Every finding on record at Adara Living

Based on record review and interviews, the facility failed to ensure two (#19 and #18) of nine residents reviewed for medication management were free from significant medication errors out of 22 sample residents.Resident #19 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, respiratory failure, peripheral vascular disease, and thrombocytopenia (a deficiency of platelets in the blood). On 8/21/25 at 6:38 p.m. Resident #19 was sent out to the emergency department from the facility due to an acute change of condition. Resident #19 was found to have low blood pressure, a decrease in responsiveness, an increase in lethargy and was unable to follow the nursing staff's commands. While at the hospital, it was documented Resident #19 suffered an accidental medication overdose after she was given another resident's medications. It was documented the resident received amlodipine (used to treat high blood pressure), metoprolol (used to relax blood vessels and slow heart rate), hydralazine (used to treat high blood pressure), and oxycodone (a narcotic pain medication). Resident #19 was administered 2 milligrams (mg) of Narcan (a medication used to reverse opioid overdose) by the paramedics, and was awake and had spontaneous respirations afterwards.Additionally, Resident #18 was administered his roommate's medications on 9/21/25.Specifically, the facility failed to:-Ensure Resident #19 did not receive another resident's (Resident #26) medications, which required transfer to the hospital for treatment; and,-Ensure Resident #18 did not receive another resident's (Resident #16) medications.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to theonsite investigation from 10/7/25 through 10/8/25, resulting in the deficiency being cited as past noncompliance with a correction date of 9/22/25.I. Medication errors on 8/21/25 and 9/21/25The facility failed to ensure a licensed nurse administered medications to the correct resident.Resident #19 was administered another resident's (Resident #26) medications, which caused the resident to experience a change in condition and the resident was sent to the hospital for treatment. Additionally, Resident #18 was administered Resident #16's medications which led to a change in condition on 9/21/25.II. Facility's plan of correctionThe corrective action plan the facility implemented in response to Resident #19 and Resident #18's medication error incidents on 8/21/25 and 9/20/25 was provided by the nursing home administrator (NHA) 10/8/25 at 4:07 p.m.The stated purpose of the plan was to address the significant medication errors and prevent any additional residents from suffering any adverse outcome.The plan revealed the following:A. Identification of other residentsAn audit of all residents was conducted to ensure an updated photo was present in the electronic medical record (EMR). New, updated photos were uploaded to each resident's EMRs, which was completed by 9/22/25.B. Systemic changesAll applicable facility policies and procedures were reviewed and revised.The assistant director of nursing (ADON) reeducated licensed nurses on the facility's policies regarding medication administration and medication error reporting. All nursing staff were educated prior to working their next shift, completed 9/22/25.The NHA did not allow the two agency nurses who improperly administered medications causing the significant medication errors to return to the facility. The NHA hired seven new nurses to the facility staff to decrease the facility's use of agency staff. The NHA limited agency staff usage to only agency staff members who had worked consistently with the facility in the past, and reviewed the licenses and competencies of each agency staff member prior to their next shift at the facility.C. MonitoringThe director of nursing (DON) or designee would observe medication administration two times per day for four weeks before evaluating to see if additional observations were needed or if the frequency of observations could be decreased at that time. Observations would occur across shifts and with various staff members, including agency staff members.Monthly medication audits were also initiated and were ongoing.The NHA implemented a performance improvement plan as a means to gather and process information from the audit. Findings would be reported at the monthly quality assurancemeetings.The facility's determined date of compliance was 9/22/25.III. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St.[NAME], Missouri, pp. 606-607, Take appropriate actions to ensure the patient receivesmedication as prescribed. To prevent medication errors, follow the seven rights of medicationadministration consistently every time you administer medications:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.IV. Facility policy and procedureThe Medication Administration policy, revised 10/3/25, was provided by the NHA on 10/8/25 at 3:58 p.m. It read in pertinent part, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering medications verifies the resident's identity before giving the resident his/her medications. