TRINIDAD REHABILITATION AND HEALTHCARE CENTER

A complaint survey, prompted by #CO2710784, Incident #2674503, Incident #2674515, Incident #2733867, Incident #2733911 and Incident #2733931 was completed on 2/17/26 to 2/18/26. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for six (#3, #1, #7, #2, #5 and #6 ) of 9 residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to: -Protect Resident #3 from physical abuse by Resident #4;-Protect Resident #1 from physical abuse by Resident #2;-Protect Resident #7 and Resident #2 from physical abuse by each other; and,-Protect Resident #5 and Resident #6 from physical abuse by each other. Findings include:I. Facility policy and procedureThe Abuse Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/18/26 at 2:04 p.m. It read in pertinent part: "All reports of resident abuse shall be reported and investigated by facility management.”II. Incident of physical abuse of Resident #3 by Resident #4 on 9/25/25A. Facility investigationThe 9/25/25 facility investigation revealed that an altercation occurred between Resident #3 and Resident #4. The investigation revealed Resident #4 positioned his wheelchair next to Resident #3. Resident #3 asked Resident #4 not to run into her with his wheelchair. Resident #4 responded and struck Resident #3 on the face, and Resident #3’s eyeglasses were bent, causing a laceration on the bridge of her nose. Resident #4 was placed on monitoring with observations every 15 minutes and moved to a room in another hallway. Resident #4 was prescribed sertraline (selective serotonin reuptake inhibitor) once a day for physical aggression. The investigation substantiated the incident of physical abuse. B. Resident #3 (victim) 1. Resident statusResident #3, age greater than 65, was admitted on 8/26/25 and discharged home on 10/8/25. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety and depression. The 9/1/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. The assessment revealed Resident #3 required substantial to maximum assistance from staff for bed mobility and transfers, and was dependent on staff for walking. Resident #3 used a manual wheelchair for mobility. The assessment documented Resident #3 had no physical or verbal behaviors towards others. 2. Record reviewThe communication care plan, initiated 9/3/25, revealed Resident #3 had impaired communication. Pertinent interventions included allowing ample time for Resident #3 to comprehend what was said, allowing time for response and using simple and direct communication to promote understanding. The 9/25/25 nurse progress note revealed Resident #3 had an incident with another resident (Resident #4). Resident #3 sustained a 0.5 centimeter (cm) by 0.5 cm laceration on the right side of her nose and a 1.5 cm by 2.0 cm laceration on the left side of her nose. The progress note documented Resident #3 was transferred to the emergency department for evaluation and had no additional injuries. The lacerations were treated by the nurse with first aid. The 10/2/25 nurse progress note revealed the resident’s lacerations were healing and Resident #3 denied pain from the lacerations. The 10/8/25 progress note revealed Resident #3 discharged home with her responsible party. C. Resident #4 (assailant) 1. Resident statusResident #4, age less than 65, was admitted on 3/30/24. According to the February 2026 CPO, diagnoses included dementia, anxiety, a history of traumatic brain injury and epilepsy. The 12/2/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. The assessment revealed Resident #4 was dependent on staff for bed mobility and transfers. dressing. Resident #4 used a manual wheelchair for mobility. The assessment documented Resident #4 had no physical or verbal behaviors towards others. 2. Record reviewThe physical aggression care plan, initiated 9/29/25, revealed Resident #4 had aggressive behavior by striking out towards another person. Pertinent interventions included educating about negative behavior, encouraging talking when frustrated or anxious, redirecting from others if behaviors were present, monitoring for signs of frustration, and escalating behaviors. The 9/29/25 nurse progress note revealed that a staff member observed Resident #4 raise his open hand towards Resident #3, but Resident #4 did not make contact with Resident #3. The progress note revealed the physician was contacted and gave a new order for sertraline 25 milligrams (mg), one time a day for physical aggression for eight days. III. Incident of physical abuse of Resident #1 by Resident #2 on 11/15/25 A. Facility investigationThe 11/15/25 facility investigation revealed Resident #1 exited her room as Resident #2 walked past her in the hallway. Resident #1 approached Resident #2 in an attempt to hold his arm and walk in the hallway. Resident #2 responded by pushing Resident #1, and Resident #1 lost her balance and fell to the ground. The investigation revealed staff intervened and separated Resident #1 and Resident #2. The nurse completed an assessment on Resident #1, who had a skin tear that was treated with first aid. Resident #2 had no injuries. The investigation revealed after the altercation, the staff separated the residents, and the staff monitored both residents every 15 minutes. The investigation substantiated the incident of physical abuse. B. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on 11/12/2020. According to the February 2026 CPO, diagnoses included dementia and difficulty walking. The 2/12/26 MDS assessment revealed Resident #1 was unable to complete the BIMS assessment. Per the staff assessment for mental status, Resident #1 had severe cognitive impairment with daily decision making and had continuous inattention and disorganized thinking. The assessment indicated Resident #1 had no physical or verbal behavior symptoms during the assessment look-back period. 2. Record reviewThe wandering care plan, initiated 4/3/25, revealed Resident #1 wandered on the secured unit. Pertinent interventions included keeping Resident #1 safe during episodes of behaviors and monitoring and documenting episodes of inappropriate behaviors. The 11/15/25 nurse progress note revealed a staff member found Resident #1 on the floor. The nurse completed an assessment of a 6.0 cm by 1.5 cm skin tear on Resident #1’s right forearm. C. Resident #2 (assailant) 1. Resident statusResident #2, age greater than 65, was admitted on 11/10/24. Diagnoses included Alzheimer's disease and dementia with behavioral disturbance. The 12/23/25 MDS assessment revealed Resident #2 was unable to complete the BIMS assessment. Per the staff assessment for mental status, Resident #2 was moderately cognitively impaired with daily decision-making. Resident #2 required supervision from staff for dressing, bed mobility, transfers, and walking. The assessment indicated Resident #2 had physical behaviors directed toward others for one to three days of the assessment look-back period. 2. Record reviewThe dementia care plan, initiated 6/12/25, revealed Resident #2 lived in the secured unit for a therapeutic environment. Pertinent interventions included encouraging Resident #2 to avoid doorways to avoid injury when others entered and exited the secured unit..The physical aggression care plan, initiated 12/1/24, revealed Resident #2 attempted to strike another resident when he felt threatened. Pertinent interventions included administering medications as ordered (12/1/24), redirecting when exhibiting behaviors (1/2/25), approaching Resident #2 in a calm manner (1/2/25) and providing a calm and safe environment (1/23/25). Review of Resident #2’s electronic medical record (EMR) revealed there were no corresponding progress notes regarding the altercation with Resident #1 on 11/15/25. IV. Incident of physical abuse between Resident #7 and Resident #2 toward each other on 11/18/25A. Facility investigationThe 11/18/25 facility investigation revealed Resident #2 and Resident #7 were in the common area. Resident #2 lifted and swung his feet over the armrest of the chair. Resident #2’s foot bumped Resident #7. Resident #7 pushed Resident #2’s foot away, Resident #2 kicked Resident #7 in the leg and Resident #7 slapped Resident #2. The investigation revealed staff separated the residents immediately and Resident #2 was placed on one-to-one care for safety monitoring. The facility investigation revealed Resident #2 had a history of pushing others away if they touched him. The nurse assessed Resident #7 and found no injuries. The investigation substantiated the incident of physical abuse. B. Resident #2 (victim and assailant) 1. Record reviewReview of Resident #2’s EMR revealed there were no corresponding nurse progress notes regarding the altercation with Resident #7 on 11/18/25. The 11/18/25 physician progress note revealed Resident #2 had refused medications. The physician and the interdisciplinary team (IDT) reviewed the resident’s non-pharmacological and pharmacological interventions for physical aggression. The physician gave a new order for aripiprazole (antipsychotic) two milliliters (ml), every morning for dementia with behaviors. C. Resident #7 (victim and assailant) 1. Resident statusResident #7, age greater than 65, was admitted on 9/10/24. According to the February 2026 CPO, diagnoses included schizoaffective disorder and depression. The 11/4/25 MDS assessment revealed Resident #7 had mild cognitive impairment with a BIMS score of 13 out of 15. Resident #7 required supervision or touching assistance from staff for bed mobility, transfers, dressing, and walking. The assessment indicated Resident #7 had no behavioral symptoms directed at others during the assessment look-back period. 