RIVER VALLEY REHABILITATION AND HEALTHCARE CENTER

The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). Life safety features that met the requirements at the time of licensure or certification shall be maintained and not be diminished. This facility, licensed for 60 beds, is a one-story, Type II (111) structure without a basement. This facility is fully protected by a National Fire Protection Association (NFPA) Type 13 automatic fire sprinkler system. This survey, conducted on August 9, 2023 was inspected for compliance to fire safety requirements contained in Chapter 19 of the 2012 edition of NFPA 101-Life Safety Code and 2012 edition of NFPA 99-Standard for Health Care Facilities.

STANDARD not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide a safe location to install Alcohol Base Hand Rub dispenser in accordance with Life Safety Code Chapter 19, Section 19.3.2.6(8). This deficient practice could affect all patient's, visitor's and staff should an electrical fault occur igniting the dispenser. This was evidence by the following. During the walkthrough of the facility, with the Maintenance Director, alcohol based hand rub dispensers (ABHR) was located directly above an electrical outlet in patient's room A09. Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected in accordance with 8.7.3, unless all of the following conditions are met:(8) Dispensers shall not be installed in the following locations:(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source. (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition sourceThe Plant Manager acknowledged the (ABHR) location deficiency during a tour of the facility.

STANDARD not met as evidenced by: Based on record review and discussion with staff during the course of the survey, it was determined that the facility failed to contain all required elements of the fire safety plan in accordance with the Life Safety Code, Section 19.7.2 and 19.7.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. During review of the facility records, with the Maintenance Director, the facilities Fire Safety Plan failed to contain the elements of the; (5) Isolation of fire (6) Evacuation of immediate area(7) Evacuation of smoke compartment(8) Preparation of floors and buildings for evacuation(9) Extinguishment of fire The Life Safety Code Section 19.7.2.3 requires that; a written health care occupancy fire safety plan shall provide for the following:(1) Use of Alarms(2) Transmission of alarm to the fire department(3) Emergency phone call to fire department(4) Response to alarms(5) Isolation of fire(6) Evacuation of immediate area(7) Evacuation of smoke compartment(8) Preparation of floors and buildings for evacuation(9) Extinguishment of fire The Director of Maintenance acknowledge the missing required element of the fire plan during the facility record review.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the transfilling of oxygen from one cylinder to another in accordance with NFPA 99 - Health Care Facilities, 11.5.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. The following evidenced this:The oxygen trans-filling room not mechanically ventilated correctly per NFPA 99. 9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers. The Plant Manager acknowledged the ventilation issue during a tour of the facility.

A recertification survey with Incident #32642 was completed on 7/10/23 to 7/13/23. Fourteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 7/10/23 to 7/13/23. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure three (#17, #43 and #45) of five residents reviewed for abuse out of 21 sample residents were free from abuse. Specially, the facility failed to:-Prevent a resident to resident altercation between Resident #43 and Resident #17; and,-Ensure Resident #45 was free from physical abuse by a family member. Findings include: I. Facility policy The Resident Safety policy, undated, was received from the nursing home administrator (NHA) on 7/11/23. It read in pertinent part: "Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends or other individuals." II. Resident to resident physical altercation between Residents #43 and #17 A. Facility investigation Incident 4/18/23 The incident occurred in the hallway between Resident #17 and Resident #43's rooms. The staff heard Resident #43 yelling and witnessed her hit the side of Resident #17's face. Resident #17 responded by grabbing Resident's #43's finger and biting it. The residents were separated by staff and assessed for injuries, no injuries noted. Neither resident could recall the event when interviewed. The residents lived across the hall from each other and neither had moved as a result of the event. The facility failed to substantiate or unsubstantiate the abuse investigation. -However, the abuse should have been substantiated due to Resident #43 hitting Resident #17's face and Resident #17 biting Resident #43's finger. B. Resident #17 (victim) 1. Resident statusResident #17, age over 85, was admitted on 10/7/21. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance. The 5/23/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and had functional impairments to her lower extremities on one side. She was unable to walk and required one-person limited assistance with locomotion. No behaviors were indicated and no wandering. 2. Record review The comprehensive care plan, revised 5/23/23, revealed the resident was at risk for elopement related to exit seeking behavior and verbalizations of wanting to leave the facility. Interventions were for the resident to wear a wander guard, periodically evaluate for continued need, offer diversions, structured activities, food, conversation, television, or books to redirect the resident. The resident required limited one-person assistance for bed mobility, transfers, locomotion, toileting, dressing, bathing, and personal hygiene. Certified nursing assistant (CNA) tasks for behavior monitoring were reviewed on 7/11/23 and revealed no behavior monitoring for the resident. Progress notes dated 2/13/23 through 4/18/23 revealed a behavior note dated 4/18/23 documented the resident had a physical altercation with another resident and the two residents were separated. The resident was put on 15 minute checks. C. Resident #43 (assailant) 1. Resident status Resident #43, age 70, was admitted on 1/10/23. According to the July 2023 CPO, diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety. The 4/18/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with locomotion. She had hallucinations and verbal and physical aggression directed at others. 2. Record review The comprehensive care plan, revised 4/18/23, identified the resident had behavior problems consisting of physical and verbal aggression towards others, wandering into other resident's rooms, and was at risk for abuse due to severe dementia with psychotic disturbances. Interventions included to approach the resident in a calm manner and if the resident was exhibiting behavior escalations, attempt to redirect or re-approach her later. Observe behavior episodes, determine underlying causes, divert attention, provide a quiet environment and remove the resident from the situation. CNA task behavior monitoring reviewed on 7/11/23 for the dates 3/1/23 to 4/18/23, revealed the resident had behaviors of hitting, kicking, accusatory behavior, threatening others, and entering other resident's rooms or space. Progress notes dated 2/13/23 through 4/18/23 revealed: -Behavior note dated 2/13/23 revealed the resident had increased behaviors related to discontinued Ativan (anti-anxiety) and start of Seroquel (antipsychotic). The resident asked the staff to get her husband (who did not live at the facility) and was not easily redirected.-Behavior note dated 2/14/23 revealed the resident had increased behaviors of wandering at night, taking items from other residents' rooms and from the nurses station. -Behavior note dated 2/17/23 revealed the resident was pacing, would not stay in her bed, and entered other residents' rooms. -Behavior note dated 2/18/23 revealed the resident continued to pace and exit seek. She was difficult to redirect. -Behavior note dated 2/19/23 revealed the resident continued to excessively pace and go into other residents' rooms naked at times. -Alert note dated 3/2/23 revealed the resident attempted to go into other residents' rooms looking for food and when redirected by staff, became angry and verbally aggressive.-Alert note dated 3/3/23 revealed the resident was verbally aggressive and threatening to kill the staff. The resident also slapped a nurse in the face. -Behavior note dated 3/5/23 revealed the resident had yelled at a nurse and threatened to kill her.-Behavior note dated 3/6/23 revealed the resident had been fixated on a nurse and yelled and screamed at her. When the nurse refused to give the resident a cigarette, the resident began to kick and bang on the medication room door and threatened to kill the nurse. -Behavior note dated 3/7/23 at 8:41 p.m. revealed the resident went into another resident's room, took her pants off, and urinated in the garbage can. Resident #43 had attempted to get into the male resident's bed, believing he was her husband when staff removed her. -Behavior note dated 3/7/23 at 9:16 p.m. revealed the resident was agitated and attempted to hit a nurse.-Alert note dated 3/8/23 revealed the resident was aggressive and threw a table top with a laptop at a nurse. -Behavior note dated 3/10/23 revealed the resident had been wandering and attempting to go into other residents' rooms. -Behavior note dated 3/11/23 revealed the resident believed the facility was her house and had gone into other residents' rooms to yell at them to leave. -Alert note dated 3/12/23 revealed the resident had been agitated, attempted to exit, and threw things at the staff. She was transferred to the hospital for a mental health evaluation and returned back to the facility. It was determined she was dehydrated and required intravenous fluids. -Behavior note dated 3/14/23 revealed the resident continued to exit seek and attempt to go into other residents' rooms. -Alert note dated 3/20/23 revealed the resident had been hallucinating and became physically aggressive with a nurse. The resident went into another resident's room and attempted to tell the resident to leave their room. When redirected, she became physically aggressive towards staff. Intramuscular Haldol (antipsychotic) was ordered and administered to the resident by staff. -Alert note dated 3/22/23 revealed the resident was sent out to the emergency room to be evaluated for diarrhea and dehydration with change in mental status.-Alert note dated 3/26/23 revealed the resident had returned from the hospital. She was still experiencing visual hallucinations, agitation and making threats towards staff. Intramuscular Haldol administered.-Order administration note dated 3/31/23 revealed the resident was given as needed (PRN) Ativan due to agitation and wandering into other residents' rooms. - Alert note dated 4/7/23 revealed the resident had been experiencing hallucinations and attempted to pick up imaginary items off the floor. -Fall occurrence note dated 4/9/23 revealed the resident sustained a fall without injury after becoming physically aggressive with two nurses.-Behavior note dated 4/18/23 revealed the resident had a physical altercation with another resident and the two residents were separated. The resident was put on 15 minute checks. III. Resident physical abuse by family member toward Resident #45A. Facility investigation Incident 4/13/23 The incident occurred in the resident's room at 4:00 p.m. Resident #45 came to staff and informed them the family member visiting had slapped her in the face. No injury was observed. When interviewed, the resident's family member admitted to slapping the resident in the face because the resident was yelling at her. The facility failed to substantiate or unsubstantiate the abuse investigation. -However, the abuse should have been substantiated due to Resident #45 being slapped in the face by her family member. 1. Resident #45 (victim)Resident #43, age over 85, was admitted on 3/2/23. According to the July 2023 CPO, diagnoses included unspecified dementia with anxiety and stroke. The 6/8/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person limited assistance with bed mobility, transfers, bathing, and toileting. The resident did not have any behaviors. 2. Record reviewThe comprehensive care plan, revised 6/8/23, revealed the resident was at risk for abuse related to recent family altercation. Interventions included removing the resident from negative situations and giving non-judgemental support, encouraging alternative communication with family such as phone calls and supervising visits with the family at all times. No behavior problems were identified in the care plan. CNA tasks for behavior monitoring were reviewed on 7/11/23 and revealed no behavior monitoring for the resident. Progress notes dated 3/14/23 through 4/14/23 revealed:-Behavior note dated 4/4/23 revealed the resident was agitated with nursing staff and refused her medications. The resident hit the spoon with the medication on it out of the nurse's hand and informed the nurse she would not be taking it. -Alert note dated 4/11/23 revealed the resident was tearful and expressed to staff her children had locked her up in a nursing facility.-Alert note dated 4/13/23 revealed the resident had reported to the staff she had been in a physical altercation with her family member which consisted of the family member slapping her in the face. The resident denied being fearful and the family member was notified they could not visit the resident during the investigation. -Alert note dated 4/24/23 revealed the family member resumed unsupervised visits after the resident called her and the family member apologized. IV. Staff interview The social services director (SSD) and the NHA were interviewed on 7/11/23 at 2:45 p.m. The SSD said if a resident's family member was on supervised visitation, he would look at what had transpired since the incident to determine with the NHA if supervised visitation needed to continue. If two residents had an altercation and were roommates or neighbors, he would ensure if it was an unsafe situation, one of the residents would be moved. The NHA stated regarding the incident with the family member slapping Resident #45, the resident became upset after the visitation became supervised and expressed depression. The resident started to refuse to change her clothes or eat until the supervised visitation ended. The NHA had a conversation with the family member to ensure the family member understood what to do if she became upset or overwhelmed with the resident's behavior instead of slapping her. Regarding the incident of the resident to resident altercation, Resident #43 became over stimulated and agitated and this caused her to become aggressive towards Resident #17. The staff had observed the two residents since the incident and determined it was an isolated incident and there was no need to move anyone's room. She did not have documentation of education with Resident #45's family member regarding dementia or how to manage her stress when visiting the resident to avoid further physical abuse. She was not aware if the CNAs or nurses knew about the incident and to watch when the family member visited for signs of psychosocial distress. CNA #4 was interviewed on 7/12/23 at 10:00 a.m. She stated Resident #43 had behaviors of delusions, hallucinations, tearfulness, verbal and physical aggression. Her aggression had decreased since May 2023 when the doctors made more medication changes. The CNAs did not know the behavior interventions for residents unless they asked the nurses. Management did not provide the CNAs with instruction on behavior modifications. Resident #17 had exit seeking behaviors but was not aggressive. Resident #45 did not have behaviors. CNA #4 was not aware of any restrictions or conflicts between Resident #45 and her family members. Licensed practical nurse (LPN) #3 was interviewed on 7/12/23 at 1:00 p.m. She stated Resident #43 had behaviors of hallucinations, delusions, yelling out for her spouse, and wandering into other residents' rooms. Resident #17 and #45 did not have behaviors she was aware of. LPN #3 was not aware of any restrictions or conflicts between Resident #45 and her family members.

