CANYON VIEW CARE CENTER

A complaint survey, prompted by #CO37730 and Incident #38015 was completed on 11/13/25 to 11/15/24. One deficiency was cited.

Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three out of six sample residents was kept safe and free from elopement. Resident #1 was admitted to the facility on 8/31/24 with a diagnosis of Parkinson's disease (a chronic, progressive neurological condition) with dyskinesia (involuntary movements). A wander/elopement risk evaluation, completed upon the resident's admission on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. Resident #1's record review revealed the following attempted and successful elopements after admission: On 9/4/24, a progress note revealed Resident #1 left the facility through the South Short Hall emergency exit and was verbally redirected inside. On 9/5/24, Resident #1 was agitated, packed his suitcase, and dragged it to the front door of the facility with his walker. The front door keypad was not armed and Resident #1 exited the facility, fell outside in the grass, and got himself up. He became aggressive when staff attempted to help him up or offered stand-by assistance. After 45 minutes, the resident agreed to sit in a wheelchair and staff transported him back inside the facility. On 9/10/24, Resident #1 displayed restlessness as he paced from one side of the building to the other for over an hour. The resident stated he was bored but refused activities the staff offered. Resident #1 went to the front of the facility and said he was waiting for the bus but it was unclear where he wanted to go. Resident #1 attempted to go out the front door but the keypad was armed which locked the door without the code. The resident walked toward another hallway, saw the emergency exit in the North Hall, exited the facility, and walked toward a bus parked outside the front of the building. The nursing home administrator (NHA) attempted to redirect the resident verbally but he was agitated and got on the bus. The facility called emergency medical services (EMS) for support. EMS arrived and after 20 minutes, Resident #1 agreed to get off the bus and into a wheelchair and was transported inside the facility.-Despite Resident #1's exit-seeking behaviors and successful elopements from the facility within 11 days of his admission on 9/4/24, 9/5/24, and 9/10/24, the facility failed to reassess the resident's elopement risk and implement interventions to prevent the resident from again eloping from the facility. On 9/11/24, Resident #1 exited the facility through the emergency exit on the South Long Hall. The door alarm on the emergency exit was not turned on and staff were informed by a resident of Resident #1's elopement. A conflicting report among staff members revealed the resident was missing for five to 30 minutes before facility staff began to search for the resident. Resident #1 was missing from the facility for 42 hours before he was found by the local search and rescue team and taken to the hospital where he was diagnosed with dehydration, three sunburns, and a deep, concerning stage 3 pressure injury which was not present at the time the resident eloped from the facility on 9/11/24. On 9/23/24, Resident #1 returned to the facility from the hospital but was hospitalized again on 10/4/24, and his pressure injury was diagnosed as a progressive stage 4. The hospital recommended surgical repair which the resident and the family declined. Resident #1 was sent to a hospice center where he passed away. The facility's failure to reassess Resident #1 as an elopement risk after his first three elopement attempts, failure to implement interventions to decrease Resident #1's risk of elopement, and failure to arm emergency exits properly, contributed to the resident's successful elopement attempt on 9/11/24. According to the NHA, the facility created an action plan and performance improvement plan to check the alarms on the emergency exit alarm at shift change, twice a day after Resident #1's elopement from the facility. She said the residents were all assessed for elopement risk and staff were provided education on the emergency exits. However, on 11/13/24, during the survey, the emergency exits on the South Hall Short and the South Hall Long were tested and the alarms were not armed and alarms did not sound when the exit doors were opened. The emergency exit in the North Hall was tested. Although the door was armed, staff failed to respond to the sound of the alarm. The facility's failure to prevent elopement, which resulted in serious harm to Resident #1, and failure to ensure a systemic, effective, and sustainable approach to prevent further elopements, created a situation of immediate jeopardy for serious harm. Finding include:I. Immediate jeopardyA. Situation of immediate jeopardyResident #1, who was diagnosed with Parkinson's disease with dyskinesia had three successful elopements from the facility, on 9/4/24, 9/5/24, and 9/10/24 before he went missing. On 9/11/24, Resident #1 eloped from the facility when the emergency exit alarms were not activated. The lack of the door alarms functioning appropriately contributed to the facility's failure to ensure the resident's safety. Additionally, on 11/13/24, during the survey, the emergency exits in the South Hall Short and the South Hall Long were tested and the alarms were not armed, which caused the alarms not to sound. The emergency exit in the North Hall was tested and, although the door was armed, staff failed to respond to the sound of the alarm. The facility had not implemented a systemic, effective, and sustainable process to ensure the alarms on the emergency exit doors were functioning properly and that staff responded timely if an exit door alarm sounded to prevent additional resident elopements. These failures created a situation of immediate jeopardy for serious harm. B. Imposition of immediate jeopardyOn 11/14/24 at 2:05 p.m., the NHA was notified of the immediate jeopardy situation created by the facility's failure to prevent Resident #1's elopement, which resulted in serious harm and the facility's failure to ensure a systemic, effective, and sustainable process to prevent further elopements. C. Facility plan to remove immediate jeopardyOn 11/15/24 at 1:00 p.m., the facility submitted a plan to remove immediate jeopardy. The plan read:"Identified concern: Resident #1 eloped the evening of 9/11/24. Upon quality assurance (QA) review of the incident, several opportunities were identified to decrease the risk of similar elopement risks. Identified the alarm at the west end of South Hall was turned off at the time of the elopement. Resident #1 had two attempts of exiting the community prior to this incident, no re-assessment was completed and no update to the care plan."Action plan:-The director of nursing (DON) or designee to complete the elopement assessment review of all residents by 9/13/24;-The DON or designee to implement or update plan of care with each resident identified at risk;-The NHA or designee will review the elopement binders and ensure that all high-risk residents are placed in the binder at each nurses' station;-The staff development coordinator (SDC) or designee will initiate a full house education on 9/12/24 regarding the elopement policy and procedures to include elopement binder, ensuring all exit alarms are on and functioning, appropriate redirection and diversional activities and how to respond to an elopement;-The director of maintenance (DOM) or designee will ensure that all door alarms are functioning on 9/12/24;-The DOM or designee to monitor and check door alarm function twice daily for seven days;-The DON or designee to review all completed elopement assessments daily Monday through Friday to ensure appropriate person-centered interventions are in place and that the elopement binder is current and updated;-The DON or designee will review all changes of condition and notes related to increased wandering or exit seeking to ensure a new elopement assessment is completed and will update the plan of care with new person-centered interventions daily as needed; and,-The action plan to be reviewed at the next quality assurance and performance improvement (QAPI) meeting and revised as needed."The plan was updated on 11/14/24 after the door alarms were not armed and immediate jeopardy was called."-The NHA or designee will review the elopement binders and ensure that all high-risk residents are placed in the binder at each nurses' station (ongoing);-All staff re-educated in elopement policy, alarm check procedures and staff response expectations. All staff were educated on the new alarm system process which was provided by the NHA and SDC.-On 11/13/24, the DOM installed new emergency push bars with alarms to emergency exit doors. The push bar requires a key to arm or disarm the alarm;-On 11/13/24, the door alarm checks were increased to hourly by floor staff and two times a shift by the NHA or designee; and;-On 11/14/24, the DOM removed the keypad alarm system."D. Removal of the immediate jeopardyThe immediate jeopardy situation was removed on 11/15/24 at 1:00 p.m., based on the implementation of the above plan to prevent elopements and to maintain resident safety. However, the deficient practice remained at a G level, isolated, actual harm. II. Facility policyThe Elopement and Wandering policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 11/14/24 at 11:05 a.m. It read in pertinent:"It is a goal of the facility to provide a safe environment using the least restrictive measure available in care for residents who are exhibiting elopement behavior. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks."A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team (IDT) during the initial care conference. The elopement risk is assessed quarterly or as needed with change of condition. "If the resident is identified as an elopement risk, the following will be maintained:Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder; and, implementing and care planning interventions to address safety and decrease risk of elopement."III. Resident #1A. Resident statusResident #1, age greater than 65, was admitted to the facility on 8/31/24 and discharged to the hospital on 10/4/24. According to the October 2024 computerized physician orders (CPO), diagnoses included nontraumatic subarachnoid hemorrhage (bleeding in the brain), cognitive-communication deficit, Parkinson's disease with dyskinesia, muscle weakness, unsteadiness on feet, and lack of coordination. The 10/4/24 minimum data set (MDS) assessment revealed Resident #1 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. Resident #1 was documented to use a walker and did not have a physical restraint for elopement. Resident #1 was dependent on staff to put on his footwear and required maximal assistance for toileting hygiene, showering, and upper and lower body dressing. B. Family interviewResident #1's representative was interviewed on 11/14/24 at 10:49 a.m. The representative said the resident was admitted to the facility for rehabilitation for a brain bleed on 8/31/24. She said on 9/11/24 she was informed a resident wanted to look outside the emergency exit on the South Hall Long and the staff disabled the alarm so the resident was able to open the door. She said the staff failed to turn the alarm back on and Resident #1 was able to leave the facility without the staff knowing. She said she was told the resident was missing at least 15 minutes before the staff realized he was gone and began looking for him. The representative said Resident#1 appeared to have slipped down a hill and laid stuck in that spot for 42 hours. She said when search and rescue found the resident, he had a large pressure sore on his left buttocks that he did not have before he eloped from the facility. The representative said Resident #1 was admitted to the hospital for treatment for about 10 days. She said the resident returned to the facility on 9/23/24 and was no longer able to walk independently. The representative said she was frustrated that the staff turned off the alarm so no one knew exactly when the resident went missing. The representative said she informed the facility that Resident #1 had a history of leaving his assisted living facility and she was unsure what the facility implemented to prevent elopement at the facility. C. Record review - repeated elopement attempts - failure of the facility to respond. A wander/elopement risk evaluation, completed on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not a risk for eloping or wandering. On 9/4/24, a behavior note documented in Resident #1's electronic medical record (EMR) revealed the resident attempted to leave the facility through an emergency exit door at the end of the South Short Hall at 1:30 p.m. The staff were able to notify the resident's representative and the management team.-The facility failed to complete a wander/elopement risk evaluation and an elopement care plan was not started. On 9/5/24, a behavior note documented in Resident #1's EMR revealed the resident was agitated at the nurses' station which caused a significant gait imbalance and the resident was at a higher risk of falling. Resident #1 became more agitated when staff encouraged him to use his walker or his wheelchair. The director of rehabilitation (DOR) provided therapeutic encouragement and the resident agreed to use his walker and go into his room. Resident #1 gathered and packed his belongings in his suitcase. Resident #1 attempted to drag his suitcase and walker which caused him to be even more off balance. The staff attempted to stand close to the resident in case he fell which caused the resident to escalate more. The resident then attempted to drag a therapy machine backwards but the machine was unable to be moved by the resident. Resident #1 pushed on the front door and went outside because the keypad on the door was not armed and the door was not locked. The DOR and additional staff followed close by for his safety. Once outside, Resident #1 became unsteady on the sidewalk. He went into the grass and fell, landing on his knees. The resident got himself up and was combative with staff. Resident #1 began walking in the middle of the street and attempted to drag his walker in an unsafe manner. Staff redirected the resident to the grass for his safety. The DOR and the NHA provided hands-on assistance to the resident which increased the resident's aggression toward staff. Resident #1 was tired and sat in a wheelchair provided by the staff and was transported to the empty activity room.-The facility again failed to complete a wander/elopement risk evaluation and an elopement care plan was not started. On 9/6/24, a skilled nursing note revealed Resident #1 had increased agitation and exit-seeking behaviors. On 9/10/24, the physician documented a visit and revealed Resident #1 was seen to follow up on his recent admission, behaviors, and exit seeking. The physician recommended re-evaluating the resident's antipsychotic medications and doses and looking into an "as needed" (PRN) medication for his behaviors in the early afternoon. The physician documented the resident was exit-seeking in the afternoon because he was bored. On 9/10/24, a behavior note revealed Resident #1 was showing signs of restlessness and he paced across the facility for over an hour. One staff member engaged the resident to ensure he was not overstimulated. The speech therapist provided a friendly conversation and attempted to redirect the resident with momentary success for approximately 15 minutes. Resident #1 said he was bored and the staff offered him different activities. Resident #1 said he liked to read and the nurse encouraged the resident to pick out several books but the resident was disinterested. The NHA provided the resident with magazine options and Resident #1 picked out two magazines but placed the magazines in the basket of his walker and continued to pace. Resident #1 told staff he was waiting for the bus but was unable to tell anyone where he was going. Resident #1 then saw a small transport bus in front of the facility. He attempted to go out the front door but the keypad was armed and the door was locked. The resident continued walking with his walker down the hallway, observed an emergency exit at the end of the North Hall, and walked toward the door. Resident #1 was able to get outside and climbed onto the bus. The bus driver attempted to redirect the resident off the bus and said the bus was not a public transportation bus. Resident #1 began escalating and refused to allow staff near him. The resident was escalating. The bus driver and the NHA disengaged with the resident and EMS was called for assistance. EMS spent approximately 20 minutes encouraging Resident #1 to get off the bus. The resident began to get fatigued and agreed to sit in the wheelchair. Resident #1 returned to his room and laid down for a nap. -The facility failed, yet again, to complete a wander/elopement risk evaluation, and start an elopement care plan. On 9/11/24, a behavior note revealed the director of nursing (DON) purchased a building activity to assist the resident with not being bored in the afternoon. On 9/11/24, a skilled nursing note revealed Resident #1 had agitation toward staff in the afternoon. On 9/11//24, an investigation was started after Resident #1 eloped. According to the investigation report:The certified nurse aide (CNA) was assisting another resident to bed while the nurse was completing a medication pass. Resident #1 was seen at 7:03 p.m. The resident was calmly sitting at the nurses' station. The staff noticed Resident #1 was no longer at the nurses' station at 7:08 p.m. The CNA thought the resident had gone to his room until another resident said a resident with a walker left out of the emergency exit on the South Hall Long. The search for the resident began and, after 30 minutes with no success, the police were called for assistance. The resident was documented as being missing for 42 hours and when the resident was found, he was assessed by emergency medical services (EMS) and transported to the hospital via ambulance. The resident was stable with no broken bones but had some scratches and bruises and a possible wound on the coccyx or lower back per the family report. Resident #1 was admitted to the facility on 8/31/24 with no signs of exit-seeking but was documented as having two exit-seeking attempts with a noted change in behavior and cognition with one to two hours of significantly increased pacing and agitation noted by staff with redirection provided to the resident. No other residents were documented as affected by the incident. The investigation concluded the cause for the alarm on the emergency door not alarming at the end of the South Hall Long was that staff had turned off the alarm for another resident and failed to arm the door afterward. On 9/12/24, an order administration note revealed Resident #1 was "MIA" (missing in action) from the facility. The facility and the grounds were searched and all staff were interviewed regarding the resident's history of exit seeking. A wander/elopement risk evaluation, completed on 9/12/24, revealed Resident #1 had attempted to elope from the facility and revealed the resident had one or more risk factors that indicated he was at high risk for elopement. Resident #1's elopement care plan, which was not initiated until 9/12/24, revealed the resident was at risk for eloping and wandering. Interventions included: the resident's current information was to stay in the elopement binder; when the resident was showing signs of agitation, staff were not to physically redirect or tell the resident he was not able to do something; monitor the resident if he went outside to ensure he was not putting item by the fence to climb over; redirect the resident by offering help, pleasant diversions, structured activities, food, conversation, television, books, and walks; provide structured activities like toileting, walking inside and outside and using reorientation strategies which included signs, pictures and memory boxes; and assess the resident for the risk of falling. On 9/17/24 an elopement note for Resident #1 revealed the resident went missing on 9/12/24 for 42 hours. The resident was located by the local search and rescue team and sent to the emergency room where he was admitted with a wound to his left buttocks, and scrotal area, abrasions on his shins, three sunburns, and dehydration. The investigation revealed the resident exited out of the emergency exit on the South Hall Long. The alarm on the door did not sound because the staff disabled the alarm and did not turn the alarm back on. The resident's exit-seeking behaviors were documented for two attempts when the resident was unable to be redirected when inside the facility which required the staff to provide Resident #1 with assistance and supervision outside until the resident became tired and agreed to return inside. D. Record review - Resident status and facility interventions on readmission. On 9/23/24 a nursing progress note revealed Resident #1 was admitted back to the facility at 3:04 p.m. The resident had returned to the facility with healing sunburns, abrasions on both of his shins and a large open wound that covered almost the entire area of his left buttocks and contained a black center. Resident #1 was bed and wheelchair-bound due to his pressure wound and was admitted to the secure unit due to eloping.-Resident #1 had a BIMS score of 11 out of 15 on 9/6/24 and a BIMS score of seven out of 15 when he returned on 9/23/24. A wander/elopement risk evaluation, completed on 9/24/24, revealed Resident #1 had attempted to elope the facility and had one or more risk factors that indicated he was at high risk for eloping when he was ambulatory. Resident #1's elopement care plan (see above), revised on 9/24/24, revealed new interventions were not implemented after he eloped again. On 9/25/24 a skilled nursing note revealed Resident #1 had pressure wounds to his sacrum and scrotal area. On 10/4/24 an alert note revealed Resident #1 had wet himself and the dressing on his wound at 12:40 a.m. The resident's pressure ulcer appeared significantly deeper than the previous day with an odor and a lot of light yellow and brown drainage. Resident #1 reported excessive pain at the wound site and was unable to receive additional pain medication for several hours. Resident #1 said he wanted to be sent to the emergency room for pain control and further evaluation. The nurse attempted to clean the wound with gauze sponges and normal saline but the pain was too much for Resident #1 to tolerate. Non-emergency transportation was arranged for the resident and he was admitted to the hospital, where his pressure sore was diagnosed as a progressive stage 4. The hospital recommended surgical repair which would leave the resident with a colostomy bag and months of healing. The resident and the family declined. Resident #1 was sent to a hospice center where he passed away. E. Observations of the emergency exit alarmsOn 11/13/24 at 9:15 a.m., the emergency exit on the South Hall Short and the South Hall Long were tested and the alarms were not armed which caused the alarms not to sound. On 11/13/24 at 9:21 a.m., the emergency exit on the North Hall was tested and, although the door was armed, staff failed to respond to the sound of the alarm. IV. Staff interviewsThe NHA, corporate consultant (CC) #1 and CC #2 were interviewed on 11/13/24 at 11:39 a.m. The NHA said the facility implemented a plan of correction, provided staff education, completed elopement risk evaluations on all of the residents and emergency exit alarm checks occurred twice a day at shift change by the floor staff and documented on logs. The NHA said she was aware the door alarms had not been armed during the observations on the morning of 11/13/24. The NHA said she spoke to the CNA who completed the checks and the CNA said the alarms beeped and indicated the alarms were on when they had been checked earlier in the day. The NHA said the facility planned to monitor the emergency exits once an hour by floor staff for the following 24-48 hours. The NHA said she checked the door alarms and the alarms were on at 11:30 a.m. She said Resident #1 did not have a pressure sore before he eloped from the facility and when the resident was admitted back on 9/23/24, he was admitted to the secured unit and not ambulatory. CC#2 said the facility did not have any current residents who were high-risk exit seekers. A person who wished to remain anonymous was interviewed on 11/14/24 at 11:30 a.m. The person said the door alarm was not on so it did not trigger when the resident exited the building. The person said the staff propped multiple doors open with rocks to make it easier to go outside to smoke or take the trash out and Resident #1 was missing almost an hour before the staff who were working realized he was missing. CNA #1 was interviewed on 11/14/24 at 12:15 p.m. CNA #1 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped it meant the alarm was activated. CNA #1 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. CNA #2 was interviewed on 11/14/24 at 12:18 p.m. CNA #2 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped, it meant the alarm was activated. CNA #2 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. CNA #3 was interviewed on 11/14/24 at 12:21 p.m. CNA #3 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped, it meant the alarm was activated. CNA #3 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. Licensed practical nurse (LPN) #1 was interviewed on 11/14/24 at 12:25 p.m. LPN #1 said she was not the staff who checked the door alarms, usually it was the CNAs but she knew how to check the alarms. LPN #1 said Resident #1 did not have the pressure sore before he eloped. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 11/14/24 at 3:29 p.m. -The DON said the resident went missing and returned to the facility with a pressure wound. -The ADON said she and the DON were the wound nurses and completed the wound care according to the hospital's wound care discharge plan. The ADON said the wound care ordered by the hospital was not a good treatment plan because the hospital ordered a cream to be placed on an opened wound instead of a regimen that included some form of medihoney with gauze and bandages. -The DON said Resident #1 was sent back to the hospital on 10/4/24 because he experienced a lot of pain from the wound and the facility was unable to treat the wound accurately. A frequent visitor (FV) to the facility was interviewed on 11/14/24 at 5:10 p.m. -The FV said a staff member first informed her Resident #1 was missing 30 to 60 minutes before the staff realized he was gone, but the facility was not really sure how long the resident was missing initially. She said another staff member told her it was about 15 minutes before the staff realized Resident #1 was missing. -The FV said the NHA told her the resident was only missing for five minutes and that the facility waited to call the police until after 11:00 p.m. She said she was not sure why the facility delayed calling the police for help. She said the residents had complained about the staff turning off the door alarms or propping the doors open all of the time since the beginning of 2024 and it was not addressed by the facility. The NHA was interviewed a second time on 11/15/24 at 11:33 a.m. The NHA said Resident #1 was not an elopement risk when he was first admitted to the facility and should have been assessed again after each elopement attempt. She said the resident's elopements were reviewed as behaviors and not the resident wanting to elope from the facility. She said the resident's care plan should have been updated after the first elopement attempt. She said elopement interventions needed to be updated after each incident, not just adding a revision date change. She said the facility had room for improvement in many areas and that was why the plan of correction was started after Resident #1 eloped.

A survey prompted by complaint #CO38494 was completed on 11/13/24 to 11/15/24. One deficiency was cited.

Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three out of six sample residents was kept safe and free from elopement. Resident #1 was admitted to the facility on 8/31/24 with a diagnosis of Parkinson's disease (a chronic, progressive neurological condition) with dyskinesia (involuntary movements). A wander/elopement risk evaluation, completed upon the resident's admission on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. Resident #1's record review revealed the following attempted and successful elopements after admission: On 9/4/24, a progress note revealed Resident #1 left the facility through the South Short Hall emergency exit and was verbally redirected inside. On 9/5/24, Resident #1 was agitated, packed his suitcase, and dragged it to the front door of the facility with his walker. The front door keypad was not armed and Resident #1 exited the facility, fell outside in the grass, and got himself up. He became aggressive when staff attempted to help him up or offered stand-by assistance. After 45 minutes, the resident agreed to sit in a wheelchair and staff transported him back inside the facility. On 9/10/24, Resident #1 displayed restlessness as he paced from one side of the building to the other for over an hour. The resident stated he was bored but refused activities the staff offered. Resident #1 went to the front of the facility and said he was waiting for the bus but it was unclear where he wanted to go. Resident #1 attempted to go out the front door but the keypad was armed which locked the door without the code. The resident walked toward another hallway, saw the emergency exit in the North Hall, exited the facility, and walked toward a bus parked outside the front of the building. The nursing home administrator (NHA) attempted to redirect the resident verbally but he was agitated and got on the bus. The facility called emergency medical services (EMS) for support. EMS arrived and after 20 minutes, Resident #1 agreed to get off the bus and into a wheelchair and was transported inside the facility.-Despite Resident #1's exit-seeking behaviors and successful elopements from the facility within 11 days of his admission on 9/4/24, 9/5/24, and 9/10/24, the facility failed to reassess the resident's elopement risk and implement interventions to prevent the resident from again eloping from the facility. On 9/11/24, Resident #1 exited the facility through the emergency exit on the South Long Hall. The door alarm on the emergency exit was not turned on and staff were informed by a resident of Resident #1's elopement. A conflicting report among staff members revealed the resident was missing for five to 30 minutes before facility staff began to search for the resident. Resident #1 was missing from the facility for 42 hours before he was found by the local search and rescue team and taken to the hospital where he was diagnosed with dehydration, three sunburns, and a deep, concerning stage 3 pressure injury which was not present at the time the resident eloped from the facility on 9/11/24. On 9/23/24, Resident #1 returned to the facility from the hospital but was hospitalized again on 10/4/24, and his pressure injury was diagnosed as a progressive stage 4. The hospital recommended surgical repair which the resident and the family declined. Resident #1 was sent to a hospice center where he passed away. The facility's failure to reassess Resident #1 as an elopement risk after his first three elopement attempts, failure to implement interventions to decrease Resident #1's risk of elopement, and failure to arm emergency exits properly, contributed to the resident's successful elopement attempt on 9/11/24. According to the NHA, the facility created an action plan and performance improvement plan to check the alarms on the emergency exit alarm at shift change, twice a day after Resident #1's elopement from the facility. She said the residents were all assessed for elopement risk and staff were provided education on the emergency exits. However, on 11/13/24, during the survey, the emergency exits on the South Hall Short and the South Hall Long were tested and the alarms were not armed and alarms did not sound when the exit doors were opened. The emergency exit in the North Hall was tested. Although the door was armed, staff failed to respond to the sound of the alarm. The facility's failure to prevent elopement, which resulted in serious harm to Resident #1, and failure to ensure a systemic, effective, and sustainable approach to prevent further elopements, created a situation for serious harm. Finding include:I. Elopement facility failuresResident #1, who was diagnosed with Parkinson's disease with dyskinesia had three successful elopements from the facility, on 9/4/24, 9/5/24, and 9/10/24 before he went missing. On 9/11/24, Resident #1 eloped from the facility when the emergency exit alarms were not activated. The lack of the door alarms functioning appropriately contributed to the facility's failure to ensure the resident's safety. Additionally, on 11/13/24, during the survey, the emergency exits in the South Hall Short and the South Hall Long were tested and the alarms were not armed, which caused the alarms not to sound. The emergency exit in the North Hall was tested and, although the door was armed, staff failed to respond to the sound of the alarm. The facility had not implemented a systemic, effective, and sustainable process to ensure the alarms on the emergency exit doors were functioning properly and that staff responded timely if an exit door alarm sounded to prevent additional resident elopements. These failures created a situation for serious harm. On 11/14/24 at 2:05 p.m., the NHA was notified of the situation created by the facility's failure to prevent Resident #1's elopement, which resulted in serious harm and the facility's failure to ensure a systemic, effective, and sustainable process to prevent further elopements. On 11/15/24 at 1:00 p.m., the facility submitted a plan which read:"Identified concern: Resident #1 eloped the evening of 9/11/24. Upon quality assurance (QA) review of the incident, several opportunities were identified to decrease the risk of similar elopement risks. Identified the alarm at the west end of South Hall was turned off at the time of the elopement. Resident #1 had two attempts of exiting the community prior to this incident, no re-assessment was completed and no update to the care plan."Action plan:-The director of nursing (DON) or designee to complete the elopement assessment review of all residents by 9/13/24;-The DON or designee to implement or update plan of care with each resident identified at risk;-The NHA or designee will review the elopement binders and ensure that all high-risk residents are placed in the binder at each nurses' station;-The staff development coordinator (SDC) or designee will initiate a full house education on 9/12/24 regarding the elopement policy and procedures to include elopement binder, ensuring all exit alarms are on and functioning, appropriate redirection and diversional activities and how to respond to an elopement;-The director of maintenance (DOM) or designee will ensure that all door alarms are functioning on 9/12/24;-The DOM or designee to monitor and check door alarm function twice daily for seven days;-The DON or designee to review all completed elopement assessments daily Monday through Friday to ensure appropriate person-centered interventions are in place and that the elopement binder is current and updated;-The DON or designee will review all changes of condition and notes related to increased wandering or exit seeking to ensure a new elopement assessment is completed and will update the plan of care with new person-centered interventions daily as needed; and,-The action plan to be reviewed at the next quality assurance and performance improvement (QAPI) meeting and revised as needed."The plan was updated on 11/14/24 after the door alarms were not armed and created a situation for serious harm:"-The NHA or designee will review the elopement binders and ensure that all high-risk residents are placed in the binder at each nurses' station (ongoing);-All staff re-educated in elopement policy, alarm check procedures and staff response expectations. All staff were educated on the new alarm system process which was provided by the NHA and SDC.-On 11/13/24, the DOM installed new emergency push bars with alarms to emergency exit doors. The push bar requires a key to arm or disarm the alarm;-On 11/13/24, the door alarm checks were increased to hourly by floor staff and two times a shift by the NHA or designee; and;-On 11/14/24, the DOM removed the keypad alarm system."The above plan was accepted on 11/15/24 at 1:00 p.m., based on the implementation of the interventions to prevent elopements and to maintain resident safety. II. Facility policyThe Elopement and Wandering policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 11/14/24 at 11:05 a.m. It read in pertinent:"It is a goal of the facility to provide a safe environment using the least restrictive measure available in care for residents who are exhibiting elopement behavior. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks."A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team (IDT) during the initial care conference. The elopement risk is assessed quarterly or as needed with change of condition. "If the resident is identified as an elopement risk, the following will be maintained:Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder; and, implementing and care planning interventions to address safety and decrease risk of elopement."III. Resident #1A. Resident statusResident #1, age greater than 65, was admitted to the facility on 8/31/24 and discharged to the hospital on 10/4/24. According to the October 2024 computerized physician orders (CPO), diagnoses included nontraumatic subarachnoid hemorrhage (bleeding in the brain), cognitive-communication deficit, Parkinson's disease with dyskinesia, muscle weakness, unsteadiness on feet, and lack of coordination. The 10/4/24 facility assessment revealed Resident #1 had a severe cognitive impairments. Resident #1 was documented to use a walker and did not have a physical restraint for elopement. Resident #1 was dependent on staff to put on his footwear and required maximal assistance for toileting hygiene, showering, and upper and lower body dressing. B. Family interviewResident #1's representative was interviewed on 11/14/24 at 10:49 a.m. The representative said the resident was admitted to the facility for rehabilitation for a brain bleed on 8/31/24. She said on 9/11/24 she was informed a resident wanted to look outside the emergency exit on the South Hall Long and the staff disabled the alarm so the resident was able to open the door. She said the staff failed to turn the alarm back on and Resident #1 was able to leave the facility without the staff knowing. She said she was told the resident was missing at least 15 minutes before the staff realized he was gone and began looking for him. The representative said Resident #1 appeared to have slipped down a hill and laid stuck in that spot for 42 hours. She said when search and rescue found the resident, he had a large pressure sore on his left buttocks that he did not have before he eloped from the facility. The representative said Resident #1 was admitted to the hospital for treatment for about 10 days. She said the resident returned to the facility on 9/23/24 and was nolonger able to walk independently. The representative said she was frustrated that the staff turned off the alarm so no one knew exactly when the resident went missing. The representative said she informed the facility that Resident #1 had a history of leaving his assisted living facility and she was unsure what the facility implemented to prevent elopement at the facility. C. Record review - repeated elopement attempts - failure of the facility to respond. A wander/elopement risk evaluation, completed on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not a risk for eloping or wandering. On 9/4/24, a behavior note documented in Resident #1's electronic medical record (EMR) revealed the resident attempted to leave the facility through an emergency exit door at the end of the South Short Hall at 1:30 p.m. The staff were able to notify the resident's representative and the management team.-The facility failed to complete a wander/elopement risk evaluation and an elopement care plan was not started. On 9/5/24, a behavior note documented in Resident #1's EMR revealed the resident was agitated at the nurses' station which caused a significant gait imbalance and the resident was at a higher risk of falling. Resident #1 became more agitated when staff encouraged him to use his walker or his wheelchair. The director of rehabilitation (DOR) provided therapeutic encouragement and the resident agreed to use his walker and go into his room. Resident #1 gathered and packed his belongings in his suitcase. Resident #1 attempted to drag his suitcase and walker which caused him to be even more off balance. The staff attempted to stand close to the resident in case he fell which caused the resident to escalate more. The resident then attempted to drag a therapy machine backwards but the machine was unable to be moved by the resident. Resident #1 pushed on the front door and went outside because the keypad on the door was not armed and the door was not locked. The DOR and additional staff followed close by for his safety. Once outside, Resident #1 became unsteady on the sidewalk. He went into the grass and fell, landing on his knees. The resident got himself up and was combative with staff. Resident #1 began walking in the middle of the street and attempted to drag his walker in an unsafe manner. Staff redirected the resident to the grass for his safety. The DOR and the NHA provided hands-on assistance to the resident which increased the resident's aggression toward staff. Resident #1 was tired and sat in a wheelchair provided by the staff and was transported to the empty activity room.-The facility again failed to complete a wander/elopement risk evaluation and an elopement care plan was not started. On 9/6/24, a skilled nursing note revealed Resident #1 had increased agitation and exit-seeking behaviors. On 9/10/24, the physician documented a visit and revealed Resident #1 was seen to follow up on his recent admission, behaviors, and exit seeking. The physician recommended re-evaluating the resident's antipsychotic medications and doses and looking into an "as needed" (PRN) medication for his behaviors in the early afternoon. The physician documented the resident was exit-seeking in the afternoon because he was bored. On 9/10/24, a behavior note revealed Resident #1 was showing signs of restlessness and he paced across the facility for over an hour. One staff member engaged the resident to ensure he was not overstimulated. The speech therapist provided a friendly conversation and attempted to redirect the resident with momentary success for approximately 15 minutes. Resident #1 said he was bored and the staff offered him different activities. Resident #1 said he liked to read and the nurse encouraged the resident to pick out several books but the resident was disinterested. The NHA provided the resident with magazine options and Resident #1 picked out two magazines but placed the magazines in the basket of his walker and continued to pace. Resident #1 told staff he was waiting for the bus but was unable to tell anyone where he was going. Resident #1 then saw a small transport bus in front of the facility. He attempted to go out the front door but the keypad was armed and the door was locked. The resident continued walking with his walker down the hallway, observed an emergency exit at the end of the North Hall, and walked toward the door. Resident #1 was able to get outside and climbed onto the bus. The bus driver attempted to redirect the resident off the bus and said the bus was not a public transportation bus. Resident #1 began escalating and refused to allow staff near him. The resident was escalating. The bus driver and the NHA disengaged with the resident and EMS was called for assistance. EMS spent approximately 20 minutes encouraging Resident #1 to get off the bus. The resident began to get fatigued and agreed to sit in the wheelchair. Resident #1 returned to his room and laid down for a nap. -The facility failed, yet again, to complete a wander/elopement risk evaluation, and start an elopement care plan. On 9/11/24, a behavior note revealed the director of nursing (DON) purchased a building activity to assist the resident with not being bored in the afternoon. On 9/11/24, a skilled nursing note revealed Resident #1 had agitation toward staff in the afternoon. On 9/11//24, an investigation was started after Resident #1 eloped. According to the investigation report:The certified nurse aide (CNA) was assisting another resident to bed while the nurse was completing a medication pass. Resident #1 was seen at 7:03 p.m. The resident was calmly sitting at the nurses' station. The staff noticed Resident #1 was no longer at the nurses' station at 7:08 p.m. The CNA thought the resident had gone to his room until another resident said a resident with a walker left out of the emergency exit on the South Hall Long. The search for the resident began and, after 30 minutes with no success, the police were called for assistance. The resident was documented as being missing for 42 hours and when the resident was found, he was assessed by emergency medical services (EMS) and transported to the hospital via ambulance. The resident was stable with no broken bones but had some scratches and bruises and a possible wound on the coccyx or lower back per the family report. Resident #1 was admitted to the facility on 8/31/24 with no signs of exit-seeking but was documented as having two exit-seeking attempts with a noted change in behavior and cognition with one to two hours of significantly increased pacing and agitation noted by staff with redirection provided to the resident. No other residents were documented as affected by the incident. The investigation concluded the cause for the alarm on the emergency door not alarming at the end of the South Hall Long was that staff had turned off the alarm for another resident and failed to arm the door afterward. On 9/12/24, an order administration note revealed Resident #1 was "MIA" (missing in action) from the facility. The facility and the grounds were searched and all staff were interviewed regarding the resident's history of exit seeking. A wander/elopement risk evaluation, completed on 9/12/24, revealed Resident #1 had attempted to elope from the facility and revealed the resident had one or more risk factors that indicated he was at high risk for elopement. Resident #1's elopement care plan, which was not initiated until 9/12/24, revealed the resident was at risk for eloping and wandering. Interventions included: the resident's current information was to stay in the elopement binder; when the resident was showing signs of agitation, staff were not to physically redirect or tell the resident he was not able to do something; monitor the resident if he went outside to ensure he was not putting item by the fence to climb over; redirect the resident by offering help, pleasant diversions, structured activities, food, conversation, television, books, and walks; provide structured activities like toileting, walking inside and outside and using reorientation strategies which included signs, pictures and memory boxes; and assess the resident for the risk of falling. On 9/17/24 an elopement note for Resident #1 revealed the resident went missing on 9/12/24 for 42 hours. The resident was located by the local search and rescue team and sent to the emergency room where he was admitted with a wound to his left buttocks, and scrotal area, abrasions on his shins, three sunburns, and dehydration. The investigation revealed the resident exited out of the emergency exit on the South Hall Long. The alarm on the door did not sound because the staff disabled the alarm and did not turn the alarm back on. The resident's exit-seeking behaviors were documented for two attempts when the resident was unable to be redirected when inside the facility which required the staff to provide Resident #1 with assistance and supervision outside until the resident became tired and agreed to return inside. D. Record review - Resident status and facility interventions on readmission. On 9/23/24 a nursing progress note revealed Resident #1 was admitted back to the facility at 3:04 p.m. The resident had returned to the facility with healing sunburns, abrasions on both of his shins and a large open wound that covered almost the entire area of his left buttocks and contained a black center. Resident #1 was bed and wheelchair-bound due to his pressure wound and was admitted to the secure unit due to eloping.-Resident #1 had a BIMS score of 11 out of 15 on 9/6/24 and a BIMS score of seven out of 15 when he returned on 9/23/24. A wander/elopement risk evaluation, completed on 9/24/24, revealed Resident #1 had attempted to elope the facility and had one or more risk factors that indicated he was at high risk for eloping when he was ambulatory. Resident #1's elopement care plan (see above), revised on 9/24/24, revealed new interventions were not implemented after he eloped again. On 9/25/24 a skilled nursing note revealed Resident #1 had pressure wounds to his sacrum and scrotal area. On 10/4/24 an alert note revealed Resident #1 had wet himself and the dressing on his wound at 12:40 a.m. The resident's pressure ulcer appeared significantly deeper than the previous day with an odor and a lot of light yellow and brown drainage. Resident #1 reported excessive pain at the wound site and was unable to receive additional pain medication for several hours. Resident #1 said he wanted to be sent to the emergency room for pain control and further evaluation. The nurse attempted to clean the wound with gauze sponges and normal saline but the pain was too much for Resident #1 to tolerate. Non-emergency transportation was arranged for the resident and he was admitted to the hospital, where his pressure sore was diagnosed as a progressive stage 4. The hospital recommended surgical repair which would leave the resident with a colostomy bag and months of healing. The resident and the family declined. Resident #1 was sent to a hospice center where he passed away. E. Observations of the emergency exit alarmsOn 11/13/24 at 9:15 a.m., the emergency exit on the South Hall Short and the South Hall Long were tested and the alarms were not armed which caused the alarms not to sound. On 11/13/24 at 9:21 a.m., the emergency exit on the North Hall was tested and, although the door was armed, staff failed to respond to the sound of the alarm. IV. Staff interviewsThe NHA, corporate consultant (CC) #1 and CC #2 were interviewed on 11/13/24 at 11:39 a.m. The NHA said the facility implemented a plan of correction, provided staff education, completed elopement risk evaluations on all of the residents and emergency exit alarm checks occurred twice a day at shift change by the floor staff and documented on logs. The NHA said she was aware the door alarms had not been armed during the observations on the morning of 11/13/24. The NHA said she spoke to the CNA who completed the checks and the CNA said the alarms beeped and indicated the alarms were on when they had been checked earlier in the day. The NHA said the facility planned to monitor the emergency exits once an hour by floor staff for the following 24-48 hours. The NHA said she checked the door alarms and the alarms were on at 11:30 a.m. She said Resident #1 did not have a pressure sore before he eloped from the facility and when the resident was admitted back on 9/23/24, he was admitted to the secured unit and not ambulatory. CC#2 said the facility did not have any current residents who were high-risk exit seekers. A person who wished to remain anonymous was interviewed on 11/14/24 at 11:30 a.m. The person said the door alarm was not on so it did not trigger when the resident exited the building. The person said the staff propped multiple doors open with rocks to make it easier to go outside to smoke or take the trash out and Resident #1 was missing almost an hour before the staff who were working realized he was missing. CNA #1 was interviewed on 11/14/24 at 12:15 p.m. CNA #1 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped it meant the alarm was activated. CNA #1 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. CNA #2 was interviewed on 11/14/24 at 12:18 p.m. CNA #2 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped, it meant the alarm was activated. CNA #2 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. CNA #3 was interviewed on 11/14/24 at 12:21 p.m. CNA #3 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped, it meant the alarm was activated. CNA #3 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. Licensed practical nurse (LPN) #1 was interviewed on 11/14/24 at 12:25 p.m. LPN #1 said she was not the staff who checked the door alarms, usually it was the CNAs but she knew how to check the alarms. LPN #1 said Resident #1 did not have the pressure sore before he eloped. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 11/14/24 at 3:29 p.m. -The DON said the resident went missing and returned to the facility with a pressure wound. -The ADON said she and the DON were the wound nurses and completed the wound care according to the hospital's wound care discharge plan. The ADON said the wound care ordered by the hospital was not a good treatment plan because the hospital ordered a cream to be placed on an opened wound instead of a regimen that included some form of medihoney with gauze and bandages. -The DON said Resident #1 was sent back to the hospital on 10/4/24 because he experienced a lot of pain from the wound and the facility was unable to treat the wound accurately. A frequent visitor (FV) to the facility was interviewed on 11/14/24 at 5:10 p.m. -The FV said a staff member first informed her Resident #1 was missing 30 to 60 minutes before the staff realized he was gone, but the facility was not really sure how long the resident was missing initially. She said another staff member told her it was about 15 minutes before the staff realized Resident #1 was missing. -The FVsaid the NHA told her the resident was only missing for five minutes and that the facility waited to call the police until after 11:00 p.m. She said she was not sure why the facility delayed calling the police for help. She said the residents had complained about the staff turning off the door alarms or propping the doors open all of the time since the beginning of 2024 and it was not addressed by the facility. The NHA was interviewed a second time on 11/15/24 at 11:33 a.m. The NHA said Resident #1 was not an elopement risk when he was first admitted to the facility and should have been assessed again after each elopement attempt. She said the resident's elopements were reviewed as behaviors and not the resident wanting to elope from the facility. She said the resident's care plan should have been updated after the first elopement attempt. She said elopement interventions needed to be updated after each incident, not just adding a revision date change. She said the facility had room for improvement in many areas and that was why the plan of correction was started after Resident #1 eloped.

A revisit survey was completed on 9/18/24 for all previous deficiencies cited on 7/23/24. The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only and are a representation of the facility's general characteristics. This facility is a type V (111) 25,548 sq ft single-story structure equipped with an automatic NFPA 13 fire suppression system and classified as fully sprinkler protected. On the Day of the Survey, the facility had a census of 74 residents licensed for 20 secured and 88 total beds. This survey, conducted August 7, 2024, included an inspection for compliance with the fire safety requirements of the National Fire Protection Association (NFPA) Chapter 19 of the 2012 edition of NFPA 101, Life Safety Code; 2012 edition of NFPA 99, Health Care Facilities Code; and all referenced standards. This facility will meet these requirements upon completion of a Plan of Correction. The survey concluded with a discussion of the deficiencies with the Administrator and Maintenance Supervisor.

Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) south long egress pathway obstructed by cars, need to add signage for no parking NFPA 101 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 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 facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) The courtyard gate not swinging in the path of egress NFPA 101 7.2.1.4.2 Door Leaf Swing Direction. Door leaves required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel under any of the following conditions:(1) Where serving a room or area with an occupant load of 50 or more, except under any of the following conditions:(a)Door leaves in horizontal exits shall not be required to swing in the direction of egress travel where permitted by 7.2.4.3.8.1 or 7.2.4.3.8.2.(b) Door leaves in smoke barriers shall not be required to swing in the direction of egress travel in existing health care occupancies, as provided in Chapter 19.(2) Where the door assembly is used in an exit enclosure, unless the door opening serves an individual living unit that opens directly into an exit enclosure(3) Where the door opening serves a high hazard contents areaNFPA 101 7.2.1.5.6 Electrically Controlled Egress Door Assemblies. Door assemblies in the means of egress shall be permitted to be electrically locked if equipped with approved, listed hardware, provided that all of the following conditions are met:(1)The hardware for occupant release of the lock is affixed to the door leaf.(2)The hardware has an obvious method of operation that is readily operated in the direction of egress.(3)The hardware is capable of being operated with one hand in the direction of egress.(4)Operation of the hardware interrupts the power supply directly to the electric lock and unlocks the door assembly in the direction of egress.(5)*Loss of power to the listed releasing hardware automatically unlocks the door assembly in the direction of egress.(6)Hardware for new installations is listed in accordance with ANSI/UL 294, Standard for Access Control System Units. This deficiency could affect occupants, including residents, staff, and visitors throughout the facility. Deficient item(s) were discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) The south short egress pathway is not marked, needs multiple exit signs, and No exit signs have been added. NFPA 101 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10 unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. NFPA 1017.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This deficiency could affect occupants, who might include residents, staff, and visitors throughout the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) lost and found need door closure2) The director of the nursing office is missing a door closure3) The maintenance/housekeeping office needs door closure reinstalled4) central supply being held open required to be closed5) The north utility room door broken6) The business office needs door closure reinstalledNFPA 10118.3.2.1* Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. NFPA 1014.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) missing gas cable on kitchen applianceNFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 549.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer ' s installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connection installation shall be configured in accordance with the manufacturer ' s installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer ' s installation instructions. This deficiency could affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by: 1) Fire Alarm Semi-Annual: Not Provided2) Fire Alarm Sensitivity test (2 Years) (72 14.4.5.3.2): Not providedBased 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. 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 Alarmand Signaling Code. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby thedetector causes a signal at the fire alarm control unit where itssensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by theauthority having jurisdictionThis deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, NFPA 70, and NFPA 54. This was evidenced by:1) Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valves2) remove abandoned electrical wiring in the boiler roomNFPA 54 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction(3) In accordance with the manufacturer ' s installation instructionsNFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70 110.27 Guarding of Live Parts.(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means:(1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons.(2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them.(3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons.(4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface. This deficiency could affect occupants, including residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:1) Fire Dampers report (4-6 years)(101 8.5.5.4.1 & 80 19.4): Not Done2) Fire dampers are not installed per requirements; the link is missing, and wire is used to keep it openNFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 105 6.5 Periodic inspection and testing. 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 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 facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Fire Drills missing 4th quarter drillsNFPA 10119.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) The fake Christmas tree needs to show proof of compliance with NFPA 101 or be removedNFPA 101 19.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:(1)They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.(2)The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.(3)The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source. These deficiencies can potentially affect occupants, including residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) The egress door at the therapy gym does not open on the right hinge2) The south long storage closet door closure is not attached, and the door does not latch3) The north exit right door not openingNFPA 101, 8.3.3.1Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80, 5.2 Inspections. 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ' s proper emergency function, the following actions shall be performed:(1)The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.(2)The door shall be tested to ensure emergency operation and closing upon completion of the repairs. These deficiencies can potentially affect occupants, including residents, staff, and visitors throughout the facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Not DoneNFPA 110 8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with the manufacturer's specificationsThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) trans-filling ventilation not working, and the room missing proper signageNFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. NFPA 99 11.5.2.3.1Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility where in patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures. NFPA 99 9.3.7.5.3.4Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system. This deficiency could affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

A recertification survey with complaint #CO36665 and #CO36666 was completed on 7/17/24 to 7/23/24. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 7/17/24 to 7/23/24. One deficiency was cited.