2. Record reviewThe behavioral care plan, initiated 10/22/25, identified Resident #7 had an incident of misconduct with another resident. Interventions included providing one-to-one social services for decreased stimuli, discussing feelings and providing non-judgmental support, increasing sessions with the mental health provider and monitoring for mood and/or behavioral changes. Review of Resident #7’s EMR revealed there were no corresponding progress notes regarding the altercation with Resident #2 on 11/18/25. V. Incident of physical abuse between Resident #5 and Resident #6 toward each other on 12/7/25A. Facility investigationThe 12/7/25 facility investigation revealed a staff member heard a male and a female resident yelling in the common area. Staff responded and observed Resident #5 and Resident #6 rolling away from each other in their wheelchairs. The investigation revealed staff separated the residents and monitored both residents every 15 minutes. The nurse completed assessments on both residents and determined Resident #6 had an abrasion above his right eye. The investigation substantiated the incident of physical abuse. B. Resident # 5 (victim and assailant) 1. Resident statusResident #5, age greater than 65, was admitted on 1/3/2020. According to the February 2026 CPO, diagnoses included dementia and Wernicke’s encephalopathy (a neurological condition caused by a vitamin deficiency). The 1/1/26 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 13 out of 15. Resident #5 required supervision and/or touching assistance for bed mobility, transfers, dressing, walking, and using a manual wheelchair for mobility. The assessment indicated Resident #5 had no behavioral symptoms directed at others during the assessment look-back period. 2. Record reviewThe physical altercation care plan, initiated 12/7/25, included pertinent interventions for monitoring at 15-minute intervals (initiated 12/8/25), educating staff on protocol to report resident altercations (initiated 12/8/25) and redirecting from Resident #6 while in the smoking area (initiated 12/8/25). Review of Resident #5’s EMR revealed there were no corresponding progress notes regarding the altercation with Resident #6 on 12/7/25. C. Resident #6 (victim and assailant) 1. Resident statusResident #6, age greater than 65, was admitted on 4/16/18. According to the February 2026 CPO, diagnoses included stroke, difficulty walking, and dementia. The 2/16/26 MDS assessment revealed Resident #6 had severe cognitive impairments with a BIMS score of six out of 15. Resident #6 required setup to maximum assistance from staff for dressing and bed mobility. Resident #6 was dependent on staff for transfers, was non-ambulatory, and required supervision/touching assistance for using a manual wheelchair. The assessment documented Resident #6 had verbal symptoms directed toward others for four to six days during the assessment look-back period. 2. Record reviewThe behavior care plan, initiated 12/7/25, included pertinent interventions for monitoring at 15-minute intervals (initiated 12/8/25), educating staff on protocol to report resident altercations (initiated 12/8/25), redirecting from Resident #5 while in the smoking area (initiated 12/8/25), and monitoring the abrasion above the right eye (initiated 12/9/25). The wheelchair safety care plan, initiated 6/25/24, revealed Resident #6 was at risk for abuse from other residents due to running into others with his wheelchair. Pertinent interventions included intervening to avoid confrontations with others, redirecting to a safe area when agitated and administering medications as ordered. The 12/7/25 nurse progress note revealed staff heard Resident #6 and a female resident arguing in the lobby. Staff investigated and observed Resident #5 and Resident #6 self-propelling their wheelchairs away from each other. The 12/7/25 facility investigation revealed Resident #6 sustained an abrasion above his right eye during the altercation with Resident #5. The 12/8/25 nurse progress note revealed no concerns regarding the abrasion above the right eyebrow. The resident had no complaints of pain. The 12/8/25 progress note revealed the physician gave a new order to start Risperdal 0.5 mg, every day at bedtime for aggression. VI. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/18/26 at approximately 2:30 p.m. RN #1 said she had worked at the facility for one year. RN #1 said after she was hired, the facility provided abuse prevention training. RN#1 said staff training included monitoring all residents for potential for altercations. RN #1 said when residents had increased risk for altercations, behavior monitoring needs were documented in residents’ care plans and also at each change of shift report. RN #1 said if residents were involved in altercations, it was facility policy to separate all the residents and to complete nursing assessments for any changes in conditions. RN #1 said it was the facility policy to place residents involved in altercations on close monitoring, every 15 minutes. The NHA, the director of nursing (DON) and the social services director (SSD) were interviewed together on 2/18/26 at 4:45 p.m. The NHA said after resident altercations, residents involved in altercations were separated and monitored closely, every 15 minutes, or sometimes one-to-one assignments were necessary if residents had increased agitation. The DON said after the altercation between Resident #3 and Resident #4, Resident #4 was transferred to another unit in the facility. The DON said the new room assignment was on a unit that had less stimuli, to avoid increased anxiety or agitation for Resident #4. The NHA said Resident #4 had no behavioral altercations towards others after he moved to his new room and after the physician adjusted his medications. The SSD said Resident #3 had no changes in her mood or behaviors after the altercation. The NHA said Resident #1 had behaviors of approaching other residents to walk with them. The NHA said Resident #1 had one-to-one monitoring when she was out of her room to prevent her from approaching and reaching out towards other residents. The DON said staff involved Resident #1 with their tasks to keep Resident #1 on one-to-one monitoring. The SSD said the physician adjusted medications for Resident #2 after he pushed Resident #1. The SSD said after Resident #2 had his medications adjusted, he had not had altercations with other residents. The NHA said after the altercation between Resident #6 and Resident #5, the common area furniture was rearranged to allow a greater passing area for residents in wheelchairs. The NHA said Resident #6 had updates to his care plan for staff to closely monitor him when he was in the common areas and outside in the smoking area. The SSD said Resident #6 had not had altercations with other residents after the physician prescribed the Risperdal. THe NHA said Resident #5 had no previous behavioral concerns. The NHA said Resident #5 was was observed striking Resident #6 in response to Resident #6’s attempt to hit Resident #5 after their wheelchairs collided. The NHA said Resident #2 sat in the common area and swung his feet over the arm of the chair. The NHA said when Resident #7 walked passed Resident #2 he came into contact with Resident #2’s foot. The NHA said Resident #7 pushed Resident #2’s foot away in an attempt to continue walking. He said Resident #2 responded by kicking Resident #7 and then Resident #2 slapped Resident #2. The NHA said after the furniture was rearranged in the common areas and after Resident #2 had aripiprazole prescribed, there were no further occurrences between Resident #2 and Resident #7.

