Walbridge Memorial Convalescent Wing

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

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

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

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

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

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

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for three (#19, #9 and #10) of four residents reviewed for mental health out of 29 sample residents.
The facility failed to offer alternative mental health services when Resident #9 expressed wanting to die but refused counseling services. Resident #9 was admitted to the facility after a hip replacement and heart issues. Less than six months after she was admitted she was diagnosed with cancer. She did not have signs or symptoms of depression until she fell on 7/4/23 and broke her right arm. She lost her independence and said she felt disgusted with herself since she needed staff to help her with all activities of daily living (ADLs). During her interview, she was withdrawn and had been isolating herself in her room. She said she may never be able to use her right arm like she used to ever again and she was upset about it. She said every night she thought about dying and was ready to go. She did not understand why she had not died yet.
The facility failed to identify, monitor and timely provide support to address the resident's newly developing depression, nor did the facility implement a person-centered care plan to include a timely referral for other types of mental health services after the resident refused formal therapy.
Furthermore, the facility failed to evaluate Resident #10 on an ongoing basis and develop a comprehensive, person-centered plan of care to meet his psychosocial needs. The facility failed to make reasonable attempts to secure professional behavioral health services when a potential need was identified that Resident #10 was developing signs and symptoms of depression. The facility failed to assess, identify and implement person-centered interventions to maximize Resident #10 goals for care. Due to the facility's failures, the resident had several days of feeling down, depressed or hopeless according to the patient health questionnaire and expressed he was trying to exist and was bored with life.
In addition, the facility failed to offer Resident #19 counseling services for her mental well-being. The facility failed to identify, monitor and timely provide support to address the resident's depression worsening after her family stopped visiting her, such as through the implementation of a person-centered care plan and timely referral for mental health services.
Findings include:
I. Facility policy
The Behavioral Health Policy, effective 8/3/23, was provided by the director of nursing (DON) on 12/14/23 at 3:01 p.m. read in pertinent: Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, and/or accommodating a resident's distress or loss of abilities.
Behavioral health care and services will:
-Ensure that the necessary care and services are person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety,
-Ensure that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being,
-Provide meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents, and the community,
-Provide an environment and atmosphere that is conducive to mental and psychosocial well-being,
-Ensure that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated,
-Identify individual resident responses to stressors and utilize person-centered interventions developed by the interdisciplinary team (IDT),
-Ensure care plans address the individualized needs of the resident and contain individualized interventions based on the diagnoses; and
-Ensure that the IDT, which includes the resident, the resident's family, and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered.
II. Resident #9
A. Resident status
Resident #9, age over 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO) diagnoses, included transient cerebral ischemic attack (stroke), squamous cell carcinoma (cancer) and heart disease.
According to the 11/1/23 minim data set (MDS) assessment Resident #9 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS did not contain an assessment of the resident for depression.
B. Resident interview
Resident #9 was interviewed on 12/14/23 at 3:02 p.m. Resident #9 said she was getting on the bus to go out for the Fourth of July parade as a group activity and fell. She said she felt disgusted with herself and was angry that she fell. Resident #9 said she could only lift her arm about 90 degrees to her body and she may never get to lift it more. She said while she healed she could not participate in group activities. She said a physical therapist (PT) went to her room to work with her. She said activities were not offered to her in her bedroom. She said she was depressed and ready to die. Resident #9 said she was admitted to the hospital after the fall to treat her injuries but could not remember how long she was admitted for (record review showed she was admitted for 10 days). She said when she returned to the facility she was no longer independent and required staff assistance for almost everything. Resident #9 said she fell again on 10/23/23 when she tried to pick a card up off the floor and slid out of her wheelchair.
Resident #9 said it was embarrassing and she scooted herself across the floor to get her call light for staff assistance. She said she was still depressed and was not sure if the facility offered her counseling services but she did not want to talk to someone. She said she did not know what else the facility could do to help her depression but every night she felt depressed and thought she was better off dead or was ready to die because of her age and she still could not walk or be independent. She said she felt like her bones were taking a long time to heal.
C. Record review
Resident #9's comprehensive care plan, revised 11/16/23, documented the resident had a decline in activity involvement due to her depression and her broken arm. An intervention for activities, revised on 8/3/23, was to explain to the resident the importance of social interaction and encourage the resident's participation by invitation and encouragement. It was also documented the resident had depression signs and symptoms due to her right broken humerus (arm) and subsequent decline in functional abilities. Interventions were documented as the following:
-Discuss with the resident any concerns, fears, issues regarding health, or other subjects,
-Monitor, document, and report any risk for harm to self as needed; and
-Monitor, document, and report any signs or symptoms of depression.
A progress note entered on 8/2/23 documented Resident #9's MDS assessment was completed. During the MDS assessment, the resident stated that had thoughts that she would be better off dead because her arm was not allowing her to do as much as she used to. She said she knew it was healing just not as fast as she wanted it to. The resident was asked if she wanted to speak to a therapist about her thoughts and she stated that she did not want to talk to anyone. The ADON and DON were notified of the findings and the ADON was going to talk to the resident.The resident was asked if she would like to attend her upcoming care plan meeting on 8/3/23. The resident stated that she did not want to attend.
A progress note entered on 8/2/23 documented the ADON spoke with Resident #9. The resident said that she had feelings of depression due to the fact that her arm still had not healed and she needed a lot of assistance from staff. The resident said at times she felt she would be better off not being here. The ADON asked the resident to further elaborate on what she meant and if she had thoughts of harming herself. The resident denied thoughts of harming herself but said she felt like she could not care for herself without so much help from staff that she may have been better off not making it through the fall that resulted in her arm injury. The ADON consoled the resident and said he understood her feelings and that it was okay for her to feel a little down about not being as independent as she was previous to her fall. The ADON told the resident he was concerned about her being too depressed or her depression worsening. The resident said she did not want to talk to anyone about the situation but she agreed to the ADON informing her physician to see if medication was needed for her depression.
A care conference held on 8/14/23. The notes documented Resident #9 had a positive outlook on life. She was not fond of being at the facility but was making the best of it. The note documented that the resident said it was hard getting old. Resident #9's patient health questionnaire (PHQ-9) was documented as a nine which indicated mild depression. Resident #9 said she did not want to talk to anyone at this time but agreed to the ADON informing her physician about possibly starting an antidepressant. The resident was having a hard time because she was not healing as fast as she wanted and was not independent like she used to be and it made her upset.
A progress note entered on 8/21/23 documented the physician visited the resident on 8/17/23. The physician said the resident's appetite was good and she still attended desired activities. The resident declined therapy and medications during the visit and would inform the staff if her depression symptoms worsened. The facility continued with therapy and the resident's current plan of care.
A progress note entered on 9/13/23 documented Resident #9's lungs had crackles in the bases. The resident denied being uncomfortable and admitted to a non-productive cough. The resident told the nurse that she did not want to go to the hospital and declined all tests. She said that she was ready to go (die) when it was her time. She allowed the nurse to give her oxygen to keep her oxygen within normal limits.
A progress note entered on 9/13/23 documented Resident #9's oxygen saturation decreased to 86% (normal limits 90% and above) on room air. The resident refused to wear oxygen. The resident stated that she did not want to go to the hospital and declined all tests. She said if it was her time to go then she was ready. The resident's physician said she would visit the resident for an assessment.
A progress note entered on 9/13/23 documented the nurse notified the resident's medical durable power of attorney (MDPOA) of Resident #9 refusing to wear her oxygen. The resident's oxygen saturation was at 77% on room air. The resident's MDPOA said he was on his way to the facility. The nurse ended the phone call and reapproached the resident to offer oxygen and the resident agreed.
A progress note entered on 9/14/23 documented the resident tested positive for rhinovirus (type of head cold) and began antibiotics.
D. Staff interviews
The ADON was interviewed on 12/14/23 at 2:30 p.m. He said before Resident #9's accident she was independent with all activities of daily living (ADLs). He said she was very private and did not want any interventions in place for her depression. The ADON said she did not want to die but if she died then she was okay with it. He said the resident declined activities because she did not want to be seen by other residents being wheeled by staff to activities. The staff encouraged the resident to participate in activities and that the other residents would not think less of her if she needed help from staff. The staff made her comfortable to participate in activities. He said the resident did not like when staff checked on her too much and would not let staff come in and sit with her. The ADON said the staff documented that they checked on her.
-However, the facility failed to document consistently when they checked on Resident #9.
The activity director (AD) was interviewed on 12/14/23 at 9:24 a.m. She said she knew the resident became more depressed after the accident because she was no longer independent. She said the fall affected Resident #9 physically however it affected her mentally and she became more withdrawn than she used to be. The AD said when the resident returned from the hospital the resident said she was giving up on life because of her injury. The AD said she would not be surprised if Resident #9 still felt this way but she did talk to her a lot and the resident seemed okay. She said the facility was not doing anything for Resident #9's depression that she was aware of.
