**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of three residents was provided the care and services necessary to ensure a safe discharge from the facility to the community out of three sample residents.Specifically, the facility failed to:-Allow Resident #1 to return to the facility after an unplanned discharge to the hospital;-Provide documentation from Resident #1's physician, including the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #1 for readmission after he was stabilized at the hospital and ready to return to the facility. Findings include:I. Facility policy and procedureThe Discharge Notice Requirements policy and procedure, revised 4/28/25, was provided by the director of nursing (DON) on 8/20/25 at 1:40 p.m. It read in pertinent part, The facility must document in the resident's record the basis for the discharge. If the basis of the discharge is the facility's inability to meet the resident's needs, the resident's record must show that the facility based this determination on the resident's assessment and status at the time of the proposed return to the facility, not on the resident's needs at the time when he/she was transferred to an acute care facility; and how the resident's needs are distinctly different from other residents' needs. More specifically, the facility can not discharge a resident based on the claim that the facility cannot meet the resident's needs if there are other residents with similar needs whose needs are being met by the facility. If the basis of the discharge is because the facility can not meet the resident's needs, the resident's behavior creates a danger to individuals in the facility, the resident's physician must document the basis for the discharge. The physicians' documentation must show the specific needs the facility can not meet; the facility's efforts to meet the resident's needs; and how and why the discharge location is better equipped to meet the resident's needs. The resident's record should show the receiving location's willingness and capacity to care for the resident.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 7/23/25. According to the July 2025 computerized physician order (CPO), diagnoses included dementia with mood disturbances, Parkinson's disease, Alzheimer's disease and adjustment disorder with anxiety.The 6/30/25 minimum data set (MDS) assessment revealed Resident #1 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment indicated Resident #1 had behavioral symptoms that were directed toward others. B. Record reviewAn elopement assessment, dated 3/27/25, revealed the resident had an elopement risk of six, which indicated the resident was at risk for elopement.A progress note, dated 7/20/25, revealed that on 7/19/25 at approximately 1:18 p.m. the medical director (MD) declined readmission of Resident #1 from the emergency department. The involuntary discharge was necessary to protect the welfare of other residents. The note documented Resident #1 had displayed increasingly unpredictable behaviors over the past few weeks. The behaviors included attempting to have sex with another dementia resident who was unable to consent, eloping from the facility and physically striking a certified nurse aide (CNA). Resident #1 was previously evaluated and interventions such as a one-to-one sitter and starting Depakote (anti-seizure medication used for behaviors) were implemented. The MD documented in her medical opinion, Resident #1 required inpatient geriatric psychiatric treatment until his behaviors stabilized. The MD documented it was unsafe to have Resident #1 in proximity of the other vulnerable residents at the facility and Resident #1 was involuntarily discharged .-There was no documentation to indicate the facility reassessed the resident after he was stabilized at the hospital.-The facility failed to document the needs the receiving facility was going to provide for the resident that the current facility was unable to provide.-Review of Resident #1's electronic medical record (EMR) did not reveal the facility completed a discharge summary for Resident #1.III. Resident #1's representative interviewThe resident's representative was interviewed on 8/20/25 at 2:10 p.m. The representative said the resident was admitted to the hospital because the facility refused to readmit the resident once he was medically cleared. The representative said the facility did not help the resident find an alternate facility. The representative felt the resident was abandoned by the facility. The representative said the resident had no behaviors at the hospital.IV. InterviewsThe case manager from the hospital was interviewed on 8/20/25 at 2:00 p.m. The case manager said the facility left Resident #1 in the hospital's care and did not help the resident find a different facility to be discharged to. She said no one from the facility reassessed Resident #1 when he was medically cleared and there was no reason for the hospital to keep the resident. She said she felt the resident was dumped at the hospital. She said Resident #1 displayed no behaviors of any type while he was in the hospital, so she was confused as to why the facility refused to readmit the resident.The DON was interviewed on 8/20/25 at 2:30 p.m. The DON said when Resident #1 was first admitted to the facility, the family said he was able to go on walks outside the facility by himself. She said during the resident's admission, she found out the resident fell outside by himself a day later when he complained of shoulder pain and explained he fell the day before. The DON said the resident was located a mile away from the facility and was hitchhiking to another state to see his ex-wife. She said there was a second incident where the resident was found a half mile away from the facility and he told the staff he wanted to go to another state. She said the resident was found naked in a female resident's room and she was unable to consent. The DON said the resident also struck a CNA in the face. She said no one from the facility reassessed the resident and she was not aware someone needed to reassess the resident when he was medically cleared prior to discharging him. The DON said the receiving facility for Resident #1 was the hospital. She said she was not aware that the hospital was not an acceptable discharge location.

**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 physical restraints for one (#1) of three residents out of five sample residents. Specifically the facility failed to: -Ensure Resident #1 had physician's orders for the placement of a wanderguard; and, -Obtain consent to move Resident #1 to the secured unit, which prevented the resident from activities that met his interests. Findings include: I. Facility policy and procedure The Physical Restraint policy, revised 10/14/22, was provided by the director of nursing (DON) on 6/16/25 at 4:05 p.m. The policy read in pertinent part, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the residence body that the individual cannot remove easily and which restrict freedom of movement or normal access to one's body. It is the policy of the facility to use restraints only under the following conditions; as a last resort after a trial period where less restrictive measures have been undertaken and proven unsuccessful; with a physician's order and only when necessary to prevent injury to the resident or others, based on a physical, functional, emotional, and medication assessment; with the consent of the resident and his or her representative; when benefits of the restraint outweigh the risks. The Wandering Resident policy, revised 3/10/25, was provided by the DON on 6/16/25 at 4:05 p.m. The policy read in pertinent part, The facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan which addresses the unique factors contributing to their wandering behavior or elopement risk. Residents with a signaling device on will be escorted by staff, volunteers or another responsible person when they leave their unit/neighborhood. The Dementia Care policy, revised 3/10/25, was provided by the DON on 6/16/25 at 4:05 p.m. The policy read in pertinent part, A systematic process will be used including input from interdisciplinary team (IDT) members to provide holistic care for residents with dementia. Gather information on resident's past and current physical, functional and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related to complications and functional impairments. Monitor for safety including wandering and need for electronic monitoring. Create individualized approaches in the care plan with measurable goals and specific interventions for management of behavioral symptoms/ behavioral expressions. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease without dyskinesia (movement disorder), without mention of fluctuations, unspecified dementia, specified severity, with mood disturbance and other behavioral disturbances, Alzheimer's disease, anxiety disorder, abnormal involuntary movements, tremors, abnormalities of the gait and mobility, difficulty in walking and generalized muscle weakness. The 3/31/25 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He did not use a mobility device for ambulation but needed supervision with most of his activities of living (ADL). The MDS assessment documented Resident #1 did not have inattention or disorganized thinking. The MDS assessment indicated it was very important to Resident #1 to go outside to get fresh air and participate in his favorite activities was very important to him. According to the MDS assessment Resident #1 did not have wandering behavior, a physical restraint or alarm. B. Resident representative interview Resident #1's representative was interviewed on 6/17/25 at 10:34 a.m. The representative said he Resident #1 left the facility to hitch hike out of state to see his spouse. She said the facility placed a wanderguard on him and had him go to the memory care secured unit during the day. She said he was not assessed for the memory care unit. She said he was now permanently on the secured unit. The representative said she and the resident's power of attorney (POA) wanted Resident #1 to have the least restrictive environment possible. She said he was used to being very independent when he was at home. The representative said she did not think the facility was providing personalized activities for Resident #1. She said walking was very important to him but the staff was not taking him on walks routinely. She said the staff were letting the resident go on the patio and not taking him for walks. Resident #1's POA was interviewed on 6/17/25 at 11:00 a.m. The POA said after Resident #1 tried to hitch-hike, the facility placed a wanderguard on Resident #1 and put him in the secured unit during the day. She said she did not agree to having Resident #1 on the secured unit and away from him from his room and personal items during the day. She said his communication skills were impaired due to aphasia (difficulty with language communication) and she was worried that he would not be able to fully communicate when he would want to go back to his room outside of the secured unit. She said the facility said they were going to have him go to the secure unit during the day without her consent. The POA said she was notified on the evening of 4/12/25 that the facility put a wanderguard on Resident #1 after his elopement on 4/12/25. She said she felt the facility should have educated him and assessed him before using a wanderguard. The POA said walks were very important to Resident #1. She said when he walked, he still felt some independence. She said he loved doing anything outside. C. Observations Resident #1 was in the secured memory care unit on 6/16/25, between 5:30 p.m. and 6:00 p.m., watching television. On 6/17/25 at 10:05 a.m. Resident #1 was in a lounge chair in the day room sleeping on the secured unit. At 11:35 a.m. he was independently drawing in the day room while a certified nurse aide (CNA) visited with him on the secured unit. At 11:58 a.m. the CNA read the newspaper to him on the secured unit. At 1:15 p.m. the resident was in his room resting on the secured unit. D. Record review The wander/elopement risk care plan, initiated 4/14/25, identified Resident #1 was at risk for elopement due to history of leaving the facility to travel out of state. The 4/17/25 interventions directed staff to monitor his calls with his spouse that could trigger his behaviors to travel out of state and ensure the resident's wanderguard was in place and functioning appropriately. Review of nursing progress notes identified Resident #1 eloped from the facility on 4/12/25. The facility placed a wanderguard on the resident and placed him on the secured unit during the day for memory care programming. The April 2025 CPO for a wanderguard was provided by the DON on 6/18/25 at 5:37 p.m. a A physician's order directed staff to place a wanderguard on Resident #1 one time between 6:30 p.m. and 10:00 p.m., ordered and discontinued on 4/12/25. -The April 2025 CPO identified the resident did not have physician's orders for the wanderguard after 4/12/25, however, the resident wore a wanderguard until he was placed on the memory care unit full time on 6/9/25 (see interviews below). The June 2025 CPO revealed a physician's order that directed staff to verify placement of the wanderguard device on Resident #1 every shift and check the device daily to confirm that it was working, ordered on 6/9/25 and discontinued on 6/17/25 (during the survey). -The 6/9/25 wanderguard physician's order for verification of the placement and confirmation that it was operational were added to the physician's orders after the resident was moved to the secured memory care unit and after the wanderguard was taken off of the resident (see interviews below). The June 2025 medication administration record (MAR) documented on 6/9/25 through the day shift on 6/17/25, the staff checked Resident #1's wanderguard daily to confirm that it was in working order and verify placement of the wanderguard device on the resident every shift. -However, according to the DON, the resident did not have a wanderguard after he was moved to the secured memory care unit on 6/9/25 (see interview below). The 3/27/25 activity assessment documented Resident #1's preferred program style was one-to-one, independent leisure and small groups. The assessment identified his past interests as walking to the store, biking, fishing, rafting, watching specific television shows and going to church. According to the activity assessment, the resident felt health, walks and church provided him life enjoyment, a meaningful daily routine and were very important to him. -The March 2025 activity participation record did not identify Resident #1 was offered or participated in group or individual leisure activities from the time of his admission on [DATE] to 3/31/25. The 4/11/25 progress note documented Resident #1 went for a walk on 4/11/25 and fell outside. According to the note, the resident was reminded to just walk around the facility. Review of the April 2025 progress notes identified Resident #1 eloped from the facility on 4/12/25. Review of participation records and progress notes between the time he admitted (3/26/25) and the time he eloped on 4/12/25, revealed he went on one walk and attended one activity. The April 2025 activity participation record documented Resident #1 was offered and participated in bingo on 4/2/25 prior to his 4/12/25 elopement. The participation record identified the resident was offered and participated in a walk and live music on 4/16/25, a drumming activity on 4/22/25, an afternoon stroll on 4/23/25 and watched a documentary and went on a walk on 4/28/25. The April 2025 participation record indicated the resident was offered and participated in seven activities in April 2025, which included three walks for the month, after he eloped. The May 2025 activity participation record documented Resident #1 was offered and participated in one or more walks on 5/6/25, 5/13/25, 5/16/25, 5/21/25, 5/22/25, 5/23/25, 5/29/25 and 5/31/25. The participation record identified the resident had eight days out 31 days that he received a walk. The participation recorded identified the resident was offered seven bingo or card games, one social on the patio and live music twice. Review of the May 2025 progress notes identified the resident wanted more opportunities for walks outside and attempted to take himself outside. The 5/17/25 nursing note documented Resident #1 triggered the wanderguard alarm when he went out the front door. The note documented that the resident said he only wanted to walk outside. -The note did not identify that the resident was provided a walk outside. The 5/21/25 nursing note documented Resident #1 triggered the wanderguard when he attempted to get on the facility elevator. The nurse reminded Resident #1 that he needed supervision to go for a walk off the unit. According to the note, the resident was told no one was available to take him on a walk. The resident then returned to his room. The 5/26/25 nursing note documented Resident #1 attempted to walk out of the facility. The note identified the resident said he just wanted to have a walk outside. According to the note, the nurse and three other staff members convinced Resident #1 to go to the memory care unit. The resident went to the memory care unit for 30 minutes, watched television and had a snack. The resident then said he wanted to go back to his room to sleep. -The note did not identify the resident was later provided a walk outside. The physician communication log identified Resident #1 had a written physician's order for placement on the secured unit on 6/9/25. The 6/10/25 activity progress note identified the activity director (AD) walked with Resident #1 outside for 30 minutes on 6/10/25. According to the note, the resident enjoyed the walk and the company. The 6/11/25 activity progress note identified Resident #1 received two walks on 6/11/25 and watered the flowers. According to the note, the resident was in a good mood and enjoyed the walks. III. Staff interviews The social services director (SSD) was interviewed on 6/17/25 at 12:20 p.m. The SSD said the nursing staff requested the physician's order for a wanderguard. He said the wanderguard was usually tried as an intervention before the resident was placed on the secured memory unit. The SSD said Resident #1 had a wanderguard and the nursing staff would try to have him go to the memory care unit for activities. He said if Resident #1 wanted to go back to his room on the non-secured side of the facility, the staff would assist him back to his room. The DON was interviewed on 6/17/25 at 12:33 p.m. The DON said a wanderguard would be implemented on a resident if the resident attempted to leave the facility and would not be able to find their way back. She said if the facility felt a resident needed a wanderguard, the facility would notify the family and the physician and get orders. The DON said the staff would make sure the wanderguard was in place and in good working order. She said Resident #1 no longer had a wanderguard on. The DON said Resident #1 was allowed to go outside of the facility on walks independently and with staff. The DON said he was just asked to let staff know when he was leaving. She said the resident did not have any restrictions before he attempted to hitchhike out of state on 4/12/25. The DON said after the elopement, the staff was very concerned about his safety. The DON said a wanderguard was placed on the resident and he was placed on the memory care unit during the day and offered supervised walks. The DON said the resident was brought to the secured memory care unit during the day and ultimately moved to the secured due to his wander risk and benefit for more activity programming. The activity assistant (AA) was interviewed on 6/17/25 at 3:22 p.m. The AA said Resident #1 liked games like bingo, cards and balloon bat and going on walks. She said the facility had religious services but not the denomination he preferred. She said the facility might be able to find someone to minister to him from his church. The DON was interviewed again on 6/18/25 at 1:18 p.m. The DON said sometimes a wanderguard would be placed on a resident in an emergency without a physician's order but the facility would then get an order. The DON was interviewed a third time on 6/18/25 at 3:46 p.m. The DON said a wanderguard was placed on Resident #1 after he eloped (on 4/12/25). She said he was provided day programming on the secured memory care unit from 4/13/25 to 5/30/25. The DON said starting on 5/30/25, he remained on the non-secured side of the facility. She said he continued to wear his wanderguard until he was moved to the secure memory care unit full time on 6/9/25. She said when a resident moved to the secured unit, the wanderguard would come off. The DON reviewed the wanderguard orders and said she did not know why Resident #1 had wanderguards orders for just one day on 4/12/25 or had orders to verify placement of the wanderguard when he was placed on the secured unit on 6/9/25. She said she would have to follow up. The AD was interviewed on 6/18/25 at 4:25 p.m. The AD said there was limited record of Resident #1's activity participation and walks in March 2025, April 2025 and May 2025. She said he may have engaged in and been offered more walks and activities but she could not say for sure because it was not documented. The AD said she knew he walked and watched television before he eloped on 4/12/25 but she did not know how often. The DON was interviewed a fourth time on 6/18/25 at 5:37 p.m. The DON said the nurse manager entered the wanderguard physician's orders incorrectly and it should not have been just for one day. She said the nurse manager must have misunderstood what the physician ordered. The DON said Resident #1 should have had active orders for the duration of use. The DON said the nurse manager should have additionally entered in the orders to verify placement and working condition of the wanderguard. She said the nurse manager must have not understood the full process of putting in a wanderguard order. The DON said she would provide education to the nurse manager. The DON said on 6/9/25 she noticed Resident #1 did not have complete orders for the wanderguard so she added the 6/9/25 physician's orders and discontinued the orders on 6/17/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure one (#23) of three residents reviewed for abuse out of 23 sample residents was kept free from abuse. Specifically, the facility failed to: -Prevent Resident #22 from slapping Resident #23; -Thoroughly investigate a resident to resident altercation between Resident #22 and Resident #23; and, -Put interventions in place to prevent future resident to resident altercations between Resident #22 and Resident #23. Findings include: I. Facility policy and procedure The Vulnerable Adult policy, reviewed 10/20/23, was provided by the nursing home administrator (NHA) at 10:15 a.m. The policy documented in pertinent part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. This includes but is not limited to freedom from corporal punishment, and voluntary seclusion in any other physical or chemical restraint not required to treat resident symptoms. Physical abuse includes hitting, slapping, pinching, and kicking. Resident to resident altercations must be reported in accordance with regulations including willful actions resulting in physical injury, mental anguish, or pain. All residents of the facility are considered vulnerable adults. Therefore, the interdisciplinary team evaluates the vulnerability of each resident and develops interventions as part of the resident plan of care. The interdisciplinary team assesses, develops care plans, and monitors residents with needs and behaviors that might lead to abuse, conflict, or neglect, exploitation of residents. These residents' needs and behaviors may include communication disorders, those that require heavy nursing care and or totally dependent, a history of aggressive behavior, behaviors such as entering other residents' rooms, and/or self-injurious behavior. The facility will initiate an investigation immediately upon identification of possible abuse, neglect, exploitation of residents, mistreatment, injuries of unknown source, resident to resident verbal or physical altercations, and or misappropriation of property. All reports of suspected/alleged resident abuse, neglect, exploitation of residents, mistreatment, injuries of unknown source and/or misappropriation of resident property shall be properly and thoroughly investigated. All interviews related to the investigation shall be conducted in private. The policy identified the procedure to investigate all suspected and allegations of resident abuse as the following: -Collect data and document the investigation findings; -Conduct a physical examination of the resident and the environment; -Review documentation and the resident medical record for events leading up to the incident; -Interview the person(s) reporting the incident; -Interview the alleged victim; -Interview any potential witnesses to the incident; -Interview the alleged perpetrator; -Interview other residents to whom the alleged perpetrator provides care or services; and, -Review the completed documentation. According to the policy, if witness reports were obtained, witnesses should sign and date such reports. Staff should analyze the incident/occurrence to determine what changes were needed, if any, to the policies and procedures to prevent further occurrences. II. Resident to resident altercation between Resident #22 and Resident #23 on 9/9/24 The NHA provided the file containing the facility' s abuse investigation of the 9/9/24 incident between Resident #22 and Resident #23 on 9/17/24 at 5:41 p.m. The investigation file included: -The progress notes for both residents on the incident; -Care plans for both residents; -A summary of the situation; -A witness statement from certified nurse aide (CNA) #3; and, -An abuse reporting flow sheet. The 9/9/24 nursing progress note for Resident #22 documented in pertinent part, This RN (registered nurse) was called to the dining room by CNA (certified nurse aide) stating that another resident got too close for this resident and this resident slapped the other resident (Resident #23) on the hand. This RN did have a conversation with this resident to tell her it was not okay to be mean to others just for being too close to them. If she is not comfortable with others that are close to her, then she needs to ask staff to move other residents away from her. It is determined that this resident due to her dementia, lacked willful intent and had no intention of causing harm. This RN will add the behavior to her care plan so we can continue to monitor. The 9/9/24 nursing progress note for Resident #23 documented in pertinent part, This RN was called out to the dining room by CNA staff stating that another resident (Resident #22) slapped at this resident' s hand for being too close. Resident (#23) was assessed, but no injury or c/o (complaints of) pain to the area are noted. This resident is very active all over the MC (memory care) unit, and does tend to upset others by touching them or in this instance, by being too close to them. This incident lacked willful intent, as the other resident had no intention of hurting this resident. Will continue to monitor and report to the next shift to monitor for any bruising. No further issues or concerns at this time. The 9/9/24 at 4:00 p.m. summary of the situation documented Resident #23 was standing near and possibly touching something of Resident #22' s. CNA #3 saw Resident #22 slap Resident #23' s hand. The CNA went over to the resident and guided Resident #23 away from Resident #22. The CNA then told Resident #22 not to hit the other residents. The unit manager was also asked to speak with Resident #22. The summary read the behavior was known and care planned for Resident #22 and Resident #23. Resident #23 repeatedly picked up items. The summary documented due to the known behaviors of both residents, the staff monitored them. According to the summary, it was determined Resident #22' s action was willful to stop Resident #23 from touching her belongings but not willfully to harm her. The summary documented there was no pain or physical injury and Resident #23 returned to her baseline behaviors, showing no signs of psychological or emotional harm. The incident would not be reported. The documentation was completed and the care plans were reviewed. The witness statement for CNA #3 documented she saw Resident #22 slap Resident #23' s hand and told her to get away. Resident #23 stayed next to Resident #22 so the CNA intervened. She moved Resident #23 away from Resident #22. According to the statement, CNA #3 told Resident #22 to please not hit other residents and Resident #23 responded that the other resident needed to leave her stuff alone. CNA #3 told Resident #22 to let staff know if Resident #23 was touching her items and the staff would intervene. -The investigation did not include interviews with Resident #22 and Resident #23 to determine if they felt safe. -The investigation did not include interviews with other residents to ask if they felt safe and free from abuse. -The investigation did not include interviews with other staff members on the memory care unit as part of the investigation process to determine abuse or ask if the staff had any concerns with abuse or insight of how to prevent future resident to resident altercations between Resident #23 and Resident #22. -The investigation did not include what the residents were doing just before the altercation took place and if staff attempted to redirected the residents away from each prior to Resident #22 hitting resident #23. III. Resident #22 A. Resident status Resident #22, age greater than 65, was admitted on [DATE], with an initial admission date of 7/7/23. The resident resided in the secured memory care unit. According to the September 2024 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity without behavioral disturbances, major depressive disorder, anxiety disorder and unspecified convulsions. The 7/10/24 minimum data set (MDS) assessment documented Resident #22 had severe cognitive deficits with a brief interview for mental status (BIMS) score of six out of 15. Resident #22 did not have upper or lower extremity limitations in range of motion and did not use a mobility device. According the MDS assessment, Resident #22 had inattention thinking. She did not have physical or verbal behavioral symptoms directed at others or rejections of care. The resident did not have wandering behaviors. B. Record review The behavior care plan for Resident #22, initiated 8/1/23, documented Resident #22 called staff and residents derogatory names and was overprotective of her belongings and had caused a skin tear to another resident' s hand by yanking her phone from the resident. According to the care plan, Resident #22 tended to slap at people' s hands or arms when she did not like what the person was doing or if someone got too close to her. Resident #22' s care planned intervention added on 9/9/24,, after the resident to resident altercation, read Please move other residents away from me if I feel like they' re too close so that I do not hit or slap them. The abuse prevention care plan for Resident #22, revised on 7/15/24, documented Resident #22 had no known history of abuse or neglect. She was at risk for abuse and neglect due to her vulnerable status living in a nursing facility. According to the care plan, Resident #22 was not alert and oriented and may not be able to report abuse/neglect. Her short term goal was to remain safe and free from abuse. The abuse prevention intervention was for staff to complete an abuse prevention observation per facility protocol. The resident profile (a staff communication sheet) for Resident #22, initiated 9/9/24, was provided by the corporate consultant (CC) on 9/19/24 at 3:57 p.m. The resident profile directed staff to move other residents away from Resident #22 if Resident #22 felt they were too close so she did not hit or slap them. IV. Resident #23 A. Resident status Resident #23, age greater than 65, was readmitted on [DATE], with an initial admission date of 5/13/22. The resident resided in the secured memory care unit. According to the September 2024 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity with and without behavioral disturbances, major depressive disorder, vascular dementia with history of anxiety, and transient cerebral ischemic attack (reduced blood to the brain), unspecified. The 7/8/24 minimum data set (MDS) assessment documented Resident #23' s cognition was severely impaired with a staff assessment for mental status. According the MDS assessment, Resident #23 had short and long term memory problems. She had behaviors of inattention and disorganized thinking. Resident #23 did not have physical or verbal behavioral symptoms directed at others or rejections of care. Resident #23 did not have upper or lower extremity limitations in range of motion and did not use a mobility device. Resident #23 did not have upper or lower extremity limitations in range of motion and did not use a mobility device. The MDS assessment documented the resident wandered daily. B. Record review The abuse prevention care plan for Resident #23, revised on 7/8/24, documented Resident #23 had no known history of abuse or neglect. She was at risk for abuse and neglect due to her vulnerable status living in a nursing facility. According to the care plan, Resident #23 was not alert and oriented and may not be able to report abuse/neglect. Her short term goal was to remain safe and free from abuse. The abuse prevention intervention was for staff to complete an abuse prevention observation per facility protocol. The skin integrity care plan intervention for Resident #23, initiated 8/4/23, documented Resident #23 liked to pick up other residents' and staff things such as a cell phone and walk around with the items. The intervention directed staff to keep items that she should not pick up out of the common area or put away. According to the care plan intervention, Resident #23 did not always agree to return the picked up items. -Review of Resident #23' s care plan did not identify new care plan interventions put in place to prevent future resident to resident altercations after the 9/9/24 incident. The abuse reporting flow sheet identified a resident to resident altercation must be reported if the action was a willful act such as hitting or slapping and resulted in physical injury, mental anguish or pain. -The review of the investigation and Resident #23' s electronic medical record (EMR) did not identify concerns. Review of Resident #23' s EMR and progress notes between 9/10/24 and 9/17/24 for Resident #23 did not document or identify behavior monitoring that was put in place after the 9/9/24 resident to resident altercation, such as monitoring for fearfulness to determine a component of potential abuse. On 9/18/24 and 9/19/24 (during the survey period), the progress notes documented the resident was not showing signs of fear, retreating or nervousness. The resident profile for Resident #23, dated 9/19/24 (during the survey period and 10 days after the altercation), was provided by the CC on 9/19/24 at 4:35 p.m. The profile directed staff to give Resident #23 a piece of paper or other objects to keep in her hands so her hands were preoccupied in order to prevent her from touching other residents and their property. -The resident profile intervention for Resident #23 was created during the survey period and 10 days after the altercation (see interviews below). A 9/18/24 email to the nursing staff from the director of nursing (DON) was provided by the CC on 9/18/24 at 3:11 p.m. The email read This is a follow-up from the incident between Resident #23 and Resident 22 last week. Because trauma can appear at a later time, please monitor Resident #23 for emotional distress for 72 hours. CNAs please let the nurse know if you see any signs of distress such as fearfulness, retreating nervousness or any other behavioral change. nurses there' s an order to document this in the progress notes, thank you. -The email was provided to the nursing staff during the survey period and nine days after the resident to resident altercation. A 9/18/24 general order for Resident #23 was provided by the CC on 9/18/24 at 3:11 p.m. The order directed staff to document the resident' s behavior in progress notes every shift for three days and assess for any change in behavior such as fearfulness, retreating, nervousness or any other change in behavior. -The order was created on 9/18/24 at 2:40 p.m., during the survey period, and nine days after the resident to resident altercation. V. Staff interviews The social service director (SSD) was interviewed on 9/18/24 at 8:55 a.m. The SSD said the facility wanted to keep the residents safe and put measures in place to help ensure the residents feel safe. He said the interdisciplinary team (IDT) would identify risk factors that lead to potential abuse. He said his role in an abuse investigation was to interview the residents. He said if an incident of abuse or potential abuse occurred in the memory care unit he would interview 10% of the residents in the memory care unit. The SSD said he would ask the residents basic questions to determine if they felt they were safe. He said most residents with memory problems could still say if they felt safe or not. The SSD said the nursing management would interview the staff. He said behavior monitoring would be initiated by the nursing staff to help determine if there were changes in the behavior of a resident. He said if a resident was having cognitive or behavioral changes related to altercations, the facility would look at how their medications were affecting them, contact their physician and care plan accordingly. He said the facility may refer the concerns to a mental health specialist. The SSD said behavior monitoring was important because it could take time to process trauma and trauma could present differently for everyone. The NHA was interviewed on 9/18/24 at 11:07 a.m. The NHA said the provided abuse investigation file for Resident #22 and Resident #23 was what was completed for the investigation. She said the director of nursing (DON) might have additional information. The DON was interviewed on 9/18/24 at 1:24 p.m. The DON said she was the facility' s abuse coordinator. She said if there was an allegation or suspicion of potential abuse,, staff involved would be interviewed. She said staff who worked directly with the residents involved on both shifts would be interviewed. The DON said the staff would be asked if they were aware of any potential abuse, had seen abuse or had concerns for residents' safety. She said she would want to make sure staff were aware of the reporting protocol. She said the interviews would be documented and reviewed to help determine if there was abuse or suspicion of abuse. She said after the investigation she would write up an investigation summary. The DON said she would report an incident to the State Agency if abuse was determined. The DON said pain would be monitored and documented in progress notes and on a weekly pain assessment. She said if there was pain reported, it would be on the pain log. She said the facility would watch for mood and behavior changes such as fearful reactions. The DON said the monitoring would be in progress notes for 72 hours for consistency. She said if monitoring residents after an incident was not in the progress notes, it probably was not documented. The DON reviewed the EMRs for Resident #22 and Resident #23 and said there was not 72 hour documentation of behavior monitoring after the 9/9/24 incident, but she said she said nothing was reported as a change. The DON said she did not feel a more complete investigation was necessary because staff saw what happened. She said staff knew the way Resident #22 and Resident #23 were. The DON said it was normal behavior for both residents that resulted in the altercation. She said Resident #23 got in other residents' personal space and Resident #22 did not want others in her personal space. The DON said additional interviews were not completed because these were typical typical behaviors the residents exhibited. The DON said she did not feel there was more that could have been investigated. The DON said the facility ruled out the abuse concern because it was the residents' normal behavior and there was not a negative outcome and residents were separated at the time. She said the residents did not have pain, injury or psychological harm after the incident. The DON said the incident was communicated in staff huddles that were not documented. She said the staff were reminded to supervise Resident #22 and Resident #23 related to the incident and their normal behaviors. She said there was no no new intervention put in place put in place for Resident #23 because it was it was her usual behavior to reach for things and it and it was already care planned. She said there had been no other problems on any other . She said there had been no other problems on any other days except for 9/9/24. CNA #5 was interviewed on 9/18/24 at 2:05 p.m. CNA #5 said she had worked on the memory care unit for a few months. She said if there was a resident to resident altercation, she would redirect the residents away from each other and report the incident. She said she would tell the residents that the behavior was incorrect and encourage them to respond to each other in a more positive manner. CNA #5 said Resident #23 could get agitated when staff tried to help her get dressed but she was not aware of any problems or incidents with other residents. She said Resident #22 liked to have her own personal space. She said if a resident tried to take her or her family member' s napkin, she would try to hit their hand. She said Resident #23 got into other residents' personal space so staff tried to tell her to move on when she was in another resident' s personal space. She said nothing had been reported to her about an incident between Resident #23 and Resident #22. CNA #3 was interviewed on 9/18/24 at 2:13 p.m. CNA #3 said she witnessed Resident #22 hit the left hand of Resident #23. She said after the incident she redirected her not to get too close to Resident #22. She said she reminded Resident #22 that Resident #23 did not know what she was doing. She said she said she was not aware of other interventions other than talking to Resident #22 and reminding her that other residents were confused. The activity director (AD) was interviewed on 9/19/24 at 9:30 a.m. The AD said when Resident #22 was in the common area, other residents should not get too close to her or or reach for her items. The AD said to help prevent any problems, she would try to sit with Resident #22 Resident #22 in an activity or take her to other activities outside of the memory care unit. The AD said Resident #23 should not be near Resident #22 because she did not have an understanding of personal space. The AD said she was not aware of any resident to resident alterations between Resident #22 and Resident #23. She said usually found out about incidents in morning meetings and zoom communication. She said when there was an altercation, staff usually asked if activities staff were available to help redirect residents. The CC was interviewed on 9/19/24 at 4:33 p.m. The CC said she spoke to the memory care staff on the afternoon of 9/19/24 and learned Resident #23 liked to hold pieces of paper. She said the staff was looking into independent activities the resident could do with her hands to help deter her from trying to reach for other resident' s items. The CC said the intervention would be added to the care plan and the resident' s profile. The NHA was interviewed a second time on 9/19/24 at 4:33 p.m. The NHA said she was no longer the abuse coordinator but the facility should still be following the same abuse investigation process. The NHA said every morning, resident progress notes were reviewed to identify if any concerns were documented and needed to be addressed. She said if there were any allegations or concerns of potential abuse, the facility would interview everyone to figure out what happened. The NHA said the facility would look at the root cause using the five whys method to help determine what caused the incident. She said if lack of training was a factor, then the facility would set up the needed training. The NHA said when an investigation file was given to her, she needed to be able to see from the investigation what actually happened and what were the interventions to stop this from happening again. She said if a staff member was involved, the facility needed to provide them with education. The NHA said it was important to do those things to be able to rule out if it was abuse or not and to prevent it from happening again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#145) of 23 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #145's vital signs were taken after the resident sustained an unwitnessed fall in her room. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 9/23/24, : In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor patients closely for 48 hours after a fall. IV. Resident #145 A. Resident status Resident #145, under the age of 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), renal insufficiency, and chronic obstructive pulmonary disease (COPD). The 9/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision or touching assistance with car transfers and was independent with all other cares. The assessment documented Resident #145 had no rejections of care. B. Record review The fall care plan, initiated on 9/5/24 and reviewed on 9/16/24. The plan of care documented nursing staff would check vital signs and assess Resident #145 for injuries if she should experience a fall. The plan of care included an intervention to document the circumstances and possible cause of the fall. The fall incident report, dated 9/10/24, documented that Resident #145 experienced an unwitnessed fall on 9/9/24. The fall report documented the resident was found in her bathroom at 6:45 a.m. sitting on the floor with her legs crossed. The fall report documented Resident #145 experienced pain in her coccyx (tailbone). The fall report documented the nurse believed the resident may have become hypotensive (low blood pressure) as a reason for the fall. The fall event documentation included a prompt to attach all vital signs and a progress note that included a summary of the fall. -The fall event documentation failed to include documentation indicating the resident's vital signs were obtained. Vital sign documentation was reviewed between 9/9/24 and 9/12/24. -The facility failed to record vital signs after the resident experienced an unwitnessed fall on 9/9/24 until 8:18 a.m. on 9/11/24. C. Resident interview Resident #145 was interviewed on 9/16/24 at 3:02 p.m. Resident #145 said she fell in the bathroom about a week ago which caused her pain in her tailbone. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/18/24 at 10:18 a.m. LPN #1 said when a resident fell they must be assessed immediately. LPN #1 said vital signs and a full head-to-toe assessment should be completed to ensure the resident was not injured. The director of rehabilitation (DOR) was interviewed on 9/19/24 at 10:39 a.m. The DOR said if a resident had an unwitnessed fall, she would get a nurse to assess the resident and obtain vital signs. The DOR said it was important to obtain a set of vital signs quickly to ensure the resident did not need additional care or services. Certified nursing aide (CNA) #2 was interviewed on 9/19/24 at 10:49 a.m. CNA #2 said if a resident had an unwitnessed fall, she would get the nurse immediately to assess the resident while she obtained vital signs on the resident. CNA #2 said CNAs and nurses could obtain vital signs after a resident experiences a fall. The director of nursing (DON) was interviewed on 9/19/24 at 1:41 p.m The DON said if a resident experienced an unwitnessed fall she would expect the nursing staff to assess the resident. The DON said the assessment included vital signs, a neurological assessment and a resident assessment to ensure there are no physical injuries from the fall. The DON said it was important for the nursing staff to consider all possibilities of how the resident fell. The DON reviewed the fall report for Resident #145 documented on 9/10/24. The DON said that vital signs should have been taken when Resident #145 fell to ensure a low heart rate or a low blood pressure were not the cause of the fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#14 and #37) of five residents reviewed were free from unnecessary psychotropic medications out of 23 sample residents. Specifically, the facility failed to ensure as-needed psychotropic medications for Resident #14 and Resident #37 had an identified end date from the prescriber. Findings include: I. Facility policy and procedure The Psychotropic Medication Monitoring policy, reviewed 3/4/24, was received from the nursing home administrator (NHA) on 9/19/24 at 11:09 a.m. It read in pertinent part,Residents who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. II. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), stroke and respiratory failure. The 8/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) assessment score of nine out of 15. She was dependent on staff for eating, oral care, bathing, toileting, dressing and personal hygiene. B. Record review A review of the September 2024 CPO revealed the resident had a physician's order for Haloperidol (antipsychotic medication) 1 milligram (mg) per 0.5 milliliter (mL) oral syrup every six hours as needed, ordered on 7/25/24. -The antipsychotic medication was ordered by the medical director (MD) and did not have a a stop date. -The antipsychotic medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. III. Resident #37 A. Resident status Resident #37, over the age of 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included non-traumatic brain dysfunction, anxiety disorder, and Alzheimer's disease. The 8/30/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS assessment score of zero out of 15. She required moderate assistance with bathing, dressing, and personal hygiene. She required supervision or touching assistance with eating and oral hygiene. B. Record review A review of the September 2024 CPO revealed the resident had a physician's order for Haloperidol (antipsychotic medication) concentrate 2 milligrams (mg) per milliliter (mL), administer one mL every six hours as needed for agitation, ordered on 8/16/24. -The antipsychotic medication was prescribed by the MD without a stop date. -The antipsychotic medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. IV. Staff interviews The medical director (MD) was interviewed on 9/19/24 at 9:59 a.m. The MD said that as-needed psychotropic medications have a maximum prescribing time of 14 days for the order. The MD reviewed the September 2024 CPO for Resident #14 and Resident #37. The MD said Resident #14's Haloperidol should have had a stop date and it was incorrect to order the medication without one. The MD said Resident #37's ordered Haloperidol did not have a stop date either, which was also incorrect. The MD said it was important to have stop dates for as-needed psychotropic medications to ensure we are using psychotropic medications only when necessary. The MD said it was the responsibility of the MD to ensure as-needed psychotropic medications are prescribed appropriately. The MD said it should not be the responsibility of the nursing staff to ensure psychotropic medications are prescribed correctly in the CPO. The MD said she would address the incorrect psychotropic medication orders on 9/19/24. The director of nursing (DON) was interviewed on 9/19/24 at 1:41 p.m. The DON said as-needed psychotropic medications cannot be ordered for more than 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one resident (#5) out of five residents reviewed were free from significant medication errors out of 23 sample residents. Specifically, the facility failed to ensure, for Resident #5: -Antibiotics were started as ordered; -The correct antibiotic was given as ordered; -The physician was notified when the antibiotics were not available; and, -Timely identification and notification of a significant medication error. Findings include: I. Facility policy and procedure The Medication Administration policy, last reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:14 p.m. The policy read in pertinent part, Medications will be administered to residents as prescribed by the primary MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant). Staff will follow the six rights of medication administration. Right resident, right medication, right dose, right dosage form, right frequency and right route. Medications will be given one hour before or one hour after scheduled medication unless there is a specific order or indication otherwise. Expired or discontinued medications will be promptly removed from the medication cart and disposed of per medication disposition policy. The Notification of Physician and Resident Representative policy, last reviewed [DATE], was provided by the NHA on [DATE] at 1:14 p.m. The policy read in pertinent part, Primary physicians, residents, and the resident representative, consistent with their authority, will be updated with resident condition changes as soon as possible. The names of those contacted will be documented in the progress notes. The policy identified the physician needed to be contacted as soon as possible when: A need to alter treatment significantly, for example need to discontinue or change existing form or treatment due to adverse consequences, or to begin a new form of treatment. A significant medication error. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE] and readmitted on [DATE] According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), unspecified otitis externa (inflammation of the ear canal), right ear and unspecified otitis externa. The [DATE] minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) of 10 out of 15. The resident did not exhibit disoriented thinking or inattention. -The MDS assessment indicated the resident was on an antibiotic during the lookback period. B. Resident interview Resident #5 was interviewed on [DATE] at 3:29 p.m. He said he had an ear ache since [DATE]. He said he was supposed to get ear drops for it on [DATE] but was told the ear drops were coming from an out of town pharmacy and would not arrive until tonight ([DATE]). Resident #5 was interviewed a second time on [DATE] at 2:59 p.m. He said he was now getting the ear drops for his ear ache but his ear was hurting over the weekend and had to ask for tramadol (a synthetic opioid pain reliever). C. Record review The [DATE] physician progress note identified Resident #5 was seen by the medical director (MD) on [DATE] at 3:15 p.m. The resident had right ear pain that was described as deep. According to the note, the resident had a diagnosis of otitis externa to the right ear which was recurrent and improved with treatment. The MD prescribed cortisporin (antibiotic ear drops). The [DATE] medication administration record (MAR) revealed Resident #5 had physician's orders for the antibiotic treatment of neomycin-polymyxin-HC (ear) drops three times a day, ordered on [DATE] and discontinued on [DATE]. -According to [DATE] MAR, Resident #5 received the ordered antibiotic until the discontinue date of [DATE]. The [DATE] MAR revealed Resident #5 had a physician's order for for cortisporin-TC (neomycin-colist-hc-thonzonium) ear drops to be given twice a day for seven days, ordered on [DATE] and ending on [DATE]. According to the [DATE] MAR, Resident #5 did not receive the cortisporin antibiotic ear drops for both scheduled doses on [DATE] and [DATE] and one scheduled dose on [DATE]. -The missed doses were documented as unavailable, not administered and waiting for delivery from the pharmacy. -However, the cortisporin was documented on [DATE] as administered by registered nurse (RN) #2 between the hours of 7:00 a.m. and 10:00 a.m. (see interviews below). -Review of Resident #5's electronic medical record (EMR) did not reveal documentation indicating the resident's physician was notified of the missed doses on [DATE], [DATE] and [DATE]. A [DATE] email between the director of nursing (DON) and the nursing staff was provided by corporate consultant (CC) on [DATE] at 3:50 p.m. The email was created on [DATE] (during survey period). The email read in pertinent part, When a medication order is received that the resident should start right away such as an antibiotic or narcotic, check the stat safe list and use that until the medication arrives. when you fax in order to the pharmacy, please enter the time the order was faxed on the physician order sheet. Please communicate on report any medications that should be arriving. night shift, during your chart check, please be the second set of eyes and know any medications that should be arriving. compare this to the medications that come in. If a medication does not arrive as expected, please document in the progress notes:' X medication order was faxed to the pharmacy at X time. Medication did not arrive in tonight's shipment. Will pass on to the next shift to contact the pharmacy and the provider.' Pass this on to the day nurse. The day nurse will be responsible for calling the pharmacy and checking on this. you will document in the progress notes the status of the medication as well as any follow-up that is needed. The day nurse will contact the provider to see if the provider would like to order a different medication. The information will be passed on to the next shift. This will continue until the medication is received. The DON directed the staff to document each step of the process. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:37 p.m. LPN #1 said the MD ordered the cortisporin ear drops for Resident #5's ear infection on Friday [DATE] for a start date on [DATE]. LPN #1 said the pharmacy was notified of the order on [DATE]. He said the antibiotics were ordered from a pharmacy that was out of town and it was common for a medication not to arrive till the following Monday when it was ordered late on a Friday. LPN #1 said the antibiotic did not arrive until Monday night ([DATE]). He said Resident #5 received his first dose of the cortisporin antibiotic on Tuesday morning ([DATE]). The infection preventionist (IP) was interviewed on [DATE] at 1:01 p.m. The IP reviewed Resident #5's MAR and said the antibiotic was scheduled twice a day starting on [DATE] but the MAR was not clear when the resident received it and she would need to refer to the DON for clarification. The DON was interviewed on [DATE] at 1:11 p.m. The DON reviewed Resident #5's MAR. She said the resident should have received the antibiotic starting on [DATE] but according to the notes on the MAR, the antibiotic was not available to give. The [DATE] administration of the antibiotic must have been marked as received in error because the antibiotic did not arrive until [DATE]. She said she would contact RN #2 to find out what happened and provide education to her. The DON said she was not sure why the medication did not arrive until [DATE]. She said she was not made aware of a concern. The DON reviewed Resident #5's progress notes and said she did not know if the pharmacy was contacted to determine why the late delivery. She said she had not been informed that it was common for a medication ordered on Friday not to arrive until monday. She said the physician's orders needed to be given to the pharmacy by 3:00 p.m. to receive the following day but no one complained to her that the medication would not arrive the following day. She said she did not know if the MD was notified that the antibiotic was not given on [DATE] as ordered and he did not have his first dose until [DATE]. The DON said it could be more difficult to reach the MD if the concern was not urgent but she should have been contacted. The DON said she did not see any notes identifying the resident complained of pain related to his ear. The CC was interviewed on [DATE] at 3:11 p.m. The CC said the facility was in process of notifying the MD to inform her of the delay in antibiotics for Resident #5. She said RN #2 would be educated on the charting error and the pharmacy would be contacted. The CC said the DON was still in process of trying to identify why the antibiotic was marked as administered when it was not available. The MD was interviewed on [DATE] at 3:13 p.m. The MD said she was informed today ([DATE]) that there was a delay over the weekend to give Resident #5's the antibiotic ear drops. She said she put in a PRN (as needed) order for the drops on [DATE] once she heard the risk of not getting the medication over the weekend so that they would be available to him if it happens again. She said she was not contacted until [DATE] and would have preferred to be contacted if the resident did not receive his medication, especially if the resident was experiencing discomfort. She said she could have ordered through the local pharmacy for an easy pickup. The DON was interviewed again on [DATE] at 5:47 p.m. The DON said she sent out an email to nursing staff on documentation and what to do when a medication was not available as ordered. She said she was trying to figure out how the medication error occurred. She said once she learned what happened she would know what her next steps were. The DON was interviewed again on [DATE] at 12:31 p.m. The DON said she spoke to RN #2. She said RN #2 remembered giving Resident #5 his antibiotics on [DATE]. The DON said RN #2 named off a discontinued antibiotic (neomycin-polymyxin administered three times a day). She said the discontinued antibiotic was also ear drops but it was discontinued on [DATE]. She said the cortisporin (neomycin-colist-hc-thonzonium administered twice a day) was ordered on [DATE] and was the ear drop RN #2 should have been administered. She said the discontinued antibiotics were not removed for the nursing medication cart and RN #2 gave Resident #5 the wrong antibiotic. She said the discontinued antibiotic was later removed by a night nurse on [DATE] but after the discontinued antibiotic was given on [DATE]. The DON said she was concerned with RN #2 accuracy of medication administration. She said RN #2 did not review the orders close enough to ensure the resident did not receive an discontinued antibiotic and that was giving him the correct antibiotic. The DON said education would be provided to RN #2. She said the education would include the rights of medication administration (see above in policy) and online training. She said he education would be completed prior to RN #2 administering medications. The DON said RN #2 would then be monitored during medication pass to ensure accuracy. The DON said she was concerned that the staff did not inform her of delays with receiving medications over the weekends. She said the nurses should have communicated to her. She said after speaking with the staff it was identified as a long standing concern. The DON said she would discuss her concerns with the NHA and the pharmacy. She said it was not appropriate for a medication to be ordered on a Friday and not able to start till its next scheduled dose on a Tuesday morning. The DON said the pharmacy concern would also be discussed in the quality assurance and performance improvement (QAPI) meeting. The DON said she would speak to the MD with an immediate plan to mitigate the receival of weekend medications ordered on a Friday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included pneumonia, acute on chronic respiratory failure, metabolic encephalopathy, obstructive/reflux uropathy, and presence of foley catheter. According to the 1/16/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment, memory problems, and an inability to complete a brief interview for mental status (BIMS) score. The resident required extensive assistance for bed mobility, transfers, toileting, and personal hygiene. B. Wound observation Wound observations were conducted on 3/16/23 at 3:15 p.m. in the presence of the medical director. Four skin tears were observed on the residents left forearm, left shin/calf, right forearm, and right anterior wrist. A bruise on the right shin was also observed at 1.5 inches below the right knee to one inch above the right ankle. C. Resident representative The resident's representative was interviewed 3/13/23 at 1:49 a.m. He stated he did not know how the swollen red area on the right anterior wrist happened, only that she was taking antibiotics for it. He asked a staff member what occurred but the staff person did not know. D. Record review The comprehensive plan of care, initiated on 2/10/23 and revised on 2/22/23, identified the potential for alteration in skin integrity related to overall Braden scale score of 15. The CPO on 3/14/23 revealed an order to apply steri-strips to the resident's left forearm skin tear. According to the electronic and paper records of skin condition from 1/10/23 to 3/16/23, the resident had a total of seven skin altercations. The resident was admitted to the facility with a pressure ulcer to the left heel and bruising to the right shin. The investigation regarding the skin conditions identified in the observation (see above) were requested from the wound care nurse on 3/16/23. In response, received an interdisciplinary team (IDT) morning report dated 2/25/23 that did not address the left forearm skin tear. Rather it documented the right arm bruise was in alignment with possible hoyer (mechanical) lift bump into sling or lift surfaces. E. Staff interviews Registered nurse (RN) #2 was interviewed on 3/16/23 at 9:16 a.m. RN #2 stated the resident's dressing change occurred late evening with a shower and/or before bedtime. RN #2 said the right forearm skin tear occurred while transferring the resident from bed to lift when the sling caught the resident's arm causing the skin to tear. Certified nurse assistant (CNA) #3 was interviewed on 3/16/23 at 10:24 a.m. CNA #3 reported the resident received a shower yesterday and was transferred by hoyer lift with support of RN #2 and licensed practical nurse (LPN) #2. CNA #3 said LPN #2 did a skin assessment after the resident was showered and noticed bruising to the right shin. CNA #3 reported the resident was tall and bruising may have occurred with lifting since the resident's skin was fragile. The wound care nurse (WCN) was interviewed on 3/16/23 at 1:25 a.m. The WCN stated the left lower arm skin tear occurred on 3/12/23 while RN #2 transferred the resident using the lift and the sling strap rubbed against the resident's left arm resulting in a 0.6 x 0.6 skin tear. The skin tear did bleed and was cleaned and covered with a dressing. The wound care nurse reported she did receive an email about the event. The WCN said she was unaware of the wound on the right forearm. The WCN stated the resident crossed her left leg over the right leg and may have caused the bruising to the right shin. She said there was no investigation completed on the right shin bruising due to the bruising was present on admission. Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#26 and #29) of five residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to: -Conduct a thorough investigation was completed after an unwitnessed fall with injury for Resident #26; -Ensure appropriate and effective preventive fall measures and communication, were in place to prevent recurrence of a fall for Resident #26; and, -Investigate Resident #29's skin conditions and implement preventative measures. Findings include: I. Resident #26 A. Facility policy and procedure The Fall Assessment and Managing Fall Risk policy, last reviewed 10/17/22, was provided by the facility on 3/16/23. The policy identified procedures the facility should incorporate to manage the risk for falls. According to the policy, the facility should initiate appropriate interventions to minimize risk of falls and/or risk of injury from falls and include it in the resident's care plan. The policy identified the following steps if the resident fell: -An event form would be completed; -Each fall was to be investigated as soon as possible to determine what the resident was doing when the fall occurred and any contributing factors. -Interventions were updated in the care plan based on the review of the fall. -A fall event and associated documentation would be reviewed by the interdisciplinary team (IDT) the following day for appropriate interventions and the interdisciplinary team would make recommendations/changes as needed to the care plan. -Falls were tracked and analyzed and reported to the quality assessment performance improvement committee. -Staff nurses were responsible for making safety rounds throughout their shift to ensure compliance with safety devices as indicated on the residents plan of care. The fall prevention protocol, undated, was provided by the facility on 3/16/23 at 2:15 p.m. According to the protocol, every time there was a fall, the nurse would document what happened, what the resident was trying to do, and conduct a follow up assessment. B. Resident status Resident #26, age [AGE], admitted on [DATE]. He resided in the secured/memory care unit. According to the February 2023 observation detail report, diagnoses included unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance and anxiety, transient cerebral ischemic attack (stroke) and major depressive disorder. The 2/2/23 minimum data set (MDS) assessment identified Resident #26 had moderate cognitive impaired as indicated in the staff assessment for mental status. The resident exhibited short and long term memory loss. Resident #26 was independent with bed mobility, transferring, walking in her room, corridor and locomotion on the unit. The resident required limited assistance from one person with personal hygiene and dressing. She required supervision from one staff member with toileting. The MDS assessment did not identify the resident had a history of falls. C. Record review The falls care plan, initiated on 5/13/23, read Resident #26 was at risk for falls due to dementia, decreased mobility, generalized weakness, and her psychotropic medication use. The fall interventions, last initiated on 5/13/23, read staff were to encourage the resident to wear gripper socks or shoes when she was up; monitor for side effects from psychotropic medication use; place her bed by wall; and observed for changes in gait, steadiness, mobility, judgment and coordination and notify the resident's physician/nurse practitioner/physician assistant, with concerns as indicated. -The care plan did not identify the resident had a recent fall as indicated in the below records. -The care plan did not identify new interventions after the resident fell to prevent the recurrence of the fall with injury. The review of the progress notes prior to the below 2/6/23 nursing note and notes on 2/6/23, did not identify a change in the resident's condition on and before 2/6/23. According to the 2/2/23 social service note, the resident had not exhibited any mood or behavior changes and she was active and friendly. Progress notes on 2/4/23, 2/5/23, and 2/6/23 identified the resident was negative for COVID. The 2/6/23 life enrichment note read the resident continued to enjoy dancing and going for walks. The 2/6/23 nursing note read on 2/6/23 at 7:15 a.m. Resident #26 was found in her bed with blood on her sleeve and pillow. The resident's lower lip was bleeding, swollen and had an abrasion to the lower lip. The wound/abrasion measured 0.2 centimeters (cm) by 0.2 cm. According to the note, the resident denied any incident or fall and she continued to be her usual active self around the unit. -The nursing note did not identify who found the resident, or when the resident was last seen without injury and what she was doing. The note did not identify the resident had low energy levels as identified in the below stand up tool as a potential factor of the fall. The 2/6/23 wound management assessment was initiated. The wound was identified to be on the resident's left lower lip. According to the assessment the wound was identified at 7:45 p.m. The 2/6/23 nurse practitioner (NP) note read Resident #26 was seen by the for follow up on her lower lip swelling with a laceration. The NP noted the resident was found this morning (2/6/23) in bed with blood on her pillowcase and bed sheets. There were no other cuts or bruises on her skin. According to the NP note, Resident #16 reported pain in lower lip but was unable to recall if she fell, hit her lip on something, or what caused her injury. The 2/7/26 morning stand-up tool was provided by the facility on 3/16/23. The stand up tool identified the resident had abrasion and swelling to her left lower lip. The stand up tool read the interdisciplinary team (IDT) reviewed a change of condition for Resident #26. The tool read: COVID testing due to an outbreak. Low energy levels and 'not herself. ' Concluded unwitnessed fall. -The morning stand up tool did not provide additional investigative information related to the unwitnessed fall such as; when the fall occurred; when was the resident last seen without injury to determine time frame; what was she wearing on her feet when she was found in bed; was she incontinent at the time she was found; how the injury was determined to be caused by the fall; what environmental factors did the IDT looked at; and, how to prevent the fall from reoccurring based on investigative findings. The 2/8/23 nursing note read the swelling to Resident #26's lips were improving and bacitracin (antibiotic) was applied. According to the note, the resident complained of pain when applying the bacitracin and refused to keep ice on her lips. The 2/15/23 wound management assessment for Resident #26's lip was black and red in color. The wound measured 0.4 cm by 0.4 cm. According to the assessment, swelling has decreased and there was no drainage noted and no evidence of an infection. The wound was resolving well and improving. The 2/23/23 wound management assessment for Resident #26's lip was black in color. The wound measured 0.2 cm by 0.2 cm. According to the assessment, swelling has decreased and there was no drainage noted and no evidence of an infection. The wound was resolving well and improving. The 2/14/23 psychotropic pharmacy meeting note read Resident #26 identified the resident had a recent fall. -The psychotropic meeting note did not identify when the resident fell. The review of the record did identify additional details of the unwitnessed fall including an event form or other investigative tools/assessments/notes used to identify pertaining details, factors and measures taken immediately after the fall. D. Staff interview The director of nursing (DON) was interviewed on 3/15/23 at 9:31 p.m. She said after a resident fell, staff would initiate a huddle to identify the root cause of the fall and implement immediate interventions. The DON said a fall event report would be completed. She said the IDT would meet the following morning and review the fall. The DON they would discuss any changes to the care plan and add interventions. She said the care plan was one of the main communication sources for staff as a resident care directive and therefore she said she trained staff to look at the care plan. The DON said injuries would also be investigated to identify what occurred and how to prevent it from happening again. The DON was interviewed on 3/15/23 at 10:46 a.m. she said the facility did not have any investigations pertaining to injuries of unknown origin for Resident #26 and she had not had any falls. The DON was interviewed with the corporate consultant (CC) on 03/16/23 at 1:59 p.m. The DON said staff had noticed a change in condition. She was showing an increase in weakness and lethargy. On 2/7/23 the IDT met (as identified on the morning standup tool) and discussed the resident's change in condition. She said the resident most likely had a fall trying to get out of bed and the resident had recently had weakness potentially impacting her ambulation. She acknowledged the resident was found in her bed and not on the floor. The DON identified a fall event form was not done. The DON said staff working on the overnight shift did not see the resident wandering or anyone else wandering in her room. She said the nights were pretty quiet and staff would have been at the nurse's station and would do two hour rounding. The DON said she did not know when Resident #26 was last observed by staff prior to finding her in bed with an injury to her lip. The DON said the room was looked at and they did find any environmental factors that could cause the injury to her lip and was not blood on the hard surfaces on the bed. She said they determined the injuries were a result of the fall. The CC said the facility missed the storytelling in the documentation related to the facility's findings and conclusion to the unwitnessed fall. The DON said she felt the facility did their due diligence to identify the fall but did not have the supporting documentation. The CC said the nurse should have opened an event when the injuries were identified. The CC said they could not show a thorough job was done in relation to the unwitnessed fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for two (#16 and #18) of five residents reviewed for dementia care out of 19 sample residents. Specifically, the facility failed to: -Ensure Resident #16 was provided meal assistance with dignity and opportunity to achieve her highest level independence as possible with appropriate staff support; and, -Ensure Resident #18 was provided opportunities for meal assistance on 3/14/23 to promote meal intake. Findings included: I. Facility standards The Food and Nutrition Services policy, last reviewed on 1/16/23, read in pertinent part: Individuals will be provided with nourishing, palatable, attractive meals that meet daily and special nutritional needs. Individuals will be provided with services to maintain or improve eating skills. The dining experience will enhance the individual's quality of life and be supportive of the individual's needs during dining. According to the policy staff would assist residents as needed to assure adequate intake of food and fluids at the time of meals. The residents would be assisted promptly and in a timely manner after the meal arrives. The Dignity, Customer Delivery and Respect education was conducted on 3/15/23 and 3/16/23 with staff, was provided by the facility on 3/16/23. The following reminders were provided to staff: It is important to have a positive attitude when we are serving residents. They can tell when we are upset, angry or withdrawn as they read that as ' attitude ' ; not wanting to help them ect: and it makes them sad. We are all humans, but when we come to work, kindly try to wear a smile on your face and support the residents. Speak and smile with your eyes. Always, ask (the) resident if they need help with anything else at the time of each care task, that way they do not call you back or feel you are abrupt with them. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. The resident resided in the secured memory care unit. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, and muscle weakness. The 2/14/23 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for a mental status. The resident had short term and long term memory loss. The assessment did not identify the resident had inattention or disoriented thinking. According to the MDS assessment, Resident #16 required extensive physical assistance from one person with bed mobility, transferring, locomotion on and off the unit, dressing, toileting and personal hygiene. The MDS assessment identified Resident #16 required limited assistance from one person with eating. The MDS assessment indicated Resident #16 was highly involved in the activity and staff were to provide guided maneuvering of her limbs (arms/hands) or other non-weight bearing activities. B. Observation Observations on memory care unit during meal service were conducted on 3/13/23, between 5:10 p.m. and 5:30 p.m. Between 5:20 p.m. and 5:22 p.m. Certified nurse aide (CNA) #1 was observed standing next to Resident #16. The CNA placed three bites of the dinner meal in the mouth of Resident #16 while she stood on the right side of Resident #16. She did not sit down to assist the resident or face the resident. Observations on memory care unit during meal service were conducted on 3/14/23, between 5:05 p.m. and 5:51 p.m. Residents were served their dinner meal at 5:12 p.m. Between 5:21 p.m. and 5:51 p.m. CNA #1 was observed providing one-on-one meal service with Resident #16. CNA #1 placed a fork in the hand of Resident #16. The CNA guided her hand with the fork to the resident ' s mouth. The resident took a couple of bites. The CNA took the fork out of the resident ' s hand and handed her a spoon. The resident did not take the spoon. The resident put her hand on her plate, she placed the pasta in mouth with her hand. CNA #1 said to the resident Don ' t grab your food like that. The resident was observed chewing her food when the CNA attempted serve Resident #16 another bite while the resident was still chewing. Resident #16 backed her head away from the spoon by her mouth. The resident continued to chew as CNA #1 attempted to give her a sip of juice from her lidded cup. She told Resident #16 Come on, take a sip of juice. The CNA placed the cup spout into the resident's mouth, holding it for a few seconds. Resident #1 attempted to reach the cup with her left hand but then pulled her head back to stop drinking. -At 5:41 p.m. the resident attempted to eat her meal without utensils. CNA #1 place the spoon again in the resident hand. The resident had difficulty self guiding her spoon to her mouth. CNA #1 said to the resident, Come put it in your mouth. The resident attempted again but as the spoon was midway to her mouth, the CNA placed the cup to the resident ' s lips to take another sip. The resident set the spoon down and the CNA proceeded to feed the resident without offering to place the spoon in the resident ' s hand again or offer guided hand assistance. For the remainder of the meal observation, CNA #1 continued to provide total meal assistance for the resident. CNA #1 frequently placed the spoon in the resident ' s mouth while the resident was still chewing the previous bite. -At 5:47 p.m. the resident refused to take another bite as she continued to chew her previous bite. The CNA told the resident to take a drink while the resident was still chewing her food. The CNA placed the cup to the resident ' s mouth and said You ready, no, why, alright take a drink, come on take a drink. The resident took a sip of the juice and the CNA continued to assist the resident. On 3/15/23 at 12:15 p.m. Resident #16 was served a hamburger on a bun cut in quarters. -At 12:19 p.m. CNA #7 asked the resident if was going to try her burger. The resident asked the CNA what the food was. The CNA placed the cut hamburger in the resident ' s hand. Resident #16 placed the hamburger back down on the plate. -At 12:26 p.m. the resident picked up the hamburger patty and proceeded to independently eat several bites of it. Between 12:26 p.m. and 1:14 p.m. Resident #16 continued to independently feed herself by eating each cut section of the bun and patty. She took small bites and allowed herself time to chew her food before taking another bite. -At 1:02 p.m. another staff member attempted to collect the resident ' s plate. CNA #7 told the another staff that Resident #16 was still eating and to leave the plate. -At 1:14 p.m. the observation of the meal service concluded as Resident #16 continued to eat her meal at her own pace. Resident #16 was observed during the dinner meal on 3/15/23. The resident was provided her dinner at 5:19 p.m. CNA #5 was observed providing meal assistance to the resident. -At 5:26 p.m. Resident #16 pushed her plate away from her. The activity director (AD) observed and place the meal back in front of Resident #16. On the direction of the AD, CNA #5 sat in the chair in between Resident #16 and another resident. Between 5:26 p.m. and 5:32 p.m. CNA #5 ' s back was toward Resident #16 with knees and feet facing the other resident. The CNA turned her shoulder, reached back and picked up Resident #16 ' s fork and quickly placed the fork in Resident #16 ' s mouth. Resident#16 pulled back in surprise. The CNA turned back around to directly face the other resident again. No additional guidance was given to Resident #16. -At 5:32 p.m. Resident #16 began to wipe the table with her napkin and did not focus on her meal. No staff offered her guidance or assistance with her meal. CNA #5 ' s back was toward the resident. -At 5:35 p.m. CNA #5 turned slightly around, reaching behind herself, picked up the fork upside down and placed the fork in the resident ' s mouth. -At 5:36 p.m. the CNA used the same motion to assist the resident again with another bite. C. Record review The CPO, initiated on 10/21/21, identified memory care was required due to dementia with behavioral disturbances and history of fall with pathological fracture secondary to osteoporosis. According to the CPO, Resident #16 was unable to safely care for herself. The nutrition care plan, initiated 5/17/18, read Resident #16 had a declining cognition and activities of daily living (ADLs) as evidenced by the need for a secured unit for safety. Interventions included one on one assistance with all meals to prevent aspiration and choking. According to the care plan, the resident needed verbal cueing, and at times, physical assistance. The cognition care plan, read Resident #16 had potential/actual alteration in her cognition due to her dementia. According to the care plan, staff should provide her with reminders, reorientation, and cues as needed. Staff should provide a calm consistent routine for the resident when providing care. III. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. The resident resided in the secured memory care unit. According to the March 2023 CPO, diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type two diabetes mellitus with other specified complications. The 12/6/22 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for a mental status. The resident had short term and long term memory loss. The assessment did not identify the resident had inattention or disoriented thinking. According to the MDS assessment, Resident #18 required extensive physical assistance from one person with bed mobility, transferring, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS assessment identified Resident #18 supervision from one person with eating. The MDS assessment identified Resident #18 required oversight, encouragement and cueing with eating. B. Observation Observations during the meal service for Resident #18 were conducted on 3/13/23, 3/14/23, and 3/15/23 during the dinner meal, and on 3/15/23 during the lunch meal. Three out four of the meals, the resident was provided with a combination of guided and total meal assistance from staff members providing one to one assistance. The resident was not provided meal assistance during the dinner meal on 3/14/23. On 3/14/23 at 5:12 p.m. residents were served their meals. Staff sat next to residents and proceeded to provide meal assistance. No staff sat next to Resident #18. -At 5:35 p.m. Resident #18 remained sitting in front of her meal. There were no bites taken off her plate. Her head was down and her eyes were closed. Staff did not attempt to arouse her or encourage her to eat. They did not offer her assistance. -At 5:45 p.m. the resident lifted her head up. Staff did not attempt to encourage and offer her assistance. -At 5:51 p.m. the resident ' s head was down with her plate of food still in front of her. The resident was not offered assistance to eat her meal. The staff did not offer the resident another meal option if she did not want to eat her provided meal. Staff did not offer to lay down the resident if she was too tired to eat. C. Record review The nutritional care plan, initiated on 9/8/22, read the resident had a low body mass index (BMI) and may benefit from cueing. The cognition care plan, initiated on 9/9/22, read the resident had actual alteration in cognition related to diagnosis of dementia. She displayed confusion/disorientation and has difficulties maintaining focus. According to the care plan, staff should use cueing and redirection for assisting the resident to maintain her highest level of cognitive function. IV. Staff interview CNA #7 was interviewed on 3/15/23 at 12:58 p.m. She said Resident #18 needed assistance with her meals. She said sometimes Resident #18 did not like the food offered so they needed to offer her other choices of food that she might like, but staff needed to encourage and assist her to eat. CNA #8 was interviewed on 3/15/23 at 1:06 p.m. He said Resident #16 usually just needed encouragement and cueing related to some confusion. He said she usually did not need feeding assistance. The CNA said she tended to eat more after everyone else was finished with their meal. He said it was all about her pace of eating. The CNA said she could use utensils but finger foods seem to work best for her. CNA #8 said staff would usually only feed her if she was struggling with the utensils. He said Resident #16 mainly needed time to eat and allow her to go at her pace. The registered dietitian (RD) was interviewed on 3/16/23 at 9:41 a.m. She said Resident #16 could usually feed herself if she was placed correctly at a table, set her up with her condiments, and had her hamburger cut in quarters. The RD said she has most often observed Resident #16 eat hamburgers. She said if Resident #16 was provided a meal that required a utensil, staff may need to place the food on the fork and place it in her hand as one as one assistance but she could usually feed herself. She said if Resident #16 needed more meal assistance such as total meal assistance by placing the food in her mouth, staff should be sitting next to her, not standing next to her. The RD said she has had to provide on the spot education with staff because she had also observed them standing during meal assistance on occasion. The RD said staff should first provide the resident cueing and then if needed hand over hand guided assistance with a utensil before they attempted to totally feed her. The RD said Resident #16 usually needed cognitive cueing to get her started with her meal. The RD said Resident #16 gets her meals served cut up but she could look into if the resident was appropriate for more finger foods to help with Resident #16 ' s independence. The RD said staff should provide her with time to eat her meal and allow her to do one task at a time. She said a lot of tasks at one time when eating, could be overwhelming for Resident #16 and add to her confusion. She said staff needed to give her time to chew, allow her to go at her pace and avoid any potential choking risks. She said the speech therapist has also posted signs to remind staff on cueing and pacing needs. The RD said she would observe a dinner meal in the near future with Resident #16. She said would look if staff needed continued training with cueing, meal task sequencing, and pacing during meals. The RD said Resident #18 has had some weight fluctuations but there had not been any significant weight loss for her. She said Resident #18 has had a decline in meal intake but was maintaining her weight though snacks and a dietary supplement. The RD said she has been focusing on food preferences for Resident #18. The RD said staff should provide the resident one to one set up, ongoing cueing and assistance as needed. The RD said staff should try to arouse her if she dozed off during a meal and cue her to help stay alert. The RD said most of the staff training would need to come from nursing for their staff and she would do on the spot training when she saw concerns. She said the training focus could include cueing, pacing, attempting to wake. The director of nursing (DON) was interviewed with the corporate consultant (CC) on 3/16/23 at 3:17 p.m. The CC with the DON said the goal for residents with eating was for them to be as independent as possible. The staff should start with cueing and prompting, as then as needed place finger foods or utensils in their hand and guide them to their mouth with hand over hand assist. The CC said staff try to encourage Resident #18 to do as much as she can for herself but she still needed to have some sit with her and encourage her to eat. She said Resident #18 takes a while to eat. They said the staff should try to keep encouraging residents to eat during meals. They said staff should have attempted to wake or have her lay down if she was too tired. The CC and the DON said the facility trained staff to provide meal assistance with dignity. The DON said Resident #16 was variable in her meal assistance needs and needed encouragement to take her time. Staff should have her take a sip and take a bite alternating. Staff should also be properly facing the resident during meal assistance. The DON said they have ongoing training with staff. She said she would remind staff to slow down and not stand during meal assistance. She said she would also speak to CNA #1 about her choice in words such as come on during meals. She said every resident was different with different needs and they were going to follow the best practice for each resident. The DON and nursing home administrator (NHA) was interviewed on 3/16/23 at 5:32 p.m. The DON said the facility would be having a skills day at the end of March 2023. She said the hands-on training would include dining assistance. She said she would continue to revisit dignity through staff conversations. The NHA said the facility would continue to conduct facility wide audits and if concerns were identified, would do on the spot training.