A survey with #CO2710783 was completed on 2/17/26 to 2/18/26. No deficiencies were cited.

A survey for Incident #2642461 was conducted 10/22/25 to 12/9/25. No deficiencies were cited. The actual survey exit date was 10/22/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider on 12/9/25.

A complaint survey, prompted by #CO2588006 and #CO2621206 was conducted on 10/7/25 to 12/5/25. Two deficiencies were cited. The actual survey date was 10/8/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/5/25.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of five residents reviewed for failure to transcribe and initiate the physician’s orders out of nine sample residents. Specifically, the facility failed to ensure Resident #’1 post hospitalization orders for hematoma care were entered into the electronic medical record (EMR) and followed. Findings include:I. Facility policy and procedureThe Hematoma Aftercare procedure, undated, was received from the nursing home administrator (NHA) on 10/9/25 at 2:36 p.m. It read in pertinent part,“Aftercare for a hematoma involves monitoring vital signs and neurological status, applying cold compresses, and promoting elevation of the affected area. Nurses should also assess for signs of complications like worsening pain or infection, carefully manage any anticoagulant medications as ordered by the physician. and educate the patient and family when to seek further medical attention.“Monitoring and assessing:-Vital signs;-Neurological status;-Signs of deterioration ; and,-Skin integrity.“Treatment and care:-Rest;-Elevation;-Cold compresses; and,-Medication management.“Patient and family education”-Activity restrictions;-Signs of complications; and,-Wound care.“Work closely with the physician to manage the hematoma and any complications; and consult with a certified wound nurse if the hematoma is complex or failing to heal properly.”II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 8/27/24 and expired in the facility on 9/14/25. According to the September 2025 computerized physician orders (CPO), diagnoses included stage four kidney disease, diabetes mellitus, unsteadiness of feet, difficulty walking, abnormal gait, depression, atrial fibrillation, dementia, macular degeneration and a history of falling. The 8/28/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #1 required substantial to maximum assistance from staff for sitting to lying in bed and partial to moderate assistance from staff for bed mobility, for sitting to standing, and transfers. Resident #1 was non-ambulatory and used a manual wheelchair for mobility. The MDS assessment documented that Resident #1 was prescribed anticoagulant, Eliquis 2.5 milligrams (mg) twice daily. B. Record review-Review of Resident #1’s comprehensive plan of care did not reveal documentation regarding the resident’s abrasion and hematoma treatments or monitoring. The 9/8/25 fall occurrence progress note revealed Resident #1 fell from his wheelchair during a transfer. The progress note read that Resident #1 fell onto his left knee and then fell and hit his head. The nurse completed an assessment and documented vital signs: blood pressure 94/52 millimeters of mercury (mmHg), temperature 97.4 degrees Fahrenheit, heart rate 49 beats per minute, and respirations 16 per minute. The progress note revealed Resident #1 had a large knot on his left forehead with a small open area oozing blood. Resident #1 was transferred to the emergency department for evaluation. The 9/8/25 nurse progress note revealed the facility nurse spoke with the hospital nurse, who reported Resident #1 had a head computerized topography (CT) scan and determined the findings were negative (no active bleeding in or around the brain) and Resident #10 was doing well and would return to the facility. The 9/8/25 hospital discharge instructions revealed Resident #1 was evaluated for a same-level fall and had an abrasion and hematoma on his head. Resident #1 was diagnosed with an abrasion and a hematoma. The special notes of the discharge instructions read in pertinent part, “the CT scan did not show any sign of internal bleeding or fracture. Please follow up with your primary care provider in two to three days. Return to the emergency department with symptoms worsening. Occasionally, hematomas can calcify. Recommend placing ice on the immediate face to help with inflammation. In two to three days, switch over to heat to help the body reabsorb the blood.” The 9/8/25 hospital discharge instructions included wound care instructions and read in pertinent part:“Abrasion care:-Your abrasion will be cleaned with water and mild soap;-An antibiotic ointment may be applied to your abrasion to prevent infection; and,-A bandage may be placed on your abrasion to keep it clean;-Clean your wound one to two times a day with soap and water;-Keep your dressing clean and dry;-Check your wound every day for signs of infection;-If directed, put ice on the injured area; and-If possible, raise the injured area above the level of your heart while you are sitting or lying down.”“Hematoma care:-If directed, to put ice on the injured area and leave the ice on for 20 minutes, two to three times a day for the first couple of days;-If directed, apply heat to the affected area as often as told by your provider with a heat source recommended. Leave the heat on for 20 to 30 minutes; and-Raise the injured area above the level of your heart while you are sitting or lying down.-However, Record review revealed the facility failed to review and reconcile medications when Resident #1 returned to the facility. The medication reconciliation form, dated 9/8/25, was blank and unsigned.-Further review of Resident #1’s EMR revealed the facility nursing staff did not transcribe or enter the new treatment orders into Resident #1’s EMR. As a result, nursing care was not provided for the abrasion and hematoma. III. Staff interviewsThe DON was interviewed on 10/7/25 at 2:00 p.m. The DON said when residents returned to the facility from the emergency department, the admitting or charge nurse was responsible for reviewing the documents for new physician’s orders or changes to existing orders. The DON said the 9/8/25 emergency department discharge instructions were not reviewed, noted, or entered into Resident #1’s EMR. The DON said when physician’s orders were not entered into the EMR, nursing staff would be unaware of specific resident needs because nurses refer to physician orders for required medications and treatments. The DON said staff monitored Resident #10 after he returned from the hospital on 9/8/25 and said she was unable to find documentation that nursing care was provided for the abrasion and hematoma. The DON said on 9/10/25, Resident #1 had a change in condition and was transferred to the emergency department. The DON said while Resident #1 was at the hospital, his family, friends, and power of attorney opted to place Resident #1 on hospice care, and Resident #10 expired on 9/14/25.

Based on observations, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of five residents reviewed for maintaining resident health records out of nine sample residents. Specifically, the facility failed to ensure physicians' progress notes for Resident #1 were available in the electronic medical record (EMR). Findings include:I. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 6/7/12. According to the October 2025 computerized physician orders (CPO), diagnoses included history of stroke, left-sided paralysis, atrial fibrillation, epilepsy, diabetes mellitus, high blood pressure, depression, chronic pain and mild intellectual disabilities. The 8/28/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #1 was dependent on staff for her activities of daily living. B. Record reviewThe record review revealed there were no physicians’ progress notes in Resident #3's EMR for the period of 1/1/25 to 10/7/25. II. Staff interviewsThe director of nursing (DON) was interviewed on 10/7/25 at 2:00 p.m. The DON said the Resident #3’s physician documented the physician evaluations and progress notes in a health record system that the facility did not maintain. The DON said if physician records were required by nursing or other health care providers, the physician records were not immediately available. The DON said the current process to obtain physician progress notes was that she contacted the physicians’ office staff with the records request, and the records were forwarded the same day or the next day by secure email messaging. The DON said the facility would review the health record requirements with the physician and develop a process to ensure physicians’ evaluations and progress notes were available in the facility’s EMR system.

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 revisit survey was completed on 7/22/24 for all previous deficiencies cited on 6/5/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility consists of two structures separated by a common wall having a two-hour fire rating, and the facility is licensed for 119 beds at the time of this survey. Building A1, constructed in 1957, is a Type V (111) single-story structure with a partial basement. Building A1 is protected throughout by a National Fire Protection Association (NFPA) Type 13 automatic fire suppression system. Building A1, equipped throughout with battery-powered emergency egress lighting units, is a Level 2 facility supported by a 12.5 KW, 208Y/120 volt, stand-by electrical system powered by a natural gas prime mover. This survey, conducted July 02, 2024 inspected building A1 for compliance to fire safety requirements for Existing Health Care Occupancies as contained in Chapter 19 of the 2012 edition of NFPA 101, the Life Safety Code. Both structures of this facility will meet these requirements with all non-conformances listed herein corrected. The surveyor discussed each deficient item with the Director of Maintenance during the survey, and again with the Director of Maintenance and the Administrator during an Exit Conference.

The Colorado Department of Public Health and Environment 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 consists of two structures separated by a common wall having a two-hour fire rating, and the facility is licensed for 119 beds at the time of this survey. Building A2 is a Type II (222), three-story structure constructed in 1968. Building A2 has been retrofitted with an NFPA Type 13 fire suppression system on levels A and B. Both buildings are classified as fully-protected per NPFA Type 13 automatic fire suppression standards. Building A2, equipped throughout with battery-powered emergency egress lighting units, is a Level 2 facility supported by a 25 KW, 208Y/120 volt, stand-by electrical system powered by a natural gas prime mover. This survey, conducted July 02, 2024 inspected building A2 for compliance to fire safety requirements for Existing Health Care Occupancies as contained in Chapter 19 of the 2012 edition of NFPA 101, the Life Safety Code. Building A2 is protected throughout by a National Fire Protection Association (NFPA) Type 13 automatic fire suppression system. The surveyor discussed each deficient item with the Director of Maintenance during the survey, and again with the Director of Maintenance and the Administrator during an Exit Conference.

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 7.2.1.4.5.11. Egress doors 2, 8 & 7 green mile racked (sticking when opening) and north wing 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:(1) The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.(3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23.(4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9. The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:(1) The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.(3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23.(4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance team at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. 1. Main stove needs placement markers to return after movement for system coverage...ie chalksNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Annual Fire Alarm report states "Semi-Annual Visual Inspection Only"NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and Maintenance discussed deficient items at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Door 22 needs repair did not latch, Door 20 needs a knob, Deadbolt in the fire door by room 14 (needs to be removed) 2. Fire doors by Green Mile Nurses station drags on floor 3. Generator room 2-hour rating needs to seal penetrations NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidenced by the following: 1. Missing April and May 2024 generator inspection reports8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

A recertification survey with complaint #CO32340 and #CO35500 was completed on 6/2/24 to 6/5/24. Nine deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/2/24 to 6/5/24. One deficiency was cited.

Based on record review and interview, the facility failed to have a complete emergency preparedness communication plan that complies with Federal, State, and local laws. Specifically, the facility failed to ensure there was a written plan for sharing information and medical documentation for residents under the facility's care, with other health providers to maintain continuity of care. Findings include:I. Facility planThe emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 6/5/24 at 11:00 a.m. -Review of the EPP revealed the facility did not have a policy based on the emergency plan to identify a method for sharing information and providing information about the general condition and location of residents under the facility's care with other health providers, as permitted, in the event of an emergency. II. Staff interviewThe EPP was reviewed with the NHA on 6/5/24 at 11:00 a.m. The NHA said the facility did not have a policy based on the emergency plan to identify a method for sharing information and providing information about the general condition and location of residents under the facility's care with other health providers, as permitted, in the event of an emergency. The NHA said it was important to update the EPP annually and as needed to keep up with the requirements.

