WINDING TRAILS POST ACUTE

A survey prompted by #CO37228, #CO37877, and #CO37900 was conducted on 10/14/24 to 10/15/24. One deficiency was cited.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents out of three sample residents reviewed for discharge planning. Specifically, the facility failed to:-Provide an appropriate discharge process for Resident #3; and,-Notify the family that Resident #3 was transferred to another skilled nursing facility until after the resident had already been transferred. Findings include:I. Facility policy and procedureThe Discharge Summary and Plan policy, revised October 2022, was provided via email by the director of nursing (DON) on 10/14/24 at 11:33 a.m. It read in pertinent part,"When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge."Policy Interpretation and Implementation"The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident."Discharge potential (the expectation of discharging the resident from the facility within the next three months."Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes:-Where the individual plans to reside;-Arrangements that have been made for follow-up care and services;-A description of the resident's stated discharge goals;-The degree of caregiver/support person availability, capacity and capability to perform required care; and,-How the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care."The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan."The resident or representative (sponsor) is asked to provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed."A member of the IDT reviews the final post-discharge plan with the resident and family at least twenty­ four (24) hours before the discharge is to take place."II. Resident #3A. Resident statusResident #3, age 79, was admitted on 10/3/23. According to the May 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, dementia without behavioral disturbances, type 2 diabetes mellitus, hypertension (high blood pressure), anemia, unsteadiness on feet and acute kidney failure. The 4/4/24 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. He required partial to moderate assistance with showers, supervision with toileting, and was independent with oral hygiene and eating. He had an indwelling catheter, and was always incontinent with bowel. The assessment indicated the resident did not have any physical or verbal behaviors directed towards others. He did not reject care from staff. He did not wander and did not have a wander elopement guard.-However, record review and interviews indicated the resident did have a wander elopement guard (see below). B. Resident #3's family member interviewsOne of Resident #3's family members was interviewed on 10/10/24 at 1:48 p.m. The family member said all of the resident's family members were very involved with the care of Resident #3. She said Resident #3 was a gentle soul and did not have negative behaviors. The family member said he did wander throughout the facility looking for sunlight to sit in. The family member said a social worker approached another family member on Wednesday 5/29/24, in the afternoon, and asked if the family would consider transferring Resident #3 to a facility with a secured unit because the facility staff felt Resident #1 was exit seeking. The family member said the other family told the social worker that the family would consider transferring Resident #3 to another facility with the request that the family be allowed to tour a few secured facilities in order to choose which facility the family felt was best for their loved one. The family member said the conversation on 5/29/24 was the first time the facility staff had spoken with the family about possibly moving Resident #3. The family member said on Friday 5/31/24 in the afternoon, just 48 hours after the conversation about possibly transferring the resident to another facility, the family was informed Resident #3 had been transferred to a different facility. The family member said the family was shocked Resident #3 had been transferred and a family member left work to go to the facility to see what had happened. The family member said by the time the family member got there, Resident #3 was already gone. The family member said the other family member gathered Resident #3's belongings and headed to the new facility where Resident #3 had been transferred. Another family member of Resident #3 was interviewed on 10/15/24 at 3:00 p.m. The family member said the family was not afforded the privilege to look at places for Resident #3 before the facility moved him. The family member said the resident was a gentle soul and he believed the situation brought the family and the resident trauma. The family member said the new facility where Resident #3 was transferred was costing the family more money than the original facility cost. The family member said no one should live through what their family had gone through because of how Resident #3 had been transferred from the facility. C. Record reviewOn 3/4/24 a family member signed a consent form for Resident #3 to have a wander guard placed. The comprehensive care plan, initiated 10/9/23, revealed Resident #3 was an elopement risk/wanderer, was disoriented to place, had a history of attempts to leave the facility unattended, had impaired safety awareness and wandered aimlessly. The resident had impaired cognitive function/dementia or impaired thought processes with dementia and wandered with no purpose. Pertinent interventions included a wander guard to alert staff to the resident's attempts to leave through the doors (initiated 5/23/24), one-to-one supervision at all times (initiated 5/24/24) and discussing concerns regarding the resident's overall status/health with the resident/family as needed (initiated 5/25/24). A 5/31/24 at 12:32 p.m. social services progress note revealed, the social service worker received an email from the receiving facility for Resident #3 that they were able to accept the resident.-However, according to family interviews (see above) and staff interviews (see below), the family was not notified until after the resident had already been transferred to the other facility. A 5/31/24 at 5:10 p.m. social service progress note revealed the former social service director (SSD), who was now one of the facility's social service assistants (SSA), left a voicemail for the family in regards to Resident #3's discharge. The progress note documented in pertinent part, "(SSD) Apologized for how social services handled the discharge by not providing proper notice and the proper documentation support in the efforts of finding proper placement for (Resident #3). SSD stated that there will be reeducation and training regarding how SSA can better and appropriately handle future discharges. Furthermore, SSD outlined the reasons for discharge regarding safety concerns with wandering around the facility. SSD explained that the new facility will be safer for the resident and that they were able to accept him in a placement in (the same city). SSD accepted full responsibility of the actions of the social services team and will ensure the proper training and education is completed."-There was no further documentation in Resident #3's electronic medical record (EMR) regarding the resident's transfer to the new facility on 5/31/24. III. Staff interviewsThe DON and the corporate consultant (CC) were interviewed together on 10/14/24 at 12:15 p.m. The DON and the CC said Resident #3 was a sweet person who had a wander guard and often tried to wander out the door. Both the DON and the CC said the discharge for Resident #3 was not done correctly. The DON and the CC said the facility did not call the family, nor did they provide the family with other facility names to go and look at before the resident was discharged to a new facility. The DON and the CC said the facility cut the family out and did not tell the family about the place or let the family go visit the new place ahead of time. The DON and the CC said the facility had a breakdown in their process for discharge. The DON and the CC said since the incident happened to Resident #3, the facility management developed a better way to ensure individuals would be discharged properly. The DON and the CC said discharges were now discussed in morning meetings and, if there would be a discharge, everyone on the interdisciplinary team (IDT) team would be involved in the discharge planning. The SSA (who was the facility's former SSD) was interviewed on 10/15/24 at 1:00 p.m. The SSA said he was the SSD at the time of Resident #3's discharge. The SSA said he was not involved in the situation until the end of the day on 5/31/24. The SSA said the resident was exit seeking and did have a wander guard on for many months. The SSA said there was a lot of miscommunication between the former nursing home administrator (FNHA) and the family of Resident #3. The SSA said as soon as the FNHA got word the receiving facility approved the resident's transfer, the FNHA sent Resident #3 there immediately. The SSA said the family was not given notice nor was the family given any choices of places to visit for Resident #3. The SSA said the situation did not happen the way a discharge was supposed to happen. The SSA said the family was not called until late afternoon on 5/31/24, after Resident #3 had already been transferred to the new facility. The SSA said he did not write any discharge care plans or a discharge summary before or after Resident #3 was discharged.

A complaint survey, prompted by #CO36507 was conducted on 7/10/24. No deficiencies were cited.

A revisit survey was completed on 7/10/24 for all previous deficiencies cited on 5/9/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 7/10/24 for all previous deficiencies cited on 5/9/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 5/9/24 for all previous deficiencies cited on 3/7/24. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure the right to refuse treatment for one (#14) of three residents reviewed out of 25 sample residents. Specifically, the facility failed to ensure Resident #14 was not treated and administered medications against his wishes. Findings include:I. Facility policyThe Residents Rights policy, revised December 2016, was provided by regional director of clinical services (RDCS) #1 on 5/9/24 at 1:14 p.m. It read in pertinent part,"These rights include the right to exercise his or her rights without interference, coercion, discrimination or reprisal from the facility, be informed about his or her rights and responsibilities and be informed of, and participate in his or her care planning and treatment."The Administering Medications policy, revised April 2019, was provided by RDCS #1 on 5/9/24 at 1:14 p.m. It read in pertinent part,"If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (medication administration record) space provided for that drug and dose."II. Resident #14A. Resident statusResident #14, age 77, was admitted on 12/18/23. According to the May 2024 computerized physician orders (CPO), diagnoses included aphasia (inability to communicate effectively) following cerebral infarction (stroke), diabetes, pulmonary embolism (blood clot), paranoid personality disorder (mental illness with pattern of distrust and suspicion of others) and dementia. The 3/20/24 minimum data set (MDS) assessment revealed Resident #14 had short and long term memory problems according to staff interviews. He was independent with eating, oral and personal hygiene and required supervision with showering and dressing. B. ObservationOn 5/9/24 at 11:40 a.m., Resident #14 was observed walking in the hallway. He was dressed and well-groomed. Resident #14 was accompanied by a staff member (had one to one supervision). The resident was speaking, however his speech was difficult to understand. C. Record reviewThe psychosocial/behavior care plan, revised 3/8/24, revealed a plan for medication as ordered, which specified "may mix medications in resident's food as resident has increased paranoia and aggression when attempting to give in pill form." On 4/17/24 at 8:00 a.m. a physician order was initiated for Risperidone 4 milligrams (mg) by mouth one time a day for irritation. The order instructed to mix medication with Resident #14's meal. On 4/26/24 at 8:00 a.m.,a physician order was initiated for Sertraline 50 mg, oral concentrate (liquid), one time per day for depression. The order was discontinued on 5/3/24. On 4/27/24 at 8:00 a.m. a physician order was initiated for Lamictal 25 mg oral solution (liquid), one time per day for 14 days, for post traumatic stress disorder (PTSD). The order was discontinued on 5/3/24 at 10:51 a.m. On 4/28/24 at 1:37 p.m. the primary care physician (PCP) note revealed Resident #14 was taking medications mixed into his hot chocolate. On 4/30/24 at 10:31 a.m. a nursing note revealed Resident #14 refused medication. The note documented the nurse tried two different times mixing the medication with his drink. The resident got suspicious and did not accept the drink containing the medications. On 5/1/24 at 12:30 p.m. a psychiatric progress note revealed the nursing staff told the physician that the resident may be catching on to medication-masking and had refused several doses. It was recommended to consider switching to flavorless Risperidone oral solution. On 5/1/24 at 5:19 p.m. the PCP note revealed Resident #14 "was taking his medications in hot chocolate until 4/28/24. The resident was now refusing. He was not taking any of his medications for days and was very irritable. The note documented that the staff felt that the resident could taste the Lamictal and that was why he was refusing his medications and was now eating less."On 5/6/24 a certified nurse aide (CNA) note documented for the 6:00 a.m. to 6:00 p.m. shift revealed Resident #14 did not eat breakfast or lunch. -A review of Resident #14's meal intake record from 4/10/24 to 5/8/24 revealed he refused to eat or ate less than 50% of meals on 4/28/24, 4/29/24, 4/30/24, 5/1/24, 5/4/24 and 5/6/24. Prior to 4/28/24, Resident #14 ate more than 50% of breakfast and lunch 90% of the time during the 4/10/24 to 5/8/24 period..D. InterviewsThe detective from the police department (DPD) was interviewed on 5/9/24 at 10:28 a.m. The DPD said he received a report the facility had forced Resident #14 to take medications by putting it into his food, possibly a chocolate shake, for the previous two weeks. The DPD said he was told the facility had contacted a mental health worker for assistance with alternate placement. He said the mental health worker reported the facility had reported hiding a prescribed medication, Risperidone, in Resident #14's food. Licensed practical nurse (LPN) #1 was interviewed on 5/9/24 at 11:54 a.m. LPN #1 said Resident #14 loved mocha coffee and enjoyed making the drink. She said the nursing staff put his medications in his drink to get him to accept the medications. LPN #1 said Resident #14 did not like pills in his mouth or handed to him and often refused medications. She said the licensed nurses had been giving medications to Resident #14 in his drink for about a month. LPN #1 said nurses spoke to the doctor about giving medications in his drink and it seemed to work. The director of nursing (DON) was interviewed on 5/9/24 at 12:55 p.m. The DON said nursing staff were crushing medication and putting it into Resident #14's hot chocolate without his knowledge. She said Resident #14 did not notice the medication was in the drink until the addition of the Lamictal and Sertraline medications were added. The DON said the new medications had an aftertaste and Resident #14 would no longer take them. She said Resident #14 began wanting to make his drink himself as he did not trust the staff and knew staff were hiding his medications in his drink. The DON said she knew staff were not supposed to disguise or mask medications and residents should always be informed what medications were being administered to them. The contract nurse consultant (CNC) was interviewed on 5/9/24 at 1:30 p.m. The CNC said she realized the facility was not to mask or disguise medications per the regulation. She said the guardian consented to hiding the medication in the resident's drink. The CNC said the team developed a plan to administer the medication without Resident #14's knowledge in order to minimize risk of harm to himself and others. The nursing home administrator (NHA) was interviewed on 5/9/24 at 2:47 p.m. The NHA said he was aware that staff were masking medications from Resident #14 and did not tell Resident #14 he was receiving the medications. He said the process of disguising the medication was care planned and Resident #14's guardian was aware. He said the resident had a right to refuse medication. Resident #14's representative was interviewed on 5/10/24 at 9:40 a.m. The representative said the facility had spoken with him about Resident #14's medications and they were hiding Resident #14's medications in his beverages. He said he did consent to the administration of medications without Resident #14's knowledge. He said the facility did not say anything to him about Resident #14's right to refuse administration of medications.

A revisit survey was completed on 5/9/24 for all previous deficiencies cited on 3/7/24. Two deficiencies were cited.

A complaint survey, prompted by #CO35369, #CO35370 and #CO35402 was conducted on 3/26/24. No deficiencies were cited.

A complaint survey, prompted by #CO34885, #CO35087, #CO35090, #CO35092, #CO35097, #CO35102, #CO35114 was conducted on 2/29/24 to 3/7/24. Thirteen deficiencies were cited.

Based on record review and interviews, the facility failed to ensure four (#18, #7, #3 and #15) out of four residents reviewed out of 38 sample residents were protected from resident to resident physical abuse by Resident #6 and Resident #14. Resident #6 admitted on 1/1/24 with a history of aggression. Between 1/17/24 and 1/18/24, Resident #6 was involved in at least three altercations with Residents #18, #7 and #3. The altercation with Resident #3 resulted in Resident #3 being transferred to the hospital for head trauma where he received twelve staples to his head. The facility was aware Resident #6 was wandering into other residents' rooms but failed to implement a plan to monitor the resident and redirect her from other residents. Additionally, the facility failed to implement a plan to prevent physical abuse to Resident #15, by Resident #14 who had known aggressive behavior. Findings include: I. Facility policyThe Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part,"Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation,or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. "The nurse will assess the individual and document related findings. The nurse will report findings to the physician. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. "The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditionsaffecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process."II. Resident to resident physical abuse by Resident #6 to Resident #18A. Incident on 1/17/24 On 1/17/24 at 11:20 a.m., the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room calmly when Resident #6 repeatedly went into Resident #18's room. Resident #18 asked her to stop coming into his room. When Resident #18 was not looking, Resident #6 took his cane. Resident #18 yelled for the nurse. When the nurse went into the room Resident #18 was pulling Resident #6's hair. The residents were separated, and the facility had decided to move Resident #6's room for "safety concerns." Resident #6 was encouraged to socialize with residents in common areas and not in resident rooms. On 1/17/24 at 11:34 a.m. the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room and calm. Resident #6 repeatedly went in Resident #18's room even though the nurse asked her not to. Resident #6 took Resident #18's cane. When the nurse arrived Resident #18 was pulling Resident #6's hair. Resident #6 said she was punched. The NHA recovered Resident #18's cane. There were no injuries noted for either resident and Resident #6 agreed to a room move for safety concerns. On 1/17/24 at 4:57 p.m. a Change of Condition Evaluation documented Resident #6 was involved in a physical and verbal altercation. The evaluation documented Resident #6 was verbally and physically aggressive. The 1/17/24 facility investigation was received from the nursing home administrator (NHA) on 3/4/24 at 10:00 a.m. The investigation documented the Resident #6 and Resident #18 were immediately separated and there were no injuries to either resident. The investigation file contained a follow up statement from Resident #18 on 1/18/24 stating he was doing better and no longer upset. The investigation contained two resident interviews. One resident said they had heard about residents fighting on 1/17/24 and one resident said another resident had tried to punch her wheelchair and she had to tell him to stop.-There were no further resident interviews and no staff interviews found in the facility's investigation file.-The investigation documented that no agencies were notified such as the police, ombudsman or State Agency (cross reference F609 for failure to report an alleged violation). B. Resident #61. Resident statusResident #6, less than age 65, was admitted on 1/11/24 and discharged to the hospital on 1/18/24. According to the January 2024 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), alcohol abuse, bulimia nervosa (eating disorder), encephalopathy (alteration in brain function or structure), borderline personality and major depression with severe psychotic symptoms. According to the 1/12/24 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. The assessment documented the resident had symptoms of feeling down, hopeless, trouble concentrating with little pleasure in doing things. The assessment documented the resident did not wander but had a wander prevention device. 2. Record reviewA Preadmission Screening and Resident Review (PASRR) Level II Notice of Determination (NOD) for Mental Illness (MI), dated 12/18/24, documented Resident #6 had an open legal case for felony menacing and Resident #6's representative reported Resident #6 had been exhibiting aggressive behavior. The PASRR Level II was in the facility medical record for Resident #6 and had a printed date in the corner of 1/12/24. Resident #6's behavior care plan, initiated 1/15/24, documented Resident #6 wandered into other resident rooms and took or touched their belongings. The goal was the resident would accept supportive strategies and demonstrate adequate control of emotions which would not result in injury to self or others. Interventions included, administer medications as ordered, document behavior, encourage resident to verbalize feelings, establish rapport, maintain a calm, slow, understandable approach, notify the physician, responsible party of aggression and abusive behavior, observe and document changes in behavior, including frequency of occurrence and potential triggers, observe for clinical factors influencing behavioral indicators, observe resident's mood and response to medication, referred for psychiatry services-The care plan did not have interventions to address the resident's known behavior of wandering into other resident rooms and taking their belongings. C. Resident #181. Resident statusResident #18, less than age 65, was admitted on 1/10/24. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depression, personality disorder, post traumatic stress disorder (PTSD) and traumatic brain injury (TBI). According to the 1/12/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. D. Staff interviewsThe NHA and the director of nursing (DON) were interviewed on 3/5/24 at 10:23 a.m. The NHA said she remembered Resident #6 took Resident #18's cane. The NHA said Resident #6 did take Resident #18's cane and the NHA found it and returned it to Resident #18. The NHA said Resident #18 then pulled Resident #6's hair. The NHA said there were no further interviews of residents because the residents on that unit could not tell staff what was going on. She said the facility had to look for non verbal things. -However, the NHA could not describe what non verbal things were looked for. The NHA said she did not notify the police because she did not have time to. She said she would notify them. The NHA said she notified the ombudsman after the second incident (see below). The NHA said Resident #6 agreed to a room move. She moved to a room on the 300 hall. III. Resident to resident physical abuse by Resident #6 to Resident #7 A. Interviews regarding the incident on 1/17/24A frequent visitor (FV) was interviewed on 3/4/24 at 2:38 p.m. The FV said she had several serious complaints regarding the facility. She said she was told Resident #6 placed a blanket around Resident #7's face. She said Resident #7 had been unable to move to protect herself. The FV said Resident #6 was then moved to a new hall where she assaulted Resident #3, resulting in 12 stitches to his face and his entire face was black and blue (see below). The FV reported that residents and staff were feeling unsafe and afraid to report facility issues such as abuse. The FV said the staff were told not to report the abuse by the DON and that she would "handle it." The FV said she called the police as well as other resident family members and reported the incidents. The FV further said staff were told not to speak to the State Agency by the NHA or there would be consequences. A restorative nurse aide (RNA) was interviewed on 3/6/24 at 1:00 p.m. He said he was present the day Resident #6 assaulted Resident #7. He could not remember the exact day it occurred. He said he remembered staff were scrambling around to keep Resident #6 out of Resident #7's room because Resident #6 had turned off Resident #7's oxygen and was holding a blanket over her face. He said a staff member had to block the door so Resident #6 would not go back in the room with Resident #7. He said Resident #6 was moved to the 100 hall. The RNA said staff told him they were not to report the incident as abuse or that Resident #6 assaulted Resident #7, but to report it as a fall. The RNA said the facility had not provided any training in mental health or dementia (cross-reference F940 for failure to develop and implement an effective staff training program). The DON was interviewed again on 3/7/24 at 12:37 p.m. The DON said she was told Resident #6 was holding a blanket around Resident #7's face around 1/17/24. She said she was not at the facility that day. The DON said the NHA was at the facility and handled the situation. The DON said the NHA should have done an investigation but she did not (cross-reference F610 for failure to investigate an alleged violation). She said the nurse on duty witnessed the assault but she was an agency nurse and had not returned the DON's calls. The DON said she found out about the incident a few days after it occurred. The DON looked at her computer and said there was no assessment of Resident #7. She said Resident #6 was then moved to a new room and that was when she assaulted Resident #3 (see below).-The phone number and name of the agency nurse was requested and not received by the end of the survey on 3/7/24.-The NHA was unavailable for an interview. B. Resident #71. Resident statusResident #7, age 81, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses include Parkinson's disease, major depression and dementia. According to the 1/30/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. She was totally dependent on staff for transfers and toileting. She required substantial to maximal staff assistance with bed mobility, dressing and personal hygiene. C. Record review-There were no progress notes in Resident #6 or Resident #7's medical record regarding the alleged assault.-There was no investigation and the alleged assault was not reported to the State Agency or the ombudsman (cross-reference F609 for failure to report an alleged violation and F610 for failure to investigate an alleged violation). IV. Resident to Resident physical abuse by Resident #6 to Resident #3A. Incident on 1/18/24On 1/18/24 at 10:28 a.m., an interdisciplinary team (IDT) note documented Resident #3 was pushed by another resident and obtained a laceration to the right eyebrow. -There were no recommendations by the IDT team. On 1/18/24 at 11:54 a.m., the nursing notes documented the nurse heard Resident #3 "fighting with the same female resident he had been fighting with all day (Resident #6)." The nurse observed arms flying at each other and Resident #3 lost his balance and fell hitting his face on the ground. There was a deep head wound from his glasses. Resident #3 complained of chin pain. On 1/18/24 at 3:38 p.m., the nurse note documented 911(emergency services) was called because the laceration to the right eyebrow area on Resident #3 was too large to steri-strip. On 1/18/24 at 3:52 p.m., a change of condition form documented that at approximately 11:30 a.m., Resident #3 was pushed by another female resident. The nurse documented she heard screams and ran to the hall to see Resident #6 push Resident #3. Resident #3 was bleeding from the right eyebrow and it was too large to apply steri-strips to. On 1/18/24 at 4:33 p.m., the nursing notes documented Resident #3 returned to the facility from the emergency room with 12 staples above his right eye. On 1/19/24 at 11:30 a.m., a provider note documented Resident #3 was involved in an altercation with another resident causing him to fall and strike his head. He presented to the ER (emergency room) with jaw pain and a large forehead laceration. On 1/20/24 at 11:30 a.m., the nursing notes documented Resident #3 continued with discoloration to his face after an altercation with another resident. The other resident had since been removed from the facility. On 1/21/24 at 3:53 a.m., the nursing notes documented Resident #3 continued with sutures to his head and bruising to the right eye, forehead and chin. The 1/18/24 facility investigation was received from the NHA on 3/4/24 at 10:00 a.m. The investigation documented Resident #3 and Resident #6 were immediately separated and Resident #6 was sent to the ER for a psychiatric evaluation. A social services interview in the investigation file, dated 1/18/24, documented Resident #3 said Resident #6 pushed him and was "trying to do harm to me." A second social services note documented that, per staff, Resident #6 had been continuously wandering to Resident #3's unit. Staff had redirected her back to her own unit. Five resident interviews dated 1/19/24 did not document further abuse.-There were no further staff interviews.-There was no documentation the State Agency, police or ombudsman were notified. (cross-reference F609 for failure to report an alleged violation). B. Resident #3 1. Resident statusResident #3, age 71, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses included intracranial hemorrhage (brain bleed), schizoaffective disorder and dementia. According to the 2/21/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of seven out of 15. He required supervision with dressing and transfers, and was independent with personal hygiene, bed mobility and toileting. C. InterviewsResident #8 was interviewed on 3/4/24 at 10:15 a.m. He said a female resident had assaulted a male resident and the police were not notified. He said the staff, a frequent visitor and a resident representative had called the police and there was now a detective involved. He provided a case number and the name of a detective. The NHA and the DON were interviewed together on 3/5/24 at 10:23 a.m. The DON said Resident #6 wandered into other resident rooms. She said she wandered into Resident #3's room and she pushed him. Resident #3 fell and cut his right eyebrow. Resident #6 was removed from the area. Resident #3 went to the ER and received seven or eight sutures. He had bruises on the right side of his face. The DON said Resident #6 was taken to the ER in the facility van for a psychiatric evaluation. The NHA said the resident wandered into other resident rooms. She wandered into the room of Resident #3. She pushed Resident #3 and he fell cutting his face. Resident #6 was then taken in the facility van to the hospital. However, Resident #6 jumped out of the facility van on the way to the hospital and was then taken by ambulance to the hospital and the facility discharged her. The NHA said the facility was not aware of the resident's history of aggression. She said the facility would be looking at referrals for new admissions more in depth. She said she would start approving residents with a history of aggression herself. The NHA said she did not know what the plan was to keep Resident #6 from wandering into other residents' rooms. She said the facility should have had a plan to monitor Resident #6 more closely. The social services director (SSD) was interviewed on 3/5/24 at 11:00 a.m. The SSD said he had not read Resident #6's PASRR Level II and was not familiar with her history. He said she was not here very long but shortly after she admitted she walked to the doorways of other residents and stared at them. This went on for a week. She had arguments with other residents, including Resident #18. The SSD did not recall exactly what happened with Resident #3. He said he remembered the residents were yelling at each other. He did not witness the altercation. He said he had noticed an increase in residents with mental health conditions coming into the facility since December 2023. The SSD said the facility had not provided any training in mental health, though he thought there should have been training. Licensed practical nurse (LPN) #4 was interviewed on 3/5/24 at 1:50 p.m. LPN #4 said she was told by other staff members Resident #6 assaulted Resident #3. She said the police had not been notified by the facility but a resident's family member had notified the police. LPN #4 said she was familiar with Resident #6. She said Resident #6 kept wandering into Resident #3's doorway. Resident #3 would tell her to leave, but Resident #6 would say "I do not have to"..The RNA was interviewed on 3/6/24 at 1:00 p.m. The RNA said shortly after he heard a female yelling "come on, come on", he went to the hall and saw Resident #3 on the floor with a gash in his head, bleeding all over. He said he was told by other staff member that Resident #6 had a rock in her hand and hit Resident #3 with it. V. Resident to resident physical abuse by Resident #14 to Resident #15A. Incident on 1/12/24The 1/12/24 facility investigation was received from the NHA on 3/4/24 at 10:00 a.m. A staff witness statement, dated 1/12/24, documented Resident #15 was pushing a chair and mistakenly hit Resident #14's foot. Resident #14 pushed Resident #15 who fell on the floor. Resident #14 then began hitting Resident #15 in the face before being pulled off of the resident. Three residents who witnessed the event were interviewed. The residents were asked:-"How are you feeling?"-"How do you feel after the incident?"-"Would you like to speak to your family or friends?"-"Is there anything I can do to help you cope with the incident?"-There were no resident interviews about abuse.-There were no staff interviews about abuse.-There was no documentation the State Agency or police were notified (cross-reference F609 for failure to report an alleged violation). B. Resident #141. Resident statusResident #14, age 77, was admitted on 12/18/23. According to the March 2024 CPO, diagnoses included paranoid personality disorder, restlessness and agitation, cerebral infarction (stroke), aphasia (speech disorder) and vascular dementia. According to the 12/20/23 MDS assessment, the resident had severe cognitive impairment and could not complete the BIMS assessment. The staff assessment for mental status documented the resident had long and short term memory loss. He required supervision with dressing, transfer and toileting. He required setup assistance with personal hygiene and was independent with bed mobility. The assessment documented the resident had delusions and verbal behaviors directed towards others. The assessment documented the resident's behavior had gotten worse and disrupted care, the living environment and interfered with social interactions. 2. Record reviewOn 1/10/24 at 3:00 p.m., the progress notes for Resident #14 documented he was hit with a chair on the right side. There were no injuries. Resident #14's care plan, initiated 12/19/23, documented the resident was at risk for behavioral symptoms due to dementia and paranoid personality disorder. He had punched another resident at another facility. Interventions were to anticipate needs and meet promptly, document and record behavioral episodes, establish a rapport with the resident, maintain a calm, slow, understandable approach, manage environmental factors to optimize comfort, observe and document changes in behavior, including frequency of occurrence and potential triggers and observe resident's mood and response to medication.-There were no changes made to Resident #14's care plan after the altercation with Resident #15 on 1/10/24. C. Resident #151. Resident status Resident #15, age 85, was admitted on 8/31/23. According to the February 2024 CPO, diagnoses included vascular dementia, anxiety and psychotic disorder with hallucinationsAccording to the 12/4/23 MDS assessment, the resident had severe cognitive impairment and could not complete the BIMS assessment. The staff assessment for mental status documented the resident had long and short term memory loss. He was independent with bed mobility, and required supervision for dressing, transfers and toileting. He required set up assistance from staff with personal hygiene. The assessment documented he had physical and verbal behavior directed towards others. 2. Record review On 1/10/24 at 3:00 p.m., the nursing progress notes for Resident #15 documented Resident #15 was pushing furniture and accidentally ran into Resident #14 who then pushed Resident #15. Resident #14 continued to swat and hit Resident #15 with his hat. The residents were separated by staff. -There was no documentation about injuries. On 1/10/24 at 7:08 p.m., the nursing notes documented that Resident #15 had no injury. C. Staff interviewsThe NHA and DON were interviewed together on 3/25/24 at 10:23 a.m. The DON said Resident #15 was moving a chair around the nursing station. She said he used to be a janitor. He bumped into Resident #14 and Resident #14 pushed Resident #15 to the ground and began hitting him with his hat. The staff separated them. The DON said there were no injuries to either resident. The DON looked at both residents' electronic medical records(EMR) and said no changes were made to the residents' care plans following the incident. She said Resident #15 did have a history of aggression. She said he had post traumatic stress disorder from being assaulted by his wife. The NHA said she thought she notified the police and ombudsman around 1/12/24. -However, there was no documentation provided to indicate the NHA had notified the ombudsman about the incident.

Based on observation, record review and interviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent retaliation for abuse reporting. Specifically, the facility failed to:-Post a conspicuous notice of employee rights, including the right of staff to be free from retaliation for reporting abuse; and,-Include protection for employees against retaliation for reporting in its abuse policy. Findings include: I. Professional referenceAccording to the Elder Justice Act notice, undated, retrieved online 3/11/24 from https://lms.healthcareacademy.com/courses/HCA_Annual/ElderJusticeAct1d/EJA_poster.pdf:"The Elder Justice Act (the Act) is a federal law passed as part of the Patient Protection and Affordable Care Act. Its aim is to combat abuse, neglect and exploitation of elders by promoting the discovery of crimes against residents of long term care facilities. It does this by requiring that specific individuals report any reasonable suspicion of a crime against anyone who is a resident of, or is receiving care from, a long term care facility. A long term care facility may not retaliate against an employee for making a report, or for causing a report to be made. This means that a facility may not discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done the employee; or file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee."II. ObservationThe facility was observed on 3/7/24 at 11:43 a.m. for signage regarding employees' right to non-retaliation. This signage was not found in the facility. II. Record reviewThe Abuse and Neglect policy, revised March 2018, was provided by the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. -The policy did not address retaliation for reporting abuse or neglect. III. Staff interviewsThe director of nursing (DON) was interviewed on 3/7/24 at 12:37 p.m. The DON said she did not know where the notice was posted that indicated the facility would not retaliate against employees for reporting abuse. She said a notice against retaliation should have been posted. Certified nurse aide (CNA) #8 was interviewed on 3/7/24 at 3:00 p.m. CNA #8 said she had never seen signage that notified staff of their right to be free from retaliation for reporting abuse.