III. Resident #10
A. Resident status
Resident #10, over the age of 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included traumatic subdural hemorrhage (bleeding in the brain post traumatic brain injury) with loss of consciousness status unknown, sequela (bleeding in the brain post traumatic brain injury), gastro-esophageal reflux disease without esophagitis, benign prostate hyperplasia without lower urinary tract symptoms (enlarged prostate gland that is not cancerous) and history of falling.
According to the 10/29/23 MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He did not exhibit disorganized thinking or inattention. He did not have behaviors, including rejections of care. The MDS assessment identified Resident #10 had several days of feeling down, depressed or hopeless.
B. Resident interview and observations
Resident #10 was interviewed on 12/11/23 at 1:11 p.m. He said she had a stroke and he needed a new brain. He said he had been in his current condition for almost ten years. Resident #10 said he was having one hell of a time just trying to exist. The resident said he was bored and bored with life.
Observations throughout the survey between 12/11/23 and 12/14/23 between the hours of 8:00 p.m. and 6:00 p.m. identified Resident #10 did not get out of bed. He ate his meals in his room. When the resident was not eating, he spent his time sleeping or watching sports channels.
C. Friend of the resident interview
A friend of Resident #10 was interviewed on 12/13/23 at 12:0 p.m. She said she tried to come see Resident #10 almost everyday around lunch time so he had some company. The resident's friend said the resident's family member had not been available to visit Resident #10 as often as he used to. She said she really did not see too many staff check in with Resident #10. He said he told her he just wanted to go to sleep and pass. The friend said she wished staff would try to encourage him to spend less time in his bed.
D. Record review
-The review of Resident #10's comprehensive care plan identified the facility failed to develop a person-centered psychosocial wellness care plan to maintain the resident's highest practicable level of physical, mental and psychosocial well being. The resident's care plan did not identify individualized approaches of care/interventions that were part of a supportive mental and psychosocial environment which was directed towards understanding, preventing, relieving, and/or accommodating the resident's distress or loss of abilities.
The 11/3/23 social service assessment read Resident #10 walked with a walker with two person assist and a gait belt for short distances. He needed help with most ADLs such as transferring, bed assist, dressing, toileting and bathing. He could eat independently in his room with set up help. Resident #10 was aware of self, family, friends, years, month, day and his surroundings. The resident did not have behaviors and his mood was pleasant. According to the social service assessment under the category of psychosocial, Resident #10 had a family member that visited and the resident was developing a good relationship with the staff. He had tried to use headphones that connected to the television so he was able to hear better but the resident could not tolerate the headphones.
-There was no additional information or needs provided under psychosocial when the resident was assessed with social services.
The 11/7/23 physical therapy evaluation documented Resident #10 refused to participate during the physical therapy evaluation. According to the evaluation, the resident said I am just going to die here in this bed and I will lie here the rest of my life until I die.
The 11/7/23 occupational therapy evaluation documented Resident #10 liked sports and the outdoors. He felt he could not stand or walk and declined occupational therapy or attempts to get out of bed during the therapy evaluation. According to the evaluation, the occupational therapist offered a trip outside, modified bowling in a seated position, and offered bingo. The occupation evaluation indicated the resident declined and said What is the point, I can't do it, I am just going to die here and I wish it would be sooner rather than later. I have too much blood in my head and no one can drain it, I don't just have a zipper up there.
-The review of the November 2023 and the December 2023 treatment administration record (TAR) and progress notes did not identify Resident 10's mood and behavior was tracked and monitored after he made statements of wanting to die on 11/7/23.
A list of residents receiving counseling supportive services was provided on 12/13/23 by the facility. The list did not identify Resident #10 received counseling supportive services even though the resident identified he had several days of feeling down, depressed or hopeless as identified by the MDS assessment and feelings of wanting to lie in bed and die as identified in the 11/7/23 physical and occupational therapy evaluations.
E. Staff interviews
The activity director (AD) was interviewed on 12/14/23 at 9:53 a.m. The AD identified Resident #10 did not participate in group or individualized activities other than watching sports on television. The AD said when she had asked him to do an activity, he told her he just needed a new brain. The AD said the resident was not part of a one-to-one program offering additional opportunities for engagement and socialization (cross-reference F679 for activity programming).
The social service director (SSD) was interviewed on 12/14/23 at 10:47 a.m. The SSD said she helped residents with emotional needs by connecting residents to counseling services and other volunteers who helped provide additional support. The SSD said she checked in with Resident #10 but had not documented her check ins. The SSD said Resident #10 had not told her he was bored with life. She said Resident #10 had said he felt he could not do what he used to do since his stroke, but he did not seem too upset by it. She said he would talk to her about his past job and sports. She said a family member that he was close to use to visit more but he has not visited Resident #10 as much lately. The SSD said counseling services might help Resident #10 break out of his shell and encourage him to come out of his room. She said she thought a physician referral for the counseling service was made for Resident #10 but she was not sure what the status was.
The SSD was interviewed again on 12/14/23 at 12:40 p.m. The SSD said she was thinking of another resident when she said she thought Resident #10 already had a physician referral for counseling services. She said a referral for counseling service was not made with the physician for Resident #10. The SSD said she was not aware Resident #10 told therapy on 11/7/23 that he wanted to remain in bed and die. She said the documented resident comments should have been communicated to her so she could have followed up sooner.
The assistant director of nursing (ADON) was interviewed on 12/14/23 at 2:26 p.m. The ADON said he just made a counseling referral for Resident #10's physician.
The nursing home administrator (NHA) was interviewed on 12/14/23 at 2:41 p.m. The NHA said the facility had some options within the community for behavioral health services including counseling services with a local hospice provider and telehealth. The NHA said she would reach out to the licensed social workers on the hospital campus and she would research other available resources with mental health services outside the community.
The NHA said the facility should have identified and communicated the expressed feelings from Resident #10 so the facility could have provided him additional support.
IV. Resident #19
A. Resident status
Resident #19, age over 65, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included dementia, recurrent major depressive disorder, left hip osteoarthritis, breast cancer and restless leg syndrome.
According to the 11/1/23 MDS assessment Resident #19 had a severe cognitive impairment with a BIMS score of five out of 15. Her depression was not documented other than her diagnosis.
B. Resident interview
Resident #19 was interviewed on 12/11/23 at 11:53 a.m. She said she felt really depressed and the facility was not helping her with it. She said her family stopped visiting her but she did not know why. She said when her family did not visit it affected her mentally. Resident #19 said she was angry but did not know why. She said she knew she did not eat enough and had lost a lot of weight.
During the interview, the resident was observed lying in her bed in the dark and she chewed on her nails constantly.
C. Record review
Review of the progress notes from January 2023 to December 2023 revealed the resident's depression signs and symptoms were not documented by the staff even though she had a diagnosis of major depression disorder and they discontinued her antidepressant on 5/22/23 and the facility restarted her antidepressant medication on 12/4/23 due to her losing weight.
Resident #19's comprehensive care plan, revised 11/16/23, documented she was dependent on staff to meet her emotional, intellectual, physical, and social needs due to her cognitive deficits and physical limitations. The interventions for staff were to offer activities to Resident #19 and allow her to decline. She used Lexapro (antidepressant medication) for her depression. The interventions for the antidepressant were to monitor for negative side effects. She was documented as having a nutritional problem due to anorexia. The interventions documented were to monitor food intake and offer nutritional supplements when she refused to eat.
-However, the facility failed to implement interventions for staff to provide support when the resident was depressed or guidance for staff to provide support for her major depressive disorder.
D. Staff interviews
The SSD was interviewed on 12/12/23 at 4:07 p.m. She said the facility had a few residents who had a hard time with depression and the facility worked with another organization to provide counseling services to the residents. She said the facility sent referrals if a resident needed counseling or therapy services and the organization provided the services once they accepted the referral. She said the facility completed pre-admission screening and resident review (PASRR) when residents were admitted . If the resident needed services the PASRR provided recommendations the facility followed.
The SSD was interviewed again on 12/14/23 at 11:00 a.m. She said Resident #19 had a PASRR II completed and there were no recommendations needed for her major depressive disorder because dementia was her primary diagnosis. She said Resident #19 was not provided counseling services and she was not sure if the resident wanted to talk to anyone about her depression.
Nurse aide (CNA) #1 was interviewed on 12/14/23 at 5:15 p.m. She said if a resident expressed depression or wanting to die she notified the nurse and made sure the resident did not have anything to harm themselves with. She said she would not leave the residents by themselves and used the call light to get help if possible.