Based on record review and interviews, the facility failed to follow established requirements for testing the emergency preparedness plan. Specifically, the facility failed to:-Analyze the facility's response to and maintain documentation of all drills, tabletop exercises and emergency events and revise the emergency plan as needed. Findings include:I. Facility PlanThe Emergency Preparedness Management Plan (EPMP) was provided by the nursing home administrator (NHA) and the director of maintenance services (DMS) on 7/23/24 at 9:01 a.m Review of the EPMP identified an actual emergency event occurred on 5/12/24 and ended on 6/7/24. The facility's hot water heater was not operational. -The EPMP did not identify that the facility analyzed annual emergency preparedness or response exercises and made revisions as needed to the EPMP based on the analysis. II. Record reviewThe Introduction to the Emergency Management Plan policy, dated 3/11/24, was provided by the NHA on 7/24/24 via email. According to the emergency management plan, its mission was to plan, prepare and respond to emergency situations and disaster scenarios. The emergency management plan's purpose was to provide an all-hazards approach to guide the facility in the event of an emergency, crisis, or a disaster scenario that would affect the safety and well-being of residents and employees, families, volunteers and facility from various emergencies. The facility's emergency management plan identified the facility's top three hazards:-Extreme temperatures,-Winter storm; and, -Utility disruptionThe facility's emergency management plan hazard vulnerability assessment identified an event with the facility's heating, ventilation, and air conditioning (HVAC) failure as medium level of probability for occurring with a risk to affect the resident's health and safety. The assessment rated the facility's level of preparedness as "fair". -Review of the EPMP identified the facility did not have a policy and procedure to maintain the facility's hot water heating systems or how to respond in the event of a hot water heater failure, even though the facility identified utility disruption was a top facility hazard and the facility a medium risk of probability of HVAC failure. -Additionally, the DMS and the HVAC vendor had identified concerns with the facility's hot water heating system prior to the failure of the hot water heater. The June 2024 quality assurance and performance improvement (QAPI) meeting minutes were provided by the NHA on 7/23/24 at approximately 9:15 a.m. The QAPI minutes documented the following in pertinent part: "Hot water heater stopped working on 5/12/24. Final repairs completed on."-The QAPI minutes did not include the date the final repairs were completed.-The QAPI minutes did not include additional review of the lack of hot water facility response or revisions made to the facility's emergency plan. III. Staff interviewsThe DMS was interviewed on 7/18/24 at 1:52 p.m. The DMS said, on 5/12/24, the hot water heater broke. He said he contacted the NHA and the regional consultant. He said he contacted a heating, ventilation and air conditioning (HVAC) service vendor and attempts were made to repair the hot water heater but it was determined the hot water heater was not repairable. He said he and the NHA started a plan of correction. He said the facility started boiling water from the kitchen, bed bath kits were ordered and hot water was collected from the hot and cold water drink dispensing towers. He said the kitchen started using paper products for meals. The DMS said the facility corporation was contacted and told it was an emergency. The corporation requested bids for a new water heater and repairs. The DMS said the facility's landlord and stakeholder had to also approve of the process. The DMS said, overall, the whole process went well and the residents seemed accepting of the changes and complained very little. The DMS said he did not believe the facility had a hot water heater policy to outline the procedures of what to do if the facility did not have hot water readily available. He said before the hot water heater broke, the facility did not have a back up plan. The DMS said the facility now had a three water heater system so if one went out, the other water heaters would still be able to provide the facility with hot water. He said each of the new hot water heaters were 100 gallons each. The DMS said the prior water heater was over 20 years old and was leaking before it stopped working. He said the HVAC vendor came out to service the heater and recommended the facility get a new water heater. The DMS said he informed the NHA and his regional consultant of the recommendations but he was not sure exactly when he informed them. He said he was told to do the best he could as long as the hot water heater was still working. The DMS said there were no follow up meetings after the new hot water heaters were installed. He said the facility did not review the event after the incident to put new procedures in place. He said the facility was still pulling everything together. The director of nursing (DON) was interviewed on 7/18/24 at 2:29 p.m. The DON said when the hot water heater broke, her main focus was the residents' personal hygiene and sanitary conditions for preparation and service. She said wound care was not impacted by the lack of hot water. The DON said more disposable paper products were ordered for meal services. She said the facility ordered shower caps, more bed bath kits and water basins. The DON said the staff tried to offer bed baths on the same days the residents were usually scheduled for their showers. She said the residents were told they could also ask for bed baths and/or wipes if they felt they needed additional bathing opportunities. She said some residents were able to bathe at their family's homes. The DON said bathing wipes were warmed to help the residents feel more comfortable. She said the temperature of the hot water from the hot water drinking dispensers was taken and used for personal washing. She said the facility verbally informed the residents about the limited hot water and families were informed by letters. She said the lack of hot water from the hot water heater lasted for about three weeks, from May 2024 to June 2024. She said the facility now had three hot water heaters so if one water heater went down the facility would still have two working hot water heaters. The DON said staff expressed some frustration during the event. She said the bed baths took more staff time and there were more resident refusals than expected. The DON said many of the residents expressed understanding of the situation. She said once the hot water heaters were replaced, all residents were back to having their regular showers scheduled. She said everything was now back to normal. The NHA was interviewed on 7/18/24 at 2:50 p.m. The NHA said when the DMS informed her of the broken hot water heater, she informed her corporate consultants and regional operation managers of the situation and started to put interventions in place. The NHA said on 5/13/24 she created a plan to review and identify needed supplies such as paper products, and bathing kits. She said she notified the residents of the situation and sent letters out by email to families. The NHA said she put together a three week plan because the HVAC vendor estimated it would take two to three weeks to have the water heater ordered and replaced. She said she discussed the costs with the corporation after getting quotes. The NHA said the facility had to decide on whether to have the hot water heater replaced quickly or take a little longer and get a better system that would include three water heaters so if one went down there would be a backup. She said by the end of the week of 5/13/24, the facility had decided to go with the three tank system. She said the hot water heaters needed to be ordered and transported from several miles away because there was nothing compatible in the area. The NHA said the HVAC vendor informed her that he would be able to do the labor within 24 to 48 hours of the delivery of the tanks. She said most of the delay for getting the hot water heater tank replaced was related to the release of the funds to the HVAC vendor so the tanks could be ordered. She said when the HVAC vendor received payment he ordered the tanks but the transportation company to deliver the tanks could only do part of the trip. She said the HVAC vendor had to find another company to transport the tanks the remainder of the way. The NHA said the tanks were delivered and installed on 6/4/24 and by 5:30 p.m. that day, the facility had running hot water throughout the facility with one domestic tank/heater operational. She said by 6/7/24, the other two tanks were installed and running. The NHA said the event was discussed in the June 2024 QAPI meeting with the interdisciplinary team (IDT) (see record review above). Corporate consultant (CC) #4 was interviewed on 7/18/24 at 4:52 p.m. CC #4 said the facility did not have a lack of hot water policy and procedure. She said the closest the facility had was the plan created on 5/13/24, after it was determined the facility would be without hot water until the parts and repairs were in place. The DMS was interviewed again on 7/22/24 at 1:40 p.m. The DMS said he did not document his observations of the leaks with the hot water heater or communication of the leaks or invoices from the HVAC vendor when they came out to look at the leaks prior to May 2024. The HVAC service vendor was interviewed on 7/22/24 at 2:10 p.m. He said he was called out to the facility on 5/10/24 because the hot water heater was not firing up. He said the water was leaking from the heat exchanger tubes. He said he recommended replacing the water heater. The HVAC vendor said he replaced the burner assembly unit and transformer on 5/10/24. The HVAC vendor said he came out again on 5/12/24 when the hot water heater was not working again. He said water was leaking onto the burners and water was leaking from the heat exchanger. He said the water heater was shut off on 5/12/24 because it was no longer safe to run it. The HVAC vendor said he was at the facility in January 2024 or February 2024. He said the expansion unit on the hot water heater had a hole in the unit, but the unit was not leaking at that time. He said, due to the price, the facility did not proceed with replacing the expansion tank. He said without a working expansion unit, he was not able to determine if there were additional problems with the system. The HVAC vendor said the facility had a separate tank that was working for domestic water. He said he did not have access to the invoices from January 2024 or February 2024 to determine the date when he came out to the facility because he was no longer working for that company. The HVAC vendor said he asked the facility if they had a policy for the hot water heater and he asked for one but never got an answer or the policy. The NHA and the DMS were interviewed together on 7/23/24 at approximately 9:15 a.m. The DMS said the facility did not have a safety meeting but plant operations were reviewed in QAPI. He said the review was mainly regarding fire drills or tabletop reviews of a potential emergency. He said the facility did not identify the lack of hot water if the hot water heater went out as a potential facility emergency, however he was concerned the hot water heater would go out in the middle of the night. He said the hot water heater was over 20 years old and there was some leaking and some corrosion on the old pipes. He said the system would shut itself off if there was a problem for safety. The DMS said, on 5/10/24, the hot water heater system would not light. The NHA was informed of the above interview with the hot water heater service vendor. The DMS said he also saw some leaking in April 2024 and had the vendor look at it, however, he said he had not informed the NHA that the hot water heater was leaking at that time. He said part of the system related to the copper coils boiler was disconnected to stop the leak. He said the facility had been operating with the one 20 year old hot water heater tank since April 2024. He said the one tank was due to be replaced. He said he did not think the corporation was aware that the facility had only one tank available that was 20 years old. The DMS said he did not record or document the past repairs, recommendations or observations to reference but he should have. The NHA said she was not aware that a new expansion tank was recommended by the vendor in January 2024 or February 2024. The NHA said during the hot water heater event, the residents were not in danger and basic needs were accommodated for. She said after the hot water heater event she learned that the facility needed to be more prepared with needed supplies, such as disposable paper products for food. She said the facility needed to make sure they had at least three days worth of supplies on site. She said the facility needed to have more bathing kits available in case of an emergency. She said the water heater event was an emergency. The NHA said, in retrospect, the facility could have benefited from an extra certified nursing assistant (CNA) on some of the busier days. She said staff did not complain a lot but she felt some of the staff needed more training on how to manage the situation with less frustration versus increasing the number of staff. She said she would like to have the staff go through additional training on crisis management. The NHA said nothing had been scheduled yet for the training and she needed to look at the training schedule to determine when it could be set up. She said she would reach out to CC #4 and other sister facilities to see if there were training materials available. The NHA said to directly prevent the lack of hot water available, the new hot water system was purchased. The NHA said she did not have documentation that a post review of the hot water event was conducted or actions moving forward to prevent similar situations other than a reference in QAPI. She said she and the dietary manager verbally talked about the needed kitchen supplies and steps to take during the water heater event, but a procedure was not created and put in place after the water heater event to help mitigate future emergencies that involved the kitchen. The NHA said she would like to have three weeks for some supplies in the event of an emergency but had to see where there was enough space to stock the supplies. The NHA said reviewing the event following the incident on what the facility learned and what the next steps were to put in motion to help with future emergencies could use improvement. The NHA said the facility did not have a specific lack of hot water plan but it would be appropriate to have a policy in place. She said she would reach out to her corporate resources on how to create the policy and procedures. She said the policy would be implemented and added to the facility's emergency plan. The NHA said if the facility had a policy and procedure available, she would have added it with her plan as part of the facility's response and use it as additional guidance.

Based on record review and interviews, the facility failed to ensure the money from personal funds accounts was managed adequately for two (#7 and #13) of five residents reviewed for personal funds out of 41 sample residents. Specifically, the facility failed to notify Resident #7 and Resident #13, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include:I. Facility policy and procedureThe Management of Residents' Personal Funds policy, revised March 2021, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, "The facility manages the residents' funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident. No service charge is levied against the resident for the management of personal funds."II. Record ReviewA. Resident #7A review of the facility's current trust account balance on 7/18/24 revealed Resident #7 had $2,083.69 in her account, which was $83.69 over the allotted $2000.00 eligibility limit for Medicaid funded residents.-There was no documentation to indicate the facility had notified Resident #7 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. B. Resident #13A review of the facility's current trust account on 7/18/24 revealed Resident #13 had $1,876.24 in her account.-There was no documentation to indicate the facility had notified Resident #13 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. III. Staff interviews The business office manager (BOM) was interviewed on 7/22/24 at 3:04 p.m. The BOM said she had not provided letters to Resident #7 and Resident #13 stating they were within $200 of the Medicaid spending limit. The BOM said she was trained by the regional personnel at the same time as a few other BOM's at other health care facilities. She said she was concerned that some business office education may have been lost in the training process. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 7/23/24 at 4:53 p.m. The NHA said she was not aware that Medicaid letters had not been sent when residents were within $200 of the spending limit. The DON said Medicaid spending limit letters should be provided to residents.

Based on observations and interviews, the facility failed to ensure residents' personal privacy for two (#18 and #49) of three residents reviewed for privacy out of 41 sample residents. Specifically, the facility failed to ensure residents had privacy during personal phone calls. Findings include:I. Facility policy and procedureThe Promoting/Maintaining Resident Dignity policy, dated 1/1/23, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part,"All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights."Maintain resident privacy."II. ObservationsOn 7/17/24 at 10:05 a.m., an unidentified resident was observed using the landline telephone at the nurse's station. Two staff members were sitting close by in the nurses station within a few feet of the resident. -No privacy was provided to the unidentified resident. On 7/19/24 at 1:41 p.m., Resident #18 was observed at the nurse's station. The resident was talking on the landline telephone. During the telephone conversation, the resident had to repeat herself in a louder voice so she could be heard on the telephone. Multiple nursing staff and residents were present within the immediate area of the telephone conversation which was easily overheard. -No privacy was provided to the resident. On 7/23/24 at 9:11 a.m., Resident #18 was observed at the nurse's station. The resident was talking on the landline telephone. The resident used her hands to attempt to block sound from the room going into the mouthpiece of the landline telephone. Multiple nursing staff and residents were present within the immediate area of the telephone conversation, which was easily overheard. -No privacy was provided to the resident. III. Resident interviewsResident #49, who was cognitively intact, was interviewed on 7/18/24 at 10:33 a.m. Resident #49 said he was not able to make private phone calls in the facility if his personal cell phone stopped working. Resident #49 said his personal cell phone ran out of battery power a month ago (June 2024) and he was unable to have private phone conversations with his wife on the facility phone. Resident #49 said he had to use the phone at the nurse's station to speak to his wife which made him uncomfortable because there were multiple staff members and residents within a few feet of him listening to the conversation. Resident #49 said since the incident when his phone ran out of battery power he ensured his phone was fully charged every day so he did not have to use the community phone at the nurse's station. Resident #18, who was cognitively intact, was interviewed on 7/22/24 at 3:12 p.m. Resident #18 said she could not make a private phone call in the facility. Resident #18 said her only option to make any phone call was to use the landline phone at the nurse's station. Resident #18 said she did not like to use the landline phone at the nurse's station because she knew staff and other residents listened to her telephone conversations. Resident #18 said she had heard nursing staff make comments about her telephone conversations while she was talking on the landline phone, which made her feel uncomfortable. Resident #49 was interviewed again on 7/23/24 at 10:58 a.m. Resident #49 said he did not know there were cell phones for resident use. Resident #49 said the staff in the facility had not informed him that cell phones for resident use were available. Resident #49 said he wished he had known about the option when he needed to make private phone calls and his personal cell phone was not available to him. Resident #18 was interviewed again on 7/23/24 at 12:56 p.m. Resident #18 said she was not aware the facility had cell phones for residents to use. Resident #18 said she was never informed by staff that cell phones were available for resident use. Resident #18 said she would like to use the cell phones for private phone calls in her room if that was available to her. III. Resident group interviewFour residents (#16, #49, #59 and #65), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. The following comments were made regarding privacy when making or receiving phone calls:-Residents said there was a shared phone available at the nurse's station on the south unit or residents could use the phone at the front desk. -The facility had cell phones but the residents had been told the cell phones were lost.-A resident said when she had to make a phone call at the nurse's station, she did not have privacy because there were staff and other residents all around her. -Another resident said if she wanted to have a private phone call she would have to ask staff to borrow one of their personal phones. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 7/23/24 at 10:11 a.m. LPN #2 said the facility had two cell phones that the residents could use but she did not know where they were located. LPN #2 said the cell phones for resident use should be kept at the nurse's station. LPN #2 said she did not know when the cell phones were last requested for personal use. LPN #2 was interviewed again on 7/23/24 at 10:24 a.m. LPN #2 said the cell phones for resident use were now being kept at the front desk. LPN #2 said she did not know when this change occurred. LPN #2 said the residents should know that cell phones were available to them. LPN #2 said she did not know when the cell phones first became available for the residents. Certified nurse aide (CNA) #7 was interviewed on 7/23/24 at 10:41 a.m. CNA #7 said she did not know if there were personal cell phones for the residents to use. CNA #7 said she had not been asked for a cell phone to make a private phone call in the facility. The director of nursing (DON) was interviewed on 7/23/24 at 4:53 p.m. The DON said the residents should have privacy during phone calls to respect the residents ' dignity and privacy. The DON said the facility should do more to inform the residents that cell phones were available for their personal use. The DON said she would type up a newsletter to distribute to the residents to ensure they were aware that the cell phones were available to them. The NHA was interviewed on 7/23/24 at 7:33 p.m. The NHA said she had not identified resident phone call privacy as an issue in the QAPI committee.

Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#29) of four residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to protect Resident #29 from physical abuse by Resident #44. Findings include:I. Facility policy and procedureThe Abuse policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 7/22/24 at approximately 12:00 p.m. It read in pertinent:"Residents have the right to be free from abuse. This includes but is not limited to verbal and physical abuse."The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention can then be implemented. When another resident jeopardizes the safety of one resident, alternative placement may be considered for that resident."II. Incident of physical abuse between Resident #44 and Resident #29 on 7/2/24A. Facility investigation of the altercation on 7/2/24The initial report, completed 7/2/24, documented two female residents in the secured dementia unit had a verbal and physical altercation. Resident #44 and Resident #29 shared a bedroom, where this incident occurred. Resident #44 told Resident #29 to "shut up." Resident #29 responded with "I do not have to, you are not my boss." Resident #44 pushed Resident #29 which resulted in Resident #29 falling to the ground. The staff immediately separated the residents for the night and Resident #29 was placed on 15-minute checks. The nurse assessed the residents and Resident #29 had a bruise to her left elbow. Certified nurse aide (CNA) #6 was interviewed and said she heard a commotion and checked in the resident's room. CNA #6 separated the residents for the night because they shared a room. A summary of the investigation revealed Resident #44 did push Resident #29 to the ground which resulted in a bruise. The allegation of the resident to resident altercation was substantiated by the facility. III. Resident #44 (assailant) A. Resident statusResident #44, age 73, was admitted on 9/7/22. According to the July 2024 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (life-threatening illness caused by thiamine deficiency) and dementia. The 6/27/24 minimum data set (MDS) assessment revealed Resident #44 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment indicated Resident #44 did not have behaviors. B. Record reviewA change of condition was completed for Resident #44 on 7/2/24. Resident #44 was documented as having had behavioral symptoms. Resident #44 exchanged aggressive words with her roommate, Resident #29, and shoved Resident #29 which caused her to fall. Resident #29 and Resident #44 were separated and Resident #29 was in another room for the night. A progress note dated 7/2/24 documented Resident #44 was unable to recall an incident that occurred with her roommate (Resident #29). Resident #44 and Resident #29 were separated and 15-minute checks were initiated. The nursing home administrator (NHA), the on-call nurse and the physician were notified. Resident #44's care plan, revised 7/3/24, documented the resident had the potential to become verbally or physically aggressive toward other residents. Interventions included ensuring the resident had a routine, providing redirection if the resident had escalating behavior, redirecting the resident when she approached other residents and redirecting other residents from Resident #44's bedroom. An interdisciplinary team (IDT) risk management note dated 7/3/24 documented the root cause of the incident was because Resident #44 was territorial and she was adjusting to a new roommate. The interventions that were put into place after the altercation were 15-minute checks and the residents were to be monitored for adjustment of becoming roommates. IV. Resident #29 (victim)A. Resident statusResident #29, age greater than 65, was admitted on 9/18/23. According to the July 2024 CPO, diagnoses included anxiety disorder, insomnia, dementia that was moderate with anxiety and Alzheimer's disease. The 4/30/24 MDS assessment revealed Resident #29 had severe cognitive impairment with a BIMS score of zero out of 15. The MDS assessment did not indicate Resident #29 had any behaviors. B. Record reviewA change of condition was completed for Resident #29 on 7/2/24. Documentation revealed she had a fall. Resident #29 was observed on the floor next to her bed on her hands and knees. Resident #29 said Resident #44 pushed her after the residents exchanged words. Resident #29 had minor pain in her left elbow. Resident #29's left elbow had an area that was two inches in diameter that was slightly discolored. The residents were separated and 15-minute checks were started. A progress note dated 7/2/24 documented in Resident #29's EMR verbalized Resident #44 shoved her and she fell. A blue bruise about two diameters in size was noted on her left elbow. An IDT note was entered in Resident #29's EMR on 7/3/24. It documented the resident received physical aggression. The root cause was identified as the residents were adjusting to a room change. The residents were separated, 15-minute checks were started and Resident #29's bruise was monitored. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 7/17/24 at 12:42 p.m. CNA #1 said the staff attempted to keep the residents separated if residents appeared upset. She said separation did not always work because the residents on the unit had dementia. CNA #5 was interviewed on 7/17/24 at 12:45 p.m. CNA #5 said staff kept a close eye on all of the residents in the dementia unit. CNA #5 said she had not witnessed a lot of resident to resident altercations on the unit. CNA #5 said the residents mainly yelled at each other. CNA #5 said the activity staff were supposed to help entertain the residents while nursing staff provided the residents' care. Licensed practical nurse (LPN) #4 was interviewed on 7/23/24 at 3:57 p.m. LPN #4 said the residents who had dementia were in an altered mental state but that was to be expected because that's how the residents were. The memory care director (MCD) was interviewed on 7/23/24 at 4:06 p.m. The MCD said the staff watched the residents who had a diagnosis of dementia very closely. She said the staff kept the resident's doors open and had staff who walked the hallways to keep an eye on the residents. She said staff offered snacks, cookies and popcorn throughout the day. The MCD said the staff were vigilant and kept an eye on the residents to prevent resident to resident altercations. She said some of the shared resident rooms were in close quarters to each other. The MCD if staff noticed any type of escalation, yelling, cussing or facial expressions the staff redirected the resident. The MCD said when the weather was cooler the staff brought the residents outside to entertain the residents. The nursing home administrator (NHA) was interviewed on 7/23/24 at 6:21 p.m. The NHA said she was not at the facility when the resident to resident altercation between Resident #44 and Resident #29 occurred. The NHA said Resident #44 and Resident #29 were roommates. The NHA said on the night of the incident (7/2/24) the residents did not remember they were roommates which started a verbal altercation. She said the staff separated the residents and there were no further incidents between the residents. The NHA said Resident #44's care plan was updated but Resident #29's care plan was not because she was the victim and staff did not think to update it.

Based on observations, record review and interviews, the facility failed to provide treatment and services to maintain hearing in a timely manner for one (#3) of one resident reviewed out of 41 sample residents. Specifically, the facility failed to ensure recommendations for Resident #3 were followed after an audiologist appointment. Findings include:I. Facility policy and procedureThe Ancillary Services policy, dated 11/4/13, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. The policy read in pertinent part, "Any resident needing or requesting ancillary services, such as dental, vision, audiology and podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice." II. Resident status Resident #3, age greater than 65, was admitted on 12/22/22. According to the July 2024 computerized physician orders (CPO), diagnoses included unspecified intracranial injury with loss of consciousness (head injury), anxiety, major depressive disorder post-traumatic stress disorder and unspecified perpetrator of maltreatment and neglect. The 4/29/24 minimum data set (MDS) assessment indicated Resident #3 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. He did not have inattention or disoriented thinking. No behavioral symptoms or care rejection were documented. The resident required limited one-person physical assistance with most activities of daily living (ADL). According to the MDS assessment, the resident's hearing was adequate and he did not use hearing aids. III. Resident interview Resident #3 was interviewed on 7/17/24 at 1:52 p.m. Resident #3 said he had not gone to bingo lately because he had not been able to hear well enough to play. He said he had difficulty hearing and had been asking to go to the physician to get his ears tested. He said he was supposed to have his ears tested a while ago but he never heard anything more about it. Resident #3 was interviewed again on 7/23/24 at 4:28 p.m. Resident #3 said he was very happy because he was told the nurse was going to put drops in his ears so he could have his ears tested. He said he had been waiting to have his hearing checked for a long time (see record review and interviews below). IV. Record review The 2/13/23 patient appointment visit information form identified Resident #3 had a physician's order to schedule an appointment with the physician/nurse for ear wax removal. According to the physician's orders, the resident had too much wax to test (Resident #3's hearing). The information form requested the facility to look in the resident's ears before scheduling an appointment and if there was a lot of earwax, remove the wax prior to the appointment. The 7/28/23 weekly nursing note read Resident #3 had difficulty hearing in some environments. A speaker may be needed to increase the volume or speak distinctly. -Review of Resident #3's physician's orders did not identify that the resident had orders to remove the earwax after the failed attempt to test his hearing with the specialist. -Review of Resident #3's progress notes did not identify the resident's earwax was removed and another appointment was made to test his hearing. -Review of the resident's comprehensive care plan revealed he did not have a care plan regarding hearing, difficulty hearing, or interventions to help with his difficulties in hearing. V. Staff interviews The social services director (SSD) and the NHA were interviewed together on 7/22/24 at 4:16 p.m. The SSD said when a resident returned to the facility after an appointment, the nurse would enter the new orders, recommendations and/or referrals in the resident's electronic medical record (EMR). The SSD said an appointment would be scheduled for follow up as needed. The SSD said she was not aware of the concerns with Resident #3's hearing. The NHA and the SSD said they reviewed the resident's EMR.The NHA said the resident last went to the audiologist on 2/13/23. She said the audiologist requested for Resident #3's excess earwax to be removed so his hearing could be tested. The NHA said she did not see an order to remove the excess earwax. She said she did not see documentation that the audiologist's orders were followed. The NHA and the SSD said neither of them were in their current positions in February 2023 and they were not sure why the recommendations were not followed up with at the time of the audiology appointment. The SSD said she would notify the director of nursing (DON) and the nurse practitioner of the orders and schedule a follow up appointment with the audiologist to test Resident #3's hearing. The SSD said she would create a grievance form to make sure the needed steps to correct the concern were taken, tracked and reviewed in the interdisciplinary team's (IDT) meeting. The DON was interviewed on 7/23/24 at 3:14 p.m. The DON said when a resident went to a specialist, the resident's nurse would review the visit summary, put the recommendations in the EMR as verbal orders and notify the nurse practitioner. She said she was informed on 7/22/24 (during the survey) Resident #3 was having a harder time hearing. The DON said she discussed the concern with the physician and the resident had a new physician's order for ear drops to help with his earwax removal. The DON said an appointment would be made when Resident #3's earwax buildup was clear. She said she did not know how the orders were missed, but the facility had implemented a new double check process to make sure all physician's orders were put into the EMR after recommendations were made from a specialist, following the appointment. The activity director (AD) was interviewed on 7/23/24 at 6:29 p.m. The AD said Resident #3 had not been going to bingo as much as he used to and, over the last couple of months, he stopped going completely. She said she was not aware Resident #3 was having a hard time hearing. She said she could have offered to have him sit by her during bingo so he could hear the numbers called out.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals for one (#49) of two residents reviewed for pain out of 41 sample residents. Specifically, the facility failed to:-Consistently and accurately assess Resident #49's pain to ensure the resident's pain was at or below the resident's stated tolerable pain level;-Ensure Resident #49's care plan included person-centered non-pharmacological interventions for pain; and,-Ensure the physician's order for routine pain medication for Resident #49 was administered as ordered. Findings include:I. Facility policy and procedureThe Pain Management policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It revealed in pertinent part,"Acceptable (tolerable) pain control is defined by the resident."All residents will be evaluated for pain by utilizing a pain evaluation tool in the electronic medical record (EMR) system. The pain evaluation will be completed upon admission, readmission, quarterly, and with any significant change in condition."The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating, and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness."II. Resident #49A. Resident statusResident #49, age less than 65, was admitted on 11/20/23. According to the July 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), right leg amputation below the knee, aortic heart valve disorder, peripheral vascular disease (narrowed blood vessels), chronic kidney disease, type two diabetes, diabetic neuropathy (nerve damage caused by diabetes) and generalized muscle weakness. The 7/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview mental status (BIMS) score of 15 out of 15. The assessment documented Resident #49 had a limb prosthesis and used both a walker and a wheelchair. The assessment documented Resident #49 was on a scheduled pain regimen and did not receive as-needed pain medications or non-medication interventions for pain in the last five days during the assessment period. The assessment documented the resident occasionally had pain, but the pain did not interfere with the resident's sleep or participation with therapy. The resident's pain rarely interfered with his day to day activities. The resident's occasional pain was mild in intensity. B. ObservationsOn 7/22/24 at 4:23 p.m., medication pass was observed with licensed practical nurse (LPN) #5. After preparing other medications for Resident #49, LPN #5 prepared pain medication. LPN #5 opened the narcotic medication lockbox, removed one oxycodone-acetaminophen 5-325 milligram (mg) tablet and placed the tablet into a medication cup. LPN #5 closed the narcotic medication box and locked the medication cart. LPN #5 turned away from the medication cart with the intention to deliver the medications to Resident #49. Upon prompting, LPN #5 reread Resident #49's physician's order for oxycodone-acetaminophen. LPN #5 said she did not know if she could give the medication to the resident at 5:00 p.m. because the physician's order was confusing on when to administer the medication. LPN #5 asked for help from LPN #2 and the director of nursing (DON). The DON clarified and updated the physician's order in the July 2024 CPO on 7/22/24. (see interview below)B. Resident interviewsResident #49 was interviewed on 7/18/24 at 10:33 a.m. Resident #49 said he had pain throughout all hours of the day and it often felt severe for him. Resident #49 said he recently received a prosthetic leg, but it caused him pain wearing it, so he did not wear the prosthetic as much as he would like. Resident #49 said he felt his pain limited his ability to perform activities of daily living (ADL) and limited his sleep. Resident #49 said he normally only slept a few hours each night and it was usually in the early morning when sleep occurred. Resident #49 said he felt constant phantom pain (a painful sensation that is perceived in a body part that is no longer present due to surgical or traumatic removal) in his right leg from the amputation and he had some occasional pains in his hands that felt like lightning to him. Resident #49 said he had tried several nerve pain medications, such as gabapentin and Lyrica, but they did not help his pain. He said the medications he was receiving did not bring his pain to a tolerable level. Resident #49 said that his pain level was a 7 or 8 out of 10 throughout the day, and his acceptable level of pain was a 3 out of 10. Resident #49 said he used lotion for his hands to relieve pain between pain medication doses, but that only reduced his pain a little and did not relieve his pain. Resident #49 said sometimes the nursing staff did not ask him what his pain level was and would just give him his pain pills when he could have them. Resident #49 said his pain medicine was last changed when he had a wound on his left leg in May 2024, but he said the wound was completely healed now. Resident #49 said he had complained of pain so much that he felt he was annoying the nursing staff. Resident #49 and his partner were interviewed together on 7/19/24 at 9:49 a.m. Resident #49 said he barely slept last night (7/18/24) because his phantom pain was shooting down his leg which kept him awake. Resident #49's partner said she felt Resident #49's pain had never been controlled by the facility despite several inquiries regarding his pain. Resident #49 and his partner said they were concerned the facility was not doing enough to manage Resident #49's pain. Resident #49 was interviewed again on 7/22/24 at 10:02 a.m. Resident #49 said he slept for a few hours between 6:00 a.m. and 8:00 a.m. this morning (7/22/24). Resident #49 said the pain in his right leg and hands prevented him from sleeping more the previous night. Resident #49 said he received his pain medication as scheduled but it did not relieve his pain. Resident #49 said his pain was constant. Resident #49 was interviewed again on 7/23/24 at 2:48 p.m. Resident #49 said he tried walking with his prosthetic leg today (7/23/24) but it caused so much pain in his leg he had to stop. Resident #49 said he was disappointed he could not walk or work to achieve his goals of walking more because of his pain today. He said he did not receive additional pain medication or non-pharmacological interventions to help him with the pain and he chose to stop walking instead. C. Record review The pain care plan, created and revised on 10/18/23, documented the resident had pain related to his right leg amputation below the knee. Interventions included administering analgesia (pain medication) as ordered, evaluating the effectiveness of the pain interventions, monitoring and documenting the cause of each pain episode, monitoring and documenting the side effects of pain medication, monitoring, recording and reporting to the nurse complaints of pain or requests for pain medication and offering non-pharmacological interventions for pain prior to administering medications.-The care plan did not identify Resident #49's pain in his hands (see pain assessment documentation below).-The care plan failed to include specific person-centered non-pharmacological interventions. The 10/17/23 pain assessment documented the resident had a hot or burning pain in the right knee, phantom pain in the right foot and pain in the sacrum. The assessment documented Resident #49 stated his pain caused him to be withdrawn from his relationships, made him withdrawn from activities, caused a decrease in physical activity, caused a loss of appetite and caused an inability to perform ADL's. Resident #49 stated that his pain prevented him from doing anything during the assessment. The assessment documented the resident's acceptable level of pain was a 2 out of 10. The 11/20/23 pain assessment documented the resident had a sharp, stabbing, and throbbing pain in the front of the right knee. The assessment documented the resident's acceptable level of pain was a 2 out of 10.-The pain assessment documented Resident #49's acceptable level of pain was a 2 out of 10, however, the physician's order to check the resident's pain level every shift documented the resident's acceptable level of pain was a 7 out of 10 (see physician's orders below). The 2/20/24 pain evaluation documented Resident #49 had a constant aching, throbbing, and tingling pain in the right knee, the left lower leg, the sacrum, and generalized aches and pains. The assessment documented the pain was worse in the evening and at night. The assessment documented the resident's acceptable level of pain was a 4 out of 10. The assessment documented that Resident #49's pain caused a decrease in physical activity, caused an inability to perform ADL's, affected Resident #49's ability to focus, and caused changes in Resident #49's mood and emotions.-The pain assessment documented Resident #49's acceptable level of pain was a 4 out of 10, however, the physician's order to check the resident's pain level every shift documented the resident's acceptable level of pain was a 7 out of 10 (see physician's orders below). The 5/20/24 pain evaluation documented Resident #49 had an aching and sharp phantom pain in his right knee, and generalized aches and pains. The evaluation documented the resident's acceptable level of pain was a 4 out of 10 on a numerical pain scale. The assessment documented that Resident #49's pain caused a decrease in physical activity, caused an inability to perform ADL's, affected Resident #49's ability to focus, and caused changes in Resident #49's mood and emotions. The assessment summary documented that pain was present and a management plan was needed, and to see the care plan for specifics.-However, the pain care plan was not updated after 10/18/23 (see care plan above).-The pain assessment documented Resident #49's acceptable level of pain was a 4 out of 10, however, the physician's order to check the resident's pain level every shift documented the resident's acceptable level of pain was a 7 out of 10 (see physician's orders below). The July 2024 CPO revealed the following physician's orders for pain management:Pain check every shift using PAINAD (pain assessment in advanced dementia) scale. Resident's acceptable level of pain is a 7, ordered on 11/20/23.-However, the pain assessments on 10/17/23, 11/20/23, 2/20/24 and 5/20/24 documented Resident #49's acceptable level of pain was a 2 or a 4 out of 10 (see pain assessments above).-The physician's order recommended using a pain evaluation for cognitively impaired residents, which was based on staff assessment. However, Resident #49 was cognitively intact and was able to state his pain level when asked. Oxycodone-acetaminophen oral tablet 5-325 milligrams (mg). Give one tablet by mouth three times a day for 8:00 a.m., 12:00 p.m., 8:00 p.m. and two tablets at 12:00 a.m., ordered on 5/30/24. A review of the medication administration record (MAR) from May 2024 to July 2024 revealed Resident #49 was documented to have received an oxycodone-acetaminophen oral tablet on 52 consecutive days at 5:00 p.m. between 5/31/24 and 7/21/24. -However, the physician's order specified the resident was to receive the medication at 8:00 p.m., not 5:00 p.m.-The MAR from May 2024, June 2024, and July 2024 failed to document non-pharmacological interventions used to address Resident #49's pain. A review of pain assessment documentation on the MAR revealed that Resident #49's pain was assessed using the PAINAD scale a total of 105 times between 5/30/24 and 7/21/24. Of those 105 assessments, Resident #49 was documented to be experiencing pain above a 4 out of 10 on 71 of those pain assessments.-A review of Resident #49's EMR revealed there was no documentation to indicate the physician was notified or the facility addressed the resident's pain when his pain level was above his stated tolerable level of pain. IV. Staff interviewsLPN #5 was interviewed on 7/22/24 at 4:48 p.m. LPN #5 said she had not assessed Resident #49's pain before obtaining his pain medication from the medication cart. LPN #5 said the physician's order for oxycodone-acetaminophen 5-325 mg for Resident #49 was confusing. LPN #5 said when a physician's orders appeared confusing, nursing staff should clarify the order to ensure the medication was administered correctly. LPN #5 said she had not clarified Resident #49's pain medication order before 7/22/24 (during the survey). LPN #2 was interviewed on 7/22/24 at 4:49 p.m. LPN #2 said she had always given Resident #49 his pain medication at 5:00 p.m. because the MAR had pain medicine scheduled for 5:00 p.m. LPN #2 said she re-read the order and was unsure if the pain medication could be given at 5:00 p.m. LPN #2 said confusing physician's orders should be clarified with the provider. LPN #2 was interviewed again on 7/23/24 at 9:11 a.m. LPN #2 said Resident #49 always had pain whenever she assessed him for pain. LPN #2 said she did not know what Resident #49's acceptable pain level was. LPN #2 said Resident #49's pain medication was last reviewed and updated in May 2024. Certified nurse aide (CNA) #7 was interviewed on 7/23/24 at 9:17 a.m. CNA #7 said Resident #49 frequently complained of pain in his leg or his hands. CNA #7 said the facility managed Resident #49's pain with pain medications. CNA #8 was interviewed on 7/23/24 at 9:26 a.m. CNA #8 said Resident #49 complained of pain every day. CNA #8 said the nursing staff had known about Resident #49's pain for a long time. CNA #8 said the facility used pain medications to help Resident #49's pain, but she was unsure how well the pain medications were working for the resident's pain. The DON was interviewed on 7/22/24 at 4:51 p.m. The DON said the physician's order for oxycodone-acetaminophen 5-325 mg for Resident #49 was confusing. The DON said the ordering provider had clicked a scheduling button to schedule a dose at 5:00 p.m. when the provider entered the order into the facility's electronic medical record system. She said this prompted the order to be scheduled at 5:00 p.m. on the MAR instead of at 8:00 p.m. as was documented in the physician's order. The DON said the order was correct but should be clarified with the provider. The DON said she would call the ordering provider and change the medication order to be more easily understood by the nursing staff.-However, the nursing staff was administering Resident #49's pain medication at 5:00 p.m. instead of 8:00 p.m. which was the time specified in the physician's order (see record review above). The DON and corporate consultant (CC) #2 were interviewed together on 7/23/24 at 4:53 p.m. The DON said it was normal for the facility to assess pain on admission, quarterly and whenever a resident experienced a change in condition. The DON said she was not aware Resident #49 was having uncontrolled pain. The DON said she was not concerned about documented discrepancies regarding Resident #49's acceptable pain level because Resident #49 had not alerted staff that he was having uncontrolled pain. CC #2 said the ordering provider had entered Resident #49's pain order incorrectly but the order had been corrected to reflect the appropriately scheduled time of administration in the July 2024 CPO.

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 out of five staff reviewed. Specifically, the facility did not complete annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2. Findings include:I. Record reviewCNA #2 (hired on 6/23/22) did not have an annual performance review completed. CNA #2 did not have an in-service education plan based on the outcome of the review. II. Staff interviewsThe director of staff development (DSD) was interviewed on 7/22/24 at 2:18 p.m. The DSD said she completed an audit of the system when she accepted her position in the beginning of 2024. She said she discovered there was an issue with staff completing their training as required. She said she worked on a spreadsheet to help track the training staff needed to complete. She said the staff completed a performance every year and if it was a good performance review, the staff received a raise. She said CNA #2 received a raise but she was unable to find their performance reviews. The nursing home administrator (NHA) was interviewed on 7/23/24 at 7:19 p.m. The NHA said if a CNA received an annual raise then an annual performance review was completed.-However, the facility was unable to provide documentation indicating CNA #2 had received an annual performance review. III. Facility follow-upOn 7/26/24 at 12:44 p.m. the NHA said CNA #2 received a raise for the 2024 year but she was unable to find her performance review.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure food was palatable and attractive when delivered to residents. Findings include:I. Resident interviewsResident #65 was interviewed on 7/17/24 at 11:54 a.m. Resident #65 said when he received his breakfast in his room it was always served cold and under seasoned. Resident #49 was interviewed on 7/18/24 at 8:40 a.m. Resident #49 said the food was bland and had no taste. He said he received cold food. Resident #13 was interviewed on 7/18/24 at 10:34 a.m. Resident #13 said breakfast was always served cold. She said she was the last resident to get her tray. Resident #28 was interviewed on 7/18/24 at 11:56 a.m. Resident #28 said the food tasted awful and the meals were frequently served cold. Resident #28 said he had received undercooked chicken so he ordered something different if chicken was being served. II. Resident group interviewFour residents (#65, #16, #59 and #49), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. Residents made the following comments:-The vegetables were soggy or uncooked; -The meals were served cold;-Food items were switched out (received chips instead of french fries);-Food items were served burnt; and, -The meat was undercooked. III. Test trayA test tray was evaluated by three surveyors on 7/22/24 at 12:29 p.m. The test tray consisted of cheesy ham and macaroni casserole, sauteed garlic and spinach, pineapple tidbits and a dinner roll. -The cheesy ham and macaroni casserole was dry, bland and did not have a cheese sauce mixed through it. - The spinach tasted plain and did not have garlic seasoning. IV. Food committee notesThe food committee notes were provided by the nursing home administrator (NHA) on 7/22/24 at 4:00 p.m. The food committee notes from 5/7/24 revealed the kitchen was still working on proper food temperatures and appealing plating. The food committee notes from 6/4/24 revealed the kitchen was still working on proper food temperatures and appealing plating. The food committee notes from 7/16/24 revealed the kitchen was working on ensuring food was properly cooked before it was served and getting the meals out on time and promptly. V. Staff interviewsThe cook (CK) was interviewed on 7/22/24 at 11:30 a.m. The CK said he seasoned the meals based on what the recipe indicated. The dietary manager (DM) and the dietary consultant (DC) were interviewed together on 7/23/24 at 10:15 a.m. The DM said she and the DC were worried about the pineapple not being on ice during the meal service and had placed the last tray of pineapple in the refrigerator to try to cool it down before the last half of the residents were served. The DC said the CK was supposed to put poultry gravy over the top of the casserole for all residents who were on a dysphagia altered diet. The DC said the cheesy ham casserole was dry and bland because the CK was adding poultry gravy to the casserole for the residents but failed to add it to the test tray. She said the CK was worried about how the gravy tasted on top of macaroni and cheese and omitted it from the test tray. The DC said she was going to review the recipes. She said she would let the kitchen staff know if the recipe indicated to provide a sauce, it needed to match the menu item and not just a form of gravy. She said the CK should have provided a cheese sauce to the residents on a dysphagia diet and the test tray, instead of gravy, since it was a macaroni and cheese type of casserole. The DM said she tried to follow-up on the residents' concerns in food committee meetings but she had a budget she had to stay under and she tried her best to please the residents while not going over the budget. The DC said the DM needed to make sure the residents were happy and not focus on the budget as much. The DC said she was going to work with the DM to fix the concerns in the kitchen.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of two kitchenettes. Specifically, the facility failed to:-Ensure residents were offered and provided hand hygiene before meals;-Ensure the kitchen staff appropriately cleaned thermometers before temperatures were obtained from ready-to-eat foods; and,-Ensure cold foods were held at 41 degrees Fahrenheit (F) or below before serving residents. Findings include:I. Resident hand hygieneA. Facility policy and procedureThe Handwashing and Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, "All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections."All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors."Wash hands with soap and water when hands are visibly soiled."Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, and before and after eating or handling food."B. ObservationsOn 7/17/24 during a continuous observation, beginning at 11:49 a.m. and ending at 12:58 p.m., the following was observed in the main dining room:At 11:55 a.m. Resident #5 was observed self-propelling herself in the dining room. The resident shook the hands of Resident #27 and Resident #70. After shaking hands, Resident #5 then self-propelled herself to a dining table. At 12:08 p.m., Resident #5 was served her lunch plate by staff, which included peas, a dinner roll, meatloaf, mashed potatoes and an ice cream cup. -The resident was not offered hand hygiene by staff members. At 12:10 p.m., Resident #5 began eating her lunch plate. Resident #5 used her fingers to scoop the ice cream out of the ice cream cup and then eat the ice cream. The resident frequently licked her fingers between bites of the ice cream she was scooping out with her fingers. After finishing her ice cream with her hands, she began picking up pieces of meatloaf, peas and mashed potatoes with her hands. The resident continued to lick her fingers between small scooping bites which she ate with her fingers. The resident had been provided with tableware but did not attempt to use it. At 12:15 p.m., Resident #70 began eating his dinner roll with his hands. -Resident #70 had not been offered hand hygiene after he shook hands with Resident #5. At 12:19 p.m., Resident #27 began eating his dinner roll with his hands. -Resident #27 had not been offered hand hygiene after he shook hands with Resident #5. At 12:36, Resident #5 finished eating. After licking her fingers, she self propelled herself in her wheelchair and shook hands with Resident #27. After shaking hands with Resident #27, Resident #5 self-propelled herself out of the dining room.-The facility failed to offer hand hygiene to Resident #5 before or after meals.-The facility failed to offer hand hygiene to Resident #27 or Resident #70 when their hands became contaminated. C. Resident interviewsResident #16 was interviewed on 7/18/24 at 10:31 a.m. Resident #16 said the facility did not offer hand hygiene before or after meals in the main dining room. Resident #16 said the facility used to have hand sanitizer on dining room tables but one resident ate the hand sanitizer and there had not been hand sanitizer available in the dining room for residents since that incident. Resident #27 was interviewed on 7/18/24 at 11:13 a.m. Resident #27 said the facility sometimes offered hand hygiene before meals but it was not done consistently. Resident #27 said he would like to be able to clean his own hands when he wanted to during meals but he said he would have to either leave his table orbother the busy staff to do so. D. Staff interviewsThe dietary manager (DM) was interviewed on 7/23/24 at 10:15 a.m. The DM said it was the nursing staff's responsibility to provide the residents with hand hygiene at meals. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/23/24 at 1:58 p.m. The IP said all residents should be offered hand hygiene before and after all meals. The IP said the dining room staff should offer hand hygiene to residents that were eating with their hands. The DON said she was not aware of any concerns with hand hygiene of residents in the dining room. II. Improper cleaning of food thermometerA. Professional referenceThe Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/28/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, revealed in pertinent part, "Equipment food-contact surfaces and utensils shall be clean to sight and touch. "Utensils shall be cleaned before using or storing food temperature measuring devices."B. Lunch observations on 7/22/24 at 11:30 a.m. The cook (CK) grabbed five thermometers to obtain the temperatures of lunch before service began. The CK uncovered one thermometer and immediately placed it in the pureed spinach. The CK uncovered the second thermometer and immediately placed it in the pureed cheesy ham and macaroni casserole. The CK uncovered the third thermometer and immediately placed it in the dinner rolls. The CK uncovered the fourth thermometer and immediately placed it in the vegetable soup. The CK uncovered the fifth thermometer and immediately placed it in the mashed potatoes.-The CK did not sanitize any of the thermometers prior to putting them into the food to obtain the temperatures. C. Staff interviewsThe CK was interviewed on 7/22/24 at 11:45 a.m. CK said he assumed the thermometers were disinfected from the last time the thermometers were used. The CK said the thermometers appeared clean. The DM and the dietary consultant (DC) were interviewed together on 7/23/24 at 10:15 a.m. The DM said the staff were to gather the thermometers, temperature recording log and alcohol wipes. She said the staff needed to use an alcohol wipe to clean the thermometer when the cover was removed because staff should not assume the thermometers were clean. The DM said she disinfected the thermometers after the CK took the initial temperatures but failed to see he did not disinfect the thermometers prior to use. The DC said the CK should have sanitized each thermometer before he placed the thermometers in the food and it was unacceptable to assume the thermometers were already sanitized. III. Correct cold food holding temperaturesA. Professional referenceThe Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/28/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/views, read in pertinent part, "Except during preparation, cooking, or cooling, or when time is used as the public health control time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less."The FDA (Food and Drug Administration) food code (3/27/23) was retrieved on 7/28/24 from https://www.fda.gov/food/fda-food-code/food-code-2022. It read in pertinent part, "Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long."B. Observations On 7/22/24 at 11:30 a.m., the CK obtained the temperature of the two trays of individually portioned pineapple sitting on the counter near the serving line. He said one tray was 45 degrees F and the other tray was 42 degrees F.C. Test trayA test tray was evaluated by three surveyors on 7/22/24 at 12:29 p.m. The test tray consisted of cheesy ham and macaroni casserole, sauteed garlic andspinach, pineapple tidbits and a dinner roll. -The temperature of the pineapple was 47.5 degrees F. D. Staff interviewsThe CK was interviewed on 7/22/24 at 11:30 a.m. The CK said he preferred the temperature of cold items to be below 39 degrees F but the pineapple was okay to be served at the temperatures he got. The DM and the DC were interviewed together on 7/23/24 at 10:15 a.m. The DM said she was concerned about the pineapple not being on ice while lunch was served. The DC said she moved the last tray of pineapple to the refrigerator until it was needed for lunch. The DC said she hoped it would keep the pineapple cold and at the proper temperature. The DC said the trays the pineapple was on should have had ice under them to keep the pineapple at the correct temperature.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#176 and #40) of three residents out of 41 sample residents. Specifically, the facility failed to:-Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #176 and Resident #40 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure staff reviewing the arbitration agreement with Resident #176 and Resident #40 and/or their representatives understood the components of the agreement. Findings include:I. The Arbitration AgreementThe Arbitration Introduction form, undated, was provided by the nursing home administrator (NHA) on 7/22/24 at 2:51 p.m. The Arbitration Introduction read in pertinent part, "Arbitration is a cost effective, private and time saving alternative means of resolving disputes outside of the courts. In arbitration, disputes are heard and decided by a private individual called an arbitrator. the disputes will not be heard or decided by a judge or jury under any circumstances. "The decision of the arbitrator is binding on both parties and any judgment on an award can be enforced by court if necessary. there is no appeal of an arbitrator's decision, so disputes can be resolved efficiently and timely."The Arbitration Agreement form, dated 2019, was provided by the NHA on 7/22/24 at 2:51 p.m. The agreement read in part: "The parties agree that any legal dispute, controversy, demand or claim shall be resolved exclusively by binding arbitration administered by (an entity that assists with arbitration, mediation and other alternative dispute resolutions with facilities throughout the United States; contact information by a single neutral arbitrator agreed upon the parties and not by a lawsuit or resort to court processes, except to the extent that's applicable by state and federal law providing judicial review of arbitration proceedings or judicial enforcement of arbitration agreements and awards."This agreement and the claim or claims to which it applies includes, but is not limited to, those that arise out of or relate to the admissions agreement, any service or health care provided by us to you, violations of any right granted to you by law or by the admission is agreement that would constitute a cause of action in court of law and include, but not limited to, breach of contract or warranty, express or implied, fraud or misrepresentation, wrongful death, survival action, negligence, gross negligence, malpractice, any claim based on any departure from accepted standards of care for medical or other health care related services, healthcare or safety. This includes all claims whether sounding in tort, in contract or based on any claim of violation of any federal, state, local or other government law, statute, regulation, ordinance, or common law and including any consumer protection act. This agreement shall not limit your right to file a grievance or complaint, formal or informal, with us or any appropriate state or federal agency."It is the intention of the parties to this agreement that it shall inure to the benefit of and bind the parties, their successors and assigns, including our agents, employees, managers or owners, and all persons who claim is derived through, as a result of or on behalf of you including that of any parent, spouse, sibling, child, guardian, executor, personal representative, administrator, conservator, legal representative or heir."Both parties to this agreement, by entering into it, have agreed the use of binding arbitration in lieu of having any dispute decided in a court of law before a jury."By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than a jury or court trial. you have theright to seek legal counsel and you have the right to rescind this agreement within 90 days from the date of signature by both parties unless this agreement was signed in contemplation of hospitalization in which case you have 90 days after discharge or release from the hospital to resend the agreement."II. Resident representative interviewResident #176's representative was interviewed on 7/22/24 at 3:45 p.m. The representative said she signed the arbitration agreement for Resident #176 but questioned the admissions coordinator (AC) about the court process. She said she told the AC, by signing the arbitration agreement, it looked like she could not sue the facility if there was ever any problem. She said she was told by the AC that a mediator would be used if there was a concern, but if mediation did not work to resolve the concern, she could still go to court. The representative said she declined a paper copy of the agreement but received it electronically. She said she had not reviewed it since she signed the agreement. III. Resident interview Resident #40 was interviewed on 7/22/24 at 5:58 p.m. Resident #40 said she signed everything the facility asked her to sign when she was admitted to the facility. She said she was not sure what she signed because could not see well enough to read it. She said she had a basic understanding of what arbitration was, and believed it was binding, but she was not told that she could not go to court if she wanted to after signing the agreement. Resident #40 said she had to rely on someone to tell her what all her paperwork read because of her impaired vision. IV. Record reviewArbitration Agreement and Arbitration Introduction forms for Resident #40 and Resident #176 were provided by the NHA on 7/22/24 at 2:51 p.m. Resident #40 signed her own Arbitration Agreement and Arbitration Introduction forms. The Arbitration Agreement and Arbitration Introduction were signed by the AC as the staff representative. Resident #40's Arbitration Agreement and Arbitration Introduction forms were signed by Resident #40 on 7/2/24 at 4:37 p.m. The Arbitration Agreement and Arbitration Introduction forms were signed by the AC on 7/2/23. Resident #176's Arbitration Agreement and Arbitration Introduction forms were signed by Resident #176's representative on 5/22/24. -Resident #176's Arbitration Agreement and Arbitration Introduction forms were signed by the AC but the signature was not dated. V. Staff interviewsThe AC was interviewed on 7/18/24 at 5:06 p.m. The AC said she had been responsible for the facility's admissions paperwork since May 2024. She said the Arbitration Agreement and Arbitration Introduction forms were part of the admission packet. She said she would review the Arbitration Agreement and Arbitration Introduction forms with the resident if they were signing forms. She said if the resident's representative signed the Arbitration Agreement and Arbitration Introduction forms, she would review the forms with them in person or send the forms to them electronically to sign and return it to her. The AC said she explained to the resident and/or their representative that they had the right to have their disputes reviewed and decided by a third party. The AC said she would usually read the Arbitration Agreement and Arbitration Introduction forms to the resident or resident's representative if they signed in person. She said if the resident's representative was not able to come into the facility to sign the Arbitration Agreement and Arbitration Introduction forms with her in person, she would email the forms to them and have them sign the forms electronically. The AC said she was not sure if the arbitration agreement was binding. She said she would have to find out. She said she was not sure if or when the resident/representative could revoke the arbitration agreement. The AC said she did not receive training on the arbitration agreement or arbitration process. She said if she or families had questions, she could contact the corporate consultant (CC #2) or someone else. She said CC #2 used to be the facility's admissions coordinator. The NHA was interviewed on 7/22/24 at 3:56 p.m. The NHA said the AC reviewed all of the admissions paperwork with the resident/resident's representative, including the Arbitration Agreement and Arbitration Introduction forms. The NHA said the resident/resident representative had the option not to sign the forms. She said the AC should explain what an arbitration agreement was. She said the resident/representative could review the Arbitration Agreement and Arbitration Introduction forms with a lawyer. The NHA said from her understanding, the arbitration agreement was not binding and the resident/representative could still go to court. The NHA said she was not sure how long the resident/repersentive had to rescind the arbitration agreement after signing it. CC #2 was interviewed on 7/23/24 at 10:24 a.m. CC #2 said she had been the facility's admissions coordinator off and on between October 2022 and March 2024. She said prior to the current AC, she would review the Arbitration Agreement and Arbitration Introduction forms with the resident/resident's representative if they signed the forms in person or she would email them the forms to them to sign and return to her. CC #2 said she would ask the resident/resident representative if they were familiar with what an arbitration agreement was and then touch on a few components of the agreement. She said she would tell them arbitration was the last step in the grievance/concern process. She said she would emphasize that the arbitration agreement could be canceled anytime within 30 days with written notice, and not signing the agreement would not affect the care and services provided at the facility. She said it was the resident/resident representative's choice to sign or not. CC #2 said the arbitration agreement was binding after 30 days. She said she did not reiterate if the resident/representative could still go to court after the 30 days. She said no one usually asked about it so she did not go over it. CC #2 said she would tell the resident/representative, arbitration was prior to other legal processes. CC #2 said she was not sure what the legal processes were after arbitration. CC #2 said most residents who signed the Arbitration Agreement and Arbitration Introduction forms did not want a copy, however, she said they were informed the Arbitration Agreement and Arbitration Introduction forms were available to them in their medical record. CC #2 said she reviewed and trained the current AC on the Arbitration Agreement and Arbitration Introduction forms but had since learned there were things the AC did not know regarding the arbitration agreement process. CC #2 said she was a facility resource and occasionally the AC would contact her with admissions questions. CC #1 was interviewed on 7/23/24 at 12:23 p.m. CC #1 said the arbitration agreement was not binding until the resident entered into the arbitration agreement and it could be revoked. She said she did not work much with arbitration and would need to get clarification from CC #2. CC #3 was interviewed on 7/23/24 at 1:25 p.m. CC #3 said the arbitration agreement needed to be in plain legal language and the resident/resident representative needed to acknowledge they understood the Arbitration Agreement and Arbitration Introduction forms. She said the arbitration agreement had to state the arbitration agreement could be revoked within 30 days but the facility's agreement would allow the resident/representative to revoke the arbitration agreement by 90 days. She said the arbitration agreement was binding after 90 days from the signing of the arbitration agreement. She said the whole point of the arbitration agreement was not to go to court if there was a dispute between the resident and the facility. CC #3 said, by signing the arbitration agreement, the resident/resident representative gave up the right to goto court. She said she hoped the facility was going over the arbitration process with the residents/representatives. The NHA was interviewed again on 7/23/24 at 1:36 p.m. The NHA said the facility would conduct an education with any staff involved or had the potential to be involved in the admissions process. She said the education would go over the components of the arbitration process. She said she would clarify the arbitration process with all residents and resident representatives who had signed the Arbitration Agreement and Arbitration Introduction forms since May 2024. She said she would contact the residents and their representatives before the 90 day deadline of signing the arbitration agreement.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Implement an effective water management plan; and,-Ensure housekeeping staff properly sanitized resident rooms. Findings include:I. Failure to have an effective water management planA. Professional referenceAccording to The Center for Disease Control (CDC) Legionella (Legionnaires Disease and Pontiac fever) (3/25/21), retrieved on 7/10/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html,"Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. "Legionella bacteria are typically found naturally in freshwater environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. "Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. "The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. "Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. "Seven key elements of a Legionella water management program are to:-Establish a water management program team-Describe the building water systems using text and flow diagrams-Identify areas where Legionella could grow and spread-Decide where control measures should be applied and how to monitor them-Establish ways to intervene when control limits are not met-Make sure the program is running as designed (verification) and is effective (validation)-Document and communicate all the activities. "Principles: In general, the principles of effective water management include:maintaining water temperatures outside the ideal range for Legionella growth; preventing water stagnation;ensuring adequate disinfection; and,maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. "Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. "A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs."According to the CDC's Controlling Legionella in Potable Water Systems, (2/3/21), retrieved on 7/10/24 from https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-Potable-Water.pdf,"Store hot water at temperatures above 140 degrees fahrenheit (F) and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible. "Store and circulate cold water at temperatures below the favorable range for Legionella (77 degrees F to 113 degrees F). Legionella may grow at temperatures as low as 68 degrees F."B. Facility policy and procedureThe Legionella Water Management Program policy, revised September 2022, was obtained from the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part,"Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella."As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team."The water management team consists of at least the following personnel: the infection preventionist, the administrator, the medical director, the director of maintenance, and the director of environmental services."The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE (The American Society of Heating, Refrigeration, and Air Conditioning Engineers) recommendations for developing a Legionella water management program."The water management program includes the following elements: -An interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that can lead to Legionella growth and specific measures used to control the introduction and/or spread of Legionella."B. Record reviewThe facility's water management plan was provided by the director of maintenance services (DMS) on 7/23/24 at 11:01 a.m. The documentation included a copy of the CDC's recommendations for developing a Legionella water management program and a diagram of the building, without identifying water systems.-The facility failed to describe the building water systems using text and flow diagrams.-The facility failed to document when the water management program was initiated.-The facility failed to identify areas where Legionella could grow and spread.-The facility failed to decide where control measures should be applied and how to monitor them.-The facility failed to establish ways to intervene when control limits were not met.-The facility failed to make sure the program was running as designed and was effective.-The facility failed to document and communicate all the activities of the water management program. C. Staff interviewsThe DMS was interviewed on 7/23/24 at 1:24 p.m. The DMS said he checked some of the water systems regularly in the building but did not keep documentation of water system maintenance. He said he was not sure if he knew where all the water lines in the building were. The DMS said he was unsure if the facility had a diagram of all of the water lines in the building. He said he did not know if the facility had identified a method for ensuring the water management program was effective. The DMS said he had not read the water management program documentation that he had provided during the survey on 7/23/24 at 11:01 a.m. The NHA and the DON were interviewed together on 7/23/24 at 4:53 p.m. The NHA and the DON said they were unaware the facility did not have a water management program. The NHA was interviewed again on 7/23/24 at 7:33 p.m. The NHA said she was not familiar with the details of what needed to be done concerning Legionella and Legionella prevention. II. Housekeeping failuresA. Professional referenceThe CDC Environment Cleaning Procedures, (3/19/24) was retrieved on 7/25/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part,"High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. "Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. ObservationsOn 7/22/24 at 1:04 p.m. housekeeper (HSKP) #1 was observed cleaning room #28. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. On 7/23/24 at 10:36 a.m. HSKP #2 was observed cleaning room #35. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. C. Record reviewHousekeeping in-service documentation, not dated, was obtained from corporate consultant (CC) #4 on 7/23/24 at 5:15 p.m. It documented the five step daily patient room cleaning procedure included emptying trash, disinfecting horizontal surfaces, spot cleaning walls, dust mopping the floor, and damp mopping the floor. It documented the seven-step washroom cleaning process included checking supplies, emptying trash, dust mopping the floor, cleaning and sanitizing the sink and tub, cleaning and sanitizing the toilet, spot cleaning walls and/or partitions, and damp mopping the floor.-The in-service documentation did not indicate who attended the training or when the training was held. -The documentation failed to identify when housekeepers should clean resident call light cords. D. Staff interviewsHSKP #1 was interviewed on 7/22/24 at 1:29 p.m. HSKP #1 said she did not clean the resident call lights when she cleaned room #28. HSKP #1 said resident call light cords should be cleaned but did not have to be cleaned every day. HSKP #2 was interviewed on 7/23/24 at 10:56 a.m. HSKP #2 said she did not clean the resident call lights in room #35. HSKP #2 said that housekeepers did clean resident call lights but not every day. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/23/24 at 1:58 p.m. The IP said the resident call lights should be cleaned because they were considered high touch surfaces that could transmit infections. The IP said resident call light cords should be cleaned every day. The IP said she had not provided the housekeeping staff with room cleaning education. The DON said the housekeeping staff were contracted outside of the facility.

