BROADVIEW HEALTH AND REHABILITATION CENTER

The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility's general characteristics. This survey conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one story, Type V (000), wood frame structure with a partial basement area used for building services. The facility is protected by an automatic fire sprinkler system and is classified as Fully Sprinklered. The 100 bed facility was surveyed on March 14, 2024 using the National Fire Protection Association, (NFPA) Life Safety Code (2012) Chapter 19, Existing Health Care Occupancies. The deficiencies cited were discussed with the Administrator and Maintenance Supervisor during the exit conference conducted at the end of the on-site survey.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected areas in accordance with Life Safety Section 8.7.1.3 and 19.3.2.1.3. This deficient practice could affect all residents and staff in the main smoke compartment including the dining area should there be smoke and heat transfer between the hazardous area and other portions of the building. The self-closing device has been removed from the door to the IT and Central Bulk Storage room in a rated hazardous area requiring 1-hour separation. 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3 ?4 -hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8The Director of Maintenance acknowledged the area enclosures and door condition during a tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain hazardous protected areas in accordance with Life Safety Section 8.7.1.1, and 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment including the dining area should there be smoke and heat transfer between the hazardous area and other portions of the building. Two 16x 24 inch openings was cut through the 1-hour fire resistance rated wall in the IT room to provide ventilation from the corridor in the Aspen hall. 8.7.1.1* 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: (1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 (2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7 (3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43The Director of Maintenance acknowledged the area enclosures and door condition during a tour of the facility.

STANDARD is not met as evidenced by: It was determined by record review and staff interview during the course of the survey, the facility failed to perform and document the exercising of all fire and smoke damper at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur. Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers install in the facility as required every four years. NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. The smoke and fire dampers deficiency item was discussed with the Director of Maintenance during record review of required documentation.

A recertification survey with complaint #CO34937 and Incident #34681 was completed on 2/12/24 to 2/15/24. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/12/24 to 2/15/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#51) of one resident reviewed for abuse out of 22 sample residents was kept free from abuse. Specifically, the facility failed to keep Resident #51 free from sexual abuse by Resident #6. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/12/24-2/15/24, resulting in the deficiency being cited as past noncompliance with a correction date 11/3/23. I. Facility policy and procedureThe Abuse Policy, dated 5/3/23, was received by the nursing home administrator (NHA) on 2/13/24 at 11:09 a.m. It read in pertinent parts: "Purpose: Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. "Intent: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. "Standards: Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Identification of abuse shall be the responsibility of every employee."Definitions: Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology. "Sexual abuse- is non-consensual sexual contact of any type with a resident. Willful-means the individual must have acted deliberately, not that he/she must haveintended to inflict injury or harm. Common Area-is expanded to recognize the inclusion of living rooms or other similarareas where residents gather. Person-centered care means to focus on the resident as the loss of control and support theresident in making their own choices; having control over their daily lives."II. Investigation report of sexual abuse involving Resident #51 and Resident #6 on 11/1/23 based on record review and interviews (see below). On 11/1/23 Resident #51 who had a diagnosis of dementia and used a wheelchair for mobility and Resident #6 who was cognitively intact and ambulated (walk) independently with use of walker were participating in a scheduled movie night activity at the facility, in the dining room across from the kitchen. Two staff members, a dietary aide (DA) and a cook (CK) were leaving the kitchen around 8:00 p.m. to clock out for the day and saw Resident #6 touching Resident #51 inappropriately. On 11/1/23 at 8:03 p.m. the activities assistant (AA) reported an incident of inappropriate touching to the NHA. The AA, who facilitated the movie activity, reported leaving the dining room to escort another resident to their room. Upon returning to the dining room, the AA was approached by the CK who provided information of witnessing inappropriate touching. The AA said he was gone from the dining room for maybe a minute. The AA reported returning to the dining room and seeing Resident #51 and Resident #6 face to face holding each other's hands. Resident #51 informed the AA she had known Resident #6 a long time. The AA reported not seeing any inappropriate touching between Residents #51 and #6, not seeing Resident #51's clothes disheveled and not seeing Resident #51 upset. Resident #51 was laughing while being escorted from the dining room by the AA. On 11/2/23, time not indicated, the DA was interviewed by the NHA and reported Resident #6 had lifted Resident #51's breast out of her shirt and was kissing her breast and touching her face. The DA told the CK to look at the interaction and instructed the CK to report to nursing that Resident #6 was touching the breast of Resident #51. The DA did not intervene. On 11/2/23, time not indicated, the CK was interviewed by the NHA and reported walking to the time clock with the DA and being told by the DA to look at Resident #51 and Resident #6. The CK reported seeing Resident #6 standing over Resident #51 and Resident #6 had his hand inside her jacket on top of her shirt in the chest area. The CK reported she had not seen Resident #51's breast exposed, being kissed or her face being touched by Resident #51. The CK said she was not sure what was going on but it seemed weird. She did not intervene. She said she told a certified nurse aide (CNA) and returned to the dining room and the AA had returned and was informed of what she had witnessed. The investigation report included two interviews with Resident #51 and one interview with Resident #6. Resident #6 was interviewed by the NHA on 11/2/23 at 8:30 a.m. Resident #6 was noted as having a brief interview for mental status (BIMS) score of zero out of 15. She was asked if she was touched inappropriately or if she was scared of anyone at the facility. Resident #6 was unable to answer, made funny faces at the NHA and laughed which was noted to be her baseline. On 11/2/23 at 9:15 a.m. Resident #51 was interviewed by the social services assistant (SSA) and said he remembered asking the AA for a banana and was instructed to ask the kitchen staff. Resident #51 said he did not remember having any interactions with other residents. On 11/3/23, time not indicated, Resident #51 was interviewed again by the SSA and said he remembered hugging a female resident who had always been very nice to him since he was admitted there. III. Facility actionsOn 11/1/23 at 8:03 p.m. the NHA was informed of a witnessed allegation of inappropriate touching by the AA. Staff was instructed to begin one-to-one supervision of Resident #51. One-to-one supervision was concluded on 11/22/23. On 11/2/23 at 8:00 a.m. the facility made notifications to families, the director of nursing (DON), police, adult protective services (APS), ombudsman, health department and continued with the investigation. On 11/2/23 the activities director (AD) and AA were educated on ensuring there was always a staff member present during group activities for supervision of the residents and asking other departments to assist as needed in transporting residents to and from activities to ensure the safety of all residents, an all staff education was conducted on 11/3/23. On 11/2/23 dietary staff were educated on types of abuse to include what to do if witnessing or knowing of an instance of allegation of abuse. Instruction specified ensuring the victim was safe by removing them from the situation. The AA, the DA and the CK previously received abuse and dementia training on 10/17/23. On 11/3/23 Resident #6's care plan was updated to include increasing supervision when in group activities. On 11/3/23 Resident #51's care plan was updated to include him being supervised while in groups with females and assisting Resident #51 back to his room first to prevent leaving him unattended, especially with other female residents and the initiation of a behavior contract (see below). The 11/3/23 behavioral contract revealed Resident #51 would not enter another resident's room without their knowledge and permission, would not attempt to kiss another resident, would not invade another resident's personal space, would not hug another resident without theirconsent, would not inappropriately grab at another resident, would not put his hands on other residents without their verbal consent, would follow the request from staff when they redirected him if he was displaying inappropriate behaviors and violating the contract may result in a 30 day involuntary discharge notice from the facility. Resident #51 was informed the contract was being written based on staff observations and he had the right to disagree with the observations and the contract was written to keep himself and other residents safe and he was able to direct questions about the contract to administration or social services. On 11/6/23 the facility concluded the investigation and sexual abuse was substantiated. IV. Resident #51 A. Resident statusResident #51, age 72, was admitted on 10/12/18. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and aphasia (loss of ability to understand or express speech). The 12/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required substantial to maximum assistance with bathing, toileting and transferringB. Record reviewThe 11/2/23 skin check revealed no skin issues were identified for Resident #51, nor was pain identified verbally or non-verbally, following the incident with Resident #6 on 11/1/23. The cognitive function care plan, initiated on 10/15/18 and revised on 10/17/22, revealed Resident #51 had impaired cognitive function and impaired thought processes related to a stroke. It indicated the resident would be able to communicate basic needs, in her own way, on a daily basis through the review date. Pertinent interventions included asking yes/no questions in order to determine the residents needs, providing cuing reorienting and supervising as needed. The communication care plan, initiated on 10/15/18 and updated 1/30/24, revealed Resident #51 had a communication problem related to having a stroke and she would call out "Bob" as a way of communication when wanting something. It indicated the resident would be able to make her needs known by answering simple yes/no questions on a daily basis. Pertinent interventions included allowing adequate time to respond, repeating as necessary, not rushing communication, requesting clarification from the resident to ensure understanding, facing the resident when speaking, making eye contact, asking yes/no questions if appropriate and using simple, brief, consistent words/cues. The activities care plan, initiated 10/10/22 and updated 11/3/23, revealed Resident #51 received biweekly one to one visits, she was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. She preferred spending time in her room watching television, listening to music, snacking or napping; she participated in activities involving food, drink, and movie nights as tolerated. It indicated the resident would express satisfaction with the type of activities and her level of