Based on staff interviews and record review, the facility failed to report alleged violations of potential abuse to the proper authority in accordance with State law for alleged violations involving eight (#4, #17, #6, #7, #3, #18, #14 and #15) of eight residents reviewed for allegations of abuse out of 38 sample residents. Specifically, the facility failed to: -Report an allegation of verbal abuse by Resident #4 to Resident #17 to the nursing home administrator (NHA), director of nursing (DON), local police or the State Agency;-Report an allegation of physical abuse by Resident #6 to Resident #7 and Resident #3;-Report an allegation of physical abuse between Resident #6 and Resident #18; and,-Report an allegation of physical abuse by Resident #14 to Resident #15. Findings include:I. Facility policy and procedureThe Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part, "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations."II. Verbal abuse by Resident #4 to Resident #17A. Resident #41. Resident statusResident #4, 65 years old, was admitted on 8/20/23. According to the March 2024 computerized physician orders (CPO), diagnoses included alcohol abuse. The 2/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was independent with all activities of daily living. 2. Record review-Review of Resident #4's nursing progress notes revealed there was no documentation about any verbal altercations with Resident #17. B. Resident #171. Resident statusResident #17, age greater than 65, was admitted on 8/18/23. According to the February 2024 CPO, diagnoses included septic right knee, lumbar abscess and chronic pain syndrome. According to the 2/19/24 MDS assessment, the resident had mild cognitive impairment with a BIMS score of 14 out of 15. She required substantial maximal assistance from staff with transfers, dressing, toileting and personal hygiene. She required moderate assistance from staff with bed mobility. 2. Resident interviewResident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said a couple months ago she was talking to one of the nurses at the nurses station. She said they were talking loudly and laughing. She said Resident #4 came out of his room, rolling fast in his wheelchair. Resident #17 said Resident #4 came up to her at the desk and threatened to harm her and hit her. Resident #17 said Resident #4 smelled of alcohol and said something about harming her if she was rude to his favorite nurse. Resident #17 said Resident #4 drank alcohol in his room. She said she had seen him hide beer cans in his clothes and the beer cans were found in the residents' computer room at night. Resident #17 said maybe Resident #4 thought she and the nurse were arguing because they were talking loudly. Resident #17 said she tried to stay away from Resident #4 now. 3. Record review-Review of Resident #17's nursing progress notes revealed there was no documentation about any verbal altercations with Resident #4. C. Staff interviewsThe NHA was interviewed on 3/5/24 at 10:24 a.m. The NHA said the nurse had not reported to her or the DON the threats made by Resident #4 to Resident #17. She said the nurse should have reported the threats as verbal abuse. The NHA was interviewed again on 3/6/24 at 9:11 a.m. The NHA said the nurse said she was having a friendly conversation with Resident #17 and having fun. The nurse said Resident #4 came out of his room and said to Resident #17 "If you do something to my friend, I am going to do something to you." The NHA said she did not ask Resident #17 if she was fearful of Resident #4. The NHA said Resident #17 said she just tried to stay away from Resident #4. III. Physical abuse by Resident #6 to Resident #7 A. Resident #61. Resident statusResident #6, age less than 65, was admitted on 1/11/24 and discharged to the hospital on 1/18/24. According to the January 2024 CPO, diagnoses included traumatic brain injury (TBI), alcohol abuse, Bulimia Nervosa (eating disorder), encephalopathy (alteration in brain function or structure), borderline personality disorder and major depression with severe psychotic symptoms. According to the 1/12/24 MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with personal hygiene, toileting, dressing, bed mobility, transfers, and ambulation. The assessment documented the resident had symptoms of feeling down, hopeless, trouble concentrating with little pleasure in doing things. The assessment documented the resident did not wander but had a wander prevention device. B. Resident #71. Resident statusResident #7, age 81, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses included Parkinson's disease, major depression and dementia. According to the 1/30/24 minimum data set MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. She was totally dependent on staff for transfers and toileting. She required substantial to maximal staff assistance with bed mobility, dressing, and personal hygiene. C. Staff interviewsThe DON was interviewed on 3/7/24 at 12:37 p.m. The DON said she was told Resident #6 was holding a blanket around Resident #7's face around 1/17/24. She said she was not at the facility that day. The DON said the NHA was at the facility and handled the situation. The DON said the NHA should have done an investigation and reported it to the police and the State Agency but she did not. She said the nurse on duty witnessed the assault, but she was an agency nurse and had not returned the DON's calls. The DON said she found out about the incident a few days after it occurred.-The NHA was unavailable for an interview on 3/7/24. D. Record review-There was no facility investigation provided for the incident (cross-reference F610 for failure to investigate abuse allegations) and no evidence the State Agency or police were notified of the allegation. IV. Physical abuse by Resident #6 to Resident #3A. Resident #3 1. Resident statusResident #3, age 71, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses included intracranial hemorrhage (brain bleed), schizoaffective disorder and dementia. According to the 2/21/24 MDS assessment, the resident had severe cognitive impairment with a BIMS) score of seven out of 15. He required supervision with dressing and transfers, and was independent with personal hygiene, bed mobility and toileting. 2. Record reviewOn 1/18/24 at 10:28 a.m., an interdisciplinary team (IDT) note documented Resident #3 was pushed by another resident and obtained a laceration to the right eyebrow. On 1/18/24 at 11:54 a.m., the nursing notes documented the nurse heard Resident #3 "fighting with the same female resident he had been fighting with all day (Resident #6)." The nurse observed arms flying at each other and Resident #3 lost his balance and fell hitting his face on the ground. There was a deep head wound from his glasses. Resident #3 complained of chin pain. B. Facility investigationThe facility investigation of the incident was received from the NHA on 3/4/24 at 10:00 a.m. -The facility investigation did not contain documentation to indicate the State Agency and police were notified of the incident. V. Physical abuse between Resident #6 to Resident #18A. Resident #18Resident #18, age less than age 65, was admitted on 1/10/24. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depression, personality disorder, post traumatic stress disorder (PTSD) and traumatic brain injury (TBI). According to the 1/12/24 MDS) assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. B. Record reviewOn 1/17/24 at 11:20 a.m. the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room calmly when Resident #6 repeatedly went into Resident #18's room. Resident #18 asked her to stop coming into his room. When Resident #18 was not looking, Resident #6 took his cane. Resident #18 yelled for the nurse. When the nurse went into the room Resident #18 was pulling Resident #6's hair. The residents were separated, and the facility had decided to move Resident #6's room for "safety concerns." Resident #6 was encouraged to socialize with residents in common areas and not in resident rooms. The facility investigation of the incident was received from the nursing home administrator on 3/4/24 at 10:00 a.m. -There was no documentation the State Agency or police were notified of the incident. VI. Physical abuse by Resident #14 to Resident #15A. Resident #141. Resident statusResident #14, age 77, was admitted on 12/18/23. According to the January 2024 CPO, diagnoses included paranoid personality disorder, restlessness and agitation, cerebral infarction (stroke), aphasia (speech disorder) and vascular dementia. According to the 12/20/23 MDS assessment, the resident had severe cognitive impairment and could not complete a BIMS. The staff assessment for mental status documented the resident had long and short term memory loss. He required supervision with dressing, transfer, and toileting. He required setup assistance with personal hygiene and was independent with bed mobility. The assessment documented the resident had delusions and verbal behaviors directed towards others. The assessment documented the resident's behavior had gotten worse and disrupted care, the living environment and interfered with social interactions. B. Resident #151. Resident statusResident #15, age 85, was admitted on 8/31/23. According to the February 2024 CPO, diagnoses included vascular dementia, anxiety and psychotic disorder with hallucinations. According to the 12/4/23 MDS assessment, the resident had severe cognitive impairment and could not complete a BIMS. The staff assessment for mental status documented the resident had long and short term memory loss. He was independent with bed mobility, and required supervision for dressing, transfers and toileting. He required set up assistance from staff with personal hygiene. The assessment documented the resident had physical and verbal behavior directed towards others. C. Record review On 1/10/24 at 3:00 p.m., the nursing progress notes for Resident #15 documented Resident #15 was pushing furniture and accidentally ran into Resident #14 who then pushed Resident #15. Resident #14 continued to swat and hit Resident #15 with his hat. The residents were separated by staff. -There was no documentation about injuries. The facility investigation of the incident was received from the NHA on 3/4/24 at 10:00 a.m. -There was no documentation the State Agency or police were notified of the incident. VII. Staff interviewThe NHA and the DON were interviewed on 3/5/24 at 10:23 a.m. The NHA said she did not recall if the abuse incidents involving Resident #4 and Resident #17, Resident #6 and Resident #7, Resident #6 and Resident #3, Resident #6 and Resident #18 or Resident #14 and Resident #15 were reported to the State Agency or the police. VIII. Additional record reviewThe State Agency system was reviewed and there were no reports submitted by the facility for the abuse incidents involving Resident #4 and Resident #17, Resident #6 and Resident #7, Resident #6 and Resident #3, Resident #6 and Resident #18 or Resident #14 and Resident #15.

Based on record review and interviews, the facility failed to ensure incidents of potential abuse were thoroughly investigated for three (#6, #18 and #7) of four residents out of 38 sample residents. Specifically, the facility failed to:-Ensure a known physical abuse incident between Resident #6 and Resident #18 was thoroughly investigated; and,-Ensure reports of physical abuse by Resident #6 to Resident #7 were followed up on and investigated. Findings include:I. Facility policyThe Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part, "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The nurse will assess the individual and document related findings. The nurse will report findings to the physician. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes." II. Physical abuse between Resident #6 and Resident #18A. Resident #61. Resident statusResident #6, age less than 65, was admitted on 1/11/24 and discharged to the hospital on 1/18/24. According to the January 2024 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), alcohol abuse, bulimia nervosa (an eating disorder), encephalopathy (alteration in brain function or structure), borderline personality disorder and major depression with severe psychotic symptoms. According to the 1/12/24 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. The assessment documented the resident had symptoms of feeling down, hopeless, trouble concentrating with little pleasure in doing things. The assessment documented the resident did not wander but had a wander prevention device. B. Resident #181. Resident statusResident #18, less than age 65, was admitted on 1/10/24. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depression, personality disorder, post traumatic stress disorder (PTSD) and traumatic brain injury (TBI). According to the 1/12/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. C. Record review On 1/17/24 at 11:20 a.m., the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room calmly when Resident #6 repeatedly went into Resident #18's room. Resident #18 asked her to stop coming into his room. When Resident #18 was not looking, Resident #6 took his cane. Resident #18 yelled for the nurse. When the nurse went into the room Resident #18 was pulling Resident #6's hair. The residents were separated, and the facility had decided to move Resident #6's room for "safety concerns." Resident #6 was encouraged to socialize with residents in common areas and not in resident rooms. On 1/17/24 at 11:34 a.m. the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room and calm. Resident #6 repeatedly went in Resident #18's room even though the nurse asked her not to. Resident #6 took Resident #18's cane. When the nurse arrived Resident #18 was pulling Resident #6's hair. Resident #6 said she was punched. The nursing home administrator (NHA) recovered Resident #18's cane. There were no injuries noted for either resident and Resident #6 agreed to a room move for safety concerns. On 1/17/24 at 4:57 p.m. a Change of Condition Evaluation documented Resident #6 was involved in a physical and verbal altercation. The evaluation documented Resident #6 was verbally and physically aggressive. The 1/17/24 facility investigation was received from the nursing home administrator (NHA) on 3/4/24 at 10:00 a.m. The investigation documented Resident #6 and Resident #18 were immediately separated and there were no injuries to either resident. The investigation file contained a follow up statement from Resident #18 on 1/18/24 stating he was doing better and no longer upset. The investigation contained two resident interviews. One resident said they had heard about residents fighting on 1/17/24 and one resident said another resident had tried to punch her wheelchair and she had to tell him to stop.-There were no further resident interviews and no staff interviews found in the facility's investigation file. D. Staff interviewThe NHA and the director of nursing (DON) on 3/5/24 at 10:23 a.m. The NHA said there were no further interviews of residents because the residents on that unit could not tell staff what was going on. She said the facility had to look for non verbal things. -However, the NHA could not describe what non verbal things were looked for.-The NHA had no explanation for the lack of staff interviews in the investigation. III. Physical abuse by Resident #6 to Resident #7 (cross-reference F600 for abuse)A. Resident #71. Resident statusResident #7, age 81, was admitted on 11/20/20 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses included Parkinson's disease, major depression and dementia. According to the 1/30/24 minimum data set MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. She was totally dependent on staff for transfers and toileting. She required substantial to maximal staff assistance with bed mobility, dressing, and personal hygiene. B. Record review -There were no progress notes in Resident #6 or Resident #7's medical records regarding the alleged assault. The facility investigation of the alleged incident was requested from the DON on 3/7/24 at 12:37 p.m. -The DON was unable to provide an investigation file for the incident between Resident #6 and Resident #7. C. Staff interviewsThe DON was interviewed on 3/7/24 at 12:37 p.m. The DON said she was told Resident #6 was holding a blanket around Resident #7's face around 1/17/24. She said she was not at the facility that day. The DON said the NHA was at the facility and handled the situation. The DON said the NHA should have done an investigation and reported it to the police and the State Agency (SA) but she did not. She said the nurse on duty witnessed the assault, but she was an agency nurse and had not returned the DON's calls. The DON said she found out about the incident a few days after it occurred.-The NHA was unavailable for an interview on 3/7/24.

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

Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#17 and #8) of three residents reviewed for pain management out of 38 sample residents. The facility failed to ensure Resident #17 and Resident #8, both with a diagnosis of chronic pain, were assessed for pain accurately and administered pain medications as ordered. Both residents reported increased levels of pain. Resident #17's 2/19/24 pain assessment documented the resident had pain which affected her day to day activity. On 2/29/24, the resident reported she did not always get her pain medication as ordered. She said her pain affected her sleep and her ability to get around. Resident #8's 2/21/24 pain assessment documented the resident had pain which affected his sleep and his day to day activity. On 2/29/24, the resident reported he had gone without pain medications on several occasions. He said he was not able to sleep or move around much when he had increased pain. Due to the facility's failures to ensure Resident #17 and Resident #8's pain medications were consistently administered as ordered, both residents sustained increased pain. Findings include:I. Facility policy and procedureThe Pain policy, revised October 2022, was received from the director of nursing (DON) on 3/5/24 at 4:09 p.m. It read in pertinent part, "The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes). It also includes a review for any treatments that the resident currently is receiving for pain. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated."II. Resident #17A. Resident statusResident #17, age greater than 65, was admitted on 8/18/23. According to the February 2024 computerized physician orders (CPO), diagnoses included septic right knee, lumbar abscess and chronic pain syndrome. According to the 2/19/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial maximal assistance from staff with transfers, dressing, toileting and personal hygiene. She required moderate assistance from staff with bed mobility. The assessment documented she had pain which affected day to day activity. B. Resident interviewResident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said the facility would run out of her scheduled and PRN (as needed) pain medication Norco (opioid pain medication). Resident #17 said the nurse would try to offer her muscle relaxers when the facility ran out of the Norco, however, she told them the muscle relaxer was not as effective as the pain medication. Resident #17 said she had two back surgeries for infections in her back, however, she continued to have back pain and chronic pain in her knees. Her pain level was 6 to 8 (on a scale of 1-10, with 10 being the worst pain) when she did not get the pain medication. She said it affected her sleep and her ability to get around when she had pain. Resident #17 said the lowest her pain level got was a two out of 10. C. Record reviewReview of Resident #17's February 2024 CPO revealed the following physician's orders: Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 milligrams (mg). Give one tablet by mouthevery four hours PRN for pain, ordered 1/30/24.-There were no parameters for when to give the medication. Celebrex capsule (Celecoxib) 100 mg. Give one capsule by mouth two times a day for pain, give with meals, ordered 2/19/24. Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 mg. Give one tablet orally three times a day for chronic pain, ordered 2/20/24. The January 2024 and February 2024 medication administration records (MAR) documented the resident had received the Norco PRN pain medication for pain levels of 0 to 8 out of 10. The February 2024 MAR further revealed the resident was given Norco PRN two to three times per day from 2/1/24 until the order was changed to scheduled three times per day on 2/20/24.-Despite nursing staff documenting Resident #17 was administered Norco two to three times per day PRN, the resident's pain assessment levels on the MAR for the administration of the Norco were frequently documented at a 0 out of 10. From 2/20/24 (after the Norco PRN physician's order was changed to scheduled Norco) until 2/24/24, the Norco medication was signed off as administered on the February 2024 MAR each day, including three doses on 2/24/24. -However, review of the Norco narcotic count sheet revealed no Norco was administered on 2/24/24.-On 2/20/24, at 8:31 a.m. and 4:49 p.m., Resident #17's Celebrex was documented as not administered for pain because it was not available. D. Staff interviewThe DON was interviewed on 3/6/24 at 10:23 a.m. She said she had compared the Norco narcotic count sheet to the February 2024 MAR. She said the resident had missed doses of Norco despite being signed off on the MAR as given. The DON said she found no evidence the Norco was taken from the facility's emergency medication supply which meant the pain medication was not administered to the resident. The DON said PRN pain medications should have parameters for when to give them. The DON said she would not expect Norco to be given for pain levels of zero. The DON said she would begin in-servicing the licensed nurses on pain control and medication administration. III. Resident #8A. Resident statusResident #8, age 68, was admitted on 8/17/23. According to the February 2024 CPO, diagnoses included osteoarthritis and chronic pain. According to the 2/21/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with bed mobility and transfers. He required set up assistance for the staff with toileting, dressing, and personal hygiene. He had pain and was on pain medication. The assessment documented pain affected the resident's sleep and day to day activity. B. Resident interviewResident #8 was interviewed on 3/4/24 at 10:15 a.m. Resident #8 said the nurses documented his pain medications (Oxycodone) and neurontin were given but they did not give him the medications. Resident #8 said sometimes the nurse would say they did not have the medications. He said he had gone without his pain medications for several days before. He said when he did not receive his pain medications he had increased pain at a pain level of 8 out of 10 and was not able to sleep or move around as much. Resident #8 said he had reported not receiving his pain medications consistently to the DON but he said he had never heard anything back from her. He said his pain levels were consistently at a level of 4 out of 10 when he received his pain medication but he always had pain. Resident #8 said his pain was never a pain level of 0 out of 10. C. Record reviewReview of Resident #8's February 2024 CPO revealed the following physician's orders:Gabapentin oral capsule 300 mg. Give 600 mg by mouth at bedtime for neuropathic pain, ordered 8/17/23. Tizanidine oral tablet 2 mg. Give one tablet by mouth two times a day for muscle spasms, ordered 1/25/24. Oxycodone oral capsule (Oxycodone HCl) 5 mg. Give 10 mg by mouth four times a day for right knee pain, ordered 8/22/24. Review of Resident #8's electronic medical record (EMR) revealed the following progress notes:On 1/12/24 at 9:35 a.m. the nursing progress notes documented the resident did not get his oxycodone because it was on order. On 1/16/24 at 11:31 a.m., 3:02 p.m. and 8:00 p.m. the nursing progress notes documented Resident #8 did not get his scheduled oxycodone because it was on order from the pharmacy. On 1/26/24 at 4:05 p.m. the nursing progress notes documented the resident's Tizanidine for muscle spasms was not given because it was on order. On 1/28/24 at 4:40 p.m. the nursing progress notes documented the resident's Tizanidine for muscle spasms was not given because it was on order. On 2/1/24 at 7:30 p.m. the nursing progress notes documented the resident did not receive his gabapentin for nerve pain because it was on order. On 2/2/24 at 4:45 a.m. the nursing progress notes documented in a behavior note, the resident said "I want all my medications." The nurse responded, "If it is not on my cart, I can not give it to you." -The missing medications were not documented.-There were no further progress notes regarding action taken to get the medication or that the physician was notified for further orders. The oxycodone narcotic count sheets were reviewed for January 2024. -There was no oxycodone signed out for any of the four dose administration times on 1/12/24, and only one of the four dose administration times (8:00 a.m.) was signed out on 1/16/24. The January 2024 MAR documented the resident had a pain level of five on 1/16/24 at 10:00 p.m. when he did not receive his oxycodone. -The resident's pain levels for the rest of January 2024 and February 2024 were frequently documented as a 0 out of 10, despite the resident's report that his pain level was never below a 4 out of 10, even when he received pain medication (see resident's interview above).-However, Resident #8 reported his pain level never went below a 4 out of 10, even when he received pain medication (see resident's interview above).-The last comprehensive pain assessment completed for Resident #8, other than the 2/21/24 MDS assessment, was on 8/17/23, six months prior to the survey. The assessment documented that the resident had frequent pain at a level of 6 out of 10. -There was no documentation of the resident's pain goals or things that made pain worse or relieved pain. D. Staff interviewThe DON was interviewed on 3/5/24 at 2:06 p.m. The DON said the licensed nurses should have notified her when they did not have the pain medication for Resident #8. She said the medication could be received from the pharmacy within two hours when requested STAT (urgent) from the pharmacy. The DON said comprehensive pain assessments were completed on admission, quarterly and as needed. She said pain was assessed every shift and documented on the MAR. She said PRN pain medication should have parameters for when to administer the medication. IV. Additional interviews The DON was interviewed again on 3/5/24 at 4:01 p.m. She said the regional nurses had reviewed the MARs and progress notes for Resident #17 and Resident #8 and said the residents did not receive their pain medications as ordered. She said this was an issue. The DON said she would investigate further to see if there was a trend with specific nurses. She said the facility had an emergency medication system where the medication could have been obtained. The DON said the nurses should have notified the provider for further orders when the pain medication was not available. The DON said she would begin educating the staff on steps to take when a narcotic pain medication was not available and obtaining parameters for when to administer pain medication. The DON said she was not sure if the frequent pain level of 0 out of 10 documented on the MARs for both residents was accurate.

Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for five (#8, #9, #3, #17 and #21) of five residents reviewed out of 38 sample residents. Specifically, the facility failed to ensure Residents #8, #9, #3, #17 and #21 received all prescribed medications, which resulted in significant medication errors of omission. Findings include:I. Facility policyThe Unavailable Medication policy, revised February 2023, was received on 3/6/23 at 10:32 a.m. from the director of nursing (DON). The policy documented in pertinent part, "Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable. "Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. "Notify physician of inability to obtain medication upon notification or awareness that medication is not available. "Obtain alternative treatment orders and/or specific orders for monitoring residents while medication is on hold."Determine whether a resident has home supply. Obtain orders to use home supply. Administer first dose after the pharmacist has verified that the medication is correct with respect to name, dose, and form of medication."If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication."II. Resident #8A. Resident statusResident #8, age 68, was admitted on 8/17/23. According to the March 2024 computerized physician orders (CPO), diagnoses included osteoarthritis and chronic pain, diabetes, major depression and bipolar disorder. According to the 2/21/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interviewResident #8 was interviewed on 3/4/24 at 9:34 a.m. Resident #8 said he frequently did not get all his medications. He said the nurses signed it off on the MAR but he did not really get the medications. He said he had gone without medications such as clonazepam and oxycodone. C. Record reviewReview of Resident #8's March 2024 CPO revealed the following physician's orders:Quetiapine Fumarate (Seroquel) oral tablet 200 milligrams (mg). Give 200 mg by mouth at bedtime for bipolar disorder, ordered 8/17/23. Oxycodone oral capsule (Oxycodone HCl) 5 mg. Give 10 mg by mouth four times a day for right knee pain, ordered 8/22/24. Clonazepam 1 mg, give one tablet at bedtime for bipolar disorder, ordered 8/17/23. Tizanidine oral tablet 2 mg. Give one tablet by mouth two times a day for muscle spasms, ordered 1/25/24. Glipizide 10 mg by mouth one time per day for diabetes, ordered 8/18/23. Loratadine 10 mg, give one tablet by mouth at bedtime for allergies, ordered 12/28/23. Gabapentin oral capsule 300 mg. Give 600 mg by mouth at bedtime for neuropathic pain, ordered 8/17/23. Review of Resident #8's nursing progress notes revealed multiple medications were not administered due to the medications being unavailable or on order from the pharmacy. Quetiapine Fumarate (Seroquel) oral tablet 200 milligrams was documented as not given because the medication was on order on:-1/7/24 at 8:43 p.m.;-1/11/24 at 8:19 p.m.; and,-1/15/23 at 9:17 p.m. Oxycodone oral capsule 5 mg was documented as not given because the medication was on order on:-1/12/24 at 9:35 a.m.;-1/16/24 at 11:31 a.m.;-1/16/24 at 3:02 p.m.; and,-1/16/24 at 8:03 p.m. Cross-reference F697 for failure to manage pain. Clonazepam 1 mg was documented as not given because the medication was not available or was on order on:-1/23/24 at 11:20 p.m.;-1/24/24 at 9:28 p.m.; and,-1/25/24 at 10:04 p.m. Tizanidine oral tablet 2 mg was documented as not given because the medication was on order on:-1/26/24 at 8:38 a.m.;-1/26/24 at 4:05 p.m.;-1/28/24 at 7:51 a.m.; and,-1/28/24 at 4:40 p.m. Glipizide 10 mg was documented as not given because the medication was on order on:-1/27/24 at 8:13 a.m.;-1/28/24 at 7:50 a.m.;-2/4/24 at 7:28 a.m.,; and,- 2/26/24 at 9:38 a.m. Loratadine 10 mg was documented as not given because the medication was on order on:-1/28/24 at 4:40 p.m.;-1/30/24 at 7:51 p.m.; and,-1/31/24 at 7:51 p.m. Gabapentin 600 mg was documented as not given because the medication was not available on:-2/1/24 at 7:30 p.m. On 2/2/24 at 4:45 a.m. a behavior progress note documented the resident said "I want all my medications" and the nurse responded "if it is not on my cart I can not give it to you." The resident requested a copy of his medication administration records (MAR).-There was no documentation in the progress notes the provider was notified for further orders when the medications were not available or on order from the pharmacy. III. Resident #9A. Resident statusResident #9, age 77, was admitted on 2/19/21 and readmitted on 1/17/24. According to the March 2024 CPO, diagnoses included chronic pain and edema (swelling). The 1/17/24 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score of 14 out of 15. B. Record reviewReview of Resident #9's March 2024 CPO revealed the following physician's orders:Potassium chloride extended release tablet 20 meq (milliequivalent). Give one tablet by mouth for hypokalemia (low potassium), ordered 6/14/23. Lasix 40 mg by mouth one time per day for edema (swelling), ordered 1/5/24. Cymbalta delayed release capsule 60 mg. Give one capsule one time per day for pain, ordered 1/5/24. Review of Resident #9's nursing progress notes revealed multiple medications were not administered due to the medications being unavailable or on order from the pharmacy. Potassium chloride extended release tablet 20 meq was documented as not given because the medication was on order on:-1/1/24 at 2:04 p.m.;-1/3/24 at 10:54 a.m.;-1/4/24 at 8:19 a.m.;-1/7/24 at 7:14 a.m.;-1/10/24 at 7:27 a.m.;-1/19/24 at 7:31 a.m.;-1/20/24 at 7:16 a.m.;-1/21/24 at 7:46 a.m.;-1/22/24 at 12:15 p.m.;-1/23/24 at 2:49 p.m.;-1/24/24 at 7:14 a.m.;-1/25/24 at 7:23 a.m.;-1/26/24 at 8:14 a.m.;-1/29/24 at 7:54 a.m.;-1/30/24 at 9:27 a.m.;-1/31/24 at 7:38 a.m.; and,-2/4/24 at 8:27 a.m. Lasix 40 mg was documented as not given because the medication was unavailable or on order on:-1/10/24 at 7:29 a.m.;-1/18/24 at 8:29 a.m.; and,-1/20/24 at 7:15 a.m. Cymbalta delayed release capsule 60 mg was documented as not given because the medication was on order on:-2/23/24 at 10:40 a.m.-There was no documentation in the progress notes the provider was notified for further orders when the medications were not available or on order from the pharmacy. IV. Resident #3A. Resident statusResident #3, age 71, was admitted on 11/20/2020, and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses included intracranial hemorrhage, schizoaffective disorder, hypertension and COVID-19. According to the 2/21/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of seven out of 15. B. Record reviewReview of Resident #3's March 2024 CPO revealed the following physician's orders:Ingrezza 80 mg. One capsule at bedtime for dyskinesia (uncontrolled involuntary muscle movement), ordered 12/6/21. Atenolol 25 mg by mouth one time per day for hypertension (high blood pressure), ordered 12/1/21. Omeprazole 20 mg one time per day for gastric reflux disease (GERD), ordered 12/1/21. Ipratropium albuterol solution 0.5 to 2.5 mg per 3 milliliters (ml). Inhale one dose every six hours for RSV (respiratory syncytial virus ) and COVID-19 for 7 days, ordered 2/22/24. Review of Resident #3's nursing progress notes revealed multiple medications were not administered due to the medications being unavailable or on order from the pharmacy. Ingrezza 80 mg was documented as not given because the medication was on order on:-1/16/24 at 10:53 p.m.; and,-1/17/24 at 7:39 p.m. Atenolol 25 mg was documented as not given because the medication was on order on:-1/22/24 at 7:33 a.m.;-1/26/24 at 7:09 a.m.; and,-2/6/24 at 11:49 a.m. Omeprazole 20 mg was documented as not given because the medication was not available on:-2/16/24 at 9:09 p.m. Ipratropium albuterol solution 0.5 to 2.5 mg per 3 ml was documented as not given because the medication was not available on:-2/28/24 at 4:46 a.m.-There was no documentation in the progress notes the provider was notified for further orders when the medications were not available or on order from the pharmacy. V. Resident #17A. Resident statusResident #17, age greater than 65, was admitted on 8/18/23. According to the February 2024 CPO, diagnoses included septic right knee, lumbar abscess and chronic pain syndrome. According to the 2/19/24 MDS assessment, the resident was cognitively intact with a BIMS score of 14 out of 15. B. Resident interviewResident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said she did not always get her prescribed medications such as Norco. C. Record reviewReview of Resident #17's March 2024 CPO revealed the following physician's orders:Potassium extended release 20 meq. Give one tablet by mouth one time a day for hypokalemia (low potassium), ordered 9/12/23. Celebrex capsule (Celecoxib) 100 mg. Give one capsule by mouth two times a day for pain, give with meals, ordered 2/19/24. Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 mg. Give one tablet orally three times a day for chronic pain, ordered 2/20/24. Review of Resident #17's nursing progress notes revealed multiple medications were not administered due to the medications being unavailable or on order from the pharmacy. Potassium extended release 20 meq was documented as not given because the medication was on order on:-1/1/24 at 8:49 a.m.;- 2/4/24 at 8:53 a.m.; and,-3/1/24 at 7:49 a.m. Celebrex capsule (Celecoxib) 100 mg was documented as not given because the medication was on order on 2/20/24 at 4:49 p.m. Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 mg was documented as being given for all three doses on 2/24/24.-However, review of the Norco narcotic count sheet revealed no Norco was given on 2/24/24.-There was no documentation in the progress notes the provider was notified for further orders when the medications were not available or on order from the pharmacy. VI. Resident #21A. Resident statusResident #21, age less than 65, was admitted on 6/18/19 and readmitted on 11/15/23. According to the February 2024 CPO, diagnoses included Alzheimer's dementia, bipolar disorder and drug induced dyskinesia (involuntary movement). The 12/18/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. B. Record reviewReview of Resident #21's February 2024 CPO revealed the following physician's orders:Propranolol 10 mg. Give 10 mg by mouth two times a day for Tardive dyskinesia, ordered 6/7/23. Zyprexa 5 mg. Give 5 mg by mouth in the afternoon for delusions, aggressive behaviors and false beliefs, ordered 1/12/24. Venlafaxine extended release 24 hours, 37.5 mg. Give 37.5 mg by mouth one time daily for inappropriate sexual behavior and manic mood swings, ordered 8/17/23. Review of Resident #21's nursing progress notes revealed multiple medications were not administered due to the medications being on order from the pharmacy. Propranolol 10 mg was documented as not given because the medication was on order on:-1/5/24 at 7:41 a.m.; and,-1/6/24 at 8:02 a.m. Zyprexa 5 mg was documented as not given because the medication was on order on:-1/27/24 at 4:26 p.m.;-1/28/24 at 5:11 p.m.; and,-1/29/24 4:45 p.m. Venlafaxine extended release 24 hours, 37.5 mg was documented as not given because the medication was on order on:-1/31/24 at 6:32 a.m.; and,-2/1/24 at 8:11 a.m.-There was no documentation in the progress notes the provider was notified for further orders when the medications were not available or on order from the pharmacy. VII. Facility record reviewThe 2/29/24 resident council minutes were received from the NHA on 2/29/24 at 10:00 a.m. The notes documented the residents had concerns with missing medications. -There was no follow up on the concern. VIII. Staff interviewsA frequent visitor (FV) was interviewed on 3/4/24 at 2:38 p.m. The FV said she had heard many complaints from residents regarding medications not being available. Licensed practical nurse (LPN) #5 was interviewed on 3/4/24 at 2:40 p.m. LPN #5 said if a medication was not available the nurse should see if it was available in the emergency medication kit. She said if it was not in the emergency medication kit the nurse should notify the provider. LPN #5 said there were many issues with the pharmacy. She said if staff reordered a medication and the pharmacy could not refill it for some reason the pharmacy did not notify the facility. She said if a refill request was sent to the pharmacy five days before a medication ran out, sometimes the facility did not receive the medication for seven days. LPN #5 said she had expressed concerns to the pharmacy consultant who visited but there had been no resolution. LPN #4 was interviewed on 3/5/24 at 1:50 p.m. LPN #4 said medications were reordered by faxing the pharmacy the medication that was needed when the medication had a few doses remaining. She said there had been many issues with medications not being available and other licensed nurses told her they had been borrowing medications from other residents. LPN #4 said the medication refills did not come timely. The director of nursing (DON) was interviewed on 3/5/24 at 1:59 p.m. The DON said she was not aware of an issue with medications not being available. She said if a medication was not available the nurse should call her, the pharmacy and the provider. The DON said nurses should not borrow medications from other residents.-A voice mail message was left for the account manager of the pharmacy on 3/6/24 at 1:33 p.m., however, the phone call was not returned during the survey.