Based on observations, record review and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable. Specifically, the facility failed to ensure appropriate communication occurred regarding the facility's 20-year old hot water heater. The facility's failure to address the concerns timely resulted in the hot water heater failing and the facility was without hot water to provide a comfortable bathing experience for residents during a three week time period. Finding include: I. Facility policy and procedureThe Promoting/Maintaining Resident Dignity policy, dated 1/1/23, was obtained from the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part,"All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights."The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences."II. Group resident interviewFour residents (#16, #49, #59 and #65), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. The following comments were made regarding the lack of hot water:-A resident said the facility had a hard time the first couple of days without hot water. The staff was not sure how to meet all the hot water needs when the hot water heater went down. The facility purchased basins to help with bathing. The staff would fill the basins with hot and cold water. -A resident said she normally had two showers a week. She said it would have been nice to have a shower but gave herself a sponge bath. She said it was hard to scrub her own back. She said the staff would offer to give her a bed bath at times. -A resident said she was worried that the lack of hot water would affect her personal hygiene and health. She said her skin had itched because she had not felt clean. -A resident said the staff would offer bed baths sometimes during the time the hot water heater was out and he would wash himself in the private areas but it was difficult. He said he felt the facility could have done more to make sure there was hot water for the showers. He said he was used to two showers a week and did not feel completely clean when he could not shower. III. Additional resident interviewsResident #16 was interviewed on 7/18/24 at 10:31 a.m. Resident #16 said the hot water went out for three or four weeks. Resident #16 said she was not able to shower during that time, and her wound care had to be provided differently than normal. Resident #16 said the lack of hot water made her feel like she wasn't getting cleaned as well or as often. Resident #16 said most residents hated the bed bath alternative that was offered during the three week period, but she said the only other choice was a cold shower. Resident #16 said she had not felt comfortable without hot water since that was a basic necessity of everyday life. Resident #65 was interviewed on 7/18/24 at 2:39 p.m. Resident #65 said he did not like either of the alternative bathing options presented so he chose to shower in cold water when the facility did not have hot water. Resident #65 said that showering with cold water day after day was an aggravating experience for him. Resident #59 was interviewed on 7/18/24 at 2:50 p.m. Resident #59 said when the hot water went out, many residents were not offered showers as often as they preferred. Resident #59 said she was offered alternative shower options but only once per week. Resident #59 said she preferred to shower three times per week. Resident #59 said she felt dirty and upset when the hot water was out and the bathing experience offered was uncomfortable for her. Resident #59 said she felt she had no other choice. Resident #10 was interviewed on 7/23/24 at 2:54 p.m. Resident #10 said the hot water was out for about three or four weeks in the facility and no one could take a hot shower. Resident #10 said she was not offered showers per her normal preference without the hot water. Resident #10 said she hated the bed bath option with water heated from the kitchen, but she would have tried that if she had ever been offered that option from staff. Resident #10 said she felt like any facility should have hot water and not being able to access warm water when she needed to had been very frustrating. Resident #40 was interviewed on 7/23/24 at 3:12 p.m. Resident #40 said she was never offered a bath in the period when the facility was without hot water. Resident #40 said she had wanted a normal hot shower like any facility should have and she just didn't want to take a cold shower. Resident #40 said she felt the bed bath option was demeaning for residents who normally showered themselves. IV. A frequent visitor (FV) was interviewed on 7/17/24 at 9:16 a.m. The FV said there was no hot water in the facility for resident showers for over three weeks between May 2024 and June 2024. She said there was a significant odor in the facility during that period of time. V. Resident council minutes The 5/28/24 resident council minutes documented the NHA said she would contact the facility's corporation on the afternoon of 5/28/24 to discuss the water heater and then would inform the residents on the water status when she knew more. The 6/24/24 resident council minutes documented the hot water heater has been fixed. VI. Record ReviewA 5/13/24 impromptu QAPI meeting agenda/summary form was provided by CC #4 on 7/18/24 at 5:30 p.m. The summary form read the form was to be used between meetings to address an opportunity for improvement which required immediate response. According to the summary, the opportunity for improvement was a malfunction of the singular hot water heater that provided hot water to the entire building. The form identified the facility's response/plan:-The HVAC vendor attempted to repair the hot water heater on 5/12/24. It was determined to be nonrepairable.-Ensure adequate paper products for the meals.-Ensure adequate bath packets for all residents three times a week for three weeks.-Notify residents and their families.-5/12/24 notification of the company and landlord. -Completion of a provided proposal for replacement on 5/13/24. -Educate staff on hand hygiene, bed baths and temperature safety. -Kitchen hot water and sanitation education.-Kitchen hot water and sanitation log. The 5/10/24 HVAC vendor invoice was provided by the DMS on 7/22/24 at 1:40 p.m. The invoice identified the water heater was inspected, repairs were made and the counter steamer transformer was replaced. The invoice read the water heater was not firing and water was leaking from the heat exchanger tubes, which was a sign that the water heater "was going bad." The 5/12/24 HVAC vendor invoice was provided by the DMS on 7/22/24 at 1:40 p.m. The invoice read the water heater was not lighting. According to the invoice, the vendor was contacted on 5/12/24 due to the water heater not operating. The vendor arrived at the facility and observed water from the water heater was leaking onto the burners and water was leaking from the tubes of the heat exchanger. After multiple attempts to light and repair the hot water heater it was determined it was no longer safe for use and needed to be replaced. An undated HVAC vendor invoice was provided by the DMS on 7/22/24 at 1:40 p.m. The invoice read the vendor received a monetary deposit on 5/30/24 and ordered the water heaters on 5/30/24. The water heaters would be delivered from two separate supply distributors. The estimated arrival delivery date of the water heaters was on 6/4/24. The demolition of the old water heater system was started on 6/4/24. The first water heater arrived on 6/4/24 and was installed and identified as in normal operation condition. According to the invoice, the original freight company that was scheduled to deliver the remaining water heaters was not available to deliver as scheduled. The HVAC vendor company offered to pick up the water heaters and deliver them to the facility on 6/7/24. Installation was started and completed between 6/7/24 and 6/10/24. The invoice read, on 6/10/24, all three water heaters were in normal operating condition. A 5/31/24 mandatory manual wash in-service was provided by CC #4 on 7/18/24 at 5:30 p.m. The attendance for the in-service was signed by 12 staff members between 5/31/24 and 6/7/24. The inservice reviewed the policy and procedure to manually wash and sanitize all cookware, silverware and serviceware that was not processed through the dish machine. The 6/10/24 HVAC vendor service receipt was provided by the DMS on 7/22/24 at 1:40 p.m. The receipt read the failure of one water heater should no longer affect the hot water supply to the facility. The June 2024 quality assurance and performance improvement (QAPI) meeting minutes were provided by the NHA on 7/23/24 at approximately 9:15 a.m. The QAPI minutes documented the following in pertinent part: "Hot water heater stopped working on 5/12/24. Final repairs completed on."-The QAPI minutes did not include the date the final repairs were completed.-The QAPI minutes did not include additional review of the lack of hot water facility response or revisions made to the facility ' s emergency plan. VII. Staff interviewsThe director of maintenance services (DMS) was interviewed on 7/18/24 at 1:52 p.m. The DMS said on 5/12/24 the hot water heater broke. He said he contacted the NHA and the regional consultant. He said he contacted a heating, ventilation and air conditioning (HVAC) service vendor and attempts were made to repair the hot water heater but it was determined the hot water heater was not repairable. He said he and the NHA started a plan of correction. He said the facility started boiling water from the kitchen, bed bath kits were ordered and hot water was collected from the hot and cold water drink dispensing towers. He said the kitchen started using paper products for meals. The DMS said the facility corporation was contacted and told it was an emergency. The corporation requested bids for a new water heater and repairs. The DMS said the facility's landlord and stakeholder had to also approve of the process. The DMS said, overall, the whole process went well and the residents seemed accepting of the changes and complained very little. The DMS said he did not believe the facility had a hot water heater policy to outline the procedures of what to do if the facility did not have hot water readily available. He said before the hot water heater broke, the facility did not have a back up plan. The DMS said the facility now had a three water heater system so if one went out, the other water heaters would still be able to provide the facility with hot water. He said each of the new hot water heaters were 100 gallons each. The DMS said the prior water heater was over 20 years old and was leaking before it stopped working. He said the HVAC vendor came out to service the heater and recommended the facility get a new water heater. The DMS said he informed the NHA and his regional consultant of the recommendations but he was not sure exactly when he informed them. He said he was told to do the best he could as long as the hot water heater was still working. The DMS said there were no follow up meetings after the new hot water heaters were installed. He said the facility did not review the event after the incident to put new procedures in place. He said the facility was still pulling everything together. Certified nurse aide (CNA) #7 was interviewed on 7/18/24 at 1:55 p.m. CNA #7 said the hot water was out for about almost a month in the facility in May 2024. CNA #7 said the facility had offered residents bed baths with water warmed from the kitchen, or prepackaged bathing cloths during that time period. CNA #7 said most residents did not like either alternative bathing option. CNA #7 said a lotof residents in the facility refused baths while the hot water was out. CNA #8 was interviewed on 7/18/24 at 2:01 p.m. CNA #8 said the facility did not have hot water for three or four weeks in May 2024. CNA #8 said the facility had offered residents prepackaged bathing cloths or bed baths during that time period. CNA #8 said many residents refused both alternative bathing options while the hot water was out. Licensed practical nurse (LPN) #1 was interviewed on 7/18/24 at 2:10 p.m. LPN #1 said the facility had offered residents prepackaged bathing cloths or a warm water basin bath as alternative bathing options while the hot water was out. LPN #1 said the residents who showered themselves independently were the most upset when the facility was without hot water. The director of nursing (DON) was interviewed on 7/18/24 at 2:29 p.m. The DON said when the hot water heater broke, her main focus was the residents' personal hygiene and sanitary conditions for preparation and service. She said wound care was not impacted by the lack of hot water. The DON said more disposable paper products were ordered for meal services. She said the facility ordered shower caps, more bed bath kits and water basins. The DON said the staff tried to offer bed baths on the same days the residents were usually scheduled for their showers. She said the residents were told they could also ask for bed baths and/or wipes if they felt they needed additional bathing opportunities. She said some residents were able to bathe at their family's homes. The DON said bathing wipes were warmed to help the residents feel more comfortable. She said the temperature of the hot water from the hot water drinking dispensers was taken and used for personal washing. She said the facility verbally informed the residents about the limited hot water and families were informed by letters. She said the lack of hot water from the hot water heater lasted for about three weeks, from May 2024 to June 2024. She said the facility now had three hot water heaters so if one water heater went down the facility would still have two working hot water heaters. The DON said staff expressed some frustration during the event. She said the bed baths took more staff time and there were more resident refusals than expected. The DON said many of the residents expressed understanding of the situation. She said once the hot water heaters were replaced, all residents were back to having their regular showers scheduled. She said everything was now back to normal. The NHA was interviewed on 7/18/24 at 2:50 p.m. The NHA said when the DMS informed her of the broken hot water heater, she informed her corporate consultants and regional operation managers of the situation and started to put interventions in place. The NHA said on 5/13/24 she created a plan to review and identify needed supplies such as paper products, and bathing kits. She said she notified the residents of the situation and sent letters out by email to families. The NHA said she put together a three week plan because the HVAC vendor estimated it would take two to three weeks to have the water heater ordered and replaced. She said she discussed the costs with the corporation after getting quotes. The NHA said the facility had to decide on whether to have the hot water heater replaced quickly or take a little longer and get a better system that would include three water heaters so if one went down there would be a backup. She said by the end of the week of 5/13/24, the facility had decided to go with the three tank system. She said the hot water heaters needed to be ordered and transported from several miles away because there was nothing compatible in the area. The NHA said the HVAC vendor informed her that he would be able to do the labor within 24 to 48 hours of the delivery of the tanks. She said most of the delay for getting the hot water heater tank replaced was related to the release of the funds to the HVAC vendor so the tanks could be ordered. She said when the HVAC vendor received payment he ordered the tanks but the transportation company to deliver the tanks could only do part of the trip. She said the HVAC vendor had to find another company to transport the tanks the remainder of the way. The NHA said the tanks were delivered and installed on 6/4/24 and by 5:30 p.m. that day, the facility had running hot water throughout the facility with one domestic tank/heater operational. She said by 6/7/24, the other two tanks were installed and running. The NHA said the event was discussed in the June 2024 quality assurance and performance improvement (QAPI) meeting with the interdisciplinary team (IDT) (see record review above). Corporate consultant (CC) #4 was interviewed on 7/18/24 at 4:52 p.m. CC #4 said the facility did not have a lack of hot water policy and procedure. She said the closest the facility had was the plan created on 5/13/24, after it was determined the facility would be without hot water until the parts and repairs were in place. The DMS was interviewed again on 7/22/24 at 1:40 p.m. The DMS said he did not document his observations of the leaks with the hot water heater or communication of the leaks or invoices from the HVAC vendor when they came out to look at the leaks prior to May 2024. The HVAC service vendor was interviewed via telephone on 7/22/24 at 2:10 p.m. He said he was called out to the facility on 5/10/24 because the hot water heater was not firing up. He said the water was leaking from the heat exchanger tubes. He said he recommended replacing the water heater. The HVAC vendor said he replaced the burner assembly unit and transformer on 5/10/24. The HVAC vendor said he came out again on 5/12/24 when the hot water heater was not working again. He said water was leaking onto the burners and water was leaking from the heat exchanger. He said the water heater was shut off on 5/12/24 because it was no longer safe to run it. The HVAC vendor said he was at the facility in January 2024 or February 2024. He said the expansion unit on the hot water heater had a hole in the unit, but the unit was not leaking at that time. He said, due to the price, the facility did not proceed with replacing the expansion tank. He said without a working expansion unit, he was not able to determine if there were additional problems with the system. The HVAC vendor said the facility had a separate tank that was working for domestic water. He said he did not have access to the invoices from January 2024 or February 2024 to determine the date when he came out to the facility because he was no longer working for that company. The HVAC vendor said he asked the facility if they had a policy for the hot water heater and he asked for one but never got an answer or the policy. The NHA and the DMS were interviewed together on 7/23/24 at approximately 9:15 a.m. The DMS said the facility did not have a safety meeting but plant operations were reviewed in QAPI. He said the review was mainly regarding fire drills or tabletop reviews of a potential emergency. He said the facility did not identify the lack of hot water if the hot water heater went out as a potential facility emergency, however he was concerned the hot water heater would go out in the middle of the night. He said the hot water heater was over 20 years old and there was some leaking and some corrosion on the old pipes. He said the system would shut itself off if there was a problem for safety. The DMS said, on 5/10/24, the hot water heater system would not light. The NHA was informed of the above interview with the hot water heater service vendor. The DMS said he also saw some leaking in April 2024 and had the vendor look at it, however, he said he had not informed the NHA that the hot water heater was leaking at that time. He said part of the system related to the copper coils boiler was disconnected to stop the leak. He said the facility had been operating with the one 20 year old hot water heater tank since April 2024. He said the one tank was due to be replaced. He said he did not think the corporation was aware that the facility had only one tank available that was 20 years old. The DMS said he did not record or document the past repairs, recommendations or observations to reference but he should have. The NHA said she was not aware that a new expansion tank was recommended by the vendor in January 2024 or February 2024. The NHA said during the hot water heater event, the residents were not in danger and basic needs were accommodated for. She said after the hot water heater event she learned that the facility needed to be more prepared with needed supplies, such as disposable paper products for food. She said the facility needed to make sure they had at least three days worth of supplies on site. She said the facility needed to have more bathing kits available in case of an emergency. She said the water heater event was an emergency. The NHA said, in retrospect, the facility could have benefited from an extra certified nursing assistant (CNA) on some of the busier days. She said staff did not complain a lot but she felt some of the staff needed more training on how to manage the situation with less frustration versus increasing the number of staff. She said she would like to have the staff go through additional training on crisis management. The NHA said nothing had been scheduled yet for the training and she needed to look at the training schedule to determine when it could be set up. She said she would reach out to CC #4 and other sister facilities to see if there were training materials available. The NHA said to directly prevent the lack of hot water available, the new hot water system was purchased. The NHA said she did not have documentation that a post review of the hot water event was conducted or actions moving forward to prevent similar situations other than a reference in QAPI. She said she and the dietary manager verbally talked about the needed kitchen supplies and steps to take during the water heater event, but a procedure was not created and put in place after the water heater event to help mitigate future emergencies that involved the kitchen. The NHA said she would like to have three weeks for some supplies in the event of an emergency but had to see where there was enough space to stock the supplies. The NHA said reviewing the event following the incident on what the facility learned and what the next steps were to put in motion to help with future emergencies could use improvement. The NHA said the facility did not have a specific lack of hot water plan but it would be appropriate to have a policy in place. She said she would reach out to her corporate resources on how to create the policy and procedures. She said the policy would be implemented and added to the facility's emergency plan. The NHA said if the facility had a policy and procedure available, she would have added it with her plan as part of the facility's response and use it as additional guidance.

A revisit survey was completed on 1/22/24 for all previous deficiencies cited on 11/7/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO33977 and Incident #33901 was completed on 11/6/23 and 11/7/23. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure three (#12, #13 and #18) of eight residents reviewed out of 19 sample residents were provided personal privacy during care. Specifically, nursing staff failed to:-Ensure privacy during medication administration and treatment for Resident #13; -Ensure staff pulled the privacy curtain and/or closed the door while Resident #18 was getting dressed; and, -Ensure privacy during nail care for Resident #12. Findings include:I. Facility policy The Statement of Resident Rights and Responsibilities, undated, was provided by the regional operations manager (ROM) on 11/7/23 via email. According to the policy statement, the residents had the right to personal privacy. The Medication Administration policy, revised 11/1/22, was provided by the nursing home administrator (NHA) on 11/7/23 at 1:40 p.m. the policy directed staff to provide privacy during medication administration. II. Resident #13A. Resident status Resident #13, age 77, was admitted on 10/26/23. According to the November 2023 computerized physician orders, diagnoses included type II diabetic mellitus with other specified complications. The 11/1/23 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The assessment identified the resident received insulin injections. B. Observation Registered nurse (RN) #1 was observed passing medication to residents in the dining room during the noon meal on 11/6/23. -At 12:06 p.m. RN #1 tested Resident #13's blood sugar levels tested by use of glucometer in the dining room. The resident was at his dining room table near other residents. The resident was not offered privacy for his diabetic management. C. Record review The medication administration record (MAR) read the resident received Lispro Injection Solution insulin subcutaneously with meals for diabetic (management). According the MAR under the order for his insulin injection, Resident #13's blood sugar levels were checked on 11/6/23 by RN #1 during the noon administration. III. Resident #18 A. Resident status Resident #18, age 84, was admitted on 8/25/23. According to the November 2023 computerized physician orders, diagnoses included dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance and need for personal assistance. The 8/31/23 minimum data set assessment indicated the resident had moderated cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. B. ObservationOn 11/7/23 at 9:34 a.m. Resident #18 was observed in her room with certified nurse aide (CNA) #1 and resident aide (RA) #2. The resident was dressing. The resident was exposed to the hallway. The resident's privacy curtain was not pulled shut. The resident's room door was not shut to provide the resident privacy as she dressed. -At 9:38 a.m. licensed practical nurse (LPN) #1 entered Resident #18's room and shut the door. 3. Resident interviewResident #18 was interviewed on 11/7/23 at 9:50 a.m. The resident said when she was dressing for the day, she did not want her privacy curtain pulled closed but she wanted the staff to shut the door for privacy. C. Record review Resident #18's activity of daily living (ADL) care plan, initiated on 8/26/23, identified Resident #18 had an ADL self-care performance deficit. According to the care plan, required assistance with dressing. IV. Resident #12On 11/7/23 at 9:12 a.m. registered nurse (RN) #2 was observed clipping a resident's toenails in the common area. There were six other residents in the common area but no residents sat directly next to the resident who received care. The resident said he did not want to go to his room to have his nails clipped. V. Staff interviews RN #1 was interviewed on 11/6/23 at 5:47 p.m. The RN said Resident #13 got insulin shots fourtimes a day and blood sugar levels were checked at meals and at night. She said medication administration and treatments were allowed in common areas and the dining room around other residents including wound care as long as the resident's bikini/brief area on their body was not exposed. She said treatments that could expose the resident should be conducted in the resident's room with the privacy curtain and or door should be closed. The social service director (SSD), the nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 11/7/23 at 1:10 p.m. The SSD said residents' right to privacy was reviewed with staff during new hire orientation. RN #2 was interviewed on 11/7/23 at 1:23 p.m. She said resident care could not be provided in the common areas if it was considered invasive care like eye drops, checking blood sugar, administering insulin, wound care or applying creams. RN #2 said she was informed by management that she could administer medications in the common areas to residents. She said she did not usually cut toenails in the common area however Resident #12 refused to go into his room so she clipped his nails in the common area on the morning of 11/7/23. She said the chairs on the side of him were empty and the certified nurse aide (CNA) helped her clean up as soon as she was finished. The NHA said during a recent facility inservice, she reminded staff to pull privacy curtains to ensure residents' privacy during toileting, bedpan use and incontinent care. She said they did not review privacy during clothing changes or clinical treatments. The DON said staff should perform clinical treatments related to infection control and privacy. The DON said staff should only assist residents to eat in the dining room, all other care should be done in the resident's room including medication administration and clinical treatment. The DON said the nursing staff should know where they could and could not do resident care. The DON was interviewed on 11/7/23 at 1:25 p.m. The observations diabetic management in the dining room with Resident #13 and the open door exposing Resident #18 to the hallway as she dressed was reviewed with the DON. She said the RN violated Resident #13's privacy in the dining room. She said clinical care should not have been done in a common area and in front of other residents. The DON said staff should have shut the door as Resident #18 was dressing. The staff could have been in a rush and task focused, forgetting to provide the resident privacy. She said the staff involved would reeducated on privacy. LPN #1 was interviewed on 11/7/23 at 3:10 p.m. The LPN said Resident #13 received Lispro insulin before meals. The LPN said a glucometer was used to determine the resident's blood sugar levels based on a sliding scale. The regional operations manager (ROM) was interviewed on 11/7/23 at 4:13 p.m. She said RN #2 should have approached the resident later to provide care in private since he refused to go into his room initially. The ROM said medications may be administered in the common areas if medications were not being explained but all other care should be completed in the resident's room or in an area that offered privacy. The ROM and the NHA were interviewed again on 11/7/23 at 4:45 p.m. The ROM said during the CNA education class, the incoming CNAs were taught the importance of privacy as part of their training before they became an employee at the facility and then it was reviewed in orientation. Observations of residents not provided privacy were shared. The ROM and the NHA said RN #1 would have a one-on-one education completed to review resident privacy regarding medication administration and treatments. The ROM said blinds and doors should be closed during resident ADL care. A former staff member for the facility was interviewed on 11/7/23 at 5:42 p.m. She said she was not trained on privacy when she attended the new hire orientation. She said the orientation primary was videos and signing off on policies and procedures. The former staff member staff she frequently observed staff not closing doors when the staff was providing resident care and observed RN #1 providing wound treatment in the dining room during a breakfast meal. VI. Record reviewThe new hire resident rights training for orientation was provided by the NHA on 11/7/23 at 1:45 p.m. The training involved the purpose of resident rights, the main categories of resident rights, ways to support and promote resident rights and the facility's responsibilities. According to the training, the facility was required to treat each resident with respect and dignity and provide care for each resident in an environment that promotes and protects their rights including privacy. The training identified that during orientation staff were trained that the residents have the right to privacy during treatment, care of personal needs and privacy in all personal, financial and medical affairs.

Based on record review and interviews, the facility failed to ensure one (#3) of three residents reviewed for dementia care received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being out of 19 sample residents. Specifically, the facility failed to:-Prevent Resident #3 from eloping the facility;-Have a procedure in place for the nurses to know which residents needed supervision when leaving the facility and which residents were able to independently leave the facility; and,-Ensure Resident #3 was assessed appropriately for his elopement risk. Findings include:I. Facility policyThe Elopement and Wandering policy, revised March 2023, was provided by the nursing home administrator (NHA) on 11/7/23 at 3:24 p.m. read in pertinent:"The purpose is to ensure the safety and well-being of all residents with potential elopement risk. A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the IDT (interdisciplinary team) during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with a change of condition. Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: The elopement resident identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement."II. Resident statusResident #3, age 68, was admitted on 12/22/22. According to the November 2023 computerized physician orders (CPO) diagnoses included unspecified intracranial injury (traumatic brain injury) with loss of consciousness of unspecified time, unspecified convulsions (seizures), bilateral pinguecula (noncancerous tumor in both eyes), age-related cataract (cloudy area in the lens of the eyes), anxiety, post-traumatic stress disorder (PTSD), unspecified psychosis not due to a substance or known physiological condition, and severe major depressive disorder with psychotic features.-A diagnosis of alcohol dependence with alcohol-induced persisting dementia was listed on Resident #3's care plan, however, it was not on his CPO.According to the 3/22/23 minimum data set (MDS) a brief interview for mental status (BIMS) assessment was completed with a score of nine out of 15. Resident #3 needed supervision or touch assistance while he used his walker to ambulate for all distances. Resident #3 was documented as not having any type of behavior. III. Resident interviewResident #3 was interviewed on 11/6/23 at 5:41 p.m. He said on 10/1/23 he went for a walk and wanted to see some old friends at his former facility. Resident #3 said he asked the staff if he could go into the community and the staff walked away so the female staff at the front desk used the button to let him out the front door since it was locked and he did not have the code. He said he was safe while he walked to see his friends about a mile away. Resident #3 said he looked both ways as he crossed the street and used the crosswalk lights to let cars know he was crossing. He said he asked a community member if the park was up ahead and the community member said yes. Resident #3 said the park was close to where he used to live so he knew he was going the right way. He said he was gone less than an hour and a half. When he arrived to his former living place his friends were not there so he lit a cigarette and turned around to return to the facility. He said a vehicle pulled up to him and he did not recognize the female at first but she asked if he was Resident #3 and he said yes. She told him "you are in big trouble buddy" and he said that was when he recognized it was a staff member. Hesaid the lady helped him back to the facility. Resident #3 said he had memory problems and he forgot to tell the facility he was leaving the facility. He said he had to have a staff member with him now whenever he left the facility which he thought was unfair. He said he used to walk eight miles a day by himself and this was only a one-mile walk and he was not injured. He said he was not scared and had a great time by himself walking through the town. IV. Record reviewThe facility missing person report was completed on 10/1/23 and documented Resident #3 had asked staff if he could go into the community. Staff verified with nurse management that the resident needed a staff member to go with him due to cognitive impairment. While the staff reached out to nursing management the resident took himself into the community. Staff noted about 10 minutes had lapsed since the last time they had eyes on Resident #3. A staff member went to the community to look for the resident while other staff completed a facility sweep. Once the staff verified the resident was not on the property the staff notified the police, the NHA, the resident's family and his physician. The NHA recommended checking the former facility Resident #3 lived at which was about one mile away. Resident #3 was found at his former facility. The NHA, police, physician and his family were notified when the resident was found. The incident lasted about 45 minutes from when the resident was last seen to when the resident was found. A staff from the nursing team assessed the resident when he returned to the facility. Resident #3 was placed on 15-minute checks for 72 hours. The resident was educated on safety about leaving the building without a staff or family member and staff were educated on safety concerns related to cognitive impairment and residents with an increased risk of elopement. Resident #3's care plan was updated on 10/1/23. It documented Resident #3 had impaired cognitive function/dementia or impaired thought processes which referred to a diagnosis of dementia (initiated and revised on 10/1/23). Interventions were documented as:Communicate with the resident/family/caregivers regarding Resident #3's capabilities and needs (initiated 10/1/23),Review his medications and record possible causes of cognitive deficit: new medications or dosage increases, anticholinergics (medications that blocked actions of neurotransmitters), opioids (narcotic medications), benzodiazepines (medications with symptoms of sleepiness), recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, or drug toxicity (initiated 10/1/23); andResident #3 had one elopement into the community. Provide reminders of safety risks of leaving the facility on his own and provide a staff member to go into the community with Resident #3 to meet his needs (initiated 10/1/23). His care plan was updated again on 10/11/23 which documented Resident #3 was an elopement risk/wanderer which referred to his cognitive deficit (initiated 10/11/23). The interventions were documented as:Identify patterns of wandering: is the wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (initiated 10/11/23,Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. The resident prefers conversations (initiated 10/11/23). A wandering/elopement risk assessment was completed on 12/22/22 and documented the resident was at low risk for wandering or elopement with a score of three out of 12. He was documented to not have a diagnosis of dementia or cognitive impairment and had no history of wandering or elopement. A wandering/elopement risk assessment was completed on 3/22/23 and documented the resident was at risk of wandering or elopement and documented him having diagnosis of dementia or cognitive impairment. -However, a score was not documented so the assessment did not show if the resident was a low, moderate, or high risk for wandering or elopement. A wander/elopement risk assessment was completed on 10/11/23 by the assistant director of nursing (ADON) that documented the resident ambulated independently, routinely wandered or paced and wandered in a manner that placed his safety at risk. The resident was documented to have a diagnosis of dementia, a diagnosis or medical condition that impacted decision-making, he verbalized wanting to leave the facility, he had previous attempts to elope before placement at the facility and had previous attempts to elope at the current facility. The summary documented the resident was an elopement risk and was educated on the facility's rules and regulations. The resident verbalized his understanding. The outcome documented the impaired cognitive status of the resident put him at increased risk of wandering outside the facility or exit seeking but this was well-managed during supervised outings or with other specific guidelines established by the IDT. Another wandering/elopement risk assessment was completed on 10/11/23 and documented the resident was at low risk for wandering or elopement with a score of three out of 12. He had no history of wandering or elopement.-However, the question of if he had a diagnosis of dementia or cognitive impairment was left blank.-The additional assessment contradicted the assessment complemented by the ADON (see above) that documented the resident was an elopement risk. V. Staff interviewsOn 11/7/23 at 11:22 a.m. a resident covered the front desk for the receptionist. He said if a resident asked to go outside he told them he could not let them out. He said if the resident did not know the code to the front door they could not go to the community unsupervised. The activities director (AD) was interviewed on 11/7/23 at 11:30 a.m. She said she did not think the resident who covered the front desk knew which residents needed staff supervision in the community. She said there was a sign-in and sign-out sheet at the front desk and the staff just needed to know which residents needed supervision. The AD said the nurses usually knew who could leave alone and who could not. She said the resident covered the front desk while the receptionist (RESP) completed mail runs or minor errands for activity programming. The AD said she set up the program but the RESP trained him. The RESP was interviewed on 11/7/23 at 12:05 p.m. She said very few residents could leave the facility alone and the NHA informed the staff of who could. She said she trained the resident at the front desk to ask the nurses if he needed to but if the residents knew the code to the front door they were safe to leave alone and if the resident knew to sign-in or sign-out that indicated they could leave alone. The RESP said the manager on duty (MOD) covered the front desk on the weekends. Licensed practical nurse (LPN) #2 was interviewed on 11/7/23 at 12:40 p.m. He said the RESP was aware who could leave alone and the resident who covered the front desk asked the nurses. LPN #2 said the nurses determine a resident could leave the facility unsupervised based on their BIMS. He said he could not provide a BIMS score range to know if a resident could leave however there was a scale that had it broken down but he could not locate it. He said he looked to see if they were competent in the community alone and if he did not feel comfortable he verified with the NHA or the director of nursing (DON). LPN #1 was interviewed on 11/7/23 at 12:51 p.m. She said the nurses needed to know the residents and the front desk staff knew which residents could leave unsupervised or who needed supervision in the community. She said it depended on their cognitive level and she completed her own test on the residents but the facility used BIMS scores and she looked at that too. LPN #1 said the front door was always locked unless you had the code to open it. She said she relied on the front desk staff to know because residents were alert and oriented to person, place, time and situation but could be a flight risk or had no safety awareness. The social services director (SSD), NHA, and regional operations manager (ROM) were interviewed on 11/7/23 at 12:57 p.m. The SSD said she completed the residents' BIMS score and talked with their families about if a resident was able to go into the community alone or supervised. The SSD made sure the staff were aware of what was approved by the IDT for each resident. The ROM said the resident who covered the front desk was pretty good about asking staff to accompany residents who needed supervision in the community. She said the facility's policy was the residents needed to have an order that said they could go on pass alone and there was an elopement binder at each nurses' station. The ROM said the elopement binder was essentially a cheat sheet for the nurses to know who needed supervision in the community and the nurses knew what the binder was and what it was used for. Certified nurse aide (CNA) #1 was interviewed on 11/7/23 at 1:13 p.m. She said she did not know how to find which residents needed supervision versus the residents who were independent in the community. She said she asked the nurses if a resident asked to go into the community. She said she liked to make sure they could go out by themselves or needed help. She said a nurse was always available or at leave a regular staff was available at all times so someone would know. Registered nurse (RN) #1 was interviewed on 11/7/23 at 1:17 p.m. She said she looked at the resident's profile and checked their preferences or the family's preferences. She said she checked to see if the resident was alert and oriented to person, place, time, and situation, and if the resident was a flight risk it was documented on their charts. RN #2 was interviewed on 11/7/23 at 1:23 p.m. She said the nurses got to know the residents and wanted to know if the residents had behaviors in the community. She said she assessed the residents, similar to other assessments, to see if they were safe alone in the community. She said if she covered a different hall she checked with other nurses or checked the resident's BIMS score. RN #2 said if the resident had a BIMS score of 13-15 (no cognitive impairment) she believed they could be unsupervised in the community but also checked the resident's history with traffic and safety situations. The social services specialist (SSS) was interviewed on 11/7/23 at 1:43 p.m. She said she checked the resident's care plan to see if the resident was supervised or unsupervised in the community. She said she usually worked a certain part of the building and was unaware of Resident #3's supervision status in the community. The activities assistant (AA) #2 was interviewed on 11/7/23 at 2:48 p.m. She said she did not know if Resident #3 was allowed to go to the community by himself because he would exit seek. She said the activities director (AD) was good at informing the AAs if residents were exit seekers and which residents needed supervision. She said she asked the nurses or the RESP if a resident needed supervision outside of the facility. The AD was interviewed on 11/7/23 at 3:01 p.m. She said she was not aware Resident #3 eloped to go see friends where he used to live. She said the activities staff provided group outings and provided a resident aide (RA) if they wanted to go on an individual outing. She said she wished he told her that was what he wanted to do before he left but she would make arrangements for visits if it helped prevent future elopements and was important to Resident #3. She said she knew he had an onset of dementia when he was admitted to the facility but he hid it very well. The SSD and NHA were interviewed on 11/7/23 at 3:18 p.m. The SSD said she looked at the resident's BIMS score and completed a wandering or elopement assessment then constructed a care plan for the resident. She said the facility documented their preferences, likes, dislikes, and triggers if they were known. The NHA said if there was a behavior witnessed at the facility they documented it in the care plan otherwise they updated the care plan after the behavior occurred. LPN #2 was interviewed on 11/7/23 at 3:57 p.m. He said the elopement binder was kept at the nurses' station but he was unable to locate it and said it was probably being updated. He said if he passed report to an agency nurse he informed them of the elopement binder and where it was kept so the next nurse was aware. The NHA and ROM were interviewed on 11/7/23 at 4:13 p.m. with the elopement binder. The NHA said the binder contained all of the residents' information for the entire facility in case they eloped, not a binder that showed which residents were at risk of eloping. The binder contained all the residents' information and included their diagnoses, their pictures, emergency contacts, and physician's contact information. The NHA said, "basically every resident is at risk for elopement and that was how the staff should treat each resident." She said the nurses checked the resident's care plan for specific residents. She said the RESP should let the nurses know if she was not aware of a particular resident. She said the MOD covered the front desk on the weekends and was there at all times except during meal times. The NHA said the MOD was aware of the residents who were flight risks from the management meetings since the MOD was a part of the IDT. She said before COVID-19 the facility had wander guards for residents at flight risk but after COVID-19 the doors remained locked and if the residents did not remember the code they needed supervision in the community. The ROM said she thought the facility had a binder for residents who were flight risks specifically.-However, the staff did not have a consistent way to check if a resident was supervised or unsupervised in the community which led to Resident #3 elopement from the facility.

A revisit survey was completed on 10/4/23 and 10/5/23 for all previous deficiencies cited on 8/24/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 10/5/23 for all previous deficiencies cited on 8/24/23. The facility is in compliance with all regulations surveyed.

An abbreviated licensure survey with complaint #CO33573 was completed from 8/22/23 through 8/24/23. One deficiency was cited.