Based on observations, record review and interviews the facility failed to comprehensively assess and care plan the continued use of personal alarms and wander guards as potential restraints for three (#17, #43 and #14) of eight residents reviewed for physical restraints out of 21 sample residents. Specifically, the facility failed to:-Obtain orders and consents for alarms prior to their application for Resident #17 and #43; and,-Review and ensure the necessity for continued use of alarms was not for staff convenience for Residents #17, #43 and #14. Findings include: I. Facility policyThe Wander Guard policy, undated, was provided by the nursing home administrator (NHA) on 7/12/23 at 11:04 a.m. It read in pertinent part:"Two separate orders will be placed in the electronic medical record when a wander guard order has been obtained:"Order will state for the nursing staff to check for placement function every shift and order will state for nursing staff to check for expiration date weekly." II. Resident #17A. Resident statusResident #17, age over 85, was admitted on 10/7/21. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance. The 5/23/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and had functional impairments to her lower extremities on one side. She was unable to walk and required one-person limited assistance with locomotion. No behaviors were indicated and no wandering. The resident had a bed alarm, chair alarm and a wander guard alarm. B. ObservationsResident #17 was observed on 7/12/23 at 9:21 a.m. Resident #17 was sitting in the front lobby by the nurses station. A wander guard alarm was visible around her ankle. During observation, the resident did not make any attempts to elope or stand up out of her chair setting off the alarms. C. Record reviewThe comprehensive care plan, revised 5/23/23, revealed the resident was at risk for elopement related to exit seeking behavior and verbalizations of wanting to leave the facility. Interventions were for the resident to wear a wander guard, periodically evaluate for continued need, offer diversions, structured activities, food, conversation, television, or books to redirect the resident. The resident required assistance from staff to complete activities of daily living (ADL) to include bed mobility and locomotion. The resident was at risk for falls related to cognitive impairment and interventions included to keep the alarm boxes out of her reach and to have alarm on at all times. -The care plan did not specify if these were chair or bed alarms. The July 2023 CPO revealed the following physician orders:Wander guard at all times related to exit seeking- ordered on 6/7/23. Behavior monitoring for the following behaviors related to wander guard: wandering outside of facility- ordered on 6/25/23.-The CPO reviewed from 1/27/23 to 7/10/23 failed to reveal physician orders for a bed alarm or chair alarm. The resident's medical record revealed a verbal consent from the power of attorney (POA) for a bed and chair alarm dated 10/9/21, two days after her date of admission 10/7/21. The consent form documented least restrictive measures would be tried first and a physician's order would be obtained (no order was located). A verbal consent from the POA for a wander guard dated 1/10/22 was in the record. The consent form documented the resident would be re-evaluated quarterly for the need of the wander guard. An elopement evaluation dated 5/26/23 revealed the resident was physically capable of leaving the facility, she had a history of wandering and elopement attempts and verbalized wanting to leave. -No other elopement evaluations were located in the resident's medical record. Progress notes reviewed from 4/29/23 to 7/10/23 failed to reveal any periodic or quarterly reviews of the resident's chair, bed or wander guard alarms. III. Resident #43A. Resident statusResident #43, age 70, was admitted on 1/10/23. According to the July 2023 CPO, diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety. The 4/18/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with locomotion. She had hallucinations and verbal and physical aggression directed at others but no wandering indicated. The resident had a bed alarm, chair alarm and a wander guard alarm. B. ObservationsResident #43 was observed on 7/11/23 from 8:58 a.m. to 9:44 a.m. Resident #43 was sitting by a water fountain in the front lobby. A wander guard alarm was visible around her ankle. During observation, the resident did not make any attempts to elope or stand up out of her chair setting off the alarms. C. Record reviewThe comprehensive care plan, revised 4/18/23, revealed the resident was at risk for elopement related to exit seeking behavior and verbalizations of wanting to leave the facility. Interventions were for the resident to wear a wander guard, periodically evaluate the wander guard for continued need, offer diversions, structured activities, food, conversation, television, or books to redirect the resident. The facility was to set up a meeting with the family to determine if the resident may need a more appropriate facility if elopement attempts continue. The resident required assistance from staff to complete ADLs to include locomotion. The resident was at risk for falls related to multiple falls and interventions included chair alarm. -The care plan did not identify a bed alarm. The July 2023 CPO revealed the following physician orders:Wander guard at all times related to exit seeking- ordered on 6/7/23. Behavior monitoring for the following behaviors related to wander guard: wandering outside of facility- ordered on 6/25/23.-The CPO reviewed from 3/26/23 to 7/10/23 failed to reveal physician orders for a bed alarm or chair alarm.-Review of the resident's medical record for a wander guard consent, bed alarm consent and chair alarm consent were not located. An elopement evaluation dated 6/27/23 revealed the resident was physically capable of leaving the facility, she had a history of wandering and elopement attempts and verbalized wanting to leave. -No other elopement evaluations were located in the resident's medical record. Progress notes reviewed from 2/6/23 to 7/10/23 failed to reveal any periodic or quarterly reviews of the resident chair, bed or wander guard alarms. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 1:54 p.m. She stated Resident #43 did not make attempts to elope any more because she was too physically weak. It had been at least three months since she had been an elopement risk. Resident #17 verbally expressed a desire to leave but was not physically capable of eloping. The bed and chair alarms were to notify the staff when the resident got up from her chair or bed. CNA #4 was interviewed on 7/12/23 at 10:00 a.m. CNA #4 stated Resident #43 did not make attempts to elope from the facility. She had a wander guard, a chair alarm and a bed alarm. The alarms were to notify the staff when she got up from her bed or chair and where she was. Resident #17 did verbally express a desire to leave the facility and would try to go to the exit doors but was not physically capable of leaving. She had a bed alarm and a chair alarm because she was a fall risk. The alarms let the staff know when she got up from her bed or chair and they needed to check on her in her room. Licensed practical nurse (LPN) #3 was interviewed on 7/12/23 at 1:00 p.m. Resident #43 did not make attempts to elope from the facility, just verbalized distress when her husband was not there visiting. She had awander guard, a chair alarm, and a bed alarm. The alarms were to notify the staff when she got up from her bed or chair and where she was. LPN #3 had not seen Resident #17 attempt to elope. She had a bed alarm and a chair because she was a fall risk and the alarms let the staff know when she got up. The NHA and director of nursing (DON) were interviewed on 7/12/23 at 2:07 p.m. The NHA stated before a wander guard alarm, bed alarm or chair alarm could be used for a resident, there needed to be an order, a consent and monitoring put into place. Chair and bed alarms were used to notify the staff when a resident got up from their chair or bed and alert the staff to check on the resident. Alarms needed to be reviewed quarterly for necessity. The elopement evaluations were in the resident's medical record. V. Facility follow-upThe NHA provided requested documentation on 7/12/23 at 5:30 p.m. that included:A signed consent by the POA for Resident #43 to have a bed alarm and chair alarm dated 4/3/23. -However, no physician orders were provided for the alarms. A verbal consent given by the POA for Resident #43 to have a wander guard alarm dated 2/10/23. -However, a physician order was not obtained until 6/1/23. A physician's order for a bed and chair alarm for Resident #17 dated 7/12/23 (during survey).-However, the alarms were initially put into place 10/9/21. VI. Resident #14 A. Resident status Resident #14, age 94, was admitted on 1/25/21. According to the July 2023 computerized physician orders (CPO), diagnoses included diabetes mellitus, dementia and insomnia. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident had disorganized thinking and had difficulty focusing attention. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident's restraint assessment did not document use of a bed alarm. B. Observation Resident #14 was lying in bed sleeping on 7/11/23 at 3:41 p.m. The bed alarm was placed on the left side underneath the resident's mattress. Resident #14 was lying in bed sleeping on 7/12/23 at 9:30 a.m. The bed alarm was placed on the left side underneath the resident's mattress. C. Record review The care plan, initiated 1/25/21 and revised 3/16/23, identified the resident was at risk for falls related to a history of falls and self-transferring. Interventions include maintaining call light within reach. Educate the resident to use call light. Place alarm boxes out of resident reach. Implement preventative fall interventions/devices. Pressure alarm to bed. -The resident did not have a physician's order for the bed alarm. -A bed alarm assessment, interdisciplinary notes, and risk benefit statement were requested during the survey. They were not provided at time of exit on 7/13/23. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 9:44 a.m. She said she was familiar with Resident #14. She said Resident #14 did not have any fall interventions in place. CNA #8 was interviewed on 7/11/23 at 1:12 p.m. He said Resident #14 did not have any fall interventions that he was aware of. Licensed practical nurse (LPN) #1 was interviewed on 7/11/23 at 1:24 p.m. He said the resident had a history of falls. He said the bed alarm was to alert staff in the event Resident #14 was trying to self-transfer out of bed. Certified nurse aide with medication authority (CNA/MA) #3 was interviewed on 7/12/23 at 9:44 a.m. She Resident #14 had a bed alarm and was supposed to have her bed in a low position. She said the bed alarm was in place to alert staff when Resident #14 was getting up and hopefully they got there in time. The nursing home administrator (NHA) and interim director of nursing (IDON) were interviewed on 7/12/23 at 2:31 p.m. The NHA said when an alarm was used for a resident, the interdisciplinary team (IDT) would assess if the alarm was necessary, a physician's order was in place, consent and a care plan documenting the alarm would have been in place prior to the alarm being installed. The NHA was told of the interviews and observations above. She said, "We look at the safety of each resident and placement of the bed alarms." She said the bed alarm for Resident #14 was in place to alert the staff when the resident was trying to get out of bed. She said, "I do not like alarms and it is my goal to remove all alarms from the facility." She said the alarms were counterproductive because they could startle a resident and annoy other residents.

