LIFE CARE CENTER OF PUEBLO

A complaint survey, prompted by #CO2690318, #CO2721799, Incident #2788023 and Incident #2788050 was completed on 2/25/26 to 2/26/26. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for one (#1) of three residents reviewed for accident hazards out of 19 sample residents. Resident #1 was admitted to the facility on 7/28/22. Resident #1’s comprehensive care plan revealed the resident was taking an anticoagulant (blood thinner) medication and goals included preventing abnormal bleeding and bruising as a result. On 12/24/25 at approximately 2:40 p.m. Resident #1 was being assisted to an activity in the dining room by the social services director (SSD) in her wheelchair without the foot pedals in place. Resident #1’s left leg was bumped on her wheelchair when her leg dropped. At 5:41 p.m. Resident #1 complained of pain to her lower left leg. At 8:52 p.m. Resident #1 was found to have a large hematoma (a closed wound where blood collects and fills a space inside the body) on her left calf which measured 8 inches by 4 inches. Resident #1’s physician was contacted and new physician’s orders were received to hold the resident’s anticoagulant medication and elevate the leg and ice as tolerated. Resident #1 was sent out to the emergency room on 12/24/25 and was treated with a splint, as-needed pain medication and orders to ice the hematoma as tolerated, and discharged back to the facility on 12/24/25. After the incident with Resident #1 on 12/24/25, education was provided to staff regarding the importance of transporting residents in their wheelchairs with foot pedals in place. However, observations during the survey (from 2/25/26 to 2/26/26) revealed staff continued to transport residents in their wheelchairs without foot pedals in place. Specifically, the facility failed to ensure staff transported Resident #1, who was on anticoagulant medication, in her wheelchair with the foot pedals in place, which resulted in a significant hematoma to the calf of the resident’s left leg, causing the resident pain and requiring a trip to the emergency room for the resident. Findings include:I. Resident #1A. Resident statusResident #1, age 83, was admitted to the facility on 7/28/22 and discharged to the hospital on 12/27/25. According to the December 2025 computerized physician orders (CPO), diagnoses included cognitive communication deficit, history of falling, unsteadiness on feet, atrial fibrillation and personal history of transient ischemic attack (stroke). The 11/20/25 minimum data assessment (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent for most activities of daily living (ADL). The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident received an anticoagulant medication. B. Record reviewThe anticoagulant medication care plan, revised 12/26/24, revealed Resident #1 was receiving anticoagulant therapy. The goal of the care plan was to minimize abnormal bleeding and bruising for Resident #1. Pertinent interventions included administering anticoagulant medications as ordered and assessing Resident #1 for side effects, including muscle or joint pain and bruising each shift. The skin integrity care plan, revised 5/2/23, revealed Resident #1 was at risk for breaks in skin integrity due to her fragile skin, decreased mobility, incontinence and edema. Pertinent interventions included padding the doorway to Resident #1’s bathroom and her roommate’s wheelchair pedals, performing weekly skin checks and providing treatments as ordered. Review of Resident #1’s December 2025 CPO revealed the following physician’s orders:Apixaban (Eliquis) (anticoagulant medication) 5 milligram (mg) tablets, give one tablet by mouth two times a day for atrial fibrillation, ordered 7/15/24. The apixiban medication was placed on hold from 12/24/25 at 7:34 p.m. through 12/26/25 at 7:09 p.m. and again from 12/27/25 at 7:49 a.m. through 12/28/25 at 11:53 a.m. A progress note, dated 12/24/25 at 3:00 p.m., revealed the SSD was assisting Resident #1 into the dining room at approximately 2:40 p.m. to play bingo when her foot dropped and her left leg hit her wheelchair. The SSD immediately stopped and Resident #1 said her leg hurt. The SSD looked at Resident #1’s leg and did not observe any marks. Resident #1 said she wanted to play bingo and the SSD continued assisting her into the dining room. The SSD told Resident #1 she would let the nurse know about the situation and proceeded to speak to Resident #1’s nurse. A progress note, dated 12/24/25 at 5:41 p.m., revealed Resident #1 was administered an as-needed pain medication due to pain in her lower left leg. A progress note, dated 12/24/25 at 7:29 p.m., revealed Resident #1’s apixaban order was held due to her recent hematoma. A progress note, dated 12/24/25 at 8:07 p.m., revealed Resident #1 received a new physician’s order for an as-needed pain medication for pain to her left leg. Resident #1 was having severe pain from her left leg hematoma despite elevating the leg and repositioning. A progress note, dated 12/24/25 at 8:52 p.m., revealed Resident #1 was notably in pain while sitting outside her doorway and waving a facility nurse down. Resident #1 was noted to have a hematoma on her left lower leg which measured approximately eight inches by four inches. Resident #1 said she ran into another wheelchair when she was being assisted into the dining room by the SSD. Resident #1 was having severe pain. The physician was contacted and new physician’s orders were obtained to elevate the resident’s leg, ice the area as tolerated, and administer tramadol (a pain medication) every six hours. Orders were obtained to hold Resident #1’s Eliquis for 48 hours and to measure and monitor the hematoma. The director of nursing (DON) and Resident #1’s representative were both notified.-Review of Resident #1’s electronic medical record (EMR) did not reveal any documentation of when and why the resident was sent out to the emergency room (see progress note below). A progress note, dated 12/25/25 at 12:30 a.m., revealed Resident #1 was admitted back to the facility from the emergency room. Resident #1’s left lower leg was wrapped in a stretch wrap, and the resident reported pain in the affected leg with movement. Resident #1’s foot of her bed was elevated and a pillow was placed under the affected leg for comfort and support. Resident #1 received an opioid pain medication (a pain medication used to treat moderate to severe pain) while in the emergency room. Resident #1’s physician was called and informed of Resident #1’s arrival back to the facility, and physician’s orders were obtained to administer another dose of an opioid pain medication before continuing to give tramadol as scheduled and inform the physician of any changes. A progress note, dated 12/25/25 at 2:37 a.m., revealed Resident #1 received instructions from the emergency room to keep a splint on her left lower leg for protection for the following few days and the splint could be removed when swelling or pain improved. A progress note, dated 12/26/25 at 6:15 p.m., revealed Resident #1 was being monitored by the nursing staff for the hematoma to her left lower leg. An on-call nurse removed Resident #1’s stretch wrap to visualize the leg, and saw the hematoma to her leg was large, bubbled and raised and dark purple in color. A splint was in place to the back of Resident #1’s leg and the leg was re-wrapped for protection. Resident #1 reported having pain and an as-needed pain medication dose was administered. Resident #1 was assisted with repositioning. Resident #1’s physician was contacted and requested the resident’s apixaban be held until 12/28/25 when the physician could evaluate the resident. Resident #1’s representative was in the facility at the time and was informed of the new physician’s orders and plan. A progress note, dated 12/27/25 at 1:47 p.m., revealed Resident #1 complained of pain to her left lower leg. The nursing staff removed the stretch wrap to check her pulses and found her pulses were even and strong. The note documented Resident #1’s hematoma was draining serous fluid. Resident #1’s leg was re-wrapped with abdominal gauze pads and clean stretch wrap. Resident #1’s representative was in the facility at the time and voiced concerns regarding Resident #1’s lower left leg. A call was placed to Resident #1’s physician and the nursing staff received physician’s orders to send Resident #1 out to the emergency room a second time. A progress note, dated 12/30/25 at 12:42 p.m. (after Resident #1 was transferred to the hospital on 12/27/25), revealed Resident #1 was assessed by a nurse and found to have an eight inch by five inch hematoma at approximately 5:30 p.m. on 12/24/25. Resident #1 was in pain, reporting a pain of 8 or 9 on a scale from 1 to 10, and would motion with her hand not to touch the hematoma site. Resident #1’s physician was contacted to report the hematoma. Resident #1’s representative was in the facility at the time and agreed to the physician’s orders to attempt to treat the hematoma in house. Report was given to the oncoming night nurse, and as-needed and scheduled pain medications were administered. A progress note, dated 1/6/26 at 2:21 p.m., revealed Resident #1 was reviewed by the interdisciplinary team (IDT), 12 days after the incident which resulted in the hematoma to the resident’s left leg. The note documented Resident #1 was a long-term care resident with decreased mobility, weakness, obesity and was on anticoagulant medication. Resident #1 was observed to have a large hematoma to her left lower leg and was in pain. Resident #1 said she hit the area with the hematoma on another wheelchair while being assisted by staff in her wheelchair. The area was assessed and all appropriate notifications were made. The nursing staff received orders from the physician to hold Resident #1’s anticoagulant medication. The area with the hematoma continued to get larger and Resident #1 was sent out to the emergency room for evaluation. Resident #1 returned to the facility afterwards, but had to return to the hospital for further evaluation (on 12/27/25). Education was provided to all staff on transporting residents with foot pedals. A skin assessment, dated 12/25/25 at 4:30 p.m., revealed Resident #1 had a 10 inch by 6 inch hematoma to her left lower leg. The assessment documented the hematoma was noted several hours after Resident #1 was in contact with another wheelchair during assistance to the dining room. Resident #1 reported pain of 8 to 9 on a scale of 1 to 10. Resident #1’s physician gave new physician’s orders for cares but Resident #1 was eventually transported to the emergency room where the hospital wrapped her leg, gave her pain medications and returned her to the facility.-However, the skin assessment was documented nearly 26 hours after Resident #1’s initial incident occurred. Hospital notes, dated 12/24/25 at 8:58 p.m., revealed Resident #1 was evaluated in the emergency room for a hematoma to her left leg. Resident #1 said she was getting pushed in her wheelchair around the facility. Resident #1 reported she was accidentally pushed into another wheelchair and her bruise had gotten bigger. Resident #1 reported she had been having pain. Resident #1 was on a blood thinner. Xrays were taken of Resident #1’s left lower leg and found no acute breaks or fractures, only soft tissue swelling. Resident #1 was discharged back to the facility on 12/24/25 at 11:52 p.m. The facility investigation of the incident, dated 12/24/25, was provided by the nursing home administrator (NHA) on 2/25/26 at 1:40 p.m. and revealed the following:Resident #1 had a hematoma to her left leg. Resident #1’s physician was notified and new physician’s orders were received to elevate the left leg, hold the resident’s apixaban order, and ice the area as the resident would tolerate. A witness statement fromthe SSD, dated 12/24/25, revealed the SSD was assisting Resident #1 in her wheelchair into the dining room to play bingo at approximately 2:40 p.m. Resident #1’s foot had dropped and hit her wheelchair while moving. The SSD immediately stopped and looked at Resident #1’s calf and did not see any marks or bruising. Resident #1 said her leg hurt but told the SSD she wanted to play bingo. The SSD said she immediately informed Resident #1’s nurse about the situation. The SSD said the resident hit her left calf. A summary of findings from the IDT, undated, revealed Resident #1 was a long-term care resident with decreased mobility, weakness, obesity and was on anticoagulant medication. Resident #1 was observed to have a large hematoma to her left lower leg and was in pain. Resident #1 said she hit the area with the hematoma on another wheelchair while being assisted by staff in her wheelchair. The area was assessed and all appropriate notifications were made. The nursing staff received orders from the physician to hold Resident #1’s anticoagulant medication. The area with the hematoma continued to get larger and Resident #1 was sent out to the emergency room for evaluation. Resident #1 returned to the facility afterwards, but had to return to the hospital for further evaluation. Education was provided to all staff on transporting residents with foot pedals, conducted 12/30/25 through 1/9/26.-However, staff continued to transport residents in wheelchairs without foot pedals in place (see observations below). III. Observations of other residentsOn 2/25/26 at 11:47 a.m. the infection preventionist (IP) was assisting an unidentified resident with transportation in their wheelchair through the facility hallway. The resident had one foot situated on their wheelchair foot pedal, while the other foot was situated between the two wheelchair foot pedals and pointing at the floor. At 12:06 p.m. certified nurse aide (CNA) #5 began assisting an unidentified resident with transportation in their wheelchair through the facility hallway. The resident was holding their feet up so they did not drag along the ground, and no wheelchair foot pedals were present on the resident’s wheelchair. At 4:38 p.m. CNA #4 was assisting Resident #10 with transportation in his wheelchair down the hallway. Resident #10 was lifting his feet up in the air so they would not drag along the ground, and no wheelchair foot pedals were present on the wheelchair. CNA #4 asked Resident #10 if he wanted him to keep pushing his wheelchair, to which Resident #10 said he did not. On 2/26/26 at 9:09 a.m. CNA #3 assisted Resident #9 in his wheelchair from one dining table in the dining room to another table. Resident #9 had foot pedals attached to his wheelchair, but the foot pedals were flipped up and not in a position for the resident to rest his feet on them. Resident #9’s feet dragged along the ground as CNA #3 pushed him. At 9:10 a.m. an unidentified housekeeping staff member was assisting an unidentified resident with transportation in their wheelchair through the facility hallway. One of the resident’s feet were situated on her foot pedals, while the other jutted between the foot pedals and pointed at the ground. IV. Staff interviewsCNA #1 was interviewed on 2/26/26 at 10:29 a.m. CNA #1 said she used foot pedals on residents’ wheelchairs when assisting them with transportation so the residents did not hit their toes or so their legs did not bend back while moving. CNA #1 said she received education on using foot pedals the month prior (January 2026) but said she was not sure why. CNA #2 was interviewed on 2/26/26 at 10:39 a.m. CNA #2 said when assisting residents with transportation in their wheelchairs, she applied foot pedals to the resident’s wheelchair and ensured their arms were tucked in while moving. CNA #2 said the nursing staff used foot pedals on the residents’ wheelchairs so the residents would not drag their feet while moving or potentially fall out of their wheelchairs. CNA #2 said she had received education on using foot pedals for residents using wheelchairs the month prior (January 2026) after a resident bumped their foot while being assisted in their wheelchair. Registered nurse (RN) #1 was interviewed on 2/26/26 at 10:54 a.m. RN #1 said facility staff needed to use foot pedals when assisting residents with transportation so they would not bump their feet or fall. RN #1 said the facility’s administration staff had done a lot of education on using foot pedals recently so all staff members, even kitchen and housekeeping staff, knew they needed to use foot pedals when assisting someone in a wheelchair. The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said facility staff should apply foot pedals to the resident’s wheelchair if the resident was being assisted with transportation. The DON said the facility had done education on the subject recently. The DON said for Resident #1’s incident on 12/24/25, the SSD had been assisting Resident #1 through a smaller door in the dining room. The DON said they did not believe Resident #1’s foot pedals were being used at the time of the incident, which was why they educated all staff on using foot pedals. The DON said Resident #1 had moved her foot during the transportation but was not sure if she had hit something on her wheelchair or had bumped into the doorway. The DON said Resident #1 had a hematoma to her left calf. The DON said Resident #1 had not complained of pain that day and was sent out to the emergency room that night (12/24/25), and had been discharged from the hospital shortly thereafter. The DON said she did not do a root cause analysis for the incident involving Resident #1. The DON said the IDT had decided to do education with staff regarding the use of foot pedals based on the information they had about the incident. The DON said she did not conduct any audits of wheelchair foot pedal usage following the incident, and said the use of foot pedals had not been identified as a concern prior to Resident #1’s incident on 12/24/25. The NHA was interviewed on 2/26/26 at 12:09 p.m. The NHA said the SSD had been escorting Resident #1 to bingo when her foot dropped and the resident hit her left leg. The NHA said the SSD asked if Resident #1 was okay, and the resident said she was and that she wanted to go play bingo. The NHA said the SSD alerted Resident #1’s nurse, and the nurse evaluated her and did not see any marks. The NHA said Resident #1 developed a hematoma to her left leg a few hours later and was sent out to the emergency room. The NHA said the administration had educated all facility staff members on proper wheelchair transportation so residents’ feet did not fall when they were being transported. The NHA said all staff members had been educated on the subject prior to their next shift, and had received additional education during an all-staff meeting on 1/15/26. The NHA said the documents in the facility investigation were the only information they had collected.-However, several staff members were observed during the survey process not using wheelchair pedals when assisting residents with transportation (see observations above).