Based on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the chemical sanitizer used to clean equipment and surfaces where food was prepared. Findings include:I. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/13/24 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part,"Chemical sanitizers that are used to sanitize equipment and utensils shall be provided and available for use during all hours of operation."A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times and be used in accordance with the EPA registered label use instructions."Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."II. Observations and interviewsOn 3/7/24 at 11:31 a.m., two red tubs of quat (benzalkonium chloride) solution were sitting on tables in the main kitchen. The dietary director (DD) said the solution was used to clean equipment and the metal tables where food was prepared. She said the staff checked the quat solution each shift and it should register 200 ppm. The DD said there was a machine that automatically mixed the solution with water and the staff only needed to refill the red buckets with it. -The solution was tested with test strips by the DD. The solution did not register on the strip. It remained at 0 ppm. -The DD dumped out the solution and retested the new solution with a new test strip. The new test strip continued to read 0 ppm. -The DD obtained a new package of test strips and tested the quat solution again. The solution tested 0 ppm again. The DD manager said she would call the company that installed the machine which dispensed the quat solution and have them come check the machine to figure out if there was an issue. She said she would use microkill wipes to clean the equipment and food preparation services in the meantime. She said she did not know if the wipes were food safe but she would find out. On 3/7/24 at 2:31 p.m., the DD said she was going to the store to purchase food safe wipes and would not use the microkill wipes because they were not food safe. The DD was interviewed again on 3/7/24 at 3:20 p.m. She said the company that installed the machine which dispensed the quat solution had come to inspect the machine. She said the problem was the facility had been using the wrong test strips to test the solution. The DD said the correct test strips had been obtained and the quat solution now tested at 200 ppm. -The test logs for February 2024 documented the quat solution tested at 200 ppm each shift. The DD said the test logs could not be accurate given the facility had the wrong test strips. She said she would be educating the dietary staff on how to test the quat solution. The DD did not know how long the facility had been using the wrong test strips.

Based on observation and interviews, the facility failed to effectively administer its resources to attain the highest practicable wellbeing for each resident. Specifically, the facility failed to: -Implement and maintain safety measures to prevent elopements with significant injury; -Prevent, report and investigate allegations of resident to resident abuse; and,-Provide sufficient leadership to address and/or avoid multiple significant concerns. Findings includeI. Quality of care-Cross reference F689 for failure to ensure residents were free from accidents and elopement which caused major injury.-Cross reference F697 for failure to implement an effective pain management program. II. Freedom from abuse -Cross-reference F600 for failure to protect residents from physical abuse. -Cross-reference F609 for failure to report alleged violations.-Cross-reference F610 for failure to investigate alleged violations. III. Nursing services-Cross-reference F760 for failure to ensure residents were free from significant medication errors. IV. Training requirements-Cross-reference F730 for failure to ensure certified nurse aides (CNA) had completed required 12 hour training based on their date of hire and annual performance review. -Cross reference F940 for failure to ensure all direct and indirect care staff were trained in dementia care, mental health diagnoses and substance abuse. V. Quality assurance and performance improvement-Cross reference F867 for failure to implement effective systems to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact qualityof care, quality of life, and resident safety. VI. InterviewsA frequent visitor (FV) was interviewed on 3/4/24 2:38 p.m. The FV said she had several serious complaints regarding the facility. She said she had heard many residents complain about not getting their medications and that the environment was "bad". She said residents and staff were afraid of retaliation from the administration for reporting things such as abuse. The FV said the facility had had a large influx of admissions with mental health and substance abuse diagnoses but the staff had not been offered any training in those areas. The FV said many residents had complained about roommates with mental health issues and requested to be moved to a new room, however, she said the residents' requests to move rooms were not being honored. The FV said Resident #7 was found with a blanket being held around her head by Resident #6. The resident could not defend herself due to her immobility. She said Resident #6 was then moved to another hall where she pushed Resident #3 down. She said the resident had head trauma and had to get 12 stitches. The FV said she saw his face which was completely black and blue. The FV said the facility staff told her they should report the abuse as a fall by the DON. The FV said neither she nor the police were notified of the incident. (Cross-reference F600 and F610). The FV said she was concerned for the safety of the residents and the staff were being intimidated and afraid to speak up. The FV was interviewed again on 3/6/24 at 11:43 a.m. The FV said the NHA led the facility by fear and retribution. The staff had been told during the current survey "there would be consequences for talking to the state." She said the NHA dismissed what the staff and residents told her. Resident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said Resident #4 threatened to harm her but there was no follow up by the administration. She said she had missed multiple doses of medication including pain medication (cross reference F697 and F760 significant medication errors). Resident #17 said the NHA and DON were aware of her concerns but there was no follow up. She said when NHA was dismissive of her concerns when she reported them and Resident #17 was made to feel like she was the problem. Resident #8 was interviewed on 3/4/24 at 10:15 a.m. He said he was told many staff had resigned due to poor management. He said he had missed several doses of his medications including pain medications. He said he had reported this to the DON but there was no follow up. He said a resident was beaten up by a female resident and the staff told him they were instructed by the DON not to call the police. He said there was a resident who drank alcohol and smoked in his room. He said residents and staff were fearful of him but nothing had been done to address the concerns. Resident #8 said the NHA did not follow up on concerns with abuse or other resident behaviors. He said she dismissed things and talked down to people. He said the corporation that provided oversight to the building needed to know what was happening at the facility. The restorative nurse aide (RNA) was interviewed on 3/7/24 at 1:00 p.m. The RNA said he was afraid to be seen talking to the state. He said the staff had been threatened and feared retaliation if they spoke up and he needed his job. He said one of the main problems was the lack of communication by the DON and the NHA. He said the NHA was "overpowering conversations, and shutting down concerns reported by the staff." The RNA said things were falling apart. He said roommates were often put together who were not appropriate such as putting those with behaviors in with residents who were unhappy with the behaviors. He said abuse by Resident #6 had not been thoroughly investigated and the staff had been told to document the abuse as a fall by the DON. The RNA said there had been an increase in admissions of residents who had mental health conditions and behaviors but no training had been provided to the staff (cross reference F940). He said many staff were afraid of retaliation by the facility and were not going to say anythingLicensed practical nurse (LPN) #4 was interviewed on 3/5/24 at 1:50 p.m. LPN #1 said she was concerned about the NHA finding out she was discussing things with the state surveyors. She said Resident #6 beat up Resident #3. She said the police were never called but a family member had heard about the abuse and called the police. She said the facility was admitting a lot more residents with mental health issues and behaviors but the staff had not received any training on how to handle the residents' behaviors. The NHA and DON were interviewed on 3/6/24 at 2:12 p.m. The NHA said the elopements were discussed but not in enough detail to identify and correct all of the issues such as Resident #2 removing her wanderguard. The NHA said she was not aware the smoking assessments had not been completed timely, and smoking assistive devices were not provided. She said they started accepting residents who smoked a few months ago but had not reviewed what the smoking program would entail. The NHA said the multiple missed medications and unavailability of medications was not identified. The NHA said the abuse investigations needed to be more thorough and she could not recall if she had reported them to the state or police.

Based on record review and interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include:I. Facility policy and procedure-The Facility Assessment policy was requested from the nursing home administrator (NHA) on 3/6/24 at 8:45 a.m. and was not received by the end of the survey on 3/7/24. II. Record reviewThe Facility Assessment, last reviewed by the facility on 3/1/24 (during the survey), was received from the NHA on 3/6/24 at 8:45 a.m. The facility assessment failed to include the following:-Staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff including those presidents with substance abuse or who where exit seeking, wandered;-Staff trainings/education necessary to provide the level and types of support and care needed for the resident population; and,-Identify facility resources needed and equipment to provide competent resident support during day-to-day operations and emergencies including the facility's wander prevention system. III. Staff interviewsThe NHA was interviewed on 3/6/24 at 8:45 a.m. The NHA said the facility assessment had many missing components. She said the facility assessment had several areas that were missing and had not been completed on the template used. The NHA said the facility assessment did not include trainings or competencies for the different staff members, information on the facility wander prevention system, facility or community risk assessment using an all hazards risk approach, description of the infection prevention and control program, list of contracts, recruitment and retention of medical practitioners, technology resources, ethnic, cultural, or religious considerations. The NHA said the emergency preparedness portion of the facility assessment had missing components such as a facility map. The NHA said she was not aware all of these items needed to be in the facility assessment.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include:I. Cross-reference citationsCross-reference F689: The facility failed to ensure resident safety with accident hazards. The facility failed to ensure residents were assessed accurately and interventions were in place to prevent further elopements after two residents eloped, resulting in one resident sustaining a fracture. The facility's failure to protect residents from accident hazards created an immediate jeopardy (IJ) situation. Additionally, the facility failed to ensure residents were assessed timely for smoking safety and provided smoking assistive devices. Furthermore, the facility failed to keep chemicals and used razors secured safely. Cross-reference F600: The facility failed to prevent abuse resulting in actual harm. Cross reference F697: The facility failed to manage residents' pain resulting in actual harm. Cross-reference F607: The facility failed to notify staff of their right to be free of retaliation for reporting abuse. Cross-reference F609: The facility failed to report allegations of abuse to officials including the State Survey Agency. Cross-reference F610: The facility failed to thoroughly investigate allegations of resident verbal and physical abuse. Cross-reference F760: The facility failed to prevent significant medication errors. Cross-reference F835: The facility failed to provide adequate administration and follow up through action and inaction. Cross-reference F838: The facility failed to ensure an accurate and complete facility assessment was completed to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Cross reference F940: The facility failed to ensure all staff received training to care for the resident population including dementia care, substance abuse and mental health. Cross reference F947: The facility failed to ensure nurse aides had 12 hours of education annually based on their date of hire and annual performance review. II. Facility policy and procedureThe QAPI policy was requested from the NHA on 3/6/24 at 2:12 p.m. -The policy was not received by the end of the survey on 3/7/24. III. Repeat deficienciesReview of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F689 for Accident hazardsDuring a recertification survey on 4/19/22, F689 was cited at a D level scope and severity, a potential for more than minimal harm, isolated. During an abbreviated survey on 3/23/23, F689 was cited at a G level scope and severity, actual harm. During a recertification survey on 6/15/23, F689 was cited at an E level scope and severity, a potential for more than minimal harm, pattern. During an abbreviated survey on 11/20/23, F689 was cited at a D level scope and severity, a potential for more than minimal harm, isolated. During an abbreviated survey on 3/7/24, cited at a J level scope and severity, immediate jeopardy to resident health and safety, isolated. F697 Pain managementDuring a recertification survey on 6/15/23, F697 was cited at an E level scope and severity, a potential for more than minimal harm, pattern. During an abbreviated survey on 3/7/24, F697 was cited at a G level scope and severity, actual harm. F838 Facility assessmentDuring a recertification survey on 4/19/22, F838 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. During an abbreviated survey on 3/7/24, F838 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. F835 AdministrationDuring a recertification survey on 4/19/22, F835 was cited at a G level scope and severity, actual harm. During an abbreviated survey on 3/7/24, F835 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. F867 QAPIDuring a recertification survey on 6/15/23, F867 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. During a recertification survey on 4/19/22, F867 was cited at a G level scope and severity, actual harm. During an abbreviated survey on 3/7/24, F867 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. IV. InterviewsThe nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 3/6/24 at 2:12 p.m. The NHA said the elopements were discussed at QAPI, but not in enough detail to identify and correct all of the issues such as Resident #2 removing her wanderguard. The NHA said she was not aware the smoking assessments had not been completed timely and smoking assistive devices were not provided. She said they started accepting residents who smoked a few months ago but the QAPI committee had not reviewed what the smoking program would entail. The NHA said the multiple missed medications and unavailability of medications was not identified or reviewed at QAPI. The NHA said the abuse investigations needed to be more thorough, however, she said that was not identified or reviewed at the QAPI meetings. The medical director (MD) was interviewed on 3/11/24 at 11:44 a.m. The MD said he thought the QAPI committee talked briefly, on 2/22/24, about the elopements that had occurred on 2/19/24. The MD said he did not realize the facility was now accepting residents who smoked. He said the facility had been a smoke free facility and he had not been informed of the change. The MD said he had not been advised of the multiple abuse allegations and altercations that had occured in the last two months. He said he should have been notified and the abuse should have been reviewed at QAPI. The MD said he was not aware the facility was having issues obtaining medications timely for residents resulting in missed doses. He said this should have been discussed at QAPI. The MD was not aware the facility had not done training on substance abuse or dementia care despite the increased admission of residents with those diagnoses.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to ensure all direct and non-direct care staff received training in dementia care, substance abuse and behavior management. Findings include:I. Facility policyThe In-Service Training Policy, revised August 2022, was received from the regional director of clinical services (RDCS) #1 on 3/11/24 at 11:44 a.m. The policy documented in pertinent part, "Required training topics include the following: Behavioral health, dementia management. Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. Based on the outcome of the facility assessment, additional training may include substance abuse."II. Record reviewStaff training records related to behavior management, dementia and substance abuse were requested from RDCS #1 on 3/7/24 at 10:46 a.m. -RDCS #1 said she was unable to find any documentation indicating the facility had provided the staff with training for behaviors, substance abuse or dementia. The Facility Assessment, last reviewed 3/1/24 (during the survey), was received from the NHA on 3/6/24 at 8:45 a.m. -The facility assessment did not identify substance abuse as part of the resident population served, despite the multiple residents with known current or history of substance abuse (cross-reference F838 for failure to complete a comprehensive facility assessment). III. InterviewsA frequent visitor (FV) was interviewed on 3/4/24 2:38 p.m. The frequent visitor said there had been a large influx of admissions for residents with mental health diagnoses with behaviors and substance abuse diagnoses but the staff had not been offered any training in how to work with the residents. The social services director (SSD) was interviewed on 3/5/24 at 11:00 a.m. The SSD said the facility had been accepting an increased number of residents with behaviors and substance abuse issues in the last few months. He said the facility had not provided any education on mental health care and behaviors or substance abuse to the staff. He said he would have thought the facility would have provided training on behavior management and things to look for and do for substance abuse but no training had been offered. The restorative nurse aide (RNA) was interviewed on 3/7/24 at 1:00 p.m. The RNA said there had been an increase in admissions of residents who had mental health conditions and behaviors but no training had been provided to him or the other staff.

Based on record review and interviews, the facility failed to ensure nurse aides received 12 hours of training based on annual performance evaluations and facility assessment. Specifically, the facility failed to ensure certified nurse aides (CNAs) #2, #3, #4, #5 and #6 received at least 12 hours of training. Findings include: I. Facility policy and procedure The In-Service Training, All Staff policy, revised August 2022, was provided by the regional director of clinical services (RDCS #1) on 3/11/24 at 11:44 a.m. It read in pertinent part:"All staff are required to participate in regular in-service education. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training."Required training topics include the following: -Effective communication with residents and family (direct care staff)-Resident rights and responsibilities, preventing abuse, neglect, exploitation, and misappropriation of resident property including:(1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property;(2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and(3) dementia management and resident abuse prevention.-Elements and goals of the facility QAPI (quality assurance performance improvement) program;-The infection prevention and control program standards, policies and procedures;-Behavioral health; and-The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.)-Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment."II. Record reviewThe Abuse reporting in-service training dated 7/6/23 for CNAs #2, #3, #4, #5 and #6 was provided by RDCS #1 on 3/7/24 at 10:46 a.m. -CNA #2 was hired 8/14/89;-CNA #3 was hired 4/7/08;-CNA #4 was hired 6/24/10;-CNA #5 was hired 11/14/16; and, -CNA #6 was hired 7/20/22.-The training document did not include the length of abuse training. -Additional annual training documentation was not provided for these CNAs by exit on 3/7/24. III. Staff interviewsRDCS #1 was interviewed on 3/7/24 at 10:46 a.m. She said she she did not have documentation for the five CNAs requested (#2, #3, #4, #5 and #6) for completion of 12 hours of annual training. RDCS #1 was interviewed on 3/7/24 at 11:10 a.m. She said the building had new ownership and annual evaluations had not been done for CNAs. She said she was not able to obtain annual evaluations and training records from the previous owner. She said the new company would begin tracking the CNAs' education.

A survey prompted by complaint #CO35344 was completed on 2/29/24 to 3/7/24. Three deficiencies were cited.

Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#17 and #8) of three residents reviewed for pain management out of 38 sample residents. The facility failed to ensure Resident #17 and Resident #8, both with a diagnosis of chronic pain, were assessed for pain accurately and administered pain medications as ordered. Both residents reported increased levels of pain. Resident #17's 2/19/24 pain assessment documented the resident had pain which affected her day to day activity. On 2/29/24, the resident reported she did not always get her pain medication as ordered. She said her pain affected her sleep and her ability to get around. Resident #8's 2/21/24 pain assessment documented the resident had pain which affected his sleep and his day to day activity. On 2/29/24, the resident reported he had gone without pain medications on several occasions. He said he was not able to sleep or move around much when he had increased pain. Due to the facility's failures to ensure Resident #17 and Resident #8's pain medications were consistently administered as ordered, both residents sustained increased pain. Findings include:I. Facility policy and procedureThe Pain policy, revised October 2022, was received from the director of nursing (DON) on 3/5/24 at 4:09 p.m. It read in pertinent part, "The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes). It also includes a review for any treatments that the resident currently is receiving for pain. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated."II. Resident #17A. Resident statusResident #17, age greater than 65, was admitted on 8/18/23. According to the February 2024 computerized physician orders (CPO), diagnoses included septic right knee, lumbar abscess and chronic pain syndrome. According to the 2/19/24 facility assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial maximal assistance from staff with transfers, dressing, toileting and personal hygiene. She required moderate assistance from staff with bed mobility. The assessment documented she had pain which affected day to day activity. B. Resident interviewResident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said the facility would run out of her scheduled and PRN (as needed) pain medication Norco (opioid pain medication). Resident #17 said the nurse would try to offer her muscle relaxers when the facility ran out of the Norco, however, she told them the muscle relaxer was not as effective as the pain medication. Resident #17 said she had two back surgeries for infections in her back, however, she continued to have back pain and chronic pain in her knees. Her pain level was 6 to 8 (on a scale of 1-10, with 10 being the worst pain) when she did not get the pain medication. She said it affected her sleep and her ability to get around when she had pain. Resident #17 said the lowest her pain level got was a two out of 10. C. Record reviewReview of Resident #17's February 2024 CPO revealed the following physician's orders: Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 milligrams (mg). Give one tablet by mouth every four hours PRN for pain, ordered 1/30/24.-There were no parameters for when to give the medication. Celebrex capsule (Celecoxib) 100 mg. Give one capsule by mouth two times a day for pain, give with meals, ordered 2/19/24. Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 mg. Give one tablet orally three times a day for chronic pain, ordered 2/20/24. The January 2024 and February 2024 medication administration records (MAR) documented the resident had received the Norco PRN pain medication for pain levels of 0 to 8 out of 10. The February 2024 MAR further revealed the resident was given Norco PRN two to three times per day from 2/1/24 until the order was changed to scheduled three times per day on 2/20/24.-Despite nursing staff documenting Resident #17 was administered Norco two to three times per day PRN, the resident's pain assessment levels on the MAR for the administration of the Norco were frequently documented at a 0 out of 10. From 2/20/24 (after the Norco PRN physician's order was changed to scheduled Norco) until 2/24/24, the Norco medication was signed off as administered on the February 2024 MAR each day, including three doses on 2/24/24. -However, review of the Norco narcotic count sheet revealed no Norco was administered on 2/24/24.-On 2/20/24, at 8:31 a.m. and 4:49 p.m., Resident #17's Celebrex was documented as not administered for pain because it was not available. D. Staff interviewThe DON was interviewed on 3/6/24 at 10:23 a.m. She said she had compared the Norco narcotic count sheet to the February 2024 MAR. She said the resident had missed doses of Norco despite being signed off on the MAR as given. The DON said she found no evidence the Norco was taken from the facility's emergency medication supply which meant the pain medication was not administered to the resident. The DON said PRN pain medications should have parameters for when to give them. The DON said she would not expect Norco to be given for pain levels of zero. The DON said she would begin in-servicing the licensed nurses on pain control and medication administration. III. Resident #8A. Resident statusResident #8, age 68, was admitted on 8/17/23. According to the February 2024 CPO, diagnoses included osteoarthritis and chronic pain. According to the 2/21/24 facility assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with bed mobility and transfers. He required set up assistance for the staff with toileting, dressing, and personal hygiene. He had pain and was on pain medication. The assessment documented pain affected the resident's sleep and day to day activity. B. Resident interviewResident #8 was interviewed on 3/4/24 at 10:15 a.m. Resident #8 said the nurses documented his pain medications (Oxycodone) and neurontin were given but they did not give him the medications. Resident #8 said sometimes the nurse would say they did not have the medications. He said he had gone without his pain medications for several days before. He said when he did not receive his pain medications he had increased pain at a pain level of 8 out of 10 and was not able to sleep or move around as much. Resident #8 said he had reported not receiving his pain medications consistently to the DON but he said he had never heard anything back from her. He said his pain levels were consistently at a level of 4 out of 10 when he received his pain medication but he always had pain. Resident #8 said his pain was never a pain level of 0 out of 10. C. Record reviewReview of Resident #8's February 2024 CPO revealed the following physician's orders:Gabapentin oral capsule 300 mg. Give 600 mg by mouth at bedtime for neuropathic pain, ordered 8/17/23. Tizanidine oral tablet 2 mg. Give one tablet by mouth two times a day for muscle spasms, ordered 1/25/24. Oxycodone oral capsule (Oxycodone HCl) 5 mg. Give 10 mg by mouth four times a day for right knee pain, ordered 8/22/24. Review of Resident #8's electronic medical record (EMR) revealed the following progress notes:On 1/12/24 at 9:35 a.m. the nursing progress notes documented the resident did not get his oxycodone because it was on order. On 1/16/24 at 11:31 a.m., 3:02 p.m. and 8:00 p.m. the nursing progress notes documented Resident #8 did not get his scheduled oxycodone because it was on order from the pharmacy. On 1/26/24 at 4:05 p.m. the nursing progress notes documented the resident's Tizanidine for muscle spasms was not given because it was on order. On 1/28/24 at 4:40 p.m. the nursing progress notes documented the resident's Tizanidine for muscle spasms was not given because it was on order. On 2/1/24 at 7:30 p.m. the nursing progress notes documented the resident did not receive his gabapentin for nerve pain because it was on order. On 2/2/24 at 4:45 a.m. the nursing progress notes documented in a behavior note, the resident said "I want all my medications." The nurse responded, "If it is not on my cart, I can not give it to you." -The missing medications were not documented.-There were no further progress notes regarding action taken to get the medication or that the physician was notified for further orders. The oxycodone narcotic count sheets were reviewed for January 2024. -There was no oxycodone signed out for any of the four dose administration times on 1/12/24, and only one of the four dose administration times (8:00 a.m.) was signed out on 1/16/24. The January 2024 MAR documented the resident had a pain level of five on 1/16/24 at 10:00 p.m. when he did not receive his oxycodone. -The resident's pain levels for the rest of January 2024 and February 2024 were frequently documented as a 0 out of 10, despite the resident's report that his pain level was never below a 4 out of 10, even when he received pain medication (see resident's interview above).-However, Resident #8 reported his pain level never went below a 4 out of 10, even when he received pain medication (see resident's interview above).-The last comprehensive pain assessment completed for Resident #8, other than the 2/21/24 facility assessment, was on 8/17/23, six months prior to the survey. The assessment documented that the resident had frequent pain at a level of 6 out of 10. -There was no documentation of the resident's pain goals or things that made pain worse or relieved pain. D. Staff interviewThe DON was interviewed on 3/5/24 at 2:06 p.m. The DON said the licensed nurses should have notified her when they did not have the pain medication for Resident #8. She said the medication could be received from the pharmacy within two hours when requested STAT (urgent) from the pharmacy. The DON said comprehensive pain assessments were completed on admission, quarterly and as needed. She said pain was assessed every shift and documented on the MAR. She said PRN pain medication should have parameters for when to administer the medication. IV. Additional interviews The DON was interviewed again on 3/5/24 at 4:01 p.m. She said the regional nurses had reviewed the MARs and progress notes for Resident #17 and Resident #8 and said the residents did not receive their pain medications as ordered. She said this was an issue. The DON said she would investigate further to see if there was a trend with specific nurses. She said the facility had an emergency medication system where the medication could have been obtained. The DON said the nurses should have notified the provider for further orders when the pain medication was not available. The DON said she would begin educating the staff on steps to take when a narcotic pain medication was not available and obtaining parameters for when to administer pain medication. The DON said she was not sure if the frequent pain level of 0 out of 10 documented on the MARs for both residents was accurate.

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

Based on record review and interviews, the facility failed to ensure four (#18, #7, #3 and #15) out of four residents reviewed out of 38 sample residents were protected from resident to resident physical abuse by Resident #6 and Resident #14. Resident #6 admitted on 1/1/24 with a history of aggression. Between 1/17/24 and 1/18/24, Resident #6 was involved in at least three altercations with Residents #18, #7 and #3. The altercation with Resident #3 resulted in Resident #3 being transferred to the hospital for head trauma where he received twelve staples to his head. The facility was aware Resident #6 was wandering into other residents' rooms but failed to implement a plan to monitor the resident and redirect her from other residents. Additionally, the facility failed to implement a plan to prevent physical abuse to Resident #15, by Resident #14 who had known aggressive behavior. Findings include: I. Facility policyThe Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part,"Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation,or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. "The nurse will assess the individual and document related findings. The nurse will report findings to the physician. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. "The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditionsaffecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process."II. Resident to resident physical abuse by Resident #6 to Resident #18A. Incident on 1/17/24 On 1/17/24 at 11:20 a.m., the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room calmly when Resident #6 repeatedly went into Resident #18's room. Resident #18 asked her to stop coming into his room. When Resident #18 was not looking, Resident #6 took his cane. Resident #18 yelled for the nurse. When the nurse went into the room Resident #18 was pulling Resident #6's hair. The residents were separated, and the facility had decided to move Resident #6's room for "safety concerns." Resident #6 was encouraged to socialize with residents in common areas and not in resident rooms. On 1/17/24 at 11:34 a.m. the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room and calm. Resident #6 repeatedly went in Resident #18's room even though the nurse asked her not to. Resident #6 took Resident #18's cane. When the nurse arrived Resident #18 was pulling Resident #6's hair. Resident #6 said she was punched. The NHA recovered Resident #18's cane. There were no injuries noted for either resident and Resident #6 agreed to a room move for safety concerns. On 1/17/24 at 4:57 p.m. a Change of Condition Evaluation documented Resident #6 was involved in a physical and verbal altercation. The evaluation documented Resident #6 was verbally and physically aggressive. The 1/17/24 facility investigation was received from the nursing home administrator (NHA) on 3/4/24 at 10:00 a.m. The investigation documented the Resident #6 and Resident #18 were immediately separated and there were no injuries to either resident. The investigation file contained a follow up statement from Resident #18 on 1/18/24 stating he was doing better and no longer upset. The investigation contained two resident interviews. One resident said they had heard about residents fighting on 1/17/24 and one resident said another resident had tried to punch her wheelchair and she had to tell him to stop.-There were no further resident interviews and no staff interviews found in the facility's investigation file.-The investigation documented that no agencies were notified such as the police, ombudsman or State Agency (cross reference F609 for failure to report an alleged violation). B. Resident #61. Resident statusResident #6, less than age 65, was admitted on 1/11/24 and discharged to the hospital on 1/18/24. According to the January 2024 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), alcohol abuse, bulimia nervosa (eating disorder), encephalopathy (alteration in brain function or structure), borderline personality and major depression with severe psychotic symptoms. According to the 1/12/24 facility assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. The assessment documented the resident had symptoms of feeling down, hopeless, trouble concentrating with little pleasure in doing things. The assessment documented the resident did not wander but had a wander prevention device. 2. Record reviewA Preadmission Screening and Resident Review (PASRR) Level II Notice of Determination (NOD) for Mental Illness (MI), dated 12/18/24, documented Resident #6 had an open legal case for felony menacing and Resident #6's representative reported Resident #6 had been exhibiting aggressive behavior. The PASRR Level II was in the facility medical record for Resident #6 and had a printed date in the corner of 1/12/24. Resident #6's behavior care plan, initiated 1/15/24, documented Resident #6 wandered into other resident rooms and took or touched their belongings. The goal was the resident would accept supportive strategies and demonstrate adequate control of emotions which would not result in injury to self or others. Interventions included, administer medications as ordered, document behavior, encourage resident to verbalize feelings, establish rapport, maintain a calm, slow, understandable approach, notify the physician, responsible party of aggression and abusive behavior, observe and document changes in behavior, including frequency of occurrence and potential triggers, observe for clinical factors influencing behavioral indicators, observe resident's mood and response to medication, referred for psychiatry services-The care plan did not have interventions to address the resident's known behavior of wandering into other resident rooms and taking their belongings. C. Resident #181. Resident statusResident #18, less than age 65, was admitted on 1/10/24. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depression, personality disorder, post traumatic stress disorder (PTSD) and traumatic brain injury (TBI). According to the 1/12/24 facility assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. D. Staff interviewsThe NHA and the director of nursing (DON) were interviewed on 3/5/24 at 10:23 a.m. The NHA said she remembered Resident #6 took Resident #18's cane. The NHA said Resident #6 did take Resident #18's cane and the NHA found it and returned it to Resident #18. The NHA said Resident #18 then pulled Resident #6's hair. The NHA said there were no further interviews of residents because the residents on that unit could not tell staff what was going on. She said the facility had to look for non verbal things. -However, the NHA could not describe what non verbal things were looked for. The NHA said she did not notify the police because she did not have time to. She said she would notify them. The NHA said she notified the ombudsman after the second incident (see below). The NHA said Resident #6 agreed to a room move. She moved to a room on the 300 hall. III. Resident to resident physical abuse by Resident #6 to Resident #7 A. Interviews regarding the incident on 1/17/24A frequent visitor (FV) was interviewed on 3/4/24 at 2:38 p.m. The FV said she had several serious complaints regarding the facility. She said she was told Resident #6 placed a blanket around Resident #7's face. She said Resident #7 had been unable to move to protect herself. The FV said Resident #6 was then moved to a new hall where she assaulted Resident #3, resulting in 12 stitches to his face and his entire face was black and blue (see below). The FV reported that residents and staff were feeling unsafe and afraid to report facility issues such as abuse. The FV said the staff were told not to report the abuse by the DON and that she would "handle it." The FV said she called the police as well as other resident family members and reported the incidents. The FV further said staff were told not to speak to the State Agency by the NHA or there would be consequences. A restorative nurse aide (RNA) was interviewed on 3/6/24 at 1:00 p.m. He said he was present the day Resident #6 assaulted Resident #7. He could not remember the exact day it occurred. He said he remembered staff were scrambling around to keep Resident #6 out of Resident #7's room because Resident #6 had turned off Resident #7's oxygen and was holding a blanket over her face. He said a staff member had to block the door so Resident #6 would not go back in the room with Resident #7. He said Resident #6 was moved to the 100 hall. The RNA said staff told him they were not to report the incident as abuse or that Resident #6 assaulted Resident #7, but to report it as a fall. The RNA said the facility had not provided any training in mental health or dementia. The DON was interviewed again on 3/7/24 at 12:37 p.m. The DON said she was told Resident #6 was holding a blanket around Resident #7's face around 1/17/24. She said she was not at the facility that day. The DON said the NHA was at the facility and handled the situation. The DON said the NHA should have done an investigation but she did not. She said the nurse on duty witnessed the assault but she was an agency nurse and had not returned the DON's calls. The DON said she found out about the incident a few days after it occurred. The DON looked at her computer and said there was no assessment of Resident #7. She said Resident #6 was then moved to a new room and that was when she assaulted Resident #3 (see below).-The phone number and name of the agency nurse was requested and not received by the end of the survey on 3/7/24.-The NHA was unavailable for an interview. B. Resident #71. Resident statusResident #7, age 81, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses include Parkinson's disease, major depression and dementia. According to the 1/30/24 facility assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. She was totally dependent on staff for transfers and toileting. She required substantial to maximal staff assistance with bed mobility, dressing and personal hygiene. C. Record review-There were no progress notes in Resident #6 or Resident #7's medical record regarding the alleged assault.-There was no investigation and the alleged assault was not reported to the State Agency or the ombudsman. IV. Resident to Resident physical abuse by Resident #6 to Resident #3A. Incident on 1/18/24On 1/18/24 at 10:28 a.m., an interdisciplinary team (IDT) note documented Resident #3 was pushed by another resident and obtained a laceration to the right eyebrow. -There were no recommendations by the IDT team. On 1/18/24 at 11:54 a.m., the nursing notes documented the nurse heard Resident #3 "fighting with the same female resident he had been fighting with all day (Resident #6)." The nurse observed arms flying at each other and Resident #3 lost his balance and fell hitting his face on the ground. There was a deep head wound from his glasses. Resident #3 complained of chin pain. On 1/18/24 at 3:38 p.m., the nurse note documented 911(emergency services) was called because the laceration to the right eyebrow area on Resident #3 was too large to steri-strip. On 1/18/24 at 3:52 p.m., a change of condition form documented that at approximately 11:30 a.m., Resident #3 was pushed by another female resident. The nurse documented she heard screams and ran to the hall to see Resident #6 push Resident #3. Resident #3 was bleeding from the right eyebrow and it was too large to apply steri-strips to. On 1/18/24 at 4:33 p.m., the nursing notes documented Resident #3 returned to the facility from the emergency room with 12 staples above his right eye. On 1/19/24 at 11:30 a.m., a provider note documented Resident #3 was involved in an altercation with another resident causing him to fall and strike his head. He presented to the ER (emergency room) with jaw pain and a large forehead laceration. On 1/20/24 at 11:30 a.m., the nursing notes documented Resident #3 continued with discoloration to his face after an altercation with another resident. The other resident had since been removed from the facility. On 1/21/24 at 3:53 a.m., the nursing notes documented Resident #3 continued with sutures to his head and bruising to the right eye, forehead and chin. The 1/18/24 facility investigation was received from the NHA on 3/4/24 at 10:00 a.m. The investigation documented Resident #3 and Resident #6 were immediately separated and Resident #6 was sent to the ER for a psychiatric evaluation. A social services interview in the investigation file, dated 1/18/24, documented Resident #3 said Resident #6 pushed him and was "trying to do harm to me." A second social services note documented that, per staff, Resident #6 had been continuously wandering to Resident #3's unit. Staff had redirected her back to her own unit. Five resident interviews dated 1/19/24 did not document further abuse.-There were no further staff interviews.-There was no documentation the State Agency, police or ombudsman were notified. B. Resident #3 1. Resident statusResident #3, age 71, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the March 2024 CPO, diagnoses included intracranial hemorrhage (brain bleed), schizoaffective disorder and dementia. According to the 2/21/24 facility assessment, the resident had severe cognitive impairment with a BIMS score of seven out of 15. He required supervision with dressing and transfers, and was independent with personal hygiene, bed mobility and toileting. C. InterviewsResident #8 was interviewed on 3/4/24 at 10:15 a.m. He said a female resident had assaulted a male resident and the police were not notified. He said the staff, a frequent visitor and a resident representative had called the police and there was now a detective involved. He provided a case number and the name of a detective. The NHA and the DON were interviewed together on 3/5/24 at 10:23 a.m. The DON said Resident #6 wandered into other resident rooms. She said she wandered into Resident #3's room and she pushed him. Resident #3 fell and cut his right eyebrow. Resident #6 was removed from the area. Resident #3 went to the ER and received seven or eight sutures. He had bruises on the right side of his face. The DON said Resident #6 was taken to the ER in the facility van for a psychiatric evaluation. The NHA said the resident wandered into other resident rooms. She wandered into the room of Resident #3. She pushed Resident #3 and he fell cutting his face. Resident #6 was then taken in the facility van to the hospital. However, Resident #6 jumped out of the facility van on the way to the hospital and was then taken by ambulance to the hospital and the facility discharged her. The NHA said the facility was not aware of the resident's history of aggression. She said the facility would be looking at referrals for new admissions more in depth. She said she would start approving residents with a history of aggression herself. The NHA said she did not know what the plan was to keep Resident #6 from wandering into other residents' rooms. She said the facility should have had a plan to monitor Resident #6 more closely. The social services director (SSD) was interviewed on 3/5/24 at 11:00 a.m. The SSD said he had not read Resident #6's PASRR Level II and was not familiar with her history. He said she was not here very long but shortly after she admitted she walked to the doorways of other residents and stared at them. This went on for a week. She had arguments with other residents, including Resident #18. The SSD did not recall exactly what happened with Resident #3. He said he remembered the residents were yelling at each other. He did not witness the altercation. He said he had noticed an increase in residents with mental health conditions coming into the facility since December 2023. The SSD said the facility had not provided any training in mental health, though he thought there should have been training. Licensed practical nurse (LPN) #4 was interviewed on 3/5/24 at 1:50 p.m. LPN #4 said she was told by other staff members Resident #6 assaulted Resident #3. She said the police had not been notified by the facility but a resident's family member had notified the police. LPN #4 said she was familiar with Resident #6. She said Resident #6 kept wandering into Resident #3's doorway. Resident #3 would tell her to leave, but Resident #6 would say "I do not have to"..The RNA was interviewed on 3/6/24 at 1:00 p.m. The RNA said shortly after he heard a female yelling "come on, come on", he went to the hall and saw Resident #3 on the floor with a gash in his head, bleeding all over. He said he was told by other staff member that Resident #6 had a rock in her hand and hit Resident #3 with it. V. Resident to resident physical abuse by Resident #14 to Resident #15A. Incident on 1/12/24The 1/12/24 facility investigation was received from the NHA on 3/4/24 at 10:00 a.m. A staff witness statement, dated 1/12/24, documented Resident #15 was pushing a chair and mistakenly hit Resident #14's foot. Resident #14 pushed Resident #15 who fell on the floor. Resident #14 then began hitting Resident #15 in the face before being pulled off of the resident. Three residents who witnessed the event were interviewed. The residents were asked:-"How are you feeling?"-"How do you feel after the incident?"-"Would you like to speak to your family or friends?"-"Is there anything I can do to help you cope with the incident?"-There were no resident interviews about abuse.-There were no staff interviews about abuse.-There was no documentation the State Agency or police were notified. B. Resident #141. Resident statusResident #14, age 77, was admitted on 12/18/23. According to the March 2024 CPO, diagnoses included paranoid personality disorder, restlessness and agitation, cerebral infarction (stroke), aphasia (speech disorder) and vascular dementia. According to the 12/20/23 facility assessment, the resident had severe cognitive impairment and could not complete the BIMS assessment. The staff assessment for mental status documented the resident had long and short term memory loss. He required supervision with dressing, transfer and toileting. He required setup assistance with personal hygiene and was independent with bed mobility. The assessment documented the resident had delusions and verbal behaviors directed towards others. The assessment documented the resident's behavior had gotten worse and disrupted care, the living environment and interfered with social interactions. 2. Record reviewOn 1/10/24 at 3:00 p.m., the progress notes for Resident #14 documented he was hit with a chair on the right side. There were no injuries. Resident #14's care plan, initiated 12/19/23, documented the resident was at risk for behavioral symptoms due to dementia and paranoid personality disorder. He had punched another resident at another facility. Interventions were to anticipate needs and meet promptly, document and record behavioral episodes, establish a rapport with the resident, maintain a calm, slow, understandable approach, manage environmental factors to optimize comfort, observe and document changes in behavior, including frequency of occurrence and potential triggers and observe resident's mood and response to medication.-There were no changes made to Resident #14's care plan after the altercation with Resident #15 on 1/10/24. C. Resident #151. Resident status Resident #15, age 85, was admitted on 8/31/23. According to the February 2024 CPO, diagnoses included vascular dementia, anxiety and psychotic disorder with hallucinationsAccording to the 12/4/23 facility assessment, the resident had severe cognitive impairment and could not complete the BIMS assessment. The staff assessment for mental status documented the resident had long and short term memory loss. He was independent with bed mobility, and required supervision for dressing, transfers and toileting. He required set up assistance from staff with personal hygiene. The assessment documented he had physical and verbal behavior directed towards others. 2. Record review On 1/10/24 at 3:00 p.m., the nursing progress notes for Resident #15 documented Resident #15 was pushing furniture and accidentally ran into Resident #14 who then pushed Resident #15. Resident #14 continued to swat and hit Resident #15 with his hat. The residents were separated by staff. -There was no documentation about injuries. On 1/10/24 at 7:08 p.m., the nursing notes documented that Resident #15 had no injury. C. Staff interviewsThe NHA and DON were interviewed together on 3/25/24 at 10:23 a.m. The DON said Resident #15 was moving a chair around the nursing station. She said he used to be a janitor. He bumped into Resident #14 and Resident #14 pushed Resident #15 to the ground and began hitting him with his hat. The staff separated them. The DON said there were no injuries to either resident. The DON looked at both residents' electronic medical records(EMR) and said no changes were made to the residents' care plans following the incident. She said Resident #15 did have a history of aggression. She said he had post traumatic stress disorder from being assaulted by his wife. The NHA said she thought she notified the police and ombudsman around 1/12/24. -However, there was no documentation provided to indicate the NHA had notified the ombudsman about the incident.