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#10) of three residents reviewed for activities out of 21 sample residents. Specifically, the facility failed to ensure Resident #10 was invited and encouraged to attend activities of her preference. Findings include: I. Facility policy and procedures The Activities Program policy, undated, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part:"Because absence of meaningful and/or enjoyable activity can lead to mental and physical deterioration in residents, the activities department will work as a member of the interdisciplinary team to keep residents functioning at the highest level possible in all dimensions of life, physical, mental, social, emotional and spiritual, (to) encourage independence and pre-institutional interests, a sense of community and self-esteem." II. Resident status Resident #10, age 87, was admitted on 5/28/21. According to the July 2023 computerized physician orders (CPO), diagnoses included adjustment disorder, insomnia, anxiety, and depression. According to the 5/12/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident did not have any behaviors. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The preference for customary routine and activities revealed the resident felt it was very important to have reading materials, keep up with news, do favorite activities, and participate in church activities. III. Record review The care plan, initiated 5/28/21, identified the resident enjoyed activities of her choice. The resident enjoyed spending time in her room napping, reading her paper and watching soap operas. The resident was Catholic and she enjoyed praying the Rosary as well as attending the Protestant groups at times. The resident enjoyed old western and Spanish music at times. The resident enjoyed exercise class, arts and crafts and visiting in the common areas. The resident would continue to enjoy activities of her choice. Interventions include engaging the resident in conversation as often as possible, invite the resident with plenty of time to attend and offer to walk with the resident to activities. The activity calendar for 7/10/23 listed the following:-10:00 a.m. prayer time-10:30 a.m. sensory group-1:00 p.m. popcorn and a movieThe activity calendar for 7/11/23 listed the following:-10:00 a.m. shopping -1:00 p.m. music therapy The activity calendar for 7/12/23 listed the following:10:00 prayer time10:30 exercise11:30 reminiscing IV. Observations A. Observations on 7/10/23 revealed the resident did not have any meaningful activity. The resident was sitting in her wheelchair in her room at the following times: 9:30 a.m., 9:35 a.m., 10:00 a.m., 10:24 a.m., 12:40 p.m., 1:04 p.m., and 1:45 p.m. -At 9:30 a.m., Resident #4 was sitting in her wheelchair in her room sleeping. -At 9:35 a.m., Resident #4 was sitting in her wheelchair next to her bed.-At 10:00 a.m., Resident #4 was sitting in her wheelchair asleep.-At 10:24 a.m., Resident #4 was sitting in her wheelchair in her room. Resident #4 was placing personal belongings into a white bag.-At 12:40 p.m. Resident #4 was sitting in her wheel chair sleeping. She had the white bag on her lap.-At 1:14 p.m. no staff were observed in the area. During the observations above, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. B. Observations on 7/11/23 revealed the resident did not have any meaningful activity. The resident was sitting in her wheelchair in the common area. Activity staff were getting several residents ready to go on a bus ride at 9:45 a.m. but did not invite Resident #4. Specifically, observations revealed: -At 9:34 a.m., Resident #4 was sitting in her wheelchair in the common area.-At 9:45 a.m., Activity staff were lining residents up to go on a bus ride-At 9:50 a.m., Resident #4 was holding her white bag on her lap sitting in her wheelchair in the common area. No activity staff asked Resident #4 if she would like to attend the bus ride.-At 10:00 a.m., Resident #4 self-propelled next to the nursing station while still holding her white bag on her lap.-At 10:03 a.m., Activity staff were assisting residents to the exit and loading them onto the bus.-At 10:07 a.m., activity staff and residents exited the building.-At 10:34 a.m., Resident #4 was sitting in her wheelchair next to the nursing station. -At 12:43 p.m., Resident #4 was sleeping in her wheelchair in the doorway to her room.-At 1:07 p.m., certified nurse aide (CNA) #8 woke Resident #4 up and asked her if she wanted to listen to music. Resident #4 said, "That just does not interest me and I get tired of music because that is what all activities do." CNA #8 then pushed Resident #4 into her room where she fell back to sleep.-At 1:17 p.m., Resident #4 was sitting in her wheelchair sleeping. During the observations above, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. C. Observations on 7/12/23 revealed the resident did not have any meaningful activity. -At 9:44 a.m. Resident #4 was in the restroom in her room.-At 10:06 a.m., the activity director (AD) was observed walking by Resident #4's room.-At 10:09 a.m., the AD returned to the common area.-At 10:19 a.m., residents were sitting in a common area in a circle. There were approximately 11 residents in the circle.-At 10:24 a.m., no activities were observed in the common area.-At 10:27 a.m., the AD started the exercise activity.-At 10:33 a.m., three residents were observed to be participating in the exercise activity.-At 10:36 a.m., the AD said, "Oh you're not feeling it today."-At 10:40 a.m., the exercise activity was completed and the AD started the reminiscing activity.-At 10:45 a.m., Resident #4 was in her room sleeping. During the observations above, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. V. Staff interviewsCNA #5 was interviewed on 7/12/23 at 1:08 p.m. She said activities were limited for the residents. She said all they did was play music, and that was not an activity. The activity director (AD) was interviewed on 7/13/23 at 10:01 a.m. The AD was informed of the observations above. She said all residents should be encouraged and invited to all activities. She said, "I am the only activity staff right now because my volunteer was off on a short vacation." She said for example the shopping trip was scheduled for 10:00 am on Tuesday. She said the residents did not want to go on a shopping trip so they changed it to a scenic drive but she did not have room for everyone who wanted to go. She said there were six regular seats in the van and two spots for wheelchairs. She said the residents who did not get to go didnot have an alternative structured activity. She said there was no other activity until 1:00 p.m. She said, "I would turn on the music for them before I left, and the other residents can either sit in the common area and listen to music or sit in front of the television in the common area." She said, "I need to do better on inviting all residents to activities and encouraging them to participate." She said it was difficult being the only activity staff in the facility. She said the negative outcome for residents not participating in activities could be boredom, isolation, depression, negative behaviors and wandering.

Based on record review, observations and interviews, the facility failed to ensure one (#7) of two residents with a pressure ulcer received the necessary treatment and monitoring according to professional standards of practice out of 21 sample residents. Specifically, the facility failed for Resident #7 to:-Measure the pressure injury upon discovery;-Document finding of pressure injury; -Care plan the pressure injury; and,-Complete a Braden scale (to assess for pressure injury risk) timely. Findings include:I. Professional referenceThe National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 7/17/23 read in pertinent part:"Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. "Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. "Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). "Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. "Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. "Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed."II. Facility policy and procedureThe Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, was provided by the nursing home administrator (NHA) on 7/13/23 at 10:00 a.m. It revealed in part, "Assessment and Recognition-"Thenurse shall describe and document/report the following:-Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudate or necrotic tissue;-Pain assessment;-Resident's mobility status;-Current treatments, including support surfaces; and,-All active diagnoses."III. Resident statusResident #7, age 72, was admitted on 3/25/19 and readmitted 6/24/22. According to the July 2023 computerized physician orders (CPO), the diagnoses included diabetes mellitus type II and heart failure. The 7/7/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. She was dependent upon staff for all activities of daily living. It indicated the resident had an unstageable deep tissue injury. IV. Record reviewThe July CPO included:-Apply skin prep and an allevyn dressing to right lateral foot was ordered on 7/5/23. The skin inspection, dated 7/6/23, noted no new skin issues observed. The resident's electronic record, reviewed on 7/10/23, did not have:-Measurements of the wound upon discovery;-An updated Braden scale (a tool used to determine skin integrity);-Any documentation of the discovery of the pressure injury; and,-A care plan for the new pressure injury or a care plan to address the resident ' s risk for skin impairment. V. InterviewsLicensed practical nurse (LPN) #1 was interviewed on 7/11/23 at 12:10 p.m. He said if a skin change was found for a resident, he would report the change to the charge nurse. He said the charge nurse would take a look at it, then the MDS coordinator would take a look at the injury. He said the charge nurse and the MDS coordinator were the individuals that developed the wound treatment. LPN #1 said Resident #7 had an unstageable wound on her right lateral foot. He said the dressing was changed once a day on his shift. He said the injury was discovered recently, possibly last week but was not sure about the actual date. The director of nursing (DON) was interviewed on 7/11/23 at 12:38 p.m. She had the MDS coordinator join in the conversation. The MDS coordinator said Resident #7 had an unstageable deep tissue injury due to crossing her feet. She said the facility had gotten an order for occupational therapy. She said the initial discovery was last Monday (7/3/23). She said the resident had an order for skin prep and Allevyn. She said she had completed an initial assessment that included measurements. She said she was sure there was a note due to her being the one who wrote the note. When told a note could not be found, the MDS coordinator left the interview. The DON said she could not find a note and would want a note placed in the chart upon discovery for a complete and thorough record for the best care for the resident. VI. Facility follow-up and interviewThe MDS coordinator stated on 7/11/23, after the interview with the DON, that a late note was written that included the initial discovery, the initial measurements, a Brasden scale and a new care plan completed on 7/11/23. The wound evaluation form dated 7/11/23 identified an unstageable pressure ulcer on the right lateral foot. The measurements were 2.5 cm length, 0.4 cm width, and 0.2 cm depth. There was no tunneling noted. The form identified the representative was notified on 7/11/23. The form included new orders to cleanse the area, apply Endoform and calcium alginate, cover with allevyn and change every three days and as needed if soiled. The care plan, dated 7/11/23, identified impaired skin integrity. Interventions included:-Complete skin inspection every seven to 10 days and as needed;-Complete wound evaluation to monitor the progress of the resident's skin condition;-Notify the nurse of any new areas of skin breakdown noted during bathing or daily care: redness, blisters, bruises, and discoloration;-Pressure reducing boots to bilateral feet as tolerated. May remove for care; and -Treatments per physician orders. The interdisciplinary team (IDT) meeting note dated 7/12/23 identified a wound to the right foot. Nursing recommendations were heel boots at all times and therapy to work with repositioning in the wheelchair for offloading. The Braden scale completed on 7/11/23 scored the resident at an 11, indicating Resident #7 was at moderate risk. The DON was interviewed on 7/13/23 at 11:24 a.m. She said when a new injury is discovered, the process was to enter into the resident's electronic chart a change of condition, a wound evaluation, and measurements. She said the missing information should have been entered into the resident's electronic medical record when the wound was discovered and assessed.