Licensed practical nurse (LPN) #1 was interviewed on 12/14/23 at 5:17 p.m. She said if a resident expressed depression or wanting to die she asked open-ended questions to get the resident to talk about what was going on and see if they were safe. She said she notified the resident's physician and the nurse supervisor. She said she did not experience a resident being depressed or heard of a resident saying they were ready to die. She said she checked the facility's policy to make sure she provided the correct amount of support to the resident and checked to see if the resident had anything to harm themselves.
-The nursing staff interviewed had not worked at the facility for a long time and did not experience any residents showing signs of depression or expressing they wanted to die.

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner.
Specifically, the facility failed to ensure:
-Expired foods were disposed of in the activity refrigerator the residents used;
-Foods were dated and sealed in the activity refrigerator;
-Foods were dated and sealed in the cabinets of the activity kitchenette; and,
-Kitchen staff practiced good hand hygiene and proper glove use while preparing and serving ready-to-eat foods to the residents.
Findings include:
I. Activity kitchenette
A. Professional reference
The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/27/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request.
B. Facility policy
The Food Storage policy, revised March 2022, was provided by the dietary director (DD) on 12/14/23 at 12:40 p.m. and read in pertinent:
All food shall be checked for spoilage. Food and nutrition products brought in by residents and families shall be evaluated by the resident's nurse for compatibility with the resident's therapeutic diet, shall be clearly labeled and dated, and shall be stored in a separate refrigerator using proper sanitation, temperature, light, moisture, ventilation, and security.
C. Observations
On 12/13/23 at 3:22 p.m., the activity refrigerator was observed to contain the following:
-A partially eaten yogurt parfait, with an expiration date of 12/12/23.
-Six cherry tomatoes in a plastic zipped bag with a paper towel inside with no date.
-Two orange slices wrapped in plastic cling wrap and were not dated.
-Two orange slices in a white ramakin dish with plastic cling wrap without a date. The top orange slice had what looked like white mold growing on it.
-An opened 32 ounce (oz) bag of shredded medium cheddar cheese with approximately one cup of cheese remaining and undated.
-A bushel of green grapes in a plastic sandwich bag that was undated. Some of the grapes were brown and mushy and there was moisture or liquid in the bag.
-A bowl of cucumber salad wrapped in plastic wrap with a date that was no longer visible.
-A chunk of unidentifiable meat with a red sauce in a plastic bag that was initialed SS and dated 12/10/23.
-A piece of cake in a small bowl with plastic wrap that was undated.
-A bowl of lima beans that was wrapped in plastic wrap and undated.
-Two whole oranges and two whole cuties (small oranges) in an unlabeled and unsealed grocery bag.
-Three whole apples in an unlabeled and unsealed grocery bag.
-Half of a sliced brown and mushy apple in a sandwich bag that was undated.
-A whole apple tied in a produce bag that was undated and unlabeled.
-Two whole cuties in the produce drawer and were mushy.
-A half-eaten container of spinach and artichoke dip in the refrigerator door that was undated and the name was illegible.
-A small disposable condiment container that was yellow in color labeled SS and dated 11/23/23. When the liquid moved there was a brown sediment on the bottom of the container.
-A stick of butter that was cut with five tablespoons remaining that was unsealed and undated.
-Approximately two tablespoons of butter in a sandwich bag that was undated.
-Approximately eight ounces of shelled walnuts in a gallon-sized plastic bag that was undated and unlabeled.
-A [NAME] jar of homemade apple butter dated 10/2022.
-A [NAME] jar of homemade strawberry jam dated 10/5/23.
-A 16 oz container of buttercream frosting with one-third of the container remaining that was undated.
At 3:30 p.m., the activity freezer was observed to contain the following:
-One white dentistry hot and cold body pack was in the freezer.
-Two purple pearl sports hot and cold body packs were in the freezer.
-A white ramakin dish of what looked like chocolate ice cream was wrapped in plastic wrap and covered in freezer burn (ice crystals) without a name or date.
At 3:40 p.m., the activity kitchenette cabinets were observed to contain the following:
-The edges of three cabinet doors, under the coffee machine, were covered in spilled coffee that was dried up and sticky.
-Opened zero-sugar wafer cookies were in a gallon plastic bag that was undated.
-Hershey's kisses were in a sandwich bag that was undated.
-A box of sugar ice cream cones was opened and undated.
-A bag of opened marshmallows was opened and undated.
-A bag of powdered sugar was opened and undated.
-A packet of ranch dressing powder had the left corner torn off and it was unsealed and undated in the cabinet drawer by the ovens.
-A four-quart Tupperware of what appeared to be sugar was unlabeled and undated and the scoop was inside the Tupperware on top of the item.
-A box of Cinnamon Toast Crunch cereal had the bag opened and shoved back down into the box that was unsealed and undated.
-A box of [NAME] Crisp Cereal was opened and the bag was shoved back down into the box and was unsealed and undated.
-A plastic bag of brown sugar was undated.
-An opened bag of white long-grain rice that was unsealed and undated.
-An opened bag of monk fruit sweetener that was undated.
-An opened bag of flour that had the opening of the bag folded over and was undated.
-An opened bag of almond flour that was undated.
-An opened bag of Splenda sweetener that was undated.
-Two 24 fluid-ounce bottles of vegetable oil were opened and undated.
-An opened bottle of sugar-free syrup was not dated in the cabinet.
-An opened six-ounce bag of pecan chips was folded over itself and was not dated.
-A baker's semi-sweet chocolate bar was opened and partially used had its wrapper folded over the bar and placed back in the box that was unsealed and undated.
-A 64 oz container of old-fashioned oats that was almost empty and undated.
-A 24-pack of two-bite assorted holiday cupcakes with four cupcakes remaining that were on the counter and undated.
D. Staff interview
The DD was interviewed on 12/14/23 at 3:16 p.m. He said he was unaware the activity kitchenette had undated and expired foods but he would ensure they got rid of the improperly sealed or expired food and was going to provide training to the floor staff.
II. Resident water cups
A. Professional reference
According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (effective 1/1/19) page 148, After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining and may not be cloth dried.
B. Observations
On 12/12/23 at 5:27 p.m. 26 normal-sized resident water cups were observed on the cart near the ice machine upside down and still wet. The cups were air drying but still wet on the cart when the cups were filled with ice water and served to the residents.
On 12/13/23 at 9:46 a.m. 36 normal-sized resident water cups were observed on the cart near the ice machine upside down and still wet. The cups were air drying but still wet when the cups were filled with ice water and served to the residents. Two coffee mugs were placed in the activity kitchenette by an unidentified dietary aide (DA) and the mugs were not dried before going into the cabinet.
At 3:45 p.m. 31 normal-sized resident water cups and one large resident water cup were observed on the cart near the ice machine. The cups were upside down and soaking wet. The cups were drying but still wet on the cart right before the cups were filled with ice water and served to the residents.
C. Staff interviews
The dietary manager (DM) was interviewed on 12/14/23 at 3:16 p.m. She said dishes, including cups needed to be completely air-dried before being used again.
The DD was interviewed on 12/14/23 at 3:16 p.m. He said the water cups needed to be completely dried before they went to the floor to be used by the residents. He said he was going to provide training to the staff for air-drying the dishes correctly.
III. Glove use and hand hygiene
A. Professional reference
According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (effective 1/1/19) pages 47 to 48 Food employees shall clean their hands before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands.
According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (effective 1/1/19) page 74 If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.
B. Facility policies
The Infection Prevention and Control for Nutritional Services policy, revised September 2020, was provided by the (DD on 12/14/23 at 12:40 p.m. and read in pertinent:
All equipment shall be thoroughly cleaned after each use. Food handlers are required to perform hand hygiene prior to contact with or the preparation of food items and beverages. Food shall be served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact. Steam tables shall be kept in clean and sanitary condition through regular cleaning. Refrigerators shall be kept in clean and sanitary condition through regular cleaning and shall be used for food and food products only. All foods that have been prepared for service, but not shredded or chopped, shall be covered, dated, and discarded after three days if not used. Food preparation tables, work areas, cooking, serving utensils, and cutting boards shall be washed and sanitized before and after coming in contact with food.
The Hand Hygiene policy, revised October 2020, was provided by the DD on 12/14/23 at 12:40 p.m. and read in pertinent:
Gloves will be used per standard precautions whenever contact with blood, body fluid, or other potentially infectious matter is present, for contact with residents or residents' non-intact skin or as a part of transmission-based precautions and when using chemicals during cleaning activities. Gloves will be changed when moving from a dirty to a clean activity during resident care. Gloves will be removed after completing care for a resident or when leaving the work activity requiring the use of gloves. Gloves will not be worn for more than one resident.
C. Observations
Dinner observations on 12/13/23 at 4:30 p.m.
