at 1:30 p.m., Resident #17 had a reddened area across the bridge of his nose and reddened lines on both sides of his nose. On 4/23/24 at 10:00 a.m., Resident #17 had a reddened area across the bridge of his nose and reddened lines on both sides of his nose. C. Record reviewThe skin breakdown care plan, initiated on 6/25/23 and revised on 4/13/24, revealed Resident #17 was at risk for skin breakdown related to wearing a CPAP at night which placed him at risk around the CPAP mask sites. It indicated Resident #17 would not have areas of redness or skin breakdown through the review date. Pertinent interventions included checking the CPAP mask for correct fit and possibly replacing the mask if needed. The 3/29/24 situation, background, assessment, recommendation (SBAR) communication form identified Resident #17 had a skin tear to the bridge of his nose on 3/29/24. The assessment of the skin tear concluded the CPAP mask for Resident #17 might be too tight. The SBAR indicated Resident #17's wife was notified and it was reported to medical provider (MP) #1 on 3/29/24. The 3/29/24 change of condition (COC) assessment indicated Resident #17 had redness to the bridge of his nose from possible tightness of the CPAP mask. The assessment further indicated the resident needed a new CPAP mask for nightly which fit properly because the current one was rubbing the bridge of his nose. The COC indicated the assistant director of nursing (ADON) had ordered him a new mask, wound care orders had been requested, the family was notified and medical provider (MP) #1 was notified. -However, review of the resident's medical record did not reveal wound care orders for treatment or monitoring. The 3/29/24 interdisciplinary (IDT) review note, written by the ADON indicated Resident #17's CPAP mask would be checked for the correct fit and determine if the mask needed to be replaced. The 4/15/24 progress note, written by the ADON, indicated a call to the CPAP equipment distributor was made and the company was notified Resident #17 needed to be fitted for a new CPAP mask. The note documented a technician from the CPAP equipment distributor would see Resident #17 at the facility on 4/16/24. The 4/16/23 progress note indicated Resident #17 was fitted for a new CPAP mask and connection tubing by the CPAP equipment distributor. The 4/25/24 incident note, written by the ADON, indicated Resident #17 had a 0.5 centimeter (cm) x 1.5 cm blanchable (temporary obstruction of blood flow) red area to the bridge of his nose from a tightly fitting CPAP mask that had recently been replaced. The incident note indicated Resident #17 reported the new mask was fitting better and orders were placed to monitor the blanchable redness to Resident #17's nose. The 4/26/24 IDT progress note indicated Resident #17 continued to a have reddened blanchable area on his nose despite the intervention of having Resident #17 fitted for a new CPAP mask. The progress note indicated Resident #17 would have a physician's order for skin prep to his nose. -However, a review of Resident #17's electronic medical records (EMR) on 4/26/24 failed to reveal a physician's order for monitoring or treating the reddened area of the nose. D. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 10:00 a.m. LPN #1 said Resident #17 had recently received a new CPAP mask because the old one was too tight and caused a reddened area to the bridge of his nose. LPN #1 reviewed Resident #17's EMR and referred to a 3/29/24 SBAR communication note (see above) noting the first appearance of a reddened area to the bridge of the resident's nose. LPN #1 was unable to locate a physician's order for wound care or to monitor the area. LPN #1 said it took a couple of weeks from the discovery of the reddened area on 3/29/24 for Resident #17 to get fitted for a new mask and skin prep was applied as a barrier between the nose and mask until he received a new CPAP mask. LPN #1 said Resident #17 did not have an order to apply skin prep as a barrier in the EMR. The ADON was interviewed on 4/25/24 at 11:30 a.m. The ADON said he was made aware of the redness to the bridge of Resident #17's nose from a risk management note documented on 3/29/24. The ADON said he checked in with the resident daily about the redness of his nose and his discomfort levels. The ADON said it was not until 4/14/24 that he felt the resident's ill-fitting CPAP mask was an issue that warranted a call to order a new one. The ADON said he did not document the conversations or track the reddened area to the bridge of Resident #17's nose. The ADON said medical provider initiated physician's orders for wound care. He was unaware of why an order was not put into the EMR for Resident #17 and said he would have to look into it. The ADON said addressing the fit of the CPAP mask sooner for Resident #17 could have prevented the continuation of the reddened area on the bridge of his nose. -Clarification from the ADON for for why wound care treatment orders were not initiated (on 4/25/24, see record review above) for Resident #17 was not provided prior to the survey exit on 4/26/24.

Based on observations, record review and interviews, the facility failed to ensure two (#15 and #10) of two residents reviewed for limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM out of 35 sample residents. Specifically, the facility failed to:-Ensure Resident #15 was monitored for the use of splints (devices that stabilize a part of your body and hold it in place); and, -Ensure Resident #10 was properly positioned in her wheelchair to ensure her head was in a comfortable position. Findings include:I. Resident #15A. Resident Status Resident #15, age 75, was admitted on 9/20/23. According to the April 2024 CPO, diagnoses included hemiplegia (severe or complete loss of strength) and hemiparesis (weakness or the inability to move on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side, arthritis (painful inflammation and stiffness of the joints) and contracture (shortening and hardening of muscles and tendons often leading to deformity) of the right hand. The 3/26/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance from one staff member for dressing, toileting and set-up assistance with personal hygiene. The assessment indicated Resident #15 had functional limitations in range of motion in her lower and upper extremities on one side. B. Observations and resident interviewResident #15 was interviewed on 4/22/24 at 10:31 a.m., Resident #15 was in her room watching television. There was a sign on the wall providing instructions for the application of a hand and elbow splint to be applied to the resident's right arm. There were two splints located on a nightstand next to Resident #15's bed. Resident #15 said only certain staff knew how to apply her splints correctly. Resident #15 said she occasionally would refuse to allow certain staff members to apply the splints since they did not know how to properly apply them. During a continuous observation on 4/23/24, beginning at 10:00 a.m. and ending at 12:00 p.m. Resident #15 was not wearing her splints. C. Record reviewThe occupational therapy (OT) evaluation and treatment plan, with a certification period of 12/12/23 to 2/9/24, revealed Resident #15 would safely wear a resting hand splint and elbow extension splint on her right hand, right wrist, right fingers and right elbow for up to two hours and Resident #15 would tolerate wearing a right elbow splint for eight hours a day to promote range of motion and maintain skin integrity. The OT evaluation indicated goals for Resident #15 included reducing contractures and increasing strength. A review of the April 2024 CPO revealed the following physician orders related to Resident #15's contractures:-Resident #15 was to wear a right elbow extension splint during evening hours to reduce contracture and maintain range of motion ROM), ordered 3/7/24; and,-Resident #15 was to wear a right right hand splint during daytime hours to reduce contracture and maintain range of motion, ordered 3/7/24.-However, the March 2024 medication and treatment administration record (MAR/TAR) and April 2024 MAR/TAR failed to include documentation to indicate Resident #15's splints had been applied per the OT recommendations. -Review of the CNA (certified nurse aide) task documentation failed to reveal documentation indicating the resident's splints were being applied per the OT recommendations. -A review of Resident #15's comprehensive care plan did not reveal a care plan focus for Resident #15's use of splints for her contractures to her right elbow and hand. D. Staff interviews CNA #1 was interviewed on 4/24/24 at 9:30 a.m. CNA #1 said she was unable to find where to chart splint use for Resident #15. CNA #1 said she was unsure what type of splints Resident #15 used. She said she thought Resident #15 might use a right hand splint. CNA #1 said the use of splints and braces were usually located in the CNA task documentation and CNAs charted on the type of splint, duration of splint being on and if a resident declined to wear it. CNA #1 said if documentation for splint use was not found in the CNA task documentation, it might be located on the TAR for the nurses to chart on. Licensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 9:35 a.m. LPN #1 said she was unable to find a physician's order for documenting Resident #15's splint use. LPN #1 said Resident #15 had a right hand splint and right elbow brace to help with her contractures. LPN #1 said Resident #15 was inconsistent with wearing the splints and it depended on the day or who was working because Resident #15's mood would fluctuate and she had a history of being non compliant with the splints. LPN #1 said staff needed to document in the resident's medical record when she refused to wear it.-Despite LPN #1's interview indicating Resident #15 sometimes refused to wear her splints, the medical record failed to reveal any documentation which indicated the resident refused her splints (see record review above). The director of rehabilitation (DOR) was interviewed on 4/25/24 at 9:32 a.m. The DOR said the therapy department was only able to add standard orders to a chart. The DOR said the therapy department was not responsible for updating the resident's plan of care. The DOR said the nursing staff and the resident, if applicable, were provided verbal education from therapy on recommendations for using splints. The DOR said she verbally communicated standing orders to the ADON or the DON and they would add the order to a resident's MAR /TAR for documentation purposes and add the information to a care plan. The DOR said she could not remember if she had spoken to the ADON or the DON about adding the order for splint use for Resident #15 to the MAR/TAR or adding it to the care plan. The DOR said Resident #15 was using an elbow brace and hand splint for her right affected arm to reduce the worsening of contractures. The DOR said Resident #15's contractures could worsen if she did not use the splints consistently. The DOR was unable to locate documentation to reveal the use of splints for Resident #15. II. Resident #10A. Resident statusResident #10, age 70, was admitted on 10/31/22. According to the April 2024 CPO, diagnoses included muscle spasm, cervicalgia (pain in the neck), major depressive disorder, chronic obstructive pulmonary disease (COPD), anxiety disorder, chronic kidney disease, chronic pain syndrome, hemiplegia and hemiparesis (inability to move one side of the body) affecting the left non-dominant side and diabetes mellitus type II. The 3/26/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for oral hygiene, toileting, bathing, upper and lower body dressing, rolling left to right, moving from sitting to lying, picking up objects and mobilizing in the wheelchair. B. ObservationsOn 4/22/24 at approximately 11:10 a.m. Resident #10 was sitting in her wheelchair with her head leaning to the right with her chin resting slightly above her collarbone. On 4/23/24 at approximately 1:00 p.m., during the resident council meeting, Resident #10 was in attendance sitting in her wheelchair slumped to the right side with her head pressed against the right side of the headrest and tilted downward. On 4/23/24 at approximately 3:35 p.m. Resident #10 was sitting in the dining room for an activity with her head tilted downward onto her chest. The position of her head made it so the resident was only able to look at the table. On 4/25/24 at approximately 12:24 p.m. Resident #10 was sitting up in her wheelchair with her head tilted to the right with her chin down towards her chest. She was trying to eat her lunch. On 4/25/24 at approximately 1:10 p.m. Resident #10 was sitting in her wheelchair with her head tilted to the right with her chin resting on her collarbone. C. Resident interviewResident #10 was interviewed on 4/22/24 at approximately 11:10 a.m. Resident #10 said she had asked for a new head brace for her wheelchair but had not gotten one. She said the head brace that was on her current wheelchair did not hold her head in an upright position which caused her pain. Resident #10 was interviewed again on 4/25/24 at approximately 1:10 p.m. Resident #10 said she felt her head was not in a good position and she needed to be repositioned in her wheelchair. She said her head was still not positioned correctly. D. Record review A review of Resident #10's comprehensive care plan did not reveal the use of the resident's wheelchair headrest or how to properly position the resident in the wheelchair. A daily skilled note dated 11/22/23 at 10:13 a.m. documented the staff looked at the resident's wheelchair headrest due to the resident stating it was broken and not working. The staff had to use towels to keep her head upright. A daily progress note dated 3/13/24 at 2:06 p.m. documented a staff member contacted the resident's medical equipment provider regarding adjustment/replacement of the wheelchair headrest on 2/26/24 and 3/13/24. The progress note documented the facility was awaiting a response for an appointment to be scheduled for the medical equipment provider to come in and adjust the headrest. A daily progress note dated 3/15/24 12:55 p.m. documented a sheepskin was applied to the resident's wheelchair headrest for comfort and skin protection while waiting for a wheelchair headrest replacement. A daily progress note dated 4/1/24 at 1:14 p.m. documented the wheelchair provider assessed the Resident #10's wheelchair, adjusted the headrest and recommended ensuring the resident was seated all the way back in the chair with her hips square and staff needed to be educated on proper alignment of the resident in her wheelchair to maximize her comfort. The Kardex (tool used by staff to provide person centered care), dated 4/25/24, was provided by registered nurse (RN) #1. It documented the resident used a soft neck brace. -The Kardex did not include how to position the resident correctly in her wheelchair. E. Staff interviewsThe DOR was interviewed on 4/25/24 at approximately 12:55 p.m. The DOR said Resident #10 received her wheelchair about two years ago (2022). She said an outside company adjusted the resident's wheelchair. She said the facility staff tried to adjust the resident's headrest but it did not help. The DOR said the resident continued to say something was wrong with her headrest. The DOR said the wheelchair provider came to the facility on 4/1/24 and they said placing a different head rest would not make any difference for her. The DOR said the wheelchair company said the facility needed to position the resident better in the wheelchair. The DOR said the wheelchair provider said resident should be all the way back in the chair and to adjust her hips first so her shoulders would follow and be straight. The DOR said the CNAs positioned the resident when they got her out of bed and into the wheelchair in the morning. The DOR said she and the assistant director of nursing (ADON) took pictures of the resident's appropriate positioning to show staff how the resident should be positioned in her wheelchair. She said the pictures were in a notebook at the nurse station. She said the resident had contractures in her neck and the headrest was for support and comfort. RN #1 was interviewed on 4/25/24 at 1:15 p.m. RN #1 said there was not a notebook at the nurses station that explained how to position Resident #10. She said the positioning information should be in the Kardex for the CNAs. She said the Kardex was an extension of the resident's plan of care to help the CNAs know how to provide individualized care to the residents.