activity involvement when asked through the review date. Pertinent interventions included escorting and assisting the resident to and from activities and increasing supervision of the resident while in groups. V. Resident #6A. Resident status Resident #6, age 81, was admitted on 6/11/19. According to the February 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), low back pain and diabetes. The 1/16/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required setup or clean up assistance with bathing, toileting and transferring. B. Resident interviewResident #6 was interviewed on 2/12/24 at 1:42 p.m. He said he had lived at the facility for many years, attended activities and was the resident council president at one time. He said he stayed in his room now and kept himself busy with activities and people could visit with him if they wanted. He said he did not attend activities anymore because he was accused of touching someone. He said he missed family who were close and hugged a lot but he could not show affection at the facility like he did at home. C. Record review The behaviors care plan, initiated 1/27/2020 and updated 11/7/23, revealed Resident #6 exhibited inappropriate social behaviors, wandering into other resident rooms at odd hours and often saying exactly what he was thinking regardless of social context clues. The resident liked to hug others with or without their consent, and, at times, made sexually inappropriate gestures towards females. A behavior contract was initiated with the resident on 11/3/23 for inappropriate behavior. It indicated the resident's inappropriate behavioral symptoms would be minimized through staff interventions by the next review date. Interventions included being alert for triggers of undesirable behavior, involving the resident's family as needed, modifying the resident's environment to minimize episodes, redirecting the resident as needed, reminding the resident and intervening as appropriate not to enter another resident's room without permission, invading personal space, hugging or touching another resident without permission, supervising the resident while in groups with females and assisting the resident back to his room first when in supervised groups. The 11/3/23 progress note indicated a conversation was had with Resident #51 regarding an observation made during an evening group activity that he may have displayed inappropriate behaviors towards a female resident. It revealed Resident #51 had a history of inappropriate behaviors towards others. A behavior contract was initiated and reviewed with Resident #51 by the social services director (SSD) to ensure the safety of Resident #51 and other residents at the facility moving forward. Resident #51 verbalized understanding of the contract and stated he was just going to keep to himself informing the SSD he came from South Texas and would hug everyone all the time as he knew them but understood how this could be perceived as inappropriate in a facility setting. VI. Staff interviewsThe DA was interviewed on 2/14/24 at 11:15 a.m. The DA said she was walking past the dining room where residents were watching a movie to clock out around 8:00 p.m. on 11/1/23 with the CK. She said she saw Resident #51 standing over Resident #6 with one hand on her face near her mouth and his other hand was down her shirt touching her breast like he was trying to lift it out of her shirt. She said she saw this in passing and she did not approach or intervene but told the CK to tell a nurse what was happening. The AD was interviewed on 2/14/24 at 11:47 a.m. The AD said she had worked at the facility for a year and a half and the 11/1/23 incident was the first allegation of inappropriate touching Resident #51 had been involved in that she knew of. The AA was interviewed on 2/14/24 at 11:57 a.m. The AA said he was present in the dining room for the duration of the movie on 11/1/23. He said Resident #51 and Resident #6 had not been sitting near one another or had any interaction during the movie. He said he escorted a resident to her room when the movie ended and was stopped in the hallway by CK when he was returning to the dining room to assist other residents. He said he was gone from the dining room for one minute, two minutes at the most. He said the CK informed him Resident #51 was seen touching Resident #6 inappropriately. The AA said he arrived in the dining room and saw Resident #51 and Resident #6 face to face holding hands as if shaking each other's hands. He said he approached the two residents and assisted Resident #51 to the nursing station and reported the allegation made by the CK to the NHA. The CK was interviewed on 2/14/24 at 3:00 p.m. She said she was exiting the kitchen to clock out with the DA. She saidshe saw Resident #51 standing in front of Resident #6 and his hands were inside her jacket and on top of her shirt near her chest. She said she did not see Resident #51 touching the breasts of Resident #6. She said she did not intervene but thought the closeness of the residents' proximity and the advancement of Resident #6's dementia could be problematic and went to inform nursing to keep an eye on them. The CK said she ran into the AA as he was returning to the dining room and informed him of what she saw and also informed Resident #6's nurse. The SSD was interviewed on 2/14/24 at 1:00 p.m. She said Resident #51 was care planned for inappropriate behaviors by a previous social services director. She said the behaviors included making sexually inappropriate comments, hugging people without asking first and poor personal boundaries. She said she had not witnessed these behaviors. The SSD and NHA were interviewed together on 2/14/24 at 1:30 p.m. The NHA said she was made aware of allegations of inappropriate touching on 11/1/23 at 8:03 p.m. by the AA and initiated an investigation. The NHA said Resident #51 was placed on immediate one-to-one supervision and Resident #6 was assessed for injury and monitored for any mood or behavioral changes through weekly skin checks and daily staff interactions. The NHA said Resident #51 remained on one-to-one supervision until 11/22/23 to establish a daily pattern and determine the need for continued supervision and monitoring. She said Resident #51 had not established a pattern of inappropriate behavior and engaged in activities in his room. The NHA said she attempted to contact Resident #6's responsible party without success and the daughter of Resident #51 had been contacted by herself and the resident. The NHA said the police and APS were notified. She said staff received abuse training to include types of abuse and what to do if abuse was witnessed and how to appropriately report events on 11/2/23. The NHA said, based on staff interviews, the facility substantiated the sexual abuse. The SSD said the care plans for both Resident #51 and Resident #6 had been updated to reflect the need for additional supervision while in groups and Resident #51 had entered into a behavioral contract (see above). The APS worker assigned to the sexual abuse case was interviewed on 2/15/24 at 4:00 p.m. She said the case was closed on her end as she felt the facility was able to continue providing the care needs for Resident #51 and the facility had put measures in place to prevent further occurrences.

Based on record review and interviews, the facility failed manage the pain of three (#15, #36 and #12) of five residents out of 22 sample residents in a manner consistent with professional standards of practice..Specifically, the facility failed to ensure residents consistently received scheduled pain medications on time. Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 2/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, "It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Right time- administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms."II. Facility policy and procedureThe Pain Management Policy, revised May 2023, was provided by the nursing home administrator (NHA) on 2/15/24 at 6:15 p.m. It read, in pertinent part:"Acceptable (tolerable) pain control is defined by the resident. Around the clock dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management."III. Resident #15A. Resident statusResident #15, age greater than 65, was admitted on 11/22/23. According to the February 2024 computerized physician orders (CPO), diagnoses included kidney disease, diabetes, skin cancer and fibromyalgia. The 11/28/23 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. The MDS assessment revealed the resident had frequent pain and was on a scheduled pain regimen. B. Record reviewResident #15's February 2024 CPO included physician orders for the following pain medications:Oxycodone 5 milligrams (mg), two times daily (scheduled for 12:00 p.m. and 8:00 p.m.). MS Contin (Morphine extended release) 15 mg, three times daily (scheduled for 8:00 a.m., 4:00 p.m., and 12:00 a.m.). Acetaminophen 650 mg, four times daily (scheduled for 8:00 a.m., 12:00 p.m., 4:00 p.m. and 12:00 a.m.)Resident #15's medication administration record (MAR) documentation was reviewed from 1/1/24 through 2/14/24 with the following findings:Oxycodone: 20 of 90 medication administrations (22.2%) were given more than one hour past the scheduled time. MS Contin: 23 of 137 medication administrations (16.7%) were given more than one hour past the scheduled time. Acetaminophen: 22 of 163 medication administrations (13.5%) were given more than one hour past the scheduled time. C. Resident interviewResident #15 was interviewed on 2/12/24 at 12:12 p.m. She said her medications were sometimes late. She said she had pain medications scheduled at 4:00 p.m. given to her at 6:00 p.m. and pain medications scheduled for 12:00 a.m. given to her at 3:00 a.m. She said it was not acceptable because she took narcotics and needed to receive them as scheduled to minimize her pain. IV. Resident #36A. Resident statusResident #36, age less than 65, was admitted on 1/22/23. According to the February 2024 CPO, diagnoses included diabetes, neuropathy (nerve damage), liver disease and urinary obstruction. The 11/30/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment revealed the resident had occasional pain. B. Record reviewResident #36's February 2024 CPO included a physician's order for the following pain medication:Methocarbamol 500 mg, two times daily (scheduledfor 8:00 a.m. and 8:00 p.m.)Resident #36's MAR documentation was reviewed from 1/1/24 through 2/14/24 with the following findings:Methocarbamol: 25 of 91 medication administrations (27%) were given more than one hour past the scheduled time. C. Resident interviewResident #36 was interviewed on 2/12/24 at 1:52 p.m. She said the nurses did not always give her pain medication on time. V. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on 11/23/22. According to the February 2024 CPO, diagnoses included cervical (neck) disc degeneration, heart disease, chronic obstructive pulmonary (lung) disease, and neuropathy (nerve damage). The 11/29/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident had frequent pain and was on a scheduled pain regimen. B. Record reviewResident #12's February 2024 CPO included a physician's order for the following pain medication:Oxycodone 5 mg, two times daily (scheduled for 8:00 a.m. and 8:00 p.m.). Resident #12's MAR documentation was reviewed from 2/8/24 (the date the pain medication was started) through 2/15/24 with the following findings:Oxycodone: Three of 14 medication administrations (21%) were given more than one hour past the scheduled time. C. Resident interviewResident #12 was interviewed on 2/12/24 at 8:52 a.m. She said the facility had given her pain medication later than the time it was supposed to be administered to her. VI. Staff interviewsRegistered nurse (RN) #2 was interviewed on 2/14/24 at 2:35 p.m. She said she had some residents tell her they were not receiving their pain medications on time during the night. Licensed practical nurse (LPN) #1 was interviewed on 2/15/24 at 2:52 p.m. She said the acceptable time period to give scheduled medications was up to one hour before and one hour after the scheduled time of the medication. The director of nursing (DON) was interviewed on 2/15/24 at 3:30 p.m. She said nursing staff should give scheduled medications up to one hour before and one hour after the scheduled time. She said the facility used a lot of agency nurses and many of them were new nurses. She said this delayed the medication administration.