Cook #1 wore gloves as she prepared plates for the residents. The meal was fried fish and chips (french fries), peas and onions, soup and ambrosia fruit salad. She started with plates that were different textures. She removed the breading from the fish and pulled the fish into smaller pieces with her gloved hands. She then pulled the french fries into smaller pieces. She scooped the peas and onions and covered the plate. After she touched the handles of the serving spoons, the plates, and meal tickets, she continued the same process of pulling the items to make smaller pieces with the same pair of gloves. When another batch of fish was completed in the fryer, cook #1 grabbed the thermometer from the container with a cleaning solution and took the temperature of the fish. She returned the thermometer to the container and continued tearing up fish with the same gloves.
The DA wore gloves as he added the ambrosia fruit salad and drinks to the meal trays. He was observed to answer the phone with his gloves on and after he hung up he did not change his gloves.
Cook #1 changed her gloves after she checked the temperature of the tater tots that came out of the fryer but grabbed another meal ticket with her new gloves and placed the cooked tater tots on the resident's plate.
The DA took off his gloves to answer the kitchen phone but put his dirty gloves on a resident's meal tray. After he hung up the phone, he threw away the gloves but did not clean or replace the meal tray his gloves were on.
Lunch observations on 12/14/23 at 11:40 a.m.
Cook #2 prepared honey-roasted chicken thighs, macaroni and cheese, apple slices and brussel sprouts for lunch. She wore gloves while she prepared the meal. She used a knife to texture the chicken thighs but did not change her gloves after she chopped the meat and used her hands to put the chicken on the resident's plate. She used scissors to cut the brussel sprouts and laid them on the tray line when she was not using them. The tray line was covered in leftover scrambled eggs from breakfast that were not cleaned up after the meal was served. [NAME] #2 touched replaced her gloves twice during the meal, however she failed to perform hand hygiene inbetween changing her gloves and touched ready to eat foods with contaminated gloves.
D. Staff interviews
Cook #1 was interviewed on 12/13/23 at 4:30 p.m. She said she wore gloves while serving meals because it made it easier. She used the gloves to texture foods too because it was faster than a knife or scissors. She said she changed her gloves any time she touched non-food items.
-However, based on observations (listed above) she changed her gloves sometimes after she touched non-food items.
The DD was interviewed on 12/14/23 at 3:16 p.m. He said he had been reminding kitchen staff the gloves were not magic gloves and did not replace hand hygiene.
IV. Facility follow-up
The DD provided a copy of the daily huddles on 12/14/23 at 12:40 p.m. The huddles documented the DD talked about proper glove use with the kitchen staff on 11/20/23, 11/22/23, 11/29/23, 11/30/23, 12/1/23, 12/4/23, 12/5/23, 12/6/23 and 12/13/23.
-Although the huddles were being held, observations above reveal improper glove use (see above).
The DD provided a copy of a food and nutrition training on 12/14/23 at 3:16 p.m. He said he created training to provide the kitchen staff and planned on having everyone train by January 2024. The training included: single-use gloves and bare-hand contact with ready-to-eat food.

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 in one of one dining rooms and two of four resident hallways.
Specifically, the facility failed to ensure:
-Residents were offered hand hygiene prior to meals in the dining room; and,
-Staff performed hand hygiene between resident rooms while passing resident room trays.
Findings include:
I. Facility policy and procedure
The Hand Hygiene policy, revised October 2020, was provided by the interim director of nursing (IDON) on 8/30/22 at 12:01 p.m. read, to reduce the transmission of pathogenic microorganisms and the incidence of healthcare associated infections. The organization endorses the CDC's (the Centers for Disease Control and Prevention) Guidelines for Hand Hygiene in HealthCare Setting recommendations for hand hygiene and artificial nails in employees who have direct contact with patients and residents. All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. Compliance with the proper hand hygiene procedure before and after patient contact is an expectation of all healthcare disciplines. The preferred method of hand hygiene for most patient and resident care settings is use of a waterless alcohol-based hand rub. When hands are visibly soiled, soap and water will be necessary to break down organic matter. Friction generated by hand rubbing and rinsing with running water is necessary to remove organic matter from the hands in some instances.
II. Dining room
1. Observations
Dinner meal service in the resident dining room was observed on 8/22/22 at 4:50 p.m. All residents in the dining room, including those who were dependent on staff for assistance and those who ambulated or moved in wheelchairs independently, were not offered hand hygiene prior to their meals.
Lunch meal service in the resident dining room was observed on 8/24/22 at 11:52 a.m. All residents in the dining room, including those who were dependent on staff for assistance and those who ambulated or moved in wheelchairs independently, were not offered hand hygiene prior to their meals.
2. Interviews
Certified nurse aide (CNA) #6 was interviewed on 8/25/22 at 11:46 a.m. She said she did offer residents hand hygiene and staff should be doing it. She said she was told previously by the facility leadership that it was supposed to be done.
CNA #5 was interviewed on 8/25/22 at 11:50 a.m. She said she was from agency and no staff at the facility had told her specifically the residents were to be offered hand hygiene, but she had been working as a CNA for 20 plus years and she knew residents should be offered hand hygiene. She said she would offer residents warm hand towels at times.
The interim director of nursing (IDON) was interviewed on 8/25/22 at 2:30 p.m. She said staff should be offering residents hand hygiene prior to meals. She said she had already identified this as an ongoing issue in the facility and it's on her list of things to implement and follow up on.
III. Room trays
A. Observations
An unknown dietary service staff member was observed delivering a dinner room tray to resident room [ROOM NUMBER] on 8/22/22 at 5:23 p.m. The staff member was wearing gloves and entered the room to deliver the tray and was observed touching his mask while helping set up the residents tray. The staff member exited the resident room with the same gloves on, no hand hygiene performed or glove change, and went back into the food tray warmer with the same gloves on moving items around. Then he exited the resident wing with the same gloves on into the back.
On 8/24/22 at 12:00 p.m. an unknown dietary service staff member was observed dropping one of her gloves on the floor. She then picked the glove up and grabbed a new glove without removing the other glove and performing hand hygiene. She then went to deliver lunch room trays to resident room [ROOM NUMBER] with the same gloves on and helped set up the residents tray on the residents bedside table moving some of the residents' things around to make room. She did not perform hand hygiene or remove the gloves but exited the room and grabbed another resident tray and delivered it to room [ROOM NUMBER]. The staff member was observed helping set up the resident and touching the resident's water cup. The staff member did not perform hand hygiene or remove their gloves upon exiting the room. She then grabbed some used trays and the food warmer and left the unit.
III. Interviews
Dietary aide #1 was interviewed on 8/25/22 at 8:09 a.m. She said she used the same gloves to deliver food trays to all the residents who eat in their rooms, and when she was done she would remove her gloves in the kitchen and wash her hands there. She said no staff at the facility had really provided her any education on hand hygiene but she had done some online training, but she said she had not finished them.
The interim director of nursing (IDON) was interviewed on 8/25/22 at 2:30 p.m She said glove use was not a substitute for hand hygiene and staff should be performing hand hygiene with alcohol based hand sanitizer going in and out of resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for dementia care out of 15 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being.
Specifically, the facility failed to create and implement a program of activities designed to meet the psychosocial needs of Resident #1, promoting quality of life through dementia care.
I. Resident status
Resident #1, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included dementia, anxiety, cardiomegaly (enlarged heart), osteoarthritis, atrial fibrillation and glaucoma.
The 5/22/22 minimum data set (MDS) assessment identified a brief interview for mental status (BIMS) could not be completed. According to the MDS the resident's cognition was moderately impaired. She exhibited short and long term memory impairment. The MDS also indicated the resident had inattention and disorganized thinking. Resident #1 required extensive physical assistance of one person with eating, bed mobility, dressing, toileting, and personal hygiene. She needed extensive physical assistance from more than two persons for transfers. The resident did not have rejections of care behaviors. The MDS identified the resident had behaviors that did not significantly interfere with her care but significantly interfered with her participation in activities and social interactions with others. According to the MDS, the resident enjoyed music, snacks and staying up past 8:00 p.m.
III. Observations
Resident #1 was observed sleeping in bed on 8/23/22 at 8:43 a.m.
-At 9:53 a.m. she was in the dining room on 8/23/22 at 9:53 a.m. with her eyes closed. The resident was provided assistance by a certified nurse aide (CNA) to eat her breakfast. She calmly accepted the assistance, opening her eyes for short periods at a time and making a small amount of incoherent verbalizations.
-At 10:11 a.m. Resident #1 was assisted to the nurses station and placed in front of poster boards staff education display. She was not offered an activity or provided individual activity supplies that were based on her interest and ability. She was not placed by a staff member or another resident. The resident sat by herself. After a few minutes, the resident began loudly counting numbers. The counting changed to repeatedly yelling out excited.
-At 10:32 a.m. the resident remained at the nursing station talking loudly to herself. She had little staff interaction. Resident #1 started to propel her wheelchair backwards using her feet, almost hitting the counter behind her. A staff member at the nurses assisted the resident away from the counter and placed her in front of the poster board display.