Based on interviews and record review, the facility failed to provide an environment free from accident hazards and risks as possible for three (#60, #52 and #43) of seven residents reviewed for accidents/hazards out of 35 sample residents. Specifically, the facility failed to-Ensure neurological checks were completed per standards of practice after Resident #60 sustained unwitnessed falls; and,-Ensure staff were properly trained to assist Resident #52 and Resident #43 with slide board transfers after the residents sustained falls during transfers. Findings include:I. Facility policy and procedureThe Fall Management policy and procedure, revised on 2/1/24, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m. It read in pertinent part, "A fall is defined as the failure to maintain an appropriate lying, sitting, or standing position, resulting in an individual's sudden, unintentional relocation either to the ground or into contact with another object below the starting point. "Neurological evaluations will be implemented with any witnessed incident/fall involving a potential head injury or all unwitnessed incident/fall."II. Failure to complete neurological checks after unwitnessed fallsA. Resident #601. Resident statusResident #60, age 75, was admitted to the facility on 8/23/23 and readmitted on 11/24/23. According to the April 2024 computerized physician orders (CPO), diagnoses included severe persistent asthma, chronic respiratory failure with hypoxia (low oxygen), visual loss in both eyes, morbid obesity, chronic pain, anxiety disorder, depression and muscle weakness. The 2/20/24 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required supervision for oral and personal hygiene. She required substantial assistance for toileting. She was dependent on staff for showering. The assessment indicated the resident had two or more falls with no injury during the review period. 2. Record reviewThe fall care plan, initiated on 8/29/23 and revised on 3/18/24, documented the resident was at risk for falls related to weakness, disorientation, history of falls and side effects of medications. The interventions included offering to take the resident to the activities room to work on a quilt, assessing the resident's bed for safety, encouraging the resident to be in common areas while awake and in her wheelchair, ensuring the resident had a safe environment, ensuring the resident was wearing appropriate footwear when ambulating and ensuring the resident's bed was in the low position while she was in bed. a. Fall incident 12/23/23 - unwitnessed A nursing note dated 12/23/23 at 12:41 a.m. documented the resident was found lying on the floor on her left side in front of the bed. The resident said she was sitting on the side of the bed and was unable to stop herself from falling. The note documented neurological checks were initiated. -However a request was made for the neurological checks following the resident's fall on 12/23/23. The director of nursing (DON) said the facility did not have documentation indicating neurological checks were completed after the resident sustained an unwitnessed fall on 12/23/23 (see interview below). b. Fall incident on 2/5/24 - unwitnessedA nurse note dated 2/5/24 at 6:43 a.m. documented an unwitnessed fall. The note documented the fall had occurred on 2/4/25 at 6:40 p.m. The resident was found on the floor and the resident's neurological status was within normal limits. -However a request was made for the neurological checks following the resident's fall on 2/5/24. The DON said the facility did not have documentation indicating neurological checks were completed after the resident sustained an unwitnessed fall on 2/5/24 (see interview below).c. Fall incident on 3/23/24 - unwitnessedA nurse note dated 3/23/24 at 3:58 p.m. documented the resident sustained an unwitnessed fall. The resident was found lying on the floor in front of her bed when staff were responding to her call light. The resident said she was trying to transfer herself to bed and her legs gave way. She said the CNA had told her she would be back to help her into bed. The resident sustained a skin tear to the right upper arm. A nurse note dated 3/24/24 at 5:31 a.m. documented the resident was continuing with neurological checks. -However a request was made for the neurological checks following the resident's fall on 3/24/24. The DON said the facility did not have documentation indicating neurological checks were completed after the resident sustained an unwitnessed fall on 3/24/24 (see interview below). 3. Staff interviewsThe DON was interviewed on 4/25/24 at approximately 11:30 a.m. The DON said Resident #60's fall on 3/23/24 was unwitnessed and neurological checks should have been completed. She said if the staff did not do neurological checks after a resident sustained an unwitnessed fall they would not be able to identify if any neurological problems had come up. She said Resident #60's fall on 3/23/24 should have been reviewed in the IDT meeting. She said new interventions should have been put into place. III. Failure to ensure staff were trained properly on resident slide board transfersA. Resident #521. Resident statusResident #52, age 68, was admitted to the facility on 6/28/23. According to the April 2024 CPO, diagnoses included chronic embolism and thrombosis (blood clots) of the left subclavian vein (a deep vein to the heart), chronic obstructive pulmonary disease (COPD), paraplegia (inability to move lower part of the body), chronic kidney disease, adjustment disorder and depression. The 4/1/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for eating and oral hygiene, required set-up assistance with upper body dressing, required maximal assistance with putting on footwear, bathing, toileting and toilet hygiene. A. Record review The care plan for falls, initiated on 7/4/23 and revised on 4/3/24, documented the resident was at risk for falls related to impaired sensation to bilateral lower extremities. Interventions included anticipating and meeting the resident needs, applying pillows to aid in positioning the resident when lying in bed, encouraging the resident to use the call light, ensuring the call light was within reach and educating the resident about having a staff member present when attempting to transfer into a car. A nursing note dated 11/1/23 at 12:03 a.m. documented CNA #2 reported the resident had slid from the bed during a slide board transfer from the wheelchair back to bed. An IDT review note dated 11/1/23 at 9:17 a.m. documented staff were re-educated on slide board transfers.-However, a lifts, transfers, gait belts, slide boards and slings educational sign in sheet, dated 10/25/23 and 11/2/23 revealed CNA #2 did not attend the educational training sessions. B. Resident #431. Resident statusResident #43, aged over 65, was admitted to the facility on 9/22/23. According to the April 2024 CPO, diagnoses included atrial fibrillation (abnormal heart beat), acute respiratory failure, depression, insomnia (inability to sleep), anxiety disorder, and muscle weakness. The 3/27/24 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required set-up assistance with oral hygiene, supervision to roll left and right. The resident required moderate assistance with upper body dressing and transitioning from sitting to lying in bed. The resident required maximal assistance with toileting hygiene, bathing, lower body dressing and putting on footwear. 2. Record review The fall care plan, initiated on 9/23/23 and revised on 11/5/23, documented the resident was at risk for falls related to weakness and side effects of medications. The interventions included: anticipating and meeting the residents needs, encouraging the resident to use the call light, using foam wedges for positioning when lying in bed, utilizing physical therapy to evaluate the resident for a cushion/pillow and make recommendations, and utilizing a pillow for positioning. A nurse note dated 10/5/23 at 4:50 p.m. documented the resident fell during a transfer. The resident said her legs were not strong enough to hold her up and that was why she fell. A nurse note dated 10/5/23 at 4:58 p.m. documented a CNA reported the resident fell on her left knee when she was unable to complete a slide board transfer. -However, a lifts, transfers, gait belts, slide boards and slings educational sign in sheet, dated 10/25/23 and 11/2/23 revealed CNA #3 did not attend the educational training sessions. C. Staff interviewsThe NHA was interviewed again on 4/24/24 at 2:29 p.m. He said there had been training for the staff on how to safely transfer a resident. He said CNA #2 was working at the time of Resident #52's fall and CNA #2 did not receive the transfer training. He said CNA #2 should have received immediate training on the correct way to complete a slide board transfer after she was involved in Resident #52's fall. The NHA said CNA #3 was working at the time of Resident #43's fall, however, he said CNA #3 did not receive the transfer training. He said CNA #3 should have received immediate training on the correct way to complete a slide board transfer after the CNA was involved in Resident #43's fall.

Based on interviews and record review, the facility failed to provide timely and effective interventions to prevent weight loss for one (#41) of four residents reviewed for weight loss out of 35 sample residents. Resident #41 was admitted to the facility for long term care on 1/14/23 and readmitted on 9/14/23 with diagnoses of hyper-IgE syndrome (a rare immunodeficiency syndrome), anemia (low blood count) and dementia. Resident #41 had multiple food allergies, including soy protein, brussels sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. On 10/1/23, Resident #41 weighed 139 pounds (lbs). On 10/15/23, Resident #41 weighed 119.2 lbs, which indicated the resident had lost 19.8 lbs. The registered dietitian (RD) requested the resident to be reweighed on 10/16/23, 10/19/23, 10/24/23 and 10/26/23. The resident was not reweighed until 10/26/23, 10 days after the initial reweigh was requested, where she weighed 116.5 lbs. The resident had lost 16.2% (22.5 lbs) in 25 days, which was considered severe. The facility did not implement a nutritional intervention to address the resident's severe weight loss until 11/7/23 when a nutritional orange juice supplement was added three times a day. The physician had ordered the resident's weight to be obtained weekly beginning 11/11/23 and ending on 1/15/24. During this time the facility failed to follow physician orders and weigh the resident consistently on a weekly basis to closely monitor the resident's weight loss. On 2/8/24, Resident #41 weighed 110.3 lbs. The resident had lost an additional 6.2 lbs from 11/6/23 to 2/8/24. Despite the resident losing an additional 6.2 lbs from 11/6/23 to 2/8/24, the facility did not implement additional nutritional interventions. On 3/15/24, Resident #41 weighed 103 lbs. On 3/19/24, 3/20/24, 3/22/24 and 3/26/24 the RD requested the resident to be reweighed. The facility did not reweigh the resident until 4/1/24 where she weighed 100.5 lbs. The resident sustained a 6.6% (7.3 lbs) weight loss, which was considered severe from 2/8/24 to 3/15/24 in one month. The facility implemented fortified mashed potatoes on 3/31/24, 16 days after the resident sustained a severe weight loss. On 4/1/24 the resident triggered for severe weight loss of 27.7% (38.5 lbs) in six months from 10/1/23 to 4/1/24. The facility did not reassess and implement further nutritional interventions to address the resident's severe weight loss. Due to the facility's failures to closely monitor the resident's weight, obtain timely reweighs and implement timely nutritional interventions, Resident #41 sustained a 27.7% (35.8 lbs) weight loss in six months, which was considered severe. Findings include:I. Facility policy and procedureThe Weight and Height Management policy and procedure, revised on 12/6/18, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m. It read in pertinent part, "Residents will be weighed a minimum of monthly by nursing, unless otherwise ordered by the physician. Upon admission, residents will be weighed weekly for four weeks unless contraindicated (resident preference, pain, end of life)."The registered dietitian (RD) will evaluate weekly admission body mass index (BMI), baseline weights and weight trends to recommend weight frequency. "The physician will be notified of significant weight loss. "If a weight change as noted above is accurate the direct care nurse or RD should review and evaluate recent acute temporary care plan to identify possible reasons for the weight change. "The RD/designee will review weights and make recommendations, based on potential weight gain or loss trends."II. Resident #41A. Resident statusResident #41, age 77, was admitted on 1/14/23 readmitted on 9/14/23. According to the April 2024 computerized physician orders (CPO), diagnoses included hyper-IgE syndrome, anemia and dementia. The 3/19/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for toileting. She required substantial/maximal assistance with personal hygiene, bed mobility, transfers and required supervision with touch assistance and cueing with eating. The assessment documented the resident was 63 inches (five foot, three inches) tall and weighed 103 lbs. The resident had a weight loss of 5% or more in one month or a weight loss of 10% in six months that was not physician prescribed. B. Record reviewThe nutrition care plan, initiated on 9/28/23 and revised on 4/3/24, revealed Resident #41 had significant unplanned weight loss. The resident had a history of significant unplanned weight loss. The care plan documented the 3/27/24 nutrition assessment of the resident's current oral intake and the supplement of six ounces (oz) nutritional white grape juice three times a day was determined to be not sufficient to meet the resident's assessed caloric needs. The resident had pneumonia on 3/8/24. The interventions included encouraging high protein foods, monitoring weights, providing a gluten restricted diet, providing her meals in her room without assistance, providing cueing and encouragement, encouraging the resident to eat and drink throughout day, monitoring the amount of food and fluid intake at meals, providing six oz of nutritional white grape juice three times a day and offering four oz of fortified mashed potatoes with gravy at lunch.-The care plan did not document how frequently the resident was to be weighed. The April 2024 CPO revealed an order for weekly weights due to significant weight loss, ordered 11/11/23 and discontinued 1/15/24. The April 2024 CPO revealed an additional order for monthly weights on the first weekend of every month, ordered 1/15/24.-A review of the resident's medical record revealed the resident's weekly weight was not obtained on 11/18/23, 11/25/23, 12/2/23, 12/16/23, 12/23/23, 1/6/24 and 1/13/24. -A review of the resident's electronic medical record (EMR) revealed the resident's weight was not obtained in January 2024. The resident's weights were documented in the resident's EMR as follows:-On 10/1/23, the resident weighed 139 lbs;-On 10/15/23, the resident weighed 119.2 lbs;-On 10/26/23, the resident weighed 116.5 lbs;-On 10/31/23, the resident weighed 116.0 lbs;-On 11/6/23, the resident weighed 116.5 lbs;-On 12/7/23, the resident weighed 115.5 lbs;-On 12/28/23, the resident weighed 114.0 lbs;-On 2/8/24, the resident weighed 110.3 lbs;-On 3/15/24, the resident weighed 103 lbs; and,-On 4/1/24, the resident weighed 100.5 lbs. The resident sustained a 16% (22.5 lbs) weight loss, which was considered severe, from 10/1/23 to 10/26/23 in less than one month. The resident sustained a 6.6% (7.3 lbs) weight loss, which was considered severe, from 2/8/24 to 3/15/24 in one month. The resident sustained a 11.9% (13.5 lbs) weight loss, which was considered severe, from 12/28/23 to 4/1/24 in three months. The resident sustained a 27.7% (38.5 lbs) weight loss, which was considered severe, from 10/1/23 to 4/1/24 in six months. The April 2024 CPO revealed the following diet and nutritional supplementation orders:-Gluten restricted diet, regular texture, regular/thin consistency, ordered 9/26/23;-Magic cup once a day, ordered 10/4/23 discontinued 11/7/23; and,-HS (bedtime) snack, ordered 9/14/23. The 9/28/23 nutrition assessment documented the resident was independent with eating. Her weight was 140.5 lbs. She was on a gluten restricted diet with multiple food allergies, which included soy protein, brussel sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. The 9/28/23 nutrition assessment further documented the resident's current oral intake at meals was not sufficient to meet her assessed calories and protein needs. The interventions included encouraging the resident to consume high protein foods, continuing four oz Magic cup ice cream (frozen nutritional supplement) every day and continuing to monitor and follow up as needed. The 10/16/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested.-However, the facility failed to obtain the reweigh when it was requested. The 10/19/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from the previous weight of 139 lbs. A reweigh was requested.-However, the facility again failed to obtain the reweigh when it was requested. The 10/24/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested.-However, the facility again failed to obtain the reweigh when it was requested. The 10/26/23 nutrition progress note documented the resident weighed 119.2 lbs which was down from her previous weight of 139 lbs. A reweigh was requested.-However, Resident #41 was not reweighed until 10/26/23, 10 days after the RD initially requested the resident to be reweighed. -When the reweigh was obtained, Resident #41 weighed 116.5 lbs and had sustained a 16.2% (22.5 lbs) weight loss in 25 days, which was considered severe, from 10/1/23 to 10/26/23. The 11/7/23 nutrition progress note documented the resident's weight loss was due to insufficient oral intake at meals. The resident's preferences were reviewed and the Magic cup was discontinued per the resident's request. The current interventions included weekly weights. The RD reviewed with the resident to eat high protein foods and recommended starting a nutritional orange juice three times a day. The progress note documented the resident fed herself and received assistance and cueing as needed.-The resident sustained a 16.2% (22.5 lbs) weight loss, which was considered severe from 10/1/23 to 10/26/23 in less than one month. The facility did not implement a new nutritional intervention to prevent further weight loss until 11/7/23. The 12/31/23 nutrition progress note documented the resident's weight was down to 114 lbs on 12/28/23. Her average oral intakes at meals were 50% and, along with the current intervention of the nutritional orange juice, were insufficient to meet current caloric and protein needs. Other current interventions included continue with encouraging high protein foods, nutritional juice and the goal of increasing oral meal intakes of equal or more than 50%.The 12/31/23 quarterly nutrition assessment progress note documented the resident had significant unplanned weight loss. The resident was on a gluten restricted diet with multiple food allergies and was able to feed herself in her room with assistance, cueing and encouragement. Her average oral intake was 58% at meals. The progress note documented the Magic cup was not sufficient to meet her assessed caloric and protein needs so six oz of nutritional orange juice three times a day was implemented to help meet nutritional needs.-The Magic cup was discontinued on 11/7/24 when the nutritional orange juice was ordered. -The resident weighed 114 lbs on 12/28/24. The facility did not implement additional nutritional interventions to prevent further severe weight loss, despite the resident's continued downward trend of weight loss. The 1/31/24 nutrition progress note documented the RD requested a weight to be taken in January.-However, there was no weight documented in the resident's weight section of the EMR for January 2024 (see resident's weights above). The 2/1/24 nutrition progress note documented the resident weighed 108.5 lbs. The resident had a decrease of more than five lbs from her previous weight. A reweigh was requested.-Review of the resident's EMR did not reveal when the resident's weight of 108.5 was obtained. The 2/5/24 nutrition progress note documented a reweigh requested. On 2/8/24 the resident weight was documented as 110.3 lbs, which continued to show a downward trend in weight loss.-However, the facility failed to add any additional nutritional interventions to prevent further weight loss. The 2/29/24 nutrition progress note documented Resident #41 ate in her room, was able to feed herself and received assistance and cueing. Her oral intakes at meals were 42% on average. The current nutrition interventions included nutritional orange juice. The 2/29/24 progress note further documented the resident's current oral intake and nutritional orange juice three times a day was not sufficient to meet nutritional needs. Resident #41 requested chocolate milkshakes.-However, review of the resident's EMR did not reveal the chocolate milkshakes were initiated per the residents request. The 2/29/24 nutrition progress note additionally documented Mighty shake (nutritional supplement) and Lyons Ready Care shakes (nutritional supplement) contained soy and the resident had a soy allergy. The nutritional orange juice three times a day was changed to nutritional white grape juice. -The RD documented the resident's oral intake and nutritional interventions were not sufficient to meet the resident's nutritional needs. However, the RD did not increase nutritional supplementation to help meet the resident nutritional needs after she had sustained further weight loss or explore other nutritional interventions or supplementation that would accommodate Resident #41's multiple food allergies. The 3/19/24 nutrition progress note documented the resident weighed 103 lbs, which was down from her previous weight of 110 lbs on 2/8/24. The RD requested for the resident to be reweighed.-However, the facility failed to obtain the reweigh when it was requested. The 3/20/24 nutrition progress note documented the RD requested the resident to be reweighed.-However, the facility again failed to obtain the reweigh when it was requested. The 3/22/24 nutrition progress note documented the RD requested the resident to be reweighed.-However, the facility again failed to obtain the reweigh when it was requested. The 3/26/24 nutrition progress note documented the RD requested the resident to be reweighed.-However, the facility again failed to obtain the reweigh when it was requested.-However, Resident #41 was not weighed until 4/1/24, 13 days after the RD initially requested the resident to be reweighed. -When the reweigh was obtained, Resident #41 weighed 100.5 lbs and had sustained a 6.6% (7.3 lbs) weight loss in one month, which was considered severe, from 2/18/24 to 3/15/24. -In the time between when the reweigh was requested and the time it was obtained, from 3/15/24 to 4/1/24, Resident #41 lost an additional 2.4% (2.5 lbs), which was not significant, but continued to demonstrate the continued downward trend of weight loss. The 3/31/24 nutrition quarterly assessment documented Resident #41 had weight loss. The note documented the resident's current oral meal intake and nutritional white grape juice three times a day was not sufficient to meet her assessed nutrition needs. The resident had a history of pneumonia on 3/8/24. The interventions included a goal of consuming 50% or greater for meals, gaining one to two lbs per week and offering four oz fortified mashed potatoes with gravy for lunch. The February 2024 medication and treatment administration record (MAR/TAR) documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days.-However, the February 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. The March 2024 MAR/TAR documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days.-However, the March 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. The April 2024 MAR/TAR documented Resident #41 was provided with six oz of nutritional white grape juice three times a day for nutritional support on multiple days.-However, the April 2024 MAR/TAR failed to document how much of the nutritional grape juice was consumed by the resident each time it was offered. A review of the April 2024 CPO and the medical record failed to reveal documentation of an interdisciplinary team (IDT) meeting regarding Resident #41's weight loss. A review of the meal intakes for Resident #41 from 3/25/24 to 4/22/24 revealed the following:-Out of 29 opportunities for breakfast, the resident ate 50% or less 11 times and 25% or less five times;-Out of 29 opportunities for lunch, the resident ate 50% or less nine times, 25% or less three times and the meal was not documented one time; and,-Out of 29 opportunities for dinner, the resident ate 50% or less seven times, 25% or less four times, refused one time and the meal was not documented three times. A review of snack intakes for Resident #41 from 3/27/24 to 4/22/24 documented the resident did not take a snack on 3/27/24, 4/7/24, 4/9/24, 4/12/24 and 4/16/24.-The documentation failed to reveal the type of snack offered and the amount consumed when the resident did accept a snack. The visual bedside Kardex report (a tool utilized by certified nurse aides (CNA) to provide personalized consistent care) indicated the resident needed to be encouraged to eat meals upright and remain upright for 30 minutes after eating. -It did not indicate Resident #41 needed supervision with touch assistance and cueing for meals. -It did not indicate the resident liked to eat her meals in her room and needed assistance when eating in her room. A review of the feeding assistance documentation for Resident #41 from 3/25/24 to 4/22/24 indicated Resident #42 received set up help only or no set up assistance from staff for meals on multiple occasions.-The feeding assistance documentation revealed Resident #41 received physical assistance with eating only one time during the 3/25/24 to 4/22/24 timeframe. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 1:50 p.m. LPN #1 said a print out was generated monthly on who needed to be monitored for weights. Residents who had trending or significant weight loss would be put on the weekly weight list. She said the RD communicated which residents needed to be weighed weekly with the nursing staff. She said Resident #41 was receiving nutritional juice three times a day with a bedtime snack. She said the resident usually ate in her room. She said she did not think Resident #41 was receiving assistance to eat while she was in her room. She said residents who had weight loss should be receiving supervision for meals. The RD was interviewed on 4/25/24 at 9:00 a.m. The RD said when residents triggered for weight loss they were put on weekly weights. The RD said if there was a change of five pounds or more from their previous weight they were reweighed to ensure the accuracy of the weight. She said she provided a list of residents that needed to be weighed to the assistant director of nursing (ADON). She said if the weights were not completed she would follow up with the ADON to ensure the weights were done. The RD said weights were monitored in addition to how well residents were doing with their supplement and their nutritional interventions. She said when residents' weights became stable they would be taken off of weekly weights and weighed monthly. She said residents who triggered for weight loss were discussed weekly at the IDT meeting. She said she did not know where the IDT discussions were documented. She said residents who needed additional assistance with meals were encouraged to eat in the dining room where staff was able to provide additional assistance and supervision or cueing if required. The RD said meal intakes were monitored for all meals and should be documented for all residents, including the residents who triggered for significant weight loss. The RD said Resident #41 triggered for weight loss on 10/15/23. She said she placed Resident #41 on weekly weights on 11/11/23 and was placed back on monthly weights on 1/15/24, because Resident #41's weight had stabilized. She said she monitored how Resident #41 did with her supplement and nutritional interventions. She said she knew the current order for Resident #41 said monthly weights but she was aware Resident #41 needed to be weighed weekly due to continued weight loss.-Despite the RD indicating in her interview that Resident #41 had been put back on monthly weights on 1/15/24, documentation of the resident's weights in the EMR revealed the resident's weight continued to trend downward consistently (see record review above).-Despite the RD indicating in her interview that she was aware the Resident #41 needed to be weighed weekly due to her continued weight loss, the facility did not put the resident back on weekly weights when she continued to lose weight (see record review above). The RD said Resident #41 had multiple food allergies and was on a gluten restricted diet with regular texture and thin liquids. She said she was placed on nutritional grape juice on 11/7/23.. She said nutritional juices contained additional calories and protein. She said Resident #41 seemed to like the nutritional grape juice better than the orange juice. She said she had added fortified mashed potatoes, which had additional butter and milk in them, to Resident #41's menu for lunch. She said the staff encouraged Resident #41 to eat in the assisted dining room but since the resident chose to eat in her room, CNAs should be providing additional supervision and cueing. CNA #3 was interviewed on 4/25/24 at 9:35 a.m. CNA #3 said residents that required assistance and supervision should ideally go to the restorative dining room for assistance. She said the Kardex would indicate if a resident needed assistance with their meals. She said Resident #41 ate in her room, however, she said she did not know if the resident required any additional assistance with meals. The NHA was interviewed on 4/25/24 at 9:30 a.m. The NHA said nutritional assessments were conducted on admission, yearly, quarterly and with a change of condition. He said he would try to locate where the nutritional IDT meetings were documented.-However, the nutritional IDT progress notes were not provided by the NHA prior to the survey exit on 4/26/24.