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication.V. Resident #19A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, respiratory failure, peripheral vascular disease, and thrombocytopenia.The 7/3/25 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident needed substantial assistance or was dependent on staff for most activities of daily living (ADL).B. Resident interviewResident #19 was interviewed on 10/8/25 at 1:35 p.m. Resident #19 said she had to go to the hospital four weeks prior to the date of the interview. Resident #19 said she was given a medication cup around a mealtime the day she had to go to the hospital (8/21/25). Resident #19 said when the nurse who gave her the medication cup walked out of the room, the resident realized the medication cup did not have her name on it. Resident #19 said she approached the nurse and tried to tell her it was not her correct medications, but the nurse insisted it was. Resident #19 said she eventually gave up and took the medications in the cup, and immediately began feeling dizzy. Resident #19 said her roommate called the nursing staff to get her help. Resident #19 said she was taken to the hospital, where a doctor flushed out her stomach. Resident #19 said it was difficult to talk about the incident and began to tear up.C. Record reviewThe October 2025 CPO revealed Resident #19 had physician's orders for the following daily scheduled medications: atorvastatin (used to treat high cholesterol) 40 mg, cranberry oral tablets (used to prevent urinary tract infections) 425 mg, duloxetine (an antidepressant) 40 mg, famotadine (used to treat acid reflux) 10 mg, lubiprostone (used to treat gastroesophageal reflux disease) 8 and 24 micrograms (mcg), vitamin D oral tablets 1250 mcg, carvedilol (used to treat high blood pressure) 6.25 mg, apixaban (blood thinner) 5 mg, oxycodone (opioid pain medication) 5 mg, oyster shell calcium (supplement used to treat osteoarthritis) 500 mg, Seroquel (an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar disorder) 12.5 mg, and acetaminophen (anti-inflammatory pain medication) 1000 mg.-Resident #19 did not have physician's orders for amlodipine, metoprolol or hydralazine, the medications she was administered on 8/21/25.A progress note, dated 8/21/25 at 3:21 p.m., revealed Resident #19 was noted to have increased lethargy and slurred speech. Resident #19's vital signs were assessed, and her blood pressure was documented as 98/58 millimeters of mercury (mmHg). Resident #19 said she felt like she took a sleeping pill. The nurse called Resident #19's physician to inform her of the situation and did not receive any new orders at that time. The nurse documented she would continue to monitor the resident and call the physician back with any changes.A progress note, dated 8/21/25 at 4:00 p.m., revealed the nurse observed Resident #19 in bed with her eyes closed. Resident #19 was not easily awakened by touch or by calling her name, but was easily aroused with a sternal rub (a painful stimulus used by medical professionals to test an unconscious person's responsiveness by rubbing the knuckles firmly on the center of the breastbone (sternum). When the nurse asked Resident #19 if she wanted to go to the hospital, Resident #19 was not able to answer clearly and moaned the word no with her eyes remaining closed. Resident #19 was not able to follow the nurse's verbal commands. Resident #19's vital signs were assessed, and her blood pressure was documented as 98/64 mmHg. Resident #19 had received her scheduled medications that morning and had tolerated them well, with her blood pressure that morning documented as 129/75 mmHg. No other sedatives or pain medications were administered during the nurse's shift. A progress note, dated 8/21/25 at 6:38 p.m., revealed the nurse called to notify Resident #19's physician about a change in condition for the resident. Resident #19 continued to have low blood pressure, a decrease in responsiveness, an increase in lethargy and was unable to follow commands. Resident #19 was sent out via emergency medical services to the hospital.Hospital notes, dated 8/22/25, revealed Resident #19 presented to the hospital somnolent (lethargic), apneic (state of respiratory depression) and hypoxic (having insufficient oxygen) after she was given another resident's medications at the facility. Resident #19, in addition to her usual daily medications, received 10 mg amlodipine, 100 mg metoprolol, 75 mg hydralazine and 10 mg of additional oxycodone. Resident #19 was administered 2 mg of Narcan and awoke and began having