-At 10:40 a.m. a CNA said hello to the resident as she was walking through the nursing station. The resident did not respond to the hello and continued to loudly repeat words.
Between 1:45 p.m. and 4:30 p.m. Resident #1 was observed sleeping in her room.
On 8/24/22 at 4:34 p.m. Resident #1 was observed sitting by herself in the dining room. She reached out her hand to a CNA who was passing by the dining room. The CNA stopped and briefly talked to the resident and offered her a drink.
III. Record review
The July 2022 activity participation record identified Resident #23 did not attend group or structured activities. The activity participation record read the resident received daily one-to-one visits with staff. The resident was marked for daily participation in canteen and staff assist. According to the activity director (AD), the resident was marked canteen daily because she ate her meals in the dining room. The AD said the resident was marked staff assist daily because she received daily activities of daily (ADLs) care.
The August 2022 activity participation record identified the activity staff continued to chart ADLs and meals as her activity on the activity participation record. The August 2022 participation record revealed the resident was not documented to have received one-to-one visits or any other group or individualized activities.
The 8/17/22 activities assessment read Resident #1 did not attend most activities. According to the assessment, the resident was offered only one-on-one visits. The one to ones consisted of comforting her verbally or holding her hand, keeping her comfortable, warm and safe. The activity assessment read Resident #1 had a decrease in her verbal skills, identifying the resident would call out repetitive and varying sentences. The assessment described the resident as sleeping more often and for longer periods of time. The activity assessment read Resident #1 enjoyed music but it had not been an effective intervention to stop the resident ' s calling out. The assessment indicated Resident #1 usually stayed close to the nurses station to be around people. The assessment identified the resident ' s family as living out of state. According to the activity assessment, the resident ' s activity related focuses remained appropriate and current per her care plan.
-The review of Resident #1 ' s care plan identified the resident did not have an activity specific care plan. The resident had some activity interventions that were intermingled in other care plans but most of the care plans interventions were not updated and potentially no longer applied to the resident ' s current needs.
The admission care plan, initiated 8/30/19, read Resident #1 was having adjustment issues related to admission (2019) affecting her safety and social interactions. Interventions to help the resident ' s adjustment issues included:
-Encourage the resident to participate in activities of choice and facilitate attendance as required.
-The resident needs the opportunity to communicate feelings regarding activity attendance. -Encourage the resident to participate in conversation with staff, other residents daily.
-Introduce the resident to residents with similar background, interests and encourage/facilitate interaction.
-Learn to recognize/help the resident to identify the resident's stressors which may be early warning signs of problem behavior. Intervene and remove stressors where possible.
-Provide the resident with as many situations as possible which give the resident control over the resident's environment & care delivery.
-Res (resident) is using Risperidone and Klonopin (antipsychotic, psychotropic medications) to help manage anxiety about placement.
-The care plan did not identify the residents interests or how to adjust the activity program to meet the resident ' s current needs and abilities, capitalizing on strengths while supporting her quality of life through activity interventions.
The dementia care plan, initiated on 8/30/19 read Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions initiated on 8/30/19, included:
-The resident will maintain her current level of cognitive function through the review date. -Communicate with the resident/family/caregivers regarding residents capabilities and needs.
-Use the resident's preferred name.
-Identify themselves at each interaction.
-Face the resident when speaking and make eye contact.
-Reduce any distractions by turning off the television, radio, and closing the door.
-Cue, reorient and supervise as needed.
-Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.
-Monitor/document/report as needed, any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.
-Present just one thought, idea, question or command at a time.
-Reminisce with the resident using photos of family and friends.
-Provide the resident with necessary cues. Staff stop and return to the resident if she became agitated.
According to the care plan, the resident understood consistent, simple, and directive sentences. Techniques that could be potentially used when offering activity interventions.
An intervention was added to the resident ' s care plan on 8/23/22 (during survey), identifying how to redirect the resident ' s behavior. The intervention read Resident #1 often verbalized short sentences repeatedly. According to the care plan, when the resident was loud and expressing in an urgent tone, staff should offer to toilet the resident or offer food and drink.
The dementia care plan identified there were communication techniques staff could use to communicate with the resident.
IV. Staff interview
The activity director (AD) was interviewed on 8/24/22 at 4:34 p.m. The AD said Resident #1 used to be very active in the community. She used to love attending bingo, outings, dogs and music. She still would hum along to the country music we play in the dining room and still liked to go outside and liked to eat ice cream. The AD said they attempted to have her wear headphones but she did not like them. The AD said Resident #1 had cognitively declined and she often did not respond to staff or engage in activities like she used to. The AD said the facility used to have a staff member in the restorative department that did hand therapy and engaged in balloon volley with the residents. She said that staff member was no longer at the facility but they have a new occupational therapy assistant that might be able to do some of those activities with her.
She said activity assistant (AA) #1 provided one-on-ones with her by talking to her and holding her hands which she used to love. The AD said now their goal was to just try to have her clean, safe and comfortable. She said the nurses would often be the ones to visit with the resident and hold her hand. The AD said the activity staff did not have enough time everyday to spend with her. She said one-to-one visits had been the biggest challenge because of time constraints and finding ways to engage lower functioning residents.
The AD said in the past two months, they have not spent much time with Resident #1. She said not having the restorative staff member working the residents was a loss because she was very good with Resident #1 and other residents.
The AD said she (AD) had attended activity workshops and had purchased various lower function activity supplies but has difficulty implementing them successfully.
The AD said she has not been able to engage Resident #1 enough and could continue to try different sensory related activities that could be geared towards her past interests and adapted to meet her needs.
The AD said all residents could benefit from the activity engagement to improve quality of life.
AA #1 was interviewed on 8/25/22 at 8:48 a.m. The AA said he no longer provided Resident #1 one-to-one visits because she does not comprehend. He said Resident #1 received a lot of attention from staff. He said staff tried to hold her hand, talk to her and try to calm her down when she hollers. He said the staff tried to calm her down by holding her hand and talking to her but it only worked for a few moments and then would proceed to hollering again. He said sometimes the resident would respond to the background music in the dining room. He said he had not attempted to use music with her during one-to-ones.
The interim director of nursing (IDON) was interviewed on 8/25/22. She said the facility last had dementia training in May 2022 but the facility could work towards increasing staff dementia education. She said the facility would look at ways to incorporate more non-pharmacological adjuncts with residents with dementia and behaviors.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VII. Resident #14
A. Resident status
Resident #14, age [AGE], was admitted on [DATE]. According to the admission computerized physician orders (CPO), diagnoses included age-related physical debility, repeated falls, and chronic atrial fibrillation.
According to the 6/12/22 MDS assessment, the resident was cognitively impaired with a score of six out of 15 on the brief interview for mental status exam. The resident required extensive one person physical assistance with bed mobility, toileting, and transfers. It was noted the resident did not have any falls since admission.
B. Record review
The admission fall assessment completed on the day of admission 3/8/22 identified the resident was at high risk for falls.
Fall #1
A fall note on 3/28/22 at 6:46 p.m. showed the resident fell. Neurological checks were within normal limits, no injuries were noted, and safety concerns were noted as the resident does not call for help and he is resistant to care assistance.
A nursing note on 3/29/22 at 1:46 p.m. detailed the resident was on alert charting for a fall without injury on 3/28/22. The patient was noted to be very resistant to calling staff for help.
A nursing note on 3/30/22 at 12:35 a.m. showed the resident was using his call light more often but the certified nurse aide (CNA) staff were still finding him attempting to transfer himself if staff did not get to his room quickly.
-There was no description of the fall in the nursing progress notes/fall notes in the electronic medical record (EMR).
A paper tracking record for improving patient safety (TRIPS) report on 3/28/22 at 3:30 p.m. noted the fall as the CNA heard a bang and went to check on the resident. He had lost his balance walking to the bathroom and fell over using his wheelchair as a walker. The resident had no complaints of pain with active range of motion and was assisted off the floor and back to his wheelchair and then to the bathroom. The resident stated he lost his balance. Immediate steps taken to prevent recurrence were to instruct the resident to call for help and increased staff monitoring.
A care plan interventions to prevent falls form was completed on 3/28/22. It was noted the registered nurse clinical consultant (RNCC) reached out to the resident's family to discuss and determine the reasons for falls. Family stated the resident was self conscious with perineal care and rejected care at times.
The resident's care plan was initiated on 3/8/22 and focused on risk for falls. It was reviewed and updated on 3/30/22 and referenced the fall on 3/28/22.
A post fall facility incident report showed the resident stated he lost his balance and his knee went out. The resident was alert and oriented to person, place, time, and situation at the time of the fall. There were no injuries. The resident was noted to prefer to use his wheelchair as a walker.