A revisit survey was completed on 1/29/24 for all previous deficiencies cited on 11/20/23. The facility is in compliance with all regulations surveyed.

A survey prompted by #CO34160, #CO34161, #CO34162 and #CO34183 was conducted on 11/15/23 to 11/20/23. Four deficiencies were cited.

Based on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for one (#1) of one resident out of six sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances expressed by Resident #1 regarding missing and late meals, missed showers, being left alone in the shower, wound dressing changes and lack of bed linen changes. Findings include:I. Facility policy and procedureThe Grievances policy, revised December 2009, was received on 11/16/23 at 3:32 p.m. from the NHA. -The policy addressed staff grievances, but did not address resident grievances. II. Resident #1A. Resident statusResident #1, age 88, admitted on 4/6/22. According to the November 2023 computerized physician orders (CPO) diagnoses included, congestive heart failure (CHF), fistula (abnormal connection of tissue due to surgery or injury) of the abdomen and large intestine and osteoarthritis. The 9/8/23 minimum data set (MDS) assessment revealed the resident did not complete a brief interview for mental status (BIMS). The assessment documented the resident had no concerns with long or short term memory. The resident was independent with bed mobility and required supervision with toileting, dressing and personal hygiene. He required partial to moderate assistance with bathing. The assessment documented the resident had no surgical wounds. B. Observations and resident interviewsResident #1 was interviewed on 11/15/23 at 12:02 p.m. Resident #1said he was concerned he frequently missed his showers. He said he had to go to the nurses station and remind them several times before he got a shower. Resident #1 said he was left alone in the shower many times. He said he could wash himself except for his back and feet. He said a staff member would wash his back and feet and leave him alone in the shower. He said he was afraid of falling. Resident #1 said his clothes were placed on his walker out of his reach in the shower room. Resident #1 said he was afraid he would fall walking from the shower chair to his walker (cross reference F-677 ADL's for dependent residents and F-689 accident prevention). Resident #1 said he ate in his room and meals were often late, 30 minutes or more. He said sometimes he did not get a meal tray at all. Resident #1 said the staff did not change his linens so he had begun doing it himself. He pointed to a pile of folded linen, sheets and a blanket on a chair. He said the staff left him clean linen to change his linens himself. Resident #1 said the staff did not change his wound dressing as ordered. He said the orders used to be to change it daily and now it was every other day. He said they did not change it daily when they were supposed to. He said the wound had begun leaking more and the staff just left it. Resident #1 was interviewed again on 11/16/23 at 9:45 a.m. Upon entering the room the resident stated, "Am I stinking up the place?" Resident #1 said he still had not had a shower. His facial hair was longer than the previous day, the room had a strong musky foul odor, and the resident had multiple dried rings of brown drainage on his gown. He lifted his gown and a wound dressing on his abdomen was saturated in brown drainage with multiple dried rings of drainage on the skin around the outside of the bandage. The bandage was dated 11/15/23. The resident said he was hoping the nurse would change the dressing when he had a shower, but he still had not had a shower. Resident #1 said the wound was a fistula from a hernia repair surgery and the wound had not healed. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/16/23 at 3:33 p.m. LPN #1said she knew Resident #1 and was frequently assigned to be his nurse. She said he had reported meal trays were late or missed. She said she had two residents this morning who also did not get room trays. LPN #1 saidshe thought the agency staff did not always get the resident's menu order and then a tray was not provided. LPN #1 said Resident #1 did report missed showers. She said nursing staff were supposed to shave him but they did not do that either. She said the agency staff would not do the showers. She said she did not know why the agency staff did not do showers. She did not know if the resident had been left alone in the shower. She said he was a fall risk and should not be left alone. LPN #1 said she knew Resident #1's abdominal wound was leaking more and smelled bad. She said it was cauterized at one point and did not leak but it had started leaking again. LPN #1 said a grievance form had not been completed for Resident #1's concerns. The director of rehabilitation (DOR) was interviewed with the physical therapy assistant (PTA) and occupational therapist (OT) on 11/20/23 at 10:10 a.m. The PTA said he was working with Resident #1 on balance and Resident #1 was not safe to be making his bed alone in his room without supervision. The OT said she was working with the resident on balance and the resident had issues with stepping backwards. She said he was not safe to be making his bed alone in his room. She said she had showered him and he should not be left alone in the shower because he was impulsive, a fall risk and needed assistance with his feet and back. The dietary manager (DM) was interviewed on 11/20/23 at 10:22 a.m. She said the certified nurse aides (CNA) took the resident's meal orders on the evening shift for the following day. She said she did not know how trays were missed. The DM said nursing staff were responsible for taking the resident's orders and should notify the kitchen if a resident did not get a meal tray. The social services director (SSD) was interviewed on 11/16/23 at 11:01 a.m. He said the staff wrote grievances for residents but a resident could write their own. He said when a grievance was written it was given to social services. Social services would then give it to the appropriate department head and keep a copy to track completion. He said grievances should be followed up on in 48 hours or less and follow up should be communicated to the resident or person who had reported the concern. The SSD said he had no grievances related to late or missing meals, missed showers, linen changes or wound care for Resident #1. He said he was not aware of the resident's concerns regarding being left alone in the shower. The director of nursing (DON) and NHA were interviewed on 11/20/23 at 9:35 a.m. The DON said bed linen should be changed on shower days and as needed. She was not aware Resident #1 changed his own linen or had concerns with linen not being changed. She said she was aware of missed showers, but there were no grievances filled out. The DON said she was aware wound care had not been signed off on the treatment administration record (TAR). She said it was due to the use of agency staff and she could not verify it had been done. She said she was not aware the wound had an odor. The NHA said the grievance process involved the staff writing a grievance form for a resident with a concern and then they slid it under the department manager's door, whichever manager was appropriate for the grievance. The manager showed it to the NHA and had 72 hours to take action and follow up. The NHA said she was not aware of grievances related to lack of bed linen changes, missed showers, missed meal trays or missed wound care. The resident's representative was interviewed via phone on 11/20/23 at 9:59 a.m. He said he had reported to the nurses and the business office manager (BOM) multiple concerns. He said the BOM was very involved with residents and not just their finances. He said she knew the residents well but had recently separated her employment with the facility. The resident's representative said he reported Resident #1 often did not get meals or got the wrong items on his tray that were not ordered. The resident's representative said the abdominal wound had been cauterized at one point but that did not work. He said his abdominal wound had been leaking a lot and smelled but the facility had not followed up with an appointment with the surgeon or dermatologist. He said the wound smelled worse now than it did before it was cauterized. The resident's representative said Resident #1 had reported missed showers and being left alone in the shower and feared falling. He said Resident #1 told him the staff told him to hurry up when he was in the shower. He said these concerns were all reported to the BOM and to the licensed nurses who were on duty at the time of the concern. A frequent visitor was interviewed on 11/27/23 at 11:56 a.m. She said she met with Resident #1, his representative, the NHA, DON and SSD on 9/26/23. She said multiple concerns were discussed including the resident being left alone in the shower with his walker and clothes out of reach and meal trays that were not delivered. C. Record review There were no grievances to review related to late or missing meals, missed showers, linen changes or wound care. The November 2023 TAR was reviewed on 11/16/23 at 10:02 a.m. -The TAR revealed no treatment to the abdominal fistula wound was signed off for 11/2/23, 11/7/23, 11/8/23, or 11/12/23. On 11/16/23 at 10:00 p.m., during the survey, an order was written for Resident #1 to have a dermatology consultation related to the abdominal wound. On 11/16/23 at 2:26 p.m. The CNA task sheet shower records documented the last shower the resident had was on 11/4/23 at 3:47 p.m. Resident #1 required partial to moderate assistance. IV. Facility follow upOn 11/21/23 at 8:50 a.m., an email was received from the DONregarding a follow up appointment for the resident's wound. The email contained a progress note dated 11/20/23 at 1:40 p.m. and documented, "Resident has fistula to right upper abdomen with excessive drainage and odor present, appointment made with his general surgeon for further evaluation on December 8, 2023 at 9:30 a.m.

Based on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain mobility for two (#1 and #2) of three residents out of six sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2, who required assistance with bathing, were showered or bathed per the resident's preference. Findings include:I. Facility policy and procedureThe Shower Bath policy, revised February 2018, was received from the nursing home administrator (NHA) on 11/20/23 at 10:16 a.m. The policy documented in pertinent part, "Documentation, The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower or bath. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. How the resident tolerated the shower or bath. If the resident refused the shower or bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Notify the supervisor if the resident refuses the shower or bath."II. Resident #1A. Resident statusResident #1, age 88, was admitted on 4/6/22. According to the November 2023 computerized physician orders (CPO) diagnoses included, congestive heart failure (CHF), fistula (abnormal connection of tissue due to surgery or injury) of the abdomen and large intestine and osteoarthritis. The 9/8/23 minimum data set (MDS) assessment revealed the resident did not complete a brief interview for mental status (BIMS). The assessment documented the resident had no concerns with long or short term memory. The resident was independent with bed mobility and required supervision with toileting, dressing and personal hygiene. He required partial to moderate assistance with bathing. The assessment documented the resident had no surgical wounds. B. Observations and interviewsResident #1 was observed in his room on 11/15/23 at 12:02 p.m. The room had a musky odor of a wound. The resident was unshaven, and there was a brown dried ring of fluid on the front of his gown. Resident #1 said he was upset that he had not had a shower today. He said the staff frequently told him they were too busy to give him a shower. He said if he went out to the nurses station and complained multiple times then sometimes he would get a shower. Resident #1 said he was supposed to get showers on Wednesdays and Saturdays and today (11/15/23) was Wednesday. Resident #1 said when he did get a shower he was frequently left alone in the shower. He said his walker and clothes were often out of his reach and he worried about falling alone in the shower. He said he could shower himself except for his feet and back. He said the staff would wash those areas and leave him alone in the shower room. Resident #1 was interviewed again on 11/16/23 at 9:45 a.m. Upon entering the room the resident stated, "Am I stinking up the place?" Resident #1 said he still had not had a shower. His facial hair was longer than the previous day, the room had a strong musky foul odor and the resident had multiple dried rings of brown drainage on his gown. He lifted his gown and a wound dressing on his abdomen was saturated in brown drainage with multiple dried rings of drainage on the skin around the outside of the bandage. The bandage was dated 11/15/23. The resident said he was hoping the nurse would change the dressing when he had a shower, but he still had not had a shower. Certified nurse aide (CNA) #2 was interviewed on 11/16/23 at 1:24 p.m. She said showers were done according to a schedule. She said they were all done on day shift, not per resident preference. CNA #2 said if the day shift missed some of the showers the evening shift was supposed to do them. She said the showers were documented in the electronic medical record. Licensed practical nurse (LPN) #1 was interviewed on 11/16/23 at 3:22 p.m. She said she knew Resident #1 and was frequently assigned to be his nurse. She said she was not assigned to him today (11/16/23). LPN #1 said Resident #1 was supposed to have a shower yesterday (11/15/23) according to the shower schedule. She said showers were done per a schedule, all of them on days and not per resident preference. LPN #1 said if the day shift missed a shower the evening shift was supposed to do the shower. LPN #1 said Resident #1 complained frequently of not getting his showers. She did not know if a grievance had been completed regarding his concern. (cross reference F 685 grievances). LPN #1 said showers were not done due to a lot of contract agency staff use. She said they did not do the showers. She said the CNAs were supposed to help Resident #1 shave when he needed to. She said he had an electric razor but needed some setup and cueing. C. Record reviewThe shower schedule at the nurses station was reviewed on 11/16/23 at 1:30 p.m. The schedule documented Resident #1 was scheduled for a shower on Saturdays and Wednesdays There were no times listed for the showers. On 11/16/23 at 2:26 p.m., the CNA task sheet shower records documented the last shower the resident had was on 11/4/23 at 3:47 p.m. Resident #1 required partial to moderate assistance. D. Administrative interviewThe director of nursing (DON) was interviewed on 11/20/23 at 9:35 a.m.. She said the nursing staff were supposed to document showers in the medical record. The DON said it was "true" showers had not been done and had been missed. She said the facility recently had started a new tracking system that had the CNAs sign off daily on showers. She said if a shower was not done that day the CNAs should document N/A for not applicable but the nursing staff had not done that. She said she could not tell, based on the lack of documentation, which day a shower was given or not. The DON said she knew missed showers were a concern. The DON looked at her laptop and said the CNA task sheets documented 11/4/23 was the last time Resident #1 had a shower. She said the nursing staff should have completed a handwritten skin monitoring sheet for each shower but she did not have any for November 2023 for Resident #1. III. Resident #2A. Resident statusResident #2, age less than 65, admitted on 9/29/17 and readmitted 7/10/23. According to the November 2023 CPO diagnoses included, hemiparesis (muscle weakness or paralysis on one side) and hemiplegia (paralysis) of the right side of the body due to cerebral infarction (stroke), major depression and neuromuscular dysfunction of the bladder. The 10/20/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS of 11 out of 15. The resident required supervision with transfers and was independent with bed mobility, toileting, and personal hygiene. He required moderate assistance with dressing and bathing. He required partial to moderate assistance with bathing. B. Record reviewOn 11/20/23 at 9:35 a.m. the CNA task sheet for Resident #2's shower documentation was reviewed from 10/17/23 through 11/20/23. -There were no showers documented for the resident during the 30 day time period from 10/17/23 through 11/20/23. The new CNA task sheet in the computer was provided by the DON on 11/20/23 at 9:35 a.m. It documented the resident had a shower almost daily. The DON again said this was not accurate. She said the nursing staff should have documented when Resident #2 had a shower and documented N/A when he did not have a shower or document if he refused. The skin monitoring handwritten sheets were provided by the DON on 11/20/23 at 9:35 a.m. The Skin Monitoring sheets documented the resident had a bed bath on 10/5/23 and 10/14/23. There was no further documentation of showers for Resident #2 for October 2023. There were no monitoring sheets for November 2023. C. InterviewsThe DON was interviewed on 11/20/23 at 9:35 a.m. She said she had no documentation indicating Resident #2 had received a shower or bath in November 2023.

Based on record review and interviews the facility failed to ensure two (#3 and #1) of three residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Specifically, the facility failed to ensure:-Resident #3 received immediate interventions including increased supervision during a change of condition to prevent falls;-Resident #3 was assessed for injury, including neurological checks, after witnessed falls with head injury and unwitnessed falls; and,-Resident #1 had a resident centered care plan to prevent falls. I. Facility policy and procedureThe Fall Risk policy, revised March 2018, was received from the nursing home administrator (NHA) on 11/20/23 at 10:16 a.m. The policy documented in pertinent part, "The nursing staff, attending physician, and consultant pharmacist will review medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls."Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable."The Neurological Assessment policy, revised October 2010, was received from the NHA on 11/20/23 at 10:16 a.m. The policy read in pertinent part, "Neurological assessments are indicated: Upon physician order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma, or when indicated by resident's condition."II. Resident #3A. Resident statusResident #3, age less than 65, admitted on 8/18/23 and readmitted on 9/22/23. According to the November 2023 computerized physician orders (CPO) diagnoses included Lewy Body dementia, chronic pain, and major depression. The 9/28/23 minimum data set (MDS) assessment revealed the resident could not complete a brief interview for mental status (BIMS). The assessment documented he had long and short term memory loss. His ability to make daily decisions was severely impaired. Resident #3 required limited one person assistance with bed mobility and dressing. He required supervision with transfers and toileting. Resident #3 required extensive one person assistance with personal hygiene. The assessment documented the resident had no falls. B. Record reviewOn 10/14/23 at 5:50 p.m., the nursing progress notes documented the resident was lethargic and sleepy. The physician gave orders to hold Norco (pain medication) and Haloperidol (antipsychotic medication). On 10/14/23 at 7:39 p.m., the nursing notes documented the resident was sleeping and not feeling well most of the day. The resident got up after dinner and was standing at the nurses desk and fell backwards hitting his head on the handrail. The physician was called and gave orders for laboratory tests, urine analysis and to increase fluids. On 10/14/23 at 7:00 p.m., an SBAR (situation, background, assessment and recommendation) assessment documented the resident fell and had a contusion (bruise). -There was no further description of the contusion or the location of the contusion. On 10/14/23 at 8:02 p.m., a Post Fall assessmentScreen documented the resident had not been eating and staying in bed prior to the fall. -There was no documentation regarding an injury.-There was no description of whether an injury had occurred. -There were no interventions to attempt to keep the resident safe such as increased supervision while the laboratory results were pending. -There were no neurological checks located in the medical record. On 10/20/23 at 1:05 p.m., an SBAR assessment documented the resident had a fall. -There was no further information provided regarding injury or interventions to keep the resident safe. It was unclear if the resident hit his head, and no neurological checks were found in the medical record. -There were no immediate interventions such as increased supervision implemented to keep the resident safe from falls. On 10/23/23 at 10:55 a.m., an IDT progress note documented the resident was on the floor in the dining room on 10/20/23. It did not indicate if the fall was witnessed. Interventions were to encourage the resident to walk slowly and staff to check to see where he was on the unit. -There was no investigation as to how the resident fell. On 11/2/23 at 10:00 a.m., the nurse practitioner (NP) documented the resident had a laceration (cut) above his left eye brow and yellow bruising to his left cheek. On 11/2/23 at 10:15 a.m., an SBAR assessment documented the resident fell and had a laceration. The new intervention was to encourage him to wear shoes.-There was no description of the fall or whether it was witnessed. -There was no description by the nurse of the laceration, location of the laceration, or treatment provided. -There were no neurological checks. On 11/3/2023 at 9:46 a.m., an IDT progress note documented the resident fell in the dining room and was non-compliant with footwear. The plan was to encourage footwear. On 11/3/23 at 10:34 a.m., a Rehabilitation Screening form recommended speech therapy. No other therapy was recommended. The form documented the resident was not experiencing a change that would require therapy intervention. On 11/6/23 at 6:55 a.m., the nursing notes documented Resident #3 fell in his room at 6:26 a.m. His body was on the floor but his legs were still on the bed. -There was no documentation of whether an injury had occurred, no neurological checks and no new interventions to keep the resident safe. On 11/6/23 at 9:01 a.m., a Rehabilitation Screen form documented the resident was experiencing a change that may require therapy intervention. Speech therapy was the only recommendation. On 11/7/23 at 10:37 a.m. a registered nurse (RN) assessment documented she was notified by the licensed practical nurse (LPN) on duty that the resident was on the floor. Upon entry to the resident's room he was lying on the floor with his legs still on the bed. The RN documented the resident had scattered abrasions (scrapes) and bruises on his torso and back, as well as both upper extremities. The resident's lower extremities were stiff and contracting causing shortening. -It was unclear if this was a new fall or in reference to the fall on 11/6/23. On 11/9/23, the November 2023 CPO documented hospice care was ordered. On 11/10/23 at 7:00 a.m., the nursing progress notes documented Resident #3 passed away at 6:45 a.m. The fall care plan, initiated 9/16/23, documented Resident #3 had an actual fall. On 10/19/23 the care plan documented to continue current interventions. On 10/20/23 the care plan documented to monitor for pain and bruising, changes in mental status and neurological checks, pharmacy review of medications, physical therapy consultation and activities that promoted exercise and strength. -There were no changes to the care plan after 10/20/23, until the survey began.-There were no interventions related to the resident's footwear. C. InterviewsThe director of nursing (DON) was interviewed on 11/16/23 at 12:21 p.m. She said the nurse should implement an intervention after a fall to keep the resident safe. She said neurological checks should be done if the resident had a witnessed fall with head injury or unwitnessed fall. She said after Resident #3's fall on 10/20/23 the intervention was to encourage him to walk slowly. She acknowledged the resident would not remember to walk slowly due to his dementia. She said she had no neurological checks for the falls on 10/14/23 10/20/23, 11/2/23 or 11/6/23. She said neurological checks should have been done after each fall due to head injury or because it was not witnessessed. The DON said there was a lack of interventions to prevent falls after each occurence. She said the staff did encourage the resident to wear shoes after the fall on 11/2/23. The DON said the resident had the foot wound, present on admission, and did not like to wear shoes. The foot wound and lack of shoes was not a new issue and he should have already been wearing non-skid socks or shoes. The DON said the care plan did not address encouraging the resident to wear non-skid footwear. III. Resident #1A. Resident statusResident #1, age 88, admitted on 4/6/22. According to the November 2023 CPO, diagnoses included congestive heart failure (CHF), fistula (abnormal connection of tissue due to surgery or injury) of the abdomen and large intestine and osteoarthritis. The 9/8/23 minimum data set (MDS) assessment revealed the resident did not complete a brief interview for mental status (BIMS). The assessment documented the resident had no concerns with long or short term memory. The resident was independent with bed mobility and required supervision with toileting, dressing and personal hygiene. He required partial to moderate assistance with bathing. The assessment documented the resident had no falls. B. Resident interviewResident #1 was interviewed on 11/15/23 at 12:02 p.m. Resident #1 said he was left alone in the shower many times. He said he was afraid of falling. Resident #1 said his clothes were placed on his walker out of his reach in the shower room. Resident #1 said he was afraid he would fall walking from the shower chair to his walker in the shower room (cross reference F-585 grievances). Resident #1 said the staff did not change his linens so he had begun doing it himself. He pointed to a pile of folded linen, sheets and a blanket on a chair. He said the staff left him clean linen to change his linens himself. Resident #1 said he fell a couple weeks ago when he had COVID-19. C. Record reviewOn 10/31/23 at 6:00 p.m., the nursing notes documented the resident was on the bathroom floor at 4:30 p.m. He said he tripped. He had no injuries and was barefoot. On 10/31/23 at 5:45 p.m., the resident was on the floor next to his bed. He had non-skid socks on. He said he was just walking in his room and fell. On 10/31/23 at 6:44 p.m., the nursing progress notes documented that two male certified nurse aides (CNA) assessed the resident after his fall and helped him up. There was no injury. There were no neurological checks. The nurse further documented the resident complained of back pain.-The resident was on Coumadin (blood thinner medication) which increased his risk of bleeding in the brain and there was no monitoring of his neurological status. On 11/1/23 at 11:25 a.m., the nursing progress notes documented the resident complained of back pain. Tylenol and a back x-ray were ordered. The x-ray report on 11/1/23 showed no acute fractures. On 11/1/23 at 10:25 a.m., the IDT documented in the progress notes the resident fell in the bathroom while trying to get up from the toilet holding the towel bar. The towel bar came off the wall. The IDT documented the resident had some new mild confusion and recommended a urine analysis. -There was no further documentation regarding the towel bar, or use of grab bars in the bathroom. The fall care plan, initiated 4/6/22, documented the resident was at risk for falls due to peripheral vascular disease (compromised circulation due to narrow blood vessels) and atrial fibrillation (irregular heart rate). The care plan documented to encourage the resident to change position slowly -, have common articles in reach, assist to transfer or ambulate as needed, reinforce use of call light 7/25/23, use wheelchair for outings, report pain, bruises and change in mental status per facility guidelines after a fall. Therapy evaluation and treatment was ordered 7/25/23. -There were no changes to the resident's care plan after his falls. -There were no interventions in the care plan related to the resident making his own bed, or checking the bathroom for grab bars. D. Staff interviewsThe DON was interviewed on 11/16/23 at 12:21 p.m. She said she did not have any neurological checks for Resident #1's falls on 10/31/23 (see below). The director of rehabilitation (DOR) was interviewed with the physical therapy assistant (PTA) and occupational therapist (OT) on 11/20/23 at 10:10 a.m. The PTA said he was working with Resident #1 on balance and Resident #1 was not safe to be making his bed alone in his room without supervision. The OT said she was working with the resident on balance and the resident had issues with stepping backwards. She said he was not safe to be making his bed alone in his room. She said she had showered him and he should not be left alone in the shower because he was impulsive, a fall risk and needed assistance with his feet and back.