Based on record review and interviews, the facility failed to ensure one (#191) of two residents out of 35 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center occurred regarding care and services provided for Resident #191. Findings include:I. Facility policy and procedureThe Dialysis Care Policy, reviewed 7/12/23, was provided by the nursing home administrator (NHA) on 4/25/24 at 10:11 a.m., It read in pertinent part,"Coordination of dialysis care will include communication about code status, change in medications, current vital signs, weight management, required treatments, care concerns and appropriate interventions and fluid restriction management limitations. This information will be sent with the resident to their dialysis appointments."II. Resident #191A. Resident statusResident #191, age 78, was admitted on 4/6/24. According to the April 2024 computerized physician orders (CPO), diagnoses included congestive heart failure (CHF) and end stage renal disease (ESRD). The 4/26/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He was dependent with toileting, required substantial/maximal assistance with transfers, partial/moderate assistance with bed mobility and set up assistance with eating. B. Record reviewThe nutrition care plan, initiated 4/22/24, documented Resident #191 was at a nutritional risk related to ESRD and dialysis. It indicated the resident received dialysis three days a week. The dialysis care plan, initiated 4/7/24, documented resident Resident #191 had ESRD and required dialysis. Interventions included dialysis as ordered, dietary to evaluate as needed, monitor fistula (a connection between the artery and vein for dialysis access) in left arm and monitor for complications from dialysis. A review of the dialysis treatment record from 4/9/24 to 4/24/24 revealed Resident #191 received dialysis on 4/9/24, 4/11/24, 4/12/24, 4/15/24, 4/17/24, 4/19/24 and 4/22/24. A review of the hemodialysis communication record forms from 4/9/24 to 4/24/24 revealed there was no hemodialysis communication form in the chart on 4/11/24, 4/12/24, 4/15/24, 4/17/24 and 4/19/24.-A hemodialysis communication form for 4/22/24 revealed the facility pre-dialysis portion of the communication form was filled out, however, the dialysis portion was not completed.-Review of Resident #191's electronic medical record (EMR) failed to reveal documentation to indicate communication between the facility and the dialysis center had occurred on 4/11/24, 4/12/24, 4/15/24, 4/17/24 and 4/19/24. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/24/24 at 11:10 a.m. LPN #1 said each resident that went to dialysis had a book that went with them to and from dialysis. She said the facility filled out the top portion of the form with vital signs, medications given and sometimes the resident's weight. She said the form was sent to dialysis with the resident along with a face sheet and medical orders for scope of treatment (MOST). LPN #1 said the form was important for communication between the facility and the dialysis center to ensure the residents were receiving continuity of care. She said the forms were a permanent part of the resident's medical record and were uploaded in the electronic medical record (EMR) by the medical records department. The dialysis registered nurse (DRN) was interviewed on 4/24/24 at 11:50 a.m. The DRN said the facility usually sent the communication form with residents that received dialysis. She said she thought she saw one for 4/22/24 for Resident #191 but she was unsure if the communication forms had been completed for the previous week. The director of nursing (DON) was interviewed on 4/24/24 at 12:30 p.m. The DON said dialysis forms were completed before dialysis by the facility staff. She said the dialysis center then filled out their portion of the form and sent it back with the resident. The DON said if the communication form did not return from the dialysis center to the facility, the facility should call the dialysis center to obtain the documentation to ensure continuity of care for the resident. She said she was unable to locate the dialysis communication forms on the missing dates for Resident #191 (see record review above). The DON said she had checked with the medical records department and was unable to locate the forms. She said she would check with the dialysis center to see if the forms were left there.-The missing dialysis communication forms were not provided by the facility by the end of the survey on 4/26/24. Registered nurse (RN) #3 was interviewed on 4/24/24 at 1:10 p.m. RN #3 said, in the rehabilitation wing of the facility, the nursing staff sent packets with residents that went to dialysis which included the dialysis communication form. He said the communication form should return in the packet back from the dialysis center. He said he was not usually at the facility when residents came back from dialysis but he said communications forms got put into a dialysis binder and then sent to medical records to be uploaded into the EMR. He said staff were unable to locate Resident #191's communications forms. RN #3 said if forms did not return back from the dialysis center, the facility staff should call the dialysis center to find out where the form was.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Based on observations, record review and interviews, the facility failed to ensure one (#5) of one resident reviewed for ancillary services, such as dental services, out of 35 sample residents received routine and 24-hour emergency dental care. Specifically, the facility failed to provide Resident #5 with timely dental care when she sustained a broken tooth. Findings include:A. Resident statusResident #5, under age 65, was admitted on 3/7/22. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, arthrodesis (joint fusion to relieve arthritis pain) and chronic pain. The 3/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with all activities of daily living (ADL). B. Resident interviewResident #5 was interviewed on 04/22/24 at 2:29 p.m. Resident #5 said a piece of her tooth fell out last month (March 2024) while she was brushing her teeth and she needed to see a dentist. Resident #5 said her tooth was painful at times and she tried not to chew her food on the left side of her mouth where the broken tooth was located. Resident #5 said she had informed multiple staff members about her tooth and her need to see a dentist. Resident #5 was interviewed again on 4/25/24 at 9:00 a.m. Resident #5 said the social services coordinator (SSC) told her she was not seen by the dentist at the facility on 4/23/24 because the dental team did not want to see residents while a state survey was in process and left the building (see record review and interviews below). C. Record reviewThe ancillary care plan, initiated 3/25/22 and revised 6/24/22, revealed Resident #5 was being seen by in house dental services. It documented the facility would ensure Resident #5's dental needs would be met. Pertinent interventions included facility staff scheduling appointments for ancillary providers as requested/needed/ordered. A 3/17/24 progress note documented at 1:18 a.m., revealed Resident #5 informed nursing staff a piece of her tooth fell out while brushing her teeth. Nursing staff documented a message had been left for Resident #5's family member and the SSC.A 3/17/24 progress note documented at 4:01 p.m., revealed Resident #5 informed registered nurse (RN) #2 she needed some teeth pulled. RN #2 documented Resident #5 needed antibiotics and a scheduled blood thinner (eliquis) to be held prior to being seen by the dentist. RN #2 documented a message had been left for the SSC with instructions to provide a healthcare provider with the dental procedure date so orders could be placed addressing the above mentioned medications. A 3/18/24 progress note documented Resident #5 was seen by a medical assistant regarding an upcoming dental procedure and Resident #5 needed preventive antibiotics and her eliquis held for three days prior to getting some teeth pulled. The progress noted revealed Resident #5 needed several teeth pulled and had a history of blood clots. A 4/22/24 progress note documented Resident #5 had a dental appointment on 4/23/24 and orders had been received from a nurse practitioner (NP) for eliquis to be held and for antibiotics to be started prior to the dental procedure. A 4/23/24 progress note written by RN #2 documented Resident #5 was not seen by the dentist (on 4/23/24) because she was not on the dental list to be seen. RN #2 documented the information regarding Resident #5 not being seen by the dentist because she was not on the list was given to the SSC. The SSC informed RN #2 Resident #5 would be on the list to be seen by the dentist when the dental team was back in the facility. D. InterviewsThe SCC was interviewed on 4/25/24 at 10:00 a.m. The SCC said residents were on a rotating schedule with a mobile dental team who came to the facility for residents' routine dental visits. The SCC said the dental team could be accommodating to residents for immediate dental needs such asa resident voicing mouth discomfort or pain or if nursing staff recognized something that needed immediate attention. The SCC said there was paperwork indicating a resident needed emergent services she had to to the dental team for residents to be seen immediately. The SCC said she was first made aware of Resident #5 having mouth pain on 3/17/24 and was told again on 4/23/24 so she put Resident #5 on the list to be seen by the dentist that same day. The SCC said she did not know if the dental team was contacted in March 2024 to schedule Resident #5 for emergency services. The SCC said she was unable to locate paperwork which indicated Resident #5 had been scheduled to see the dentist related to her broken tooth in March 2024. The SCC said the team's dental assistant told her they did not want to be in the facility (on 4/23/24) when a state survey was ongoing and had left the facility. The vice president of operations (VPO) for the dental team company was interviewed on 4/26/24 at 11:00 a.m. The VPO said it was her understanding the facility had asked the dental team to leave the building during the survey process and the VPO was currently working with the facility's administration team to get clarification. The VPO said Resident #5 was not on the list to be seen on 4/23/24 and the dental team was not notified in March 2024 that Resident #5 needed to be seen for emergency dental services. The VPO said if the facility had requested Resident #5 be seen for emergency dental services, the dental team would have received paperwork from the facility requesting emergency dental services. The VPO said she would begin the process to have Resident #5 seen by the dentist as soon as possible for her broken tooth.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication regimen review (MRR) by not providing physicians with the pharmacist recommendations so the physicians could respond to the recommendations timely which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include:I. Facility policyThe Quality Management Plan/QAPI program (Quality Assurance and Performance Improvement) policy and procedure, revised 11/15/2018, was provided by the nursing home administrator (NHA) on 4/26/24 at 12:50 p.m. It read in pertinent part, "Our quality assurance and performance improvement (QAPI) program objective is to evaluate the availability, appropriateness, effectiveness, and effectiveness, and efficiency of resident care, and is a continuous program of evaluating medical, nursing care, social services, activities, dietary, housekeeping, maintenance, infection control, and pharmacy services."Quality Assurance encompasses all departments within our communities that provide care and services to our residents and impact clinical care, quality of life, residents' choice, and transitions of care. This includes care and services provided to our Rehab and Long-Term Care residents by each department in our organization. "Procedure 1. Quality Assurance Performance Improvement (QAPI) meetings are scheduled a minimum of monthly but occur more frequently as decided by the NHA and include the medical director(s), nursing home administrator, director of nursing, pharmacist, department managers and frontline staff or residents as appropriate. The nursing home administrator ensures that the meeting is routinely scheduled, an agenda specific to that community is established and data and information is recorded. "2. Topics of discussion may include, but are not limited to, skin and wounds, infection prevention and control, accidents/incidents, admissions/hospitalizations, concerns/complaints, self-reported occurrences, pharmacy, survey follow-up, QAPI PIPs (performance improvement plans), weights, quality measures, medical records, and other areas identified through data collection, meetings, and events/incidents. Committee members are assigned to address and monitor specific topics based on their areas of expertise or their functions. "3. Reports are submitted in writing and discussions at the meetings include any recommendations from the committee and the Medical Director. "4. Other committees are established as needed to identify and address areas of concern and report to the Quality Assurance Performance Improvement committee as directed. "5. Projects and ongoing programs are measured at routine intervals and may be analyzed using Root Cause Analysis, Plan-Do-Study-Act (PDSA) and Fishbone Analysis as needed to ensure that the interventions are appropriate to the problem. Monitoring may consist of monthly data collection and new interventions may be recommended to achieve the desired goals of the particular topic. "6. Quality Assurance Performance Improvement is an ongoing, living, and ever-changing program that adapts itself to the unique needs of each community. Through the various sources of data and their facility assessment, each community identifies its personal focuses/issues and addresses them by creating unique goals and interventions. Monitoring occurs until goals are achieved or surpassed, then may be periodically reviewed to ensure sustained compliance."II. Cross-reference citationsCross-reference F756: The facility failed to provide the physicians with the pharmacist recommendations from the MRR so the physicians could respond to those recommendations. The facility's failure to follow up and act on the pharmacist recommendations put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviewsMedical provider (MP) #1 was interviewed on 4/25/24 at 4:35 p.m. MP #1 said the medical director was out of the country and was not available for an interview. MP #1said, during the psychiatric pharmacology review meetings, residents' medication histories, gradual dose reductions (GDR) of psychotropic medications and indications for residents' medications were reviewed. He said it was important to minimize or stop unnecessary medications if possible. He said the MRR forms from the pharmacist were put in a box at the nurses station and the providers, including nurse practitioners and physician assistants, would check the box when they were at the facility. He said the turnaround time for completing MRR forms was as soon as possible. MR #1 said the providers could either agree or disagree with the pharmacist's recommendations. He said if a provider disagreed with the recommendations, they would usually include a note as to why. He said after the recommendations were completed it was put back in the box for the director of nursing (DON) to process and send back to the pharmacist, unless it was a time critical recommendation and then it would be taken to the DON immediately. MP #1 said he was not aware that MRRs had not been given by the DON to the medical providers and the consultant pharmacist (CP) had been without a response from the providers since January 2024. He said it was important to follow up on the recommendations to ensure each residents' drug regimen was appropriate and to prevent adverse outcomes related to medications from occurring for the residents. The NHA was interviewed on 4/26/24 at 12:22 p.m. The NHA said the facility had a QAPI committee which met monthly and consisted of the required members and department heads. He said the committee last met on 4/16/24 and the pharmacist had attended via phone. He said the committee identified concerns through daily reviews, tracking and trending, key indicators and trends against benchmarks. He said the QAPI committee did analysis of concerns and determined what actions needed to be taken. The NHA said the QAPI committee did a performance improvement plan (PIP) at least yearly. He said the committee currently was addressing falls, weight loss, pressure ulcers, employee turnover and recruitment, survey review, activities, maintenance and life safety concerns. He said the committee had the infection preventionist (IP) addressing antibiotic stewardship and vaccination rates. The NHA said the committee was addressing skin tears through incidents or risk management, medication errors, rehospitalizations, quality measures, team reports, pharmacy updates and physician updates. The NHA said some of the topics discussed at the QAPI committee meetings came from risk meetings and morning interdisciplinary team (IDT) meetings. The NHA said the QAPI committee had not identified concerns from the MRR. He said the pharmacist's recommendation had not been provided to the physicians so that the physicians could respond in a timely manner.