Based on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law for one (#26) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility failed to report an allegation on 10/19/21 of potential staff-to-resident sexual abuse and/or physical abuse by Resident #1. Cross-reference F610, failure to timely and thorough investigation of an allegation of abuse. Cross-reference F742 failure to ensure the resident received appropriate treatment to attain the highest practicable mental and psychosocial well-being. Findings include: I. Facility policy The Abuse Prohibition-Occurrence Reporting policy, last reviewed 10/5/21, was provided by the facility on 11/30/21. The policy read in part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property and exploitation All residents of the facility are considered vulnerable adults due to their physical or mental disability or dependence on institutional services Each employee is responsible to report suspected alleged violations of mistreatment, neglect, exploitation of residence, and abuse of residents and/or misappropriation of resident property immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the event that caused the allegation does not involve abuse or does not result in serious bodily injury to the designated facility staff. The administrator/executive director will be notified immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or results in serious bodily injury, or no later than 24 hours if the events that caused the allegation do not involve abuse or do not result in serious bodily injury by one of the above. Staff may go immediately to the administrator/executive director if desired. Report all alleged violations and substantiated incidents immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that causes the allegation does not involve abuse or does not result in serious bodily injury to the state agency and all other agencies required (electronically using the Colorado Health Facilities portal). The Resident Rights-Abuse Reporting policy, dated June 2016, was provided by the facility on 11/30/21. The policy read in part, It is the policy of this facility that evidence or reports of abuse be thoroughly investigated and reported to the appropriate authorities. II. Record review The behavior progress note on 10/19/21 at 5:50 a.m read at 10:00 p.m. (10/18/21), Resident #26 was yelling and swearing at one of the CNAs while the resident was getting changed. During the morning rounds (10/19/21), Resident #26 started to yell and hit the CNA while she was getting changed. The provider was notified via the communication log. The nursing progress note on 10/19/21 read a CNA reported to the nurse at approximately 9:30 p.m. a bruise to the right arm of Resident #26. The nurse assessed and confirmed the bruise. The bruise was identified as reddish in color, warm to touch, and swollen. The bruise measured 8.1 centimeters (cm) by 5.0 cm. A body audit was done with no other skin issues noted. According to the progress note, the resident stated a male doctor caused the bruise. The note indicated the nurse manager (NM) was notified and an email was sent to the director of nursing (DON) and social service director (SSD). The provider was notified via a communication log. The physician assist (PA) round note on 10/20/21 read the resident's bruise was evaluated. The bruise was confirmed as 8 cm by 5 cm and healing well. According to the note, the resident was unsure how she obtained it. Nursing staff reported behaviors of swearing at staff while she was being dressed on 10/19/21. The resident reported the area was tender on 10/19/21 but did not report pain on 10/20/21. The 10/21/2021 nursing note read Resident #26's bruise to the right forearm had a knot in the center of the large bruise but did not complain of pain. The late entry SSD note written on 11/29/2021 at 4:52 p.m.(during the survey) for 10/19/21 read staff reported Resident #29 had a bruise on her right arm. According to the late entry note, the resident acquired a bruise to her arm when she was combative during cares. The SSD noted the resident continued to have significant behaviors with cares at times and was verbally and physically aggressive with staff. The nursing home administrator (NHA) provided the 10/19/21 abuse investigation on 11/30/21 at 11:33 a.m. The facility did report the allegation of physical abuse by a provider/male caregiver. A conclusion to the investigation statement read It was concluded that no abuse occurred on 10/19/21 to Resident #26. The resident appeared to have acquired the bruise due to combative outbursts during cares. As an intervention, the facility installed padding on hard surfaces of the bed. Resident #26 displays behavioral expressions such as combative towards staff, hallucinations, and calling staff vulgar names. III. Staff interviews The nursing home administrator (NHA) was interviewed on 11/29/21 at 3:02 p.m. The NHA said staff reported all allegations of abuse to her. She said anything deemed as reportable that meets the criteria would be reported and investigated. The NHA said the director of nursing (DON) or the nurse on call submitted the reportable allegations to the State Agency. The NHA was asked about the bruise and allegation that was documented on 10/19/21 for Resident #26. According to NHA, she was not familiar with the allegation a male doctor caused a bruise. The 10/19/21 note was reviewed with the NHA. The DON was interviewed on 12/1/21 at 2:53 p.m. The DON reviewed the facility's abuse protocol. She said staff should report immediately any suspected abuse, even if it was questionable. Staff were required to report the suspicions to their supervisor. The DON and the NHA were notified. The DON said an investigation would be immediately started with interviews of staff and residents. The DON said the allegation on 10/19/21 with the bruise was not reported because she was combative with care. She said the nurse charted the resident was combative. The DON said it was concluded the resident hit the bed rail. She said she felt the allegation was checked into, so it was decided not to report it any further.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to thoroughly and timely investigate allegations of physical and sexual abuse involving one (#26) of three residents reviewed for abuse out of 20 sample residents. Specifically, the facility fail to: -Thoroughly investigate an allegation of abuse with injury by a provider after a substantial sized bruise was discovered on the arm of Resident #26; and, -Initiate a timely investigation of documented potential sexual abuse of Resident #26 occuring on 11/20/21. Cross-reference F742 failure to ensure the resident received appropriate treatment to attain the highest practicable mental and psychosocial well-being. Cross-reference F609 failure to report an allegation of physical abuse with injury. Findings include: I. Facility policy and procedure The Abuse Prohibition-Occurrence Reporting policy, last reviewed 10/5/21, was provided by the facility on 11/30/21. The policy read in part, The resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property and exploitation All residents of the facility are considered vulnerable adults due to their physical or mental disability or dependence on institutional services. (Named corporation) attempts to establish an environment that is as homelike as possible and includes cultures and environment that treat each resident with respect and dignity .All investigations of supported/alleged resident abuse, neglect, exploitation of residents, mistreatment, injury of unknown source and/or misappropriation of resident property shall be properly and thoroughly investigated. According to the policy the facility should Collect data and document investigative findings. The policy identified the investigation may include, but not limited to: -Physical examination of the resident and environment; -Review documentation and the resident's medical record for events leading up to the incident; -Interview the person(s) report of the incident; -Interview the alleged victim; -Interview any potential witnesses to the incident; -Interview other residents to whom the allegation perpetrator provided care or services; and -Review and complete the documentation. The Resident Rights-Abuse Reporting policy, dated June 2016, was provided by the facility on 11/30/21. The policy read in part, It is the policy of this facility that evidence or reports of abuse be thoroughly investigated Charts, reports, observations of residents, and incident reports, are reviewed to identify events, occurrences, patterns and trends that may constitute abuse. II. Resident #26 status Resident #26, age [AGE], was admitted on [DATE], with an initial admission date of 4/26/18. According to the December 2021 computerized physician orders (CPO), the resident's diagnoses included unspecified dementia with behavioral disturbance, hallucinations, and hypertension. The 10/18/21 minimum data set (MDS) assessment documented Resident #26 had severe cognitive deficits with a brief interview for mental status (BIMS) score of five out of 15. According the MDS, Resident #26 did not have inattention, or disorganized thinking. The MDS identified under psychosis, revealed the resident had both hallucinations and delusions. The MDS did not indicate the resident had verbal, physical behaviors directed at others during the MDS look back period, however, she did exhibit other behavioral symptoms not directed at others. The MDS revealed her behavioral symptoms put her at risk for significant illness or injury and significantly interfered with her care. The MDS indicated rejections of care. Resident #26 required extensive assistance of two or more staff for bed mobility, transfers, dressing, and toileting. She requires extensive assistance from one staff member for personal hygiene and locomotion on and off the unit. III. Resident interview Resident #26 was interviewed on 11/29/21 at 2:46 p.m. Resident #26 said she did not want to have male staff work with her. She said she was not afraid of them but if she had a weapon, she would kill them. She said she did like to talk about it but tells the female staff who were nice to her. IV. Record review The abuse prevention care plan, initiated on 4/27/18, read Resident #26 had potential for abuse/neglect due to her vulnerable status living in the facility. According to the care plan, the resident had physical and cognitive impairment, visual hallucinations, resisted care and hitting staff during care. The skin care plan, initiated on 4/27/18 read Resident #26 was at risk for skin breakdown due to a history of falls with left hip fracture, decreased mobility, generalized weakness, inpaired cognition, oxygen use and incontinence. 1. Allegation of physical assault a. Progress notes The behavior progress note on 10/19/21 at 5:50 a.m read at 10:00 p.m. (10/18/21), Resident #26 was yelling and swearing at one of the CNAs while the resident was getting changed. During the morning rounds (10/19/21), Resident #26 started to yell and hit the CNA while she was getting changed. The provider was notified via the communication log. The nursing progress note on 10/19/21 read a CNA reported to the nurse at approximately 9:30 p.m. a bruise to the right arm of Resident #26. The nurse assessed and confirmed the bruise. The bruise was identified as reddish in color, warm to touch, and swollen. The bruise measured 8.1 centimeters (cm) by 5.0 cm. A body audit was done with no other skin issue noted. According to the progress note, the resident stated a male doctor caused the bruise. The note indicated the nurse manager (NM) was notified and an email was sent to the director of nursing (DON) and social service director (SSD). The provider was notified via a communication log. The physician assist (PA) rounds note on 10/20/21 read her bruise was evaluated. The bruise was confirmed as 8 cm by 5 cm and healing well. According to the note, the resident was unsure how she obtained it. Nursing staff reported behaviors of swearing at staff while she was being dressed on 10/19/21. The resident reported the area was tender on 10/19/21 but did not report pain on 10/20/21. The 10/21/21 nursing note read Resident #26's bruise to the right forearm had a knot in the center of the large bruise but did not complain of pain. The late entry SSD note on 11/29/21 at 4:52 p.m. (during the survey) for 10/19/21 read staff reported Resident #29 had a bruise on her right arm. According to the late entry note, the resident acquired a bruise to her arm when she was combative during cares. The SSD noted the resident continued to have significant behaviors with cares at times and was verbally and physically aggressive with staff. The nursing home administrator (NHA) provided the 10/19/21 abuse investigation on 11/30/21 at 11:33 a.m. According to the NHA the investigation packet she provided was the complete investigation pertaining the 10/19/21 allegation. The investigation included: -The SSD 11/29/21 late entry progress (see above). -A 10/19/21 interview with Resident #26: Resident #26 was asked how everything was going for her at the facility, the resident responded Okay. She was asked if she was afraid of anyone while at the facility, she responded No. She was asked if anyone came into her room she did not want in her room, she responded No. She was asked if anyone hurt or neglected you in any way while you are a resident at the facility, she responded No. No additional questions were asked of the resident. -An at risk for skin breakdown care plan (see above). -A resident interview audit which was conducted between 7/27/21 and 7/28/21: Six residents were asked if they felt safe at the facility including Resident #26. Five of the six residents replied yes, they felt safe. Resident #26 said yes and no according to the audit. The audit documented Resident #26 said Just as safe as anywhere else. If I tell you I will be moved and I don't want to be moved. -A second resident interview audit was conducted between 8/2/21 and 8/10/21:22 out of 23 residents said they felt safe at the facility. Resident #26 said she did not feel safe. She was asked why she did not feel safe and she responded my thinking. She said moving to California was what would make her feel safe. -A conclusion to the investigation statement: The conclusion read It was concluded that no abuse occurred on 10/19/21 to Resident #26. The resident appeared to have acquired the bruise due to combative outbursts during cares. As an intervention, the facility installed padding on hard surfaces of the bed. Resident #26 displays behavioral expressions such as combative towards staff, hallucinations, and calling staff vulgar names. The facility did not substantiate abuse. The review of the 10/19/21 investigation of a large bruise to with an allegation of abuse by a provider did not include: -Other resident interviews after 10/19/21 allegation. The last resident interviews were conducted in July 2021 and August 2021. -Staff interviews. -Witnesses to the incident the facility reported caused the bruise to determine if the resident hit the hard surface of the bed during her 10/19/21 combative behavior. -A statement or interview from who she hit, where she hit them and did she use her right arm to hit them, potentially causing the bruise. -A skin assessment on 10/19/21 immediately after she hit the hard surface of the bed/and or staff member to determine if there was an injury or redness to her skin. The skin assessment was conducted at 10:46 p.m. on 10/19/21 after a bruise was identified. -A interview or schedule of her providers to determine if she was seen by a male doctor on 10/19/21. 2. Allegation of sexual assault A. Progress notes The 11/20/21 at 2:28 a.m. combative behavior note documented Resident #26 was being changed by aid when she started to yell, this nurse assisted aid in attempts to change resident, but resident was upset at male aid stating that he touched her inappropriately. Resident was screaming, cursing and scratching at male aid. This nurse was able to calm resident down by removing male aid from room and having female aid assist in performing peri-care. Apologized to resident, resident was content by end of conversation and left in bed with call light in reach. The nursing note on 11/20/2021 at 11:51 a.m. read Resident #26 said she was not happy with the care at the facility. No additional follow up was documented regarding her statement. The nursing home administrator (NHA) provided the abuse investigation on 12/1/21. The investigation included: -The initial report from the surveyor -Progress notes -Interview with Resident #26 -Interview with LPN #3 -Interview with CNA#10 -Interview with CNA #11 -Police notification -Resident #26 abuse audits -Resident abuse audits -Education to LPN #3 -Education to CNA #10 -Staff education -Staff schedule on 11/20/21 -A conclusion summary to the investigation. The facility did not substantiate abuse. The conclusion summary read: It was concluded that no abuse occurred on 11/20/21 to Resident #26 by staff at the facility. Police supported this conclusion and did not open a case number on this report. The resident displays behavioral expressions such as combative towards staff, hallucinations, calling staff vulgar names such as racial slurs and making false accusations. The nurse that cared for the resident this night (11/20/21) did not report to her supervisor the documentation on 11/20/21 of the resident was upset at male aide stating that he touched her inappropriately because in her mind she did not interpret it as that. She stated, it was a known behavior that she makes false accusations. The nurse said she heard the resident hollering and was outside the residence door and heard the residents say don't touch me. This statement is what the nurse was referring to when documenting touched her inappropriately. The nurse stated that she did not hear the resident make any comments about sexual touching. Abuse audits were completed of the facility residents residing at the facility on 11/30/21. No additional residents reported abuse and all interviewed felt safe. Education was completed to staff regarding when to report suspicious suspicion of abuse/neglect. B. Staff interviews The nursing home administrator (NHA) was interviewed on 11/29/21 at 3:02 p.m. The NHA said staff reported all allegations of abuse to her. She said anything deemed as reportable that meets the criteria would be reported and investigated. The NHA said the director of nursing (DON) or the nurse on call submitted the reportable allegations to the State Agency. The NHA was asked about the bruise and allegation that was documented on 10/19/21 for Resident #26. According to NHA, she was not familiar with the allegation a male doctor caused a bruise. The 10/19/21 note was reviewed with the NHA. The NHA was asked about the allegation of abuse documented on 11/20/21. The NHA reviewed the note and said the nurse should have contacted her supervisor to see if the allegation was reportable and start an investigation. The NHA said she would follow up the 10/19/21 and 11/20/21 Resident #26 documented incidents. The NHA was interviewed again on 11/30/21 at 1:55 p.m. The 10/19/21 investigation packet materials were reviewed with the NHA. The NHA said they did not have resident interviews pertaining to the 10/19/21 allegation of abuse with a bruise but would start interviews today (11/30/21) for all residents. The NHA confirmed what they provided as their investigation on 10/19/21 was what they had for the investigation. The NHA said they reported and started an investigation for the 11/20/21 allegation of abuse on 11/29/21 after it was reported by the state surveyor. The social service director (SSD) was interviewed on 12/1/21 at 10:27 a.m. She said her role in allegations of abuse was to interview residents related to feeling safe at the facility. She said she would usually do a random sample of residents who needed more staff assistance with ADLs. She said residents with mild to severe cognitive loss could still tell her