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when handling residents’ meal trays and water pitchers;-Ensure staff handled residents’ drinkware and silverware in a sanitary manner; and,-Ensure staff donned (put on) face masks appropriately during a facility outbreak with COVID-19. Findings include:I. Failed to ensure staff performed appropriate hand hygiene when handling residents’ meal trays and water pitchersA. Professional referenceAccording to The Centers for Disease Control and Prevention’s (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 3/3/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, “Hand hygiene protects both healthcare personnel and patients.“Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics.“Clean your hands immediately before touching a patient and after touching a patient or the patient’s surroundings.”B. Facility policy and procedureThe Resident Dining Services policy and procedure, revised 4/29/25, was provided by the nursing home administrator (NHA) on 2/26/26 at 1:17 p.m. It read in pertinent part, “Staff involved in dining/food services will perform hand hygiene prior to distributing trays to the residents and when serving food to residents.”C. ObservationsOn 2/25/26 at 12:07 p.m. certified nurse aide (CNA) #4 was going from room to room collecting residents’ water pitchers, refilling them with ice water and returning the pitchers to the residents’ rooms. CNA #4 entered an unidentified resident’s room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 held the resident’s straw with his bare hand so the resident could sip from the water pitcher. CNA #4 then returned the resident’s water pitcher to her room, and continued going from room to room down the hallway refilling water pitchers. -CNA #4 did not perform hand hygiene between each resident’s room or after handling the resident’s straw. At 1:00 p.m. CNA #5 was assisting an unidentified resident in the dining room with putting her shirt back on. CNA #5 then went to look for the resident’s lunch tray and moved several other residents’ trays before finding the tray that belonged to the resident. CNA #5 assisted the resident with putting her shirt on again and oriented the resident to her meal tray. CNA #5 then continued passing out meal trays to other residents in the dining room.-However, CNA #5 did not perform hand hygiene after assisting the resident with putting her shirt on or between each resident’s meal tray. At 1:09 p.m. CNA #5 entered an unidentified resident’s room to deliver her room tray. CNA #5 oriented the resident to her meal tray and began to assist the resident with cutting up her food. CNA #5 then left the resident’s room, grabbed another room tray and entered another resident’s room.-However, CNA #5 did not perform hand hygiene between each resident when assisting with meal delivery. D. Staff interviewsThe infection preventionist (IP) was interviewed on 2/26/26 at 11:18 a.m. The IP said staff members should perform hand hygiene before handling room trays and after leaving residents’ rooms, especially if they assisted the residents with handling their food or opening packets. The director of nursing (DON) was interviewed on 2/26/26 at 11:32 a.m. The DON said staff members should perform hand hygiene between each tray when delivering meal trays. The DON said the facility had identified concerns in this area and had been doing audits of meal hand hygiene a few months ago. The DON said the facility had provided education to the nursing and dietary staff at the time the concerns were identified, and put signs on the meal delivery carts as a reminder to perform hand hygiene. The DON said the facility’s administration staff still saw occasional issues with hand hygiene during meals, but said the audits had decreased the rate of issues significantly. -However, observations conducted during the survey process revealed concerns with staff performing hand hygiene between tray deliveries and in filling water pitchers (see observations above). II. Failed to ensure staff handled residents’ drinkware and silverware in a sanitary mannerA. ObservationsOn 2/25/26 at 12:07 p.m. CNA #4 was going from room to room collecting residents’ water pitchers, refilling them with ice water, and returning the pitcher to the residents’ rooms. CNA #4 entered an unidentified resident’s room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 grabbed the outside of his mask and pulled his mask down to speak with the resident. Using the same bare hand, CNA #4 held the resident’s straw so she could sip from the water pitcher. CNA #4 then returned the resident’s water pitcher to her room, and continued going from room to room down the hallway refilling water pitchers. -CNA #4 did not perform hand hygiene before or after handling the resident’s straw or after handling his mask. On 2/26/26 at 9:13 a.m. CNA #3 began assisting an unidentified resident with eating breakfast. CNA #3 unwrapped the napkin around the resident’s silverware and held her fork and knife by the cutting surface and tines. CNA #3 grabbed the resident’s coffee mug by the rim of the mug and handed it to her. CNA #3 then began cutting up the resident’s food. At 9:16 a.m. CNA #3 grabbed the unidentified resident’s mug by the rim and pulled it closer to himself to add a packet of sugar to her coffee. CNA #3 then used the handle of the resident’s knife to stir her coffee. CNA #3 had previously used the knife to cut the resident’s food. B. Staff interviewsThe IP was interviewed on 2/26/26 at 11:18 a.m. The IP said staff members should not touch the area on silverware where a resident’s mouth would go. The IP said staff members should not grab mugs or cups by the top, and said it was not okay to grab areas where the resident’s mouth would then touch. The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said staff should not handle the rims of residents’ cups or the end of the residents’ silverware that the resident would then put into their mouth. III. Failed to ensure staff donned face masks appropriately during a facility outbreakA. Facility policy and procedureThe Universal Source Control policy and procedure, revised 7/7/25, was received from the NHA on 2/26/26 at 1:17 p.m. It read in pertinent part, “Source control is the use of respirators or well-fitting face masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing or coughing.“Source control is recommended for individuals in healthcare settings who reside or work on an area of the facility experiencing an outbreak of respiratory infection.”“Healthcare professionals should be instructed that if they must touch or adjust their facemask they should perform hand hygiene immediately before and after.”B. ObservationsOn 2/25/26 at 12:07 p.m. CNA #4 entered an unidentified resident’s room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 grabbed the outside of his mask and pulled his mask down to speak with the resident. CNA #4 bent down and put his face beside the resident’s ear while doing so. After speaking with her, CNA #4 pulled his mask back up and encouraged the resident to drink. CNA #4 repeated this process moments later.-CNA #4 did not perform hand hygiene after handling his mask, and his mask did not cover his mouth and nose while in close contact with the resident. On 2/26/26 at 9:09 a.m. CNA #3 was in the dining room assisting residents with getting to their seats for the breakfast meal service. CNA #3 was wearing a surgical mask which was pulled down below his mouth. At 9:13 a.m. CNA #3 sat next to an unidentified resident and began assisting her with eating. CNA #3 continued to wear his surgical mask under his mouth. C. Staff interviewsThe IP was interviewed on 2/26/26 at 11:18 a.m. The IP said the facility was in outbreak status at the moment for COVID-19, but did not have any current cases of COVID-19 in the resident population. The IP said their most recent positive case was a staff member who had tested positive for COVID-19 the week prior (week of 2/16/26). The IP said the facility’s last day of outbreak status would be on 2/28/26. The IP said he had been enforcing surgical mask use for staff members, especially when they were in resident care areas. The IP said staff should wear their masks so they covered both their nose and their mouth. The IP said he had to provide spot-education to a few employees the day prior (2/25/26) to ensure their noses were covered by their masks. The IP said staff members should perform hand hygiene after handling the outside of their mask, as the mask was technically considered to be a contaminated surface. The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said staff members should be wearing face masks in the facility hallways and resident care areas during the facility’s COVID-19 outbreak. The DON said staff members’ masks should cover both their nose and their mouth. The DON said if a resident was having difficulty communicating and the staff member needed to lower their mask to communicate with them, the staff member should avoid pulling their mask down in a hallway. The DON said the staff member should try to bring the resident to a room or office to facilitate communication.

