GRACE MANOR CARE CENTER

A complaint survey, prompted by #CO31623 was conducted on 4/17/23-4/19/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning and independent function), was admitted to the facility on 3/7/22. The facility failed to follow standards of practice in providing incontinence care by not having all supplies ready and letting go of the resident after helping the resident into the sitting position on the edge of bed. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in his quarterly 1/6/23 minimum data set (MDS) assessment. The facility failed to provide and implement two person bed mobility/toileting and dressing assistance and failed to consistently provide two person bed mobility/toileting and dressing assistance after the fall according to record review, interviews and in accordance with the post fall intervention and education provided by the director of nursing (DON). Due to the facility's failures, and the staff's failure to take proper and reasonable care when providing bed mobility/toileting and dressing assistance resulted in the resident falling from seated on the edge of bed to the floor landing on his head, neck, and shoulder. It resulted in the resident sustaining injuries of a head injury, scalp hematoma (bleeding on brain), facial bruising, cervical spine strain, and right shoulder contusion. His pain went from a baseline of 0 out of 10 (on a pain scale with 10 being the worst pain) to 8 out of 10 resulting in a decrease in functional ability and he required evaluation and treatment at the emergency department (ED). Findings include:I. Facility policy and procedureThe Falls and Fall Risk, Managing policy and procedure, revised March 2018, was provided by the DON on 4/18/23 at 10:41 a.m. It read in pertinent part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls."II. Resident #1A. Resident statusResident #1, age 86, was admitted on 3/7/22. According to the April 2023 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies, muscle weakness, unsteadiness on feet, and repeated falls. The 1/6/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance with two persons for transfers, bed mobility, toilet use, dressing, and locomotion on the unit. He required extensive assistance with one person for personal hygiene, and bathing. The resident did not require scheduled pain medication regimen and pain assessment revealed the resident had no pain (0/10) in the last five days. The 3/10/23 annual MDS assessment (after the fall on 2/27/23) revealed the resident required and received scheduled pain medication regimen, PRN (as needed) pain medications, and non-medication interventions for pain. The pain assessment revealed the resident had frequent pain in the last five days with a pain intensity of 7 out of 10. B. Resident interviewResident #1 was interviewed on 4/18/23 at 1:00 p.m. He said the fall on 2/27/23 occurred when the nurse aide (NA) left him on the edge of bed and she went to go pick something up and that was when he fell to the floor from the bed. Resident #1 said he did not have pain before the fall but the pain was quite a bit after. He said he really felt it in his neck, he had a black eye and a goose egg on the right side of his head. He said after they picked him up he noticed the right shoulder pain. He was sent to the ED. He said the Tylenol was not helping his pain the first weeks because he was very sore with a great amount of pain. He said the staff tried muscle relaxant medication but that did not seem to help. Resident #1 said he could not get out of bed unless he had help, usually one person but sometimes two. C. Record reviewReview of the ADL care plan revealed the resident required assistance with activities of daily living (ADLs) related to weakness with decreased mobility, history of fall falls prior to admission and during admission, unsteadiness, history of transient ischemic attacks (TIAs). Residents' ADL function was unpredictable from day to day, initiated 3/7/22, and revised 3/13/23. Interventions related to bed mobility, transfers and dressing included, bed mobility one to two person assist, initiated 10/24/22 and revised 3/15/23; dressing one to two person assist, initiated 3/7/22, and revised 3/15/23; resident was not to be left on edge of bed unattended, initiated 2/27/23; toileting two person assist, initiated 3/7/22, revised 10/24/22; and transfers two person assist, initiated 3/7/22, and revised 3/15/23.-Although the 1/6/23 MDS assessment had been coded as requiring extensive assistance with two persons for transfers, bed mobility, toilet use, and dressing during the seven day period. The ADL care plan revealed it had not been developed to include two persons physical assistance consistently. Review of the fall care plan revealed the resident was at risk for falls related to multiple falls prior to admission with fractured ribs, weakness, decreased mobility, unsteady balance, unsteady gait, diagnosis of history of idiopathic normal pressure hydrocephalus (fluid on the brain), history of TIA/cerebrovascular accident (stroke). Decreased safety awareness and confusion at times, initiated 3/7/22 and revised 10/31/22. New interventions introduced following fall on 2/27/23 was, "resident is not to be left on edge of bed unattended." initiated 2/27/23. Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part:2/27/23 at 9:26 a.m., "Full Description of Fall: staff alerted this nurse that resident had fallen onto floor. Nurse walked into room and saw resident laying on his right side on the floor. No shoes on, staff was present and in the bathroom when he fell. Resident's Description of Fall: states to have fallen off the bed while sitting on the edge and was not able to keep himself up. States to have hit head, no other complaints during assessment. Description of Environment Where Fall Occurred: Resident Assessment: Full assessment completed, resident sustained a goose egg on top of right forehead, extremities equally strong and baseline ROM (range of motion) intact, no pain complaints other than a headache during assessment. Alert and oriented per baseline. Vitals and neuros started per protocol. Provider, DON and daughter notified. Resident assisted off the floor two person assist and sat into wheelchair to finish getting dressed, resident taken to breakfast by choice. While eating he complained about having right arm pain and nausea. Daughter in to visit and requests that resident be seen in ED. Vital Signs / Neurological Checks: 160/91, 76, 18, 98.3, 95% , alert and oriented x3 (to person, place and time) per baseline. Injuries: first aid provided, 'goose egg' top of right forehead. Pain: Level (1-10), Pain: 4 from headache. No other complaints while doing assessment. Later while eating breakfast complains of right arm pain and nausea. Fall intervention(s): immediate & suggested long term: no more sitting on edge of bed per usual. Physician notification: messaged provider to personal phone. Responsible party notification and response: daughter and first contact."The 2/27/23 at 8:27 a.m. emergency department physician note revealed in pertinent part, "Chief complaint: Fall at 7:15 a.m. History of present illness: Wheelchair bound two-person assist at baseline presenting in the emergency department for evaluation after a fall. Patient resides at a nursing facility, they put him on the side of the bed and left the room. Patient fell off the bed and landed on his right side. Patient complaining of head, neck and right shoulder pain. He also complains of nausea when sitting up. A complete 10-point review of systems was performed and was negative. Head: right frontal hematoma with associated tenderness to palpation. Neck: Mild right paraspinal tenderness to palpation. Musculoskeletal: right shoulder-positive mild posterior lateral tenderness to palpation. Imaging CT (computerized tomography) head -Right front scalp swelling with intact calvarium. CT cervical spine: No acute traumatic injury to the cervical spine. Right shoulder x-ray: No acute fracture. Assessment: Scalp hematoma, head injury, cervical spine strain as well as right shoulder contusion, also persistent UTI (urinary tract infection). Family will discuss two-person assistance issues with the nursing facility."2/27/23 at 11:33 a.m. "Nursing note: resident back from ED, comes back with orders for Keflex 500 mg (milligrams) PO (by mouth) TID (three times per day) for ten days, first dose given at the hospital for UTI (urinary tract infection), Occupational Therapy (OT), additional instructions include ice to head 20 minutes on 60 off, Acetaminophen prn, gentle range of motion and stretching, and check in two days for a recheck. Resident to return as needed."2/28/23 at 10:00 a.m. "Nursing note: post fall monitoring continued, resident 'sore' feeling neck and right shoulder pain, prn ibuprofen administered resident laid down to rest. Chiropractor coming into the facility to see resident later this afternoon. Neuros (neurological) and vitals WNL (within normal limits)."3/1/23 at 7:17 a.m. "Orders-Administration note: Resident states neck pain from recent fall. Requests PRN med (medication)."3/1/23 at 8:51 a.m. "Orders-Administration note: PRN administration was ineffective. Follow-up Pain Scale was: 5."3/1/23 at 10:03 a.m. "Orders-administration note: Resident reports pain at neck and right arm and requests PRN med. Daughter states that tylenol has not been helping the discomfort, but that ibuprofen has been helping. Resident has a follow up doctor appointment today at 10:30 a.m."The 3/1/23 physician progress note, in pertinent part, for follow up from the ER (emergency room), "History of present illness: resident presents for follow up status post rolling out of his bed accidently. Apparently the CNA that was taking care of the patient was unaware that she had to watch and he fell out of bed. Patient was placed into bed and then left unattended; he ultimately rolled out landing on his right side. Patient has multiple bruises on the face, neck, and shoulder. Patient was evaluated in the ER with multiple studies including CT scans with negative fractures. Patient voices agreement that he would like to get his ibuprofen scheduled. Physical examination: Pleasant elderly male, wheelchair dependent with facial bruising consistent with his history of fall from bed. Facial bruising of the head, face right side. Spasticity of the strap neck muscles right greater than left no cervical spine tenderness. Assessment: Multiple contusions and dysuria (painful or difficult urination)."3/2/23 at 9:46 p.m. "Nursing note: seems out of sorts, was telling the aides that he needed to lay down and he already was and then he asked to take him out of the car when he was lying in bed."3/9/23 at 8:08 a.m. "Nursing note: provider phoned and gave order for biofreeze to be applied to neck and shoulders TID for residents discomfort."3/10/23 at 8:43 p.m. "Nursing note: This resident is S/P (status post) unwitnessed fall in his room on 3/5/2023. His vital signs remain stable and his neurological examination remains benign, at his baseline. Will continue to monitor."-Another fall on 3/5/23, seven days after fall with injury on 2/27/23. There was no charting in the progress notes of the 3/5/23 fall until 3/10/23, five days later. 3/14/23 at 10:09 a.m. Fall note description of fall, in pertinent part, "resident was found on floor between his wheelchair and recliner in room, laying on his right side. Call light was next to the wheelchair but was not able to reach while on the floor. When asked how long he had been there, he states it was just a few minutes. Residents' wheelchair wheels were unlocked at the time due to the resident self propelling himself. Resident's description of fall: resident states that he could not remember what he was reaching for but was reaching for something and slid out of his wheelchair, and due to wheels being unlocked, wheelchair rolled away. Description of environment where fall occurred: Resident was transferring himself to his recliner from his wheelchair. Wheelchair brakes were unlocked at the time of all. His call light was beside his chair and he wasn't able to use it after the fall. He did not use it before the fall either. Resident assessment: full assessment complete and VS (vital signs) taken. Neuro's are all intact. Denies pain at this time. Vital signs / neurological checks: VS and neuro's were intact with