Based on observations, record review and interviews the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on two of two units out of four units. Specifically, the facility failed to:-Ensure staff had access to and wore PPE in COVID-19 positive resident rooms;-Provide education to staff on use of PPE and disinfection of multi use equipment; and,-Test and document results of staff who had been potentially exposed to COVID-19. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019, retrieved 11/19/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html"Ensure everyone is aware of recommended IPC (infection prevention and control) practices in the facility. Post visual alerts like signs or posters at the entrance and in strategic places, (waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations (when to use source control and perform hand hygiene), dating these alerts can help ensure people know that they reflect current recommendations."Source control options for HCP (healthcare personnel) include a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filter or higher. Source control is recommended for individuals in healthcare settings who: Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over ( no new cases of SARS-CoV-2 infection have been identified for 14 days); Eye protection (goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters."A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed."Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day one (where day of exposure is day zero), day three, and day five."II. Facility policyThe COVID-19 policies including PPE usage and testing was requested from the director of nursing (DON) on 11/16/23 at 9:00 a.m. The Coronavirus disease (COVID-19) Staff Testing policy revised May 2023, was received from the DON on 11/16/23 at 10:43 a.m. The policy documented in pertinent part, "Testing for Staff Exposed to Individuals with COVID-19. Following a higher risk exposure staff will, have a series of three viral tests for SARS-Co V-2 infection. Testing is done immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. "Testing Asymptomatic Staff during an Outbreak Investigation. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. Outbreak response is guided by the infection preventionist, in conjunction with the public health authority for the facility jurisdiction. Viral testing of all staff (regardless of vaccination status) is conducted if there is an outbreak in the facility. Testing approaches may consist of contact tracing (focused testing) or broad-based (facility-wide or group level) testing."If there is the ability to identify close contacts of the individual with SARS-CoV-2 infection, contact tracing and focused testing are conducted. Testing is conducted immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Testing is generally not done for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing is considered for those who have recovered in the prior 31-90 days; however,an antigen test instead of NAAT is recommended. If testing of close contacts reveals additional cases of SARS-Co V-2 infection, contact tracing is continued to identify residents with close contact to the newly identified individual(s) with SARS-CoV-2 infection. If all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission, broad-based testing is conducted."Broad-Based Testing. When utilizing broad-based testing, all residents and staff identified as close contacts or on the affected unit(s) are tested, regardless of vaccination status. Testing is done immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5."Additional Measures during Outbreak Investigation. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration is given to use of empiric use of transmission-based precautions for residents and work restriction of staff with higher-risk exposures. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of transmission-based precautions for residents and work restrictions for staff who meet criteria are discontinued. If additional cases are identified, strong consideration is given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing will continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing ( every 3 days) will be considered."III. Observations The 100 hall was observed on 11/15/23 at 9:40 a.m. One resident room, at the beginning of the hall, had a droplet isolation sign. The sign indicated an N95 mask, eye protection, gown and gloves were required to enter the room. There were no other rooms with droplet isolation signs. An isolation cart was observed outside the door of the resident room. -The cart did not contain N95 masks, eye protection or alcohol based hand rub (ABHR). The only ABHR available for hand hygiene was midway down the hall on the opposite side from the resident's room. The 300 hall was observed on 11/15/23 at 10:01 a.m. Two rooms had droplet isolation signs on the doors with isolation carts outside the door in the hallway. -There were no N95 masks, face shields or ABHR on the isolation carts. On 11/16/23 at 12:28 p.m., a visitor came through the front door without a mask. The receptionist at the front desk greeted her, but did not offer the visitor a mask. The visitor proceeded down the hallway into resident care areas. On 11/16/23 at 3:32 p.m., the receptionist was observed at the front desk of the facility speaking to residents without a mask. The receptionist said she thought the masks were optional, and she had not received any education on mask use. IV. Record reviewThe COVID-19 line listing was received on 11/15/23 at 5:30 p.m. from the NHA. The line listing revealed the outbreak began on 10/26/23, with a total of 29 cases by 11/7/23. Symptoms included fevers up to 101.2, low oxygen saturation levels, congestion, lethargy, and shortness of breath. Four residents required hospitalization. V. InterviewsThe DON was interviewed on 11/15/23 at 8:55 a.m. She said the facility had 29 cases of COVID-19 in the last two weeks. The DON said currently the facility had three residents who were still on droplet isolation for COVID-19 and all three resided on the 100 hall. Registered nurse (RN) #1 was interviewed on 11/15/23 at 9:52 a.m. She said the resident in the room with the droplet isolation sign had COVID-19. RN #1 said the staff should have worn an N95 mask, gown, face shield and gloves before entering the room. She looked in the isolation cart and said there were no N95 masks, face shields or ABHR for hand hygiene. Certified nurse aide (CNA) #1 approached and joined the interview with RN #1. She said she had been wearing a surgical mask because there were no N95 masks all morning. She said there used to be N95 masks in the carts but there had never been eye protection available or ABHR on the isolation cart. CNA #1 said there was no ABHR on any of the isolation carts that she could remember. RN #1 said she too had been wearing a surgical mask in the room to provide care because there were no N95 masks available on the cart. She said she had not worn eye protection. She said the only ABHR available was down the hall midway on the opposite side or in the resident's room. CNA #1 had a vital sign tower she plugged into the wall. She said the vital sign equipment was shared with all residents including those in isolation for COVID-19. CNA #1 said she cleaned the vital sign equipment with disinfecting wipes after each use. However, she could not remember the dwell or contact time for the disinfecting wipes. She went to the nurse's station and looked around for a container of the wipes and could not find any. CNA #2 was interviewed on 11/15/23 at 10:06 a.m, She said vital sign equipment and mechanical lifts were shared by all residents, including those in isolation. She said the equipment was cleaned with alcohol wipes after use. She could not find any alcohol wipes, and said they must be in the supply room. The infection preventionist (IP) was interviewed on 11/15/23 at 10:16 a.m. She said the facility had three residents who were still in isolation for COVID-19. She said the facility had 29 positive residents at one time on halls 100, 200, and 300. She said the outbreak began around 10/26/23 and the virus was thought to be spread from a resident who was admitted to the facility a few days prior with known COVID-19. She said the resident who admitted with COVID-19 was put on droplet isolation on admission. The IP said an N95 mask, gown, gloves and face shield were required to enter the COVID-19 positive rooms. She said a surgical mask was required to be worn by staff throughout the facility and recommended for visitors. If staff did not have the supplies they should have asked someone. The IP said she checked the isolation carts for supplies when she was here during the week but she did not know who was responsible for checking to ensure they were stocked on the weekends. The IP said each isolation cart should have a bottle of ABHR for hand hygiene. She said she had checked the carts prior to the interview for PPE but she had not checked to see if they had ABHR available on the carts. The IP said she thought she provided staff education on hand hygiene and PPE use for COVID-19 during the outbreak. However, she said she had no documentation of any education provided. The IP said all staff and residents were tested at thebeginning of the outbreak. She said there was no documentation of the staff testing. She said the resident's tests were located in their medical record. The IP said equipment such as vital sign equipment and lifts were shared by all residents including those in isolation. She said the equipment was supposed to be cleaned with disinfecting wipes after every use. She said alcohol wipes would not be effective for various equipment surface areas and types of viruses and bacteria. She did not recall if she had done education on cleaning equipment during the outbreak. The DON was interviewed on 11/16/23 at 1:08 p.m. She said all staff, regardless of exposure, were tested during the outbreak one time and if they had symptoms. She said there was no documentation of the staff testing. The DON said staff were educated on PPE use during the outbreak. She said she did not have any documentation of education provided. The nursing home administrator (NHA) was interviewed on 11/16/23 at 3:40 p.m. She said surgical masks should have been worn by the staff throughout the facility and an N95 mask should be worn in COVID-19 positive rooms. The NHA said she would provide education to the receptionist.

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

A revisit survey was completed on 9/5/23 for all previous deficiencies cited on 6/15/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/10/2023 and 07/16/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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 a one (1) story, Type V (111) construction with a partial basement that is used for support services only, there is no resident access. The facility is licensed for 150 beds. The facility was constructed in 1981. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler system, and is classified as Fully Sprinklered. This survey was conducted on July 14, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."Each of the deficiencies cited was discussed with the Administrator and Maintenance Director during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain did not maintain the exit discharge in accordance with NFPA 101. No stairs from mech room to emergency generator | Two foot drop from facilityNFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations, it was determined that the facility failed to maintain egress doors in accordance with NFPA 101. Multiple delayed egress doors need adjustment through facility | Identified to maintenance person during survey7.2.1.6.1 Delayed-Egress Locking Systems. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:(3)* An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a)The force shall not be required to exceed 15 lbf (67 N).(b)The force shall not be required to be continuously applied for more than 3 seconds.(c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator maintenance director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency. Exit gate needs UL listed exit signNFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101. Hole in wall in oxygen transfer roomDoor penetrations around handle for oxygen transfer room8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3Protecting the area with automatic extinguishing systems in accordance with Section 9.7Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. Stove needs chalks on wheels Hood Suppression overdue semi annual reportNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. No semi annual fire alarm reportNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101Backflow inspection overdue last completed May 22NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administator and maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain corridor doors in accordance with NFPA 101. This was evidenced by the following:Fire door not latching by room 315Room 313 does not close with closer19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:Fire wall above ceiling penetrations by room 401NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain proper gas practices in accordance with Life Safety Section 9.1 and NFPA 54, 11.1.2. This was evidenced by the following:Gas orifice on the dryer rated for 0-2000 feet in laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer ' s installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire Drills not more than an hour apartNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A recertification survey was conducted from 6/11/23 to 6/15/23. Fourteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/11/23 to 6/15/23. No deficiencies were cited.

Based on observations, record review, and interviews, the facility failed to promote and maintain resident's dignity for one (#302) of three residents reviewed for meal assistance out of 36 sample residents. Specifically, the facility failed to ensure Resident #302 was offered his breakfast and lunch in a timely manner. Findings include:I. Resident statusResident #302, over the age 65, was admitted on 5/18/23. According to the June 2023 computerized physician orders (CPO), diagnosis included muscle weakness, chronic obstructive pulmonary disease (COPD), type 2 diabetes and chronic pain syndrome. According to the 5/25/23 minimum data set (MDS) assessment, the resident had moderate impaired cognitive function with a brief interview for mental status (BIMS) score of ten out of 15. He required extensive assistance with two person physical assistance with bed mobility, transfers and one person physical assistance with dressing. He required supervision with set up assistance for eating. The resident had no behaviors and no rejection of care. II. ObservationsOn 6/11/23 at 12:25 p.m. the resident was lying awake in bed. He had his lunch tray set up by the bedside and was able to reach for items from the bedside table. -At 12:30 p.m. certified nurse aide (CNA) #9 entered the resident's room and asked him if he was done with his lunch. The CNA left the room with the lunch tray with the resident not consuming any part of the meal. CNA #9 did not offer the resident any alternative meal. A continuous observation was conducted on 6/13/23 at 9:19 a.m. to 3:00 p.m. revealed Resident #302 did not receive his breakfast. -The resident confirmed he had not eaten breakfast and was still waiting for the staff to bring his meal.-At 12:00 p.m. the resident said he had not eaten any meal except a bottle of Ensure supplement registered nurse (RN) #1 gave him.-At 12:15 p.m. the room tray cart arrived into the unit hall. The resident remained in his room in bed. -At 1:00 p.m. the staff completed passing the room trays and Resident #302 did not receive a lunch meal.-At 1:30 the resident used the telephone in his bedroom to call the front desk to request food, however no staff answered the telephone. The resident remained in bed attempting several times to call the front desk for assistance.-At 2:40 p.m. the resident informed RN #1 about him not receiving any breakfast and lunch.-At approximately 2:57 p.m. the social service director arrived with the resident's lunch tray. III. Staff interviewCNA #4 was interviewed on 6/13/23 at 3:00 p.m. The CNA said she did not notice the resident did not get his tray as there were too many staff assisting with the passing of the room trays. CNA #4 said the meal tickets were distributed the previous day and some of the residents take their time in deciding what they prefer to eat therefore it was possible the CNAs could forget to go back for the remaining tickets resulting in missing room trays. RN #1 was interviewed on 6/13/23 at 3:15 p.m. The RN acknowledged that she did not see the resident eating breakfast. The RN said was unaware that the resident had not been given any food since the beginning of her shift. She said she would ensure the CNAs double checked to make sure everyone who eats in their room was served their meal. The social services director (SSD) was interviewed on 6/15/23 at 9:20 a.m. The SSD said he was told to deliver the lunch tray to Resident #302. He said he was assisting the CNAs who were busy with other tasks. The SSD said the resident refused a lot of the meals they provided him and would usually ask for a peanut butter and jelly sandwich. The dietary manager (DM) and the registered dietitian (RD) were both interviewed 6/15/23 at 1:00 p.m on how meal tickets were printed. The DM said meal tickets were printed in the kitchen then sent to the nurses station a day before the meal. The tickets went back to the DM the night before. There were two residents that held out and had a hard time deciding what they wanted. The RD said it would be up to the nursing staff to tell the kitchen there was a missing tray. When the DM got the tickets back she highlighted them so she knew they had all the residents' meal tickets. If a tray was missing, the nursing staff would need to notify the dietary staff that a resident did not get a tray.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to:-Include the email address of the State Survey agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include:I. Resident group interviewThe group interview was conducted on 6/14/23 at 10:00 a.m. with four residents (#36, #19, #41 and #6) identified by assessment and facility as interviewable. All four residents said they did not know where the facility posted information in regard to pertinent State Agencies' contact information and was not reviewed in the resident council meeting. Resident #19 said she was provided a website address for complaints by the facility ombudsman, but did not have a phone number or email address. Resident #6 said he had not been informed of his right to or provided information on how to formally complain to State Agencies about the care he was receiving. III. Staff interviews and observationThe social service director (SSD) was interviewed on 6/15/23 at 10:30 a.m. He said he did not know who posted the contact information for State Agencies currently, but said the previous nursing home administrator (NHA) used to post them. The NHA was interviewed on 6/15/23 at 11:30 a.m. She said she was unsure where the State Agency contact information was posted but would find out. The NHA followed up at 12:36 p.m. on 6/15/23 and stated the mandatory postings for the State Agencies were at the entrance to the administrative offices. On 6/15/23 at 12:36 p.m. observation of the mandatory posting for the State Agency was made in the lobby entrance of the facility. An eight inch by 11 inch frame was hung on the wall next to the administrative offices hallway, and was hung approximately 60 inches up from the floor. The frame contained a paper with the names, addresses and phone numbers of State Agencies. The font of the contact information was approximately size 12 font with some areas that were bold but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents that were not mobile.

Based on observations, record review and staff interviews, the facility failed to provide services for two (#8 and #29) out of 36 sample residents according to professional standards of practiceSpecifically, the failed to: -Ensure Resident #8's vital signs, specifically the resident's blood pressure, was monitored prior to the administration of a blood pressure medication; and,-Notify the physician when Resident #29's blood sugars were out of parameters and follow physician's orders for insulin. Findings include:I. Resident #29A. Professional referenceAccording to Khashayar, F., Arif, J. (2022) Beta Blockers. Stat Pears. National Library of Medicine, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK532906 on 6/24/23."Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur."The patient's heart rate and blood pressure require monitoring while using beta-blockers."According to Kizior, R. J., Hodgson, K. J. (2023). Labetalol. Saunders Nursing Drug Handbook. Elsevier. P. 651."Assess B/P (blood pressure), heart rate immediately before drug administration (if pulse is 60 beats per minute or less or systolic B/P is lower than 90 mmHg, withhold medications and contact physician."B. Resident statusResident #8, age 76, was admitted on 7/5/22. According to the June 2023 computerized physician orders (CPO) the diagnosis included atrial fibrillation and hypertensive (high blood pressure) chronic kidney disease. The 3/8/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required the extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene, the limited assistance of one person for transfers and supervision with eating. C. ObservationsOn 6/13/23 at 3:48 p.m. licensed practical nurse (LPN) #4 was observed dispensing Labetalol (an alpha and beta blocker blood pressure medication) 300 milligrams (mg) for Resident #4. LPN #4 did not check the record for the resident's most recent vital signs and did not obtain a blood pressure or pulse prior to administration. LPN #4 then administered the Labetalol medication to Resident #8. D. Record reviewThe June 2023 CPO documented a physician order of Labetalol 300 mg twice daily, ordered 11/25/22.-The CPO did not document any vital signs parameters for when to hold the Labetalol medication or when to notify the physician of irregular vital sign results. The June 2023 medication and treatment administration record (MAR/TAR) did not document how often the resident's vital signs should be checked. The June 2023 vital signs summary revealed Resident #8's blood pressure and pulse were not assessed or documented on 6/6/23, 6/7/23, 6/8/23, 6/9/23, 6/10/23, 6/11/23, 6/12/23 and 6/13/23. E.. Staff interviewsLPN #1 was interviewed on 6/15/23 at 2:30 p.m. She said blood pressure, pulse and vital signs needed to be assessed prior to the administration of blood pressure medication. She said ordered parameters were then followed. She said if there were no parameters and the blood pressure and pulse were below a resident's baseline then the physician should be notified. The director of nursing (DON) was interviewed on 6/15/23 at 4:24 p.m. He said blood pressure and pulse should be monitored prior to the administration of a blood pressure medication. He said physician ordered parameters were followed. He said when blood pressure parameters were not ordered, monitoring for signs and symptoms of low pressure, including an assessment of vital signs should be done. II. Resident #29A. Professional referenceNational Library of Medicine. (2022, February 1). Low Blood Sugar-Self Care. U.S. Department of Health and Human Services National Institute of Health. https://medlineplus.gov/ency/patientinstructions/000085.htm#:~:text=Low%20blood%20sugar%20is%20called,a%20cause%20for%20immediate%20action retrieved on 6/26/23."Low blood sugar is called hypoglycemia. A blood sugar level below 70 milligrams per deciliter (mg/dL) can harm you. A blood sugar level below 54 mg.dL is cause for immediate action."Symptoms can include: weakness, shaking, sweating, headache, hunger, feeling uneasy, cranky, trouble thinking, double or blurry vision, fast heart beat. Sometimes blood sugar may be too low even if there are no symptoms: fainting, seizure and coma."Mouri, M., Badireddy, M. (2023, April 24). Hyperglycemia. Stat Pearls. U. S. Department of Health and Human Services National Institute of Health. https://www.ncbi.nlm.nih.gov/books/NBK430900/ retrieved on 6/26/23."The prognosis of individuals with hyperglycemia depends on how well the levels of blood glucose are controlled. Chronic hyperglycemia can cause severe life and limb threatening complications. Countless studies have shown that untreated hyperglycemia shortens lifespan and worsens the quality of life."B. Resident statusResident #29, age 85, was admitted on 2/2/22. According to the June 2023 CPO, the diagnoses included congestive heart failure (CHF), atrial fibrillation, chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The 4/20/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required the limited assistance of two people for transfers, the limited assistance of one person for bed mobility, dressing and personal hygiene, the supervision of one person for toileting and set up only for eating. C. Record reviewThe insulin dependent care plan was initiated on 8/10/22. Interventions included administer medication per physician order, obtain glucometer readings and report abnormalities as ordered, obtain lab results and notify physician of results, report symptoms of hyperglycemia (high blood sugar) and report symptoms of hypoglycemia (low blood sugar). The June 2023 CPO revealed a physician order of Humalog 20 units subcutaneously three times a day, hold if insulin was less than 110, notify physician if greater than 400, discontinued on 6/3/23. The June 2023 MAR documented the blood glucose reading of 435 milligrams/deciliter (mg/dL) on 6/1/23 at 12:00 p.m. The June medication and administration record (MAR/TAR) documented the administration of 20 units of Humalog on 6/1/23 at 12:00 p.m.-A review of the MAR and progress notes failed to reveal documentation that the physician was notified of blood glucose according to ordered parameters. The June 2023 CPO revealed a physician order of Humalog 40 units subcutaneously at dinnertime, hold insulin if blood glucose was less than 110, ordered on 6/3/23. The June 2023 MAR documented the blood glucose reading of 90 mg/dL on 6/6/23 at 5:00 p.m. The June 2023 MAR/TAR documented the administration of 40 units of Humalog on 6/6/23 at 5:00 p.m.-A review of the MAR and progress notes failed to reveal documentation that Humalog insulin was held according to ordered physician parameters. D. Staff interviewsLPN #1 was interviewed on 6/15/23 at 9:38 a.m. She said Resident #29's blood sugars had been running high and the resident had parameters for when to hold and when to notify the physician. She said the resident had parameters to hold insulin if blood sugar was less than 110 and to notify the physician of greater than 400. She said if a resident was exhibiting signs of low or high blood sugar, such as lethargy, diaphoresis (sweating) or confusion she said a blood sugar should be checked and the physician notified. The DON was interviewed on 6/15/23 at 3:00 p.m. He said resident blood sugars were monitored based on physician ordered parameters. He said insulin should be held and physician notified, according to the ordered parameters. He said if a resident was exhibiting symptoms of a low or high blood sugar, such asconfusion and change in mental status, a blood sugar should be obtained and physician notified.

V. Resident #44A. Resident statusResident #44, over age 90, was admitted on 4/1/22. According to the June 2023 CPO, the diagnoses included a compression fracture of lumbar vertebrae, low back pain, dementia, acute and chronic respiratory failure, chronic obstructive pulmonary disease, protein-calorie malnutrition, gout, chronic kidney disease stage 3 and the need for assistance with personal care. The 4/21/23 MDS assessment revealed a BIMS was not completed and the resident marked as rarely/never understood. The resident had a short term and long term memory problem, her cognitive skills for daily decision making were severely impaired and she rarely/never made decisions and was easily distracted. She required extensive assistance of one person with bed mobility, transfers, mobility on and off the unit, dressing, eating, toileting and personal hygiene. Resident #44 held food in her mouth or had residual food in her mouth after meals. B. Observations6/13/23 evening meal-At 4:50 p.m., the resident was assisted to the dining room. -At 4:55 p.m., the assistant director of nurses (ADON) served the resident two 240 milliliters (ml) of juice.-At 5:11 p.m., the resident was served her meal. She was served Mexican meatballs over rice, squash, cottage cheese, yogurt and pears. -At 5:16 p.m., an unidentified certified nurse aide (CNA) sat next to the resident and began to assist the resident to eat. She started with cottage cheese. The resident was not provided the opportunity to feed herself, as the CNA started to assist the resident.-At 5:22 p.m., the CNA then started to provide spoonfuls of the yogurt. The resident had not been offered any of her main meal. -At 5:30 p.m., the CNA asked the resident if she was full. The resident responded yes. The resident was not offered the main meal and was not provided any additional assistance. 6/14/23 breakfast-At 8:02 a.m., the resident received her meal. The CNA put jelly on her toast. The resident started to eat the yogurt. -At 8:07 a.m., she received 280 ml of coffee.-At 8:08 a.m., the business office manager said hi to the resident and asked if she was doing ok. The resident was eating the toast independently.-At 8:20 a.m., she had not received any encouragement to eat. -At 8:31 a.m., the resident was sleeping at the table, no staff had approached her to provide encouragement.-At 8:33 a.m, she was asked by CNA #10 if she was done and if she was full. However, the resident had only eaten a few bites of yogurt and half of the slice of toast. She was not offered an alternative.-At 8:44 a.m., the social service director asked the resident if she wanted some toast. She responded yes and she ate a few bites of the toast. -At 8:50 a.m., she was assisted out of the dining room. She ate half of the toast which was served to her. C. Record reviewResident #44's activities of daily living (ADL) care plan documented a self care deficit related to bilateral lower extremity weakness, acute and chronic respiratory failure, oxygen use, a history of right hip fracture, dementia, copd (chronic obstructive pulmonary disease), high blood pressure, retinopathy (eye damage), osteoarthritis, gout, acute lumbar compression fracture, and chronic compression fracture; initiated 4/1/22 and revised on 4/7/23. Her care plan goal was to receive assistance necessary to meet needs of her ADLs; initiated 4/1/22. Pertinent interventions included the need for one person assistance with bed mobility, hygiene, toileting, set up assistance for meals, oral care, locomotion on and unit as needed; initiated 6/27/22 and revised 2/13/23. Resident #44's care plan for a potential for alteration in nutritional status was related to her history of dementia with memory impairments; the resident took an extended length of time to complete meals related to cognitive deficits. The patient had a recent fracture and a recent decline in ADLs and needed to be fed meals on occasion; initiated 4/17/23. Pertinent care plan interventions included to provide meal set up assistance as necessary. When the patient was unable or unwilling to feed herself, she needed to be fed by staff; initiated 4/17/23. The 4/17/23 nutritional assessment documented the resident with a recently reported need for increased feeding assistance and she often needed to be fed meals more than she previously had. Resident #44's kardex (resident care overview) dated 6/14/23 documented Resident #44 needed one person assist with bed mobility, hygiene, toileting and set up assist for meals. -The kardex did not include that resident needed to be assisted with meals on occasion. The 3/2/23 registered dietitian (RD) nutrition note written 1:04 p.m. documented, "during lunch meal today in the dining room, pt (patient) observed to be able to feed self intermittently but needed frequent cues/prompting/encouragement. Pt (patient) did need to be fed at various times during the meal related to her becoming distracted and loss of focus on meal."D. Staff interviewsThe registered dietitian (RD) was interviewed on 6/15/23 at 3:35 p.m. She said residents who needed meal assistance should have that information in the kardex in the resident's electronic medical record as it was not printed on the resident's meal ticket. Certified nurses aide (CNA) #2 was interviewed on 6/15/23 at 4:20 p.m. She said she knew what assistance residents needed at meals had because there was a binder right against a cabinet wall that provided her the information she needed. She also used the resident's kardex. Based on observation, record review, and interviews, the facility failed to ensure three (#9, #33 and #44) of six residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene out of 36 sample residents. Specifically, the facility failed to:-Ensure Resident #9 was provided consistent bed baths according to the plan of care; -Ensure Resident #33 was provided timely meal assistance, consistent nail care and frequent toothbrushing; and, -Provide eating assistance for Resident #44, who required extensive assistance with eating. Findings include:I. Facility policy and procedureThe Activity of Daily Living (ADLs) policy, revised May 2023, was provided by the nursing home administrator (NHA) on 6/15/23 at 10:38 a.m. It read in pertinent part, "Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's activities of daily living (ADL) abilities are maintained or improved and do not diminish. Activities of daily living include; hygiene, bathing, oral care, dining, feeding."II. Resident #9A. Resident statusResident #9, over the age 65, was admitted on 3/30/22. According to the June 2023 computerized physician orders (CPO), diagnosis included, atherosclerosis, osteoarthritis, chronic pain, unspecified skin changes and paraplegia (paralysis of lower body). The minimum data set (MDS) assessment dated 3/22/23 revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was dependent on staff for her ADL care and required extensive assistance with two person physical assistance with bed mobility, and transfers. The resident had no display of behaviors during care and no rejection of care. B. Resident interview and observationResident #9 was interviewed on 6/11/23 at 11:30 a.m. The resident said she had not received a bed bath in three weeks. Resident #9 said there was a particular staff member that always found an excuse not to provide her a bed bath. The resident said she came to the facility with a skin issue which had been resolved and would like to maintain proper hygiene to avoid any skin breakdown. The resident said she had been receiving bed baths since she could not stand. Resident #9 was observed in her bed on 6/12/23 at 9:50 a.m. and at 4:15 p.m. the resident said she had notreceived her bedbath. Resident #9 was observed in bed on 6/13/23 at 8:30 a.m. to 1:00 p.m. and from 2:15 p.m. she did not leave her room.-However, it was documented that she received a shower at 1:59 p.m. on 6/13/23. Resident #9 was observed in bed on 6/14/23 at 10:00 a.m. and 5:30 p.m. She said she was not given a bed bath. C. Record reviewThe resident ADL care plan, initiated on 3/3022 and revised on 2/2/23, revealed the resident had self care deficit due to impaired mobility with a diagnosis of paraplegia and history of pressure ulcers. The care plan indicated Resident #9 required a two-person assist with bathing, bed mobility and dressing. Further record review revealed that Resident #9 prefer bed baths. A 30 day review of the facility shower and bath records revealed Resident #9 had one shower and a bed bath within the 30 day period. -The facility failed to provide a requested three months of bathing documentation for Resident #9. III. Resident #33A. Resident status Resident #33, over the age of 65, was admitted on 10/19/21. According to the June 2023 CPO, diagnosis included, osteoporosis, vascular dementia with other behavioral disturbances, muscle weakness, right hand muscle contracture and osteoarthritis. The 4/5/23 MDS assessment revealed the resident had moderate impaired cognitive ability with a BIMS score of eleven out of 15. She required extensive assistance of two-person with bed mobility, transfers, toileting, dressing and personal care. The resident required one person physical assistance with eating. Rejection of care was not exhibited by the resident. B. Resident representative interview and observationOn 6/12/23 at approximately 10:05 a.m. Resident #33 was in bed. She had food stains around her mouth and hue near her gum line which appeared to be plague and tartar. The resident had discoloration of teeth as she spoke. Her fingernails were half an inch long and jagged. On 6/13/23 at 3:54 p.m. the resident was observed in bed with her daughter visiting. The resident fingernails remain half an inch long. The resident's representative was interviewed at 4:00 p.m. She said her mother was not receiving consistent ADL care such as nail care, toothbrushing and timely meal assistance. She said her mother sometimes had to wait a long period of time in order to receive assistance with her meals. The resident representative said Resident #33 had contractures and she was worried there were not adequate interventions currently in place to prevent the resident's fingernails from growing into the resident's skin which could result in skin breakdown. On 6/14/23 at 5:20 p.m. CNA#1 delivered Resident #33 dinner and immediately left to continue passing other diner trays. The resident waited for ten minutes and began yelling for help, however there were not staff close enough to be able to hear the resident. At 5:50 p.m. CNA #5 arrived to assist the resident with eating, which was 30 minutes after the tray arrived to her room. C. Record reviewResident #33 care plan revealed the resident has ADL self care deficit related to weakness, impaired mobility, contractures to the left and right hand. The resident comprehensive care plan, last revised 9/29/22, documented a care focus for meal assistance. The care focus revealed Resident #33 was dependent on staff for all ADLs. The interventions included, one person physical assistance with meals, oral care and nail care. IV. Staff interviewCNA #5 was interviewed on 6/14/23 at 8:06 a.m. CNA #5 said Resident #33 required one person physical assistance with ADLs such as bathing, oral care, meals and fingernail care. CNA #5 said the staff usually finish passing all room trays before they could provide meal assistance to those who required it. CNA #7 was interviewed on 6/14/23 at 8:15 a.m. CNA #7 said the facility did not utilize shower and bath aides. She said all showers were performed by the floor CNAs and sometimes it was difficult to meet the residents' needs. CNA #7 said Resident #9 preferred bed baths and did not refuse. The assistant director of nursing (ADON) was interviewed on 6/14/23 at 8:25 a.m. The ADON said toothbrushing was provided according to residents' preference and the plan of care. The ADON said Resident #33 fingernails were difficult to trim and cut as it required a special tool to be able to provide nail care. She said the only staff who was trained to provide nail care for Resident #33 was no longer working at the facility. The ADON said she contacted the staff member who was no longer employed with the facility to see if she could help her locate the device for the fingernail care for Resident #33.