A survey prompted by #CO2690319 was completed on 2/25/26 to 2/26/26. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for one (#1) of three residents reviewed for accident hazards out of 19 sample residents. Resident #1 was admitted to the facility on 7/28/22. Resident #1’s comprehensive care plan revealed the resident was taking an anticoagulant (blood thinner) medication and goals included preventing abnormal bleeding and bruising as a result. On 12/24/25 at approximately 2:40 p.m. Resident #1 was being assisted to an activity in the dining room by the social services director (SSD) in her wheelchair without the foot pedals in place. Resident #1’s left leg was bumped on her wheelchair when her leg dropped. At 5:41 p.m. Resident #1 complained of pain to her lower left leg. At 8:52 p.m. Resident #1 was found to have a large hematoma (a closed wound where blood collects and fills a space inside the body) on her left calf which measured 8 inches by 4 inches. Resident #1’s physician was contacted and new physician’s orders were received to hold the resident’s anticoagulant medication and elevate the leg and ice as tolerated. Resident #1 was sent out to the emergency room on 12/24/25 and was treated with a splint, as-needed pain medication and orders to ice the hematoma as tolerated, and discharged back to the facility on 12/24/25. After the incident with Resident #1 on 12/24/25, education was provided to staff regarding the importance of transporting residents in their wheelchairs with foot pedals in place. However, observations during the survey (from 2/25/26 to 2/26/26) revealed staff continued to transport residents in their wheelchairs without foot pedals in place. Specifically, the facility failed to ensure staff transported Resident #1, who was on anticoagulant medication, in her wheelchair with the foot pedals in place, which resulted in a significant hematoma to the calf of the resident’s left leg, causing the resident pain and requiring a trip to the emergency room for the resident. Findings include:I. Resident #1A. Resident statusResident #1, age 83, was admitted to the facility on 7/28/22 and discharged to the hospital on 12/27/25. According to the December 2025 computerized physician orders (CPO), diagnoses included cognitive communication deficit, history of falling, unsteadiness on feet, atrial fibrillation and personal history of transient ischemic attack (stroke). The 11/20/25 comprehensive assessment revealed the resident had moderate cognitive impairments. The resident was independent for most activities of daily living (ADL). The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident received an anticoagulant medication. B. Record reviewThe anticoagulant medication care plan, revised 12/26/24, revealed Resident #1 was receiving anticoagulant therapy. The goal of the care plan was to minimize abnormal bleeding and bruising for Resident #1. Pertinent interventions included administering anticoagulant medications as ordered and assessing Resident #1 for side effects, including muscle or joint pain and bruising each shift. The skin integrity care plan, revised 5/2/23, revealed Resident #1 was at risk for breaks in skin integrity due to her fragile skin, decreased mobility, incontinence and edema. Pertinent interventions included padding the doorway to Resident #1’s bathroom and her roommate’s wheelchair pedals, performing weekly skin checks and providing treatments as ordered. Review of Resident #1’s December 2025 CPO revealed the following physician’s orders:Apixaban (Eliquis) (anticoagulant medication) 5 milligram (mg) tablets, give one tablet by mouth two times a day for atrial fibrillation, ordered 7/15/24. The apixiban medication was placed on hold from 12/24/25 at 7:34 p.m. through 12/26/25 at 7:09 p.m. and again from 12/27/25 at 7:49 a.m. through 12/28/25 at 11:53 a.m. A progress note, dated 12/24/25 at 3:00 p.m., revealed the SSD wasassisting Resident #1 into the dining room at approximately 2:40 p.m. to play bingo when her foot dropped and her left leg hit her wheelchair. The SSD immediately stopped and Resident #1 said her leg hurt. The SSD looked at Resident #1’s leg and did not observe any marks. Resident #1 said she wanted to play bingo and the SSD continued assisting her into the dining room. The SSD told Resident #1 she would let the nurse know about the situation and proceeded to speak to Resident #1’s nurse. A progress note, dated 12/24/25 at 5:41 p.m., revealed Resident #1 was administered an as-needed pain medication due to pain in her lower left leg. A progress note, dated 12/24/25 at 7:29 p.m., revealed Resident #1’s apixaban order was held due to her recent hematoma. A progress note, dated 12/24/25 at 8:07 p.m., revealed Resident #1 received a new physician’s order for an as-needed pain medication for pain to her left leg. Resident #1 was having severe pain from her left leg hematoma despite elevating the leg and repositioning. A progress note, dated 12/24/25 at 8:52 p.m., revealed Resident #1 was notably in pain while sitting outside her doorway and waving a facility nurse down. Resident #1 was noted to have a hematoma on her left lower leg which measured approximately eight inches by four inches. Resident #1 said she ran into another wheelchair when she was being assisted into the dining room by the SSD. Resident #1 was having severe pain. The physician was contacted and new physician’s orders were obtained to elevate the resident’s leg, ice the area as tolerated, and administer tramadol (a pain medication) every six hours. Orders were obtained to hold Resident #1’s Eliquis for 48 hours and to measure and monitor the hematoma. The director of nursing (DON) and Resident #1’s representative were both notified.-Review of Resident #1’s electronic medical record (EMR) did not reveal any documentation of when and why the resident was sent out to the emergency room (see progress note below). A progress note, dated 12/25/25 at 12:30 a.m., revealed Resident #1 was admitted back to the facility from the emergency room. Resident #1’s left lower leg was wrapped in a stretch wrap, and the resident reported pain in the affected leg with movement. Resident #1’s foot of her bed was elevated and a pillow was placed under the affected leg for comfort and support. Resident #1 received an opioid pain medication (a pain medication used to treat moderate to severe pain) while in the emergency room. Resident #1’s physician was called and informed of Resident #1’s arrival back to the facility, and physician’s orders were obtained to administer another dose of an opioid pain medication before continuing to give tramadol as scheduled and inform the physician of any changes. A progress note, dated 12/25/25 at 2:37 a.m., revealed Resident #1 received instructions from the emergency room to keep a splint on her left lower leg for protection for the following few days and the splint could be removed when swelling or pain improved. A progress note, dated 12/26/25 at 6:15 p.m., revealed Resident #1 was being monitored by the nursing staff for the hematoma to her left lower leg. An on-call nurse removed Resident #1’s stretch wrap to visualize the leg, and saw the hematoma to her leg was large, bubbled and raised and dark purple in color. A splint was in place to the back of Resident #1’s leg and the leg was re-wrapped for protection. Resident #1 reported having pain and an as-needed pain medication dose was administered. Resident #1 was assisted with repositioning. Resident #1’s physician was contacted and requested the resident’s apixaban be held until 12/28/25 when the physician could evaluate the resident. Resident #1’s representative was in the facility at the time and was informed of the new physician’s orders and plan. A progress note, dated 12/27/25 at 1:47 p.m., revealed Resident #1 complained of pain to her left lower leg. The nursing staff removed the stretch wrap to check her pulses and found her pulses were even and strong. The note documented Resident #1’s hematoma was draining serous fluid. Resident #1’s leg was re-wrapped with abdominal gauze pads and clean stretch wrap. Resident #1’s representative was in the facility at the time and voiced concerns regarding Resident #1’s lower left leg. A call was placed to Resident #1’s physician and the nursing staff received physician’s orders to send Resident #1 out to the emergency room a second time. A progress note, dated 12/30/25 at 12:42 p.m. (after Resident #1 was transferred to the hospital on 12/27/25), revealed Resident #1 was assessed by a nurse and found to have an eight inch by five inch hematoma at approximately 5:30 p.m. on 12/24/25. Resident #1 was in pain, reporting a pain of 8 or 9 on a scale from 1 to 10, and would motion with her hand not to touch the hematoma site. Resident #1’s physician was contacted to report the hematoma. Resident #1’s representative was in the facility at the time and agreed to the physician’s orders to attempt to treat the hematoma in house. Report was given to the oncoming night nurse, and as-needed and scheduled pain medications were administered. A progress note, dated 1/6/26 at 2:21 p.m., revealed Resident #1 was reviewed by the interdisciplinary team (IDT), 12 days after the incident which resulted in the hematoma to the resident’s left leg. The note documented Resident #1 was a long-term care resident with decreased mobility, weakness, obesity and was on anticoagulant medication. Resident #1 was observed to have a large hematoma to her left lower leg and was in pain. Resident #1 said she hit the area with the hematoma on another wheelchair while being assisted by staff in her wheelchair. The area was assessed and all appropriate notifications were made. The nursing staff received orders from the physician to hold Resident #1’s anticoagulant medication. The area with the hematoma continued to get larger and Resident #1 was sent out to the emergency room for evaluation. Resident #1 returned to the facility afterwards, but had to return to the hospital for further evaluation (on 12/27/25). Education was provided to all staff on transporting residents with foot pedals. A skin assessment, dated 12/25/25 at 4:30 p.m., revealed Resident #1 had a 10 inch by 6 inch hematoma to her left lower leg. The assessment documented the hematoma was noted several hours after Resident #1 was in contact with another wheelchair during assistance to the dining room. Resident #1 reported pain of 8 to 9 on a scale of 1 to 10. Resident #1’s physician gave new physician’s orders for cares but Resident #1 was eventually transported to the emergency room where the hospital wrapped her leg, gave her pain medications and returned her to the facility.-However, the skin assessment was documented nearly 26 hours after Resident #1’s initial incident occurred. Hospital notes, dated 12/24/25 at 8:58 p.m., revealed Resident #1 was evaluated in the emergency room for a hematoma to her left leg. Resident #1 said she was getting pushed in her wheelchair around the facility. Resident #1 reported she was accidentally pushed into another wheelchair and her bruise had gotten bigger. Resident #1 reported she had been having pain. Resident #1 was on a blood thinner. Xrays were taken of Resident #1’s left lower leg and found no acute breaks or fractures, only soft tissue swelling. Resident #1 was discharged back to the facility on 12/24/25 at 11:52 p.m. The facility investigation of the incident, dated 12/24/25, was provided by the nursing home administrator (NHA) on 2/25/26 at 1:40 p.m. and revealed the following:Resident #1 had a hematoma to her left leg. Resident #1’s physician was notified and new physician’s orders were received to elevate the left leg, hold the resident’s apixaban order, and ice the area as the resident would tolerate. A witness statement from the SSD, dated 12/24/25, revealed the SSD was assisting Resident #1 in her wheelchairinto the dining room to play bingo at approximately 2:40 p.m. Resident #1’s foot had dropped and hit her wheelchair while moving. The SSD immediately stopped and looked at Resident #1’s calf and did not see any marks or bruising. Resident #1 said her leg hurt but told the SSD she wanted to play bingo. The SSD said she immediately informed Resident #1’s nurse about the situation. The SSD said the resident hit her left calf. A summary of findings from the IDT, undated, revealed Resident #1 was a long-term care resident with decreased mobility, weakness, obesity and was on anticoagulant medication. Resident #1 was observed to have a large hematoma to her left lower leg and was in pain. Resident #1 said she hit the area with the hematoma on another wheelchair while being assisted by staff in her wheelchair. The area was assessed and all appropriate notifications were made. The nursing staff received orders from the physician to hold Resident #1’s anticoagulant medication. The area with the hematoma continued to get larger and Resident #1 was sent out to the emergency room for evaluation. Resident #1 returned to the facility afterwards, but had to return to the hospital for further evaluation. Education was provided to all staff on transporting residents with foot pedals, conducted 12/30/25 through 1/9/26.-However, staff continued to transport residents in wheelchairs without foot pedals in place (see observations below). III. Observations of other residentsOn 2/25/26 at 11:47 a.m. the infection preventionist (IP) was assisting an unidentified resident with transportation in their wheelchair through the facility hallway. The resident had one foot situated on their wheelchair foot pedal, while the other foot was situated between the two wheelchair foot pedals and pointing at the floor. At 12:06 p.m. certified nurse aide (CNA) #5 began assisting an unidentified resident with transportation in their wheelchair through the facility hallway. The resident was holding their feet up so they did not drag along the ground, and no wheelchair foot pedals were present on the resident’s wheelchair. At 4:38 p.m. CNA #4 was assisting Resident #10 with transportation in his wheelchair down the hallway. Resident #10 was lifting his feet up in the air so they would not drag along the ground, and no wheelchair foot pedals were present on the wheelchair. CNA #4 asked Resident #10 if he wanted him to keep pushing his wheelchair, to which Resident #10 said he did not. On 2/26/26 at 9:09 a.m. CNA #3 assisted Resident #9 in his wheelchair from one dining table in the dining room to another table. Resident #9 had foot pedals attached to his wheelchair, but the foot pedals were flipped up and not in a position for the resident to rest his feet on them. Resident #9’s feet dragged along the ground as CNA #3 pushed him. At 9:10 a.m. an unidentified housekeeping staff member was assisting an unidentified resident with transportation in their wheelchair through the facility hallway. One of the resident’s feet were situated on her foot pedals, while the other jutted between the foot pedals and pointed at the ground. IV. Staff interviewsCNA #1 was interviewed on 2/26/26 at 10:29 a.m. CNA #1 said she used foot pedals on residents’ wheelchairs when assisting them with transportation so the residents did not hit their toes or so their legs did not bend back while moving. CNA #1 said she received education on using foot pedals the month prior (January 2026) but said she was not sure why. CNA #2 was interviewed on 2/26/26 at 10:39 a.m. CNA #2 said when assisting residents with transportation in their wheelchairs, she applied foot pedals to the resident’s wheelchair and ensured their arms were tucked in while moving. CNA #2 said the nursing staff used foot pedals on the residents’ wheelchairs so the residents would not drag their feet while moving or potentially fall out of their wheelchairs. CNA #2 said she had received education on using foot pedals for residents using wheelchairs the month prior (January 2026) after a resident bumped their foot while being assisted in their wheelchair. Registered nurse (RN) #1 was interviewed on 2/26/26 at 10:54 a.m. RN #1 said facility staff needed to use foot pedals when assisting residents with transportation so they would not bump their feet or fall. RN #1 said the facility’s administration staff had done a lot of education on using foot pedals recently so all staff members, even kitchen and housekeeping staff, knew they needed to use foot pedals when assisting someone in a wheelchair. The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said facility staff should apply foot pedals to the resident’s wheelchair if the resident was being assisted with transportation. The DON said the facility had done education on the subject recently. The DON said for Resident #1’s incident on 12/24/25, the SSD had been assisting Resident #1 through a smaller door in the dining room. The DON said they did not believe Resident #1’s foot pedals were being used at the time of the incident, which was why they educated all staff on using foot pedals. The DON said Resident #1 had moved her foot during the transportation but was not sure if she had hit something on her wheelchair or had bumped into the doorway. The DON said Resident #1 had a hematoma to her left calf. The DON said Resident #1 had not complained of pain that day and was sent out to the emergency room that night (12/24/25), and had been discharged from the hospital shortly thereafter. The DON said she did not do a root cause analysis for the incident involving Resident #1. The DON said the IDT had decided to do education with staff regarding the use of foot pedals based on the information they had about the incident. The DON said she did not conduct any audits of wheelchair foot pedal usage following the incident, and said the use of foot pedals had not been identified as a concern prior to Resident #1’s incident on 12/24/25. The NHA was interviewed on 2/26/26 at 12:09 p.m. The NHA said the SSD had been escorting Resident #1 to bingo when her foot dropped and the resident hit her left leg. The NHA said the SSD asked if Resident #1 was okay, and the resident said she was and that she wanted to go play bingo. The NHA said the SSD alerted Resident #1’s nurse, and the nurse evaluated her and did not see any marks. The NHA said Resident #1 developed a hematoma to her left leg a few hours later and was sent out to the emergency room. The NHA said the administration had educated all facility staff members on proper wheelchair transportation so residents’ feet did not fall when they were being transported. The NHA said all staff members had been educated on the subject prior to their next shift, and had received additional education during an all-staff meeting on 1/15/26. The NHA said the documents in the facility investigation were the only information they had collected.-However, several staff members were observed during the survey process not using wheelchair pedals when assisting residents with transportation (see observations above).