no problems noted. No injuries and no pain at this time. Fall Intervention: Immediate and suggested long term: Reacher device implemented. Physician notification and response: No orders noted from doctor. Responsible party notification and response: Daughter notified. Administration and Director of Nursing Notification: Both were notified of the fall."3/15/23 at 7:19 a.m. "Orders-administration note: Resident states that neck pain 'was getting a lot better' , but reports pain at right upper arm from previous fall."3/16/23 at 5:14 p.m. "Nursing note: Resident had complaints of pain in his right arm below his shoulder spoke with PCP (primary care physician) and order to have X-rays taken tomorrow was given and to extend his scheduled IBU (ibuprofen) for another 10 days. Daughter notified of new orders and will be present during x-rays."3/23/23 at 9:58 a.m. Annual care conference in pertinent part, "Care conference summary, late entry: Care plan reviewed at length and appropriate questions asked and answered. Daughter voiced a concern regarding one night shift CNA (certified nurse aide) continues to transfer resident alone, without a second person. DON will follow up on this."Review of the bed mobility task support provided for the past 30 days documentation revealed the following:3/19/23 at 9:04 a.m. two person physical assistance was provided. 3/20/23 at 2:28 a.m., 12:33 p.m., 8:38 p.m. one person physical assistance was provided. 3/21/23 at 10:19 a.m., 7:22 p.m. one person physical assistance was provided. 3/21/23 at 10:38 a.m. two person physical assistance was provided. 3/22/23 at 1:57 p.m., 7:15 p.m. one person physical assistance was provided. 3/23/23 at 1:30 p.m. one person physical assistance was provided. 3/24/23 at 2:58 a.m., 10:19 a.m. two person physical assistance was provided. 3/25/23 at 1:17 a.m., 7:41 p.m. one person physical assistance was provided. 3/25/23 at 10:10 a.m. two person physical assistance was provided. 3/26/23 at 9:55 a.m. one person physical assistance was provided. 3/26/23 at 9:55 a.m., 11:34 p.m. two person assistance was provided. 3/27/23 at 12:56 p.m. one person physical assistance was provided. 3/27/23 at 9:58 p.m. two person physical assistance was provided. 3/28/23 at 2:32 p.m. one person physical assistance was provided. 3/29/23 at 2:29 a.m., 10:18 a.m. one person physical assistance was provided. 3/30/23 at 4:19 a.m., 2:29 a.m. one person physical assistance was provided. 3/30/23 at 9:38 p.m. two person physical assistance was provided. 3/31/23 at 9:49 a.m. two person physical assistance was provided. 3/31/23 at 8:08 p.m. one person physical assistance was provided. 4/1/23 at 9:31 a.m. two person physical assistance was provided. 4/2/23 at 12:24 a.m. one person physical assistance was provided. 4/2/23 at 9:26 a.m. two person physical assistance was provided. 4/3/23 at 2:55 a.m., 10:11 a.m. one person physical assistance was provided. 4/4/23 at 12:23 a.m. one person physical assistance was provided. 4/4/23 at 2:57 p.m. two person physical assistance was provided. 4/5/23 at 1:48 a.m., 10:05 a.m. one person physical assistance was provided. 4/6/23 at 5:23 a.m., 1:19 p.m. one person physical assistance was provided. 4/7/23 at 2:01 a.m., 12:55 p.m. one person physical assistance was provided. 4/8/23 at 5:59 a.m., 1:11 p.m. two person physical assistance was provided. 4/8/23 at 10:46 p.m. one person physical assistance was provided. 4/9/23 at 11:50 a.m. two persons physical assistance was provided. 4/10/23 at 2:05 a.m., 10:17 a.m., 7:27 p.m. one person physical assistance was provided. 4/10/23 at 10:17 a.m. two person physical assistance was provided. 4/11/23 at 5:59 p.m. one person physical assistance was provided. 4/12/23 at 12:30 a.m., 1:47 p.m. one person physical assistance was provided. 4/12/23 at 8:19 p.m. two person physical assistance was provided. 4/13/23 at 5:58 p.m. two person physical assistance was provided. 4/14//23 at 1:47 a.m., 7:56 p.m. two person physical assistance was provided. 4/14/23 at 2:09 p.m. no setup or physical help from staff. 4/15/23 at 1:24 p.m. one person physical assistance was provided. 4/16/23 at 5:41 a.m. two person physical assistance was provided. 4/16/23 at 3:30 p.m. one person physical assistance was provided. 4/17/23 at 12:01 a.m. two person physical assistance was provided.-Although, the DON educated the staff to provide two person assistance (see below) after Resident #1's fall and the daughter requested it during the recent care conference, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. Fall risk tool assessment conducted 2/8/23 and 2/27/23 revealed high risk of fall. The February 2023 MAR (medication administration record) pain level was documented as 0 out of 10 on 2/26/23; and 7 out of 10 on 2/27/23 (after fall). Occupational therapy (OT) evaluation, dated 3/2/23, revealed right shoulder pain with movement, prior pain with movement 0 out of 10, current baseline (3/2/23) pain with movement 8 out of 10 resulting in increasing difficulty with transfers, completing ADLs and low activity tolerance. III. Facility's investigation of Resident #1's fallThe post fall investigation noted in pertinent part, "Fall investigation: Fall 2/27/23-Staff alerted the nurse that the resident had fallen forward onto the floor. Nurse walked into room and saw resident laying on his right side, bed was half way up off the floor, call button was within reach, room well lit. Root cause analysis: Poor core strength to body, resident was weak at this time. IDT (interdisciplinary team) recommendations: Do not leave resident on the side of the bed unattended. Was abuse & neglect ruled out?