Based on observations, interviews and record review, the facility failed to ensure one (#47) of one resident out of 22 sample residents received the proper treatment and assistive devices to maintain hearing..Specifically, the facility failed to:-Obtain an order for ear wax drops in order for the audiologist to perform a hearing test for Resident #47; and,-Obtain a follow-up appointment with the audiologist to address Resident #47's concerns with his hearing ability. Findings include:I. Facility policy and procedureThe Ancillary Services policy and procedure, dated 11/4/13, was received by the nursing home administrator (NHA) on 2/14/24 at 4:40 p.m. It read in pertinent part: "Purpose: Ancillary services, including, but not limited to, dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines at the resident/responsible family member's request and as needed."Policy: Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice."Procedure: Social Services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. All orders for the treatment of the resident's ancillary services must be in writing and the resident's attending physician must be made aware of any treatments or medications ordered by an ancillary service provider."II. Resident #47A. Resident statusResident #47, age 81, was admitted on 6/16/2020. According to the February 2024 computerized physician orders (CPO), diagnoses included unspecified hearing loss. The 1/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. He was dependent on staff for assistance with bathing, toileting, and transferring. B. Observation and interviewResident #47 was interviewed in his room on 2/12/24 at 11:42 a.m. The resident said he was hard of hearing and the facility was not helping to improve his hearing. Resident #47 said he was seen by the hearing doctor (audiologist) "months ago" but had too much wax in his ears. He said he should have been seen again but never had another appointment. Resident #47 said he enjoyed watching television in his room but either had to sit so close to the television he could not see the picture but hear the sound or lie down in bed and see the picture but not hear the sound. He said he was bothered by this. Resident #47 said he did not have hearing aids and wanted a pair. C. Record review:The communication care plan, initiated on 6/19/20 and revised on 1/18/24, revealed Resident #47 was hard of hearing but did not wear hearing aids. It indicated the resident would effectively communicate his needs through the next review date. Pertinent intervention included consulting audiology. The 4/6/23 audiology patient visit note revealed Resident #47's hearing test was not completed related to occluding cerumen, bilaterally (both ear canals were blocked with earwax). It revealed the audiologist was unable to remove the wax and recommended Resident #47 receive ear drops with irrigation for seven consecutive days right before the next scheduled appointment and for facility to schedule a second attempt at a hearing test. The 7/19/23 audiology patient visit note revealed Resident #47 had not received ear wax drops and a test would be attempted at a future visit. -There was no documentation in Resident #47's electronic medical record (EMR) to indicate the facility had obtained a physician's order for ear wax drops after the 4/6/23 or the 7/19/23 audiology visits.-There was no documentation in the resident's EMR that indicated the resident had been scheduled for another audiology appointment following the 7/19/23 appointment. C. Staff interviewsThe social services director (SSD) was interviewed on 2/14/24 at 9:00 a.m. She said when the audiologist was finished seeing patients the patient visit notes were given to social services. The SSD said if a medication recommendation was made, the information was given to the resident's nurse who would discuss the recommendation with the doctor so an order could be obtained. The SSD was interviewed again on 2/14/24 at 2:00 p.m. The SSD said the recommendation made by the audiologist on 4/6/23 for Resident #47 to receive ear wax drops with irrigation had not been communicated to the nursing department by social services, nor had the recommendation been communicated after the second visit on 7/19/23. The SSD said she had spoken to Resident #47 at 11:30 a.m. on 2/14/24 (after the concern was brought to the facility's attention). She said he reported difficulty in hearing and was in agreement to schedule an audiology appointment. The NHA was interviewed on 2/14/24 at 3:00 p.m. The NHA said when the audiologist was finished seeing residents and had written their visit notes, copies of the notes went to the social services department. She said it was social services' responsibility to review the notes and disburse information to the appropriate disciplines for follow up. She said if there was a recommendation from the audiologist for ear wax being removed prior to an exam happening nursing should have been informed so they could have contacted the physician to review and initiate the appropriate order. The NHA said she would work with nursing and social services to achieve completion of an ear exam to include the order for ear wax drops prior to exam for Resident #47.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of four medication carts and in one of one medication storage room. Specifically, the facility failed to ensure:-Medications were labeled with the date opened; and, -Expired and discontinued medications were removed from the medication carts in a timely manner. Findings include:I. Professional referencesAccording to the manufacturer Sanofi Aventis US, How to Use Your Lantus Solostar Pen (August 2022), retrieved on 2/20/24 from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf, "After 28 days, throw your opened Lantus pen away, even if it still has insulin in it."According to the manufacturer NovoNordisk, Taking Novolog-Insulin Aspart (March 2023), retrieved on 2/20/24 from https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, "Storage after use - keep at room temperature or refrigerated up to 28 days. Dispose after 28 days, even if there is insulin left in the pen or vial."According to the manufacturer Biocon Biologics, Semglee, Insulin Glargine-yfgn (2023), retrieved on 2/20/24 from https://www.semglee.com/en/semglee-pen#:~:text=Don't%20use%20SEMGLEE%20after,after%20you%20first%20use%20it.&text=Don't%20reuse%20or%20share,get%20a%20serious%20infection%20yourself, "Once you take Semglee out of cool storage, for use or as a spare, you can use it for up to 28 days. Do not use it after this time."According to the manufacturer Eli Lilly and Company, Humalog U-100 Insulin (February 2024), retrieved on 2/20/24 from https://www.humalog.com/u100, "Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin."According to the National Institutes of Health, Daily Med, Breyna (September 2020), retrieved on 2/20/24 from https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=dc529fc4-bddb-4673-8202-dc401f86166f, "The inhaler should be discarded when the labeled number of inhalations have been used or within three months of removal from the foil pouch."According to the National Institutes of Health, Daily Med, Spiriva Respimat (October 2023), retrieved on 2/20/24 from https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=7b656b14-fcaa-2741-f6f0-e0be48971c02, "After assembly, the Spiriva Respimat inhaler should be discarded at the latest three months after first use, or when the locking mechanism is engaged, whichever comes first."According to the Food and Drug Administration, Aplisol-Tuberculin Purified Protein Derivative (November 2013), retrieved on 2/20/24 from https://www.fda.gov/files/vaccines%2C%20blood%20%26%20biologics/published/Package-Insert---Aplisol.pdf, "Vials in use for more than 30 days should be discarded."II. Facility policy and procedureThe Storage of Drugs and Biologicals Policy, revised November 2020, was provided by the nursing home administrator (NHA) on 2/15/24 at 6:15 p.m. The policy read in pertinent part:"Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed." III. Observations and interviewsOn 2/13/24 at 11:09 a.m., the Aspen unit medication cart was observed with registered nurse (RN) #2. The following items were found:A used Insulin Glargine (Lantus) 100 units/milliliter (ml) pen was not labeled with the date it was opened. A used Insulin Aspart Flex Pen (NovoLog) 100 units/ml pen was not labeled with the date it was opened. A used Insulin Glargine-yfgn 100 units/ml penwas not labeled with the date it was opened. Two used Insulin Lispro (Humalog) 100 units/ml kwik pens were not labeled with the date they were opened. A used Budesonide and Formoterol Fumarate (Breyna) inhaler was not labeled with the date it was opened. A used Tiotropium Bromide (Spiriva Respimat) inhaler was not labeled with the date it was opened. A used container of Hydromorphone 1 milligram (mg)/ml with an expiration date of 2/10/24. RN #2 said the insulin and inhalers should have been labeled with the date opened and the Hydromorphone discarded upon expiration. On 2/13/24 at 12:00 p.m., the Snowmass North unit medication cart was observed with licensed practical nurse (LPN) #2. The following items were found:A used Insulin Glargine (Lantus) 100 units/ml pen with a date opened label of 1/11/24. The nurse said she did not know how long the insulin could be used before it needed to be discarded. -The insulin should have been discarded on 2/8/24, 28 days after opening. An opened package of Morphine 100 mg/five ml. LPN #2 said the resident used the medication when she was on hospice services and the order had since been discontinued. -The Morphine order had been discontinued on 1/10/24. On 2/13/24 at 12:30 p.m., the Silver Key medication storage room was observed with LPN #3. The following items were found:An open vial of Tuberculin Purified Protein Derivative (Aplisol), Five TU/0.1 ml, with a house stock label dated 7/25/23. -The package was not labeled with the date it was opened. -The medication should have been discarded 30 days after opening. An Insulin Levimir Flex Pen 100 units/ml with resident label attached. LPN #3 said the resident died a few weeks prior to the survey. She said the medication should have been discarded immediately after the resident died. On 2/13/24 at 3:25 p.m., two pill packages containing Bactrim medication were on top of the Snowmass medication cart. Certified nurses aide (CNA) #2, who was a certified medication tech, walked away from the cart. At 3:40 p.m., CNA #2 returned to the medication cart and the Bactrim pills remained on top of the cart. CNA #2 said the pills should have been locked in the cart and she proceeded to put them in the cart. IV. Staff interviewsThe director of nursing (DON) was interviewed on 2/13/24 at 11:25 a.m. She said insulin and inhalers should be labeled with the date when opened and she would expect the insulin to be discarded 28 days after opened. The DON was interviewed again on 2/15/24 at 3:46 p.m. She said discontinued medications should be removed from carts and storage within 48 hours.