Based on record review, observations and staff interviews, the facility failed to ensure three (#4, #45 and #43) of eight residents reviewed for accident hazards out of 21 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of falls. Specifically, the facility failed to implement effective fall precautions to prevent the re-occurrence of falls for Resident #45 and Resident #43, contributing to major injuries: On 3/31/23 with a third fall within a week, Resident #43 fell suffering a laceration to her forehead and was sent to the emergency room for sutures; andOn 7/7/23 with a fifth fall within two months, Resident #45 fell suffering a fractured hip. The facility further failed to ensure a physician order and adequate safety measures were followed for two-person assistance with transfers and the proper mechanical lift was used during transfers for Resident #4. Findings include:I. Resident #43A. Resident statusResident #43, age 70, was admitted on 1/10/23. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety. The 4/18/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and locomotion. The resident had two falls since admission, one with injury and one without injury. B. Record reviewThe comprehensive care plan, revised 4/18/23, revealed the resident was at risk for falls related to multiple falls. Interventions were to offer diversions, use a chair alarm, educate the resident to call for assistance before transferring, place the resident in sight of staff when awake, implement fall prevention interventions, use non-skid footwear and educate the resident to use the call light. The July 2023 CPO revealed there were no current therapy orders for the resident and there were no physician orders for fall prevention devices. A review of medication administration records from 3/14/23 to 4/18/23 revealed the following changes to the resident's psychotropic medications: -Seroquel (antipsychotic) 25 MG (milligram)- give 1 tablet a day for unspecified dementia- ordered on 2/8/23 discontinued 3/26/23.-Haldol (antipsychotic) 5 MG- give 0.5 ML (milliliter) intramuscular injection one time as needed for unspecified dementia- ordered 3/20/23 discontinued 4/8/23.-Seroquel 25 MG- give 2 tablets a day for unspecified dementia- ordered on 3/26/23 discontinued 3/27/23.-Ativan (benzodiazepine) 1 MG- give 1 tablet a day for unspecified dementia- ordered on 3/14/23 discontinued 3/26/23.-Trintellix (antidepressant) 10 MG- give 1 tablet a day for major depressive disorder- ordered on 3/26/23 discontinued 3/27/23.-Depakote (anticonvulsant) 125 MG- give 1 tablet a day for unspecified dementia- ordered on 3/26/23 discontinued 3/26/23.-Amitriptyline (antidepressant) 25 MG- give 1 tablet every 6 hours as needed (PRN) for major depressive disorder- ordered on 3/26/23 discontinued 4/18/23.-Hydroxyzine (antianxiety) 25 MG- give 1 tablet every 6 hours PRN for anxiety- ordered 3/26/23 discontinued 4/18/23.-Depakote 125 MG- give 2 tablets twice a day for unspecified dementia- ordered on 3/26/23 discontinued 4/12/23.-Amitriptyline 75 MG- give 1 tablet a day for major depressive disorder- ordered on 3/27/23 discontinued 4/4/23.-Ativan 0.5 MG- give 1 tablet twice a day for unspecified dementia- ordered on 3/27/23 discontinued 3/27/23.-Ativan 0.5 MG- give 1 tablet every 6 hours PRN for anxiety- ordered on 3/29/23.-Seroquel 25 MG- give 3 tablets a day for unspecified dementia- ordered 3/27/23 discontinued 3/30/23.-Seroquel 25 MG- give 2 tablets a day for unspecified dementia- ordered 3/30/23 discontinued 4/12/23.-Ativan injectable solution 2 MG- inject 1 MG intramuscularly one time a day for unspecified dementia- ordered 4/12/23 discontinued 4/12/23.-Depakote 125 MG- give 4 tablets twice a day for unspecified dementia- ordered on 4/12/23.-Risperidone (antipsychotic) 1 MG- give 1 tablet a day for unspecified dementia- ordered on 4/13/23. A review of the resident's fall occurrence evaluations revealed:Fall occurrence evaluation dated 3/26/23 revealed the resident had a witnessed fall at 2:15 p.m. in the common area. The resident was sitting in her wheelchair and stood up, lost her balance and fell to the floor. No injury sustained. Interventions included to add diversionary activities, and refer to therapy. The follow up note added to the occurrence on 3/27/23 revealed an anti lock rollback device was placed on the wheelchair to prevent the chair from rolling back. Fall occurrence evaluation dated 3/31/23 revealed the resident had a witnessed fall at 9:30 a.m. in the common area when trying to stand up and then sit back down in her wheelchair. The wheelchair rolled out from behind her and the resident fell to the floor. No injury was sustained. There was no mention why the anti lock roll back device was ineffective. Interventions were to add diversionary activities, refer to therapy and educate the staff to keep the resident in sight during waking hours. The follow up note added to the occurrence evaluation later that day revealed the resident already had a chair alarm. Fall occurrence evaluation dated 3/31/23 revealed the resident had an unwitnessed fall at 7:15 p.m. in the private dining area. The resident was in the private dining area with two other residents but no staff. A nurse at the nurses station heard a loud noise and then observed the resident on the floor. The resident had a laceration to her forehead and was sent to the emergency room for sutures. Fall interventions were to add diversionary activities, refer to therapy and educate the staff to keep the resident in sight during waking hours. -There was no mention why the resident had not been in the staff's sight at time of the fall. There were no new interventions added as a result of the fall. Fall occurrence evaluation dated 4/9/23 revealed the resident had a witnessed fall at 1:45 p.m. in the common area. The resident stood up from her wheelchair at which time her chair alarm sounded and the nurse went to provide assistance. The resident was agitated, declined to sit back in her wheelchair, becoming verbally and physically aggressive with the nurse then fell as a result. The occurrence documented the fall was caused by the resident's continuous anxiety, agitation and argumentative noncompliant behavior with staff. Interventions were to add diversionary activities, refer to therapy, educate the resident to call for assistance and educate the staff to keep the resident in sight during waking hours. Fall occurrence dated 5/30/23 revealed the resident had a witnessed fall at 4:45 a.m. in the common area. The resident had attempted to stand and walk. The resident had removed her chair alarm. Interventions were to add diversionary activities, non-skid footwear, refer to therapy, chair alarm, educate the resident to call for assistance before transferring and educate the staff to keep the resident in sight during waking hours. A review of the physician visit notes revealed visits on 5/2/23, 5/30/23 and 6/20/23. During the physician's visits, neither the resident's frequent falls or frequent psychotropic medication changes were mentioned. II. Resident #45A. Resident statusResident #45, age over 85, was admitted on 3/2/23. According to the July 2023 CPO, diagnoses included unspecified dementia with anxiety and stroke. The 6/8/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person limited assistance with bed mobility, transfers, bathing and toileting. The resident had two or more falls since admission without injury. B. Record reviewThe comprehensive care plan, revised 6/8/23, revealed the resident was at risk for falls related to multiple falls, history of self transferring, and impaired cognition with decreased safety awareness. Interventions were to offer diversions, use a chair alarm, use hip protectors, fall mat to the resident's floor, educate the resident to call for assistance before transferring, place the resident in sight of staff when awake, implement fall prevention interventions, use non-skid footwear, and educate the resident to use call light. The July 2023 CPO revealed the following physician orders:Occupational therapy for 8 weeks to decrease fall risks to include room modification and wheelchair modification- ordered on 7/5/23. Physical therapy for 12 weeks for therapeutic neuromuscular reeducation- ordered on 6/22/23.-The review did not show any physician orders for fall prevention devices. A review of the resident's fall occurrence evaluations revealed:Fall occurrence evaluation dated 5/16/23 revealed the resident was heard yelling at 7:45 p.m. for help in her room after putting on her call light. She was found lowering herself to the floor in front of her recliner. The resident was wearing shoes. The occurrence documented the resident had been on her call light repetitively during the shift and had complained to the staff regarding the length of time it was taking for help to arrive. When the staff educated the resident to use her call light before attempting to transfer, it was documented the resident stated she had fallen because no one ever came to help her. No injuries were sustained. Interventions were to add a fall mat next to her bed, educate the resident to call for assistance, ensure the wheelchair is within reach, add non-skid footwear add non-skid strips in front of her recliner. -There was no mention of more frequent checks or education with staff on answering her call light promptly. Fall occurrence evaluation dated 5/30/23 revealed the resident had an unwitnessed fall at 3:30 p.m. The resident was found on the floor in her room on her hands and knees in front of her wheelchair. The resident was documented as stating she fell out of her chair. No injury was sustained. Interventions were to add diversionary activities, to add a fall mat next to her bed, educate the resident to call for assistance, ensure the wheelchair is within reach and add hip protectors. Fall occurrence evaluation dated 6/21/23 revealed the resident had an unwitnessed fall at 11:00 p.m. The resident was found on the floor of her bathroom after turning on her call light. The fall resulted in a skin tear to the left outer arm and an abrasion to the left side of head with no bleeding. The resident had taken herself to the bathroom without assistance. Interventions were to add a fall mat next to her bed, educate the resident to call for assistance, and add non-skid footwear. Physical and occupational therapy to evaluate and treat. -There was no mention of more frequent checks or education with staff on answering her call light promptly. Fall occurrence evaluation dated 7/4/23 revealed the resident had an unwitnessed fall at 8:15 a.m. The staff found the resident sitting on the floor in between her bed and wheelchair. Staff concluded the resident did not use her call light for assistance and was not wearing footwear. No injuries were sustained. Interventions were to add a chair alarm, add a fall mat next to her bed, educate the resident to call for assistance, add non-skid footwear, add hip protectors, and ensure the wheelchair is within reach. The follow up note added to the occurrence evaluation revealed the resident had attempted to transfer herself and took off her alarm. It was documented she informed the staff she could do what she wanted to do and she was not going to wear hip protectors or the facility's non-skid socks. Fall occurrence evaluation dated 7/7/23 revealed the resident had turned on hercall light at 9:30 p.m. and was found in her bathroom sitting up against the wall. It was documented the resident was yelling her leg was broken and she was in pain. The resident was sent to the emergency room to evaluate and treat. The occurrence documented possible contributing factors to the fall were the resident had not used her call light, however it was documented in the occurrence the resident turned on her call light to alert the staff of her fall. Interventions were to put her bed in the low position, add a fall mat next to her bed, educate the resident to call for assistance, add non-skid footwear, add bed alarm, add hip protectors, and ensure wheelchairs within reach. The follow up note added to the occurrence evaluation revealed the resident had fractured her hip. III. Staff interviewsCertified nurse aide with medication authority (CNA/MA) #1 was interviewed on 7/11/23 at 1:45 p.m. She stated she did not know where the fall prevention interventions for the residents were in the medical record. Registered nurse (RN) #1 attempted to assist CNA/MA #1 to locate fall prevention interventions. RN #1 stated it was in the resident's care plan but she did not know if the certified nurse aides (CNAs) had access to the residents' care plans. CNA #7 was interviewed on 7/11/23 at 1:50 p.m. He stated fall prevention interventions were in the CNA system but he did not have access because he was still training. He had to ask the nurses or CNAs what the residents' fall interventions were. He thought there was a care plan binder at the nurse's station but was unable to find it. CNA #1 was interviewed on 7/11/23 at 1:54 p.m. She stated she checked the resident's care plan to see the fall prevention interventions or the CNA system (kardex). She said Resident #43's fall interventions were a chair alarm, a fall mat, and a low bed. (A fall mat and low bed were not interventions in the resident's care plan). The fall interventions for Resident #45 were a low bed and bed alarm. (A low bed and bed alarm were not in the resident's care plan). CNA #4 was interviewed on 7/12/23 at 10:00 a.m. She stated Resident #43 had become a high fall risk after she had numerous medication changes. She did not know what her fall interventions were. CNA #4 said the fall interventions for Resident #45 were bed and chair alarms. If there were fall interventions added to a resident's care plan, the CNAs could not see the additions. The CNAs had to ask the nurses what the fall interventions were. The director of nursing (DON) was interviewed on 7/12/23 at 2:07 p.m. She stated the CNAs and nurses had access to the residents' care plans to find the fall interventions. There was also a communication binder kept at the nurses station for updates to residents' care. She could not answer why the staff stated they did not know about resident specific fall interventions. IV. Facility follow-up At the time of survey exit, 7/13/23, the NHA stated she would be able to submit documentation showing resident specific fall interventions for Resident #43 and Resident #45. The NHA sent follow up documents after survey exit on 7/14/23 at 4:24 p.m. The documentation included fall care plans for Resident #43 and Resident #45. Resident #43's comprehensive fall care plan revealed interventions added 7/13/23 (during survey) of assisting the resident to the gazebo to look at flowers, add bed alarm, anti-roll back device on wheelchair, ensure physical needs were met, and therapy screen for safety. Resident #45's comprehensive fall care plan revealed interventions added 7/13/23 of physical therapy to evaluate and treat. In the NHA email communication, she revealed resident specific fall interventions were added to a communication sheet kept at the nurses station where staff, to include CNAs, were to review sheets daily and sign the sheet once they read it. The NHA was unable to provide documentation showing the particular staff who had expressed not knowing the fall interventions during the survey had signed any of the fall intervention communication sheets or were aware of the sheets' existence. V. Failure to provide safe transfer assistance for Resident #4 A. Facility policy The Lifting and Transferring Resident Policy, undated, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part:"Residents are lifted and transferred safely in all instances."