Based on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for one (#2) of one resident out of 37 sample residents. Specifically, the facility failed to invite Resident #2's representative to participate in the care conferences to review the resident's plan of care. Findings include: I. Facility policy The Care Planning - Interdisciplinary Team policy, revised March 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, "The interdisciplinary team is responsible for the development of resident care plans."The resident, the resident's family and/or the resident's legal representative or surrogate are encouraged to participate in the development of and revisions to the resident's care plan."If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record." II. Resident #2 A. Resident status Resident #2, age 79, was admitted on 1/19/24. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, severe dementia with mood disturbances, sleep apnea, hearing loss and insomnia (difficulty sleeping). The 5/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He was dependent on staff for toileting, showering, personal hygiene, and dressing. He required supervision for eating and substantial assistance with oral hygiene. B. Resident representative interview The resident's representative was interviewed on 6/3/24 at 9:42 a.m. She said the facility did not invite her or the other resident's representatives to the care conferences. She said she was frustrated because the only time she was updated on the resident's care was when the facility wanted to change his risperdal (antipsychotic medication). She said the facility did not communicate with her and it took a long time to get the resident enrolled in hospice care. C. Record review The 1/23/24 multidisciplinary care conference note revealed the Resident #2's representative did not attend the care conference. The 4/30/24 multidisciplinary care conference note revealed the resident's representative did not attend the care conference. The 5/7/24 multidisciplinary care conference note revealed the residen'ts representative did not attend the care conference. The 5/16/24 multidisciplinary care conference note revealed the resident's representative did not attend the care conference. A review of the Resident #2's electronic medical record (EMR) on 6/5/24 at 9:00 a.m. revealed there was no documentation that the resident's representative was contacted to attend the care conferences on 1/23/24, 4/30/24, 5/7/24 and 5/16/24. III. Staff interviews The social services director (SSD) was interviewed on 6/5/24 at 10:40 a.m. The SSD said the MDS coordinator was responsible for coordinating care conferences. The SSD said care conferences were completed at least quarterly. The SSD said a care conference was held more frequently if the resident had a change in condition. The SSD said the social services department, the MDS coordinator, the dietary manager, the activities department and restorative services attended the care conferences. The SSD said the social services department was responsible for inviting the resident's representative. The SSD said a card was sent, by mail, 45 days before the care conference date. The SSD said the resident's representative called to confirm if they could or could not attend the conference. The SSD said if the representative did not call, social services was responsible for calling the representative the day before the care conference and when the care conference started. The SSD said the social services department documentedin a progress note that a card was sent and if the resident's representative was contacted. The SSD said the social services department did not invite Resident #2's representative to any care conferences because she thought the representative did not want to be a part of the resident's care plan. The SSD said she should have called the representative to allow them to accept or decline. The SSD said she would contact the Resident #2's representative for future care conferences. The SSD said she would document in a progress note if the representative wanted to attend the care conferences. The director of nursing (DON) was interviewed on 6/5/24 at 11:11 a.m. The DON said Resident #2's representative should have been invited to the care conferences that took place. The DON said the social services department was responsible for inviting the resident or resident's representative to care planning conferences.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#87) of three residents reviewed for accidents/hazards out of 37 sample residents. Specifically, the facility failed to ensure Resident #87 had an order for a medication (Aleve) found at his bedside or a self medication assessment. Findings include:I. Resident statusResident #87, age 69, was admitted on 5/6/24. According to the June 2024 computerized physician's order (CPO), diagnoses included difficulty walking, muscle weakness and abnormality of gait. The 5/15/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. II. Record reviewThe care plan, initiated 5/7/24 and updated 5/14/24, identified the resident had activities of daily living (ADL) self care performance deficits. Interventions included supervising and assisting the resident with ADLs. A review of Resident #87's electronic medical record (EMR) did not reveal the resident had a physician's order for Aleve (pain medication). A review of Resident #87's EMR did not reveal a self medication assessment. III. Observations and interviewThere was a bottle of Aleve was on a television tray in Resident #87's room on 6/2/24 at 11:15 a.m. There was a bottle of Aleve was on a television tray in Resident #87's room on 6/3/24 at 2:05 p.m. There was a bottle of Aleve was on a television tray in Resident #87's room on 6/4/24 at 10:41 a.m. Licensed practical nurse (LPN) #2 retrieved the bottle of Aleve. She said Resident #87 did not have a physician's order for Aleve. Resident #87 said he only had it for when he had a headache. He said he did not need to tell a doctor about a headache. He said he had purchased the bottle while out of the facility. LPN #2 said she would let the provider know and ask for an as needed (PRN) medication for headaches. She removed the bottle from the resident's room. IV. Staff interviewThe director of nursing (DON) was interviewed on 6/4/24 at 11:30 a.m. The DON said the facility did not have any residents who were allowed to self administer medications. She said staff should have seen the bottle of Aleve and removed it from the resident's room.. She said if Resident #87 needed medication for headaches, the facility could ask the provider for a PRN medication order.

Based on interviews and record review, the facility failed to ensure two (#18 and #19) of four residents investigated for abuse out of 37 sample residents were kept free from physical abuse. Specifically, the facility failed to:-Prevent a physical altercation between Resident #93 and Resident #19, and,-Prevent a physical altercation between Resident #71 and Resident #18. Findings include:I. Facility policyThe Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, reviewed September 2022, was provided by the nursing home administrator (NHA) on 6/2/24 at 3:36 p.m. The policy read in pertinent part, "Findings of all investigations are documented and reported." "Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.""All allegations are thoroughly investigated. The administrator initiates investigations."The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility."II. Altercation on 3/21/24 between Resident #93 and Resident #19A. Facility investigation of the altercation on 3/21/24The witness statement dated 3/21/24 by certified nurse aide (CNA) #7, noted she heard some yelling and saw Resident #19 on the floor being kicked by Resident #93. The victim statement dated 3/21/24 documented Resident #19 said he saw Resident #93 leaving his room with his belongings. Resident #19 told Resident #93 to give the items back. Resident #93 then slammed Resident #19 to the ground and started kicking Resident #19. Resident #19 stated he was afraid of Resident #93. A progress note dated 3/21/24 at 11:30 a.m. identified Resident #93 was in Resident #19's room. Resident #19 confronted Resident #93 for taking his belongings. Resident #93 pushed Resident #19 into the wall then threw Resident #19 to the floor and kicked Resident #19. Resident #93 admitted to pushing Resident #19. B. Resident #191. Resident statusResident #19, age 69, was admitted on 8/26/13, and readmitted on 8/23/22. According to the June 2024 computerized physician's orders (CPO), diagnoses included paranoid schizophrenia (mental illness that affects a person's thoughts and behaviors), type II diabetes and chronic obstructive pulmonary disease (COPD). The 4/20/24 minimum data set (MDS) assessment documented the resident was moderately cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment did not identify behaviors during the assessment period. 2. Record reviewThe care plan, initiated 6/29/23, identified Resident #19 had the inability to problem solve. Interventions included the staff were to remind Resident #19 to ask for help. The care plan, initiated 6/29/23, identified the diagnosis of schizophrenia to include paranoid ideation. Interventions included the target behaviors of paranoia and people persecuting him. Staff were to monitor for the behaviors. The progress note, dated 3/21/24 at 10:50 a.m. identified the following injuries to Resident #19 from the altercation with Resident #93:-A scalp contusion to the forehead, -An abrasion to the right arm measuring 0.5 centimeters (cm) by 0.3 cm;-An abrasion to the left hand measuring 0.1 cm by 0.5 cm; -An abrasion to the right arm measuring 1.2 cm by 0.5 cm; and,-A contusion to the right side of the forehead measuring 4.3 cm by 4 cm. The progress note dated 3/21/24 at 3:21 p.m. noted the resident had returned from the hospital with a contusion on the right side of the forehead that had been cleansed with normal saline (NS) and Bacitracin (topical antibiotic ointment) was applied. There were abrasions to his left and right arms also. C. Resident #931. Resident statusResident #93, age 72, was admitted on 3/11/24 and discharged to the hospital on 3/21/24. According to the March 2024 CPO, diagnoses included Alzheimer's disease, dementia and amnesia (memory loss). The 3/20/24 MDS assessment documented the resident had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment did not identify any behaviors during the look back period. 2. Record reviewThe care plan, initiated 3/11/24, identified the resident had a diagnosis of dementia which made it hard for him to know time or place. Interventions included if he became upset, try to find out the cause and address it or resolve it. The care plan, initiated 3/13/24, identified Resident #93 was at risk for impaired psychiatric/mood status secondary to amnesia, dementia, anxiety, and Alzheimer's disease. Interventions included providing a calm and safe environment when the patient was emotional or frustrated and allowing time to voice his feelings. The multidisciplinary care conference form dated 3/19/24, identified Resident #93 would get confused regarding which room was his and he needed redirection to find his room. Interventions included potentially placing a sign on his door as a visual cue.-The facility failed to update Resident #93's care plan with the intervention discussed in the care conference on 3/19/24. The progress noted dated 3/21/24 at 11:30 a.m. identified the provider gave a verbal order to send Resident #93 to the hospital for an evaluation after the altercation. Resident #93 did not return to the facility following his discharge to the hospital. D. Staff interviewsCNA #3 was interviewed on 6/4/23 at 1:55 p.m. CNA #3 said Resident #93 had a habit of wandering into other resident's rooms and saying items he found were his. She said when the altercation on 3/21/24 occurred, she saw Resident #19 on the floor getting kicked. She said she helped separate both the residents and called the administrative staff. She said Resident #19 had a scrape on his knees and a rug burn on his head. She said the other residents were afraid of Resident #93. The NHA was interviewed on 6/5/24 at 12:30 p.m. The NHA said the facility immediately separated the residents and each resident was placed on one on one staff monitoring until they were both sent to the hospital to see if they had suffered any injuries beyond the noted ones by the staff. She said the facility worked hard to prevent abuse in any form. III. Altercation on 5/28/24 between Resident #18 and Resident #71A. Facility investigationHousekeeper (HSK) #1's statement, dated 5/28/24, indicated Resident #71 yelled at Resident #18, then got up and went over and slapped Resident #18 in the face. She said she could not hear what they were saying to each other. The investigation documented that during the investigation, Resident #71 continued to deny slapping Resident #18 even after showing him the video evidence. A progress note, dated 5/28/24 at 3:42 p.m., noted Resident #18 went outside to smoke and Resident #71 slapped him. Resident #18 was taken back inside the facility by staff. Resident #18 was noted to have a red mark on his left cheek. B. Resident #181. Resident statusResident #18, age 69, was admitted on 6/25/14 and readmitted on 4/16/18. According to the June 2024 CPO, diagnoses included cerebral infarction (stroke), aphasia (difficulty talking) and left side weakness. The 3/20/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment identified one episode of verbal behaviors during the assessment period. 2. Record reviewThe care plan, revised 2/20/24, identified Resident #18 would display behaviors that included knocking people down. Interventions included allowing Resident #18 to express his feelings in appropriate ways, analyzing the behavior for a possible cause and effect relationship and explaining his behavior was not acceptable. C. Resident #711. Resident statusResident #71, age less than 65, was admitted on 2/14/23 and discharged home on 5/28/24. According to theMay 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart disease and respiratory failure. The 3/20/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment identified one episode of verbal behaviors during the assessment period. 2. Record reviewThe care plan, initiated 10/16/23, identified Resident #71 had impaired psychiatric/mood status related to depression. Interventions included providing him with quality listening time and encouraging expressions of feelings.-The facility failed to identify and care plan that Resident #71 displayed verbal behaviors towards others (see MDS assessment above). The progress note, dated 5/28/24 at 3:21 p.m. documented Resident #71 began yelling at Resident #18. Resident #71 stood up and slapped Resident #18 on the left cheek. A nurse in the building heard a commotion, went outside to see what was going on. The nurse took Resident #18 into the facility. When Resident #71 was questioned, he denied he hit Resident #18. Resident #71 was shown the video of him hitting Resident #18 on the left cheek. Resident #71 was put on a one on one staff monitoring. IV. Staff interviewsThe social services assistant (SSA) was interviewed on 6/4/24 at 2:30 p.m. The SSA said Resident #71 was planning to leave the facility at the end of May 2024. She said he had not displayed any kind of aggressive behavior toward another resident before. She said he denied the assault even after he watched the video. She said Resident #18 had a reddened cheek after the incident. The NHA was interviewed on 6/5/24 at 12:30 p.m. The NHA said Resident #71 had not displayed aggressive behaviors previous to the altercation. She said after the one on one was started, Resident #71 signed out of the facility against medical advice (AMA) shortly after the altercation. She said everyone who lived at the facility had the right to be free from any form of abuse to include physical abuse.