Fall #2
A paper TRIPS report on 7/4/22 at 9:00 a.m. showed the resident lifted the recliner all the way and slid out on the floor. The resident was fully assessed and assisted back into the recliner. The resident was reeducated on how to properly use the recliner. Immediate steps taken to prevent recurrence were noted as instructing residents to call for assistance and increased staff monitoring. No injuries were noted. The resident was wearing shoes at the time.
A nursing note on 7/5/22 at 12:38 a.m. showed the resident was on alert charting for sliding out of his recliner after raising it all the way up.
A care plan interventions to prevent falls form was completed on 7/4/22. It indicated appropriate footwear and anticipate resident needs.
-The TRIPS report showed the resident was wearing shoes at the time of the fall.
A post-fall incident report dated 7/4/22 at 9:50 a.m. did not reveal any new information about the fall or new interventions.
-There were no new updates, revisions, or review of the resident's care plan after this fall.
Fall #3
A TRIPS report dated 7/26/22 at 5:15 p.m. showed the resident was found on the floor in front of his recliner. The recliner was up as far as it could go and the resident was dumped out of the recliner onto the floor. No injuries were reported.
A nursing incident note on 7/26/22 at 7:08 p.m. detailed the fall as the resident's recliner was in the highest position and the resident reported he was trying to raise his feet and pushed the wrong button causing him to slide out of the chair on the floor. Staff determined to switch out the recliner with one that did not lift him up since he was no longer standing on his own and using a hoyer (mechanical) lift for transfers. A nursing note the next day (7/27/22) confirmed the recliner was replaced the morning after the fall.
A care plan intervention to prevent falls was completed on 7/26/22 and indicated an intervention to change the recliner as the resident had lifted the recliner so high it dumped him on the floor on more than one occasion.
The post-fall investigation dated 7/26/22 showed the staff determined to remove the standing assist recliner from the resident's room.
-The care plan was not updated to specify the resident should not have this type of recliner.
Fall #4
A fall note on 8/12/22 at 5:43 a.m. showed the resident was found on the floor laying on his left side next to the bed. He was assessed by the nurse and no injuries were noted.
The TRIPS form on 8/12/22 showed no injuries and the resident had slipped out of his bed thinking someone came into his room. Immediate steps taken to prevent recurrence were left blank on the form despite the form's instructions requiring at least one intervention be listed.
A care plan intervention to prevent falls was completed on 8/12/22. It was signed by a licensed practical nurse with the resident's name and date of birth , but was left blank in the body of the form.
The facility's post fall incident report showed the resident was found lying on the floor. The resident was noted to be very confused and was currently being treated for a urinary tract infection (UTI) and on antibiotic treatment for it.
A nursing note on 8/12/22 at 4:44 p.m. showed a fall mat was placed bedside while the resident was at rest.
-The fall mat was not documented in the care plan or anywhere else to alert staff of its need.
Fall #5
A fall note on 8/18/22 at 5:36 a.m. showed the resident was found on the floor lying on his left side next to the bed. He was assessed and found to have no injuries and transferred back to bed. The fall mat was noted to not have been in place at the time of the fall. The CNA was noted to have been inserviced on the importance of making sure safety measures were in place before leaving after caring for residents.
The TRIPS report on 8/18/22 showed the resident had stated he was ready to get up for the reason for the fall, and immediate steps taken to prevent recurrence was the CNA was inserviced concerning the use of the fall mat.
A care plan intervention to prevent falls was completed on 8/18/22. It noted for a fall from bed to ensure a mat beside and to assess for need of pain medications. It also noted appropriate footwear.
A post-fall incident report dated 8/18/22 did not reveal any new information related to the fall. However, under the notes section a follow up investigation performed by the IDON on 8/24/22 (six days after fall and during survey) showed the resident was started on a new drug, mirtazapine on 8/15/22, and started to showed increased confusion and had two falls on 8/18/22. The resident was taken to the ED (emergency department) on 8/19/22 and evaluated for altered mental status. He was started on IV (intravenous) antibiotics for three days and mirtazapine was discontinued on 8/18/22. On 8/24/22 it was noted the resident's confusion was continuing to slowly improve.
-No updates or reviews to the care plan were completed.
Fall #6
A TRIPS report dated 8/18/22 (same day as Fall #5) showed the resident experienced an unwitnessed fall. There was no description of the fall noted. The immediate steps taken to prevent recurrence were left blank. It was noted the resident had reopened a scab on his right forearm. No other injuries were noted.
A care plan intervention to prevent falls was completed on 8/19/22. It was noted a wedge pillow was to be added to the residents' interventions.
The post fall incident report dated 8/18/22 at 10:00 p.m. detailed the fall. Another resident used their call light to alert staff when they heard someone yelling for help. The nurse heard Resident #14 yelling for help and found him on the floor laying on his right side next to the bed on the fall mat. The resident had an abrasion to the right wrist and a reopened scab over the area above the right eye. The post fall investigation done by the IDON showed the resident was started on a new drug, mirtazapine on 8/15/22, and started to show increased confusion and had two falls on 8/18/22. The resident was taken to the ED on 8/19/22 and evaluated for altered mental status. He was started on IV antibiotics for three days and mirtazapine was discontinued on 8/18/22. On 8/24/22 it was noted the resident's confusion was continuing to slowly improve (the same information provided for Fall #5).
Nursing notes showed resident was sent to the hospital for evaluation of altered mental status on 8/19/22 at 9:45 a.m. and returned the same day at 2:45 p.m. with an intravenous catheter (IV) and would receive IV antibiotics for three days for a UTI.
-The wedge pillow was not added to the resident's care plan, nor was there a review or any updates to the care plan.
The resident's kardex (CNA staff directive) as of 8/24/22 did not reference a fall mat or wedge pillow for safety.
C. Observations
On 8/23/22 at 10:28 a.m. Resident #14 was observed in bed with no fall mat in place.
D. Interviews
CNA #2 was interviewed on 8/24/22 at 2:40 p.m. She said if she were working with a resident she was unfamiliar with, she would reference the kardex and was where she would find out information about how the resident transfers or safety precautions in place.
CNA #6 was interviewed on 8/25/22 at 9:18 a.m. She said she had not been on shift when Resident #14 had fallen. She said she could reference the care plan to find out fall interventions for residents and she thought she had done that once before for Resident #14. She said she could also ask her nurse about fall interventions and if the nurse did not know they would reference the care plan.
CNA #4 was interviewed on 8/25/22 at 10:52 a.m. She said Resident #14 seemed to be doing better since she first started a few weeks previous and was pretty alert today and able to make his needs known. She said he was rolling out of bed and they were implementing a fall mat next to his bed. She said he would use his call light at times as well, and ensuring that was within reach was important.
The IDON and RNCC were interviewed on 8/25/22 at 4:05 p.m. The RNCC said in the last two or three weeks Resident #14 went from limited assistance and eating independently to now requiring extensive assistance from staff, and she attributed this to an acute infection process related to his UTI. She said he was able to press his call light and make most of his needs known.
The IDON said he was getting less confused and looking better but she was unaware of how alert he was.
The RNCC staff mostly communicated fall interventions and safety awareness in handoff report (staff report about residents from shift to shift), but it should be care planned as well. She said staff did not utilize the kardex as a general rule as it was not maintained.
The IDON said she would be implementing a huddle book that will have all updated information about residents' falls and safety interventions, and it would be available for all staff to review.
They both acknowledged that fall interventions should be updated in the care plan and staff should be utilizing those interventions with residents.
Based on record review, observations and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for four (#1, #14, #15 and #23) residents out of seven residents reviewed for falls and accidents out of 15 sample residents.
Specifically, the facility failed to implement timely interventions and create effective approaches to prevent the recurrence of falls. The facility failed to create and implement a structured fall management program to help mitigate falls and fall recurrences.
Resident #23 fell 12 times from 1/17/22 to 8/15/22. Many of the falls resulted in minor injuries. The resident sustained a fracture on 7/24/22, which was his eleventh fall. There were limited new interventions put in place after each of the falls. Interventions primarily included the staff monitoring and the reminder to the resident to use his call light for assistance. Resident #23 had impaired cognitive status and did not recall his falls as identified in both the 7/24/22 emergency department report and during an 8/24/22 resident interview. Almost all of the resident's falls were related to his need to use the bathroom. The resident would use his walker and wore shoes or non-skid socks to get up and attempt to take himself to and from the bathroom independently. The fall reports completed by the facility identified the resident was often not toileted an hour before the falls or it was unknown if the resident was toileted an hour before the falls. His interventions did not identify the toileting pattern or put specific toileting interventions in place.
Resident #1 fell five times from 3/8/22 to 8/12/22. Most of her falls resulted in minor injuries such as skin tears. On her fourth fall that occurred on 4/17/22, the resident hit her head and face on a dresser and sustained lacerations requiring sutures. The resident had limited interventions put in place after each fall to prevent the recurrence of the falls.