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when handling residents’ meal trays and water pitchers;-Ensure staff handled residents’ drinkware and silverware in a sanitary manner; and,-Ensure staff donned (put on) face masks appropriately during a facility outbreak with COVID-19. Findings include:I. Failed to ensure staff performed appropriate hand hygiene when handling residents’ meal trays and water pitchersA. Professional referenceAccording to The Centers for Disease Control and Prevention’s (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 3/3/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, “Hand hygiene protects both healthcare personnel and patients.“Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics.“Clean your hands immediately before touching a patient and after touching a patient or the patient’s surroundings.”B. Facility policy and procedureThe Resident Dining Services policy and procedure, revised 4/29/25, was provided by the nursing home administrator (NHA) on 2/26/26 at 1:17 p.m. It read in pertinent part, “Staff involved in dining/food services will perform hand hygiene prior to distributing trays to the residents and when serving food to residents.”C. ObservationsOn 2/25/26 at 12:07 p.m. certified nurse aide (CNA) #4 was going from room to room collecting residents’ water pitchers, refilling them with ice water and returning the pitchers to the residents’ rooms. CNA #4 entered an unidentified resident’s room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 held the resident’s straw with his bare hand so the resident could sip from the water pitcher. CNA #4 then returned the resident’s water pitcher to her room, and continued going from room to room down the hallway refilling water pitchers. -CNA #4 did not perform hand hygiene between each resident’s room or after handling the resident’s straw. At 1:00 p.m. CNA #5 was assisting an unidentified resident in the dining room with putting her shirt back on. CNA #5 then went to look for the resident’s lunch tray and moved several other residents’ trays before finding the tray that belonged to the resident. CNA #5 assisted the resident with putting her shirt on again and oriented the resident to her meal tray. CNA #5 then continued passing out meal trays to other residents in the dining room.-However, CNA #5 did not perform hand hygiene after assisting the resident with putting her shirt on or between each resident’s meal tray. At 1:09 p.m. CNA #5 entered an unidentified resident’s room to deliver her room tray. CNA #5 oriented the resident to her meal tray and began to assist the resident with cutting up her food. CNA #5 then left the resident’s room, grabbed another room tray and entered another resident’s room.-However, CNA #5 did not perform hand hygiene between each resident when assisting with meal delivery. D. Staff interviewsThe infection preventionist (IP) was interviewed on 2/26/26 at 11:18 a.m. The IP said staff members should perform hand hygiene before handling room trays and after leaving residents’ rooms, especially if they assisted the residents with handling their food or opening packets. The director of nursing (DON) was interviewed on 2/26/26 at 11:32 a.m. The DON said staff members should perform hand hygiene between each tray when delivering meal trays. The DON said the facility had identified concerns in this area and had been doing audits of meal hand hygiene a few months ago. The DON said the facility had provided education to the nursing and dietary staff at the time the concerns were identified, and put signs on the meal delivery carts as a reminder to perform hand hygiene. The DON said the facility’s administration staff still saw occasional issues with hand hygiene during meals, but said the audits had decreased the rate of issues significantly. -However, observations conducted during the survey process revealed concerns with staff performing hand hygiene between tray deliveries and in filling water pitchers (see observations above). II. Failed to ensure staff handled residents’ drinkware and silverware in a sanitary mannerA. ObservationsOn 2/25/26 at 12:07 p.m. CNA #4 was going from room to room collecting residents’ water pitchers, refilling them with ice water, and returning the pitcher to the residents’ rooms. CNA #4 entered an unidentified resident’s room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 grabbed the outside of his mask and pulled his mask down to speak with the resident. Using the same bare hand, CNA #4 held the resident’s straw so she could sip from the water pitcher. CNA #4 then returned the resident’s water pitcher to her room, and continued going from room to room down the hallway refilling water pitchers. -CNA #4 did not perform hand hygiene before or after handling the resident’s straw or after handling his mask. On 2/26/26 at 9:13 a.m. CNA #3 began assisting an unidentified resident with eating breakfast. CNA #3 unwrapped the napkin around the resident’s silverware and held her fork and knife by the cutting surface and tines. CNA #3 grabbed the resident’s coffee mug by the rim of the mug and handed it to her. CNA #3 then began cutting up the resident’s food. At 9:16 a.m. CNA #3 grabbed the unidentified resident’s mug by the rim and pulled it closer to himself to add a packet of sugar to her coffee. CNA #3 then used the handle of the resident’s knife to stir her coffee. CNA #3 had previously used the knife to cut the resident’s food. B. Staff interviewsThe IP was interviewed on 2/26/26 at 11:18 a.m. The IP said staff members should not touch the area on silverware where a resident’s mouth would go. The IP said staff members should not grab mugs or cups by the top, and said it was not okay to grab areas where the resident’s mouth would then touch. The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said staff should not handle the rims of residents’ cups or the end of the residents’ silverware that the resident would then put into their mouth. III. Failed to ensure staff donned face masks appropriately during a facility outbreakA. Facility policy and procedureThe Universal Source Control policy and procedure, revised 7/7/25, was received from the NHA on 2/26/26 at 1:17 p.m. It read in pertinent part, “Source control is the use of respirators or well-fitting face masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing or coughing.“Source control is recommended for individuals in healthcare settings who reside or work on an area of the facility experiencing an outbreak of respiratory infection.”“Healthcare professionals should be instructed that if they must touch or adjust their facemask they should perform hand hygiene immediately before and after.”B. ObservationsOn 2/25/26 at 12:07 p.m. CNA #4 entered an unidentified resident’s room, collected her water pitcher and brought it to the resident to encourage her to drink. CNA #4 grabbed the outside of his mask and pulled his mask down to speak with the resident. CNA #4 bent down and put his face beside the resident’s ear while doing so. After speaking with her, CNA #4 pulled his mask back up and encouraged the resident to drink. CNA #4 repeated this process moments later.-CNA #4 did not perform hand hygiene after handling his mask, and his mask did not cover his mouth and nose while in close contact with the resident. On 2/26/26 at 9:09 a.m. CNA #3 was in the dining room assisting residents with getting to their seats for the breakfast meal service. CNA #3 was wearing a surgical mask which was pulled down below his mouth. At 9:13 a.m. CNA #3 sat next to an unidentified resident and began assisting her with eating. CNA #3 continued to wear his surgical mask under his mouth. C. Staff interviewsThe IP was interviewed on 2/26/26 at 11:18 a.m. The IP said the facility was in outbreak status at the moment for COVID-19, but did not have any current cases of COVID-19 in the resident population. The IP said their most recent positive case was a staff member who had tested positive for COVID-19 the week prior (week of 2/16/26). The IP said the facility’s last day of outbreak status would be on 2/28/26. The IP said he had been enforcing surgical mask use for staff members, especially when they were in resident care areas. The IP said staff should wear their masks so they covered both their nose and their mouth. The IP said he had to provide spot-education to a few employees the day prior (2/25/26) to ensure their noses were covered by their masks. The IP said staff members should perform hand hygiene after handling the outside of their mask, as the mask was technically considered to be a contaminated surface. The DON was interviewed on 2/26/26 at 11:32 a.m. The DON said staff members should be wearing face masks in the facility hallways and resident care areas during the facility’s COVID-19 outbreak. The DON said staff members’ masks should cover both their nose and their mouth. The DON said if a resident was having difficulty communicating and the staff member needed to lower their mask to communicate with them, the staff member should avoid pulling their mask down in a hallway. The DON said the staff member should try to bring the resident to a room or office to facilitate communication.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5.15.9 The right to be free from mental and physical abuse and from physical and chemical restraints, except those restraints initiated through the judgment of professional staff for a specified and limited period of time or on the written authorization of a practitioner. 15.15 The right to be treated courteously, fairly and with the fullest measure of dignity and to receive a written statement of the services provided by the facility, including those required to be offered on an as-needed basis.

A complaint survey, prompted by #CO39819 was conducted on 5/8/25. No deficiencies were cited.

A revisit survey was completed on 10/14/24 for all previous deficiencies cited on 8/7/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 10/14/24 for all previous deficiencies cited on 8/7/24. The facility is in compliance with all regulations surveyed.

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

A survey prompted by complaint #CO37226 was completed on 8/5/24 to 8/7/24. Two 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 one (#3) of three residents reviewed for abuse out of 13 sample residents. Resident #3 was admitted to the facility on 1/24/24 with a diagnosis of constipation. On 6/5/24, in the early morning hours, Resident #3 called for assistance. The resident told the staff that she was constipated and needed assistance or she wanted to go to the hospital. Registered nurse (RN) #1 came to her room. Certified nurse aide (CNA) #5 assisted Resident #3 to roll over. RN #1 began to insert a suppository and felt a hard stool in the resident's rectum. As RN #1 removed the stool from Resident #3's rectum, the resident was crying and yelling in pain and asking RN #1 to stop. However, RN #1 continued to proceed with the removal of the stool, while the resident was crying in pain, which caused mental anguish, emotional distress and fear for Resident #3. Additionally, the facility failed to document any information related to Resident #3's fecal impaction and the procedure that occurred in Resident #3's electronic medical record (EMR). Findings include:I. Professional referencesAccording to Setya A, Mathew G, Cagir B. (2023). Fecal Impaction. National Institutes of Health, retrieved on 8/6/24 from https://www.ncbi.nlm.nih.gov/books/NBK448094/, "Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The treatment options are the rectal administration of stool softening agents, usually enemas or suppositories or a digital evacuation of the impacted fecal mass. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger."Treas, L.S., Barnett, K.L., & Smith, M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), pages 2087-2090, retrieved on 8/6/24, read in pertinent part, "Position patient on left side which helps with medication retention because the descending colon is on the left side, it also helps relax the external anal sphincter (rectum). "The patient should not experience pain during the administration of a suppository, but they will feel pressure. Encourage deep breathing to aid in relaxation of the sphincter. Pushing a suppository through a constricted sphincter causes discomfort." II. Facility policy and procedureThe Abuse and Neglect policy and procedure, dated August 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 9:11 a.m. It read in pertinent part, "Nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. It is the policy and practice of this facility that all residents will be protected from all types of abuse. Prohibiting and preventing all forms of abuse. Identifying what constitutes abuse. Reporting abuse."III. Physical abuse by RN #1 toward Resident #3 on 6/4/24The 6/5/24 facility investigation was received from the nursing home administrator (NHA) on 8/6/24 at 12:45 p.m. The investigation was related to an allegation of sexual abuse on 6/4/24. Resident #3 was interviewed by the facility on 6/5/24 at 4:00 p.m. Resident #3 said she had been feeling constipated and had requested a suppository. Resident #3 said RN #1 had inserted more than three fingers inside her rectum, moving them around, during the medication administration. Resident #3 told RN #1 that it was hurting and to stop, but RN #1 did not stop. Resident #3 said she was told by RN #1 not to push her call light again after the incident. Resident #3 said she did not feel safe in the facility. The roommate of Resident #3 was interviewed by the facility on 6/5/24 at 9:15 a.m. The roommate reported that RN #1 said she had come off of herbreak to deal with Resident #3. The roommate said Resident #3 had repeatedly yelled for RN #1 to stop. The roommate said RN #1 had hurt Resident #3 and she had heard her scream. The roommate said she had begun to pray for Resident #3. RN #1 was interviewed by the facility on 6/5/24 at 11:15 a.m. RN #1 said she administered a suppository after digitally removing stool from the Resident #3's rectum. RN #1 said the care only lasted 15 to 20 seconds. RN#1 said Resident #3 never told her to stop. The facility unsubstantiated Resident #3's sexual abuse related to the resident's emergency department (ED) visit had not noted trauma to the resident's rectal area.-However, according to the ED visit documentation, the resident's rectum was mildly red (see record review below). IV. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/24/24 and discharged to home on 6/7/24. According to the June 2024 computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The 4/24/24 facility assessment revealed the resident was cognitively intact. The facility assessment documented the resident was receiving renal dialysis. V. Resident's representative interviewThe resident's representative was interviewed on 8/7/24 at 12:55 p.m. The representative said Resident #3 resided at the facility, until she moved her from the facility on 6/7/24. She said her mother had experienced a traumatic event at the facility. She said her mother had a history of constipation. She said Resident #3's mother had died at an early age of a bowel obstruction and so Resident #3 was very cautious about her bowels. She said Resident #3 told her she was held down while RN #1 gave her a suppository. She said Resident #3 was crying out to stop and RN #1 did not stop. She said the resident was afraid to stay in the facility. The resident's representative said Resident #3 was a religious woman and she felt she was rectally assaulted to the extent that she continued to have nightmares about the abuse. She said the resident was humiliated and embarrassed and that was why she did not report the abuse the night the incident occurred. She said Resident #3 told the social worker at the dialysis center of the abuse. The representative said the dialysis center social worker (DSW) reported the incident to adult protective services. VI. Record ReviewThe admission record dated 1/24/24 revealed Resident #3 admitted to the facility with a medical diagnosis of a history of constipation. A 6/5/24 emergency department report for Resident #3 documented there was a small external hemorrhoid at the 11 o'clock position of the resident's rectum that was not bleeding and there were no overt tears, trauma, bleeding or bruising. The note documented the rectum did not appear to be irritated but was mildly red inside. A 6/5/24 facility nursing progress note documented a facility RN got a report from the emergency department that Resident #3 was alright and did not have bleeding or tears from the rectum. Another 6/5/24 facility nursing progress note documented Resident #3 had come back from the emergency department and was hungry. The 6/6/24 nurse practitioner note documented the nurse practitioner followed-up regarding the resident's sexual assault allegation. The note said the resident voiced to the nurse practitioner that she was constipated and the nurse forcefully digitally stimulated her. The note documented the resident was seen at the hospital and no evidence of trauma was noted on the exam. The note documented an investigation of the incident was in progress with nursing staff. A review of the resident's electronic medical record (EMR) did not reveal other documentation regarding the procedure that was done on 6/5/24 that prompted the resident to go to the emergency department, the allegation made, or any psychosocial harm on 6/5/24. VII. Staff interviewsRN #1 was interviewed on 8/6/24 at 7:24 p.m. RN #1 said Resident #3 had requested a suppository (laxative). RN #1 said she entered Resident #3's room with CNA #5 to administer the suppository. RN #1 said she had explained the need for digital disimpaction (procedure of removing stool from the rectum with the index finger) to Resident #3. RN #1 said the resident was educated that the stool needed to be removed for the suppository to work properly. RN #1 said she had heard the resident moaning as stool was removed from the rectum. RN #1 said the resident did say to stop, but it had been after the disimpaction and after her finger had already entered the rectum to administer the suppository. RN #1 then said she had never heard the resident say to stop. RN #1 said after the event she had heard from others that the resident had said to stop. RN #1 said the resident may have said stop, but she did not hear it until she was done. RN #1 said she may have forgotten to chart the administration of the suppository. Certified nurse aide (CNA) #5 was interviewed on 8/6/24 at 7:24 p.m. CNA #5 said Resident #3 had complained of constipation and had been turning her call light on every fifteen minutes asking for something to help her with her constipation. CNA #5 said Resident #3 had told her that the day shift nursing staff had not given her anything to relieve her of her constipation. CNA #5 said Resident #3 said she had been passing hard little balls of feces throughout the day and evening shifts. CNA #5 said she told RN #1 and that it took her a while to come into Resident #3's room to give her the suppository. CNA #5 said that Resident #3 understood the procedure. CNA #5 said once RN #1 came in to give the suppository, she helped roll Resident #3 onto her right side and held Resident #3's hand with her right hand and had her left hand on Resident #3's hip. CNA #5 said RN #1 did explain the procedure to her, that she needed to get the feces out for the suppository to work. CNA #5 said Resident #3 was crying and yelling for RN #1 to stop because the digging was painful. CNA #5 said RN #1 did not stop. CNA #5 said RN #1 was "really digging the bowel movement out" and RN #1 should have stopped when Resident #3 was yelling for her to stop. CNA #5 said she did not feel comfortable asking RN #1 to stop because she was a new CNA and also because RN #1 was the charge nurse on duty. A frequent visitor (FV) was interviewed on 8/7/24 at 9:24 a.m. She said she got a phone call from the resident's representative the morning of 6/5/24. The FV said the resident's representative told her Resident #3 had been receiving a suppository and was digitally probed to the point where it felt as if she had been sexually assaulted, so much so that the representative took her to the emergency department for a sexual assault examination. The FV said the resident's representative told her that Resident #3 was fearful and traumatized from the experience. The NHA and the director of nursing (DON) were interviewed together on 8/7/24 at 10:15 a.m. The DON said RN #1 should have applied lubrication to her gloved finger before she inserted her finger into Resident #3's rectum. The DON said RN #1 should have removed as much stool as required to administer the suppository. The DON said RN #1 should have stopped when told to stop by the resident. The DON said if a resident said stop, it was their right and it did not matter what care was being performed at the time. The DON said RN #1 should have stopped the procedure and provided education to the resident. She said RN #1 should have provided options (continuing with the disimpaction, stopping the procedure completely or calling a provider) and allowed the resident to decide how they proceeded. The DON said there should be documentation in the resident's EMR of the digital stool removal. The NHA said he was the abuse coordinator for the facility. The NHA said on 6/5/24 he was notified of a sexual abuse allegation by Resident #3's dialysis center. The NHA said after he had received a notification of sexual abuse, he contacted the DON and the regional director. The NHA said he did not remember who notified him. The NHA said he called the DON, the regional team, the ombudsman and the police. He said he then reported Resident #3's allegation of rape to the State Agency reporting site. The NHA said the investigation had begun immediately upon the facility's notification of the allegation. The NHA said RN #1 and CNA #5 were placed on administrative suspension for approximately five days during the investigation. The NHA read aloud the facility-conducted interview of Resident #3's roommate. The NHA said he had seen and read the interview before. The NHA said his first instinct would have been that there had been potential abuse. The dialysis center social worker (DSW) returned a phone call (placed during the survey) and was interviewed on 8/15/24 at 9:33 a.m. The DSW said on 6/5/24 Resident #3 arrived for dialysis appearing disheveled, tearful and her demeanor was out of character. The DSW said as the dialysis staff attempted to calm down Resident #3, she had begun to shake and had cried. The DSW said Resident #3 told the dialysis staff that a CNA held her down and a nurse forced a suppository inside her. The DSW said Resident #3 said she had told them to "stop, never mind, she did not want the suppository anymore, she just wanted to go to sleep." Resident #3 said the nurse did not stop. The DSW said Resident #3 used the words, "fearful, scared, and retaliation."