-Nurses assess and determine lifting and transfer requirements and the procedure used for each resident.-All residents must be lifted or transferred according to the determined procedure.-Procedure appears in Resident Care Plan and Resident Profile.-Residents who require assistance in transferring are transferred using a gait/transfer belt or with a lift.-All members of the nursing staff, nurses, and nursing assistants are responsible for using good body mechanics, knowing the proper procedures, and properly operating assistive devices.-Approved techniques for lifting, transfer, and body mechanics are discussed and demonstrated during each orientation program for nursing personnel.-Mechanical lift procedures are used on any resident unable to independently pivot or transfer. B. Resident #4 status Resident #4, age 93, was admitted on 11/27/21. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, chronic respiratory failure, chronic obstructive pulmonary disease, and post-traumatic stress disorder (PTSD). According to the 5/13/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had wandering behaviors. He required total assistance for bed mobility, transfers, grooming and toilet use. C. Record review The care plan, initiated 11/27/21 and revised 3/5/23, identified the resident had an activities of daily living (ADL) self-care performance deficit related to cognitive impairment, history of falls, and impaired mobility. Interventions include allowing time for the resident to express feelings of frustration regarding the need for assistance in ADL tasks. Encourage the resident to use call light when assistance is needed. Sit to stand lift for transfers. The July 2023 CPO included: staff should use an electric sit to stand lift and two persons for all transfers. Start date 6/6/23. D. ObservationOn 7/10/23 at 10:05 a.m., certified nurse aide (CNA) #7 entered Resident #4's room, closed the door and placed Resident #4 on the toilet by himself. CNA #7 did not use a sit to stand lift to transfer Resident #4 onto the toilet. CNA #7 exited the resident's room leaving Resident #4 on the toilet. CNA #7 returned approximately five minutes later and removed Resident #4 from the toilet and placed her into her recliner. CNA #7 transferred Resident #4 by himself not utilizing the sit to stand lift. E. Interviews Licensed practical nurse (LPN) #1 was interviewed on 7/10/23 at 10:10 a.m. LPN #1 was told of the observation. He said Resident #4 needed two person assistance with all transfers and a sit to stand was to be used on all transfers. LPN #1 said a negative outcome could be a fall, skin tear or any negative outcome. CNA #7 was interviewed on 7/10/23 at 10:20 a.m. CNA #7 said he was somewhat familiar with Resident #4. He said Resident #4 required a lift but did not know what type of lift was required when transferring Resident #4. CNA #7 said he did not use a sit to stand lift to transfer Resident #4 and there was no lift in the resident's room. The occupational therapist was interviewed on 7/12/23 at 10:07 a.m. The OT was told of the observation of Resident #4 on 7/10/23. He said he was just observing and assessing two CNAs with transfers of Resident #4. He said it was reported to him about the one person transfer of Resident #4 and he was reeducating CNAs on the importance of transferring a resident safely. He said the therapy department would report back to the director of nursing (DON). The DON was interviewed on 7/12/23 at 1:13 p.m. She said it had been reported to her about the CNA transferring the resident. She said staff were supposed to familiarize themselves with the residents' care plan, kardex and know if the resident was a two person transfer and required a lift prior to providing resident care. She said the CNA should have not transferred the resident by themselves and reeducation was started immediately. She said a negative outcome would be a fall, skin tear or serious injury.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#4 and #40) of two residents reviewed for supplemental oxygen use out of 21 sample residents. Specifically, the facility failed to:-Administer oxygen in accordance with the physician's order for Resident #4; and,-Ensure a physician's order was in place for Resident #40's continuous oxygen use. Findings include:I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration." II. Resident #4 A. Resident status Resident #4, age 93, was admitted on 11/27/21. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and post-traumatic stress disorder (PTSD). According to the 5/13/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had wandering behaviors. He required total assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Record review The care plan, initiated 11/27/21 and revised 3/5/23, identified the resident had an impaired respiratory status related to hypoxia. Interventions included oxygen as ordered by the physician. Provide oxygen as needed when a resident exhibits signs/symptoms of difficulty breathing, short of breath, inadequate oxygen (cyanosis), low oxygen saturation. Monitor for increased anxiety associated with shortness of breath, provide reassurance. The July 2023 CPO included an order dated 2/6/23 for oxygen at 3 liters per minute (LPM) continuously via nasal cannula every shift due to diagnosis of COPD. C. Observation On 7/10/23 at 10:36 a.m. Resident #4 was sitting in her recliner with her oxygen cannula on the side of her face. The resident's oxygen concentrator was set on four liters per minute (LPM). On 7/11/23 at 12:54 p.m. Resident #4 was sleeping in her recliner with her cannula on the side of her face. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 9:26 a.m. He said oxygen was a medication. He said the resident was supposed to be on three LPM continuously. LPN #1 went to the resident's room and stated the resident was not wearing her oxygen cannula correctly as it was on the side of her face. LPN #1 helped Resident #4 put on her cannula and exited the resident's room. He said he adjusted Resident #4's LPM to three where it should have been. He said a negative outcome could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream). The DON was interviewed on 7/12/23 at 1:13 p.m. She said oxygen was a medication. She said Resident #4's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls, and hypoxic events and could have put the residents in respiratory distress. III. Resident #40 A. Resident status Resident #40, age 89, was admitted on 3/7/23. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes dysphasia, and malignant neoplasm of the prostate. According to the 7/1/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen (02) therapy. B. Record Review The care plan, initiated 3/13/23, identified the resident had impaired respiratory status related to chronic obstructive pulmonary disease (COPD)/emphysema. Interventions include monitoring for increased anxiety associated with shortness of breath; provide reassurance. Monitor for signs/symptoms of respiratory distress and report to physician (increased respirations, low 02 saturation, inadequate oxygen (cyanosis), increased heart rate, restlessness, headaches, increased lethargy, increased confusion, atelectasis (collapse of lung), pleuritic pain (chest pain), accessory muscle usage). Oxygen as ordered by physician. -The July 2023 CPO did not include a physician's order for oxygen. C. Observation and interview On 7/10/23 at 1:35 p.m., the resident was observed watching television in the common area. He had his portable oxygen concentrator on the back of his wheelchair and he was wearing his oxygen cannula. On 7/11/23 at 1:39 p.m., the resident was observed in his room sitting in his wheelchair next to the bed. He was wearing his portable oxygen concentrator. Resident #40 said he had been wearing oxygen for a long time. D. Staff interview CNA #8 was interviewed on 7/12/23 at 9:09 a.m. CNA #8 said Resident #40 had been wearing oxygen ever since he started working at the facility, which had been approximately one year. Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 9:26 a.m. LPN #1 said oxygen was a medication and required a physician order. LPN #1 was told of the observations. LPN #1 checked his computer to verify the physician's order. He stated Resident #40 did not have a physician order for his oxygen. He said the resident should have had a physician order to have his oxygen on. The DON was interviewed on 7/12/23 at 1:13 p.m. The DON said Resident #40 should have had the physician order in place for his continuous oxygen use.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for three of five certified nurse aides (CNAs), two of two licensed practical nurses (LPNs) and two of two registered nurses (RNs). Specifically, the facility:-Failed to complete competencies as identified in the facility assessment for CNA #2, #4, and #6; -Failed to complete competencies as identified in the facility assessment for LPN #1 and #2; and -Failed to complete competencies as identified in the facility assessment for RN #1 and #2. I. Facility assessmentThe facility assessment, reviewed 1/8/23, identified the staff training provided by the facility to meet the needs of the residents, which read in pertinent part:"Staff training/education and competenciesTraining Topics:Communication - effective communications for direct care staffResident's rights and facility responsibilities - ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residentsAbuse, neglect, and exploitation - training that at a minimum educates staff on- (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program Culture change (that is, person-centered and person-directed care)Required in-service training for nurse aides. In-service training must:-Be sufficient to ensure the continuing competence of nurse aides and all staff but must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Required training of feeding assistants - through a State-approved training program for feeding assistantsIdentification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of lifeCultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents)Person-centered care - This should include but not be limited to person-centered care planning, education of resident and family /resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advance care planningActivities of daily living - bathing (e.g., tub, shower, sitz, bed), bed-making (occupied and unoccupied), bedpan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brushing teeth or dentures), providing resident privacy, range of motion (upper or lower extremity), transfers, using gait belt, using mechanic liftsDisaster planning and procedures - active shooter, elopement, fire, flood, power outage, tornadoInfection control- hand hygiene, isolation, standard universal precautions including use of personal protective equipment, precautions, environmental cleaningMedication administration - injectable, oral, subcutaneous, topicalMeasurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetoneResident assessment and examinations - admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessmentCaring for persons with Alzheimer's or another dementia Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis careCaring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing nonpharmacological interventions."II. Training recordsThe training records were requested on 7/11/23 at 11:23 a.m. The facility was not able to provide competencies for the requested staff as identified in the facility assessment. III. InterviewThe nursing home administrator (NHA) was interviewed on 7/11/23 at 2:15 p.m. She said the facility had planned a "skills school" for August 2023 to include skill stations for all of the staff. She said the facility did not have current annual competencies for the requested staff. She said it was important to ensure staff could perform skills safely and correctly to provide the best care to the residents.