-No abuse. Further investigation for this fall: Completed neuros starting 2/27/23. Nurse aide (NA) #1 had left Resident #1 unattended."NA#1 statement: "I sat the patient up on the side of the bed while getting ready and dressed before getting assistance to transfer per usual, I stepped into the restroom to get him depend, and as I walked out I heard a thump and found him on the floor, and went to alert the nurse right away.""Resident did return from the hospital by facility van. He has a diagnosis of a concussion. No brain bleed, or broken bones. "On the spot re-education, date 2/27/23, conducted by DON: For Resident #1, "Resident needs two person assistance for all dressing and transfer cares. Never leave him unattended sitting on the edge of bed. His core strength is unpredictable."Inservice training class, 3/9/23, conducted by clinical administrators. "Subjects covered: abuse, neglect, donning and doffing of PPE (personal protective equipment), relias training policy, above and beyond program, Protocol on where and how to find care plans and the importance of them, Resident care including education on a Resident #1."The ADL Assistance Spot Checks paperwork was blank and had not been conducted after the fall. IV. Staff interviewsNA #1 was interviewed via telephone on 4/18/23 at 12:37 p.m. She said she obtained her certificate for NA on 12/15/22 and she was currently working toward completing her certified nurse aide (CNA) certificate. She said that Resident #1 required two person assistance for transfers, and for dressing it was usually one person assist. She said for toileting he required two person assistance and for bed mobility one person assistance for rolling and transfer from lying down to the sitting position. NA #1 said at the time of the fall on 2/27/23 she needed to let go of the resident who was seated on the edge of bed and go into the bathroom to get a brief. NA #1 said the staff usually changed him in bed but she noticed there was no brief and normally two people would help. NA #1 said the other staff member was busy with another resident. NA #1 said with Resident #1's incontinence care we would stand him and pull up pants and complete tasks that way. NA #1 said typically she would have gathered her supplies first. She said when she realized she did not have all of her supplies with her she should not have left Resident #1 seated on the edge of the bed unattended but she did and he fell. She said after he fell she checked the resident and told him she would go get the nurse. NA #1 said the DON talked to her about everything after and told her not to transfer the resident by herself and if she needed to get anything to lie the resident down and not to leave the resident unattended in an unsafe position. NA#1 said bed mobility for Resident #1 was now two person assistance for safety. Registered nurse (RN) #1 and DON were interviewed on 4/18/23 at 2:08 p.m. They said the information for the care plan was gathered in the first week after admission and went off of what the CNAs were charting of actual functioning needs. They said they made a decision on the care levels needed but they did not always care plan for extensive assistance for two people even though that was on the MDS assessment. They said the care plan may not match the MDS assessment in the functional level because the person varies. They said if the MDS assessment documented the resident needed two person assistance they may have needed it once in seven days. RN #1 said Resident #1 had his fall during bed mobility but she did not make any changes to his bed mobility care plan because he was fluctuating between needing one to two person assistance. The DON said prior to the fall bed mobility was typically one person assistance, our intervention after that time was to not be left on the edge of bed without hands on support and to transfer off the bed with two person assistance. After the fall we determined he needed one person support on the edge of bed, he had been a two person assistance for transfers, and toileting for a long time. The DON said the care plan had not been updated yet to match the training she provided to the staff which was to provide two person assistance for all dressing and all transfer cares for best safety. The DON said she meant to put two person assistance with all transfer cares (including bed mobility, transfers, toileting, and dressing) on the resident's care plan. The DON said she would update the care plan to two person assistance because that was what she said in the training she provided to the staff and to the family in the care conference. The DON, RN #1, social services coordinator (SS) acknowledged the record review of the last 30 day (after the fall) task CNA documentation for transferring and toileting revealed one person assistance was provided frequently, although the care plan stated to provide two person assistance. The DON, RN #1, and SS acknowledged the last 30 day (after the fall) task CNA documentation for bed mobility and dressing revealed one person assistance was frequently provided although the DON had educated the staff on 2/27/23 to provide two person assistance. The DON said she would re-educate the staff on ADL charting and the care levels that Resident #1 needed. The DON said she wanted Resident #1 to have two person assistance for all cares for his safety. CNA #1 was interviewed on 4/18/23 at 4:09 p.m. She said the incontinence care procedure was first to sanitize your hands and put on gloves and explain to the resident the procedure. CNA #1 said she would get supplies first when she walked into a room such as spray, wipes, and a brief. CNA #1 said then she got the resident positioned safely to change them. CNA #1 said if she needed to leave the resident, she lowered the bed and if there was a resident that she could not take her hands off, then she would use the call light for another staff member to come and help. CNA #2 was interviewed on 4/18/23 at 4:16 p.m. She said the incontinence care procedure was to knock on the door, sanitize hands, put on gloves, and tell the resident why she was there. CNA #2 said she would gather supplies first such as peri wash, wipes, briefs, and dry clothes. CNA #2 said then she would transfer the resident to the toilet or the bed depending on the resident. CNA #2 said if she forgot something, she would lay the resident down, cover them up, lower the bed then go get what she needed. CNA #2 said there were some residents that she knew not to let go of while changing them and she would have two people assist for safety. The NHA was interviewed on 4/18/23 at 4:52 p.m. The NHA acknowledged that if the NA had not taken her hand off the resident and walked away the resident would not have fallen. The NHA said it was an accident.