Based on record review and interviews the facility failed to ensure residents were treated with dignity and respect for three (#1, #12 and #9) of four residents out of 13 sample residents. Resident #1, who was non-weight bearing on his right leg due to a broken ankle required staff assistance to transfer from his wheelchair to and from the toilet. According to Resident #1, certified nurse aide (CNA) #1 was rude to him when he requested assistance with transferring to the toilet and told him he could use the bathroom himself. CNA #1 did assist the resident onto the toilet, however when Resident #1 requested assistance to transfer back to his wheelchair after using the bathroom, CNA #1 entered the resident's room and refused to assist him. CNA #1 informed the resident "we are not doing this again" and left the resident's room without assisting him. Resident #1 said he had to remain on the toilet until another CNA responded to his call light and came to assist him from the toilet back to his wheelchair. Resident #1 said the experience made him feel humiliated. On another occasion, Resident #1 said CNA #1 approached him in the dining room and when he did not respond to her, she laughed at him and rudely said "What's the matter with you, you don't have a mouth now" and "That's right, you're mad at me." Resident #1 again said the experience with CNA #1 humiliated him. Resident #1 said CNA #1 entered his room to answer his call light and he asked her to leave because he did not want to receive care from her due to his past experiences with her. The resident said he told CNA #1 he was going to report her behavior to the nursing home administrator (NHA) and CNA #1 responded by saying "I've already told therapy about you." Resident #1 said her statement made him feel scared. Resident #1 said he was afraid other staff would treat him poorly if CNA #1 was bad-mouthing him. Resident #1 said he reported CNA #1's behavior to the NHA, however, he said nothing had changed and CNA #1 now snickered at him and heckled him in the hallway when he passed by. He said she sometimes stood outside his room and stared at him or laughed at him. He said he had started to keep his door closed when CNA #1 was working but he preferred to have his door open. Due to the facility's failure to ensure Resident #1 was treated with respect and dignity by CNA #1 and the facility's failure to follow up effectively with CNA #1 to ensure CNA #1's behaviors toward Resident #1 were corrected, Resident #1 suffered psychosocial harm due to feelings of humiliation from the treatment he received and fear that other staff would also treat him poorly. Additionally, Resident #12 and Resident #9 reported they were not treated with dignity and respect by staff on occasion. The residents felt staff were rude, degrading and did not care for them. Findings include:I. Facility policy and procedureThe Dignity policy and procedure, dated September 2023, was provided by the nursing home administrator (NHA) on 8/7/24 at 3:12 p.m. It read in pertinent part, "Each resident has the right to be treated with dignity and respect. Interactions with staff must focus on maintaining and enhancing the resident's self-esteem and self-worth, as well as honor and value their input. The facility must protect and promote the rights of the resident."II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 6/12/24. According to the August 2024 computerized physician orders (CPO), diagnoses included fracture of upper and lower end of right fibula, closed fracture with routine healing, lack of coordination, muscle weakness, difficulty in walking and pressure ulcer of the right ankle. The 6/17/24 facility assessment revealed the resident was cognitively intact. The resident was dependent on staff assistance for toilet transfers. The assessment revealed the resident was strictly non-weight bearing on his right extremity related to his fractured fibula. B. Resident interviewResident #1 was interviewed on 8/5/24 at 4:31 p.m. Resident #1 said he was admitted to the facility for rehabilitation after breaking his ankle. He said he was unable to bear any weight on his right ankle related to the surgery. He said because of his surgery, he needed staff assistance to get on and off of the elevated commode that was placed over the toilet in his bathroom. Resident #1 said he had used his call light to request assistance transferring from his wheelchair onto the commode. He said CNA #1 was rude and refused to help him. Resident #1 said CNA #1 told him he could go to the bathroom by himself. Resident #1 said he told her he could not because he was non-weight bearing and weak. He said CNA #1 told him that it was (expletive language) that he needed assistance. Resident #1 said while he was seated on the commode after having a bowel movement he used the call light to request assistance to transfer back to his wheelchair. Resident #1 said CNA #1 entered his bathroom in response to the call light, said "we're not doing this again" and exited the room. He said she left him seated in the bathroom soiled. He said he felt humiliated. Resident #1 said he had to continue to push the call light until another CNA came to the bathroom to assist him. Resident #1 said he was approached on another occasion in the dining room by CNA #1. He said she was rude and hateful toward him. Resident #1 said CNA #1 aske him "What's the matter with you, you don't have a mouth now?" He said she then laughed at him and said "That's right, you're mad at me" and walked away. Resident #1 said again he felt humiliated. Resident #1 said he no longer wanted to receive care from CNA #1. He said CNA #1 came into his room another time, after he pushed the call light. He said he asked her to leave and he would wait for another CNA or nurse to come assist him. He said CNA #1 argued with him about leaving. Resident #1 said he told CNA #1 that he was going to report her behavior to the NHA. Resident #1 said, in response, she told him "I've already told therapy about you." He said CNA #1's statement made him feel scared. Resident #1 said he was afraid other staff would treat him poorly if CNA #1 was bad-mouthing him. Resident #1 said he reported CNA #1 to the NHA, however, he said her behavior toward him had not changed. Resident #1 said after he reported CNA #1's behavior to the NHA, she began to "bully" him in the hallways. He said she snickered and heckled him while passing him in the hallways. Resident #1 said CNA #1 had begun to stand outside his doorway and stared or laughed at him. He said he had begun to keep his door shut during her scheduled shifts, however, he said he preferred for his door to remain open. C. Record ReviewReview of Resident #1's August 2024 CPO revealed a physician's order that indicated the resident was to 7/26/24 continue strict non-weight bearing to his right lower extremity for four more weeks. D. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 8/5/24 at 5:35 p.m. The NHA said he remembered receiving a complaint from Resident #1 about CNA #1. The NHA said Resident #1 had been upset with CNA #1 because she had been rude. The NHA said the resident was unable to express an exact allegation and had reported the complaint to him in the hallway. The NHA said he had not spoken with CNA #1 because he had been unsure exactly what to speak to her about. The DON said she had spoken with CNA #1. The DON said Resident #1 had reported that CNA #1 had been rude to him on a Friday, however, she said CNA #1 did not work on Fridays. The DON said when she approached CNA #1 about Resident #1's complaint, CNA #1 told her she had no issues with the resident. The DON said it may be easy for a resident to become confused as to the day of the week. The NHA said CNA #1 had been told not to provide cares to Resident #1 unless it was necessary, such as when another staff member could not provide assistance to the resident. The NHA said the facility did not change the hallway assignment for CNA #1 so she would no longer be providing care for Resident #1 because she had been told not to answer his call light. The NHA said he did not investigate or file a grievance on Resident #1's behalf because it had appeared to be a customer service issue.-However, per Resident #1's interview, he continued to have problems with CNA #1 (see resident interview above). The NHA was interviewed again on 8/7/24 at 10:15 a.m. The NHA said a Resident's Rights training had been attended by every employee during their orientation and then annually thereafter. III. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on 3/23/2020. According to the August 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), dependence on oxygen, weakness and difficulty in walking. The 5/22/24 facility assessment revealed the resident was cognitively intact. The resident required assistance with activities of daily living (ADL). B. Resident interviewResident #12 was interviewed on 8/7/24 at 2:00 p.m. Resident #12 said most staff treated her with dignity and respect. However, she said today (8/7/24) the bath aide (CNA #7) was an (expletive language) to her. She said CNA #7 refused to put lotion or ted hose (compression stockings) back on her after her shower. She said CNA #7 told her she did not have time. She said this morning (8/7/24) her breakfast tray came late and her coffee was cold. She said this happened frequently so she asked when her tray was picked up to have two cups of hot coffee brought to her. However, Resident #12 said, this morning (8/7/24) CNA #8 told her she did not have time to go get the hot coffee so she would have to wait until lunch. Resident #8 said it made her feel like she was not important and it was degrading to her. She said she tried not to bother the staff unless she needed to. She said she had complained in the past, but it did not do any good. Resident #12 said the CNAs gossiped about residents who complained. C. Staff interviewThe NHA was interviewed on 8/7/24 at 2:30 p.m. The NHA said he was informed of the above interview with Resident #12. He said the resident should have received the care she requested. He said he would investigate the situation and go talk to Resident #12. He said the facility staff could use some training on customer service. He said he would talk to the dietary manager about the coffee being cold. IV. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 4/25/24. According to the August 2024 CPO, diagnoses included COPD, type II diabetes mellitus with neuropathy, heart failure, neurocognitive disorder with Lewy bodies and hemiplegia and hemiparesis (weakness to one side of the body). The 5/10/24 facility assessment revealed the resident had moderate cognitive impairment. B. Resident interviewResident #9 was interviewed on 8/6/24 at 9:05 a.m. Resident #9 said licensed practical nurse (LPN) #1 did not treat her with respect and dignity. She said LPN #1 was rude and would not listen to her. She said when she had chest pain LPN #1 would not believe her. Resident #9 said LPN #1 just did not care for her. She said she tried to avoid her when she was the nurse for the day. C. Staff interviewThe social service assistant (SSA) was interviewed on 8/6/24 at 9:30 a.m. The SSA spoke with Resident #9 about her concern and told the resident she would investigate. The SSA said the staff were to treat residents with respect. She said Resident #9 was able to make her needs known. She said she would check in with the resident periodically to see how she was doing.

A complaint survey, prompted by #CO37004, #CO37009 and #CO37010 was conducted on 8/5/24 to 8/7/24. Five deficiencies were cited.