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 must provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for CNA #2, CNA #4 and CNA #6. Findings include:I. Record reviewCNA #2 (hired 8/1/19) , CNA #4 (hired 3/30/2020) and CNA #6 (hired 6/8/22) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. InterviewThe director of nursing (DON) was interviewed on 7/11/23 at 3:15 p.m. She said the facility had not completed any annual performance reviews, but did have a plan going forward to complete the reviews by August 2023.

Based on record review and interviews, the facility failed to ensure three (#43, #201 and #36) of eight residents were free from unnecessary psychotropic medications out of 21 sample residents. Specifically, the facility failed to:-Monitor targeted behaviors for psychotropic medications for Residents #43, #102, and #36; -Ensure consents were obtained prior to medication administration for Residents #43 and #201; and,-Ensure as needed (PRN) orders did not extend 14 days without documented clinical rationale from the physician or a physician evaluation of the resident for Residents #43 and #201. Findings include: I. Facility policyThe Psychotropic Medication Use policy dated July 2022, was provided by the nursing home administrator (NHA) on 7/12/23 at 11:04 a.m. It read in pertinent part:"Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record."PRN psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics: if the prescriber or the attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. For psychotropic medications that are antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication." II. Resident #43A. Resident statusResident #43, age 70, was admitted on 1/10/23. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder, and anxiety. The 4/18/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with locomotion. She had hallucinations and verbal and physical aggression directed at others. B. Record reviewThe comprehensive care plan, revised 4/18/23, revealed the resident was taking an anticonvulsant medication for dementia, a benzodiazepine medication for anxiety, and an antipsychotic medication for dementia. Interventions were to consult with the physician and pharmacist for dose reductions, monitor for side effects, monitor for worsening signs of depression, and review risk and benefits with the family. The July 2023 CPO revealed the following physician orders:-Monitor for behaviors related to Seroquel (antipsychotic) such as hitting and aggression- ordered on 3/28/23 (resident stopped taking this medication 4/12/23).-Lorazepam (benzodiazepine) 0.5 MG (milligrams)- give 1 tablet by mouth every 6 hours as needed (PRN) for anxiety - ordered on 3/29/23.-Depakote (anticonvulsant) 125 MG- give 4 capsules by mouth two times a day for unspecified dementia- ordered on 4/12/23.-Monitor for behavior related to Depakote such as physical aggression- ordered on 4/13/23.-Risperidone (antipsychotic) 1 MG- give 1 tablet by mouth for unspecified dementia- ordered on 4/13/23.-An order for behavior tracking for the Risperidone was not located. A review of the resident medication administration records (MAR) from 3/1/23 to 7/1/23 revealed:-The resident had originally started Lorazepam on 3/14/23 before dose change on 3/29/23.-The resident had originally started Depakote on 3/26/23 before dose change on 4/12/23.-The resident had not been prescribed Seroquel since 4/14/23.-The resident had a one-time order on 3/21/23 for Haldol (antipsychotic) 2 MG intramuscular injection for unspecified dementia. Haldol was administered 3/21/23, 3/26/23, and 4/8/23. A review of scanned documents in the resident's medical record revealed a signed consent from the power of attorney (POA) for Depakote dated 4/3/23 (start date of medication was 3/26/23), a signed consent from the POA for Risperidone dated 4/13/23, and a signed consent from the POA for Lorazepam dated 4/3/23 (start date of medication was 3/14/23). -There was no consent located for the injectable Haldol from the POA.A review of progress notes dated 3/21/23 to 7/10/23 revealed:Order administration notes dated 3/21/23 revealed PRN intramuscular Haldol 2 MG was requested from the physician for physical aggression. The injection was administered and effective. Order administration notes dated 3/26/23 at 6:40 p.m. revealed PRN intramuscular Haldol 2 MG was administered after the resident returned from a hospitalization due to low potassium. The resident was unsteady on her feet, appeared sedated and was having hallucinations. Fall occurrence progress note dated 3/26/23 at 8:10 p.m. revealed the resident attempted to stand in the common area and lost her balance resulting in a fall. Social services assessment note dated 4/17/23 revealed the resident had two doses of intramuscular Haldol for unmanageable behaviors. Order administration notes revealed PRN Lorazepam was administered between 4/8/23 and 7/10/23, 31 times without a documented non pharmalogical intervention tried and failed first. There were only two order administration notes within this time frame where non pharmological interventions were tried with the resident.-There were no progress notes located documenting a consent being given by the POA for the injectable Haldol. -There were no progress notes located documenting the reason injectable Haldol was administered on 4/8/23. Medication regimen review from the pharmacist dated 4/4/23 revealed documentation was needed for the clinical rationale if continuing the PRN Lorazepam after 14 days.-There were no physician visit notes or progress notes between 4/8/23 to 7/10/23 documenting the necessity for the extended use of the PRN Lorazepam after the 14-day period. III. Resident #201A. Resident statusResident #201, age 81, was admitted on 6/21/23. According to the July 2023 CPO, diagnoses included unspecified dementia with agitation. The 6/21/23 MDS assessment had not been done. No other MDS assessments were located in the resident's record. B. Record reviewThe comprehensive care plan, initiated 6/23/23, revealed the resident was taking a scheduled antipsychotic medication for dementia. Interventions were to consult with the physician and pharmacist for dose reductions, monitor for side effects, monitor for worsening signs of depression, and review risk and benefits with the family. -There was no care plan focus for PRN antipsychotics. The July 2023 CPO revealed the following physician orders:-Monitor for behaviors related to Seroquel (antipsychotic) such as hitting - ordered on 6/21/23 (resident stopped taking this medication 6/22/23).-Haldol (antipsychotic) 1 MG- give 1 tablet by mouth every 6 hours as needed for anxiety or aggression - ordered on 6/22/23.-Monitor for behaviors related to Haldol such as yelling- ordered on 6/22/23.-Risperidone (antipsychotic) 0.5 MG- give 1 tablet by mouth for unspecified dementia- ordered on 6/29/23.-An order for behavior tracking for the Risperidone was not located. A review of the resident MARs from 6/1/23 to 7/10/23 revealed:-The resident had originally started Risperidone on 6/22/23;-The resident had not been prescribed Seroquel since 6/22/23. A review of scanned documents in the resident's medical record revealed a signed consent from the power of attorney (POA) for Risperidone dated 6/29/23 (start date of medication was 6/22/23). -No consent form was located for the Haldol PRN.A review of progress notes dated 6/21/23 to 7/10/23 revealed:Order administration note dated 7/3/23 at 1:05 p.m. revealed the resident received a PRN dose of Haldol for an x-ray. Order administration note dated 7/3/23 at 4:03 p.m. revealed the resident received a PRN dose of Haldol. No indication or non pharmological interventions were documented. The PRN was given less than 6 hours since the last dosage, contrary to the physician order.-There were no physician visit notes or progress notes between 6/21/23 and 7/10/23 documenting the necessity for the extended use of the PRN Haldol after the 14-day period. IV. Staff interviewsLicensed practical nurse (LPN) #3 and registered nurse (RN) #2 were interviewed on 7/12/23 at 1:00 p.m. LPN #3 stated when the nurse gives a PRN psychotropic medication to a resident, they need to attempt a non pharmalogical intervention first and document if it was successful or not before administering the medication. For PRN medications like Lorazepam, a new order is required from the physical every 14 days and there should be a physician's visit note in the medical record documenting the rationale for the extension. For Resident #201 and Resident #43, LPN #3 was unable to find physician visit notes in the medical records regarding extending their PRN psychotropic. LPN #3 did not know the requirement to extend a PRN antipsychotic such as Haldol. RN #2 stated she did not know the requirement to extend a PRN antipsychotic such as Haldol. The NHA and director of nursing (DON) were interviewed on 7/12/23 at 2:07 p.m. The NHA stated when a new resident is admitted to the facility, if the resident is taking psychotropic medications, behavior monitoring is started. The DON put the behaviors and non pharmological interventions in the communication binder for the staff to read. The facility must obtain consents from the resident's responsible party or from the resident for all psychotropic medications. When a nurse administered a PRN psychotropic medication to a resident, a non pharmological intervention must be tried first and if the intervention was ineffective, there must be documentation in the progress notes before the PRN medication was given. PRN psychotropic medications given for anxiety, like Lorazepam, required a new order and clinical rationale from the physician to continue as a PRN. A PRN antipsychotic medication, like Haldol, required a new order, and an assessment by the physician and then documented clinical rationale for continued PRN usage. The NHA and DON acknowledged the PRN psychotropic medications for Resident #201 and Resident #43 should have consents and should have been reviewed after every 14 days if continued. V. Facility follow upOn 7/12/23 at 5:30 p.m. the NHA provided a verbal consent for Depakote from the POA for Resident #43 dated 7/12/23 (medication was started 3/26/23), a signed consent for Risperdal from the POA for Resident #201 dated 6/29/23 (medication was started 6/22/23), and a verbal consent for Haldol from the POA for Resident #201 dated 7/11/23 (medication was started 6/22/23).-No physician rational or physician evaluation was provided for the extended use of the PRN for Resident #43 or Resident #201.-No consent for the intermuscular PRN Haldol for Resident #43 was provided. VI. Resident #36A. Resident statusResident #36, over the age of 65, was admitted on 9/23/22 and readmitted on 6/12/23. According to the July 2023 CPO, diagnoses included anorexia, chronic ischemic heart disease, muscle weakness, anxiety disorder and restless legs syndrome. The 5/26/23 MDS assessment revealed the resident had a severe cognitive impairment ability with a BIMS score of four out of 15. She required extensive assistance of two-person with transfers and toileting. One person assistance with dressing, and personal care. There were no behaviors and rejection of care. B. ObservationResident #36 was observed on 7/12/23 at approximately 1:15 p.m. at a group musical activity. The resident started yelling out for help and a staff member notified CNA/MA #1. The resident was given her afternoon medication but continued to yell out for help. CNA/MA #1 assisted the resident to her room momentarily. At 1:28 p.m. CNA/MA #1 brought the resident back to the nursing station. The resident continued to yell out for her mother. At 1:35 p.m. CNA/MA #1 notified the NHA about the resident's behaviors. The NHA who was also a registered nurse assisted the resident to her room and completed a physical assessment of the resident. At 1:42 p.m. the resident was brought back to the nursing station and she continued to call for her mother to help her. At 1:46 p.m. CNA/MA #1 assisted the resident to her room and left her with a call light in the resident's reach. The resident's behavior intensified, crying out loud for help. The resident remained in her wheelchair crying for help. At 2:15 pm, CNA #10 arrived to transfer the resident into bed. The resident then stopped crying for help. C. Record reviewThe care plan, initiated 9/30/22 revealed Resident #36 was taking Zoloft 1 tablet 25 milligrams one time a day for anxiety disorder. The interventions included to monitor for and report to physician/PA (physician assistant) adverse effects of antidepressant medication use ( suicidal ideations, worsening depression, panic attacks, irritability, monitor for signs of mood changes or distress and monitoring patient health questionnaire (PHQ-9). The care plan did not include non pharmacological interventions for the resident. The July 2023 CPO documented the following: Zoloft oral tablet 25 (mg) 1 tablet a day related to anxiety disorder with a start date of 6/13/23.-The MAR and TAR did not include behavioral tracking for the use of Zoloft for anxiety and behavior disorder. D. Staff interviewsCNA #10 was interviewed on 7/12/23 at 2:20 p.m. The CNA said the resident did not like sitting up in her wheelchair and would have a behavior outburst when left in her wheelchair. The CNA said the staff should assist the resident to bed as she was on her break at the time the resident was yelling for help. CNA #10 said the resident usually had behaviors when she became anxious. The CNA said the resident usually calms down when she was positioned in her recliner in her room or assisted to bed. CNA/MA #1 was interviewed on 7/12/23 at 2:35 p.m. The CNA/MA said the resident was complaining about her colostomy bag and stomach pain. The CNA/MA said the resident was assessed by the NHA and the resident was included on the list of residents who were to be seen by the visiting physician later that afternoon. The CNA/MA said the resident frequently exhibited destructive behaviors and she was on medication to help calm her down. The nursing home administrator (NHA) was interviewed on 7/12/23 at 2:46 p.m. The NHA said the resident had frequent behaviors when she became anxious. She said the resident was taking Zoloft 25 mg, 1 tablet a day for anxiety. The NHA said the interdisciplinary team (IDT) meets to discuss psychotropic medications which were entered on the medication and treatment administration (MAR and TAR) to track behaviors to ensure the effectiveness of the medications. The NHA said the facility had not been monitoring Resident #35 behaviors and could not tell how often the resident has those behaviors and the effectiveness of her antidepressant medications. The NHA said the nursing should be tracking Resident #35 behaviors and provide non-pharmacological interventions prior to administering her anxiety medication.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of two medication carts and one of one medication storage rooms. Specifically, the facility-Failed to date an Anoro ellipta inhaler;-Failed to date two vials of tuberculin when opened; -Failed to discard an expired Victoza pen; and,-Failed to discard an unknown pill in a plastic cup in the medication cart. Findings include: I. Professional referencesAccording to the Anoro Ellipta inhaler website, retrieved 7/17/23 from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Anoro_Ellipta/pdf/ANORO-ELLIPTA-PI-PIL-IFU.PDF, "Discard ANORO ELLIPTA 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart."According to the Tubersol package insert, retrieved 1/25/23 from: https://www.fda.gov/media/74866/download, "A vial of TUBERSOL which has been entered and in use for 30 days should be discarded."According to the Victoza insulin pen website, retrieved 7/17/23 from: https://www.novo-pi.com/victoza.pdf, "After first use of the VICTOZA pen, the pen can be stored for 30 days at controlled room temperature (59°F to 86°F) or in a refrigerator (36°F to 46°F)." II. Facility policyThe Medication Storage policy, revised February 2023, provided by the nursing home administrator (NHA) on 7/11/23 at 1:08 p.m. included, "multi-dose vials that have been opened of accessed (needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial."III. Observations and interviewsThe medication cart for halls A and B on 7/10/23 at 10:15 a.m. had an Anoro inhaler that had not been dated when opened and an unknown pill in a plastic cup. Registered nurse (RN) #1 said the inhaler was not opened on her shift and she did not know what the pill was. She said it was important to ensure the safety of the medication for the resident. The medication storage room on 7/10/23 at 10:20 a.m. had two open multi-dose tuberculin vials without an open date. RN #1 said the vials should have been dated when opened. The medication cart for halls E and F on 7/11/23 at 9:43 a.m. had a Victoza insulin pen with an open date of 6/9/23. Licensed practical nurse (LPN) #1 said he was not aware the pen was expired. He said the pen should have been discarded after 30 days of opening. He said it was important to discard the pen after 30 days of opening to make sure the medication was effective. IV. InterviewThe director of nursing (DON) was interviewed on 7/13/23 at 11:24 a.m. She said it was standard of practice to date medications when opened for the safety of the residents, to discard expired medications for the safety of the residents and to discard an unknown pill when found. She said it was important to ensure no harmful effects happen to the residents.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure cutting boards were free from deep scratches and stains. Findings include: I. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, "Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized." II. Observation The initial kitchen tour conducted on 7/10/23 at 9:30 a.m. revealed four large plastic cutting boards. There were brown, green, red, and large white cutting boards on the serving line. All the cutting boards were heavily scored and stained. On 7/11/23 at 9:06 a.m., dietary aide (DA) #2 was cutting bread on the plastic brown cutting board. On 7/12/23 11:15 a.m. DA #4 was observed cutting tomatoes on the green cutting board. III. Staff interview The dietary manager (DM) was interviewed on 7/13/23 at 9:56 a.m. The DM was told of the observations of the cutting boards in the kitchen. He said the cutting boards were visibly stained and showed wear. He said he would replace them immediately. He said the deep scratches could be a potential for bacteria to grow.