Based on record review and interviews, the facility failed to manage severe intractable pain for one (#3) of 16 sample residents. Resident #3 was admitted to the facility from the hospital on 8/4/23 with severe pain from cancer that had metastasized to her bones. Resident #3's goal was rehabilitation therapy and strengthening so she could be discharged home with family. Resident #3 had severe pain and physician orders for regularly scheduled and as-needed (PRN) pain medications. However, the resident was only given one dose of PRN pain medication, her daily ordered pain patch was never administered during her stay at the facility, and Resident #3 continued to suffer excruciating pain rated at severe levels, of 8, 9, and 10 out of 10 on 8/4, 8/5, 8/6 and 8/7/23. Her physician was not notified at any time about her severe intractable pain. On 8/7/23, she was readmitted to the hospital and did not return to the facility. Findings include: I. Facility policy The Pain Management policy, dated 5/3/23, provided by the regional director of operations (RDO) on 5/24/23 at 3:00 p.m., included in pertinent part:"Pain is subjective and is what the resident says it is, existing when and where the resident says it does."Purpose: To accurately assess and achieve pain control. This does not necessarily mean the resident is pain free. Acceptable (tolerable) pain control is defined by the resident."Procedure: The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness."All subsequent pain evaluations will be documented on the Pain Evaluation in PCC (point click care, the electronic medical records system) and/or the MAR (medication administration record) as applicable, to include location, intensity rating and response to pain management interventions."Document your findings on the Pain Evaluation in PCC and/or MAR as applicable."Considerations:Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) analgesic administration. (Every shift pain checks on the MAR should be completed after the resident receives the routine medication.)Titration is the manipulation of dose (up or down) to attain the greatest pain control with the least amount of side effects. Rescue doses (bolus) may be prescribed for periodic breakthrough or incident pain related to activity, treatment and/or diagnostic procedures. Residents are started on an appropriate bowel program whenever analgesic medications are prescribed. Associated symptoms are evaluated and aggressively treated. Nausea, vomiting, itching, somnolence, anxiety, depression, fear of addiction, fatigue and insomnia are amenable to simple remedies. Left untreated they can have a profoundly negative effect on the resident's morale and pain perception. Success rate is increased utilizing a multi-disciplinary, multi-treatment modality approach and using a combination of analgesic and adjuvant drugs and therapies. Do not forget the non-pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage and humor therapy. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan." II. Resident status Resident #3, age 81, was admitted on 8/4/23 with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. According to the 8/4/23 nursing admission assessment, Resident #3 was alert and oriented to person, place, time, and situation. She needed extensive assistance for transfers, bed mobility, eating, and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10 and was unable to state her acceptable level of pain. She exhibited grimacing, clenched jaw, frowning, tearfulness/crying, a furrowed brow, moaning, grunting and was frightened. Her pain was relieved by medication and cold (ice packs). Her pain management medications were morphine sulfate twice daily and oxycodone 10 mg every four hours PRN (as needed). The admission nurse documented Resident #3 was "in constant pain."-Resident #3's pain patch (see order below) was not documented in the assessment as a pain relief measure. III. Record review - failure to manage Resident #3's severe intractable pain as expected per facility policy, as care planned, and as ordered. A. Care planResident #3's care plan, initiated on 8/4/23 and not revised, identified pain related to bone cancer with the goal for inadequate pain relief to be minimized. Interventions included: administer analgesia (pain medication) as per orders; evaluate the effectiveness of pain intervention; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; monitor/document for probable cause of each pain episode, remove/limit causes where possible; monitor/document for side effects of pain medication; observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls; report occurrences to the physician; notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain; offer non-pharmacological interventions for pain prior to administering medication and PRN. -Non-pharmacological interventions for Resident #3 were not specified or person-centered. The facility failed to administer analgesia per orders, evaluate the effectiveness of pain interventions to alleviate symptoms and resident satisfaction with the results, and failed to notify the physician when Resident #3's pain was not relieved, or timely when she experienced side effects including nausea/vomiting and constipation (see nurse's note prior to hospital discharge below). B. OrdersThe CPO documented the following pertinent orders:-Monitor pain every shift using 0-10 pain scale;-Acetaminophen 8 hour oral tablet extended release 650 mg, every eight hours as needed for pain;-Lidocaine external patch 5%, apply to right inner thigh topically one time a day for pain, remove in 12 hours;-Morphine Sulfate ER oral tablet extended release 30 mg, three times a day for pain; and-Oxycodone HCI oral tablet 10 mg, every four hours as needed for pain. C. Nursing progress notes, therapy notes, medication administration record, and vital signs/pain level documentation during Resident #3's stay (in pertinent part)On 8/4/23 at 5:02 p.m., order notes documented the Acetaminophen order was outside of the recommended dose or frequency, because "the daily dose of 650 mg is below the usual dose of 1,300 to 3,900 mg." -There was no evidence the physician was called for order clarification. On 8/4/23 at 5:10 p.m., an administration note documented, "Resident arrived and is having severe pain, Oxycodone (10 mg) pulled from STAT (emergency) safe." -The medication administration record (MAR) documented 10 mg Oxycodone was given on 8/4/23 at 5:10 p.m., and documented as ineffective. However, there was no evidence the physician was notified of the resident's severe pain and that the pain medication was ineffective.-Further, there was no evidence of non-pharmacological interventions, where the pain was or a description of the pain, and no evidence nursing staff assessed the effectiveness of the medication until six hours after the Oxycodone was administered (see below). The physical therapy (PT) evaluation and plan of treatment documented on 8/4/23 read in pertinent part, the reason for referral was medical history of breast and vulva cancer with bone metastasis, osteoarthritis, Crohn's disease, status post left knee surgery, failed chemotherapy and radiation in past. The resident "Had onset of severe pain R (right) inguinal (groin) area approximately 5 (five) weeks ago, has not been ambulatory x (for) 4-5 weeks d/t (due to) pain. Pt (patient/resident) underwent recent resection (surgical removal) of mass right groin with biopsy positive for reoccurrence of vulva CA (cancer)."Precautions: full code, intractable pain - must have medications prior to treatment, bone metastases."Patient has pain levels at 10/10. A and O x 4 (alert and oriented to person, time, place, situation), tearful, moaning secondary to pain. Pt undecided vs possible hospice?Severe pain, surgical site, right groin, lower extremities." On 8/4/23 at 8:00 p.m., scheduled morphine was documented as given.-There was no evidence the effectiveness of the morphine was assessed. At 11:15 p.m., six hours after the PRN Oxycodone administration (and more than three hours after morphine administration), it was documented in nursing progress notes as "Ineffective" and the resident's follow-up pain scale was "10" out of 10. -There was no documentation of what was done to relieve Resident #3's severe 10 out of 10 pain, which per pain scale assessment is defined as excruciating, even though the resident's pain was documented as "severe" when the Oxycodone was given. There was no documentation that the physician was notified. The ordered Lidocaine patch was not added to the MAR and was never documented as administered. On 8/5/23, scheduled morphine was documented as given at 8:00 a.m. and 2:00 p.m. However, at 9:37 a.m. Resident #3's pain level was 10 according to vital signs/pain level documentation.-No PRN pain medication was given and the physician was not notified. On 8/5/23, no time documented, a PT treatment encounter note documented in pertinent part, "Intractable pain - must have meds prior to treatment, bone metastasis, severe pain. Educated pt about pressure sores and continuing to move LEs (lower extremities) and rest in neutral. Pt reports she is unable to do this because of pain levels. Spoke w/ nursing about pain management. Pt participates in therapy today but is extremely limited d/t levels of pain. Son is present with her today and reports that she needs to be doing therapy. Spoke with nursing regarding pain management. Response to session interventions: Patient not finding relief from pain meds provided by nursing, very tearful and sobbing, moaning and holding self, not allowing or participating in motion. Goals for therapy include going home and not long term functional status. Goal is independence with personal care to allow son to care for resident at home." On 8/5/23 at 8:00 p.m., scheduled morphine was given per the MAR. At 8:25 p.m., Resident #3's pain level was documented as 8 out of 10 on the vital signs/pain level sheet.-No PRN pain medication was given and the physician was not notified of Resident #3's unrelieved pain. On 8/6/23 at 8:00 a.m., scheduled morphine was given. At 8:16 a.m., Resident #3's pain level was 9 out of 10 per the vitals/pain level sheet.-There was no documentation the nurse re-assessed the effectiveness of the morphine. On 8/6/23 at 2:00 p.m., scheduled morphine was given.-There was no documentation of effectiveness and no pain level was documented. On 8/6/23 at 8:00 p.m., scheduled morphine was given. On 8/6/23 at 8:40 p.m., Resident #3's pain level remained severe at 8 out of 10 per the vitals/pain level sheet. -There were no further pain level assessments on 8/6/23. No PRN pain medications were given. The physician was not notified of the resident's severe pain. On 8/7/23 at 8:00 a.m., scheduled morphine was given. On 8/7/23 at 8:58 a.m., Resident #3's pain level remained severe at 8 out of 10 per the vitals/pain level sheet.-There was no documentation the physician was notified or that PRN pain medication was offered. PT treatment encounter note on 8/7/23, no time noted, documented in pertinent part, (The resident had) "Intractable pain - must have meds prior to treatment, bone metastasis, no BM (bowel movement) x 10 days, abdominal distension."Pt with abdominal distension, bloating and gas, pt had suppository placed with no results. Pt seen for abdominal massage to facilitate movement of fecal matter. Performed gentle knee to chest x 5 (five) held each x 1 (one) minute, fb (followed by) 10 minutes of stroke from pelvis to ribs, fb effleurage tracing the colon moving clockwise...able to palpate several hard lumps in transverse colon which moved during course of treatment from R upper to L (left) upper segment. Performed kneading to L upper abdomen fb umbilical region and finally gentle vibration to abdomen to help facilitate passing of gas. As treatment was concluding paramedics entered the room to transport patient for disimpaction as she was unable to pass any gas or fecal matter." On 8/7/23 at 1:00 p.m., a change of condition note, and a 1:59 p.m. nurse's note documented Resident #3's vitals were taken at 9:34 a.m. Resident #3 was documented as alert and oriented to herself with confusion noted to place, time and situation. She used pads/briefs due to incontinence; her urine was "slightly red in color." The date of her last BM was blank. Her abdomen was "distended and hard. N/v (nausea/vomiting) noted. Resident stated that when she vomited she had dark red spots in the vomit. Nurse noted that resident does have a dx (diagnosis) of malignant neoplasms throughout body. Resident has not had a BM since admission here. No bowel sounds noted. Abdomen is distended and board like." Breath sounds were diminished with shortness of breath upon exertion. Heart sounds, radial pulses and pedal pulses were normal. "Resident verbalizes presence of pain. Resident stated that her lower abd (abdomen) and pelvic area with her right leg hurt at a level 8 on the pain scale." The physician was notified and "he stated to send her to the ER (emergency room) for bowel intervention. Suppository ordered. Medication side effects: no. Notes on medications/treatments: no... Resident is receiving PT (physical therapy) and OT (occupational therapy) services. Resident requires 2 staff member extensive assist with ADLs (activities of daily living) and bed mobility. She has been bed bound since admit d/t (due to) extreme pain and inability to move r/t (related to) cancer." The 8/7/23 PT discharge summary documented in pertinent part, "Direct, hands-on care with patient this reporting period focused on the following skilled interventions: bed mobility, positioning, therapeutic abdominal massage and discussion with PTA (physical therapy assistant) re(garding) plan of care, caregiver and patient education and training, equipment assessment. Poor response d/t severe intractable pain, distension of abdomen and dx (diagnosis) of bone metastasis. Correspondence with primary caregivers to facilitate development and follow-through of patient's plan of treatment. Functional skills reviewed with team members, reviewed patient's plan of treatment and treatment services with interdisciplinary team members and treatment results communicated to interdisciplinary team." E. Summary of Resident #3's pain managementResident #3 was discharged to the hospital on 8/7/23. During her stay at the facility, Resident #3 had received scheduled morphine three times per day and PRN Oxycodone one time on the evening of 8/4/23. She did not receive and there was no evidence she was offered PRN Oxycodone on 8/5, 8/6, or 8/7/23. She neverreceived the ordered Lidocaine patch or PRN Acetaminophen for pain. Her pain level was always documented as severe at 8, 9, or 10 out of 10; however, nursing staff failed to notify the physician of her severe intractable pain. IV. Staff interviews Licensed practical nurse (LPN) #3, the nurse who admitted Resident #3 on 8/4/23, was interviewed on 8/23/23 at 5:45 p.m. She said she recalled Resident #3 required total care and was in a lot of pain. "She was in bad shape; it was so sad." She said just touching the resident's arm or moving her leg caused her severe pain. Repositioning her in bed was extremely painful. LPN #3 said the nurses gave Resident #3 what they could for pain but "nothing touched her pain." She said she did not call the doctor to report Resident #3's severe pain. "The doctor knew. She came from the hospital." The assistant director of nursing (ADON) was interviewed on 8/23/23 at 6:00 p.m. She said the evening Resident #3 was admitted she gave her the PRN Oxycodone from the emergency kit and she was gone for the weekend after that and did not see Resident #3 again. Certified nurse aide (CNA) #1 was interviewed on 8/23/23 at 7:15 p.m. She said she only worked with Resident #3 the one Sunday night she was in the facility (8/6/23). "She was in a lot of pain." She said Resident #3 was having leg pain and they applied ice through the night. The resident ended up "vomiting a bit." She said she reported the resident's pain and vomiting to the nurse but she did not recall if the nurse went in to see the resident. "She (Resident #3) didn't want to take the Oxy (Oxycodone); she was worried about her bowels." The CNA said Resident #3 ended up going to the hospital after that.-The resident's vomiting was not documented in nursing notes on 8/6/23, nor was it documented in nursing notes that ice was ever applied, or that Resident #3 did not want to take Oxycodone because of constipation side effects. LPN #2 was interviewed on 8/24/23 at 9:00 a.m. She said she was not Resident #3's direct care nurse, but assisted with transfers and compassionate care as part of a nursing team effort. She recalled Resident #3's stay in the facility as a "sad situation, cancer with mets (metastasis) to the bones; she needed medication management." She said to her understanding PT had gone in to address Resident #3's issues the day she was admitted. The LPN became tearful as she talked about Resident #3's pain. "I don't think you can touch that (type of pain)." She said Resident #3 was sent to the emergency room to alleviate her pain. The director of rehabilitation (DOR), a physical therapist, was interviewed on 8/24/23 at 10:52 a.m. with the regional therapy mentor (RTM) present. The DOR said the nursing staff asked her to see Resident #3 after she was admitted to the facility on 8/4/23. She said she moved in on Friday afternoon and left Monday morning. The DOR said she was concerned about working with Resident #3 aggressively because she was in so much pain. She did a PT assessment and it took almost two hours to get her relaxed and comfortable enough to get situated in bed. "She complained about her pain. The nurses were very concerned about how to position her because she was so uncomfortable when she arrived. She wasn't tolerating any of it so they got me in right away." She said she and Resident #3 discussed bed mobility and she spent almost the entire therapy session time trying to find a comfortable position for her. She said the ADON spent quite a bit of time working on trying to get her comfortable. She said they were able to pull the resident up in the bed and get her into a supine position as opposed to on her side. "She was still hurting. It did look like 10/10 pain - it said so in the chart so I knew what to expect. She was nonverbal for the first half hour and then was able to agree to let us move her, give us some information, and was able to be more verbal so the pain medication must have helped."-However, that one dose of PRN Oxycodone was the only one Resident #3 was documented to have received during her stay in the facility. The NHA, DON, and RDO were interviewed on 8/24/23 at 3:48 p.m. regarding pain management for residents with intractable pain. The DON said they could "only provide what the hospital sends." The RDO said she would expect nursing staff to offer PRN pain medications and document if a resident declined the medications. The RDO said she would notify the physician or send the resident out to the hospital if there were concerns about her symptoms. "I understand there were some constipation concerns. I'd want it clearly documented so we knew the story." She acknowledged the nursing notes did not give a good picture of what was provided for Resident #3 regarding pain and symptom management. She said in Resident #3's case she would expect the nurses to notify the physician. The RDO said she had conducted nurse training regarding pain management expectations (see below), which had been provided to all the nurses currently on duty in the facility. V. Facility follow-up (during survey) A Pain Management Education document, dated 8/23/23, was provided by the RDO on the morning of 8/24/23. Seven nurses signed to verify they had received the training on 8/23/23 per the education sign-in sheet. The training included the following: "All residents need to be assessed for pain every shift. Document all non-pharmaceutical interventions provided to relieve pain. Offer PRN pain medications as appropriate and document effectiveness. Administer all routine medications per provider order. If non-pharmaceutical and pharmaceutical pain management interventions are ineffective you must notify the provider. If interventions are ineffective, you must document additional interventions offered and implemented. Document the outcome of all interventions both pharmaceutical and non-pharmaceutical. When interventions are ineffective you must document other interventions attempted. Tell the story. Take credit for the care you provide." The RDO said in an interview at 5:15 p.m. on 8/24/23, that each nursing staff would receive the training prior to working their next shift. VI. Family interviewResident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. He said, "Mom had bone cancer with horrible pain." He said he arrived at the facility about two or three hours after she was admitted. "When I get there she's kind of curled up in a ball. She said they hadn't given her anything for pain." He went to the nurse's station and asked what they were doing for the resident's pain and they said they could probably find some Oxycodone or something for her. "They found Mom one pill after I went there and expressed my concern about the pain she was in. At that point, I just wanted to get my mom the help she needed. The pill didn't even touch the pain, the bone cancer was so severe." He said when he left the facility on 8/4/23 it was evening and the sun was starting to set. "Mom was absolutely still in pain. She was still crying, literally crying, and she was a tough woman. To see her cry from pain I knew something was extremely serious and bad."He said nobody ever showed him or Resident #3 the physician's orders so he would know what she was supposed to have for pain. He said Resident #3 asked several times for pain meds and they said they had to check and see what her next scheduled medication was, then they would return and say she had to wait another half hour or whatever. The resident's son said he did not know there were any "as-needed" pain medications available for Resident #3 until she was later admitted to the hospice inpatient facility. "I'm angry that she suffered because nobody told me she had as-needed pain medications. They made no attempt to manage the pain. They just left her in the corner of that room ... Too many people to care for and they just didn't have time for her." The resident's son said Resident #3 was admitted to the hospital from the facility. He refused to allow the hospital to return her to the facility and ensured she went home with him from the hospital. From there she was admitted to the hospice inpatient facility where he said they managed her pain and treated her with dignity until her death on 8/20/23.

A survey prompted by #CO33285, #CO33293 and #CO33435 was conducted 8/22/23 through 8/24/23. Seven deficiencies were cited.

Based on interviews and record review, the facility failed to ensure resident rights to be treated with respect and dignity in keeping with their individuality for five (#3, #12, #13, #14 and #16) out of 16 sample residents. Specifically, the facility failed to:-Provide dignified assistance when Resident #3 requested a bedpan instead of instructing her to use her brief and be changed at a later time;-Provide timely and dignified call light response when Resident #3 needed assistance with pain medications and care; and-Provide timely and dignified call light response when Residents #12, #13, #14 and #16 needed assistance with care when they were choking, incontinent or needed colostomy care or assistance to the bathroom. Findings include: I. Facility policy The Dignity policy, revised February 2021, provided by the regional director of operations (RDO) on 8/24/23, included in pertinent part:Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance. II. Resident #3 A. Resident status Resident #3, age 81, was admitted on 8/4/23 with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. A minimum data set (MDS) assessment was not completed due to Resident #3's recent admission. According to the 8/4/23 nursing admission assessment, Resident #3 was alert and oriented to person, place, time and situation. She needed extensive assistance for transfers, bed mobility, eating and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10. Resident #3 was admitted to the facility on 8/4/23 and discharged to the hospital on 8/7/23. B. Family interview Resident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. He said Resident #3 was admitted to the facility in severe intractable pain from bone cancer, which was not alleviated during her entire stay in the facility (cross-reference F697, pain management). He said when she rang her call light it took them 30 to 45 minutes to come to her room to even get her her pain medicine. When he went to the nurse's desk to ask for a bedpan per Resident #3's request, the nurse on duty told him, "She's wearing a diaper; it's okay, she doesn't need one." He said, "When I heard that I just got angry and walked away; I didn't know what to do. My mom's in agony, my blood's boiling. 'How can I help my Mom?' was the only thing going through my mind. They didn't bring the bedpan and didn't come in to check on her. I was used to the hospital where you push a button and the nurse comes. When we tried to get people in there it took forever for them to come and see what she needed." He said after waiting too long for call light response for his mother he would "usually just holler for the nurse or I'd just go get one. And then we'd wait and wait and wait and wait and wait." He said during those times Resident #3 needed something to drink, incontinence care or pain medication. C. Record reviewResident #3's care plan dated 8/4/23 identified bladder incontinence. Interventions included: the resident uses disposable briefs, clean peri-area with each incontinence episode, encourage fluids during the day to promote prompted voiding responses, check frequently and as required for incontinence, clean and dry perineum, and change clothing as needed after incontinent episodes. The activities of daily living (ADL) self-care performance deficit care plan dated 8/4/23 documented the resident required assistance for toileting and needed extensive assistance by two staff to move between surfaces. "Encourage the resident to use bell to call for assistance."-Frequent checks for incontinence were not defined in the care plan. The potential for bowel incontinence and offering a bedpan per resident needs and requests was not included in the care plan, although the resident requested and was denied access to a bedpan. Although the resident was encouraged per the care plan to use the bell to call for assistance, timely staff response was not care planned or provided per family interview. Review of Resident #3's activities of daily living (ADL) toilet use documentation revealed the resident was assisted with toileting/incontinence care only five times during her stay in the facility: on 8/5/23 at 2:30 a.m., 8/5/23 at 12:19 p.m., 8/5/23 at 11:59 p.m., 8/6/23 at 5:59 p.m., and 8/7/23 at 1:01 p.m. III. Resident interviews Interviews with residents who were cognitively intact and interviewable revealed facility failures to provide dignified care and timely call light response. Specifically: Resident #12 was interviewed on 8/22/23 at 944 a.m. She said she waited 20 minutes for call light response during lunch on 8/21/23, and she was choking. "Somebody could have died. There's no sense in that." She said a staff person walked up and was playing with the air conditioner in the hall and left for a few minutes, "and my light's going off. She should've come in and just checked." She said call light response was a problem for everyone. "I've heard people going down the hall screaming for help and it went on for a long time. When I hear it I'll push my button and say 'can't you guys hear that? Please help this person.' The halls echo so much I can hear all the way down to the end of the hall when someone is in distress." Resident #13 was interviewed on 8/22/23 at 11:25 a.m. She said call light response time during lunch was slow. "Yesterday it took 20 minutes; I needed help changing my depends." She said it felt "bad" especially when she had been sitting in the same one all day. She said it happened about once a day, at mealtimes and other times during the day. "I need to get changed right away otherwise my privates start burning." She said sometimes the staff just could not keep up with the call lights. "They have RAs (resident assistants) who come and answer the light but they can't do anything and half the time they forget to tell the CNAs that I need help." Resident #16 was interviewed on 8/22/23 at 3:32 p.m. She said she had waited an hour for call light response when she needed her pants changed after incontinence. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 8/24/23 at 8:14 a.m. She said residents had complained to her about slow call light response and lack of incontinence care. She said it had also been reported to her that staff had told a resident to use their brief instead of providing bathroom assistance or a bedpan. She could not recall further details and said it had been several months ago. Certified nurse aide (CNA) # 2 was interviewed on 8/24/23 at 10:43 a.m. She said some of the residents complained about slow call light response. She said some of the staff, even nurses, would say about residents "they're on hospice" or "they're dying" indicating they did not need anything, or that hospice staff would take care of their needs, not facility nursing staff. The staffing coordinator (SC) was interviewed on 8/24/23 at 3:30 p.m. She said a long-term former CNA was fired two weeks ago for resident care, dignity and neglect issues, and treating other staff poorly. She said an RA had reported to her that the former CNA (#4) had told Resident #13 to use her brief and she would change her later. She heard another report that CNA #4 had refused to provide assistance to Resident #14 after her colostomy exploded because she was not her resident, and left her in that condition for 10 minutes. The SC said she had reported these concerns to the nursing home administrator (NHA), she thought, and CNA #4 was fired for these and multiple other reasons. CNA #3 was interviewed on 8/24/23 at 3:30 p.m. She said with current staffing on south hall it was hard to answer call lights timely and "residents do complain." The director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 8/24/23 at 3:48 p.m. The DON and NHA said they were not aware of the concerns documented above. The NHA said they would investigate and provide staff education. They said their expectation for call light response was five minutes or less and residents should be treated with dignity and respect.

Based on interviews and observations, the facility failed to consistently ensure a phone was available for resident use for two (#13 and #3) out of 16 sample residents. Specifically, the facility failed to consistently provide operational phones for residents to use from their rooms or other private areas. Resident #3 was told by staff that there was no facility phone available for resident use. Resident #13 said it was hard to access a private phone at the facility if her cell phone did not work. Findings include: I. Resident/family interviews Resident #13 was interviewed on 8/22/23 at 11:25 a.m. She said it was hard to access a private phone conversation. "My cell phone doesn't always have service because Wi-Fi's often down. The Wi-Fi here is terrible; it's down most of the time." She said she could always make a call at the nurses' desk but it was not private. Resident #3's son was interviewed on 9/6/23 at 11:04 a.m. He said Resident #3 was in the facility from 8/4/23 through 8/7/23 (Friday through Monday) and was bed bound in severe pain (cross-reference F697). Her son said she had her cell phone but there was a problem with it. She could not find her charger and when her battery died she asked for a phone to call him. "They said they didn't have an outside line for patients so she couldn't call to ask me to bring her anything or anything else." He said this occurred on Saturday or Sunday, and he had no idea which staff told her that. "Her roommate's son came to visit and called me and said Mom couldn't get an outside line." II. Observations and staff interviews Observations throughout the day from 8/22 through 8/24/23 revealed residents often used the phone at the nurse's desk on south hall. The phone was not in a private or quiet location and residents could not make calls there without their conversations being overheard. The nurse's desk was adjacent to a busy hallway intersection, the therapy gym, a medication cart, staff offices, and a staff restroom. Licensed practical nurse (LPN) #4 was interviewed on 8/24/23 at 8:14 a.m. She said they had a resident cell phone which was "usually" charged but she opened a drawer at the nurse's desk, checked the cell phone inside the drawer and found that it was dead. She said she did not know where the charger was; it was usually attached to the phone. She said they had a second one, which she found sitting out on the nurse's desk labeled for resident use, which she checked and said it was "charged and ready to go." She said they should also have a cordless phone for residents who had difficulty using a cell phone, but she did not know where it was at the time. The social services director (SSD) was interviewed on 8/24/23 at 8:52 a.m. She said the residents had cell phones and cordless phones available to them for private conversations. She was not aware of any concerns with them not being provided to residents or not functioning properly. The nursing home administrator (NHA), director of nursing (DON) and regional director of operations (RDO) were interviewed on 8/24/23 at 3:48 p.m. The NHA said she had heard of a problem with cell service and facility phones. She said they ordered a new facility phone system, installed 11 new office phones, went through the entire building and did summary wiring which took two or three days, two weeks ago. She said the phones should not be a problem "except when the power goes out." She said they were looking at different options to boost the facility Wi-Fi. The NHA, DON and RDO said they did not know why staff would tell residents there was no private facility phone for them to use. The RDO said they would ensure staff were educated that phones were available for private resident use and should be provided upon resident request.

Based on record review and interviews, the facility failed to ensure the medical durable power of attorney (MDPOA) and the physician were notified of changes in condition for one (#2) out of 15 sample residents. Specifically the facility failed to:-Add the resident's MDPOA to the charting system with contact information;-Notify the MDPOA and physician of the resident's high blood glucose (BG);-Notify the MDPOA when the nurse observed black coffee ground-like stool; and-Notify the MDPOA of Resident #2's death in a timely manner. Cross-reference F684, quality of care regarding diabetic and anticoagulant management and monitoring. Findings include:I. Resident statusResident #2, age 75, was admitted on 3/10/23 and passed away on 3/14/23 at 10:13 p.m. in the facility. According to the March 2023 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis of the right internal jugular vein (what happens when a blood clot blocks a vein in your neck), acute kidney failure, chronic kidney disease stage 3B, other specified symptoms and signs involving the circulatory and respiratory system, disorder of arteries and arterioles (small branches from arteries), pulmonary hypertension (a condition that affects the blood vessels in the lungs), nonrheumatic tricuspid (valve) insufficiency (one or more abnormal structures that can be in any one of the four heart chambers), hyperkalemia (increased potassium in the blood), anemia (low amount of healthy red blood cells), encephalopathy (decreased blood flow or oxygen to the brain), and type two diabetes mellitus (DM) without complications. The 3/21/23 minimum data set (MDS) showed the resident had cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. II. Record reviewResident #2's care plan was implemented on 3/14/23 however only his wishes to be a full code (receive full treatment) were documented in the care plan. -The facility failed to enter any diabetic management or anticoagulant therapy into the care plan. The MDPOA was never listed in Resident #2's medical chart by the facility. The resident was admitted with orders for insulin administration which noted to "call the doctor if blood glucose was greater than 300 for more than two checks in a row, check at least every one to four hours, drink water, and call the doctor for an adjustment."Resident #2's blood glucose was entered into the facility's charting system as follows:3/10/23 at 8:45 p.m. BG levels were 2223/11/23 at 9:46 a.m. BG levels were 5533/11/23 at 9:51 a.m. BG levels were 5533/11/23 at 1:26 p.m. BG levels were 5993/11/23 at 5:55 p.m. BG levels were 5943/11/23 at 7:35 p.m. BG levels were 4623/12/23 at 6:50 a.m. BG levels were 4063/12/23 at 1:00 p.m. BG levels were 5993/12/23 at 4:13 p.m. BG levels were 5883/12/23 at 7:26 p.m. BG levels were 4903/13/23 at 9:37 a.m. BG levels were 5993/13/23 at 9:58 a.m. BG levels were 5993/13/23 at 2:20 p.m. BG levels were 5993/13/23 at 5:48 p.m. BG levels were 5993/14/23 at 7:03 a.m. BG levels were 4673/14/23 at 7:09 a.m. BG levels were 4673/14/23 at 7:16 a.m. BG levels were 4673/14/23 at 11:28 a.m. BG levels were 4423/14/23 at 4:57 p.m. BG levels were 4993/14/23 at 5:02 a.m. BG levels were 499-There was no evidence the resident's physician or MDPOA were notified of his high blood sugar levels until 3/13/23 at 8:40 p.m. The medical record review revealed a verbal order was received from the resident's doctor on 3/13/23 at 6:59 p.m. for sliding scale insulin administration based on his blood sugar readings. If his blood glucose read over 500 the nursing staff needed to notify the doctor. This was entered into the facility's charting system. The sliding scale was documented as follows:"Insulin Aspart with Niacinamide 100 unit/milliliter: Inject as per sliding scale: If BG levels were 71-149=0 units, If BG levels were 150-

Based on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents. Specifically, the facility failed to ensure:-Residents were not subjected to uncomfortable noise levels in their rooms;-Resident room doors opened properly and safely;-Resident rooms were clean, comfortable, free of urine and cigarette smoke odors and in good repair;-Common areas were homelike and well-maintained; and-Bed linens were in good condition. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, provided by the regional director of operations (RDO) on 8/24/23, included in pertinent part:Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes to the extent possible the characteristics of the facility that reflect a personalized, homelike setting to include:-clean, sanitary and orderly environment;-clean bed and bath linens that are in good condition;-pleasant, neutral scents;-comfortable sound levels. II. Resident/family interviews Resident #13 was interviewed on 8/22/23 at 11:25 a.m. She said it was too loud in the facility at night and it kept her awake. "They (staff) walk up and down the halls and talk. And my roommate snores really bad. We have to leave the room door open, otherwise it's too hot in here." Resident #13 said she loved her roommate and did not want to move but she wanted an eye mask to block out the light at night. Upon trying to exit the resident's room at 12:07 p.m., the door stuck and would not open. Resident #13 said that happened all the time and she rang her call light. A staff person arrived and tried to push open the door from the outside but was unsuccessful. A certified nurse aide was able to shove the door open by pushing her body against it at 12:09 p.m. Staff said the doors stuck sometimes due to humidity. Resident #4 was interviewed on 8/22/23 at 2:56 p.m. She said it was too noisy at night. "It's mostly staff standing right outside your door talking and having a good time. The kitchen door bothers me the most. I've requested many times that they fix it because at night when it slams the whole place shakes." She said it had gotten better after they posted a sign on the kitchen door saying "please close the door gently."She said staff were hoarding wheelchairs and medical equipment in the therapy gym, on the back porch and in the shower room, which bothered her and was not homelike. She said the flower beds at the front were not cared for by staff. She said they were full of weeds and residents and family members had to water and maintain them. She said she saw a resident struggling to sweep up the mulch that had migrated onto the sidewalk. Resident #6 was interviewed on 8/22/23 at 3:32 p.m. The surface of her bedside table was damaged and uncleanable and unsightly. The formica top had peeled off in a six-inch diameter area on the outer corner. "Good luck getting that fixed," she said. "It's an old building with lots of challenges." Resident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. His mother was in the facility from the afternoon of 8/4/23 (Friday) through the morning of 8/7/23 (Monday), suffering intractable severe pain (cross-reference F697). He said, "Mom got no sleep or rest there at all. It was loud, noisy." He said staff were often standing on a deck right outside her window, talking. "Her roommate was great but couldn't hear so the TV was blaring and people talking right outside the window, so it was horrible." He said they would ask for the TV to be turned down but the volume would slowly turn back up to uncomfortable levels. He said the linens on her bed were "dirty from the get-go. She had a ratty blanket that looked like something from a homeless shelter: dirty, stained." On Sunday afternoon he observed the same stains as the evening she arrived, and said, "These are dirty sheets." He said they got changed on the third day. III. Observations and staff interviews A. Urine odors and disrepair in resident rooms Observations throughout the day on 8/22/23 during resident interviews revealed multiple rooms smelled of urine. Observations on 8/22/23 and 8/24/23 of resident rooms #31 and #29 respectively revealed the pervasive smell of urine, unsightly damage to walls and flooring, sticky surfaces on bedside tables and dressers, damaged chests of drawers, water damaged dividers between a small closet intended for two residents to use, worn and pilled bedspreads, privacy curtains that did not completely close at the room entry, and a brown smear that looked like feces on the footboard of the bed by the window in room 29. The housekeeping director, interviewed on the afternoon of 8/22/23 and 8/24/23, said the rooms had been deep cleaned and were ready for residents to move in. She was unable to smell urine but acknowledged the other conditions in the room and said she would ask a housekeeper to deep clean the room again. She said it was an old building and the urine odor may have seeped into the walls and flooring. The nursing home administrator (NHA) was interviewed on the afternoon of 8/24/23 and said she was unable to smell urine. She said she smelled "wet wood." She said she did not know what the brown smear on the footboard of the bed but she would ensure the room was cleaned. She acknowledged the other conditions in the resident rooms and said it was an old building and they did not have a maintenance manager. A corporate maintenance person had been assisting them with repairing the cooling and plumbing system. B. Institutional resident activity room and unkempt flower beds at building entrance Observations from 8/22 through 8/24/23 revealed the resident activity/television (TV) room was not homelike. There were only two upholstered chairs, positioned against the wall and to the side where the TV could not be easily viewed. The rest of the room furnishings consisted of office furniture, a conference table, and a work desk in the corner that staff were sometimes observed using as office space. The flower beds at the front of the building were overgrown with weeds that were encroaching onto the sidewalk. IV. Record reviewThe most recent resident council meeting minutes dated 7/31/27 were provided by the NHA on 8/22/23. Twelve residents were present during the meeting and concerns were documented in pertinent part as follows:"Old business: Group concerns were not completely addressed. (The activity director) will make sure that the group concerns go out to make sure we can come up with a solution."Maintenance: Televisions are too loud in hallways, between the hours of 10 pm and 4 am."V. Additional staff interviews Licensed practical nurse (LPN) #4 was interviewed on 8/24/23 at 8:14 a.m. She said she had heard concerns from residents about loud roommate TVs and Resident #14 had complained about cigarette smoke coming in her window. The nursing home administrator (NHA), director of nursing (DON) and regional director of operations (RDO) were interviewed on 8/24/23 at 3:48 p.m. The observations and resident/family concerns above were discussed. They agreed with the resident comment that the building was old and had lots of challenges. They said they were without a maintenance director and the corporate maintenance person was addressing repair issues in the meantime. They said they would address the maintenance, housekeeping and homelike environment concerns.

Based on record review and interviews the facility failed to assess, report, and treat high blood sugar and potential side effects of anticoagulants (blood thinner) for one (#2) of 15 sample residents. Specifically the facility failed to:-Get clarifying orders for an sliding scale insulin and transcribe admission order for insulin upon admission for Resident #2;-Notify the physician and medical durable power of attorney (MDPOA) in a timely manner about Resident #2's extremely high blood glucose levels -Call rather than fax the physician and call the MDPOA to report that the resident bowel movements were tarry black stools and resembling coffee grounds;-Update Resident #2's care plan for diabetes and anticoagulant management; and-Have a physician examine and assess the resident upon admission due to his complicated diagnoses and condition changes. Cross-reference F580, for failure to notify the resident physician and MDPOA of the resident change of condition. Findings include:I. Facility policiesThe Diabetic Management Policy, revised 7/28/23, was provided by the nursing home administrator (NHA) on 8/23/23 and read in pertinent part:"Upon admission the interdisciplinary team (IDT) evaluates the diabetic resident and implements a plan of care:-To ensure orders are received and are accurately related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow in communicating with the physician. Procedure:9. If a resident has high blood sugar, follow physician-ordered parameters. If the blood glucose (BG) is above 'high' parameter, the physician must be contacted for further interventions."The Anticoagulation Policy, revised 4/14/23, was provided by the NHA on 8/23/23 and read in pertinent part:"The facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Procedure5. A care plan will be developed for anticoagulants to promote safe use of the medications;6. Monitoring for adverse effects and interventions for prevention, documentation will be completed by exception."-However, the NHA said the facility did not have these policies in place in March 2023 due to their corporation change. The NHA did not have access to the former corporate policies that were in effect at the time of Resident #2's stay at the facility. II. Professional standardsAccording to the Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) ID L34834 blood glucose monitoring in a skilled nursing facility, https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34834, last revised 11/7/19, accessed 8/29/23, in pertinent part:"When blood glucose (blood sugar) values are below 60 (low) or over 300 (high), the physician must be notified of the results immediately ...When reporting an abnormal blood glucose value to the physician, the previous two or more, as appropriate, should also be provided for trending purposes."According to the Eliquis (anticoagulant) medication information resource, https://packageinserts.bms.com/medguide/medguide_eliquis.pdf, last revised September 2021, in pertinent part:"Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: Unexpected bleeding or bleeding that lasts a long time from the gums, nosebleeds that happen often, bleeding that is severe or you cannot control; red, pink, or brown urine, red or black stool, coughing up blood, vomiting blood, unexpected pain or joint pain, headaches, feeling dizzy, or feeling weak."According to Gastrointestinal (GI) Bleed: Nursing Diagnoses, Care Plans, Assessment & Interventions, Nurse Together website, https://www.nursetogether.com/gastrointestinal-bleed-nursing-diagnosis-care-plan/#physical-assessment, updated 7/30/23, accessed 8/30/23, in pertinent part: "Assess for GI bleeding. Note the following GI bleeding symptoms:-CNS (central nervous system): decreased mentation, decreased level of consciousness, lightheadedness, fainting (syncope), dizziness-HEENT: pale eyes, mucosa, and lips-Respiratory: decreased oxygen saturation, shortness of breath-Cardiovascular: chest pain, tachycardia, hypotension-Gastrointestinal: abdominal pain, abdominal cramping, presence of anal fissures, hemorrhoids, masses, bright red or coffee-ground blood in the vomitus (hematemesis), black, tarry stools (melena)-Hematologic: anemia-Integumentary: skin pallor."III. Resident statusResident #2, age 75, was admitted on 3/10/23 and passed away on 3/14/23 at 10:13 p.m. in the facility. According to the March 2023 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis ( a blood clot blocks a vein in your neck) of the right internal jugular vein , acute kidney failure, chronic kidney disease stage 3, other specified symptoms and signs involving the circulatory and respiratory system, disorder of arteries and arterioles (small branches from arteries), pulmonary hypertension (a condition that affects the blood vessels in the lungs), nonrheumatic tricuspid (heart valve) insufficiency (one or more abnormal structures that can be in any one of the four heart chambers), hyperkalemia (increased potassium in the blood), anemia (low amount of healthy red blood cells), encephalopathy (decreased blood flow or oxygen to the brain), and type two diabetes mellitus (DM) without complications. The 3/21/23 minimum data set (MDS) revealed the resident had cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. IV. Record reviewA. Care planResident #2's care plan was initiated on 3/14/23, however only his wishes to be a full code (full treatment) were documented in the care plan. -The facility failed to enter any diabetic management or anticoagulant therapy into the care plan. B. Hospital discharge facility admission ordersA guideline for insulin dosing was provided upon resident #2s' admission to the facility. The orders were not transcribed into the resident's CPO or on the medication administration record MAR) for nurses to assess when administering the resident medications. Admission orders documents that the resident was prescribed two types of insulin; the orders were documented as follows:"Xultophy (long acting insulin), inject 15 units daily at the same time every morning."Fiasp (generic name aspart) (fast acting insulin), administer insulin before each meal, up to four times a day according to the following fast acting administration scale per blood glucose (BG) assessment results:If BG is less than 70: treat with 15-20 grams of quick-acting sugar,If BG is 70-150 inject 2 units of Fiasp,If BG is 151-200 inject 3 units of FiaspIf BG is 201-250 inject 4 units of Fiasp,If BG is 251-300 inject 5 units of Fiasp,If BG is 300-350 inject 6 units of Fiasp,If BG is 351-400 inject 7 units of Fiasp,If BG is 401 or great inject 8 units of Fiasp,If BG is greater than 300 for more than two checks in a row, start checking BG levels at least every one to four hours, (have the patient) drink water, and call the doctor for an adjustment (treatment recommendations) ."C. Physician orders from 3/10/23 through 3/15/23Review of the March 2023 MAR revealed the following pertinent orders included:"Lantus solostar (long acting insulin) subcutaneous (SQ) solution pen-injector 100 unit/ML, inject 4 unit SQ one time a day for DM 2, ordered 3/10/23 and discontinued 3/12/23;"Lantus solostar SQ solution pen-injector 100 unit/ML, inject 4 unit SQ one time a day for DM2, ordered 3/12/23 at 12:52 a.m. and discontinued on 3/15/23 at 9:33 a.m."-No parameters were documented for when to notify the physician for high or low blood sugar levels; and the resident's insulin orders for fast acting insulin were not documented into the CPO or MAR records. D. Blood sugar levelsResident #2's blood sugars entered into the MAR read as follows:3/10/23 at 8:45 p.m. BG was 2223/11/23 at 9:46 a.m. BG was 5533/11/23 at 9:51 a.m. BG was 5533/11/23 at 1:26 p.m. BG was 5993/11/23 at 5:55 p.m. BG was5943/11/23 at 7:35 p.m. BG was4623/12/23 at 6:50 a.m. BG was 4063/12/23 at 1:00 p.m. BG was5993/12/23 at 4:13 p.m. BG was5883/12/23 at 7:26 p.m. BG was 4903/13/23 at 9:37 a.m. BG was 5993/13/23 at 9:58 a.m. BG was 5993/13/23 at 2:20 p.m. BG was 5993/13/23 at 5:48 p.m. BG was 5993/14/23 at 7:03 a.m. BG was 4673/14/23 at 7:09 a.m. BG was 4673/14/23 at 7:16 a.m. BG was 4673/14/23 at 11:28 a.m. BG was 4423/14/23 at 11:32 a.m. BG was 4423/14/23 at 4:57 p.m. BG was 4993/14/23 at 5:02 a.m. BG was 499-There was no evidence the resident's physician or MDPOA were notified of his high blood sugar levels until 3/13/23 at 8:40 p.m. Following notification to the physician of the resident elevated BG levels, the medical record review revealed a verbal order was received from the resident's doctor on 3/13/23 at 6:59 p.m. for a sliding scale for insulin administration based on the resident BG readings. The order was not transcribed to the resident's MAR and the medication until 3/14/23 (see nursing note below).-The order read: if the resident's BG assessment was over 500 notify the doctor. The MAR documented the following new orders. "Insulin Aspart with Niacinamide (fast acting insulin) 100 unit/milliliter: Inject as per sliding scale: If If BG is 71-149=inject 0 units, If BG is 150-199=inject 3 units,If BG is 200-249=inject 5 units,If BG is 250-299=inject 7 units,If BG is 300-349=inject 10 units,If BG is 350-399=inject 12 units,If BG is 400-499=inject 14 units,Subcutaneously three times a day for diabetes type 2. Call the prescribing physician for BG results less than 70 or if above 500. -However the nursing staff never documented they notified the doctor of blood sugar levels greater than 500 (once the new order was received) (see nurse's note below) when the facility received the new order for blood sugar levels over 500. E. Nursing progress notesProgress note dated 3/13/23 at 8:40 p.m., read: "Called doctor office today in regards to resident's high blood sugar. His blood sugar all day and other days too, have been over 599, the meter just reads 'HI.' We received his aspart insulin that should be given on a sliding scale but did not receive the sliding scale. The doctor gave a verbal order for the aspart sliding scale which was put in as a new order."Progress note dated 3/14/23 at 6:57 p.m., read: "This licensed practical nurse (LPN) was asked by a certified nurse aide (CNA) to come and observe the resident stool that was in the toilet and some was dried to the toilet seat. Upon entering there was an odor and the stool was black in color and may have had possible coffee ground appearance. Fax sent to his doctor. Resident reports that it has been like this for a while."F. Anticoagulant ordersReview of the resident's March 2023 MAR revealed he was taking Aspirin 81 milligrams (mg) once per day and Apixaban (Eliquis an anticoagulant blood thinning medication) 20 mg - two 5 mg tablets twice per day. V. Staff interviewsThe director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 8/23/23 at 6:41 p.m. The RDO said Resident #2 was not at the facility long enough after admission to be seen by the doctor. The nursing staff completed a phone call with the doctor for his insulin order on 3/13/23. Resident #2 was also on Lantus (a type of insulin) and Lispro (a type of insulin) 4 units with each meal. He was admitted with high blood sugar. The DON, NHA and RDO were interviewed again on 8/24/23 at 3:42 p.m. The RDO said the nurses should have notified the doctor soon for Resident #2's high blood sugar and every time they obtained a high blood sugar from him. Resident #2 had stool that looked like black coffee grounds on 3/13/23. The progress notes entered in the facility's charting system said a fax was sent to the doctor's office and although the doctor usually received the faxes fairly quickly the nurses should have called the doctor and informed him over the phone. The RDO acknowledged that diabetic management and anticoagulant use and monitoring should have been included in Resident #2's care plan.