A revisit survey was completed on 1/26/24 for all previous deficiencies cited on 11/29/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/26/24 for all previous deficiencies cited on 11/29/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/26/24 for all previous deficiencies cited on 11/29/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO34216 was conducted on 11/28/23 to 11/29/23. One deficiency was cited.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one Resident (#1) out of three residents reviewed for blood sugar managements out of a total sample of six residents. Resident #1, who had a diagnosis of diabetes and was on diabetic medication, did not have his blood glucose levels consistently monitored by the facility. Resident #1 was sent to the hospital on 10/18/23 when he was lethargic with a diagnosis of hyperglycemia. For three days, 10/25/23 to 10/27/23, Resident #1 had high blood glucose readings above 300 milligrams per deciliter (mg/dl), with normal being 70-130 mg/dl. The facility staff failed to monitor the resident for signs and symptoms of high glucose levels. Two weeks later, on 11/2/23, the resident was sent to the hospital with hyperglycemia. Findings include:I. Professional reference The Mayo clinic Hyperglycemia in Diabetes, revised on August 2022, retrieved on 11/30/23 at https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631, read in pertinent part,"For many people who have diabetes, the American Diabetes Association generally recommends the following target blood sugar levels:Between 80 and 130 mg/dL before mealsLess than 180 mg/dL two hours after meals."If the blood sugar level is 240 mg/dL or above, use a urine ketones test kit. If the urine test is positive, the body may have started making the changes that can lead to diabetic ketoacidosis. It's important to treat hyperglycemia (high blood sugar level). If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart."Symptoms of hyperglycemia develop slowly over several days or weeks. The longer blood sugar levels stay high, the more serious symptoms may become. If hyperglycemia isn't treated, it can cause toxic acids, called ketones, to build up in the blood and urine. This condition is called ketoacidosis. Symptoms include: fruity-smelling breath, dry mouth, abdominal pain, nausea and vomiting, shortness of breath, confusion, and loss of consciousness."II. Facility policy and proceduresThe Diabetic Management policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 11/29/23. The policy read: "Diabetic Management involves both preventative measures and treatment of complications. From admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurately related to blood glucose monitoring and anti-diabetic agents. "Blood glucose orders should include parameters to follow in communicating with the physician. To ensure appropriate nutritional orders are in place (enteral nutrition, diet, supplements, snacks). To ensure preventative skin care measures are in place. To ensure monitoring for signs and symptoms of hyperglycemia or hypoglycemia episodes."Routine Care:Blood glucose values are taken per the physician order. Antidiabetic agents (insulin or oral antidiabetic agents) are administered per physician order. Sliding Scale insulin is administered per physician orders. Diabetic foot care is provided during daily routine care. Residents are monitored for signs and symptoms of complications. Any identified complication is reported timely to the physician."III. Resident statusResident #1, age 90, was admitted on 12/4/19. According to the November 2023 computerized physician orders (CPO), diagnoses included diabetes, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), aortic aneurysm (an excessive enlargement of an artery), emphysema (damage of lung tissue) and Alzheimer's dementia. The 11/14/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required substantial/maximal assistance with meals and was dependent on staff for other activities of daily living (ADLs). IV. Record ReviewThe care plan for diabetes, initiated on 4/26/23 and revised on 11/13/23, revealed the resident had diabetes. Interventions included to check skin routinely, administer medication as ordered by physician, monitor and document any signs of hypo or hyperglycemia. -Resident #1's care plan did not mention specific treatment that the resident was receiving for diabetes. The medical administration record (MAR) for November 2023 revealed the resident was receiving the following medication:Glipizide 5 milligrams (mg), one tablet every day for diabetes; and,Fasting blood sugars to be taken as needed for signs and symptoms of hypoglycemia and hyperglycemia, if blood sugar is 70 mg/dl or below or 400 mg/dl or above, call a physician. The order was initiated on 4/26/23.-Resident #1's fasting blood sugar levels were not checked (the MAR was not signed) as needed in October and November 2023. A. Hospitalization on 10/18/23On 10/12/23, a nurse progress note documented the resident was lethargic. His vital signs were within normal limits. -The blood glucose level was not checked at the time. On 10/15/23 a nurse progress note documented that the resident refused all meals and "was sleeping and would not fully wake up." -The blood glucose level was not checked at the time. On 10/17/ 23 the resident was assessed by nurse practitioner (NP) #1 due to "nursing report decreased verbalizations, increased time in bed, decreased meal intake." At the time of the visit NP #1 documented "patient with no verbal response or interactions with provider or staff."The note read resident's diabetes was managed with oral medication and blood sugars were no longer monitored. Regarding fatigue, it was documented: "Frail elderly gentleman, with history of recurrent pneumonia. Persistent fatigue most likely secondary to advanced age."-The blood glucose level was not checked at that time of the visit. On 10/18/23 at 6:06 p.m. a nurse progress note documented "resident having increased lethargy, abnormal lung sounds, and decreased level of consciousness." Provider on call was contacted, chest x-ray and labs were ordered. -The note did not include the resident's vital signs and blood sugar levels.-At 8:48 p.m. the resident was assessed by a next shift nurse who documented the resident's vital signs within normal limits and blood sugar of 500 mg/dl. "Resident's family requested hospitalization." The emergency medical technician's report documented the resident was unconscious in bed, minimally responsive to pain. Resident #1's family was on scene and requested transport to the hospital. The hospital admission summary dated 10/18/23 revealed the chief complaint was altered mental status. The primary reason for admission was encephalopathy (damage or disease that affects the brain). The resident was unresponsive and was reacting only to painful stimuli. He was admitted to the intensive care unit and started on sliding scale insulin. During the hospital stay the resident was diagnosed with sepsis (life threatening complication from infection), encephalopathy and hyperglycemia (high blood sugar) and acute kidney insufficiency with dehydration. On 10/25/23 the resident was discharged back to the nursing facility. Discharge orders did not include any changes to the diabetes treatment. The resident started back on Glipizide, an oral medication for diabetes. -Upon readmission blood sugar checks were not initiated. B. Hospitalization on 11/2/23At the time of admission to the nursing facility on 10/25/23 the resident was alert and oriented. The progress note on 10/25/23 documented that the resident's daughter requested blood sugar checks to be initiated for the resident. The on call provider was contacted by the nursing staff and blood sugar checks were initiated four times a day for two days. -The order did not specify when and if a physician should be contacted. According to the October 2023 MAR, the resident's blood sugars were consistently above normal range: On 10/25/23 the blood sugar was 232 mg/dl;On 10/26/23 it was 238, 276, 378, 382 mg/dl; and, On 10/27/23 it was 294, 390 and 365 mg/dl. On 10/27/23 blood sugar checks were discontinued.-The review of progress notes from 10/25/23 to 10/27/23 revealed no evidence that abnormal blood sugar levels were reported to the physician. A progress note on 10/30/23 documented "patient very sleepy today, was too tired to eat breakfast. Lunch he ate but needed to be woken up continuously throughout the meal."On 10/31/23 the resident was assessed by NP #1. The note mentioned that the resident's diabetes was managed with Glipizide and daily blood sugars were no longer monitored. -There was no mention regarding the resident's elevated blood sugars between 10/25/23 and 10/27/23. At the time of the assessment, the resident's blood sugar was not checked. The nurse progress note on 10/31/23 documented nursing staff reached out to NP #1 to report that the resident was "not getting up" and "non arousable for meals." NP #1's response was she would reach out to the family "to discuss further options."On 11/1/23 the resident was assessed by NP #1. The note mentioned the resident's diabetes was managed with Glipizide and daily blood sugars were no longer monitored and persistent fatigue most likely secondary to advanced age. The interdisciplinary team (IDT) note on 11/2/23 documented the resident was reviewed due to recent hospitalization on 10/25/23. The fasting blood sugar levels for the resident were running between 100 and 400 mg/dl and he was no longer on blood sugar checks per doctor's order. On 11/2/23 at 2:15 the nurse progress note revealed "EMTs (emergency medical technicians) are here to transfer the resident to the emergency room." The transfer was related to altered mental status and hyperglycemia (increased blood sugar). Resident's blood sugar level was documented by EMTs as 590 mg/dl." The hospital admission note dated 11/2/23 read: "Patient presents with worsening generalized weakness, hyperglycemia and increased oxygen requirement. He feels somewhat short of breath but denies chest pain. He has rhonchorous (abnormal) lung sounds. Remainder of his exam is only significant for clinical dehydration. He is hyperglycemic without evidence of DKA (diabetic ketoacidosis). He does have an acute kidney injury, likely from dehydration. Chest x-ray does not show significant infiltrate. He has received intravenous (IV) insulin and IV fluids. He has continued pneumonia with elevated lactate, hyperglycemia without DKA and dehydration with an acute kidney injury. I feel that his elevated lactate is more due to his dehydration and hyperglycemia. I do not feel that he is septic. He is not tachycardic (fast heart rate) and not febrile (fever)."Resident #1 came back to the nursing facility on 11/8/23, after six days of hospitalization. He was started on sliding scale insulin and blood sugar checks. V. Staff interviewsNP #1 was interviewed on 11/29/23 at approximately 1:00 p.m. She said she could not recall in detail- Resident's #1 hospitalizations for the last couple of months. She reviewed her notes and did not locate any information regarding Resident#1's blood sugar levels between 10/25/23 and 10/27/23. She said she did not review the October 2023 MAR and was not aware that the resident's blood sugar levels were high at that time. Licensed practical nurse (LPN) #2 was interviewed on 11/29/23 at 2:30 p.m. She said signs and symptoms of high blood sugar included thirst and changes in level of consciousness. She said residents who were diabetic, but not on insulin, should always be monitored for signs and symptoms of high blood sugar. She said blood sugar levels in the range of 300 mg/dl should be reported to the physician as it was an abnormally high level. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:50 p.m. He said Resident #1 had an as needed order for blood sugar checks to be completed. He said the order read the physician should only be notified if blood sugar levels were above 400 mg/dl. The director of nursing (DON) was interviewed in the presence of the nursing home administrator (NHA) on 11/29/23 at 3:45 p.m. She said the facility's policy and procedures for diabetes management did not define when to contact the physician. She said it was up to physicians to place an order and specify when they should be contacted. She said the nursing staff followed facility protocol and physician orders. She said Resident #1's order read to notify physicians only if blood sugar levels were below 70 mg/dl or above 400 mg/dl. VI. Facility follow-upOn 11/29/23 the facility submitted a letter signed by a primary care physician (PCP) for Resident #1. The letter read: "On the dates of October 25, 26 and 27, 2023, regarding (Resident #1), the nurses followed proper protocol and standing orders for reporting blood sugars with the parameters of calling MD for blood sugar less than 70 or greater than 400."-However, Resident #1 was hospitalized for hyperglycemia on 10/18/23 and two weeks later was hospitalized on 11/2/23 due to the facility's failure to continue to monitor the resident's blood glucose levels.