Based on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#40) of two residents reviewed for hospice services out of 21 sample residents. Specifically, the facility failed to:-Have a written agreement for Resident #40 that included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and,-Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. Findings include: I. Resident #40 status Resident #40, age 89, was admitted on 3/7/23. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes, dysphasia, and malignant neoplasm of the prostate. According to the 7/1/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident was receiving hospice services. II. Record reviewThe July 2023 ordered "Admit to hospice." Start date 7/7/23. Review of the resident's medical record revealed: -The facility did not have a care plan for Resident #40 identifying hospice care. -The care plan failed to delineate the responsibilities of the facility versus what the hospice would provide in terms of services. -The facility failed to have the hospice aide/nurse notes available in the resident's file at the facility. -The facility failed to have a designated staff member with a clinical background coordinating care for the resident between the hospice agency and the facility. III. Interviews Certified nurse aide (CNA) #8 was interviewed on 7/12/23 at 9:09 a.m. He said he was not aware Resident #40 was receiving hospice care. Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 9:26 a.m. He said hospice was providing services but did not know what their schedule was and when they came into the facility. He said he had never spoken with anyone from hospice, and said there was not a hospice book at the nursing station. CNA #1 was interviewed on 7/12/23 at 9:48 a.m. She said the resident was on hospice but she did not know when hospice was supposed to be in the facility. She said she did not know anything about a hospice book. The director of nursing (DON) was interviewed on 7/12/23 at 1:13 p.m. The DON said she was not familiar with the regulation specific toward hospice care. She said she thought social services was the coordinator between hospice providers but she was not for sure. She said the facility had no formal orientation for hospice aides or nurses. The DON said the facility should have had a care plan delineating the responsibilities of the facility versus what the hospice would provide in terms of services. The hospice director (HD) was interviewed on 7/13/23 at 11:01 a.m. The HD said the registered nurse (RN) was in the facility on 7/12/23. She said the RN was in the facility every other week or as needed (PRN). She said the facility had not provided any orientation other than a tour of the facility by facility staff. She said the RN had just dropped off the hospice notebook yesterday when she visited the facility. The HD said hospice had their own care plan and did not share a care plan with the facility. The HD said they have been providing hospice services since 6/23/23.

Based on observations, record reviews and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections for residents. Specifically, the facility failed to ensure:-Ensure staff offered residents hand hygiene appropriately; and,-Ensure proper hand hygiene standards were followed by staff during dining service. Findings include:I. Facility policies and proceduresThe Handwashing and Hand Hygiene policy, undated, was provided by the director of nursing (DON) on 7/12/23 at 3:30 p.m. It read in pertinent part:"Proper hand washing technique is used for the prevention of transmission of infectious diseases. All personnel working in the facility were required to wash their hands before and after a resident's contact, before and after performing any procedure, after sneezing or blowing noses, and after physical contact.-Hand sanitizing wipes or sanitizer will be available at all table settings.-Staff will encourage residents to utilize hand sanitizing wipes to prevent infections.-Residents who need assistance will be assisted by nursing and dietary staff."II. ObservationsOn 7/11/23 at 11:20 a.m., residents started arriving at the dining room for lunch. The meal served for lunch were tacos, fresh fruits and cupcakes for dessert. Most of the residents were wheeling themselves with their hands to the dining room and others were being assisted by the facility staff.-At 11:35 a.m. the dietary aides and nursing staff started serving water and beverages. A few of the residents required assistance with eating and were being assisted by staff.-At 11:50 a.m. Resident #35 arrived at the dining room wheeling himself by touching and rolling the wheels on his wheelchair with his hands. Resident #35 was served his lunch, however, the staff did not offer hand hygiene to the resident. Though the resident had silverware, he started eating with his hands without any form of hand hygiene. There were no hand sanitizing wipes on any of the dining tables. None of the residents were offered hand hygiene before and after lunch. On 7/12/23 at 12:15 p.m. certified nurse aide (CNA) #9 was assisting a resident with eating. The CNA noticed that another resident needed assistance with her oxygen cannula. The CNA assisted the resident by touching and adjusting the oxygen cannula by the tip of the tube, therefore, touching the nostril of the resident with oxygen. The CNA proceeded to the table and continued assisting the other resident without performing hand hygiene. III. Staff interviewsDietary aide (DA) #3 was interviewed on 7/12/23 at 1:10 p.m. The DA said performing hand hygiene was very important to prevent the transmission of infectious diseases. The DA said the residents should be provided with hand hygiene before and after meals. The DA said the facility had not been consistent with providing hand sanitizing wipes for the residents. The DA said the current practice could lead to the spread of infectious diseases. CNA #9 was interviewed on 7/12/23 at 1:30 p.m. The CNA said every resident should be offered hand hygiene before and after each meal to prevent the spread of infectious diseases. She said some of the residents were able to wheel themselves to the dining room by rolling the wheels of their wheelchairs with their hands and should be offered hand hygiene before meals. CNA #9 said she should have performed hand hygiene after assisting the resident with the oxygen cannula before proceeding to continue to assist the other resident with their meal. The CNA said she had a pocket hand sanitizer in her pocket but forgot to use it. She said performing hand hygiene after coming into contact with a resident could prevent the spread of infectious diseases. The director of nursing (DON) was interviewed on 7/12/23 at 2:15 p.m. The DON said the staff should follow the general guidelines of performinghand hygiene before and after assisting residents with care. She said residents should be offered hand hygiene before and after meals. The DON said staff were trained to utilize the hand sanitizing stations available throughout the facility and to carry a small pocket hand sanitizing gel with them at all times. The DON said the current practice could lead to the spread of germs and infectious diseases. The nursing home administrator (NHA) was interviewed on 7/12/23 at 2:15 p.m. The NHA said the staff were trained to perform proper hand hygiene and to offer hand hygiene to all residents before and after meals. The NHA said the facility would provide education to the nursing staff and dietary aides on hand hygiene.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management and abuse prohibition training. Specifically, the facility:-Failed to ensure CNAs received dementia management training for two of five CNAs; and-Failed to ensure CNAs received abuse prohibition training for two of five CNAs. Findings include: I. Training review Five CNAs were reviewed for the annual required dementia management training. Training records revealed two (CNA #3 and CNA #6) of the five CNAs reviewed did not have the required annual dementia training. Five CNAs were reviewed for the annual required abuse training. Training records revealed two (CNA #3 and CNA #6) of the five CNAs reviewed did not have the required annual abuse training. II. InterviewThe nursing home administrator (NHA) was interviewed on 7/11/23 at 2:15 p.m. She said the facility had planned a "skills school" for August 2023 to include abuse and dementia training for the staff. She said the facility did not have current training for the current staff identified. She said it was important to ensure staff had the correct training to provide the best care to the residents.

A licensure survey was completed on 7/10/23 to 7/13/23. One deficiency was cited.