Based on record review and interviews the facility failed to ensure residents were treated with dignity and respect for three (#1, #12 and #9) of four residents out of 13 sample residents. Resident #1, who was non-weight bearing on his right leg due to a broken ankle required staff assistance to transfer from his wheelchair to and from the toilet. According to Resident #1, certified nurse aide (CNA) #1 was rude to him when he requested assistance with transferring to the toilet and told him he could use the bathroom himself. CNA #1 did assist the resident onto the toilet, however when Resident #1 requested assistance to transfer back to his wheelchair after using the bathroom, CNA #1 entered the resident's room and refused to assist him. CNA #1 informed the resident "we are not doing this again" and left the resident's room without assisting him. Resident #1 said he had to remain on the toilet until another CNA responded to his call light and came to assist him from the toilet back to his wheelchair. Resident #1 said the experience made him feel humiliated. On another occasion, Resident #1 said CNA #1 approached him in the dining room and when he did not respond to her, she laughed at him and rudely said "What's the matter with you, you don't have a mouth now" and "That's right, you're mad at me." Resident #1 again said the experience with CNA #1 humiliated him. Resident #1 said CNA #1 entered his room to answer his call light and he asked her to leave because he did not want to receive care from her due to his past experiences with her. The resident said he told CNA #1 he was going to report her behavior to the nursing home administrator (NHA) and CNA #1 responded by saying "I've already told therapy about you." Resident #1 said her statement made him feel scared. Resident #1 said he was afraid other staff would treat him poorly if CNA #1 was bad-mouthing him. Resident #1 said he reported CNA #1's behavior to the NHA, however, he said nothing had changed and CNA #1 now snickered at him and heckled him in the hallway when he passed by. He said she sometimes stood outside his room and stared at him or laughed at him. He said he had started to keep his door closed when CNA #1 was working but he preferred to have his door open. Due to the facility's failure to ensure Resident #1 was treated with respect and dignity by CNA #1 and the facility's failure to follow up effectively with CNA #1 to ensure CNA #1's behaviors toward Resident #1 were corrected, Resident #1 suffered psychosocial harm due to feelings of humiliation from the treatment he received and fear that other staff would also treat him poorly. Additionally, Resident #12 and Resident #9 reported they were not treated with dignity and respect by staff on occasion. The residents felt staff were rude, degrading and did not care for them. Findings include:I. Facility policy and procedureThe Dignity policy and procedure, dated September 2023, was provided by the nursing home administrator (NHA) on 8/7/24 at 3:12 p.m. It read in pertinent part, "Each resident has the right to be treated with dignity and respect. Interactions with staff must focus on maintaining and enhancing the resident's self-esteem and self-worth, as well as honor and value their input. The facility must protect and promote the rights of the resident."II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 6/12/24. According to the August 2024 computerized physician orders (CPO), diagnoses included fracture of upper and lower end of right fibula, closed fracture with routine healing, lack of coordination, muscle weakness, difficulty in walking and pressure ulcer of the right ankle. The 6/17/24 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 resident was dependent on staff assistance for toilet transfers. The assessment revealed the resident was strictly non-weight bearing on his rightextremity related to his fractured fibula. B. Resident interviewResident #1 was interviewed on 8/5/24 at 4:31 p.m. Resident #1 said he was admitted to the facility for rehabilitation after breaking his ankle. He said he was unable to bear any weight on his right ankle related to the surgery. He said because of his surgery, he needed staff assistance to get on and off of the elevated commode that was placed over the toilet in his bathroom. Resident #1 said he had used his call light to request assistance transferring from his wheelchair onto the commode. He said CNA #1 was rude and refused to help him. Resident #1 said CNA #1 told him he could go to the bathroom by himself. Resident #1 said he told her he could not because he was non-weight bearing and weak. He said CNA #1 told him that it was (expletive language) that he needed assistance. Resident #1 said while he was seated on the commode after having a bowel movement he used the call light to request assistance to transfer back to his wheelchair. Resident #1 said CNA #1 entered his bathroom in response to the call light, said "we're not doing this again" and exited the room. He said she left him seated in the bathroom soiled. He said he felt humiliated. Resident #1 said he had to continue to push the call light until another CNA came to the bathroom to assist him. Resident #1 said he was approached on another occasion in the dining room by CNA #1. He said she was rude and hateful toward him. Resident #1 said CNA #1 aske him "What's the matter with you, you don't have a mouth now?" He said she then laughed at him and said "That's right, you're mad at me" and walked away. Resident #1 said again he felt humiliated. Resident #1 said he no longer wanted to receive care from CNA #1. He said CNA #1 came into his room another time, after he pushed the call light. He said he asked her to leave and he would wait for another CNA or nurse to come assist him. He said CNA #1 argued with him about leaving. Resident #1 said he told CNA #1 that he was going to report her behavior to the NHA. Resident #1 said, in response, she told him "I've already told therapy about you." He said CNA #1's statement made him feel scared. Resident #1 said he was afraid other staff would treat him poorly if CNA #1 was bad-mouthing him. Resident #1 said he reported CNA #1 to the NHA, however, he said her behavior toward him had not changed. Resident #1 said after he reported CNA #1's behavior to the NHA, she began to "bully" him in the hallways. He said she snickered and heckled him while passing him in the hallways. Resident #1 said CNA #1 had begun to stand outside his doorway and stared or laughed at him. He said he had begun to keep his door shut during her scheduled shifts, however, he said he preferred for his door to remain open. C. Record ReviewReview of Resident #1's August 2024 CPO revealed a physician's order that indicated the resident was to 7/26/24 continue strict non-weight bearing to his right lower extremity for four more weeks. D. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 8/5/24 at 5:35 p.m. The NHA said he remembered receiving a complaint from Resident #1 about CNA #1. The NHA said Resident #1 had been upset with CNA #1 because she had been rude. The NHA said the resident was unable to express an exact allegation and had reported the complaint to him in the hallway. The NHA said he had not spoken with CNA #1 because he had been unsure exactly what to speak to her about. The DON said she had spoken with CNA #1. The DON said Resident #1 had reported that CNA #1 had been rude to him on a Friday, however, she said CNA #1 did not work on Fridays. The DON said when she approached CNA #1 about Resident #1's complaint, CNA #1 told her she had no issues with the resident. The DON said it may be easy for a resident to become confused as to the day of the week. The NHA said CNA #1 had been told not to provide cares to Resident #1 unless it was necessary, such as when another staff member could not provide assistance to the resident. The NHA said the facility did not change the hallway assignment for CNA #1 so she would no longer be providing care for Resident #1 because she had been told not to answer his call light. The NHA said he did not investigate or file a grievance on Resident #1's behalf because it had appeared to be a customer service issue.-However, per Resident #1's interview, he continued to have problems with CNA #1 (see resident interview above). The NHA was interviewed again on 8/7/24 at 10:15 a.m. The NHA said a Resident's Rights training had been attended by every employee during their orientation and then annually thereafter. III. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on 3/23/2020. According to the August 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), dependence on oxygen, weakness and difficulty in walking. The 5/22/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required assistance with activities of daily living (ADL). B. Resident interviewResident #12 was interviewed on 8/7/24 at 2:00 p.m. Resident #12 said most staff treated her with dignity and respect. However, she said today (8/7/24) the bath aide (CNA #7) was an (expletive language) to her. She said CNA #7 refused to put lotion or ted hose (compression stockings) back on her after her shower. She said CNA #7 told her she did not have time. She said this morning (8/7/24) her breakfast tray came late and her coffee was cold. She said this happened frequently so she asked when her tray was picked up to have two cups of hot coffee brought to her. However, Resident #12 said, this morning (8/7/24) CNA #8 told her she did not have time to go get the hot coffee so she would have to wait until lunch. Resident #8 said it made her feel like she was not important and it was degrading to her. She said she tried not to bother the staff unless she needed to. She said she had complained in the past, but it did not do any good. Resident #12 said the CNAs gossiped about residents who complained. C. Staff interviewThe NHA was interviewed on 8/7/24 at 2:30 p.m. The NHA said he was informed of the above interview with Resident #12. He said the resident should have received the care she requested. He said he would investigate the situation and go talk to Resident #12. He said the facility staff could use some training on customer service. He said he would talk to the dietary manager about the coffee being cold. IV. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 4/25/24. According to the August 2024 CPO, diagnoses included COPD, type II diabetes mellitus with neuropathy, heart failure, neurocognitive disorder with Lewy bodies and hemiplegia and hemiparesis (weakness to one side of the body). The 5/10/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. B. Resident interviewResident #9 was interviewed on 8/6/24 at 9:05 a.m. Resident #9 said licensed practical nurse (LPN) #1 did not treat her with respect and dignity. She said LPN #1 was rude and would not listen to her. She said when she had chest pain LPN #1 would not believe her. Resident #9 said LPN #1 just did not care for her. She said she tried to avoid her when she was the nurse for the day. C. Staff interviewThe social service assistant (SSA) was interviewed on 8/6/24 at 9:30 a.m. The SSA spoke with Resident #9 about her concern and told the resident she would investigate. The SSA said the staff were to treat residents with respect. She said Resident #9 was able to make her needs known. She said she would check in with the resident periodically to see how she was doing.

Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for one (#3) of three residents reviewed for abuse out of 13 sample residents. Resident #3 was admitted to the facility on 1/24/24 with a diagnosis of constipation. On 6/5/24, in the early morning hours, Resident #3 called for assistance. The resident told the staff that she was constipated and needed assistance or she wanted to go to the hospital. Registered nurse (RN) #1 came to her room. Certified nurse aide (CNA) #5 assisted Resident #3 to roll over. RN #1 began to insert a suppository and felt a hard stool in the resident's rectum. As RN #1 removed the stool from Resident #3's rectum, the resident was crying and yelling in pain and asking RN #1 to stop. However, RN #1 continued to proceed with the removal of the stool, while the resident was crying in pain, which caused mental anguish, emotional distress and fear for Resident #3. Additionally, the facility failed to document any information related to Resident #3's fecal impaction and the procedure that occurred in Resident #3's electronic medical record (EMR). Findings include:I. Professional referencesAccording to Setya A, Mathew G, Cagir B. (2023). Fecal Impaction. National Institutes of Health, retrieved on 8/6/24 from https://www.ncbi.nlm.nih.gov/books/NBK448094/, "Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The treatment options are the rectal administration of stool softening agents, usually enemas or suppositories or a digital evacuation of the impacted fecal mass. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger."Treas, L.S., Barnett, K.L., & Smith, M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), pages 2087-2090, retrieved on 8/6/24, read in pertinent part, "Position patient on left side which helps with medication retention because the descending colon is on the left side, it also helps relax the external anal sphincter (rectum). "The patient should not experience pain during the administration of a suppository, but they will feel pressure. Encourage deep breathing to aid in relaxation of the sphincter. Pushing a suppository through a constricted sphincter causes discomfort." II. Facility policy and procedureThe Abuse and Neglect policy and procedure, dated August 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 9:11 a.m. It read in pertinent part, "Nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. It is the policy and practice of this facility that all residents will be protected from all types of abuse. Prohibiting and preventing all forms of abuse. Identifying what constitutes abuse. Reporting abuse."III. Physical abuse by RN #1 toward Resident #3 on 6/4/24The 6/5/24 facility investigation was received from the nursing home administrator (NHA) on 8/6/24 at 12:45 p.m. The investigation was related to an allegation of sexual abuse on 6/4/24. Resident #3 was interviewed by the facility on 6/5/24 at 4:00 p.m. Resident #3 said she had been feeling constipated and had requested a suppository. Resident #3 said RN #1 had inserted more than three fingers inside her rectum, moving them around, during the medication administration. Resident #3 told RN #1 that it was hurting and to stop, but RN #1 did not stop. Resident #3 said she was told by RN #1 not to push her call light again after the incident. Resident #3 said she did not feel safe in the facility. The roommate of Resident #3 was interviewed by the facility on 6/5/24 at 9:15 a.m. The roommate reported that RN #1 said she had come off of her break to deal with Resident #3. The roommate said Resident #3 had repeatedly yelled for RN #1 to stop. The roommate said RN #1 had hurt Resident #3 and she had heard her scream. The roommate said she had begun to pray for Resident #3. RN #1 was interviewed by the facility on 6/5/24 at 11:15 a.m. RN #1 said she administered a suppository after digitally removing stool from the Resident #3's rectum. RN #1 said the care only lasted 15 to 20 seconds. RN#1 said Resident #3 never told her to stop. The facility unsubstantiated Resident #3's sexual abuse related to the resident's emergency department (ED) visit had not noted trauma to the resident's rectal area.-However, according to the ED visit documentation, the resident's rectum was mildly red (see record review below). IV. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/24/24 and discharged to home on 6/7/24. According to the June 2024 computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The 4/24/24 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 MDS assessment documented the resident was receiving renal dialysis. V. Resident's representative interviewThe resident's representative was interviewed on 8/7/24 at 12:55 p.m. The representative said Resident #3 resided at the facility, until she moved her from the facility on 6/7/24. She said her mother had experienced a traumatic event at the facility. She said her mother had a history of constipation. She said Resident #3's mother had died at an early age of a bowel obstruction and so Resident #3 was very cautious about her bowels. She said Resident #3 told her she was held down while RN #1 gave her a suppository. She said Resident #3 was crying out to stop and RN #1 did not stop. She said the resident was afraid to stay in the facility. The resident's representative said Resident #3 was a religious woman and she felt she was rectally assaulted to the extent that she continued to have nightmares about the abuse. She said the resident was humiliated and embarrassed and that was why she did not report the abuse the night the incident occurred. She said Resident #3 told the social worker at the dialysis center of the abuse. The representative said the dialysis center social worker (DSW) reported the incident to adult protective services. VI. Record ReviewThe admission record dated 1/24/24 revealed Resident #3 admitted to the facility with a medical diagnosis of a history of constipation. A 6/5/24 emergency department report for Resident #3 documented there was a small external hemorrhoid at the 11 o'clock position of the resident's rectum that was not bleeding and there were no overt tears, trauma, bleeding or bruising. The note documented the rectum did not appear to be irritated but was mildly red inside. A 6/5/24 facility nursing progress note documented a facility RN got a report from the emergency department that Resident #3 was alright and did not have bleeding or tears from the rectum. Another 6/5/24 facility nursing progress note documented Resident #3 had come back from the emergency department and was hungry. The 6/6/24 nurse practitioner note documented the nurse practitioner followed-up regarding the resident's sexual assault allegation. The note said the resident voiced to the nurse practitioner that she was constipated and the nurse forcefully digitally stimulated her. The note documented the resident was seen at the hospital and no evidence of trauma was noted on the exam. The note documented an investigation of the incident was in progress with nursing staff. A review of the resident's EMR did not reveal other documentation regarding the procedure that was done on 6/5/24 that prompted the resident to go to the emergency department, the allegation made, or any psychosocial harm on 6/5/24. VII. Staff interviewsRN #1 was interviewed on 8/6/24 at 7:24 p.m. RN #1 said Resident #3 had requested a suppository (laxative). RN #1 said she entered Resident #3's room with CNA #5 to administer the suppository. RN #1 said she had explained the need for digital disimpaction (procedure of removing stool from the rectum with the index finger) to Resident #3. RN #1 said the resident was educated that the stool needed to be removed for the suppository to work properly. RN #1 said she had heard the resident moaning as stool was removed from the rectum. RN #1 said the resident did say to stop, but it had been after the disimpaction and after her finger had already entered the rectum to administer the suppository. RN #1 then said she had never heard the resident say to stop. RN #1 said after the event she had heard from others that the resident had said to stop. RN #1 said the resident may have said stop, but she did not hear it until she was done. RN #1 said she may have forgotten to chart the administration of the suppository. Certified nurse aide (CNA) #5 was interviewed on 8/6/24 at 7:24 p.m. CNA #5 said Resident #3 had complained of constipation and had been turning her call light on every fifteen minutes asking for something to help her with her constipation. CNA #5 said Resident #3 had told her that the day shift nursing staff had not given her anything to relieve her of her constipation. CNA #5 said Resident #3 said she had been passing hard little balls of feces throughout the day and evening shifts. CNA #5 said she told RN #1 and that it took her a while to come into Resident #3's room to give her the suppository. CNA #5 said that Resident #3 understood the procedure. CNA #5 said once RN #1 came in to give the suppository, she helped roll Resident #3 onto her right side and held Resident #3's hand with her right hand and had her left hand on Resident #3's hip. CNA #5 said RN #1 did explain the procedure to her, that she needed to get the feces out for the suppository to work. CNA #5 said Resident #3 was crying and yelling for RN #1 to stop because the digging was painful. CNA #5 said RN #1 did not stop. CNA #5 said RN #1 was "really digging the bowel movement out" and RN #1 should have stopped when Resident #3 was yelling for her to stop. CNA #5 said she did not feel comfortable asking RN #1 to stop because she was a new CNA and also because RN #1 was the charge nurse on duty. A frequent visitor (FV) was interviewed on 8/7/24 at 9:24 a.m. She said she got a phone call from the resident's representative the morning of 6/5/24. The FV said the resident's representative told her Resident #3 had been receiving a suppository and was digitally probed to the point where it felt as if she had been sexually assaulted, so much so that the representative took her to the emergency department for a sexual assault examination. The FV said the resident's representative told her that Resident #3 was fearful and traumatized from the experience. The NHA and the director of nursing (DON) were interviewed together on 8/7/24 at 10:15 a.m. The DON said RN #1 should have applied lubrication to her gloved finger before she inserted her finger into Resident #3's rectum. The DON said RN #1 should have removed as much stool as required to administer the suppository. The DON said RN #1 should have stopped when told to stop by the resident. The DON said if a resident said stop, it was their right and it did not matter what care was being performed at the time. The DON said RN #1 should have stopped the procedure and provided education to the resident. She said RN #1 should have provided options (continuing with the disimpaction, stopping the procedure completely or calling a provider) and allowed the resident to decide how they proceeded. The DON said there should be documentation in the resident's electronic medical record (EMR) of the digital stool removal. The NHA said he was the abuse coordinator for the facility. The NHA said on 6/5/24 he was notified of a sexual abuse allegation by Resident #3's dialysis center. The NHA said after he had received a notification of sexual abuse, he contacted the DON and the regional director. The NHA said he did not remember who notified him. The NHA said he called the DON, the regional team, the ombudsman and the police. He said he then reported Resident #3's allegation of rape to the State Agency reporting site. The NHA said the investigation had begun immediately upon the facility's notification of the allegation. The NHA said RN #1 and CNA #5 were placed on administrative suspension for approximately five days during the investigation. The NHA read aloud the facility-conducted interview of Resident #3's roommate. The NHA said he had seen and read the interview before. The NHA said his first instinct would have been that there had been potential abuse. The dialysis center social worker (DSW) returned a phone call (placed during the survey) and was interviewed on 8/15/24 at 9:33 a.m. The DSW said on 6/5/24 Resident #3 arrived for dialysis appearing disheveled, tearful and her demeanor was out of character. The DSW said as the dialysis staff attempted to calm down Resident #3, she had begun to shake and had cried. The DSW said Resident #3 told the dialysis staff that a CNA held her down and a nurse forced a suppository inside her. The DSW said Resident #3 said she had told them to "stop, never mind, she did not want the suppository anymore, she just wanted to go to sleep." Resident #3 said the nurse did not stop. The DSW said Resident #3 used the words, "fearful, scared, and retaliation."