Based on observations, record review and interviews, the facility failed to ensure one (#80) of three residents with skin conditions of 37 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to identify, assess, monitor and care plan a large growth on Resident #80's face. Findings include:I. Resident statusResident #80, age over 65, was admitted on 10/31/23. According to the June 2024 computerized physician's order (CPO), diagnoses included atrial fibrillation (irregular heart beat), dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD). The 4/20/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. II. ObservationOn 6/2/24 at 1:15 p.m. Resident #80 was observed to have a large growth that was approximately the size of a pear on the right side of his face in front of his right ear. III. Record reviewA 11/1/23 physician's note identified a mass on the right side of Resident #80's face by the mandible (jaw). A 12/20/23 physician's note identified the mass on the right side of the resident's face near the mandible. A 2/21/24 physician's note identified a large mass on the right side of the resident's face. A 4/16/24 physician's note identified a large growth on the right side of the resident's face by the mandible.-Resident #80's care plan did not address the growth on the right side of the resident's face.-The resident's admission assessment did not identify the resident had a growth on the right side of his face. -The facility did not have any assessments or monitoring of the growth on the right side of his face. IV. InterviewsCertified nurse aide (CNA) #8 was interviewed on 6/4/24 at 10:10 a.m. CNA #8 said Resident #80 had always had the growth on his face. She said she did not think there were any special treatments for the growth. She said the family did not want any procedures done to the growth. She said if staff saw any changes to the growth she would report the changes to the nurse. Registered nurse (RN) #1 was interviewed on 6/5/24 at 9:00 a.m. RN #1 said the growth on Resident #80's face had always been there. She said she did not have an order to monitor the area. She said if she saw a change in the area she would have notified the director of nursing (DON). She said the family did not want any treatment to the area. The DON was interviewed on 6/5/24 at 11:15 a.m. The DON said the facility should have identified the growth upon initial assessment when the resident was admitted to the facility. She said she did not know why the growth was not being monitored by the facility staff. She said she did not know why there was not a care plan identifying the growth and indicating that the family wished to not remove the growth. She said the provider would see the resident later that day (6/5/24) and she would provide education to have the staff start monitoring the area. She said she would have a care plan started to identify the growth and the wishes of the family for non-treatment.