A revisit to the 1/31/24 survey was completed on 3/15/2024. The facility was in compliance with the regulation surveyed.

A complaint survey, prompted by #CO34685 was conducted on 1/30/24 to 1/31/24. One deficiency was cited.

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 (#1 and #2) of three residents reviewed for pressure injuries/ulcers out of five sample residents. Specifically, the facility failed to:-Ensure Resident #2's was provided and encourage proper repositioning to prevent the development of new pressure injuries; and;-Ensure Resident #1's pressure injury treatment was consistently changed per physician orders. Findings include:I. Professional referenceAccording 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, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/1/24, "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 LossPartial 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 should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull 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 LossFull 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 UnknownFull 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 UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and proceduresThe Pressure Wound Prevention and Skin Management facility policy, revised 1/20/24, was received from the nursing home administrator on 1/31/24 at 9:58 a.m. The policy documented in pertinent part, "The primary purpose of the pressure wound prevention and skin management is to reduce the occurrence of pressure injuries and promote healing of wounds. Identification, prevention, and treatments will be based on National Pressure Injury Advisory Panel (NPUAP) definitions, recommendations, and practice standards. Treatment should be based on individual needs."III. Resident #2 A. Resident statusResident #2, age 86, was admitted on 4/11/23. According to the January 2024 computerized physician orders (CPO), diagnoses included unspecified dementia, heart failure and malnutrition. The 1/9/24 minimum data set (MDS) assessment revealed the resident was significantly cognitively impaired with a brief interview for mental status score of one out of 15 on the brief interview for mental status (BIMS). She required total assistance with eating, hygiene, dressing, position changes in bed, and transfers to the wheelchair. B. ObservationResident #2 was at risk for pressure injuries. Observations showed the resident was not repositioned every two hours as recommended by the wound physician (see interview below). On 1/30/24 at 2:59 p.m., the resident was lying in bed. The resident did have an air mattress. Continuous observations began at 3:29 p.m. -At 3:29 p.m., the resident continued to be in the same position. She continued to lay on her back with no repositioning. -At 4:53 p.m., licensed practical nurse (LPN) #2 administered medication to the resident; however, did not offer to reposition the patient.-At 5:45 p.m., the resident was assisted with her dinner meal while she continued lying on her back. The unidentified certified nurse aide (CNA) did not offer to reposition the resident before or after offering assistance with her meal. -At 6:25 p.m., the resident was turned onto her side by the director of nurses (DON) with a positioning device. On 1/30/24 between 3:29 p.m. and 6:25 p.m. the resident was not encouraged, offered or provided repositioning and had two new pressure ulcers (see wound observation below). C. Wound observationsThe resident's wound was observed on 1/31/24 at 9:21 a.m. with the wound physician and the DON. The DON removed the dressing and two new coccyx stage 2 pressure ulcers that were medial on the coccyx with one wound superior to the other. The wound physician measured the coccyx pressure ulcers as one centimeter (cm) x 1 cm x 0.1 cm and 0.5 cm x 0.5 cm x 0.1 cm. Both wounds were identified as new by the wound team. The wound physician said he was not notified of new wounds on this resident. D. Record reviewThe Braden scale completed 1/8/24 revealed the resident only responds to painful stimuli or had sensory impairment over half of the body. The resident scored an 11 which indicated she was at high risk for pressure injury. The care plan, 1/9/24, showed the resident had one stage 4 pressure injury and one stage 2 pressure injury. Pertinent goals included prevention of pressure injuries, care and treatment for existing pressure injuries, and comfort-focused care. -The stage 2 pressure injury healed per the wound physician documentation on 1/17/24. The January 2024 treatment administration record (TAR) showed a physician order for pressure relieving devices, floating heels in bed and frequent incontinence care per the resident's needs. The review of wound physician notes revealed the resident was at risk for pressure injuries and she currently had a stage 4 to the thoracic spine following surgical debridement and a stage 2 on coccyx had healed on 1/17/24. E. Staff interviewsCNA #1 was interviewed on 1/31/24 at 9:02 a.m. CNA #1 said Resident #2 could not make her needs known and required assistance with turning, bathing, meals and transfers. CNA #1 said the resident usually accepted care and was cooperative. The wound physician was interviewed on 1/31/24 at 11:22 a.m. The wound physician said the resident's pressure ulcers were unavoidable, however, the resident should be turned every two hours in bed and every 15 minutes when sitting in the chair. The DON was interviewed on 1/30/24 at 6:34 p.m. The DON said she was familiar with Resident #2's skin issues. She said Resident #2 had a stage 4 pressure injury to her upper back and the previous stage 2 on her coccyx was healed. The DON was interviewed again on 1/31/24 at 1:49 p.m. The DON said two stage 2 pressure ulcers found today on Resident #2 were new and unknown to staff. The DON said when an area of skin concern, such as redness, nursing staff were to notify the physician, family and the DON. IV. Resident #1A. Resident statusResident #1, over the age of 65, was admitted on 1/5/22. According to the January 2024 computerized physician orders, diagnoses included kyphosis (curvature of the spine), osteoarthritis and a pressure wound on his mid back. The MDS assessment from 1/23/24 documented the resident had no cognitive impairments with a score of 14 out of 15 on the BIMS assessment. -The MDS failed to document the pressure injury status. B. Resident interviewResident #1 and his representative were interviewed on 1/30/24 at 5:00 p.m. The resident said there was a wound on his back that has been there on and off for about two years. He said he had been wheelchair and bed bound since then, and with his severe kyphosis, it was in a difficult spot to heal. He said the nurses were not always the best at getting the dressing changed and sometimes it comes off and causes him to have pain. When it was on properly, he said the wound did not cause him pain. The representative said she brought in a sheepskin cushion for the back of his chair because the facility did not provide anything. She said she brought in wound care supplies from the local pharmacy because the staff were always using different dressings and she was concerned the wound was worsening. C. ObservationsDuring the interview with Resident #1 and representative on 1/30/24 at 5:00 p.m. the representative lifted the jacket of the resident up to expose the dressing. The large foam dressing covered the wound and was dated 1/27 with initials. On 1/30/24 at 5:45 p.m., the DON observed the date on the dressing was last changed on 1/27/24. D. Record reviewThe January 2024 CPO showed an order for the mid back pressure ulcer stage 2. The order read to cleanse with wound cleanser, skin prep to periwound and apply optifoam gentle with silver. This was to be completed every Monday, Wednesday, and Saturday with a start date of 1/17/24. The January 2024 treatment administration report (TAR) the order to change the dressing on Resident #1's mid back pressure ulcer stage 2 wound was completed on 1/29/24 during the day. -However, observations (see above) showed the dressing was last changed on 1/27/24. E. Staff interviewsLPN #1 was interviewed on 1/30/24 at 5:17 p.m. He said Resident #1's dressing got changed every Monday, Wednesday, and Saturday and as needed (PRN). After reviewing the treatment administration record, he said the last dressing was changed on 1/29/24 (Wednesday). He said the wound dressing orders included cleansing the wound with wound cleanser, skin prep around the wound, silver dressing and cover with a foam dressing. He said skin assessments were done weekly on Wednesdays. He said if he noticed something new, he would report it to the assistant director of nurses (ADON) and the DON.The DON was interviewed on 1/30/24 at 5:45 p.m. The DON said wound rounds were done with the wound doctor every Wednesday morning. She said nurses were supposed to be providing care and treatment per the physician order. The DON and clinical nursing consultant (CNC) were interviewed on 1/31/24 at 1:30 p.m. The DON said there was a lack of education with nursing staff regarding dressing changes. She said she spoke to LPN #1 regarding the missed dressing change for Resident #1, provided education about dressing changes and following physician orders. The DON said she was not aware dressing changes were not getting done and said the facility had adequate supplies and staffing to get the dressing changes completed per physician orders. She said she occasionally stepped in to help with dressing changes when asked by families or staff.

A complaint survey, prompted by #CO33627 and Incident #31766 was completed on 9/25/23 to 10/4/23. No deficiencies were cited.

A revisit to the 1/11/2023 revisit was completed on 4/5/2023. The facility was in compliance with the regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on February 3, 2023.for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."Building A1 is a one (1) story, Type V (000) wood frame construction. The facility has a partial basement that is used for staff support functions and has no resident access. The facility was constructed in 1957 and is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler system. Buildings A1 and A2 are separated by 2-hour rated construction. Building A2 is a one (1) story, Type V (111) wood frame construction. The facility was constructed in 2009 and known a Rehabilitation. The building is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic anti-freeze fire sprinkler system. The facility is licensed for 95 beds and the census on the date of the survey was 79. The results of this survey were discussed with the Maintenance Director, Facility Administrator and the Maintenance Director during the survey as well as during the exit conference conducted on February 3, 2023.

Based on observation during the survey, it was determined that the facility failed to maintain proper proper exit signage in accordance with Life Safety Section 7.10.1.5.1This was evidenced by the following:1. Not an exit sign needs to be removed and replaced with proper exit signage near the generator doors and by the exit on west exit hallway'NFPA 101 7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Failure to maintain the proper exit signage has the potential to harm all occupants, staff, and visitors within the building should a delay occur due to improper signage for exits. This deficiency was discussed during record review and during the exit conference

Based record review it was determined that the facility failed to complete the required fire drills with the required varying times in the schedule in accordance with the Life Safety Code Section 19.7.1.6 This was evidenced by the following: 1. January and September drills were not separated by the required 1 hr. Corrected while on site. NFPA 101 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. Failure to maintain the required varying times has the potential to harm all occupants, staff, and visitors within the building should staff become complacent with knowing the times of a drill. This documentation deficiency was discussed during record review and during the exit conference

A recertification survey with complaint #CO30462 was completed from 1/4/23-1/11/23. Nine deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/4/23 to 1/11/23. No deficiencies were cited.