A revisit to the 1/11/2023 survey was completed on 3/2/2023. The facility was in compliance with the regulations surveyed.

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

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (000), wood framed structure with a partial basement used for support services only. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1964 with a new wing and kitchen area added in 2017 and is license for 31 beds. This re-certification survey conducted on February 02, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. This was evidenced by the following:The Activity Office/Storage doors is equipped with locking/latching devices were two releasing operation were required to operate the door. Life Safety Code 101 Section 7.2.1.5.3. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The Director of Maintenance acknowledged the condition of the door during the time of the tour.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following. The boiler room considered as a hazardous area, the door was not equipped with a self-closing device, as required. Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing. The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:1. No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system annually for not less than 1 ½ hours. 2. The battery-powered emergency lighting in the basement would not illuminate when the test button was pressed. 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following: Corridor doors were not maintained to close and positively latch, as required. 1. Door opening in the cross-corridor of Long Hal would not latch and close completely into the door frames creating a 20- minute smoke barrier. 2. Corridor doors were not maintained to close and positively latch, as required. Door to resident's room 1 and 22 would not close and latch into the door frame without excessive force and would not resist the passage of smoke. The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke. The Director of Maintenance acknowledge the corridor door condition during the facility tour.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents throughout the facility due to increased potential hazards of electrical fire. This was evidence by the following:The facility is utilizing power strips as a substitute for fixed wiring to supply power to juice machine within the dinning room. NFPA 70, National Electrical Code section 400-8 requires, in part, that flexible cords and cables not use as a substitute for the fixed wiring of a structure, and that they not be attached to a building surface. The Maintenance Director acknowledged the electrical installations during a tour of the facility.

A recertification survey was conducted from 1/9/23 to 1/11/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/9/23 to 1/11/23. No deficiencies were cited.

Based on observation, record review and interviews, the facility failed to ensure two (#20 and #13) of five residents were free from unnecessary psychotropic medications out of 18 sample residents. Specifically, the facility failed to monitor targeted behaviors for psychotropic medications for Resident #20 and #13. Findings include: I. Facility policy and procedure The Behavior Evaluation, Intervention and Monitoring policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 1/11/23 at 9:25 a.m. It revealed in pertinent part,"The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. "Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strive to understand, prevent or relieve the resident's distress or loss of abilities."Interventions and approaches will be based on a detailed evaluation of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. Behavior symptoms will be incorporated into the care plan. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms."II. Resident #20A. Professional referenceMosby's 2023 Nursing Drug Reference, Thirty-Sixth Edition, a current drug reference, summarized drug information:Lorazepam/Ativan is a benzodiazepine medication that is used to treat anxiety disorders, insomnia, and agitation. Side effects include dizziness, drowsiness, confusion, fatigue, depression, insomnia, weakness, vomiting, and anorexia. Sertraline/Zoloft is an antidepressant medication that is used to treat major depression. It is effective to treat panic disorders, social anxiety disorder, and generalized anxiety order. Side effects include agitation, dizziness, fatigue, confusion, and anxietyMemantine/Namenda is an anti-Alzheimer's medication that is used to treat moderate to severe dementia in Alzheimer's disease. Side effects include dizziness, confusion, and fatigue. Olanzapine/Zyprexa is an antipsychotic medication used to treat acute agitation, bipolar disorders, or schizophrenia. Side effects include agitation, hostility, dizziness, confusion, drowsiness, nausea, anorexia, tardive dyskinesia, and seizures. Residents that receive psychotropic medications must be monitored to include side effects, responses to as needed doses, mental status, orientation, sleep pattern disturbances, suicidal thoughts, and renal function over prolonged therapy. B. Resident statusResident #20, over the age 65 years, was admitted on 10/17/22. According to the January 2023 computerized physician orders (CPO) diagnoses included dementia with agitation, unspecified anxiety disorders, restlessness, agitations, and other specified depressive episodes. The 10/11/22 minimum data set (MDS) assessment revealed the resident's brief interview for mental status (BIMS) with a score of one out of 15, which indicated the resident had severe cognitive impairment. The resident required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident required limited assistance for eating. C. ObservationsOn 1/9/22 at 9:00 a.m. Resident #20 was observed sitting in her wheelchair near the nurse's station. She appeared lethargic, confused, and did not interact with staff. On the morning of 1/9/23 the resident was administered Namenda 5 milligrams, Zoloft 50 milligrams, and Lorazepam 1 milligram. -At 11:36 a.m. the resident was assisted into the dining room by certified nurse assistant (CNA) #1-At 11:38 a.m., the resident was served her noon meal. Dietary aide (DA) #1 assisted with the resident's eating because the resident could not keep her eyes open and when the resident tried to pick up her silverware she dropped the silverware and food into her lap and was unable to use her "sippy cup" without DA #1 holding it to her mouth. The resident did not open her eyes for most of the meal but she allowed staff to assist her with eating. During the meal, the resident yelled out one time and she was easily redirected by staff.