Based on observations, record review and interviews, the facility failed to ensure one (#27) of five out of 36 sample residents with a pressure ulcer had preventative measures and received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to:-Have consistent skin assessments documented in Resident #27's electronic medical record; and, -When Resident #27 developed a stage 2 pressure ulcer to his right ankle, interventions for his feet and ankles were not implemented until nine days after the wound developed. Findings include:I. Professional referenceThe Joint Commision (March 2022). Quick Safety 25: Preventing pressure injuries. The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) (2019). The International Guideline (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline). https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/#.Y9gDenbMI2w retrieved on 6/21/23 at 9:35 a.m."Risk Assessment should be considered as the starting point. The earlier a risk is identified the more quickly it can be addressed. Use the structured risk assessment tool to identify patients at risk as early as possible. Refine the assessment by identifying other risk factors, including existing pressure injuries, and other diseases such as diabetes and vascular problems."Stage 2 Pressure Injury: Partial thickness loss of skin with exposed derms. The wound bed is viable, pin or red, moist and may represent as an intact or ruptured serum-filled blister. Adipose is not visible and deeper tissues are not visible."Stage 4 Pressure Injury: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscure the extent of tissue loss, this is unstageable pressure injury."II. Facility policy and procedureThe Skin Integrity and Wound Management policy procedure, revised on 2/1/23, was provided by the nursing home administration (NHA) on 6/15/23 at 10:38 a.m. It read in pertinent part,"Identify the patient's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information."Document newly identified skin/wound impairments as a change in condition."Perform and document skin inspection on all newly admitted/readmitted patients weekly thereafter and with any significant change of condition."III. Resident #27A. Resident statusResident #27, age 89, was admitted on 9/5/19. According to the computerized physician orders (CPO) the diagnoses included Alzheimer's disease, type 2 diabetes mellitus and stage 2 pressure ulcer. The 4/24/23 minimum data set (MDS) assessment revealed the resident was not at risk for developing pressure ulcers. The 5/19/23 minimum data set (MDS) assessment revealed the resident was had severe cognitive impairment with a brief interview for mental status score of seven out 15 and required the extensive assistance of two people with dressing, toileting, extensive assistance of one person for bed mobility, transfers, personal hygiene and supervision with set up for eating. The resident had one pressure ulcer at stage 2 and was at risk for developing pressure ulcers. B. Record reviewThe skin integrity care plan, initiated on 11/16/2020 revised on 2/1/22, indicated the resident was at risk of alteration in skin integrity related to diabetes. Intervention included elevate heels and utilize heel boots, encourage repositioning as needed, observe skin condition with activities of daily living, report abnormalities and pressure reduction mattress. The stage 2 pressure ulcer care plan to right lateral malleolus (right outside ankle bone) was initiated on 4/18/23. Interventions included administer analgesics, bilateral ankle protectors with padding to the lateral side of ankle and skid socks over, encourage repositioning from side to back during the night shift, Prevalon boots to bilateral feet on at bedtime from 9:00 p.m. to 4:00 a.m. and wound team to follow until resolved. -A comprehensive review of the care plan revealed no further interventions were added after the wound was identified as unstageable on 5/25/23 and when the wound was identified as stage 4 on 6/8/23. The 11/5/22 nursing skin assessment progress notes revealed no new skin issues. The 2/24/23 Braden assessment revealed a score of 19 which indicated the resident was not at risk for developing a pressure injury.-However, according to the wound physician (see below) residents with diabetes were at risk for pressure wounds, especially to their feet. The 4/18/23 nursing skin assessment progress notes revealed a small pressure wound on the right lateral ankle which was tender and reddened.-The last skin assessment prior to 4/18/23 was done 11/5/22. The 4/19/23 Braden assessment revealed a score of 16 which indicated the resident was at risk for developing a pressure injury, after the resident had been identified with a pressure injury. The 4/19/23 nursing skin assessment progress notes documented a root cause analysis was completed for the new wound on right lateral ankle stage 2. Risk factors identified were resident lying on the right side exclusively while in bed, difficult to education related to poor cognition, diabetes and weakness. Interventions were to encourage to lay on back while in bed, add a derma float mattress, supplements for wound healthing and involvement of the wound care physician. It revealed that he was not currently a candidate for Prevalon boots due to his fall risk and attempting to get out of bed on his own. The 4/20/23 wound physician notes documented a stage 2 pressure wound of the right lateral ankle measuring 0.4 x 0.6 x0.1 centimeters (cm). The 4/26/23 wound physician notes documented a stage 2 pressure wound of the right lateral ankle measuring 0.4 x 0.4 x 0.1 cm. The 4/27/23 nursing skin assessment progress notes revealed derma float mattress (alternating pressure air mattress) was removed secondary resident was falling out of it, continued education to keep of his right side and wearing Prevalon boots from 9:00 p.m. to 4:00 a.m and the addition of heel protectors above ankle to offload pressure.-A comprehensive review of the nursing skin assessment progress notes revealed no documentation of an assessment between 11/5/22 and 4/18/23 when the stage 2 pressure ulcer was identified. The derma flo mattress and Prevalon boots were not documented as in place progress notes until after the identification of the stage 2 pressure injury. The 6/8/23 wound physician notes documented a stage 4 pressure wound of the right lateral ankle full thickness measuring 0.3 x 0.4 x 0.2 cm.-The wound progressed to a stage 4, however it was healing and measures were place (see wound physician interview). -A comprehensive review of the nursing skin assessment progress notes revealed no documentation of an assessment between 11/5/22 and 4/18/23 when the stage 2 pressure ulcer was identified. The Prevalon boots were not implemented until after the identification of the stage 2 pressure injury. IV Staff interviewsThe wound nurse (WN) was interviewed on 6/15/23 at 9:15 a.m. She said residents with diabetes were automatically considered a high risk for developing pressure ulcers. She said she did a skin assessment every week and it was documented every week on a form and given to the director of nursing (DON). She said the resident was on a regular pressure relieving mattress prior to the identification of the pressure wound. She said a derma float mattress was placed after the identification of the pressure wound but it was removed due to the resident falling out of bed while he was on it. She said they initiated the Prevalon boots and he wore these when he was in bed at bedtime because he would not stay off of his right side while he was sleeping. She said they have placed padded heel protectors. She said the resident had difficulty remembering to stay off of his right side due to his low BIMS score. The wound care physician was interviewed on 6/15/23 at 1:45 p.m. He said that Resident #27 had a stage 4 pressure injury due to the injury over a bony area and the appearance of a ligament in the wound bed but he said it was healing. He said residents that were diabetic were at a higher risk, regardless of Braden assessment scores, for developing pressure wounds, specifically on their feet. He said preventative measures should be in place for these residents. These interventions included elevation of feet off of bed and application of heel boots while in bed. He said a weekly skin assessment should be performed to help identify potential or existing skin problems. He said preventative measures that should be in place in the future included use of the heel boots, protective padding in the wheelchair and awareness of the staff to protect his feet and right ankle at all times. The DON was interviewed on 6/15/23 at 1:15 p.m. He said he had recently started at the facility less than a month ago and was not familiar with Resident #27's pressure ulcer. He said weekly skin assessments should be completed and documented on the resident's medical record. He said diabetics were at a high risk for developing pressure wounds, specifically wounds on feet. He said when a wound was first identified a root cause analysis should be performed and documented again if the wound progresses. He said preventative measures for diabetic residents were foot check during skin assessment, dietary assessments for supplements, keeping skin clean and dry, podiatry involvement and use of heel boots.

Based on observations, record review and interviews, the facility failed to ensure that the resident's environment was free from accident hazards for four (#15, #28, #29, #39 and #47) of six out of 36 sample residents. Specifically, the facility failed to: -Conduct a post fall investigation after Resident #29 had fallen and consistently implement fall measures;-Resident #15 and #39 had effective fall interventions in place;-Resident #28 fall interventions in place and the care plan was updated with appropriate post fall interventions; and,-Resident #47 fall interventions were consistently implemented. Findings include:I. Facility policy and procedureThe Falls Management policy and procedure, reviewed 6/15/22, was provided by the nursing home administrator (NHA) on 6/14/23 at 11:21 a.m. It revealed in pertinent part,"All patients will be assessed for risk of falls upon admission, with reassessments routinely (quarterly, post-fall) performed to determine ongoing need for fall prevention precautions. In the event a fall occurs, an assessment will be completed to determine possible injury."Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care."Adjust and document individualized intervention strategies as patient condition changes."II. Resident #29A. Resident statusResident #29, age 85, was admitted on 2/2/22. According to the June 2023 computerized physician orders (CPO), the diagnoses included congestive heart failure (CHF), atrial fibrillation, chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The 4/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required the limited assistance of two people for transfers, the limited assistance of one person for bed mobility, dressing and personal hygiene, the supervision of one person for toileting and set up only for eating. It indicated the resident had two or more falls since admission with one injury. B. ObservationsOn 6/14/23 at 11:00 a.m. Resident #29 was sitting in a wheelchair. Licensed practical nurse (LPN) #1 entered the room and caught the resident attempting to get up out of wheelchair on her own without calling for assistance. After LPN #1 exited the room, Resident #29 was observed without footwear or non-skid socks, extra long oxygen tubing curled up next to resident on floor could be a trip hazard and the call light attached to drawer on bedside night stand behind resident's wheelchair, out of reach. On 6/15/23 at 9:35 a.m. Resident #29 was sitting in a wheelchair wearing one non-skid sock and the call light was out of reach of the resident's wheelchair on the bedside nightstand. C. Record reviewThe fall care plan, initiated 8/3/22 revised 1/10/23, indicated the resident was at risk for falls due to weakness, shortness of breath, diabetes mellitus and chronic pain. Interventions included midline positioning in bed, automatic brakes on wheelchair, encourage resident to call for assistance before using the restroom, encourage resident to wear non skid socks at bedtime, encourage transfer and changing positions slowly, ensure grabber is in reach and report development of pain, bruises, change in mental status, activities of daily living (ADL) function, appetite or neurological status post fall.-A comprehensive review of the care plan did not reveal additional interventions after the 6/3/23 fall (see below). The 6/3/23 at 5:33 a.m. nursing progress notes revealed Resident #29 was found lying next to the foot of the bed. The resident was assessed to have a skin tear to the back of left arm and unable to get off of the floor due to back, left arm and leg pain. The resident was transferred to hospital for further evaluation. The 6/3/23 at 9:50 a.m. nursing progress notes revealed the resident was returned from hospital with a neck sprain and skin tear to left elbow requiring steri-strips. Neurological checks were initiated.-The 6/3/23 fall investigation was not conducted by the interdisciplinary team after the fall. D. Staff interviewsCertified nursing assistant (CNA) #1 was interviewed on 6/15/23 at 9:15 a.m. She said Resident #29 who was at a risk or had a history of falling, should be checked frequently, call light should be within reach at all times, wear non-slip socks or footwear and those residents on oxygen therapy with extra long tubing should have tubing kept off of the floor to avoid trip hazards. Licensed practical nurse (LPN) #2 was interviewed on 6/15/23 at 11:35 a.m. She said Resident #29, who was at risk and a history of falling should be checked frequently, slip strips on floor, non-skid socks, call light should be in reach and oxygen and other trip hazards should be kept off of the floor. The director of nursing (DON) was interviewed on 6/15/23 at 3:35 p.m. He said after a fall, a review by the interdisciplinary team (IDT) in a post fall huddle and a post fall investigation should be conducted to identify possible contributing factors with a review of medications, the environment in the resident's room, a screening and evaluation by physical therapy and least restrictive interventions including non-skid socks. Once mitigating factors were identified interventions should be implemented and care planned. He said post fall assessments and investigations were in need of improvement at the facility. III. Resident #15A. Resident statusResident #15, over the age 65, was admitted on 1/29/23. According to the June 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness, history of falling,chronic obstructive pulmonary disease, right shoulder pain, major depressive disorder, primary osteoarthritis and fracture of nasal bones. The 3/15/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15 with no behaviors. The resident required extensive staff assistance with two person physical assist for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS also revealed the resident had fallen since the last assessment and she had no rejection of care. B. Resident observationsOn 6/12/23 at 10:22 a.m. the resident sat in a wheelchair in her room. She used her feet and hands to assist in moving around in her wheelchair. On 6/13/23 at 11:30 a.m. and at 4:15 p.m. the resident was self propelling herself going to the dinning room for lunch and dinner in her wheelchair. She leaned forward using her feet to assist her movement in the wheelchair. On 6/14/23 at 8:30 a.m. the resident was observed in bed with her call light approximately five feet away from the resident's reach. The resident was trying to get assistance getting out of bed but could not reach her call light. She attempted to reach her call light from her bed but could not reach. Resident #15 started yelling for help. Resident #15 was on the edge of her bed almost about to fall out of bed attempting to reach her call light so licensed practical nurse (LPN) #3 was alerted and she immediately went into the resident's room and realized the resident was trying to get up by herself since she was unable to reach her call light to call for assistance. C. Resident interviewThe resident was interviewed on 6/14/23 at 11:15 a.m. Resident #15 said she had a big fall about a month ago and hit her face on the floor. Resident #15 said the fall was so bad that her entire face was bruised up and swollen. The resident said she was reaching out to pick an item from the floor and fell forward out of her wheelchair hitting her face on the ground. D. Record reviewThe resident care plan, last revised on 3/16/23, identified the resident was at high risk for falls due to history of falls. Pertinent interventions included for staff to reinforce wheelchair safety as needed such as locking brakes, staff to encourage anti slip socks or shoes at all times as resident allows, staff to have commonly used articles within easyreach, staff to provide resident with a reacher to facilitate picking objects up of the floor and staff to reinforce the to call for assistance and wait for staff assistance. Progress note event reported by the charge registered nurse dated 4/21/23 at 3:15 p.m., documented "Note Text: RN assessment: This nurse was called to the resident's room by another staff nurse stating the resident had a fall. Upon entering the room this nurse noted multiple staff assisting the resident. Resident was sitting on the floor with the left side of body leaning against the wall. Staff member holding tissue to resident's nose bleeding and bruising noted, and a small hematoma to the left side of forehead. Resident states it hurts a little bit but wanted to know if her nose was broken. Resident was able to sit upright on the floor by herself with no complaints of pain to any other areas excepther nose. This nurse assessed the resident for injuries besides those mentioned above. Small abrasion to right knee noted. Range of motion to all extremities no pain or resistance met. Vital signs taken B/P 123/78,HR 69, Resp 18, O2 stat 90% on room air. Resident states she was trying to propel herself in a wheelchair then went flying out of her chair. Resident had shoes and the area was clear of clutter. Resident's chart was assessed for any blood thinners before assisting her back to her wheelchair. Resident is on blood thinners at this time. Resident was able to assist staff with being transferred back to her wheelchair. Staffnurse will follow all other fall protocols."-After the resident fall on 4/21/23, there was no subsequent education with staff or preventative measures put in place to prevent a recurrence. The care plan did not have added or new interventions such as frequent checks on the resident by staff, resident's call light within reach at all times. E. Staff InterviewLPN #3 was interviewed on 6/15/23 at 8:30 a.m. The LPN said Resident #15's call light was on the floor out of the resident's reach. The LPN said the resident was at risk for falls and should have had her call light within reach. The LPN said Resident #15 could have fallen and injured herself as she was trying to reach for her call light. IV. Resident #39A. Resident statusResident #39, over the age 65, was admitted on 11/20/2020 and readmitted on 8/2/22. According to the June 2023 CPO, diagnoses included Parkinson's disease, repeated falls, need for assistance with personal care, muscle weakness, major depressive disorder, dementia, age related osteoporosis and psychotic, mood, and anxiety disturbances. The 5/2/23 MDS assessment revealed the resident was cognitively impaired with a BIMS of six out of 15 with no rejection of care. The resident required extensive staff assistance with two person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. She required one person's physical assistance with meals. The MDS also revealed the resident had fallen since the last assessment and she had no rejection of care. B. Resident observationsOn 6/12/23 at 10:00 a.m. the resident was lying in bed. Her call light was on the floor next to the left bedside drawer in her room. The right side bedroom drawer was approximately four feet away from her bed. On the right side of her bed was the resident's reacher on the floor out of the resident's reach. On 6/13/23 at 4:22 p.m. the resident was in bed with her body tilted to her left side of the mattress. The resident's reacher was located on the floor at the right side of the resident's bed with part of the reacher underneath the resident's bedroom drawer. Her bed was in a midline position with no floor mat available in the resident's room. On 6/14/23 at approximately 9:25 a.m. Resident #39 was in her bed with her upper body leaning to the right side of the mattress with no floor mat available in the room. The bed was in midline position which appeared to have been left in that position for staff comfort during care. The resident's reacher was still on the floor at the right side of the resident's bed out of the resident's reach. C. Record reviewA review of Resident #39 medical records revealed the cause of the last two fall episodes were as a result of the resident reaching for her phone to answer a call and reaching for other items from her bedside table/drawer. The resident's care plan, initiated on 8/2/22 and last revised on 10/20/22, documented that the resident was at high risk for falls due to diagnosis of Parkinson's disease, generalized muscle weakness, spinal stenosis, osteoporosis, antidepressant use and tremors. Pertinent interventions included, staff to always check with resident prior to leaving resident room, ask if they could get the resident anything she needs in her bedside drawers or ensuring the drawer was accessible to the resident. Staff to ensure environment checks and review use of reacher with resident and return demonstration by the resident, staff to have commonly used articles within resident's easy reach, having reacher in reach of resident to assist resident with grabbing items. The nursing progress note documented by the charge registered nurse on 5/23/23 at 2:30 p.m., "Called to the resident's room following an unwitnessed fall. Upon arrival, the resident was observed on the floor on her left side. Resident stated that she was trying to reach for her phone that was on the nightstand and slid off the bed. Contributing factors for the fall include the bed was not in the low position, and phone was out of reach. She reported having hit the left side of her head. The resident complained of mild local discomfort to head from the fall. An assessment was completed and range of motion was at her baseline and showed no injury. The resident was assisted back to bed utilizing a hoyer lift with assistance from other staff. Bed returned to the low position, call light device within reach as well as bedside table within reach. The Resident was reminded to use call light when needing assistance and demonstrated its use."V. Staff interviewsCNA #3 was interviewed on 6/15/23 at 9:25 a.m. The CNA confirmed Resident #39's reacher was on the floor out of the resident's reach. The CNA said the resident required two person assistance for repositioning and dressing. The CNA said the resident had fallen out of her bed trying to reach her phone from her bedside table. She said the resident was provided a reacher to assist with grabbing items. The CNA said the resident could not get to her reacher as it was located on the floor. She said the resident might fall and hurt herself trying to get her reacher from the floor. The director of nursing (DON) was interviewed on 6/15/23 at 2:39 p.m. The DON said the interdisciplinary team would look into various ways after a resident's fall and identify potential causes for the fall and implement interventions to prevent future fall. The DON said the nursing team were to follow the interventions such as ensuring resident's call lights and reachers were within resident's reach. The DON said Resident #15 and #39 could have fallen out of their bed and caused potential injury to themselves trying to reach items with the call light not accessible. VI. Resident #28A. Resident statusResident #28, age 90, was admitted on 6/28/18. According to the June 2023 CPO, diagnoses included acute systolic (congestive) heart failure, weakness, vascular dementia, chronic atrial fibrillation (irregular rapid heartbeat), heart disease, cataracts, high blood pressure and history of falls. The 3/15/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident required extensive assistance from one person for bed mobility, transfers, moving on and off the unit, dressing, toilet use and personal hygiene. She needed supervision and set up help only for eating. Her balance during transitions and walking was marked as not steady and she used a wheelchair as a mobility device. The MDS assessment revealed the resident had a history of multiple falls that included injury. B. Resident observations and interviewResident #28 was interviewed on 6/12/23 at 1:42 p.m. She said she could not remember exactly when she fell but thought it was a couple days ago. She said she typically used her walker to walk to the restroom by herself. Resident #28 had green bruising to her cheeks and forehead. Her call light was out of reach on her nightstand. She sat in her wheelchair and was not wearing non-skid socks. On 6/13/23 at 10:21 a.m., Resident #28 was in her room, asleep and leaning forward in her wheelchair. She was not wearing non-skid socks and her call light was on her night stand in the drawer. The call light was not within reach. At 1:59 p.m. Resident #28 was in her room asleep in her wheelchair. Her call light was on her nightstand and out of reach. She was not wearing non-skid socks. At 2:27 p.m. Resident #28 was in her room, asleep and leaning forward in her wheelchair. At 2:32 p.m. a certified nurse aide (CNA) removed Resident #28's roommate's lunch tray while Resident #28 was asleep in her wheelchair and leaning forward. On 6/14/23 at 1:30 p.m Resident #28 was reading while in her wheelchair. She was not wearing non-skid socks. C. Record reviewResident #28's fall care plan was initiated on 6/28/18. She was identified as a fall risk due to her history of a fall with fracture, history of stroke, unsteady gait, confusion and impulsiveness. The goal, initiated 6/28/18, was to minimize falls with an injury. The most recent and pertinent fall interventions included:-Reinforce need to call for assistance; initiated and revised on 12/21/22.-Encourage resident to wear non-skid socks when resident up and out of bed; initiated 12/22/22.-Offer to lay down between meals; initiated 3/6/23.-Have commonly used articles within easy reach; initiated 4/23/18 and revised 3/16/23.-Implement use of preventative device wheelchair, ensure that brakes were in working condition; initiated 2/25/21 and revised 3/16/23.-There were no interventions added to Resident #28's care plan after the fall on 5/21/23. A physician progress note 5/21/23 at 12:34 p.m. documented a request to be seen by nursing, and the staff reported the patient fell out of her wheelchair and did strike her forehead. A general progress note on 5/21/23 at 1:16 p.m. documented, "This nurse heard a loud thump and a resident yell 'help me' this nurse ran to resident's room and found her laying on the floor on her right side in front of her wc (wheelchair) with blood slowly dripping for (sic) her forehead. At this time another aid came into room and went for the RN (registered nurse) supervisor who assessed the resident for further injuries. Resident has skin tear to her right outer elbow measuring approx one and a half inches. Resident picked up from the floor with assist from aids and nurse, resident able to stand, ROM WNL (range of motion within normal limits). Pressure applied to forehead and dressed with pressure guaze (sic) and taped. Tear approximated, steri-strips applied and covered with telfa bandage. Neuros (neurological check) and vitals started. Resident's son informed via voicemail, nurse practitioner (NP) informed of fall via phone conversation. Resident was dressed and wearing non-slips socks at the time of fall. Patient states she just fell out of her wc (wheelchair). She believes she fell asleep and fell forward hitting her head on the wood floor. Pt (patient) denied pain at this time."-The fall investigation was requested from the facility for the fall and the progress note (see above) was provided. A general progress note on 5/21/23 at 2:35 p.m. documented, "This nurse was notified by the assigned CNA (certified nurse aide) that res (resident) had a fall. Res (resident) was found laying on the floor on her right side in front of the wheelchair near by her bed. Res (resident) was slowly bleeding from the forehead and from right outer elbow. Res (resident) was alert and oriented and mentioned that she did not hit her hip and denied pain, VSS (vital signs stable), ROM (range of motion)-baseline. Res (resident) was picked up from the floor with other 2 staffs (two staff members). Res (resident) stated that she fell asleep and just fell out of her wheelchair on the floor. Dressing done to the skin tear at right elbow and pressure applied on the forehead. Neuros (neurological exam) initiated."A general progress note on 5/22/23 at 12:38 a.m. documented, "Resident continues with bruising and abrasion to forehead. No bleeding noted or increased swelling noted to forehead, slight discoloration and swelling to the upper bridge of the nose. The resident was able to tell a nurse that she had fallen onto the floor earlier today."-There was no documentation of an IDT (interdisciplinary team) review of the 5/21/23 fall.-A review of the progress notes from 4/1/23 to 6/11/23 revealed there was no documentation of fall interventions attempted for Resident #28 during this time frame, although it was documented she was wearing non-skid socks on 5/21/23, the day of her fall. D. Staff InterviewsThe director of nursing (DON) was interviewed on 6/15/23 at 3:00 p.m. He said it would have been appropriate for the staff to ask Resident #28 if she preferred to sit differently or wake her up if she was observed in her wheelchair sleeping and leaning forward. He said the facility was working on their fall investigation process and investigations should include witness reports and the resident's story of what happened. The regional clinical consultant (RCC) was interviewed on 6/15/23 at 3:00 p.m. He said every fall was reviewed by the IDT team and appropriate interventions would be put in place; a resident's fall interventions were based on cause and care planned. CNA #2 was interviewed on 6/15/23 at 4:20 p.m. She said she knew what interventions residents had if they were at fall risk because there was a binder right against a cabinet wall that provided her the information she needed. She used the residents' kardex (resident care overview) and knew fall interventions could include non-skid socks and a low bed. E. Facility follow-upThe facility provided follow up information on 6/20/23 at 11:52 a.m. The follow up documented, "Resident #28's most recent fall was 03/04/2023" and that "the state agency is unable to consider these falls during this recertification survey." (The facility was cited for falls previous to the survey on 6/15/23) -However, according to Resident #28's progress notes revealed she had a fall on 5/21/23. In addition, the resident did have prior falls, fall interventions were not consistently implemented (see observations above). VII. Resident #47A. Resident statusResident #47, age 88, was admitted on 12/10/21. According to the June 2023 CPO, diagnoses included left femur fracture, joint replacement surgery, moderate protein calorie malnutrition, dementia, legal blindness, low BMI (body mass index), history of falling, high blood pressure and glaucoma. The 3/23/23 MDS assessment revealed the BIMS score was six out of 15 indicating severe cognitive impairment. The resident required extensive assistance from one person for bed mobility and transfers, dressing and personal hygiene. She was totally dependent and needed one person assistance with mobility on and off the unit and supervision with set up only for eating. Her balance during transitions and moving on and off the toilet was not steady and she was able to stabilize only with assistance. The MDS assessment revealed Resident #47's vision was severely impaired and she had functional limitation in her range of motion due to impairment in her upper and lower extremities on one side. B. Resident observations and interviewsResident #47 was interviewed on 6/12/23 at 10:14 a.m. She said she did not know where her call light was and she had a hard time finding her call light because she could not see. The resident's bed was not in a low position. On 6/13/23 at 10:11 a.m. Resident #47 was in her bed; the bed was not in a low position. At 1:50 p.m. Resident #47 was in her bed; the bed not was in a low position. On 6/14/23 at 9:27 a.m. Resident #47 was in her bed eating breakfast; the bed was not in a low position. At 9:52 a.m. Resident #47 was in her bed, her breakfast tray had been removed and the bed was in a low position. On 6/15/23 at 9:42 a.m. Resident #47 said she was a mess and was holding her hands up. She said she did not know where her call light was and she said it's on and off if they (the staff) answer it.' The call light was observed on the floor and her bed was not in a low position. At 4:00 p.m. Resident #47's bed was not in a low position. C. Record reviewResident #47's fall care plan revealed the resident was at risk for falls due to a history of falls, unsteady gait, legal blindness, history of fainting, and a fall with a left hip fracture; initiated 12/10/21 and revised on 3/20/23. Pertinent interventions included for Resident #28's bed to be in a low position; initiated on 3/20/23. Resident #47's kardex safety interventions were listed as follows: bed in a low position, fall risk, have commonly used items within easy reach and reorient the resident to the room and placement of personal items as the resident was blind. D. Staff interviewsThe DON was interviewed at 3:00 p.m. He said care plan interventions printed to the resident's kardex. The RCC was interviewed on 6/15/23 at 3:00 p.m. He said a bed in a low position could be different for each resident and the staff go over specifics for each resident at the shift report. -Information was requested to see the documentation so the staff knew the various low positions assigned to different residents but it was not provided. CNA #8 was interviewed on 6/15/23 at 4:24 p.m. He said he used a resident's kardex for fall interventions. He observed Resident #47's bed at this time and said it was not in a low position, he said that low position was supposed to be close to the floor. CNA #2 was interviewed at 4:30 p.m. She said she used the resident's kardex for fall interventions. She observed Resident #47's bed and said the bed was not in a low position.

Based on observations, record review and staff interviews the facility failed to ensure one (#50) of reviewed for hydration out of 36 sample residents was provided sufficient fluids to maintain hydration health. Specifically, the facility failed to provide and offer fluids to Resident #50, who had a history of dementia and was dependent resident, outside of mealtimes. Findings include:I. Professional referenceBruno, C., Collier, A., Holyday, M., Lambert, K. (2021, October 13). Interventions to Improve Hydration in Older Adults: A Systematic Review and Meta-Analysis. Nutrition. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537864/ retrieved on 6/27/23."Dehydration is the most common fluid and electrolyte complication amongst the elderly. It is highly prevalent in hospitalized and institutionalized settings. Nursing homes have also identified inadequate fluid intake amongst 50-90% of residents. "Dehydration increases risk of morbidity and mortality. This is because lower hydration levels are associated with incidences of acute confusion, constipation, urinary tract infections (UTI ' s), exhaustion, falls and delayed wound healing."Older adults are at increased risk of dehydration due to age related physiological changes, such as decreased thirst sensation and impaired renal function. This risk is often exacerbated in those with mental illness or stroke."II. Resident #50A. Resident statusResident #50, age 72, was admitted on 7/18/22. According to the June 2023 computerized physician orders (CPO), the diagnoses included Alzheimer ' s disease with early onset, intracranial injury and symptomatic epilepsy. The 4/5/23 minimum data set ( MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. She had severe cognitive impairment with decisions of daily decision making. She required the extensive assistance of two people for bed mobility, transfers, dressing, toileting, personal hygiene and the extensive assistance of one person for eating. B. ObservationsOn 6/13/23 at 12:50 p.m. the resident was lying in bed and a caregiver was observed assisting the resident with lunch and offering fluids from a styrofoam lidded container. At 2:00 p.m. the caregiver was gone, the bedside table was pushed to the far wall from the resident ' s bed with the same styrofoam lidded container. No additional fluids were at the bedside or within reach of the resident. At 3:00 p.m. an unidentified staff member entered the room to check on the resident. The bedside table continued to be on the far wall with the styrofoam lidded container. The staff member was observed not bringing any additional fluids into the room or offering the resident fluids. On 6/14/23 at 8:42 a.m. the resident was observed lying on back and an unidentified staff member was observed assisting the resident with breakfast. On a continuous observation of the resident on 6/14/23 starting at 9:00 a.m. and ending at 12:15 p.m. At 9:00 a.m. the staff member removed the breakfast tray from the room. The bedside table was pushed away from the bed out of reach from the resident with a lidded styrofoam cup. At 9:45 a.m. unidentified staff entered the room and provided incontinence care and repositioned the resident. Staff did not bring in or offer any fluids during the encounter. At 12:15 p.m. the resident was lying in bed and the bedside table positioned out of reach of the resident with the lidded styrofoam container. No additional fluids were observed being brought in or offered. B. Record reviewThe nutrition care plan, initiated on 1/9/23 revised 4/3/23, indicated that the resident was at risk for alterations in nutritional status due to a history of seizures, assistance needed for activities of daily living (ADL), non verbal, dementia and on hospice. Interventions included collaborating care with hospice, provide required assistance for meals, provide verbal cues and encouragement, provide snacks and alternatives. The hydration care plan was initiated on 7/19/22. Interventions included collaborate care with hospice, honor advanced directors for nutritional and hydration support, report changes and signs of fluid deficit, report signs of fluid overload, report edema. A comprehensive review of the care plan failed to reveal person centered approaches for maintaining hydration related to the resident's requirement for extensive assistance for nutrition and hydration. The June 2023 CPO revealed a physician order of regular diet with regular texture, thin fluids, ordered 7/18/22. The 7/22/22 nutritional registered dietitian (RD) assessment revealed the resident had a daily fluid requirement of 1,650 milliliters (mls) per day. The hydration and fluids offered record, including meals, was reviewed from 6/1/23 to 6/15/23 the following times when fluids were offered:-6/1/23 at 12:25 a.m, 1:03 p.m. and 8:26 p.m.-6/2/23 at 1:58 a.m., 1:59 p.m. and 9:33 p.m.-6/3/23 at 1:41 a.m., 1:59 p.m. and 9:59 p.m.-6/4/23 at 3:53 a.m., 9:27 a.m. and 9:53 p.m.-6/5/23 at 5:59 a.m., 1:59 p.m, and 9:59 p.m.-6/6/23 at 12:10 a.m., 12:58 p.m., 9:59 p.m. 11:35 p.m.-6/7/23 at 1:59 p.m. and 6:35 p.m.-6/8/23 at 12:30 a.m., 7:58 a.m., 6:00 p.m. and 11:03 p.m.-6/9/23 at 11:25 a.m. and 6:54 p.m.-6/10/23 at 1:02 p.m. and 9:59 p.m.-6/11/23 at 1:41 a.m., 12:11 p.m. and 3:22 p.m.-6/12/23 at 5:59 a.m, 1:59 p.m.-6/13/23 at 1:59 p.m., 9:53 p.m., 10:54 p.m.-6/14/23 at 9:34 a.m. and 9:59 p.m.-6/15/23 at 5:59 a.m., 1:47 p.m. 2:24 p.m.-A comprehensive review of the hydration record and the medical record failed to reveal fluid amounts that were offered during these times. The hydration record failed to document consistent offering of fluids at meal time and between meals. III. InterviewsCertified nursing assistant (CNA) #2 was interviewed on 6/15/23 at 9:45 a.m. She said fluids should be offered in between meals for all residents and Resident #50, who was a dependent resident, should be assisted with her fluid intake. She said water and additional fluids should be within reach and styrofoam water cups should be refilled if empty. Licensed practical nurse (LPN) #1 was interviewed on 6/15/23 at 12:15 p.m. She said residents should be offered fluids frequently between mealtimes and fluids should be placed within reach. She said Resident #50, who was a dependent resident, should be offered and assisted with her fluid intake. She said the styrofoam cup was refilled with water every shift. She said the facility did not have a beverage cart and staff did not make rounds to offer fluids. She said there was a limited supply of alternative beverages available on the unit. The director of nursing (DON) was interviewed on 6/15/23 at 3:15 p.m. He said water should be passed every shift to residents. He said staff would refill the styrofoam cups with water and residents did not have a measured water pitcher. He said the certified nurse aides should be making rounds and offering additional fluids between meals depending on the resident's preference for additional fluids.