Based interviews and record review the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#13 and #133) of six residents reviewed out of 33 sample residents. Specifically, the facility failed to:-Respect the wishes of Resident #13 to receive showers and not bed baths; and-Provide showers according to Resident #133's plan of care/preference. Findings include:I. Facility policy The Dignity, Voice, and Choice policy and procedure, revised 8/10/22, was provided by the nursing home administrator (NHA) on 1/10/22 at 4:00 p.m. It revealed in pertinent part,"Residents will be cared for in a manner and environment that maintains or enhances their dignity, privacy, and respect in full recognition of their individuality."Choices and decision making belong to our residents."Bathing services are provided per residents' preferences, time, day, caregiver, shower or bath preferences and are honored as much as reasonably possible. "Choices include, if they would like a bath or a shower."II. Resident #13A. Resident statusResident #13, age 70, was admitted on 2/22/2020 and readmitted on 11/18/2020. According to the January 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, morbid obesity, hypertension (high blood pressure), and myopathy (muscle weakness). The 9/27/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with dressing. He had total dependence on staff for transfers, toilet use, personal hygiene, and to transfer from his bed to a wheelchair. He required substantial/maximum assistance with bathing. He did not reject care from staff. B. Resident interviewResident #13 was interviewed on 1/4/23 at 10:35 a.m. He said "I only receive bed baths, never showers. I have been asking for a real shower for months. I have not had a real shower in four months. I am a big man and need a lift to get out of bed." He said he needed the staff to use a lift to transfer him from his bed to a shower chair. He said his only concern at the facility was that he did not receive showers. He said he wanted showers twice a week. He said he did not want bed baths. He said he had told the nursing staff for several months that he wanted a real shower but the staff did not provide it. He said he told the social worker (see interview below) about wanting a real shower about a week ago. He said he had not heard back from any staff yet about the situation. Resident #13 was interviewed again on 1/9/23 at 2:31 p.m. He said last Friday (1/6/23) during the state survey the director of nursing (DON) came to speak to him. He said the DON said from now on staff would provide showers and not bed baths for him. He said he received a shower last Friday (1/6/23) for the first time in several months. He said he understood the concern with him being a large man. He said the staff did just fine with the lift. He said at least for now the staff was working on providing him showers. C. Record reviewThe 9/15/22 comprehensive care plan revealed Resident #13 required extensive assistance of one staff member with bathing and showering. He needed assistance to get out of bed. He had total dependence on three staff members to utilize a lift for transfers. The resident's weight on 12/30/22 revealed the resident weighed 369 pounds. The bath report sheets for Resident #13 were provided by the nursing home administrator (NHA) on 1/10/23 at 8:52 a.m. Each bath report sheet had the resident's name on them and the date. Not all of Resident #13's bath sheets documented what he received, a bed bath or a shower. The following November 2022 bath report sheets did not reveal if the resident received a bed bath or a shower on 11/1/22, 11/4/22, 11/8/22, 11/11/22, 11/18/22, 11/25/22, and 11/29/22.-On 11/15/22 the bath report sheet documented the resident had received a bed bath. The December 2022 bath report sheets revealed:-The resident received a bed bath on 12/6/22, 12/16/22, 12/20/22, and 12/30/22.-The resident's bath report sheets did not record what type of bathing (shower or bed bath) was received on 12/2/22, 12/9/22, 12/13/22, 12/23/22, and on 12/27/22. The January 2023 bath report sheets revealed:-On 1/3/23 and 1/6/23 the bath report sheets did not document what type of bathing was provided (shower or a bed bath). The 12/28/22 care conference notes were provided by the social service assistant (SSA) on 1/10/23 at 10:15 a.m. The notes revealed (the resident) wanted showers with facility staff using a (mechanical) lift. III. Staff interviewsThe SSA was interviewed on 1/10/23 at 10:10 a.m. She said Resident #13 had a recent care conference and he requested to receive showers not bed baths. She said he requested the staff use a mechanical lift for him to get him out of bed and into a shower chair. She said information obtained in care conferences were passed on to the departments that could resolve the situation. The DON was interviewed on 1/10/23 at 12:45 p.m. He said the facility had a technical issue with the mechanical lift. He said the issue had been recently fixed and now the lift worked. He said Resident #13 would be provided with a mechanical lift to get out of bed and into a shower chair so that he could receive showers and not bed baths. The DON said he did go in Resident #13's room last Friday (1/6/23) and resolved the situation. He said the resident had received mostly bed baths when he wanted a shower instead. IV. Resident #133A. Resident statusResident #133, age 88, was admitted on 10/10/22 and discharged on 10/28/22. According to the October 2022 computerized physician orders (CPO), the diagnoses included fracture of the left femur (hip), history of falls and a history of seizures. The 10/17/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review According to the certified nurse aide (CNA) tasks sheet, the resident was scheduled to receive bathing on Wednesday and Friday evenings, per Resident #133's preference. The 10/13/22 grievance form documented the resident and her responsible party had a concern that the resident was not receiving showers according to her preference or plan of care. The resident did not receive a shower on her scheduled day of 10/12/22. The resolution indicated the CNA was provided education regarding providing showers according to the shower schedule. The bath sheets provided by the facility, during the survey process, documented the resident receiving a shower on 10/13/22 and 10/26/22, only twice out of six opportunities. C. Staff interviews The director of nursing (DON) and the infection preventionist (IP) were interviewed on 1/10/23 at 5:30 p.m. He said when a resident was admitted to the facility, an interview was conducted to determine the resident's shower preferences. He said the resident was then placed on the shower schedule based on those preferences. The IP confirmed Resident #133 did not receive bathing according to her preferences.

Based on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for two (#36 and #58) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to prevent:-Resident #36 from physical abuse by Resident #83. Resident #83 had documented aggressive behaviors prior to the physical abuse incident on 8/22/22; and, -Resident #58 from physical abuse by Resident #17. Resident #17 had prior behaviors which the facility documented that she did not get along with prior roommates. Findings include:I. Professional referenceAccording to the Centers for Disease Control (CDC) website, "Preventing Elder Abuse" https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 1/12/23), "Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse."Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning."II. Facility policy and procedureThe Abuse and Neglect policy and procedure was provided by the nursing home administrator via email on 1/10/22 at 5:24 p.m. It revealed in pertinent part,"All residents have the right to be free from abuse."Residents will not be subjected to abuse from anyone including staff, residents."Definitions"Abuse "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of any resident, even those in a coma, may cause physical harm, pain, or mental anguish."Physical abuse"Includes hitting, slapping, punching, and kicking of residents. This refers to behaviors directed at residents and not staff or visitors." III. Altercation between Resident #36 and #83A. Incident on 8/22/22The 8/22/22 incident progress note revealed, "It was reported another resident came behind (the) resident and punched him in the right shoulder. Resident is not afraid of the other resident. PA (physician assistant) was notified, DON (director of nursing) notified, resident is (own) responsible party and axo3." (alert and oriented to person, place, and time)The interdisciplinary (IDT) progress notes were provided by the nursing home administrator (NHA) on 1/9/23 at 11:07 a.m. It revealed in pertinent part,-On 8/22/22 "It was reported another resident came behind (the) resident and punched him in the right shoulder, resident is not afraid of the other resident."-On 8/23/22 "Writer (former NHA) followed up with (the) resident regarding being hit by another resident. (Resident #36) reports that (the) other resident (#83) hit him in the shoulder blade. Resident reports it did not hurt, and he is okay. Writer asked if he was fearful of (the) resident and he reports no, he understands (the) resident is confused and did not know what he was doing. Writer told him to let her know if any concerns arise."-On 8/24/22 "Residents separated. Skin assessment completed, no concerns identified. Resident is not fearful and expresses no concerns. Continue to monitor other resident given diagnosis of dementia."B. Residents #36 1. Resident status (victim) Resident #36, age 74, was admitted on 12/21/21. According to the January 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), acquired absence of right and left leg below the knee, morbid obesity, bipolar disorder, pain in the right shoulder, and depression. The 12/13/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with bed mobility, transfers, dressing, and toilet use. He utilized limb prosthesis. 2. Resident interviewResident #36 was interviewed on 1/5/23 at 11:02 a.m. He said some guy followed him from the lunchroom to his bedroom. He said he (Resident #36) propelled his wheelchair back into his (Resident #36's) bedroom. He said Resident #83 came into his room. He said he "Kept wailing, punching me on my shoulder over and over again. At least 10-12 times he punched me. I was aggravated. I told him to stop but he wouldn't let up. I yelled for a certified nurse aide (CNA) #1." He said CNA #1 pulled Resident #83's wheelchair away from me. He said his shoulder hurt for a few minutes. He said as long as the man was not smacking him he felt safe. He said he thought the man was psychologically impaired. He said he heard a rumor that the man did not live in the facility any longer. He said CNA #1 told Resident #83 to let go of my wheelchair. He said CNA #1 told him she was sorry that he had to go through being hit by the other resident. He said the man would not stop punching him until CNA #1 heard him yell for help. C. Resident #83 (perpetrator) 1. Resident statusResident #83, age over 80, was admitted on 8/1/22 and discharged on 9/10/22. According to the September 2022 computerized physician orders (CPO), the diagnoses included dementia, anxiety disorder, major depressive disorder, and hypertension (high blood pressure). The 8/8/22minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required extensive assistance with bed mobility, transfers, locomotion on and off the unit, toilet use, dressing, and personal hygiene. 2. Record review The August 2022 medication administration treatment record (MAR) documented the resident was given the following medications on the day of the abuse 8/22/22: -Buspirone, 5 MG (milligrams) every morning and at bedtime for anxiety ordered on 8/1/22.-Risperidone 6 MG (milligrams one time per day for behavioral and psychological symptoms of dementia (BPSD) and mood disorder ordered on 8/2/22. The nursing progress notes (prior to the 8/22/22 incident) revealed,-On 8/6/22 the resident (#83) approached a certified nurse aide (CNA) from behind and began punching her in the arm and shoulder. The CNA removed herself from the situation and told a nurse. The nurse spoke to the resident who said, "Yeah I did it because you are a stupid (expletive)."-On 8/9/22 the resident (#83) was wandering in and out of other resident rooms and was exit seeking.-On 8/13/22 the resident (#83) called a CNA racist and sexist names, and tried to hit her.-On 8/18/22 the resident (#83) was documented hitting staff when they tried to put him to bed.-On 8/21/22 redirected (Resident #83) several times going in and out of other resident's rooms. The behavioral progress notes (prior to the 8/22/22 incident) revealed in pertinent part,-On 8/7/22 Resident #83 hit a kitchen employee in the lower back and clenched an activity employee's fingers very hard. Resident had a history of non-compliant with care, wandering, and impulsive behaviors. The wife was called and said in the past humor helped redirect him when he behaved in that manner.-On 8/11/22 Resident #83 kicked staff, threatened to harm staff, was exit seeking, used profanity at staff. Resident was able to be redirected 50% of the time and 50% he was not.-On 8/11/22 resident was exit seeking and when a staff member tried to redirect him he grabbed the staff members name tag off of her neck, kicked them in the shin, and called them profanities. He did not respond to interventions. The 8/23/22 administrative progress note revealed after the 8/22/22 incident, resident had dementia and did not have intent (to hit). The 8/9/22 comprehensive care plan on revealed an intervention to please provide the resident with space if he became overwhelmed, this would allow him time to calm down, and to reapproach him at another time (by staff). The 8/29/22 comprehensive care plan on revealed the resident frequently became aggressive with others, to include both staff and fellow residents. It was often difficult to redirect him, but at times responded to being offered coloring, magazines, videos or music. Behavior notes after the incident 8/22/22 revealed, On 8/23/22 the resident was combative towards a CNA when trying to change him. The 8/25/22 care conference note revealed, the resident at times was agitated and exhibited behaviors (such as combativeness) toward others. D. Staff interviewsThe NHA was interviewed on 1/10/23 at 9:45 a.m. She said she was not the administrator when Resident #83 hit Resident #36. She said the current director of nursing (DON) was not working in the facility at that time either. She said the social service director at the time of the incident did not work in the facility any longer either. She said Resident #83 was in the facility from 8/1/22 to approximately 9/11/22. She said Resident #83 came from the company's sister facility (within the same corporation) in the same state. She said at the time it was thought that a change would do the resident good. She said there were other incidents with Resident #83 also after the resident-to-resident incident with Resident #36. She said Resident #83 had been moved to a memory care unit in a different facility. She said she would provide what paperwork she did have about the altercation. She said she did not know why the former administration did not prevent Resident #83 from abusing Resident #36. -She said there was no paperwork about Resident #83's transfer into the facility. She said when a person transferred from a sister facility the paperwork was different than when a person admitted from somewhere else. She said there was no paperwork to provide about Resident #83's behavior or what the reason was for his transfer to the current facility. She said the electronic records contained his approximately six weeks in the facility and that was all that was available. She said there were no referral notes from the transferring facility about the resident. She said she did not know why the resident was transferred from the sister facility to their facility. -The NHA at 10:00 a.m. provided a facility physical abuse report on 8/28/22 of Resident #83. This physical abuse occurred six days after the prior physical abuse on 8/22/22. Resident #83 went into another resident's room and hit them in the back several times. Resident #83 on the same day hit another resident while passing them in the hallway. She said interventions for the residents were implemented, which included the resident being moved to a facility with a memory care unit. CNA #1 was interviewed via the phone on 1/10/23 at 10:28 a.m. She said she remembered the incident that happened to Resident #36. She said she was in the hallway in front of the nurses station when she heard yelling from Resident #36's room. She said she ran to the room and could see Resident #83 repeatedly punching Resident #36 in the back. She said it was far more than one time. She said Resident #83 would not stop punching when she and Resident #36 told Resident #83 to stop. She said she had to pull Resident #83's wheelchair backwards to get him to stop punching. She said she moved Resident #83 into the hallway and called for the registered nurse (RN) to come to the room. She said that she and the RN offered to call the police but Resident #36 said he was okay and did not need the police called. She said because the resident said he did not need the police the facility staff did not call the police and report the incident. She said she had observed many days Resident #83 prior to the incident going into other resident rooms that were not his. When asked if Resident #36's description of the incident was correct, that he was "Wailed on, punched, 10-12 times," CNA #1 said what Resident #36 said what happened in the incident was correct. The DON was interviewed on 1/10/22 at 12:45 p.m. He said he was not the director of nursing at the facility when the incident occurred between Resident #36 and Resident #83. He said he was the DON at the sister facility where Resident #83 lived. He said he remembered two staff members from the admitting facility came to the sister facility to do a psychiatric evaluation on the resident but that was all he knew. He said he thought it was because the resident wandered. He said the other facility had stairs and this facility did not have any stairs. E. Facility follow-up On 1/12/23 at 4:40 p.m. the NHA emailed the following information. It revealed in pertinent part,"No allegations of abuse were reported. The resident (#83) who was involved with the behavior had a BIMS of 3 (severe impaired cognition). It was not possible for the community to establish intent, knowingly, recklessly, or willfully."The facility did not report the 8/22/22 resident-to-resident physical abuse stating the resident had a BIMS of 3 as a reason. The NHA wrote "the resident was unable to have the capacity to commit a willful act and therefore could not be deliberate." -However, the facility did report the same resident (#83) on 8/28/22 (six days later) to the State Agency for resident-to-resident abuse. His mental status had not changed in six days following the first incident and was not a variant at that time to report the second abuse. "The resident who was in receipt of the behavior did not want to contact the police."-Mandatory reporters must contact the authorities in cases of physical abuse even if the resident did not want the police notified. The NHA wrote in her email the term wailing was used by the surveyor. The term wailing was used by the victim in an interview (see Resident #36 and CNA #1 interviews above). -Resident #36 was punched by Resident #83 (see incident progress note). IV. Altercation between Resident #58 and Resident #17A. Incident 12/15/22The facility reported on 12/15/22 at 8:30 p.m. a CNA witnessed Resident #17 kick Resident #58. The CNA separated the two residents. The summary of the care plan after the altercation revealed, the resident had a diagnosis of a psychotic disorder with delusions and a mood disorder. She exhibited mood/behaviors as evidenced by her anxiety and tearfulness. She was triggered by some interactions with peers. The interventions put in place after the incident was not to have the two roommates live in the same room any longer. B. Resident #58Resident #58, age under 90, was admitted on 1/26/21 and readmitted on 12/30/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, atrial fibrillation, cerebral infarction (stroke), stage three chronic kidney disease, peripheral vascular disease, and depression. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She had disorganized thinking, and had delusions. She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. C. Resident #171. Resident statusResident #17, age over 80, was admitted on 1/27/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), psychotic disorder with delusions, unspecified dementia with behavioral disturbances, mood disorder, depression, repeated falls, and age related macular degeneration. The 11/1/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required staff supervision or touch to move from a seated to standing position and to transfer from her bed to a chair. Since admission she had fallen with and without injuries. The resident had disorganized thinking, and had difficulty with focused attention at times. 2. Record review The 2/16/22 and revised on 3/11/22 comprehensive care plan revealed the resident had a diagnosis of psychotic disorder with delusions and a mood disorder. The resident was triggered by some interactions with peers. The resident did not realize/understand that some of her peers were quiet and preferred to keep to themselves. Due to this the resident felt she was not welcomed or that she annoyed others. She reported to staff that everyone was "out to get me, or they hate me." The resident had a history of not allowing a roommate to engage in certain activities of choice within a shared room, not letting the roommate leave or use the restroom. The resident denied that she engaged in that behavior. The resident was educated on adjustment to roommate and proper reactions but did not recall the education/interventions provided.-Goal: The resident would be redirected within minutes of staff intervention and will not suffer any psychosocial distress from her behavior/mood.-Interventions: Redirect the resident to a different location/environment/scenery during increased times of behaviors and/or mood distress. The 3/21/22 comprehensive care plan revealed the resident had paranoia. She had roommates that did not want to be her roommate anymore due to her exhibiting paranoia behaviors. The resident raised her voice at others, pointing her fingers, and touching their belongings. Her paranoia also caused her to barricade herself in her room. The 3/11/22 comprehensive care plan psychosocial need revealed the resident had behaviors that showed a difficulty getting along with roommates/peers. The 9/2/22 comprehensive care plan revealed the resident had a history of depression, bipolar, and psychotic disorder. A review of the social service progress notes for Resident #17 revealed:-On 4/1/22 the resident brought the social worker to her room. The resident raised her voice at her roommate for previously opening a window and for the roommate having a fan pointed towards her. The resident grew agitated at her roommate for being agreeable to what she wanted and continued to raise her voice at the roommate. -On 4/6/22 the resident said she was happy with her roommate but "it would not last."-On 4/7/22 said that a male stole hers and her roommates television remotes. The resident continued to refuse psychiatric medications or counseling. The resident said "everyone thinks I'm crazy, but I'm not, only I know the truth."-On 4/15/22 the resident appeared to be agitated, moving in circles in her power (wheel) chair and making statements. She said "So help me God, send me to the crazy house." Resident had moments of frantic behavior, took the roommates' remote and said it was hers, and tossed a phone from the social worker's hand. -On 5/15/22 the resident made statements in regards to her prior roommate saying, "Me and her really had it out. She was lying and taking my stuff."A review of the nursing behavioral progress notes for Resident #17 revealed:-On 4/1/22 the resident was awake most of the night worrying about her roommate and the roomate's male friend. The resident was fixated on whether the male was a son, husband, or boyfriend. The conversation was "all over the place, skipping from one subject to another not finishing the previous subject, and (the) resident displaying some agitation/anxiety."On 4/22/22 a nurse practitioner after a post hospital emergency room (ER) visit documented the resident had made statements of self harm and resident went to the hospital for a mental evaluation. She was returned to the facility because of the underlying diagnosis of dementia. The facility was seeking other placement for the resident. She continued to be paranoid. The resident said she was kidnapped, and that the kidnappers treated her very well. She said her wheelchair was bugged and people could listen to her conversations. She had ongoing beliefs that people were coming into her room at night to mess with her oxygen. D. Staff interviewsThe nursing home administrator (NHA) was interviewed on 1/10/23 at 9:45 a.m. She said Resident #17 had not lived with another roommate since the incident when she kicked her roommate. She said an analysis was done and revealed the two residents were incompatible roommates.