-At 4:15 p.m. the resident was assisted by staff into the dining room in her wheelchair. Her eyes were open.-At 4:17 p.m. she was asleep after being assisted to the dining room table. -At 4:30 p.m. she continued to sleep while at the table. CNA #1 sat next to the resident and tried to wake her up to eat. The resident did not respond to the CNA's questions given her choices of crackers in her soup. -At 4:32 p.m. the CNA tried again to wake the resident to eat her grilled cheese sandwich, but the resident remained unresponsive to staff.-At 4:35 p.m. the CNA approached the resident to wake her for her meal and she remained unresponsive. The resident oriented for approximately one minute and -At 4:36 p.m. she went back to sleep with food in her mouth. The CNA and an additional staff member called her loudly by name six times before she responded and opened her eyes. The resident then began to chew and swallow the food in her mouth.-At 4:39 p.m. registered nurse (RN) #1 told the CNA the resident had been up since early that morning at which time the CNA informed the RN the resident had taken a nap in her bed that afternoon. The RN said the resident should return to her room for a nap and finish her evening meal at a later time. On 1/10/23 at 10:15 a.m. the resident was alert and yelling out for her son. Review of the resident's medication record revealed the nurse held the lorazepam 1 mg dose. C. Record reviewThe resident's CPO included:Lorazepam for anxiety 0.25 milligrams daily. The order was active 10/11/22-10/13/22. On 10/18/22-11/2/22 the Lorazepam 0.25 milligram order was update/changed to be administered every 12 hours as needed when the resident experiences anxiety/depression. On 11/1/22-11/12/22 the Lorazepam 0.5 milligrams order was updated/changed to be administered every six hours as needed when the resident experienced restlessness or agitation. On 1/4/23 the Lorazepam order was increased to 1.0 milligrams, was ordered and scheduled twice a day for anxiety. On 10/12/22 Zoloft 50 milligram was ordered and scheduled for every morning 1 tab every morning depression. On 10/11/22 Namenda 5 milligrams was ordered and scheduled for every morning for dementia. On 10/13/22 Zyprexa was ordered and scheduled for every evening for anxiety and depression. Behavior tracking was ordered to be assessed every shift. In October 2022, the resident had no behaviors. In November 2022, the resident had restlessness documented on 11/11/22 and 11/12/22. On 11/11/22 she responded effectively to interventions of redirection, staff listened emphatically, and staff validated her feelings. On 11/13/22 the resident had agitation and interventions of redirection, staff listened emphatically, and staff validated her feelings were ineffective. In December 2022, the resident had agitation episodes on 12/2/22, 12/12/22 and 12/13/22 and it was documented she responded to interventions of redirection, validating her feelings, and empathetic listening. In January 2023, the resident was agitated on 1/1/23. The record review indicated the resident responded effectively to interventions of redirection, staff listened emphatically, and staff validated her feelings, and activity. On 1/3/23 the resident had an episode of agitation, notes regarding what interventions were not located in the resident's medical record. The medication administration record revealed: In November 2022 the resident was administered as needed doses of lorazepam three times, with two (11/16/22 and 11/14/22) of the three times, behavioral details were not documented. In December 2022 the resident was administered three as needed doses of lorazepam, 12/22/22, 12/29/22, and 12/30/22 and the record revealed no documented behaviors for those doses.-There were no documented non-pharmacological interventions prior to the administration of the as needed lorazepam. The progress notes revealed: On 1/3/23 a progress note discussed increasing the lorazepam dose with the resident's son to which he gave consent. After that consent was obtained from the son, the physician was contacted to obtain the new medication orders/dosing changes. On 1/4/23 there was a telemedicine visit with a physician. There was no documentation in the medical record the physician reviewed the behavior changes and need for increased dosing of lorazepam. The resident's care plan included a focus for antidepressant, antipsychotic, anti-anxiety, and ACE (anti-hypertensive medication) inhibitor. The care plan focus was initiated on 10/11/22 and revised 12/15/22. Interventions indicated the staff were to monitor for side effects for anti-anxiety medication, anti-psychotropic medication, and antidepressant medication. The care plan to monitor the resident's mood and behavior that began when the resident began yelling out, having aggression, and refusing assistance from staff. This care focus was initiated on 10/14/22 and revised on 11/4/22. The interventions listed included: allow resident time to calm down and reapproach at a later time, evaluate the need and refer to psychological counseling as recommended by physician, monitor and document each behavior event. D. InterviewsThe social services designee (SSD) was interviewed on 1/10/23 at 9:41 a.m. regarding the review and scheduling of residents with the facility psychotropic review committee. The SSD residents that received psychotropic medications were reviewed by the psychotropic review committee every quarter. The SSD elaborated if a resident was not scheduled for review but was taking psychotropic medications and exhibited behaviors such as restlessness or sleep disturbances the psychotropic review committee could review the resident on an as needed basis. Resident #20 was admitted in October 2022 and was scheduled