Based on record review and interviews, the facility failed to manage severe intractable pain for one (#3) of 16 sample residents. Resident #3 was admitted to the facility from the hospital on 8/4/23 with severe pain from cancer that had metastasized to her bones. Resident #3's goal was rehabilitation therapy and strengthening so she could be discharged home with family. Resident #3 had severe pain and physician orders for regularly scheduled and as-needed (PRN) pain medications. However, the resident was only given one dose of PRN pain medication, her daily ordered pain patch was never administered during her stay at the facility, and Resident #3 continued to suffer excruciating pain rated at severe levels, of 8, 9, and 10 out of 10 on 8/4, 8/5, 8/6 and 8/7/23. Her physician was not notified at any time about her severe intractable pain. On 8/7/23, she was readmitted to the hospital and did not return to the facility. Findings include: I. Facility policy The Pain Management policy, dated 5/3/23, provided by the regional director of operations (RDO) on 5/24/23 at 3:00 p.m., included in pertinent part:"Pain is subjective and is what the resident says it is, existing when and where the resident says it does."Purpose: To accurately assess and achieve pain control. This does not necessarily mean the resident is pain free. Acceptable (tolerable) pain control is defined by the resident."Procedure: The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness."All subsequent pain evaluations will be documented on the Pain Evaluation in PCC (point click care, the electronic medical records system) and/or the MAR (medication administration record) as applicable, to include location, intensity rating and response to pain management interventions."Document your findings on the Pain Evaluation in PCC and/or MAR as applicable."Considerations:Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) analgesic administration. (Every shift pain checks on the MAR should be completed after the resident receives the routine medication.)Titration is the manipulation of dose (up or down) to attain the greatest pain control with the least amount of side effects. Rescue doses (bolus) may be prescribed for periodic breakthrough or incident pain related to activity, treatment and/or diagnostic procedures. Residents are started on an appropriate bowel program whenever analgesic medications are prescribed. Associated symptoms are evaluated and aggressively treated. Nausea, vomiting, itching, somnolence, anxiety, depression, fear of addiction, fatigue and insomnia are amenable to simple remedies. Left untreated they can have a profoundly negative effect on the resident's morale and pain perception. Success rate is increased utilizing a multi-disciplinary, multi-treatment modality approach and using a combination of analgesic and adjuvant drugs and therapies. Do not forget the non-pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage and humor therapy. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan." II. Resident status Resident #3, age 81, was admitted on 8/4/23 with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. A minimum data set (MDS) assessment was not completed due to Resident #3's recent admission. According to the 8/4/23 nursing admission assessment, Resident #3 was alert and oriented to person, place, time, and situation. She needed extensive assistance for transfers, bed mobility, eating, and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10 and was unable to state her acceptable level of pain. She exhibited grimacing, clenched jaw, frowning, tearfulness/crying, a furrowed brow, moaning, grunting and was frightened. Her pain was relieved by medication and cold (ice packs). Her pain management medications were morphine sulfate twice daily and oxycodone 10 mg every four hours PRN (as needed). The admission nurse documented Resident #3 was "in constant pain."-Resident #3's pain patch (see order below) was not documented in the assessment as a pain relief measure. III. Record review - failure to manage Resident #3's severe intractable pain as expected per facility policy, as care planned, and as ordered. A. Care planResident #3's care plan, initiated on 8/4/23 and not revised, identified pain related to bone cancer with the goal for inadequate pain relief to be minimized. Interventions included: administer analgesia (pain medication) as per orders; evaluate the effectiveness of pain intervention; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; monitor/document for probable cause of each pain episode, remove/limit causes where possible; monitor/document for side effects of pain medication; observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls; report occurrences to the physician; notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain; offer non-pharmacological interventions for pain prior to administering medication and PRN. -Non-pharmacological interventions for Resident #3 were not specified or person-centered. The facility failed to administer analgesia per orders, evaluate the effectiveness of pain interventions to alleviate symptoms and resident satisfaction with the results, and failed to notify the physician when Resident #3's pain was not relieved, or timely when she experienced side effects including nausea/vomiting and constipation (see nurse's note prior to hospital discharge below). B. OrdersThe CPO documented the following pertinent orders:-Monitor pain every shift using 0-10 pain scale;-Acetaminophen 8 hour oral tablet extended release 650 mg, every eight hours as needed for pain;-Lidocaine external patch 5%, apply to right inner thigh topically one time a day for pain, remove in 12 hours;-Morphine Sulfate ER oral tablet extended release 30 mg, three times a day for pain; and-Oxycodone HCI oral tablet 10 mg, every four hours as needed for pain. C. Nursing progress notes, therapy notes, medication administration record, and vital signs/pain level documentation during Resident #3's stay (in pertinent part)On 8/4/23 at 5:02 p.m., order notes documented the Acetaminophen order was outside of the recommended dose or frequency, because "the daily dose of 650 mg is below the usual dose of 1,300 to 3,900 mg." -There was no evidence the physician was called for order clarification. On 8/4/23 at 5:10 p.m., an administration note documented, "Resident arrived and is having severe pain, Oxycodone (10 mg) pulled from STAT (emergency) safe." -The medication administration record (MAR) documented 10 mg Oxycodone was given on 8/4/23 at 5:10 p.m., and documented as ineffective. However, there was no evidence the physician was notified of the resident's severe pain and that the pain medication was ineffective.-Further, there was no evidence of non-pharmacological interventions, where the pain was or a description of the pain, and no evidence nursing staff assessed the effectiveness of the medication until six hours after the Oxycodone was administered (see below). The physical therapy (PT) evaluation and plan of treatment documented on 8/4/23 read in pertinent part, the reason for referral was medical history of breast and vulva cancer with bone metastasis, osteoarthritis, Crohn's disease, status post left knee surgery, failed chemotherapy and radiation in past. The resident "Had onset of severe pain R (right) inguinal (groin) area approximately 5 (five) weeks ago, has not been ambulatory x (for) 4-5 weeks d/t (due to) pain. Pt (patient/resident) underwent recent resection (surgical removal) of mass right groin with biopsy positive for reoccurrence of vulva CA (cancer)."Precautions: full code, intractable pain - must have medications prior to treatment, bone metastases."Patient has pain levels at 10/10. A and O x 4 (alert and oriented to person, time, place, situation), tearful, moaning secondary to pain. Pt undecided vs possible hospice?Severe pain, surgical site, right groin, lower extremities." On 8/4/23 at 8:00 p.m., scheduled morphine was documented as given.-There was no evidence the effectiveness of the morphine was assessed. At 11:15 p.m., six hours after the PRN Oxycodone administration (and more than three hours after morphine administration), it was documented in nursing progress notes as "Ineffective" and the resident's follow-up pain scale was "10" out of 10. -There was no documentation of what was done to relieve Resident #3's severe 10 out of 10 pain, which per pain scale assessment is defined as excruciating, even though the resident's pain was documented as "severe" when the Oxycodone was given. There was no documentation that the physician was notified. The ordered Lidocaine patch was not added to the MAR and was never documented as administered. On 8/5/23, scheduled morphine was documented as given at 8:00 a.m. and 2:00 p.m. However, at 9:37 a.m. Resident #3's pain level was 10 according to vital signs/pain level documentation.-No PRN pain medication was given and the physician was not notified. On 8/5/23, no time documented, a PT treatment encounter note documented in pertinent part, "Intractable pain - must have meds prior to treatment, bone metastasis, severe pain. Educated pt about pressure sores and continuing to move LEs (lower extremities) and rest in neutral. Pt reports she is unable to do this because of pain levels. Spoke w/ nursing about pain management. Pt participates in therapy today but is extremely limited d/t levels of pain. Son is present with her today and reports that she needs to be doing therapy. Spoke with nursing regarding pain management. Response to session interventions: Patient not finding relief from pain meds provided by nursing, very tearful and sobbing, moaning and holding self, not allowing or participating in motion. Goals for therapy include going home and not long term functional status. Goal is independence with personal care to allow son to care for resident at home." On 8/5/23 at 8:00 p.m., scheduled morphine was given per the MAR. At 8:25 p.m., Resident #3's pain level was documented as 8 out of 10 on the vital signs/pain level sheet.-No PRN pain medication was given and the physician was not notified of Resident #3's unrelieved pain. On 8/6/23 at 8:00 a.m., scheduled morphine was given. At 8:16 a.m., Resident #3's pain level was 9 out of 10 per the vitals/pain level sheet.-There was no documentation the nurse re-assessed the effectiveness of the morphine. On 8/6/23 at 2:00 p.m., scheduled morphine was given.-There was no documentation of effectiveness and no pain level was documented. On 8/6/23 at 8:00 p.m., scheduled morphine was given. On 8/6/23 at 8:40 p.m., Resident #3's pain level remained severe at 8 out of 10 per the vitals/pain level sheet. -There were no further pain level assessments on 8/6/23. No PRN pain medications were given. The physician was not notified of the resident's severe pain. On 8/7/23 at 8:00 a.m., scheduled morphine was given. On 8/7/23 at 8:58 a.m., Resident #3's pain level remained severe at 8 out of 10 per the vitals/pain level sheet.-There was no documentation the physician was notified or that PRN pain medication was offered. PT treatment encounter note on 8/7/23, no time noted, documented in pertinent part, (The resident had) "Intractable pain - must have meds prior to treatment, bone metastasis, no BM (bowel movement) x 10 days, abdominal distension."Pt with abdominal distension, bloating and gas, pt had suppository placed with no results. Pt seen for abdominal massage to facilitate movement of fecal matter. Performed gentle knee to chest x 5 (five) held each x 1 (one) minute, fb (followed by) 10 minutes of stroke from pelvis to ribs, fb effleurage tracing the colon moving clockwise...able to palpate several hard lumps in transverse colon which moved during course of treatment from R upper to L (left) upper segment. Performed kneading to L upper abdomen fb umbilical region and finally gentle vibration to abdomen to help facilitate passing of gas. As treatment was concluding paramedics entered the room to transport patient for disimpaction as she was unable to pass any gas or fecal matter." On 8/7/23 at 1:00 p.m., a change of condition note, and a 1:59 p.m. nurse's note documented Resident #3's vitals were taken at 9:34 a.m. Resident #3 was documented as alert and oriented to herself with confusion noted to place, time and situation. She used pads/briefs due to incontinence; her urine was "slightly red in color." The date of her last BM was blank. Her abdomen was "distended and hard. N/v (nausea/vomiting) noted. Resident stated that when she vomited she had dark red spots in the vomit. Nurse noted that resident does have a dx (diagnosis) of malignant neoplasms throughout body. Resident has not had a BM since admission here. No bowel sounds noted. Abdomen is distended and board like." Breath sounds were diminished with shortness of breath upon exertion. Heart sounds, radial pulses and pedal pulses were normal. "Resident verbalizes presence of pain. Resident stated that her lower abd (abdomen) and pelvic area with her right leg hurt at a level 8 on the pain scale." The physician was notified and "he stated to send her to the ER (emergency room) for bowel intervention. Suppository ordered. Medication side effects: no. Notes on medications/treatments: no... Resident is receiving PT (physical therapy) and OT (occupational therapy) services. Resident requires 2 staff member extensive assist with ADLs (activities of daily living) and bed mobility. She has been bed bound since admit d/t (due to) extreme pain and inability to move r/t (related to) cancer." The 8/7/23 PT discharge summary documented in pertinent part, "Direct, hands-on care with patient this reporting period focused on the following skilled interventions: bed mobility, positioning, therapeutic abdominal massage and discussion with PTA (physical therapy assistant) re(garding) plan of care, caregiver and patient education and training, equipment assessment. Poor response d/t severe intractable pain, distension of abdomen and dx (diagnosis) of bone metastasis. Correspondence with primary caregivers to facilitate development and follow-through of patient's plan of treatment. Functional skills reviewed with team members, reviewed patient's plan of treatment and treatment services with interdisciplinary team members and treatment results communicated to interdisciplinary team." E. Summary of Resident #3's pain managementResident #3 was discharged to the hospital on 8/7/23. During her stay at the facility, Resident #3 had received scheduled morphine three times per day and PRN Oxycodone one time on the evening of 8/4/23. She did notreceive and there was no evidence she was offered PRN Oxycodone on 8/5, 8/6, or 8/7/23. She never received the ordered Lidocaine patch or PRN Acetaminophen for pain. Her pain level was always documented as severe at 8, 9, or 10 out of 10; however, nursing staff failed to notify the physician of her severe intractable pain. IV. Staff interviews Licensed practical nurse (LPN) #3, the nurse who admitted Resident #3 on 8/4/23, was interviewed on 8/23/23 at 5:45 p.m. She said she recalled Resident #3 required total care and was in a lot of pain. "She was in bad shape; it was so sad." She said just touching the resident's arm or moving her leg caused her severe pain. Repositioning her in bed was extremely painful. LPN #3 said the nurses gave Resident #3 what they could for pain but "nothing touched her pain." She said she did not call the doctor to report Resident #3's severe pain. "The doctor knew. She came from the hospital." The assistant director of nursing (ADON) was interviewed on 8/23/23 at 6:00 p.m. She said the evening Resident #3 was admitted she gave her the PRN Oxycodone from the emergency kit and she was gone for the weekend after that and did not see Resident #3 again. Certified nurse aide (CNA) #1 was interviewed on 8/23/23 at 7:15 p.m. She said she only worked with Resident #3 the one Sunday night she was in the facility (8/6/23). "She was in a lot of pain." She said Resident #3 was having leg pain and they applied ice through the night. The resident ended up "vomiting a bit." She said she reported the resident's pain and vomiting to the nurse but she did not recall if the nurse went in to see the resident. "She (Resident #3) didn't want to take the Oxy (Oxycodone); she was worried about her bowels." The CNA said Resident #3 ended up going to the hospital after that.-The resident's vomiting was not documented in nursing notes on 8/6/23, nor was it documented in nursing notes that ice was ever applied, or that Resident #3 did not want to take Oxycodone because of constipation side effects. LPN #2 was interviewed on 8/24/23 at 9:00 a.m. She said she was not Resident #3's direct care nurse, but assisted with transfers and compassionate care as part of a nursing team effort. She recalled Resident #3's stay in the facility as a "sad situation, cancer with mets (metastasis) to the bones; she needed medication management." She said to her understanding PT had gone in to address Resident #3's issues the day she was admitted. The LPN became tearful as she talked about Resident #3's pain. "I don't think you can touch that (type of pain)." She said Resident #3 was sent to the emergency room to alleviate her pain. The director of rehabilitation (DOR), a physical therapist, was interviewed on 8/24/23 at 10:52 a.m. with the regional therapy mentor (RTM) present. The DOR said the nursing staff asked her to see Resident #3 after she was admitted to the facility on 8/4/23. She said she moved in on Friday afternoon and left Monday morning. The DOR said she was concerned about working with Resident #3 aggressively because she was in so much pain. She did a PT assessment and it took almost two hours to get her relaxed and comfortable enough to get situated in bed. "She complained about her pain. The nurses were very concerned about how to position her because she was so uncomfortable when she arrived. She wasn't tolerating any of it so they got me in right away." She said she and Resident #3 discussed bed mobility and she spent almost the entire therapy session time trying to find a comfortable position for her. She said the ADON spent quite a bit of time working on trying to get her comfortable. She said they were able to pull the resident up in the bed and get her into a supine position as opposed to on her side. "She was still hurting. It did look like 10/10 pain - it said so in the chart so I knew what to expect. She was nonverbal for the first half hour and then was able to agree to let us move her, give us some information, and was able to be more verbal so the pain medication must have helped."-However, that one dose of PRN Oxycodone was the only one Resident #3 was documented to have received during her stay in the facility. The NHA, DON, and RDO were interviewed on 8/24/23 at 3:48 p.m. regarding pain management for residents with intractable pain. The DON said they could "only provide what the hospital sends." The RDO said she would expect nursing staff to offer PRN pain medications and document if a resident declined the medications. The RDO said she would notify the physician or send the resident out to the hospital if there were concerns about her symptoms. "I understand there were some constipation concerns. I'd want it clearly documented so we knew the story." She acknowledged the nursing notes did not give a good picture of what was provided for Resident #3 regarding pain and symptom management. She said in Resident #3's case she would expect the nurses to notify the physician. The RDO said she had conducted nurse training regarding pain management expectations (see below), which had been provided to all the nurses currently on duty in the facility. V. Facility follow-up (during survey) A Pain Management Education document, dated 8/23/23, was provided by the RDO on the morning of 8/24/23. Seven nurses signed to verify they had received the training on 8/23/23 per the education sign-in sheet. The training included the following: "All residents need to be assessed for pain every shift. Document all non-pharmaceutical interventions provided to relieve pain. Offer PRN pain medications as appropriate and document effectiveness. Administer all routine medications per provider order. If non-pharmaceutical and pharmaceutical pain management interventions are ineffective you must notify the provider. If interventions are ineffective, you must document additional interventions offered and implemented. Document the outcome of all interventions both pharmaceutical and non-pharmaceutical. When interventions are ineffective you must document other interventions attempted. Tell the story. Take credit for the care you provide." The RDO said in an interview at 5:15 p.m. on 8/24/23, that each nursing staff would receive the training prior to working their next shift. VI. Family interviewResident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. He said, "Mom had bone cancer with horrible pain." He said he arrived at the facility about two or three hours after she was admitted. "When I get there she's kind of curled up in a ball. She said they hadn't given her anything for pain." He went to the nurse's station and asked what they were doing for the resident's pain and they said they could probably find some Oxycodone or something for her. "They found Mom one pill after I went there and expressed my concern about the pain she was in. At that point, I just wanted to get my mom the help she needed. The pill didn't even touch the pain, the bone cancer was so severe." He said when he left the facility on 8/4/23 it was evening and the sun was starting to set. "Mom was absolutely still in pain. She was still crying, literally crying, and she was a tough woman. To see her cry from pain I knew something was extremely serious and bad."He said nobody ever showed him or Resident #3 the physician's orders so he would know what she was supposed to have for pain. He said Resident #3 asked several times for pain meds and they said they had to check and see what her next scheduled medication was, then they would return and say she had to wait another half hour or whatever. The resident's son said he did not know there were any "as-needed" pain medications available for Resident #3 until she was later admitted to the hospice inpatient facility. "I'm angry that she suffered because nobody told me she had as-needed pain medications. They made no attempt to manage the pain. They just left her in the corner of that room ... Too many people to care for and they just didn't have time for her." The resident's son said Resident #3 was admitted to the hospital from the facility. He refused to allow the hospital to return her to the facility and ensured she went home with him from the hospital. From there she was admitted to the hospice inpatient facility where he said they managed her pain and treated her with dignity until her death on 8/20/23.

Based on record review, interviews and observation, the facility failed to assess and ensure nutritional and hydration parameters were met and food and drink preferences provided for four (#3, #12, #13 and #4) out of 16 sample residents, and failed to provide dietary preferences for multiple additional facility residents as voiced by resident council members. Specifically, Resident #3 was admitted to the facility on 8/4/23 and discharged to the hospital on 8/7/23 with severe intractable pain from metastatic cancer with the goal for strengthening so she could move home with her family. Her nutritional and hydration needs were not assessed, care planned or provided. Current facility residents including Residents #12, #13 and #4 likewise said during individual interviews and in resident council their food preferences were not honored and/or available and the facility was not responsive to their stated concerns. Findings include: I. Resident #3 A. Resident status Resident #3, age 81, was admitted on 8/4/23 with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. A minimum data set (MDS) assessment was not completed due to Resident #3's recent admission. According to the 8/4/23 nursing admission assessment, Resident #3 was alert and oriented to person, place, time and situation. She needed extensive assistance for transfers, bed mobility, eating and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10. Resident #3 was admitted to the facility on 8/4/23 and discharged to the hospital on 8/7/23. B. Family interview Resident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. He said the facility did not honor his mother's food and drink choices. He said she had asked for cranberry juice at 7:00 a.m. on 8/5/23 and at 9:00 a.m., "nothing"happened. He said he went to the kitchen and got it for her. He said they finally brought her cranberry juice with her lunch at 1:00 p.m. He said by then he had gotten her several drinks upon her request. "I just sat with her most of the day so she could get what she needed." He said the nurse on duty was getting annoyed with him and treating him like he was a nuisance. Resident #3's son said Resident #3 told him they had never asked her what she wanted for breakfast but they asked her roommate. She said they just brought her oatmeal. "I've never seen Mom eat oatmeal."She wanted 2 scrambled eggs, cream of wheat and cranberry juice, so he went to the kitchen and asked them to give her that same thing every morning. "She wasn't happy that her roommate got a real breakfast while she got a bowl of oatmeal."He said, "She wasn't able to eat more than a taste or two of this or that anyway, just enough to keep a mouse alive but that's not the point." He said he never saw the staff offer his mother protein drinks, shakes, supplements or snacks. C. Record review Resident #3's care plan, initiated 8/4/23, did not include approaches regarding nutrition or hydration. The activities of daily living (ADL) care plan did not include approaches regarding dining. The bladder incontinence care plan included an intervention to encourage fluids. Physician orders dated 8/4/23 documented a regular diet, regular texture with thin consistency fluids. There was no documentation in Resident #3's medical record of food and drink preferences, likes and dislikes. There was no evidence of an assessment of the resident's nutritional and hydration needs. According to Resident #3's ADL and meal documentation report, she needed supervision, oversight, encouragement or cueing for meals. Her meal intakes were:-On 8/423: Zero (refused) dinner and 120 ml (milliliters) of fluid;-On 8/5/23: 51-75% for breakfast with 240 ml of fluid, zero for lunch with 75 ml of fluid, and 26-50% for dinner with 240 ml of fluid;-On 8/6/23: Zero for breakfast and 480 ml of fluid, zero for lunch and 200 ml of fluid, and 26-50% for dinner with 240 ml of fluid;-On 8/7/23: Nothing was documented for food or fluid intake. -Resident #3 was not documented to consume sufficient food or fluids. Average daily intake recommended for older adults is a minimum of 1500 ml. There was no documentation her physician was notified of her poor intake, and no evidence she was offered her favorite foods or even nutritional supplements to assist in meeting her nutritional needs. II. Observation Observation on 8/22, 8/23 and 8/24/23 revealed a sign posted on the kitchen door that read as follows: "Kitchen hours were 0630-1830 (6:30 a.m. to 6:30 p.m.). If you need something before or after the open and closed times please ask your nursing station." III. Resident interviews Resident #12 was interviewed on 8/22/23 at 9:44 a.m. She said she had not been feeling well the previous evening, and at about 6:20 p.m. she asked what she could eat that would be easy on her throat that night. "The kitchen was closed and I couldn't get anything but snacks and I think that should change. Finally one of my favorite CNAs (certified nurse aides) came in and said she'd bring me some blueberry yogurt and that I could handle." She said it would be nice if they would serve macaroni and cheese more often because she liked it and it was easy to swallow. Resident #13 was interviewed on 8/22/23 at 11:25 a.m. She said, "Sometimes you knock on the kitchen door and nobody will answer, even during daytime hours." She said she knocked on the kitchen door when she needed coffee. "They don't get here till 6:30 a.m. and they close the kitchen at 6:30 pm. I could have used some coffee last night when I couldn't sleep." Resident #4, the resident council president, was interviewed on 8/22/23 at 2:56 p.m. She said they very seldom were served the food that was on the menu and the staff always had an excuse. She said food ran out all the time, including basics like condiments, coffee, peanut butter and sugar. She said when the residents voiced their concerns in resident council, the facility response was "always the same: we're working on it." IV. Record review Twelve residents attended the most recent resident council meeting on 7/31/23, according to resident council minutes provided by the nursing home administrator (NHA) on 8/22/23. Resident council meeting minutes documented the following in pertinent part: "Old business: Group concerns were not completely addressed. (The activity director) will make sure that the group concerns go out to make sure we can come up with a solution." "Dietary: Condiments concern did not get taken care of, still not enough supply. Not enough fresh fruit, running out of supplies, French fries are too hard or too cold, still same issue with the menu not matching what they are getting, too much rice and carrots, too many flies in the dining room, toast is soggy, the kitchen running out of ice." "Activities: Would like popsicles for snacks." V. Staff interviews The dietary manager was interviewed on the morning of 8/24/23. She said residents could access whatever they needed from the kitchen during the day, and from nursing staff before and after posted kitchen hours. She said nursing staff could always access juices, coffee, hot chocolate, soups, sandwiches, macaroni and cheese, yogurt, ice cream, whatever residents requested. The director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 8/24/23 at 3:48 p.m. They acknowledged the nutritional concerns and poor food and fluid intake documented for Resident #3. The nurses shouldnever tell residents they could not access food or drinks from the kitchen, but should find out what residents wanted and get it for them. They said they were in the process of completing an investigation, audit and plan of correction regarding dietary and nutritional concerns.

A revisit survey was completed on 8/21/23 for all previous deficiencies cited on 7/27/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO32702 and #CO32998 was conducted on 7/26/23 to 7/27/23. One deficiency was cited.

Based on observations and resident and staff interviews, the facility failed to ensure the building was kept at comfortable and safe temperatures. Specifically, the facility failed to maintain comfortable and safe temperatures in the resident rooms and hallways for three of four units. Findings include:I. Professional referenceAn article posted on the Centers of Disease Control and Prevention (CDC) website, titled Tracking in Action: Extreme Heat, reviewed 5/30/23, was retrieved on 8/2/23 at https://www.cdc.gov/nceh/features/trackingheat/. The article read in pertinent part:"Extreme heat events, or heat waves, are one of the leading causes of weather-related deaths in the United States. When temperatures rise in the summer, extremely hot weather can cause sickness or even death. Heat stress is heat-related illness caused by your body's inability to cool down properly. The body normally cools itself by sweating. But under some conditions, sweating just isn't enough. In such cases, a person's body temperature rises rapidly. Very high body temperatures may damage the brain or other vital organs." II. Facility policy and procedureThe Loss of Air Conditioning/High Heat procedure guide, undated, was provided by the nursing home administrator (NHA) on 7/27/23. The procedure guide provided general actions to implement in a high temperature/heat situation. According the the guide, the facility may implement the following:-"Use fans and portable air conditioning units, if available.-Keep blinds, curtains, drapes, closed in areas of the building that received direct sunlight.-Open doors and windows, as necessary to take advantage of available breezes.-Avoid activities that may excite residents or require physical exertion.-Keep residents out of direct sunlight.-Turn off lights as well as other heat-producing appliances whenever possible.-Had plenty of liquids for residents and staff.-Monitor vital signs of residents and staff."III. Resident council minutesThe June 2023 resident council minutes identified the residents in the 6/27/23 council meeting expressed concerns with the inside temperature of the facility. According to the minutes, the residents said the facility had "uncomfortably high temperatures." The minutes read the interim nursing home administrator (INHA) told the residents the swamp coolers were all turned on the weekend of 6/24/23. The INHA said there were two portable units in use at the nurses stations and fans in the dining room. A frequent facility visitor said she had received complaints of the high temperatures in the facility. The INHA said part of the problem was related to staff training. The INHA said staff were using the vent setting on the coolers instead of the cool setting. The frequent visitor said in the past, the facility was going to install new swamp coolers. The minutes read staff said the delay might be partially due to new management and ownership. -There were no additional actions identified on the minutes or associated resident council action plan/grievance follow up for resolution after the 6/27/23 resident council concern. IV. Resident interviews and observations On 7/26/23 and 7/27/23 temperatures in the facility were measured on the four facility hallways, multiple resident rooms, and common areas. The below observations identified multiple temperatures over 81 degrees F and/or residents expressing discomfort with temperatures in the facility on other three facility halls. During the survey on 7/26/23 and 7/27/23, additional evaporative coolers were found and/or purchased and positioned throughout the facility. A. The westside south hallOn 7/26/23, the westside of the facility had two hallways with a nursing station between the south hallway and the secured memory care unit, located north of the nursing station.-At 12:19 p.m. a large portable cooler was positioned in front of the nursing station portable cooler. There was not a portal cooler positioned down the south hallway where theresident rooms were located. There were ceiling vents blowing air in the hallway. The outside temperature was 90 degrees F. -At 12:23 p.m. the hallway temperature in front of room 24 was 82.2 degrees Fahrenheit (F). -At 12:25 p.m. the temperature in room 23 was 82.2 F. The resident said the room was "hotter than hell." The window was observed open. The resident said staff opened it the night before but has not closed in yet. She said the facility provided her with a small fan that had helped a little. The resident said she had not complained about the heat in her room. She said they already knew it was "hotter than the dickens" in the facility. The resident said the dining room was one of the few comfortable rooms in the facility. She said staff kept her water container filled and recently started offering popsicles. The resident said she tried to do as little as possible when it was so hot. -At 12:33 p.m. the hallway outside of room 23 was 83.1 degrees F. -At 12:41 p.m. the temperature in room 17 was 84 degrees F. There were two fans in the room and the window was closed. The resident said she was fine with the temperature but the roommate had told her that she felt the room was "overheated." -At 4:52 p.m. the hallway outside of room 16 was 82.5 degrees F. The temperature in room 16 was 81.3 degrees F. The temperature outside was 98 degrees F. -At 5:10 p.m. the hallway outside of room 18 was 83.1 degrees F. The temperature in room 18 was 82.7 degrees F. -At 5:13 p.m. room 21 was 83.3 degrees F. -At 5:20 p.m. the temperature in room 23 was taken a second time. The room temperature rose to 85.5 degrees F. The resident said she felt hot. -At 5:26 p.m. the hallway outside of room 22 was 86.5 degrees F. -At 5:32 p.m. the temperature in room 22 was 85.7 degrees F. The resident said that her room had been hot lately, but today (7/26/23) was the first day it felt a little better. She said she thought it was because the temperatures outside were starting to cool down. The temperature outside was 97 degrees with some cloud cover. -At 8:19 p.m. the temperature in room 23 was 84.5.-At 8:23 p.m. an evaporative cooler in the hall near room 18 was not on. On 7/27/23 at 1:28 p.m. the temperature in room 17 was 81.6. Two residents were in the room. Both residents said the temperature in the room was better than it was the night before. One of the residents said she was anticipating the room to get warmer later that day. She said the room was usually "boiling" by late afternoon. -At 1:35 p.m. the temperature in room 23 was 81.6. The hallway outside the room was 82.7 degrees F. B. Eastside north hall On 7/26/23 at 2:50 p.m. a resident was observed outside of room 34, under a vent. The ceiling vent was blowing cold air. The resident said her room was too warm and she was trying to cool off. The window was open and the fan was off and positioned facing her roommates bed. The resident said the fan was the roommates and she could not touch it. She said she would like to have a fan for her side of the room. -At 2:58 p.m. the temperature in room 33 was 81.1. The window was open and the fan was not on. The temperature outside was 96 degrees F. The hallway temperature in front of room 33 was 81.3 degrees F. -At 5:53 p.m. the temperature in room 33 was taken a second time. The temperature rose to 82.7 degrees F. The hallway temperature outside of his room was 81.5 degrees F. -At 6:01 p.m. the temperature in room 31 was 82 degrees F. -At 6:05 p.m. the temperature in room 29 was 81 degrees F. The resident said she was hot and the fan did not help. -At 8:43 p.m. a resident said he would like his room to be cooler but his room was cooler at night then during the day. -At 8:50 p.m. a resident was observed in the hallway under a ceiling vent for a second time. She said the hallway was cooler than her room. The one fan in the room was blowing directly towards her roommate's side of the room. On 7/27/23 at 12:38 p.m. the resident was in bed. The window was open directly by his head and the fan was not on. The resident said he felt pretty warm and it was usually pretty warm in the building. C. Eastside south hall On 7/26/23, the hallway temperature and four sample resident room temperatures were taken on 7/26/23 between 1:15 p.m. and 6:10 p.m. -At 1:26 p.m. the temperature in room 44 was 80.2 degrees F. The resident said she was comfortable at the moment but in the evenings, her room was very warm which affected her sleep. -At 6:10 p.m. the temperature in room 39 was 82 degrees F. Two residents resided in the room. Both residents were wearing hospital gowns and said their choice in clothing was to help keep cool. The residents said they were hot but they have had times in their room where they felt hotter. One of the residents said the staff offered her a popsicle earlier. She said she wanted a popsicle but the staff member offered it at the same time her meal was served so she could not take the popsicle.-At 8:28 p.m. the temperature in room 41 was 79.7. He said he was comfortable because there was an evaporative cooler just outside of his room. -At 8:39 p.m. the temperature in room 47 was 83.6 degrees F. The resident was asleep without cover and in just a brief. He had two fans in his room and an evaporative cooler. -At 8:57 p.m. the temperature in room 44 was 82 degrees F. The resident was sleeping. She wore only under garments with no covers. There were two evaporative coolers blowing cool air in the hallway. On 7/27/23 at 1:50 p.m. the temperature in room 47 was 82 degrees F. The resident said he was hot and his room was always hot so he only wore a brief to try to stay cool. He said he had two fans and used his own evaporative cooler. The resident said the facility added a tower fan in his room today (7/27/23). He said they only just added the hallway evaporative coolers in the last couple of days. He said his room was still hot. IV. Resident group interviewFive residents (#1, #2, #3, #4 and #5) were interviewed on 7/26/23 at 3:10 p.m. The following comments were made in the group interview regarding the temperature of the facility and the facility response.-Resident #2 said the maintenance department had been working on the swamp coolers on the roof but her room was always hot. Resident #1 said she and her roommate each had a fan but the room was still hot. She said she told the NHA. She said a thermostat was placed in her room to measure how hot the room was. She said she recorded the temperatures in the room for four to five days and reported them to the NHA but it did not change anything. She said she did not get an evaporative cooler in her room until this week, after her family member complained to the NHA. The resident said the evaporative cooler helped lower the temperature in her room but her room remained between 80 degrees F and 82 degrees F during the day. She said her room was still 80 degrees F at night. She said the facility needed something for the other residents in the facility. Resident #1 said she was worried about the other residents. She said the residents could get sick from the heat. She said residents go to the dining room at night because it was cooler there than the rooms. Resident #2 said she went to the dining room at night to watch television but other residents have told her they were in the dining room because their room was hot and they could not sleep. Resident #3 said the temperature in the facility has been hot since the beginning of summer. She said she had three fans in her room but it was still too hot to sleep. Resident #1 said the resident's concerns with the high temperature in the facility were brought up by the resident council last month. She said residents did not usually bring up individual concerns on concern forms because nothing happens to change the concern. She said residents were told that the facility was looking into it or it would take time to fix. She said in June 2023 the facility started putting some of the evaporative coolers in some of the hallways but the facility was still hot. Resident #1 said the coolers needed to be filled with water but staff did not always have time to do it. She said the high heat zapped everyone's energy. Resident #1 said between noon and 6:00 p.m. was the hottest time of day. She said the residents need to keep hydrated. She said the facility passed out popsicles yesterday and was going to make snow cones today. Resident #1 said staff had passed out popsicles only once before when it was hot. Resident #2 said the facility used to pass water from a cart three times a day but had stopped after COVID. Staff would tell her it was not their job. Resident #3 said the facility had a hydration time in the dining room as an activity but she was concerned about the residents who did not come to the dining room. V. Family interviews A frequent facility visitor was interviewed on 7/26/23 at 4:00 p.m. The visitor said she had been at the facility four times in the last month. She said she was at the facility on 7/21/23. She said the temperature outside was 104 degrees in the late afternoon. The visitor said there were two large evaporative coolers at the nursing stations but not by the resident rooms. She said a room on the westside of the building in the south hall was 86 degrees F. The resident was sweaty. The ceiling vents in the hallway were just blowing warm air. She said the hallway on the eastside of the facility was 84 degrees F. The room had only one little fan for two residents. The visitor said the temperature in room 25 was 82 degrees F. The room did not cool down until the family started to complain. She said that was when the facility placed an evaporative cooler in room 25 on 7/25/23. The visitor said she returned to the facility on 7/25/23 and the corporate consultant (CC) was passing out popsicles. She said the maintenance director had been working all week on the roof making repairs to the air conditioning system. A family member for a resident in room 25 was interviewed on 7/27/23 at 9:27 a.m. She said the room temperature was between 82 degrees to 85 degrees. She said a fan did not help bring down the temperature in the room. The family member said she complained to the NHA on 7/20/23 but was told by the NHA that there was nothing that could be done about the facility temperature until the CC was at the facility on 7/24/23. The family member said she requested a thermostat to be placed in room 25 and an evaporative cooler placed in the room. The family member said an evaporative cooler was not placed in room 25 until 7/25/23. Another family member for the resident who also resided in room 25 was interviewed on 7/27/23 at 12:14 p.m. She said she had a major problem with the temperature since the temperature of the room reached 85 degrees F. She said she had to contact the NHA on 7/24/23. She said the evaporative cooler was not in place until after her 7/24/23 call to the NHA. VI. Staff InterviewsThe CC was interviewed on 7/26/23 at 5:25 p.m. She said she had been monitoring the temperatures. The CC took the temperature in room 23 and said it was 86 degrees F. The CC said there were concerns of high temperatures in the facility last week. She said the facility ordered evaporative coolers online but the coolers were on backorder. She said they had purchased some evaporative coolers for rooms and halls on 7/25/23 from a physical store. Certified nurse aide (CNA) #1 was interviewed at 5:30 p.m. She said the facility had been very warm in the building for several weeks. She said she just checked on a resident in his room and his back was very sweaty. She said it was hard to work in the high heat and residents have been complaining about high heat. The CC was interviewed on 7/26/23 at 5:51 p.m. The CC said she would send someone tonight (7/26/23) to the store to get the store's last evaporative cooler. The CC was interviewed again on 7/26/23 at 6:15 p.m. She said she just found a few more evaporative coolers in the facility storage shed and placed the coolers around the facility. The CC said the nurses all had timers and would fill the coolers every two hours. CNA #2 was interviewed on 7/26/23 at 9:03 p.m. as she cooled off in front of the evaporative cooler in front of the nursing station. She said the facility was warm but some residents liked it. Registered nurse (RN) #1 was interviewed on 7/26/23 at 9:08 p.m. He said if a resident was sweaty and hot, staff would have them sit in the common area near the cooler. He said at night, the residents would have less clothes on to sleep. The housekeeping supervisor was interviewed on 7/27/23 at 10:05 a.m. She said she did not mind the temperature in the facility during the day but she noticed the facility started to warm up after 4:00 p.m. The maintenance service director (MSD) was interviewed on 7/27/23 at 10:20 a.m. The MSD said the facility had 14 swamp coolers and two refrigerated coolers. He said both of the refrigerated coolers and one of the swamp coolers were not working. He said he had been trying to repair the coolers and needed repair parts. He said the facility cooling system was not working at full capacity, causing the warm temperatures in the facility. He said temperatures in the facility needed to be between 72 degrees and 81 degrees. He said he was monitoring temperatures. He said the temperatures averaged between 79 degrees and 81 degrees, which were within appropriate range but he said he felt it was still too warm for comfort. He said he did not log the specific temperatures, only checked if the temperatures were when the appropriate range (81 degrees or less). The NHA was on 7/27/23 at 10:50 a.m. She said the facility did not have a staff member in the maintenance department for four months. She said the current MSD was hired in June 2023 and started making repairs to the roof swamp coolers. She said on 7/13/23, the MSD located a vendor who could supply the needed parts. The NHA said funding for the parts was approved on 7/26/23. She said she was hoping the repairs would be completed next week. She said the facility, for the last couple of weeks, had been placing evaporative coolers around the facility. The NHA said fans have been placed in resident rooms and a hydration cart went up and down the halls. The NHA said the residents had not complained of the temperature in the facility until last week. The June 2023 resident council concern regarding "uncomfortably high temperatures" was shared with the NHA. She said she was not present for the resident for the council meeting and was not aware the residents expressed the temperature concern in June 2023. The NHA said staff had a verbal education on 7/21/23 and a formal education today (7/27/23) regarding facility temperature maintenance (see below). The NHA said the MSD monitored the temperatures a couple times a day. The activity director was interviewed on 7/27/23 at 12:50 p.m. She said the residents had been complaining about the heat. She said when she returned from vacation on 7/24/23, she noticed the heat so she started doing extra hydration carts. She said popsicles were offered the other day and today (7/27/23) she would serve watermelon. The NHA was interviewed again on 7/27/23 at 3:10 p.m. She said she just received purchasing authorization for the repair work needed for the facility cooling system. VII. Record reviewAn employee education form was provided by the NHA on 7/27/23. The education form identified on 7/27/23 twelve staff members were directed to perform the following tasks to aid in the building temperature management:-Monitor all resident windows. Closed the windows to one to two inches wide to encourage appropriate air flow and/or prevent too much air flow. Educate the residents of the risks and benefits of the open windows to prevent increased warmth in the room.-Keep all resident doors open as they allow. Educate residents of risks/benefits to prevent increased warmth in the room. -Pull down all blinds as the resident allows. Provide education of risks/benefits to prevent increased warmth in the room. -Pass ice water and other cold beverages before, after and in between meals to promote hydration. Encourage the residents to increase intake. -Check all portable coolers to ensure the coolers were filled with water to maintain function and cooler air. The coolers should be running at all times. The facility temperature management timeline was provided by the NHA on 7/27/23. The timeline included:-A box of 10 arctic air water coolers and eight stand up oscillating fans were delivered to the facility on 5/30/23. -The MSD was hired on 6/26/23.-A work order was submitted to the MSD on 7/3/23 for temperatures on the eastside south hall. The work order was completed on 7/7/23.-An evaporative cooler was purchased on 7/4/23. -A credit application was sent to the corporate office for a local vendor parts purchase.-Swamp cooler belts were purchased by the MSD on 7/13/23 and again on 7/14/23.-An evaporative cooler was purchased for the therapy gym on 7/15/23.-Additional swamp cooler repairs parts were purchased on 7/19/23.-A discussion with the regional maintenance consultant was conducted on 7/21/23 to implement a plan of purchase based on the identified repair needs. -The MSD purchased four more evaporative coolers. The MSD placed two of the coolers in the facility and held the other two evaporative to determine the best locations within the facility.-Additional evaporative coolers were placed in the facility on 7/26/23.

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

A revisit survey was completed on 3/24/23 for all previous deficiencies cited on 1/26/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 3/24/23 for all previous deficiencies cited on 1/26/23 . The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only and are a representation of the facility's general characteristics. This facility is a type V (111) 25,988 sq ft single story structure, that is equipped with an automatic NFPA 13 fire suppression system, and classified as fully sprinkler protected. On the Day of the Survey, the facility had a census of 76 residents licensed for 88. This survey, conducted February 21, 2023, included an inspection for compliance with the fire safety requirements of by the National Fire Protection Association (NFPA) Chapter 19 of the 2012 edition of NFPA 101, Life Safety Code; 2012 edition of NFPA 99, Health Care Facilities Code; and all referenced standards. This facility will meet these requirements upon completion of a Plan of Correction. The survey concluded with a discussion of the deficiencies with the Administrator, and Maintenance Supervisor. The following deficiencies are covered under the 1135 waiver:1) No documentation for semi-annual Fire Alarm inspection. 2) No documentation for quarterly fire sprinkler inspections. 3) No documentation for weekly/monthly/annual Emergency generator inspections. 4) No documentation for annual fire door inspection.

Based on observation and staff interview during the course of the survey conducted on February 21, 2023, it was determined the facility failed to maintain the means of egress doors in accordance with NFPA 101, 19.2.2 and 7.2.1. The following evidenced this:1)Both South Hall egress doors noted to have one leaf that does not fully operate and requires more than 15 lbf to open. Life Safety Code Section 19.2.2.2.4, in part, does not allow doors within the required means of egress to be equipped with latch or lock that requires the use of a tool or key from the egress side unless permitted. Section 19.2.2.2.4(2), in part, requires delayed-egress locks to comply with 7.2.1.6.1. Section 7.2.1.6.1.1, in part, requires delayed-egress to comply with all the criteria identified in (1) thru (5). Section 7.2.1.6.1.1(3)(a) force not to exceed 15 lbf, (b) force not required to be continuously applied for more than 3 seconds, (c) initiation of the release process to activate an audible signal, (d) once lock is released, relocking by manual means only. The means of egress deficiency has the potential to affect occupants exiting, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey on February 21, 2023, it was determined the facility failed to maintain the discharge from exits in accordance with 19.2.7 including Survey and Certification 05-38 This was evidenced by the following:1)Concrete outside of egress door in North Hall and South Long Hall has greater than a 1/4" elevation change. Maintenance Director acknowledged the condition of the door during the time of the tour. The discharge from exits deficiencies could affect all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Through observation during the walk-through portion of the survey on February 21, 2023, it was determined the facility failed to have required exit signage in accordance with NFPA 101, evidenced by:1)Missing exit signage at South Nurse station. 2)Exit signage needs rehung at North Nurses station. The deficiency has the potential to affect occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey on February 21, 2023, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. The following evidenced this:1)Liquid O2 stored in soiled utility room, which is a non rated room. The Hazard Area Enclosure deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. The maintenance director acknowledged the hazardous area enclosures and door condition during a tour of the facility.

During the review of the facility records, with the staff on February 21, 2023, documentation was not available to confirm that the facility had kitchen-hood-exhaust-system is installed in accordance by NFPA 96. The following evidenced this:1)Ansul system inspection report shows that system is NOT tied into the fire alarm or does not have proper notification. The Cooking Facilities deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. The maintenance director acknowledge the lack of monitoring of the system during record review.

Through a review of the records and discussion during the survey on February 21,2023, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.5) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). The following evidenced this:1)Smoke alarm need rehung near North Hall nurse station. The Fire Alarm System deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. Maintenance Director acknowledged the condition of testing the fire alarm system during the record review.

Based on record review, observation and staff interview during the course of the survey conducted on February 21, 2023, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this:1)Fire sprinkler heads near walk in cooler noted to be to loaded with dust and debris. 2)Fire sprinkler system in South Hall noted to be obstructed by ceiling drywall. Must implement fire watch until system has been corrected. 3)Fire sprinkler heads in South hall noted to have drywall mud/texture/paint on working portion. The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on record review and staff interview during the survey, February 21, 2023, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 19.7.1. The following evidenced this: 1)Fire drills were not conducted at "varied" times throughout the year. The fire drill deficiencies have the potential to affect all occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

A survey prompted by complaint #CO30787 was completed 1/19/23 to 1/26/23. Two deficiencies were cited.

Based on observations, interviews and record review, the facility failed to provide adequate nutrition and hydration to one (#43) of eight residents reviewed out of 41 sample residents. Resident #43 received hospice services and was documented to have unavoidable weight loss. However, the facility failed to assess Resident #43's dietary and drink preferences, assess and implement dietary interventions, provide fortified foods as recommended by the registered dietitian, and provide food and drink access to ensure the resident received the assistance needed for his comfort, enjoyment and dignity, and to ensure he did not go hungry and thirsty. These failures contributed to Resident #43 experiencing severe weight loss within the previous month, and within the previous five months after his admission to the facility. Findings include: I. Facility policies A. The Weight policy, revised May 2021, provided by the interim nursing home administrator/director of operations (INHA/DO) on the evening of 1/26/23, documented in part: "Weights will be regularly monitored to assure the identification, evaluation and initiation of care planning for residents who have experienced actual weight loss or weight gain. "Significant weight changes include: 5% loss/gain in weight in a month, 7.5% loss/gain in three months, 10% loss/gain in weight in six months. "The dietitian and the IDT (interdisciplinary team) will review residents with significant weight changes and develop a care plan accordingly. "Individualized interventions will be recommended and initiated to meet weight goals as clinically possible depending on the resident's weight status." B. The Hydration policy, dated 2021, provided by the INHA/DO on the evening of 1/26/23, documented in part: "The facility offers each resident sufficient fluid, including water and other fluids, consistent with resident needs and preferences to maintain proper hydration and health." "The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care." "Interventions will be individualized to address the specific needs of the resident. Offer the resident a variety of fluids during and between meals. Provide assistance with drinking. Ensure beverages are available and within reach." II. Resident status Resident #43, age 74, was admitted on 9/19/22. According to the January 2023 computerized physician orders, diagnoses included neurocognitive disorder with Lewy bodies (progressive dementia leading to declines in thinking, reasoning and independent function), chronic kidney disease stage 3, chronic congestive heart failure, and chronic obstructive pulmonary disease. According to the 10/2/22 admission facility assessment, Resident #43 had severe cognitive impairment with no brief interview for mental status (BIMS) score, and delirium indicators of inattention. He had mood indicators of trouble sleeping or sleeping too much, feeling tired, and little interest or pleasure in doing things. No behavioral symptoms or care rejection were documented. He needed limited assistance with transfers and walking; encouragement/supervision/set-up with eating; and extensive assistance with toilet use, dressing and personal hygiene. He was unsteady during transfers and used a walker and wheelchair. There were no range of motion limitations. He received hospice services. There were no choking or swallowing problems. Weight loss/gain was unknown. He was 67 inches tall and weighed 194 pounds. He took antipsychotic and antianxiety medications. III. Observations and family interview Observations of Resident #43 during the survey on 1/19, 1/22, 1/23, 1/24, 1/25 and 1/26/23 revealed he spent most of his time in bed on his back. His over-bed table with water pitcher or covered food plate was against his privacy curtain and out of his reach. During observations on 1/19/23, the resident's lips and mouth were dry, and he appeared thin, frail and weak. During subsequent observations, his over-bed table and water pitcher were out of his reach. On 1/24/23 at 3:15 p.m., Resident #43's wife was observed in the hallway walking toward Resident #43's room with a hospice nurse. As she approached Resident #43's room, she said she visited him almost every day, and added, "This is what they do, leave his lunch across the room and don't help him, and he's sound asleep, and his food is getting cold." She said this happened "day after day" and he had lost a lot of weight. The resident was sleeping on his back, and his over-bed table with his lunch tray was out of his reach. Resident #43's wife was interviewed on 1/24/23 at 4:30 p.m. She said she had been told by staff that they had 35 patients on his hall and "couldn't just cater to (Resident #43) all day." She said sometimes when she entered his room and saw his water and food out of his reach, "I think about all the times that he has to go without." She said he had lost so much weight he looked like "bone with skin wrapped around it." "He lays in that bed with food all over him, and his sheets." She said when he was too weak to feed himself, she scooped up the food for him bite by bite, hand over hand, and helped him get it to his mouth. She said she tried to visit him at lunch or dinner so she could go to the dining room and eat with him, and she sometimes brought him a little Jell-O pudding or yogurt, bananas and oranges, because "he never gets fresh fruit." "The food looks like it's been sitting out, it's not even edible, it tastes like (expletive), and it smells bad. The other night when I was here with (Resident #43) they had a big pile of goulash. I tried it and (Resident #43) drew my hand away and said 'No.' He would eat the carrots they served and said 'It's cold,' and the carrots were cold." Breakfast observations on 1/25/23 revealed:-At 8:30 a.m., Resident #43's tray was delivered and placed on his over-bed table out of his reach. He reached out for it several times and indicated he wanted it moved closer to him.-Licensed practical nurse (LPN) #3 entered his room to check on him at 8:50 a.m. When he indicated to her that he wanted his breakfast moved closer to him, she asked him to wait until certified nurse aide (CNA) #6 came in to assist him so he did not choke. He motioned again for his breakfast to be moved toward him.-At 8:59 a.m., CNA #6 knocked and entered his room, asking if he was ready to eat. She wheeled his over-bed table in front of him, uncovered his plate of biscuits and gravy, and Resident #43 started eating immediately. He fed himself well and drank from his water pitcher with a straw, holding the water pitcher in both hands. He had not been served coffee or juice, and when asked why, CNA #6 asked him if he wanted those. Resident #46 responded that he wanted apple juice. CNA #6 said she would be right back, as she had to find juice. While CNA #6 was gone, he finished his meal and drank more water from his pitcher.-At 9:05 a.m., LPN #3 checked on Resident #43 and asked if he was finished. He reiterated he wanted juice, but no more food. At 9:07 a.m., CNA #3 brought him a glass of apple juice and an orange juice, which he drank well. CNA #3 stayed with him as he drank his juice.-At 9:34 a.m., Resident #43 was sleeping on his back. His over-bed table had been moved out of his reach again; his plate and cups were gone and his water pitcher remained. On the afternoon of 1/25/23, Resident #43's wife visited and brought him a coffee drink and a piece of iced lemon cake, which he drank and ate. On 1/25/23 at 6:06 p.m., Resident #43 was observed in bed with his dinner tray in front of him. He had finished his fluids and fruit cocktail dessert, but his plate of lasagna, vegetable and dinner roll were untouched. No staff were in sight to assist, encourage, or offer him an alternate meal. -Observations and interviews with the resident's family and staff revealed he enjoyed eating and drinking the foods and fluids of his choice, and needed encouragement, supervision and cueing, and assistance at times. IV. Record review The care plan, initiated 9/20/22, identified a nutritional problem related to his diagnoses, a lacto-ovo (dairy and eggs) vegetarian diet, and receiving hospice services with expected unavoidable weight loss related to terminal processes. The goal was food and fluids as desired for comfort. Interventions were: assist the resident with developing a support system to aid in weight loss efforts, including friends, family, other residents, volunteers; invite the resident to food related activities; observe any signs/symptoms of dysphagia (swallowing difficulty); ensure twice daily (currently on hold, revised 12/8/22) fortified foods; provide and serve supplements as ordered; lacto-ovo vegetarian diet/regular texture/thin liquids; and registered dietitian (RD) to evaluate and make diet change recommendations as needed.-The nutrition care plan was not updated to include actual severe weight loss, preferred foods other than a vegetarian diet, and did not accurately document the resident's dietary supplements or types of liquids. The hospice care plan, initiated 9/27/22 and revised 1/24/23 (during the survey), identified end- stage diagnoses of chronic kidney disease stage 3 and Lewy body disease. Interventions included: provide with food and fluids as desired for physical and emotional comfort. Resident #43's dietary card identified a lacto-ovo vegetarian (vegetarianism that includes consumption of eggs and dairy) dysphagia diet with nectar thickened liquids. His Thursday 1/26/23 lunch menu included a ground barbecue veggie chicken patty, barbecue sauce, roasted green beans, cheesy mashed potatoes, a dinner roll with margarine, banana pudding, and nectar-thickened coffee or hot tea.-No other food preferences were identified in the resident's medical record. The Weights and Vitals Summary revealed the following documented weights for Resident #43:9/19/22 (admission) - 199.2 pounds10/2/22 - 194.2 pounds11/1/22 - 191.8 pounds12/4/22 - 177.6 pounds1/3/23 - 171.6 pounds-He had experienced severe weight loss at 14.2 pounds, 7.4%, within one month from 11/1/22 to 12/4/22; and 27.6 pounds, 13.86%, since his admission five months before. The 9/19/22 Nursing Admit Assessment documented Resident #43 weighed 199.2 pounds and was 67 inches tall. He was reported to spend most of his time asleep, and was on hospice. The 9/20/22 admission Nutrition Evaluation documented a weight of 199.2 pounds. Usual body weight was unknown. Weight trends were unavailable. The resident was noted with a history of not eating for a few days and then binging. His fluid intakes were "good." His calorie needs were 1825-2190 kcals (calories) and fluid needs were 1825-2190 milliliters (ml). His diet was lacto-ovo vegetarian/regular texture/thin liquids. No issues with chewing or swallowing were documented. His typical intake was about 50 to 100%. His relevant medications were Zofran/bowel movement meds, Lorazepam (antianxiety) and Risperidone (antipsychotic). No edema was present. The recommendation was to add Ensure twice daily between meals to aid in weight maintenance and consume foods and fluids as desired for comfort. Meal intake records for November 2022 revealed the resident ate 76-100% of his meals 15 times, 51-75% of his meals 16 times, 26-50% of his meals three times, and 0-25% of his meals nine times. There was no documented meal intake 11/1-11/10/22, on 11/12/22 or on 11/20/22 (12 out of 30 days). The 11/15/22 Nutrition Evaluation documented Resident #43 had a "steady decline since admission of 7.4 lb loss x 2 months, 2.4 lb loss x 1 mo, weight losses unintentional and unfavorable, but anticipated, as resident was admitted to hospice on 10/19/22 (although the resident had been on hospice since admission). Goal for comfort measures now." The evaluation further documented in pertinent part, "In interview was unable to give good usable information. Resident appears moderately nourished, consuming about 50% of meals. On Ensure BID (twice daily) to provide those extra calories and protein to help maintain weights."-There was no evidence of an interview with the resident's wife, who could have shared Resident #43's food preferences, assistance needs, and further nutritional history. The 12/7/22 Nutrition Evaluation documented the resident's most recent weight was 177.6 pounds on 12/4/22. His usual body weight was 190 to 200 pounds. His weight trends were "loss." The resident triggered for "significant weight loss of 7.4% x30 days, 10.8% x 90 days. Weight loss unintentional and unfavorable but expected (due to) recent move to hospice and goal for comfort measures." His estimated nutrition needs were 2421 kcals/day and hydration needs were 2421 ml/day. No chewing or swallowing issues were noted. He needed supervision and setup help with meals and ate in his room. No edema was noted. No nausea/vomiting/diarrhea were noted although there was some constipation. An interdisciplinary team progress note dated 12/15/22 documented in part, "Res(ident) is showing noted weight loss of 14 pounds in 1 month, current weight of 177.6 pounds. Will resume Ensure BID, res is a hospice patient. (Former) DON (director of nursing) will request order for unavoidable weight loss." Meal intake records for December 2022 revealed the resident ate 76-100% of his meals 20 times, 51-75% of his meals 25 times, 26-50% of his meals five times, and 0-25% of his meals nine times. There was no documented meal intake on 12/4, 12/10, 12/11, 12/17, or 12/24/22 (five days). Meal intake records for January 2023 (1/1 through 1/26/23) revealed he ate 76-100% of his meals 16 times, 51-75% of his meals 25 times, 26-50% of his meals eight times, and 0-25% of his meals six times. There was no documented meal intake on 1/7, 1/14, or 1/21/23 (three days). Review of Resident #43's fluid intake records from 11/1/22 through 1/26/23 revealed he consumed less than half his assessed fluid needs. An IDT note on 1/18/23 at 1:55 p.m. documented, "Supervised in dining room and he allows to go." The January 2023 medication administration record (MAR) documented an order for Ensure/Boost for weight maintenance, ordered 9/20/22, which was held from 1/1 to 1/6/23 and discontinued on 1/25/23. Resident #23 consumed 100 percent of this supplement 10 times between 1/18 and 1/25/23. V. Staff interviews CNA #3 was interviewed on 1/25/23 at 3:40 p.m. She said Resident #43 was changed to thickened liquids about three weeks ago, and "does better on the thickened liquids." She said they tried to keep his over-bed table away because he "tries to crawl out of bed and trips." She said she checked on him every two hours, although sometimes it was closer to every three hours, to see if he was sleeping, needed to be changed or wanted to get up. "The only times he ever gets up is when he has in his mind he wants to get up to the bathroom." She said she tried to offer and assist him with fluids every time she checked on him, when he was awake, and he always drank well. She said usually when she set him up for breakfast he ate well. She said it was difficult to assist all the residents who needed help with eating and drinking in a timely manner, due to short staffing. LPN #3 was interviewed on 1/25/23 at 4:45 p.m. She said since Resident #43 was on thickened liquids and an aspiration risk, they wanted a staff person to be with him for safety when he ate in case he choked. She said it was best if they delivered a resident's tray and set them up to eat immediately. She said Resident #43 could feed himself but did better with thickened liquids because he had a tendency to gulp, and actually vomited as a result the other day. The registered dietitian (RD) and corporate RD were interviewed by phone on 1/26/23at 3:30 p.m. They said they added Resident #43 to fortified foods because his wife asked to have him removed from liquid supplements. (No documentation of this could be found in progress notes.)They said per his medical record, he had an unavoidable weight loss and was on a general decline. As of 1/3/23, he had a six-pound weight loss from the beginning of December 2022 to January 2023, which was anticipated with his overall disease progression."He still has some variable meal intakes for sure. Overall he ate about 51-100% on those meals and a few do dip down below at 0-25%." The RD said that added cueing and help with his meals could help Resident #43, but she did not specifically care plan for that, and she had not observed him eating. They said they needed to work with the CNAs and nurses on Resident #43's hall to ensure he received the assistance he needed, and they could double check with the kitchen regarding fortified foods. They said they would educate the staff to make sure they were providing all the help Resident #43 could get, and make sure the nurses were putting his food and fluids in front of him as well. They said they could not give him supplements because of his gastrointestinal issues, but fortified foods might help. They acknowledged they did not have a preferences list for him, usually the food service manager should visit with the resident upon admission, but they would talk to the family and get those preferences. They knew only that he was lacto-ovo vegetarian and disliked pork. They said they could also recommend adding snacks. They acknowledged his documented fluid intakes were not good, and said they could add extra fluids throughout the day for hydration purposes as well. They said his antipsychotic medications could be affecting his appetite as well, blunting the appetite, making him sleepier and "a little more out of it." They said they discussed Resident #43 at the last IDT meeting on 1/18/23 but recommended nothing more than what they had just mentioned, and to encourage him to go to the dining room if he would allow. They acknowledged that would be his choice and he should receive the assistance he needed in his room. (See IDT progress note above, which was very brief and did not document that an RD was present.) The dietary manager was interviewed on 1/26/23 at 7:12 p.m. He said Resident #43 was not on fortified foods, for example, added protein. He said he tried to fortify all the foods he served to the residents by adding cream, milk and butter.

Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for seven (#32, #40, #49, #56, #57, #71 and #226) of nine residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #32 was free from physical harm and mental anguish. Resident #32 was hit repeatedly in the face by Resident #56 on 12/18/22, resulting in facial lacerations, swelling, and feelings of fearfulness and anxiety. Resident #56 continued to exhibit intimidating behaviors towards that resident in the days following the 12/18/22 altercation. In addition, the facility failed to ensure Resident #40, Resident #49, Resident #57, Resident #71 and Resident #226 on the secured/memory care unit were free from resident-to-resident altercations. Findings include:I. Facility policy The Elder Justice Act and Reporting Suspected Crimes Against Residents policy and procedure, dated 2017, was provided by the facility on 1/26/23. The policy read its purpose was: "To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation." II. Incident #1 A. Resident status 1. Resident #32, age 95, was readmitted on 12/6/22. He resided in the secured/memory care unit. According to the January 2023 computerized physician orders (CPO), diagnoses included delirium due to known physiological condition, and unspecified dementia with unspecified severity without behavioral disturbance. The 12/13/22 facility assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident exhibited inattention, disorganized thinking and an altered level of consciousness. The resident did not exhibit behaviors of concern during the seven day assessment period. The review of the January 2023 care plan did not identify the resident was at risk for abuse or the resident had an actual resident to resident altercation. 2. Resident #56, age 83, was admitted on 10/31/22. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease; major depression; and, unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/22 facility assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. The resident exhibited disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The behavior care plan, initiated 1/21/23, identified Resident #56 had the potential to be physically aggressive towards others related to his dementia. B. Record reviewAn investigation of alleged physical abuse was initiated on 12/18/22. According to the investigative record, Resident #32 was in bed when his roommate (Resident #56)was documented to trip over Resident #32's walker and hit Resident #32 in the face on 12/18/22 at 6:30 p.m. The report read Resident #32 had a small superficial laceration on the bridge of his nose and upper lip. The report identified the staff controlled his bleeding and cleaned his wounds. The report indicated the police was contacted, Resident #32 and Resident #56 were separated in two different rooms, and were put on one-to-one monitoring until they fell asleep. The investigation report's conclusion read the facility was unable to substantiate physical abuse at this time because there was no injury. The facility was unable to determine intent, due to the assailant's (Resident #56) cognitive status at time of the incident. Under the investigation's conclusion was a handwritten note that read "Asked to change to substantiate." Upon clarification, the interim nursing home administrator/director of operations (INHA/DO) reviewed the investigation and requested the nursing home administrator (NHA) to substantiate the abuse findings, as identified in a 1/25/23 interview below. The 12/18/23 change of condition nursing note/situation-background-assessment-recommendations form (SBAR) read Resident #56 started talking fast and oddly, stating "Everyone wants to kill me." According to the note, Resident #56 standing over Resident #32, punching Resident #32 in the face. The 12/19/22 at 2:18 a.m. nursing note read Resident #32 appeared to still be a little anxious due to an altercation with his roommate. The 12/19/22 at 12:44 p.m. nursing note read Resident #32 was sent to the hospital per his family's request, post assault by his roommate. The note identified the resident had been punched in the face and received a split lip, bruise under his left eye, and swollen nose with a laceration to the bridge of the nose. The 12/19/22 emergency department (ED) report read Resident #32 suffered facial injuries from unspecified assault, likely "being punched in the face." Resident #32 had swelling and contusions to his face and nose. The ER report read emergency medical services (EMS) reported Resident #32 was assaulted on 12/18/22. According to the report, the resident was hit five times in the face. Resident #32 was provided pain medication, ice, and discharged back to the facility's memory care unit. The 12/20/22 nursing note read Resident #32 was up all night due to fear of being assaulted again. The resident was provided with one-to-one attention. According to the note, Resident #56 continued to pace near Resident #32 for about three hours. The 12/20/22 administration note, documented in the medical record of Resident #56, read Resident #56 was pacing and "staring down" another resident. The resident was placed on one-to-one monitoring and implemented a medication change to help with his agitation. The 12/24/22 nursing note read Resident #32 did not want to remain at the facility. According to the note, Resident #32 was afraid and not sleeping well after being hit. The note read the staff assured him that he was safe now that he was close to the nursing office and his roommate was in another room. The 12/27/22 nursing note read Resident #32 still spoke about feeling fearful after being punched. III. Incident #2 and #3 with Resident #57 and Resident #226A. Resident status 1. Resident #57, age 71, was admitted on 9/7/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke's encephalopathy (a brain disorder causing confusion), anxiety disorder, and delusional disorders. The 12/19/22 facility assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident exhibited disorganized thinking and inattention. According to facility assessment, the resident exhibited physical and verbal behaviors directed towards others. The behavior care plan, initiated on 1/24/23, read the resident had the potential to become verbally or physically aggressive towards other residents. Her care plan goal was to not harm or be harmed by others. 2. Resident #226, age 62, was admitted on 12/9/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, early onset, bipolar disorder, and unspecified dementia with unspecified severity with agitation. The 12/22/22 facility assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident exhibited disorganized thinking and inattention. The resident exhibited physical and verbal behaviors directed towards others, impacting their care and social interactions. According to the facility assessment, Resident #226 put others at significant risk for injury. The behavior care plan, initiated on 12/27/22, read the resident had potential for physical and verbal outbursts related to her dementia, bipolar disorder, and poor impulse control. B. Record review 1. Incident on 12/11/22 between Resident #226 and Resident #57The 12/11/22 at 4:00 p.m. behavior note documented in the medical record of Resident #226 read Resident #226 was very anxious, and briskly pacing in and out of rooms, and up and down the hall. According to the note, a resident (Resident #57) started to yell at her. Resident #226 proceeded to throw juice at Resident #57. The 12/11/22 at 4:02 p.m behavior note documented in the medical record of Resident #57 read Resident #57 was yelling at a newly admitted resident to the facility. A resident (Resident #226) proceeded to throw juice at Resident #57, making contact with Resident #57's chest. According to the note, Resident #57 felt frustrated and needed to be cleaned up. An investigation of a resident to resident altercation was initiated on 12/11/22, however, according to the investigative record, the event was incorrectly documented on 9/23/22 at 4:00 a.m. between Resident #226 and #57. The investigation documented the yelling and juice incident and identified all residents (on the memory care/secured unit) were placed on observation for any changes in behavior due to the incident. As a result of the incident, the facility was to create a non-pharmacological plan to assist with the behaviors of Resident #226. The 12/12/22 at 4:57 a.m. behavior note identified the resident had an increase in behaviors following the incident. The behavior note read Resident #57 got out of bed several times throughout the shift, wandering the hallway and exit seeking. According to the note, the resident would be verbally abrasive and "shoot the finger" several times when the staff guided her back to her room. 2. Incident on 12/24/22 between Resident #226 and Resident #57The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #226 read Resident #226 was leaving an activity when another resident (Resident #57) said a few "grumpy things" to Resident #227. Resident #226 "lightly slapped" Resident #57's face and walked away. The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #57 read another resident (Resident #226) was restless and walked near Resident #57 and her friend. Resident #57 told the resident in a "gruff" voice not to come near her. Resident #226 lightly slapped Resident #57. According to the note, a light pink mark appeared (on her face) lasting a few minutes. There was no broken skin or bruising. The residents were separated. An investigation of alleged physical abuse was initiated on 12/25/22. The review of the physical abuse report, identified the physical altercation was reported to the State Agency on 12/25/22 at 9:17 a.m. almost 24 hours after the incident occurred. According to the investigative record, on 12/24/22 at approximately 11:55 a.m. Resident #57 was participating in an activity. When the activity ended, Resident #226 approached another resident Resident #57. Resident #226 entered Resident #57's personal space, slapping Resident #57 on the cheek with her hand. The incident was witnessed by a certified nursing aide (CNA). The police were called, the residents were separated, and monitored. The 12/25/22 nursing note documented in the medical chart of Resident #226 read police were notified related to the incident. No additional details were included in the progress note. IV. Incident #4A. Resident status 1. Resident #71, age 81, was admitted on 12/22/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 12/30/22 facility assessment revealed the resident had severe cognitive impairment with a BIMS) score of 2 out of 15. The resident exhibited inattention and disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The physical aggression care plan, initiated 1/20/23, read Resident #71 received physical aggression from another resident. 2. Resident #40, age 73, was admitted on 9/7/22. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included neurocognitive disorder with Lewi bodies and anxiety disorder. The 11/10/22 facility assessment revealed the resident had severe cognitive impairment with a BIMS score of 1 out of 15. The resident did not exhibit inattention or disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The physical aggression care plan, initiated 1/21/23, read Resident #40 had the potential to exhibit physical aggression towards staff and other residents. The care plan read the resident would quickly pace when agitated and could be difficult to be redirect. The review of the care plan did not identify the resident had an actual physical altercation with another resident. B. Record review An investigation of alleged physical abuse was initiated on 1/10/23. According to the investigative record, Resident #40 was witnessed to be agitated and pacing the halls when he saw Resident #71 and "struck her on the back" on 1/10/23 at 6:15 p.m The investigation report indicated that police were called and residents were separated and monitored. The report read Resident #71 said she was not afraid following the incident. She said she was surprised and thought she might have gotten in his way. There was no identified injury to Resident #71. The 1/10/22 SBAR communication assessment for Resident #40 read "Resident has been sundowning more often and becoming combative with other residents and staff." IV. Staff interviewRegistered nurse (RN) #3 was interviewed on 1/19/23 at 4:40 p.m. RN #3 identified a resident who was physically injured during a resident to resident altercation in the secured/memory care unit. The RN said Resident #32 was punched in the face by Resident #56 resulting in wounds to his face and an evaluation at the hospital. The intertrim nursing home administrator/corporate director of operations (INHA/DO) was interviewed on 1/25/23 at 5:34 p.m. The INHA/DO said there were multiple factors to determine abuse including injury, intent, resident reaction, she said even threatening could be considered abuse. She said the investigation determined if the alleged abuse occurred. She said the former nursing home administrator (NHA) reported an the allegation of physical abuse between Resident #32 and Resident #56. She said the former NHA conducted the investigation and reported the allegation of abuse was unsubstantiated related to Resident #56's cognitive ability and unknown intent. The INHA/DO said she reviewed the former NHA's report and educated the NHA what factors needed to be considered to determine if the abuse was substantiated. The INHA/DO said Resident #32 was physically injured. She acknowledged the resident was documented to be afraid after the incident which impacted his sleep. The INHA/DO requested the former NHA to substantiate the physical abuse based on intent and injury. The incidents and intentions between Resident #56 and #71 and Resident #57 and #226 were reviewed with the INHA/DO. She said incidents were not identified as accidents. The residents were either agitated or prompted prior to the incidents. The INHA/DO said she was concerned about the handling of the abuse process with the former NHA. She said she would weekly reviews with the former NHA and provide education but the former NHA would not follow the education. She said she also requested the former NHA to send her all the allegations of abuse for her own review but the former NHA would frequently not send them to her. The INHA/DO said the facility self identified they had a breakdown in the system. She said she created a plan of correction because they know there were issues. The INHA/DO said the former NHA was relieved of her duties on 1/18/23 and the facility proceeded to conduct abuse documentation audits and conduct staff in-services on 1/18/22 and 1/19/23 (first day of survey.) The INHA/DO was interviewed again on 1/26/23 at 6:54 p.m. The INHA/DO said she was not initially aware of the extent of the 12/18/22 incident between Resident #32 and #56, as reported to her by the former NHA. She said she was told that Resident #56 did not intentionally hit Resident #32. She said after further review and after the final report was submitted, the INHA/DO determined the physical altercation was intentional. The INHA/DO said during her continued review of the abuse process and prevention, she had determined interventions to prevent future abuse needed to be more centered, and investigations needed to follow the procedure steps to ensure all information was gathered. The INHA/DO said education was also conducted on 12/19/22 for abuse prevention. The INHA/DO said the education conducted on 1/18/22 and 1/19/23 were focused on staff and their response to resident to resident altercations. She said the education included what the staff could do to minimize the risk of abuse, how to de-escalate abuse, and how to engage and redirect the residents. V. Additional information provided by the facilityThe following documents were provided by the facility on 1/26/23:-A information form addressed to the secured/memory care staff. The form read the listed residents had been involved in verbal and physical altercations with other residents. The list of residents included Resident #40, Resident #56, and Resident #57. Resident specific interventions were identified. The form requested staff to attempt to utilize the interventions to prevent altercations from occurring. -Staff and interviews on knowledge of resident abuse and if residents felt safe. The interviews were conducted on 1/19/23 and 1/20/23.-Facility audits of abuse management and interventions conducted on 1/19/23. -The abuse staff in-service conducted on 1/18/23 and 1/19/22 included types of abuse and steps to take if staff witnessed abuse or knew of an instance or allegation of abuse and a review of the abuse policy. According to the in-service any negative interactions involving residents could potentially be abused and the administrator must be notified. VII. Resident #49-incidents of verbal and physical abuse directed toward other residents A. Resident status 1. Resident #49 Resident #49, age 64, was admitted on 3/11/21. According to the January 2023 CPO, diagnoses included alcohol-induced persisting dementia, Wernicke's encephalopathy and generalized anxiety disorder. The 1/2/23 facility assessment documented Resident #49 was cognitively intact with a BIMS score of 15 out of 15, and had psychosis indicators or hallucinations and delusions. No behavioral symptoms or rejection of care were documented. He needed supervision, oversight, cueing and encouragement for all activities of daily living. 2. Resident #59 Resident #59, under age 50, was admitted on 10/14/22. According to the 10/14/22 facility assessment, he was admitted for rehabilitation after a fracture. He had moderate cognitive impairment with a BIMS score of nine out of 15. No behavioral symptoms were documented. He used a wheelchair and needed limited assistance with most ADLs. 3. See above for status of Residents #40 and #56. No information was available regarding the former/discharged resident. B. Record review Resident #49's behavioral care plan, initiated 8/9/21 and revised 1/20/23, identified a behavior problem related to anxiety disorder and dementia, with increased agitation when other residents entered his room and "may be verbally loud with them." The goal was for fewer episodes of anxiety. The interventions were: administer medications as ordered, allow choices within decision-making abilities, anticipate and meet resident needs, assist to develop more appropriate methods of coping and interacting, provide opportunity for positive interactions, engage in television football games when on, provide jobs around the facility such as sweeping floors in the Willow (secure) unit, discuss the resident's behavior and explain why behavior is inappropriate or unacceptable, intervene as necessary to protect the rights and safety of other residents, approach in a calm manner, divert attention, remove from situation and take to alternate location as needed, keep stop sign across his door to deter other residents entering his room, offer craft kits, Lego sets and painting as resident enjoyed taking things apart and putting them back together. The resident "benefits from a private room" was added as an intervention on 1/20/23 (during the survey). The wandering care plan, initiated 3/12/21 and revised 1/20/23, documented Resident #49 had a history of wandering, and no longer met the criteria to reside on the secure unit and had not wandered since moving off the unit. "He is alert and oriented and knows location in the building." Staff were to frequently orient and monitor Resident #49 for new behavior of wandering (added 1/20/23 during the survey). The care plan for potentially aggressive behavior related to poor impulse control was initiated on 1/24/23 (during the survey), and identified Resident #49 had a history of pulling wheelchairs out from under other residents, causing them to fall. The goal was for the resident to demonstrate effective coping skills. Interventions included: the resident's triggers for physical aggression are residents wandering into his room; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate needs; if resident is pushing another resident in a wheelchair or attempting to help them, thank him for his offer but inform him that staff are there to take care of other residents; the resident prefers to be alone in his room with the door closed; resident will come out of his room for food and drinks; staff to offer observation when resident is out due to history of altercations with others; resident prefers a private room. C. Abuse incidents Review of facility investigative reports revealed Resident #49 was the assailant in four incidents between 11/10/22 and 11/30/22. Three incidents occurred while Resident #49 resided in the Willow secure neighborhood, and one incident occurred after he was moved in with a roommate on the North hall. 1. 11/10/22 abuse incident against Resident #40 At 8:30 p.m. on 11/10/22, Resident #40 was "checking door knobs" and before staff could get to him, opened Resident #49's door and walked into the room. Resident #49 then punched Resident #40 in the face, leaving a red mark above Resident #40's right eyebrow. Resident #49 was put on 15-minute checks and the police were notified. Resident #49 had earlier, at 4:23 p.m., been documented having "multiple yelling and outbursts this afternoon inside and outside of his room. Redirecting several times unsuccessfully. Will continue to monitor." 2. 11/16/22 verbal abuse incident against Resident #56 Resident #49 threatened Resident #56 for assisting another male resident who was in a wheelchair. Resident #49 told a staff person that Resident #56 was "trying to move his dad, and was yelling at Resident #56, "Do you want to fight?" and the other resident put up his fists. Staff had to intervene and sent Resident #49 "to his room to cool down." The nurse documented that Resident #49's Seroquel had just been increased on 11/16/22 after "another previous altercation." 3. 11/27/22 verbal and physical abuse incident against a former resident/roommate Resident #49 yelled profanities at his roommate and slung a pair of jeans at him, hitting him in the face, no apparent injuries were noted. The residents were separated and monitored, and police were called. Resident #49 kept referring to the victim as his dad, and said he was trying to get his dad to "behave" because his restlessness was keeping him awake. The victim did not demonstrateincreased tearfulness or self-isolation, and there were no signs of fear or feeling unsafe. No changes were made to the treatment plan other than to increase monitoring. Resident #49 was noted to become "easily agitated." Review of nursing notes revealed Resident #49 moved on 11/28/22 from the Willow secure neighborhood to a room on the North hall because "secure unit placement not needed." 4. 11/30/22 verbal and physical abuse incident against Resident #59, a former roommate On 11/30/22, a CNA witnessed Resident #49 pulled his roommate's wheelchair out from under him while he was trying to sit in it, causing his roommate to fall. There were no apparent injuries. Resident #49 was heard saying to Resident #59 that he was going to "kill him." Resident #49 was placed on one-to-one monitoring and Resident #59 was moved to a different room. Resident #59 later did not remember exactly what happened but was glad not to be with "that roommate." All staff members interviewed concurred that Resident #49 "needs a private room." -No further abuse incidents were documented involving Resident #49 after 11/30/22. D. Observations Resident #49 was observed throughout the survey on 1/19, 1/22, 1/23, 1/24, 1/25 and 1/26/23 spending most of his time in his room on the South hall, with his door closed, leaving only briefly to get drinks, snacks and food. He was independent with ambulation, and spoke quietly. He resided on the opposite side of the facility from the Willow and North neighborhoods. E. Staff interview The INHA/DO was interviewed on 1/23/23 at 4:00 p.m. She said Resident #49 was territorial and did not like other residents in his room. He was not appropriate for the Willow secure unit, and had an altercation with his roommate after he was moved from Willow. She said that since he has had a private room, he had done well, kept to himself, and only left his room to get something to eat or drink. The INHA/DO said she had to piece together the report documents (above) regarding the abuse incidents because she was unable to find all of the former NHA's investigative documentation. -The facility failed to keep residents free and safe from verbal and physical abuse by Resident #49.

A recertification survey with complaints #CO30579, #CO30583 and #CO30616 was completed from 1/19/23 to 1/26/23. Fifiteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/19/23 to 1/26/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to take action to resolve grievances of the resident council group, affecting 10 (#34, #24, #22, #23, #35, #60, #62, #54, #7 and #68) of 41 sample residents, and potentially affecting all the residents who lived in the facility. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings. Findings include: I. Resident group interview A resident group interview was conducted on 1/23/23 at 10:30 a.m. with 10 residents who were resident council officers, regularly attended resident council meetings, and were identified by the facility as interviewable. Residents said the facility did not have enough staff. "They have good staff, just not enough of them." As a result, "It takes longer to respond to a call light." One resident said his roommate was "in bad shape" and he had to keep an eye on him because he was unable to call staff for assistance. "One thing we lack is a bath aide, because baths are a problem. I have a bath scheduled today but don't know if I'll get it." Residents said baths had been a problem for about two months. Residents said they had baths scheduled but did not get them. They "hope" to get their baths. Residents said sometimes the traveler/agency staff were "less than respectful." One resident said a certified nurse aide (CNA) who gave her a shower spoke to her in an undignified manner. The residents said the food was "sometimes horrendous." There was not enough fresh food, too much processed food, "even the fruit is canned." Residents said some people needed help to cut their meat and there were no staff assigned to that, "and there you go again without enough help. If they forget something (in the dining room) you have to wait and raise your hand for something as simple as ketchup." The food was sometimes burned. "We don't get anything made from scratch. Even the mashed potatoes and scrambled eggs are powdered. They run out of food sometimes. So they will substitute something, and residents get grouchy, irritable, and nasty with cooking staff. The highlight of our days is eating and it's not as pleasant as it should be." The residents said they did not know what the next meal would be. "They have these awful menus they get from some company but they have to follow the silly menu," and there was too much repetition. Residents gave examples of chicken fingers served three times a week, fish twice a week, the same vegetable for a month, then they would switch to a different vegetable. One resident said he had to buy his own food. Residents said snacks were not offered, other than a tray on the nurses' station "and then certain people will come along and take them all and there's not enough left for others and that's not good. They don't go around and offer snacks to everyone. They don't replenish the supply." Residents said they were not served snacks they liked, such as candy bars, Goldfish, Fig Newtons, and fresh fruit. They said the staff said they had to get fresh fruit donated in order to serve it. They sometimes had bananas, but they were overripe and "black" when they came from the supplier. One resident said she used to eat blueberries every day when she lived at home. Another resident said it would be nice to have bananas, raspberries, strawberries and fruit smoothies. "These issues have been reported." One resident said he had submitted multiple complaint forms but "nothing gets done from the kitchen." (Cross-reference F804, palatable foods.) Residents said their rooms and bathrooms were not clean enough, and they did not have enough clean towels and washcloths. Residents said there were not enough places to meet with family or in private indoors when the weather is cold. The facility rooms were very small, they had roommates, and had no private place to talk on the phone or visit with family and friends. The conference room was a resident activity room, but it was taken from resident access without asking. Residents said they were promised by management yesterday (1/23/23) that the conference room would be returned to the residents for their private use. Residents said staff had taken over the common areas for offices and/or storage. "You can't even get into the activities offices. Staff need to get rid of old puzzles missing pieces and get a couple of new ones. Too much crap, that's what's wrong with the staff offices." They said the South hall phone did not work. Residents said there were not enough activities staff. "On Sundays we don't have any activities, only manicures." Residents said they would like more checkers, cards and chess games, and a reading club. These activities were suggested and never seemed to be offered, only "kindergarten (juvenile) crafts and many residents were not interested. Some residents said they would like more bingo with "better prizes," and other residents said they would like "more other things besides bingo." The residents reiterated that these issues had been shared with staff at one point or another. Residents said the facility did not take action on the grievances and suggestions of the resident group. II. Resident council meeting minutes The resident council minutes reviewed for the past six months revealed the following: A. 7/1/22 - residents were told by the former dietary manager they could only get fresh fruits and veggies from Costco, that activities would be getting Palisade peaches and make a peaches and cream dessert out of them. Residents were happy with that. They were working on a contract with another farm. No other resident concerns were documented. There was no discussion of old business. B. 8/15/22 - residents said dietary staff never served what they said was going to be on the menu. Residents said they would like to have peaches bought, even with the donation. Residents asked maintenance staff about adding the different channels they had voted on to meet their interests. The maintenance manager said he was waiting to hear back from the company. C. 9/22/22 - residents said nursing staff need more help at night. They were not getting their baths on schedule. Dietary staff were serving too much pasta, there were still no fresh fruits or vegetables, wait time was 25 minutes for meals, residents sometimes did not know what they were having for meals, and meals were not posted. Residents requested more volunteer workers for activities. D. 10/20/22 - dietary staff did not post menus, salads were great, meals were late, residents requested hand wipes, the new dietary manager said he would take care of those concerns and he would be getting fresh fruit in. E. 11/17/22 - regarding the dietary department, the new DM introduced himself, residents said they were not receiving tickets from certified nurse aides (CNAs), the Thanksgiving dinner menu was discussed, the DM suggested if residents wanted to eat quickly they could eat in the dining room. Regarding housekeeping, residents said corners were not getting cleaned very well, the corridor was dirty, they had seen spiders, and dusting needed to be done. F. 12/22/22 - residents requested more green salad, the holiday meal menu was discussed, the vents needed to be cleaned, and the residents would like to get a pool table. G. 1/19/23 - regarding the nursing department, residents expressed a concern about bathing. Regarding the dietary department, the DM said the oven was out of order, he was training staff not to burn rolls, serve less processed food, no sauces or gravy to go with pork or other meats, reviewed the weekend idea of take-out Saturday, having a suggestion box for meals. The residents had several ideas and suggestions about activities. III. Facility follow-up On 1/25/23 at 10:20 a.m., the interim NHA provided the one concern form generated from the resident council. She said she had checked the grievance log for the last six months and this was all she found, from their most recent meeting. She said in the future they would be following up with action plans. The Concern Form, dated 1/24/23, read, "Residents not receiving baths. Residents stated had burnt rolls." The name was "resident council" and the best way to contact the individual was in the resident council president's room. The concern form action/resolution read, "In resident council (INHA/DO) explained that they have a plan set in place to better bath schedule. (The dietary manager) has been working on training staff better." The form was signed on 1/24/23 by the interim NHA. There was a check-mark next to the question "Is the individual who raised the concern satisfied with the resolution?" -There was no evidence of detailed plans to address these two, or any other, resident concerns. There was no resident signature or evidence of a discussion with the resident council president or follow-up with the resident group. The INHA/DO and interim NHA were interviewed about the findings above on 1/26/23 at 4:30 p.m. They said they would follow up and address the resident concerns from the group interview. The interim NHA said the conference room would be turned back into the residents' space, with a sitting area, private phone, and library. One of the residents was interested in being the librarian and starting a reading club. They said resident grievances had not been investigated and resolved previously because of the lack of leadership from the former administration. They planned to provide education for the leadership team, and a grievance logging and tracking system to ensure timely response time and proper follow-up.

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#4) out of five residents reviewed for advanced directives out of 41 sample residents. Specifically, the facility failed to ensure a facility nurse assigned to Resident #4 knew where to locate Resident #4's advance directives to ensure the directives would be carried out in case of emergency. Findings inclue: I. Facility policyThe Communication of Code Status policy, revised January 2023, was provided by the facility on 1/25/23 at 6:47 p.m. The policy read: "It is the policy of this facility to adhere to the residents' rights to formulate advanced directives. In accordance to these rights, the facility will Implement procedures to communicate a resident's code status to those individuals who need to know this information." According to the policy, the designated sections in the medical record to find the resident's code status was the physician orders under code status, and the miscellaneous tab in the electronic medical record for the MOST form. II. Resident statusResident #4, age 67, was admitted on 12/22/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included major depression disorder, unspecified injury of the head, unspecified intracranial (within the skull) injury with loss of consciousness of unspecific duration, aneurysm (the ballooning or weakening area of an artery) of unspecific site, and unspecific convulsions (sudden, violent, irregular movement of the body.) The 12/30/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. He required supervision with all activities of daily living (ADLs). III. Observation and staff interviewLicensed practical nurse (LPN) #2 was interviewed on 1/24/23 at 4:48 p.m. The LPN #2 said residents' advanced directives were scanned and placed in the electronic medical record for reference. LPN #2 looked in the electronic medical record for Resident's #4's medical orders for scope of treatment (MOST) form. The LPN said the MOST form had not been uploaded yet. LPN #2 said the hard copy of the MOST form would be located at the nursing station in a binder. The LPN reviewed the binder and could not find the MOST form. The nurse said if Resident #4 had a medical emergency and needed to identify the resident's advanced directives to determine his code status, and the MOST form was not available, he said the first thing he would do was call 911, then he would check with the medical record director (MRD) for the resident's advanced directives. He said if the medical emergency took place when the MRD was not available, he would attempt to contact the resident's family. The LPN was asked if the resident was coding, how would he immediately know if he needed to perform CPR (cardiopulmonary resuscitation) and could not find the resident's MOST form. LPN #2 said he would refer to his nurse report which identified all his residents'code status.' The LPN did not refer to the resident's CPO or care plan to identify the resident's advance directive. The LPN showed the list of residents from his nursing cart and identified Resident's #4's code status was typed next to the resident's name. The code status next to the resident's name read "DNR" (do not resuscitate.) -The review of the resident's MOST form (later provided by the facility) and the resident's CPO, identified the Resident #4 wanted CPR and full treatment. The MRD was interviewed on 1/24/23 5:56 p.m. The MRD said she had Resident #4's MOST form had not been placed in the binder at the nursing station or uploaded yet because she was still waiting for it to be signed by the physician. She said the MOST form was currenting in her office and the physician should be at the facility in a few days. The MRD said she was new to the facility as identified the facility needed a new process with documents the physician needed to sign. She said while the MOST form was waiting to be signed, there should have still been a copy of it in the binder at the nurses' station for quick reference. She said normally she would have identified the concern in an audit but she had only been at the facility for the past two weeks and had not had an opportunity to audit everything. The MRD said the nurse could also referred to the resident's CPO. The MRD pulled up the CPO for Resident #4 and confirmed his advanced direct orders were in place and identified the resident was full code. The MRD said the LPN should have known to refer to the CPO for the resident's correct code status. She said she would in-service the LPN. IV. Record reviewThe CPO, dated 12/23/22, read: CPR; full treatment; artificial nutrition. The care plan, initiated 1/4/23, read "I choose to have CPR. I will have all of my wishes and advanced directives honored until I request otherwise, or until the next review period. Please provide CPR. The MOST form was provided by the interim nursing home administrator/director of operations (INHA/DO) on 1/24/23 at approximately 5:30 p.m. The MOST form identifying Resident #4 wanted full treatment medical interventions and wanted CPR in the event of a cardiopulmonary arrest. The MOST form was signed and dated by the resident's power of attorney (POA) on 12/22/22. The MOST form was not signed by the physician. V. Facility follow-upA blank copy of the nurse report was provided by the night nurse after the change of shift on 1/24/23 at 7:06 p.m. The nurse report identified the DNR status next the name of Resident #4 was scratched out and "FULL" was hand written above the scratched out DNR. A 1/24/23 employee education form was provided by the facility on 1/26/23. The education reviewed the communication of code status policy. The education was signed off by the facility nurses, including LPN #2. The education included an added on to the policy. Under designated sections on where to find the residents' code status, now included "MOST form binder at nurses station."

Based on observations, record review and interviews, the facility failed to ensure one (#25) of 12 residents reviewed out of 41 sample residents was provided personal privacy during care. Specifically, nursing staff failed to ensure they pulled the privacy curtain and keep the door closed while providing incontinence care for Resident #25. Findings include:I. Resident #25 status Resident #25, age 90, was admitted on 3/30/21. According to the January 2023 computerized physician orders, diagnoses included Alzheimer's disease, reduced mobility, and need for assistance with personal care. The 11/17/22 minimum data set assessment documented severe cognitive impairment, physical behavior directed toward others, and no care rejection. She needed extensive assistance with activities of daily living. II. Observation On 1/19/23 at 5:00 p.m., certified nurse aide (CNA) #3 was observed leaving Resident #25's room pushing a Hoyer (mechanical) lift ahead of her and parking it in the hallway. She had left the door open and the privacy curtain was not pulled. CNA #11 was providing peri care for Resident #25 who was naked and exposed from the waist down. The resident's roommate was in the room; she and anyone walking down the hallway could have observed Resident #25. CNA #11 told CNA #3 to "close the door." III. Record review Resident #25's care plan, initiated on 11/23/21, identified, "I am incontinent of bowel and bladder. I have Alzheimer's and am not always able to use the bathroom or know when I need to void." The interventions included check and change to maintain dignity. IV. Staff interviews CNA #6 was interviewed on 1/25/23 at 4:14 p.m. regarding the observation above. She acknowledged she should have pulled the curtain and closed the door, but said she was "in a hurry because they don't have enough staff." (Cross-reference F725, sufficient nursing staffing.) The interim nursing home administrator/director of operations (INHA/DO) and director of nursing mentor were interviewed on 1/25/23 at 5:18 p.m. regarding the observation above. The INHA/DO said the failure to pull the privacy curtain and close the door while providing resident care was not in keeping with their corporate policy. They said they would provide additional staff training regarding resident rights, dignity and respect.

Based on observations and interviews, the facility failed to consistently ensure a safe, clean, comfortable, homelike environment in resident rooms, shower/tub rooms and common areas in four of four neighborhoods. Specifically, the facility failed to ensure:-Resident rooms and bathrooms were properly cleaned and maintained;-Wash cloths and towels were available in residents' bathrooms; and-Shower/tub rooms were functional, safe and properly cleaned. Cross-reference F565, grievances of the resident group. Findings include: I. Observations during the initial facility tour on 1/19/23 at 9:30 a.m., and throughout the survey on 1/22, 1/23, 1/24, 1/25 and 1/26/23, revealed resident rooms and bathrooms were not thoroughly cleaned and needed repairs, and clean towels and wash cloths were not readily available for residents. Specifically, dust build-up and debris were not swept from under beds and furniture, toilets were soiled or stained and not properly cleaned, privacy curtains were soiled and/or stained, bedside and over-bed tables were sticky with dried fluids and food, window blinds did not open and close properly, fall mats were sticky and covered with hair and debris, some windows did not properly open and close, and there were frequently insufficient wash cloths or hand towels in residents' bathrooms. Walls, doors and heat registers were damaged and needed repair. The linen closets were not stocked with wash cloths or sufficient towels for residents' use. Nursing staff were observed looking for wash cloths they were unable to find. The Hoyer and Sara mechanical lifts stored in the North and South hallways were soiled with white matter and other debris on the surfaces residents would hold or put their feet, with white matter and debris, and needed to be cleaned. The windows in the dining area of the Willow secure neighborhood were opaque and unsightly due to lime deposits, and needed to be cleaned. II. The environmental tour was conducted with the maintenance manager (MM) on 1/26/23 at 12:05 p.m. A. In the South hall shower room:-Black mold/mildew was observed along the entire bottom edge of the shower area;-The safety belt in the lift chair for the tub lift was worn and rough, creating a skin tear hazard;-The toilet had black mold/mildew around the water line and under the rim, readily visible from across the room;-The toilet seat was stained, damaged, unsightly, and needed to be replaced;-There was no toilet paper or toilet paper holder near the toilet;-The ceiling plaster was damaged and unsightly. The MM got a roll of toilet paper and placed it on the back of the toilet. He wiped the shower grout with a tissue revealing a brown substance, and said he would notify housekeeping that the shower needed to be cleaned. He said he would replace the toilet seat, add a toilet paper holder, repair the ceiling, and notify housekeeping to clean the toilet. He said he would start pressure-washing the shower tiles quarterly and as needed. B. In the North shower room:-The tub was not working;-The ceiling light above the tub was not working, flashed on and off when the switch was turned on, and there was standing water inside the light fixture cover;-Orange mildew was observed around the bottom back edge and right corner of the shower. The MM said the tub was not working and parts would be ordered. He was not sure when the tub would be functional. He said a light replacement was on order, with no confirmed date of receipt, but hopefully 2/3/23. The MM said the roof and ceiling had been leaking, and he had repaired the roof but was waiting to see if the repairs he had done would stop the leaking. He could not repair the ceiling, light or tub until the roof repairs were confirmed, either next time it rained, or when he got up on the roof with a hose to test it. He said in the meantime residents and staff were still using the shower portion of the shower/tub room, because the light still worked in the shower. He was unable to speak to whether or not this was safe, or when the repairs would be done, but he would discuss with the nursing home administrator (NHA). C. A tour of accessible resident rooms revealed examples of the concerns in most rooms in the facility. In room 26:-The window latch in the bathroom did not work;-The picture window did not open and close properly;-The fall mat was rolled up, covered with debris, and needed to be wiped down and the floor swept underneath;-The heat register and walls were damaged and needed touch-up paint;-The bathroom was full of wheelchairs and medical equipment. The sink was inaccessible to the residents, and difficult for caregivers to access. The toilet bowl had a ring around the water line and dark spots inside that looked like black mold;-The privacy curtains were stained and soiled. The MM said he would repair the items and notify housekeeping. He said he was not sure on the cleaning schedule for privacy curtains but he would find out. In room 25:The privacy curtain on the window side did not pull closed, and the privacy curtain on the door side was soiled and stained. The MM said he would pull them down and replace them. In room 24:There was no privacy curtain or track for the bed by the window. The MM said it had probably been taken down when the room was repainted, and he did not realize it had not been replaced. He said he would replace the track and the curtain immediately. In room 22:-There were no wash cloths in the residents' bathroom;-The over-bed table for the resident by the window had a damaged surface with half the plastic cover pulled off, and was uncleanable. The maintenance manager documented the above concerns, said he would follow up with the housekeeping supervisor and the NHA, and would repair what he could as soon as possible.

Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for seven (#32, #40, #49, #56, #57, #71 and #226) of nine residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #32 was free from physical harm and mental anguish. Resident #32 was hit repeatedly in the face by Resident #56 on 12/18/22, resulting in facial lacerations, swelling, and feelings of fearfulness and anxiety. Resident #56 continued to exhibit intimidating behaviors towards that resident in the days following the 12/18/22 altercation. In addition, the facility failed to ensure Resident #40, Resident #49, Resident #57, Resident #71 and Resident #226 on the secured/memory care unit were free from resident-to-resident altercations. Findings include:I. Facility policy The Elder Justice Act and Reporting Suspected Crimes Against Residents policy and procedure, dated 2017, was provided by the facility on 1/26/23. The policy read its purpose was: "To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation." II. Incident #1 A. Resident status 1. Resident #32, age 95, was readmitted on 12/6/22. He resided in the secured/memory care unit. According to the January 2023 computerized physician orders (CPO), diagnoses included delirium due to known physiological condition, and unspecified dementia with unspecified severity without behavioral disturbance. The 12/13/22 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. The resident exhibited inattention, disorganized thinking and an altered level of consciousness. The resident did not exhibit behaviors of concern during the seven day assessment period. The review of the January 2023 care plan did not identify the resident was at risk for abuse or the resident had an actual resident to resident altercation. 2. Resident #56, age 83, was admitted on 10/31/22. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease; major depression; and, unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. The resident exhibited disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The behavior care plan, initiated 1/21/23, identified Resident #56 had the potential to be physically aggressive towards others related to his dementia. B. Record reviewAn investigation of alleged physical abuse was initiated on 12/18/22. According to the investigative record, Resident #32 was in bed when his roommate (Resident #56)was documented to trip over Resident #32's walker and hit Resident #32 in the face on 12/18/22 at 6:30 p.m. The report read Resident #32 had a small superficial laceration on the bridge of his nose and upper lip. The report identified the staff controlled his bleeding and cleaned his wounds. The report indicated the police was contacted, Resident #32 and Resident #56 were separated in two different rooms, and were put on one-to-one monitoring until they fell asleep. The investigation report's conclusion read the facility was unable to substantiate physical abuse at this time because there was no injury. The facility was unable to determine intent, due to the assailant's (Resident #56) cognitive status at time of the incident. Under the investigation's conclusion was a handwritten note that read "Asked to change to substantiate." Upon clarification, the interim nursing home administrator/director of operations (INHA/DO) reviewed the investigation and requested the nursing home administrator (NHA) to substantiate the abuse findings, as identified in a 1/25/23 interview below. The 12/18/23 change of condition nursing note/situation-background-assessment-recommendations form (SBAR) read Resident #56 started talking fast and oddly, stating "Everyone wants to kill me." According to the note, Resident #56 standing over Resident #32, punching Resident #32 in the face. The 12/19/22 at 2:18 a.m. nursing note read Resident #32 appeared to still be a little anxious due to an altercation with his roommate. The 12/19/22 at 12:44 p.m. nursing note read Resident #32 was sent to the hospital per his family's request, post assault by his roommate. The note identified the resident had been punched in the face and received a split lip, bruise under his left eye, and swollen nose with a laceration to the bridge of the nose. The 12/19/22 emergency department (ED) report read Resident #32 suffered facial injuries from unspecified assault, likely "being punched in the face." Resident #32 had swelling and contusions to his face and nose. The ER report read emergency medical services (EMS) reported Resident #32 was assaulted on 12/18/22. According to the report, the resident was hit five times in the face. Resident #32 was provided pain medication, ice, and discharged back to the facility's memory care unit. The 12/20/22 nursing note read Resident #32 was up all night due to fear of being assaulted again. The resident was provided with one-to-one attention. According to the note, Resident #56 continued to pace near Resident #32 for about three hours. The 12/20/22 administration note, documented in the medical record of Resident #56, read Resident #56 was pacing and "staring down" another resident. The resident was placed on one-to-one monitoring and implemented a medication change to help with his agitation. The 12/24/22 nursing note read Resident #32 did not want to remain at the facility. According to the note, Resident #32 was afraid and not sleeping well after being hit. The note read the staff assured him that he was safe now that he was close to the nursing office and his roommate was in another room. The 12/27/22 nursing note read Resident #32 still spoke about feeling fearful after being punched. III. Incident #2 and #3 with Resident #57 and Resident #226A. Resident status 1. Resident #57, age 71, was admitted on 9/7/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke's encephalopathy (a brain disorder causing confusion), anxiety disorder, and delusional disorders. The 12/19/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident exhibited disorganized thinking and inattention. According to MDS assessment, the resident exhibited physical and verbal behaviors directed towards others. The behavior care plan, initiated on 1/24/23, read the resident had the potential to become verbally or physically aggressive towards other residents. Her care plan goal was to not harm or be harmed by others. 2. Resident #226, age 62, was admitted on 12/9/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, early onset, bipolar disorder, and unspecified dementia with unspecified severity with agitation. The 12/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident exhibited disorganized thinking and inattention. The resident exhibited physical and verbal behaviors directed towards others, impacting their care and social interactions. According to the MDS assessment, Resident #226 put others at significant risk for injury. The behavior care plan, initiated on 12/27/22, read the resident had potential for physical and verbal outbursts related to her dementia, bipolar disorder, and poor impulse control. B. Record review 1. Incident on 12/11/22 between Resident #226 and Resident #57The 12/11/22 at 4:00 p.m. behavior note documented in the medical record of Resident #226 read Resident #226 was very anxious, and briskly pacing in and out of rooms, and up and down the hall. According to the note, a resident (Resident #57) started to yell at her. Resident #226 proceeded to throw juice at Resident #57. The 12/11/22 at 4:02 p.m behavior note documented in the medical record of Resident #57 read Resident #57 was yelling at a newly admitted resident to the facility. A resident (Resident #226) proceeded to throw juice at Resident #57, making contact with Resident #57's chest. According to the note, Resident #57 felt frustrated and needed to be cleaned up. An investigation of a resident to resident altercation was initiated on 12/11/22, however, according to the investigative record, the event was incorrectly documented on 9/23/22 at 4:00 a.m. between Resident #226 and #57. The investigation documented the yelling and juice incident and identified all residents (on the memory care/secured unit) were placed on observation for any changes in behavior due to the incident. As a result of the incident, the facility was to create a non-pharmacological plan to assist with the behaviors of Resident #226. The 12/12/22 at 4:57 a.m. behavior note identified the resident had an increase in behaviors following the incident. The behavior note read Resident #57 got out of bed several times throughout the shift, wandering the hallway and exit seeking. According to the note, the resident would be verbally abrasive and "shoot the finger" several times when the staff guided her back to her room. 2. Incident on 12/24/22 between Resident #226 and Resident #57The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #226 read Resident #226 was leaving an activity when another resident (Resident #57) said a few "grumpy things" to Resident #227. Resident #226 "lightly slapped" Resident #57's face and walked away. The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #57 read another resident (Resident #226) was restless and walked near Resident #57 and her friend. Resident #57 told the resident in a "gruff" voice not to come near her. Resident #226 lightly slapped Resident #57. According to the note, a light pink mark appeared (on her face) lasting a few minutes. There was no broken skin or bruising. The residents were separated. An investigation of alleged physical abuse was initiated on 12/25/22. The review of the physical abuse report, identified the physical altercation was reported to the State Agency on 12/25/22 at 9:17 a.m. almost 24 hours after the incident occurred. According to the investigative record, on 12/24/22 at approximately 11:55 a.m. Resident #57 was participating in an activity. When the activity ended, Resident #226 approached another resident Resident #57. Resident #226 entered Resident #57's personal space, slapping Resident #57 on the cheek with her hand. The incident was witnessed by a certified nursing aide (CNA). The police were called, the residents were separated, and monitored. The 12/25/22 nursing note documented in the medical chart of Resident #226 read police were notified related to the incident. No additional details were included in the progress note. IV. Incident #4A. Resident status 1. Resident #71, age 81, was admitted on 12/22/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 12/30/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS) score of 2 out of 15. The resident exhibited inattention and disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The physical aggression care plan, initiated 1/20/23, read Resident #71received physical aggression from another resident. 2. Resident #40, age 73, was admitted on 9/7/22. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included neurocognitive disorder with Lewi bodies and anxiety disorder. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 1 out of 15. The resident did not exhibit inattention or disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The physical aggression care plan, initiated 1/21/23, read Resident #40 had the potential to exhibit physical aggression towards staff and other residents. The care plan read the resident would quickly pace when agitated and could be difficult to be redirect. The review of the care plan did not identify the resident had an actual physical altercation with another resident. B. Record review An investigation of alleged physical abuse was initiated on 1/10/23. According to the investigative record, Resident #40 was witnessed to be agitated and pacing the halls when he saw Resident #71 and "struck her on the back" on 1/10/23 at 6:15 p.m The investigation report indicated that police were called and residents were separated and monitored. The report read Resident #71 said she was not afraid following the incident. She said she was surprised and thought she might have gotten in his way. There was no identified injury to Resident #71. The 1/10/22 SBAR communication assessment for Resident #40 read "Resident has been sundowning more often and becoming combative with other residents and staff." IV. Staff interviewRegistered nurse (RN) #3 was interviewed on 1/19/23 at 4:40 p.m. RN #3 identified a resident who was physically injured during a resident to resident altercation in the secured/memory care unit. The RN said Resident #32 was punched in the face by Resident #56 resulting in wounds to his face and an evaluation at the hospital. The intertrim nursing home administrator/corporate director of operations (INHA/DO) was interviewed on 1/25/23 at 5:34 p.m. The INHA/DO said there were multiple factors to determine abuse including injury, intent, resident reaction, she said even threatening could be considered abuse. She said the investigation determined if the alleged abuse occurred. She said the former nursing home administrator (NHA) reported an the allegation of physical abuse between Resident #32 and Resident #56. She said the former NHA conducted the investigation and reported the allegation of abuse was unsubstantiated related to Resident #56's cognitive ability and unknown intent. The INHA/DO said she reviewed the former NHA's report and educated the NHA what factors needed to be considered to determine if the abuse was substantiated. The INHA/DO said Resident #32 was physically injured. She acknowledged the resident was documented to be afraid after the incident which impacted his sleep. The INHA/DO requested the former NHA to substantiate the physical abuse based on intent and injury. The incidents and intentions between Resident #56 and #71 and Resident #57 and #226 were reviewed with the INHA/DO. She said incidents were not identified as accidents. The residents were either agitated or prompted prior to the incidents. The INHA/DO said she was concerned about the handling of the abuse process with the former NHA. She said she would weekly reviews with the former NHA and provide education but the former NHA would not follow the education. She said she also requested the former NHA to send her all the allegations of abuse for her own review but the former NHA would frequently not send them to her. The INHA/DO said the facility self identified they had a breakdown in the system. She said she created a plan of correction because they know there were issues. The INHA/DO said the former NHA was relieved of her duties on 1/18/23 and the facility proceeded to conduct abuse documentation audits and conduct staff in-services on 1/18/22 and 1/19/23 (first day of survey.) The INHA/DO was interviewed again on 1/26/23 at 6:54 p.m. The INHA/DO said she was not initially aware of the extent of the 12/18/22 incident between Resident #32 and #56, as reported to her by the former NHA. She said she was told that Resident #56 did not intentionally hit Resident #32. She said after further review and after the final report was submitted, the INHA/DO determined the physical altercation was intentional. The INHA/DO said during her continued review of the abuse process and prevention, she had determined interventions to prevent future abuse needed to be more centered, and investigations needed to follow the procedure steps to ensure all information was gathered. The INHA/DO said education was also conducted on 12/19/22 for abuse prevention. The INHA/DO said the education conducted on 1/18/22 and 1/19/23 were focused on staff and their response to resident to resident altercations. She said the education included what the staff could do to minimize the risk of abuse, how to de-escalate abuse, and how to engage and redirect the residents. V. Additional information provided by the facilityThe following documents were provided by the facility on 1/26/23:-A information form addressed to the secured/memory care staff. The form read the listed residents had been involved in verbal and physical altercations with other residents. The list of residents included Resident #40, Resident #56, and Resident #57. Resident specific interventions were identified. The form requested staff to attempt to utilize the interventions to prevent altercations from occurring. -Staff and interviews on knowledge of resident abuse and if residents felt safe. The interviews were conducted on 1/19/23 and 1/20/23.-Facility audits of abuse management and interventions conducted on 1/19/23. -The abuse staff in-service conducted on 1/18/23 and 1/19/22 included types of abuse and steps to take if staff witnessed abuse or knew of an instance or allegation of abuse and a review of the abuse policy. According to the in-service any negative interactions involving residents could potentially be abused and the administrator must be notified. VII. Resident #49-incidents of verbal and physical abuse directed toward other residents A. Resident status 1. Resident #49 Resident #49, age 64, was admitted on 3/11/21. According to the January 2023 CPO, diagnoses included alcohol-induced persisting dementia, Wernicke's encephalopathy and generalized anxiety disorder. The 1/2/23 MDS assessment documented Resident #49 was cognitively intact with a BIMS score of 15 out of 15, and had psychosis indicators or hallucinations and delusions. No behavioral symptoms or rejection of care were documented. He needed supervision, oversight, cueing and encouragement for all activities of daily living. 2. Resident #59 Resident #59, under age 50, was admitted on 10/14/22. According to the 10/14/22 MDS assessment, he was admitted for rehabilitation after a fracture. He had moderate cognitive impairment with a BIMS score of nine out of 15. No behavioral symptoms were documented. He used a wheelchair and needed limited assistance with most ADLs. 3. See above for status of Residents #40 and #56. No information was available regarding the former/discharged resident. B. Record review Resident #49's behavioral care plan, initiated 8/9/21 and revised 1/20/23, identified a behavior problem related to anxiety disorder and dementia, with increased agitation when other residents entered his room and "may be verbally loud with them." The goal was for fewer episodes of anxiety. The interventions were: administer medications as ordered, allow choices within decision-making abilities, anticipate and meet resident needs, assist to develop more appropriate methods of coping and interacting, provide opportunity for positive interactions, engage in television football games when on, provide jobs around the facility such as sweeping floors in the Willow (secure) unit, discuss the resident's behavior and explain why behavior is inappropriate or unacceptable, intervene as necessary to protect the rights and safety of other residents, approach in a calm manner, divert attention, remove from situation and take to alternate location as needed, keep stop sign across his door to deter other residents entering his room, offer craft kits, Lego sets and painting as resident enjoyed taking things apart and putting them back together. The resident "benefits from a private room" was added as an intervention on 1/20/23 (during the survey). The wandering care plan, initiated 3/12/21 and revised 1/20/23, documented Resident #49 had a history of wandering, and no longer met the criteria to reside on the secure unit and had not wandered since moving off the unit. "He is alert and oriented and knows location in the building." Staff were to frequently orient and monitor Resident #49 for new behavior of wandering (added 1/20/23 during the survey). The care plan for potentially aggressive behavior related to poor impulse control was initiated on 1/24/23 (during the survey), and identified Resident #49 had a history of pulling wheelchairs out from under other residents, causing them to fall. The goal was for the resident to demonstrate effective coping skills. Interventions included: the resident's triggers for physical aggression are residents wandering into his room; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate needs; if resident is pushing another resident in a wheelchair or attempting to help them, thank him for his offer but inform him that staff are there to take care of other residents; the resident prefers to be alone in his room with the door closed; resident will come out of his room for food and drinks; staff to offer observation when resident is out due to history of altercations with others; resident prefers a private room. C. Abuse incidents Review of facility investigative reports revealed Resident #49 was the assailant in four incidents between 11/10/22 and 11/30/22. Three incidents occurred while Resident #49 resided in the Willow secure neighborhood, and one incident occurred after he was moved in with a roommate on the North hall. 1. 11/10/22 abuse incident against Resident #40 At 8:30 p.m. on 11/10/22, Resident #40 was "checking door knobs" and before staff could get to him, opened Resident #49's door and walked into the room. Resident #49 then punched Resident #40 in the face, leaving a red mark above Resident #40's right eyebrow. Resident #49 was put on 15-minute checks and the police were notified. Resident #49 had earlier, at 4:23 p.m., been documented having "multiple yelling and outbursts this afternoon inside and outside of his room. Redirecting several times unsuccessfully. Will continue to monitor." 2. 11/16/22 verbal abuse incident against Resident #56 Resident #49 threatened Resident #56 for assisting another male resident who was in a wheelchair. Resident #49 told a staff person that Resident #56 was "trying to move his dad, and was yelling at Resident #56, "Do you want to fight?" and the other resident put up his fists. Staff had to intervene and sent Resident #49 "to his room to cool down." The nurse documented that Resident #49's Seroquel had just been increased on 11/16/22 after "another previous altercation." 3. 11/27/22 verbal and physical abuse incident against a former resident/roommate Resident #49 yelled profanities at his roommate and slung a pair of jeans at him, hitting him in the face, no apparent injuries were noted. The residents were separated and monitored, and police were called. Resident #49 kept referring to the victim as his dad, and said he was trying to get his dad to "behave" because his restlessness was keeping him awake. The victim did not demonstrate increased tearfulness or self-isolation, and there were no signs of fear or feeling unsafe. No changes were made to the treatment plan other than to increase monitoring. Resident #49 was noted to become "easily agitated." Review of nursing notes revealed Resident #49 moved on 11/28/22 from the Willow secure neighborhood to a room on the North hall because "secure unit placement not needed." 4. 11/30/22 verbal and physical abuse incident against Resident #59, a former roommate On 11/30/22, a CNA witnessed Resident #49 pulled his roommate's wheelchair out from under him while he was trying to sit in it, causing his roommate to fall. There were no apparent injuries. Resident #49 was heard saying to Resident #59 that he was going to "kill him." Resident #49 was placed on one-to-one monitoring and Resident #59 was moved to a different room. Resident #59 later did not remember exactly what happened but was glad not to be with "that roommate." All staff members interviewed concurred that Resident #49 "needs a private room." -No further abuse incidents were documented involving Resident #49 after 11/30/22. D. Observations Resident #49 was observed throughout the survey on 1/19, 1/22, 1/23, 1/24, 1/25 and 1/26/23 spending most of his time in his room on the South hall, with his door closed, leaving only briefly to get drinks, snacks and food. He was independent with ambulation, and spoke quietly. He resided on the opposite side of the facility from the Willow and North neighborhoods. E. Staff interview The INHA/DO was interviewed on 1/23/23 at 4:00 p.m. She said Resident #49 was territorial and did not like other residents in his room. He was not appropriate for the Willow secure unit, and had an altercation with his roommate after he was moved from Willow. She said that since he has had a private room, he had done well, kept to himself, and only left his room to get something to eat or drink. The INHA/DO said she had to piece together the report documents (above) regarding the abuse incidents because she was unable to find all of the former NHA's investigative documentation. -The facility failed to keep residents free and safe from verbal and physical abuse by Resident #49.

Based on record review and interviews, the facility failed to ensure level I and level II preadmission screening and resident review (PASRR) were completed for four (#4, #5, #37 and #57) out of five residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #37, with a known psychological disorder, was properly assessed with a PASRR level I or level II assessment; -Ensure Resident #5 and #57 had a level I PASRR screening completed timely; and, -Have the training and knowledge to follow up with PASRR screening identified concerns for Resident #4. Findings include: I. Resident #57A. Resident statusResident #57, age 71, was admitted on 9/7/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke's encephalopathy (a brain disorder causing confusion), anxiety disorder, and delusional disorders. The 12/19/22 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident exhibited disorganized thinking and inattention. B. Record review The review on the Resident #57 medical records on 1/23/23, did not reveal evidence that a level I PASRR preliminary assessment was completed since the resident's 9/7/22 admission, to determine if the resident qualified for additional services. C. Staff interview The social services director (SSD) was interviewed on 1/25/23 at 10:25 a.m. The SSD confirmed Resident #57 did not have a level I PASRR completed. The SSD said she did not know she was responsible for all the facility residents' PASRRs. She said she was only completing the PASRRs for residents not residing on the memory care/secured unit. She said the life enrichment coordinator LEC was assigned to do the PASRRs for the memory care unit but she has not had access to the program to submit the PASRR. The SSD said the LEC had been requesting access for months. The SSD said she just found out from management that she should have been completing all the PASRRs till the LEC had access. The SSD was interviewed again on 1/25/23 at 4:35 p.m. She said the LEC now had access to complete the PASRRs for the residents on the memory care unit and as of 1/25/23 she submitted all needed PASRRs. D. Facility follow upThe authorization request summary and level I PASRR screening for Resident #57 was provided by the interim nursing home administrator/director of operations (INHA/DO) on 1/24/23 at 5:15 p.m. The authorization request identified the level one screening was submitted on 1/24/23 at 4:56 p.m. -The screening was done four months after the resident was admitted to the facility. A PASRR submission list, dated 1/25/23, was provided by the SSD on 1/25/23 at 6:23 p.m. The list identified six other residents that required level I screening. The level I screenings were submitted on 1/25/22. II. Resident #4 A. Resident statusResident #4, age 67, was admitted on 12/22/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included major depression disorder, post-traumatic stress disorder (PTSD), unspecified psychosis not due to a substance or known physiological condition, anxiety disorder and other specified mental disorders due to known physiological condition. The 12/30/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of seven out of 15. He required supervision with all activities of daily living (ADLs). B. Record reviewThe review on the Resident #4's medical records on 1/23/23, did not reveal evidence that a level I PASRR preliminary assessment was completed. The resident was admitted to the facility on 12/22/22. The authorization request summary and level I PASRR screening for Resident #4 was provided by the interim nursing home administrator/director of operations (INHA/DO) on 1/24/23 at 5:15 p.m. The authorization request identified the level I screening was submitted by the SSD on 1/4/23 but the review of the outcome read "Technical Denial " however the PASRR screening indicated the resident had major mental illness and used antipsychotic, mood stabilizer, or antidepressant. C. Staff interviewThe SSD was interviewed on 1/25/23 at 10:25 a.m. The SSD said she did not know why the resident denied or what the technical denial meant. She said she received notice of the technical denial on either 1/9/23 or 1/10/23 but she did not know the phone number on who to contact in relation to PASRR. The SSD said he should have qualified for a PASRR level II and a telehealth appointment set up because of his diagnosis. The SSD said she had only been at the facility for four months and would have to ask her corporate consultant on how to proceed. The SSD was interviewed again on 1/25/23 at 4:35 p.m. She said today (1/25/23) her consultant provided her with a phone to follow up with PASRR concern for Resident #4 found out why his authorization form read there was a technical denial. The SSD said she forgot to upload the resident's history and physical from the physician. The SSD said the concern had now been corrected and they will use the 1/4/23 level one date. She said if she had not corrected the concern, the resident would have been at risk for not receiving services. The SSD said her corporate consultant would provide her with a PASRR training in the next couple of days. III. Resident #37 A. Record review Resident #37 was admitted on 10/21/22 with a diagnosis of bipolar disorder, according to the 12/9/22 MDS assessment. She was cognitively intact with a BIMS score of 14 out of 15, and had no behavior or mood symptoms. She took antipsychotic medication daily. However, MDS section N450 documented no antipsychotics were received and no gradual dose reduction or medication review was needed. No PASRR level I or II could be found in the resident's medical record. B. Staff interview The SSD was interviewed on 1/25/23 at 9:45 a.m. She confirmed that Resident #37 had a bipolar diagnosis, and would probably need a level II, but she checked and found that no level I was done. She said it was her understanding the level I was due within 30 days of the resident's move-in and they did not think Resident #37 would stay beyond 30 days. The SSD said, "It's my fault; I'll do it right now. This is important so residents can be evaluated for psychiatric reasons." C. Facility follow-up The SSD provided a copy of the level I authorization request summary she had submitted for Resident #37 on the afternoon of 1/25/23. It documented Resident #37 had a diagnosis of bipolar disorder, indications of a major mental illness related to "bipolar disorder of her history," and was taking Seroquel and Valproic Acid Solution. The SSD also provided a copy of the response from the utilization review and management contractor, dated 1/25/23, which documented, "A decision cannot be made at this time because we were unable to obtain the necessary information." To process the review, the following information was needed within five business days: "The most recent history and physical, or any medical documentation with a review of systems and vitals (actual vital data/vital #'s are required), from within the last 6 months." The SSD said she had not read the letter and was not aware additional information was needed from the utilization review and management contractor. She acknowledged this might be the reason other PASRR level II requests had been delayed. She said she would send the follow-up information to the contractor. IV. Resident #5 A. Record review Resident #5 was admitted on 11/9/22 with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; delusional disorders; dissociative and conversion disorders; bipolar disorder, current episode depressed moderate; and mood (affective) disorder. The 11/18/22 MDS assessment documented no level II PASRR and no major mental illness. She was cognitively intact with a BIMS score of 14 out of 15. She felt tired with little energy, had problems with sleeping and overeating, and sometimes felt down, depressed or hopeless. She had behavioral symptoms not directed toward others. She had dementia and psychotic disorder. She took antidepressants daily. There was no evidence of a PASRR level I or level II in the resident's medical record. On 11/16/22, Resident #5's medical record documented she was threatening suicide and hitting her head on the wall, saying she would go crazy if she had to stay in the facility. She was referred to the local mental health center, who could not admit her, and was then sent to the emergency room on 11/16/22. She returned from the hospital the same day, after it was determined she was not at risk for harming herself or others. The resident's care plan, initiated 11/30/22 and revised 1/3/23, identified mental health diagnoses, delusions, threats of self-harm, and a history of trauma. The resident was referred to the local mental health center for counseling. Review of physician orders revealed she was started on Propranolol for anxiety on 12/5/22; and Seroquel, an antipsychotic, on 1/21/23 for "bipolar disorder with behaviors and exhibited auditory and visual hallucinations." Nursing and social services notes in the resident's medical record revealed she was considering a transfer to a local assisted living facility. B. Staff interview The SSD was interviewed on 1/25/23 at 10:05 a.m. She checked and found that a PASRR level I authorization request was entered on 11/25/22, but there was no response from the contractor. She said the facility did not have a policy and procedure for follow-up with the contractor when they did not receive a timely response. "They often won't respond until they have a provider for the resident to use." She said she was not even sure how to contact the contractor to see if the request was misplaced or still under review. She said she would have to check with her social services mentor. On the afternoon of 1/25/23, the SSD provided a copy of Resident #5's authorization request summary dated 11/25/22. The resident's last name was misspelled, the review outcome was "technical denial," and under insurance "no coverage was found" (although the resident's medical record documented she was Medicaid pending and had insurance). It was documented the resident had a major mental illness although all her mental health diagnoses (see above) were not listed. She was taking Sertraline, an antidepressant medication. The SSD acknowledged she might have sent incomplete information to the contractor, and would have to contact them to find out what further information was needed in order to proceed with the request for a PASRR level II. -No further information was provided. The facility failed to ensure complete and accurate information was submitted and that PASRR level I and II assessments were completed for residents in a timely manner, in order to assess and provide mental health services.

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

Based on observations, interviews and record review, the facility failed to provide adequate nutrition and hydration to one (#43) of eight residents reviewed out of 41 sample residents. Resident #43 received hospice services and was documented to have unavoidable weight loss. However, the facility failed to assess Resident #43's dietary and drink preferences, assess and implement dietary interventions, provide fortified foods as recommended by the registered dietitian, and provide food and drink access to ensure the resident received the assistance needed for his comfort, enjoyment and dignity, and to ensure he did not go hungry and thirsty. These failures contributed to Resident #43 experiencing severe weight loss within the previous month, and within the previous five months after his admission to the facility. Findings include: I. Facility policies A. The Weight policy, revised May 2021, provided by the interim nursing home administrator/director of operations (INHA/DO) on the evening of 1/26/23, documented in part: "Weights will be regularly monitored to assure the identification, evaluation and initiation of care planning for residents who have experienced actual weight loss or weight gain. "Significant weight changes include: 5% loss/gain in weight in a month, 7.5% loss/gain in three months, 10% loss/gain in weight in six months. "The dietitian and the IDT (interdisciplinary team) will review residents with significant weight changes and develop a care plan accordingly. "Individualized interventions will be recommended and initiated to meet weight goals as clinically possible depending on the resident's weight status." B. The Hydration policy, dated 2021, provided by the INHA/DO on the evening of 1/26/23, documented in part: "The facility offers each resident sufficient fluid, including water and other fluids, consistent with resident needs and preferences to maintain proper hydration and health." "The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care." "Interventions will be individualized to address the specific needs of the resident. Offer the resident a variety of fluids during and between meals. Provide assistance with drinking. Ensure beverages are available and within reach." II. Resident status Resident #43, age 74, was admitted on 9/19/22. According to the January 2023 computerized physician orders, diagnoses included neurocognitive disorder with Lewy bodies (progressive dementia leading to declines in thinking, reasoning and independent function), chronic kidney disease stage 3, chronic congestive heart failure, and chronic obstructive pulmonary disease. According to the 10/2/22 admission minimum data set (MDS) assessment, Resident #43 had severe cognitive impairment with no brief interview for mental status (BIMS) score, and delirium indicators of inattention. He had mood indicators of trouble sleeping or sleeping too much, feeling tired, and little interest or pleasure in doing things. No behavioral symptoms or care rejection were documented. He needed limited assistance with transfers and walking; encouragement/supervision/set-up with eating; and extensive assistance with toilet use, dressing and personal hygiene. He was unsteady during transfers and used a walker and wheelchair. There were no range of motion limitations. He received hospice services. There were no choking or swallowing problems. Weight loss/gain was unknown. He was 67 inches tall and weighed 194 pounds. He took antipsychotic and antianxiety medications. III. Observations and family interview Observations of Resident #43 during the survey on 1/19, 1/22, 1/23, 1/24, 1/25 and 1/26/23 revealed he spent most of his time in bed on his back. His over-bed table with water pitcher or covered food plate was against his privacy curtain and out of his reach. During observations on 1/19/23, the resident's lips and mouth were dry, and he appeared thin, frail and weak. During subsequent observations, his over-bed table and water pitcher were out of his reach. On 1/24/23 at 3:15 p.m., Resident #43's wife was observed in the hallway walking toward Resident #43's room with a hospice nurse. As she approached Resident #43's room, she said she visited him almost every day, and added, "This is what they do, leave his lunch across the room and don't help him, and he's sound asleep, and his food is getting cold." She said this happened "day after day" and he had lost a lot of weight. The resident was sleeping on his back, and his over-bed table with his lunch tray was out of his reach. Resident #43's wife was interviewed on 1/24/23 at 4:30 p.m. She said she had been told by staff that they had 35 patients on his hall and "couldn't just cater to (Resident #43) all day." She said sometimes when she entered his room and saw his water and food out of his reach, "I think about all the times that he has to go without." She said he had lost so much weight he looked like "bone with skin wrapped around it." "He lays in that bed with food all over him, and his sheets." She said when he was too weak to feed himself, she scooped up the food for him bite by bite, hand over hand, and helped him get it to his mouth. She said she tried to visit him at lunch or dinner so she could go to the dining room and eat with him, and she sometimes brought him a little Jell-O pudding or yogurt, bananas and oranges, because "he never gets fresh fruit." "The food looks like it's been sitting out, it's not even edible, it tastes like (expletive), and it smells bad. The other night when I was here with (Resident #43) they had a big pile of goulash. I tried it and (Resident #43) drew my hand away and said 'No.' He would eat the carrots they served and said 'It's cold,' and the carrots were cold." (Cross-reference F804, palatable foods.) Breakfast observations on 1/25/23 revealed:-At 8:30 a.m., Resident #43's tray was delivered and placed on his over-bed table out of his reach. He reached out for it several times and indicated he wanted it moved closer to him.-Licensed practical nurse (LPN) #3 entered his room to check on him at 8:50 a.m. When he indicated to her that he wanted his breakfast moved closer to him, she asked him to wait until certified nurse aide (CNA) #6 came in to assist him so he did not choke. He motioned again for his breakfast to be moved toward him.-At 8:59 a.m., CNA #6 knocked and entered his room, asking if he was ready to eat. She wheeled his over-bed table in front of him, uncovered his plate of biscuits and gravy, and Resident #43 started eating immediately. He fed himself well and drank from his water pitcher with a straw, holding the water pitcher in both hands. He had not been served coffee or juice, and when asked why, CNA #6 asked him if he wanted those. Resident #46 responded that he wanted apple juice. CNA #6 said she would be right back, as she had to find juice. While CNA #6 was gone, he finished his meal and drank more water from his pitcher.-At 9:05 a.m., LPN #3 checked on Resident #43 and asked if he was finished. He reiterated he wanted juice, but no more food. At 9:07 a.m., CNA #3 brought him a glass of apple juice and an orange juice, which he drank well. CNA #3 stayed with him as he drank his juice.-At 9:34 a.m., Resident #43 was sleeping on his back. His over-bed table had been moved out of his reach again; his plate and cups were gone and his water pitcher remained. On the afternoon of 1/25/23, Resident #43's wife visited and brought him a coffee drink and a piece of iced lemon cake, which he drank and ate. On 1/25/23 at 6:06 p.m., Resident #43 was observed in bed with his dinner tray in front of him. He had finished his fluids and fruit cocktail dessert, but his plate of lasagna, vegetable and dinner roll were untouched. No staff were in sight to assist, encourage, or offer him an alternate meal. -Observations and interviews with the resident's family and staff revealed he enjoyed eating and drinking the foods and fluids of his choice, and needed encouragement, supervision and cueing, and assistance at times. IV. Record review The care plan, initiated 9/20/22, identified a nutritional problem related to his diagnoses, a lacto-ovo (dairy and eggs) vegetarian diet, and receiving hospice services with expected unavoidable weight loss related to terminal processes. The goal was food and fluids as desired for comfort. Interventions were: assist the resident with developing a support system to aid in weight loss efforts, including friends, family, other residents, volunteers; invite the resident to food related activities; observe any signs/symptoms of dysphagia (swallowing difficulty); ensure twice daily (currently on hold, revised 12/8/22) fortified foods; provide and serve supplements as ordered; lacto-ovo vegetarian diet/regular texture/thin liquids; and registered dietitian (RD) to evaluate and make diet change recommendations as needed.-The nutrition care plan was not updated to include actual severe weight loss, preferred foods other than a vegetarian diet, and did not accurately document the resident's dietary supplements or types of liquids. The hospice care plan, initiated 9/27/22 and revised 1/24/23 (during the survey), identified end- stage diagnoses of chronic kidney disease stage 3 and Lewy body disease. Interventions included: provide with food and fluids as desired for physical and emotional comfort. Resident #43's dietary card identified a lacto-ovo vegetarian (vegetarianism that includes consumption of eggs and dairy) dysphagia diet with nectar thickened liquids. His Thursday 1/26/23 lunch menu included a ground barbecue veggie chicken patty, barbecue sauce, roasted green beans, cheesy mashed potatoes, a dinner roll with margarine, banana pudding, and nectar-thickened coffee or hot tea.-No other food preferences were identified in the resident's medical record. The Weights and Vitals Summary revealed the following documented weights for Resident #43:9/19/22 (admission) - 199.2 pounds10/2/22 - 194.2 pounds11/1/22 - 191.8 pounds12/4/22 - 177.6 pounds1/3/23 - 171.6 pounds-He had experienced severe weight loss at 14.2 pounds, 7.4%, within one month from 11/1/22 to 12/4/22; and 27.6 pounds, 13.86%, since his admission five months before. The 9/19/22 Nursing Admit Assessment documented Resident #43 weighed 199.2 pounds and was 67 inches tall. He was reported to spend most of his time asleep, and was on hospice. The 9/20/22 admission Nutrition Evaluation documented a weight of 199.2 pounds. Usual body weight was unknown. Weight trends were unavailable. The resident was noted with a history of not eating for a few days and then binging. His fluid intakes were "good." His calorie needs were 1825-2190 kcals (calories) and fluid needs were 1825-2190 milliliters (ml). His diet was lacto-ovo vegetarian/regular texture/thin liquids. No issues with chewing or swallowing were documented. His typical intake was about 50 to 100%. His relevant medications were Zofran/bowel movement meds, Lorazepam (antianxiety) and Risperidone (antipsychotic). No edema was present. The recommendation was to add Ensure twice daily between meals to aid in weight maintenance and consume foods and fluids as desired for comfort. Meal intake records for November 2022 revealed the resident ate 76-100% of his meals 15 times, 51-75% of his meals 16 times, 26-50% of his meals three times, and 0-25% of his meals nine times. There was no documented meal intake 11/1-11/10/22, on 11/12/22 or on 11/20/22 (12 out of 30 days). The 11/15/22 Nutrition Evaluation documented Resident #43 had a "steady decline since admission of 7.4 lb loss x 2 months, 2.4 lb loss x 1 mo, weight losses unintentional and unfavorable, but anticipated, as resident was admitted to hospice on 10/19/22 (although the resident had been on hospice since admission). Goal for comfort measures now." The evaluation further documented in pertinent part, "In interview was unable to give good usable information. Resident appears moderately nourished, consuming about 50% of meals. On Ensure BID (twice daily) to provide those extra calories and protein to help maintain weights."-There was no evidence of an interview with the resident's wife, who could have shared Resident #43's food preferences, assistance needs, and further nutritional history. The 12/7/22 Nutrition Evaluation documented the resident's most recent weight was 177.6 pounds on 12/4/22. His usual body weight was 190 to 200 pounds. His weight trends were "loss." The resident triggered for "significant weight loss of 7.4% x30 days, 10.8% x 90 days. Weight loss unintentional and unfavorable but expected (due to) recent move to hospice and goal for comfort measures." His estimated nutrition needs were 2421 kcals/day and hydration needs were 2421 ml/day. No chewing or swallowing issues were noted. He needed supervision and setup help with meals and ate in his room. No edema was noted. No nausea/vomiting/diarrhea were noted although there was some constipation. An interdisciplinary team progress note dated 12/15/22 documented in part, "Res(ident) is showing noted weight loss of 14 pounds in 1 month, current weight of 177.6 pounds. Will resume Ensure BID, res is a hospice patient. (Former) DON (director of nursing) will request order for unavoidable weight loss." Meal intake records for December 2022 revealed the resident ate 76-100% of his meals 20 times, 51-75% of his meals 25 times, 26-50% of his meals five times, and 0-25% of his meals nine times. There was no documented meal intake on 12/4, 12/10, 12/11, 12/17, or 12/24/22 (five days). Meal intake records for January 2023 (1/1 through 1/26/23) revealed he ate 76-100% of his meals 16 times, 51-75% of his meals 25 times, 26-50% of his meals eight times, and 0-25% of his meals six times. There was no documented meal intake on 1/7, 1/14, or 1/21/23 (three days). Review of Resident #43's fluid intake records from 11/1/22 through 1/26/23 revealed he consumed less than half his assessed fluid needs. An IDT note on 1/18/23 at 1:55 p.m. documented, "Supervised in dining room and he allows to go." The January 2023 medication administration record (MAR) documented an order for Ensure/Boost for weight maintenance, ordered 9/20/22, which was held from 1/1 to 1/6/23 and discontinued on 1/25/23. Resident #23 consumed 100 percent of this supplement 10 times between 1/18 and 1/25/23. V. Staff interviews CNA #3 was interviewed on 1/25/23 at 3:40 p.m. She said Resident #43 was changed to thickened liquids about three weeks ago, and "does better on the thickened liquids." She said they tried to keep his over-bed table away because he "tries to crawl out of bed and trips." She said she checked on him every two hours, although sometimes it was closer to every three hours, to see if he was sleeping, needed to be changed or wanted to get up. "The only times he ever gets up is when he has in his mind he wants to get up to the bathroom." She said she tried to offer and assist him with fluids every time she checked on him, when he was awake, and he always drank well. She said usually when she set him up for breakfast he ate well. She said it was difficult to assist all the residents who needed help with eating and drinking in a timely manner, due to short staffing. (Cross-reference F725, sufficient nursing staffing.) LPN #3 was interviewed on 1/25/23 at 4:45 p.m. She said since Resident #43 was on thickened liquids and an aspiration risk, they wanted a staff person to be with him for safety when he ate in case he choked. She said it was best if they delivered a resident's tray and set them up to eat immediately. She said Resident #43 could feed himself but did better with thickened liquids because he had a tendency to gulp, and actually vomited as a result the other day. The registered dietitian (RD) and corporate RD were interviewed by phone on 1/26/23 at 3:30 p.m. They said they added Resident #43 to fortified foods because his wife asked to have him removed from liquid supplements. (No documentation of this could be found in progress notes.)They said per his medical record, he had an unavoidable weight loss and was on a general decline. As of 1/3/23, he had a six-pound weight loss from the beginning of December 2022 to January 2023, which was anticipated with his overall disease progression."He still has some variable meal intakes for sure. Overall he ate about 51-100% on those meals and a few do dip down below at 0-25%." The RD said that added cueing and help with his meals could help Resident #43, but she did not specifically care plan for that, and she had not observed him eating. They said they needed to work with the CNAs and nurses on Resident #43's hall to ensure he received the assistance he needed, and they could double check with the kitchen regarding fortified foods. They said they would educate the staff to make sure they were providing all the help Resident #43 could get, and make sure the nurses were putting his food and fluids in front of him as well. They said they could not give him supplements because of his gastrointestinal issues, but fortified foods might help. They acknowledged they did not have a preferences list for him, usually the food service manager should visit with the resident upon admission, but they would talk to the family and get those preferences. They knew only that he was lacto-ovo vegetarian and disliked pork. They said they could also recommend adding snacks. They acknowledged his documented fluid intakes were not good, and said they could add extra fluids throughout the day for hydration purposes as well. They said his antipsychotic medications could be affecting his appetite as well, blunting the appetite, making him sleepier and "a little more out of it." They said they discussed Resident #43 at the last IDT meeting on 1/18/23 but recommended nothing more than what they had just mentioned, and to encourage him to go to the dining room if he would allow. They acknowledged that would be his choice and he should receive the assistance he needed in his room. (See IDT progress note above, which was very brief and did not document that an RD was present.) The dietary manager was interviewed on 1/26/23 at 7:12 p.m. He said Resident #43 was not on fortified foods, for example, added protein. He said he tried to fortify all the foods he served to the residents by adding cream, milk and butter.

Based on observations, record review, and interviews, the facility failed to ensure one (#42) out of one resident who required dialysis care, out of 41 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility:-Failed to blood pressure (BP) measurements were not checked on the right arm where the dialysis fistula/shunt was located; and,-Failed to ensure communication between the dialysis center and the facility. Findings include:I. Facility policy and procedureThe Hemodialysis policy and procedure, dated 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 12:35 p.m., and included the following: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practices. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will coordinate and collaborate with the dialysis facility to assure that the resident's needs related to dialysis treatments are met and there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access device was located. II. Resident #42 statusResident #42, age younger than 60, was admitted on 1/15/2020, and then readmitted on 6/8/22. According to the January 2023 computerized physician orders, diagnoses included diabetes, end stage renal disease, dependence on renal dialysis, and vascular dementia. The minimum data set (MDS) assessment, dated 10/3/22, revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance with most activities of daily living (ADL), had inattention behavior continuously present, and no psychosis or behavioral symptoms. The current MDS failed to identify the resident received the special treatment and program of dialysis while he was a resident. A. Record reviewThe care plan, initiated 1/16/2020 and revised on 1/11/23, identified the resident needed hemodialysis related to end stage renal disease on Tuesdays, Thursdays and Saturdays at a local dialysis center. The approaches included checking and changing the dressing daily at the access site, the Dialysis Communication Record was sent to the dialysis center with each appointment, and return of the form was ensured after the appointment was completed, and do not draw blood or take blood pressure in arm with graft. In addition, the resident would often not let staff remove the dressing after dialysis, and the dialysis wanted a more forceful approach to remove the dressing, but it was explained to the dialysis staff that the resident had the right to refuse. The electronic medical record revealed a section titled, "Tasks," that included resident specific interventions and included ADL care requirements and vital signs information that certified nurse aides (CNA) and nursing staff could refer to for planned care. The documentation did not include specific instructions to not check BPs on his right arm. 1. Current ordersThe CPO revealed the following orders:-Consistent carbohydrate renal diet, no concentrated sweets. The order was started 1/5/23.-1500 milliliter (ml) fluid restriction every 24 hours and document amount consumed every 12 hours. The order was started 1/25/23.-Auscultate and palpate arteriovenous (AV) fistula shunt, check for bruit and thrill x2 in eight hours post-return from dialysis in the evenings every Tuesday, Thursday, and Saturday. The order was started 2/4/21.-Dialysis three times a week at (name of dialysis center) on Tuesday, Thursday and Saturday mornings at 9:00 a.m. Monitor vital signs, weights, nutritional and fluid needs or other restriction, lab results. The order was started 2/1/2020. However, there were no orders with instructions not to check blood pressures on his right arm where the AV fistula was. 2. Dialysis clinic communicationThe Dialysis Communication Forms and dialysis clinic notes were reviewed from 11/1/22 through 1/24/23, and revealed the following:The dialysis clinic notes, dated 11/1/22, documented "Patient came into treatment with soiled briefs that appeared to be old/dried/caked. This has been an ongoing problem."There was no communication form for 11/8/22, 11/10/22 or 11/12/22. The dialysis clinic notes, dated 11/12/22, documented "Patient arrived to treatment on 11/12 with soiled dressing still on access from 11/10."There was no communication form for 11/26/22. There was no communication form for 12/1/22 or 12/3/22. There was no communication form for 12/10/22, 12/17/22 or 12/24/22. On 1/7/23, the dialysis center reported the resident requested to be taken off dialysis early that day. There was no communication form for 1/10/23. In total, there were 10 dialysis appointments during the 85-day period that did not include communication between the facility and the dialysis center. 3. Blood pressure checked on right armThe Blood Pressure Vital Signs Summary was reviewed from 9/17/22 through 1/26/23 and revealed the following:On 9/17/22, the BP was checked on the right arm twice, at 7:58 a.m. and 3:24 p.m. On 9/24/22, the BP was checked on the right arm. On 11/29/22, the BP was checked on the right arm twice, at 8:24 a.m. and 4:06 p.m. On 11/30/22, the BP was checked on the right arm. On 12/1/22, the BP was checked on the right arm twice, at 8:30 a.m. and 4:16 p.m. On 12/6/22, the BP was checked on the right arm. On 12/17/22, the BP was checked on the right arm. On 1/5/23, the BP was checked on the right arm. On 1/10/23, the BP was checked on the right arm. B. Resident observationsOn 1/24/23 at 2:22 p.m., the resident's room was observed and did not include any posted instructions or guidance to not check BPs on his right arm. On 1/25/23 at 5:00 p.m., Resident #42 was sitting in his wheelchair in the hallway near the nurses' station, wearing a short-sleeved shirt that revealed his AV shunt in his upper right arm. It was open to air and appeared clean and dry. On 1/26/23 at 10:16 a.m., Resident #42 was pushed in his wheelchair to the reception area of the facility by registered nurse (RN) #1 to wait for transportation to the dialysis clinic. The Dialysis Communication Form was crumpled up and sticking up out of a bag that was draped over the back of his wheelchair handles. At 10:36 a.m., he left the facility with the transportation service to go to dialysis. III.Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 1/26/23 at 1:50 p.m., and he said CNAs would refer to the electronic medical records "Tasks" section for specific interventions and guidance for each resident for vital signs. He said if there was anything unique to the resident, that was where the information would be located. CNA #6 was interviewed on 1/26/23 at 1:58 p.m., and she said she routinely worked with Resident #42. She said there was not any documentation or Kardex type form for CNAs to follow about resident specific information. She said they verbally told each other during shift report that a BP could not be checked on Resident #42's right arm because of his dialysis catheter. She said if there was something more formal and written down with specific information, she did not know what that was or where she would look. RN #4 was interviewed on 1/26/23 at 6:06 p.m., and she said she had worked at the facility for over 15 years. She said both nursing and CNA staff took vital signs in the facility, and it was not assigned or designated to be completed by either CNAs or nurses. She said she preferred to check the vital signs herself on the residents she cared for. LPN #4 was interviewed on 1/26/23 at 7:54 p.m., and she said she routinely worked with Resident #42. She said both CNAs and nurses check vital signs in the facility, and she showed each of her CNAs his fistula and instructed them not to take the BP on his right arm. CNA #10 was interviewed on 1/26/23 at 7:55 p.m., and she said she knew Resident #42 well. She said residents who had a dialysis catheter should have their BP checked on the opposite arm that the shunt was in, so for Resident #42, it should be checked on his left arm. The DON was interviewed on 1/26/23 at 6:12 p.m. and she said she had worked at the facility for approximately one week. She said she thought communication between the facility and the dialysis clinic was facilitated by a communication sheet that was sent with the resident from the facility, and then returned with them from the dialysis clinic. It should include information such as the resident's blood glucose, vital signs, amount of fluid taken off at dialysis, how the resident tolerated it, and anything significant that happened should be included in the communication. The DON was not yet aware of how effective or ineffective the communication was with the dialysis clinic, and was not aware of any concerns the facility had received regarding Resident #42. She was not aware of the 10 dialysis appointments that did not have communication forms, and said the forms were important and should be looked at by the nursing staff because there should be orders on those. If there were orders, the orders needed to be implemented. If there were no orders included, the nurse needed to note that they reviewed the form, and then it was sent to medical records to be scanned into the resident's electronic chart. The DON said if a resident had an AV fistula in their arm, the blood pressure should be checked in the opposite arm because there was a risk of damaging the dialysis catheter access site. She said she was not aware Resident #42 had numerous BPs checked on his right arm that had his fistula, and said the facility should provide education for the CNAs and nurses on when not to check a blood pressure on a limb, and gave the example for residents who had a dialysis catheter, or perhaps had a mastectomy (removal of breast) and was at risk for lymphedema (swelling due to fluid).

Based on observations, interviews and record review, the facility failed to provide and deploy sufficient nursing staffing to meet the needs of residents in keeping with their comprehensive care plans, and ensure their highest practicable quality of care. Specifically, the facility failed to provide sufficient staffing to provide a dignified and respectful resident environment, keep residents free from abuse, prevent falls and accidents, provide adequate nutrition and hydration, and provide dementia care and services. Findings include: Cross-reference F565, grievances of the resident group involving care and services issues; F600, freedom from abuse; F689, falls and accidents; F692, nutrition and hydration; and F744, dementia care. I. Resident status According to the 1/25/23 Resident Census and Conditions report, 75 residents lived in the facility. For bathing, 37 residents needed assistance of one or two staff and 13 were dependent. For dressing, 69 residents needed assistance. For transfers, 60 residents needed assistance and five were dependent. For toilet use, 63 residents needed assistance and five were dependent. For eating, 71 residents needed assistance. Fifty residents had incontinence, but there were no bowel and bladder programs. Thirty-five residents had dementia and 15 had behavioral health needs. Forty-six residents received psychoactive medications, and 25 residents (one-third of the population) received antipsychotic medications. Two residents had pressure ulcers and six residents had significant unplanned weight loss. II. Resident/family interviews Resident #53 was interviewed on 1/23/23 at 11:28 a.m. and said call light response could take up to an hour, and frequently took 30 to 40 minutes. Staff had "lots of turnovers," so it was hard to get to know staff, "three days a week, always different." The resident said it could be "uncomfortable with personal care" and they felt "embarrassed." Resident #37 was interviewed on 1/19/23 at 10:37 a.m. and said sometimes there was only one certified nurse aide (CNA) to cover the whole south hall. She did not remember when but she talked to the former nursing home administrator (NHA) "about last incident," but she could not recall the last time she had spoken with management. She said the former NHA said they were "trying everything to hire CNAs." She said the longest time she had to wait after using the call light was "45 minutes to an hour." Resident #225 was interviewed on 1/19/23 at 11:11 a.m. She said it sometimes took staff a while to answer her call light, because "they're too busy." She said she had experienced incontinence as a result. Resident #18 was interviewed on 1/19/23 at 11:38 a.m. She said sometimes staff were short-handed and slow getting to her. She said she did not receive baths often enough. Resident #43's wife was interviewed on 1/24/23 at 4:30 p.m. She said she visited almost every day and assisted her husband with lunch or dinner. She said staff had told her they had 35 patients on the South hall and could not just cater to Resident #43 all day. She said they did not have enough staff to assist her husband to eat and drink. Resident #28's wife was interviewed on 1/26/23 at 1:00 p.m. She said she visited daily and assisted her husband with at least one meal. She said they did not have enough staff to assist her husband. "It's hard because the CNAs are running themselves ragged. CNAs can only do so much." III. Staff interviews Registered nurse (RN) #5, who worked in the Willow secure neighborhood on the weekend, was interviewed on 1/22/23 at 12:45 p.m. She was working with one certified nurse aide (CNA) who was passing out lunch trays to residents. She said there were not enough staff and residents were "doing without attention" and residents experienced falls as a result. She said there were no activities staff on Willow on Friday, Saturday or Sunday, and to her, staffing levels were not safe due to resident care needs, fall risks and behavioral issues. She said they could not call on North hall staff to help because they were short-staffed too. She said things were good until the former administration took over, then it became a "nightmare." She said some of their good veteran staff had left and gone to work at other facilities. She said the former interim director of nursing (DON) had been helpful, and the new DON had been back to Willow several times to "check the lay of the land," but normally the managers on duty never stepped foot in the Willow neighborhood. RN #5 said that on Willow, "There should always be two CNAs, but there are not. I know the night nurse has complained too." She said they did not have a good system for alerting staff that they needed assistance, with their antiquated phone system. She said it was impossible for staff to leave for lunch because they would be putting their residents and team members at risk. She said one resident on Willow got agitated and aggressive, so they had to watch him closely. CNA #6 was interviewed on 1/25/23 at 3:40 p.m. She said there were only two CNAs on the south hall and she felt at least three CNAs and an RA (resident assistant) would help out because "there are lots of residents here. There are four residents who need two-person assist on the south short hall. It's hard to manage. Showers get put to the side sometimes. Sometimes I'll have eight showers to do in a day. I've talked to them about getting more CNAs on this hall and they've talked about it. With not as many CNAs it's hard; having the CNA class here has been very helpful." RN #2 was interviewed on 1/22/23 at 2:20 p.m. She said she and CNA #2 were typically the only staff on North hall on the weekends. She said they worked well together and had a system to get residents' needs met, but they had to prioritize care. She said residents were just not getting showers on the weekends because there were not enough staff. CNA #8 was interviewed on 1/24/23 at 9:30 a.m. She said with a full census and two CNAs on North hall, they would have difficulty getting showers done again today (Monday). She said she needed to assist four residents with their meals, who ate in their rooms and had not yet been assisted. She acknowledged their coffee and food could be cold by now. CNAs #8 and #9 and the RA were interviewed on 1/25/23 at 4:30 p.m. They worked on the North hall and said ideal staffing was at least two CNAs. They said they provided resident showers after rounds, refilled water pitchers twice per shift, morning and afternoon. CNA #8 said they tried to do rounds together so they had two people to assist with transfers when needed. They said they thought the night shift team could use another CNA. "She could use someone else and weekends are tough." They said having a bath aide for each side of the building (one each for North & South) would be nice. "Weekends really need more staff." LPN #3 was interviewed on 1/25/23 at 4:45 p.m. She said they usually had two nurses and two CNAs, but needed one extra person on the South hall, "That would be wonderful." CNA #3 was interviewed on 1/25/23 at 4:14 p.m. She said she was often in a hurry because they did not have enough staff. She said she sometimes had to transfer residents with mechanical lifts by herself because there were not have enough staff, not from bed to chair but from chair to bed, because the surface was larger and it was safer. She said it was the same with rolling a resident in bed who needed two-person assistance, that she had had to do this alone because she sometimes could not find another staff person to help her. She acknowledged it was an accident risk but they did not have enough staff to do otherwise and meet residents' needs. She said if someone was going to get hurt, she would ensure it was her, not the resident. She said they had only one CNA at night on each hall, and with that level of staffing residents were neglected. She said they needed three CNAs and an RA on each hall (North and South). LPN #2 was interviewed on 1/25/23 at 5:04 p.m. He said on Thursdays, staffing could be "kind of sketchy because there's only one CNA (on North hall) and that's not enough. He said getting CNAs hired and trained was difficult. "Weekends and nights are a lot worse. One CNA isn't enough. Night shift and weekends it's not enough and residents don't get baths. We need a bath aide for each side (North and South). I've made it very clear to my CNAs, absolutely come grab me and I'll be right there." LPN #1 was interviewed on 1/26/23 at 10:26 a.m. She said they did not have enough staff on South hall, and needed three CNAs and two nurses. The South long hall was the skilled hall and "almost everyone is a two-person transfer." She said, "Anything can happen, especially with the residents on the skilled side being fresh out of the hospital, care would go easier and smoother if there were three CNAs and two nurses. I think three CNAs should be good, but if we had four we could have one doing showers all day." She said, "Staffing could go smoother." She said there had been some call-offs and it was happening more frequently, and sometimes coverage to replace staff call-offs was "limited." She added, "When there's only one CNA (on South hall), there's only so much that person can do. Nurses help out, but we've still got to make sure we handle the medical portion." IV. Leadership interview The interim nursing home administrator/director of operations (INHA/DO), director of nursing mentor, and current interim NHA were interviewed on 1/26/23 at 7:15 p.m. The INHA/DO said ideal facility staffing with current census was:-Three CNAs on South hall with two nurses;-Two CNAs on North hall with one nurse;-Two CNAs on Willow secure unit with one nurse. They said nursing management was frequently in the facility on weekends, and it was up to facility leadership on how to structure staff in the building. They said they did not realize that four residents on North hall needed total assistance with eating until after the fact. They said they were assessing resident preferences for bathing for residents who were missing baths, to ensure they were offering at a time when residents preferred. They said their goal was to have all the residents' preferences assessed week, but they could not do so "because of the survey," but hoped to have it done and updated "next week." She said they reviewed with nursing staff how many staff were needed, would acquire more agency staff if needed, they were doing Indeed resume searches to look for resumes updated within the last two weeks, and were reaching out to get an RA to go through the next CNA class. Staff had been educated. They continually educated staff and reminded them to ask management for help. The INHA/DO said census and acuity were not being considered by the prior NHA. "We're still determining if we have sufficient staff and it's a constant work in progress. We are increasing hourly pay, and looking at doing sign-on bonuses, which we are not opposed to."V. Record review The staffing daily sheets were reviewed from 12/1/22 to 1/26/23. The schedule called for an RA assigned to each of the three halls per shift (three total RAs). Those positions were never filled. The ideal staffing discussed by the INHA/DO for CNAs was never documented as provided. Actual CNA staffing was two for all of South hall, one for North, and one for Willow. The facility failed to provide sufficient nursing staffing to meet the residents' needs.

Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for six (#32, #40, #56, #57, #71 and #226) of nine residents reviewed for mood and behavior out of 41 sample residents. Specifically, the facility failed to effectively identify and implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse. Specifically, to create an environment to: -Provide consistent and engaging group activities when routine activity was not available; and, -Ensure the activity environment was appropriate for all residents in the memory care unit based on the resident ' s comprehensive care plan. Findings include:I. Professional referenceThe Alzheimer's Association Tips for Dementia Caregivers in Long-Term or Community-Based Settings, retrieved on 2/5/23 from: https://www.alz.org/professionals/professional-providers/coronavirus-covid-19-tips-for-dementia-caregivers?_ga=2.60771437.1764019204.1600198071-1912608917.1600198071&_gac=1.254029244.1600198071.eaiaiqobchmiqfd6qvlr6wivqdbach2thgoceaayasaaegl_8pd_bwe. It read in pertinent part,"Nonverbal dementia-related behaviors may be an option or response for a person living with dementia to communicate a feeling, unmet need or intention. These behaviors are triggered by the interaction between the individual and his or her social and physical environment. A response may include striking out, screaming, or becoming very agitated or emotional. The dementia care provider's role is to observe and attempt to understand what the person living with dementia is trying to communicate."Root causes of dementia-related behaviors may include:-Pain.-Hunger.-Fear, depression, frustration.-Loneliness, helplessness, boredom.-Hallucinations and/or overstimulation.-Changes in environment or routine.-Difficulty understanding or misinterpreting the environment.-Difficulty expressing thoughts or feelings.-Unfamiliarity with personal protective equipment or clothing, such as gowns or masks.""Strategies to observe and respond to dementia-related behaviors include:-Rule out pain, thirst, hunger or the need to use the bathroom as a source of agitation.-Speak in a calm low-pitched voice.-Try to reduce excess stimulation.-Ask others what works for them.-Validate the individual's emotions. Focus on the feelings, not necessarily the content of what the person is saying. Sometimes the emotions are more important than what is said.-Understand that the individual may be expressing thoughts and feelings from their own reality, which may differ from generally acknowledged reality. Offer reassurance and understanding, without challenging their words, can be effective.-Through behavioral observation and attempted interventions, try to determine what helps meet the person's needs and include the information in the individualized plan of care.-Be aware of past traumas (veterans, abuse survivors, survivors of large-scale disasters). Never physically force the person to do something."Proactive strategies for addressing dementia-related behaviorsIt can be difficult to anticipate and respond to dementia-related behaviors in a changing environment-especially in emergency situations. However, applying some of the following strategies may help:-Provide a consistent routine.-Use person-centered care approaches for all individuals living with dementia during activities of daily living-every interaction or task is an opportunity for engagement.-Promote sharing of person-centered information across the care team.-Encourage all staff to treat individuals living with dementia with dignity and respect.-Put the person before the task."II. Facility policy and procedureThe Dementia care policy and procedure, revised January 2023, was provided by the facility on 1/26/23. The policy read in pertinent part: "Is the policy of the facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia to meet his or her highest practical, physical, mental and psychological well-being. According to the policy the facility would access, develop and implement care plans through the interdisciplinary team approach that included the residents, their family, and/or resident representative to the extent possible. The care plan goal would be achievable and the facility would provide resources necessary for the residents to be successful in their goals. Care and services would be person-centered and reflect each residents individual goals while maximizing the residents ' dignity, autonomy, privacy, socialization, independence, choice, and safety. III. Resident to resident altercation on 12/18/22 between Resident #56 and Resident #32A. Resident status 1. Resident #56Resident #56, age 83, was admitted on 10/31/22. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, major depression, and unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident exhibited disorganized thinking. The resident required extensive physical assistance of one person for transferring, dressing, and toileting. The MDS assessment revealed the resident required limited physical assistance of one person for bed mobility, walking in his room, walking in corridor, locomotion on and off the unit. 2. Resident #32Resident #32, age 95, was readmitted on 12/6/22. He resided in the secured/memory care unit. According to the January 2023 computerized physician orders (CPO), diagnoses included delirium due to known physiological condition, and unspecified dementia with unspecified severity without behavioral disturbance. The 12/13/22 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. The resident exhibited inattention, disorganized thinking and an altered level of consciousness. The resident did not exhibit behaviors of concern during the seven day assessment period. B. Record reviewThe 10/31/22 Morse fall scale for Resident #56 identified the resident was a high fall risk. According the scale, Resident #56 has a history of falls, did not use ambulatory aids, exhibited weak gait and was forgetful of his own safety limits. The fall care plan, initiated on 11/1/22, read Resident #56 was a high risk for falls. The care plan directed staff to anticipate and meet his needs. Additional fall interventions were not implemented until after 12/27/22.-The review of the resident ' s fall care plan and comprehensive care plan did not identify the resident needed limited physical assistance of one person for ambulation including in his room as it was last identified in the 11/10/22 MDS assessment. An investigation of alleged physical abuse was initiated on 12/18/22. According to the investigative record, Resident #32 was in bed when his roommate (Resident #56) was documented to trip over Resident #32 ' s walker and hit Resident #32 in the face on 12/18/22 at 6:30 p.m. The investigation identified Resident #32 had injuries to his face as a result of Resident #56 tripping on his roommate's walker and then hitting him in the face. The 12/18/22 change of condition/situation-background-assessment-recommendations form (SBAR) for Resident #56 read Resident #56 started talking fast and oddly, stating "Everyone wants to kill me." According to the note, Resident #56 standing over Resident #32, punching Resident #32 in the face. The 12/20/22 administration note for Resident #56, read Resident #56 was pacing and "staring down" another resident. The resident was placed on one-to-one monitoring and implemented a medication change to help with his agitation. The behavior care plan for Resident #56 , initiated 1/21/23, identified Resident #56 had the potential to be physically aggressive towards others related to his dementia. -The care plan did not identify the resident had an actual resident to resident altercation. The physical aggression care plan was initiated over one month after the 12/18/22 physical altercation. The 12/24/22 nursing note for Resident #32 read Resident #32 did not want to remain at the facility. According to the note, Resident #32 was afraid and not sleeping well after being hit. The 12/27/22 nursing note read Resident #32 still spoke about feeling fearful after being punched. The review of the January 2023 care plan did not identify the resident was at risk for abuse, the resident had an actual resident to resident altercation, or how to support the resident after the physical altercation. IV. Resident to resident altercation between Resident #40 and Resident #71A. Resident status 1. Resident #40, age 73, was admitted on 9/7/22. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included neurocognitive disorder with Lewi bodies and anxiety disorder. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. The resident did not exhibit inattention or disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. 2. Resident #71, age 81, was admitted on 12/22/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 12/30/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS) score of two out of 15. The resident exhibited inattention and disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. B. Record review The review of the progress notes for Resident #40 between 12/15/22 and 1/10/23 read he had several incidents of verbal and physical aggression towards residents and staff lead up the a physical altercation between Resident #40 and Resident #71. The resident continued to have behaviors after the altercation. The December 2022 and January 2023 progress notes also identified the resident was experiencing gentital discomfort from a chronic condition and had an appointment/ procedure addressing the condition pending, potentially escalating his behaviors. An investigation of alleged physical abuse was initiated on 1/10/23. According to the investigative record, Resident #40 was witnessed to be agitated and pacing the halls when he saw Resident #71 and "struck her on the back" on 1/10/23 at 6:15 p.m. The physical aggression care plan, initiated 1/21/23, read Resident #40 had the potential to exhibit physical aggression towards staff and other residents. According to the care plan the resident had the potential to yell and cuss at others The care plan read the resident would quickly pace when agitated and could be difficult to be redirect. The care plan directed staff to take the resident for a walk if the resident was overstimulating. Observe the resident for any potential triggers that may increase the resident ' s agitation such as noise level, overstimulation, other residents entering his space. Offer the resident his own place to sit in the dining room/activity room, as sage distance from other residents. -The care plan was not initiated until survey and after the resident had ongoing behaviors of physical and verbal aggression towards residents and staff leading up to the altercation. -The care plan did not identify the resident had an actual physical altercation with another resident. The review of the comprehensive care plan for Resident #40 identified the resident ' s gentital discomfort (as identified in progress notes) was not included in the resident ' s care plan until 1/20/23, during the survey. The intervention, initiated on 1/24/23, read his testicle enlargement could cause the resident agitation. The physical aggression care plan for Resident #71, initiated 1/20/23, read Resident #71 received physical aggression from another resident. The care plan directed staff to provide reassurance, monitor, redirect, and offer meaningful activities. V. Incident #2 and #3 with Resident #57 and Resident #226A. Resident status 1. Resident #57, age 71, was admitted on 9/7/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke ' s encephalopathy (a brain disorder causing confusion), anxiety disorder and delusional disorders. The 12/19/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident exhibited disorganized thinking and inattention. According to MDS assessment, the resident exhibited physical and verbal behaviors directed towards others. 2. Resident #226, age 62, was admitted on 12/9/22. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, early onset, bipolar disorder, and unspecified dementia with unspecified severity with agitation. The 12/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident exhibited disorganized thinking and inattention. The resident exhibited physical and verbal behaviors directed towards others, impacting their care and social interactions. According to the MDS assessment, Resident #226 put others at significant risk for injury. B. Record review 1. Incident on 12/11/22 between Resident #226 and Resident #57The 12/11/22 at 4:00 p.m. behavior note documented in the medical record of Resident #226 read Resident #226 was very anxious, and briskly pacing in and out of rooms, and up and down the hall. According to the note, a resident (Resident #57) started to yell at her. Resident #226 proceeded to throw juice at Resident #57. The 12/11/22 at 4:02 p.m behavior note documented in the medical record of Resident #57 read Resident #57 felt frustrated regarding the juice altercation and needed to be cleaned up. The 12/11/22 investigation of a resident to resident altercation read the facility was to create a non-pharmacological plan to assist with the behaviors of Resident #226. The 12/12/22 at 4:57 a.m. behavior note for Resident #57 identified the resident had an increase in behaviors following the incident. The behavior note read Resident #57 got out of bed several times throughout the shift, wandering the hallway and exit seeking. According to the note, the resident would be verbally abrasive and "shoot the finger" several times when the staff guided her back to her room. The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #226 indicated the behaviors between Resident #226 and Resident #57 escalated. The note read Resident #226 was leaving an activity when another resident (Resident #57) said a few "grumpy things" to Resident #227. Resident #226 "lightly slapped" Resident #57 ' s face and walked away. The behavior care plan, initiated on 12/27/22, read the resident had potential for physical and verbal outbursts related to her dementia, bipolar disorder, and poor impulse control. The care plan was not initiated until the resident had two resident to resident altercations. The behavior care plan, initiated on 1/24/23, read the resident had the potential to become verbally or physically aggressive towards other residents. Her care plan goal was to not harm or be harmed by others. The care plan did not identify the resident had actual physical altercation. The care plan read to encourage the resident to participate in activities throughout the day redirected the resident to painting (see observation below), coloring, walks or one to one visits. -The behavior/aggression care plan was not initiated until 1/24/23 during the survey. The activity care plan, initiated on 9/18/22, read the resident preferred to go to activities such as arts and crafts, color art, balloon toss or other group activities. According to the care plan the resident needed activities that were appropriate for her ability level and needed assistance to attend the activities. VI. Resident #57 activity observation and interview On 1/23/23 at 3:50 p.m. Five residents were observed in the activity room/dining room. One of the residents was watching television and another played with puzzle blocks. The two residents looked around the room with purposeful direction and one resident slept. -At 4:05 p.m. Resident #57 and two residents entered the memory care unit with the AD. The AD said the residents were at a music program off of the unit. -At 4:09 p.m. the activity director informed the resident in the lounge they were going to have a painting/coloring group. The AD assisted residents to tables in the activity/dining room. The group included three residents.-At 4:12 p.m. Resident #57 said she wanted to paint and sat down at the table. The AD provided her with a piece of paper. -4:17 p.m. Resident #57 requested a bigger paint brush. The AD told her she would have to get one off the unit. Resident #57 said she wanted to go with the AD. The AD escorted her and two hall residents of the unit. The painting group disbursed. One resident walked around the activity room holding her blank sheet of paper. -At 4:23 p.m. the AD returned with the three residents and left the unit. -At 4:25 p.m. Resident #57 asked the certified nurse aide (CNA) where the AD went because she (the resident) could paint. The CNA said the AD went to get something. -At 4:27 p.m. Resident #57 told her tablemate "All I said to her (AD) was ' I want to paint. ' I had to ask for a brush. I have no idea what they wanted, she just told me to paint. Resident #57 held up her blank piece of paper and said to her tablemate, "See this pretty picture I painted, wait, where did it go?" -At 4:32 p.m. the AD returned with ice cream and went to the nurses station to prepare it for another resident. -At 4:39 p.m. Resident #57 asked CNA #9 for help with painting set up and was having difficulty with her paper. The CNA informed the AD. The AD told Resident #57 that she would find her watercolor paints. -At 4:40 p.m. the AD left the unit. Residents who wanted to paint were walking around the unit without engagement. -At 5:02 p.m. The AD returned to the unit. Most of the residents who wanted to paint were walking around the activity room and hall. A resident asked the AD for coffee when she returned to the unit. The AD proceeded to get coffee for the resident. The AD did not set up Resident #57 with watercolor painting. -At 5:15 the AD sat down at the computer to chart and socialized with the staff at the nurse ' s station. Several residents walked around the unit waiting for dinner and asking for snacks and water. Resident #57 was interviewed on 1/24/23 at 5:07 p.m. She said she liked to stay busy and liked to paint. She said everything kept changing. The resident did not elaborate on what kept changing. VII. Staff interview Activity assistant (AA) #1 was interviewed on 1/25/23 at 8:47 a.m. The AA #1 said she normally worked Monday through Thursday but was on vacation so she was not available on 1/23/23. She said it was important for residents in the memory care unit to stay in engaged. She said staff needed to be prepared for the activities so residents could be engaged. The interim nursing home administrator/director of nursing (INHA/DO) was interviewed on 1/26/23 at 6:54 p.m. The INHA/DO said the facility was always looking at how to improve dementia care and would be focusing on dementia care interventions. She they were trying to focus on person centered interventions, staff education, meeting staffing needs. She said the facility identified the need for increased behaviors in the afternoon. She said they always try to have two CNA ' s on the unit and during that they have an activity aide and or the life enrichment coordinator. She said they were also working on utilizing a resident assistant as extra one-to-one supervision. She said the facility identified an increase in incidents of resident to resident altercations and falls on the dementia unit so AA #1 was scheduled in the memory care unit because of her strong ability to engage them. The INHA/DO said activities on the unit were important because the residents need to stay engaged. She said meaningful engagement reduced the risk of negative resident interactions and behaviors. She said activities promote the best quality of life and were included as intervention to help reduce resident to resident altercations. The observations on the AD on the memory care unit was reviewed with the INHA/DO. The INHA/DO said the AD did not spend a lot of time on the memory care unit. She said the former NHA did not help the department heads such as the AD, so they could identify and correct concerns. The INHA/DO said the facility was looking on during dementia specific training and CPI (crisis prevention institute) training for facility staff. The activity director was interviewed on 1/26/23 at 9:19 a.m. The AD said her job was to provide mental, social, and physical well-being to the residents and provide quality of life and happiness. She said residents ' who have cognitive difficulties need to have activities structured to their individual needs and abilities. She said some residents could be just set up with an activity and walk away, other residents needed to have more help. She said the main thing was to make sure there was a good setup for the activity. The AD said the majority of residents in the memory care center could not self initiate their own activities and had short attention spans. She said many of the residents needed someone to guide them in the activity. The AD said she has had dementia training. The AD said she learned activities could help with behavior by calming the residents, offering them walks and redirecting the behavior. She said a behavior is just an unmet need and the staff needed to find out what the need was. The AD said activities could also help resident altercations and fall prevention by providing extra supervision, making sure the residents were comfortable and had lots of attention. The AD said the residents on the memory care unit would benefit from an ongoing activity program but sometimes she and her staff are having to run back and forth between the memory and the main unit. She said the situation had recently improved but for a while they were pulled in multiple places such as helping residents with smoke breaks, personal shopping, and banking. She said she had also recently hired new staff. The AD said when they did not have enough activity staff coverage they tried to to bring some of them to some of the activities of the unit but it was hard to try to meet all the residents' needs for residents that reside in memory care unit and residents not in the unit so sometimes the activity staff would just try to check on them. She said when someone was on vacation or when someone was ill, she tried to cover the activities as much as possible.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 16%, or four errors out of 25 opportunities for error. Findings include:I. Facility policy and procedureThe Medication Administration and General Guidelines policy and procedure, dated November 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 6:53 p.m. It included medications were administered as prescribed, in accordance with State regulations using good nursing principles and practices. The proper steps in the administration of medications included adherence to the six rights of medication administration including:1) Right dose2) Right route3) Right resident4) Right Medication5) Right time6) Right documentation II. Medication error observations and interviews A. Licensed practical nurse (LPN) #3 was observed preparing and administering medications to Resident #42 on 1/25/23 at 5:13 p.m. The resident's order was for insulin Lispro solution 100 units/milliliter; inject seven units subcutaneously three times a day. Call doctor if BG (blood glucose) is less than 80 or consistently above 450. Hold if BG is less than 120. The order was started 1/5/23. According to the manufacturer's specifications, provided by the INHA/DO on 1/26/23 at 6:53 p.m., the following steps should be taken prior to administering the medication:"Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and '0' is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps."At 5:22 p.m., the LPN dialed seven units into the dose knob on the pen and administered the insulin to the resident. She did not prime the pen prior to injection. LPN #3 was interviewed on 1/25/23 at 5:24 p.m. She said she did not routinely prime insulin pens prior to dialing in the amount of insulin that was ordered to be administered and stated, "Only when the pens are brand new." She said she had not been taught to prime insulin pens prior to administering the insulin, and was not aware that they needed to primed. B. Registered nurse (RN) #1 was observed preparing and administering medications to Resident #18 on 1/26/23 at 9:18 a.m. The resident's order was for Aspirin tablet 325 milligrams (mg) by mouth one time a day for maintenance. The order was started on 1/6/23. The RN poured out one aspirin tablet into a soufflé cup from an over-the-counter bottle with a label that read, "81 mg chewable" aspirin and administered it to the resident at 9:21 a.m. She did not give the ordered dose of the medication. RN #1 was interviewed at 9:52 a.m. and said, "I made a med error." She searched through the medication cart and found an over-the-counter bottle of aspirin tablets, 325 mg that should have been given to the resident instead of the 81 mg tablet. She said when a medication error was made, she would need to fill out an SBAR (Situation, Background, Assessment, Recommendation) form, contact the doctor, and inform the resident and the family of the error. RN #1 said she was a new nurse at the facility and had been working there for a short time. She said she had worked on all of the neighborhoods so far, but had not been there long enough to have any type of routine and that was difficult for her. She said her training and orientation to the facility was "brief," and had never worked on her current hall before. C. RN #1 was observed preparing and administering medications to Resident #18 on 1/26/23 at 9:18 a.m. The resident's order was for Metamucil Fiber Packet (psyllium, bulk-forming laxative); Give 3.4 grams by mouth one time a day for constipation. The order was started on 1/6/23. The RN said the facility did not have Metamucil Fiber Packets in stock, so she picked up a bottle of Clear Lax (polyethylene glycol powder, an osmotic-type laxative), measured out 17 grams and diluted it in approximately six ounces of water. The RN administered the Clear Lax to the resident at 9:20 a.m., and did not give the ordered dose of the medication. RN #1 was interviewed at 9:52 a.m., and said the Clear Lax did not contain the ordered 3.4 grams of fiber that was ordered and a traveling agency nurse who oriented her had instructed her that Clear Lax was what they were supposed to use instead. She said the two medications were not the same or interchangeable, and said she had made another medication error. She said she would fill out an SBAR form, contact the doctor, and inform the resident and the family of the error. D. RN #1 was observed preparing and administering medications to Resident #18 on 1/26/23 at 9:18 a.m. The resident's order was for Vitamin D3 tablet, give 1,000 units by mouth one time a day for a supplement. The order was started on 1/6/23. The RN searched the cart for the medication but was unable to locate it. She looked in the medication cart on the neighboring hall and in the medication storage room, but was unable to find the Vitamin D3 tablets in the 1,000 unit dose. The RN said she would have to search for the correct dose and the medication was not administered to the resident. At 6:33 p.m., the minimum data set coordinator (MDSC) was asked if the medication had been located and given to the resident that day and she said it had not been. She said if medications were not available to be administered to residents, a progress note should be written by the nurse, and that was not completed either. III. Director of nurses (DON) interviewThe DON was interviewed on 1/26/23 at 6:12 p.m., and she said she was new to the facility and had been working as the DON for approximately one week. She said new nurses to the facility needed at least two to three days of orientation with the medication cart in order to become familiar with the residents, their medications, and the electronic medication administration record. The DON said insulin pens were supposed to be primed with two units of insulin prior to injecting the ordered amount of insulin in order to ensure air was purged from the syringe and that the correct amount of medication was administered. The DON said the LPN made a mediation error by not priming the insulin pen and should write an incident report about the error, document what happened, notify the physician, the family, the DON and write a progress note about it. The DON said she was not yet familiar with how the facility ensured medications were available for nurses to administer to the residents at their scheduled times, and said they received daily deliveries from the pharmacy every evening. She said if an over-the-counter medication was running low, they could send someone to the store to buy it. Otherwise, there was a piece of paper located in the medication storage room where nurses were supposed to write down over-the-counter medications when they were getting low on the supply, and then a staff member would purchase them. The DON said RN #1 had made a medication error when she administered 81 mg of aspirin instead of the ordered 325 mg, and had not been informed of the error by the nurse. The DON said Metamucil fiber packets and Clear Lax were not the same medication and were not interchangeable. She said she was not aware of an instruction for nurses to give the Clear Lax as a substitute for the Metamucil, and considered it a medication error. The DON said the Vitamin D3 1,000 unit dosage was not currently in stock in the facility, but should be available for nurses to give, since it was an ordered medication. She had been made aware of the omitted medication approximately one hour prior and considered it a medication error because the medication had not been given.

Based on observations, record review and staff interviews, the facility failed to ensure one (#42) of 10 residents reviewed for medication administration of 41 sample residents were free from a significant medication error that involved insulin. Specifically, the insulin pen was not primed prior to injection for Resident #42. Findings include:A. Facility policy and procedureThe Medication Administration and General Guidelines policy and procedure, dated November 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 6:53 p.m. It included medications were administered as prescribed, in accordance with State regulations using good nursing principles and practices. The proper steps in the administration of medications included adherence to the six rights of medication administration including:1) Right dose2) Right route3) Right resident4) Right Medication5) Right time6) Right documentation B. Medication error 1. Observation Licensed practical nurse (LPN) #3 was observed preparing and administering medications to Resident #42 on 1/25/23 at 5:13 p.m. The resident's order was for insulin Lispro solution 100 units/milliliter; inject seven units subcutaneously three times a day. Call the doctor if BG (blood glucose) is less than 80 or consistently above 450. Hold if BG is less than 120. The order was started 1/5/23. According to the manufacturer's specifications, provided by the INHA/DO on 1/26/23 at 6:53 p.m., the following steps should be taken prior to administering the medication:"Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and ' 0 ' is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps."At 5:22 p.m., the LPN dialed seven units into the dose knob on the pen and administered the insulin to the resident. She did not prime the pen prior to injection. 2. LPN #3 interviewLPN #3 was interviewed on 1/25/23 at 5:24 p.m. She said she did not routinely prime insulin pens prior to dialing in the amount of insulin that was ordered to be administered and stated, "Only when the pens are brand new." She said she had not been taught to prime insulin pens prior to administering the insulin, and was not aware that they needed to be primed. C. Director of nurses (DON) interviewThe DON was interviewed on 1/26/23 at 6:12 p.m., and she said she had been working at the facility as the DON for approximately one week. She said new nurses to the facility needed at least two to three days of orientation with the medication cart in order to become familiar with the residents, their medications, and the electronic medication administration record. The DON said insulin pens were supposed to be primed with two units of insulin prior to injecting the ordered amount of insulin in order to ensure air was purged from the syringe and that the correct amount of medication was administered. The DON said the LPN made a mediation error by not priming the insulin pen and should write an incident report about the error, document what happened, notify the physician, the family, the DON and write a progress note about it.

Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure:-Resident food was palatable in taste, texture, appearance and temperature; and, -Meals were served at a palatable temperature. Findings include:I. Facility policy The Quality and Palatability policy, revised September 2007, was provided by the corporate dietary manager (CDM) on 1/25/23 at 2:44 p.m. The policy read in pertinent part: "Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet residents' needs." The policy defined food attractiveness as the appearance of the food when served to residents. The policy defined "food palatable" as the taste and/or flavor of the food. The policy defined "proper (safe and appetizing) temperature" as food at the appropriate temperature as determined by the type of food to ensure resident satisfaction and minimize the risk for scalding and burns. II. Resident interviewsResident #53 was interviewed on 1/19/23 at 10:25 a.m. He said the food was "garbage" till the last couple months. He said the dietary department now had a new crew and the food was better than before but still could use a lot of improvements. Resident #53 said the food was often cold. He said in general he did not like most of the meal options available so he would usually just order a cheeseburger. He said the meals frequently change from what was advertised on the menus. The resident said the menus note the meals were subject to change without notice but then he did not know what would be served that day. Resident #4 was interviewed on 1/19/23 at 10:25 a.m. He said the food often had no flavor, bland. Resident #37 was interviewed on 1/19/23 at 10:53 a.m. She said the food was served hot in the dining room, but for room trays "lunch and dinner are sometimes cold because there are not enough staff to serve residents in their rooms. They need more people working in the kitchen." Resident #225 was interviewed on 1/19/23 at 11:11 a.m. Her oatmeal from breakfast was still on her bedside table, and looked cold and hardened. She took a very small bite and said she would "have to give it up." She said the food was not good. She had a large box of snacks at her bedside which contained homemade cookies and candy. Resident #18 was interviewed on 1/19/23 at 11:38 a.m. She said the food was "slopped in the plate and doesn't look appetizing or they give you way too much and you don't want to eat it. It doesn't taste like my cooking. I always used a little garlic and a little bit of different stuff and it gave it a little bit better flavor." She said she preferred smaller portions but did not receive them. Resident #125 was interviewed on 1/19/23 at 11:44 a.m. She said the alternate meals every day were hot dog, grilled cheese, or a hamburger, no other alternates were offered for meals. She said today's lunch was cheese pizza, garlic bread, salad, canned fruit, and no alternative was given. Last night nurses brought her apple slices and peanut butter. She said yesterday's lunch (1/18/23) was only two chicken fingers; they did not offer an alternative meal. Last night (1/18/23) they brought shredded pork, no bun on the menu. Instead they brought ground pork with a dollop of mayo on top of a slice of white bread, canned fruit cocktail, and cooked cabbage. "They said they were offering pulled pork." She said they brought snacks when she requested them. She asked for soda, but a CNA told her they did not have soda. Resident #27 was interviewed on 1/19/23 at 1:58 p.m. She said she needed larger portions of food. She did not get enough to eat and had to provide foodon her own. She was eating a large portion of what looked like beans and rice or thick gumbo, and said this was leftover food that dietary staff gave to her. Resident #28's wife was interviewed on 1/22/23 at 1:41 p.m. She said, "Food service here is terrible; sometimes lunch is served at 2:00 p.m." She said she came in and assisted her husband with his lunch every day, and she could see "they don't have enough dietary staff."Resident #34 was interviewed on 1/22/23 at 2:00 p.m. He said, "The food here is crummy. I've been trying to get them to change dietary companies for years. They buy the cheapest stuff they can, no fresh fruits and vegetables." He said he had to buy his own food at the store. "By the time you get bananas (in the facility) they're usually black because Sysco (food vendor) stores them next to the freezer. The food's getting worse and worse. They say they'll change the menus but they just change the names. All the meals are getting later and later, most of the time they're just reheating stuff."Resident #53 was interviewed again on 1/24/23 at 9:27 a.m. He said he was just finishing his breakfast and it was served late but usually was. He said the breakfast was better today but his coffee was cold. Resident #19 was interviewed on 1/24/23 at 9:36 a.m. She said her breakfast this morning was ice cold, but she was able to eat a little bit. Resident #52 was interviewed on 1/24/23 at 1:30 p.m. She said the facility had a new cook and for a short time, the food tasted better. However, she said now she was not able to eat some of the food provided because it was not seasoned at all and was bland. She said the French fries were "always cold." She said if her food was not hot when it was served, she was not going to eat it. She explained that she could ask the staff to reheat it, but then it was a matter of waiting 10 minutes or more before she could eat. She said the ice cream had to be eaten right away because it was "already like soup" when it was served to her with her meals. She said powdered eggs were served for breakfast every morning and she did not like those; she preferred to eat a muffin, coffee cake or a donut instead, and would like to have those options. The resident explained white rice was served multiple times each week and it would be nice to have a variety of brown or fried rice to choose from. III. Record reviewA. Meal timesThe dietary manager (DM) provided the posted daily meal times on 1/23/23. Meal posting read:-Breakfast served at 7:45 a.m. -Lunch is served at 11:45 a.m.-Dinner served at 4:45 p.m. B. Menu The lunch menu was provided by the dietary manager on 1/23/22. The 1/24/23 lunch menu indicated in the meal preparation and service observation:-Chicken salad sandwich; -Potato chips;-Hearty vegetable soup; and, -Broccoli salad (The broccoli salad was not served, see below)III. ObservationsA. Meal delivery The dining meal times of actual service was observed on the memory care unit and on the North hall. Observations identified the meals were served after the posted times (identified above.) In the memory care unit, the residents frequently had to wait to be served after the meals arrived as staff became available. On 1/19/23 at 12:21 p.m. the dietary manager dropped off the covered food cart on the memory care unit. -At 12:23 p.m. the CNA #9 started encouraged and assisted residents to the to the dining tables-At 12:32 p.m. CNA #12 began passing meal trays to residents in the memory care unit dining room. On 1/23/23 at 5:30 p.m. residents in the memory care unit are observed walking around the dining room. Residents began asking for snacks and water. -At 5:33 p.m. the diner meal cart arrived in the memory care unit. The residents were assisted to their table. -At 5:36 p.m. the activity director (AD) begins passing out one tray to a resident in the memory care unit. -At 5:38 p.m. the AD passed the second tray out to another resident. No other staff member was available to assist passing the trays. -At 5:43 p.m. the AD passed the third tray. The CNAs were then available to help pass the rest of trays after assisting a resident in a resident room. On 1/24/23 at 8:48 a.m. on the memory care unit the meal cart arrived. The activity assist (AA) identified not all needed food items were on the cart. The AA left the unit to go to the kitchen. At 8:55 a.m. the AA returned to the unit and the first meal tray was served. Additional meal trays followed. On 1/24/23 at 8:58 a.m the breakfast cart arrived in the North hall for room delivery. Most residents in the main dining room were already done with their breakfast. B. 1/24/23 meal preparation and test tray Observations of the meal lunch preparation and plating was conducted on 1/24/23 between 11:15 a.m. and 1:04 p.m. The observation identified the dietary staff had difficulty bringing the temperature down of their cold meals items, specifically the salads. The dietary staff could not bring the temperature down of the planned broccoli cold salad, identified from the menu, so they quickly prepped a garden salad to replace the broccoli and requested the registered dietitian (RD) sign off on the change. The dietary staff also struggled to get the temperature down of the chicken salad sandwiches so they placed the sandwiches back in the refrigerator and would retrieve a couple at a time when plating. The difficulty with cold item temperatures slowed the meal service down and also impacted the temperature of the meals served to residents and the type of salad offered to the residents. A test tray was requested on 1/24/23 in response to residents' concerns of poor taste and temperature of the food. The test tray was the lunch meal of hearty vegetable soup, a garden salad and a chicken salad sandwich. On 1/24/23 at 1:04 p.m. the dietary manager plated and covered the test tray.-At 1:05 p.m. the test tray arrived in the North hall to be picked up as the last resident room tray.-At 1:15 the last resident room served at the test tray was picked up.-At 1:17 p.m. test tray temperatures were conducted. The garden salad, identified as a cold item was 56.8 degrees Fahrenheit (F);The chicken salad, identified as a cold item, was 60.6 degrees F. The vegetable soup, identified as a hot item, was 93.4 degrees F.-The cold items were above palatable temperatures for cold items and the soup was below palatable temperature for hot items. The appearance and taste of the food items were also reviewed. The vegetable soup was not appetizing in temperature, taste and appearance. The soup was lukewarm in temperature. The broth was watery and all the vegetables rested at the bottom of the bowl. The vegetables were bland in color and difficult to distinguish what type of vegetables they were but most of the vegetables had the appearance of canned green beans. Most of the vegetables tasted like each other and bland. The broth of the soup was salty. C. Room traysDuring lunch in the main dining room on 1/19/23 at 12:42 p.m., the meal was pizza, tater tots, salad, ice cream and canned fruit cocktail. A few residents had cheeseburgers. Resident #23 said they were served "too much processed food and not enough fresh." She said it was not the kitchen staff's fault, because they worked very hard, but because of "corporate, the kitchen is limited in what they can buy and provide." Resident #18 said the tater tots were greasy and she could not eat them. 1. Lunch observations of room tray service on 1/24/23 revealed: The first lunch tray was served in the dining room at 12:03 p.m. and the drink cart was being passed throughout the dining room. At 12:06 p.m., lunch trays were brought out one at a time with multiple staff serving the residents. At 12:16 p.m., Resident #23 said, "See why we need more help in here?" She was getting items for another resident and said, "We need somebody to cut open salad dressing packets." She added, "This chef is the best thing that's happened to us and he comes from (a city an hour and a half away). The residents love him. He'd get them anything they want, make them something special." A staff person walked by and told Resident #23 she needed a walkie-talkie. Resident #23 returned to the table and told a resident the dietary staff were making her "something special." At 12:26 p.m., most of the residents in the dining room had been served and were eating. -A tray cart was delivered to the Willow secure neighborhood at 12:42 p.m. The second meal cart went to the South hall at 12:49 p.m. At 12:51 p.m., two CNAs were passing trays to resident rooms on South hall. -At 1:02 p.m. the third meal cart was delivered to the North neighborhood. -At 1:08 p.m. Resident #28's wife was starting to assist him with a pureed meal of mashed potatoes with gravy and pale brown meat. The meal was brown and there were no vegetables. She tasted the meat and said she could not tell what it was. She said the milk was still cold, but the ice cream was melted on the bottom and soft when she opened it. She said she "might have to do like yesterday and go get a frozen one." Resident #28's roommate, Resident #64, had his meal on his over-bed table but he was sound asleep. He was dependent for eating. 2. Breakfast room tray service observations on 1/26/23 revealed: -At 9:08 a.m., the room tray cart was observed on South hall. The oatmeal was uncovered. Three CNAs were passing out trays to residents. -At 9:15 a.m. Resident #43's breakfast tray was in front of him on his over-bed table and he had eaten most of it. He said he had enough to eat and requested another orange juice. His CNA said she could go to the kitchen to get some and would do so after passing the tray she was holding. She returned at 9:24 a.m. with a glass of juice for Resident #43. At 9:32 a.m. he was resting with his eyes closed; his over-bed table was pushed away from him against the privacy curtain. -At 9:34 a.m. Resident #64, who was dependent for eating, was sleeping. His untouched breakfast was on his bedside table. -At 9:35 a.m. breakfast trays were being passed on the North neighborhood by CNA #3 and CNA #13, who told CNA #3 there were no drinks on the meal cart. CNA #3 said she would have to go back to the kitchen, "That's what they do" (send out meal trays without drinks). One resident said he needed a second milk and she said she was going to get it. CNA #13 asked if she was going to get drinks for everyone or if she was just going for one person. CNA #13 said it was her first day here and she had been a CNA for a long time but "it's just the disorganization." CNA #13 continued to pass trays to residents' rooms. At 9:41 a.m. CNA #3 returned with six drinks including one milk and five juices. Only the one milk was covered. The life engagement coordinator (LEC/CNA) approached CNA #3 and said "everything should be covered." She handed CNAs #3 and #13 a stack of lids for the drinks and oatmeal. CNA #3 said the oatmeal was always sent out uncovered; "That's how the kitchen does it." -At 9:49 a.m., the LEC/CNA began to assist with passing out breakfast trays. She asked CNA #3 to go assist Resident #2 who needed to be assisted with their meal. At 9:51 a.m., CNA #13 had just begun assisting Resident #64, who was dependent for eating. CNA #3 was observed going back to the kitchen, saying Resident #2 asked for a cup of coffee. -At 9:54 a.m., the LEC/CNA was taking a tray out of the meal cart with an uncovered cup of coffee. She said all the residents who requested coffee should have had it on their trays. She said coffee should be covered and she hoped it was hot. If not, she said she would warm it up for the residents. D. Staff interview Registered nurse (RN) #5 was interviewed on 1/22/23 at 12:45 p.m. She said she worked on the Willow secure unit on the weekends. She said, "I've been complaining about meals forever because food portions are too small, unattractive and ice cold." She said she had filled out concern forms weekly for about a year. She said the kitchen staff did not show up until 8:20 a.m. that morning (Sunday), breakfast was at 10:00 a.m. and lunch was served at noon. She said meals were sometimes served an hour and a half late, which meant residents went without food for 16 to 17 hours. She said for snacks, they had nothing but graham crackers. She opened the refrigerator and demonstrated there were two half sandwiches packaged and dated 1/19/23 and individual packets of vanilla ice cream in the freezer. The other items were residents' personal foods provided by their families. She said they were provided no pudding or yogurt, and she would sometimes bring it in herself. CNA #9 was interviewed on 1/23/23 at 5:21 p.m. She said lately the memory care unit was not receiving the dinner cart until almost 6:00 p.m. CNA #8 was interviewed on 1/24/23 at 9:32 a.m. She said she needed to go assist four residents who were dependent with their meals and had not yet been assisted "They eat in their rooms. The residents say meals here aren't good and are frequently late." She acknowledged the residents' food would be cold by now, due to the delay. The CDM was interviewed on 1/25/23 at 2:55 p.m. She said after the observation of the 1/24/23 lunch services, she did an inservice with the dietary staff on food temperatures and food preparation. She said the staff did not realize the planned meal was a multiple cold salad day and they did not give themselves enough preparation time to ensure the cold items were both ready at the time of service and at the appropriate temperature. The CDM was asked about the preparation of the 1/24/23 vegetable soup. She said the dietary staff did follow the recipe but should have also provided an adaptation to the recipe to add both color and flavor, improving the overall taste. She said the cook should have added more of a tomato base to help the taste of the soup for the residents not on a renal diet. The dietary manager (DM) and the CDM were interviewed on 1/26/23 at 2:48 p.m. The CDM said they needed to look into a better system to maintain the temperatures of both the cold and hot items once they were sent out to the halls for room delivery and the memory care unit. The CDM said dietary services used to have a separate beverage cart but the former administrator asked them not to use it and to put all items in one cart to make it easier on the nursing staff when meals were delivered. The DM said now was had to constantly come in the kitchen to request additional beverages, slowly down the service and delivery of resident meals. The DM said all food and drink items should be properly covered to maintain proper temperature and avoid exposure. The DM said the timing of the delivery was something they were trying to work on and has been getting better the last few days. He said dietary staff were working on consistency and had new cooks understand the importance of meal timing. He said he wanted to see each meal to only take about 13 seconds to plate for service. The CDM said they needed to work with nursing on the meal delivery process once the meals leave the kitchen. This would help maintain meal temperatures. The DM said he had not heard a lot of food concerns from residents. He said in November 2022 resident council, the residents did express concerns on the taste and temperature of food. He said there was no action plan generated but after hearing of the concerns, he focused on food flavor and temperature when training the cooks. He said they also encourage residents to give suggestions for special monthly and weekly meals. He said a few months ago, dietary services also purchased a new plate warmer and pelts to maintain the heat. The DM said residents in the past did not want a separate dining committee but he would approach the idea with residents so dietary could continue to get their food input and improve overall service.

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchen during meal services, and one of two dining rooms. Specifically, the facility failed to:-Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; and,-Ensure resident food was served at the appropriate temperature. Findings include:I. Professional standardsThe Centers for Disease Control and Prevention (CDC), reviewed 8/5/22, retrieved on 2/4/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under Four Steps to Food Safety read to "Wash your hands for at least 20 seconds with soap and warm or cold water before, during, and after preparing food and before eating." According to the CDC, food should be chilled promptly because "bacteria could multiply rapidly if left at room temperature or in the ' Danger Zone ' between 40 degrees F (Fahrenheit) and 140 degrees F."II. Facility policyThe Food Preparation policy, revised September 2007, was provided by the corporate dietary manager (CDM) on 1/26/23 at 2:44 p.m. The policy read in pertinent part: -"All foods Are prepared in accordance with the FDA (Food and Drug Administration) Food Code;-All staff will practice proper hand washing techniques and glove use;-Dining service staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination;-The dining service director/cook(s) Will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F. (Fahrenheit) and/or less than 135° F. per state regulation.-All foods will be held at appropriate temperatures, greater than 135 degrees F. for a hot holding, and less than 41 degrees F. for cold food holding."III. ObservationsA. Above safe temperatures for resident consumption Observations of lunch preparation and plating were conducted on 1/24/23 between 11:15 a.m. and 1:04 p.m. The observation identified the dietary staff had difficulty bringing the temperature down of their cold meals items to safe temperatures. -At 11:49 a.m. the cold items of chicken salad sandwiches and broccoli salad were placed on the prep counters. The temperature of a chicken salad sandwich was taken. The thermometer read 55 degrees F. The DM tempted the sandwich again and it read 54.1 degrees F. The DM said the temperatures did not make sense because the sandwiches just came out of the freezer. -At 11:52 a.m. a second pan of chicken salad sandwiches were pulled out and the temperature was obtained. The sandwiches read 39.1 degrees F. The DM said he would serve the chicken salad sandwiches directly out of the refrigerator. -At 11:58 a.m. the temperature of the broccoli salad was taken. The broccoli salad temperature was at 54.3 degrees F. The corporate dietary manager (CDM) said they would serve the broccoli salad and change the salad option to a garden salad and inform the registered dietitian (RD). A small bin of the garden salad was placed in ice. -At 12:02 p.m. the plating of resident meals began. The DM manager pulled two chicken sandwiches out a time to place them on plates from both pans (the first pan of sandwiches were not held at the appropriate temperature). The DM opened and closed the refrigerator door each time he retrieved the sandwiches. -At 12:08 p.m. the dietary aide prepared additional garden salads. -At 12:12 p.m. the CDM placed the larger portion of garden salad with ice. -At 12:16 p.m the salad was added to the plates.-At 12:20 p.m. the CDM tempted the garden salad again and it read 49.1 degrees F. She said the salad was two degrees below palatable but it was not going to stay that way. She said temperatures of cold items would rise once the items were in the halls on room trays. The CDM said cold food items like the salad should be below 52 degrees F. She said if the salad was mayo based (such as the chicken salad), she would like the salad to be close to 40 degrees F.-At 12:24 p.m. the CDM placed the garden salad in a metal bin surrounded by ice and partially covered it with a metal lid. At 12:45 p.m. the DM said he needed to have a cold bin near the steamline, after having to walk back and forth to the refrigerator to retrieve the individual chicken salad sandwiches. B. Hand hygiene Continuous observations on the memory care unit were conducted on 1/19/23 between 11:20 a.m and 12:50 p.m. Between 11:20 a.m. and 12:20 p.m. residents hand hygiene was not performed in preparation of the upcoming meal service. -At 12:21 p.m. the meal cart arrived in the memory care unit. -At 12:23 p.m. the residents were assisted to the dining tables. They were not offered hand hygiene. -At 12:32 p.m. the residents' meals were passed. Residents were not offered hand hygiene before their meals were served. -At 12:36 p.m. CNA #9 sat down next to a resident and wiped his hands with a sanitizer wipe before she proceeded to assist him in eating. The other residents were identified to eat independently in the dining room. They were not assisted in wiping their hands with sanitizer wipes, alcohol based hand rub (ABHR) or soap and water before they ate their meal.-At 12:48 p.m. CNA #12 had a handful of packets of condiments in her hand that she was passing out. She dropped a packet on to the floor when she was attempting to open one of the packets up. She picked the packet off the floor and placed it in the other hand. She did not use hand hygiene after picking the packet off the floor. The CNA proceeded to open and pass the packets out, using both hands. Continuous observations on the memory care unit were conducted on the memory care unit on 1/23/23 between 3:50 p.m and 5:45 p.m. Between 3:50 p.m. to 5:33 p.m. residents hand hygiene was not performed in preparation of the upcoming meal service of pork stir fry rice with vegetables and a dinner roll. -At 5:33 p.m. the meal cart arrived in the memory care unit. Residents were not provided hand hygiene. Between 5:38 p.m. and 5:45 p.m. the passing of meals began. The residents proceeded to eat following the delivery of each meal. No resident hand hygiene was provided. C. Uncovered food and drinkObservations on the South hall on 1/26/23 during the breakfast identified inconsistent coverage of the drinks and oatmeal. During the meal delivery, bowls of oatmeal on the meal trays were identified to be uncovered and exposed to the open air and potential contaminants. -At 9:35 p.m. staff identified there were limited beverages sent with the meal cart. CNA #3 went to the kitchen.-At 9:41 a.m. CNA #3 returned with individual cups of milk and juice. The one glass of milk was the only beverage covered. The five glasses were uncovered. The life engagement coordinator (LEC/CNA) informed CNA #3 that everything should be covered. She handed CNAs #3 and #13 a stack of lids for the drinks and oatmeal. CNA #3 said the oatmeal was always sent out uncovered; "That's how the kitchen does it."IV. Staff interviewThe corporate dietary manager (CDM) was interviewed on 1/25/23 at 2:55 p.m. She said after the observation of the 1/24/23 lunch services, she did an inservice with the dietary staff on food temperatures and food preparation. She said the staff did not realize the planned meal was a multiple cold salad day and they did not give themselves enough preparation time to ensure the cold items were both ready at the time of service and at the appropriate temperature. The dietary manager (DM) and the CDM were interviewed on 1/26/23 at 2:48 p.m. The CDM said they needed to look into a better system to maintain the temperatures of both the cold and hot items once they are sent out to the halls for room delivery and the memory care unit. The DM said all food and drink items should be properly covered to maintain proper temperature and avoid exposure. The DM said the timing of the delivery was something they were trying to work on. The CDM said dietary staff needed to work with nursing staff on the meal delivery process once the meals left the kitchen. This would help maintain meal temperatures. The CDM said she would need to work with nursing to improve hand hygiene of residents and potential cross-contamination concerns. V. Facility follow-upThe CDM provided dietary staff inservice forms on 1/25/23 at 2:44 p.m. The in-services forms indicated the dietary staff received education on 1/25/23 regarding food quality, palatability and food preparation following the above 1/24/23 meal observation.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/02/2023 and 01/08/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.