Based on record review, observations, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for three (#2, #303 and #24) of three residents reviewed for pain out of 36 sample residents. Specifically, the facility failed to complete a thorough pain assessment for Resident #2, #24 and #303 which included, recognizing the onset, presence of and characteristics of pain. Findings include:I. Facility policy and procedureThe Pain Management policy, dated 10/24/22, received from the nursing home administrator on 5/14/23 read in pertinent part, "Patients will be evaluated as part of the nursing process for the presence of pain upon admission/readmission, quarterly, with change in condition or change in pain status, and as required by state regulations. Assess and identify the presence of pain and need for pain management. Assessment components include, but we are not limited to:"-Pain locations-Pain level,-Pain onset-Pain descriptions,-Factors that worsen pain,-Factors that improve pain-Pain medication history including medication assisted treatment for opioid use."II. Failure to complete a thorough pain assessment 1. Resident #2A. Resident statusResident #2, age 73, was admitted on 9/2/2020. According to the June 2023 computerized physician orders (CPO) diagnoses included, fibromyalgia, major depressive disorder and anxiety disorder. The 1/4/23 minimum data set (MDS) showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS) assessment. The resident required extensive assistance from one staff member for activities of daily living. The resident had a scheduled pain regimen and received a non-pharmaceutical pain regimen. B. Resident interviewResident #2 was interviewed on 6/12/23 at 2:27 p.m. The resident said she had chronic pain from fibromyalgia. She said she had been on different medicines, however, she continued to have uncontrolled pain. She said the pain was in her shoulders. C. Pain management planThe June 2023 CPO showed an order for the resident's pain level to be checked every shift. -The physician order failed to show what pain scale was to be used. The June 2023 CPO and recent physician telephone orders revealed current orders for pain control include:-Gabapentin 800 milligrams (mg) capsule by mouth three times a day for diabetes mellitus with diabetic neuropathy with a start date of 4/1/23; -Morphine Sulfate ER (extended release) oral tablet 30 mg. Give 30 mg by mouth every eight hours related to pain in right shoulder, fibromyalgia with a start date of 3/31/23; and, -Morphine Sulfate ER oral tablet 15 mg. Give 15 mg by mouth as needed 30 minutes prior to therapy PRN (as needed) once in a 24 hour period with a start date of 3/31/23. D. Pain assessment and care planThe care plan, last reviewed on 4/26/23, identified the resident had potential for pain related to impaired mobility, fibromyalgia, and history of chronic pain. Pertinent approaches included to implement non pharmacological interventions, positioning, chamomile tea, distraction and activity such as reading a book and notify the physician if pain worsens.-The medical record failed to show a pain assessment was completed to identify the potential for pain, recognizing the onset, presence of pain and failed to assess the characteristics of pain. -There was no assessment to include the history of pain and factors which precipitate or exacerbate pain and pain goal. The daily pain assessment completed on the MAR failed to show the pain scale to be used. The pain assessment documented both the numerical and the pain assessment in advanced dementia scale (PAINAD) were used interchangeably. From 5/13/23 to 6/13/23 showed PAINAD was used 10 times and the numeric was used 20 times. -However, there was no direction as to which pain scale should be used. E. Staff nterviewLicensed practical nurse (LPN) #1 was interviewed on 6/14/23 at 2:00 p.m. The LPN said the resident did have pain from fibromyalgia. She said they check her pain one time a day. She said she used the numeric pain scale. She said the resident had prescribed pain medication and repositioning helped with her pain. The director of nursing (DON) was interviewed on 6/15/23 at 1:47 p.m. The DON said the resident should be evaluated with a complete pain assessment on admission, quarterly and with a change of condition. He said the resident's pain level was checked daily. He reviewed the record and said there was no complete assessment to determine the resident's pain level. He said because the resident was cognitively intact a numeric pain scale was to be used. 2. Resident #24A. Resident statusResident #24, age 78, was admitted on 7/4/21. According to the June 2023 computerized physician orders (CPO), diagnoses included dementia, senile degeneration of the brain, anxiety, chronic kidney disease stage one, chronic constipation, stage two pressure ulcer, spondylosis (spinal degeneration) and dysphagia (difficulty swallowing). The 6/7/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted, with the resident indicated by the response marked she was rarely to never understood or understands. Resident #24 needed extensive assistance with two person assistance for her bed mobility, transfers, movement on and off the unit, dressing and toilet use. She needed assistance from one person for eating and personal hygiene. She was totally dependent on staff for bathing and needed the assistance of one person. The MDS assessment coded the resident as having a scheduled pain regimen and but did not receive an as needed pain regimen. The MDS indicated a pain assessment interview should be conducted; the staff assessment for pain should not be conducted. B. Resident representative interviewResident #24's daughter was interviewed on 6/12/23 at 11:11 a.m. She said her mom would answer a yes or no question inappropriately. She said a question had to be asked in two different ways just to make sure Resident #24 was giving an appropriate answer. She said her mom had a harder time communicating recently and her mom did put mixtures of random words together. C. Resident observations and interviewResident #24 was interviewed on 6/13/23 at 3:50 p.m. Resident #24 was asked if her hip hurt, and she responded yes. Resident #24 was then asked if her hip felt good and she responded yes. Resident #24 was unable to answer open-ended questions without jumbling random words together and continued pleasant conversation with random words and sentences. D. Record reviewResident #24's care plan for pain documented pain at left leg, history related to tibial and fibular (leg bones) fractures, history of left hip related to a history of fall with a fracture, diagnosis of spondylosis (spinal degeneration) cervical region and lumbar region and osteoarthritis; initiated 2/2/23 and revised on: 3/22/23Resident #24's care plan pain goal was zero (out of 10) and pain or analgesia were not to affect participation in activities of choice or daily care; initiated 2/1/23. Pertinent care plan interventions included:-Administer pain medication per physician orders; initiated 2/1/23.-Implement non-pharmacological interventions such as music, massage, a warm/cool compress, and positioning to assist with pain and monitor for effectiveness; initiated 2/1/23.-Notify the physician if pain frequency/ intensity was worsening or if current analgesia (pain relief) regimen has become ineffective; initiated 2/1/23. The pain assessment in advanced dementia (PAINAD) dated 3/11/23 documented the pain rating eduction was completed for the resident, her most recent pain level was zero (out of 10). The PAINAD read in pertinent part, "The pain assessment in advanced dementia (PAINAD) scale is used for patients who cannot verbally communicate about their pain. This may include patients who are unable to complete the pain interview section of the MDS, have cognitive impairment or cannot verbally communicate. The PAINAD scale evaluates the realms of breathing, independent of vocalization; negative vocalizations; facial expression; body language; and consolability."-The pain assessment dated 3/11/23 failed to identify the potential for pain, recognizing the onset, presence of pain and failed to assess the characteristics of pain used for this resident. It failed to include the history of pain and factors which precipitate or exacerbate pain. The medical practitioner note on 5/19/23 at 4:30 p.m. documented, "on Tylenol for pain. Will monitor for extremity weakness. Will consider opioid for worsening pain."The pain assessment dated 6/12/23 asked the resident if she had pain or hurting any time in the last 5 days? The answer no was checked.-The pain assessment dated 6/12/23 failed to identify the potential for pain, recognizing the onset, presence of pain and failed to assess the characteristics of pain. It failed to include the history of pain and factors which precipitate or exacerbate pain. The assessment used was not the pain assessment for advanced dementia. E. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 6/15/23 at 9:55 a.m. She said Resident #24 moaned or changed how she sat if she was in pain. She said Resident #24's facial expression changed so when she was transferred you could see by the look on her face if she was in pain;sometimes she could say yes or no if she was in pain but she typically did not express pain verbally. Licensed practical nurse (LPN) #1 was interviewed on 6/15/23 at 9:41 a.m. She said Resident #24 indicated pain through her facial expression and her body became tight and tense. The director of nursing (DON) was interviewed on 6/15/23 at 1:45 p.m. He said in general pain was assessed daily and prior to any as needed (PRN) medications and could be numerical or facial. A pain assessment for the resident should have been completed upon admission, quarterly and with a change of condition. He said non-pharmacological pain interventions would be implemented for all residents. He said Resident #24 should have had a pain assessment on 6/12/23 using the pain assessment for advanced dementia. 3. Resident #303A. Resident statusResident #303, over the age of 65, was admitted on 6/15/18 and readmitted on 1/26/22. According to the June 2023 CPO diagnoses included chronic pain, chronic obstructive pulmonary disease (COPD), muscle weakness, chronic kidney disease and osteoarthritis. The 6/6/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. She required two person assistance with bed mobility, transfers, dressing, personal hygiene and toileting. She required set-up assistance with supervision for meals. The resident had no behaviors and rejection of care. Resident #303 received scheduled with no as needed pain medication. B. Record reviewThe care plan, revised on 10/25/22, documented the resident had pain at her left hip and shoulder related to history of fall with fracture. The care plan revealed the resident refused non pharmacological interventions such as repositioning, offering chamomile tea, distraction, and activities. Other interventions included anticipating the resident's need for pain medication, notify the physician of any nonverbal expressions of pain such as moaning, striking out, grimacing, crying and change in breathing.-According to the June 2023 CPO, Resident #303 was prescribed Percocet 5-325 (milligrams), 1 tablet by mouth two times a day for pain with a start date of 1/26/22.-The June 2023 medication administration and treatment records revealed no pain level to be obtained prior to administering pain medication. The pain assessment evaluation completed on 3/3/23 revealed a pain numeric number to be obtained prior to administering pain medication.-There was no record of pain level documented in the resident's medical chart.-The facility failed to ensure Resident #303 wasproperly assessed for pain and the administration of pain medication. C. Staff interviews LPN #3 was interviewed on 6/14/23 at 10:41 a.m. The LPN said the resident was on scheduled pain medication (percocet 5-325) two times a day for back pain. The LPN said she obtains the resident's pain scale usually 45 minutes after the administration of the pain medication.

Based on record review and interviews the facility failed to ensure that residents were free of unnecessary psychotropic medications for two (#33 and #50) of five residents reviewed for psychotropic medications out of 36 sample residents. Specifically, the facility failed to:-Ensure that Resident #50 had behavior monitoring for target behaviors in place while on an antipsychotic and failing to conduct a gradual dose reduction (GDR); and, -Ensure that Resident #33 had behavior monitoring for target behaviors and followed through on recommendation for GDR for a psychotropic medication. Findings include:I. Facility policy and procedureThe facility was unable to provide a Psychotropic Medication or Behavioral Monitoring policy when requested on 6/15/23. II. Professional referenceHarrison. S. L., Cations, M, et al. (12/11/18). Approaches to Deprescribing Psychotropic Medications for Changed Behaviors in Long Term Care Resident Living with Dementia. Drugs & Aging. https://link.springer.com/article/10.1007/s40266-018-0623-6 retrieved on 6/22/23. It read in pertinent part, "Non-pharmacological approaches are recommended as first line treatment for changed behaviors, yet psychotropic medications remain highly prevalent in long term aged care settings."Interventions to deprescribe psychotropic medications should be multifactorial, including lowering the dose of the medication over time, educational interventions and psychological support."Desprescribing practices should be person centered, and an individualized desprescribing protocol should be in place, followed by careful monitoring of the individual."III. Resident #50A. Resident statusResident #50, age 72, was admitted on 7/18/22. According to the computerized physician orders (CPO), the diagnoses included Alzheimer's disease with early onset, intracranial injury (closed head injury) and epilepsy (seizure disorder). The 4/5/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. She had severe cognitive impairment with decisions of daily decision making. She required the extensive assistance of two people for bed mobility, transfers, dressing, toileting, personal hygiene and the extensive assistance of one person for eating. The resident was not exhibiting hallucinations, delusions, physical or verbal behavioral symptoms or behaviors rejecting direct care. B. Record reviewThe behavior care plan, initiated 7/21/22 revised 1/9/23, indicated that resident was at risk for behavioral symptoms due to Alzheimer's disease and had exhibited behaviors of smearing bodily waste, agitation with staff and combative during care. Interventions included assisting resident to floor when she attempts, bed kept in lowest position to the floor, collaborate care with hospice, observe for mental status and behavior changes with new medication or changes in dosage, provide sensory items for comfort, non-pharmacological interventions such as approach calmly, consistent approaches to care attempt to minimize stimulation with hand massage, provide sensory items. On 11/3/22 the physician orders revealed an order for Seroquel 50 milligrams (mg) at bedtime. On 11/4/22 the physician orders revealed an order for Seroquel 25 mg twice daily (50 mg). The June 2023 medication and treatment administration record (MAR/TAR) revealed documentation for monitoring side effects of antipsychotic medications.-The MAR and TAR failed to reveal documentation of behavioral monitoring.-A review of the CPO failed to reveal orders for behavioral monitoring.-A comprehensive review of the medical record failed to reveal behavioral monitoring to include defined behaviors. The 4/12/23 pharmacist medication regimen review revealed recommendations for monitoring of dyskinesia (abnormality or impairment for voluntary movement) for Seroquel. C. InterviewsCertified nursing assistant #2 was interviewed on 6/15/23 at 1:30 p.m. She said she has not witnessed any physicalor verbally disruptive behaviors and she had not refused care. Licensed practical nurse (LPN) #1 was interviewed on 6/15/23 at 1:35 p.m. She said Resident #50 spent her day lying in bed and was nonverbal. She said she would occasionally verbalize "amen." She said when she was in pain she would tap her chest and head. She said in November 2022 she had exhibited behaviors by getting out of bed and smearing bodily waste on the floor and wall and taking off her clothes. She said she had not been exhibiting any behaviors recently. She said she was not aware of any behavior documentation monitoring and was not aware of any discussion of a gradual dose reduction for Seroquel. The director of nursing (DON) was interviewed on 6/15/23 at 3:30 p.m. He said behavior monitoring should be conducted for residents on antipsychotic medications. He said behavior monitoring was usually documented on the resident's TAR as a checkmark and documented on the progress notes for the identified behaviors..The social services director (SSD) was interviewed on 6/15/23 at 4:10 p.m. He said if there were observed behaviors from a resident, they were documented in the resident's progress notes. He said the care plan would have the defined behaviors or they would be outlined in the antipsychotic medication order. The psychotropic drug committee reviewed resident's psychotropic drugs every three months. He said Resident #50 had a past history of smearing bodily waste and other behaviors. He said she was not currently exhibiting these behaviors. IV. Resident #33A. Resident status Resident #33, over the age of 65, was admitted on 10/19/21. According to the June 2023 CPO, diagnoses included osteoporosis, vascular dementia with other behavioral disturbances, muscle weakness, right hand muscle contracture and osteoarthritis. The 4/5/23 MDS assessment revealed the resident had moderate impaired cognitive ability with a BIMS score of eleven out of 15. She required extensive assistance of two-person with bed mobility, transfers, toileting, dressing and personal care. Rejection of care was not exhibited by the resident. B. Record reviewThe June 2023 CPO documented the following:Quetiapine fumarate tab 25 milligrams (mg) by mouth three times daily for vascular dementia with behavioral disturbances with a start date of 11/25/22. Lexapro 20 (mg) by mouth one time a day for delusion, seeing spiders crawling and boxes on her chest related to vascular dementia with behavioral disturbances with a start date of 2/17/23.-The MAR and TAR did not include behavioral tracking for the use of Seroquel and Lexapro. Diazepam 2 (mg) by mouth one time a day for anxiety and paranoid delusion for 30 days with a start date 5/12/23. The social services note documented on 5/23/23 at 10:59 a.m. revealed a review of psychotropic medications. The recommendation was a potential taper off Quetiapine. The social services note further revealed that it was agreed upon to revisit the recommendation at the June 2023 medication review meeting. -Records indicate new medication Diazepam was started on 5/12/23 before the medication review date of 5/23/23. There was no indication of any dosage reduction for the Quetiapine even though a new psychotropic medication was added. C. Staff interviewsCNA #1 was interviewed on 6/15/23 at 6:25 p.m. The CNA said the resident continued to hallucinate despite the added medication. The CNA said the resident usually hallucinated when she woke up from a nap saying there were spiders crawling through her window, however with staff reassurance the resident was able to return to baseline. The director of nursing (DON) was interviewed on 6/15/23 at 1:46 p.m. The DON said the facility was in the process of adding behavior tracking and non-pharmacological interventions for residents on psychotropic medications.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for two residents (#2 and #49) out of 36 sample residents. Specifically, the facility failed to:-Ensure resident refrigerator temperatures were monitored for refrigerated food storage; and, -Provide the resident and/or resident representative with information on their right to store food and the process for doing so. I. Facility policyThe Refrigerators: Patient In-Room policy, dated 9/1/22, was provided by the NHA on 6/15/23 at 1:00 p.m. It read in pertinent part, "Food supplied by the patient/responsible party that required refrigeration must be labeled with the date the food was placed in the refrigerator. Food considered unsafe for consumption or beyond the expiration date will be discarded by staff upon notification to the patient or patient representative. The patient and/or patient representative will be provided with the In Room Refrigerator Acknowledgement form. A refrigerator /freezer temperature log will be maintained for every patient refrigerator. Nursing will observe and record temperatures of the refrigerator on a daily basis using the refrigerator/freezer temperature log. Housekeeping will clean refrigerators inside and out including walls, door and shelves, and will defrost the freezer when applicable. Nursing will monitor for proper food labeling and the date food was placed in the refrigerator. Staff will discard food beyond expiration or perishable food held in the refrigerator three days following the date on the label."II. Resident interview and observationResident #2 was interviewed on 6/12/23 at 2:15 p.m. The resident said she kept food in her personal refrigerator in her room. She said that she needed some help taking care of it. She said she was unable to, however, and no staff would help her. The refrigerator was overfilled with undated food items and food containers. The refrigerator had food spills and was sticky. A thermometer was not located inside. There was no log for the refrigerator temperatures. The progress note dated 5/21/23 documented, "Resident was very rude and demanding of nurse while in her room for nightly med (medication) pass. Became agitated when told nurse was unable to rearrange her refrigerator at this time d/t (due to) passing hs (hour of sleep) meds."Resident #49 was interviewed on 6/13/23 at 10:51 a.m. The resident said that she had a personalized refrigerator to keep snacks. She asked who could help her to keep the refrigerator clean. The resident said no staff maintained the refrigerator for her. The refrigerator contained candy, undated pudding and soda. There was no thermometer which could be located. There was no log for the refrigerator temperatures. On 6/15/23 at approximately 2:00 p.m., the dietary manager observed Resident #2 and Resident #49's personal refrigerator in their rooms. She said there were no temperature logs and they needed to be cleaned. Two other personal refrigerators on the 400 hall were observed to not have temperature logs. III. Record reviewTemperatures were not recorded and temperature logs were not used for resident refrigerators. IV. Staff interviewsLicensed practical nurse (LPN)#1 was interviewed on 6/15/23 at 10:55 a.m. She said there used to be a binder the night shift nurse used to record resident refrigerator temperatures in and the night shift was responsible for checking the log. The temperature logs now were supposed to be in the resident's room and the night shift nurse should record the refrigerator temperature on the log. The logs were supposed to be on the resident refrigerator and be in the resident room. The nursing home administrator (NHA) was interviewed on 6/15/23 at 12:25 p.m. She said they did not have the temperature logs for resident refrigerators but the dietary department would manage the logs going forward. She said they did not have the previous logs for the resident refrigerators or a performance improvement plan in place. The social services director was interviewed on 6/15/23 at 12:30 p.m. He said he was not sure who did the education for resident refrigerators but to ask the registered dietitian (RD). The RD said there was education in the resident admission packet. She said there were no temperature logs and no education provided to the family. V. Facility follow-upThe RD was interviewed on 6/15/23 at 2:00 p.m. She said the facility had updated the resident refrigerator temperature logs, educated the residents and had them sign their In Room Refrigerator Acknowledgement form.

Based on observation, record review and interviews, the facility failed to establish a communication process that included how the communication would be documented between the facility and the provider for one (#24) of two residents reviewed for hospicare care out of 36 sample residents. Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #24. Findings include:I. Facility and hospice agreementThe Nursing Facility Agreement with Resident #24's hospice agency, dated 3/9/22, read in pertinent part, "Medical Chart: Facility and hospice will prepare and maintain complete medical records for hospice patients receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by hospice will be filed and maintained in the facility chart. The facility and hospice will each have access to the hospice patients records maintained by the other party for verification of patient care and financial information pertinent to the agreement."The facility will designate a member of the facility's interdisciplinary group (IDG) who is responsible to work with hospice personnel to coordinate care provided to the hospice patient. The IDG is responsible for establishing the manner of how communication will be documented between hospice and the facility to ensure the needs of the hospice patient are addressed and met 24 hours per day."II. Resident statusResident #24, age 78, was admitted on 7/4/21. According to the June 2023 computerized physician orders (CPO), diagnoses included dementia, senile degeneration of the brain, anxiety, chronic kidney disease stage one, chronic constipation, stage two pressure ulcer, spondylosis (spinal degeneration) and dysphagia (difficulty swallowing). The 6/7/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted, with the resident indicated by the response marked that she was rarely to never understood or understands. Resident #24 needed extensive assistance with two person assistance for her bed mobility, transfers, movement on and off the unit, dressing and toilet use. She needed assistance from one person for eating and personal hygiene. She was totally dependent on staff for bathing and needed the assistance of one person. She was receiving hospice care and services. III. Resident representative interviewResident #24's daughter was interviewed on 6/12/23 at 11:11 a.m. She said her mom was on hospice and it seemed hospice staff used to see her mom daily but now the hospice staff only come once a week and she felt the reports from the facility were inaccurate. She said the hospice chaplain did call her but she did not think the hospice staff were doing what she thought they initially agreed upon, which included one-to-one companionship. She said she thought her mom was getting a bed bath instead of a shower. IV. Record reviewThe June 2023 CPO revealed the resident was admitted to hospice services on 6/23/22 with a primary diagnosis of senile dementia of the brain. A review of Resident #24's hospice care plan focus resident was on hospice care related to a diagnosis of senile dementia of the brain; created on 5/20/22 and revised 3/3/23. Pertinent inventions were as follows:-Certified nurse aide (CNA) schedule Tuesday and Thursday (two times/week). Nurse scheduled Wednesdays (one time/week). Social worker scheduled one time a month and PRN (as needed). Chaplain scheduled one time a month and PRN; initiated 5/20/22 and revised 9/26/22.-Administer medication per physician orders; initiated 6/23/22.-Assist the resident to reposition; initiated 6/23/22 -Assist with ADL (activities of daily living) care and pain management as needed; initiated 6/23/22.-Collaborate care with hospice; initiated 5/22/22 and revised 6/23/22.-Report skin breakdown, lack of analgesia (pain reliever) effectiveness, unexpected weight loss or decline in appetite; created 6/23/22.-Honor advanced directives; initiated 6/23/22. A review of Resident #24's medical chart revealed hospice CNA communication logs were present from 2/28/23 to 4/27/23 with visits happening twice a week during. A review of Resident #24's 4/18/23 nursing progress note at 6:09 p.m. documented, "Resident wound cares provided by hospice nurse, no changes reported, resident tolerated well. No signs of nonverbal pain cues."-There were no nurse progress notes provided by hospice in Resident #24's chart from the 4/18/23 visit. A review of Resident #24's 3/16/23 social services progress note at 8:52 a.m. documented, "It was determined at the conclusion of the meeting that there will no longer be monthly meetings and hospice will just attend quarterly care conferences."-There were no progress notes provided by the hospice nurse, social worker or chaplain included in Resident #24's medical chart. There were no CNA visit progress notes in Resident #24's medical chart before 2/28/23 or after 4/27/23. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/15/23 at 9:41 a.m. She said said the hospice staff for Resident #24 check out with a facility nurse post visit and hospice nurse aides fill out a bath sheet after a visit with Resident #24. She said there was no hospice form to sign, the hospice agency did not use any hand held electronic devices for their visits and left no documentation at the time of their visit. The director of nursing (DON) was interviewed on 6/15/23 at approximately 3:30 p.m. He said the hospice staff only checked out with a facility nurse and he would clarify where the hospice notes were so staff could see the plan of care and if hospice was fulfilling their duties. He said hospice notes were supposed to be sent to him via email but he was not yet on the distribution list and had not been receiving them since he had started at the facility about three weeks previous.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, quality of life, quality of care and infection control. Findings include:I. Facility policyThe Quality Assurance and Performance Improvement (QAPI) Plan, revised June 2023, was received from the nursing home administrator (NHA) on 6/12/23. The plan read in pertinent parts, "All staff and stake holders are involved in QAPI to improve the quality of life and quality of care that our patients and residents experience. The Center's approach to QAPI culture and processes is standardized by implementing the following key elements: data driven and comprehensive, addressing all aspects of care, quality of life and resident centered rights and choice. Review, analyze trends and identify potential improvement opportunities for the following, based on the Analysis and Action plan process completed prior to the Quality Assurance Performance Improvement Committee (QAPIC) performance data where trends are worsening or levels have exceeded targets are completed prior to the quality assurance performance improvement committee."II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correctF 550During the recertification on 4/19/22 (Resident rights/dignity) was cited at a "D" scope and severity. During the recertification survey on 6/15/23, the facility was cited at a "D" scope and severity. F 677During the recertification on 4/19/22 (ADL care provided to dependent residents) was cited at a D and severity. During the recertification survey on 6/15/23, the facility was cited at "E" scope and severity. F 686During the recertification on 4/19/22 (Pressure injury) was cited at a "J" scope and severity. During the recertification survey on 6/15/23, the facility was cited at a "D" scope and severity. F 689During the recertification on 4/19/22 (accident hazard) was cited at a "D" scope and severity. During an abbreviated survey on 3/23/23, the facility was cited at harm level of a "G." During the recertification survey on 6/15/23, the facility was cited at "E" scope and severity. F867During the recertification survey on 4/19/22 (quality assurance) was cited at a "F" scope and severity. During the recertification survey on 6/15/23, the facility was cited at a "F" scope and severity. F 880During the recertification survey on 4/19/23 (infection control) was cited at a "L" scope and severity. During the abbreviated survey on 2/9/22 F 880 (infection control) was cited at a "E" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "F" scope and severity. III. Cross-reference citationsF550Cross-reference F550 Dignity: The facility failed to ensure residents were treated with respect and dignity. F658Cross-reference F658 Professional standards: The facility failed to ensure residents received care in accordance with professional standards of practice. F686Cross-reference F686 Pressure injury: The facility failed to ensure residents were free from pressure injury. F689Cross-reference F689 accident hazard: The facility failed to ensure residents were safe from falls. F697Cross-reference F697 Pain: The facility failed to manage pain in a manner consistent with professional standards of practiceIV. InterviewThe nursing home administrator (NHA) and the corporate executive director were interviewed on 6/15/23 at 5:46 p.m. The NHA said she had been employed at the facility for the last three weeks. She said she had not been through a QAPI committeemeeting, however she had reviewed the minutes. She said the interdisciplinary team (IDT) met monthly. The pharmacist and the medical director. The NHA said the meeting had an agenda. She said the agenda changed monthly. She said from the meeting outside committees would be formed. She said resident council, grievances and any happenings in the building were used to identify issues. The NHA said resident falls were discussed in the daily meeting. She said all falls or "near misses." She said the committee needed to build safety committees and risk management. She said they needed to talk more in depth about the falls. She said a root cause for each fall needed to be determined. The NHA said the facility had a wound physician and an outside consulting company was involved with the pressure injuries. The registered nurse from the outside consulting company did the wound rounds with the wound nurse. She said the facility discussed the wounds regularly. The NHA said the facility had not gotten too in depth on pain discussions. She said they had adjusted pain parameters in assessments. The NHA said the director of nursing should be involved with the parameters for insulin and blood sugars. The NHA was aware there were areas in quality of care which needed to be addressed. The corporate executive said the facility needed to work on follow through, as processes and interventions had fallen through the cracks.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to ensure that toiletry items were marked in the shared bathroom. Findings include:I. ObservationsAn observation of residents' shared bathrooms was completed on 6/13/23 at 11:15 a.m. There were about eight shared resident bathrooms with personal hygiene items such as toothbrushes, toothpaste, hair comb, razors, urinal containers and deodorant were not marked. A second observation of the residents' shared bathrooms and central bathroom was completed on 6/14/23 at 3:20 p.m. Toothbrushes and deodorant at the central bathroom were not labeled. The call light string of the call light device had brown stains around the string. Towels in shared bathrooms were not marked and some rooms did not have any towels at all. II. Residents interviewResident #28 was interviewed on 6/15/23 at 9:50 a.m. The resident said her and her roommate did not really know which towel belonged to who. She said both her and the roommate just use whichever towel they grab. III. Staff InterviewAn environmental walk through was conducted with the assistant director of nursing (ADON) on 6/15/23 at 10:10 a.m. The ADON confirmed the hygiene items were not labeled and said it was an infection control issue. She said the overnight staff were supposed to complete bathroom checks each night to ensure that toiletry items were available and labeled for all residents.

Based on observations and staff interviews, the facility failed to ensure resident bathrooms ventilation fans were functioning on three of four resident bathrooms. Specifically, the facility failed to ensure vents were properly working in residents bathrooms. Findings include:I. ObservationsAn observation of the residents' environment was completed on 6/13/23 at 3:20 p.m. There were exhaust fans installed in the ceiling of each resident's bathrooms. The exhaust fans in the bathroom of room 102, 107 and 304 did not generate air movement with the switch turned on. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans were not functioning at that moment. II. Staff InterviewAn environmental walk through was conducted with the maintenance director (MTD) on 6/14/23 at 3:20 p.m. The MTD checked the ventilation systems in each of the above bathrooms and confirmed that they were not functioning. The MTD said he had the heating, ventilation and air conditioning (HVAC) company outside and would ask them to check the motors of the ventilation system. The MTD came back at 3:45 p.m. and said the ventilation motors on the west and east side of the building as well as two air handlers were out and not working, explaining why those vents in some bathrooms were not working. He said the HVAC company has given the facility a quote to fix the motors.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 5/10/23 for all previous deficiencies cited on 3/23/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 5/10/23 for all previous deficiencies cited on 3/23/23. The facility is in compliance with all regulations surveyed.