Based on observations, record review, and interviews the facility failed to use a person-centered approach when determining the use of bed rails for four (#27, #36, #40, and #70) of ten residents reviewed for bed rails out of 37 sample residents. Specifically, for Resident #27, #36, #40 and #70, the facility failed to:-Assess the resident for risk of entrapment prior to installing the bed rails;-Obtain consent, which included the risks versus benefits of bed rails, from the resident and/or the resident's representative prior to bed rail installation; and,-Conduct quarterly assessments of the bed rails to evaluate the safety and/or continued need for bed rails. Findings include:I. Professional referenceThe U.S. (United States) Food and Drug Administration (FDA) Recommendations for Health CareProviders Using Adult Portable Bed Rails (2/27/23), was retrieved on 6/8/24 fromhttps://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails. It read in pertinent part, "Avoid the routine use of adult bed rails without first conducting an individual patient or residentassessment. "Evaluation is needed to assess the relative risk of using the bed rail compared with not using itfor an individual patient." II. Facility policy and procedureThe Bed Safety and Bed Rails policy and procedure, revised August 2022, was provided by the nursing home administration (NHA) on 6/8/24 at 12:00 p.m.. It read in pertinent part, "Residents' beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails are prohibited unless the criteria for use have been met."Consideration is given to the residents' safety, medical conditions, comfort and freedom of movement, as well as input from residents and resident families regarding previous sleeping habits and bed environment."Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks."The maintenance department provides a copy of inspections to the administrator and reports results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action."III. Resident #27A. Resident statusResident #27, over the age of 65, was admitted on 1/29/16. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure, chronic pain syndrome, and arthritis of the right shoulder. The 3/20/24 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 supervision with transfers, toileting, personal hygiene, eating, and bed mobility. -The assessment documented Resident #27 did not use bed rails. B. Observations On 6/3/24 at 9:40 a.m., Resident #27 was sitting in her wheelchair in her room with one metal half bed rail attached to the resident's bed. On 6/4/24 at 1:15 p.m., Resident #27 was lying in bed with one metal half bed rail attached to her bed. C. Resident interview Resident #27 was interviewed on 6/4/24 at 9:17 a.m. Resident #27 said the side rail helped her with transfers. She said the bed rail had been attached to the bed since she arrived in the room. D. Record review -The June 2024 CPO revealed Resident #27 had no physician's order for a bed rail on one side of the resident's bed to help with mobility. The comprehensive care plan, initiated and revised on 6/11/23, revealed Resident #27 had impaired mobility, poor range of motion and was at risk for falls.-The care plan failed to include an intervention for the use of a bed rail for Resident #27. -A comprehensive review of the resident's electronic medical record (EMR) failed to reveal a bed rail evaluation and consent prior to the initiation of the one bed rail as a positioning enabler. -The EMR failed to reveal quarterly assessments for theevaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. IV. Resident #36A. Resident statusResident #36, under the age of 65, was admitted on 10/31/17. According to the June 2024 CPO, diagnoses included paraplegia, type 2 diabetes mellitus, bipolar disorder and difficulty in walking. The 5/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision assistance with toileting, showering, dressing, personal hygiene and mobility. -The assessment documented Resident #36 did not use bed rails. B. ObservationOn 6/3/24 at 9:50 a.m. and 6/4/24 at 3:02 p.m., one bed rail was observed on the left side of Resident #36's bed. On 6/5/24 at 9:05 a.m. Resident #36 was lying down in bed with a bed rail attached to her bed on the left side. C. Resident interviewResident #36 was interviewed on 6/5/24 at 9:06 a.m. Resident #36 said she was offered a new bed by the facility and the new bed arrived with one side rail. The resident said she used the side rail to assist her with transfers and positioning during incontinence care. She said the bed rail prevented her from falling out of bed. D. Record reviewThe care plan, revised on 4/11/24, revealed Resident #36 was at risk for falls due to impaired mobility related to the diagnosis of paraplegia. Interventions included to assess the need for assistive/supportive devices.-The care plan failed to include an intervention for the use of a bed rail for Resident #36. -A review of Resident #36's June 2024 CPO revealed there was no physician's order for the resident's bed rail. -The resident's EMR revealed Resident #36 was not evaluated for the use of a bed rail, there was no consent for bed rails, and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. V. Resident #40 A. Resident status Resident #40, over the age of 65, was admitted on 7/7/20. According to the June 2024 CPO, diagnoses included muscle weakness, anemia, abnormality of gait and movement and pain. The 4/5/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance for mobility and maximum assistance with showers, personal hygiene, and toilet transfers. -The assessment documented Resident #40 did not use bed rails. B. Observation On 6/3/24 at 10:00 a.m. and 6/4/24 at 2:15 p.m., Resident #40 was sitting in her wheelchair in her room. A bed rail was observed attached to the right side of the resident's bed. C. Resident interview Resident #40 was interviewed on 6/3/24 at 11:04 a.m. Resident #36 said the bed rail was for her to hold on to to assist her with turning herself during incontinence care at night. D. Record review The resident's care plan, revised on 2/11/24, revealed Resident #40 had potential for skin integrity impairment due to immobility. The care plan documented the use of a right-sided grab bar (bed rail) attached to the resident's bed for assistance in repositioning. -A review of Resident #40's June 2024 CPO revealed there was no physician's order for the resident's bed with the bed rail. -The resident's EMR revealed Resident #40 was not evaluated to use a bed rail. There was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. VI. Resident #70 A. Resident status Resident #70, age greater than 65, was admitted on 10/26/23. According to the June 2024 computerized CPO, diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), muscle weakness, chronic pain and rheumatoid arthritis. The 4/30/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required supervision assistance with showers, toileting and personal hygiene. -The assessment documented Resident #70 did not use bed rails. B. Observation On 6/3/24 at 10:30 a.m. and 6/4/24 at 1:57 p.m. bed rails were observed on both sides of Resident #70's bed. C. Record review The care plan, revised on 10/30/23, revealed Resident #70 was at risk for falls related to obesity, muscle weakness, pain and rheumatoid arthritis. -It indicated the use of a grab bar (bed rail) for assistance with bed mobility. -A review of Resident #70's June 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #70 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VII. Staff interviews The physical therapy assistant (PTA) was interviewed on 6/5/24 at 11:00 a.m. The PTA said the bed rails were handles added to the sides of the bed to assist residents during transfers and repositioning. The PTA said. if used appropriately, bed rails could help residents become independent. She said she had noticed several resident's beds with the bed rails and would assume all of the residents had physician's orders and assessments completed for the bed rails. She said the maintenance department should be monitoring the functioning of the bed rails. The maintenance supervisor (MS) was interviewed on 6/5/24 at 11:15 a.m. The MS said he installed the bed rails of the residents' beds when he received a maintenance order from nursing staff. He said he thought, before an order was placed for a bed rail, the nursing staff would ensure the proper assessment for the bed rails had been completed. The MS said there was no ongoing monitoring of the bed rails once he initially installed them. The director of nursing (DON) was interviewed on 6/5/24 at 12:42 p.m. The DON said it was the policy of the facility to complete a bed rail assessment prior to attaching bed rails to a bed. She said the therapy department was responsible for completing bed rail assessments. She said once the decision was made to attach bed rails to a resident's bed frame, it was the responsibility of nursing staff to obtain informed consent from the resident or resident's representative. The DON said it was the responsibility of the nursing unit nurse manager to update a resident's care plan to identify the bed rail use as an intervention. The DON said when bed rails were attached to residents' bed frames there should be ongoing routine maintenance checks for functioning. The DON said routine maintenance checks were not being done and she would immediately ensure consent, assessment, and routine monitoring of all bed rails.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #5 and CNA #6. Findings include:I. Record reviewCNA #2 (hired on 2/1/11), CNA #3 (hired on 7/26/11), CNA #5 (hired on 4/5/23) and CNA #6 (hired on 1/26/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. InterviewThe director of nursing (DON) was interviewed on 6/4/24 at 12:30 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of the reviews. She said going forward she would ensure the performance reviews were completed annually to ensure the best care was being delivered to the residents.

