THORNTON CARE CENTER

A complaint survey, prompted by #CO2564182, #CO2588957, #CO2593641, Incident #2592961 and Incident #2593007 was conducted on 8/18/25 to 9/2/25. Three deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure three (#10, #11 and #14) of 14 residents reviewed for grievances were provided prompt efforts by the facility to resolve a grievance out of 14 sample residents. Specifically, the facility failed to respond to grievances from Resident #10, Resident #11 and Resident #14 when they reported to facility staff that room temperatures were uncomfortable and hot. Findings include:I. Facility policy and procedureThe Resident Rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/18/25 at 1:45p.m. It read in pertinent part,“Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the right to voice grievances and have the facility respond to the grievances.”II. ObservationsOn 8/19/25 at 12:45 the following temperatures were taken throughout the facility:On the west unit: -Room #14, was 81.1 degrees Fahrenheit (F).-Room #17 was 83.7 degrees F.-The hallway common area was 84.4 degrees F.-The hallway was 82.2 degrees F.-Room #26 was 88.9 degrees F.The main entryway was 81.7 degrees F.The West unit had two water coolers in the hallway. One water cooler was off and the water cooler at the end of the hallway was blowing warm air. Five residents sat in wheelchairs in the common area, where the room temperature was 84.4 degrees F.On the east unit:-Room #50 was 87.4 degrees F. III. Resident interviewsResident #11 and his representative were interviewed together on 8/19/25 at 12:55 p.m. Resident #11 said his room was uncomfortably warm, even with a floor fan. He said the floor fan did not help to keep his room cool and he had to sit directly in front of it to stay cool. The resident's representative said the room felt too warm. Resident #11 said he had complained about hot room temperatures to staff and said he felt that staff did not care. Resident #14 was interviewed on 8/19/25 at 5:10 p.m. Resident #14 said his room and hallways were very warm during the summer days. Resident #14 said his room could not be cooled because the air coolers were located at opposite ends of the hallway and the cool air did not effectively reach his room. He said he had a fan in his room, but it was small and only moved the hot air around his room. Resident #10 was interviewed on 8/20/25 at 9:45 a.m. Resident #10 said her room was hot and the thermometer hanging on her inside wall frequently registered temperatures in the upper 80’s and up to 94 degrees F. Resident #10 said she had reported her concerns about room temperatures to facility staff and management several times and the room temperature had remained uncomfortable and hot. She said her room was located at the end of a hallway and far away from the water coolers. IV. Record reviewA request for grievances regarding the temperature of the residents' rooms and the common area was made on 8/19/25 at 1:09 p.m. The NHA said there were no documented grievances regarding the temperatures of the facility. -However, Resident #10 said she had reported her concerns to the staff regarding the temperatures of her room (see interview above). V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 1:10 p.m. LPN #1 said the room temperatures in the facility's hallways were always high. She said she was unsure when the water cooler was turned off and said only maintenance personnel were authorized to adjust the cooling fans. LPN #1 said on hot days, residents were provided with extra ice. Certified nurse aide (CNA) #1 was interviewed on 8/19/25 at 1:05 p.m. CNA #1 said the facility hallways were hot and he said the cooler fan was off because a resident complained it was cold in the hallway. The NHA was interviewed on 8/19/25 at 1:15 P.M. The NHA said he was unaware of acceptable room temperatures and said he had no current complaints from residents about room temperatures. The NHA was interviewed again on 8/19/25 at 2:40 p.m. The NHA said the maintenance director (MTD) was aware the cooling fan was not working in the morning (on 8/19/25) on the West unit and replaced a fan motor. The NHA said the cooling fan was now operational and the MTD had verified that all the facility's water coolers were operational. The NHA said on hot days, the facility provided extra ice and popsicles to the residents, closed dark shades, checked on residents frequently and offered outdoor activities. The NHA was interviewed a third time on 8/20/25 at 9:40 a.m. The NHA said the facility had rented two large water coolers for the West and East units because the residents' room temperatures remained high on 8/19/25. The MTD was interviewed on 8/20/25 at 2:25 p.m. The MTD said the facility was an old building and the water coolers were old and inefficient. The MTD said the two rented water coolers were effective to cool the facility hallways and residents' room temperatures to safe temperatures.

Based on observations, record review and interviews, the facility failed to ensure two (#1 and #4) of five residents reviewed for accident hazards received adequate supervision out of 14 sample residents. Resident #1 was admitted to the facility with diagnoses of neurocognitive disorder, brain injury with loss of consciousness and arthritis. According to documentation, Resident #1 had four falls from 6/6/25 to 7/9/25. Two falls required evaluation and treatment at the hospital emergency department. The fall on 6/21/25 caused a pelvic fracture, and after a fall on 7/9/25, the resident was monitored and was allowed to go on an activity trip to a local restaurant for lunch on the same day. While at the restaurant, the resident had another fall on 7/9/25 and was transferred to the emergency department. The hospital physician determined Resident #1 had fainted due to dehydration. On 6/8/25 at 11:00 a.m., a staff member found Resident #1 on the floor in the main entrance common area. A nurse assessed Resident #1 and determined Resident #1 was not injured from the fall. The risk management fall review note was reviewed and documented the root cause of the fall was from an unsteady balance. Resident #1’s fall prevention care plan interventions were updated 6/18/25 (10 days later) and included calling staff for assistance when she felt weak or dizzy. On 6/21/25 at 11:21 a.m., staff found Resident #1 on the floor in the main entrance common area. A nurse assessed the resident and notified the provider that Resident #1 complained of head and neck pain. Resident #1 was transferred to the emergency room and was diagnosed with a pelvic fracture. The 6/21/25 risk management fall review note was reviewed and revealed the root cause of the fall was due to a personal history of traumatic brain injury with a loss of consciousness. There were no changes made to Resident #1’s fall prevention care plan after the fall. On 7/9/25 at 5:25 a.m., Resident #1 fell and was found by staff in a non-verbal condition. A nurse assessed Resident #1 and documented Resident #1 was verbally responsive after a few minutes. There was no documentation of ongoing nursing assessments after the fall, and there were no immediate changes to the resident’s fall prevention care plan. On 7/9/25 at 11:01 a.m., Resident #1 traveled on a facility sponsored outing to a restaurant. While at the restaurant, Resident #1 was found on the floor in the bathroom and was transferred to the emergency department. The resident had not been assisted by staff to use the restroom during the outing. The resident was diagnosed with syncope (fainting) from dehydration. The 7/16/25 risk management fall review note documented Resident #1 fell twice on 7/9/25 due to poor safety awareness and having an unsteady gait. The 7/23/25 interdisciplinary team (IDT) progress note documented a physical therapy evaluation was initiated for Resident #1, which was 14 days after the fall. Additionally, Resident #4, who was assessed to have Alzheimer's disease, history of a stroke, right sided paralysis, history of falling, sepsis and cognitive communication deficits was transported by her spouse to an optometry appointment on 8/4/25. While at the appointment, Resident #4 fell from her motorized scooter and sustained a head laceration and thoracic spine fracture. Upon initial facility admission, the facility assessed Resident #4 to be independent while operating a manual wheelchair. However, the resident had a power-wheelchair. There was no documentation the facility completed an assessment to determine if Resident #4 had the cognitive or physical ability to operate a power-mobility equipment/wheelchair/scooter safely. There was no documentation the IDT reviewed or revised Resident #4’s care plan after the 8/4/25 fall. Specifically, the facility failed to: -Ensure Resident #1, who was assessed to have a fall history, a history of brain injury, moderate cognitive impairment, memory impairment and required teaching insegments, remained free of falls with injury; and,-Ensure Resident #4, who had fractured joints upon arrival to the facility was assessed for an ongoing ability to safely operate her power-mobility equipment/scooter to prevent Resident #4 from falling from the scooter while at an appointment. Findings include:I. Facility policy and procedureThe Fall Management policy, dated 2/29/24, was provided by the nursing home administrator (NHA) 8/20/25 at 2:20 p.m. It revealed in pertinent part, "The purpose of this fall management policy is to modify or eliminate risk factors and thereby attempt to reduce the likelihood of falls with significant injury. “A fall reduction program will be established and maintained to assess all residents to determine their risk for falls. A plan will be implemented based on the resident’s assessed needs.”To be effective a fall reduction program will include a fall risk evaluation, care planning and implementation of interventions, and ongoing evaluation of the process.“A fall risk evaluation will be completed within 24 hours of admission and a baseline care plan will be initiated for residents determined to be at risk for falls.“Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy.“Educate and communicate implemented interventions to direct care staff via verbal report.“Document the residents' response to fall prevention interventions and revise interventions if the interventions are not successful.“If a resident experiences an unwitnessed fall, neurological checks will be initiated.“The facility will review all falls daily during the morning quality meeting.“The fall review will include review of the incident report, review that a care plan was initiated, revise the plan of care after a fall as necessary.”II. Resident # 1A. Resident statusResident #1, age greater than 65, was admitted on 4/18/25, discharged to the hospital on 7/9/25 and was readmitted on 7/10/25. According to the August 2025 computerized physician orders (CPO), diagnoses included neurocognitive condition without behavioral disturbance, unspecified intracranial injury with loss of consciousness, insomnia, osteoarthritis and history of falling. The 4/24/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent from staff assistance for bed mobility, sitting and standing, transferring and walking with a walker. B. Resident interview and observationResident #1 was interviewed on 8/20/25 at 12:10 p.m. Resident #1 said she was happy at the facility. Resident #1 said she enjoyed walking to activities, to visit with her friends and to the dining room for meals. Resident #1 said if she needed help in the common areas she was not sure what she should do and said she would sit and rest on a chair. Resident #1 said she did not need very much assistance and said she was unsure when she should request assistance from staff. Resident #1 said staff gave her several instructions that were confusing. Resident #1 was observed ambulating independently on 8/18/25, 8/19/25 and 8/20/25 throughout the facility using a front-wheeled walker. Resident #1 ambulated slowly with short jerking steps and had a limp on her right side. Resident #1 was observed sitting at a table by herself in the common area, near the main entrance, where she made flower arrangements. The common area did not have access to a call light to use if a resident needed assistance, and the resident was not provided with a way to notify staff if she needed help. C. Record reviewResident #1's fall care plan, initiated 4/18/25, revealed Resident #1 was at risk for falls related to a neurocognitive disorder, intracranial injury with loss of consciousness, impaired balance, poor safety awareness, history of falls and osteoarthritis in her right knee. Interventions included ensuring Resident #1 wore appropriate footwear when ambulating (initiated 4/18/25), ensuring Resident #1 had her call light in reach, encouraging Resident #1 to use her call light, responding promptly to requests for assistance, encouraging Resident #1 to participate in activities to promote exercise for strengthening (initiated 4/23/25), calling for assistance with feeling weak and dizzy (initiated 6/18/25), assessing and meeting Resident #1's needs, providing adaptive devices as needed, educating Resident #1 about safety reminders and what to do when a fall occurs, encouraging rest periods when signs of fatigue are noted, requesting a medication review with the pharmacist (initiated 7/18/25), using a wheelchair on all outings for fall prevention, and a physical therapy evaluation (initiated 7/23/25). Resident #1’s functional performance care plan, initiated 4/18/25, revealed Resident #1 had a self-care deficit related to epilepsy, neurocognitive disorder, intracranial injury with loss of consciousness, impaired balance, poor safety awareness, history of falls and osteoarthritis in her right knee. Interventions included using the call bell to call for assistance (initiated 4/18/25), transferring independently between surfaces (initiated 4/23/25) and using a walker for ambulation (initiated 5/1/25). Resident #1’s cognitive care plan, initiated 4/23/25, revealed Resident #1 had impaired cognition or thought processes related to cognitive disorder, history of traumatic brain injury and moderate cognitive impairment. Interventions included using task segmentation to support short term memory deficits and breaking tasks into one step at a time.-Resident #1 had a fall prevention care plan that identified Resident #1 was assessed to have moderate cognitive impairment. The resident was not assessed to determine if she understood the fall prevention and safety awareness interventions included on the care plan. Resident #1 walked independently throughout the facility with her walker and there were no assessments to indicate that Resident #1 had the cognitive ability to locate and activate a call light to request assistance from her room or common areas when she felt weak or dizzy. D. Falls 1. Fall #1 The 6/11/25 nurse progress note, documented on 6/8/25 at 11:00 a.m., revealed Resident #1 was found on the floor, in the common area of the main entrance, sitting on her buttocks. The nurse completed an assessment and found no injuries. The nurse documented Resident #1 said she felt unsteady on her feet and sat down on the floor. The 6/16/25 IDT progress note revealed the IDT determined the cause of the fall was due to Resident #1’s clinical diagnoses. The IDT recommended a new intervention for Resident #1 to call for assistance when she felt weak or dizzy. -However, the IDT made no referrals to the therapy department for evaluation of Resident #1’s unsteadiness and weakness in an attempt to prevent future falls. 2. Fall #2 The 6/21/25 at 12:36 p.m. nurse progress note, documented on 6/21/25 at 11:21 a.m., revealed that Resident #1 was found on the floor, in the common area of the main entrance. The nurse completed a physical assessment and documented Resident #1 was non-verbal. The nurse documented neurological assessments were initiated, however, the facility was unable to provide the documentation of the neurological assessments. The progress note documented that Resident #1 complained of head and neck pain, and was transported to the emergency department for evaluation. The 6/21/25 hospital discharge summary revealed Resident #1 was diagnosed with a hip bruise, a pelvic fracture and sacroiliac (pelvis) joint dysfunction. General discharge instructions included: -Rest as needed, return to your normal activities as told by your health care provider, ask your health care provider what activities are safe for you;-Do exercises as told by your health care provider or physical therapist;-Keep all follow-up visits; and,-Call 911 if you have increased pelvic swelling, pain or redness of a leg or chest pain. -The 6/24/25 IDT progress note revealed there were no new care plan interventions initiated to include the discharge instructions and there were no changes made to Resident #1’s fall prevention care plan. 3. Fall #3The 7/9/25 at 6:00 a.m. nurse progress note documented Resident #1 was found on the floor in the hallway outside the nurses’ station. The nurse documented Resident #1 denied pain during assessment, was assisted to her feet and went to the common area by the main entrance. -The nurse documented neurological assessments were started; however, there were no neurological assessments in the resident’s electronic medical record (EMR) for the fall. -Further, there was no documentation to indicate that Resident #1 had ongoing monitoring after the fall, which might reveal changes to vital signs or a change in condition. The 7/9/25 5:25 a.m. fall investigation revealed Resident #1 had a predisposing physiological factor of a walking imbalance, had her walker with her and was carrying several personal belongings. There were no changes made to the resident's plan of care after the fall. 4. Fall #4The 7/9/25 11:01 a.m. fall investigation revealed Resident #1 fell at a local restaurant while she was on an outing with the facility’s activities department. The progress note revealed emergency services were contacted while at the restaurant. Resident #1 was evaluated at the hospital and was diagnosed with recurrent syncope with falls from dehydration. The 7/9/25 fall investigation revealed Resident #1 had predisposing factors of gait imbalance and a recent change in cognition. The 7/10/25 hospital discharge summary revealed Resident #1 told the hospital physician the syncope episodes happened upon standing up after being seated. Review of Resident #1’s EMR revealed the facility failed to provide the resident with increased supervision for timely intervention from staff to prevent falls upon standing. The 7/16/25 at 7:58 p.m. IDT progress note revealed the IDT determined the cause of the 7/9/25 falls were poor safety awareness and an unsteady gait. The 7/23/25 IDT note documented Resident #1 was educated to use a wheelchair on future outings to prevent falls due to the unsteady gait and disease processes. The progress note further documented the IDT initiated a referral for physical therapy, which was 14 days after the falls on 7/9/25. III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 6/18/25. According to the August 2025 CPO, diagnoses included Alzheimer's disease, stroke, right side paralysis, history of falling, sepsis and cognitive communication deficit. The 8/2/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. Resident #4 was independent from staff assistance for bed mobility and sitting up in bed, and required set-up assistance from staff for sitting and standing, and transferring from a chair to a bed. Resident #4 was independent from staff assistance for mobility using a manually propelled wheelchair. Resident #4’s ability for car transfers was not assessed. B. Record reviewResident #4’s fall care plan, initiated 6/22/25, revealed Resident #4 was at risk for falls related to encephalopathy (a group of conditions that cause brain dysfunction), type 2 diabetes mellitus, Alzheimer’s disease and a history of falling at home. Interventions included ensuring Resident #4 had a call light in reach and encouraging Resident #4 to use the call light for assistance as needed and responding promptly to all requests for assistance (initiated 6/22/25), encouraging Resident #4 to participate in activities to promote exercise for strengthening (initiated 6/22/25), ensuring adequate lighting and visual aids were in place (initiated 6/22/25), ensuring Resident #4 wore appropriate footwear when mobilizing in a wheelchair (initiated 6/22/25) and physical therapy as ordered (initiated 6/22/25). Resident #4’s impaired cognitive function care plan, initiated 8/8/25, revealed Resident #4 had impaired thought processes related to Alzheimer's disease. Interventions included discussing concerns about confusion, disease processes and facility placement with Resident #4 (initiated 8/8/25) and monitoring for changes in cognitive function (initiated 8/8/25). Resident #4’s functional mobility care plan, initiated 6/22/25, revealed Resident #4 had a self-care deficit related to Alzheimer’s disease, encephalopathy and limited mobility. Interventions included using a power wheelchair for mobility throughout the facility (initiated 6/22/25) and encouraging Resident #4 to use the call bell to call for assistance (initiated 6/22/25). The 8/4/25 at 3:04 p.m. nurse progress note documented Resident #4 was out of the facility with her spouse for an optometry appointment. While at the appointment, Resident #4 fell from her wheelchair and was transported to the emergency department for evaluation. The 8/4/25 at 3:01 p.m. hospital summary documented Resident #4 was evaluated in the emergency department. The emergency department physician ordered computed tomography (CT) scans for Resident #4. The 8/4/25 CT scan revealed Resident #4 sustained a thoracic spine compression fracture. The treatment recommendation was for Resident #4 to wear a thoracic brace and return to the facility. The 8/4/25 at 6:47 p.m. nurse progress note documented the social services director (SSD) asked the nurse to obtain a pass for Resident #4 to attend an optometry appointment. The progress note documented that Resident #4 left the facility, accompanied by her spouse. The spouse returned to the facility later and informed the nurse that Resident #4 was left unattended while he parked his vehicle, and while unattended, Resident #4 fell to the ground. The spouse told the nurse Resident #4 had an open area on her head and was transported by paramedics to the hospital. On 8/5/25, the IDT outing evaluation for a pass was completed. The IDT determined Resident #4 had poor safety awareness and recommended Resident #4 not leave the facility independently, but she could have a therapeutic pass when accompanied by an adult. -There was no documentation to indicate the facility provided education to the resident’s spouse for safe car transfers and to not leave Resident #4 unattended while on outings. Review of Resident #4’s EMR revealed there was no documentation to indicate the IDT reviewed the fall or updated Resident #4’s plan of care for fracture care or completed a wheelchair/scooter use and safety evaluation at the time of admission or after the fall on 8/4/25. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 8/19/25 at 12:55 p.m. RN #1 said that he was aware Resident #1 had a history of falls and said Resident #1 was independent with walking around the facility. RN #1 said Resident #1 participated in therapy and appeared to be stronger when she walked with her walker. RN #1 said staff monitored Resident #1 frequently and provided assistance as needed. RN #1 said he was unsure why Resident #1 had repeated falls. Licensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 1:10 p.m. He said Resident #4 used a wheelchair and had a brace for her spine fracture. LPN #1 said Resident #4 required narcotic pain medication for pain in her spine. LPN #1 said nurses kept up-to-date report sheets with important notes for each resident. LPN #1 said that after a resident had a fall, the status of each fall and monitoring should be included in the shift report. LPN #1 said that if documentation in the EMR was not immediate, the shift report was the only way for nurses to track resident status. LPN #1 said it was important for staff to know why residents fell so that staff could monitor the residents and provide safe care. The activities director (AD) was interviewed on 8/20/25 at approximately 2:45 p.m. The AD said that on 7/9/25, he took residents on a scheduled activity/outing to a local restaurant. The AD said Resident #1 fell while inside the restaurant and paramedics were contacted. The AD said staff did not update him on Resident #1's status before the outing and he was unaware that Resident #1 had a fall earlier in the day. The NHA and the director of nursing (DON) were interviewed together on 8/20/25 at 1:20 p.m. The NHA said the IDT reviewed every fall, the day after a fall occurred. The DON said the IDT was responsible for reviewing care plan interventions and updating residents’ care plans when appropriate. The DON said she was unable to locate documentation of the IDT fall reviews, but she said she documented the risk reviews for each fall in the residents’ EMR. The DON said Resident #1 liked to walk to the common area to socialize and arrange flowers. The DON said staff found the resident on the floor after her falls on 6/8/25 and 6/21/25 and the IDT determined Resident #1 had an unsteady balance. The DON said Resident #1 was educated to use her call light to ask for assistance from staff or to call out for assistance because call lights were not available in common areas. The DON said the IDT reviewed the 7/9/25 at 5:25 a.m. fall and determined the cause of the fall was because Resident #1 had poor safety awareness because she was carrying personal belongings while trying to ambulate with her walker to the common area. The DON said it was important for nurses to monitor residents after they had a fall in case the resident had any injury. She said residents that were being monitored after a fall should not attend outings away from the facility. The DON said Resident #4 went to an appointment at Walmart on 8/4/25 and was accompanied by her spouse. She said she was unable to locate who made the appointment and who arranged and approved for the spouse to provide transportation. The DON said the IDT did not review the fall because Resident #4 fell at a store, was treated by paramedics, and was transferred to the hospital. The DON said neurological assessments were completed after unwitnessed falls or when a resident had a head injury. The DON was unable to locate neurological assessments for the 8/4/25 fall. The NHA said he recalled discussing Resident #1 and Resident #4 after their falls but was unsure of corresponding recommendations made by the IDT. The NHA said the documentation of the reviews that were completed by the IDT were not documented in either residents’ EMRs, but he had a daily log that indicated the reviews had occurred. The NHA said he was unable to find IDT documentation pertinent to falls for Resident #1 and Resident #4. The NHA said the IDT needed to improve documentation of clinical discussions.

Based on record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#1) of two residents reviewed for medication documentation out of 14 sample residents. Specifically, the facility failed to ensure Resident #1’s electronic medical record (EMR) contained complete and accurate documentation related to the administration of the resident’s scheduled levetiracetam (a medication used to treat epilepsy, a seizure disorder) medication. Findings include:I. Facility policy and procedureThe Administering Medications policy, dated 8/4/25, was provided by the nursing home administrator (NHA) on 9/2/25 at 11:05 a.m. The policy read in pertinent part,“Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications.“Record the results of medications administered per facility policy and procedure. Each time a medication is administered it must be documented.”II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 4/18/25, discharged to the hospital on 7/9/25, and was readmitted on 7/10/25. According to the August 2025 computerized physician orders (CPO), diagnoses included epilepsy (a seizure disorder), neurocognitive condition without behavioral disturbance, unspecified intracranial injury with loss of consciousness, insomnia, osteoarthritis, sacrum (pelvic) fracture and history of falling. The 4/24/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent from staff assistance for bed mobility, sitting and standing, transferring and walking with a walker. B. Record reviewReview of Resident #1’s August 2025 CPO revealed the following physician's orders:Levetiracetam 1000 milligrams (mg) twice a day for seizures, administer at 6:00 a.m. and 4:00 p.m., ordered on 6/5/25. A review of Resident #1’s July 2025 (from 7/1/25 to 7/31/25) medication administration record (MAR) revealed that a code of “9” was documented for the administration of levetiracetam on 7/8/25 and 7/9/25. According to the MAR, the code of “9” indicated “other/see progress notes.”-A review of Resident #1’s progress notes on 7/8/25 and 7/9/25 failed to reveal documentation to indicate whether or not the levetiracetam medication was administered to the resident as ordered on those dates. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/2/25 at 4:27 p.m. LPN #1 said he was the nurse assigned to administer medications to Resident #1 on 7/8/25 and 7/9/25. He said he documented a code of “9” for the resident’s levetiracetam on both of those dates because he had been unable to locate the medication in order to administer it. He said on 7/8/25 and 7/9/25, another nurse had been able to find the medication in the facility’s supply of emergency medications. LPN #1 said he had administered the medication to Resident #1 after receiving the doses from the nurse. LPN #1 said he should have documented a corresponding progress note in the EMR after the medication was administered. The director of nursing (DON) was interviewed on 8/25/25 at 4:27 p.m. The DON said LPN #1 should have documented a corresponding progress note in the EMR after Resident #1’s levetiracetam was administered on 7/8/25 and 7/9/25. The DON said LPN #1 was a new employee at the facility and he had been unsure how to document that the medication was administered after he had already entered a code of “9” on the MAR.

A revisit survey was completed on 5/15/25 for all previous deficiencies cited on 4/1/25. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected. Waived deficiencies will be corrected at a later date in accordance with the waiver. No other deficiencies were cited and no response is needed.

A complaint survey, prompted by #CO39620 and Incident #38896 was completed on 3/31/25 to 4/1/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for two (#2 and #5) of three residents reviewed for abuse out of six sample residents. Specifically, the facility failed to: -Protect Resident #2 and Resident #5 from sexual abuse by Resident #3; and,-Ensure staff report an incident of sexual abuse in a timely manner. Findings include:I. Facility policy and procedureThe Abuse policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 4/1/25 at 10:00 a.m. It read in pertinent part,"Sexual abuse is non-consensual sexual contact of any type with a resident."If resident abuse, neglect, or exploitation is suspected, the suspicion must be reported immediately to the administrator."The facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents or family members who may have knowledge of the incident." II. Incident of sexual abuse of Resident #2 by Resident #3 on 1/1/25A. Facility investigationReview of the facility's investigation revealed that on 1/2/25 Resident #2 reported that on 1/1/25, Resident #3 lifted his shirt when she passed him in the hallway. She said he lifted his shirt and his genitals were exposed. Resident #2 said Resident #3 was making her very uncomfortable and he was laughing and smiling while exposing himself. Resident #2 said her roommate, Resident #5, told Resident #3 to leave Resident #2 alone. Resident #2 said she was trying to stay away from Resident #3 because he made her uncomfortable and he left his pants unzipped so when he lifted his shirt his penis was exposed. Resident #3 was interviewed by the facility on 1/2/25 and he denied lifting his shirt around other residents or exposing his genitals. The facility interviewed additional residents and staff and there were no witnesses to Resident #3's behavior and no other residents were concerned with their safety or expressed fear of Resident #3. The facility unsubstantiated the abuse because there were no witnesses and Resident #3 denied the allegation.-However, abuse occurred as Resident #2 and Resident #5 (see interview below) both said Resident #3 had a history of exposing his penis to them on multiple occasions. -Additionally, it was identified on Resident #3's care plan, revised 9/20/24, that he had a history of masturbating and exposing himself in public (see care plan below). B. Resident #3 (assailant) 1. Resident statusResident #3, age greater than 65, was admitted on 6/11/24. According to the April 2025 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (brain disorder), alcohol induced dementia and impulse disorder. The 2/28/25 minimum data set (MDS) assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment indicated the resident had physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing and abusing others sexually) on one to three days during the assessment review look-back period. 2. Record reviewResident #3's impulse control care plan, revised 9/20/24, documented Resident #3 had the potential to be verbally aggressive, flip people off, masturbate in public spaces and show his privates (penis) to female residents and staff. Interventions included administering medications as ordered, analyzing triggers, assessing for sensory deficits, anticipating the resident's needs, giving the resident as many choices as possible about care and activities, monitoring observed behaviors and monitoring signs of the resident posing danger to himself or others.-The facility failed to have person-centered interventions to keep Resident #3 from exposing himself to others. C. Resident #2 (victim) 1. Resident statusResident #2, age greater than 65, was admitted on 10/27/22. According to the April 2025 CPO, diagnoses included stage 4 chronic kidney disease, depression, dependence on supplemental oxygen, acute on chronic diastolic (congestive) heart failure and difficulty walking. The 3/17/25 MDS assessment revealed Resident #2 was cognitively intact with a BIMS score of 13 out of 15.2. Resident interviewResident #2 was interviewed on 3/31/25 at 3:15 p.m. Resident #2 said Resident #3 often stood in his bedroom doorway with the door and privacy curtain open. She said Resident #3 would lift his shirt and expose his penis when she walked by his room. Resident #2 said Resident #3 exposed himself to her numerous times and when she reported it to a staff member, she was told the staff would talk to Resident #3 but she said nothing ever came from it and Resident #3 continued to expose himself to her. Resident #2 said she was scared and did not feel safe and comfortable around Resident #3. Resident #2 said Resident #3 was a few doors down around the corner and she said she faced the wall whenever she walked to the dining room so she could not see anything Resident #3 was doing. Resident #2 said she feared that Resident #3 would escalate and do something more and the facility was not keeping her safe. III. Resident #5 (victim)A. Resident statusResident #5, age greater than 65, was admitted on 1/31/24. According to the April 2025 CPO, diagnoses included respiratory failure with hypoxia (low oxygen in the blood), schizoaffective (mental illness) disorder, acute right heart failure and anxiety. The 3/28/25 MDS assessment revealed Resident #5 had moderate cognitive impairment with a BIMS score of 12 out of 15. B. Resident interviewResident #5 was interviewed on 3/31/25 at 3:20 p.m. Resident #5 said Resident #3 often stood in his bedroom doorway with the door and privacy curtain open. She said Resident #3 would lift his shirt and expose his penis when she walked by his room. Resident #5 said Resident #3 exposed himself to her numerous times and when she reported it to a staff member, she was told the staff would talk to Resident #3 and she said nothing ever came from it. Resident #5 said the incidents made her uncomfortable and mad. Resident #5 said she told Resident #3 she would "chop it off" and Resident #3 laughed at her. She said Resident #3 always laughed or smiled while exposing himself and it was disgusting. IV. Staff interviewsThe activity assistant (AA) was interviewed on 3/31/25 at 4:10 p.m. The AA said she was aware that Resident #2 had reported that Resident #3 exposed himself to her in January 2025. She said she overheard Resident #2 telling another resident that Resident #3 exposed himself to her the first week of February 2025. The AA said she did not report what she overheard Resident #2 say in February 2025 to management because Resident #2 giggled about the situation and did not seem upset. The activity director (AD) was interviewed on 3/31/25 at 4:15 p.m. The AD said he had seen Resident #3 in his room with the door open, exposing himself. The AD said he did not report it because the resident was in his room, but he said he probably should have reported it because if he could see Resident #3, that meant other residents could too. The NHA, corporate consultant (CC) #1 and CC #2 were interviewed together on 3/31/25 at 3:42 p.m. The NHA said Resident #2 reported the situation to a staff member and there was a little delay in the incident being reported to the NHA. He said he provided the staff education on reporting abuse allegations to management. He said Resident #2 and Resident #3 were separated and placed on frequent checks and other residents were interviewed to see if anyone else saw what happened. He said Resident #5 was not interviewed during the investigation because the incident occurred in the dining room and she was not there when it happened. The NHA said the allegation was unsubstantiated because a witness was not able to be located. The NHA said he was unaware the incident was still occurring, but he said he would start a new investigation, based on Resident #2 and Resident #5's comments (see resident interviews above). He said he was going to move Resident #3 to a room away from Resident #2 and Resident #5 to make them more comfortable. Certified nurse aide (CNA) #1 was interviewed on 4/1/25 at 12:10 p.m. CNA #1 said Resident #3 had behaviors that included showing his penis to others. CNA #1 said she was unsure of any interventions in place to prevent Resident #3 from exposing himself to others, but she said she could check the care plan, if needed, for interventions.-However, Resident #3's care plan failed to include interventions to prevent the resident from exposing his genitals to others (see care plan above). The NHA and CC #1 were interviewed together again on 4/1/25 at 12:15 p.m. The NHA said he started an investigation immediately after being informed Resident #3 continued to expose himself to Resident #2 and Resident #5. The NHA said all of the residents in the facility were interviewed and no one else had concerns about Resident #3 or reported witnessing the resident exposing himself to others. The NHA said the staff were asked to remind Resident #3 to "zip-up" in the dining room.-However, Resident #2 and Resident #5 said Resident #3 exposed his genitals to them on multiple occasions when they were walking in the hallway, not in the dining room (see resident interviews above).

A revisit to the 12/19/2024 survey was completed on 2/18/2025. The facility was in compliance with the regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on January 14, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) wood frame construction with a partial basement that is used for support services and there is no resident access. The facility was constructed in 1962. The facility is licensed for 101 beds, and the census on the survey date was 63. The facility is fully sprinkled and protected by National Fire Protection Association (NFPA) 13 automatic wet-pipe system, and two (2) anti-freeze fire sprinkler systems. The anti-freeze fire sprinkler systems protect the front canopy and the kitchen cooler and freezer. The survey results were discussed with the Maintenance Director and the Facility Administrator during the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 7.9.2.1, 7.9.3.1.1, and NFPA 110, 7.3.1 This was evidenced by the following:1. Emergency lighting at the generator transfer switch is inoperative. NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting. NFPA 110, 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This deficient practice could affect occupants and staff if emergency lighting is needed during a power loss. This was discussed during the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 101, Life Safety Code, Section 19.3.2.1.2This was evidence by the following:1. Excessive storage in east TV sitting room creates a hazardous environment. 2. Excessive storage in private room off the dining room has excessive storage that creates a hazardous environment. NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguardedby a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. NFPA 101, 19.3.2.1.2 Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. This deficiency could affect all occupants and staff within this smoke compartment. This deficiency was discussed during the exit conference.

Based on record review it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) This deficient practice could affect all residents, and staff should a fire occur, and the suppression system fails to operate effectively due to non-code compliant conditions with the kitchen hood suppression system. This was evidence by the following:1. No records or documentation for kitchen hood suppression system 6/mo. inspection and testing. The Maintenance Director acknowledged the lack of documentation and maintenance records. NFPA 96, 11.2.1 Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. This deficiency was discussed with the Administrator and Maintenance Director during the exit conference.

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. This was evidenced by the following: 1. Fire alarm wiring in main lobby is not secured. 2. Smoke detector not secured to it's base in west hall near room 7. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 12.2.4* The installation of all pathway wiring, cable, and equipment shall be in accordance with NFPA 70, National Electrical Code, and the applicable requirements of 12.2.4.1 through 12.2.4.5. NFPA 70, 760.24 Mechanical Execution of Work. Fire alarm circuits shall be installed in a neat workmanlike manner. Cables and conductors installed exposed on the surface of ceilings and sidewalls shall be supported by the building structure in such a manner that the cable will not be damaged by normal building use. Such cables shall be supported by straps, staples, cable ties, hangers, or similar fittings designed and installed so as not to damage the cable. The installation shall also comply with 300.4(D). Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should damage occur to fire alarm wiring and devices. The deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.1 and NFPA 101, 19.7.6, and 4.6.12. This was evidenced by the following. 1. Improperly installed fire sprinkler escutcheon in kitchen dishwashing area. NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and inspected and tested periodically. Section 19.7.6, 4.6.12, and NFPA 25, 5.2.1 NFPA 13, 6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly. This deficiency could affect the sprinkler operation to protect the area. This was discussed during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3This was evidenced by the following: 1. Smoke doors in west hall do not close completely,NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-closing corridor doors and/or gaps in the door smoke seal. This was discussed during exit conference.

Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. Fire drill records and signed attendance sheets are not organized in the LSC binder. 2. No records or inadequate documentation of fire drills for 2nd shift in the second quarter. 3. Fire drills were not conducted during varying times. NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. This was evidenced by the following deficiencies:1. Improper use of power strips powering refrigerators in rooms 5, 10, 11, and 17.2. Improper use of power strips powering appliances in west employee breakroom. 3. Exposed and open wiring in room 64. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficient practice could affect all occupants and staff throughout the smoke compartment if improper maintenance of electrical equipment causes a fire. The deficiency was discussed during the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. Records or documentation for generator battery monthly conductance testing are inaccurate. 2. No records or documentation for generator load bank testing. NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting. Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1NFPA 110, 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. The deficiencies have the potential to affect all occupants, which might include staff, residents, and visitors should the generator fail to start during an emergency. This was discussed during the record review and again during the exit conference.

A recertification survey with complaint #CO37735, #CO38290, #CO38502 and #CO38536 was completed from 12/11/24 to 12/19/24. Twenty-two deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/11/24 to 12/19/24. No deficiencies were cited.

IV. Resident #23A. Resident statusResident #23, age 69, was admitted on 2/1/21. According to the December 2024 CPO, diagnoses included hemiplegia (paralysis or weakness on one side of the body), malnutrition, peripheral vascular disease (circulation condition with narrowing of blood vessels) and neurogenic (nerve) dysfunction of the bladder. The 9/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required set-up assistance from staff with oral hygiene, supervision for toileting and substantial to moderate assistance with showering/bathing. B. Resident interview and observationResident #23 was interviewed on 12/11/24 at 11:56 a.m. Resident #23 said he had not had a shower in two weeks because the facility did not have enough staff to help him shower. Resident #23 said he had been using wipes to wash himself. He said he was supposed to have a shower twice per week and he needed help to get him into the shower each time. C. Record reviewResident #23's care plan, revised 4/8/24, revealed Resident #23 preferred to shower on Monday, Wednesday and Fridays and he required supervision by one staff member. Review of the shower schedule posted at the nurse's station revealed Resident #23 was scheduled to receive showers every week on Monday and Friday.-However, Resident #23's care plan indicated he preferred to shower Monday, Wednesday and Friday. Resident #23's bathing/showering record from 9/1/24 to 11/30/24 was provided by the DOCS on 12/17/24 at 1:33 p.m. The bathing/shower records provided and the treatment administration record (TAR) for December 2024 were reviewed from 10/16/24 to 12/16/24. The records revealed the following:Resident #23 refused one shower on 11/4/24.-There was no other documentation to indicate Resident #23 had refused other scheduled showers. Per the bathing/showering record documentation from 10/16/24 to 12/16/24, Resident #23 received eight showers out of 16 opportunities. There was no documentation indicating the resident had received a shower since 11/29/24, indicating the resident had not received a shower in 17 days.-Other than the documented refusal on 11/4/24, review of the resident's bathing records revealed no documentation to indicate why the resident missed his showers or what interventions were attempted for Resident #23's missed showers. D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 12/17/24 at 10:38 a.m. CNA #4 said Resident #23 required assistance with showering. She said Resident #23 liked showering and did not refuse them. CNA #1 said it did not surprise her that Resident #23 had not received regular showers as there was not always enough staff to provide showers to every resident. CNA #3 was interviewed on 12/17/24 at 10:56 a.m. CNA #3 said Resident #23 did not refuse showers. CNA #3 said Resident #23 liked CNA #3 to provide assistance with showers as she also shaved the resident. The DON and the DOCS were interviewed together on 12/17/24 at 3:46 p.m. The DOCS said there was no documentation in Resident #23's electronic medial record (EMR) that indicated the resident had received a shower from 11/29/24 to 12/13/24. The DON said she would expect Resident #23 to receive two showers each week, or eight showers in a four week period. The DON and the DOCS said they recognized the staff were not documenting showers and were going to develop a plan to provide staff education regarding documentation of showers received. III. Resident #33A. Resident statusResident #33, age 67, was admitted on 2/6/21. According to the December 2024 CPO, diagnoses included dementia, cerebral infarction (stroke), post traumatic stress disorder (PTSD) and depression. The 10/11/24 MDS assessment revealed Resident #33 had moderate cognitive impairments with a BIMS score of 10 out of 15. The resident was independent with oral hygiene and toileting. He required partial to moderate assistance with showering. B. Resident interviewResident #33 was interviewed on 12/19/24 at 2:12 p.m. Resident #33 said he cleaned himself up at the sink in his room. C. Record reviewResident #33's care plan, revised 10/30/23, revealed Resident #33's shower preference sheet was updated and Resident #33 preferred to shower three times per week. Review of the shower schedule posted at the nurse's station revealed Resident #33 was scheduled to receive showers every week on Monday, Wednesday and Friday. Resident #33's bathing/showering record from 9/1/24 to 11/30/24 was provided by the DOCS on 12/17/24 at 1:33 p.m. The bathing/shower records provided and the TAR for December 2024 were reviewed from 10/16/24 to 12/16/24. The records revealed the following:Resident #33 refused three showers on 10/28/24, 11/4/24 and 11/18/24. Resident #33 received 11 showers out of 24 opportunities. There was no documentation indicating the resident had received a shower since 11/29/24, indicating the resident had not received a shower in 17 days.-Other than three refusals, review of the resident's bathing records revealed no documentation to indicate why the resident missed his showers or what interventions were attempted for Resident #33's missed showers, particularly since 11/29/24. D. Staff interviewsCNA #4 was interviewed on 12/17/24 at 10:28 a.m. CNA #4 said Resident #33 always wanted to take his showers and said she did not think Resident #33 ever refused showers. CNA #4 said Resident #33 was always ready for showers and sometimes waited in the hallway with his shower items. CNA #3 was interviewed on 12/17/24 at 11:00 a.m. CNA #3 said Resident #33 did not refuse showers. CNA #3 said she thought she had helped him shower the previous week. The DON and the DOCS were interviewed together on 12/17/24 at 3:48 p.m. The DOCS said he did not find any documentation for Resident #33's showers from 11/29/24 until 12/16/24. The DON said she would expect Resident #33 to receive 12 showers in a four week period (three per week). The DON said she would expect staff to document every shower provided and every refusal by residents in their EMRs. Based on observations, record review and interviews, the facility failed to honor resident choices for five (#35, #39, #6, #23 and #33) of 28 residents out of 41 sample residents. Specifically, the facility failed to honor Resident #35, Resident #39 and Resident #6, Resident #23 and Resident #33's preferences including shower frequency and times. Findings include:I. Facility policy and procedureThe Resident Rights policy and procedure, revised December 2021, was received from the nursing home administrator (NHA) on 12/19/24 at 11:54 a.m. It revealed in pertinent part "At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing, of their rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility."A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident."The resident has the right to reside and receive services in the facility with reasonable accommodations of resident preferences except when to do so would endanger the realty and safety of the resident or other residents. "The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident." The Bath, Shower/Tub policy, revised February 2018, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. The policy read in pertinent part,"The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident, all assessment data, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, the signature and title of the person recording the data. Notify the supervisor if the resident refuses the shower/tub bath."II. Resident #35A. Resident statusResident #35, age greater than 65, was admitted on 1/28/22 and readmitted on 10/25/23. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease, type 2 diabetes mellitus and major depressive disorder. The 10/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with transfers, toileting, dressing and showering. She did not have any behaviors or refusals of care. B. Resident interviewResident #35 was interviewed on 12/18/24 at 9:09 a.m. Resident #35 said she wanted to have a shower at least once a week. She said she had not had a shower in the past four weeks. Resident #35 did not know why she was not given a shower weekly as she requested. She said she was incontinent of bowel and bladder and she often felt dirty and like no one cared about her when she did not receive her showers. C. Record reviewA review of Resident #35's bath record revealed the resident last received a shower on 11/18/24. Documentation did not reveal the resident had refused any showers. On 11/25/24, 11/28/24, 11/30/24 and 12/5/24 the residents shower was documented as not applicable. III. Resident #39A. Resident statusResident #39, age greater than 65, was admitted on 8/22/22 and readmitted on 10/26/23. According to the December 2024 CPO, diagnoses included congestive heart failure, chronic respiratory failure and chronic kidney disease. The 10/30/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with transfers, toileting, and dressing and required supervision with showers. She did not have any behaviors or refusals of care. B. Resident interviewResident #39 was interviewed on 12/18/24 at 9:10 a.m. Resident #39 said she did not get two showers a week as she preferred. She said she knew it bothers her roommate because she made the room smell bad. Resident #39 said it made her feel bad when she smelled bad and like no one at the facility cared about her. She said she only refused showers when they were offered in the morning because she preferred to have them in the late afternoon or evening. C. Record reviewA review of Resident #39's bath record revealed the resident received four showers in the past 30 days on 11/20/24, 11/27/24, 11/29/24 and 12/11/24. The resident refused showers on 11/17/24, 11/24/24, 12/1/24 and 12/4/24. Showers were documented as not applicable on 11/13/24, 11/15/24, 11/22/24, 12/6/24 and 12/8/24. IV. Resident #6A. Resident statusResident #6, age less than 65, was admitted on 7/11/17. According to the December 2024 CPO, diagnoses included atherosclerotic heart disease, borderline personality disorder and chronic obstructive pulmonary disease (COPD). The 10/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for showers. C. Resident interviewResident #6 was interviewed on 12/11/24 at 3:15 p.m. Resident #6 said she had requested a shower three times a week. The resident said she typically received her shower on Sundays, however she did not always receive the other two. She said it was related to staffing. C. Record reviewThe care plan last updated on 7/30/24 identified the resident had a self care deficit related to activity intolerance, morbid obesity and COPD. Pertinent interventions included the resident preferred her showers on Wednesday and every other day in the mid day. The 10/27/23 personal bathing preference form documented the resident preferred to bathe three times a week. -However, the care plan indicated the resident liked to shower every other day. The care plan last updated on 7/30/24 identified the resident had a self care deficit related to activity intolerance, morbid obesity and COPD. Pertinent interventions included the resident preferred her showers on Wednesday and every other day in the mid day. The bath records for November 2024 (11/1/24 to 11/30/24) revealed the resident received eight (11/3/24, 11/10/24, 11/12/24, 11/14/24, 11/19/24, 11/24/24, 11/26/24 and 11/28/24) showers out of 12 opportunities for three times a week. D. Resident group interviewA group interview was conducted on 12/17/24 at 1:05 p.m. with five residents (#115, #28, #4, #16, and #17) who were interviewable based on assessment and facility. The residents said they did not get a choice on how many showers they received or the time of day they received their showers. The residents said they were lucky to get one shower a week. E. Staff interviewThe director of nursing (DON) was interviewed on 12/17/24 at 6:10 p.m. The DON said when a resident was admitted to the facility the resident filled out a preference sheet form that indicated how many showers a week they would like. She said the residents should get as many showers as they had requested. The DON said she identified the staff were not documenting showers and was going to develop a plan to provide staff education regarding documentation of showers received.

Based on record review and interviews, the facility failed to ensure one (#13) of one resident out of 41 sample residents was compensated for paid services at or above prevailing rates. Specifically, the facility failed to ensure Resident #13 was paid in a timely manner. Findings include:I. Facility policy and procedureThe Resident Therapeutic Stipend Program (TSP) policy, dated 6/1/23, was provided by the nursing home administrator (NHA) on 12/19/24 at 4:55 p.m. It read in pertinent part, "The task/duties/activities performed by the resident are appropriate, and the resident has the mental and physical capacity to perform the task/duties/activities. The plan of care specifies the nature of the services performed. All services performed under TSP (therapeutic stipend program) are paid. "Duties will be outlined, and the resident must agree to the description of duties prior to starting the program. The resident will be trained/educated on the program duties to be provided, as well as safety protocols and safe work practices (infection control, proper body mechanics), prior to beginning the program. The resident and community understand that the resident has the right to decline to participate in the Resident Therapeutic Volunteer/Stipend Program or to provide services to the community at any time. There is documentation in the plan of care regarding the need or desire for the resident to participate in the program and provide services to the community. The Care Team (Social Service designee, Activities Director or another designee), will track program participation and quality of commitments each week. The compensation to the resident, for the services performed, will never exceed $50.00 per month. The statement of agreement specifies the stipend rate for the services completed as well as the location, frequency and requirements to receive the stipend."II. Resident #13A. Resident statusResident #13, age less than 65, was admitted on 6/15/16 and readmitted on 6/27/24. According to the December 2024 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, type 2 diabetes mellitus, heart failure and schizoaffective disorder (mental illness). The 10/1/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required maximum assistance from staff with dressing and toileting and used a motorized wheelchair for mobility throughout the facility. B. Resident interviewResident #13 was interviewed on 12/11/24 at 10:36 a.m. Resident #13 said she participated in a work program at the facility. Resident #13 said she worked three days a week calling Bingo and also worked in the resident soda store. The resident said she was supposed to be paid 50 dollars a month. The resident said she had not been paid at all for her time in November 2024. The resident said she did not know when she would get paid. C. Record reviewA review of the resident's comprehensive care plan included participation in a therapeutic stipend program by calling and organizing weekly bingo games and running the soda store. The goals were for the resident to complete her commitment log by the assigned due date with initials of care partners for each day she participated. -The work program commitment log was completed for November 2024 however the resident was not paid until 12/12/24 (see interview below). III. Staff interviews The business office manager (BOM) was interviewed on 12/18/24 at 10:20 a.m. The BOM said the work stipend program was run by the activity director (AD). She said she printed the checks from corporate as soon as she received them but there was no consistency to when they were received. The AD was interviewed on 12/18/24 at 11:14 a.m. The AD said he had been working at the facility in this role for two months and was new to the process. The AD said he was responsible for submitting the request for residents to be paid for the workstipend program. He said he submitted the request to corporate by email and then the vendor sent a check to the business office at the facility. The AD said he did not submit the request correctly for November 2024 and it caused a delay in the payment to the residents. He said the check was cashed for November on 12/12/24 (during the survey) and deposited into the residents petty cash accounts.

Based on observations and interviews, the facility failed to ensure residents' personal funds accounts were managed adequately for the facility and accessible to the residents for four (#23, #6, #46 and #47) of four residents out of 41 sample residents. Specifically, the facility failed to ensure residents were able to access their personal funds accounts during banking hours, after hours and on the weekends. Findings include:I. Resident interviewsResident #23 was interviewed on 12/11/24 at 12:02 p.m. Resident #23 said he did not have access to his money on weekends. Resident #23 said sometimes he also could not access his money on weekdays, including times the facility had run out of money to provide the residents during regular banking hours. Resident #6 was interviewed on 12/11/24 at 3:18 p.m. Resident #6 said she was unable to access her money on weekends. Resident #46 was interviewed on 12/11/24 at 4:45 p.m. Resident #46 said he was able to access his personal funds Monday through Friday, but the money was not available on weekends. Resident #47 was interviewed on 12/11/24 at 7:45 p.m. Resident #47 said he was unable to obtain money when he needed it. Resident #47 said he had to cancel plans with a friend because his personal funds were not available to him. II. Resident group interviewThe resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted of five residents (#115, #28, #4, #16 and #17) who were identified as interviewable by the facility and assessment. The residents said they wanted their personal funds to be available on the weekends. III. ObservationOn 12/17/24 at 1:04 p.m. a sign was observed on the door of the activity department office. The sign indicated the resident banking hours were Monday through Friday from 9:30 a.m to 3:30 p.m. IV. Staff interviewsThe business office manager (BOM) was interviewed on 12/16/24 at 3:30 p.m. The BOM said the resident council had voted for banking hours and had also voted to not have money available to the residents on weekends in September 2024. The activity director (AD) was interviewed on 12/18/24 at 11:21 a.m. The AD said the residents came to the activity department to obtain personal funds. The AD said the personal funds that were available were limited a week ago. The AD said there were times he could not give the residents the amount of money they requested. The AD said a resident requested $50.00 a week ago and the AD was only able to give the resident $30.00. The AD said the resident said they would wait to obtain the money until they could receive the full $50.00. The AD said the resident received the $50.00 requested the next day. The AD said the resident council voted on banking hours and availability of funds, which did not include weekends. The BOM was interviewed a second time on 12/18/24 at 11:50 a.m. The BOM said it was her understanding that residents needed to have access to funds on weekends. The BOM said there had been times during banking hours when the residents could not access $50.00 and she did not know how often this had occurred. The BOM said there was not an established minimum balance to initiate obtaining additional money. The nursing home administrator (NHA) and the regional director of operations (RDO) were interviewed together on 12/18/24 at 5:19 p.m. The RDO said the facility did not have a set amount of money that needed to be in the personal funds box on a daily basis. The RDO said he had not heard there were issues with personal funds availability at the facility. The RDO said the facility's prior administrator had been concerned about theft and had made a decision to limit the availability of personal funds after hours. The RDO said the residents should be able to access personal funds on weekends. The RDO said the resident council could not vote to restrict personal funds further than what was required and there was a plan in place for the facility to have the resident council restrictions removed. The RDO said the facility was going to ensure there was resident access to personal funds after banking hours and on weekends. The RDO said it was important to establish a process for replacing money available when the bank balance decreased to a certain level as the replacement process could take up to two days. The RDO said the BOM and the AD might have been waiting too long to initiate this process when funds were getting too low.

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for 14 out of 65 resident rooms. Specifically, the facility failed to ensure:-Residents were provided clean washcloths and hand towels in their rooms on the East and West units;-Resident #6's closet was cleaned timely; and,-The clogged toilet in a resident's bathroom was cleaned timely and appropriately. Findings include:I. Facility policy and procedureThe Homelike Environment Policy, revised 2021, was provided by the director of clinical services (DCOS) on 12/17/24 at 6:58 p.m.. The policy read in pertinent part, "The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment, personalized room furniture and room arrangements, clean bed and bath linens that are in good condition, pleasant neutral scents, and comfortable sound levels."II. Failed to ensure residents were provided clean washcloths and hand towelsA. ObservationsOn 12/11/24 at 3:15 p.m., room #26 had no hand towels or washcloths. On 12/12/24 at 9:44 a.m. room #24 had no hand towels or washcloths. On 12/12/24 9:40 a.m., room #51 had no hand towels or washcloths. On 12/16/24 beginning at 2:12 p.m., the following observations were made:-Room #30 had no hand towels or washcloths;-Room #24 had no hand towels or washcloths;-Room #25 had no hand towels or washcloths;-Room #29 had no hand towels or washcloths;-Room #12 had no hand towels or washcloths;-Room #3 had no hand towels or washcloths;-Room #10 had no hand towels or washcloths;-Room #9 had no hand towels or washcloths;-Room #4 had no hand towels or washcloths;-Room #54 had no hand towels or washcloths; and,-Room #3 had no hand towels or washcloths. On 12/17/24 at 6:25 p.m. the linen closets on the East and West units contained linen towels. B. Resident group interviewThe resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted offive residents (#115, #28, #4, #16, and #17) who were interviewable based on assessment and facility. The residents said they continued to have concerns about the lack of towels. The residents said linen towels were not available. The residents said the housekeepers would remove the dirty towels and not replace them with clean towels. The residents said there were not enough towels and they had to use paper towels to wash and dry their faces. C. Resident interviewResident #49 was interviewed on 12/16/24 at 2:20 p.m. Resident #49 said he was not offered any towels. He said that he wished he had linen towels available. D. Staff interviewThe director of nursing (DON) was interviewed on 12/17/24 at 6:10 p.m. The DON said the nursing staff were responsible for passing out towels to the residents. She said towels should be passed out on each shift. She said she was not aware the towels were not being passed out. She said she would correct the issue immediately. The nursing home administrator (NHA) was interviewed on 12/17/24 at 6:19 p.m. The NHA said the facility had recently purchased quite a lot of towels. He said there was no shortage of towels. III. Failed to ensure Resident #6's closet was cleaned appropriately On 12/11/24 at 3:15 p.m., Resident #6's closet had remnants of dried feces on the floor of the closet, on the door and along the wall. A. Resident interview and observationResident #6 was interviewed on 12/11/24 at 3:15 p.m. Resident #6 said in September 2024 a few months ago she was scheduled for a colonoscopy. She said when she was completing the preparation for the colonoscopy, she got up to go to the bathroom and fell. She said when she fell, feces sprayed all over the floor. She said there continued to be bowel movement on the closet floor and splattered on the wall. She said she had requested it to be cleaned up, however it had not been cleaned. Resident #6's closet had remnants of dried feces on the floor of the closet. There was also dried feces on the door and along the wall. B. Staff interviewsThe regional director of operations (RDO) was interviewed on 12/18/24 at approximately 2:00 p.m. The RDO said he observed the dried feces on the floor of Resident #6's closet and the wall. He said it would be cleaned immediately. An unidentified houskeeper was interviewed on 12/19/24 at approximately 8:30 a.m. an She said the resident's rooms were cleaned daily. III. Failure to ensure the clogged toilet in a residents bathroom was cleaned timely and appropriatelyA. Observation and resident interviewsOn 12/12/24 the following was observed in Resident #51's room and the East unit:At 9:33 a.m. an unidentified housekeeper exited room #51 and placed a wet floor sign in front of the door to the room. After the unidentified housekeeper exited the area, the toilet in the bathroom was observed to have a backup of water approximately an inch from the toilet seat. The water in the toilet was dark brown and contained feces, and toilet paper was visible in a mound on top of the water. A plunger was in the corner of the bathroom with plastic wrapped around the rubber end of the plunger. A resident that resided in room #51 said he reported that the toilet was plugged to the housekeeper who cleaned his room. At 11:19 a.m. the toilet in room #51 was observed and revealed the same concern as the previous observation (at 9:33 a.m.)At 1:31 p.m. the toilet in room #51 was observed and the water had receded to a normal level in the toilet and the toilet paper was no longer visible. The toilet water was dark brown and contained fecal matter. A resident who resided in room #51 said a staff member tried to work on the toilet but he was not sure who the staff member was. B. Staff interviewsThe maintenance director (MTD) was interviewed on 12/12/24 at 3:10 p.m. The MTD said he had not received training on how to clean bodily fluids so he followed up with the nurse in the east hall where room #51 was located. The MTD said he received a work order for a plugged toilet in room #51, so he told the nurse in the east hall that there was a toilet that needed to be unplugged. The MTD said the certified nurse aides (CNA) were told to glove up and have a trash bag to unplug the toilet. The MTD said this was the process at the facility for the last four years. Registered nurse (RN) #2 was interviewed on 12/16/24 at 2:25 p.m. RN #2 said the MTD asked her on 12/12/24 where the CNA was working. RN #2 said the MTD told her (RN# 2) the toilet in room #51 was clogged and the facility staff had put in a work order for the clogged toilet. RN #2 said the MTD told the nurse go into room #51's bathroom, reach in the toilet and remove the paper and stool from the toilet. RN #2 said the MTD did not instruct the staff which PPE to use and told RN #2 that the nursing staff were trained on bodily fluids so it was a nurse or CNAs job to unplug the toilet. RN #2 said a CNA unplugged the toilet in room #51. The RDO was interviewed on 12/18/24 at 12:30 p.m. The RDO said after speaking to the facility's regional plant operations support, plunging or unplugging a toilet was something all staff could do. The RDO said if staff were unable to repair a toilet in a timely manner, the residents could use another bathroom in the facility. The RDO said there were plungers in the facility that could be used to plunge the toilets. The RDO said the housekeeping staff could plunge the toilet. The RDO said while the nursing staff was able to plunge a toilet, the preference was the CNA to prioritize resident care as it was a more specialized area, although a CNA could plunge the toilet if needed.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of verbal abuse for two (#37 and #21) of five residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to thoroughly investigate allegations of verbal abuse for Resident #37 and #21. Findings include:I. Facility policy and procedureThe Abuse policy, dated 2/29/24, was received from the nursing home administrator (NHA) on 12/11/24. The policy read in pertinent part, "This community 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."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."Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again."In addition to an investigation by the police department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident. "Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 (five) working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken." II. Resident #37A. Resident #37Resident #37, age less than 65, was admitted on 8/19/24. According to the December 2024 computerized physician orders (CPO), diagnoses included fluid overload, cognitive communication deficit and hypertension. The 11/19/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. She was dependent on staff for activities of daily living (ADL). B. Resident interviewResident #37 was interviewed on 12/12/24 at 9:38 a.m. Resident #37 said Resident #31 yelled at her and scared her. She said it made her feel unsafe. On 12/12/24 at 2:44 p.m. the NHA was informed of Resident #37's report of not feeling safe because Resident #31 yelled at her. C. Record reviewA complaints concern card, dated 12/12/24, documented that Resident #37 reported she did not feel comfortable/safe with another resident (Resident #31) who yelled at her. The form documented the facility would make sure the two residents did not sit near each other in the dining room. -The complaints form did not include any further documentation to indicate the facility completed an investigation of Resident #37's allegation. -The form failed to include staff interviews, interviews from other residents, or further interviews with Resident #37 or Resident #31.-The facility was unable to provide documentation of an investigation related to Resident #37's allegation of verbal abuse from Resident #31. D. Staff interviewsThe social services consultant (SSC) was interviewed on 12/16/24 at 11:55 a.m. The SSC said anytime there was an allegation of abuse, an investigation should be completed and interventions put into place to make residents feel safe. The NHA was interviewed on 12/19/24 at 10:09 a.m. The NHA said he spoke with Resident #37 on 12/12/24 about her concern with Resident #31. He said she did not report feeling afraid, but she wanted to be kept separated from Resident #31. He said his interview with Resident #37 constituted an investigation of the allegation. He said based on the findings of his interview with a resident he would determine if the facility needed to complete an investigation of the incident. The NHA said based on what Resident #37 told him when he interviewed her, he did not think the incident needed to be investigated as an allegation of abuse. -The NHA did not provide documentation of his interview with Resident #37 before the survey exit on 12/19/24. E. Facility follow upThe director of clinical services (DOCS) provided additional information via email on 12/20/24 at 3:01 p.m. The email documented that, upon notification of a potential concern, the facility had acted timely and interviewed Resident #37. The email indicated the interview conducted by the NHA was completed and at no time did Resident #37 claim to have been the victim of abuse. The concern was transcribed to a grievance form and the resident signed to express satisfaction with the proposed resolution to the concern.-However, the facility did not provide documentation of the NHA's interview with Resident #37 or documentation of further investigation into the incident. III. Resident #21 A. Resident statusResident #21, age greater than 65, was admitted on 11/14/23 and readmitted on 8/3/24. According to the December 2024 CPO, diagnoses included congestive heart failure, major depressive disorder and anxiety disorder. The 11/19/24 MDS assessment revealed Resident #21 was cognitively intact with a BIMS score of 13 out of 15. He was independent with personal hygiene, dressing and eating. The assessment documented the resident did not exhibit any behavioral symptoms. B. ObservationsOn 12/12/24 at 3:09 p.m. Resident #21 requested his scheduled Lyrica medication (a prescription medication used to treat nerve and muscle pain). Resident #21 was very upset and yelled, "This place does not care, I would rather die than be here." At 3:13 p.m., Resident #21 left his room in his wheelchair to go outside to smoke. As he approached the outside door, Resident #44 got in front of him and told him he looked guilty. Resident #21 began yelling at Resident #44 and told her to shut up and get out of the way. Resident #21 was very angry and told Resident #44 if he wanted her opinion he would give it to her. Resident #21 moved past Resident #44 and went outside. Resident #44 followed Resident #21 outside and continued talking to him. At 3:14 p.m., Resident #21 got more angry, moved closer to Resident #44 and waved his hands in front of Resident #44's face aggressively. At 3:16 p.m. registered nurse (RN) #1 was summoned after yelling for her attention for two minutes. RN #1 went outside to address the situation between Resident #21 and Resident #44. At 3:18 p.m., Resident #21 returned inside. At 3:35 p.m. the NHA was informed of the incident between Resident #21 and Resident #44. C. Record review A review of Resident #21's electronic medical record (EMR) on 12/19/24 did not reveal any documentation of the reported incident between Resident #21 and Resident #44 reported to RN #1 and the NHA on 12/12/24. The facility investigation was requested on 12/18/24 and again on 12/19/24. The NHA provided a grievance form that he completed on 12/12/24. The grievance form documented Resident #21 was agitated but did not have any concerns. The grievance form did not include any interviews with Resident #44, staff or other residents. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 12/12/24 at 3:40 p.m. CNA #2 said when residents were agitated and aggressive towards another resident, the staff attempted to separate the residents and redirect them. She said it was also the staff's responsibility to report the incidents to the NHA. CNA #2 said she was not aware of any incident that occurred between Resident #21 and Resident #44 on 12/12/24. The SSC was interviewed on 12/17/24 at 11:47 a.m. The SSC said any time an allegation of any type of abuse was reported, an investigation should be done. She said the investigation should include interviews with the parties involved, staff and witnesses. The SSC said once the interviews were completed, the facility should follow up with interventions, education with staff and anything else that would help the residents feel safe. The NHA was interviewed on 12/19/24 at 9:57 a.m. The NHA said any time allegations were made of verbal or physical abuse, they should be investigated. He said the residents involved should be interviewed to determine if the investigation should proceed. The NHA said he, or his designee, were responsible for investigating all allegations. The NHA said he interviewed Resident #21 and Resident #44 and neither resident expressed any concerns. He said he followed up a couple of days after the incident and both residents reported that they felt uncomfortable. The NHA said he reviewed reports for each resident for 24 hours after the incident to look for changes in the residents and did not find anything that would have increased either residents' agitation on the day of the incident.-However, the facility did not provide documentation of the NHA's interview with Resident #21 or Resident #44 or documentation of further investigation into the incident.

Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#216) of three residents out of 41 sample residents. Specifically, the facility failed to provide Resident #216 with an appropriate discharge process. Findings include:I. Facility policy and procedureThe Discharge Planning policy, dated 2/29/24 was provided by the director of clinical services (DOCS) on 12/19/24 at 1:34 p.m. It read in pertinent part, "The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identity changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. The results of the evaluation and the final discharge plan will be discussed with the resident or the resident's representative. All relevant information will be provided in a discharge summary to avoid delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living arrangement. If discharge to community is determined to not be feasible, the facility will document who made the determination and why. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge."II. Resident statusResident #216, under the age of 65, was admitted on 8/4/24 and discharged on 10/19/24 to the emergency department. According to the October 2024 computerized physician orders (CPO), diagnoses included diverticulitis (inflamed pouches in the large intestine), frontal lobe deficit following cerebral infarction (disrupted blood flow to the brain), hemiplegia and hemiparesis, major depressive disorder, anxiety disorder and acute kidney failure. The 10/19/24 minimum data set (MDS) assessment documented the resident required set up assistance with eating and was independent with all other activities of daily living (ADL). The assessment documented the resident had physical and verbal behaviors directed at others. The assessment documented there was no active discharge planning in place. A review of the resident's electronic medical record (EMR) revealed on 8/20/24 the resident was documented as moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. III. Record reviewThe 30-day notice of involuntary discharge, dated 9/24/24, was provided by the DOCS on 12/18/24. The discharge notification documented the letter informed Resident #216 the facility issued an involuntary discharge in the interest of Resident #216's safety and welfare as well as the safety and welfare of other residents who resided within the facility. Resident #216 was to be discharged from the facility on 10/24/24. A review of Resident #216's EMR documented in a 10/19/24 provider note at 2:19 p.m. that a nurse called to report the facility was immediately discharging Resident #216 from the facility as he assaulted a staff member who was injured and the nurse reported the resident was given a final warning 30 days ago (9/24/24) for violent behavior. The nurse on duty requested to send Resident #216 with his medications. A review of Resident #216's EMR revealed a progress note written on 10/19/24 at 4:50 p.m. that Resident #216 left the facility at 4:30 p.m. with staff transportation to a local hospital. Resident #216 took his belongings with him, which included: wallet, phone, phone charger, hat, slippers, pictures and cross necklaces. The emergency department (ED) provider notes, dated 10/19/24, documented Resident #216 was apparently hostile with his care facility so he was not allowed back that night (10/19/24). The ED had anticipated Resident #216 was to be transferred back to his long-term care facility, however the facility had refused to take the resident back because of his behavior. -However, a review of Resident #216's EMR failed to reveal documentation which indicated the resident had been provided education related to his immediate discharge or that the resident understood his immediate discharge from the facility. IV. Staff interviewsThe regional director of operations (RDO) was interviewed on 12/19/24 at 10:30 a.m. The RDO said Resident #216 had fallen on 10/19/24 and initially refused to go to the emergency department and returned to his room. The RDO said while Resident #216 was in his room, the facility management team had a call to discuss Resident #216. The RDO said the facility wanted to ensure that Resident #216 received proper care because the resident took coumadin (a blood thinner) and had fallen. The RDO said the facility determined, because of the numerous previous conversations with the resident regarding his behavior, the facility needed to figure out an immediate discharge because Resident #216 was putting other residents at risk. The RDO said Resident #216 agreed later the same day (10/19/24) to be sent to the hospital to be assessed. The RDO said because the manager on duty was involved in an occurrence earlier in the day with Resident #216 where he assaulted a staff member, the facility had the charge nurse on duty discuss Resident #216's discharge with the emergency department. The RDO said any manager on duty could and should document conversations and refusals of care in the resident's EMR.