Based on record review and interviews, the facility failed to develop and update a comprehensive care plan for three (#53, #58 and #7) out of 33 sample residents for services that were to be furnished to attain or maintain the practicable physical, mental and psychosocial well-being. Specifically, the facility failed to:-Ensure Resident #53's comprehensive care plan addressed the resident's use of antidepressant medication; -Ensure Resident #58's use of anticoagulant medication was addressed in the comprehensive care plan with person-centered interventions; and,-Ensure Resident #7's behaviors were identified in the comprehensive care plan with person-centered interventions in place. Finding include:I. Facility policy and procedureThe Person Directed Care Plan policy and procedure, revised on 7/12/22, was provided by the nursing home administrator (NHA) on 1/12/23 at 11:47 a.m. It read, in pertinent part,"Baseline care plans will be completed within 48 hours of admission by the required departments and a copy or summary will be shared with the resident/representative prior to the completion of the Comprehensive Assessment. Care Plan Assessments will be completed by 14th calendar day after a resident's admission, 14 days after the Assessment Reference Date on an annual, significant change, or significant correction MDS has been completed."Care plans will be developed consistent with the residents' specific conditions, risks, needs, behaviors, preferences, and current standards of practice. Measurable goals and individualized interventions will be identified."The care plan will be revised and updated as necessary to reflect the resident's current status."II. Resident #53A. Resident statusResident #53, age 88, was admitted on 3/21/19. According to the January 2023 computerized physician order (CPO), the diagnoses included dementia and adjustment disorder with depressed mood. The 11/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required supervision with one person assistance with transfers, dressing and toileting. She was independent with set up assistance for bed mobility, personal hygiene and eating. She did not exhibit any physical or verbal behaviors directed at others. It indicated the resident did not exhibit any behaviors during the assessment period. B. Record reviewThe January 2023 CPOs documented the following:-Lexapro 5 MG (milligram) by mouth once per day for depression-ordered on 5/20/22. A review of the resident's comprehensive care plan failed to identify the resident's use of an antidepressant administration. The 8/18/22 care conference note documented the resident reported feeling lonely. The 11/8/22 social services progress note documented the resident was feeling down due to medical and family issues. However, this was not addressed in the resident's comprehensive care plan. The facility failed to identify the resident's depression, the resident's reporting of feeling down and lonely in the comprehensive care plan and put effective person-centered approaches in place. C. Staff interviewsRegistered nurse #2 was interviewed on 1/10/23 at 2:05 p.m. She said that Resident #53 was very nice but she often stayed in her room and did not participate in group activities or go to the dining room. She said that the resident did like visiting with people. She said the resident was not tearful but expressed being lonely. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He confirmed that the behavior identified on Resident #53's comprehensive care plan was not current. He said that the resident had expressed feelings of being depressed and that an antidepressant had been started. He confirmed that when a resident was placed on an antidepressant, current behaviors, identifying causes of depression, antidepressant medication monitoring and other interventions such as counseling should be identified on the comprehensive care plan with identified person-centered approaches. III. Resident #58A. Resident statusResident #58, age 89, was admitted on 1/26/21. According to the January 2023 CPO, the diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbances, mood disturbances, and anxiety. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record reviewThe January 2023 CPO documented the following physician order:-Apixaban (Eliquis) Oral Tablet 5 MG (millgram) (anticoagulant), give 1 tablet by mouth every morning and at bedtime for afib. The comprehensive care plan was reviewed on 1/9/23. It did not reveal a care plan for Resident #58's use of an anticoagulant medication. Cross-reference F684: the facility failed to ensure Resident #58 was monitored for the side effects for the use of an anticoagulant medication. C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 1/10/23 at 1:10 p.m. She said Resident #58 ' s was prescribed Apixaban, which was an anticoagulant medication. She confirmed the resident ' s use of the anticoagulant medication was not identified on the comprehensive care plan. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said monitoring side effects identified in the comprehensive care plan of any residents who received anticoagulant medications. He said the MDS coordinator was responsible to ensure a care plan identifying the use of the medication was in place. IV. Resident #7A. Resident statusResident #7, age 95, was admitted on 2/5/21. According to the January 2023 CPO, the diagnoses included mild cognitive impairment of uncertain or unknown etiology, mixed incontinence, rash and nonspecific skin eruption, depression, unspecified. The 10/18/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Record reviewThe 12/12/22 progress note documented Resident #7 blocked a nurse in the doorway when she attempted to assist another resident. It indicated that Resident #7 had concerns with going out for appointments as she had not left the facility for an appointment in a long time and was nervous to do so. The 12/20/22 nursing progress note documented that Resident #7 was having inappropriate sexual behaviors. Resident #7 asked a certified nurse aide (CNA) to rub cream on her labia and anus in a sexual manner. A review of the resident's electronic medical record did not reveal documentation that the resident's behavioral history had been identified in the comprehensive care plan and did not indicate any person-centered interventions to address the resident's behaviors. C. Staff interviewsThe social services assistant (SSA) was interviewed on 1/5/23 at 12:00 p.m. She said she was aware of the behaviors displayed by Resident #7. She said that Resident #7 did not like to leave the facility for appointments because of incontinence issues and a facial rash. She said she was aware Resident #7 had exhibited sexual inappropriateness. She said that behaviors should be identified in the comprehensive care plan. She said social services was responsible for creating the care plans involving behaviors. She confirmed a care plan had not been developed that identified Resident #7's behaviors.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#67) of seven out of 33 sample residents. Specifically, the facility failed to ensure that Resident #67, who was high risk and had skin breakdown, was offered and repositioned in a timely manner. Findings include:I. Professional referenceAccording to Pechlivanoglou, P. et al. Turning high risk patients: An economic evaluation of repositioning frequency in long term care. Journal of the American Geriatrics Society. 2018 July; 66(7): 1409-1414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6097929/ retrieved on 1/12/23."According to current US (United States) practice guidelines, nursing home residents should be repositioned as frequently as required by their condition. Practice guidelines in Canada and the US recommend that patients at high risk of pressure ulcers be repositioned every two hours."II. Resident #67A. Resident statusResident #67, age 80, was admitted on 6/2/22 and readmitted 12/27/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included type 2 diabetes mellitus (DM), peripheral vascular disease (PVD), aphasia (difficulty speaking) from a cerebral vascular accident (stroke), hypertension and chronic kidney disease. The 10/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting and limited assistance of one person for personal hygiene. B. ObservationsOn 1/5/23 at 9:00 a.m. Resident #67 was observed lying in bed on his back.-At 11:05 a.m. an unidentified physical therapist entered room and offered Resident #67 physical therapy. The resident declined, the physical therapist left the room and the resident remained in the same position.-At 11:40 a.m. an unidentified certified nursing assistant (CNA) delivered a lunch tray to Resident #67 and placed it on the bedside table. The resident was not offered repositioning and remained in the same position.-At 3:40 p.m. Resident #67 was observed lying in the same position. During a continuous observation on 1/9/23 beginning at 8:50 a.m. and ended at 12:50 p.m. Resident #67 was observed lying in bed on his back.-At 10:20 a.m. an unidentified CNA entered the resident ' s room and removed the resident ' s breakfast dishes. She did not offer or provide repositioning to the resident.-At 11:50 a.m. lunch meal tray was delivered to the resident by an unidentified CNA. She did not offer or provide repositioning to the resident. The resident was observed with the lunch plate sitting on his stomach while he was eating.-At 12:50 p.m. the resident was observed lying on back with a lunch plate sitting on his stomach.-No repositioning was offered or provided to Resident #67 for four hours. On 1/10/23 at 10:10 a.m. registered nurse (RN) #2 and CNA) #3 entered Resident #67 ' s room to provide incontinence care. CNA #3 unfastened the resident ' s incontinence brief and assisted the resident to turn on his left side and held the resident ' s position during peri care. RN #2 donned gloves and pulled briefs away from the resident. Resident #67 was incontinent with a small soft bowel movement. RN #2, using wipes, wiped front to back. The resident ' s left buttock was reddened and excoriated from moisture associated skin damage (see record review below). RN #2 applied barrier cream and a clean brief. CNA #3 repositioned Resident #67 to the left side and tucked the pillow behind the resident's back. C. Record reviewThe skin integrity care plan, initiated on 6/15/22 and revised on 10/4/22, documented that the resident had an increased risk for skin breakdown related to decreased mobility and episodes of incontinence. The interventions included checking for incontinence at routine intervals, providing cleansing pericare thoroughly after incontinent episodes, providing daily skin check by the CNA ' s during care, encouraging the resident to change positions frequently and assisting if unable, floating the resident ' s heels while in bed and applying a pressure relieving bed mattress. The January 2023 CPO documented a physician ' s order to apply barrier cream with zinc and leave open to air two times per day to the left buttock for moisture associated skin damage (MASD). The 12/28/22 wound care physician assessment documented the resident had sustained MASD to the left buttock on 12/27/22, measuring 10 cm (centimeters) width x 2 cm length. IV. Staff interviewsCNA #3 was interviewed on 1/10/23 at 10:30 a.m. He said that residents who were dependent on staff should be rounded on for incontinence care every hour and repositioned every two hours. He said that Resident #67 was unable to reposition himself and required staff assistance. The director of nursing was interviewed on 1/11/23 at 5:30 p.m. He confirmed that residents with decreased mobility that required extensive assistance, with a past and current history of skin breakdown, should be offered to be repositioned every two hours. He said Resident #67 required assistance from facility staff with repositioning. He said due to the resident ' s history of skin breakdown and current skin condition, he should be offered to be repositioned every two hours.

Based on observations, interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#58) out of 33 sample residents. Specifically, the facility failed to ensure Resident #58 was monitored for use of an anticoagulant medication. Findings include:I. Resident statusResident #58, age 89, was admitted on 1/26/21 and readmitted on 12/31/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included long term (current) use of anticoagulants. The 12/6/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. II. ObservationOn 1/5/23 at 1:10 p.m. Resident #58's top left forearm was observed to have a large brown oval shaped skin discoloration. III. Record reviewThe January 2023 CPO documented the following:-Apixaban (Eliquis) Oral Tablet 5 MG (millgram) (anticoagulant), give one tablet by mouth every morning and at bedtime for afib.-The comprehensive care plan was reviewed on 1/9/23 and did not reveal documentation that the facility had identified the resident's use of an anticoagulant medication or were monitoring the resident for the use of the medication. Cross-reference F656: the facility failed to ensure the comprehensive care plan identified Resident #58 ' s use of an anticoagulant medication. A review of the medication administration records (MAR) and treatment administration records (TAR) for November 2022, December 2022, and January 2023 revealed no physician orders for the monitoring of side effects for use of an anticoagulant medication. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 1/10/23 at 1:10 p.m. She said anticoagulant medication use should be monitored for bleeding and bruising daily and as needed. She said a physician's order should be written to monitor for the side effects of the anticoagulant use. She said Resident #58's was prescribed Apixaban, which was an anticoagulant medication. She said Resident #58's medical record did not have a physician's order to monitor the side effects of the use of an anticoagulant medication. She confirmed the resident's use of the anticoagulant medication was not identified on the comprehensive care plan. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said monitoring side effects should be located in the MAR and identified in the comprehensive care plan of any residents who received anticoagulant medications. He said the MDS coordinator was responsible to ensure the physician's order for monitoring and a care plan identifying the use of the medication was in place.