for her quarterly committee review during 1/23/23. The SSD stated Resident #20 had not been reviewed by the committee on an as needed basis although she exhibited agitation in November and December 2022 which required three changes to the lorazepam antianxiety medication. CNA #2 was interviewed on 1/10/23 at 1:00 p.m. The CNA said she was familiar and worked frequently with Resident #20. She stated after the resident was admitted she had behaviors of yelling. She stated staff learned when the resident yelled she was perhaps feeling cold. The staff were able to anticipate the needs of the resident and kept her warm with a lap blanket dressing with warmer clothes. The CNA stated the resident responded to reassurance from staff, such as holding her hand and talking about her son. The CNA stated she was aware the resident had an episode in the dining room on 1/9/22 when the staff had difficulty arousing the resident. The CNA stated the resident has had similar responses before and the staff treat the episodes as extreme fatigue and assist the resident to her bed for rest. The CNA stated she notified the nurse when she helped the resident to bed because of the extreme fatigue. Licensed practical nurse (LPN) #1 was interviewed 1/10/23 at 1:30 p.m. regarding the medications she administered the resident on 1/9/23. The LPN stated she administered Namenda 5 milligrams, Zoloft 50 mg, and lorazepam 1 milligram. The LPN stated the lorazepam was a scheduled medication and it was administered regardless of behaviors present in the resident. The LPN stated when she administered the lorazepam the resident was sitting in her wheelchair and able to swallow the tablet without difficulty. The LPN stated she was aware the resident had previous episodes of extreme fatigue on previous days and when that happened the resident was assisted to her bed. The director of nursing (DON) was interviewed on 1/10/23 at 2:55 p.m. She stated nurses should assess and document resident behaviors and side effects related to antidepressants, antianxiety, and antipsychotic medications. She verified the behavior tracking order was inclusive of all medication groups and side effects which prevented the identification and tracking of specific behaviors and how medication use was effective or not. The DON stated she was aware of the episode on 1/9/23 in which the resident was difficult to arouse in the dining room. The episode was not documented in the medical record (see observation), the DON stated the nurse should document the patient assessment, the nurse's response, physician notification, and continue to monitor the resident's status.-The nurse did not contact the physician regarding the resident on 1/9/23. E. Facility follow-up On 1/11/23 at 3:05 p.m. the DON provided a signature page for "on the spot re-education" which was signed by all staff nurses. The education regarding behavior management of residents began on 1/10/23 and was completed on 1/11/23. III. Resident #13A. Resident statusResident #13, age 67, was admitted on 7/5/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included other specified depressive episodes and unspecified mood affective disorder. The 10/4/22 minimum data set (MDS) assessment revealed that the resident had mild cognitive impairment with a brief interview of mental status (BIMS) score of twelve out of 15. No behaviors were identified in the MDS assessment for the resident. B. Record reviewThe mood and behavior care plan, initiated on 7/8/22, revealed the resident had a history of altered mood related to unspecified mood affective disorder and other specified anxiety disorders. Interventions indicated to monitor and document each behavioral event. The January 2023 CPO revealed the following physician orders for psychotropic medications:-Cymbalta 30 MG (milligrams)- give one tablet by mouth for unspecified depressive episodes- ordered 9/26/22 and discontinued 12/28/22.-Venlafaxine 75 MG (milligrams)-give one tablet via G-tube (gastrostomy tube, a tube in the stomach) for unspecified depressive episodes-ordered 12/28/22. A review of the physician progress notes revealed in pertinent part:The 7/22/22 progress note stated the resident had an underlying mood disorder but with no mention of behaviors or treatment plan. The 8/17/22 progress note was without any mention of a psychological condition. The 10/26/22 progress note stated that the resident had requested an increase in her Cymbalta for depression, which was later discontinued in favor of Venlafaxine for depression. There was no mention of the resident explaining why she wanted the increase. The patient health questionnaire-9 (PHQ-9) for depression dated 7/10/22 revealed the resident admitted with a score of nine out of twenty seven indicating mild depression. The PHQ-9 conducted again on 10/3/22 revealed a score of twelve out of twenty seven indicating moderate depression. The medication administration records (MAR) dated July 2022 through January 2023 showed active behavior tracking for lack of motivation, lack of appetite, or sadness and irritability. -There were no behaviors marked for this time period. C. Staff interviewsThe SSD was interviewed on 1/10/23 at 9:41 a.m. The SSD said Resident #13 had not been reviewed in the psychotropic meeting. The SSD had recently submitted a level 2 PASRR for an evaluation due to increased behaviors of manipulation towards staff. Resident #13 would behave contradictory towards staff, presenting more independence in her activities of daily living (ADL) for some staff and then would present as more debilitated for other staff members. -However, the resident had no behavior tracking documented despite having changes in medications, increased symptoms, and having been at the facility for over five months. RN #1 was interviewed on 1/10/23 at 1:28 p.m. She stated that Resident #13 could be difficult to provide care for. The resident micro managed the care the staff provided and would participate in care with some staff and with other staff would demand more assistance. RN #1 said she believed it was due to whether the resident trusted staff or not. CNA #1 was interviewed 1/10/23 at 1:35p.m. CNA #1 said that Resident #13 could do things like