Based on record review and interviews, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for one (#216) of three residents reviewed for discharge out of 41 sample residents. Specifically, the facility failed to reassess Resident #216's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and directed the hospital that the resident was not allowed to return to the facility. Findings include:I. Facility policy and procedureThe Discharge Planning policy, dated 2/29/24 was provided by the director of clinical services (DOCS) on 12/19/24 at 1:34 p.m. It read in pertinent part, "The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This will include identifying ways for residents to be active participants and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identity changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. The results of the evaluation and the final discharge plan will be discussed with the resident or the resident's representative. All relevant information will be provided in a discharge summary to avoid delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living arrangement. If discharge to community is determined to not be feasible, the facility will document who made the determination and why. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge."II. Resident statusResident #216, under the age of 65, was admitted on 8/4/24 and discharged on 10/19/24 to the emergency department. According to the October 2024 computerized physician orders (CPO), diagnoses included diverticulitis (inflamed pouches in the large intestine), frontal lobe deficit following cerebral infarction (disrupted blood flow to the brain), hemiplegia and hemiparesis, major depressive disorder, anxiety disorder and acute kidney failure. The 10/19/24 minimum data set (MDS) assessment documented the resident required set up assistance with eating and was independent with all other activities of daily living (ADLs). The assessment documented the resident did not have an active discharge plan. The assessment documented the resident had physical and verbal behaviors directed at others. A review of the resident's electronic medical record (EMR) documented on 8/20/24 the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. III. Record reviewA review of Resident #216's EMR revealed a progress note written on 10/19/24 at 4:50 p.m. that Resident #216 left the facility at 4:30 p.m. with staff transportation to a local hospital. Resident #216 took his belongings with him, which included: wallet, phone, phone charger, hat, slippers, pictures and cross necklaces. The emergency department (ED) provider notes, dated 10/19/24, documented Resident #216 was apparently hostile with his care facility so he was not allowed back that night (10/19/24). The ED had anticipated Resident #216 was to be transferred back to his long-term care facility, however the facility had refused the resident because of his behavior. -However, review of Resident #216's EMR revealed there was no documentation to indicate the facility had reassessed the resident after his transfer to the ED to determine if the resident was able to return to the facility.-There was no documentation in Resident #216's EMR to indicate what needs the facility could not meet after the resident's transfer to the ED.IV. Staff interviewsThe regional director of operations (RDO) was interviewed on 12/19/24 at 10:30 a.m. The RDO said Resident #216 had fallen on 10/19/24 and initially refused to go to the emergency department and returned to his room. The RDO said while Resident #216 was in his room, the facility management team had a call to discuss Resident #216. The RDO said the facility wanted to ensure that Resident #216 received proper care because the resident took coumadin (a blood thinner) and had fallen. The RDO said the facility determined, because of the numerous previous conversations with the resident regarding his behavior, the facility needed to figure out an immediate discharge because Resident #216 was putting other residents at risk. The RDO said Resident #216 agreed later the same day (10/19/24) to be sent to the hospital to be assessed. The RDO said because the manager on duty was involved in an occurrence earlier in the day with Resident #216 where he assaulted a staff member, the facility had the charge nurse on duty discuss Resident #216's discharge with the emergency department. The RDO said any manager on duty could and should document conversations and refusals of care in the resident's EMR.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#64) out of four sample residents reviewed for discharge out of 41 sample residents. Specifically, the facility failed to ensure the discharge summary included a recapitulation of the resident's stay, a final summary of the resident's status and recapitulation of the residents stay at the facility for Resident #64. Findings include:I. Facility policy and procedureThe Discharge Summary and Plan last revised October 2022 was provided by the director of clinical services (DOCS) on 12/19/24. The policy read in percent part, "When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident."II. Resident #64A. Resident statusResident #64, age less than 65, was admitted on 8/14/24 and discharged home with family on 10/11/24. According to the December 2024 computerized physician orders (CPO) diagnoses included congestive heart failure, pulmonary hypertension, severe protein calorie malnutrition and psychoactive substance abuse. The 8/20/24 minimum data set (MDS) had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The MDS coded the resident had inattention and disorganized thinking. The resident was dependent on staff for personal hygiene. -The discharge planning review dated 8/16/24 documented the resident planned on staying long-term in the facility. B. Record reviewThe 10/11/24 progress note documented the nurse practitioner was notified and advised the nurse that the resident could have a four day pass, but advised that the resident needed to obtain his medications. The nurse spoke to the resident and his emergency contact on the phone. The nurse advised the resident to come back to the facility to obtain his medications while he was out on pass. The nurse explained the risk of being without his meditations for four days. The resident said he was going to try and pick up the medications. The 10/11/24 nurse practitioner note documented in the progress note showed the provider was notified the resident left the facility to see his mother in the hospital. The note further documented the resident was not returning for four days. The nurse educated the resident to return to the facility to collect his chronic medications. -Review of Resident #64's electronic medical record (EMR) failed to show documentation which indicated a final summary of the resident's status and recapitulation of the residents stay. C. Staff interviewsRN #1 was interviewed on 12/19/24 at 10:30 a.m. RN #1 said she was the nurse on duty when Resident #64 left the facility by choice to see his mother who had suffered a stroke.. RN #1 said she provided the resident with a one day supply of his medications. She said the resident was on Eliquis (blood thinner), which was an important medication he needed. She said he then called and said he would be out for four more days and she said his medications were ordered by the physician. RN #1 said the resident's mother picked up the medications from the facility. She said the resident did not return to the facility. She said could not locate that a discharge summary was completed.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#32 and #48) of eight residents reviewed out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #32, who was dependent on staff for bathing, received her scheduled showers.-Ensure Resident #48, who was blind, received meal assistance. Findings include:I. Facility policy and procedureThe Bath, Shower/Tub policy, revised February 2018, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. The policy read in pertinent part,"The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident, all assessment data, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, the signature and title of the person recording the data. Notify the supervisor if the resident refuses the shower/tub bath."II. Resident #32A. Resident statusResident #32, age less than 65, was admitted on 9/17/21. According to the December 2024 computerized physician's orders (CPO), diagnoses included dementia, kidney disease, anxiety, cerebral aneurysm (bulge or ballooning of a blood vessel in the brain) and blindness. The 11/5/24 minimum data set (MDS) assessment revealed Resident #32 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set-up assistance from staff with oral hygiene and was dependent for toileting and showering/bathing. B. Resident interview and observationResident #32 was interviewed on 12/11/24 at 10:23 a.m. Her hair was disheveled and there was a large amount of tangled hair on the back of her head, approximately two inch by two inch area. The resident had body odor. Resident #32 said she had knots in her hair and had not showered in at least a week. Resident #32 said the staff had to use a lift to assist her with showering. Resident #32 said the staff frequently missed providing her showers. C. Record reviewResident #32's care plan, revised 10/30/24, revealed Resident #32's shower preference sheet had been updated and she was dependent on one staff to provide showers, and one to two staff to assist with personal hygiene and oral care. Review of the shower schedule posted at the nurse's station revealed Resident #32 was scheduled to receive showers every week on Monday and Friday. Resident #32's bathing/showering record from 9/1/24 to 11/30/24 was provided by the DOCS on 12/17/24 at 1:33 p.m. The bathing/shower records provided and the treatment administration record (TAR) for December 2024 were reviewed from 10/16/24 to 12/16/24. The records revealed the following:Resident #32 refused one shower on 12/13/24 (during the survey).-There was no other documentation to indicate Resident #23 had refused other scheduled showers. Resident #32 received 13 showers out of 16 opportunities. There was no documentation indicated the resident had received a shower since 11/29/24, indicating the resident had not received a shower in 17 days..-Other than the documented refusal on 12/13/24, review of Resident #32's bathing records revealed no documentation to indicate why the resident missed her showers or what interventions were attempted for Resident #32's missed showers. D. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/17/24 at 9:58 a.m. LPN #1 said Resident #32 was very cooperative and did not refuse any care, including bathing. Certified nurse aide (CNA) #4 was interviewed on 12/17/24 at 10:14 a.m. CNA #4 said Resident #32 was dependent on staff and the staff used a lift to provide her showers. CNA #4 said Resident #32 did not refuse showers. CNA #4 said there was often one day per week when there were not enough staff present to complete all of the residents' showers. CNA #4 said when a resident did not receive a shower, staff tried to provide the shower the following day. CNA #4 said she reported to the nurse when a resident did not receive a shower. CNA #3 was interviewed on 12/17/24 at 10:52 a.m. CNA #3 said Resident #32 did not usually refuse to shower, however, CNA #3 said Resident #32 told her that she refused to shower on 12/16/24 because CNA #3 was not working that day. The director of nursing (DON) and the DOCS were interviewed together on 12/17/24 at 3:39 p.m. The DOCS said Resident #32's shower record contained multiple entries of "not applicable" and he did not understand why this was documented. The DOCS said there were no showers documented for Resident #32 between 11/29/24 and 12/16/24. The DOCS said there were no additional documented shower refusals. The DON said she would expect Resident #32 to receive showers as scheduled. III. Resident #48A. Resident statusResident #48, age 68, was admitted on 10/3/22. According to the December 2024 CPO, diagnoses included unspecified macular degeneration (decreased vision), dysphagia, depression and cognitive communication deficit. The 9/27/24 MDS assessment showed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident had moderately impaired vision. The resident was independent in eating. B. Resident interviewResident #48 was interviewed on 12/11/24 at approximately 3:00 p.m. Resident #48 said she was legally blind and she could only see shadows. C. ObservationsDuring a continuous observation of the dinner meal on 12/12/24, beginning at 5:09 p.m. and ending at 5:11 p.m. the following was observed:At 5:09 p.m.,Resident #48 received her meal. An unidentified CNA served the resident her meal. The unidentified CNA told the resident what was on her plate, but did not tell her where the food was located on the plate. Resident #48 was putting her hands over the plate attempting to locate the fish sandwich. At 5:11 p.m., the resident said out loud, "I do not know where my food is but I will try to eat it."During a continuous observation of the dinner meal on 12/16/24, beginning at 5:06 p.m. and ending at 5:08 p.m., the following was observed: dinner mealAt 5:06 p.m., the resident received her meal. CNA #5 told the resident what was on her plate, but not the location of the food on the plate. At 5:08 p.m., the resident was provided a packet of salt and pepper with her meal. The resident opened the salt packet. She did not know which each packet was, so she held the packet over her food and put her finger into the salt that was pouring out to identify if it was salt or pepper. When she received her meal and the salt and pepper packets the staff did not identify. D. Record reviewThe care plan, revised on 5/9/24, identified the resident had impaired visual function related to cataracts. Pertinent approaches included to tell the resident where her food items were located and to be consistent. E. Staff interviewsCNA #8 was interviewed on 12/18/24 at 5:00 p.m. CNA #8 said Resident #48 was blind and that she needed to know the location of her food. She said she was able to eat independently, but needed to be told where the food was located. The assistant director of nursing (ADON) was interviewed on 12/18/24 at 5:29 p.m. The ADON said Resident #48 was legally blind. She said the staff needed to tell the resident where her food was on her plate, not just what was on the plate. She said she would provide training to the staff.

Based on observations, interviews and record review, the facility failed to ensure one (#9) of four residents reviewed for activities of 41 sample residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Specifically the facility failed to offer and provide a personalized activity program for Resident #9. Findings include:I. Resident #9A. Resident statusResident #9, age greater than 65, admitted on 5/6/2020. According to the December 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, history of falling and dementia. The 9/20/24 minimum data set (MDS) assessment revealed the resident had both short term and long term memory impairments and had severely impaired decision making skills through staff assessment. The resident was dependent on staff for activities of daily living (ADL). The 12/23/23 MDS assessment revealed it was very important for the resident to have books, newspapers and magazines to read, to listen to music, to go outside to get fresh air and for the resident to participate in religious services or practices. B. Observations On 12/12/24 at 10:22 a.m. Resident #9 was lying in bed. There was no music playing in the room. On 12/16/24 at 11:30 a.m. Resident #9 was sitting in her wheelchair by herself in the common area with no activity or no staff interacting with her. On 12/16/24 at 4:30 p.m. Resident #9 sitting alone in the common area. She had no meaningful activity, and no one was interacting with her. On 12/17/24 at 10:36 a.m., the resident was awake in bed. There was no music playing in the room, and no meaningful activity. C. Resident #9's representative interview The resident's representative was interviewed on 12/18/24 at 10:30 a.m. The representative said religion was very important to her mother. She said the resident used to attend Bible studies, attend church and she would read the bible. She said when she visits she reads from her mother's Bible. D. Record reviewThe care plan, revised on 9/9/24, identified the resident enjoyed many different activities. She liked both group and individual activities. She was currently receiving one on one visits related to her hospice diagnosis. Independent and active interests included reading the Bible. Pertinent approaches include encouraging the resident to participate by inviting the resident to programs of interest and providing the resident a monthly calendar. A review of the resident's electronic medical record (EMR) revealed the last time the resident was offered a one on one activity was on 9/24/24 and it was declined by the resident. Participation records from 11/8/24 to 12/8/24 for spiritual activities, such as church and Bible study, documented the resident was not available on 12/8/24. There was no other documentation indicating the resident was offered or attended spiritual activities. Participation records from 11/8/24 to 12/8/24 for creative expression, such as music, documented the resident attended a group activity on 12/6/24 and one refusal on 11/24/24. There was no other documentation indicating the resident was offered or attended spiritual activities. Participation records from 11/8/24 to 12/8/24 for sensory revealed no data indicating the resident was offered or attended sensory activities. Review of the EMRrevealed no documentation that the resident was on a one on one program. The hospice notes did not show any documentation that a volunteer or chaplain visited with the resident. Review of the resident's EMR did not reveal a record to show the resident was assisted to go outside per her preference. E. Staff interviewThe activity director (AD) was interviewed on 12/18/24 at 10:44 a.m. The AD said he recently started working at the facility. He said there was activity staff present at the facility seven days a week. He said he had two assistants. He said he was getting to know all of the residents. He said he did not have sensory programs on the calendar, but that was something he was looking at adding to the calendar. The AD said Resident #9 would benefit from sensory stimulation. He said he invited her to musical groups. He said the resident was not on a one to one program. He said he would have one of his assistants read the Bible to the resident, as he was not aware that was important to the resident. He said he was not aware the resident liked to go outside. The AD said it would be a benefit to have the nursing staff to help bring and invite residents to the activities.

Based on record review and interviews, the facility failed to ensure one (#24) of two residents out of 41 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure treatment was provided to Resident #24's skin injury in a timely manner. Findings include:I. Resident #24A. Resident statusResident #24, age less than 65, was admitted on 7/23/21. According to the December 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, history of other venous thrombosis (a condition where a blood clot, or thrombus, forms in a vein and blocks blood flow) and embolism (occurs when a blockage, called an embolus, lodges in a blood vessel and prevents blood from flowing). The 11/13/24 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 resident was independent with activities of daily living (ADL). B. ObservationsOn 12/11/24 at 9:46 a.m. Resident #24 was observed to have his pant leg pulled up. He had a fast food napkin stuck to his left shin which was bleeding. Resident #24 said he had injured his leg by falling at his daughter's house on 12/7/24. On 12/12/24 at 2:32 p.m. Resident #24's leg was observed with registered nurse (RN) #1. RN #1 measured the resident's skin tear on his left shin. She asked the resident what happened and Resident #24 said he fell at his daughter's house on Saturday (12/7/24). RN #1 cleaned and applied a dressing to the resident's skin tear. C. Record reviewReview of Resident #24's skin daily skin observation forms from 12/7/24 to 12/12/24 documented the resident's skin was monitored daily from 12/7/24 through 12/12/24 and there were no concerns.-However, observations on 12/11/24 and 12/12/24 revealed Resident #42 had a skin tear on his left shin which the resident reported he obtained from a fall at his daughter's house on 12/7/24 (see observations and resident interview above). -Review of Resident #24's electronic medical record (EMR) failed to reveal the resident's left shin skin tear was identified by the facility and was treated/monitored prior to 12/12/24.-Resident #24's EMR failed to reveal the resident's physician was notified of the skin tear..An undated wound education was received from the director of nursing (DON) on 12/12/24 at 3:09 p.m. The education documented that when a new area of skin breakdown on a resident was identified, it was important that the nurse was notified immediately. It was the responsibility of the nurse to notify the physician, initiate a risk management occurrence and obtain treatment orders. The education included that appropriate documentation of the skin concern was required. II. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/12/24 at 2:20 p.m. LPN #1 said she was not aware of Resident #24's skin tear on his leg. She said she did go into the resident's room yesterday (12/11/24) to administer medications, however, she said she did not notice the resident's leg and the resident did not tell her about his skin tear. RN #1 was interviewed on 12/12/24 at 2:50 p.m. RN #1 said she was not aware of Resident #24's left leg skin tear. She said she had been off for the past few days. RN #1 said she notified the physician and received orders to treat the skin tear (on 12/12/24).

Based on observation, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#23) of seven residents reviewed for vision services out of 41 sample residents. Specifically, the facility failed to ensure Resident #23's new glasses were obtained in a timely manner. Findings include:I. Resident #23A. Resident statusResident #23, age 69, was admitted on 2/1/21. According to the December 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis or weakness on one side of the body), peripheral vascular disease (disorder of the blood vessels), mood disorder and chronic obstructive pulmonary (lung) disease. The 9/26/24 minimum data set (MDS) assessment revealed Resident #23 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent with eating and dressing and required supervision or substantial assistance with most other activities of daily living (ADL). The MDS assessment documented the resident had adequate vision with eye glasses. B. Resident observation and interviewResident #23 was interviewed on 12/11/24 at 12:30 p.m. Resident #23 was not wearing eyeglasses. Resident #23 said he had seen an eye doctor, but the facility had not assisted him with getting new eyeglasses. Resident #23 said he was told the eyeglasses were ordered after his appointment a few months ago, but he had not received them. C. Record reviewThe 10/21/24 eye consult office visit revealed Resident #23 had an eye exam. The note had a new prescription for eyeglasses included with a note to deliver glasses two weeks from receipt of payment. The prescription was signed by the physician on 10/21/24.-Review of Resident #23's electronic medical record (EMR) did not reveal documentation to indicate the resident had received his new eye glasses.. II. Staff interviewsThe social services consultant (SSC) was interviewed on 12/17/24 at 12:01 p.m. The SSC said she would review Resident #23's EMR to check if the resident had received his new glasses. The SSC said she expected eyeglasses to be ordered within one month of an issued prescription. Certified nurse aide (CNA) #3 was interviewed on 12/17/24 at 10:59 a.m. CNA #3 said she had not seen Resident #23 with glasses on before and she did not know if he needed them. The SSC was interviewed a second time on 12/17/24 at 4:42 p.m. The SSC said Resident #23 had received a prescription for new eyeglasses when he saw the eye doctor on 10/21/24, however, she said the facility did not initiate a request for funding the purchase of Resident #23's eyeglasses until 12/13/24 (during the survey). The SSC said the request for the funding process should have been initiated shortly after the eye exam on 10/21/24. The SSC said the facility had not yet ordered the eyeglasses as of 12/13/24. She said the facility would order Resident #23's eyeglasses immediately.

Based on observation, interview and record review the facility failed to provide adequate supervision during use of assistive devices to keep residents free from safety hazards for three (#9, #26 and #24) of seven residents out of 41 sample residents. Specifically, the facility failed to: -Ensure care planned fall interventions were utilized consistently for Resident #9;-Ensure foot pedals were attached to Resident #9 and Resident #26's wheelchairs when facility staff were pushing the residents in their wheelchairs;-Ensure Resident #26 was transferred appropriately from her chair to her wheelchair using a gait belt (a device used to help prevent falls); and,-Ensure Resident #24 was assessed appropriately for safe smoking. Findings include:II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 5/6/2020. According to the December 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, history of falling and dementia. The 9/20/24 minimum data set (MDS) assessment revealed the resident had both short term and long term memory impairments. The resident had severely impaired daily decision making skills. The resident was dependent on staff for activities of daily living (ADL). The MDS assessment indicated the resident had not experienced any recent falls. B. Failure to ensure care planned fall interventions were utilized consistently 1. Facility policy and procedureThe Fall Management policy, dated 2/29/24, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m. It read in pertinent part, "The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. Research has shown that structured fall reduction programs can substantially reduce the rate of falls and fall related injuries in nursing facilities; however falls may likely occur. Risk factors that are internal to the resident included the resident's physical health and functional status. External factors include medication side effects, the use of appliances, and environmental conditions. To be effective, a fall reduction program is characterized by four components: Fall risk evaluation, care planning and implementation of interventions, ongoing evaluation process and a commitment by caregivers to make it work."Each resident will be reevaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy. Document in the resident's electronic medical record (EMR) the resident's response to interventions and revise the interventions if they are not successful. Monthly the quality assurance and performance improvement (QAPI) committee will review residents with falls for updated interventions and/or recommendations."2. Observations On 12/12/24 at 10:22 a.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/12/24 at 2:30 p.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/16/24 at 10:15 a.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/16/24 at 3:35 p.m. Resident #9 was lying in bed. There was no fall mat beside the bed. On 12/17/24 10:36 a.m. licensed practical nurse (LPN) #1 observed Resident #9 was in bed with no fall mat beside the resident's bed. LPN #1 looked in Resident #9's room and was unable to find the fall mat that was supposed to be beside the resident's bed when the resident was in bed. 3. Record reviewReview of Resident #9's December 2024 CPO revealed the resident had a physician's order to have a fall mat on the floor next to her bed while she was in the bed, revised 12/16/24 (during the survey). The care plan, initiated 9/9/24, identified Resident #9 was at high risk for falls. Pertinent interventions were to have a fall mat to the side of the bed when she was lying down. 4. Staff interviewsLPN #1 was interviewed on 12/17/24 at 10:36 a.m. LPN #1 reviewed Resident #9's care plan and confirmed the resident was to have a fall mat next to the bed when she was lying in bed. LPN #1 said the resident had not had any recent falls, however, she said she was a contracted agency nurse who had only been at the facility for three months. After confirming the fall mat was not beside Resident #9's bed, LPN #1 said she would locate a fall mat for the resident. The director of nursing (DON) was interviewed on 12/17/24 at 6:10 p.m. The DON said Resident #9 was on hospice services and was at risk for falls. She said the fall mats were available in the facility. She said she would ensure Resident #9 received the fall mat. C. Failure to have wheelchair foot pedals attached during transport 1. ObservationsOn 12/12/24 at 11:00 a.m. Resident #9 was being pushed into the dining room in her wheelchair by an unidentified staff member. There were no foot pedals attached to her wheelchair, which caused the resident to hold her feet up off the floor. On 12/12/24 at 4:23 p.m. Resident #9 was being pushed to the dining room in her wheelchair by certified nurse aide (CNA) #11. The resident did not have any foot pedals on her wheelchair, which caused the resident's feet to dangle. 2. Record reviewThe care plan, initiated 9/9/24, identified the resident was a high risk for falls. Pertinent interventions were to ensure the resident had proper footwear when mobilizing in her wheelchair. -The care plan did not include an intervention to ensure Resident #9's foot pedals were in place when transporting the resident in her wheelchair in order to prevent potential falls. III. Resident #26A. Resident statusResident #26, age greater than 65, was admitted on 9/27/22. According to the December 2024 CPO, diagnoses included atherosclerotic heart disease, hypertension, dementia and cognitive communication deficit. The 10/23/24 MDS assessment revealed the resident had both short term and long term memory impairments. The resident had severely impaired daily decision making skills. The resident was dependent on staff for ADLs. B. Failure to have wheelchair foot pedals attached during transport 1. ObservationsOn 12/12/24 at 4:23 p.m. Resident #26 was being pushed to the dining room in her wheelchair by CNA #5. The resident did not have any foot pedals on her chair which caused the resident's feet to dangle. On 12/16/24 at 8:57 a.m. Resident #26 was being pushed to her room in her wheelchair by CNA #6. The resident did not have any foot pedals on her wheelchair which caused the resident's feet to dangle. On 12/16/24 at 11:26 a.m. Resident #26 was being pushed into the dining room in her wheelchair by an unidentified staff member. There were no foot pedals on her wheelchair which caused the resident's feet to dangle. On 12/17/24 at 4:32 p.m. Resident #26 was being pushed to the dining room in her wheelchair by CNA #5. The resident did not have any foot pedals on her chair which caused the resident's feet to dangle. 2. Record reviewThe care plan, revised 7/30/24, identified Resident #26 was at risk for falls related to dementia, unsteady gait and history of falls. Pertinent interventions were to ensure the resident had proper footwear when mobilizing in her wheelchair.-The care plan did not include an intervention to ensure Resident #26's foot pedals were in place in order to prevent potential falls when the resident was being pushed in her wheelchair. The fall risk assessment dated 8/3/24 revealed Resident #26 as a high fall risk. 3. Staff interviewThe DON was interviewed on 12/17/24 at 6:10 p.m. The DON said Resident #9 and Resident #26's feet should not have been dangling while they were being transported in their wheelchairs (see Resident #9 and Resident #26's observations above). She said foot pedals needed to be used and all residents' wheelchairs should have the foot pedals. The DON said staff should not push a resident in their wheelchair if they had to hold their feet up. She said there was no system in place as to where the foot pedals were kept so they were easily accessible to staff for the transportation of residents. C. Failure to ensure resident was transferred appropriately from her chair to her wheelchair using a gait belt 1. Facility policy and procedureThe Safe Lifting and Movement of Residents policy, revised July 2017, was received from the DOCS on 12/18/24. The policy read in pertinent part, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts and lateral boards) and mechanical lifting devices."2. ObservationsOn 12/12/24 at 11:56 a.m. Resident #26 was assisted from her stationary chair to her wheelchair by an unidentified CNA. The CNA held both of the resident's hands while she pulled her to a standing position. The resident then pivoted to the wheelchair. -The CNA failed to use a gait belt on Resident #26 during the transfer. On 12/12/24 at 4:26 p.m. Resident #26 was assisted from her stationary chair to her wheelchair by CNA #5. CNA #5 held both of the resident's hands while she pulled her to a standing position. The resident then pivoted to the wheelchair. -CNA #5 failed to use a gait belt on Resident #26 during the transfer. On 12/17/24 at 4:29 p.m. Resident #26 was assisted from her stationary chair to her wheelchair by CNA #5. CNA #5 held both of the resident's hands while she pulled her to a standing position. The resident then pivoted to the wheelchair. -CNA #5 failed to use a gait belt on Resident #26 during the transfer. 3. Record reviewThe care plan, updated 10/29/24, identified Resident #26 was at risk for falls related to unsteady gait. Pertinent interventions included transferring the resident with supervision to substantial assistance.-The care plan failed to include the use of a gait belt during transfer. 4. Staff interviewsThe DON was interviewed on 12/17/24 at 6:10 p.m. The DON said when a resident was assisted to a standing position, a gait belt was to always be used for the safety of the resident. She said the nursing staff were trained to use the gait belt, however, she was not sure when the last training related to gait belt use was. The occupational therapist (OT) was interviewed on 12/18/24 at 4:53 p.m. The OT said a gait belt should be used when assisting a resident to a standing position. She said the trunk (upper body) had the best control and pulling on a resident's arms was not good, as there were a lot of muscles which could get injured. IV. Resident #24A. Resident statusResident #24, age less than 65, was admitted on 7/23/21. According to the December 2024 CPO, diagnoses included type 2 diabetes, history of other venous thrombosis (a condition where a blood clot, or thrombus, forms in a vein and blocks blood flow) and embolism (occurs when a blockage, called an embolus, lodges in a blood vessel and prevents blood from flowing). The 11/13/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was independent in ADLs B. Failure to ensure the resident was assessed for safe smoking 1. Facility policy and procedureThe Traditional Tobacco and Electronic Smoking Device Policy, revised on 5/10/23, was provided by the DOCS on 12/19/24 at 1:03 p.m. It read in pertinent part, "All residents who smoke or desire to smoke will be appropriately assessed to determine if the resident requires supervision and protective equipment during smoking. The assessment tool used for this purpose is the (name of the electronic medical record) Smoking Risk Assessment."Smoking assessment and potential restrictions shall be completed upon admission, quarterly at the time of unsafe smoking behavior or suspicion of smoking in an undesignated area or upon any change of condition, which would impact the residents ability to smoke and or smoke safely." 2. Resident observation and interviewOn 12/11/24 at 9:49 a.m. Resident #24 was sitting on his bed near his bedside table. There was black ash on the table. The resident's room and the resident smelled of cigarette smoke. Resident #24 said he smoked cigarettes and that he was independent with smoking and could go out to smoke whenever he wished. 3. Record reviewThe care plan, revised 8/19/24, identified Resident #24 was an independent unsupervised smoker. Pertinent interventions included instructing and informing the resident about the facility policy on smoking, locations, times and safety concerns, monitoring the resident for any unsafe smoking practices and observing the resident's clothing and skin for signs of cigarette burns. The 9/23/24 progress note documented Resident #24 continued with his normal daily habit of smoking outside. The 11/23/24 progress note documented Resident #24 was observed going into the West charting room, grabbing another resident's box containing cigarettes, putting the other resident's box of cigarettes into his pants and walking out of the nurses station. The nurse and the manager on duty went into Resident #24's room and requested the box back. The resident gave the cigarettes back to the nurse. The 12/5/24 psychological follow up note documented Resident #24 had a history of smoking cigarettes in his room. Review of Resident #24's smoking assessments revealed the following:The 5/3/24 smoking risk evaluation documented the resident was safe and independent with smoking. The 11/13/24 smoking risk evaluation documented the resident did not smoke cigarettes. The evaluation form documented the resident said he did not currently have any cigarettes to smoke. The 12/16/24 progress note documented the resident was observed smoking in his room. Resident #24 denied smoking in his room and denied having cigarettes or lighters. The 12/18/24 smoking risk evaluation (completed during the survey) documented Resident #24 did not smoke only in designated areas and did not follow the smoking rules. The evaluation conclusion was the resident was supervised while smoking. 4. Staff interviewsThe social services consultant (SSC) was interviewed on 12/17/24 at 11:53 a.m. The SSC said the social worker for the facility was out of the facility. The SSC said she was not familiar with Resident #24 but would review the resident's records for the smoking assessment. The DON was interviewed on 12/17/24 at 6:10 p.m. The DON said the smoking evaluation was to be completed when the resident was admitted and on a quarterly basis or change of condition. The DOCS was interviewed on 12/19/24 at approximately 12:00 p.m. The DOCS said the DON was completing an assessment on the resident. He said he did not understand how the resident was not assessed for smoking.

Based on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one (#1) of two residents out of 41 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to:-Consistently and accurately monitor pre- and post-dialysis weights for Resident #1; -Consistently document Resident #1's post-dialysis weight from the dialysis communication form in the resident's electronic medical record (EMR); and,-Ensure communication forms between the facility and the dialysis center were obtained consistently and completed thoroughly for Resident #1. Findings include:I. Facility policy and procedureThe Hemodialysis Residents policy, dated 2/29/24, was provided by the director of clinical services (DOCS) on 12/17/24 at 10:30 a.m. It read in pertinent part, "The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes in coordination and collaboration with the dialysis center. A dialysis communication record is initiated and sent to the dialysis center each appointment and ensure it is received upon return. Post hemodialysis care includes to check vital signs post dialysis or per the physician's order. Documentation includes the dialysis communication record. Key medical record documentation elements include weight."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 7/12/19. According to the December 2024 computerized physician orders (CPO), diagnoses included ischemic cardiomyopathy (a condition that occurs when the heart muscle is damaged due to a lack of blood supply), dysphagia (difficulty swallowing), type 2 diabetes mellitus, heart disease, chronic kidney disease, and vascular dementia. The 11/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He was dependent on total assistance from staff for toileting, bathing, dressing, and bed mobility. He needed substantial to maximum assistance with personal hygiene and transfers and set up help only with eating and oral hygiene. The MDS assessment documented the resident received dialysis treatment. B. Record review A review of the December 2024 CPO revealed a physician's order to document Resident #1's post-dialysis weights on Monday, Wednesday and Friday; please take post-dialysis weight from the dialysis form, ordered 10/1/24 for weight monitoring. A review of Resident #1's EMR revealed the following:-The 10/7/24 dialysis communication form did not have a pre- or post-dialysis weight on the form and a post-dialysis weight was not recorded in the resident's EMR.-The facility did not have a completed 10/9/24 dialysis communication form and a post-dialysis weight was not recorded in the resident's EMR.-The facility did not have a completed 10/11/24 dialysis communication form and a post-dialysis weight was not recorded in the resident's EMR.-The facility did not have a completed 10/14/24 dialysis communication form.-The facility did not have a completed 10/16/24 dialysis communication form.-The facility did not have a completed 10/23/24 dialysis communication form.-The facility did not have a completed 10/25/24 dialysis communication form.-The facility did not have a completed 11/4/24 dialysis communication form.-The facility did not have a completed 11/11/24 dialysis communication form.-The facility did not have a completed 11/13/24 dialysis communication form and a post-dialysis weight was not recorded in the resident's EMR.-The facility did not have a completed 11/18/24 dialysis communication form and a post dialysis weight was not recorded in the resident's EMR.-The facility did not have a completed 11/27/24 dialysis communication form.-The facility did not have a completed 11/29/24 dialysis communication form and a post-dialysis weight was not recorded in the resident's EMR.-The 12/4/24 dialysis communication form did not have a pre- or post-dialysis weight on the form and a post-dialysis weight was not recorded in the resident's EMR.III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 12/16/24 at 4:23 p.m. RN #2 said the certified nurse aides (CNA) were supposed to weigh a resident prior to their dialysis appointment. RN #2 said dialysis communication forms were kept at the nurses station and a communication form was sent to dialysis treatment with the resident. RN #2 said the resident was weighed at dialysis treatment and the dialysis communication form should have been returned to the facility with the resident's post-dialysis weights. The director of nursing (DON) and the director of clinical services (DOCS) were interviewed together on 12/18/24 at 4:55 p.m. The DON said the facility should use the resident's post-dialysis weight documented at the facility. -However, the 10/1/24 physician's order indicated the post-dialysis weight from the dialysis communication form should be documented, not the weight obtained at the facility (see record review above). The DOCS said the post-dialysis weight was used as it was the most accurate weight for the resident and the expectation was the post-dialysis weight recorded on the dialysis communication sheet was recorded in the resident's EMR. The DOCS said the facility's process to acquire dialysis communication forms was not consistent and if the facility did not receive the forms, facility staff would need to request the forms from the dialysis center. The DOCS said after the communication form was received, the DON should review the forms and then send the form to medical records to be placed in the residents' EMR.