Based on record review and interviews, the facility failed to ensure four (#17, #18, #58 and #62) of six residents received adequate supervision to prevent accidents out of 33 sample residents. Specifically, the facility failed to:-Develop and implement a person-centered care plan that identified Resident #17 fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #17;-Ensure registered nurse (RN) assessments were completed following falls for Resident #18;-Ensure Resident #58 plan of care identified that the resident was a wander risk and had eloped from the facility on one occasion with person-centered interventions to prevent further elopement episodes, ensure a physician's order was in place with consent obtained for the use of the wanderguard system and monitored the placement and function of the wanderguard; and,-Ensure Resident #62 was being monitored during meals due to his high aspiration rate. Findings include:I. Resident #17A. Resident statusResident #17, age over 65 years, was admitted on 1/27/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), psychotic disorder with delusions, unspecified dementia with behavioral disturbances, mood disorder, depression, repeated falls and age related macular degeneration. The 11/1/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required staff supervision or touch to move from a seated to standing position and to transfer from her bed to a chair. Since admission she had fallen with and without injuries. The resident had disorganized thinking, and at times had difficulty with focused attention. B. Resident interviewResident #17 was interviewed on 1/9/23 at 10:06 a.m. She was lying on her bed with her call light plugged in and hanging on the floor, with the call light button wrapped around her wheelchair wheels at the foot of her bed. She said she did not know how to get someone to help her go to the bathroom so she just had to go to the bathroom in her bed. She said she did not know where her call button was to call staff for help. Resident #17 was interviewed again on 1/10/23 at 9:20 a.m. She was seated in her wheelchair with her bedside table in front of her, seated next to the head of her bed. The call light hung straight down the wall with the call light button on the floor. She said she could call for help when she pushed the red button on the call light. She said she did not know where her call light was today. She said the call light was good to have because it let the staff know she needed help. C. Record reviewThe 7/18/22 comprehensive care plan revealed in pertinent part,-Focus: Resident #17 was at risk for falls with over estimating what she can do for herself. The resident had a history of falls.-Goal: Resident #17 will not sustain an injury if a fall occurs through the next review date.-Interventions: Ensure her call light was within reach. Encourage her to call for help. Increase frequency of rounding for safety. A sign (would be) on the bathroom door reading 'call for assist.' A sign (would be) in her room to encourage her to call for assistance. The desktop file system which documented a summary of the resident's care to the nursing staff was provided by the NHA on 1/9/23 at 12:00 p.m. It revealed in pertinent part,-Ensure the resident's call light was within reach. Increase frequency of rounding for safety. Monitor resident's whereabouts. Sign on bathroom door (to read) "call for assist." Frequent checks (by nursing staff) to make sure the call light was within reach (see director of nursing interview below about frequent checks). D. ObservationsOn 1/4/23, 1/5/23, 1/9/23, and 1/10/23 there was no sign on her bathroom door reading 'call for assist.' She also did not have a sign in her rooms to encourage her to call for assistance (see comprehensive care plan above). Call light observationsThe resident's call light was plugged in at the foot of her bed up on the wall approximately five to six feet. From the plug on the wall hung a long cord. At the other end of the cord was a hand held, off white device that fit in the palm of a hand, with a red top bottom to push. When the call light's red bottom was pushed it alerted the nursing staff that a resident had called for help. The entry door into the resident's room also had a light above it. When a resident pushed the red button, the light above the door lit up also. The call light in the resident's room was not within her reach or pinned nearby. The call light hung straight down the wall, and the call button was on the floor on the following dates,-On 1/5/23 at 9:09 a.m, 11:00 a.m., and 11:17 a.m. (at 11:21 a.m. the resident had fallen out of bed and onto the floor, see observation below).-On 1/9/23 at 10:06 a.m., 2:33 p.m., 2:55 p.m., 3:25 p.m., and 4:30 p.m. -On 1/10/23 at 9:20 a.m. E. Resident fall during surveyOn 1/5/23 at 11:17 a.m. the resident was seated on the floor with her back against her bed and her legs straight out in front of her. Her call light was hung straight down the wall, between the wall and her bed, with the call light on the floor. The call light was not within reach for the resident to grab and push the button for help. The resident's body was wrapped in a large peach colored comforter. Certified nurse aide (CNA) #5 entered the room at 11:21 a.m. and then called down the hallway for the licensed practical nurse (LPN) #2. CNA #5 sat on the bed next to the resident who sat on the floor. LPN #2 entered the room, asked the resident about the fall and if she had hit her head. LPN #2 then left the room and brought back registered nurse (RN) #3. After RN #3 spoke to the resident, she told the resident someone would take her vitals, and then the three staff members helped Resident #17 get back into bed. CNA #5 told Resident #17 she needed to remember to use her call light. CNA #5 went to place the call light next to the resident and discovered the call light did not have a clip on it to pin to the blanket so that it would remain in place. CNA #5 tried to turn the call light on but it did not work. LPN #2 said he would get a call light for the resident that was not broken. LPN #2 brought in a new call light, plugged it in, tested that it worked, and pinned it next to the resident who was lying in bed. F. Staff interviews after the 1/5/23 fallCNA #5 was interviewed on 1/5/23 at 11:45 a.m. She said she did not know the resident's call light did not work. She said today the resident did not have her call light within reach. CNA #5 said she did not know where any signs were in the resident's room to remind her to use her call light. CNA #5 said today the resident was wrapped in the comforter blanket that was on her bed. She said the resident could fall in her comforter blanket because it was big and bulky. LPN #2 was interviewed on 1/5/23 at 4:00 p.m. He said today Resident #17 was moved to a room closer to the nurses station. He said staff would be able to observe her more closely. He said she had frequent falls (1/5/23 was fall #9 for the resident when she was moved closer to the nurses station). Registered nurse (RN) #1 was interviewed on 1/9/23 at 4:30 p.m. She said she had never seen Resident #17 utilize her call light. She said she did not know where the resident was currently in the building. She said some days the resident rested in bed and other days she moved freely in the building in her wheelchair. G. Fall investigationsOn 1/9/23 at 10:45 a.m. the nursing home administrator (NHA) provided the fall investigations for the resident. Resident #17 had nine falls between 9/6/22 and 1/5/23. The interdisciplinary team (IDT)notes after the resident's falls documented all falls were unwitnessed. The NHA said on the bottom right corner of each fall investigation were handwritten initials of managers who attended the morning meetings. Also on the bottom right corner were handwritten notes of interventions (See director of nursing interview below about the handwritten intervention notes).-On 9/7/22 Resident provided with a 42" (inches) bed (fall 9/6/22).-On 9/14/22 Staff to smooth out blankets when rounding (fall 9/13/22).-On 9/19/22 Collect labs on resident to see if anything clinical was going on (fall 9/17/22).-On 10/13/22 Prioritize rounding to include (the) resident in the beginning of rounds. Declutter floor during rounds (fall 9/13/22).-On 11/2/22 Resident currently in isolation due to having COVID-19. Increase the frequency of safety checks, due to the door having to be closed (fall 11/2/22).-On 11/3/22 Keep the door open during the isolation period (second fall on 11/2/22).-On 12/9/22 Encourage (the) resident to keep bed in a lower position (fall 12/8/22).-On 1/5/23 Resident to be moved to room closer to the nurses station (fall 1/5/23).-On 1/10/22 Increase frequency of rounding on the resident (fall 12/27/22). Interventions added on 1/10/23 during the survey, which was 13 days after the fall. H. Staff interviewsCNA #2 was interviewed on 1/10/23 at 11:25 a.m. She said Resident #17 did not utilize her call light. She said when the resident wanted help she would just scream and yell for staff to come and help her. She said she did not know where signs were in the resident's room to remind the resident to use her call light. The director of nursing (DON) was interviewed on 1/10/23 at 2:00 p.m. He said resident falls were discussed in morning meetings when the interdisciplinary team (IDT) met. He said Resident #17's falls were reviewed, and then the IDT would sign their initials on the bottom of the fall incidents. He said at the bottom of the fall incident sheets interventions were hand written as well as the initials of the IDT members who were in the meeting that day. He said the intervention information was verbally communicated to the nursing staff on the floor. He said he did not have proof that the information was provided in a meeting to the floor staff about the resident's interventions for her falls. He said with an intervention of frequent rounding he did not know how often that was. He said generally the nursing staff were to check on residents approximately every two hours. He said frequent rounding would mean more checks on the residents. He said he did not have documented staff education that intervention was communicated to the staff. He said he did not know exactly how often extra rounding (checks) meant. He said he did not have any written logs that the staff had checked extra times on the resident. He said he did not have a physician order/documentation in the resident's electronic medical records (EMR) that the interventions to increase frequency of rounding for the resident's falls were implemented. He said in the EMR it was documented the call light was within reach when the light was observed on the floor and not in reach. He said he would educate the staff right away to make sure no one checked the call light was in reach in the EMR when it was not. I. Facility follow-upOn 1/12/23 at 4:41 p.m. the NHA emailed information about Resident #17. The NHA wrote, "Different interventions are put in place and if it recognized the intervention was not effective, a new intervention would be implemented." She wrote the IDT reviewed each fall and interventions were implemented.-There was no documentation the handwritten interventions via the IDT team were communicated after each fall to the nursing staff according to the interview with the DON (see above). The DON verified in an interview increased rounding was an intervention yet there was no documentation the staff increased rounding nor was there documentation the staff were educated to do so. The DON said he did not know how much or when exactly increased rounding meant in the intervention. II. Failure to conduct and document RN assessments after fallsA. Professional referenceColorado Department of Regulatory Agencies, State Board of Nursing: Practice Act and Laws. 2022. https://dpo.colorado.gov/Nursing/Laws retrieved on 1/19/23 at 2:21 p.m."The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the registered nurse (RN) or medical doctor (MD) for further or 'full' assessment."B. Resident statusResident #18, age 80, was admitted on 4/2/22. According to the January 2023 CPO, the diagnoses included congestive heart failure, chronic kidney disease stage 3, hypertension, depression and dementia. The MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with one person assistance with transfers and dressing independent with one person assistance with toileting and independent with set up for bed mobility, eating and personal hygiene. C. Record reviewThe 12/28/22 nursing progress notes documented that licensed practical nurse (LPN) #3 was assisting Resident #18 when she started coughing and lost her balance and slid down the bathroom wall to the floor. The resident was assisted back to bed by three staff members. It indicated the registered nurse (RN) was notified.-A review of the resident's medical record did not reveal documentation that an RN completed an assessment of the resident prior to the resident being moved from the floor or following the fall in the bathroom. D. Staff interviewsThe director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He confirmed that an RN must conduct an assessment after a fall occurred and before the resident was assisted off the floor. He said that the RN assessment should be documented in the resident's medical record. III. Failure to ensure monitoring was in place for resident who silently aspiratesA. Resident statusResident #62, age 63, was admitted on 5/17/21. According to the December 2023 CPO, diagnoses included multiple sclerosis, dysphagia (swallowing difficulty), pneumonia, chronic obstructive pulmonary disease (COPD), gastrostomy tube. The November 2022 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required the supervision of one person with transfers, dressing and was independent with the assistance of one person with toileting and independent with set up for bed mobility, eating and personal hygiene. B. ObservationsOn 1/4/23 at 12:00 p.m. Resident #62 was observed sitting up and eating lunch of a regular consistency in his room. Staff were not observed in his room or immediately outside of his room. The resident had an occasional loose cough while eating his meal. On 1/9/23 at 11:30 a.m. Resident #62 was observed sitting up and eating lunch of a regular consistency of chicken, sweet potatoes and vegetables in his room. Staff were not observed in his room or immediately outside of his room. The resident had an occasional loose cough while eating his meal. C. Record reviewThe nutrition care plan, initiated on 5/26/21 and revised on 6/17/22, revealed that the resident's ordered diet was nothing by mouth (NPO) due to dysphagia and high risk of aspiration pneumonia, choking and death. The interventions included encouraging the resident to eat in the dining room to ensure he was observed while eating, reminding the resident of the risks associated with not following the recommended diet and encouraging the resident to follow the diet recommendations. The January 2023 CPOs documented:-Diet order: NPO - ordered on 5/17/21;-Check the gastric residuals every shift. If residuals are more than 200 ml (milliliters) hold the tube feeding - ordered on 10/26/21-On 1/4/23 tube feeding Jevity to start every night at 5:30 p.m. On 8/26/21 a videofluoroscopic swallow study was completed and revealed moderate to severe oropharyngeal dysphagia with silent aspiration and an ineffective cough. The recommendations included direct swallow therapy, conducting a conversation with the resident about goals of care and discussing the risk. It directed that modifications to the resident's diet were recommended to mitigate the resident's risk of aspiration with a brief speech follow up and aspiration precautions if the resident chose to pursue an oral diet. On 10/28/21 an acknowledgement of the risks of pursuing an oral diet which included coughing, choking, rehospitalization, aspiration pneumonia and death was signed by the resident.-There was no additional documentation in the chart reviewing the resident's risk of aspiration due to having a regular diet after 10/18/21. D. Staff interviewsCertified nursing assistant (CNA) #4 was interviewed on 1/10/23 at 11:25 a.m. She said that Resident #62 was NPO but he chose to eat a regular diet. She said they tried to watch the resident closely because he had a history of aspiration pneumonia. She said he sometimes would eat in the dining room but he preferred to eat in his room. Registered nurse (RN) #2 was interviewed on 1/10/23 at 11:35 a.m. She said that resident was NPO but wanted to eat by mouth and refused his tube feedings. She said he had a recent aspiration pneumonia and could tell he was having respiratory difficulty by checking his oxygen saturation and providing oxygen. She was not aware of any special precautions or monitoring while the resident was eating. The registered dietitian (RD) was interviewed on 1/10/23 at 5:05 p.m. She said that the resident's diet order was NPO but he chose to eat by mouth. She said he continued to be administered medications and additional water through his gastrostomy tube. She said he did not want staff to monitor him during meals. She confirmed that the interdisciplinary team (IDT) had not discussed how to effectively monitor the resident's risk for aspiration. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said the resident should not be eating but he chose to eat a regular diet after multiple conversations with staff and providers regarding the risk. He said that the resident should be monitored for aspiration and interventions such as sitting up, staff listening for signs of choking and coughing. IV. Resident #58A. Resident statusResident #58, age 89, was admitted on 1/26/21. According to the January 2023 CPO, the diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbances, mood disturbances, and anxiety. The 12/6/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. B. ObservationsOn 1/5/23 at 1:10 p.m. a wanderguard device was observed attached to left side of the crossbar underneath the wheelchair seat of Resident #58. On 1/9/23 at 9:30 a.m. Resident #58 was observed sitting at the nursing station asking staff, repeatedly, to call her parents. The facility staff redirected Resident #58 to a group activity.-At 1:52 p.m. Resident #58 was observed to be in her room alone talking to herself. The resident was crying and placed her face into the palms of her hands.-At 2:57 p.m. Resident #58 remained sitting in her room, sleeping in her wheelchair. C. Record reviewThe 12/12/22 social services progress note revealed that on 12/11/22 Resident #58 had been found outside of the facility by a staff member after her daughter was unable to locate her in the facility. It indicated a wander risk assessment was completed on 12/11/22 and a wanderguard was placed on the resident's wheelchair. The 12/11/22 wander risk assessment documented the resident was at a high risk. It indicated she was ableto move about the facility without staff assistance in her wheelchair, wandered aimlessly within the facility or off the facility groundsThe 12/13/22 interdisciplinary team progress note revealed that staff were encouraged to check on the resident frequently following a visit from her family, as the resident would look for visitors after they left the facility. A review of the resident's electronic medical record did not reveal documentation that the resident's history of wandering or episode of elopement from the facility on 12/11/22 had been addressed in the comprehensive care plan. It did not include any person-centered interventions to prevent the resident from eloping from the facility.-The facility failed to obtain a physician's order for the use of the wanderguard device and consent prior to placing the device upon the resident.-The facility failed to ensure the wanderguard device was placed in a location that would not be lost, and that staff were monitoring the placement and function. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/10/23 at 3:00 p.m. She said she was not familiar with the implementation of the wanderguard system at the facility because she worked for an agency. She said she did not know if Resident #58 was an elopement risk or wandered throughout the facility. Certified nurses aide (CNA) #2 was interviewed on 1/10/23 at 3:00 p.m. She said Resident #68 was a wander risk and had a wanderguard device. She said the facility staff escorted the resident to and from meals and activities. The social services assistant (SSA) was interviewed on 1/10/23 at 3:30 p.m. She said that if a resident was observed wandering, an interdisciplinary (IDT) discussion occurred regarding the implementation of a wanderguard device. She said consent should be obtained from a legal representative prior to placing the wanderguard device. She said the resident's legal representatives were asked to provide verbal consent. She said the conversation should be documented in a progress note in the resident's medical record. She confirmed that the resident's comprehensive care plan did not directly address the resident's history of wandering and episode of elopement. She said in the "fall risk" care plan, it was identified that the resident was at risk for wandering. She confirmed there were no interventions to address the resident's risk of elopement. She said the facility had placed the wanderguard device on the resident's wheelchair. She said it was placed on the wheelchair because Resident #58 was typically in her wheelchair. She said other residents in the facility had been observed trying to take off the wanderguard when it was placed on their person, so they decided to place it on the wheelchair. She said Resident #58 did not have any episodes of trying to remove the wanderguard device. She said the facility had not attempted to place it on the resident's wrist or ankle. The director of nursing (DON) was interviewed on 1/10/23 at 5:30 p.m. He said that when a resident was identified as an elopement risk the legal representative and physician was notified. He said the IDT determined interventions to put into place such as changing the location of the resident's room or initiating a wanderguard device. He said when a wanderguard device was placed, a physician's order should be obtained for the use of the wanderguard device and a physician's order to check the placement and function every day. He acknowledged that placement of the wanderguard device on the wheelchair could be problematic as there was a possibility of the resident being in a separate location as the wheelchair, or the wheelchair could get mixed up with another resident's