Based on record review and interviews, the facility failed to ensure three (#2, #21, #54) of five residents reviewed for unnecessary medications out of 37 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #2, Resident #21 and Resident #54 had appropriate non-pharmacological interventions for behaviors initiated; and, -Ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained from the resident or resident's representative before the resident's use of a psychotropic medication for Resident #2, Resident #21 and Resident #54. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, "Non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for the discontinuation of medications when possible."Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes the indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences and preventing, identifying and responding to adverse consequences."Residents and representatives have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident and representative the risks related to not taking the medication as well as appropriate alternatives."II. Resident #2 A. Resident status Resident #2, 79 years old, was admitted on 1/19/24. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, severe dementia with mood disturbances, sleep apnea, hearing loss and insomnia (difficulty sleeping). The 5/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of zero out of 15. He was dependent on staff for toileting, showering, personal hygiene, and dressing. He required supervision for eating and substantial assistance with oral hygiene. The resident exhibited verbal and other behavioral symptoms not directed towards others one to three days. The resident took antipsychotic, antidepressant and hypnotic medications on a routine basis. B. Resident representative interview The resident's representative was interviewed on 6/3/24 at 9:42 a.m. She said the resident had a terrible time when he was admitted to the facility. She said she was frustrated because the facility tried a couple of times to decrease his Risperdal (medication used to treat mood disorders). She said it was difficult for him with the constant changes in the strength of the Risperdal because his behaviors like spitting and kicking were managed. She said when the facility tried to lower the strength his behaviors were not managed. She said she wished they kept him at the dose where his behaviors were managed. She said she did not know if the facility tried non-pharmacological interventions in addition to the antipsychotic medications he was prescribed. C. Record review The dementia and Alzheimer's care plan, revised on 2/2/24, revealed the resident had impaired cognitive function related to dementia with delusions and Alzheimer's disease. Interventions included monitoring for side effects of medication and disease conditions that could affect his cognition and orientation, redirecting as needed and notifying hospice and the primary care physician of any significant changes in resident's baseline cognitive status. The psychiatric and mood status care plan, revised on 2/2/24, revealed the resident was at risk for impaired mood status related to dementia, Alzheimer's disease and depression. Interventions included monitoring and reporting to hospice of any signs or symptoms of acute psychosis or changes from resident's baseline and monitoring sleep pattern changesThe psychotropic medication care plan, revised on 1/29/24, revealed the resident took psychotropic medications related to insomnia, dementia and depression. Interventions included monitoring for adverse effects of antidepressant medication and antipsychotic medication, monitoring for effectiveness and completing a quarterly review for gradual dose reduction if appropriate. -A review of the comprehensive care plan revealed there was not an intervention that identified person-centered non-pharmacological interventions. The June 2024 CPO revealed the following physician orders: Lexapro (medication used to treat depression) 5 milligrams (mg). Administer one tablet by mouth one time a day related to dementia with mood disturbance, ordered 5/2/24. Trazodone (antidepressant medication) 100 mg. Administer one tablet by mouth at bedtime for insomnia, ordered 4/18/24. Risperdal 1 mg. Administer one tablet by mouth two times a day for hospice related to dementia with severe mood disturbance, ordered 5/11/24. Lorazepam (anti-anxiety medication) 2mg/ml (milliliters). Administer 0.5 ml by mouth every four hours as needed for anxiety, agitation and for hospice, ordered 6/4/24. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include a calm approach, positive reassurance, one on one, quiet environment, offering fluids or snacks, diversion activities, re-orientation and redirection. Document "Y" for interventions were attempted and "N" for no interventions were attempted, ordered 1/20/24. -The January 2024 MAR revealed non-pharmacological interventions were not offered on 24 of 31 days. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 18 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 30 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 30 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's electronic medical record (EMR) revealed there was no documentation to indicate person centered non-pharmacological behavioral interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read "Consent to use" and one box read "Refuse the use." The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent form for Resident #2's Lorazepam revealed the resident's representative had signed the form, however, neither of the boxes on the consent form was marked to indicate whether or not the representative gave consent to use or refused the use of the medication for Resident #2. III. Resident #21 A. Resident status Resident #21, 71 years old, was admitted on 11/24/20. According to the June 2024 CPO, diagnoses included paranoid schizophrenia (psychosis that affects thoughts and behavior), extrapyramidal and movement disorder (a drug-induced disorder that causes uncontrollable movement), hallucinations, insomnia and anxiety. The 2/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required partial assistance with oral hygiene, personal hygiene and showering. He required substantial assistance with toileting and dressing. B. Record review The anxiety care plan, revised on 7/16/23, revealed the resident had an anxiety disorder that caused continuous pacing. Interventions included eliminating or correcting underlying causes of problems, offering drink or food, sitting with him, and promoting relaxation exercises. The aggressive behavior care plan, revised on 7/16/23, revealed the resident had a history of aggressive behaviors towards staff and peers. Interventions included offering the resident to listen to classical music, providing deep breathing exercises, going on short walks, and providing him with his teddy bear. The antipsychotic medication care plan, revised on 7/16/23, revealed the resident was at risk for adverse side effects. Interventions included monitoring for target behaviors of pacing, yelling and hallucinating. The June 2024 CPO revealed the following physician orders: Clozapine (antipsychotic medication) 100 mg. Administer one tablet by mouth one time a day at 8:00 a.m. and administer three tablets by mouth one time a day at 8:00 p.m. for paranoid schizophrenia, ordered 2/1/23. Clonazepam 0.5 mg. Administer one tablet by mouth one time a day for anxiety, ordered 2/1/23. Trazodone 50 mg. Administer one tablet by mouth at bedtime for insomnia, ordered 2/1/23. Risperidone 1 mg. Administer one tablet by mouth two times a day for paranoid schizophrenia, ordered 2/1/23. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include repositioning, pillows for support, cold compress and massage. Document "Y" for interventions were attempted and "N" for no interventions were attempted, ordered on 2/12/24. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 23 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's EMR revealed there was no documentation to indicate person centered non-pharmacological behavior interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read "Consent to use" and one box read "Refuse the use." The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent forms for Resident #21's clozapine, clonazepam, trazodone and risperidone revealed the resident's representative had signed the consent forms for each psychotropic medication, however, neither of the boxes on the consent forms was marked to indicate whether or not the representative gave consent to use or refused the use of the medications for Resident #21. IV. Resident #54A. Resident status Resident #54, age greater than 65, was admitted on 11/12/20. According to the June 2024 CPO, diagnoses included severe dementia with agitation, insomnia and muscle weakness. The 2/15/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. She required partial assistance with oral hygiene, toileting, dressing and personal hygiene. She required substantial assistance with showering. B. Record review The antipsychotic drug use care plan, revised on 2/2/24, revealed the resident was at risk for side effects and falls. Interventions included assessing the resident for adverse side effects, completing quarterly psychotropic medication review and administering medications as ordered. The sleep care plan, revisedon 6/23/23, revealed the resident had difficulty with insomnia. Interventions included monitoring sleep patterns, providing a pharmacy consultant review of medication and side effects. The June 2024 CPO revealed the following physician orders: Donepezil (medication used for Alzheimer's disease) 5 mg. Administer one tablet by mouth at bedtime for dementia with severe agitation, ordered 9/25/23. Risperdal 0.25 mg. Administer one tablet by mouth at bedtime for agitation for dementia with agitation, ordered 6/3/24. Trazodone 50 mg. Administer 1.5 tablets by mouth at bedtime for insomnia, ordered 5/18/24. Memantine 10 mg. Administer one tablet by mouth two times a day for severe dementia with agitation, ordered 3/19/24. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include calm approach, positive reassurance, one on one, quiet environment, fluids/snacks, diversion activities, re-orientation and redirection. Document "Y" for interventions were attempted and "N" for no interventions were attempted, ordered 12/29/23. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include repositioning, pillows for support, cold compress and massage. Document "Y" for interventions were attempted and "N" for no interventions were attempted, ordered 12/29/23. -The January 2024 (1/1/24 to 1/31/24) MAR revealed non-pharmacological interventions were not offered on 14 of 31 days. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 18 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 24 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's EMR revealed there was no documentation to indicate person centered non-pharmacological behavior interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read "Consent to use" and one box read "Refuse the use." The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent forms for Resident #54's Risperdal, trazodone, donepezil and memantine revealed the resident's representative had signed the consent forms for each psychotropic medication, however, neither of the boxes on the forms was marked to indicate whether or not the representative gave consent to use or refused the use of the medications for Resident #54. V. Staff InterviewsLicensed practical nurse (LPN) #2 was interviewed on 6/5/24 at 9:46 a.m. LPN #2 said she tried non-pharmacological interventions when a resident was anxious or had facial grimacing. She said interventions included playing music, playing a video or porch time. She said she documented non-pharmacological interventions in progress notes as a behavior note. LPN #2 said said Resident #2's effective non-pharmacological interventions included repositioning, lying down in the recliner or in his bed, playing music and playing an action movie. LPN #2 said Resident #21's effective non-pharmacological interventions included offering him to read a book, complete a puzzle and word searches. LPN #2 said Resident #54's effective non-pharmacological interventions included to keep her near staff, provide one on one care, talk to the resident and read the newspaper. LPN #2 said consent for psychotropic medications was obtained at the time of admission by the admissions department. She said once a resident was admitted, social services was responsible for obtaining consent when a resident was prescribed a new psychotropic medication. She said she checked the resident's EMR to ensure a consent form was on file for each psychotropic medication. The social services director (SSD) was interviewed on 6/5/24 at 10:40 a.m. The SSD said the social services department and the nursing staff determined behaviors that needed to be monitored. The SSD said she completed a demographics form upon a resident's admission to the facility. She said she wrote any behaviors that needed to be monitored in the comment section. The SSD said she wrote non-pharmacological interventions in the same area. She said nursing staff were responsible to offer and to document the non-pharmacological interventions that were attempted. She said the nurse documented the behavior and interventions in a behavior progress note. The SSD said she was familiar with Resident #2, Resident #21 and Resident #54. The SSD said Resident #2 found Native American music was helpful when he had behaviors. The SSD said Resident #21 found if staff walked with him or talked to him about different topics was helpful when he had behaviors. The SSD said Resident #54 found reading flower and family magazines was helpful when she had behaviors. The SSD said informed consents should be signed before a psychotropic medication was administered. She said the admissions department was