A survey prompted by complaint #CO34439 was completed 11/28/23 to 11/29/23. One deficiency was cited.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one Resident (#1) out of three residents reviewed for blood sugar managements out of a total sample of six residents. Resident #1, who had a diagnosis of diabetes and was on diabetic medication, did not have his blood glucose levels consistently monitored by the facility. Resident #1 was sent to the hospital on 10/18/23 when he was lethargic with a diagnosis of hyperglycemia. For three days, 10/25/23 to 10/27/23, Resident #1 had high blood glucose readings above 300 milligrams per deciliter (mg/dl), with normal being 70-130 mg/dl. The facility staff failed to monitor the resident for signs and symptoms of high glucose levels. Two weeks later, on 11/2/23, the resident was sent to the hospital with hyperglycemia. Findings include:I. Professional reference The Mayo clinic Hyperglycemia in Diabetes, revised on August 2022, retrieved on 11/30/23 at https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631, read in pertinent part,"For many people who have diabetes, the American Diabetes Association generally recommends the following target blood sugar levels:Between 80 and 130 mg/dL before mealsLess than 180 mg/dL two hours after meals."If the blood sugar level is 240 mg/dL or above, use a urine ketones test kit. If the urine test is positive, the body may have started making the changes that can lead to diabetic ketoacidosis. It's important to treat hyperglycemia (high blood sugar level). If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart."Symptoms of hyperglycemia develop slowly over several days or weeks. The longer blood sugar levels stay high, the more serious symptoms may become. If hyperglycemia isn't treated, it can cause toxic acids, called ketones, to build up in the blood and urine. This condition is called ketoacidosis. Symptoms include: fruity-smelling breath, dry mouth, abdominal pain, nausea and vomiting, shortness of breath, confusion, and loss of consciousness."II. Facility policy and proceduresThe Diabetic Management policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 11/29/23. The policy read: "Diabetic Management involves both preventative measures and treatment of complications. From admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurately related to blood glucose monitoring and anti-diabetic agents. "Blood glucose orders should include parameters to follow in communicating with the physician. To ensure appropriate nutritional orders are in place (enteral nutrition, diet, supplements, snacks). To ensure preventative skin care measures are in place. To ensure monitoring for signs and symptoms of hyperglycemia or hypoglycemia episodes."Routine Care:Blood glucose values are taken per the physician order. Antidiabetic agents (insulin or oral antidiabetic agents) are administered per physician order. Sliding Scale insulin is administered per physician orders. Diabetic foot care is provided during daily routine care. Residents are monitored for signs and symptoms of complications. Any identified complication is reported timely to the physician."III. Resident statusResident #1, age 90, was admitted on 12/4/19. According to the November 2023 computerized physician orders (CPO), diagnoses included diabetes, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), aortic aneurysm (an excessive enlargement of an artery), emphysema (damage of lung tissue) and Alzheimer's dementia. A 11/14/23 facility assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required substantial/maximal assistance with meals and was dependent on staff for other activities of daily living (ADLs). IV. Record ReviewThe care plan for diabetes, initiated on 4/26/23 and revised on 11/13/23, revealed the resident had diabetes. Interventions included to check skin routinely, administer medication as ordered by physician, monitor and document any signs of hypo or hyperglycemia. -Resident #1's care plan did not mention specific treatment that the resident was receiving for diabetes. The medical administration record (MAR) for November 2023 revealed the resident was receiving the following medication:Glipizide 5 milligrams (mg), one tablet every day for diabetes; and,Fasting blood sugars to be taken as needed for signs and symptoms of hypoglycemia and hyperglycemia, if blood sugar is 70 mg/dl or below or 400 mg/dl or above, call a physician. The order was initiated on 4/26/23.-Residents fasting blood sugar levels were not checked (the MAR was not signed) as needed in October and November 2023. A. Hospitalization on 10/18/23On 10/12/23, a nurse progress note documented the resident was lethargic. His vital signs were within normal limits. -The blood glucose level was not checked at the time. On 10/15/23 a nurse progress note documented that the resident refused all meals and "was sleeping and would not fully wake up." -The blood glucose level was not checked at the time. On 10/17/ 23 the resident was assessed by nurse practitioner (NP) #1 due to "nursing report decreased verbalizations, increased time in bed, decreased meal intake." At the time of the visit NP #1 documented "patient with no verbal response or interactions with provider or staff."The note read resident's diabetes was managed with oral medication and blood sugars were no longer monitored. Regarding fatigue, it was documented: "Frail elderly gentleman, with history of recurrent pneumonia. Persistent fatigue most likely secondary to advanced age."-The blood glucose level was not checked at that time of the visit. On 10/18/23 at 6:06 p.m. a nurse progress note documented "resident having increased lethargy, abnormal lung sounds, and decreased level of consciousness." Provider on call was contacted, chest x-ray and labs were ordered. -The note did not include the resident's vital signs and blood sugar levels.-At 8:48 p.m. the resident was assessed by a next shift nurse who documented the resident's vital signs within normal limits and blood sugar of 500 mg/dl. "Resident's family requested hospitalization." The emergency medical technician's report documented the resident was unconscious in bed, minimally responsive to pain. Resident #1's family was on scene and requested transport to the hospital. The hospital admission summary dated 10/18/23 revealed the chief complaint was altered mental status. The primary reason for admission was encephalopathy (damage or disease that affects the brain). The resident was unresponsive and was reacting only to painful stimuli. He was admitted to the intensive care unit and started on sliding scale insulin. During the hospital stay the resident was diagnosed with sepsis (life threatening complication from infection), encephalopathy and hyperglycemia (high blood sugar) and acute kidney insufficiency with dehydration. On 10/25/23 the resident was discharged back to the nursing facility. Discharge orders did not include any changes to the diabetes treatment. The resident started back on Glipizide, an oral medication for diabetes. -Upon readmission blood sugar checks were not initiated. B. Hospitalization on 11/2/23At the time of admission to the nursing facility on 10/25/23 the resident was alert and oriented. The progress note on 10/25/23 documented that the resident's daughter requested blood sugar checks to be initiated for the resident. The oncall provider was contacted by the nursing staff and blood sugar checks were initiated four times a day for two days. -The order did not specify when and if a physician should be contacted. According to the October 2023 MAR, the resident's blood sugars were consistently above normal range: On 10/25/23 the blood sugar was 232 mg/dl;On 10/26/23 it was 238, 276, 378, 382 mg/dl; and, On 10/27/23 it was 294, 390 and 365 mg/dl. On 10/27/23 blood sugar checks were discontinued.-The review of progress notes from 10/25/23 to 10/27/23 revealed no evidence that abnormal blood sugar levels were reported to the physician. A progress note on 10/30/23 documented "patient very sleepy today, was too tired to eat breakfast. Lunch he ate but needed to be woken up continuously throughout the meal."On 10/31/23 the resident was assessed by NP #1. The note mentioned that the resident's diabetes was managed with Glipizide and daily blood sugars were no longer monitored. -There was no mention regarding the resident's elevated blood sugars between 10/25/23 and 10/27/23. At the time of the assessment, the resident's blood sugar was not checked. The nurse progress note on 10/31/23 documented nursing staff reached out to NP #1 to report that the resident was "not getting up" and "non arousable for meals." NP #1's response was she would reach out to the family "to discuss further options."On 11/1/23 the resident was assessed by NP #1. The note mentioned the resident's diabetes was managed with Glipizide and daily blood sugars were no longer monitored and persistent fatigue most likely secondary to advanced age. The interdisciplinary team (IDT) note on 11/2/23 documented the resident was reviewed due to recent hospitalization on 10/25/23. The fasting blood sugar levels for the resident were running between 100 and 400 mg/dl and he was no longer on blood sugar checks per doctor's order. On 11/2/23 at 2:15 the nurse progress note revealed "EMTs (emergency medical technicians) are here to transfer the resident to the emergency room." The transfer was related to altered mental status and hyperglycemia (increased blood sugar). Resident's blood sugar level was documented by EMTs as 590 mg/dl." The hospital admission note dated 11/2/23 read: "Patient presents with worsening generalized weakness, hyperglycemia and increased oxygen requirement. He feels somewhat short of breath but denies chest pain. He has rhonchorous (abnormal) lung sounds. Remainder of his exam is only significant for clinical dehydration. He is hyperglycemic without evidence of DKA (diabetic ketoacidosis). He does have an acute kidney injury, likely from dehydration. Chest x-ray does not show significant infiltrate. He has received intravenous (IV) insulin and IV fluids. He has continued pneumonia with elevated lactate, hyperglycemia without DKA and dehydration with an acute kidney injury. I feel that his elevated lactate is more due to his dehydration and hyperglycemia. I do not feel that he is septic. He is not tachycardic (fast heart rate) and not febrile (fever)."Resident #1 came back to the nursing facility on 11/8/23, after six days of hospitalization. He was started on sliding scale insulin and blood sugar checks. V. Staff interviewsNP #1 was interviewed on 11/29/23 at approximately 1:00 p.m. She said she could not recall in detail- Resident's #1 hospitalizations for the last couple of months. She reviewed her notes and did not locate any information regarding Resident#1's blood sugar levels between 10/25/23 and 10/27/23. She said she did not review the October 2023 MAR and was not aware that the resident's blood sugar levels were high at that time. Licensed practical nurse (LPN) #2 was interviewed on 11/29/23 at 2:30 p.m. She said signs and symptoms of high blood sugar included thirst and changes in level of consciousness. She said residents who were diabetic, but not on insulin, should always be monitored for signs and symptoms of high blood sugar. She said blood sugar levels in the range of 300 mg/dl should be reported to the physician as it was an abnormally high level. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:50 p.m. He said Resident #1 had an as needed order for blood sugar checks to be completed. He said the order read the physician should only be notified if blood sugar levels were above 400 mg/dl. The director of nursing (DON) was interviewed in the presence of the nursing home administrator (NHA) on 11/29/23 at 3:45 p.m. She said the facility's policy and procedures for diabetes management did not define when to contact the physician. She said it was up to physicians to place an order and specify when they should be contacted. She said the nursing staff followed facility protocol and physician orders. She said Resident #1's order read to notify physicians only if blood sugar levels were below 70 mg/dl or above 400 mg/dl. VI. Facility follow-upOn 11/29/23 the facility submitted a letter signed by a primary care physician (PCP) for Resident #1. The letter read: "On the dates of October 25, 26 and 27, 2023, regarding (Resident #1), the nurses followed proper protocol and standing orders for reporting blood sugars with the parameters of calling MD for blood sugar less than 70 or greater than 400."-However, Resident #1 was hospitalized for hyperglycemia on 10/18/23 and two weeks later was hospitalized on 11/2/23 due to the facility's failure to continue to monitor the resident's blood glucose levels.