Resident #15 fell out of a bathing chair because the chair track was not secured on 5/23/22. The resident sustained minor injuries. The bathing chair securement/functional operation was not part of routine preventive maintenance checks before or after the incident on 5/23/22 to help ensure the bath chair was safe for use. The facility could not provide evidence that staff were educated on proper use of the bathing chair and what to look for when operating the bathing chair to prevent recurrence. Interviews with certified nurse aides (CNAs) that were responsible for bathing residents identified they were not educated by the facility of the potential malfunctions and actions to take when operating the bathing chair with a resident.
Resident #14 fell six times since his 3/8/22 admission to 8/19/22. Resident #14's last four falls all occurred from 7/4/22 to 8/19/22. The facility failed to update the care plan with new interventions and consistently implement interventions such as a fall mat at the resident's bed side.
Findings include:
I. Facility policy and procedure
The Fall Management Program policy, revised February 2021, was provided by the facility on 8/25/22. According to the Fall Management Program policy, the facility was to incorporate a fall management program. The policy read in pertinent part: The (facility) operates in a culture of safety. Staff, residents and family members are encouraged to report any problems or potential problems. A fall management team is responsible for information gathering and developing a plan of action to deal with falls, near misses and other safety concerns. Any resident at risk for falling is entered into the fall management program.
The policy directed staff to take the follow preventive measures when resident safety concerns were identified:
-Increase toileting frequency of the resident by staff;
-Increase staff supervision and assistance for residents during specific high-risk times;
-Increase monitoring using alarms;
-Provide proper pain management;
-Ensure the resident was using safe footwear;
-Add a fall mat;
-Provide specific behavioral management.
The policy indicated the facility would complete an initial care plan, a TRIPS Report and an incident report, to ensure concerns were adequately addressed after a fall. The policy identified the director of nursing (DON) and the assistant director of nursing (ADON) were responsible for monitoring staff compliance and response to interventions. According to the policy, the interdisciplinary team (IDT) in efforts to prevent fall recurrence, would elevate and intervene as needed with:
-Resident urinary needs that could potentially cause unsafe transfers;
-Adequacy of resident monitoring;
-Bed safety;
-Wheelchair seating;
-Environment; and
-Underlying medical conditions and chronic conditions.
II. Resident #23
A. Resident status
Resident #23, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included cardiomegaly, dementia without behavioral disturbances, fracture of unspecified part of the neck of the left femur.
The 7/31/22 minimum data set (MDS) assessment indicated Resident #23 was moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident required limited assistance of one with bed mobility, dressing, personal hygiene, transfers, locomotion, and toileting. According to the MDS assessment, Resident #23 had two or more falls since his admission. He did not have rejections of care.
B. Resident interview
Resident #23 was interviewed on 8/24/22 at 11:06 a.m. He said he used his call bell regularly for assistance and they said staff answer the call light promptly. He said he did not remember if he had fallen or not. Resident #23 said he did not have current pain.
C. Observations
Resident #23 was sitting up in his lounge chair on 8/22/22 at 4:08 p.m. He said he was not in pain and did not have any concerns. His call light was placed near his reclining chair and was within reach.
Resident #23 was observed in bed on 8/23/22 at 3:04 p.m. The resident was awake and laid flat on his back. Resident #23 said he had some pain in his back. Resident #23 said he was not aware of any current wounds or injuries. He did not have positioning cushions or a wedge between him and the edge of the bed. His bed was not in its lowest position. He did not have a fall mat next to his bed. His call light cord was next to him on his bed but the call button rested on the floor.
Resident #23 was observed sleeping flat on his back in bed on 8/24/22 at 10:24 a.m. The resident had a pillow/wedge positioned on his left side between him and the edge of the bed. His call light was within reach. His bed was not in its lowest position. He did not have a fall mat next to his bed.
-At 11:06 a.m. the resident had no changes to his position and continued to lay flat on his back. The resident still had a pillow/wedge positioned on his left side between him and the edge of the bed. His call light was still within reach. His bed was not in its lowest position. He did not have a fall mat next to his bed.
-At 5:44 p.m. Resident #23 was observed sleeping in his bed. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed.
Resident #23 was observed in bed sleeping on 8/25/22 at 8:51 a.m. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. His bed was set at its lowest position.
-At 10:29 a.m. the resident remained sleeping in bed. There was no change in his position. He did not have a cushion, pillow or wedge between him and the edge of the bed. His call light was in place. His bed was not in its lowest position. He did not have a fall mat next to his bed. His bed was set at its lowest position.
D. Record review
Fall #1
The 1/17/22 incident report read Resident #23 found on the floor next to his recliner at 1:45 p.m The resident stated he tripped coming back from the bathroom. The incident report indicated the fall was unwitnessed and he was ambulating without assistance but used his walker. The resident sustained minor injuries. He had a bruise to left elbow, a skin tear to back right hand, and a reddened area to left iliac crest (top of the pelvis.)
The paper tracking record for improving patient safety (TRIPS) report indicated the resident was wearing shoes at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. He did not place his call light on to request assistance. Report identified the interventions put in place after the fall was:
-The resident was instructed to call for help.
-Increase staff monitoring.
Fall #2
The 1/19/22 TRIPS report read Resident #23 was found on his bedroom floor at 9:30 p.m. He wore non-skid socks at the time of the fall and used his walker. The fall was not witnessed. According to the report, it was unknown if the resident was toileted within an hour of the fall. He did not place his call light on to request for assistance. The resident sustained minor injuries of two skin tears. The report identified the intervention put in place after the fall was:
-The resident was instructed to call for help.
An incident report for the 1/19/22 fall was not provided.
Fall #3
The 1/23/22 incident report read Resident #23 found on his bedroom floor at 6:25 p.m. Resident #23 said he was attempting to move over his bedside table from in front of him so he could go to the bathroom. The incident report indicated the fall was unwitnessed and he was ambulating without assistance but used his walker. The resident did not sustain injuries. According to the incident report, the resident agreed to use his call light. The call was provided and secured to his blanket. The incident report indicated a sign was placed at the resident's bedside, reminding him to call for staff assistance before ambulating.
The 1/23/22 TRIPS report indicated the resident was wearing non-skid socks at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for help but the report did not clarify if he did not wait for staff assistance after placing his call light on. He did not place his call light on to request for assistance.The report identified the intervention put in place after the was:
-The resident was instructed to call for help.
Fall #4
The 1/29/22 incident report read Resident #23 was found sitting on the floor in front of his reclining chair at 5:15 p.m. Resident #23 said he was attempting to move his bedside table from in front of him so he could go to the bathroom. The incident report indicated the fall was unwitnessed. The resident did not sustain injuries.
The 1/29/22 TRIPS report indicated the resident was wearing shoes at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the interventions put in place after the fall were:
-The resident was instructed to call for help.
-Use his walker.
The care plan for falls, last revised on 2/23/22, read Resident #23 was at high risk for falls. Interventions initiated on 8/7/19 were:
-Ensure the resident's call light was in reach.
-Provide prompt response to all requests of assistance.
-Follow the fall protocol.
-The resident uses a walker to ambulate.
Fall #5
The 3/2/22 incident report read Resident #23 was found sitting on his floor at 6:10 a.m. According to the incident report he tripped over his feet while walking to his recliner. The resident sustained a skin tear to his right elbow and skin tear to the back of his right hand as a result of the unwitnessed fall. The resident complained of chest pain. X-rays were conducted and there were no fractures found to his chest. He wore non-skid socks and used his walker at the time of the fall.
The 3/2/22 TRIPS report indicated the resident was going either to or from the bathroom at the time of the fall which contradicted the incident report. He wore non-skid socks and used his walker at the time of the fall. According to the report, it was unknown if the resident was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help.The report identified the interventions put in place after the fall were:
-The resident was instructed to call for help.
-Increase staff monitoring.
Fall #6
The 3/14/22 incident report read Resident #23 was found on the floor near his bed. His shoes were on and his walker was next to him. He was found laying on his right side with a blanket under his head. He denied pain, however he had an abrasion to his right shoulder and a bruise to his right thigh as a result of his unwitnessed fall. The resident stated that he came back from the bathroom and his knees went out from him.
The 3/14/22 TRIPS report identified the resident was found on the floor at 9:15 p.m. The TRIPS indicated the resident wore shoes and used his walker at the time of the fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the intervention put in place after the fall was:
-The resident was instructed to call for help.
Fall #7
The 4/5/22 incident report read Resident #23 was found on the floor near his bed at 8:00 a.m. The resident said he lost his balance while he tried to get back in bed after using the bathroom. According to the report, Resident #23 was not toileted within an hour of the fall. The resident did not sustain injuries as a result of his unwitnessed fall.