responsible for obtaining consent for any medications the resident took at the time of admission. She said the psychotropic medication consent form was part of the admissions paperwork the resident or representative reviewed and signed. She said the consent forms contained a section for each type of psychotropic medication, what side effects would be monitored and what the risks and benefits were for each type of psychotropic medication. The SSD said the resident or the resident's representative authorized the facility that psychotropic medications may or may not be administered by an initial next to the phrase "Consent to use" or the phrase "Refuse the use" on the consent form. The initials were to be obtained on the form in addition to a resident or resident representative's signature. The SSD said she was not sure what the nurses did when a resident was prescribed a new psychotropic medication. She said she thought the nurses called the resident's representative to review the medication, why it was prescribed, the side effects and the risks versus benefits of the medication. She said she thought the nurses obtained verbal consent and documented the conversation in a progress note. The SSD said she mailed a two page consent form to the resident's representative. She said once the consent was mailed back, she added the informed consent form to the resident's EMR. The SSD said she did not check the progress notes to see if the nurses documented their phone call to the resident's representative. She said she should start checking the nurses progress note. The SSD confirmed Resident #2, Resident #21 and Resident #54 were administered psychotropic medications without a signed informed consent. The director of nursing (DON) was interviewed on 6/5/24 at 11:11 a.m. The DON said the nurses did not consistently offer and did not document if non-pharmacological interventions were offered. She said non-pharmacological interventions should be documented in the resident's MAR. She said the type of non-pharmacological interventions offered and used should be documented in the resident's MAR.The DON said when an existing resident was prescribed a new psychotropic medication the nurse called to notify the resident's representative. The DON said the nurse only contacted the resident's representative to inform them the resident had started a new medication. The DON said the resident's representative did not review why it was prescribed, the side effects, and the risks versus benefits. She said informed consents should be obtained before the nurse administered a new psychotropic medication to a resident. The DON said she would change the process so nursing staff was responsible for obtaining informed consents on psychotropic medications. The DON confirmed Resident #2, Resident #21 and Resident #54 were administered psychotropic medications without a signed informed consent.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the facility's kitchen and dining room. Specifically, the facility failed to:-Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled;-Ensure cooking utensils were dried appropriately;-Ensure food preparation area vents were free from hanging dust and lint;-Ensure the main dining room refrigerator maintained a safe operating temperature; and,-Ensure dented food cans were not used. Findings include: I. Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled. A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 6/13/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, "Time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. "A date marking system may include using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine, marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded and/or marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded." B. Observations On 6/2/24 at 2:15 p.m. the following was observed at the main dining room nourishment refrigerators during the initial kitchen tour:-In the dining room refrigerator, there were two opened gallons of milk. Both of the gallons of milk were not labeled with the date they were opened or the date they were to be used by. -Additionally, one of the gallons of milk did not have a lid on it. On 6/3/24 at 2:30 p.m. the south side unit refrigerator was observed to have a half-used bottle of mango juice which was not dated with the date it was opened or a use by date. C. Staff interviews Dietary aide (DA) #1 was interviewed on 6/4/24 at 2:40 p.m. DA #1 said opened beverages were to be dated and labeled to ensure every staff member knew when the beverage should be discarded. He said one of the gallons of milk in the dining room refrigerator had no lid and needed to be thrown away. He said residents could become sick from drinking milk products that had been left open without the lid or were past the date they should be discarded. II. Ensure cooking utensils were dried appropriately. A. Professional referenceThe Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 6/13/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, "Equipment and Utensils, Air-drying required. After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food and may not be cloth dried." B. Facility policy The nursing home administrator (NHA) provided the Dishwashing policy, with no revision date, on 6/11/24. The policy read in pertinent part, "The dishwashing procedures and techniques are well developed, understood, and carried out in compliance with the state and local health codes to assure the safety of the residents." C. Observation On 6/4/24 at 3:30 p.m. a volunteer and an unidentified staff member were observed using paper towels to dry eating and cooking utensils, such as silverware, plates, pots and pans, before placing them on the dish rack. D. Staff interview The dietary manager (DM) was interviewed on 6/4/24 at 4:00 p.m. The DM said the staff used paper towels to dry clean dishes to hurry the drying process so they could use the utensils again. The DM said she was unsure if utensils should be dried with paper towels and said she would verify the process with her supervisor. III. Ensure food preparation area vents were free from hanging dust and lint. A. Professional reference According to The Food and Drug Administration (FDA) Food Code (2019) p. 441, retrieved on 6/8/24 from https://www.fda.gov/media/164194/download?attachment, "Surface Characteristics: Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible."Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents." B. Facility policy and procedures The Sanitation policy, undated, was provided by the NHA on 6/11/24 at 12:01 p.m. It read in pertinent part, "Sanitation conditions are maintained at all times in the dietary department. Effective procedures for cleaning all equipment are well developed and are followed consistently." C. Observations On 6/2/24 at 3:30 p.m., during the initial kitchen tour, two vents in the food preparation area were observed to have hanging dust and cobwebs. On 6/4/24 at 3:00 p.m. the two vents in the food preparation area continued to have lint and dust around them. The cook was observed preparing mechanical and pureed food directly underneath the area where the vents were located. D. Staff interviews The DM was interviewed on 6/4/24 at 4:00 p.m. The DM said there was a daily, weekly and monthly cleaning schedule for maintaining the kitchen in a sanitary condition. The DM said the hanging dust and cobwebs around the vents in the food preparation area was unsanitary. The DM said the maintenance department were responsible for cleaning the high sky ceiling vents. She said a work order had been submitted. The DM said the hanging dust would be cleaned after hours by the maintenance department once the kitchen had completed all food services for the day. The maintenance supervisor (MS) was interviewed on 6/5/24. The MS said he was a new employee and was still being trained. The MS said he had received a work request for the cleaning of the kitchen vents but had not cleaned them yet. IV. Ensure the main dining room refrigerator maintains a safe operating temperature A. Professional reference The Food and Drug Administration (FDA) Food Code (2022), reviewed 1/18/23, was retrieved on 6/8/24 from https://www.fda.gov/food/retail-food-protection/fda-food-code. It read in pertinent part, "Bacterial growth and/or toxin production can occur if time/temperature control for safe food remains in the temperature 'danger zone' of 41 degrees Fahrenheit (F) to 135 degrees F for too long." B. Facility policy The Refrigerators and Freezers policy, undated, was provided by the NHA on 6/11/24 at 12:01 p.m. It read in pertinent part, "All refrigerated foods are stored in such a manner to keep them safe and free from contamination. The temperature of each refrigerated unit will be maintained below 40 degrees Fahrenheit (F)" C. Observations On 6/2/24 at 3:30 p.m. during the initial kitchen tour, the refrigerator in the main dining room, which contained beverages and snack foods, was observed with a temperature of 51 degrees F. On 6/4/24 at 4:00 p.m. the dining room refrigerator continued to have a temperature of 51 degrees F. D. Staff interview The DM was interviewed on 6/4/24 at 4:00 p.m. The DM said all nourishment refrigerators should maintain an operating temperature of 40 degrees F and below. She said it was unsafe for beverages and food items to remain too long in the food danger zone. The DM said all beverages and food items in the dining room refrigerator would be discarded and she would request maintenance to check the refrigerator. The DM was interviewed again on 6/5/24 at 11:30 am. The DM said the beverages and snack foods in the dining room refrigerator had been removed and the refrigerator would not be in use again until maintenance ensured that it was operating at a proper temperature. V. Ensure dented food cans were not used. A. Professional referenceAccording to the United States Department of Agriculture (USDA), retrieved on 6/13/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous. It read in pertinent part, "Never use food from cans that are leaking, bulging, or badly dented, cracked jars or jars with loose or bulging lids, canned food with a foul odor or any container that spurts liquid when opening. Such cans could contain clostridium botulinum. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam."While extremely rare, a toxin produced by it is the worst danger in canned goods. Don't taste such foods. Even a minuscule amount of botulinum toxin can be deadly. Recommended storage times are as follows: two to five years for low-acid foods (such as meat, poultry, fish, and vegetables; 12-18 months for high-acid foods (such as juices, fruit, pickles, tomato soup, and sauerkraut)." B. ObservationsOn 6/2/24 at 3:30 p.m., during the initial kitchen tour, one dented can of crushed pineapple and two dented cans of fancy shredded sauerkraut were observed on the canned food rack in the pantry. On 6/4/24 at 4:20 p.m. there was one dented crushed orange can observed on the canned food rack in the pantry. C. Staff interview The DM was interviewed on 6/5/24 at 11:30 am. She said she had previously removed the dented food cans from the rack but they somehow got put back on the food rack. The DM said staff were educated and were aware not to place dented food cans on the rack to be used. The DM said she had removed the dented can and would offer education to the kitchen staff immediately to avoid staff using any dented food cans. VI. Additional interviews The regional registered dietitian (RRD) was interviewed on 6/5/24 at 11:35 a.m. The RRD said dented food cans could allow bacteria growth which could be detrimental to the health of the residents. The RRD said kitchen utensils should be air dried according to facility policy and staff should avoid the use of paper towels to dry plates and silverware. She said drying utensils with paper towels could cause cross contamination leading to illnesses. The RRD said all opened beverages should be dated and labeled when opened. The NHA was interviewed on 6/5/24 at 11:50 a.m. The NHA said she had initiated training for the DM to complete and would ensure that all kitchen staff were appropriately retrained immediately to maintain proper refrigerator temperatures, air dry eating and cooking utensils and to ensure all opened items in the unit's refrigerators were dated and labeled. She said all dented food cans would be separated and returned to the vendor for credit or replacement.

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#89) of five residents receiving hospice services out of 37 sample residents. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures. Findings include:I. Facility policyThe Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/5/24. It read in pertinent part,"Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents."II. Resident statusResident #89, age 78, was admitted on 4/26/24. According to the June 2024 computerized physician's orders (CPO), diagnoses included neoplasm of the prostate, chronic kidney disease and malignant neoplasm of bone. The 5/5/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment identified the resident received hospice services during the assessment period. III. Staff interviewsCertified nurse aide (CNA) #1, who worked for a hospice agency, was interviewed on 6/3/24 at 4:25 p.m. He said he had been providing hospice services at the facility for about a year and a half. He said he was familiar with the facility, having worked there previously. He said he had not received an orientation to the facility to include the facility policy and procedures since providing care as a hospice aide. The director of nursing (DON) was interviewed on 6/4/24 at 12:30 p.m. The DON said she was not aware the facility needed to provide an orientation to the facility and the facility policy and procedures to the hospice aides. She said going forward she would provide orientation to the hospice aides prior to providing care in the facility.