Based on record review and interviews, the facility failed to have evidence that all alleged abuse were thoroughly investigated for one (#3) of three residents reviewed for abuse of 13 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of abuse. Findings include:I. Facility policy and procedureThe Abuse and Neglect policy and procedure, dated August 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 9:11 a.m. It read in pertinent part, "The facility must develop and implement written policies and procedures to investigate any such allegations. Have evidence that all alleged allegations of abuse are thoroughly investigated."II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/24/24 and discharged to home on 6/7/24. According to the June 2024 computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The 4/24/24 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. B. Resident's representative interviewThe resident's representative was interviewed on 8/7/24 at 12:55 p.m. The representative said Resident #3 resided at the facility, until she moved her from the facility on 6/7/24. She said her mother had experienced a traumatic event at the facility. She said her mother had a history of constipation. She said Resident #3's mother had died at an early age of a bowel obstruction and so Resident #3 was very cautious about her bowels. She said Resident #3 told her she was held down while registered nurse (RN) #1 gave her a suppository. She said Resident #3 was crying out to stop and RN #1 did not stop. She said the resident was afraid to stay in the facility. The resident's representative said Resident #3 was a religious woman and she felt she was rectally assaulted to the extent that she continued to have nightmares about the abuse. She said the resident was humiliated and embarrassed and that was why she did not report the abuse the night the incident occurred. She said Resident #3 told the social worker at the dialysis center of the abuse. Cross-reference F600 for failure to keep a resident free from abuse. C. Facility investigation of incident between RN #1 and Resident #3The 6/5/24 facility investigation was provided by the nursing home administrator (NHA) on 8/6/24 at 12:45 p.m. The investigation was related to an allegation of sexual abuse in the early morning hours of 6/5/24. The roommate of Resident #3 was interviewed by the facility on 6/5/24 at 9:15 a.m. The roommate reported that RN #1 said she had come off of her break to deal with Resident #3. The roommate said Resident #3 had repeatedly yelled for RN #1 to stop. The roommate said RN #1 had hurt Resident #3 and she had heard her scream. The roommate said she had begun to pray for Resident #3. RN #1 was interviewed by the facility on 6/5/24 at 11:15 a.m. RN #1 said she administered a suppository after digitally removing stool from the Resident #3's rectum. RN #1 said the care only lasted 15 to 20 seconds. RN #1 said Resident #3 never told her to stop. On 6/5/24 at approximately 3:00 p.m. the facility interviewed certified nurse aide (CNA) #5. CNA #5 said she helped RN #1 administer the suppository by rolling Resident #3 onto her side. CNA #5 said the nurse had to remove feces to get the suppository placed inside Resident #3. CNA #5 said RN #1 told Resident #3 "I can't stop because I am trying to pull feces out so I can put the suppository in."Resident #3 was interviewed by the facility on 6/5/24 at 4:00 p.m. Resident #3 said she had been feeling constipated and had requested a suppository. Resident #3 said RN #1 had inserted more than three fingers inside her rectum, moving them around, during the medication administration. Resident #3 told RN #1 that it was hurting and to stop, but RN #1 did not stop. Resident #3 said she was told by RN #1 not to push her call light again after the incident. Resident #3 said she did not feel safe in the facility. The investigation revealed the facility interviewed one additional staff member who was working the floor at the time of the incident.-However, the two additional staff members who were working at the time of the incident were not interviewed as part of the investigation. According to review of the facility's investigation, three additional staff members from different shifts were interviewed and asked if they had ever witnessed staff members being sexually inappropriate with residents and if they had any concerns about the way staff members handled residents. The facility interviewed five additional residents, asking each of them the following questions:-Has a staff member ever been sexually inappropriate with you;-Are you fearful of any staff members;-Do you feel safe; and,-Is there anything else you want the facility to know?-However, the facility failed to ask the residents any questions related to if any of them had ever experienced any care from staff that they felt had been provided in a forceful physical way. The facility unsubstantiated Resident #3's sexual abuse related to the resident's emergency department (ED) visit had not noted trauma to the resident's rectal area.-However, the facility failed to investigate the potential that physical abuse occurred due to the forceful way RN #1 administered the suppository to Resident #3, despite Resident #3 asking the nurse to stop. D. Record ReviewAn emergency department (ED) visit progress note, dated 6/5/24 at 3:23 p.m., documented Resident #3 appeared to be nervous. Resident #3 said she had been rectally assaulted, possibly for disimpaction, but against her will. The note documented the resident had a small external hemorrhoid at the 11 o'clock position of the rectum that was not bleeding and there were no overt tears, trauma, bleeding or bruising. The note further documented the rectum did not appear to be irritated but was mildly red inside. III. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 8/7/24 at 10:15 a.m. The NHA said he was the abuse coordinator for the facility. He said he was notified of a sexual abuse allegation on 6/5/24. The NHA said he followed the investigation procedure for a sexual abuse allegation. The DON said the facility had not substantiated the sexual abuse allegation because the emergency room discharge stated no signs of trauma or assault. The DON said RN #1 had been interviewed by a CNA who was helping out the social services department and was not a licensed social worker. The DON said she had not conducted the interviews because RN #1 was the DON's sister, so she had removed herself from the investigation. She said she did not think the assistant director of nursing (ADON) had conducted an interview with RN #1 in her place when she removed herself from the investigation. The NHA said the interviews during the investigation should have been conducted by a qualified social worker or someone from the management team, and not the CNA who was not a licensed social worker. During the interview, the NHA read aloud the interview that the facility had conducted with Resident #3's roommate. After reading the interview, the NHA said his first instinct would have been that there had been potential physical abuse, however, he said he did not recognize it at the time of the incident. The NHA said every staff member who was working on the shift when the incident occurred should have been interviewed.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents reviewed for discharge planning out of 13 sample residents. Specifically the facility failed to assist Resident #3 in the development of a safe and appropriate discharge plan. Findings include:I. Facility policy and procedureThe Against Medical Advice (AMA) Discharges policy and procedure, August 2023, was provided by the nursing home administrator (NHA) on 8/7/24 at 2:30 p.m. It read in pertinent part, "If a resident wishes to be discharged prior to the completion of medical treatment or against the advice of the attending physician to a setting that does not appear to meet their needs or appears unsafe, the facility will treat this a refusal of care. "The facility will complete the required documentation and provide written discharge instructions as with any discharge. If a discharge AMA cannot be prevented, a practitioner must evaluate the resident's mental capacity to be sure that the resident can understand the condition, the nature and effect of the proposed treatment, and the inherent risk/benefit in pursuing the treatment and not pursuing the treatment. "Documentation should include the resident's decision-making capacity, disclosed risks, and the resident's understanding of those risks. As with any discharge, the facility is required to provide written discharge instructions, including follow-up with practitioners, medication management, the need for continued therapy, and any durable medical equipment necessary. Notify the resident practitioner, the facility's social services department, and a facility administrator of the resident's desire to leave the facility AMA."The AMA documentation includes: decision-making capacity, discussion of treatment goals (risks of not completing goals with resident understanding those risks), date and time the practitioner was notified of residents desire to discharge AMA, discharge arrangements made with caregiver/family member, written discharge instructions provided, person to whom resident was discharged, signed copy of the AMA form, physical assessment findings and education provided to resident and family (with understanding of that teaching)."II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/24/24 and discharged to home on 6/7/24. According to the June 2024 computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The 4/24/24 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 required a hoyer lift for transfers related to a recent left leg below the knee amputation. The MDS assessment did not indicate the resident had an ongoing discharge plan. B. Resident's representative interviewThe resident's representative was interviewed on 8/7/24 at 12:55 p.m. The resident's representative said her mother had informed her of an incident which occurred in the early morning of 6/5/24. She said her mother had told her later in the morning (6/5/24) that she was scared and did not want to continue to live at the facility. The resident's representative said she spoke with the NHA to inform him of the abuse allegation. The resident's representative said Resident #3 went to dialysis on 6/5/24 and then to the hospital to be examined for a sexual assault allegation. The resident's representative said Resident #3 returned to the facility on 6/5/24 so the family could have time to obtain a Hoyer lift (mechanical lift) and a medical bed in order to make preparations so Resident #3 could be discharged from the facility to live with her. The resident's representative was a certified nurse aide (CNA) and an emergency medical technician (EMT). The resident's representative said she had told the facility she wanted Resident #3 to discharge home with her, however, she needed time to prepare. The resident's representative said the NHA told her if she was taking Resident #3 out of the facility it would be AMA and he had forced her to sign the AMA paperwork on the discharge date of 6/7/24. The resident's representative said the facility did not send any discharge instructions, medications or a list of the current medications that Resident #3 was currently prescribed. She said Resident #3 went nearly two weeks without her blood thinner medication and other medications. The resident's representative said the facility did not send any paperwork with the resident. The resident's representative said the facility did not provide any assistance with the discharge planning process. C. Record reviewThe AMA form, dated 6/7/24, was signed by the resident's daughter, the ombudsman and a registered nurse (RN). The discharge form documented, in pertinent part, "I am being discharged against the advice of the attending physician and the facility administration. I acknowledge that I have been informed of the risks involved and hereby release the attending physician and the facility from all responsibility for and from anything that may result from such discharge. I am also aware that I will be responsible for any costs incurred tha my insurance company refuses to cover."-Review of Resident #3's electronic medical record (EMR) did not reveal documentation indicating the facility had assisted the resident with discharge goals. -The EMR failed to document the reasons for the AMA discharge, who had made the decision for the AMA discharge or if the interdisciplinary team (IDT) was involved with the decision to discharge the resident AMA.-The EMR failed to document if the resident's physician or the medical director (MD) was notified of Resident #3's AMA discharge. -A review of Resident #3's June 2024 CPO did not reveal a physician's order for the resident's discharge. -The EMR did not reveal documentation to indicate that a discharge summary or any discharge documentation was sent with the resident. III. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 8/7/24 at 10:15 a.m. The DON said it was not been safe for Resident #3 to discharge home with family. The DON said the family had told the facility they were unable to care for the resident at home. The DON said the resident did return to the facility after dialysis and the emergency department on 6/5/24 and was not discharged AMA until 6/7/24. The DON said the facility had wondered why Resident #3 had come back to the facility after her emergency department visit if the family had not wanted her there. The DON said when the resident was first admitted to the facility she had planned to return home with her family. The DON said the resident's representative and the resident had made the decision to stay at the facility, as it was going to be difficult for the resident's representative to care for the resident at home. The DON said the facility made the decision to discharge Resident #3 AMA due to the fact that the resident's representative had told them she could not take care of her at home but was insisting on taking the resident home anyway. The DON said the resident's physician had not been notified prior to Resident's #3's discharge or that the resident left AMA. The DON said Resident #3's EMR should have included documentation that she had been discharged home. The DON said it was standard practice for the facility to notify adult protective services (APS) when a resident was discharged AMA, however, the DON said APS had not been contacted by the facility regarding Resident #3's AMA discharge. The social services director (SSD), and the DON were interviewed together on 8/7/24 at 2:45 p.m. The SSD said a discharge summary should have been written and given to the family upon discharge. The SSD said she did not know why a physician's discharge order was not obtained. The SSD said although she was newly employed and was not hired at the time of Resident #3's discharge, she said the practice was for the social worker to lead the discharge planning process. She said the social worker was to offer services and make referrals when needed. The SSD said the IDT was to complete a summary of the resident's stay. The SSD said she reviewed Resident #3's EMR and said there was not any documentation or evidence which showed the resident was offered any services or discharge planning assistance. She said pertinent phone numbers, such as advocacy contact numbers, were not provided. The MD was interviewed on 8/7/24 at 3:19 p.m. via telephone. The MD said there should have been a physician's discharge order when Resident #3 was discharged from the facility. The MD said the attending physician should have been notified and participated in the AMA discharge process. The MD said he was not notified that Resident #3 had been discharged AMA.The dialysis center social worker (DSW) was interviewed on 8/15/24 at 9:33 a.m. via telephone. The DSW said the facility had not completed a safe discharge for Resident #3. The DSW said the facility left the resident's representative on her own with the discharge. The DSW said the facility did not provide discharge instructions, a medication list or the necessary equipment for Resident #3 to successfully discharge. The DSW said she picked up oxygen supplies at a medical supply company for Resident #3.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#3) of three residents reviewed for quality of care out of 13 sample residents. Specifically the facility failed to:-Follow the physician's standing orders for bowel management for Resident #3;-Document the bowel medications that were administered to Resident #3;-Document the nursing medication reassessment;-Document the nursing abdominal and peri-rectal assessment; and,-Document the digital fecal disimpaction (procedure of removing stool from the rectum with a finger) procedure for Resident #3. Findings include:I. Professional referenceSetya A, Mathew G, Cagir B. (2023). Fecal Impaction. National Institutes of Health. Retrieved on 8/6/24 from https://www.ncbi.nlm.nih.gov/books/NBK448094/. It read in pertinent part, "Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The treatment options are the rectal administration of stool softening agents, usually enemas or suppositories or a digital evacuation of the impacted fecal mass. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger."Treas, L.S., Barnett, K.L., & Smith, M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), page 2065 was retrieved on 8/15/24. It read in pertinent part, "A health record permanently documents: the care, in chronological order, performed by healthcare providers, responses to medications, interventions, and procedures. "Document the medication, time, dose, and route given, preadministration assessments, and your signature. Document all therapeutic and adverse effects of the medication. Also document your nursing interventions and teaching of potential adverse effects." Treas, L.S., Barnett, K.L., & Smith, M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), pages 2087-2090 was retrieved on 8/6/24. It read in pertinent part, "Position patient on left side which helps with medication retention because the descending colon is on the left side, it also helps relax the external anal sphincter (rectum). The patient should not experience pain during the administration of a suppository, but they will feel pressure. Encourage deep breathing to aid in relaxation of the sphincter. Pushing a suppository through a constricted sphincter causes discomfort." II. Facility policy and procedureThe Bowel Protocol policy and procedure, dated September 2023, was provided by the NHA on 8/7/24 at 8:44 a.m. It read in pertinent part, "Provide effective interventions for signs and symptoms of constipation. Nursing staff will record, in the electronic health record (EHR), each time a resident has a bowel movement."The Nursing Facility Standing Orders and Constipation policy and procedure, dated June 2019, was provided by unit care coordinator (UCC) #1 on 8/6/24 at 12:12 p.m. It read in pertinent part, "The nurse may order the following if no bowel movement for three days: milk of magnesia; dulcolax suppository, fleets enema or senna. If standing orders are followed and not effective, report assessment of impaction, bowel sounds, vital signs, last BM (bowel movement) quality and quantity, presence of blood in stool, recent administration of narcotics and fluid intake."III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/24/24 and discharged home on 6/7/24. According to the June 2024 computerized physician orders (CPO), diagnoses included constipation, gastro-esophageal reflux disease (GERD), nausea, diabetes mellitus type 2, end stage renal disease and left leg below the knee amputation. The 4/24/24 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 MDS assessment revealed dependent status required two staff assistance with hoyer for transfers. B. Resident's representative interviewThe resident's representative was interviewed on 8/7/24 at 12:55 p.m. The representative said Resident #3's mother died at an early age from a bowel obstruction and therefore she was always concerned about her bowel regimen because she was fearful of an obstruction. C. Record reviewThe June 2024 CPO revealed the following physician's order for bowel management:-Standing order/protocols, ordered on 4/3/24; -Colace 100 mg (milligrams) (laxative) oral capsule as needed, ordered on 4/3/24; -Fleet enema 7-19 grams (g) per 118 milliliter (ml) enema as needed, ordered on 4/3/24; -Miralax (3350 powder) 17 g with 120 to 240 ounces (oz) of fluid as needed, ordered on 4/9/24; -Bisacodyl 10 mg suppository as needed, ordered on 6/2/24; -Miralax (1450 powder) 17 g with eight oz ounces of fluid was ordered daily, ordered on 6/6/24 (started after the disimpaction procedure on 6/5/24); and,-Senna-docusate sodium 8.6-50 mg oral tablet was ordered nightly, ordered on 6/6/24 (started after the disimpaction procedure on 6/5/24). The bowel and bladder elimination tracking record (5/28/24 to 6/7/24) revealed the following:On 5/28/24, the resident had a large bowel movement. On 5/29/24, it was documented a response was not required. On 5/30/24, it was documented a response was not requiredOn 5/31/24, there was no documentation. On 6/1/24, it was documented a response was not required. On 6/2/24 at 12:55 a.m., it was documented a response was not requiredOn 6/2/24 at 5:39 p.m., it was documented the resident had a small bowel movement. On 6/3/24, it was documented a response was not required. On 6/4/24 at 12:51 a.m., it was documented the resident had a medium bowel movement.-According to the May 2024 medication administration record (MAR) the resident did not receive any as needed laxatives, softeners or enemas after she had gone four days (5/29/24 to 6/2/24) without any bowel movement. -The facility failed to follow the standing physician's orders for bowel management.-Review of Resident #3's electronic medical record (EMR) did not reveal documentation regarding RN #1's assessment of the resident's bowel status or the procedure for the fecal disimpaction and suppository administration in the early morning hours of 6/5/24 (see interviews below). IV. Staff interviewsUnit care coordinator (UCC) #1 was interviewed on 8/6/24 at 12:00 p.m. UCC #1 said all medications that were administered needed to be documented as administered in the resident's EMR. UCC #1 said there was a standing order list (a list of common medical issues with steps and medications for the nurses to utilize). UCC #1 said constipation was one of the common issues that occurred with residents that was included on the standing physician's orders. The director of nursing (DON) was interviewed on 8/6/2024 at 3:48 p.m. The DON said residents' bowel movements were charted by the certified nurse aides (CNA). The DON said the standing physician's orders for bowel protocol began with the most gentle laxative and increased in strength if it was found to be unsuccessful. The DON said the nurses would give a stool softener, then milk of magnesia (laxative), then a suppository or enema. The DON said registered nurse (RN) #1 did not document in Resident #3's EMR that she performed a fecal disimpaction or administered the suppository on 6/5/24. RN #1 was interviewed on 8/6/24 at 7:24 p.m. RN #1 said Resident #3 had complained of constipation on the previous day (6/4/24). RN #1 said she had given Resident #3 milk of magnesia (laxative) and miralax (laxative) which helped the resident have a few small bowel movements. RN #1 said the resident had requested a Bisacodyl suppository (laxative).-However, RN #1 did not document that she had administered the resident milk of magnesia, miralax or the suppository (see record review above). RN #1 said as part of her assessment, she had listened to bowel sounds, palpated her stomach and verified that the resident was able to pass gas. RN #1 said she had explained to the resident that there was a need for digital fecal disimpaction. RN #1 said the resident was educated that stool needed to be removed for the suppository to work properly. RN #1 said she lubricated her finger and massaged the lubrication around the edge of the rectum. She said some small stool exited the rectum with the lubrication and palpation around the resident's rectum. RN #1 said there were many little, hard, shaped balls of stool in different sizes from small to quarter sized. RN #1 said she may have forgotten to chart the administration of the suppository and the fecal disimpaction. The DON was interviewed a second time on 8/7/24 at 10:15 a.m. The DON said RN #1 should have documented the abdominal and rectal assessment, digital stool removal and the fecal disimpaction. The DON said all medications and treatments given to residents should be documented on the MAR when given.