if they were fearful. She said she submitted the interviews to the DON. She said the DON usually led the investigations. The SSD said she did not conclude the investigations either. The SSD said she was aware of the 10/19/21 allegation with the bruise. She said it was brought up in a team meeting. She recalled the team discussing the bruise was caused when the resident was combative with staff. She said she did not interview other residents because it was clear the bruise to her right forearm was caused during care because of the location of the bruise. She said nursing would have interviewed staff. The SSD said she did not document her follow up with the resident after the allegation. She said she did not document the 10/19/21 allegation until 11/29/21. She said she forgot but usually would put in a note timely. The nurse manager (NM) was interviewed on 12/1/21 at 2:36 p.m. The NM said she was aware of Resident #26's combative behavior. She said she was notified that the 10/19/21 bruise was acquired from combative behavior with care. The DON was interviewed on 12/1/21 at 2:53 p.m. The DON reviewed the facility's abuse protocol. She said staff should report immediately any suspected abuse, even if it was questionable. Staff were required to report the suspicions to their supervisor. The DON and the NHA were notified. The DON said an investigation would be immediately started with interviews of staff and residents. The DON said the allegation on 10/19/21 with the bruise was not reported because she was combative with care. She said the nurse charted the resident was combative. The DON said it was concluded the resident hit the bed rail. The DON said she did not conduct the investigation. She said the investigation was completed by the SSD. The DON reviewed the investigation. She said she could not tell by the investigation what staff member was hit during the combative behavior, what arm the resident used to hit the staff member to conclude that was the cause of the injury or if the resident was observed hitting the bed rail. The DON said she did not conduct staff interviews and confirmed staff interviews were not included in the provided investigation. She said she would have expected staff to have been interviewed. She said the resident should have had a skin check if she hit something during the combative behavior. The DON said there should have been more of a thorough investigation. She said she felt the allegation was checked into so it was decided not to report (cross-reference F609). The DON confirmed the only documented action on 10/19/21 after the allegation of abuse with a bruise included in the investigation packet was Resident #26's interview. The DON said she was not aware of the 11/20/21 investigation because she was out the facility during the time the investigation would have occured. The 11/20/21 incident was reported when the DON became aware of the charted progress note on 11/20/21. She said the regional director of quality (RDQ) interviewed LPN #3. The LPN said she did not know why she charted the resident said she was touched inappropriately, it was not what the resident said. The DON said the abuse was not substantiated. The RDQ, the DON, and the NHA were interviewed on 12/1/21 at 4:27 p.m. regarding the 11/20/21 facility investigation. The RDQ said LPN #3 was interviewed on 11/29/21 and again on 11/30/21 regarding 11/20/21. The RDQ said the LPN said the resident required ADL care three times during the night. The RDQ said during the first round of care, CNA #11 (female) was providing the ADL care. Resident #26 started yelling and using racial slurs against CNA #11. CNA #10 (male) entered the room. The resident allowed CNA #10 to complete the care while LPN listened in from outside the room. On the second round of ADL care needs, Resident #26 did not express concerns. On the third round on care needs on 11/20/21, the LPN sent CNA #10 because the resident seemed more receptive to him. The resident was heard yelling. The LPN entered the room and observed CNA #10 cleaning the resident. LPN #3 had CNA #10 left the room and she completed the ADL care as the resident laughed and joked around with LPN. The RDQ said the direct statement the resident said according to the LPN was dont touch her, not touched her inappropriately as she documented in the resident's medical chart/record. The LPN said she did not report because the resident had a history of making false accusations and did not take the statement of sexual touching. LPN #3 told the RDQ the resident did not make a comment about sexual touching. The NHA said staff were educated on the requirement of alleged abuse to a resident. She said staff were responsible to ensure the residents felt safe and free from harm. She said they also have to complete competencies on abuse and neglect. LPN#3 did not feel it was something she needed to be reported. The RDQ said touched inappropriately should not have been documented. The RDQ and the NHA were interviewed again on 12/2/21 at 10:05 a.m. The RDQ said if the facility did not have timely investigations, then they would not have timely details. They said systematic changes based on the 11/20/21 investigation would include the daily review of all resident progress notes by the SSD and the DON. The SSD and the DON could identify if concerning words were documented for need to follow up. The NHA pertaining to the 10/19/21 allegation said it was determined the bruise was caused when she hit the CNA. She said she did not know who the CNA was. She said the facility padded bed railing. She said it could have been a combination of circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assure that services being provided met professional standards of quality for one (#20) of one resident reviewed for professional standards. Specifically, the facility failed to ensure Resident #20 had physician orders before performing wound care. Findings include: I. Facility policy and procedure A skin integrity policy and procedure last revised 2/4/21, provided by the nurse manager (NM) on 11/30/21 at 4:39 p.m. read: (Facility) seeks to utilize an interdisciplinary approach to promote best practice in areas of skin injury prevention and promotion of healing. Skin care, risk assessment and wound care treatment plans are based on resident focused goals of pressure relief, improved or sustained skin integrity, mobility, comfort, infection prevention, healing and/or palliation. It is the policy of (facility) that a resident entering the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and to provide care and services consistent with professional standards of practice to promote the prevention of pressure injury development, promote the healing of existing pressure injuries and to prevent the development of additional pressure injuries. Wound documentation guidelines: - Implement appropriate treatment from wound care protocol, or physician's orders and enter order into treatment record in electronic medical record (EMR). - Complete a new comprehensive skin risk assessment if area is pressure, arterial, venous, diabetic, neuropathic or mixed etiology. - Update care plan including nursing assistant assignment sheet or profile with new interventions. - Document in designated area in EMR related to the skin alteration including specific location. of alteration, physical description of alteration and measurements. - Document notifications that were made related to new alteration. Treatment plans: - Appropriate treatment plans will be determined through MD/NP orders and an interdisciplinary team (IDT) approach to wound prevention and healing. The resident and representative will be updated upon discovery and routinely thereafter of any skin integrity issue, what it is, potential causal factors and treatment plan. - Resident lifestyle and preferences, as with all treatment plans will be taken into consideration. - Should the resident and/or representative elect not to follow the treatment plan for any reason, the risks and benefits of making those decisions will be explained and documented in the resident record. - Continued education will be provided on an ongoing basis for risks and benefits of non-compliance and non-compliance will be care planned. - All skin integrity issues, potential and actual will be reviewed at care conferences or more often with changes in condition. Measuring and describing wounds: - Location - Type - Length and width - Depth - Tissue types - Undermining or tunneling - Staging (only for pressure ulcers) - Thickness of injury - Drainage amount and type - Odor - Presence of pain - Describe wound edges and periwound - Progress of healing II. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), diagnoses included dementia, cerebral infarction, ataxia, aphasia, anemia, depression, anxiety, difficulty walking, and fracture of right patella. The 10/13/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident was known to have delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident #20 required extensive assistance with activities of daily living (ADL) and used a wheelchair for mobility. She required supervision and verbal cues with eating. The resident experienced frequent incontinence of urine and bowels. The resident was at risk for pressure injuries with no wounds documented upon admission. IV. Record review The resident had a baseline care plan initiated 10/8/21and revised 11/2/21 that read in pertinent part: Skin integrity: At risk for alteration of skin integrity related to: Overall Braden score of 18, with individual risks identified: at risk for sensory perception, moisture due to incontinence of bladder and bowel, decreased activity, immobility, nutrition, shear and friction. Staff was to implement the following interventions: Pressure redistribution cushion in wheelchair, turn and reposition every two hours, avoid more than 30 degree side lying elevation or bed elevation, lift resident rather than sliding, complete visual body observation weekly, manage incontinence, moisturize skin, certified nurse aides (CNA) to observe skin daily during cares, pressure redistribution mattress, and position body with pillows/support devices, protect bony prominences. Bed mobility and range of motion (ROM): Resident #20 required assistance with bed mobility. Staff was to assist with repositioning every two hours. A CPO dated 10/13/21- 11/5/21 documented: Resident #20 was to have a comprehensive skin risk with Braden (skin risk assessment) observation weekly for four weeks after admission. A Braden scale performed 10/27/21 documented a score of 17 out of 22 indicating the resident was at risk for skin breakdown. A Braden scale performed 11/3/21 documented a score of 15 out of 22 indicating the resident was at risk for skin breakdown. A visual body inspection dated 11/27/21 documented in pertinent part: Resident #20 had a new pressure injury noted. See wound management for details. Pressure wound to right buttock with foam dressing intact. (There was no documentation of any wounds in the wound management section of EMR). A nursing progress note dated 11/27/21 documented: Resident #20 had a dime sized blanchable red spot to her right gluteal cleft. Mepilex was in place and removed to inspect skin. Staff to encourage turning frequently in bed and not to sit in a chair for long periods of time. Continue to monitor. A nursing progress note dated 11/30/21 documented: Resident #20's coccyx area was reddened and had scabbed/dry areas, no open areas were noted. The nurse practitioner (NP) was notified and would examine the wound. A nursing progress note dated 11/30/21 from the director of nursing (DON) documented: Small dime size area to right upper coccyx was assessed by the NP and was clarified to be chafing of the skin. A new order was written for betadine daily for seven days to keep open to air and protect from pressure. Resident #20 was able to move independently in her bed and was able to ambulate with assistance. The resident's daughter was notified of the findings and was agreeable to plan. A nurse practitioner (NP) progress note dated 11/30/21 documented: Resident #20 seen for follow up on skin shear on her right buttock noticed on 11/26/21. The RN who found the wound placed a dressing on it and wrote in a communication book, which the NP read 11/29/21. The NP was unable to see the resident on 11/29/21 as the resident was up in her wheelchair each time she tried to assess her. Plan to dab the wound with betadine daily for seven days and keep open to air/protect the wound from pressure. The betadine provides antiseptic and helps dry up the wound, it should form a scab and heal within seven days. No dressing needed as there was no drainage. Monitor the wound daily for healing. IV. Observations On 11/30/21 at 9:26 a.m. Resident #20's buttock was observed with CNA #2. The resident had a quarter sized wound on her right inner buttock that was red with scattered open/slightly scabbed areas. There was no dressing present. V. Staff interviews CNA #2 was interviewed during observation on 11/30/21 at 9:26 a.m. She said that there was a dressing on Resident #20's buttock that morning that the resident pulled off with toileting. Registered nurse (RN) #1 was interviewed on 11/30/21 at 9:34 a.m. She said she looked in the EMR and could not find orders for Resident #20 to have wound care. She said that they had to have physician orders even for a mepilex bandage to be placed. She stated that she would not be doing wound care for the resident since there were no orders. The NM was interviewed on 11/30/21 at 1:06 p.m. She said that the mepilex she charted on being present in progress note dated 11/27/21 was present on Resident #20's buttock before she assessed it and she was not the one who placed the bandage. She said that the provider should have been notified of the wound when it was discovered and orders should have been put in place before the bandage was placed on the resident. The NP was interviewed on 11/30/21 at 3:45 p.m. She said that she worked with a wound specialist from the local hospital to determine wound care regimen for residents. She said that she was on vacation when Resident #20's wound was first discovered so she was not aware of it until 11/29/21 and she was not able to assess it until 11/30/21. She said that she examined Resident #20's buttock wound on 11/30/21 and believed the wound to be caused by shearing and not pressure. She said she was going to order betadine to treat and leave the wound open to air. The NM was interviewed again on 11/30/21 at 4:00 p.m. She said that there is an on-call physician available when the NP is not available for staff to report changes to. She said the on-call physician should have been called when the new wound was observed. VI. Follow-up A CPO dated 11/30/21 documented: Apply hydrofoam dressing to right buttock, change every three days until healed. Complete pressure relief on the right buttock. A wound management detail report dated 11/30/21 documented Resident #20 had chafing on coccyx with dry scabbed areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for one (#5) of five residents reviewed for ADLs out of 20 sample residents. Specifically, the facility failed to provide consistent cueing and dining assistance when required for Resident #5, who had a diagnosis of dementia and required additional assistance at times. Findings include: I. Facility policy and procedures The Feeding of Residents by Staff policy, revised 12/9/19, was provided by the nurse manager (NM) on 12/2/21 at 1:32 p.m. It documented staff should encourage residents to eat and allow plenty of time in a relaxed and unhurried manner. It documented staff should encourage residents to feed themselves self-finger foods, if able. The Dining Room Service policy, revised 1/5/21, was provided by the NM on 12/2/21 at 1:32 p.m. It documented residents would be provided with services to maintain or improve eating skills. It documented the dining experience will enhance the individual's quality of life and be supportive of the individual's needs during dining. It documented assistance at mealtime must be appropriate for individual needs. The policy documented, Appropriate staff will assist as needed to assure adequate intake of food and fluids at the meal. Individuals will be assisted promptly and in a timely manner after the meal arrives. II. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, dementia in other diseases with behavioral disturbance and depressive episodes. Resident #5 resided in the facility's secured memory care unit (MCU). The 9/16/21 minimum data set (MDS) assessment did not document a brief interview for mental status (BIMS) score, but documented the resident was cognitively impaired with both short-term and long-term memory problems. It documented that this resident needed supervision of one for eating. B. Resident observations Resident #5 was initially observed when entering the MCU for the first time on 11/29/21 at 11:40 a.m. At this time, the staff were overheard stating that Resident #5 would be having his lunch in his room. -At 12:13 p.m., Resident #5's lunch was delivered to his room. -At 12:25 p.m., Resident #5's lunch tray had been left uncovered and was on his bedside table, with the food getting cold. No staff was observed assisting the resident with his meal or encouraging him to eat. The resident was lying in bed with his eyes closed. No staff approached the resident to let the resident know his meal had been delivered or offered to warm his food up for him. -At 12:27 p.m., a staff member was observed entering the resident's room to encourage the resident to eat, set up the resident's tray on the bedside table and placed the table over the resident in bed. The staff left the resident's room after this observation. -At 12:34 p.m., Resident #5 remained alone in his room, holding a glass of orange juice, but did not drink it. No staff were observed entering the resident's room and encouraging him to eat or drink anything. -At 12:35 p.m., licensed practical nurse (LPN) #1 stopped in to check on the resident's general status, but did not stay to encourage him to eat or see if he had eaten anything yet. -At 12:48 p.m., Resident #5 was observed to be still holding his orange juice in the same position as he had been at 12:34 p.m. (See above). The resident had not eaten any of his food at this time. No staff were interacting with the resident at this time. -At 1:16 p.m., Resident #5 was still in bed, but the bedside table had been moved to the side of the bed. The resident did not eat or drink anything and staff was not observed assisting this resident with his meal at any time. -At 1:35 p.m., Resident #5 was observed to be independently feeding himself the food on his lunch tray, which had been sitting out uncovered for one hour and twenty-two minutes and would have been cold by then. Resident #5 was observed on 11/30/21 at 12:25 p.m. He was lying in bed and his lunch was on the bedside table, pulled over the resident in bed. The resident was awake, but not eating and no staff were supervising him or encouraging him to eat or drink anything. -At 1:15 p.m., Resident #5 remained in bed, but had not eaten much of his lunch. -At 5:25 p.m., Resident #5 was observed sitting up on the side of his bed with his meal on the bedside table. He was independently eating at this time. Resident #5 was observed on 12/1/21 at 8:45 a.m. His breakfast tray was uncovered and placed on his bedside table, positioned at the side of the bed. Resident #5 was in bed, in a darkened room, with his eyes closed. His food and drinks had not been touched. -At 8:55 a.m., certified nurse aide (CNA) #4 was observed entering Resident #5's room and verbally encouraging the resident to eat. He positioned the bedside table over the bed within the resident's reach and assisted him to sit up straighter to eat. The CNA then began fixing the resident's television. The CNA was not observed cueing or encouraging the resident with his meal again prior to leaving the resident's room. -At 12:14 p.m., the resident was observed at a table by himself, in the MCU dining room. His meal had been delivered approximately 10 minutes earlier and no staff were observed providing assistance or encouragement with his meal. -At 12:37 p.m., Resident #5 was observed eating spinach with his hands. He was not using the weighted utensils provided for him and staff were not encouraging him to use them. -At 12:41 p.m., the resident was observed taking the spinach out of his mouth that he had been chewing on and putting it on his plate. -At 12:44 p.m., CNA #3 was finally observed approaching the resident and asking him if he wanted anything else to drink. This observation occurred shortly after CNA#3, observed this writer, checking on Resident #5. -At 12:50 p.m., Resident #5 had eaten approximately 50% of his meal. Resident #5 was observed on 12/2/21 at 8:15 a.m. He was seated by himself at a table in the MCU dining room. He was eating at this time, as evidenced by his having eaten approximately 50% of his meal and was using his weighted utensils at this time. -At 12:24 p.m., the resident was observed eating at a separate table by the window. Shortly after this observation, staff were observed taking him to the toilet and lying him in bed after using the bathroom. He had eaten approximately 50% of his meal. III. Record review A. Care plans The care plan dated 6/8/18 and revised 9/13/21 documented the resident was at risk for decline in his ability to feed himself due to the diagnosis of dementia and the progressive nature of the disease. It documented the resident was on a mechanical soft diet. Interventions included staff to provide supervision and assist with eating. It documented Resident #5 required set up with his meals. It documented the resident may need occasional mealtime cueing and encouragement. B. Progress notes The progress note dated 9/10/21 documented, Resident seen today to follow up on recent functional decline. He has had a poor appetite, has increasing difficulty ambulating and rarely leaves his room to dine in the dining room. This note was written by the facility's nurse practitioner (NP). The progress note dated 9/14/21 related to a nutrition review change of condition with decreased ADL's (9/10-9/16/21) documented nutrition interventions including cueing and assistance with meals. The nutritional evaluation documented, Resident with significant decline in functional status per clinical presentation and NP notes. Monitor resident at high nutrition risk weekly and continue to support nutritional needs. The progress note dated 11/16/21 documented that the resident occasionally becomes upset when other residents are disruptive in the dining area, but he is easily redirectable. The progress note dated 11/27/21 documented, DIET CONCERN: Resident does not seem to be eating on his own. Recommend resident eat in the common area for each shift or have 1:1 to help him eat. The resident seemed to have difficulty this shift with drinking from a straw. This nurse was able to feed him his lunch and Ensure and noticed a considerable decline in interest in eating. C. Meal intakes The documented meal intake for the observed lunch on 11/29/21 documented Resident #5 only ate 25-50% of his meal. On 11/30/21, Resident #5 consumed 26-50% of his breakfast and 51-75% of his lunch. On 12/1/21, Resident #5 consumed 51-75% of his breakfast and lunch and only 26-50% of his dinner. On 12/2/21, Resident #5 consumed 26-50% of his lunch and 51-75% of his dinner. D. Miscellaneous records The Minimum Effective Dose Committee (MED) Review dated 9/16/21 documented the resident was declining and was eating poorly. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/30/21 at 1:30 p.m. He said Resident #5 was kind of a loner, but could get very frustrated at times with noise. He said the resident's change of condition and recent decline in ADLs, specifically needing increased motivation and cueing to eat, was part of the Alzheimer's disease process. The registered dietician (RD) was interviewed on 11/30/21 at 1:58 p.m. She said she visited the facility weekly and knew Resident #5 well. She said the resident had been steadily declining and was discussed in the weekly nutrition at risk meeting. She said Resident #5 has been requiring a lot more cueing and some adaptive equipment to be more independent with eating. She said his dentures do not fit well and his power of attorney will not approve the expenditure for new ones. She said Resident #5 was ordered a mechanical soft diet even before his dentures became ill-fitting. She said the resident had never choked or struggled with swallowing during meals, but he went through phases of good and bad days due to his level of dementia. She said she had encouraged staff to keep trying to get him to come out for meals, as he ate much better in the dining room. She said the theme of current interventions were to have staff get him out of his room for meals or having staff routinely go into his room and encourage him to eat. She said she would expect all staff to be supervising and encouraging this resident with his meals. CNA #4 was interviewed on 12/1/21 at 9:00 a.m. He said the breakfast trays were delivered a bit earlier that morning and Resident #5 received his breakfast at approximately 8:00 a.m. that morning. He said he did not think the resident was interested in eating this morning because when he usually brought the resident's meal, he began eating right away. He said he had worked in the facility for about two weeks. He said the resident was more interested in having his television working than eating. He was asked if anyone offered to warm up the resident's food, as it had been sitting there without a cover for almost one hour. He said he would warm up the resident's food if they asked, but Resident #5 did not ask for his food to be reheated. CNA #3 was interviewed on 12/1/21 at 12:50 p.m. She said she tried to get Resident #5 to come out of his room for meals whenever she worked in the MCU. She said the resident did not eat much of his lunch yet and she would follow up with him to see if he wanted to have a peanut butter and jelly sandwich because sometimes he would eat both a sandwich and his regular meals. At this time, she said Resident #5 was finally beginning to eat this meal well. At this time, the resident had eaten approximately 50% of his regular meal. CNA #3 was interviewed again on 12/1/21 at 4:20 p.m. She said in relation to Resident #5, He does better out here (in the MCU common area dining room) eating. The NM was interviewed on 12/2/21 at 11:10 a.m. She said Resident #5 did need supervision and cueing for meal intakes at times. She said she did expect staff to check on this resident often for encouragement at meal times. She said the only times staff should not be encouraging the resident to eat was when he did not feel like eating or when their presence was actually distracting him from eating. She said these occasions should be documented, however. The social services director (SSD) was interviewed on 12/2/21 at 11:15 a.m. in relation to meal assistance for this resident who had sustained a significant weight loss. She said she would expect staff to be encouraging him and supervising him during meals, especially when he was eating in his room and not out in the main dining area. She said residents with cognitive deficits who reside in the MCU are unable to ask for their needs, like heating up meals, and the staff need to anticipate their needs. She said she could advocate for the residents and provide additional training to facility staff about consistent meal assistance with confused residents. CNA #1 was interviewed on 12/2/21 at 12:30 p.m. She said Resident #5 should always be supervised, assisted and encouraged with his meals. She said she personally cued the resident by handing him his weighted utensils and after that, he would usually start eating himself. She said he ate approximately 50% of his lunch on this date. She said when this resident ate his meals in his room, one CNA should be in there with him at all times to ensure his dentures were properly fitting and for ongoing encouragement and assistance with eating. LPN #2 was interviewed on 12/2/21 at 12:40 p.m. She said Resident #5 was somewhat of a puzzle. She said bringing him out into the main dining room for meals would sometimes benefit him and sometimes not. She said he did not like loud noises. She said her practice was to go into the room and tell the resident it was meal time. If he refused to come out to the dining area for his meal, she would ensure the resident was seated on the side of his bed with the meal on his bedside table directly in front of him. She said residents usually eat better when they are in a communal group setting. She said the kitchen staff delivered the room trays, not the CNAs working on the MCU. She said she would love for the CNAs to sit with this resident for encouragement during meal times, but sometimes the resident wanted to be alone. She said it was the staff's responsibility to anticipate resident needs and not expect cognitively impaired residents to ask for their food to be warmed up; they would just start eating the cold, unappetizing food. She said she would suggest having new MCU staff take the eight-hour training related to dementia care prior to ever working the floor on the MCU to have the basic skills to assist confused residents appropriately. The nurse practitioner consultant (NPC) was interviewed on 12/2/21 at 1:30 p.m. She said staff should be assisting and encouraging residents with their meals as often as they can. She said additional training for new staff prior to actually working on the MCU would be beneficial for everyone. The director of nursing (DON) was interviewed on 12/2/21 at 2:00 p.m. She said Resident #5 was a very particular gentleman and if he was in bed with his eyes closed, that meant you should not mess with him. She said, if he opened his eyes when staff approached, all was good. She said staff should be anticipating resident's needs and not waiting for them to ask for assistance, especially the residents residing in the MCU. She said staff could always ask the residents what they need and do more for them. She said it would be a good idea to have staff newly assigned to the MCU take the dementia training prior to working the floor rather than taking the course later on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE] and discharged on 12/2/21. According to the December 2021 computerized physician orders (CPO), diagnoses included hypercalcemia (high calcium levels), acute kidney failure, weakness, hypertension (high blood pressure), depression, and gout. The 10/12/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of two people with transfers and toileting. She required supervision while walking in the room. The resident had a fall that resulted in major injury. B. Resident interview Resident #31 was interviewed on 11/29/21 at 1:48 p.m. She said that she had a fall about three weeks prior when working with the physical therapist (PT). She said that her legs just gave out and she just went down to her knees. She said she was not injured during the fall. She also said she had a fall in the prior month while walking to the restroom. She said she was not sure what caused the fall to happen, just that she was walking with a certified nurse aide (CNA) to the restroom and just fell backwards. She said she did hit her head and had to be evaluated. She said she did not have any lasting effects from the fall. C. Record review The resident had a baseline care plan initiated 10/7/21 and revised 11/22/21 that read in pertinent part: Resident #31 required assistance with ambulation and transfers. She required the assistance of one person with a front wheeled walker for transfers, and assistance of two staff with a front wheeled walker during ambulation. The resident was at risk for falls and staff was to remind the resident to change positions slowly, use non-slip socks for the resident, and observe the resident for changes in gait, steadiness, mobility, judgement and coordination. -The resident required staff assistance prior to the fall that occurred on 10/8/21. A nursing progress note dated 10/8/21 documented in pertinent part: Resident #31 fell while being taken to the restroom. She got up with the assistance of one staff member to the walker and started ambulating towards the door and fell backwards. She hit her head and twisted her knee. The resident's daughter insisted on getting the resident back to bed before she was assessed. Three-person assistance was used to get the resident back into her bed. The NP was notified of the fall and came in to evaluate the resident. A NP progress note dated 10/8/21 documented in pertinent part: Resident #31 was evaluated after fall. The resident was walking back from the bathroom with a front wheeled walker and assistance of one staff member when she lost her balance. She fell on her tailbone and hit the back of her head. The residents' vitals and neurological signs were stable. The resident did not lose consciousness. The resident reported a headache and pain in her tailbone. The family requested the resident to go to the emergency department (ED) for a CAT scan. A CPO dated 10/8/21 documented: Send Resident #31 to the local hospital for CAT scan of the head and evaluation. A CAT scan of the head for Resident #31 dated 10/8/21 documented no hemorrhage or acute intracranial abnormality. A CAT scan of the abdomen and pelvis dated 10/8/21 documented that Resident #31 had an undisplaced fracture of the left 11th rib and a small left pleural effusion (fluid around the lungs). An X-ray of the left knee dated 10/8/21 documented that there was no injury to the left knee. A fall incident report dated 10/8/21 documented the nursing note from 10/8/21. The form marked evaluation notes as: Staff instructed to remind the resident to change positions slowly and care plan updated. It did not have additional information, evaluation, or investigation section filled out in the report. A NP progress note dated 10/11/21 documented in pertinent part: Resident #31 seen for follow-up on 11th left rib fracture sustained after fall on 10/8/21. Robaxin (muscle relaxer) was added to medications for pain. A CPO dated 11/1/21 documented: Apply a warm pack to Resident #31 ' s left knee for phlebitis three times a day. A PT progress note dated 11/2/21 documented in pertinent part: Resident #31 fell during therapy. Resident and PT were practicing going up and down steps with parallel bars when the residents left knee buckled and she needed controlled assistance to land on her knees. The resident was able to lean her hands onto the wheelchair in front of her to assist with descent. The PT then assisted the resident to a sitting position on the floor and alerted nursing staff. The resident was wearing a gait belt and non-slip socks at the time of the fall. A nursing progress note dated 11/2/21 documented in pertinent part: Resident #31 was working with the PT and fell while she was walking up stairs. Nurse saw the resident sitting on the floor. She was alert and oriented with no changes in range of motion. The resident complained of pain and Tylenol was given. The resident was able to walk with a cane and assistance of staff back to her bed. There were no bruises or open wounds noted. A fall incident report dated 11/2/21 that Resident #31 had a witnessed fall to the floor. The fall was witnessed by a PT and there was no injury. The resident was practicing going up and down a step. She was wearing a gait belt and had non-slip socks on. The nurse practitioner (NP) was in the building and notified of the fall. The resident ' s medications were reviewed and the care plan was updated. A nursing progress note dated 11/3/21 documented in pertinent part: Resident #31 was assessed for follow up to a witnessed fall on 11/2/21. The resident did not experience any injury from the fall. D. Staff interviews The director of nursing (DON) was interviewed on 12/02/21 at 11:09 a.m. She acknowledged that she did not have thorough documentation on the investigation report for the fall on 10/8/21, as the majority of the investigation form was not filled out. She said that facility did update the resident ' s care plan, changed her to a two person assist, and the CNA was using a gait belt; the facility just did not complete the follow-up documentation. Based on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#9 and #31) residents of five residents reviewed for falls and accidents out of 20 sample residents. Specifically, the facility failed to: -Ensure identified interventions were implemented in practice and on the care plan for Resident #9; -Ensure appropriate and effective interventions were in place to prevent the re-occurrence of falls for Resident #9; -Ensure fall process oversight by reviewed timely by the interdisciplinary team (IDT) for Resident #9; and, -Ensure investigations of the falls were thorough, complete, and accurate for Resident #9 and Resident #31. Findings include: I. Facility policy The Fall Assessment and Managing Fall Risk policy, last reviewed on 7/20/21, was provided by the nurse manager (NM) on 12/2/21 at 11:25 a.m. The policy read in pertinent part: Residents are assessed for fall risk during the pre-admission process, upon admission, quarterly, with a significant change in status, and as needed. Fall risk and appropriate interventions to minimize risk of falls and/or risk of injury from falls is included in the care plan. Each fall is investigated as soon as possible to determine what the resident was doing when the fall occurred and any contributing factors including: -Interview with the resident to help determine the cause of the fall; -Environmental review; -Review of the resident's transfer and ambulation status; -Review of equipment / devices in use at the time of the fall; and -Review of medications. Based on the review of the fall, interventions in the care plan are updated as indicated. Fall event and associated documentation in the electronic health record (EHR), is reviewed by the interdisciplinary team (IDT) the following day (Friday, Saturday, Sunday falls are reviewed on Monday except in the event of a holiday) for appropriate interventions. The IDT will make recommendations/changes as needed to the care plan, and profile or assignment sheet. Falls are tracked and analyzed and information is reported to the quality assurance performance improvement committee. Staff nurses are responsible to make safety rounds throughout their shift to ensure compliance with required safety devices as indicated on the residents plan of care. Interventions to reduce the incidence of falls and prevent injuries are reviewed with the resident and/or resident representative, keeping in mind the resident's desire for maintaining independence. II. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere without behavioral disturbances, unspecified dementia without behavioral disturbance, unspecified symptoms and signs involving cognitive functions and awareness, cognitive communication deficit, muscle weakness, other abnormal abnormalities gait and mobility, cerebral infarction, repeated falls, history of falls, and difficulty walking. The 9/24/21 minimum data set (MDS) assessment documented the resident had severe cognitive deficits with a brief interview for mental status (BIMS) score of three out of 15. It documented the resident required limited assistance of one person for bed mobility, transfers, personal hygiene and walking in her room. She requires extensive assistance from one for locomotion on and off the unit, dressing, and toileting. According to the MDS Resident #9 had multiple falls since her 6/22/21 admission, including a fall with injury. B. Observations Observations were conducted between 11/29/21 and 12/2/21. The resident was primarily observed in her low bed with the lights off sleeping or watching television or in the dining room for meals. On 11/29/21 at 12:47 p.m. Resident #9 was in her bed. A fall mat was beside her bed. A stack of wrapped chocolates was placed on a dresser by the door. The chocolate was not within the resident's reach (refer to fall #1 below). On 11/30/21 at 4:23 p.m. Resident #9 was in the day room. Staff were present at the nursing station but the resident was not in their direct view. The resident was waving her hand with a distraught facial expression. The resident requested to go to her room. The social service director (SSD) at the nurses ' station was informed. -At 4:25 p.m. the SSD informed certified nurse aide (CNA) #2. The CNA encouraged the resident to stay up but the resident insisted on returning to her room. The CNA laid the resident down in bed. On 12/1/21 at 8:30 a.m. CNA #6 was observed exiting out of the room of Resident #9. The resident was in bed and barefoot. Her fall mat was not beside her bed (as indicated for fall interventions below). B. Record review 1. Care plan The fall care plan, last revised on 11/18/21 read Resident #9 was at risk for falls due to Alzheimer's disease, decreased mobility, generalized weakness, adjustment disorder, apraxia, hyperglyceridemia, chronic pain, hypertension (HTN), impulsivity, poor safety awareness. She had a history of a cardiovascular accident (CVA) with right side weakness, a history of falls, incontinence, and used medication PRN (as needed) for sleep. The plan short term goal for Resident #9 was to remain free from falls through 90 days. The care plan included the following interventions to attempt to meet the goal: -The intervention initiated on 6/24/21 documented the resident needed to wear gripper socks or shoes when she was up out of bed. -The intervention initiated on 6/24/21 documented staff to observe for changes in gait, steadiness, mobility, judgment and coordination. According to the intervention, staff was to notify her provider with concerns as indicated. -The intervention initiated on 7/2/21 documented the resident was to use a pendant call light. -The intervention initiated on 7/2/21 documented signs were placed in the room to remind me to use a pendant to call and wait for assistance. -The intervention initiated on 7/12/21 documented staff to the toilet every two hours and PRN (as needed). -The intervention initiated on 7/16/21 documented on the bed by wall in room per the resident and her family's preference. -The intervention initiated on 7/20/21 documented anti-rollbacks were applied to her wheelchair. -The intervention initiated on 7/23/21 documented staff to offer to assist her to the bed rather than have her sit in her wheelchair when she was in her room. -The intervention initiated on 8/6/21 documented staff to remove the riser from the toilet. -The intervention initiated on 8/6/21 documented staff to utilize a fold down grab bar on the left side of the toilet. -The intervention initiated on 8/16/21 documented staff to remove her shoes/slippers off while she was in bed. -The intervention initiated on 10/8/21 documented staff to offer toileting before and after meals and offer to lay me down when returning to room following meals/activities/etc. -The intervention initiated on 10/22/21 documented a fall mat was to be placed on the side of the bed away from the wall. -The intervention initiated on 10/22/21 documented staffed was to keep her bed at the same height as blue tape on the wall (lower than standard height), at every shift. -The intervention initiated on 10/22/21 documented physical therapy (PT) was to evaluate and treat Resident #9. -The intervention initiated on 11/12/21 documented the resident had an order for staff to verify pendant call light was in place on every shift, times five days. -The intervention initiated on 11/18/21 documented the facility planned to move the resident to a room near nurses' station for quicker response when a room was available. According to the care plan intervention, the resident does not wait for staff support when she calls for help. 2. Resident falls a. Fall #1 The 9/16/21 progress note read Resident #9 fell on 9/16/21 at 4:45 p.m. The resident was found by a CNA on the floor beside her bed. The resident had pain to the back of the head with three centimeters (cm) in diameter swelling. The physician and family were notified and neurological checks were completed. No new orders were put in place. According to the note, the resident wore her pendant call light around her neck. Resident #9 said was going to get chocolate and did not call for staff assistance. The 9/16/21 fall incident investigation report documented the 9/16/21 fall was unwitnessed with injury. She was observed lying flat on her back bedside the bed. She was last observed and toileted at 4:20 p.m. She was discovered on the floor when she pushed her call light after she fell. The fall incident investigation indicated care planned interventions were in place at time of fall. The resident was barefoot at the time of the fall and not wearing her glasses. According to the investigation, the cause of fall was determined as the resident attempted independent ambulation without requesting assistance to retrieve her chocolate. The solution implemented to prevent the occurrence of the fall was documented to place chocolate within reach at her bedside. The investigation identified the fall was reviewed by the IDT on 9/24/21. The fall was not reviewed timely. The fall was reviewed eight days after the resident fell. The investigation report documented her care plan was reviewed and updated as indicated however, the review of the above care plan did not include placing chocolate at her bedside. b. Fall #2 The 9/17/21 progress note documented Resident #9 had a fall on 9/17/21 at 6:30 a.m. The resident was discovered by the registered nurse (RN) during her