Based on observations, record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#6 and #44) of six residents reviewed for medication errors out of 41 sample residents. Specifically, the facility failed to:-Order and administer the correct medication (hydroxyzine) for Resident #6's itching, and not the incorrect medication (hydralazine), for high blood pressure. -Ensure Resident #44 did not receive excessive dosage of acetaminophen. Finding include:I. Failed to ensure the correct medication was ordered and administeredA. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed., E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment?.? ?"?Professional Standards such as nursing scope ?and standards of practice apply to the activity of medication administration?. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. ?Many medication errors ?can be linked ?in some way to an inconsistency ?in adhering to these seven rights?: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."According to the Institute for Safe Medication Practices (ISMP), revised 2024, retrieved on 12/23/24 from: https://www.consumermedsafety.org/safety-articles/one-drug-pair-name-that-often-results-in-confusion, There Were Often Medication Error Reports That Result From Confusion With Drug Names That Look or Sound Alike. "One look-alike and sound-alike pair that often results in confusion is hydralazine and hydroxyzine. Hydralazine is used to treat high blood pressure. Hydroxyzine is an antihistamine used in the treatment of allergic reactions such as itching, rash, hives, sneezing and runny nose. Hydroxyzine is also used to treat anxiety, difficulty sleeping and nausea. Contributing factors leading to these frequent mix-ups are: The first four letters of their names are identical, they are frequently stored next to one another on pharmacy shelves, they are listed alongside one another on computer screens and they have similar dosage strengths (10,25,50 and 100 mg). B. Facility policy and procedureThe Medication Administration policy, revised 2/29/24, was provided by the director of clinical services (DOCS) on 12/17/24 at 9:39 a.m. It read in pertinent part,"Medications are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to the administration of the medication. Document the interaction with the physician in the nursing progress notes and elsewhere in the medical record, as appropriate."C. Resident #61. Resident statusResident #6, age less than 65, was admitted on 7/11/17. According to the December 2024 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), insomnia (difficulty sleeping), type 2 diabetes and dependence on oxygen. The 10/29/24 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 resident required substantial assistance with personal hygiene. 2. Resident interviewResident #6 was interviewed on 12/11/24 at 3:23 p.m. Resident #6 said a certified nurse aide with medication authority (CNA-Med) tried to give her the wrong medication recently. She said she looked at the pill cup and said "this is not right." She said that she told the CNA-Med she would not take the medication. Resident #6 said the facility later provided the correct anti-itch medicine. Resident #6 was interviewed a second time on 12/18/24 at 10:00 a.m. The resident said she was given the wrong medication. She said that she thought she took the incorrect medication once and she knew that she caught the error on the last attempt at administration. 3. Record reviewThe October 2024 CPO revealed a physician's order for hydroxyzine, 25 milligrams (mg) by mouth every 12 hours as needed for itching, ordered on 10/1/24 and discontinued on 11/7/24. The November 2024 CPO revealed a physician's order for hydralazine 25 mg by mouth every 12 hours as needed for pruritus (itching), ordered on 11/7/24 and discontinued on 11/16/24 at 10:55 p.m..-This order was discontinued on 11/16/24 at 10:55 p.m., after the resident reported the technician had tried to give the wrong medication.-The November 2024 medication administration record (MAR) revealed Resident #6 had received one dose of hydralazine 25 mg on 11/7/24, 11/13/24, and 11/15/24. The pharmacist monthly review progress note on 11/10/24 at 1:12 p.m. revealed the medication regimen review (MRR) was completed. -This review was documented during the time of the active hydralazine order and administration. A nursing progress note on 11/16/24 at 11:00 p.m. documented Resident #6 requested hydroxyzine for itching. Resident #6 was taking hydroxyzine for itching as needed. The medication was discontinued on 11/7/24 and hydralazine was ordered for itching. The resident was assessed and there were no abnormalities found. Resident #6 reported hydralazine caused hypotension (low blood pressure) in the past and declined taking the medication for itching. The registered nurse (RN) called the provider regarding the resident's request for hydroxyzine. The resident had not had the medication today, but reports feeling anxious about it being on medication list. An order was received to discontinue the hydralazine and a new physician's order was obtained for hydroxyzine 25 mg as needed every 12 hours for pruritus. The resident's blood pressure was monitored every four hours for 24 hours to ease the resident's anxiety. The November 2024 CPO revealed the following physician's orders:-Hydroxyzine 25 mg by mouth every 12 hours as needed for pruritus, ordered on 11/16/24; and, -Take Resident #6's blood pressure every four hours for the next 24 hours and to call the provider if systolic blood pressure reading was less than 100, ordered on 11/16/24. D. Staff interviewsCNA-Med #1 was interviewed on 12/17/24 at 7:19 p.m. CNA-Med #1 said on 11/16/24, Resident #6 asked for an as needed medication. CNA-Med #1 said he looked at the physician's orders and saw the hydralazine as needed order. He said he did not know it was a blood pressure medication. CNA #1 said Resident #6 then told him, "this is not the right med," and she refused to take it. CNA #1 said he then told the charge nurse and that was when they discovered it was the wrong medication. He said he did not administer the medication to Resident #5 on 11/16/24. The registered pharmacist consultant (RPH) was interviewed on 12/18/24 at 10:08 a.m. The RPH said hydralazine was a medication used for high blood pressure, not for itching. She said hydralazine could be a high risk medication if it decreased a resident's blood pressure too much. The RPH said if Resident #6 had received more doses of hydralazine, her blood pressure could have dropped. The RPH said if the medication caused a drop in blood pressure, it could cause the resident to have dizziness or fall. The RPH said based on the information she had, the hydralazine was ordered incorrectly on 11/7/24. She said the hydralazine and the hydroxyzine were very common look alike, sound alike medications. The RPH said the pharmacists did a "double take" to make sure the medication ordered was correct. The RPH said when the nurse signed the MAR for a particular medication, it indicated that the medication was given. The RPH said it appeared that the nursepractitioner (NP) accidentally put in the hydralazine order and discontinued the hydroxyzine order on 11/7/24. The RPH said there was not a physician's order for hydroxyzine 11/7/24 to 11/16/24. She said Resident #6's blood pressure remained stable when she was administered the three doses of hydralazine. The RPH said if Resident #6 had been on other medications for high blood pressure, the outcome could have been worse. The NP was interviewed on 12/18/24 11:30 a.m. The NP said she did not remember if she was in the building or if a licensed nurse took the hydralazine order via the telephone for Resident #6. She said she did not recall the situation. She said she did not think she would have ordered hydralazine but she may have. The NP said she just knew the medication was wrong. She said she was prescribed the hydroxyzine. The resident's primary care physician (PCP) #1 was interviewed on 12/18/24 at 12:05 p.m. PCP #1 said she was made aware of the medication error involving Resident #6 last week. She said safety measures were put into place so medication errors did not occur. She said however, unfortunately they all failed. She said the licensed nurse was to verify the order was correct prior to ordering the medication, the pharmacist was to verify the medication with the diagnosis prior to sending out the medication to the facility and the provider was to verify the medication order was correct prior to signing the order. PCP #1 said when she learned of this medication error, she asked all providers to not sign off on batch verbal orders (many orders at one time). She said she instructed the providers to review each order separately prior to signing them. PCP #1 was interviewed a second time on 12/18/24 at 1:28 p.m. PCP #1 said Resident #6 was not harmed by receiving the wrong medication. She said the biggest risk to the resident was hypotension (low blood pressure). The PCP said the possibility existed that Resident #6 could have been harmed from receiving doses of the wrong medication, but it was unlikely. She said Resident #6 had blood pressures that were high enough to support doses of hydralazine. PCP #1 said there were no plans to order antihypertensives (high blood pressure medications) for Resident #6. The DOCS was interviewed on 12/18/24 at 2:33 p.m. The DOCS said the progress note documented in Resident #6's electronic medical record (EMR) summarized the incident. He said a medication error report should have been started at the time, but was not. He said he now had started one. The DOCS said the order was entered by a nurse educator who reviewed the residents' orders on 11/7/24 and then the order was signed off by the NP. He said it was standard nursing practice to sign off orders and there was no specific training provided at the facility for this purpose. The DOCS said he agreed with PCP #1 that the nurse was supposed to verify the order prior to entering the order in the EMR, the pharmacist was supposed to check the drug prior to sending to the facility and the provider should have verified the drug was correct. The DOCS said he did not know why the correct drug for itching (hydroxyzine) was discontinued on 11/7/24. The DOCS said the facility had assigned education to nurses and a consultant was going to provide in person education to staff. The DOCS said a daily order review was implemented due to this event. He said the facility was working with the pharmacy to develop an action plan moving forward. The DOCS said a medication incident report should have been created when the medication error was discovered and he had now created an incident report (during the survey). The RPH was interviewed a second time on 12/18/24 at 3:21 p.m. The RPH said the pharmacists did not check the indication for medications when they dispensed the medications to the facility. She said the pharmacists check for allergies and drug interactions. The RPH said the pharmacist would not have stopped the hydralazine from being dispensed due to the wrong diagnosis. The RPH said the consultant pharmacist's role was to check for the diagnoses when they performed the monthly medication regimen review for residents. The RPH was interviewed a third time on 12/19/24 at 11:20 a.m. The RPH said the documentation in the EMR for MRR completed on 11/10/24 meant the MRR was downloaded and review of medications had begun. The RPH said the hydralazine order for Resident #6 was brought up at the Psych Pharm review meeting on 11/13/24 and a facility representative said the medication would be discontinued. The RPH said she did not know why the medication was not discontinued on 11/13/24 (the medication was later discontinued on 11/16/24 after Resident #6 identified the incorrect medication). II. Failed to prevent excessive acetaminophen dosageA. Professional referenceAccording to manufacturer of Tylenol Professional, revised 2023, retrieved on 12/26/24 from: https://www.tylenolprofessional.com/products-dosage-adult, "Acetaminophen is not to exceed six 500 mg caplets in 24 hours (3000 mg/day), unless directed by a doctor. A professional discretionary dosage: If pain or fever persists at the total labeled daily dose, healthcare professionals may exercise their discretion and recommend up to 4000 mg per day."B. Resident #441. Resident statusResident #44, age less than 65, was admitted on 8/8/23. According to the December 2024 CPO, diagnoses included chronic osteomyelitis (bone infection), post-procedural pain, dementia and chronic obstructive pulmonary (lung) disease. The 10/7/24 minimum data set (MDS) assessment revealed Resident #44 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required supervision or set-up assistance for eating and personal hygiene and required supervision with lower body dressing. 2. ObservationOn 12/16/24 at 12:18 p.m., licensed practical nurse (LPN) # 1 was administering acetaminophen 650 milligrams (mg) and hydrocodone 7.5 mg/acetaminophen 325 mg to Resident #44.-This represented a total dose of 975 mg acetaminophen given at that time. 3. Record reviewA review of the October 2024 CPO revealed the following physician's orders:-Acetaminophen 1000 mg by mouth three times a day for pain (active order from 10/4/24 to 11/11/24).-Hydrocodone 7.5 mg/ acetaminophen 325 mg four times a day for chronic pain (active order from 10/4/24 to 11/4/24). -Acetaminophen 1000 mg by mouth every 24 hours as needed for pain, not to exceed 3000 mg per day (active order since 9/30/24). The October 2024 medication administration record (MAR) revealed Resident #44 received 4300 mg acetaminophen on the following dates: 10/18/24, 10/20/24, 10/23/24, 10/27/24, 10/28/24 and 10/30/24.-If all scheduled doses were administered as ordered, the resident would have received 4300 mg per day. The resident declined acetaminophen on several occasions. If all scheduled doses and the as needed acetaminophen doses were administered as ordered, the resident would have received 5300 mg per day. A review of the December 2024 CPO revealed Resident #44 had the potential to receive up to 4250 mg per day of acetaminophen. Active orders included:-Acetaminophen 650 mg by mouth four times a day for pain;-Hydrocodone 7.5 mg/ acetaminophen 325 mg four times a day for chronic pain; and,-Acetaminophen 1000 mg by mouth every 24 hours as needed, not to exceed 3000 mg, acetaminophen per day (scheduled doses together equaled 3250 mg, not including as needed dose). B. Staff interviewsRN #1 was interviewed on 12/16/24 at 3:00 p.m. RN #1 said after she reviewed Resident #44's orders, she realized the resident had received 3250 mg of acetaminophen daily per scheduled doses and had the potential to receive an additional 1000 mg of acetaminophen if the as needed order were given. LPN #1 was interviewed on 12/16/24 at 3:05 p.m. LPN #1 said the pharmacist and the nurses were responsible for checking orders to ensure that residents did not receive too much acetaminophen. The RPH was interviewed on 12/16/24 at 3:45 p.m. The RPH said the limitation of acetaminophen containing products was a newer practice over the past eight years and was dependent on the resident's status. The RPH said Resident #44 should not receive more than 4000 mg acetaminophen per day. The RPH said the as needed order for acetaminophen should have been discontinued prior to the scheduled acetaminophen dosing. The RPH said the pharmacist should probably have caught that the 3000 mg limitation was not standard of practice. The RPH was interviewed a second time on 12/16/24 at 4:11 p.m. The RPH said she spoke with the PCP #1 who said Resident #44 could receive up to 4000 mg per day of acetaminophen and the PCP contacted the facility to eliminate the as needed acetaminophen order. The RPH said the resident could have received up to 4250 mg acetaminophen per day as it had been ordered if staff had not paid attention to it. The RPH was interviewed a third time on 12/17/24 at 11:13 a.m. The RPH said according to the MAR, Resident #44 received 4300 mg acetaminophen on 10/18/24, 10/20/24, 10/23/24, 10/27/24, 10/28/24 and 10/30/24. The RPH said liver toxicity could occur due to doses above 4000 mg. She said symptoms of this toxicity could include nausea, vomiting and agitation. The RPH said the resident did not develop toxicity, but the back to back 10/27/24 and 10/28/24 administration of 4300 mg acetaminophen were concerning because they were back to back and there was a higher potential for the resident to experience toxicity during that time. The director of nursing (DON) and the DOCS were interviewed together on 12/17/24 at 3:05 p.m. The DON said the acetaminophen maximum daily dose was limited to 3000 mg, then was increased to 4000 mg if the resident did not have other conditions which compromised the resident. The DON said she would expect a nurse to abide by an order which limited acetaminophen to 3000 mg per day. The DOCS said the pharmacy completed an audit for residents with acetaminophen orders on 12/16/24 (during the survey) to ensure appropriate dosing. The DOCS said PCP #1 had requested removal of as needed acetaminophen 1000 mg orders. The DON said the 4300 mg of acetaminophen administered to Resident #44 on six dates could have affected her liver. PCP #1 was interviewed on 12/18/24 at 12:22 p.m. PCP #1 said she had reviewed documentation for several residents at the facility who were scheduled for excessive amounts of acetaminophen. PCP #1 said a performance improvement project had been initiated to review medication lists for every resident and verify acetaminophen doses from all sources (during the survey). PCP #1 said Resident #44 should not receive more than 3500 mg acetaminophen per day based upon her risk factors. PCP #1 said the 1000 mg as needed acetaminophen order had been removed from Resident #44's orders. She said the nursing staff were responsible for ensuring residents did not receive too much acetaminophen. III. Facility follow-upThe Medication Error Action Plan, dated 12/17/24 (during the survey), was provided by the DOCS on 12/18/24 at 3:13 p.m. The action plan included the following:"-Residents involved in medication errors were assessed and monitored for complications without significant findings (completed 12/18/24).-Risk management incident reports were created for both incidents to include notification to providers (completed 12/18/24).-All licensed nurses have been assigned training on medication administration (completed 12/18/24).-All licensed nurses will complete a medication administration competency (planned completion 12/24/24).-Audit completed by pharmacy consultant to ensure no further issues noted with acetaminophen dosing (completed 12/18/24).-Audit completed for antianxiety and antihypertensive medications to ensure appropriate diagnoses with no issues identified (completed 12/18/24).-Medical director notified of medication errors. Medical director has initiated performance improvement plan for providers (completed 12/18/24).-Agency nursing staff to be oriented prior to working first shift in community QM to provide updated agency orientation packet (ongoing).-Orders to be reviewed daily by designee to ensure appropriate diagnosis and medication. (ongoing).-Quality mentor to complete random weekly med pass observations (ongoing).-Review action plan at next QAPI meeting (ongoing)."

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of two medication storage rooms and two of four medication storage carts. Specifically, the facility failed to:-Dispose of medications from the medication storage refrigerators and medication carts after residents had been discharged;-Ensure medications were labeled with dates opened;-Ensure expired medications were removed and discarded from medication carts and storage refrigerators; and,-Maintain temperature logs for the medication refrigerators. Findings include:I. Facility policy and procedureThe Storage of Medications policy, revised November 2020, was provided by the director of clinical services (DOCS) on 12/17/24 at 9:39 a.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."Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed."II. Observations and interviewOn 12/12/24 at 2:05 p.m. the West hall medication storage room refrigerator was observed with registered nurse (RN) #1. A temperature log for the medication refrigerator was not present in the room. The temperature reading inside of the refrigerator was observed to be 40 degrees fahrenheit (F). RN #1 said she would find the temperature log for the refrigerator. The following items were found in the medication refrigerator:-An opened vial of Tuberculin Purified Protein Derivative 10 milliliters (ml) which was not labeled with the date opened. RN #1 said the medication had been opened and used. RN #1 said she was not sure how long the medication could be used once it was opened. RN #1 said the medication should be discarded because she did not know when it was opened.-An opened Insulin Glargine (Basaglar) 100 units/ml pen which was not labeled with the date it was opened. RN #1 said she thought the insulin would be good for 30 days after opening, but was going to discard it since it did not have a date opened label on it. On 12/12/24 at 2:26 p.m. the East hall medication storage room was observed with licensed practical nurse (LPN) #2. A temperature log for the medication refrigerator was not present in the room. LPN #2 said she would ask where the temperature log was located. The following items was found in the refrigerator:-An opened vial of Tuberculin Purified Protein Derivative 10 ml which was not labeled with the date opened. LPN #2 said the medication was good for 30 days after opening, but since it was not labeled with a date opened, it should be discarded.-A Cathflo 2 milligram (mg) package (for dissolving blood clots) was labeled with a discharged resident's name. LPN #2 said the resident had been discharged on 4/9/23.-An unopened Cathflo 2 mg package with an expiration date of December 2023.-Six Phenalephrine (hemorrhoid) 0.25 mg suppositories with an expiration date of May 2023. -A vial of Retacrit 10,000 units was labeled with a discharged resident's name. LPN #2 said the resident had been discharged on 11/20/24.-Two vials of Engerix B 20 micrograms (mcg)/ml with an expiration date of June 2024.-One container of Prevnar 20 injectable medication was labeled with a discharged resident's name. LPN #2 said the resident had been discharged on 8/12/24.-A Lantus Solostar insulin pen was labeled with a discharged resident's name. The LPN said the resident had been discharged on 11/22/24. LPN #2 said medications should be removed from the refrigerator within 48 hours of a resident's discharge. LPN #2 said tuberculin and Engerix medications should be labeled with a date upon opening. LPN #2 said nursing staff should be checking the medication refrigerator and medication carts for expired medications at least weekly. On 12/12/24 at 3:11 p.m. the East hall medication cart #1 was observed with RN #2. The following items were found:-An opened Combivent Respimat 20 mcg/100 mcg inhaler was not labeled with the date opened. RN #2 said she would discard the medication if it was not dated when opened because she did not know how long it could be used after opening.-An opened Trelegy Elipta 200 mcg inhaler was not labeled with the date opened. RN#2 said she would check with the nursing supervisor to see how long the inhaler could be used. -A bottle of Amlactin lotion with an expiration date of October 2023. On 12/12/24 at 3:35 p.m. the West hall medication cart #2 was observed with LPN #1. The following item was found:-An opened Wixela fluticasone propionate and salmeterolinhaler 250/50 mcg inhaler was not labeled with the date opened. LPN #1 said the inhaler should have a date opened label on it. III. Additional staff interviewsLPN #1 was interviewed on 12/12/24 at 3:29 p.m. LPN #1 said she knew there was a thermometer in the west medication refrigerator, but did not know who checked the temperatures or maintained the log of refrigerator temperatures. The director of nursing and the DOCS were interviewed together on 12/17/24 at 3:19 p.m. The DON said staff brought her expired medications, undated medications and medications from residents who were discharged. The DON said the opened insulin pen, tuberculin purified protein and inhalers needed to be labeled with the date opened or they should be discarded. The DOCS said the facility would provide a temperature monitoring log for the refrigerators if one was available. (The log was not provided by the completion of the survey). The DON said it was the responsibility of the night shift nurses to check and record the medication refrigerator temperatures. The DON said medications should be removed from the refrigerator or medication cart on the day of a resident's discharge. The DON said expired medications should be discarded immediately. The DON said the expiration dates in the refrigerators should be checked by nursing staff when temperatures were checked daily.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for two (#48 and #61) of six residents out of 41 sample residents. Specifically, the facility failed to:-Provide a balanced menu with a variety; and,-Provide alternate items of preference for Resident #61 and #48 when requested. I. Provide a balanced menu with a variety of starch optionsA. Facility policy and procedureThe Resident Food Preferences policy, revised July 2017 was provided by the director of clinical services (DOCS) on 12/18/24 at 9:42 a.m. The policy read in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Upon the resident's admission or within 24 hours after his/her admission, the dietitian or nursing staff will identify a resident's food preferences. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. The resident has a right not to comply with therapeutic diets. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with."The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's quality assessment and performance improvement (QAPI) committee will periodically review the issues related to food preferences and try to identify more widespread concerns about meal offerings, food preparation."B. Resident interviewsResident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The resident's representative said the food was repetitive and it looked like the same thing over and over, and the menu lacked variety. Resident #24 was interviewed on 12/11/24 at 4:44 p.m. Resident #24 said the food was repetitive and that he did not like the taste of the food. He said the facility served too much chicken. He said the food was not good. Resident #47 was interviewed on 12/11/24 at 5:30 p.m. Resident #47 said the food quality was poor and attending the food meetings did not make a difference. Resident #47 said he talked to the new dietary manager (DM), who had been at the facility for almost three months, about various things and he was told to give it time. C. Resident group interviewThe resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted offive residents (#115, #28, #4, #16 and #17) who were interviewable based on assessment by the facility. The residents said they continued to have concerns about the food. The residents' concerns were as follows:-The menu was repetitive and carrots, rice and potatoes were served too much; and,-Mixed vegetables were served too frequently. The residents said they had a food committee and they had complained about the food during resident council meetings. However, the group said they felt they were not listened to by the facility. The residents said the kitchen staff needed to take pride in their cooking. D. Record reviewThe 10/21/24 resident council meeting minutes were provided by the DOCS on 12/17/24 at 10:00 a.m. The minutes documented the residents voiced that too much rice was being served at meals and residents wanted more of a variety in menu choices. A four week cycle menu was provided by the nursing home administrator (NHA) on 12/12/24 at 11:12 a.m. A review of the weektwo menu (served during the survey) revealed repeated menu items. Potatoes were a repeated side item for three of the four lunch and dinner meals on the following days:-On 12/15/24 the dinner menu was shepherds pie as the main entree and contained potatoes.-On 12/16/24 the lunch menu was Salisbury steak served with a side of mashed potatoes.-On 12/16/24 the dinner menu was breaded fish on a bun and served with potato wedges. Pasta was a repeated side item for four of the six lunch and dinner meals on the following days:-On 12/19/24 the lunch menu was Italian sausage with parmesan noodles.-On 12/20/24 the lunch menu was cornflake chicken breast with macaroni and cheese.-On 12/20/24 the dinner menu was meatballs with marinara sauce and spaghetti noodles.-On 12/21/24 the lunch menu was chicken alfredo with spaghetti noodles. E. Staff interviewsThe dietary manager (DM) was interviewed on 12/17/24 at approximately 1:30 p.m. The DM said the facility staff had not mentioned to her that the residents had complained the menus were repetitive. The DM said normally if a resident complained a CNA would inform the dining staff, and bring the resident's initial meal tray to the kitchen to get the resident something else to eat. District supervisor (DS) #2 was interviewed on 12/17/24 at approximately 1:30 p.m. DS #2 said she had previously helped the facility with menu management and had consulted with the regional dietitian to review the menus including the residents' likes and dislikes. DS #2 said if the residents prefer, for example, to have fish removed from the menu, the residents could list another preferred menu item, give the managers that feedback and then make the changes to the menu. DS #2 said she would start reviewing the menus to change out some of the repetitive options. II. Failed to provide items of preference for Resident #61 and Resident #48A. Resident #611. Resident statusResident #61, age greater than 65, was admitted on 11/18/24. According to the December 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), acute respiratory failure, pulmonary fibrosis (scarring of lung tissue) and late onset dementia. The 11/24/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. Resident #61 was dependent on assistance for bathing, needed substantial assistance with transfers, dressing, toileting hygiene and oral hygiene, supervision with personal hygiene and set up help with eating. 2. Resident representative interview and observationsResident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The representative said she was worried about Resident #61's weight because he did not eat well. The representative said she complained about the food to multiple staff at the facility and told a staff member Resident #61 was not eating well and needed encouragement to eat. The representative said she requested a menu and the certified nurse aides (CNA) told her they were unsure where to find a menu. The representative said Resident #61 finished the Mexican food the family brought him from home and the resident preferred Mexican food. The following was observed during the 12/11/24 noon meal:At 12:01 p.m., the room trays were delivered to the east unit. CNA #8 delivered a tray to Resident #61. She assisted the resident into his chair by the bedside table by holding his hand for assistance. CNA #8 set the tray in front of the resident and left the room. The following was observed during the 12/16/24 noon meal:At 12:05 p.m. CNA #9 brought Resident #61 his tray. She assisted him to sit in a chair. CNA #9 set a meal tray in front of Resident #61 and left the room.-However, staff did not offer Resident #61 any items of preference or encouragement. 3. Record reviewResident #61's nutrition care plan, initiated 11/27/24, documented he had a nutritional problem or potential nutritional problem related to sepsis, Alzheimer's disease, polyneuropathy (nerve disease causing numbness and pain), polyosteoarthritis (arthritis in multiple joints), GERD and fatty liver. The family reported a history of weight loss prior to his admission to the facility. Pertinent interventions initiated 11/27/24 included obtaining the resident's food preferences and offering as able and offering food alternates of equal nutritional value. A review of the resident's electronic medical record (EMR) revealed the following:An 11/27/24 progress note written at 4:25 p.m. documented Resident #61's family member asked if there was an alternate menu and if the resident could have a banana and yogurt for breakfast, and Mexican food only for lunch and dinner to eat. An 11/27/24 progress note documented written at 5:47 p.m. documented Resident #61's daughter brought food for the resident to eat at dinner and said she would try to contact the dietary department to figure out food options for Resident #61. A 12/1/24 progress note written at 5:36 p.m. documented the facility told Resident #61's representative the facility could offer choices available in the kitchen but could not force feed the resident. If the resident had favorite food items he would eat, the facility could provide them and make sure the resident had them to eat. Resident #61's food and nutrition food preferences, dated 12/9/24 were provided by the DOCS on 12/17/24 at 9:39 a.m. The food preferences revealed the resident preferred Mexican foods, bananas, yogurt, beans, rice, cheese, chicken, sweets and fruit. The resident's least favorite foods were listed as pasta, carbohydrates and red meat. He had recently lost weight.-However, Resident #61's care plan was not updated to reflect Resident #61's preferences. 4. Staff interviewsCNA #9 was interviewed on 12/17/24 at 11:00 a.m. CNA #9 said Resident #61 needed encouragement to eat. CNA #9 said she heard Resident #61 had complained about the food quality previously and she would tell the dietitian if she received a complaint about food quality. The district supervisor (DS) #1 was interviewed on 12/17/24 at approximately 1:30 p.m. DS #1 said a resident's food preferences were usually captured within 24 hours of the resident's admission to the facility. DS #1 said the DM would then enter the preferences into the menu system so they appeared on the resident's meal card. The DM was interviewed on 12/17/24 at approximately 1:30 p.m. The DM said she was not familiar with Resident #61's meal preferences or that he preferred Mexican food. B. Resident #481. Resident statusResident #48 age 68, was admitted on 10/3/22. According to the December 2024 CPO, diagnoses included unspecified macular degeneration (decreased vision), dysphagia, depression and cognitive communication deficit. The 9/27/24 MDS assessment showed the resident had cognitive impairments with a BIMS score of three out of 15. The resident was prescribed a therapeutic mechanically altered diet. 2. Record reviewThe December 2024 CPO revealed a physician's order for a regular diet, dysphagia advanced texture and regular consistency. The order documented she could have a regular grilled cheese. 3. ObservationOn 12/16/24 at 5:24 p.m., the resident had not eaten her meal. She said she would like to have a grilled cheese with ham sandwich. CNA #10 was alerted that Resident #48 wanted a a ham and grilled cheese sandwich. CNA #10 went to the kitchen window to put in the request. The registered dietitian (RD) went to the kitchen window and said Resident #48 could not have the ham on the grilled cheese. At 5:36 p.m., the resident received a grilled cheese sandwich. The resident asked if there was ham on her sandwich. CNA #10 said no, and the resident asked why she did not get ham on her sandwich the CNA said it was because of her diet order. 4. Staff interviewsCNA #10 was interviewed on 12/16/24 at 5:27 p.m. CNA #10 said she had requested a ham and cheese grilled cheese sandwich for Resident #48 however, the RD told him she could not have one and ordered only a grilled cheese sandwich. The RD was interviewed on 12/17/24 at 6:02 p.m. The RD said Resident #48 was prescribed a dysphagia diet and she could have a grilled cheese sandwich. She said she could not have the ham for safety reasons. She said she reached out to the speech therapist and she did update the diet so that she was able to have chopped ham. The RD was interviewed again on 12/18/24 at 4:00 p.m. The RD said when Resident #48 requested ham on her sandwich, she thought the resident was only approved to have a grilled cheese sandwich and not ham because of the residents prescribed modified texture diet. The RD said she was being over cautious when she said the resident could not have ham on her sandwich.

Based on interviews, observations and record review, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, were palatable in taste, appearance and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance and temperature. Findings include:I. Resident interviewsResident #13 was interviewed on 12/11/24 at 10:38 a.m. Resident #13 said the food was not hot. Resident #35 was interviewed on 12/11/24 at 2:17 p.m. Resident #35 said the food was never hot. Resident #61's representative was interviewed on 12/11/24 at 2:45 p.m. The resident's representative said Resident #61 told her the food had no flavor. Resident #6 was interviewed on 12/11/24 at 3:25 p.m. Resident #6 said the food was not good. Resident #6 said the grilled cheese sandwiches were not cooked correctly and were not grilled, but microwaved instead. Resident #6 said the food was often served cold and had no flavor. Resident #24 was interviewed on 12/11/24 at 4:44 p.m. Resident #24 said the food was repetitive and that he did not like the taste of the food. He said the facility served too much chicken. He said the food was not good. Resident #47 was interviewed on 12/11/24 at 5:30 p.m. Resident #47 said the food quality was poor and attending the food meetings did not make a difference. He said a hamburger patty could be thrown at the wall and it would put a hole in the wall. Resident #47 said he talked to the new dietary manager (DM), who had been at the facility for almost three months, about various things and he was told to give it time. Resident #47 said the food was overcooked and crusty. II. ObservationsDuring a continuous observation on 12/12/24, beginning at 4:15 p.m. and ending at 5:05 p.m., the following was observed during the meal preparation and service in the main kitchen:At 4:25 p.m. cook (CK) #1 took the temperature of the hot food. The philly cheesesteak sandwiches were in a food service pan fully assembled for meal service. The temperature of the tater tots was 99 degrees F. The temperature of the mixed vegetables was 160 degrees F. At 4:30 p.m. assembly of resident meal trays for the west hall room tray delivery started and the meal trays were delivered to the west hall at 4:39 p.m. At 4:40 p.m. assembly of resident meal trays for the east hall room tray delivery started. At 4:44 CK #1 pulled a second pan of assembled philly cheesesteak sandwiches out of the hot holding pan and placed the sandwiches in the hot holding table for service. Resident meal trays were assembled and placed in the cart. At 4:45 p.m. the test tray was assembled and placed in the east hall room delivery cart. At 4:45 p.m. the cart with the test tray left the kitchen and arrived in the east hall at 4:46 p.m. At 4:47 p.m. the first room tray was delivered to a resident. At 4:56 p.m. the test tray was removed from the cart. The test tray was immediately evaluated by three surveyors after the last resident had been served their room try for dinner. The test tray consisted of a philly cheesesteak sandwich, tater tots, mixed vegetables and canned fruit for dessert.-The tater tots were 108 degrees F.-The mixed vegetables were 119.7 degrees F.-The tater tots were over-salted. The vegetables were overcooked and limp, with a bland flavor and dull color. The bun on the philly cheesesteak was hard and chewy on each end of the bread. A small portion of the cheese was burned. On 12/12/24 at 5:00 p.m., Resident #115 received her meal in the dining room. The resident attempted to eat the philly cheesesteak sandwich, but she did not. Resident #115 asked for a new sandwich because she said the bread was too hard. III. Resident group interviewThe resident group interview was conducted on 12/17/24 at 1:05 p.m. The group consisted offive residents (#115, #28, #4, #16 and #17) who were interviewable based on assessment by the facility. The residents said they continued to have concerns about the food. The residents' concerns were as follows:-The meals were often served cold;-The quesadillas and grilled cheese sandwiches were often served burnt;-The food had no flavor and was bland in taste;-The meat was tough, particularly the pork chops and chicken;-The tater tots served on the 12/12/24 evening meal were too salty;-The philly cheesesteak sandwich which was served 12/12/24 during the evening meal had hard bread and the residents did not the like cheddar cheese that was used rather than the traditional swiss cheese; -The vegetables were under cooked;-The menu was repetitive and carrots, rice and potatoes were served too much; and,-Mixed vegetables were served too frequently. The residents said they had a food committee and they had complained about the food during resident council meetings. However, the group said they felt they were not listened to by the facility. The residents said the kitchen staff needed to take pride in their cooking. IV. Record reviewResident council meeting notes were reviewed for October 2024 and November 2024. The 10/31/24 resident council minutes documented the following comments from residents:-The chicken and pork were overcooked and tough;-Too much rice was served at meals; and,-The residents would like to have more variety. The 11/21/24 resident council minutes documented the following comments from residents:-The food was horrible. Residents left the dining room in disgust;-The pork and chicken were still too tough to eat;-Alternative meals were not offered; and,-Food was served cold. V. Staff interviewsThe nursing home administrator (NHA) was interviewed on 12/18/24 at 12:25 p.m. The NHA said he had heard concerns about food quality and it was discussed during resident council meetings. The NHA said he had sampled some random meals and the meals he sampled had been good. The NHA said he had not sampled a meal sent in the room tray cart. The NHA said the facility had recently switched food vendors and some residents perceived that the food quality might be different but he had not noticed a difference. The DM was interviewed on 12/18/24 at 3:00 p.m. The DM said when the facility held the food committee meeting with the residents, residents said there were concerns about the temperature of the food. The DM said the dietary staff, including herself, had tasted the food. The DM said the main issue she heard from the residents was about oatmeal in the morning and a few things from the menu were not as hot as they could be. The DM said she tasted a test tray about a week ago and there were no concerns with the test tray. District supervisor (DS) #1 was interviewed on 12/18/24 at 3:00 p.m. DS #1 said the facility completed a test tray audit before the 15th of every month to assess food quality. The DM said she thought the facility needed to build the sandwiches on the line during meal service instead of assembling them ahead of time for better quality. The DM said she was trying to train the staff to batch cook the tater tots and the tater tots served for the evening meal on 12/12/24 were cooked in one batch ahead of time.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure dishes were sanitized correctly in the three compartment sink; and,-Ensure safe and appropriate storage of food items in the walk-in refrigerator. Findings include:I. Failed to ensure dishes were sanitized correctly in the three compartment sinkA. Professional referenceThe Food and Drug Administration (FDA) Food Code, January 2023, was retrieved on 12/24/24 from https://www.fda.gov/food/fda-food-code/food-code-2022. It read in pertinent part, " Manual warewashing, sink compartment requirements: The three compartment requirement allows for proper execution of the three step manual warewashing procedure. If properly used, the three compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual warewashing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same three steps: application of cleaners and the removal of soil; removal of any abrasive and removal or dilution of cleaning chemicals; and, sanitization. "Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning."The Oasis 146 multi-quat sanitizer directions for use, dated 2015, were observed posted above the three compartment sink in the main kitchen on 12/17/24 at 11:30 a.m. The directions read in pertinent part, "Apply Oasis 146 Multi-Quat Sanitizer at proper use solution. Expose all surfaces of the equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry."B. Facility policy and procedureThe Warewashing policy, revised February 2023, was provided by the director of clinical services (DCOS) on 12/16/24 at 11:15 a.m. The policy read in pertinent part, "The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. Temperature and/or sanitizer concentration logs will be completed, as appropriate."B. Sanitizer instructionsThe Oasis 146 multi-quat sanitizer directions for use, dated 2015, were observed posted above the three compartment sink in the main kitchen on 12/17/24 at 11:30 a.m. The directions read in pertinent part, "Apply Oasis 146 Multi-Quat Sanitizer at proper use solution. Expose all surfaces of the equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry."C. Resident interviewResident #47 was interviewed on 12/12/24 at 5:30 p.m. Resident #47 said the dishes were frequently dirty and when he received his meals there were sometimes spots of dried food on the plates from the facility 's dish washing process. C. ObservationsOn 12/11/24 at 10:05 a.m. the following was observed:At 10:05 a.m. an unidentified dietary aide (DA) washed a rack of plate covers. The unidentified DA placed the rack of plate covers on a rolling cart. The dietary manager (DM) pushed the rolling cart and dish rack to rest in front of the sanitizer compartment of the three compartment sink. The DM removed the plate covers from the dish rack two at a time and submerged them in the sanitizer compartment of the three compartment sink. The DM immediately removed the plate covers one by one and placed them back on the dish rack to dry. -The DM failed to leave the plate covers in the sanitizer for at least one minute according to the directions. The plate covers were submerged from five to twenty-five seconds instead of at least one minute according to the instructions in theposted dishwashing procedure. D. Staff interviewsThe DM was interviewed on 12/11/24 at 10:05 a.m. The DM said the dietary staff were washing the dishes in the dish machine and sanitizing the dishes in the three compartment sink until their chemical sanitizer for the dish machine arrived. The DM said the dishes needed to be in contact with the sanitizer for more than 30 seconds.-However, according to the manufacturer 's recommendations the dishes needed to be submerged into the sanitizer for at least one minute. The DM was interviewed again on 12/18/24 at 3:00 p.m. The DM said she thought she had left the plate covers submerged in the sanitizer compartment for at least a minute. II. Failed to store food items appropriately in the walk in refrigeratorA. Professional referenceThe Cold Food Storage Chart (expires 10/31/26) was retrieved on 12/23/24 from https://www.foodsafety.gov/food-safety-charts/cold-food-storage-charts. It revealed in pertinent part, "Follow the guidelines below for storing food in the refrigerator and freezer. The short time limits for home-refrigerated foods will help keep them from spoiling or becoming dangerous to eat: Hamburger and ground meats store one to two days under refrigeration. Fresh poultry such as chicken, whole or in pieces, stored one to two days under refrigeration." B. Facility policy and procedureThe Labeling and Dating policy, undated, was provided by the DOCS on 12/16/24 at 11:15 a.m. The policy read in pertinent part, "Items removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date. Leftovers must be labeled and dated with the date they are prepared and the use by date."The Food Retention and Storage guide, undated, was provided by the DOCS on 12/16/24 at 11:15 a.m. It read in pertinent part, "A time/temperature control for safety food (TCS): a food that required time/temperature control for safety to limit pathogenic microorganism growth or toxin formation. Raw meat, poultry, and seafood once thawed can be refrigerated for one to two days. C. ObservationsOn 12/11/24 at 9: 25 a.m. the following was observed on one shelf in the walk in refrigerator in the main kitchen:-An undated, clear five pound (lb) bag of raw chicken breasts;-An undated clear bag of raw chicken thighs under the bag of chicken breasts;-A clear lexan container raw of chicken thighs covered with plastic wrap, labeled with the date 11/29 and 12/10;-Three undated five lb tubes of raw ground beef in a metal baking pan;-Shredded parmesan cheese in a clear lexan container covered with a red lid with no date, not labeled or dated;-Raw chicken thighs in a metal baking pan labeled with the date 12/8. D. Staff interviewsThe DM was interviewed on 12/17/24 at approximately 1:30 p.m. The DM said the proteins were pulled from the freezer and placed in the walk in refrigerator a day prior to use. The DM said the meat was not labeled because the staff removed the meat from the box to cook for resident meals and the unlabeled meat in the walk-in refrigerator was leftover. The DM said the facility cooked the leftover meat to cook for staff meals. The DM said the ham on the shelf next to the raw chicken was used for sandwiches and salads and should be on a different shelf.-However, the chicken thighs dated 12/8, and 12/10 did not indicate if these dates were pull date or expiration dates. District supervisor (DS) #1 was interviewed on 12/17/24 at approximately 1:30 p.m. DS #1 said the facility should use a pull thaw system to label the meat with the date it was pulled from the freezer and the meat 's expiration date and the facility was planning to implement that practice.

Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#9) of two residents out of 41 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #9's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include:I. Resident #9A. Resident statusResident #9, age greater than 65 was admitted 5/6/2020. According to the December 2024 computerized physician orders (CPO) diagnoses included acute kidney failure, history of falling and dementia. The 9/20/24 minimum data set (MDS) assessment documented the resident had both short term and long term memory impairments and had severely impaired decision making skills per staff assessment. The resident was dependent on staff for activities of daily living (ADL). The MDS assessment indicated the resident was receiving hospice services. B. Resident representative interviewResident #9's representative was interviewed on 12/18/24 at 10:30 a.m. The representative said Resident #9 was receiving hospice services. She said she was not sure if the chaplain had been in to see her mother through hospice. She said a chaplain was supposed to visit. C. Record reviewThe December 2024 CPO revealed a physician's order for Resident #9 indicating the resident was admitted to hospice on 12/18/23. The care plan, revised on 6/26/24, documented the resident received additional support services through hospice. Pertinent interventions included the hospice nurse visited one to times a week, the hospice certified nurse aide (CNA) visited twice a week to assist with showers, hospice staff was to participate in care, and the facility staff were to work cooperatively with the hospice team to ensure the residents spiritual, emotional, intellectual, physical and social needs were met. A hospice notebook was provided by registered nurse (RN) #1 on 12/17/24 at 10:00 a.m. Review of the notebook revealed the last note in the notebook from hospice was from 9/5/24 from the hospice RN. The CNA's last note was 10/31/24. The electronic medical record (EMR) failed to reveal any progress notes from the hospice services provider. D. Staff interviewsRN #1 was interviewed on 12/17/24 at 10:00 a.m. RN #1 said Resident #9 was on hospice services. She said the hospice nurse came once or twice a week. She said when the hospice RN visited the resident she would check in with the facility nurse and would also inform the staff of any changes. She said the hospice CNA visited twice a week to provide a shower to Resident #9. RN #1 said a social worker and a chaplain also visited. She said the facility had a notebook which was used for hospice documentation. She said any other notes would be scanned into the EMR. RN #1 said she reviewed the medical record and she was not able to find any up to date notes from hospice. She said the health information department would scan the documents into the EMR. The health information specialist (HIS) was interviewed on 12/17/24 at approximately 10:30 a.m. The HIS said there were no notes for Resident #9 from the hospice agency. She said she would contact the agency and then would develop a plan to ensure the hospice notes were received timely.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to operate a quality assurance (QA) program in a manner to identify and address concerns related to quality of care. Findings include:I. Facility policy and procedureThe Quality Management Plan/Quality Assurance and Performance Improvement (QMP/QAPI) Plan policy, dated 9/29/23, was provided by the director of clinical services (DOCS) on 12/19/24 at 2:43 p.m. It read in pertinent part, "The facility has an on-going quality management and quality assurance and performance improvement (QAPI) program designed to objectively and systematically monitor and evaluate the residents' care and health care services. The comprehensive program is designed to provide care that is optimal within the available resources and is consistent with the achievable goals. The objectives include to ensure that monitoring quality of residents' care is performed systematically and continuously, ensure communication among all departments in improving resident care and identifying programs through the use of on-going monitors by focusing on identification, analysis and resolution of problems, and evaluate the results of actions taken by each department and maximize the use of resources available within the facility."It is the goal of the facility to integrate QMP/QAPI into all care and service areas of the organization. The following will be key areas of focus of the facility: clinical care, quality of life, resident choice and care transitions. Effective performance improvement efforts will focus on the development, maintenance and periodic improvement of systems that influence organizational outcomes."II. Cross-referenced citationsCross-reference F561 self-determination: The facility failed to honor resident choices. Cross-reference F566 right to perform facility services or refuse: The facility failed to ensure residents were compensated timely for work performed. Cross-reference F567 management of personal funds: The facility failed to ensure personal funds accounts were managed adequately. Cross-reference F584 safe, clean, comfortable and homelike environment: The facility failed to ensure residents were provided with a safe, clean, comfortable and homelike environment. Cross-reference F610 investigation of an alleged violation: The facility failed to investigate allegations of abuse. Cross-reference F622 transfer and discharge requirements: The facility failed to ensure residents were allowed to remain in the facility. Cross-reference F626 permitting residents to return to the facility: The facility failed to ensure a resident was able to return to the facility. Cross-reference F661 discharge summary: The facility failed to ensure an appropriate discharge summary was in place. Cross-reference F677 activities of daily living for dependent residents: The facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living. Cross-reference F679 activities meet the interests and needs of each resident: The facility failed to ensure residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Cross-reference F684 quality of care: The facility failed to provide treatment and care in accordance with professional standards of practice. Cross-reference F685 treatment or devices to maintain hearing and vision: The facility failed to ensure proper treatment and services to maintain hearing and vision. Cross-reference F689 free of accident hazards: The facility failed to ensure residents remained as free from accident hazards as possible. Cross-reference F698 dialysis communications: The facility failed to ensure residents received dialysis services consistent with professional standards of practice. Cross-reference F760 significant medication errors: The facility failed to ensure residents were free from significant medication errors. Cross-reference F761 storage and labeling of medications: The facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled. Cross-reference F800 diet meets the needs of each resident: The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Cross-reference F804 nutritive value and food palatability: The facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Cross-reference F812 kitchen sanitation: The facility failed to prepare and serve food in a sanitary manner. Cross-reference F880 infection control: 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. III. Staff interviewsThe nursing home administrator (NHA), the regional director of operations (RDO) and the DOCS were interviewed together on 12/19/24 at 2:17 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and over video call if the medical director could not attend in person. The NHA said the QAPI format reviewed various topics on a worksheet that were marked as compliant or non-compliant. The RDO said if the facility identified a major issue that could not wait to be addressed until the next QAPI meeting, the facility called a meeting sooner rather than later. The DOCS said the facility identified smoking assessments were not completed and reviewed the process multiple times but had not identified the assessments as a systemic issue. The DOCS said enhanced barrier precautions (EBP) was identified as an issue under the previous director of nursing (DON) and said it was an oversight due to changing facility leadership positions. The NHA said the facility had not identified residents needing assistance at meal time as an issue. The NHA said the facility had a schedule for managers to be present in the dining room at meal time and observe if residents needed additional assistance. The NHA said the facility had discussed activities but had not identified it as a concern and activities had their own section to complete on the QAPI form. The RDO said the facility team did discuss residents scheduled for one-to-one activities. The DOCS said the new activity director (AD) had been with the facility for about a month and was trying to create some stability and revamp the activity department. The RDO said the facility instituted floor huddles to discuss with the facility staff what issues the staff had identified, to build culture and create an open environment for staff to discuss concerns.

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. Specifically the facility failed to: -Ensure staff wore appropriate personal protective equipment (PPE) while changing a resident's bedding who was on enhanced barrier precautions (EBP); -Ensure the water management program (WMP) identified specific areas where legionella could grow and spread and decided where and how to monitor control measures to prevent legionella and waterborne pathogen growth and document the monitoring; -Ensure staff followed appropriate hand hygiene during resident care and ensure shared vital signs equipment was sanitized between use; and,-Ensure residents were offered hand hygiene at meals and staff performed appropriate hand hygiene during room tray delivery. Findings include:I. Failure to ensure staff wore the appropriate personal protective equipmentA. Professional referenceThe Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 12/23/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities."Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization."Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing."B. Facility policy and procedureThe Enhanced Barrier Precautions policy, dated 1/6/23, was provided by the director of clinical services (DOCS) on 12/17/24 at 6:58 p.m.. The policy read in pertinent part, "Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents. Residents with MDRO or who have indwelling medical devices will have an order written for initiation of EBP. A care plan will be initiated for the use of EBP."EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and complicated wound care. EBPs are indicated if contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBP's remain in place for the duration of the resident's stay or discontinuation of the indwelling medical device that placed them at increased risk as they can still serve as a source of transmission. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required."C. Resident interview and observationResident #1 was interviewed on 12/12/24 at 9:25 a.m. Resident #1 said he went to dialysis appointments on three days a week. Resident #1 had a fistula on his right arm. D. ObservationsOn 12/16/24 the following was observed:Resident #1 had an EBP sign on his door. The sign read in pertinent part, "Providers and staff must also wear gloves and a gown for the following high contact resident care activities: dressing, transferring, providing hygiene, changing briefs or assisting with toileting. The cart is labeled with an EBP cart with an orange label."Certified nurse aide (CNA) #7 entered room Resident #1's room at 10:03 a.m. and carried two clear trash bags into the room. CNA #7 while wearing gloves, removed an incontinence pad from Resident #1's bed and placed it in the trash. CNA #7 then pulled up the blankets on Resident #1's bed toward the head of the bed and pulled the blankets back again. CNA #7 placed two new incontinence pads on the bed and then pulled the blankets up over the bed and incontinence pads. On Tuesday 12/17/24 the following was observed:At 9:56 a.m. Resident #1 was seated in his wheelchair in his room. CNA #7 and an unidentified staff member assisted Resident #1 in putting on his coat while Resident #1 was seated in his wheelchair. Neither staff member wore a gown. CNA #7 assisted Resident #1 inside his room and closed the door to Resident #1's room. At 9:57 a staff member opened the door and the Resident #1 had his coat fully on and the (mechanical lift) sling was on the back of his chair. The resident said he was going to dialysis. The unidentified staff member assisted the resident down the hallway in his wheelchair. CNA #7 continued to work in Resident #1's room and removed the bed sheets from Resident #1's bed and placed them against the wall in the room. CNA #7 was not wearing a gown. He removed his gloves and exited the room. -CNA #7 and the unidentified staff member failed to wear a gown while they assisted Resident #1 to put on his coat and while CNA #7 changed Resident #1's bedding. D. Staff interviewsRegistered nurse (RN) #2 was interviewed on 12/16/24 at 2:25 p.m. RN #2 said she did not remember if CNA #7 had on a gown when he assisted Resident #1 the morning of 12/16/24. RN #2 said CNA #7 had assisted the resident to get dressed for dialysis and she entered the room to be a second person for Resident #1's transfer. RN #2 said she did not don (put on) a gown because she did not provide direct care to Resident #1 and was only the second person in the room for his transfer. RN #2 said a Resident #1 was on EBP because he received dialysis treatment. She said CNA #7 had dressed Resident #1 and put him in the sling. CNA #6 was interviewed on 12/17/24 at 10:15 a.m. CNA #6 said staff should wear a gown when changing a resident's sheets if the resident was on EBP. CNA #6 said if a resident was on EBP there was a sign on the door with EBP instructions, especially if the resident had a catheter. CNA #6 said once care was completed, the staff removed the PPE and left the used PPE in the trash in the resident's room. She said everything inside the trash was removed when she exited the room. CNA #6 said staff should not don a gown if they did not provide direct care to a resident on EBP, only if staff provided patient care and handled sheets. CNA #7 was interviewed on 12/17/24 at 11:52 a.m. CNA #7 said he should have a gown on when he changed a resident's sheets and a resident was on EBP. CNA #7 said EBP were to decrease the chance of infection spreading. CNA #7 said he thought because Resident #1 left the room he no longer needed to wear a gown when he changed the resident's bedding. The DOCS was interviewed on 12/18/24 at 1:00 p.m. The DOCS said the facility had some new CNAs working. The DOCS said EBP training was done electronically. He said the EBP training was part of the onboarding process and should be reviewed on an ongoing basis. The DOCS said he identified EBP needed attention on an audit prior to the survey and assigned it to the previous DON to follow up on. The DOCS said EBP were discussed daily in the facility's morning meeting. II. Water management program A. Professional referenceThe CDC recommendations for Legionella (3/15/24) were retrieved on 12/20/24 from https://www.cdc.gov/control-legionella/php/wmp/index.html. It read in pertinent part, "Many buildings need a water management program (WMP) for their building water system or specific devices. WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens. Developing and maintaining a WMP is a multi-step process that requires continuous review. The seven steps of a Legionella WMP are to: Establish a WMP team; describe the building water systems; identify areas where legionella could grow and spread; decide where to apply and how to monitor control measures; establish interventions when control limits are not met; ensure the program runs as designed and is effective and document and communicate all the activities. "Use flow diagrams and a written description to describe the building water systems. Include details like: How water enters the building, how water is distributed in the building, location of hot tubs, water heaters or boilers, and cooling towers, and where the building connects to the municipal water supply. Identify where potentially hazardous conditions could occur in the building water systems. Examples include areas where water temperature could promote Legionella growth or where water flow might be low. Establish control measures and limits for each hazardous condition."Control measures are actions taken in the building water systems to limit growth and spread of Legionella. They can include adding disinfectant, cleaning, and heating. Control limits are acceptable values for the control measures being monitored. They can include a maximum, minimum, and range of values. Control points are locations where control measures are applied."B. Facility policy and procedureThe Legionella Surveillance policy, not dated, was provided by the nursing home administrator (NHA) on 12/16/24 at 1:30 p.m. The policy read in pertinent part, "Legionella surveillance is one component of the facility's water management plans for reducing the risk of legionella and other opportunistic pathogens in the facility's water systems. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies."Primary prevention strategies include: Cooling towers and potable water systems shall be routinely maintained. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations. Non-potable water systems shall be routinely cleaned and disinfected. Nebulation devices shall be filled only with sterile fluid. Cold water shall be stored above 140 degrees Fahrenheit (F) and circulated at a minimum return of 124 (F).""Stagnate - dead legs - Areas not in use by residents and staff are identified by maintenance and placed on a weekly flush and disinfection schedule." -The Legionella Surveillance policy did not identify specific areas and locations where legionella could grow and spread; and decide where to apply and how to monitor and document control measures. The policy failed to include specific facility locations monitored such as water filters, pipes, valves and fittings, and medical devices (such as CPAP machines). The policy did not include how to monitor and document the control measures. C. ObservationsOn 12/16/24 at 9:30 a.m. the southeast wing, resident rooms #55, #56, #57, #59, and #60, were observed to be empty of residents. The rooms were not occupied. D. Record reviewThe water flush log was reviewed on 12/19/24. It revealed the unoccupied rooms were flushed in July 2024 and October 2024. E. Staff interviewsThe regional director of operations (RDO) was interviewed on 12/16/24 at 2:08 p.m. The RDO said the facility's legionella surveillance policies were reviewed annually and as needed in monthly quality assurance andperformance improvement meeting (QAPI). -However, the policy did not contain a date it was reviewed. The maintenance director (MTD) was interviewed on 12/19/24 at 9:55 a.m. The MTD said the facility had a hallway of unoccupied resident rooms and these rooms contained dead legs (plumbing system with infrequent water flow). The MTD said these rooms had been unoccupied for several months. The MTD said he ran the water from one of the sinks in the southeast wing to check the water temperature and he maintained a log of his findings. He was not aware of any requirements to track the rooms or amount of time to run the water for legionella surveillance. The MTD said he went weekly to one of the unoccupied resident rooms to temperature check the water but he did not flush the toilets or run the faucets for any length of time outside of getting an accurate water temperature. -However, documentation of monitoring and disinfection were not available. III. Ensure staff followed appropriate hand hygiene during resident care and ensure shared vital signs equipment was sanitized between useA. Professional reference According to the CDC Recommendations for Hand Hygiene for Healthcare Workers, (2024), retrieved on 12/24/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, "CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: immediately before touching a patient and after touching a patient or a patient's surroundings."According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 12/11/24 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly, "Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin."C. ObservationsCertified nursing aide (CNA) #7 was observed on 12/11/24 at 10:30 a.m. taking the blood pressure of a resident. CNA #7 then continued to the next task to answer a call light while still holding the blood pressure cuff and the thermometer. He did not perform handwashing after he left the room. CNA #7 then went into another resident's room to take the vital signs of another resident. The CNA did not clean the blood pressure machine prior to taking the vitals of the other resident. D. Staff interviewsThe IP was interviewed on 12/16/24 at 2:00 p.m. The IP said the staff should perform hand hygiene after each task and especially in between residents. She said she would provide education regarding hand hygiene. IV. Ensure staff followed appropriate hand hygiene during delivery of the meal trays. A. Professional referenceThe CDC (2024), Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 12/24/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, "Perform hand hygiene before touching a patient, after touching a patient or their surroundings, immediately after glove removal."According to Treas, L.S., Barnett, K.L., & Smith, M.H. (2022.) Basic Nursing: Thinking, Doing and Caring, (Third edition), pages 1601, 1604-1605, "Use standard precautions to prevent the transmission of infection. Implement measures to prevent healthcare-associated infections (HAIs). HAIs are the leading complication of healthcare and one of the ten leading causes of death in the United States. Hand hygiene can remove transient flora (microbes acquired by touching objects or people)." B. ObservationsDuring a continuous observation of the lunch on 12/11/24, beginning at 12:01 p.m. and ending at 12:28 p.m. the following was observed:At 12:01 p.m., the room trays were delivered to the East unit. Certified nurse aide (CNA) #8 delivered a tray to room #63. Sheassisted the resident into the chair at the table by holding his hand for assistance. She did not offer hand hygiene to the resident. She did not perform hand hygiene when she left the room. At 12:07 p.m., CNA #8 proceeded to pass a room tray to room #47. She put gloves on and assisted the resident in bed with positioning. She did not offer hand hygiene to the resident. There was no handwipe on the tray. At 12:10 p.m., CNA #7 was pouring drinks and placing them on the room trays. At 12:21 p.m., CNA #7 went into room #19B and delivered the resident's meal. The CNA did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. At 12:23 p.m., CNA #7 entered room #17A, and delivered the resident's meal. The CNA did not offer hand hygiene to the resident, did not perform hand hygiene for himself when he left the room. At 12:26 p.m., CNA #7 entered room #20B and delivered the resident's meal. The CNA did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. At 122:7 p.m., CNA #7 went into room #10A and delivered the resident's meal. CNA #7 did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. At 12:28 p.m., CNA #7 went into room #10A and delivered the resident's meal. He did not offer hand hygiene to the resident and did not perform hand hygiene for himself when he left the room. On 12/16/24 at t 12:03 p.m., CNA #9 served room #51 his meal. She did not offer hand hygiene to the resident. She did not perform hand hygiene when she left his room. At 12:05 p.m. the CNA #9 then proceeded to serve room #63 his tray. She assisted him to sit in the chair. She did not offer him hand hygiene prior to leaving the room. C. Staff interviewsCNA #7 was interviewed on 12/11/24 at 12:31 p.m. CNA #7 said he did not touch anything in the room when he dropped off meal trays. He said he should have performed hand hygiene before and after each meal delivery. The IP was interviewed on 12/16/24 at 2:00 p.m. The IP said residents should be offered hand hygiene prior to receiving their meals. She said the staff had been educated about offering hand hygiene prior to meals. The IP said the staff should also perform hand hygiene after each task and especially in between residents. She said she would provide education again.

A revisit survey was completed on 9/11/24 for all previous deficiencies cited on 8/7/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO36977 was conducted on 8/7/24. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure three (#1, #2 and #3) of five residents received treatment and care in accordance with professional standards of practice out of five sample residents. Specifically, the facility failed to administer pain medications in a timely manner per the physician orders for Resident #1, Resident #2 and Resident #3. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."II. Facility policy and procedure The Medication Administration policy and procedure, dated 2/29/24, was received from the director of clinical services (DCS) on 8/7/24 at 5:15 p.m. It revealed in pertinent part, " Resident medications are administered in accurate, safe, timely and sanitary manner."Physician Orders-Medications are administered in accordance with written orders of the attending physicians or physician extender."Verify the medication label against the medication administration record (MAR) for accuracy of drug frequency, duration, strength and route."III. Resident #3A. Resident statusResident #3, age less than 65, was admitted on 6/15/16. According to the August 2024 computerized physician orders (CPO), diagnoses include fracture of the right fibula (broken bone of the lower leg), chronic obstructive pulmonary disease (abnormal oxygen exchange), type 2 diabetes (abnormal glucose) and schizoaffective disorder (mental disorder). The 7/1/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated Resident #3 received pain medications scheduled and as needed. B. Resident interviewResident #3 was interviewed on 8/7/24 at 3:15 p.m. Resident #3 said her medications were rarely administered on time. Resident #3 said she had not received her morning medications today (8/7/24) until almost 11:00 a.m (see record review below). She said her night time pain medications on 8/6/24 were not administered to her until around 10:00 p.m (see record review below). Resident #3 said she had been educated by the facility staff that her pain medications needed to be scheduled and on time to achieve the best pain control. Resident #3 said she had submitted a couple of formal grievances to the facility concerning her medications being given late (see record below) and she had instructed the facility to tell staff to wake her if medications were due to be administered so she could ensure she got them as ordered. C. Resident grievancesOn 6/5/24 Resident #3 filed a grievance form related to missing medications. The form documented she did not receive her medications because the nurse failed to wake her to administer them. The facility follow up indicated the facility obtained a physician's order to wake the resident for all scheduled medications. Resident #3 filed a second grievance form on 7/2/24 related to medications being administered late. The form documented the resident complained about getting her medications two to three hours late. The facility representative spoke with Resident #3 about the timeliness of her medications. The facility followed up with the nurse who administered the medications late and the nurse was educated about the time window for medication administration. -However Resident #3 continued to receive her medications late (see administration records below). D. Record ReviewAccording to the August 2024 CPO Resident #3 had the following physician's order for pain management:Morphine sulfate ER (extended release) (opioid pain medication) 15 milligrams (mg), administer 45 mg two times a day, ordered 6/30/24. Hydrocodone-Acetaminophen (opioid pain medication) 10-325 mg twice daily, ordered 6/27/24. Acetaminophen (pain medication) 1000 mg three times daily, ordered on 6/27/24. According to the August 2024 medication administration record (MAR), Resident #3's morphine sulfate was to be administered at 8:00 a.m. and 8:00 p.m. -On 8/1/24 the 8:00 a.m. administration was administered at 9:49 a.m., 49 minutes after the allowed medication administration window. On 8/1/24 the administration times for the morphine sulfate were changed to 6:00 a.m and 7:00 p.m. per the August 2024 MAR. Review of the morphine sulfate administrations documented on the August 2024 MAR revealed the following:-On 8/1/24 the 7:00 p.m. dose was administered at 8:40 p.m., 40 minutes after the allowed medication administration window; -On 8/2/24 the 6:00 a.m. dose was administered at 10:49 a.m., three hours and 49 minutes after the allowed medication administration window;-On 8/3/24 the 6:00 a.m. dose was administered at 7:46 a.m., 46 minutes after the allowed medication administration window;-On 8/4/24 the 6:00 a.m. dose was administered at 10:22 a.m., three hours and 22 minutes after the allowed medication administration window;-On 8/4/24 the 7:00 p.m. dose was administered at 10:26 p.m., two hours and 26 minutes after the allowed medication administration window;-On 8/5/24 the 6:00 a.m dose was administered at 8:00 a.m., one hour after the allowed medication administration window; -On 8/6/24 the 7:00 p.m. dose was administered at 9:10 p.m., one hour and 10 minutes after the allowed medication administration window; and, -On 8/7/24 the 6:00 a.m. dose was administered at 10:45 a.m. three hours and 45 minutes after the allowed medication administration window. The August 2024 MAR revealed Resident #3's hydrocodone-acetaminophen was scheduled to be administered at 6:00 a.m. and 4:00 p.m. Review of the hydrocodone-acetaminophen administrations documented on the August 2024 MAR revealed the following:-On 8/1/24 the 6:00 a.m. dose was administered at 9:49 a.m., two hours and 49 minutes after the allowed medication administration window; -On 8/1/24 the 4:00 p.m. dose was administered at 5:22 p.m., 22 minutes after the allowed medication administration window;-On 8/2/24 the 4:00 p.m. dose was administered at 6:05 p.m., one hour and five minutes after the allowed medication administration window; -On 8/3/24 the 6:00 p.m. dose was administered at 7:46 a.m., 46 minutes after the allowed medication administration window;-On 8/4/24 the 6:00 a.m. dose was administered at 10:22 a.m., three hours and 22 minutes after the allowed medication administration window; -On 8/4/24 the 4:00 p.m. dose was administered at 5:17 p.m., 17 minutes after the allowed medication administration window;-On 8/5/24 the 6:00 a.m. dose was administered at 8:00 a.m., one hour after the allowed medication administration window; and,-On 8/7/24 the 6:00 a.m. dose was administered at 10:47 a.m., three hours and 47 minutes after the allowed medication administration window. According to the August 2024 MAR, the scheduled administration times for Resident #3's acetaminophen 1000 mg were 9:00 a.m., 1:00 p.m. and 9:00 p.m. Review of the acetaminophen administrations documented on the August 2024 MAR revealed the following:-On 8/2/24 the 9:00 a.m. dose was administered at 10:18 a.m., 18 minutes after the allowed medication administration window; -On 8/2/24 the 1:00 p.m. dose was administered at 2:45 p.m., 45 minutes after the allowed medication administration window; -On 8/4/24 the 9:00 a.m dose was administered at 10:15 a.m., 15 minutes after the allowed medication administration window; -On 8/4/24 the 9:00 p.m. dose was administered at 10:25 p.m., 25 minutes after the allowed medication administration window; and, -On 8/7/24 the 9:00 a.m. dose was administered at 10:41 a.m., 41 minutes after the allowed medication administration window. IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 1/30/19. According to the August 2024 CPO, diagnoses include hemiplegia (inability to move one side of the body) affecting left side, dementia, type 2 diabetes, chronic pain and chronic obstructive pulmonary disease. The 7/18/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated Resident #1 received scheduled pain medications and as needed pain medications. Resident #1 had pain almost constantly. B. Resident interviewResident #1 was interviewed on 8/7/24 at 2:05 p.m. Resident #1 said he was not sure when he would get pain medication as every nurse brought him medications at different times. C. Record reviewAccording to the August 2024 CPO, Resident #1 had the following physician's order for pain management:Acetaminophen 1000 mg three times a day for pain, ordered on 1/29/24. According to the August 2024 MAR, Resident #1's acetaminophen was scheduled to be administered at 9:00 a.m., 1:00 p.m. and 9:00 p.m. These administration times were discontinued on 8/2/24 after the 9:00 a.m. dose. On 8/2/24 the acetaminophen physician's order changed to administer the acetaminophen at 6:00 a.m., 11:00 a.m. and 7:00 p.m. Review of the acetaminophen administrations documented on the August 2024 MAR revealed the following:-On 8/2/24 the 11:00 a.m. dose was administered at 12:39 p.m., 39 minutes after the allowed medication administration window;-On 8/3/24 the 6:00 a.m. dose was administered at 9:48 a.m., two hours and 48 minutes after the allowed medication administration window;-On 8/3/24 the 7:00 p.m. dose was administered at 10:59 p.m., two hours and 59 minutes after the allowed medication administration window;-On 8/4/24 the 6:00 a.m. dose was administered at 8:50 a.m., one hour and 50 minutes after the allowed medication administration window;-On 8/5/24 the 6:00 a.m. dose was administered at 8:26 a.m., one hour and 26 minutes after the allowed medication administration window;-On 8/5/24 the 11:00 am dose was administered at 1:04 p.m., one hour and four minutes after the allowed medication administration window; -On 8/5/24 the 7:00 p.m. dose was administered at 10:46 p.m., two hours and 46 minutes after the allowed medication administration window;-On 8/6/24 the 6:00 a.m. dose was administered at 8:03 a.m., one hour and three minutes after the allowed medication administration window; -On 8/6/24 the 11:00 a.m. dose was administered at 12:32 a.m., 32 minutes after the allowed medication administration window; -On 8/7/24 the 6:00 a.m. dose was administered at 10:54 a.m., three hours and 54 minutes after the allowed medication administration window; and, -On 8/7/24 the 11:00p a.m. dose was administered at 1:13 p.m., one hour and 13 minutes after the allowed medication administration window. V. Resident #2A. Resident statusResident #2, age than 65, admitted on 8/26/16. According to the August 2024 CPO, diagnoses include dysphagia (impaired swallowing) following cerebral infarction (disrupted blood flow to the brain), hemiplegia affecting the right side, dementia and hypertension (increased blood pressure). The 7/24/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15. The MDS assessment indicated the resident had pain almost constantly. The resident had received scheduled pain medications and as needed pain medication. B. Record ReviewAccording to the August 2024 CPO, Resident #2 had the following physician's order for pain management: Tramadol (pain medication) 50 mg once daily, ordered on 8/2/24. According to the August 2024 MAR, Resident #2's tramadol was to be administered at 6:00 a.m. Review of the tramadol administrations documented on the August 2024 MAR revealed the following:-On 8/3/24 the 6:00 a.m. dose was administered at 7:53 a.m., 53 minutes after the allowed medication administration window; -On 8/4/24 the 6:00 a.m. dose was administered at 10:34 a.m.. three hours and 34 minutes after the allowed medication administration window; -On 8/5/24 the 6:00 a.m. dose was administered at 9:41 a.m., two hours and 41 minutes after the allowed medication administration window;-On 8/6/24 the 6:00 a.m. dose was administered at 7:18 a.m.,18 minutes after the allowed medication administration window; and, -On 8/7/24 the 6:00 a.m. dose was administered at 10:58 a.m., three hours and 58 minutes after the allowed medication administration window. VI. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/7/24 at 4:42 p.m. LPN # 1 said scheduled pain medications should be given timely. She said pain medications needed to be administered within one hour before or one hour after the scheduled administration time for effective pain management. LPN #1 said it was hard to control breakthrough pain. LPN #1 said she would call the physician to make sure it was okay to administer the medication outside of the time frame and document in a progress note. -However, review of Resident #1, Resident #2 and Resident #3's EMRs did not include documentation indicating the physician had been contacted for any medications given outside of the safe administration time. LPN #2 was interviewed on 8/7/24 at 4:46 p.m. LPN #2 said pain medications should be administered as scheduled. She said it was important to administer pain medications as ordered to help manage pain. LPN #2 said medications needed to be given within one hour before or one hour after the scheduled time. LPN #2 said the physician should be called to make sure it was safe for the medications to be given late. The DCS was interviewed on 8/7/24 at 6:00 p.m. The DCS said pain medications should be administered as scheduled for effective pain management. The DCS said pain medication given late or early could be problematic for a resident by not being effective to control pain or that the resident may have too much medication in their system. The DCS said the physician should be notified if the medication was given outside the safe administration window. The DCS said the facility had identified a problem within the facility when it came to administration times of medications. She said the nurses had too many options for administration times to choose from when entering the verbal physician's orders into the electronic system. The director of nursing (DON) was interviewed on 8/7/24 at 6:11 p.m. The DON said if pain medications were not administered timely, the pain relief could not be effective for the resident. The DON said the nurses could administer medications one hour before or one hour after the scheduled administration time. She said if the medication was administered outside the allowed one hour before or one hour after window, it was considered to be given late. The DON said the physician should be notified if a medication was administered outside the medication administration window and a progress note should be written on every occurrence of late administration. The DON said the facility needed to address the administration times to ensure medications were given at safe administration times to be more effective for pain control. The DON said she had noted the nurses spending a lot of time administering medication because the facility had so many medication administration times available and wanted to decrease the medication administration times to be more uniform. The DON said, until the facility addressed the medication administration times ,the nurses were to follow scheduled medication administration times in the resident's MAR.