A survey for Incident #31091 was conducted on 3/21/23-3/23/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of two residents reviewed for accidents out of four sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of medically complex conditions, was admitted to the facility on 1/29/19. 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 rolling her to her side. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in her significant change 11/17/22 minimum data set (MDS) assessment. The facility failed to provide and implement two person bed mobility/toileting assistance and failed to consistently provide two person bed mobility/toileting assistance after the fall according to record review, interviews and in accordance with the resident's care plan. Due to the facility's failures, and the staff's failure to take proper and reasonable care when providing bed mobility/toileting assistance resulted in a fall from the bed that resulted in the resident sustaining injuries of a right and left femur (thigh) fractures, a right head laceration requiring seven staples, and required hospitalization for three days. Findings include:I. Facility policy and procedureThe Falls Practice Guide policy, dated December 2011, was provided by the nursing home administrator (NHA) on 3/23/23 at 3:50 p.m. It read in pertinent part, "The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Comprehensive care plan: Based upon the findings of the MDS (minimum data set) and CAAs (care area assessment) and following review of risk factors, environmental factors and other clinical conditions, the patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors."II. Resident statusResident #1, age 89, was admitted initially on 1/29/19, and readmitted on 1/19/23. According to the March 2023 computerized physician orders (CPO), diagnoses included left femur fracture, right femur fracture, muscle weakness, and anxiety disorder. The significant change 11/17/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, dressing, toilet use, bathing and personal hygiene. Transfers did not occur over the entire seven day period. There were no behavioral symptoms or rejection of care. The significant change 1/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. There were no behavioral symptoms or rejection of care. The resident was always incontinent of bowel and bladder. III. Resident interviewResident #1 was interviewed on 3/21/23 at 11:39 a.m. She said certified nurse aide (CNA) #1 was going to change her and she rolled her to the side. Resident #1 said she was in a position that made her slip out of the bed and she fell to the wood floor. Resident #1 said she was in a state of shock and the police came and helped to calm her on the floor. Resident #1 said she was moved from the floor and put on a stretcher; she felt shocked, scared and stunned. Resident #1 said she felt numb at first and she did not feel like screaming when it happened. Resident #1 said she started feeling the pain on the way to the hospital. Resident #1 said now she had two people to change her, before the fall she had one person help with bed mobility. Resident #1 said her legs hurt now if she moved them and there was a large black scab on the top/back of her head. Resident #1 said there were certain places on her body that were still tender and she still had a fear of falling. IV. Record reviewCare plan:Review of the ADL care plan established prior to the 1/17/23 fall revealed that it had not been developed to include two persons physical assistance for bed mobility, dressing, toilet use, bathing and personal hygiene although the 11/17/22 MDS had been coded as requiring such care, which was the highest level of care needed during the seven day period. The ADL care plan was updated after the 1/17/23 fall and added "two assist with bed mobility, toileting, daily hygiene, dressing," date initiated 2/13/23.-The resident had returned to the facility on 1/19/23, after her hospitalization. The care plan was not updated and revised to include two person assistance with bed mobility until 2/13/23, 28 days after the resident's fall on 1/17/23. Review of the urinary incontinence care plan revealed it was updated and added after the 1/17/23 fall "two person assist during incontinence care" date initiated 1/19/23. Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part:1/17/23 at 2:45 p.m., "Registered nurse (RN) assessment: This nurse was called to resident's room by staff nurse stating resident had fallen out of bed while being changed by certified nursing aide (CNA). Upon entering the room noted resident laying on the floor faced down with a towel under her face. Bleeding noted from gash on the right side of resident's head. Had a small skin tear to right shoulder. Resident was able to state her name and state she was in pain and wanted to get off the floor. Another RN obtaining vital signs at this time. Clear area around resident for safety. While RN applied gauze to gash in head for pressure this nurse, head neck in alignment with assistance of CNA to turn resident over. Upon turning resident over noted a skin tear to resident right knee and right foot. Resident was still alert and oriented upon assessment. EMS (emergency medical services) arrives to take over. Fall protocol in place."1/17/23 at 3:31 p.m., "CNA was turning resident and rolled her over and let go for just a second and she rolled off the bed. The bed was in the high position. Resident was laying on her right side on her stomach. Called RN #1 and RN #2 to come assist. Call to 911 was placed and paramedics with (name) came at once. This writer called the daughter of resident and left her message of what was happening with her mother. Call and message was also left with RN at (provider) to inform medical doctor (MD) #1 and nurse practitioner (NP) #1. Resident received a laceration to right side of her (head) also scraped her knees and tore scabs off as well off her toes. She also had marks to her upper back and mid back on right side. Paramedics here and took at 3:25 p.m."1/17/23 at 3:39 p.m., "This RN responded to resident's reported fall while LPN (licensed practical nurse) called 911. Resident observed to be lying on the floor with a bleeding laceration to her head. The resident and CNA both reported that the resident fell while being turned in bed. Initial assessment showed that resident's vital signs were within her baseline limits (pulse 85, O2 (oxygen saturation) 90, BP (blood pressure) 143/93). A/O (alert and oriented) x 4. Resident reported 10/10 pain, generalized, on her buttocks, and on her head. Tenderness to palpation in bilateral pelvic area. PERRLA (pupils equal, round, reactive to light and accommodation). Resident had a laceration to the right side of her head. Scabs on bilateral knees and toes opened during the fall and were bleeding. New small open area on buttocks resulting from the fall. Abrasions on the right shoulder and mid-back were also observed. EMT's arrived and took over resident care and transfer."1/18/23 at 10:06 a.m.,"IDT (interdisciplinary team) met to review fall from bed yesterday, remains in hospital. Was sent to hospital and remains there. Will review when returns."1/19/23 at 1:17 p.m., "Resident readmitted to the facility from community hospital via stretcher with (name) at 11:15 a.m. following post fall with diagnosis of bilateral femur fractures. Medication regimen reviewed with physician assistant (PA) #1, no issues found. Resident was A & O (alert and oriented) x3 (person, place and time), able to make her needs known. Resident was on a regular diet, regular texture, poor appetite, and eats meals by herself with a setup tray. Incontinence with bowel and bladder. Resident was on 2 L (liters) O2 (oxygen) via NC (nasal cannula). Dressing was changed on the bilateral lower leg today as per a report given by hospital RN. Resident had bruises on the back of bilateral hands and right forearm from the IV (intravenous) site. Resident was admitted to hospice at the hospital. Hospice admission nurse was in the building today to see the resident. Resident denies any pain at this time, states she was only in pain when her leg was moved. The resident had a new order for PRN (as needed) oxycodone. NP from optum informed about readmission and new order. Daughter updated about patient's condition and new order. Call light placed within reach. Bed was in the lowest position. V/S (vital signs) 120/54, 97.5, 63, 92% on 2L O2 via NC."1/20/23 at 10:38 a.m., "Update: Patient was sent out to hospital on 1/17/23 status post (s/p) fall with increased pain and laceration to right side of head. Pt was admitted to hospital where she was diagnosed with bilateral femur fractures. Pt was admitted to hospice services for end of life care. Patient readmitted to this facility on 1/19/23. Upon admission, per nursing note, patient with seven staples on right side of her scalp with crusted blood/OTA (open to air), bruise on back of both hands and RFA (right forearm) from IV site. Recent weight not available. Continue diet per order. Will restart supplements."1/21/23 at 1:06 p.m., "Resident continues on charting for readmission s/p fall. Resident had seven staples to head that are clean, dry and intact. Resident's bed in low position and requires the assistance of two persons to assist with changing. Resident had not complained of any pain or discomfort related to fall."Hospital records:The 1/17/23 emergency room physician note revealed in pertinent part, "Reason for consult: Fall at nursing home. History of present illness: Resident #1 is an 89 year old female presenting with traumatic injuries sustained after falling at a skilled nursing facility. She was sent to the ED by medical transport for evaluation with her advanced directive documents and medication list. She was found to have bilateral distal femur fractures on plain film. Trauma surgery consultation was requested. Resident #1 was unable to provide history due to advanced dementia and was moaning in pain. Physical exam: Elderly female moaning in pain. Laceration right parietal (near the top of head) region."The 1/18/23 hospitalist progress note revealed in pertinent part, "Assessment and Plan: This is an 89 year old female with a history of chronic lymphedema with chronic venous stasis ulcerations and wounds presenting to the emergency department after a fall during transfer resulting in bilateral distal femoral fractures. Toe abrasion; closed head injury; mechanical fall-laceration clean, dry, repaired in ED (emergency department), trauma surgery following. Mental status: She was disoriented. Psychiatric: comments: Moaning in pain."Review of the bed mobility task support provided for the past 30 days documentation revealed the following:-2/22/23 at 5:02 p.m. one person physical assistance was provided.-2/22/23 at 10:08 p.m. one person physical assistance was provided.-2/24/23 at 1:51 p.m. one person physical assistance was provided.-2/25/23 at 1:59 p.m. one person physical assistance was provided.-2/26/23 at 1:59 p.m. one person physical assistance was provided.-2/27/23 at 1:24 p.m. one person physical assistance was provided.-3/1/23 at 1:59 p.m. one person physical assistance was provided.-3/5/23 at 1:09 a.m. one person physical assistance was provided.-3/5/23 at 1:40 p.m. one person physical assistance was provided.-3/6/23 at 5:53 a.m. one person physical assistance was provided.-3/6/23 at 4:45 p.m. one person physical assistance was provided.-3/8/23 at 1:59 p.m. on person physical assistance was provided.-3/9/23 at 1:36 p.m. one person physical assistance was provided.-3/10/23 at 6:45 p.m. one person physical assistance was provided.-3/13/23 at 12:42 a.m. one person physical assistance was provided.-3/13/23 at 1:59 p.m. one person physical assistance was provided.-3/17/23 at 1:59 p.m. one person physical assistance was provided.-3/18/23 at 2:41 p.m. one person physical assistance was provided.-3/22/23 at 2:38 a.m. one person physical assistance was provided.-3/23/23 at 4:15 a.m. one person physical assistance was provided.-Although the newly revised care plan read, "two assist with bed mobility" updated after Resident #1's fall, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. Review of the toileting task support provided for the past 30 days documentation revealed the following.-2/20/23 at 5:16 p.m. one person physical assistance was provided.-2/22/23 at 8:17 p.m. one person physical assistance was provided.-2/24/23 at 6:28 p.m. one person physical assistance was provided.-3/3/23 at 11:40 a.m. one person physical assistance was provided.-3/5/23 at 1:18 a.m. one person physical assistance was provided.-3/9/23 at 1:36 p.m. one person physical assistance was provided.-3/10/23 at 11:37 p.m. one person physical assistance was provided.-3/18/23 at 2:59 a.m. one person physical assistance was provided.-3/18/23 at 1:26 p.m. one person physical assistance was provided.-3/18/23 at 2:42 p.m. one person physical assistance was provided.-Although the newly revised care plan read, "two person assist during incontinence care" updated after Resident #1's fall, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. V. Facility's investigation of Resident #1's fallThe post fall investigation noted, "Incident report: date of incident 1/17/23 at 3:00 p.m. Location: resident's room. Description of incident: CNA #1 was turning to change her and she rolled her over too far and she fell off the bed which was in the high position. Describe care provided to the patient following incident: CNA #1 was turning the resident and rolled her over and let her go for just a second and she rolled off the bed. The bed was in a high position. Resident was laying on her right side on her stomach. RN #1 and RN #2 were called to come assist. Call to 911 was placed and paramedics came at once. The resident's daughter was called and a message was left of what was happening with her mother. Call and message the physician. Resident received a laceration to the right side of head, scraped her knees and tore scabs off her toes. She had marks on her upper back and mid back on right side. Paramedics arrived and took at 3:25 p.m. Patient was taken to the hospital 1/17/23 at 3:35 p.m. Summary of alleged incident: CNA #1 was turning resident to change her, and she rolled her over too far and she fell off the bed which was in the high position. Disposition by NHA: After a thorough investigation, neglect was unsubstantiated. It was determined that the CNA followed the patient's care plan/task list related to ADL cares. Employee (CNA #1) was brought back from suspension. Patient returned from the hospital on 1/19/23 with bilateral fractures to the femur. Care plan was reviewed and updated to two-person assistance related to bed positioning/mobility and ADL cares due to change in resident condition. Education was initiated with CNAs related to positioning, fall prevention and reviewing tasks lists prior to caring for a patient. An audit was put into place to monitor the position of patients when providing cares and monitoring correct transfer status. This will be monitored weekly for 4 weeks."Statements: Resident #1 on 1/19/23 at 11:30 a.m. "I have never felt abused or neglected by CNA #1. I am absolutely certain, I love that gal. It wasn't her fault. She's one of my best friends. I know how to report abuse or neglect."Multiple residents interviewed and all had no problems with CNA #1. CNA #1 on 1/17/23 and 1/18/23 (time not documented), the person conducting the interview was the NHA. "Around 2:20 pm I went to the room to perform vitals. At this time, she (Resident #1) requested to be changed. I started cares. She (Resident #1) was rolled onto her left side, per patient request and care plan. I let go of the patient to turn to grab her brief on the side of me, at this time the patient started to roll off the bed. I tried to catch her but was unsuccessful. I immediately notified my nurse for assistance."Multiple staff members interviewed and all had no problems with CNA #1. RN #2 on 1/30/23 (time not documented), "LPN #1 notified her of the fall. She instructed LPN #1 to call 911 while RN #1 and she assessed and stabilized the resident."VI. Staff interviewsThe NHA was interviewed on 3/23/23 at 2:00 p.m. She said CNA #1 was not suspended until 1/20/23 (the fall occurred 1/17/23) as they were not aware of the extent of Resident #1's injuries until later and as they got into the investigation for the fall it was determined there could be a suspicion of neglect so that was when they suspended her for three days (1/20/23, 1/21/23, and 1/22/23). The NHA said she was the abuse coordinator, but it was collaborative with the IDT. The NHA said after the fall they met as a team and put in three corrective plans-staff education, a skills fair with hand on return demonstration, and monitoring/auditing. The NHA said she addressed having the MDS assessment match the care plan to make sure it matched the required assistance levels. She said the team was monitoring staff to see if they were transferring according to the kardex (brief overview of individual patient care). The NHA said prior to the fall the MDS assessment did not match the care plan and the kardex but that was how she wanted it completed now. The NHA said if the MDS assessment said a resident needed two person assistance then it needed to be two person assistance on the care plan. The NHA said a CNA could not change how much assistance a resident needs. She said if the kardex said the resident needed two person assistance then that's what should be given. The NHA said it was important for CNAs to document correctly the level of assistance given to a resident in order to follow the proper transfer status, and important for safety of the patient and staff. The NHA said she would start immediate education on proper documentation and monitoring of incontinence care and bed mobility since it was brought to her attention, during the survey, that currently CNAs were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1. CNA #1 was interviewed on 3/23/23 at 2:39 p.m. She said she went to change Resident #1 and she was rolled to her side, and when she got the brief, Resident #1 fell off the bed. CNA #1 said Resident #1 was panicky and upset and thought she was going to die. CNA #1 said Resident #1 was in a lot of pain when the paramedics picked her up, she was crying, moaning in pain and scared. CNA #1 said the bed was too high, her mattress was too small in width, and Resident #2 should have been a two person assist with bed mobility and incontinence care. CNA #1 said her usual incontinence care techniques were to get everything ready, roll the resident over, clean them, and put on a new brief. CNA #1 said she failed to have all of her supplies ready and she just got herself out of order and she let go of the resident and just was not thinking. CNA #1 said mainly Resident #1 should have been a two person assistance. RN #2 was interviewed on 3/23/23 at 2:50 p.m. She said she was the facility's infection preventionist and nurse educator. She said since Resident #1's fall she had been conducting audits related to transfers (but not specifically to bed mobility and toileting). RN #2 said the questions on the audit read, "Did staff follow the care plan related to transfers? Residents positioned safely in bed during and after transfer? Staff able to verbalize the correct transfer status and position?" RN #2 said the audits came after Resident #1's fall and was designed to capture bed mobility and transfer status. RN #2 said she was now doing the audit one time per month. RN #2 said since it was brought to her attention, during the survey, that staff were not following the care plan related to bed mobility and incontinence care and were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1, she would now rewrite the audit and redo the education. The MDS coordinator (MDS #1) and director of nursing (DON) were interviewed on 3/23/23 at 12:48 p.m. MDS #1 said she did a quarterly MDS assessment every three months, and annual MDS assessment (every 365 days). MDS #1 said if there was a significant change MDS assessment then that was a new starting date and it included a full assessment. MDS #1 said the full MDS assessments trigger the care plan to be updated and different departments contribute to the care plan. MDS #1 said she did the ADL, continence and falls sections of the assessment. MDS #1 said she decided what went to the kardex and she hand made the kardex from the care plan. MDS #1 said Resident #1's 11/17/22 MDS assessment was the last full assessment before the fall on 1/17/23 and that was the MDS assessment her care plan came from. MDS #1 said the 11/17/22 MDS assessment read that Resident #1's bed mobility was extensive assistance with two persons but that was not what she had put on the care plan, but with the audits she would start doing that now. MDS #1 said she would now put residents who required two person assistance on the MDS assessment with two person assistance on the care plan. MDS #1 said before the fall if the MDS assessment said the resident required two person assistance she would not put that on the care plan. MDS #1 said she had put down "care in pairs" on the care plan for Resident #1. MDS #1 said she did not put it on the care plan prior because a resident often would need one person assistance usually with occasional two persons assistance. MDS #1 and the DON said that Resident #1 should have two person assistance at all times for bed mobility and incontinence care, it was now on the resident's care plan and on the kardex. The MDS #1 and DON said it was important to follow for the resident's safety and health. MDS #1 and the DON said they would find out which CNAs were not providing two person assistance and write them up, since it was brought to their attention during the survey, that currently CNAs were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1. MDS #1 and the DON said it was important to have accurate documentation for best resident care and safety. CNA #2 was interviewed on 3/23/23 at 3:45 p.m. She said her process for incontinence care for a resident in bed was to first sanitize hands, get a brief, peri care spray and other supplies. She cleaned the resident in the front first, then rolled them to the side and held the resident while cleaning the backside. CNA #2 said after completion of incontinence care, she put a brief under the resident and centered it and rolled the resident onto their back and pulled the brief up and tabs it, checking to make sure it was straight. CNA #3 was interviewed on 3/23/23 at 3:53 p.m. She said staff should round every two hours to check on the residents. She said her process for incontinence care was to first close the door or curtain, sanitize hands, get supplies ready such as brief, wipe, and peri spray. CNA #3 said she would tell the resident what she was going to do, wipe the front first, then roll resident to the side holding them, and pull out the old brief, put on a new brief, and roll to the middle to get them situated and connect tabs, then roll to the other side to straighten brief. The DON was interviewed on 3/23/23 at 4:06 p.m. She said when staff provided incontinence care they were to first knock, tell the resident why they were there. She said they should gather equipment and supplies such as wipes, and a brief. She said the staff then provided peri-care and undo one side of the brief and tuck under, roll back and pull the dirty brief out and pull the new brief up and reposition. The DON said the staff should be touching and holding the resident when they were rolled. The DON said what went wrong with Resident #1 during incontinence care and the fall on 1/17/23 was CNA #1 reached for something and let go of Resident #1 and because the bed was positioned so high it led to an injury. The DON said it was important for resident safety for the staff to know how to provide proper incontinence care.

A survey prompted by complaint #CO31600 was completed 3/21/23 to 3/23/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of two residents reviewed for accidents out of four sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of medically complex conditions, was admitted to the facility on 1/29/19. 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 rolling her to her side. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in her significant change 11/17/22 minimum data set facility assessment. The facility failed to provide and implement two person bed mobility/toileting assistance and failed to consistently provide two person bed mobility/toileting assistance after the fall according to record review, interviews and in accordance with the resident's care plan. Due to the facility's failures, and the staff's failure to take proper and reasonable care when providing bed mobility/toileting assistance resulted in a fall from the bed that resulted in the resident sustaining injuries of a right and left femur (thigh) fractures, a right head laceration requiring seven staples, and required hospitalization for three days. Findings include:I. Facility policy and procedureThe Falls Practice Guide policy, dated December 2011, was provided by the nursing home administrator (NHA) on 3/23/23 at 3:50 p.m. It read in pertinent part, "The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Comprehensive care plan: Based upon the findings of the MDS (minimum data set, facility assessment) and CAAs (care area assessment) and following review of risk factors, environmental factors and other clinical conditions, the patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors."II. Resident statusResident #1, age 89, was admitted initially on 1/29/19, and readmitted on 1/19/23. According to the March 2023 computerized physician orders (CPO), diagnoses included left femur fracture, right femur fracture, muscle weakness, and anxiety disorder. The significant change 11/17/22 facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, dressing, toilet use, bathing and personal hygiene. Transfers did not occur over the entire seven day period. There were no behavioral symptoms or rejection of care. The significant change 1/25/23 facility assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. There were no behavioral symptoms or rejection of care. The resident was always incontinent of bowel and bladder. III. Resident interviewResident #1 was interviewed on 3/21/23 at 11:39 a.m. She said certified nurse aide (CNA) #1 was going to change her and she rolled her to the side. Resident #1 said she was in a position that made her slip out of the bed and she fell to the wood floor. Resident #1 said she was in a state of shock and the police came and helped to calm her on the floor. Resident #1 said she was moved from the floor and put on a stretcher; she felt shocked, scared and stunned. Resident #1 said she felt numb at first and she did not feel like screaming when it happened. Resident #1 said she started feeling the pain on the way to the hospital. Resident #1 said now she had two people to change her, before the fall she had one person help with bed mobility. Resident #1 said her legs hurt now if she moved them and there was a large black scab on the top/back of her head. Resident #1 said there were certain places on her body that were still tender and she still had a fear of falling. IV. Record reviewCare plan:Review of the ADL care plan established prior to the 1/17/23 fall revealed that it had not been developed to include two persons physical assistance for bed mobility, dressing, toilet use, bathing and personal hygiene although the 11/17/22 facility assessment had been coded as requiring such care, which was the highest level of care needed during the seven day period. The ADL care plan was updated after the 1/17/23 fall and added "two assist with bed mobility, toileting, daily hygiene, dressing," date initiated 2/13/23.-The resident had returned to the facility on 1/19/23, after her hospitalization. The care plan was not updated and revised to include two person assistance with bed mobility until 2/13/23, 28 days after the resident's fall on 1/17/23. Review of the urinary incontinence care plan revealed it was updated and added after the 1/17/23 fall "two person assist during incontinence care" date initiated 1/19/23. Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part:1/17/23 at 2:45 p.m., "Registered nurse (RN) assessment: This nurse was called to resident's room by staff nurse stating resident had fallen out of bed while being changed by certified nursing aide (CNA). Upon entering the room noted resident laying on the floor faced down with a towel under her face. Bleeding noted from gash on the right side of resident's head. Had a small skin tear to right shoulder. Resident was able to state her name and state she was in pain and wanted to get off the floor. Another RN obtaining vital signs at this time. Clear area around resident for safety. While RN applied gauze to gash in head for pressure this nurse, head neck in alignment with assistance of CNA to turn resident over. Upon turning resident over noted a skin tear to resident right knee and right foot. Resident was still alert and oriented upon assessment. EMS (emergency medical services) arrives to take over. Fall protocol in place."1/17/23 at 3:31 p.m., "CNA was turning resident and rolled her over and let go for just a second and she rolled off the bed. The bed was in the high position. Resident was laying on her right side on her stomach. Called RN #1 and RN #2 to come assist. Call to 911 was placed and paramedics with (name) came at once. This writer called the daughter of resident and left her message of what was happening with her mother. Call and message was also left with RN at (provider) to inform medical doctor (MD) #1 and nurse practitioner (NP) #1. Resident received a laceration to right side of her (head) also scraped her knees and tore scabs off as well off her toes. She also had marks to her upper back and mid back on right side. Paramedics here and took at 3:25 p.m."1/17/23 at 3:39 p.m., "This RN responded to resident's reported fall while LPN (licensed practical nurse) called 911. Resident observed to be lying on the floor with a bleeding laceration to her head. The resident and CNA both reported that the resident fell while being turned in bed. Initial assessment showed that resident's vital signs were within her baseline limits (pulse 85, O2 (oxygen saturation) 90, BP (blood pressure) 143/93). A/O (alert and oriented) x 4. Resident reported 10/10 pain, generalized, on her buttocks, and on her head. Tenderness to palpation in bilateral pelvic area. PERRLA (pupils equal, round, reactive to light and accommodation). Resident had a laceration to the right side of her head. Scabs on bilateral knees and toes opened during the fall and were bleeding. New small open area on buttocks resulting from the fall. Abrasions on the right shoulder and mid-back were also observed. EMT's arrived and took over resident care and transfer."1/18/23 at 10:06 a.m.,"IDT (interdisciplinary team) met to review fall from bed yesterday, remains in hospital. Was sent to hospital and remains there. Will review when returns."1/19/23 at 1:17 p.m., "Resident readmitted to the facility from community hospital via stretcher with (name) at 11:15 a.m. following post fall with diagnosis of bilateral femur fractures. Medication regimen reviewed with physician assistant (PA) #1, no issues found. Resident was A & O (alert and oriented) x3 (person, place and time), able to make her needs known. Resident was on a regular diet, regular texture, poor appetite, and eats meals by herself with a setup tray. Incontinence with bowel and bladder. Resident was on 2 L (liters) O2 (oxygen) via NC (nasal cannula). Dressing was changed on the bilateral lower leg today as per a report given by hospital RN. Resident had bruises on the back of bilateral hands and right forearm from the IV (intravenous) site. Resident was admitted to hospice at the hospital. Hospice admission nurse was in the building today to see the resident. Resident denies any pain at this time, states she was only in pain when her leg was moved. The resident had a new order for PRN (as needed) oxycodone. NP from optum informed about readmission and new order. Daughter updated about patient's condition and new order. Call light placed within reach. Bed was in the lowest position. V/S (vital signs) 120/54, 97.5, 63, 92% on 2L O2 via NC."1/20/23 at 10:38 a.m., "Update: Patient was sent out to hospital on 1/17/23 status post (s/p) fall with increased pain and laceration to right side of head. Pt was admitted to hospital where she was diagnosed with bilateral femur fractures. Pt was admitted to hospice services for end of life care. Patient readmitted to this facility on 1/19/23. Upon admission, per nursing note, patient with seven staples on right side of her scalp with crusted blood/OTA (open to air), bruise on back of both hands and RFA (right forearm) from IV site. Recent weight not available. Continue diet per order. Will restart supplements."1/21/23 at 1:06 p.m., "Resident continues on charting for readmission s/p fall. Resident had seven staples to head that are clean, dry and intact. Resident's bed in low position and requires the assistance of two persons to assist with changing. Resident had not complained of any pain or discomfort related to fall."Hospital records:The 1/17/23 emergency room physician note revealed in pertinent part, "Reason for consult: Fall at nursing home. History of present illness: Resident #1 is an 89 year old female presenting with traumatic injuries sustained after falling at a skilled nursing facility. She was sent to the ED by medical transport for evaluation with her advanced directive documents and medication list. She was found to have bilateral distal femur fractures on plain film. Trauma surgery consultation was requested. Resident #1 was unable to provide history due to advanced dementia and was moaning in pain. Physical exam: Elderly female moaning in pain. Laceration right parietal (near the top of head) region."The 1/18/23 hospitalist progress note revealed in pertinent part, "Assessment and Plan: This is an 89 year old female with a history of chronic lymphedema with chronic venous stasis ulcerations and wounds presenting to the emergency department after a fall during transfer resulting in bilateral distal femoral fractures. Toe abrasion; closed head injury; mechanical fall-laceration clean, dry, repaired in ED (emergency department), trauma surgery following. Mental status: She was disoriented. Psychiatric: comments: Moaning in pain."Review of the bed mobility task support provided for the past 30 days documentation revealed the following:-2/22/23 at 5:02 p.m. one person physical assistance was provided.-2/22/23 at 10:08 p.m. one person physical assistance was provided.-2/24/23 at 1:51 p.m. one person physical assistance was provided.-2/25/23 at 1:59 p.m. one person physical assistance was provided.-2/26/23 at 1:59 p.m.one person physical assistance was provided.-2/27/23 at 1:24 p.m. one person physical assistance was provided.-3/1/23 at 1:59 p.m. one person physical assistance was provided.-3/5/23 at 1:09 a.m. one person physical assistance was provided.-3/5/23 at 1:40 p.m. one person physical assistance was provided.-3/6/23 at 5:53 a.m. one person physical assistance was provided.-3/6/23 at 4:45 p.m. one person physical assistance was provided.-3/8/23 at 1:59 p.m. on person physical assistance was provided.-3/9/23 at 1:36 p.m. one person physical assistance was provided.-3/10/23 at 6:45 p.m. one person physical assistance was provided.-3/13/23 at 12:42 a.m. one person physical assistance was provided.-3/13/23 at 1:59 p.m. one person physical assistance was provided.-3/17/23 at 1:59 p.m. one person physical assistance was provided.-3/18/23 at 2:41 p.m. one person physical assistance was provided.-3/22/23 at 2:38 a.m. one person physical assistance was provided.-3/23/23 at 4:15 a.m. one person physical assistance was provided.-Although the newly revised care plan read, "two assist with bed mobility" updated after Resident #1's fall, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. Review of the toileting task support provided for the past 30 days documentation revealed the following.-2/20/23 at 5:16 p.m. one person physical assistance was provided.-2/22/23 at 8:17 p.m. one person physical assistance was provided.-2/24/23 at 6:28 p.m. one person physical assistance was provided.-3/3/23 at 11:40 a.m. one person physical assistance was provided.-3/5/23 at 1:18 a.m. one person physical assistance was provided.-3/9/23 at 1:36 p.m. one person physical assistance was provided.-3/10/23 at 11:37 p.m. one person physical assistance was provided.-3/18/23 at 2:59 a.m. one person physical assistance was provided.-3/18/23 at 1:26 p.m. one person physical assistance was provided.-3/18/23 at 2:42 p.m. one person physical assistance was provided.-Although the newly revised care plan read, "two person assist during incontinence care" updated after Resident #1's fall, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. V. Facility's investigation of Resident #1's fallThe post fall investigation noted, "Incident report: date of incident 1/17/23 at 3:00 p.m. Location: resident's room. Description of incident: CNA #1 was turning to change her and she rolled her over too far and she fell off the bed which was in the high position. Describe care provided to the patient following incident: CNA #1 was turning the resident and rolled her over and let her go for just a second and she rolled off the bed. The bed was in a high position. Resident was laying on her right side on her stomach. RN #1 and RN #2 were called to come assist. Call to 911 was placed and paramedics came at once. The resident's daughter was called and a message was left of what was happening with her mother. Call and message the physician. Resident received a laceration to the right side of head, scraped her knees and tore scabs off her toes. She had marks on her upper back and mid back on right side. Paramedics arrived and took at 3:25 p.m. Patient was taken to the hospital 1/17/23 at 3:35 p.m. Summary of alleged incident: CNA #1 was turning resident to change her, and she rolled her over too far and she fell off the bed which was in the high position. Disposition by NHA: After a thorough investigation, neglect was unsubstantiated. It was determined that the CNA followed the patient's care plan/task list related to ADL cares. Employee (CNA #1) was brought back from suspension. Patient returned from the hospital on 1/19/23 with bilateral fractures to the femur. Care plan was reviewed and updated to two-person assistance related to bed positioning/mobility and ADL cares due to change in resident condition. Education was initiated with CNAs related to positioning, fall prevention and reviewing tasks lists prior to caring for a patient. An audit was put into place to monitor the position of patients when providing cares and monitoring correct transfer status. This will be monitored weekly for 4 weeks."Statements: Resident #1 on 1/19/23 at 11:30 a.m. "I have never felt abused or neglected by CNA #1. I am absolutely certain, I love that gal. It wasn't her fault. She's one of my best friends. I know how to report abuse or neglect."Multiple residents interviewed and all had no problems with CNA #1. CNA #1 on 1/17/23 and 1/18/23 (time not documented), the person conducting the interview was the NHA. "Around 2:20 pm I went to the room to perform vitals. At this time, she (Resident #1) requested to be changed. I started cares. She (Resident #1) was rolled onto her left side, per patient request and care plan. I let go of the patient to turn to grab her brief on the side of me, at this time the patient started to roll off the bed. I tried to catch her but was unsuccessful. I immediately notified my nurse for assistance."Multiple staff members interviewed and all had no problems with CNA #1. RN #2 on 1/30/23 (time not documented), "LPN #1 notified her of the fall. She instructed LPN #1 to call 911 while RN #1 and she assessed and stabilized the resident."VI. Staff interviewsThe NHA was interviewed on 3/23/23 at 2:00 p.m. She said CNA #1 was not suspended until 1/20/23 (the fall occurred 1/17/23) as they were not aware of the extent of Resident #1's injuries until later and as they got into the investigation for the fall it was determined there could be a suspicion of neglect so that was when they suspended her for three days (1/20/23, 1/21/23, and 1/22/23). The NHA said she was the abuse coordinator, but it was collaborative with the IDT. The NHA said after the fall they met as a team and put in three corrective plans-staff education, a skills fair with hand on return demonstration, and monitoring/auditing. The NHA said she addressed having the facility assessment match the care plan to make sure it matched the required assistance levels. She said the team was monitoring staff to see if they were transferring according to the kardex (brief overview of individual patient care). The NHA said prior to the fall the facility assessment did not match the care plan and the kardex but that was how she wanted it completed now. The NHA said if the facility assessment said a resident needed two person assistance then it needed to be two person assistance on the care plan. The NHA said a CNA could not change how much assistance a resident needs. She said if the kardex said the resident needed two person assistance then that's what should be given. The NHA said it was important for CNAs to document correctly the level of assistance given to a resident in order to follow the proper transfer status, and important for safety of the patient and staff. The NHA said she would start immediate education on proper documentation and monitoring of incontinence care and bed mobility since it was brought to her attention, during the survey, that currently CNAs were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1. CNA #1 was interviewed on 3/23/23 at 2:39 p.m. She said she went to change Resident #1 and she was rolled to her side, and when she got the brief, Resident #1 fell off the bed. CNA #1 said Resident #1 was panicky and upset and thought she was going to die. CNA #1 said Resident #1 was in a lot of pain when the paramedics picked her up, she was crying, moaning in pain and scared. CNA #1 said the bed was too high, her mattress was too small in width, and Resident #2 should have been a two person assist with bed mobility and incontinence care. CNA #1 said her usual incontinence care techniques were to get everything ready, roll the resident over, clean them, and put on a new brief. CNA #1 said she failed to have all of her supplies ready and she just got herself out of order and she let go of the resident and just was not thinking. CNA #1 said mainly Resident #1 should have been a two person assistance. RN #2 was interviewed on 3/23/23 at 2:50 p.m. She said she was the facility's infection preventionist and nurse educator. She said since Resident #1's fall she had been conducting audits related to transfers (but not specifically to bed mobility and toileting). RN #2 said the questions on the audit read, "Did staff follow the care plan related to transfers? Residents positioned safely in bed during and after transfer? Staff able to verbalize the correct transfer status and position?" RN #2 said the audits came after Resident #1's fall and was designed to capture bed mobility and transfer status. RN #2 said she was now doing the audit one time per month. RN #2 said since it was brought to her attention, during the survey, that staff were not following the care plan related to bed mobility and incontinence care and were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1, she would now rewrite the audit and redo the education. The facility coordinator (FC #1) and director of nursing (DON) were interviewed on 3/23/23 at 12:48 p.m. FC #1 said she did a quarterly facility assessment every three months, and annual facility assessment (every 365 days). FC #1 said if there was a significant change facility assessment then that was a new starting date and it included a full assessment. FC #1 said the full facility assessments trigger the care plan to be updated and different departments contribute to the care plan. FC #1 said she did the ADL, continence and falls sections of the assessment. FC #1 said she decided what went to the kardex and she hand made the kardex from the care plan. FC #1 said Resident #1's 11/17/22 facility assessment was the last full assessment before the fall on 1/17/23 and that was the facility assessment her care plan came from. FC #1 said the 11/17/22 facility assessment read that Resident #1's bed mobility was extensive assistance with two persons but that was not what she had put on the care plan, but with the audits she would start doing that now. FC #1 said she would now put residents who required two person assistance on the facility assessment with two person assistance on the care plan. FC #1 said before the fall if the facility assessment said the resident required two person assistance she would not put that on the care plan. FC #1 said she had put down "care in pairs" on the care plan for Resident #1. FC #1 said she did not put it on the care plan prior because a resident often would need one person assistance usually with occasional two persons assistance. FC #1 and the DON said that Resident #1 should have two person assistance at all times for bed mobility and incontinence care, it was now on the resident's care plan and on the kardex. The FC #1 and DON said it was important to follow for the resident's safety and health. FC #1 and the DON said they would find out which CNAs were not providing two person assistance and write them up, since it was brought to their attention during the survey, that currently CNAs were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1. FC #1 and the DON said it was important to have accurate documentation for best resident care and safety. CNA #2 was interviewed on 3/23/23 at 3:45 p.m. She said her process for incontinence care for a resident in bed was to first sanitize hands, get a brief, peri care spray and other supplies. She cleaned the resident in the front first, then rolled them to the side and held the resident while cleaning the backside. CNA #2 said after completion of incontinence care, she put a brief under the resident and centered it and rolled the resident onto their back and pulled the brief up and tabs it, checking to make sure it was straight. CNA #3 was interviewed on 3/23/23 at 3:53 p.m. She said staff should round every two hours to check on the residents. She said her process for incontinence care was to first close the door or curtain, sanitize hands, get supplies ready such as brief, wipe, and peri spray. CNA #3 said she would tell the resident what she was going to do, wipe the front first, then roll resident to the side holding them, and pull out the old brief, put on a new brief, and roll to the middle to get them situated and connect tabs, then roll to the other side to straighten brief. The DON was interviewed on 3/23/23 at 4:06 p.m. She said when staff provided incontinence care they were to first knock, tell the resident why they were there. She said they should gather equipment and supplies such as wipes, and a brief. She said the staff then provided peri-care and undo one side of the brief and tuck under, roll back and pull the dirty brief out and pull the new brief up and reposition. The DON said the staff should be touching and holding the resident when they were rolled. The DON said what went wrong with Resident #1 during incontinence care and the fall on 1/17/23 was CNA #1 reached for something and let go of Resident #1 and because the bed was positioned so high it led to an injury. The DON said it was important for resident safety for the staff to know how to provide proper incontinence care.