A revisit survey was completed on 7/2/24 for all previous deficiencies cited on 5/9/24. The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility's general characteristics. The facility is a one story wood frame structure, Type V (111) construction, without a basement. The facility was licensed for one hundred eighty seven (187) beds and operated as a non-secured facility at the time of this survey. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system that includes a wet system as well as a dry pipe system. The survey was conducted on June 05, 2024 for compliance to fire safety requirements of NFPA 101, Life Safety Code (LSC), 2012 edition, Chapter 19 for Existing Health Care Occupancies. After correction of the following deficiencies, the facility will meet these requirements.

STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit leading to an exit discharge is compromised. This was evidenced by the following: Means of egress exit doors in the Physical Therapy not equipped with Panic Fire Exit Hardware. NFPA 101-2012, Chapter 7, Panic Hardware and Fire Exit Hardware. Section 7.2.1.7.2. Only approved panic hardware shall be used on door assemblies that are not fire-rated door assemblies. Only approved fire exit hardware shall be used on fire-rated door assemblies. New panic hardware and new fire exit hardware shall comply with ANSI/UL 305, Standard for Safety Panic Hardware and ANSI/BHMAA156.3, Exit Devices. This exit discharge deficiency was discussed during the exit conference with the Administrator.

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

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

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following. Facility failed to provide proper exit signage in the dining room and kitchen, directional arrows were pointing in the wrong direction. Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

STANDARD is not met as evidenced by: During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection as required by NFPA 96, (Chapter 11, Section 11.2.1-11.6.1). This deficient practice could affect all residents, and staff should a fire occur due to failure to operate effectively due to non-code compliant inspections and servicing. This was evidence by the following. 1. The facility was unable to provide further documentation indicating the inspection and servicing of the kitchen-suppression-system every six months. 2. The language and wording for the placard is not properly written or approved by the authority having jurisdiction. The Maintenance Director acknowledge the lack of inspections and servicing of the system. NFPA 96, Chapter 11, Section 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. 10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher. 0.2.2.1 The language and wording for the placard shall be approved by the authority having jurisdiction

STANDARD not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to operate if a fire was to occur. This was evidenced by the following:1. At the time of the survey, no documentation was available to indicate the Annual Testing of the fire alarm system had occurred in the past year. 2. During the review of the records, documentation was not available to verify the sensitivity testing of the smoke detectors per NFPA 101 2012 Edition 19.3.4.1, 9.6.1.3, NFPA 72 7-3 and 7-3.2.1.2012 Life Safety Code 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. 2013 NFPA 72 - 7-3.2.1*Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range.it shall be tested using any of the following methods: The Director of Maintenance acknowledge the lack of testing of the fire alarm system in the past year during the tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following: Door opening in the cross-corridor of A Hall would not latch and close completely into the door frames creating a 20- minute smoke barrier. The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke. The Director of Maintenance acknowledge the corridor door condition during the facility tour.

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following: Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct fire drills as follows:1st shift, 3rd and 4th quarters2nd shift, 1st quarter3rd shift, 3rd quarter Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. The Director of Maintenance acknowledge the conditions of fire drills deficiency during record review of the facility.

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following. The facility failed to provide documentation at the time of the survey to reflect that the emergency generator was inspected weekly from June 1, 2023 through May 31, 2024. Diesel annual fuel quality test not conducted as annually using applicable ASTM Standards. NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 110, Section 8.3.8 a fuel quality test shall be performed at least annually using approved ASTM standards. The emergency power supply system deficiency item was discussed with the Maintenance Director during the survey and again during the exit conference with the Administrator.