A revisit survey was completed on 8/7/24 for all previous deficiencies cited on 6/20/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 8/7/24 for all previous deficiencies cited on 6/20/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO34507, #CO36419 and Incident #35786 was conducted on 6/17/24 to 6/20/24. Three deficiencies were cited.

Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#7, #8, #9 and #10) of four residents reviewed for abuse out of 12 sample residents. Resident #7 was admitted to the facility on 2/1/24 with diagnoses that included a history of mood disorder, depression and alcohol abuse. On 3/9/24 Resident #7 called certified nurse aide (CNA) #1, who was an agency CNA, a racial slur. CNA #1 went to Resident #7's bed, placed his forearm across the resident's left side and leaned on top of the resident. CNA #1 repeatedly told Resident #7 he needed to apologize for calling him a racial slur. CNA #1 then left the room. Resident #7 reported he cried out in pain all night following the incident. On the morning of 3/10/24 Resident #7 was transferred to the hospital when his oxygen saturation level (level of oxygen in the blood) dropped into the 70 percent (%) to 79% range. At the hospital, Resident #7 was diagnosed with multiple rib fractures and a pneumothorax (collapsed lung). Additionally, the facility failed to:- Prevent physical abuse between Resident #8 and Resident #9, both with known physical aggression, which resulted in an eye injury to Resident #8; and, - Prevent physical abuse by Resident #11, a resident with known aggressive behaviors, to Resident #10 which resulted in skin injuries to Resident #10's neck and arm. Findings include: I. Facility policyThe Abuse policy, dated 2/29/24, was received from the regional director of clinical services (RDCS) on 6/20/24 at 2:12 p.m. The policy documented in pertinent part, "Employees have a unique position of trust with vulnerable residents."Resident abuse is defined as the willful infliction of injury, unreasonable confinement,intimidation, or punishment of a resident resulting in physical harm or pain, mentalanguish, deprivation of goods or services that are necessary to attain or maintain physical,mental, or psychosocial well-being. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm."Pre-assessment of potential residents is done during the admission process to screen forpotential signs of abusive behavior. Residents at risk for abusive situations are identified and appropriate care plans are developed. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials, according to state law. Reporting can be completed verbally or in writing. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The facility assesses each potential resident prior to admission. This assessment includes abehavior history. Persons with a significant history or high risk of violent behavior are carefullyscreened and assessed for appropriateness of admission. If a resident experiences a behavior change resulting in aggression toward other residents, the facility will implement interventions for protection of the alleged assailant and other residents."II. Physical abuse by certified nurse aide (CNA) #1 toward Resident #7 on 3/9/24A. Facility investigationThe facility investigation was received from the nursing home administrator (NHA) on 6/17/24 at 12:40 p.m. The investigation documented the abuse by CNA #1 toward Resident #7 occured on 3/10/24 and an investigation was started on 3/11/24. The investigation further documented the following:Resident #7 had a history of aggression. Resident #7 was interviewed by the facility on 3/12/24. Resident #7 said (CNA #1) came into his room and he called CNA #1 a racial slur. He said CNA #1 put his forearm on the resident's chest and pressed down. CNA #1 was interviewed on 3/12/24. He said he was assigned to the resident's room. He said he had helped Resident #7's roommate to and from bed. He said Resident #7 reported some difficulty breathing and he had notified the night nurse. Resident #7's roommate was interviewed. The facility's investigation documented the roommate said he was not aware of what happened with his roommate. Registered nurse (RN) #1 was interviewed by the facility on 3/12/24. RN #1 said, at approximately 6:15 a.m., she went to assess Resident #7 who had complaints of pain. The resident said he had pain in his chest where a CNA had fallen on him. The resident could not elaborate due to his shortness of breath.-The facility's investigation did not include an interview with the night nurse, RN #3, who worked from 6:00 p.m. on 3/9/24 to 6:00 a.m. on 3/10/24, according to the facility's nursing schedule. The investigation documented that there were no witnesses to the event and CNA #1 said he had only "gone in to assist Resident #7's roommate and nothing else." It documented Resident #7 could be resistant to care. The investigation further documented there was no mention of abuse in CNA #1's statement. The investigation documented the facility staff were educated on abuse and the police were notified on 3/12/24. The investigation documented the abuse was unsubstantiated by the facility.-However, according to the interview with the NHA, the abuse was substantiated (see interview below). A document titled Abuse Education (no date) was attached to the facility's investigation of the incident. Seventeen staff names and signatures were listed as receiving the education. B. Resident #71. Resident statusResident #7, age 69, was admitted on 2/1/21 and readmitted on 3/26/24. According to the June 2024 computerized physician orders (CPO), diagnoses included multiple rib fractures, traumatic hemopneumothorax (blood and air in collapsed lung), depression, mood disorder and alcohol abuse. According to the 3/29/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #7 required substantial to maximal assistance with transfers and toileting and supervision with personal hygiene and bed mobility. 2. Resident interviewResident #7 was interviewed on 6/18/24 at 2:01 p.m. Resident #7 said in the beginning of March 2024, in the evening, he had a male CNA (CNA #1) providing his care. Resident #7 said CNA #1 had been in his room, on his side of the room, multiple times that evening when his roommate called for assistance. He said he repeatedly told CNA #1 that his roommate had called, not him. Resident #7 said he called CNA #1 some "bad names" as CNA #1 was leaving his room. Resident #7 said CNA #1 came back into the room and laid across the left side of his chest, with his forearm pressed into the resident's left chest. He said CNA #1 yelled at him, in his face, to apologize. Resident #7 said CNA #1 then left his room. Resident #7 said he had pain in his left rib cage and was short of breath the entire evening and night. Resident #7 said he put his call light on several times but CNA #1 would come back in the room and turn it off. He said another resident in close proximity to him also turned on the call light throughout the night, but no staff came to help him. Resident #7 said he was nervous and anxious that he could be harmed again by another staff person. 3. Additional resident interviewA resident, who wished not to be identified, was interviewed on 6/18/24 at 2:08 p.m. The resident resided in close proximity to Resident #7. The resident said he did not see what happened to Resident #7. He said he heard a commotion and then Resident #7 cried out in pain. He said Resident #7 cried in pain all night. The unidentified resident said both he and Resident #7 put on their call lights for help throughout the night but no one responded. He said he did not know if someone shut the call light off or the staff just did not come. He said both he and Resident #7 were up all night. 4. Record reviewA chest x-ray in Resident #7's electronic medical record (EMR), dated 3/7/24, two days before the incident with CNA #1, documented the resident had right airspace lung disease. He had no pneumothorax and there was no mention of an issue with his ribs. A nurse progress note, dated 3/10/24 at 12:32 a.m., documented Resident #7 had shortness of breath, dyspnea (difficulty breathing) and wheezing but no pain. The resident had a diagnosis of pneumonia and was on antibiotics. However, in report to the day nurse on the morning of 3/10/24, the night nurse reported the resident was in pain (see RN #1's interview below). Resident #7's medication administration record (MAR) for March 2024 was reviewed. The MAR documented the resident had no pain on 3/9/24. However, in report to the day nurse on the morning of 3/10/24, the night nurse reported the resident was in pain (see RN #1's interview below). The hospital note dated 3/20/24 documented Resident #7 had trauma to the left chest and had multiple rib fractures with a large left pneumothorax due to someone sitting on him. On 4/2/24 the facility's provider documented Resident #7 returned from the hospital after a traumatic pneumothorax with a chest tube and multiple rib fractures. The resident said someone sat on him. The provider documented the hospital records were unclear but laboratory results revealed evidence of a possible myocardial infarction (heart attack) as well. 5. Staff interviewsA voice mail message was left on 6/17/24 at 1:56 p.m. for the agency RN (RN #3) who worked from 6:00 p.m. on 3/9/24 to 6:00 a.m. on 3/10/24. There was no return call from RN #3 by the end of the survey on 6/20/24. A voice mail message was left on 6/19/24 at 1:09 p.m. for the agency CNA (CNA #2) who worked with CNA #1 on 3/9/24 in the evening. There was no return call CNA #2 by the end of the survey on 6/20/24. RN #1 was interviewed with the nursing home administrator (NHA) on 6/17/24 at 1:35 p.m. RN #1 said on the morning of 3/10/24 she was getting report from the night shift nurse (RN #3) who said Resident #7 had been in pain throughout the night. RN #1 said RN #3 told her it was generalized pain. RN #1 said soon after, a CNA came to her and asked her to go see Resident #7 because his oxygen saturation level was in the 70% to 79% range. RN #1 could not recall who the CNA who reported the information to her was. She said she went to see the resident and he was short of breath and had chest pain. She said she put 10 liters per minute (lpm) of oxygen on him and called 911. RN #1 said Resident #7 could hardly speak but said "CNA, my chest, my fault." RN #1 said she did not look at his chest. She said the resident was then transferred to the hospital. RN #1 said she called the hospital for a report and was told Resident #7 had multiple rib fractures to the left side and a pneumothorax. RN #1 said the resident's comment about the CNA was reported to the NHA that day. The NHA said the hospital case manager called him on 3/11/24 and notified him that Resident #7 said a CNA had injured him. He said he went to the hospital and interviewed the resident on 3/11/24. The NHA said Resident #7 told him the male CNA (CNA #1) on 3/9/24 sat on him and pressed his forearm into the resident's chest. The resident admitted to having called CNA #1 names. The NHA said the allegation of abuse was substantiated and he notified the police and board of nursing. Additionally, he said he called CNA#1's agency and notified them that he could not return to the facility. The medical director (MD), who was contacted prior to the end of the survey on 6/20/24 at 9:40 a.m. and was interviewed on 6/24/24 at 9:57 a.m. The MD said she became the medical director at the beginning of June 2024. The MD said a resident with fractured ribs would most likely have had pain immediately when the ribs were fractured. She said the pain could have been delayed if the resident was in shock. The MD said Resident #7's pneumothorax could have affected his oxygenation levels as well the pain. She said the pneumothorax could have happened at the time of the rib fractures or later in the night if he had taken a deep breath. III. Resident to resident physical abuse between Resident #8 and Resident #9 on 4/14/24A. Facility investigationA facility investigation of physical abuse between Resident #8 and #9 on 4/14/24 was received from the NHA on 6/19/24 at 2:52 p.m. The investigation documented the following:Resident #9 was interviewed on 4/15/24 and said Resident #8 did not like her cell phone ring tone and Resident #8 shoved her in the chest so she decided to hit him. Resident #8 was interviewed on 4/15/24. He said Resident #9 asked him for cigarettes earlier that day (4/14/24). He said when he heard her phone ring, he did not like the ring tone and told her to change it. She said no. Resident #8 said Resident #9 began to leave and he followed her and tried to hit her, and she turned around and hit him in the face. A staff witness said she was going to the kitchen and she saw Resident #8 run his wheelchair into Resident #9. She said she then saw Resident #9 hit Resident #8 in the face. She said she and other staff members pulled the residents apart.-The investigation documented both residents had a history of physical and verbal aggression.-The investigation documentation revealed the assailant was placed on frequent checks. It was unclear which resident was the assailant. B. Resident #81. Resident statusResident #8, age less than age 65, was admitted on 4/5/24. According to the June 2024 CPO, diagnoses included alcohol abuse, anxiety and seizures. According to the 4/5/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #8 was independent with bed mobility, transfers, toileting, dressing and personal hygiene. 2. Record reviewThe behavior care plan, initiated 1/18/24, documented Resident #8 had a history of drinking at the facility, physical and verbal aggression and poor impulse control. He had a history of yelling, screaming, cursing, making verbal threats, hitting and pushing. Interventions included administering medications as ordered, assisting the resident to develop more appropriate methods of coping, encouraging expression of feelings, behavior monitoring, providing positive interactions, explaining procedures, discussing the resident's behavior, intervening as necessary to protect the rights and safety of others, approaching the resident in a calm manner, diverting the resident's attention and removing the resident from the situation. -There were no new interventions added to the care plan after the altercation on 4/14/24. C. Resident #91. Resident statusResident #9, age less than age 65, was admitted on 3/14/23 and readmitted on 5/28/24. According to the June 2024 CPO, diagnoses included anxiety, depression, cocaine dependence and adult physical abuse. According to the 3/29/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #9 required substantial to maximal assistance with transfers and toileting and supervision with personal hygiene and bed mobility. 2. Record reviewOn 3/30/24 at 11:29 a.m. the nursing progress notes documented Resident #9 was yelling and cursing at the nurse. On 4/13/24 at 10:44 a.m., one day prior to the physical abuse, the nursing progress notes documented Resident #9 was cursing at the nurse, physically attempted to remove the nurse from the room and attempted to stand and go after the nurse. The staff had to hold the resident back. The nurse documented the resident was "unsafe to herself and to be around."-The nursing progress notes were reviewed between 4/13/24 and 4/14/24. No additional monitoring or intervention for Resident #9's behavior was put in place. The physical and verbal aggression care plan, initiated 8/22/23 was reviewed. The care plan documented Resident #9 had poor impulse control and a history of yelling, cursing and hitting others. Interventions included assessing and anticipating the resident's needs, monitoring behaviors, and when the resident was agitated, intervene before the agitation escalated, guiding the resident away from sources of distress and using calm conversation. -There were no new interventions added to the care plan after the altercation on 4/14/24. D. Staff interviewsThe NHA was interviewed with the RDCS on 6/19/24 at 2:52 p.m. The NHA said on 4/14/24 Resident #9's cell phone rang in the dining room. Resident #8 did not like the ringtone. Resident #9 attempted to leave the dining room but Resident #8 followed her and hit her in the chest. Resident #9 had sternal pain. Resident #8 then hit Resident #9 in the face resulting in broken blood vessels in Resident #8's right eye. The NHA said Resident #8 and Resident #9 had a history of verbal and physical aggression. He said there was no plan for monitoring behaviors in the dining room. The NHA said after the incident occurred, both residents were put on frequent monitoring. -However, there was no frequent monitoring documented on the care plan or in the progress notes for Resident #8 or #9. The NHA said the physical abuse toward both residents was substantiated and witnessed by staff in the dining room. IV. Resident to resident physical abuse of Resident #10 by Resident #11 on 5/31/24A. Facility investigationAn investigation of physical abuse to Resident #10 by Resident #11 on 5/31/24 was received from the NHA on 6/19/24 at 2:52 p.m. The investigation documented the following: Resident #10 and #11 were roommates. Resident #10 said Resident #11 had grabbed her arm and put the call light cord on her neck. A staff member interview on 5/31/24 documented she heard Resident #10 calling for help and when she went in the resident's room Resident #11 had a call light on the neck of Resident #10. Additionally the skin on the arm of Resident #10 looked like it had been twisted. A licensed nurse interview on 5/31/24 documented she went to the resident's room after a CNA came to get her. She said Resident #10 had redness to her neck and arm. Resident #11 was placed on frequent checks and then sent out to the hospital due to the risk she posed to other residents (see below). B. Resident #101. Resident statusResident #10, age less than age 65, was admitted on 3/16/22 and readmitted on 3/8/24. According to the June 2024 CPO, diagnoses included major depression, heart failure and diabetes mellitus. According to the 6/13/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #10 required substantial to maximal assistance with bed mobility, transfers, toileting, personal hygiene and dressing. 2. Record reviewOn 5/31/24 at 8:05 a.m. the nursing notes documented at 12:30 a.m. a CNA heard Resident #10 calling out for help. Upon entering room Resident #10's roommate Resident #11 was twisting skin on Resident #10's arms and had the call light wrapped around Resident #10's neck. Resident #10 was "extremely frightened." Slight redness was noted on the resident's arms and on the neck. Resident #10 reported slight pain that quickly resolved. Frequent checks were performed to reassure Resident #10 throughout the night. Resident #10 reported anxiety which improved when the resident was informed a CNA would stay until the roommate was removed and that staff would check on her through the night.-There was no care plan in the resident's EMR related to the abuse. C. Resident #111. Resident statusResident #11, age less than age 65, was admitted on 1/22/22 and readmitted on 8/22/23. According to the June 2024 CPO, diagnoses included dementia, anxiety and agitation. According to the 3/31/24 MDS assessment, the resident had severe cognitive impairment and a BIMS score was not completed. She had short and long term memory loss with moderate impairment of daily decision making, disorganized thinking and physical behavior toward others. Resident #11 required substantial to maximal assistance with toileting, personal hygiene, dressing and supervision with transfers and bed mobility. 2. Record reviewOn 5/22/24 at 7:36 p.m. the provider documented the resident had increased aggression and a history of aggressive behavior. On 5/30/24 at 5:09 p.m. the nursing notes documented the resident was fascinated by an ambulance that had come to the facility and she tried to get on the gurney brought by the emergency medical services (EMS) staff. The resident could not be redirected and became aggressive, pushing and pinching the staff. The nurse tried to comfort the resident but was pushed away.-There was no behavior care plan in place until 6/10/24, after the physical altercation with Resident #10, despite Resident #11 exhibiting aggressive physical behaviors prior to the incident (see Resident #11's care plan below). On 5/31/24 at 7:53 a.m. the nursing progress notes documented that at approximately 12:30 a.m., Resident #10 called out for help. Resident #11 was found by a CNA with the call light wrapped around the neck of Resident #10 and she was pulling the call light. Resident #10 said Resident #11 had also grabbed her by the forearms and twisted her skin. The nurse called administration and a decision was made to send Resident #11 to the hospital for the safety of Resident #11 and other residents. On 5/31/24 at 8:15 a.m. an SBAR (situation, background, assessment recommendation) note documented Resident #11 was sent to the hospital due to her behavior. The note documented she needed "close observation for resident, staff, and other resident safety." The resident returned that afternoon at an undocumented time. On 5/31/24 at 6:12 p.m. The nursing notes documented the resident was moved to a different unit due to the "incident" and was monitored. The behavior care plan, initiated 6/10/24 (10 days after the incident with Resident #10) documented Resident #11 had potential to be physically aggressive with a history of harm to others. The goal was the resident would seek out a staff member when agitation occurred. Interventions included administering medications, analyzing time of day, places , triggers, circumstances and what deescalated behaviors, assessing and addressing sensory deficits, anticipating the resident's needs, Modifying the environment, such as dim lights and keeping the door closed, monitoring and documenting behaviors and interventions, monitoring and documenting signs and symptoms of the resident posing danger to herself or others, when the resident was agitated, intervening before agitation escalated, guiding the resident away from distress, engaging with the resident calmly and re-approaching the resident later. D. Staff interviewThe NHA was interviewed with the RDCS on 6/19/24 at 2:52 p.m. He said Resident #10 reported Resident #11 put a call light on her neck and pinched her arm. The NHA said Resident #11 had a history of pacing and grabbing furniture. He said Resident #10 had redness to her arm and neck. He said the abuse was unsubstantiated because Resident #11 had dementia. He said he moved Resident #11 to a private room after the altercation.

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

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include:I. Cross-referenced citationsCross-reference F686: The facility failed to ensure pressure injuries were assessed and interventions were implemented timely to prevent worsening of the wounds and infection. The facility failed to ensure wound treatment was implemented as ordered for a resident who developed a wound infection with osteomyelitis (inflammation of the bone due to infection). The facility's failure to assess and treat pressure injuries created an immediate jeopardy (IJ) situation with actual serious harm. Cross-reference F600: The facility failed to prevent abuse resulting in a G level citation, isolate, with actual harm. II. Facility policy and procedureThe facility QAPI policy was requested from the nursing home administrator (NHA) on 6/20/24 at 2:10 p.m. -The policy was not received by the end of the survey on 6/20/24. III. Repeat deficienciesReview of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F686 Pressure injuries:During a recertification survey on 4/19/22, F686 was cited at a G level scope and severity, isolated, actual harm. F600 Abuse prevention: During a recertification survey on 10/26/23, F600 was cited at a G level scope and severity, isolate, actual harm. During a recertification survey on 3/7/24, F600 was cited at a D level scope and severity, potential for more than minimal harm, isolated. F867 QAPIDuring a recertification survey on 7/21/22, F867 was cited at an E level scope and severity, a potential for more than minimal harm, pattern. IV. InterviewsThe nursing home administrator (NHA) was interviewed on 6/20/24 at 2:10 p.m. The NHA said residents with pressure injuries were reviewed at QAPI. However, he said the lack of assessment and timely treatment of wounds identified during the survey was an "eye opener." The NHA said the facility had missed things in their review of the wounds. The NHA said he did not have a clinical background and therefore did not check any of the clinical information himself. The NHA said the staff needed more training on abuse and how to appropriately prevent, report and intervene in abuse situations. He said the facility additionally needed to keep a better record of training that was completed with staff on abuse. The medical director (MD) was interviewed on 6/24/24 at 9:57 a.m. The MD said she had become the medical director of the facility two weeks ago (beginning of June 2024). She said the facility had been using a lot of agency staff and they were working on recruiting staff for hire by the facility. She said she felt this contributed to the facility's failures. The MD said she knew the facility had changed wound care providers recently, but she was not aware wounds were not being assessed by the facility or treated timely. The MD said she did not recall the staff to resident abuse when a staff person laid on a resident intentionally, causing multiple rib fractures and a pneumothorax. However, she said she had not been with the facility long.

A survey prompted by complaint #CO36539 was completed on 6/17/24 to 6/20/24. Two deficiencies were cited.

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

Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#7, #8, #9 and #10) of four residents reviewed for abuse out of 12 sample residents. Resident #7 was admitted to the facility on 2/1/24 with diagnoses that included a history of mood disorder, depression and alcohol abuse. On 3/9/24 Resident #7 called certified nurse aide (CNA) #1, who was an agency CNA, a racial slur. CNA #1 went to Resident #7's bed, placed his forearm across the resident's left side and leaned on top of the resident. CNA #1 repeatedly told Resident #7 he needed to apologize for calling him a racial slur. CNA #1 then left the room. Resident #7 reported he cried out in pain all night following the incident. On the morning of 3/10/24 Resident #7 was transferred to the hospital when his oxygen saturation level (level of oxygen in the blood) dropped into the 70 percent (%) to 79% range. At the hospital, Resident #7 was diagnosed with multiple rib fractures and a pneumothorax (collapsed lung). Additionally, the facility failed to:- Prevent physical abuse between Resident #8 and Resident #9, both with known physical aggression, which resulted in an eye injury to Resident #8; and, - Prevent physical abuse by Resident #11, a resident with known aggressive behaviors, to Resident #10 which resulted in skin injuries to Resident #10's neck and arm. Findings include: I. Facility policyThe Abuse policy, dated 2/29/24, was received from the regional director of clinical services (RDCS) on 6/20/24 at 2:12 p.m. The policy documented in pertinent part, "Employees have a unique position of trust with vulnerable residents."Resident abuse is defined as the willful infliction of injury, unreasonable confinement,intimidation, or punishment of a resident resulting in physical harm or pain, mentalanguish, deprivation of goods or services that are necessary to attain or maintain physical,mental, or psychosocial well-being. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm."Pre-assessment of potential residents is done during the admission process to screen forpotential signs of abusive behavior. Residents at risk for abusive situations are identified and appropriate care plans are developed. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials, according to state law. Reporting can be completed verbally or in writing. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The facility assesses each potential resident prior to admission. This assessment includes abehavior history. Persons with a significant history or high risk of violent behavior are carefullyscreened and assessed for appropriateness of admission. If a resident experiences a behavior change resulting in aggression toward other residents, the facility will implement interventions for protection of the alleged assailant and other residents."II. Physical abuse by certified nurse aide (CNA) #1 toward Resident #7 on 3/9/24A. Facility investigationThe facility investigation was received from the nursing home administrator (NHA) on 6/17/24 at 12:40 p.m. The investigation documented the abuse by CNA #1 toward Resident #7 occured on 3/10/24 and an investigation was started on 3/11/24. The investigation further documented the following:Resident #7 had a history of aggression. Resident #7 was interviewed by the facility on 3/12/24. Resident #7 said (CNA #1) came into his room and he called CNA #1 a racial slur. He said CNA #1 put his forearm on the resident's chest and pressed down. CNA #1 was interviewed on 3/12/24. He said he was assigned to the resident's room. He said he had helped Resident #7's roommate to and from bed. He said Resident #7 reported some difficulty breathing and he had notified the night nurse. Resident #7's roommate was interviewed. The facility's investigation documented the roommate said he was not aware of what happened with his roommate. Registered nurse (RN) #1 was interviewed by the facility on 3/12/24. RN #1 said, at approximately 6:15 a.m., she went to assess Resident #7 who had complaints of pain. The resident said he had pain in his chest where a CNA had fallen on him. The resident could not elaborate due to his shortness of breath.-The facility's investigation did not include an interview with the night nurse, RN #3, who worked from 6:00 p.m. on 3/9/24 to 6:00 a.m. on 3/10/24, according to the facility's nursing schedule. The investigation documented that there were no witnesses to the event and CNA #1 said he had only "gone in to assist Resident #7's roommate and nothing else." It documented Resident #7 could be resistant to care. The investigation further documented there was no mention of abuse in CNA #1's statement. The investigation documented the facility staff were educated on abuse and the police were notified on 3/12/24. The investigation documented the abuse was unsubstantiated by the facility.-However, according to the interview with the NHA, the abuse was substantiated (see interview below). A document titled Abuse Education (no date) was attached to the facility's investigation of the incident. Seventeen staff names and signatures were listed as receiving the education. B. Resident #71. Resident statusResident #7, age 69, was admitted on 2/1/21 and readmitted on 3/26/24. According to the June 2024 computerized physician orders (CPO), diagnoses included multiple rib fractures, traumatic hemopneumothorax (blood and air in collapsed lung), depression, mood disorder and alcohol abuse. According to a comprehensive assessment completed on 3/29/24, the resident was cognitively intact. Resident #7 required substantial to maximal assistance with transfers and toileting and supervision with personal hygiene and bed mobility. 2. Resident interviewResident #7 was interviewed on 6/18/24 at 2:01 p.m. Resident #7 said in the beginning of March 2024, in the evening, he had a male CNA (CNA #1) providing his care. Resident #7 said CNA #1 had been in his room, on his side of the room, multiple times that evening when his roommate called for assistance. He said he repeatedly told CNA #1 that his roommate had called, not him. Resident #7 said he called CNA #1 some "bad names" as CNA #1 was leaving his room. Resident #7 said CNA #1 came back into the room and laid across the left side of his chest, with his forearm pressed into the resident's left chest. He said CNA #1 yelled at him, in his face, to apologize. Resident #7 said CNA #1 then left his room. Resident #7 said he had pain in his left rib cage and was short of breath the entire evening and night. Resident #7 said he put his call light on several times but CNA #1 would come back in the room and turn it off. He said another resident in close proximity to him also turned on the call light throughout the night, but no staff came to help him. Resident #7 said he was nervous and anxious that he could be harmed again by another staff person. 3. Additional resident interviewA resident, who wished not to be identified, was interviewed on 6/18/24 at 2:08 p.m. The resident resided in close proximity to Resident #7. The resident said he did not see what happened to Resident #7. He said he heard a commotion and then Resident #7 cried out in pain. He said Resident #7 cried in pain all night. The unidentified resident said both he and Resident #7 put on their call lights for help throughout the night but no one responded. He said he did not know if someone shut the call light off or the staff just did not come. He said both he and Resident #7 were up all night. 4. Record reviewA chest x-ray in Resident #7's electronic medical record (EMR), dated 3/7/24, two days before the incident with CNA #1, documented the resident had right airspace lung disease. He had no pneumothorax and there was no mention of an issue with his ribs. A nurse progress note, dated 3/10/24 at 12:32 a.m., documented Resident #7 had shortness of breath, dyspnea (difficulty breathing) and wheezing but no pain. The resident had a diagnosis of pneumonia and was on antibiotics. However, in report to the day nurse on the morning of 3/10/24, the night nurse reported the resident was in pain (see RN #1's interview below). Resident #7's medication administration record (MAR) for March 2024 was reviewed. The MAR documented the resident had no pain on 3/9/24. However, in report to the day nurse on the morning of 3/10/24, the night nurse reported the resident was in pain (see RN #1's interview below). The hospital note dated 3/20/24 documented Resident #7 had trauma to the left chest and had multiple rib fractures with a large left pneumothorax due to someone sitting on him. On 4/2/24 the facility's provider documented Resident #7 returned from the hospital after a traumatic pneumothorax with a chest tube and multiple rib fractures. The resident said someone sat on him. The provider documented the hospital records were unclear but laboratory results revealed evidence of a possible myocardial infarction (heart attack) as well. 5. Staff interviewsA voice mail message was left on 6/17/24 at 1:56 p.m. for the agency RN (RN #3) who worked from 6:00 p.m. on 3/9/24 to 6:00 a.m. on 3/10/24. There was no return call from RN #3 by the end of the survey on 6/20/24. A voice mail message was left on 6/19/24 at 1:09 p.m. for the agency CNA (CNA #2) who worked with CNA #1 on 3/9/24 in the evening. There was no return call CNA #2 by the end of the survey on 6/20/24. RN #1 was interviewed with the nursing home administrator (NHA) on 6/17/24 at 1:35 p.m. RN #1 said on the morning of 3/10/24 she was getting report from the night shift nurse (RN #3) who said Resident #7 had been in pain throughout the night. RN #1 said RN #3 told her it was generalized pain. RN #1 said soon after, a CNA came to her and asked her to go see Resident #7 because his oxygen saturation level was in the 70% to 79% range. RN #1 could not recall who the CNA who reported the information to her was. She said she went to see the resident and he was short of breath and had chest pain. She said she put 10 liters per minute (lpm) of oxygen on him and called 911. RN #1 said Resident #7 could hardly speak but said "CNA, my chest, my fault." RN #1 said she did not look at his chest. She said the resident was then transferred to the hospital. RN #1 said she called the hospital for a report and was told Resident #7 had multiple rib fractures to the left side and a pneumothorax. RN #1 said the resident's comment about the CNA was reported to the NHA that day. The NHA said the hospital case manager called him on 3/11/24 and notified him that Resident #7 said a CNA had injured him. He said he went to the hospital and interviewed the resident on 3/11/24. The NHA said Resident #7 told him the male CNA (CNA #1) on 3/9/24 sat on him and pressed his forearm into the resident's chest. The resident admitted to having called CNA #1 names. The NHA said the allegation of abuse was substantiated and he notified the police and board of nursing. Additionally, he said he called CNA#1's agency and notified them that he could not return to the facility. The medical director (MD), who was contacted prior to the end of the survey on 6/20/24 at 9:40 a.m. and was interviewed on 6/24/24 at 9:57 a.m. The MD said she became the medical director at the beginning of June 2024. The MD said a resident with fractured ribs would most likely have had pain immediately when the ribs were fractured. She said the pain could have been delayed if the resident was in shock. The MD said Resident #7's pneumothorax could have affected his oxygenation levels as well the pain. She said the pneumothorax could have happened at the time of the rib fractures or later in the night if he had taken a deep breath. III. Resident to resident physical abuse between Resident #8 and Resident #9 on 4/14/24A. Facility investigationA facility investigation of physical abuse between Resident #8 and #9 on 4/14/24 was received from the NHA on 6/19/24 at 2:52 p.m. The investigation documented the following:Resident #9 was interviewed on 4/15/24 and said Resident #8 did not like her cell phone ring tone and Resident #8 shoved her in the chest so she decided to hit him. Resident #8 was interviewed on 4/15/24. He said Resident #9 asked him for cigarettes earlier that day (4/14/24). He said when he heard her phone ring, he did not like the ring tone and told her to change it. She said no. Resident #8 said Resident #9 began to leave and he followed her and tried to hit her, and she turned around and hit him in the face. A staff witness said she was going to the kitchen and she saw Resident #8 run his wheelchair into Resident #9. She said she then saw Resident #9 hit Resident #8 in the face. She said she and other staff members pulled the residents apart.-The investigation documented both residents had a history of physical and verbal aggression.-The investigation documentation revealed the assailant was placed on frequent checks. It was unclear which resident was the assailant. B. Resident #81. Resident statusResident #8, age less than age 65, was admitted on 4/5/24. According to the June 2024 CPO, diagnoses included alcohol abuse, anxiety and seizures. According to a comprehensive assessment cmpleted on 4/5/24, the resident was cognitively intact. Resident #8 was independent with bed mobility, transfers, toileting, dressing and personal hygiene. 2. Record reviewThe behavior care plan, initiated 1/18/24, documented Resident #8 had a history of drinking at the facility, physical and verbal aggression and poor impulse control. He had a history of yelling, screaming, cursing, making verbal threats, hitting and pushing. Interventions included administering medications as ordered, assisting the resident to develop more appropriate methods of coping, encouraging expression of feelings, behavior monitoring, providing positive interactions, explaining procedures, discussing the resident's behavior, intervening as necessary to protect the rights and safety of others, approaching the resident in a calm manner, diverting the resident's attention and removing the resident from the situation. -There were no new interventions added to the care plan after the altercation on 4/14/24. C. Resident #91. Resident statusResident #9, age less than age 65, was admitted on 3/14/23 and readmitted on 5/28/24. According to the June 2024 CPO, diagnoses included anxiety, depression, cocaine dependence and adult physical abuse. According to a comprehensive assessment completed on 3/29/24, the resident was cognitively intact. Resident #9 required substantial to maximal assistance with transfers and toileting and supervision with personal hygiene and bed mobility. 2. Record reviewOn 3/30/24 at 11:29 a.m. the nursing progress notes documented Resident #9 was yelling and cursing at the nurse. On 4/13/24 at 10:44 a.m., one day prior to the physical abuse, the nursing progress notes documented Resident #9 was cursing at the nurse, physically attempted to remove the nurse from the room and attempted to stand and go after the nurse. The staff had to hold the resident back. The nurse documented the resident was "unsafe to herself and to be around."-The nursing progress notes were reviewed between 4/13/24 and 4/14/24. No additional monitoring or intervention for Resident #9's behavior was put in place. The physical and verbal aggression care plan, initiated 8/22/23 was reviewed. The care plan documented Resident #9 had poor impulse control and a history of yelling, cursing and hitting others. Interventions included assessing and anticipating the resident's needs, monitoring behaviors, and when the resident was agitated, intervene before the agitation escalated, guiding the resident away from sources of distress and using calm conversation. -There were no new interventions added to the care plan after the altercation on 4/14/24. D. Staff interviewsThe NHA was interviewed with the RDCS on 6/19/24 at 2:52 p.m. The NHA said on 4/14/24 Resident #9's cell phone rang in the dining room. Resident #8 did not like the ringtone. Resident #9 attempted to leave the dining room but Resident #8 followed her and hit her in the chest. Resident #9 had sternal pain. Resident #8 then hit Resident #9 in the face resulting in broken blood vessels in Resident #8's right eye. The NHA said Resident #8 and Resident #9 had a history of verbal and physical aggression. He said there was no plan for monitoring behaviors in the dining room. The NHA said after the incident occurred, both residents were put on frequent monitoring. -However, there was no frequent monitoring documented on the care plan or in the progress notes for Resident #8 or #9. The NHA said the physical abuse toward both residents was substantiated and witnessed by staff in the dining room. IV. Resident to resident physical abuse of Resident #10 by Resident #11 on 5/31/24A. Facility investigationAn investigation of physical abuse to Resident #10 by Resident #11 on 5/31/24 was received from the NHA on 6/19/24 at 2:52 p.m. The investigation documented the following: Resident #10 and #11 were roommates. Resident #10 said Resident #11 had grabbed her arm and put the call light cord on her neck. A staff member interview on 5/31/24 documented she heard Resident #10 calling for help and when she went in the resident's room Resident #11 had a call light on the neck of Resident #10. Additionally the skin on the arm of Resident #10 looked like it had been twisted. A licensed nurse interview on 5/31/24 documented she went to the resident's room after a CNA came to get her. She said Resident #10 had redness to her neck and arm. Resident #11 was placed on frequent checks and then sent out to the hospital due to the risk she posed to other residents (see below). B. Resident #101. Resident statusResident #10, age less than age 65, was admitted on 3/16/22 and readmitted on 3/8/24. According to the June 2024 CPO, diagnoses included major depression, heart failure and diabetes mellitus. According to a comprehensive assessment completed on 6/13/24, the resident was cognitively intact. Resident #10 required substantial to maximal assistance with bed mobility, transfers, toileting, personal hygiene and dressing. 2. Record reviewOn 5/31/24 at 8:05 a.m. the nursing notes documented at 12:30 a.m. a CNA heard Resident #10 calling out for help. Upon entering room Resident #10's roommate Resident #11 was twisting skin on Resident #10's arms and had the call light wrapped around Resident #10's neck. Resident #10 was "extremely frightened." Slight redness was noted on the resident's arms and on the neck. Resident #10 reported slight pain that quickly resolved. Frequent checks were performed to reassure Resident #10 throughout the night. Resident #10 reported anxiety which improved when the resident was informed a CNA would stay until the roommate was removed and that staff would check on her through the night.-There was no care plan in the resident's EMR related to the abuse. C. Resident #111. Resident statusResident #11, age less than age 65, was admitted on 1/22/22 and readmitted on 8/22/23. According to the June 2024 CPO, diagnoses included dementia, anxiety and agitation. According to a comprehensive assessment completed on 3/31/24, the resident had severe cognitive impairment. She had short and long term memory loss with moderate impairment of daily decision making, disorganizedthinking and physical behavior toward others. Resident #11 required substantial to maximal assistance with toileting, personal hygiene, dressing and supervision with transfers and bed mobility. 2. Record reviewOn 5/22/24 at 7:36 p.m. the provider documented the resident had increased aggression and a history of aggressive behavior. On 5/30/24 at 5:09 p.m. the nursing notes documented the resident was fascinated by an ambulance that had come to the facility and she tried to get on the gurney brought by the emergency medical services (EMS) staff. The resident could not be redirected and became aggressive, pushing and pinching the staff. The nurse tried to comfort the resident but was pushed away.-There was no behavior care plan in place until 6/10/24, after the physical altercation with Resident #10, despite Resident #11 exhibiting aggressive physical behaviors prior to the incident (see Resident #11's care plan below). On 5/31/24 at 7:53 a.m. the nursing progress notes documented that at approximately 12:30 a.m., Resident #10 called out for help. Resident #11 was found by a CNA with the call light wrapped around the neck of Resident #10 and she was pulling the call light. Resident #10 said Resident #11 had also grabbed her by the forearms and twisted her skin. The nurse called administration and a decision was made to send Resident #11 to the hospital for the safety of Resident #11 and other residents. On 5/31/24 at 8:15 a.m. an SBAR (situation, background, assessment recommendation) note documented Resident #11 was sent to the hospital due to her behavior. The note documented she needed "close observation for resident, staff, and other resident safety." The resident returned that afternoon at an undocumented time. On 5/31/24 at 6:12 p.m. The nursing notes documented the resident was moved to a different unit due to the "incident" and was monitored. The behavior care plan, initiated 6/10/24 (10 days after the incident with Resident #10) documented Resident #11 had potential to be physically aggressive with a history of harm to others. The goal was the resident would seek out a staff member when agitation occurred. Interventions included administering medications, analyzing time of day, places , triggers, circumstances and what deescalated behaviors, assessing and addressing sensory deficits, anticipating the resident's needs, Modifying the environment, such as dim lights and keeping the door closed, monitoring and documenting behaviors and interventions, monitoring and documenting signs and symptoms of the resident posing danger to herself or others, when the resident was agitated, intervening before agitation escalated, guiding the resident away from distress, engaging with the resident calmly and re-approaching the resident later. D. Staff interviewThe NHA was interviewed with the RDCS on 6/19/24 at 2:52 p.m. He said Resident #10 reported Resident #11 put a call light on her neck and pinched her arm. The NHA said Resident #11 had a history of pacing and grabbing furniture. He said Resident #10 had redness to her arm and neck. He said the abuse was unsubstantiated because Resident #11 had dementia. He said he moved Resident #11 to a private room after the altercation.