The 4/5/22 TRIPS report indicated the resident wore non-skid socks and used his walker at the time of the fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident did not use his call light for help. The report identified the interventions put in place after the fall were:
-The resident was instructed to call for help.
-Increase staff monitoring.
Fall #8
The 4/30/22 incident report read Resident #23 was found on his bedroom floor. The resident said he lost his balance when he tried to get up from the toilet. He then crawled into his bedroom. The resident sustained a skin tear to his right elbow and a skin tear to his right upper arm as a result of his unwitnessed fall. The identified intervention was to remove a cane from his room and place the call light within his reach.
The 4/30/22 TRIPS report identified the resident fell at 12:45 p.m. The TRIPS report read he wore non-skid socks and used a cane at the time of the fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for assistance. The report did not clarify he used his call light before or after his fall, to call for assistance. The report did not identify additional interventions.
The fall care plan intervention initiated on 6/2/22, after the resident had eight falls in 2022, read:
-Ensure the resident was wearing appropriate footwear when ambulating. According to the intervention, the resident wears black tennis shoes.
The 6/22/22 minutes for the all-staff meeting were provided by the interim director of nursing (IDON) on 8/24/22 at 5:27 p.m. According to the minutes, staff were informed that they needed to be aware of the various interventions that have been established for the fall risk residents. The minutes read a fall subcommittee would be implemented in the near future to look carefully at the residents who were at risk for falls and had history of falls. The subcommittee would review and brainstorm to see if new interventions needed to be incorporated. The minutes identified that the former director of nursing would ask staff for their input on resident falls.
Fall #9
The 6/23/22 incident report read Resident #23 was found on his bedroom floor. He was trying to go to the bathroom. The resident did not sustain injuries from his unwitnessed fall.
The 6/23/22 TRIPS report identified the resident fell at 2:30 p.m. The TRIPS report read he wore shoes at the time of his fall. According to the report, Resident #23 was not toileted within an hour of the fall. The TRIPS report identified the resident did use his call light for assistance. The report did not clarify he used his call light before or after his fall, to call for assistance. The report did not identify interventions put in place after the fall.
Fall #10
The 7/8/22 incident report read Resident #23 was found on his bedroom floor laying supine in front of his bed. The call light was activated after he fell. He said he was coming from the bathroom and slipped. He was trying to go to the bathroom. The resident sustained a skin tear to his left elbow from his unwitnessed fall. According to the incident report, interventions included increased staff monitoring and education to use the call light when needing assistance and ambulating.
The 7/8/22 TRIPS report identified the resident fell at 1:30 p.m. The TRIPS report read he wore shoes and used a walker at the time of his fall. According to the report, it was unknown if Resident #23 was toileted within an hour of the fall. The TRIPS report indicated an additional intervention of a physical and occupational therapy referral.
The 7/8/22 Morse fall scale for Resident #23 was conducted. According to the Morse scale scoring key, a resident with a score of 45 or greater was at high risk for falling. Resident #23 was assessed to have a high fall risk score of 90.
Fall #11
The 7/24/22 incident report read Resident #23 was found on his bedroom floor laying on his right side at 10:43 a.m. He said he was heading back from the bathroom when his feet came out from under him. The resident sustained a skin tear to his left hand and a bruise to his right elbow from his unwitnessed fall. The resident was able to move all of his extremities and denied pain. The incident report noted no other injuries were observed. The resident was assisted off the floor and placed in his recliner. The incident report indicated new orders for a chair alarm were put in place due to his frequent falls and refusal to use his call light.
The 7/24/22 TRIPS report identified the resident fell at 1:30 p.m. The TRIPS report his feet were bare other than TED hose (compression stockings) but he used his walker at the time of his fall. According to the report, Resident #23 was toileted within an hour of the fall. The TRIPS report did not indicate additional interventions were put in place other than the chair alarm.
The 7/24/22 at 3:00 p.m. hospital emergency department (ED) report revealed Resident #23 was brought to the emergency room related to groin pain. According to the ED report, the resident fell the morning on 7/24/22, was assessed by the facility staff who identified skin tears but otherwise seemed fine. The ER report read the afternoon of 7/24/22, the resident started to complain of right side groin pain and was limping so he was brought to the ER for an evaluation. The ED report indicated the resident denied pain at the time of the ER evaluation and did not recall the fall.
The 7/24/22 x-ray findings were provided by the facility on 8/25/22. The resident had images of his bilateral hips. The images did not reveal acute fr[TRUNCATED]

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to have an updated comprehensive care plan for one (#14) out of 15 sample residents.
Specifically, the facility failed to implement nutrition care planning for a resident identified for weight loss and nutrition at risk for Resident #14.
Findings include:
I. Facility policy and procedure
The Care Plans policy, revised February 2021, provided by the interim director of nursing (IDON) on 8/29/22 at 2:00 p.m. read, To provide a multidisciplinary plan of care for each resident admitted to the [NAME] Wing. Provide guidelines for review of care plans. Care plan will provide guidelines for persons involved in residents cares as to preferences and needs. Upon admission to the [NAME] Wing an admission evaluation and interim care plan will be completed using input from resident and family if available and resident allows participation of family in interview. Care plan will then be developed within two weeks of admission and will be reviewed a minimal of quarterly thereafter with input collected from resident, family if appropriate, physician, nursing, dietary, activities, social services, and any other professionals involved in resident's care.
Procedure:
A. Upon admission, a basic care plan will be implemented by the admitting RN (registered nurse)
B. Administrative Assistant will place MDS (minimu data set assessment) papers out for staff. Activity Director will conduct the activity assessment and the Social Services Coordinator will conduct the BIMS (brief interview for mental status) and the PHQ-9 (mood interview) found in the RAI (resident assessment instrument) manual. Nursing staff will conduct the pain assessment provided as part of the MDS paperwork, after the seven day evaluation period the resident care meeting will occur with the multidisciplinary team, resident and family.
C. Further information collected through interaction with the resident, care conference and MDS, will be used to create a more comprehensive plan of care, within two weeks of admission.
D. Review of care plan will occur by a nurse at a minimum of quarterly and more often if changes to care needs arise.
E. Obtain input from all areas of residents' needs/ cares. This may include not only services provided at the [NAME] Wing but input from other areas such as PT (physical therapy), OT (occupational therapy), and other therapies as appropriate.
II. Resident #14
A. Resident status
Resident #14, age [AGE], was admitted on [DATE]. According to the admission computerized physician orders (CPO) diagnoses included age-related physical debility, repeated falls and chronic atrial fibrillation.
According to the 6/12/22 minimum data set (MDS) the resident was cognitively impaired with a score of six out of 15 on the brief interview for mental status exam. The resident was not identified for weight loss.
III. Record review
According to the resident's weight tracking, the resident was identified by the electronic medical record (EMR) as having significant weight loss of five percent over 30 days on 7/26/22.
The July 2022 nutrition at risk notes provided by the facility showed the resident was identified by the facility for weight loss and nutrition at risk. A suggestion was to implement a magic cup trial.
A nutrition note on 7/27/22 at 1:53 p.m. read, Dietician communicated to RN (registered nurse) that resident has had weight loss. RN spoke with resident and he is open to daily Ensure; he likes strawberry. Order obtained for daily ensure - started today.
Ensure daily for weight loss was added to the resident CPO on 7/27/22.
-There was no resident-specific care plan for nutrition at risk or weight loss noted for the resident until 8/25/22 (during the survey).
IV. Interviews
The IDON and registered nurse clinical consultant (RNCC) were interviewed on 8/25/22 at 4:05 p.m. The IDON said for the last three months the RNCC was maintaining the care plans. She would review them and update them quarterly with the MDS and any significant changes, and the previous director (no longer employed at the facility) was supposed to update the care plans for anything acute in between the quarterly MDS assessments. The IDON said nutrition and weight loss should be care planned for and they had a new assistant director of nursing starting on 9/12/22 and that person would be taking over, maintaining, and improving the residents care plan process.
V. Facility follow-up
The resident's care plan for nutrition, initiated 8/25/22 (during the survey), focused, the resident has a nutrition problem related to a decline in function and lack of appetite. The goal was the resident would maintain adequate nutritional status. Interventions included:
-Invite the resident to activities that promote additional intake,
-Monitor for pocketing, choking, coughing, drooling, and holding food in mouth,
-Monitor and report to MD (medical doctor) as needed for signs or symptoms of malnutrition, emaciation, muscle wasting, and significant weight loss,
-Obtain and monitor labs/diagnostic work as ordered and report results to MD. Follow up as needed,
-Occupation therapy to screen for adaptive feeding equipment,
-Provide ensure and serve as ordered,
-Provide and serve diet as ordered. Residents occasionally needs staff assistance; and
-Registered dietician to evaluate and make diet change recommendations as needed.