walking or standing but decided she did not want to, saying she was tired. Sometimes she would refuse to use the toilet and would rather use the brief. She stated that the resident did not want to participate in care as much as she was capable of. The SSD and DON were interviewed on 1/10/22 at 2:46 p.m. The SSD stated that Resident #13's antidepressant medication Cymbalta was changed due to the medication getting stuck in her G-tube during administration as well as her increase in behaviors of manipulating staff. A PASRR level 2 was submitted due to the medication change and increased behaviors. The SSD could not explain why the resident did not have behaviors marked in her behavior tracker for the entire period of time she had been at the facility. The SSD stated that there was not a process to train the nurses on what individual behaviors were for each resident. The SSD confirmed that since she did not conduct interviews or observations for the psychotropic drug meeting and only did a record review, a resident who had not displayed behaviors on their behavior tracker for the same period of time as Resident #13, would be recommended for a discontinuation or dose reduction of their medications. The SSD said the behavior tracker was that established target behaviors would be included and the nurses would document the behaviors that the resident displayed. The tracker would then be reviewed every quarter. The SSD acknowledged that the behaviors indicated on the trackers were generic signs/symptoms/and interventions and the same on every resident's tracker. They did not customize the tracker to reflect the individualized behaviors or interventions of each resident. The regional nurse consultant (RNC) was interviewed on 1/10/23 at 4:16 p.m. The current process for the behavior tracking was that one tracker was established for each resident. The tracker would include all the psychotropic medications the resident was taking regardless of drug class. The nursing home administrator (NHA) was interviewed on 1/11/23 at 1:23 p.m. She said that the facility would immediately begin working on going through each resident with behavior tracking and creating trackers for each medication as well as individualizing each tracker.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure hand hygiene was performed during medication administration. Findings include:I. Professional referenceCenters for Disease Control and Prevention (CDC). Hand Hygiene in Healthcare Settings: Hand Hygiene Guidance. Reviewed January 30, 2020. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 1/24/23. "Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic task (placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal." II. Facility policy The Medication Administration and Management policy, revised June 2019, was provided by the director of nurses (DON) on 1/10/23 at 1:50 p.m. The policy read in pertinent part: Administration of medication:-sanitize hands;-administer the medication as outlined; and,-wash hands with soap and water or antiseptic gel and follow the same guidelines for administering medication to the next resident. Steps for administration of eye medications: -wash hands and don gloves that are provided;-administer the eye drops as directed;-dispose gloves; and, -wash hands with soap and water or antiseptic gel and follow the same guidelines for administering medication to the next resident. III. ObservationsOn 1/10/23 at 8:40 a.m. licensed practical nurse (LPN) #1 was observed as medications were administered. LPN #1 prepared medications for Resident #17 and entered the dining room. As the LPN approached the resident, the LPN touched the resident's face, mouth, and scratched her head. The medications were administered, and the LPN returned to the medication cart. There was no hand hygiene performed after the medication administration. The LPN prepared Resident #1's medications and entered the resident's room. The LPN assisted the resident with items on her meal tray, then administered the medications. The LPN returned to the medication cart. The LPN failed to perform hand hygiene. The LPN prepared medications for Resident #16 and entered the resident's room. The LPN was searching for tissues, the LPN was observed scratching her head and touching and moving her hair/ponytail from one side of her head to the other. The LPN provided the resident with tissue and administered eye drops. She then administered oral medications, and then administered the final eye drops. The LPN completed the medication pass without performing hand hygiene administrations and did not don gloves for administration of eye medication. She performed hand hygiene after exiting the room. On 1/10/23 at 12:10 p.m. LPN #1 was observed as medications were administered. The LPN prepared medications for Resident #11 and approached the resident in the dining room. The LPN rubbed her nose, touched her mouth, face, eyeglasses, hair, and scratched her head. After administration, while walking to the medication cart, the LPN touched her nose, cheeks, eyeglasses, pill cups and other items on the medication cart. The LPN failed to perform hand hygiene. IV. Interviews LPN #1 was interviewed on 1/10/23 at 1:30 p.m. She stated she had previously received education regarding hand hygiene and was surprised she did not perform hand hygiene in the above observations. The LPN stated hand hygiene should be performed before and after administering medications. She acknowledged that in addition to hand hygiene, gloves should be worn while administering eye medications. The director of nursing (DON) was interviewed on 1/10/23 at 3:25 p.m. The DON stated when the nurse was administering medication hand hygiene was to be performed before and after administering medications to a resident. She stated if eye drops were administered, the nurse should complete hand hygiene and don gloves prior to administering the eye medication. V. Facility follow-up On 1/11/23 at 3:05 p.m. the DON provided a signature page for "on the spot re-education" which was signed by all staff nurses. The education was in regards to completing hand hygiene with medication administration, which began on 1/10/23 and was completed on 1/11/23.