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

A revisit survey was completed on 12/14/23 for all previous deficiencies cited on 10/26/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 12/14/23 for all previous deficiencies cited on 10/26/23. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on November 21, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This facility consists of a one-story wood frame structure, Type V (000) construction. There are 90-minute fire rated doors separating the resident sleeping areas from the lobby and dining room areas. Resident sleeping areas utilizes Type V (111) construction including fire damper in the ceilings. There is a partial basement that is used for support services only and there is no resident access. The facility is licensed for 101 beds and the census on the date of the survey was 65. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 by an automatic wet-pipe fire sprinkler system and two anti-freeze loops that protects the outside canopy and the kitchen. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Facility Administrator and Maintenance Director during the exit conference. NOTE: During the survey the facility had isolation in place for active Covid cases. It was reported that 48 of the 65 residents were affected.

Based on observation and staff interview, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following: 1. Emergency exit door from dining room is difficult to open. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbs. of force. This deficient practice could affect all residents, staff and visitors throughout the smoke compartment should this exit discharge be needed during an emergency. The exit deficiency was discussed during the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 21.2.9 and 7.9.3.1.1. This was evidenced by the following:1. Dining room emergency light south wall is inoperative. 2. Emergency lights failed testing due to low batteries in Aspen Cafe, Basement fire exit stairwell, Therapy gym, and Clean Laundry room. NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect occupants and staff if emergency lighting is needed during a power loss. This was discussed during the exit conference

Based on record review it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) This deficient practice could affect all residents, and staff should a fire occur and the suppression system fails to operate effectively due to non-code compliant conditions with the kitchen hood suppression system. This was evidence by the following:1. No records or documentation for kitchen hood suppression system 6/mo. inspection and testing. The Maintenance Director acknowledged the lack of documentation and maintenance records. NFPA 96, 11.2.1 Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. This deficiency was discussed with the Administrator and Maintenance Director during the exit conference.

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the NFPA 101, Life Safety Code Section 19..3.4.1 and NFPA 72. This was evidenced by:1. No records or documentation for 2-year smoke detector sensitivity testing. 2. Annual inspection report indicates that the batteries for power supply units failed testing. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system. NFPA 72, 14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. NFPA 72, 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 Sensitivity shall be checked every alternate year. This deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.1 and NFPA 101, 19.7.6, and 4.6.12. This was evidence by the following. 1. Sprinkler escutcheon missing Main corridor outside of dining room. 2. Missing two quarterly fire sprinkler inspection reports. 3. No records or documentation for anti-freeze fire protection annual testing. 4. No records or documentation for fire sprinklers 50/yr service life. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12, and NFPA 25, 5.2.1 NFPA 25, 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. NFPA 25, 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). This deficiency could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was discussed during the exit conference.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3This was evidenced by the following: 1. Fire doors near room 1 do not latch when closed. NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. This was discussed during exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Ceiling tile in front conference room & above main entry are not secured in place. 2. East boiler room has ceiling and wall penetrations. 3. Central boiler room has ceiling penetrations. NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. The smoke barrier deficiencies have the potential to affect all residents, visitors, and staff within those smoke compartments. The deficiencies were discussed during the exit conference.

Based on record review and staff interview during the survey, the facility failed to maintain all corridors in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; Section 4.3.12.1.1 - Egress Corridors. This was evidenced by the following: 1. During record review and the walk-through of the facility, it was found that the facility utilizes swamp coolers to provide cooling for the corridors and to provide cooling in resident rooms and adjacent areas, which turns all the corridors into plenum spaces. (Facility has a current waiver in place for this deficiency) 2. No records or documentation for smoke damper 4-year inspection and maintenance. The deficiencies may affect all residents and staff in all smoke compartments. NFPA 90A, 4.3.12.1.1* Egress corridors in nursing and long term care facilities, shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted. NFPA 90A, 4.3.12.2 Exits. Exit passageways, stairs, ramps, and other exits shall not be used as a part of a supply, return, or exhaust air system serving other areas of the building. 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. This was discussed during the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. Fire drills were not conducted during varying times and conditions for the1st shift in the 2nd & 3rd quarters and for the 2nd shift in all quarters. NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. This was evidenced by the following deficiencies:1. Electrical outlet near main entry shows evidence of arching. 2. Broken switch plate on dining room wall outside of kitchen. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and skillful manner. This deficient practice could affect all occupants and staff throughout the smoke compartment if improper maintenance of electrical equipment causes a fire. These deficiencies were discussed during the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. No records or documentation of generator battery monthly conductance testing. 2. No records or documentation for generator load bank testing. NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting. Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1NFPA 110, 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. The deficiencies have the potential to affect all occupants, which might include staff, residents, and visitors should the generator fail to start during an emergency. This was discussed during the record review and again during the exit conference.

A recertification survey with complaint #CO31225, #CO33985 and Incident #33964 was completed on 10/23/23-10/26/23. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/23/23 to 10/26/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to ensure one (#14) out of 41 sample residents were compensated for paid services at or above prevailing rates. Specifically, the facility failed to for Resident #14:-Ensure the resident was paid a fair and decent wage for a therapeutic work program;-Ensure there was a care plan for the work program;-Ensure the contract matched what workload the resident performed; and, -Allowed the resident to work without a signed contract. Findings include:This deficiency was cited previously during a recertification survey 7/21/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. I.. Resident statusResident #14, age under 65, was admitted on 11/30/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included generalized anxiety disorder, borderline personality disorder and diabetes. The 7/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. He required supervision with all activities of daily living. II. Resident interviewResident #14 was interviewed on 10/24/23 at 12:22 p.m. Resident #14 said she participated in a work program at the facility. Resident #14 said she worked seven days a week calling Bingo for one hour and then worked for 45 minutes four times a week at the resident store. The resident said she was supposed to be paid 50 dollars a month. The resident said she had not been paid at all. The resident said she had talked to the social worker and the nursing home administrator (NHA). The resident said they did not tell her when she would get paid. III. Record review-A review of the resident ' s comprehensive care plan failed to include a work plan. The 9/29/23 therapeutic work program form documented Resident #15 was interested in participating in a therapeutic work program. It indicated the resident was assigned to call bingo three times a week. The reward/compensation was documented as $50 per week.-The contract did not document how many hours per week. The resident called Bingo seven days a week and not three days a week. In addition, it failed to include the work the resident performed in the store. -The contract for the work program was signed over three months after the resident started working on 6/19/23 (see activity assistant interview). IV. Staff interviews The nursing home administrator (NHA) was interviewed on 10/26/23 at 2:30 p.m. The NHA said Resident #14 was in the work program. The NHA did not know how long she was in the work program. The NHA said Resident #14 worked in the resident store. The NHA said Resident #14 was to be paid 50 dollars a month. The NHA said they were waiting for their corporation to approve the work contract. The NHA said the work program should be in the resident ' s care plan. The NHA said the work program was not in Resident #14 ' s care plan. Activities assistant (AS) #1 was interviewed on 10/26/23 at 2:50 p.m. AS #1 said according to documentation Resident #14 had started the work program on 6/19/23. Resident #14 called Bingo seven days a week for one hour and worked in the resident store 45 minutes four times a week. AS #1 said the residents who performed work were not getting paid timely and it was an ongoing issue.

Based on observations, record review and interviews, the facility failed to ensure one (#170) of one resident reviewed out of 41 sample residents was provided personal privacy in her room. Specifically, the facility failed to provide a privacy curtain to ensure Resident #170 had privacy while in bed. Findings include:I. Facility policy and procedureThe Resident Rights policy, revised in February 2021, was provided by the director of clinical services on 10/26/23 at 12:28 p.m. It read in pertinent part: "Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality."II. Resident statusResident #170, age 66, was admitted on 10/10/23. According to the October 2023 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (mild to severe loss of strength) on right side, overactive bladder, localized swelling, mass and lump right upper limb and history of falling. The 10/16/23 minimum data set (MDS) assessment revealed Resident #170 was cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. Resident #170 required moderate assistance of one to two people with bed mobility and most other activities of daily living (ADLs). III. Resident observation and interviewResident #170 was interviewed on 10/23/23 at 1:35 p.m. Resident #170 said she would like a privacy curtain for her personal privacy. Resident #170's room revealed a privacy curtain was missing from the track. Resident #170 had a roommate and the two beds were parallel from the doorway with a track in between for a privacy curtain. Resident #170 was interviewed on 10/25/23 at 2:23 p.m. Resident #170 said she would like to have privacy in her bed while watching television. IV. Record reviewThe ADL care plan, initiated on 10/10/23, revealed Resident #170 had an ADL self-care performance deficit due to recent fall with injury. Interventions revealed Resident #170 required moderate assistance with bathing/showering, dressing, and partial moderate assistance of one or two for transferring. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 10/26/23 at 1:58 p.m. CNA #1 said in order to provide privacy for residents in their rooms the door and curtain should be closed. If a resident did not have a curtain, minimally the door should be closed. CNA #1 said she was not sure why there was not a curtain in Resident #170's room and was not sure how she had privacy in the room once her roommate was present. Licensed practical nurse (LPN) #2 was interviewed 10/26/23 at 2:12 p.m. LPN #2 said to provide privacy for a resident the curtain should be pulled and the door closed. If a resident did not have a curtain, then a curtain should be requested for them from management. LPN #2 was not sure how a resident would have privacy from their roommate if they did not have a curtain. Registered nurse (RN) #1 was interviewed 10/26/23 at 2:06 p.m. RN #1 said she would close the resident's door and curtain to ensure privacy for a resident. RN #1 said if a resident did not have a curtain she said she did not know how to provide privacy to a resident from their roommate while in bed. The nursing home administrator (NHA) was interviewed on 10/26/23 at 4:00 p.m. The NHA said each resident should be treated with respect and dignity. The NHA said every resident should have a privacy curtain. The NHA said the only reason a resident would not have a privacy curtain was if it was being washed or it was damaged. The NHA said if a resident did not have a curtain then one would be obtained for them as soon as possible.

Based on record review, and interviews, the facility failed to ensure two (#61 and #53) out of three residents reviewed out of 33 sample residents, as well as other facility residents, were protected from resident-to-resident abuse by Residents #54, #120, and #31. Residents #54 and #61 According to a sexual abuse investigation dated 8/8/23, Resident #61 reported Resident #54 had sexually assaulted her. Resident #54 had a known history of child abuse, was on the sex abuse registry due to an assault of an elderly person, and had recently gotten off parole for crimes he had committed in the past. A 4/12/23 behavioral assessment documented that facility staff reported Resident #54 had made inappropriate sexual comments since his admission on 3/23/23. Notwithstanding Resident #54's current and past history, the facility failed to take steps, before Resident #61 reported sexual abuse, to develop and implement person-centered, sufficient, and effective interventions to prevent potential sexual abuse. The facility's failure to take steps to prevent abuse contributed to Resident #61 becoming fearful, and triggered the initiation of psychosocial support to address her fear. Residents #120, #31 and #53Interview revealed Resident #53 was verbally abused and physically abused by Residents #120 and #31. Findings include: I. Facility policyThe Abuse policy and procedure, revised May 2023, was provided by the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part that: -"(The facility) 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." -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. -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. -When residents who have been admitted exhibit behavior that presents a danger to others, interventions shall be taken to ensure the safety of other residents and staff."II. Resident #54 and Resident #61A. Residents' status 1. Resident #54 Resident #54, age 80, was admitted on 3/23/23 and readmitted on 5/18/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included heart disease and chronic kidney disease. According to the 10/8/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial/moderate assistance with dressing and putting on footwear. The resident was independent in all other activities of daily living (ADLs). The resident used a motorized wheelchair. The resident did not exhibit psychosis. Resident #54 did not receive psychological therapy. 2. Resident #61Resident #61, age 72, was admitted on 3/27/23. According to the October 2023 CPO, the diagnoses included dementia with behavioral disturbances. According to the 9/25/23 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a BIMS score of 7 out of 15. She required extensive assistance of one person with all activities of daily living (ADLs) except eating and locomotion. The resident had no signs of depression. 3. Report of sexual abuseAccording to a sexual abuse investigation dated 8/8/23, Resident #54 allegedly touched Resident #61 on her breasts and private areas. Resident #61 said, "he's so nasty." He touched me here, here, and here, anywhere he could grab." Resident #61 repeatedly said Resident #54 was a nasty man. The investigation read that Resident #61 was an at-risk adult with a BIMS of 1 and wheelchair assisted. Resident #54 was a registered sex offender from 2014 and finished probation in 2023. He goes to meetings monthly with the (local) Police Station. The resident also has a history of potentially using verbal slurs towards other residents. The investigation read that the care plan for Resident #54 read staff should monitor unsafe situations and redirect residents as needed along with continuing to monitor Resident #54 secondary to a history of sexual crimes against children. The investigation further read that Resident #54 was suspected of sexual assault. Resident #61 initially did not show any fear once the alleged assailant was placed on 1:1 (supervision) but after a couple of days, the alleged victim started making comments that she was afraid of a man. The investigation concluded the facility was unable to substantiate or unsubstantiate that the allegation had occurred as (the facility) could not determine when or if this incident happened since the alleged victim was a poor historian. However, with the reaction of the alleged victim (Resident #61), the facility was going to treat the incident as if it had happened. The alleged assailant (Resident #54) will stay on a 1:1 (supervision) until he (is) able to be placed in an appropriate placement. The victim has been referred to Mental Health Services since she was making statements of fear. Resident #54 was placed on 1:1. Referrals were sent out to multiple facilities that had all-male units. Resident #61 was at physical baseline but has increased statements of being afraid. Mental Health Services had been ordered for the resident. B. The facility failed to take sufficient steps before Resident #61 reported sexual abuse to protect residents, including Resident #61, from potential abuse. 1. Record review revealed the facility had prior knowledge of Resident #54's inappropriate behavior. A review of a behavioral health assessment, dated 4/12/23, revealed Resident #54 was referred for psychotherapeutic services and evaluations due to sexual assault and a history of sexually inappropriate behavior. It documented the resident was a registered sex offender due to the assault of an elderly person. The facility staff reported Resident #54 had made inappropriate sexual comments since admission (3/23/23). Recommendations included for the resident to participate in evidence-based psychotherapy four times a month for four months. According to a progress note dated 7/7/23, Resident #54 was found in a female resident's room when another male resident came into the room to ensure the female resident was alright. The male resident said, "he had to protect the female resident from (Resident #54)."2. Notwithstanding evidence of Resident #54's current and past history of sexually inappropriate behavior, the facility failed to develop a sufficient and effective resident-centered care plan to protect at-risk residents from potential abuse by Resident #54. As noted in the facility's sexual abuse investigation above, the resident's care plan dated 7/18/23, read the resident had a history of sexual crimes against children. It further read the resident finished parole in 2023. The resident had monthly meetings with a local police station on the 8th of every month. The resident was a registered sex offender. Interventions included: -Monitoring for unsafe situations and intervening if needed. -Staff should be made aware of stipulations required, like monthly check-ins. However, the care plan was neither resident-centered nor adequate.-The care plan failed to identify what constituted an unsafe situation, whether it was an unsafe situation for others or the resident and failed to include what level of supervision was expected based on his known history of inappropriate sexual behavior and sexual crimes. Monitoring was not defined. -The care plan failed to instruct staff how to intervene given his history, failed to identify effective interventions, and failed to outline what steps staff were expected to take when inappropriate behaviors occurred, including how to intervene, who to notify, and where to document his behavior so that it could be monitored and interventions developed and revised when ineffective. -The care plan failed to include any reference to the incident on 7/7/23 and failed to trigger new interventions to prevent further incidents of potential sexual abuse. C. Staff interviewsStaff interviews confirmed the facility's knowledge of Resident #54's inappropriate behavior and the facility's failure to take steps to protect residents, including Resident #61. 1. Certified nurse aide (CNA) #2 was interviewed on 10/26/23 at 10:56 a.m. CNA #2 said Resident #54 was a registered sex offender. CNA #2 said the resident had been inappropriate with staff and other residents. CNA #2 said they verbally told the nurses when the resident was inappropriate, but there was no documentation of it. CNA #2 said the staff had not had extra training on how to work with a resident who had a criminal record of sexual abuse. CNA #2 said Resident #54 did not have interventions put in place until after the incident with Resident #61. CNA #2 said before that incident, Resident #54 would go into female residents' rooms and staff did not redirect him. The social services assistant (SSA) was interviewed on 10/26/23 at 12:39 p.m. The SSA said the facility was aware that Resident #54 had been incarcerated for sexual abuse against a child. The SSA said they did not have specific education for the staff when working with an individual who was a registered sex offender. The SSA said they did not put specific interventions into place for Resident #54 until after the incident with Resident #61. The SSA said since the incident, Resident #54 was on one-on-one supervision and the facility had tried to place him in a different facility. The SSA said Resident #61 was fearful of Resident #54 and was teary after the incident calling the resident a "bad man."The nursing home administrator (NHA) was interviewed on 10/26/23 at 3:30 p.m. The NHA said the facility was aware on admission, that Resident #54 had been incarcerated for sexual abuse and was on the sex offender registry. The NHA said they did not have additional training for staff on how to work with a registered sex offender. The NHA said staff should tell somebody if they saw Resident #54 being inappropriate. The NHA said there was not a specific place to document this and it was done verbally. The NHA said they did not put interventions in place until after the incident with Resident #61. The NHA said Resident #54 was allowed to go into female residents' rooms and roam freely throughout the facility. The NHA confirmed Resident #61's severe cognitive impairment and recognized it placed the resident at risk for abuse. The NHA said they got Resident #61 mental health care because she was teary and afraid after the event. The NHA said residents have the right to remain abuse-free. The NHA said after the incident with Resident #61, Resident #54 was put on one-on-one and they are trying to get him placed in a different facility. III. Resident #53 and Residents #120 and #1 - failure to prevent resident-to-resident abuseA. Resident #53's status 1. Resident #53, age under 60, was admitted to the facility on 11/18/22. According to the October 2023 CPO, diagnoses included lymphoma and kidney disease. The 9/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with all daily activities. He did not display physical or verbally aggressive behavior toward staff or other residents. B. Failure to prevent resident-to-resident abuse involving Resident #53Resident #53 was interviewed on 10/23/23 at 2:30 p.m. He said he was verbally abused and physically assaulted by two different residents in the facility. He said more than six months ago he was beaten by Resident #120, who was no longer in the facility. He said Resident #120 previously used foul language towards him and disliked the sound of his TV which was too loud in his opinion. He said one day, Resident #120 aggressively walked into his room, threw him on the floor, and hit him in the face several times before staff were able to intervene. The second incident of physical abuse occurred less than six months ago. He said he was approached in the hallway by Resident #31, who threatened to hurt him and used a walking cane to hit him on the head. He said Resident #31, like Resident #120 was no longer in the facility and he felt safe. C. Record reviewA review of the facility investigations of the above incidents revealed the facility investigated and substantiated abuse and reported both incidents to the police and the state agency. The investigations included interviews with the victim and alleged perpetrators, as well as staff who worked at the time of the incident and other residents in the facility. Skin assessments in both instances revealed minor injuries that did not require hospitalization. Both residents no longer were residing in the facility at the time of the survey. Resident #120 was discharged in January 2023 and Resident #31 in September 2023. B. Staff interviewsCNA #2 was interviewed on 10/26/23 at 11:15 a.m. She said she used to work with all three residents. She said they all had their good and bad days. Resident #120 disliked loud noises and was particularly sensitive to them in the afternoon. Resident #31 did not have any aggressive behaviors toward her or other residents. Licensed practical nurse (LPN) #2 was interviewed on 10/26/23 at 11:45 a.m. She said she did not observe any aggressive behaviors with the above residents. She said she was aware of the incidents but did not work at the time when they occurred. The nursing home administrator (NHA) was interviewed on 10/26/23 at 4:41 p.m. He said all residents in the building should be free from abuse. He said the incident with Resident #120 occurred prior to his time as NHA in the building. The second incident, with Resident #31, was in September 2023. He said the facility investigated both incidents and took actions to make sure residents in the building were free from abuse.

Based on record review and staff interviews, the facility failed to ensure two (#1 and #53) residents reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 41 sample residents. Specifically, the facility failed to:-Have a registered nurse assess Resident #1 after the fall; and, -Administer pain medications on time to Resident #53. Findings include:I. Resident #1A. Resident statusResident #1, age 72, was admitted on 8/5/23. According to the October 2023 computerized physician orders (CPO), diagnoses included history of stroke, atrial fibrillation and diabetes type two. The 10/3/23 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. He required assistance from one person with most activities of daily living. He did not display behaviors and did not refuse the care. B. Resident interview Resident #1 was interviewed on 10/23/23 at 12:43 p.m. He said he had one fall in the facility that resulted in a hip fracture. He could not recall the exact time or details of the fall. He said sometimes he would wait a long time for anyone to come and help him to the bathroom and he would self transfer. He said that was the reason for his fall. C. Record reviewThe incident report completed by licensed practical nurse (LPN) #3 dated 8/1/23, revealed the resident had an unwitnessed fall on 8/1/23 when he attempted to self transfer. The incident report read: "resident stated he was trying to use a walker, resident fell into his bottom. No injury noted, no signs and symptoms of distress. Two people assisted (him)back to sitting position."-The incident report did not include assessment by a registered nurse. The resident's range of motion was not checked to rule out the possibility of fracture or serious injury. -The review of vital signs revealed residents vital signs such as blood pressure, heart rate, temperature, oxygen saturation and pain level were not completed at the time of the fall. On 8/2/23 resident was assessed by a nurse practitioner due to increased pain in right hip. The resident did not tolerate the range of motion, and an x-ray of the hip was ordered. The x-ray revealed a new right hip fracture and the resident was sent to the hospital. Hospital discharge summary revealed resident was discharged back to facility on 8/5/23 with inoperable hip fracture and recommendation for physical therapy. Upon request, the facility was unable to locate RN assessment for Resident #1 after the fall. D. Staff interviewsCertified nurse aide (CNA)#2 was interviewed on 10/26/23 at 3:20 p.m. She said she worked with Resident #1 frequently. The resident was able to use the call light and consistently used it. She said she was working with him before the fall and after the fall in August 2023. She said the resident's baseline stayed the same. He always required the assistance of one person with transfers, he was using a wheelchair for ambulation and he was only walking with physical therapy. The physical therapist (PT) #1 was interviewed on 10/26/23 at 2:40 p.m. She said the resident was working with physical therapy prior to the fall and was still working after the fall. He was able to ambulate with a walker in the presence of a therapist. During the day, he required assistance from one person for transfers and help in the bathroom. Licensed practical nurse (LPN)#2 was interviewed on 10/26/23 at 3:15 p.m. She said the resident was at risk for falls and he was on a toileting program. The resident was able to use the call light and ask for assistance, although sometimes he did attempt to self transfer. She said after the fall every resident should be assessed by a registered nurse and findings should be documented in the incident report or progress notes. She said vital signs were always completed after the fall and documented in electronic medical records. The interim director of nursing (DON) was interviewed on 10/26/23 at 4:30 p.m. She said after the fall every resident must be assessed by a registered nurse. She said the assessment was important to find any serious injuries such as fractures. She said vital signs should be taken and documented in the medical record at the time of the assessment. She said the fall for Resident #1 occurred before her working in the building and she was not aware that RN assessment was not completed. She said she would review with all nurses the importance of RN assessment and proper documentation after the fall. II. Resident #53 A. Resident statusResident #53, age under 60, was admitted on 11/18/22. According to the October 2023 computerized physician orders (CPO), diagnoses included lymphoma (cancer) and kidney disease. The 9/5/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent with all daily activities. He did not display physically or verbally aggressive behavior towards staff or other residents. B. Resident interviewResident #53 was interviewed on 10/23/23 at 2:30 p.m. He said he was receiving pain medications for chronic pain in his back. He said the nurses frequently did not bring medications on time. He said he voiced his concerns to nursing staff on many occasions, but medications were still administered late. C. Record reviewAccording to the October 2023 medication administration order (MAR), the resident had the following medications to be administered: -Oxycodone 10 milligrams for pain to be administered at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. (four hour intervals)Review of the MAR timestamps for 10/2/23, 10/12/23, and 10/14/23 revealed that medication was not administered as scheduled. Specifically, on 10/2/23 the scheduled dose for 10:00 p.m., was administered at 11:39 p.m. On 10/12/23 all scheduled medications were signed as administered at 6:00 pm for the entire day. On 10/14/23 oxycodone was administered in intervals that were either more than four hours apart (between 6:00 p.m. and 10:00 p.m. dose) or less than two hours 30 minutes (between 2:00 p.m. and 6:00 p.m. dose).-No corresponding notes were located under the progress notes to explain the inconsistency of medication administration. D. Staff interviewsLPN # 4 was interviewed on 10/26/23 at 3:34 p.m. She said she was administering the medications to the resident on 10/12/23. She said all medications were signed as given at 6:00 p.m. because the computer was not working on that day and that was how it was recorded. She said she gave all medications on time. Regarding scheduled oxycodone, she said medication was scheduled to be administered every four hours and should be administered as scheduled. The interim (DON) was interviewed on 10/26/23 at 4:30 p.m. She said all medications should be administered as scheduled. She said oxycodone medication for Resident #53 was scheduled to be given every four hours and should have been given every four hours. She said giving medication too early could result in increased drowsiness and giving medication too late could result in breakthrough pain. She said she was not aware that medication was not administered as scheduled. She said she would review the MARs and provide education to the nurses who were administering medications timely.

Based on observations, record review and interviews, the facility failed to ensure two (#15 and #6) of five residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene out of 41 sample residents. Specifically, the facility failed to provide consistent bathing to maintain good personal hygiene for Resident #15 and Resident #6. Findings include:I. Resident #15A. Resident status Resident #15, under the age of 65, was admitted to the facility on 10/25/19. According to the October 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, bipolar disease and anxiety disorder. According to the 8/3/23 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for a mental status score of 11 out of 15. The resident required extensive assistance from one person for all activities of daily living (ADLs). The resident was dependent on staff for bathing. The resident did not reject care. B. ObservationOn 10/23/23 at 12:40 p.m. the resident had body odor. The resident was in bed with the door shut and the body odor could be smelled from the hallway. The resident hair was greasy and matted. On 10/24/23 at 12:48 p.m. the resident was in their bed with the door open. The resident had body odor that could be smelled from the hallway and his hair was matted and greasy. On 10/26/23 at 11:55 a.m. the resident had body odor and his hair appeared greasy. C. Record reviewAccording to ADL care plan Resident #15 had a fear of falling and frequently refused showers. Interventions included the following: if Resident #15 refused showers offer a bed bath instead. Resident #15 had showers on Tuesday and Friday. According to the August 2023 shower/bathing documentation Resident #15 had three bed baths and zero showers out of an estimated eight opportunities for bathing. According to the September 20203 shower/bathing documentation Resident #15 had seven bed baths and zero showers out of an estimated eight opportunities for bathing. According to the October 2023 (10/1/23 to 10/26/23) shower/bathing documentation Resident #15 had three bed baths and zero showers out of an estimated eight opportunities for bathing. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 10/26/23 at 10:45 a.m. LPN #2 said residents should receive two baths a week. LPN #2 said it was important for residents to receive baths to prevent skin breakdown and odor. LPN #2 said the facility used bath aides. LPN #2 said Resident #15 was not difficult to work with and did not refuse care often. Certified nurse aide (CNA) #2 was interviewed on 10/26/23 at 10:56 a.m. CNA #2 said residents receive two showers a week. CNA #2 said the facility had bath aides that gave baths to the residents. CNA #2 said bath aides were sometimes used for other tasks if the facility was short staffed. CNA #2 said sometimes the CNAs would give residents showers or bed baths if they had time. CNA #2 said Resident #15 was afraid to take showers. CNA #2 said the shower aides would try to offer bed baths to Resident #15. CNA #2 said Resident #15 would not often refuse baths. II. Resident #6A. Resident statusResident #6, age 65, was admitted on 1/11/11. According to the October 2023 computerized physician orders (CPO), diagnoses included a history of stroke, atrial fibrillation and diabetes type two. The 8/30/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required assistance from one person with most activities of daily living. He did not display behaviors and did not refuse the care. The resident required moderate assistance with showers. Preferences for customary routine and activities indicated it was very important for the resident to choose between shower and bed bath. B. Resident interview Resident#6 was interviewed on 10/23/23 at 12:43 p.m. He said his showers were consistently skipped. He said his preference was to receive at least two showers per week during the day time. She said staff would come to his room and say they could not provide shower because they were too busy and did not have a shower aide. He said some CNAs were nice and they gave him showers on the days when the shower aide was absent. C. Record review-The resident's comprehensive care plan did not indicate the resident's preferences for showers. The review of shower logs between 9/29/29 and 10/26/23 showed the resident received four showers in the last 30 days out of an estimated eight opportunities for bathing. The progress notes for October 2023 did not include documentation of refusals for showers. D. Staff interviewsCNA #2 was interviewed on 10/23/23 at 1:15 p.m. She said Resident #6 was scheduled to receive showers twice a week. She said the resident did not refuse the care and always accepted showers. She said today they did not have a shower aide and would have to accommodate showers for residents and routine care on the floor. CNA #1 was interviewed on 10/26/23 at 2:54 p.m. She said Resident #6 usually received showers twice a week and did not refuse the care. She said she would always try to give a shower to the resident when he asked. She said some days were more busy than others and if any showers were skipped, they should have been reported to the next shift and nurse. LPN #2 was interviewed on 10/26/23 at 3:14 p.m. She said Resident #6 did not refuse the care and was able to tell staff if he needed a shower. She said shower preferences should be documented on the care plan to make sure staff were aware of the resident's preferences. The interim director of nursing was interviewed on 10/26/23 at 4:16 p.m. She said resident showers should be accommodated based on the needs and preferences. She said it should be documented in the resident's care plan. In addition, any refusals or skipped care should be documented in progress notes to ensure the continuity of care.