A complaint survey, prompted by #CO33906 and #CO33925 was completed on 11/28/23-11/29/23. One deficiency was cited.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one (#3) of three residents out of six sample residents. Specifically, the facility failed to ensure:-Licensed practical nurse (LPN) #1 followed appropriate infection control procedures during wound care for Resident #3; and, -Certified nurse aide (CNA) #1 followed appropriate infection control procedures during incontinence care for Resident #3. Findings include:A. Residents #3 statusResident #3, age 83, was admitted on 9/6/23. According to the January 2023 computerized physician orders (CPO), diagnosis included sepsis and enterocolitis due to clostridium difficile (C-diff). The 9/11/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance of two or more people with bed mobility, transfers, toileting and personal hygiene. The resident was always incontinent of bowel and bladder. The resident was on contact isolation precautions for C-diff, and an isolation cart with protective personal equipment (PPE) was observed next to the room. B. Incontinence care observationOn 11/28/23 at 11:36 a.m. CNA #1 provided incontinence care to Resident #3. She cleaned the resident's perianal area after the bowel movement. After she completed cleaning the skin, she disposed of the soiled briefs and wipes. She did not change her gloves and proceeded with the application of a clean brief and lotion. She repositioned the resident and arranged her personal items on the table wearing the same gloves. C. Wound care observationOn 11/28/23 at 11:53 a.m. LPN #1 was observed completing a wound dressing change for Resident #3. LPN #1 brought a pair of scissors and a marker to the room. She placed the marker on the resident's bed side table after she labeled the wound care dressing. The scissors were used to cut the resident's dressing and were set on the resident's bed. After the dressing was changed, LPN #1 picked up the scissors and marker and placed both into her scrub shirt pocket under the isolation gown she was wearing. She washed her hands and exited the room. -LPN #1 did not sanitize the scissors or the marker before placing them in her pocket. D. Staff interviewsCNA #1 was interviewed on 11/28/23 at 12:20 p.m. She said she was taught to change her gloves only after she completed incontinence care. She said she was not aware that she was supposed to change her gloves after she cleaned the resident's skin and before handling a clean brief and applying lotion. LPN #1 was interviewed on 11/28/23 at 12:30 p.m. She said she placed the scissors and marker in her pocket before she left the room. After that she said she cleaned both with chlorine wipes and placed them back into her pocket. She said it was the way she did things and she had no other means of carrying the marker and scissors. The director of nursing (DON) was interviewed on 11/28/19 at 3:57 p.m. She said her expectations for nurses and CNAs were to follow proper clean technique during wound and incontinence care. Specifically, she said gloves should be changed after incontinence care and before touching clean briefs and resident's personal items. Regarding the wound care she said scissors and markers should not be carried in pockets. Pockets are not considered a clean environment and could result in cross contamination. All items that were brought to the resident's room should have been cleaned after use and stored at the nurses station or the resident's room if appropriate.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

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 04/17/2023 and 04/23/2023, 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 complaint survey, prompted by #CO31152 was conducted on 3/8/22 to 3/14/23. One deficiency was cited.

Based record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#3) of six out of six sample residents. Specifically, the facility staff failed to investigate an unwitnessed fall that Resident #3 said it occurred in her room that resulted in bruising. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 3/8/23 to 3/14/23, resulting in the deficiency being cited as past noncompliance with a correction date of 3/6/23. There were no additional issues identified with resident falls. I. Facility policies and proceduresThe Fall Management policy, revised January 2023, was provided by the nursing home administrator (NHA) on 3/9/23 at 10:14 a.m. The policy revealed the facility assisted each resident in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, assistive devices and/or functional programs; as appropriate, to minimize the risk for falls. The interdisciplinary team (IDT) evaluated each resident's fall risks and a care plan was developed with implementation, based on this evaluation, with ongoing review. A fall was described as an event in which an individual unintentionally came to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (a resident pushes another resident). The event might be witnessed, reported, or presumed when a resident was found on the floor or ground, and could occur anywhere. When a fall occurred, the resident would be assessed for injury by a nurse. The nurse would enter the event information into risk management. complete a post fall assessment and initiate the Interdisciplinary Post Fall Review UDA (used defined assessment). The nurse would communicate the resident's fall to the attending physician, the resident's representative and documents in the medical record. The nurse would communicate the resident's fall to the IDT and initiate interventions to reduce the potential of additional falls. The IDT would review all resident falls within 24-72 hours to evaluate circumstances and probable cause for the fall. The resident's care plan would be reviewed and/or revised as indicated. Fall trending and analysis information would be reported to the Quality Assurance and Performance Improvement (QAPI) Committee. In the event a resident had a fall and it was determined they hit their head (the fall was witnessed, it was obvious there was a head injury, or the patient could verbalize they hit their head), or it could not be determined if they hit their head ( the fall was unwitnessed or the resident could not verbalize if they hit their head), the nurse would initiate the following actions: all items that were listed under Fall Event above are completed and neurological assessments would be completed and documented per instructions. II. Performance improvement project (PIP)/facility's actions The PIP for falls, initiated on 2/20/23, was provided by the NHA on 3/9/23 at 10:14 a.m. The opportunity for improvement revealed the facility staff were to review falls in a timely manner, conduct registered nurse (RN) assessments, neurological assessments, post fall assessments and have immediate interventions in place. The IDT would review the fall within 24-72 hours for recommendations and care plan updates. The PIP also revealed that residents' care plans were vague and not resident specific. The specific, measurable, achievable, relevant and time bound (SMART) goal was for all falls there would be a situation, background, assessment and recommendation (SBAR), RN assessment, neurological assessments if the resident's head was involved or the resident had an unwitnessed fall including falls that were reported by the resident, post fall assessment, Morse Fall Scale, IDT review and progress note within 24-72 hours, and a care plan update. Care plans would be comprehensive and include resident specific interventions as appropriate. The PIP root cause was staff turnover and the high use of agency staffing. PIP obstacles were staff education and the high changeover of staff. The projected outcome for the PIP was for all falls to be reviewed in a timely manner, RN assessments, neurological assessments, post fall assessments and immediate interventions would be in place to keep residents safe. The IDT would review falls within 24-72 hours with care plans updated and further recommendations.-Start date of 2/21/23: Audit of all residents with falls in the last 60 days to ensure RN assessments, neurological assessments, post fall assessments, immediate interventions, IDT review and care plan revisions have been completed. Actual completion date was 2/24/23.-Start date of 2/27/23: Audit of all new admissions in the last 90 days to ensure preventative fall measures were in place and a Morse Fall Scale was completed. Actual completion date was 3/3/23.-Start date of 2/27/23: Audit of all residents at risk for falls for comprehensive care plan for fall prevention. Care plans would include risk act factors such as seizures. Actual completion date was 3/6/23.-Start date of 2/21/23: Educate IDT to review all falls within 24-72 hours that must include complete SBAR, RN assessment, post fall review, Morse Fall Scale, immediate new intervention by a licensed nurse, IDT note of review, new recommendations, and care plans updated. Actual completion date was 2/21/23.-Start date of 2/21/23: Educate licensed nurses to complete SBAR, RN assessment, neurological assessments if the resident's head was involvement, or an unwitnessed including falls reported by residents, Morse Fall Scale, and implement immediate new intervention until IDT reviewed for further recommendations, such as a licensed nurse could implement, increased rounding, ensuring call lights in reach, add mat to floor, educating the resident, pacing sign to use call light etc. Actual completion date was 2/28/23.-Start date of 2/21/23: educate licensed nurses to implement fall precautions for new admission at risk. Preadmission, review referral information for fall risk, implement fall plan on arrival. Actual completion date was 2/28/23.-Start date of 2/21/23: Falls protocol in agency book. Actual completion date was 3/2/23.-Start date of 2/21/23: Evaluate effectiveness in monthly QAPI (quality assurance and performace improvement) Meeting. Nurse managers will do daily checks for RN assessments, neurological assessments, post fall assessments and immediate interventions for all current resident and future admission falls. Target date to be determined; status ongoing.