Based on record review, observations and staff interviews, the facility failed to ensure three (#4, #45 and #43) of eight residents reviewed for accident hazards out of 21 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of falls. Specifically, the facility failed to implement effective fall precautions to prevent the re-occurrence of falls for Resident #45 and Resident #43, contributing to major injuries: On 3/31/23 with a third fall within a week, Resident #43 fell suffering a laceration to her forehead and was sent to the emergency room for sutures; andOn 7/7/23 with a fifth fall within two months, Resident #45 fell suffering a fractured hip. The facility further failed to ensure a physician order and adequate safety measures were followed for two-person assistance with transfers and the proper mechanical lift was used during transfers for Resident #4. Findings include:I. Resident #43A. Resident statusResident #43, age 70, was admitted on 1/10/23. According to the July 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with psychotic disturbances, major depressive disorder and anxiety. The 4/18/23 facility assessment documented the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of four out of 15. She required a wheelchair for mobility and one-person extensive assistance with bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and locomotion. The resident had two falls since admission, one with injury and one without injury. B. Record reviewThe comprehensive care plan, revised 4/18/23, revealed the resident was at risk for falls related to multiple falls. Interventions were to offer diversions, use a chair alarm, educate the resident to call for assistance before transferring, place the resident in sight of staff when awake, implement fall prevention interventions, use non-skid footwear and educate the resident to use the call light. The July 2023 CPO revealed there were no current therapy orders for the resident and there were no physician orders for fall prevention devices. A review of medication administration records from 3/14/23 to 4/18/23 revealed the following changes to the resident's psychotropic medications: -Seroquel (antipsychotic) 25 MG (milligram)- give 1 tablet a day for unspecified dementia- ordered on 2/8/23 discontinued 3/26/23.-Haldol (antipsychotic) 5 MG- give 0.5 ML (milliliter) intramuscular injection one time as needed for unspecified dementia- ordered 3/20/23 discontinued 4/8/23.-Seroquel 25 MG- give 2 tablets a day for unspecified dementia- ordered on 3/26/23 discontinued 3/27/23.-Ativan (benzodiazepine) 1 MG- give 1 tablet a day for unspecified dementia- ordered on 3/14/23 discontinued 3/26/23.-Trintellix (antidepressant) 10 MG- give 1 tablet a day for major depressive disorder- ordered on 3/26/23 discontinued 3/27/23.-Depakote (anticonvulsant) 125 MG- give 1 tablet a day for unspecified dementia- ordered on 3/26/23 discontinued 3/26/23.-Amitriptyline (antidepressant) 25 MG- give 1 tablet every 6 hours as needed (PRN) for major depressive disorder- ordered on 3/26/23 discontinued 4/18/23.-Hydroxyzine (antianxiety) 25 MG- give 1 tablet every 6 hours PRN for anxiety- ordered 3/26/23 discontinued 4/18/23.-Depakote 125 MG- give 2 tablets twice a day for unspecified dementia- ordered on 3/26/23 discontinued 4/12/23.-Amitriptyline 75 MG- give 1 tablet a day for major depressive disorder- ordered on 3/27/23 discontinued 4/4/23.-Ativan 0.5 MG- give 1 tablet twice a day for unspecified dementia- ordered on 3/27/23 discontinued 3/27/23.-Ativan 0.5 MG- give 1 tablet every 6 hours PRN for anxiety- ordered on 3/29/23.-Seroquel 25 MG- give 3 tablets a day for unspecified dementia- ordered 3/27/23 discontinued 3/30/23.-Seroquel 25 MG- give 2 tablets a day for unspecified dementia- ordered 3/30/23 discontinued 4/12/23.-Ativan injectable solution 2 MG- inject 1 MG intramuscularly one time a day for unspecified dementia- ordered 4/12/23 discontinued 4/12/23.-Depakote 125 MG- give 4 tablets twice a day for unspecified dementia- ordered on 4/12/23.-Risperidone (antipsychotic) 1 MG- give 1 tablet a day for unspecified dementia- ordered on 4/13/23. A review of the resident's fall occurrence evaluations revealed:Fall occurrence evaluation dated 3/26/23 revealed the resident had a witnessed fall at 2:15 p.m. in the common area. The resident was sitting in her wheelchair and stood up, lost her balance and fell to the floor. No injury sustained. Interventions included to add diversionary activities, and refer to therapy. The follow up note added to the occurrence on 3/27/23 revealed an anti lock rollback device was placed on the wheelchair to prevent the chair from rolling back. Fall occurrence evaluation dated 3/31/23 revealed the resident had a witnessed fall at 9:30 a.m. in the common area when trying to stand up and then sit back down in her wheelchair. The wheelchair rolled out from behind her and the resident fell to the floor. No injury was sustained. There was no mention why the anti lock roll back device was ineffective. Interventions were to add diversionary activities, refer to therapy and educate the staff to keep the resident in sight during waking hours. The follow up note added to the occurrence evaluation later that day revealed the resident already had a chair alarm. Fall occurrence evaluation dated 3/31/23 revealed the resident had an unwitnessed fall at 7:15 p.m. in the private dining area. The resident was in the private dining area with two other residents but no staff. A nurse at the nurses station heard a loud noise and then observed the resident on the floor. The resident had a laceration to her forehead and was sent to the emergency room for sutures. Fall interventions were to add diversionary activities, refer to therapy and educate the staff to keep the resident in sight during waking hours. -There was no mention why the resident had not been in the staff's sight at time of the fall. There were no new interventions added as a result of the fall. Fall occurrence evaluation dated 4/9/23 revealed the resident had a witnessed fall at 1:45 p.m. in the common area. The resident stood up from her wheelchair at which time her chair alarm sounded and the nurse went to provide assistance. The resident was agitated, declined to sit back in her wheelchair, becoming verbally and physically aggressive with the nurse then fell as a result. The occurrence documented the fall was caused by the resident's continuous anxiety, agitation and argumentative noncompliant behavior with staff. Interventions were to add diversionary activities, refer to therapy, educate the resident to call for assistance and educate the staff to keep the resident in sight during waking hours. Fall occurrence dated 5/30/23 revealed the resident had a witnessed fall at 4:45 a.m. in the common area. The resident had attempted to stand and walk. The resident had removed her chair alarm. Interventions were to add diversionary activities, non-skid footwear, refer to therapy, chair alarm, educate the resident to call for assistance before transferring and educate the staff to keep the resident in sight during waking hours. A review of the physician visit notes revealed visits on 5/2/23, 5/30/23 and 6/20/23. During the physician's visits, neither the resident's frequent falls or frequent psychotropic medication changes were mentioned. II. Resident #45A. Resident statusResident #45, age over 85, was admitted on 3/2/23. According to the July 2023 CPO, diagnoses included unspecified dementia with anxiety and stroke. The 6/8/23 facility assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required a wheelchair for mobility and one-person limited assistance with bed mobility, transfers, bathing and toileting. The resident had two or more falls since admission without injury. B. Record reviewThe comprehensive care plan, revised 6/8/23, revealed the resident was at risk for falls related to multiple falls, history of self transferring, and impaired cognition with decreased safety awareness. Interventions were to offer diversions, use a chair alarm, use hip protectors, fall mat to the resident's floor, educate the resident to call for assistance before transferring, place the resident in sight of staff when awake, implement fall prevention interventions, use non-skid footwear, and educate the resident to use call light. The July 2023 CPO revealed the following physician orders:Occupational therapy for 8 weeks to decrease fall risks to include room modification and wheelchair modification- ordered on 7/5/23. Physical therapy for 12 weeks for therapeutic neuromuscular reeducation- ordered on 6/22/23.-The review did not show any physician orders for fall prevention devices. A review of the resident's fall occurrence evaluations revealed:Fall occurrence evaluation dated 5/16/23 revealed the resident was heard yelling at 7:45 p.m. for help in her room after putting on her call light. She was found lowering herself to the floor in front of her recliner. The resident was wearing shoes. The occurrence documented the resident had been on her call light repetitively during the shift and had complained to the staff regarding the length of time it was taking for help to arrive. When the staff educated the resident to use her call light before attempting to transfer, it was documented the resident stated she had fallen because no one ever came to help her. No injuries were sustained. Interventions were to add a fall mat next to her bed, educate the resident to call for assistance, ensure the wheelchair is within reach, add non-skid footwear add non-skid strips in front of her recliner. -There was no mention of more frequent checks or education with staff on answering her call light promptly. Fall occurrence evaluation dated 5/30/23 revealed the resident had an unwitnessed fall at 3:30 p.m. The resident was found on the floor in her room on her hands and knees in front of her wheelchair. The resident was documented as stating she fell out of her chair. No injury was sustained. Interventions were to add diversionary activities, to add a fall mat next to her bed, educate the resident to call for assistance, ensure the wheelchair is within reach and add hip protectors. Fall occurrence evaluation dated 6/21/23 revealed the resident had an unwitnessed fall at 11:00 p.m. The resident was found on the floor of her bathroom after turning on her call light. The fall resulted in a skin tear to the left outer arm and an abrasion to the left side of head with no bleeding. The resident had taken herself to the bathroom without assistance. Interventions were to add a fall mat next to her bed, educate the resident to call for assistance, and add non-skid footwear. Physical and occupational therapy to evaluate and treat. -There was no mention of more frequent checks or education with staff on answering her call light promptly. Fall occurrence evaluation dated 7/4/23 revealed the resident had an unwitnessed fall at 8:15 a.m. The staff found the resident sitting on the floor in between her bed and wheelchair. Staff concluded the resident did not use her call light for assistance and was not wearing footwear. No injuries were sustained. Interventions were to add a chair alarm, add a fall mat next to her bed, educate the resident to call for assistance, add non-skid footwear, add hip protectors, and ensure the wheelchair is within reach. The follow up note added to the occurrence evaluation revealed the resident had attempted to transfer herself and took off her alarm. It was documented she informed the staff she could do what she wanted to do and she was not going to wear hip protectors or the facility's non-skid socks. Fall occurrence evaluation dated 7/7/23 revealed the resident had turned on her call light at 9:30 p.m. and was found in her bathroom sitting up against the wall. It was documented the resident was yelling her leg was broken and she was in pain. The resident was sent to the emergency room to evaluate and treat. The occurrence documented possible contributing factors to the fall were the resident had not used her call light, however it was documented in the occurrence the resident turned on her call light to alert the staff of her fall. Interventions were to put her bed in the low position, add a fall mat next to her bed, educate the resident to call for assistance, add non-skid footwear, add bed alarm, add hip protectors, and ensure wheelchairs within reach. The follow up note added to the occurrence evaluation revealed the resident had fractured her hip. III. Staff interviewsCertified nurse aide with medication authority (CNA/MA) #1 was interviewed on 7/11/23 at 1:45 p.m. She stated she did not know where the fall prevention interventions for the residents were in the medical record. Registered nurse (RN) #1 attempted to assist CNA/MA #1 to locate fall prevention interventions. RN #1 stated it was in the resident's care plan but she did not know if the certified nurse aides (CNAs) had access to the residents' care plans. CNA #7 was interviewed on 7/11/23 at 1:50 p.m. He stated fall prevention interventions were in the CNA system but he did not have access because he was still training. He had to ask the nurses or CNAs what the residents' fall interventions were. He thought there was a care plan binder at the nurse's station but was unable to find it. CNA #1 was interviewed on 7/11/23 at 1:54 p.m. She stated she checked the resident's care plan to see the fall prevention interventions or the CNA system (kardex). She said Resident #43's fall interventions were a chair alarm, a fall mat, and a low bed. (A fall mat and low bed were not interventions in the resident's care plan). The fall interventions for Resident #45 were a low bed and bed alarm. (A low bed and bed alarm were not in the resident's care plan). CNA #4 was interviewed on 7/12/23 at 10:00 a.m. She stated Resident #43 had become a high fall risk after she had numerous medication changes. She did not know what her fall interventions were. CNA #4 said the fall interventions for Resident #45 were bed and chair alarms. If there were fall interventions added to a resident's care plan, the CNAs could not see the additions. The CNAs had to ask the nurses what the fall interventions were. The director of nursing (DON) was interviewed on 7/12/23 at 2:07 p.m. She stated the CNAs and nurses had access to the residents' care plans to find the fall interventions. There was also a communication binder kept at the nurses station for updates to residents' care. She could not answer why the staff stated they did not know about resident specific fall interventions. IV. Facility follow-up At the time of survey exit, 7/13/23, the NHA stated she would be able to submit documentation showing resident specific fall interventions for Resident #43 and Resident #45. The NHA sent follow up documents after survey exit on 7/14/23 at 4:24 p.m. The documentation included fall care plans for Resident #43 and Resident #45. Resident #43's comprehensive fall care plan revealed interventions added 7/13/23 (during survey) of assisting the resident to the gazebo to look at flowers, add bed alarm, anti-roll back device on wheelchair, ensure physical needs were met, and therapy screen for safety. Resident #45's comprehensive fall care plan revealed interventions added 7/13/23 of physical therapy to evaluate and treat. In the NHA email communication, she revealed resident specific fall interventions were added to a communication sheet kept at the nurses station where staff, to include CNAs, were to review sheets daily and sign the sheet once they read it. The NHA was unable to provide documentation showing the particular staff who had expressed not knowing the fall interventions during the survey had signed any of the fall intervention communication sheets or were aware of the sheets' existence. V. Failure to provide safe transfer assistance for Resident #4 A. Facility policy The Lifting and Transferring Resident Policy, undated, was provided on 7/12/23 at 1:47 p.m. by the nursing home administrator (NHA). It read in pertinent part:"Residents are lifted and transferred safely in all instances."-Nurses assess and determine lifting and transfer requirements and the procedure used for each resident.-All residents must be lifted or transferred according to the determined procedure.-Procedure appears in Resident Care Plan and Resident Profile.-Residents who require assistance in transferring are transferred using a gait/transfer belt or with a lift.-All members of the nursing staff, nurses, and nursing assistants are responsible for using good body mechanics, knowing the proper procedures, and properly operating assistive devices.-Approved techniques for lifting, transfer, and body mechanics are discussed and demonstrated during each orientation program for nursing personnel.-Mechanical lift procedures are used on any resident unable to independently pivot or transfer. B. Resident #4 status Resident #4, age 93, was admitted on 11/27/21. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, chronic respiratory failure, chronic obstructive pulmonary disease, and post-traumatic stress disorder (PTSD). According to the 5/13/23 facility assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had wandering behaviors. He required total assistance for bed mobility, transfers, grooming and toilet use. C. Record review The care plan, initiated 11/27/21 and revised 3/5/23, identified the resident had an activities of daily living (ADL) self-care performance deficit related to cognitive impairment, history of falls, and impaired mobility. Interventions include allowing time for the resident to express feelings of frustration regarding the need for assistance in ADL tasks. Encourage the resident to use call light when assistance is needed. Sit to stand lift for transfers. The July 2023 CPO included: staff should use an electric sit to stand lift and two persons for all transfers. Start date 6/6/23. D. ObservationOn 7/10/23 at 10:05 a.m., certified nurse aide (CNA) #7 entered Resident #4's room, closed the door and placed Resident #4 on the toilet by himself. CNA #7 did not use a sit to stand lift to transfer Resident #4 onto the toilet. CNA #7 exited the resident's room leaving Resident #4 on the toilet. CNA #7 returned approximately five minutes later and removed Resident #4 from the toilet and placed her into her recliner. CNA #7 transferred Resident #4 by himself not utilizing the sit to stand lift. E. Interviews Licensed practical nurse (LPN) #1 was interviewed on 7/10/23 at 10:10 a.m. LPN #1 was told of the observation. He said Resident #4 needed two person assistance with all transfers and a sit to stand was to be used on all transfers. LPN #1 said a negative outcome could be a fall, skin tear or any negative outcome. CNA #7 was interviewed on 7/10/23 at 10:20 a.m. CNA #7 said he was somewhat familiar with Resident #4. He said Resident #4 required a lift but did not know what type of lift was required when transferring Resident #4. CNA #7 said he did not use a sit to stand lift to transfer Resident #4 and there was no lift in the resident's room. The occupational therapist was interviewed on 7/12/23 at 10:07 a.m. The OT was told of the observation of Resident #4 on 7/10/23. He said he was just observing and assessing two CNAs with transfers of Resident #4. He said it was reported to him about the one person transfer of Resident #4 and he was reeducating CNAs on the importance of transferring a resident safely. He said the therapy department would report back to the director of nursing (DON). The DON was interviewed on 7/12/23 at 1:13 p.m. She said it had been reported to her about the CNA transferring the resident. She said staff were supposed to familiarize themselves with the residents' care plan, kardex and know if the resident was a two person transfer and required a lift prior to providing resident care. She said the CNA should have not transferred the resident by themselves and reeducation was started immediately. She said a negative outcome would be a fall, skin tear or serious injury.

A complaint survey, prompted by #CO30678 was conducted on 2/6/23 to 2/7/23. No deficiencies were cited.