Based on observations, record review, and interviews, the facility failed to ensure the resident environment was as free from accident hazards as possible for one (#15) of five out of 41 sample residents. Record review revealed Resident #15 fell repeatedly. The facility failed to ensure effective interventions were developed, that care-planned interventions were implemented and that neurological checks were consistently initiated when the resident's falls were unwitnessed. I. Resident #15A. Resident status Resident #15, under the age of 60, was admitted to the facility on 10/25/19. According to the October 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, bipolar disease, and anxiety disorder. According to the 8/3/23 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for a mental status score of 11 out of 15. The resident required extensive assistance from one person for all activities of daily living (ADLs). The resident had two or more falls since admission. B. Record review - repeat fallsAccording to the resident's fall care plan, dated 4/24/23, the resident was at risk for falling because of incontinence, impulsiveness, decreased spatial awareness, and behaviors. Interventions included: clip call light to the resident; ensure the resident was placed in the middle of the bed; and fall mat next to the bed. Further, staff should frequently round on the resident, the bed should be in the lowest position while the resident is in bed, and bolster overlay to mattress. 1. Fall 5/7/23According to a fall investigation dated 5/7/23, the resident was found lying on the floor. The resident had the sheet under him on the ground. The fall investigation documented the reason for the fall was the sheet slipping. A therapy note dated 5/9/23 at 6:26 a.m., read physical therapy completed an assessment due to the resident sliding out of his bed. The assessment included the following interventions: an air mattress and bolsters to reduce the risk of further bed slide-outs. A progress note dated 5/10/23 also referenced that the resident had an unwitnessed fall on 5/7/23 and read that therapy would assess the resident for an air mattress and bolster. -However, according to the resident's care plan, dated 4/24/23, the resident should have already had a bolster overlay on his mattress. No other interventions were implemented following the resident's 5/7/23 fall. 2. Fall 6/7/23According to a fall investigation dated 6/7/23, the resident had an unwitnessed fall. The resident was found on the floor on a fall mat. The resident said he rolled out of his bed. No other information was documented in the fall investigation. A progress note, dated 6/14/23, documented the resident had an unwitnessed fall on 6/7/23. The resident had slipped out of bed. Interventions included that the resident was placed on more frequent rounding. However, frequent rounding was already in place on the 4/24/23 care plan. Further, there was no instruction to staff on what constituted "more frequent" rounding. 3. Fall 8/1/23According to progress notes, dated 8/1/23, the resident had an unwitnessed fall. The root cause was the resident was unable to reposition in their bed. Ensure the grab bar was in the resident's new room. A nurse's progress note, dated 8/2/23, read the resident was found on his bottom on the floor on the fall mat with his head in the air. A full assessment was performed. No head injury was observed. -Per the nursing home administrator, interviewed on 10/25/23 at 3:00 p.m., the fall was not investigated and although the fall was unwitnessed, there were no neurological (neuro) checks following the 8/1/23 fall. 4. Falls 8/16/23According to a fall investigation, dated 8/16/23, the resident had two separate falls on 8/16/23. The resident was assessed by a registered nurse (RN) on 8/17/23 in the afternoon after receiving information the resident had two unwitnessedfalls. The resident had an abrasion on the left kneecap. The RN could not confirm if the abrasion was from one of the two falls. -There was no further information on the root cause for either fall. -There was one investigation for the two falls which, along with the nurse's assessment and neuro checks, were untimely; the investigation and nurse's assessment were conducted a day after the falls occurred. neuro checks were conducted yet another day later on 8/18/23. 5. Fall 8/22/23According to a fall investigation, dated 8/22/23, the resident had an unwitnessed fall and was found on the floor on a fall mat. A progress note, dated 8/23/23, documented the resident had rolled out of bed over the bolsters which were not upright in the bed. Interventions included moving the resident closer to the nurses' station. -Although the fall was unwitnessed, there was no evidence of neuro checks for this fall. D. Documentation of physical and behavioral effects of repeat falls. 1. In addition to an abraded knee sustained with his fall on 8/16/23 (see above), a nursing progress note dated 8/30/23, documented the resident had a bruise and significant swelling on his right arm. The bruising appeared to be old but there was significant swelling. The facility ordered X-rays to rule out a fracture. According to a risk management note dated 8/31/23, the resident had a bruise on his right arm. The root cause was believed to be recent falls. 2. According to the resident's ADL care plan dated 4/24/23, the resident has a fear of falling and would refuse showers because he was afraid of falling. A review of showering documentation confirmed the resident refused showers. Cross-reference F677. E. Failures in facility response to resident's repeated falls. 1. Failure to develop and/or implement effective interventions See above; there were no new interventions put into place after falls for all but one fall on 8/22/23. See above; the resident's fall care plan revealed an update on 6/8/23 to include more frequent rounds on the resident; however, frequency was not redefined for staff and the resident continued to fall. Further, the care plan revealed an update on 7/24/23 for nurses to check that the bolsters were on the resident's bed properly; however, the resident was documented on 8/23/23 to have rolled over the bolster. Finally, on 8/23/23, the care plan was updated again to include moving the resident closer to the nurse's station, but observations on 10/23/23 (see below) revealed he had not been moved. 2. Observations - failure to implement planned interventionsOn 10/23/23 at 1:38 p.m., the resident's room was located at the end of the hall, far from the nursing station. The resident was in his bed, the bed was not lowered and there was no fall mat on the ground. A bolster was not observed on the bed. The resident was rolling around in his bed. On 10/24/23 at 12:40 p.m., the resident was in his bed, close to the edge. The bed was raised and there was no fall mat on the floor. The resident had spastic movements and got closer to the edge of the bed with each movement. There was a side table and chair up against his bed. On 10/25/23 at 1:38 p.m., the resident was in his bed, asleep. The staff had put his bolster on his bed and the bed was lowered. However, there was a chair and table placed up against the resident's bed. II. Staff interviews A. The NHA was interviewed on 10/25/23 at 3:00 p.m. The NHA said the resident fall on 8/1/23 did not have a fall investigation. The NHA said there should have been a fall investigation. The NHA said they made leadership changes after recognizing fall investigations were not being performed. B. Certified nurse aide (CNA) #2 was interviewed on 10/26/23 at 10:56 a.m. CNA #2 said the residents who are at high fall risk have a bee sticker on their door. CNA #2 said Resident #15 had a bee on his door and was at high risk of falling. CNA #2 said Resident #15 had multiple falls. CNA #2 said fall interventions included the resident having a fall mat. CNA #2 said the fall mat was often found leaning against the wall and not next to the resident's bed. CNA #2 said the bed should be lowered to the ground. CNA #2 said she had often found the bed not lowered to the floor. CNA #2 said when a resident falls the CNAs let a nurse know so they could assess the resident. CNA #2 said residents who have unwitnessed falls have 15-minute neuro checks. C. Licensed practical nurse (LPN) #2 was interviewed on 10/26/23 at 10:45 a.m. LPN #2 said residents who are at high risk of falling should have interventions put in place. LPN #2 said Resident #15 was at high risk of falling. LPN #2 said interventions for Resident #15 were lowering the bed and fall mats next to the resident's bed. LPN #2 said if a resident had an unwitnessed fall, nurses should do 15-minute neuro checks on the resident. LPN #2 said when a resident falls, nurses should do a full head-to-toe assessment. LPN #2 said a fall investigation should be initiated. 4. The director of nursing (DON) was interviewed on 10/26/23 at 1:54 p.m. The DON said residents who had unwitnessed falls should have 15-minute neuro checks. The DON said neuro checks are important to rule out head injury. The DON said if neuro checks were not performed, it could delay the resident being sent out to the hospital. The DON said if an RN was not available to do the initial assessment, staff should at minimum do a virtual assessment with an RN. The DON said during a fall investigation, the team should find the root cause and implement interventions to prevent falls. The DON said new interventions should be put into place after each fall to help prevent additional falls. The DON said staff should follow the interventions that were put into place. The DON said if a resident had a history of falling out of bed, there should not be objects like tables or chairs against the bed. The DON said there should not be items near the bed because if a resident falls out of bed they could hurt themselves worse.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles in two out of four medication carts. Specifically, the facility failed to label insulin pens with an open date and store them according to the manufacturer's recommendation. Findings include:I. Manufacturer's recommendationsInsulin Glargine package insert read in pertinent part: "Insulin Glargine pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded."Insulin Lispro package insert read in pertinent part: "Insulin Lispro pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded."II. Observations of medications stored improperly and interviews 1. Cart #1 on West hallwayOn 10/26/23 at 2:30 p.m. the medication cart was inspected in the presence of the registered nurse (RN)# 2. The following observations were made:-Two open pens of Insulin Glargine100 units/milliliter (ml) were not labeled with the open date. One of the pens was missing the cap. RN #2 was interviewed during the observation and said she did not know why the open insulin pens were not labeled with an open date. She said she did not administer the insulin on her shift. She said it was important to label the medications as they have different expiration dates. 2. Cart #2 on West hallwayOn 10/26/23 at 2:40 p.m. the medication cart on the West hallway was inspected in the presence of the licensed practical nurse (LPN) #5. The following observations were made:-An open pen Insulin Lispro 100 units/milliliter (ml) was not labeled with the open date. LPN #5 was interviewed during the observation and said she did not know why the insulin pen was not labeled with an open date. She said the pen was good for 28 days after opening. III. Administrative interviewThe interim director of nursing (DON) was interviewed on 10/26/23 at 53:30 p.m. She said the nurses should know what medications required to be dated and how long they were good for. She said it was the responsibility of every nurse to check medication prior to administration and make sure it was not expired. She said she would provide education to the nurses to make sure they knew which medications should be labeled with an open date.

Based on record review and interviews, the facility failed to ensure the resident was assisted in making transportation arrangements to and from appointments for two (#52 and #53) of two out of 41 sample residents. Specifically, the facility failed to assist Resident #52 and Resident #53 with transportation for ongoing outside medical appointments. Findings include:I. Resident #52A. Resident statusResident #52, age 75, was admitted on 5/11/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included peripheral artery disease (circulatory condition) and hypertension. The resident was hit by a car while riding her bicycle before moving to the facility. The 7/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She was independent with all activities of daily living. She used a wheelchair. B. Resident interviewResident #52 was interviewed on 10/24/23 at 4:12 p.m. Resident #52 said she was temporarily at the facility due to an accident. Resident #52 said the facility did not offer aquatic therapy. Resident #53 said this therapy was needed for her to heal from her accident. Resident #52 said she had to make her own appointments and get her own transportation. Resident #52 said she did not think it was appropriate for her to have to provide her own transportation. Resident #52 said the facility did not ask her if she would like the facility to provide transportation. Resident #52 said she had told the social worker she would like the facility to provide transportation. C. Record review Review of the resident's medical record from May 2023 to 10/26/23 revealed no social services progress notes related to the staff assisting the resident in making transportation arrangements. II. Resident statusResident #53, age under 65, was admitted on 11/18/22. According to the October 2023 CPO, diagnoses included lymphoma (cancer) and kidney disease. The 9/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with all daily activities. He did not display physically or verbally aggressive behavior towards staff or other residents. B. Resident interviewResident #53 was interviewed on 10/23/23 at 2:30 p.m. Resident said that several times a week he needed to go to the outside lab for a blood draw related to his lymphoma. He said facility staff on multiple occasions failed to schedule transportation to and from the lab. On one occasion, a few weeks ago, he ended up waiting for three hours for a driver to pick him up from the lab. He said because facility staff consistently mismanaged the transportation, he had to take it into his own hands and manage his transportation. C. Record reviewReview of the progress notes between August 2023 and October 2023 did not reveal any arrangements or communication regarding the resident's transportation to the lab. III. Staff interviewThe social service assistant (SSA) was interviewed on 10/26/23 at 12:39 p.m. The SSA said the facility was responsible for providing the residents with transportation to outside appointments. The SSA said the facility used an outside transportation service. The SSA said if the transportation service did not have an available driver the facility would cancel the resident's appointment. The SSA said the facility had a 48-hour window before the resident's appointment. The SSA said it was the resident's responsibility to request transportation for an appointment. The SSA said residents would have to physically go to the social worker's office to make this request. -However, the SSA should assist the resident in making transportation arrangements who had limitations with going to the social worker's office. The SSA said Resident #52 did not often leave her room. The SSA said Resident #52 would go on outside appointments regularly. The SSA said Resident #52 would get her own transportation. The SSA said Resident #52 wanted to get her own transportation. The SSA said the resident did not like the driver the facility had before they had started to use the transportation service. The SSA was not sure if Resident #52 knew they had changed drivers.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to follow the correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include: I. Facility policy and procedureThe Menu policy, revised September 2017, was provided by the director of clinical services (DCS) on 10/26/23 at 12:28 p.m. It read in pertinent part: "Menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines."A registered dietitian/nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious or ethnic preferences, as appropriate."Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal."II. Failure to follow the correct portion sizes to ensure adequate nutrition was provided to the residentsDuring a continuous observation during the lunch meal on 10/25/23 beginning at 11:15 a.m. and ending at 12:37 p.m. the following was revealed:The portion control chart located by the steam table revealed the gray scoop was a size 8, with a capacity of four ounces equaling half cup. Dietary aide (DA) #3 used the following utensils and size:Tongs for the cheese pizza cut into triangular slices;A gray four-ounce scoop for ravioli; and, A tong for garlic bread. The lunch menu consisted of thin crust cheese pizza, tossed salad with dressing, garlic bread and fruit cocktail. The menu revealed the substitutions for pizza for residents with a renal diet was one cup of buttered ravioli and for residents with a dysphagia (swallowing difficulty) diet was one cup of ravioli with sauce. The menu revealed the portion sizes for pizza were:-The small portion was one half slice of pizza;-The regular portion was one slice of pizza; and,-The large portion was one and one half slices of pizza. During the lunch service the following was observed:-DA #3 used the gray #8 size (half cup) scoop throughout service to serve the ravioli equaling a half cup or about four to five raviolis to all the residents who were on a dysphagia diet and/or renal diets and who ordered ravioli as a substitute. According to the menu, one cup of ravioli was supposed to be served. -DA #3 served one slice of pizza to five tickets that read large portions that were supposed to get one and a half slice pizza. -DA #3 served one slice of pizza to two tickets that read double portions that were supposed to get two slices of pizza. III. Staff interviewsDA #1 was interviewed on 10/26/23 at 1:40 p.m. DA #1 said the serving size of the raviolis was four to five pieces per plate. The dietary manager (DM) was interviewed on 10/26/23 at 1:33 p.m. The DM said the regular portion of cheese pizza was one slice, the large portion was one and a half slices and the double portion was two slices of pizza. The DM said the regular portion of ravioli would be one cup or two scoops of the gray scoop whose capacity was four ounces or half cup. The DM said she did not know how much four pieces of ravioli would be because they go by ounces or the scoop amount. The registered dietitian (RD) was interviewed on 10/26/23 at 3:03 p.m. The RD said it was important for the residents to receive the correct portioning. The RD said residents who were to receive large and double portions of food were due to specific medical conditions. The RD said it was important for residents who were ordered to have large and double portions to receive the correct amount of protein. The protein enabled the residents with wounds to heal faster and supported their overall health. The RD said it was very important for residents on a renal diet to receive the correct portion sizes to support their health.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure food was palatable in taste, texture and appearance. Findings include:I. Facility policy and procedureThe Food and Palatability policy, revised in September 2017, was provided by the director of clinical services on 10/26/23 at 12:28 p.m. It read, in pertinent part: "Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. "The cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention." II. Resident interviewsResident #56 was interviewed on 10/23/23 at 12:24 p.m. Resident #56 said the food did not taste good and he did not like it. Resident #56 said because if he did not like the food served, he did not eat consistently. Resident #14 was interviewed on 10/23/23 at 1:30 p.m. Resident #14 said the mashed potatoes had a weird taste and the gravy was salty. Resident #14 said the food was either very salty or had no seasoning. Resident #14 said the food was horrible. Resident #19 was interviewed on 10/23/23 at 1:38 p.m. Resident #19 said the food was awful, it was bland and the renal diet was dry and unpalatable. The mashed potatoes tasted like they came out of a box and the fruit punch was watery and bland. The food presentation did not look palatable. Resident #40 was interviewed on 10/23/23 at 2:37 p.m. Resident #40 said the food did not taste good, it was unappetizing and bland. Resident #44 was interviewed on 10/23/23 at 2:40 p.m. Resident #44 said the food did not taste like anything, it was bland and not good. Resident #49 was interviewed on 10/23/23 2:53 p.m. Resident #49 said the food did not taste good, it was bland. III. Resident group interviewOn 10/25/23 at 2:32 p.m. the resident group interview was conducted with Resident #32, #38, #41, #45 and #46. Several of the residents in the interview said the food was not good. Resident #41 said the facility had new kitchen staff who said the food would be better but it was not appetizing. Resident #41 said the kitchen indicated they were going to serve bistro food but they had not. Resident #45 said the food was unappetizing. Resident #45 said the pork chops served for lunch were unappetizing and he did not like them. IV. ObservationsA test tray was made on 10/24/23 at 12:35 p.m. The test tray was plated at the end of meal service. The test tray consisted of a regular diet meal with encrusted pork loin with an onion sauce, au gratin potatoes, roasted brussel sprouts, dinner roll and butterscotch pudding parfait. The test tray was evaluated by three surveyors.-The encrusted pork loin was bland and had a slightly dry internal texture. The onion sauce helped the pork loin with the moisture but it was bland and flavorless;-The au gratin potatoes were cheesy but tasted salty and had a gluey sticky texture; -The roasted brussel sprouts were flavorless, watery and mushy; and, -The butterscotch pudding parfait tasted like butterscotch but had a metallic flavor. V. Record reviewResident council minutes dated 7/31/13 did not identify who attended the meeting. The dietary area noted a resident wanted more green chile burritos. -There was no documentation kitchen staff attended the meeting. Resident council minutes dated 8/31/13 did not identify who attended the meeting and did not address any dietary concerns. -There was no documentation kitchen staff attended the meeting. Resident council minutes dated 9/28/23 did not include dietary concerns or attendance to identify who attended the meeting. There was only one reference to food indicating it was cold. -There was no documentation kitchen staff attended the meeting. VI. Staff interviewsDietary aide (DA)#1 was interviewed on 10/26/23 at 12:46 p.m. DA #1 said all the recipes were available to the kitchen staff and were followed for each meal. DA #1 said the kitchen staff attended the monthly resident council meeting to discuss food. The dietary manager (DM) was interviewed on 10/26/23 at 1:33 p.m. The DM said she was unaware there were resident complaints about the food. The DM said they attended the monthly resident council meetings to discuss any food concerns. The DM said they completed a monthly survey of 10% of the resident population to determine the quality of the food. The DM said the surveys did not identify resident food concerns or complaints.

Based on observations and staff interviews, the facility failed to ensure safe practices were implemented to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically, the facility failed to ensure appropriate use of gloves when handling ready-to-eat foods. I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised January 2019, read in pertinent part, "Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and before handling or putting on single-use gloves for working with food, and between removing soiled gloves and putting on clean gloves."II. Facility policies and proceduresA. The Food Preparation policy, revised September 2017, was provided by the director of clinical services (DCS) on 10/26/23 at 12:28 p.m. It read in pertinent part: "All foods are prepared in accordance with the FDA (Food and Drug Administration) food code. "All staff will practice proper hand washing techniques and glove use."Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful, biological, and chemical contamination."All staff will use serving utensils appropriately to prevent cross contamination."B. The Handwashing procedure for Dining Services,no date, was provided by the DCS on 10/26/23 at 12:28 p.m. It read in pertinent part: "Gloves are not meant to be used as a replacement for handwashing. They are only effective if proper handwashing is completed. Employees must wash their hands immediately after they remove gloves or other personal protective equipment. Hand hygiene continues to be the primary means of preventing the transmission of infection."The following is a list of some situations that require hand hygiene: before and after eating or handling food, after handling soiled equipment or utensils, in between glove changes when changing tasks, when you take one step away from your workstation, between tasks (for example when switching between cutting chicken and cutting onions)." III. ObservationsOn 10/25/23 the following observations were made during lunch service between 11:15 a.m and 12:35 p.m. Observation of dietary aide (DA) #1 during lunch service on the cold/grill line.-DA #1 washed her hands and donned new gloves. DA #1 touched the handles on the stove with her right hand, then touched two hamburger buns with both hands using the same gloves.-DA #1 used the same gloves, as she obtained two mandarin oranges, peeled them and placed them in a bowl to be served. -DA #1 took off her gloves, washed her hands and donned new gloves. DA #1 touched the handle on the pan with her left hand. DA #1 then retrieved a tortilla and placed it in a pan, she touched the handle of the pan with her right hand, then touched cheese and placed it on the tortilla. DA #1 then touched the handle of the pan with her left hand and used a spatula with right hand to pick up the tortilla and placed it on the sideboard. DA #1 a held the tortilla with the palm of her left hand to cut and then placed it on a plate using both hands. -DA #1 took off her gloves, washed her hands and donned new gloves. DA #1 retrieved bread from a bag and placed it on the side board. DA #1 opened the refrigerator and took out a package of ham with her right hand. DA #1 closed the refrigerator with her left hand, opened the package of ham, took out a portion size and placed it on the sideboard. DA #1 opened the refrigerator, replaced the packaged ham and closed the refrigerator door. DA #1 touched the portioned ham with gloves in one hand and used a knife to cut it with the other. DA #1 then gathered the ham in both hands and placed it on the bread and finished making the sandwich. Observation of DA #2 during lunch service on the cold/grill line.-DA #2 washed her hands and donned new gloves. DA #2 retrieved pickles out of an open pickle jar with tongs, placed a lid on the pickle jar, opened the refrigerator (with her foot), placed pickle jar in the refrigerator with both hands and closed the refrigerator (with her foot). DA #2 then opened a large potato chip bag, reached in and grabbed chips and placed them on the plate. DA #2 then retrieved a tomato and held it with a gloved hand, diced it and placed it on a bed of lettuce using both hands.-DA #2 took off her gloves, washed her hands and donned new gloves. DA #2 then picked up cheese out of the cooler, retrieved hamburger buns out of a bag and placed them on the side board. DA #2 picked up tongs and retrieved a hamburger out of a pan on the stove. DA #2 placed the hamburger on the bun, then touched the cheese and placed the cheese on the burger. Using two hands DA #2 then placed the bun on top of the burger and put the cheeseburger on a plate.-DA #2 took off her gloves, washed hands and donned new gloves. DA #2 retrieved bacon out of the refrigerator (opened and closed it with her foot), opened the package and placed the bacon on a plate. DA #2 then used both of her gloved hands to open the microwave, set the time and temperature and turned the microwave on. When the microwave was finished, DA #2 opened and closed the microwave with both gloved hands and retrieved the bacon. DA #2 then touched the sandwich bread, placed the bacon on the bread and completed the sandwich using both gloved hands. III. Staff interviews DA #1 was interviewed on 10/25/23 during lunch service between 11:15 a.m and 12:35 p.m. DA #1 said when making food the kitchen staff washed hands then donned gloves before touching food. The kitchen staff changed out gloves when they were soiled. The dietary manager (DM) was interviewed on 10/26/23 at 1:33 p.m. The DM said staff were to wash hands and don gloves prior to working with ready to eat foods. The DM said good hand hygiene practice was to discard gloves, wash hands and don new gloves after touching other surfaces in the kitchen such as refrigerators, microwaves, handles and tongs. The DM said it was important not to touch ready to eat foods after touching other surfaces otherwise it could contaminate the food. It was good practice to use tongs for food after touching other surfaces during service. The DM said it could be difficult to keep track of what was touched while completing special orders.

A survey prompted by complaint #CO34134 was completed 10/23/23 to 10/26/23. One deficiency was cited.

Based on record review, and interviews, the facility failed to ensure two (#61 and #53) out of three residents reviewed out of 33 sample residents, as well as other facility residents, were protected from resident-to-resident abuse by Residents #54, #120, and #31. Residents #54 and #61 According to a sexual abuse investigation dated 8/8/23, Resident #61 reported Resident #54 had sexually assaulted her. Resident #54 had a known history of child abuse, was on the sex abuse registry due to an assault of an elderly person, and had recently gotten off parole for crimes he had committed in the past. A 4/12/23 behavioral assessment documented that facility staff reported Resident #54 had made inappropriate sexual comments since his admission on 3/23/23. Notwithstanding Resident #54's current and past history, the facility failed to take steps, before Resident #61 reported sexual abuse, to develop and implement person-centered, sufficient, and effective interventions to prevent potential sexual abuse. The facility's failure to take steps to prevent abuse contributed to Resident #61 becoming fearful, and triggered the initiation of psychosocial support to address her fear. Residents #120, #31 and #53Interview revealed Resident #53 was verbally abused and physically abused by Residents #120 and #31. Findings include: I. Facility policyThe Abuse policy and procedure, revised May 2023, was provided by the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part that: -"(The facility) 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." -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. -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. -When residents who have been admitted exhibit behavior that presents a danger to others, interventions shall be taken to ensure the safety of other residents and staff."II. Resident #54 and Resident #61A. Residents' status 1. Resident #54 Resident #54, age 80, was admitted on 3/23/23 and readmitted on 5/18/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included heart disease and chronic kidney disease. According to the 10/8/23 facility assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial/moderate assistance with dressing and putting on footwear. The resident was independent in all other activities of daily living (ADLs). The resident used a motorized wheelchair. The resident did not exhibit psychosis. Resident #54 did not receive psychological therapy. 2. Resident #61Resident #61, age 72, was admitted on 3/27/23. According to the October 2023 CPO, the diagnoses included dementia with behavioral disturbances. According to the 9/25/23 facility assessment, the resident was severely cognitively impaired with a BIMS score of 7 out of 15. She required extensive assistance of one person with all activities of daily living (ADLs) except eating and locomotion. The resident had no signs of depression. 3. Report of sexual abuseAccording to a sexual abuse investigation dated 8/8/23, Resident #54 allegedlytouched Resident #61 on her breasts and private areas. Resident #61 said, "he's so nasty." He touched me here, here, and here, anywhere he could grab." Resident #61 repeatedly said Resident #54 was a nasty man. The investigation read that Resident #61 was an at-risk adult with a BIMS of 1 and wheelchair assisted. Resident #54 was a registered sex offender from 2014 and finished probation in 2023. He goes to meetings monthly with the (local) Police Station. The resident also has a history of potentially using verbal slurs towards other residents. The investigation read that the care plan for Resident #54 read staff should monitor unsafe situations and redirect residents as needed along with continuing to monitor Resident #54 secondary to a history of sexual crimes against children. The investigation further read that Resident #54 was suspected of sexual assault. Resident #61 initially did not show any fear once the alleged assailant was placed on 1:1 (supervision) but after a couple of days, the alleged victim started making comments that she was afraid of a man. The investigation concluded the facility was unable to substantiate or unsubstantiate that the allegation had occurred as (the facility) could not determine when or if this incident happened since the alleged victim was a poor historian. However, with the reaction of the alleged victim (Resident #61), the facility was going to treat the incident as if it had happened. The alleged assailant (Resident #54) will stay on a 1:1 (supervision) until he (is) able to be placed in an appropriate placement. The victim has been referred to Mental Health Services since she was making statements of fear. Resident #54 was placed on 1:1. Referrals were sent out to multiple facilities that had all-male units. Resident #61 was at physical baseline but has increased statements of being afraid. Mental Health Services had been ordered for the resident. B. The facility failed to take sufficient steps before Resident #61 reported sexual abuse to protect residents, including Resident #61, from potential abuse. 1. Record review revealed the facility had prior knowledge of Resident #54's inappropriate behavior. A review of a behavioral health assessment, dated 4/12/23, revealed Resident #54 was referred for psychotherapeutic services and evaluations due to sexual assault and a history of sexually inappropriate behavior. It documented the resident was a registered sex offender due to the assault of an elderly person. The facility staff reported Resident #54 had made inappropriate sexual comments since admission (3/23/23). Recommendations included for the resident to participate in evidence-based psychotherapy four times a month for four months. According to a progress note dated 7/7/23, Resident #54 was found in a female resident's room when another male resident came into the room to ensure the female resident was alright. The male resident said, "he had to protect the female resident from (Resident #54)."2. Notwithstanding evidence of Resident #54's current and past history of sexually inappropriate behavior, the facility failed to develop a sufficient and effective resident-centered care plan to protect at-risk residents from potential abuse by Resident #54. As noted in the facility's sexual abuse investigation above, the resident's care plan dated 7/18/23, read the resident had a history of sexual crimes against children. It further read the resident finished parole in 2023. The resident had monthly meetings with a local police station on the 8th of every month. The resident was a registered sex offender. Interventions included: -Monitoring for unsafe situations and intervening if needed. -Staff should be made aware of stipulations required, like monthly check-ins. However, the care plan was neither resident-centered nor adequate.-The care plan failed to identify what constituted an unsafe situation, whether it was an unsafe situation for others or the resident and failed to include what levelof supervision was expected based on his known history of inappropriate sexual behavior and sexual crimes. Monitoring was not defined. -The care plan failed to instruct staff how to intervene given his history, failed to identify effective interventions, and failed to outline what steps staff were expected to take when inappropriate behaviors occurred, including how to intervene, who to notify, and where to document his behavior so that it could be monitored and interventions developed and revised when ineffective. -The care plan failed to include any reference to the incident on 7/7/23 and failed to trigger new interventions to prevent further incidents of potential sexual abuse. C. Staff interviewsStaff interviews confirmed the facility's knowledge of Resident #54's inappropriate behavior and the facility's failure to take steps to protect residents, including Resident #61. 1. Certified nurse aide (CNA) #2 was interviewed on 10/26/23 at 10:56 a.m. CNA #2 said Resident #54 was a registered sex offender. CNA #2 said the resident had been inappropriate with staff and other residents. CNA #2 said they verbally told the nurses when the resident was inappropriate, but there was no documentation of it. CNA #2 said the staff had not had extra training on how to work with a resident who had a criminal record of sexual abuse. CNA #2 said Resident #54 did not have interventions put in place until after the incident with Resident #61. CNA #2 said before that incident, Resident #54 would go into female residents' rooms and staff did not redirect him. The social services assistant (SSA) was interviewed on 10/26/23 at 12:39 p.m. The SSA said the facility was aware that Resident #54 had been incarcerated for sexual abuse against a child. The SSA said they did not have specific education for the staff when working with an individual who was a registered sex offender. The SSA said they did not put specific interventions into place for Resident #54 until after the incident with Resident #61. The SSA said since the incident, Resident #54 was on one-on-one supervision and the facility had tried to place him in a different facility. The SSA said Resident #61 was fearful of Resident #54 and was teary after the incident calling the resident a "bad man."The nursing home administrator (NHA) was interviewed on 10/26/23 at 3:30 p.m. The NHA said the facility was aware on admission, that Resident #54 had been incarcerated for sexual abuse and was on the sex offender registry. The NHA said they did not have additional training for staff on how to work with a registered sex offender. The NHA said staff should tell somebody if they saw Resident #54 being inappropriate. The NHA said there was not a specific place to document this and it was done verbally. The NHA said they did not put interventions in place until after the incident with Resident #61. The NHA said Resident #54 was allowed to go into female residents' rooms and roam freely throughout the facility. The NHA confirmed Resident #61's severe cognitive impairment and recognized it placed the resident at risk for abuse. The NHA said they got Resident #61 mental health care because she was teary and afraid after the event. The NHA said residents have the right to remain abuse-free. The NHA said after the incident with Resident #61, Resident #54 was put on one-on-one and they are trying to get him placed in a different facility. III. Resident #53 and Residents #120 and #1 - failure to prevent resident-to-resident abuseA. Resident #53's status 1. Resident #53, age under 60, was admitted to the facility on 11/18/22. According to the October 2023 CPO, diagnoses included lymphoma and kidney disease. The 9/5/23 facility assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with all daily activities. He did not display physical or verbally aggressive behavior toward staff or other residents. B. Failure to prevent resident-to-resident abuse involving Resident #53Resident #53 was interviewed on 10/23/23 at 2:30 p.m. He said he was verbally abused and physically assaulted by two different residents in the facility. He said more than six months ago he was beaten by Resident #120, who was no longer in the facility. He said Resident #120 previously used foul language towards him and disliked the sound of his TV which was too loud in his opinion. He said one day, Resident #120 aggressively walked into his room, threw him on the floor, and hit him in the face several times before staff were able to intervene. The second incident of physical abuse occurred less than six months ago. He said he was approached in the hallway by Resident #31, who threatened to hurt him and used a walking cane to hit him on the head. He said Resident #31, like Resident #120 was no longer in the facility and he felt safe. C. Record reviewA review of the facility investigations of the above incidents revealed the facility investigated and substantiated abuse and reported both incidents to the police and the state agency. The investigations included interviews with the victim and alleged perpetrators, as well as staff who worked at the time of the incident and other residents in the facility. Skin assessments in both instances revealed minor injuries that did not require hospitalization. Both residents no longer were residing in the facility at the time of the survey. Resident #120 was discharged in January 2023 and Resident #31 in September 2023. B. Staff interviewsCNA #2 was interviewed on 10/26/23 at 11:15 a.m. She said she used to work with all three residents. She said they all had their good and bad days. Resident #120 disliked loud noises and was particularly sensitive to them in the afternoon. Resident #31 did not have any aggressive behaviors toward her or other residents. Licensed practical nurse (LPN) #2 was interviewed on 10/26/23 at 11:45 a.m. She said she did not observe any aggressive behaviors with the above residents. She said she was aware of the incidents but did not work at the time when they occurred. The nursing home administrator (NHA) was interviewed on 10/26/23 at 4:41 p.m. He said all residents in the building should be free from abuse. He said the incident with Resident #120 occurred prior to his time as NHA in the building. The second incident, with Resident #31, was in September 2023. He said the facility investigated both incidents and took actions to make sure residents in the building were free from abuse.

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 10/09/2023 and 10/15/2023, 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 #CO32213 and #CO32229 was conducted on 5/30/23 to 6/1/23. No deficiencies were cited.

A complaint survey, prompted by #CO31982 and #CO31998 was conducted 5/9/23. No deficiencies were cited.