-Start date of 2/21/23: Modify Action Items in monthly QAPI meeting based on effectiveness. Target date to be determined; status ongoing. III. Resident #3A. Resident statusResident #3, age 59, was admitted on 11/9/22 and was discharged on 1/22/23 to another facility. According to the January 2023 computerized physician orders, pertinent diagnoses included altered mental status, metabolic encephalopathy (problem in the brain), muscle weakness, repeated falls, epilepsy, conversion disorder with seizures or convulsions. The 1/6/23 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview of mental status (BIMS) score of 11 out of 15. The resident did not have any behaviors. The resident required staff supervision for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. B. Record reviewThe care plan for falls related to gait, balance problems, and unaware of safety needs was initiated on 2/20/23. The interventions were for staff to anticipate and meet the resident's needs; ensure the resident's call light was within reach, and encourage the resident to use the call light for assistance as needed. Staff were to respond promptly for all requests for assistance and follow the facility fall protocols. -This care plan did not include that staff were to monitor resident's skin for excessive bruising. The plan also did not include that the resident would fall and would not tell staff that she had fallen in a timely manner. The care plan for an actual fall with related poor balance and unsteady gait was initiated on 2/20/23. Some of the interventions were to continue to work with therapy on balance and strengthening. Therapy would continue to work with the resident for safe functional ability. Staff would complete neurological assessments per protocol and physician orders. -The plan also did not include that the resident would fall and would not tell staff that she had fallen in a timely manner. A Weekly Head to Toe Skin Check, dated 12/30/22 at 3:50 p.m., was performed by the director of nursing (DON). The skin check revealed new and existing bruises to the right shoulder measuring 1.5 centimeters (cm) by 1.0 cm; left buttock measuring 5 cm: right trochanter measuring 18 cm by 3 cm; and left knee (no measurements). The left buttock was circular in size and the left knee bruise was very faded. The bruise to the left arm was fading and was approximately 5 cm by 2 cm. The bruise to the right shoulder was fading and old. An Evaluation and Management encounter note dated 12/30/22 by a nurse practitioner (NP) revealed the DON reported that the resident had a bruise on her hip with some pain. The resident tended to bump into things and had an unsteady gait. The resident did have a history of falling, was a poor historian and was very forgetful. The resident had repeated (two) falls since her admission and now had some bruising and pain on the hip. The resident did not remember how the bruising occurred. The resident answered questions to the best of her ability; but she was repetitive in answers, had poor safety awareness and wandered with the use of a walker. The NP wrote she was unsure of the resident's ability to give accurate information due to conflicting statements she made. The assessment and plan revealed the resident had repeated falls. The resident was to continue with physical/occupational therapies and safety measures per facility protocol. The resident had a history of falling and had some bruising on the hip. The NP ordered x-rays to evaluate the hip and monitor for improvement. This encounter was electronically signed on 1/12/23 at 9:59 p.m. The physician order dated 12/30/22 at 4:01 p.m., revealed to obtain a right hip x-ray due to the resident's complaint of pain and bruising. The SBAR dated 12/30/22 at 5:06 p.m., revealed the resident had a bruise to the right hip starting on 12/30/22. A right hip x-ray was to be taken as ordered. The resident was unsteady on her feet and tremulous (shaking). The resident bumped into walls and other things. The resident's daughter said the resident frequently fell at home. The daughter believed the resident might have fallen or bumped into something like a door or her walker. A nurse note by a licensed practical nurse (LPN) dated 12/31/22 at 12:51 p.m., revealed the resident's skin was assessed. The resident had bruises that had already been reported and no new bruising was observed. Staff would continue to monitor and educate the resident to walk slower and try not to bump into things. A Morse Fall Scale assessment was completed on 1/1/23 at 6:00 p.m. The assessment revealed the resident had a score of 80 or was a high fall risk. The resident had a history of falling and required a cane or walker for ambulation. The resident exhibited a weak gait and was forgetful of her own safety limits. An Acute Visit note dated 1/4/23 by a NP revealed the 1/12/23 x-rays of the right hip revealed no acute fractures, dislocations or osseous abnormalities. The resident appeared to be weight bearing without limping or wincing. The resident has not had any seizures since her admission. The resident had repeated falls, was to continue with physical/occupational therapies and safety measures per facility protocol. The resident had a history of falling and had some bruising on the hip. The NP ordered x-rays of the hip to evaluate, reviewed the results with the resident and nursing: there were no acute findings. The resident was to continue therapies and monitored for improvement. This was electronically signed 1/12/23 at 10:20 p.m. A progress note dated 1/5/23 at 9:42 p.m., by the assistant director of nursing (ADON) revealed IDT reviewed the risk plans of care for the resident. The resident was alert with confusion. The resident was a high risk for falls with a score of 80 and had two falls since admission. The resident had no current skin issues. The SBAR dated 1/8/23 at 6:00 p.m., by the DON revealed bruising to the resident's pubic area that started on 1/8/23. The resident reported that she fell out of bed and this was the cause of the bruise. The resident was a frequent faller, wandered about the facility, and kept her room door closed. The resident was able to get up from the floor by herself. Staff were to monitor the resident's whereabouts and attempt to keep the resident's room door open to frequently observe the resident. The resident had a bruise to the right hip and lateral. The bruise was scattered and appeared to be blood that traveled from the hip. The bruising to the hip was almost healed. The bruise was observed with a certified nurse aide (CNA) and the resident's daughter. Nurse note dated 1/8/23 at 6:10 p.m., by registered nurse (RN) #1, revealed the resident's daughter was in the facility and called this nurse to the resident's room due to a large purple bruise with swelling to the resident's pubic bone area. The CNAs told her that the resident had a shower yesterday and the bruise was not present. The resident said the bruise occurred when she fell out of her bed the other day. The resident said a doctor had come in and checked her out. The resident was adamant that she fell out of bed. The nurse manager on call was notified. Physician's order dated 1/9/23 at 2:03 p.m., revealed to obtain an x-ray of the resident's pelvis related to pain and bruising. Nurse note dated 1/10/23 at 8:54 a.m., by the DON revealed the pelvic x-ray done 1/9/23 was negative for fracture.-Review of the resident's record did not reveal a fall investigation when the resident had indicated she had fallen on 1/8/23. Evaluation and management note dated 1/10/23 by NP revealed the resident had a reduction in cognition, increased confusion, wandering and a reduction in activities of daily living. Resident had a recent bruise on a hip and did not remember how it occurred. The assessment and plan revealed the resident had baseline cognitive deficits that were consistent with likely underlying dementia. Due to the resident's wandering, falls and poor safety awareness; the resident would qualify for a secure dementia care unit for her safety. This note was electronically signed 1/12/23 at 11:04 p.m. On 1/11/23 at 4:15 a.m., the resident was on 15-minute checks that ended on 1/18/23 at 7:44 a.m. A Weekly Head to Toe Skin check dated 1/13/23 at 6:04 p.m., by the DON revealed existing bruises, bruising to the right hip and the bruise was flowing downward toward the symphysis pubis. The groin and right trochanter (hip) had no measurements and was noted as old bruises. Nurse note dated 1/22/23 at 1:31 p.m. by RN #1 revealed the resident complained of being dizzy, had slow speech and was unable to sit upright or stand. The resident's pupils were equal and reactive. The resident had equal hand grips. The resident said she tried to get up during the night, fell backward and hit her head on the wall. No bruising was noted. This was the first time the resident had mentioned she had a fall last night. The resident said she had not told any staff about the fall. While this writer was on the to a physician, the resident's daughter came out of the resident's room and complained the resident had right arm numbness and appeared to have a left facialdroop. The physician ordered the resident to be sent to the emergency department by ambulance for evaluation. A call was placed to 911 and the resident left the facility at 1:00 p.m. The daughter accompanied the resident. The ADON was notified. Hospital Encounter Notes dated 1/22/23 1:27 p.m., revealed the resident had neurological disorders of dementia, altered mental status and a seizure disorder. The notes revealed negative x-rays for the pelvis and bilateral femurs. The resident had significant bruising over the thighs and hips. The resident had tenderness with palpation of the right hip and pubic symphysis on exam with known ecchymosis to the pelvic prior to admission. The resident's abdomen was soft and non-distended, and moderately tender to palpation at the suprapubic region with overlying ecchymosis. The resident was tender to palpation to the pubic symphysis, right hip with no lower extremity edema, non-tender and symmetrical. There was ecchymosis (discoloration due to bleeding typically a bruise) to the introits (entrance) in a ring like fashion without any superior tracking to the bruise at the pelvic bone. When asked about the pelvic bruising the resident's daughter she said the resident fell. IV. Additional fall documentsThe NHA provided a typed/signed document dated 1/8/23 (not timed) that was not included in the resident's medical record. The document revealed the NHA had interviewed the resident regarding the bruise to the pubic area and the resident said it was the result of her falling out of bed. The resident said she fell out of bed last night or the night before. The resident said she was not fearful or scared of any staff or residents. She said she was not injured by anyone and that she liked residing in the facility. The resident had no changes in mood or behavior. The resident consistently said pubic bruise was caused by her falling out of bed. The NHA wrote that the resident's daughter said her mother had a history of falling and getting herself up from off the floor. The daughter said when she took care of her mother at home, she would fall and not say anything, bruising would be observed and then the resident would say that she had fallen. The NHA wrote that the daughter said she felt this pubic bruising was from a fall out of the bed. The interventions were to monitor the residents' whereabouts, encourage the resident to keep her room door open so she can be observed for falls (resident liked to keep the door closed). The conclusion revealed the resident had a history of falls where she had gotten herself up and not reported the fall. There was no allegation of abuse made by the resident toward another person, the resident consistently said she fell out of bed, which caused the bruising. The resident had no change in mood or behavior that was observed by staff or the resident's daughter. There was no suspicion of abuse to the resident. Staff would continue to monitor the resident. The DON provided a typed document regarding interventions for falls and bruising for this resident dated 3/14/23 at 10:14 