rounds. The RN found the resident sitting on the floor in front of her toilet. The resident was assessed for injury and helped back to her wheelchair. She did not present injury from the fall and denied hitting her head. According to the note, the RN asked why she did not use her call light at the time, she responded, No one told me to. They said they would be back. The note indicated the provider and the family were notified and neurological checks were ongoing for 24 hours related to her second unwitnessed fall. The 9/17/21 nurse practitioner (NP) note read Resident #9 was seen for follow up after her two unwitnessed falls. The NP documented the resident fell while trying to get out of bed to get chocolate. She hit her head and reported pain in the back of her head. She fell again the following morning when trying to get off of the toilet. The 9/17/21 fall incident investigation report documented the 9/17/21 fall was unwitnessed without injury. She was found in the bathroom. According to the investigation, staff was unsure what time she was last observed prior to the fall but was placed on the toilet by night shift. The call light was not on when she was discovered. The fall incident investigation indicated care planned interventions were in place at time of fall. The resident was wearing non-skid slippers at the time of the fall and not wearing her glasses. According to the investigation, the cause of the fall was determined that the resident was non-compliant and did not ask for help. The solution implemented to prevent the occurrence of the fall was documented to make sure her call light pendant was placed on her body and provide medication to decrease the urgency to urinate. The investigation identified the fall was reviewed by the IDT on 9/24/21. The fall was not reviewed timely. The fall was reviewed seven days after the resident fell. The investigation report documented her care plan was reviewed and updated as indicated however, the review of the above care plan identified staff were instructed as of 6/28/21, not to leave Resident #9 alone while she was in the bathroom/on the toilet. The September 2021 CPO did not include an order to include a change in medication to decrease urgency to urinate. c. Fall #3 The 10/2/21 progress note read Resident #9 fell at 5:57 p.m. The resident was not injured and her provider was notified. She denied pain and neurological checks were implemented per protocol. The 10/2/21 fall incident investigation report documented the 10/2/21 fall was unwitnessed without injury. She was observed by a CNA sitting on the floor of her room in front of her wheelchair. According to the investigation the call light was on when she fell. She was last observed at 5:30 p.m. According to the resident, she was sitting in her wheelchair before she fell. According to the investigation, it was unclear if the resident had taken herself back to her room or if she was left by staff in her wheelchair in her room. The investigation did not identify staff were interviewed after the fall to determine if staff took her to her room and left her in her wheelchair in her room. The solution implemented to prevent the occurrence of the fall was documented for the resident to be walked to dine through the restorative program, offer toileting before and after meals and activities, and place in bed when she returned to her room. The investigation identified the fall was reviewed by the IDT on 10/8/21. The fall was not reviewed timely. The fall was reviewed six days after she fell. According to the evaluation notes in the investigation report, the root cause of the fall was identified as the resident was not toileted or assisted to her bed following the return to her room. The evaluation notes identified intervention to offer her to be toileted and lay down following return to her room, however, the review of the above care plan identified staff were instructed as of 7/23/21 to offer to assist her to the bed when she was in her room. The 10/4/21 NP progress note indicated the NP followed up on the unwitnessed fall. According to the NP, the fell last night (10/3/21) at 8:00 p.m. According to the note, the resident denied having a headache or double vision. The NP referred the resident to optometry for vision check as cause of falls. The NP recommended staff to reinforce safety precautions with the resident (however, the resident had a severe cognitive impairment with a BIMS of three). In an interview with DON, she confirmed the resident did not have another fall on 10/3/21 at 8:00 p.m. She said the fall occurred on 10/2/21 at 5:57 p.m. d. Fall #4 The 10/22/21 nurse not read Resident #9 was up today (10/22/21) without complaints of pain or discomfort related to fall yesterday (10/21/21). According to the note, staff monitored call pendant and checked on the resident more often to prevent falls. The note indicated the staff strived to keep her in the day room where she could be supervised. -Review of the progress notes did not identify a nurse note written on 10/21/21 providing details of the fall after it occurred. The 10/25/21 NP note identified Resident #9 had an unwitnessed fall without injury on 10/21/21 at 4:15 p.m. The NP note indicated it was unknown if the resident hit her head but vitals and neurological checks were initiated at time of the fall. The resident denied pain and could not remember how she fell. The NP recommended staff to reinforce use of her call light and keep her in the dining room where she could be visible by staff to prevent falls. -The intervention to keep Resident #9 in the dining room to be visible by staff was not implemented on the care plan. The 10/22/21 fall incident investigation report documented the resident was found in her room sitting on the floor next to her bed without injury. According to the investigation report, the resident did not use her call light pendant, got up on her own and fell. The resident told staff she was getting up to walk. The resident was assisted to stand and cried out but denied pain. According to the investigation report form, staff were to investigate internal, external, and/or operational factors that led to the fall. The investigation report did not indicate the internal, external, and operational factors were reviewed and left the section blank. The investigation did not include when the resident was last observed or toileted. The investigation did not indicate a solution to prevent the occurrence of the fall. The investigation did not indicate when and if the fall was reviewed by the IDT. The investigation did not identify if prior care planned safety interventions were in place. Most of the investigation report was left blank. The investigation report indicated the care plan was reviewed and updated. Under the evaluation notes staff would do more frequent room checks, approach the family with a possible room move closer to the nurse station when available. According to the evaluation notes, the bed continued to be in a low position and the call light was in place. -The intervention to move the resident to a room closer to the nurses ' station when available was not implemented on the care plan until 11/18/21 following another fall (refer to DON interview a room was not available). The intervention to provide more frequent checks on the resident was not implemented on the care plan. e. Fall #5 The 11/12/21 progress note read Resident #9 found on the floor, across the room from her bed. She was found lying on her back and incontinent. According to the note, she denied pain and injuries were noted. She passed by her wheelchair and walker before she fell. The note read the resident could not verbalize where she was going due to her aphasia. She was assisted up off the floor with two staff and taken into the restroom to be cleaned up. The note indicated the resident did not call for assistance after being instructed to to ask for assistance. She was again instructed not to get up without calling for help. The 11/14/21 progress note identified the resident continued to make a crying voice when transferring or sitting up in bed but denied pain. The note indicated the resident had a small abrasion on right knee related to fall on 11/12/21 and antibiotic ointment applied. The 11/14/21 NP progress note read the NP followed up with the resident after her unwitnessed fall. The NP identified the resident had three one cm circumference red abrasions on right knee. According to the note, the resident could not remember how she fell and continued to fall despite repeated attempts to educate the resident to use the call light for assistance. The NP documented physical therapy (PT) recommended a pivot disc for night staff to help with transfers. -However, the resident continued to fall when she transferred herself. No additional recommendations were provided. The 11/12/21 fall incident investigation report documented the 11/12/21 fall as unwitnessed. According to the investigation, the resident was found at 1:00 a.m. on the floor with her legs stretched out. She was last observed and toileted at 12:00 a.m. The call light was not on at time of her fall. The resident was barefoot and was not wearing her glasses. The investigation report read she had no injuries however in days following, staff and the NP identified abrasions to her right knee. The factors that caused her to fall constituted not calling for assistance. Her call light was within reach. The identified solution to eliminate recurrence of the fall was to continue to instruct her to use the call light for assistance prior to getting up on her own. The intervention was to provide frequent observations to check on her. The investigation report indicated the care plan was reviewed and updated however, the intervention for frequent checks was not included in the care plan. The evaluation notes in the report read the resident did not have her call pendant at time of her fall. However, the 7/2/21 care planned intervention directed staff to have a call light pendant in place and remind the resident of use. According to the evaluation notes, the intervention was to have staff toilet her more often. However, according to the 7/12/21, staff were to toilet her as needed and every two hours. The resident was last toileted at 12:00 a.m. The care plan was updated on 11/12/21. The 11/12/21 intervention read Order to verify pendant call light in place times five days. The care plan did not clarify if the staff should only ensure the pendant was in place every shift for the following five days after the fall or if the direction was to ensure the pendant was in place only five days a week. The review of the CPO did not include an order for staff to verify call pendant was in place and how often. The IDT team reviewed the fall on 11/12/21. No additional information related to the fall was provided. On 11/18/21 the intervention to move the resident to a room near nurses' station for quicker response when a room was available, was added to the care plan. -However, a resident room close to the nurses ' station was not available (see DON interview). f. Fall #6 The 11/20/21 progress note read Resident #9 was in her wheelchair and tried to get up. She was witnessed to have slid out of the wheelchair and onto the floor landing on the right side of her body. She was assessed and assisted back to her chair. No injuries were noted. The 11/20/21 fall incident investigation report documented the 11/20/21 fall at 7:05 p.m. in the day room. The resident did not have an injury related to the fall. The report marked the fall as both witnessed and unwitnessed. The progress note associated indicated it was witnessed. The investigation report did not clarify who witnessed the fall. The investigation report read the resident was found on her left side, the progress note read the resident was found on her right side. The report indicated the resident was last observed at 6:45 p.m. and did not indicate when she was last toileted. The resident wore glasses and her slippers at the time of her fall. The identified internal, external, and/or operational factors that lead to the fall as the resident had right side weakness, confusion at times, and aphasic. The solution identified on the report read to assist the resident back to her wheelchair and remind her to use her call light pendant. The intervention to the fall was to reinforce the need for her to call for assistance and watch her closely. The investigation report did not clarify if staff were or were not watching her closely when she fell in the day room. The investigation report indicated the IDT team reviewed the fall on 11/20/21. No additional information related to the fall was provided. No new interventions were added to the care plan. The care plan was not updated to include staff to watch the resident closely or provide frequent checks on the resident. Staff intervention focus was to continue to remind her to call for assistance (however, the resident with a BIMS of three indicating severe cognitive impairment.) g. Fall #7 The 11/24/21 at 10:29 a.m. progress note read night shift reported Resident #9 had frequently used her call light without identified needs. According to the note, the resident was found at 7:30 a.m. by a CNA on the floor during rounds. She did not present an injury. The note indicated staff would follow the resident closely today (11/24/21). The 11/24/21 at 12:31 p.m. progress note read a bruise was developing to the right aspect of the bridge of Resident #9's nose with mild swelling. The resident denied pain. The 11/24/21 fall incident investigation report documented the 11/24/21 fall at 7:30 a.m. According to the description of the fall investigation section, the resident was found on the floor, face down. Neurological checks were unchanged from her baseline and she was alert and responsive. The resident denied pain. The investigation report noted the fall was unwitnessed. The investigation did not identify if the resident was injured. The investigation report did not identify when the resident was last observed or toileted. The investigation did not provide additional details of the fall including if her wall mounted call light was within reach, if she was wearing her call pendant. The investigation did not include internal, external, or environmental factors. Most of the investigation report was left blank. The evaluation notes in the investigation report read staff continued with routine rounding and whenever there was activity noise from the resident's location. According to the evaluation, the staff was waiting on a room to open up near the nursing station where staff would be able to quickly access the resident and get to her faster as she is too swift. The note indicated a room closer to the nurses ' station would allow increased monitoring and her preferred location was her room. She had a CVA and was impulsive. The evaluation note read it was not necessary to complete any actions as the resident attempts to transfer and just make independent movements in her room soon after receiving activity of daily living ( ADL) support. Staff will continue routine rounds and as needed rounding. The question asking staff if the care plan was reviewed and updated was marked No. The review of the care plan did not identify new interventions that were added after the 11/24/21 fall to prevent reoccurrence of falls. The investigation report did not identify a date when the fall was reviewed or if the fall was reviewed with IDT. The 11/30/21 NP progress note read Resident #9 was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to provide adequate maintenance for prevention of infection of a peripherally intravenous (PIV) line for one (#83) of one resident reviewed for PIV care services of 20 sample residents. Specifically, the facility failed to implement computerized physician orders (CPO) and failed to follow professional standards for Resident #83's PIV maintenance. Findings include: I. Professional reference [NAME] A. (2019). The National Institute of Health. The case for using a disinfecting cap for needle free connectors. British journal of nursing (Mark [NAME] Publishing), 28(14), S22-S27. Retrieved on 12/8/21 from: https://doi.org/10.12968/bjon.2019.28.14.S22 The published evidence demonstrates that passive disinfecting caps can help reduce infection rates associated with different types of central venous catheters by protecting needle free connectors from colonisation by pathogens and serving as a clear indicator that the line has been disinfected. II. Facility policy and procedure The IV- Peripheral Catheter Care (Insertion, Removal, Flushing) policy, last revised 9/13/19, was provided by the nurse manager (NM) on 11/30/21 at 11:50 a.m. and documented the following: -Selection of peripheral short catheters is based on prescribed therapies, duration of treatments (typically less than one week), availability of peripheral access sites, diagnosis, potential complications, and staff experience. III. Resident status Resident #83, age [AGE], was admitted on [DATE]. According to the December 2021 CPO, diagnoses included urinary tract infection (UTI), pseudomonas (bacterial infection), personal history of traumatic brain injury (TBI), dementia, and depression. A minimum data set (MDS) assessment had not been completed for Resident #83 at the time of the survey. IV. Resident interview and observation Resident #83 was interviewed on 11/29/21 at 11:55 a.m. She stated she had an intravenous (IV) catheter due to a UTI. She said she had it for five days since being admitted to the facility. She said that she received antibiotics through the IV twice a day at 9:00 a.m. and 9:00 p.m. to treat the infection. She stated that the dressing had not been changed. She said the IV she came to the facility with went bad and stopped working and the facility staff had to put another one in. Resident #83's IV was observed in the resident's right arm. There was no date observed on the dressing or the PIV dressing, and the IV line was not capped with an alcohol swab cap. The resident was observed to have bruising on bilateral upper extremities from multiple IV insertion attempts. On 12/2/21 at 12:54 p.m. the resident still did not have a swab cap on her IV and the dressing was still not dated. V. Record review The resident had a baseline care plan initiated 11/26/21 and revised 11/30/21 that read in pertinent part: Resident #83 was at risk for decline in her medical condition due to UTI in which she received IV antibiotics for seven days to treat. -There was no IV care documentation in the resident's care plan. A nursing progress note dated 11/24/21 documented RN attempted to insert IV three times without success. The resident refused to let RN make any more attempts after the three and asked to wait until morning. A CPO dated 11/24/21 documented: Document in progress notes any symptoms of UTI: Fever, acute dysuria or acute pain, suprapubic pain or tenderness, gross hematuria, new or marked increase in incontinence, frequency or urgency. Include characteristics of urine and how antibiotics is tolerated/effective. Discontinue documentation upon completion of antibiotics. A nursing progress note dated 11/25/21 documented: RN attempted to insert IV three times without success. The physician assistant (PA) was notified. A nursing progress note dated 11/25/21 documented: RN unable to get IV access for antibiotic, will try again the next morning. The provider was notified. A CPO dated 11/25/21 documented: Make one more attempt at IV insertion. If unsuccessful, try again tomorrow. If unsuccessful tomorrow, send to the ER for antibiotic infusion. A nursing progress note dated 11/25/21 documented: Resident #83's daughter was present and informed about unsuccessful IV insertion attempts, another attempt would be made the next day and if unsuccessful the resident would be sent to the emergency room. A nursing progress note dated 11/26/21 read in pertinent part: RN placed IV to left forearm without difficulty. A nursing progress note dated 11/27/21 read in pertinent part: Registered nurse (RN) attempted to flush left forearm IV, flush caused discomfort and IV was observed to be infiltrated (leaking out of vein into surrounding tissue). The IV was removed with no problems. A new IV was placed to the right cephalic vein with no problems noted. A CPO dated 11/29/21 documented that Resident #83 was to receive Cefepime (antibiotic) via IV line for 14 days. A CPO dated 11/30/21 documented: Change IV tubing every 24 hours. A CPO dated 11/30/21 documented: Change PIV site no more often than every 72-96 hours unless there are complications. A CPO dated 11/30/21 read: Ok to keep IV in for longer than 96 hours if patent and no signs or symptoms of phlebitis (inflammation of vein). Staff training documentation on inserting a peripheral IV and IV administration using an elastomeric device was provided by the director of nursing (DON) on 12/1/21 at 11:25 a.m. Training was completed by the NM, DON, and RN #1. -No other employees had received IV training. VI. Staff interviews RN #1 was interviewed on 11/30/21 at 8:39 a.m. She said that she believed the IV tubing should be changed every three days, however she acknowledged that there was no current order for it. She said that the tubing should be labeled with the date it was first used, however there was no label so she said she would change the tubing before IV administration since she was not sure when it had last been changed. She stated that she believed that the PIV catheter should be changed every three days as well, however was not certain. The DON was interviewed on 11/30/21 at 1:17 p.m. She stated that she believed the PIV was placed 11/27/21. She said that she believed the PIV catheter and the tubing were each good for 72 hours then should be changed, but she would need to double check. She said that it should have been documented in a progress note on when it should be changed (however, no progress note documentation found, see above). She acknowledged that there should be CPO for IV care. She said that there should have been an alcohol swab cap on the end of the IV line when not in use. She said that she had requested that a peripherally inserted central catheter (PICC) be placed for Resident #83 since there had been some difficulty maintaining IV access with the resident, however she had not received a response from the physician yet. She said only RNs performed IV care at the facility, and she believed that the RN ' received online training for IV care annually. The DON was interviewed again on 12/1/21 at 8:38 a.m. She said that she followed up and found that the IV tubing was only good for 24 hours and the PIV catheter needed to be changed every 72-96 hours. She said that orders were now entered in for IV care for Resident #83. She acknowledged that the facility did have alcohol swab caps for the end of PIV and that they should be used to prevent infection.