Based on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss timely in one (#42) of two sample residents out of 33 sample residents. Specifically, the facility, after identifying weight loss in a resident at high risk for nutritional and hydration deficits, failed to provide effective person centered interventions to assist in preventing additional weight loss and further deterioration of nutrition and hydration status. Findings include:I. Professional referenceRoigk, P. (2018). Chapter 8: Nutrition and Hydration. In K. Hertz and J. Santy-Tomlinson Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). Springer Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 1/17/23 at 4:58 p.m."According to the North American Nursing Diagnoses Association (NANDA) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are: Body mass index (BMI)<18.5 kg/m2, unintended weight loss>10% in the last 3-6 months, BMI < 20 kg/m2 and unintended weight loss>5% in the last 3-6 months, fasting period>7 days."II. Resident #42A. Resident statusResident #42, age over 65, was admitted on 12/20/19. According to the January 2023 computerized physician orders (CPO), the diagnoses included dementia and protein-calorie malnutrition. The 11/15/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15 with deficits in short and long term memory. She required extensive one person assistance for bed mobility, transfers, dressing, eating, toileting and personal hygiene. B. Observations On 1/5/23, during a continuous observation starting at 9:00 a.m. and ending at 12:00 p.m., Resident #42 was observed sitting in the dining room in a wheelchair with her head in her lap. Her breakfast plate was full and the resident did not make an attempt to eat. A glass of orange juice was observed with 50-60 milliliters in glass and a coffee cup 60-75% full. Staff were not observed attempting to encourage or assist resident with eating her meal.-At 9:35 a.m., an unidentified staff member wheeled the resident outside of the dining room and sat alone in a wheelchair in the hallway.-At 9:45 a.m. unidentified certified nursing assistant (CNA) wheeled the resident back to her room.-From 10:00 a.m. to 12:00 p.m. Resident #42 was observed lying in bed. There were no fluids, water pitcher or food observed in the resident's room. Staff was not observed entering the room to offer any hydration or snacks.-At 3:40 p.m. Resident #42 was observed lying in bed in the same position. A water pitcher or snacks were not observed in the resident's room. On 1/9/23 at 9:50 a.m. Resident #42 was observed sitting in her wheelchair in her room. Fluids, water pitcher or snack items were not observed in the resident's room.-At 10:05 a.m. Resident #42's roommate asked the resident if she was thirsty and would like something to drink.-At 10:10 a.m. Resident #42's roommate turned on the call light and asked an unidentified CNA for a water pitcher for Resident #42. A water pitcher was brought into the room for Resident #42 by the CNA. The resident's roommate encouraged her to drink the water.-At 10:20 a.m. Resident #42 was wheeled out to the glass doorway by an unidentified CNA. Resident #42 was holding a cookie, took one bite out of the cookie and then placed it on the hallway railing. The cookie was removed by an unidentified housekeeper and placed in the trash.-At 11:10 a.m. Resident #42 was wheeled to the dining room for lunch by unidentified CNA.-At 12:20 a.m. Resident #42 was observed sitting in the dining room with her head in her lap. The resident's plate was full and food was untouched. The resident did not make any attempt to eat. Staff were not observed encouraging or assisting resident with eating. C. Record reviewThe nutrition care plan, initiated on 1/16/20 and revised 9/30/22, indicated the resident's body mass index (BMI) was 17.1 kg/m2 (underweight) with ideal body weight of 104-115 pounds (lbs) with a goal weight of 110 lbs. The interventions included monitoring the resident's weights, providing a regular diet with minced and moist consistency and gastrointestinal soft and thin liquids, encouraging the resident to eat and drink, monitoring the resident's eating and drinking, providing 4 ounces (oz) of mighty shake twice a day, providing 4 oz vanilla or strawberry ice cream twice a day, offering 4 oz of fortified mashed potatoes with gravy with lunch, providing whole milk at meals and encouraging snacks in between meals. The resident's weights were documented as follows:-6/4/22: 98 lbs-9/2/22: 97.1 lbs-11/23/22: 96 lbs; and,-12/9/22: 93.5 lbs. The 1/8/23 quarterly nutrition assessment, completed during the survey process, documented Resident #42 had a weight loss of 2.5 pounds or 2.6% in one month, 3.6 pounds or 3.71% in three months and 4.5 pounds or 4.59% in six months. The resident's ideal body weight was 104 lbs to115 lbs with a goal weight of 110 lbs. It indicated the resident's seven day daily intake average was 33% solids and three day daily average 1,060 ml of fluids. The registered dietitian (RD) documented the resident's current oral intake appeared not sufficient to meet the resident's assessed calories and protein needs. A comprehensive review of diet and supplementation orders revealed:-Bedtime snack (hs) for snack support was ordered on 1/9/2020.-Diet order of regular diet, minced and moist texture with GI (gastrointestinal) soft diet, ordered on 7/15/2020.-Supplement order of sugar free mighty shake 4 oz. four times a day for nutritional support was ordered on 12/3/22.-Supplement order of 4 ounces (oz) of strawberry or vanilla ice cream once a day was ordered on 1/8/23.-The facility failed to implement a supplement until 12/3/22, when the supplement of a 4 oz mighty shake was ordered. The bedtime snack and minced and moist diet (altered diet) were added in 2020. D. Staff interviewsCertified nurse assistant (CNA) #4 was interviewed on 1/10/23 at 12:20 p.m. She said that Resident #42 would only eat if someone sat with her and encouraged her. She said the resident required frequent cueing and often took 45 minutes to eat a meal. She said the resident was offered mashed potatoes all the time but she would only eat it occasionally. She said in between meals the resident was offered Ensure and ice cream. She said she had suggested that the resident move to the restorative therapy aide table so that she could get more assistance during meals. She said the program had not been in place since the start of the COVID-19 pandemic and had been told that they were working on re-establishing the program. She said the CNAs were responsible to provide the resident with cueing for her meals even if she was not at the restorative table. The registered dietitian (RD) was interviewed on 1/10/23 at 1:10 p.m. She said the resident had dementia and had been slowly losing weight but had not reached a significant weight loss. She said Resident #42 was not eating well but had ordered supplements for the resident. She said she was not aware that the resident did not eat on her own and required assistance. She said the resident's meal intake was variable the past seven days. She said she had reduced the mighty shake to twice per day because the resident was refusing it at bedtime. She said the resident accepted Grandma's Cookies, but refused ice cream in the morning and evening. She said she was not aware the resident refused the fortified mashed potatoes. She said that the facility was trying to re-establish the restorative aide program, but it was not running at that time. She confirmed the mighty shake supplement was not added until December 2022 and the ice cream until that week, during the survey process.

Based on interviews and record review, the facility failed to establish parameters for pain medication for two (#50 and #5) of two residents in a manner consistent with professional standards of practice out of 33 sample residents. Specifically, the facility failed to:-Pain parameters were implemented on pain medications ordered and the location of pain was identified on the physician order for Resident #50; and, -Pain parameters ordered for pain medications were followed for Resident #5. Findings include:I. Facility policy and procedureThe Pain Management policy and procedure, reviewed 11/1/18, was provided by the nursing home administrator (NHA) on 1/12/23 at 11:47 a.m. It revealed in pertinent part,"The pain interview will include: record review for scheduled, PRN, and non-medication pain interventions; residents will be evaluated to determine ability to answer questions based on minimum data set (MDS) 3.0 guidelines. If a resident is unable to respond to questions or cue cards, staff interviews will be completed using the same assessment form, frequency of pain during the last 5 days, interference with sleep and activities of daily living, location, description and intensity of pain, goal to manage pain, what makes the pain better or worse, including non-pharmacological interventions."Nurses will evaluate/rate resident's pain a minimum of every shift and as needed (PRN). Ratings will be documented on the medication administration record (MAR). In addition, repetitive use of PRN pain medications should be evaluated to determine the cause of pain and if alternative medications or additional interventions are indicated. Acute temporary care plans will be initiated as needed based on evaluations and changes of condition."II. Resident #50A. Resident status Resident #50, age 95, was admitted on 6/8/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included congestive heart failure, hypertension, chronic kidney disease, atrial fibrillation, multiple sclerosis, and dementia. The 12/6/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of six out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting and supIt indicated the resident was on a scheduled pain medication regimen, did not receive PRN pain medications and received non-pharmacological interventions for pain. B. Record reviewThe pain care plan, initiated 6/21/22, documented the resident was at risk for pain. The interventions included assessing and documenting the resident's pain every shift, assessing and documenting the effectiveness of non pharmacological and pharmacological interventions, administering as needed (PRN) pain medications and offering non pharmacological interventions for pain first (ice, heat, repositioning). A review of Resident #50's comprehensive care plan did not reveal person-centered approaches with identification of the location and type of pain the resident experienced. It did not include personalized non pharmacological interventions to address the resident's pain. The December 2022 and January 2023 medication administration record (MAR) documented the resident was prescribed the following medications:showed-Oxycodone 5 milligram (mg) tablet-one tablet every eight hours for pain-ordered 11/2/22.-Oxycodone 5 mg tablet by mouth every four hours as needed for pain rated on pain scale 6-10 with 10 being the worst pain on the scale)- ordered 11/2/22.-Morphine Sulfate 20mg/5 milliliters (ml). Give 5 mg by mouth every four hours as needed for chronic pain-ordered 11/5/22.-Tylenol tablets give 650 mg by mouth every six hours as needed for pain 1-10, do not exceed 3000 mg in 24 hours-ordered 6/10/22. A comprehensive review of December 2022 and January 2023 MAR failed to document a location and type of the resident's pain being treated for Tylenol, Oxycodone and Morphine Sulfate. The physician orders did not include specific pain scale parameters for the Morphine Sulfate. C. Staff interviewsRegistered nurse (RN) #2 was interviewed on 1/10/23 at 10:35 a.m. She said that before a resident was administered pain medication, the resident was assessed for the location and intensity of the pain using a numerical scale for verbal residents and facial expressions for residents with dementia. She said non-pharmacological interventions were offered prior to administering pain medication. She said for pain medication, Tylenol was offered first, for a pain rating of 1 to 5 and if the resident's pain was 6 to 10, then narcotic medications were administered. She said that all pain medications should have parameters to indicate when to administer the medications. The director of nursing (DON) was interviewed on 1/10/23 at 5:20 p.m. He said that pain should be assessed and non-pharmacological interventions attempted prior to administration of pain medications. He said pain medications were administered according to ordered parameters by the physician. He confirmed that if pain medications did not have parameters, the physician or provider should be contacted and the order clarified prior to administration. III. Resident #5 A. Resident status Resident #5, age 78, was admitted on 1/11/22. According to the January 2023 computerized physician orders (CPO) diagnoses included major depression disorder, arthritis and end of stage renal disease. According to the 10/18/22 minimum data set (MDS) assessment, the resident did not have any short-term or long-term memory impairment. The resident was totally dependent on staff assistance with bed mobility, transferring, dressing, and personal hygiene. It indicated the resident received scheduled and as needed pain medication. B. Record reviewThe pain care plan, revised on 1/11/22, documented the resident had a potential for pain related to arthritis. It indicated the resident refused non-pharmaceutical interventions and preferred pain medication. The interventions included anticipating the resident's need for pain medication, notifying the physician if interventions were unsuccessful and observing and reporting changes in the resident's usual routine, sleep pattern and a decrease in functional abilities. According to the December 2022 CPO, Resident #5 was prescribed Oxycodone 5 mg (milligram), one tablet by mouth every six hours as needed for a severe pain level of 6-10.-It was administered on one occasion without a documented pain level, one occasion with a pain level documented as 0, and on two occasions when the pain level was documented as a 4. According to the January 2023 CPO Resident #5 was prescribed Oxycodone 5 mg (milligram), one tablet by mouth every six hours as needed for severe pain level 7-10-It was administered on ten occasions (1/1/23 to 1/10/23), with four of those occasions documented as administering the medication outside the prescribed pain scale range of 6 out of 10.-The facility failed to administer the prescribed medication according to the physician ordered parameters. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/10/23 at 2:40 p.m. She said Resident #5 was prescribed a scheduled oxycodone dose and an as needed oxycodone dose. She said the resident was administered the as needed Oxycodone according to a pain scale indicated in the physician's order. She said that the pain scale for the as needed Oxycodone was documented to administer the medication for a 7-10 pain scale. She said she had administered the medication when the resident's pain level did not meet the prescribed pain scale for administration. The director of nursing (DON) was interviewed on 1/10/23 at 5:20 p.m. He said the physician's orders should be followed when administering medications. He said that the nurse should follow the pain scale according to the physician's order. He said that the nurse should call the physician if they needed clarification or to get approval to administer the medication outside the ordered parameters.

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 development and transmission of disease and infection on one out of three units. Specifically, the facility failed to:-Ensure contaminated gloves were removed and hand hygiene was performed after providing incontinence care and before touching the barrier cream tube;-Ensure soiled gloves from incontinence care were removed and hand hygiene performed before touching outside packaging of incontinence wipes; and,-Ensure soiled packaging of incontinence wipes and barrier cream were disposed of prior to placing it on the nightstand. Findings include:I. Professional referenceCenters for Disease Control and Prevention (CDC). Hand Hygiene in Healthcare Settings: Hand Hygiene Guidance. Reviewed January 30, 2020. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 1/12/23. "Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic task (placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal."II. Observations-On 1/10/23 at 10:10 a.m. registered nurse (RN) #2 was observed wiping Resident #67's buttocks after a bowel incontinence episode. RN #2 was observed, with soiled gloves of fecal material, touching the outside packaging of the incontinence wipes and soiling the package with fecal material. -RN#2 without removing her gloves, picked up the barrier cream on the nightstand, dispensed the cream onto her gloved hand, applied the cream to the resident's buttocks and placed the barrier cream tube on the resident's nightstand.-RN #2, after placing the barrier cream tube on the nightstand, removed the gloves and donned a new pair of gloves. She did not perform hand hygiene in between the glove change. -RN #2 placed a new incontinence brief and incontinence pad on the resident, picked up soiled incontinence wipes and placed them on the nightstand. III. Staff InterviewsCertified nursing assistant (CNA) #3 was interviewed on 1/10/23 at 10:30 a.m. He said that gloves should be changed after incontinence care was provided and when the gloves were visibly soiled. RN #2 was interviewed on 1/10/23 at 10:35 a.m. She said during incontinence care, gloves needed to be changed after touching a dirty area, before touching a clean area and at the completion of incontinence care. The director of nursing (DON) was interviewed on 1/10/23 at 11:15 a.m. He said that hand hygiene should be performed after doffing gloves and prior to donning a new pair of gloves. He said hand hygiene should be performed at the completion of incontinence care. He said gloves should be changed when they were visibly soiled and after the gloves had touched a dirty area. He said hand hygiene should be performed and gloves changed before touching the incontinence wipes outer packaging and the barrier cream. He confirmed that the incontinence wipes with outer packaging and barrier cream tube should be disposed of instead of placing it on the nightstand since it had been touched with visibly soiled gloves.