a.m. The document revealed the resident's metal bed edges were padded with foam on 1/8/23. The resident was placed on 15-minute checks from 1/11/23 to 1/18/23. The resident was encouraged to keep her room door open in order to allow staff to observe. The resident's room was close to the nurse's station. The staff performed frequent staff rounding to ensure the resident was safe. The staff encouraged the resident to use a walker at all times in and out of her room. The resident was encouraged to slow down when ambulating in order to pay attention to where she was going. The staff performed care in pairs with the resident. Therapy staff worked with the resident for strengthening, balance, gait and transfers. V. Staff interviewsCNA #1 was interviewed on 3/13/23 at 3:22 p.m. She said the resident's daughter came to the facility (Wednesday) and she was asked to accompany the daughter into the resident's room because she wanted to show her something. She said herself, the resident and the resident's daughter went into the bathroom and the resident pulled down her pants. The resident had new bruising to the pubic area that was dark purple and black red in color. The area was slightly swollen. The CNA said the resident said she did not know how this happened but she thought she had fallen. She said the resident did have an old bruise to her right hip and it was yellow in color. She said on the Saturday prior to this Wednesday, the pubic bruise was not there. She said the resident did not make any statements that she had been hit/abused nor that she was afraid of any staff or residents. The CNA said the resident was not cognitive enough to make her own decisions. She said the resident called her by the name of an old high school friend and not by her real name. She said the resident sometimes got angry at CNAs that she did not like and did not want them to provide care to her. She said the resident always bumped into things and this also occurred when she used her walker. She said the resident probably had falls, especially in her room, that she did let anyone know had occurred. She said some of the interventions to help prevent falls for this resident were to encourage her to keep the door to her room open, have her sit near the nurse's station, use her walker at all times during ambulation (sometimes she forgot), foam piping (noodles) on the metal frame of the bed, and the use of a soft fabric recliner in her room. She said the daughter told her that the resident bruised easily. Licensed practical nurse (LPN) #1 was interviewed on 3/13/23 at 3:38 p.m. She said she saw the bruise on the resident's right hip on a Monday. She said the bruise looked new and purple. She said the pubic bruise was not on the previous skin check. She said she did a skin check on the following Monday (one week later) and there was a bruise to the pubic area (purple and starting to change colors). She said she was not told how it occurred. She said it might have been blood draining from the other bruises to this area. She said all of the other bruises were fading. She said the resident consistently ran into things. She said the resident was fast and impulsive in her actions. She said the resident did not say any staff or residents had hit her. She said for interventions the staff encouraged her to keep the door to her room open. She said at times the resident liked to keep the door closed. The staff also encouraged her to keep using her walker, walk slower, stay close to the nurse's station and the facility placed foam noodles on the bedframe and footboard. She said if the resident fell, she might or might not tell the staff. She said the daughter told her that the resident bruised easily. RN #1 was interviewed on 3/14/23 at 8:16 a.m. She said the daughter found the bruise and called her into the resident's room. She said the resident had a bruise on the pubic bone and it was dark purple and the area did not appear to be swollen. She said the hip bruise was fading and had a yellow-green color. She said the resident said she fell off the bed and was unable to remember when this occurred. She said the resident did not make any statements that anyone had hurt her. She said there was a CNA that she did not like and made statements at times that this CNA hit her (the facility had conducted two separate abuse investigations when the resident made two separate statements about this CNA and both of them were unsubstantiated). She said the resident would often make statements that were not true. She said the resident had the ability to get herself up from off the floor and often bumped into stuff. She said some of the fall interventions for this resident were to remind the resident to use her front wheeled walker (she forgot at times), encourage the resident to keep her room door open, encourage the resident not to sit on the floor (she liked to sit on the floor) and implement 15-minute checks as necessary. She said the resident liked to stand up at the foot of the bed, retrieve items from her dresser, and then lean forward (bent at the pubic area, over the footboard) as she placed the items on the bed. She said this might have caused the pubic bruise. The account manager (AM) was interviewed on 3/14/23 at 11:55 a.m. She said she was the resident's ambassador (advocate) and spoke with the resident almost on a daily basis. She said to her knowledge the resident had never mentioned any staff or resident was abusive to her. She said the resident never mentioned that she had any bruising. She said the resident was off balance at times when she walked and at times did not use her walker. She said the resident did not tell her if/or when she fell. The social services director (SSD) and the social services assistant (SSA) were interviewed on 3/14/23 at 12:06 p.m. They said they talked with the resident almost daily when passing down the hallways. They said the resident never mentioned anything about any staff or residents abusing her. They said the resident never mentioned anything regarding bruising. They said the resident did have a few falls in the facility. They said the resident used a front wheeled walker with a seat. They said when they observed the resident, she was always using the walker. They said the resident walked briskly and was focused on her walking and not her surroundings. They said when they talked with the resident's daughter, she never mentioned anything about falls or bruising. The NHA was interviewed on 3/14/23 at 9:00 a.m. He said there were no concern or complaint forms from the resident or the family regarding abuse, bruising (especially in the pubic area) or falls. He said neither the hospital nor the police had contacted him regarding abuse or bruising of the resident. He said the facility had completed two investigations regarding the resident's allegation of staff hitting her. He said for each allegation, there were two staff members present (care in pairs), no evidence of abuse and both were unsubstantiated. He said the resident did have a bruise to the pubic area and had made a statement that she had fallen. The NHA said the resident had the ability to get herself up from the floor without staff assistance. The NHA said there were no care plans for the bruising, bumping into walls (things) nor about telling staff she had fallen in a timely manner after a fall. On 3/14/23 at 1:10 p.m., an interview was conducted with the NHA, DON, director of clinical Services (DCS) and the director of operations (DOO). The DON said the bruising to the pubic area was scattered and not one large bruise. The DON said there were no measurements of the bruising due to the scattering. The DON said there was no large bruise to this area and the area was not swollen. The DON said the daughter brought the bruise to the pubic area to the attention of RN #1. The DON said she observed the bruising to the pubic area and then wrote the SBAR. The DON said the resident told her that she fell out of bed and this was the cause of the bruise. The DON said the resident had dementia and did not say when she fell out of bed. The DON said the RN that wrote the note on 1/8/23 at 6:10 p.m., did not specify the time she and the daughter went into the room and this might be the reason her SBAR was timed before the nurse note. The DSC agreed there was no documentation in the NP notes of bruising in the pubic area. The DCS said the resident's multiple bruises were measured on the Weekly Head to Toe Skin Check dated 12/30/22 at 3:50 p.m., by the DON in the presence of the resident's daughter. The DCS said there were additional skin checks that were completed on the resident, however there were no additional measurements for those bruises. The DCS said there was no documentation that the bruises worsened. The DCS said that there was no clinical rationale to keep measuring the bruises. The DCS said it was believed that the bruising was due to the resident bumping into things. The DCS said it was thought that the bruising of the hip had traveled to the pubic area. The DCS said the facility had ruled out abuse by interviewing the resident and no investigation had been conducted. The DCS said the resident was not fearful and had no concerns with staff. The DCS said since there was no investigation, the Ombudsman nor the police had been contacted. The DCS said since the resident told them how the pubic bruise had occurred from a fall out of bed, they did not consider it a bruise of unknown origin. The DCS said after the resident said she had fallen out of bed, the facility did not do a post fall assessment of the resident, neurological assessments, complete a SBAR of the fall, complete Morse Fall Scale, IDT review nor complete an incident report. The DCS said the facility had developed a performance improvement project (PIP) for falls. The DCS said there were no specific care plans for the resident walking into things or for not telling staff of her falls in a timely manner. The DCS said the resident was at risk for falls and this statement encompassed the safety concerns for the resident. The DCS said the resident's forgetfulness encompassed the resident not telling staff of her falling in a timely manner. The DCS said the was impulsive and the resident's fall interventions were to encourage the resident to walk slower in the facility, place foam padding on the metal bed rails, encourage the resident to keep her room door open, encourage her to use her walker in her room, encourage the resident to use her walker in the hallways, have the resident's room close to the nurse's station, have physical/occupational therapies, frequent staff rounding and placed the resident on 15-minute checks for seven days. The DCS said the daughter had told the facility that the resident had fallen at home, gotten herself up from the floor and did not tell her about the fall at that time. The DCS said the resident's fall interventions were not listed on her care plans and this was part of the PIP.

A revisit survey was completed on 1/9/23 for all previous deficiencies cited on 11/17/22. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/9/23 for all previous deficiencies cited on 11/17/22. The facility is in compliance with all regulations surveyed.