spontaneous respirations. On exam, Resident #19 was drowsy but awoke easily to verbal stimuli. Resident #19 was monitored and did not have any further complications. Resident #19 was discharged from the hospital back to the facility on 8/22/25 with the primary diagnosis of accidental overdose.A social services note, dated 8/22/25 at 4:21 p.m., revealed the facility's social worker met with Resident #19. Resident #19 said she was happy to be back, and said she knew the person who caused an error in her medication would never come back to the facility.The facility investigation, dated 8/22/25, was received from the NHA on 10/8/25 at 10:26 a.m. and revealed the following:A statement from the nurse on duty that day documented that on 8/21/25 a medic from the emergency medical services called the facility to update them on Resident #19's status. The medic said they had administered Narcan and Resident #19 became responsive afterward. Resident #19 told the paramedics that she had taken a cup of pills on her bedside table and had seen another cup of pills and took them as well. Resident #19 said she realized when she put the cup down, it had Resident #26's name on it. The nurse documented that she had asked the nurse administering medications multiple times if she needed help, which the nurse denied each time. The nurse documented Resident #26 did not receive her morning medications until close to 1:00 p.m. on 8/21/25.Resident #19 was interviewed on 8/22/25 at 12:15 p.m. Resident #19 said she was in her room around breakfast time and a nurse came in and gave her her medications. Resident #19 said she looked at the medications and they did not look like the ones she usually took. Resident #19 said she looked at the medication cup and it had another resident's (Resident #26) name on it. Resident #19 said she tried to call the nurse back into her room but was unable to do so. Resident #19 said she went to her roommate to try to have her look at the cup to see if she was reading the name correctly, but her roommate was unable to read what was written on the cup. Resident #19 said she went to the nurse's medication cart to ask the nurse if the medications were hers. Resident #19 said the nurse looked at her computer and said the medications were for Resident #19. Resident #19 asked multiple times, and the nurse insisted multiple times the medications were hers. Resident #19 felt she either had to take the medications in the cup or not take any medications, so she decided to take them. Resident #19 said around lunchtime that day (8/21/25) she began feeling weird and foggy, and kept drifting off to sleep. Resident #19 said someone had to hold her up so she would not fall out of her wheelchair. Resident #19 said she did not know how some people could take so many medications.Resident #26 was interviewed on 8/22/25 at 12:00 p.m. Resident #26 said she had not received her scheduled morning medications until almost 1:00 p.m. on 8/21/25. Resident #26 said she had to ask the nurse for her morning medications before she received them, and once requested the agency nurse promptly came in to administer her medications.All facility nursing staff were in-serviced on medication administration policy and procedure starting 8/23/25 and ending 8/24/25.D. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/8/25 at 9:42 a.m. RN #1 said the process for medication administration involved looking at the medication administration record (MAR) to see what medications were due for a resident, gathering the medications for that resident and cross-checking the resident's name in the EMR, medication, dose, route, and the expiration date of the medication. RN #1 said she used the five medication rights when administering medications. RN #1 said when administering medications, she asked the resident to identify themselves before giving them their medications. RN #1 said if the resident could not identify themselves, she referenced the resident's photo and room number listed on the EMR to verify the resident's identity, or used another staff member to verify the resident's identity. RN #1 said all of the photos in the facility's EMR system had been updated within the last two months to ensure the photos accurately reflected the resident's appearance. RN #1 said she had received additional training on the five rights of medication administration two weeks prior (September 2025), as there had been some confusion with medication administration.RN #1 said it was important to ensure she had the correct resident, as someone could accidentally administer the resident's medications to their roommate. RN #1 said if a medication error occurred, she needed to immediately notify the resident's physician with the medications the resident received. RN #1 said the physician would be able to tell the nurse whether the resident needed to be sent out to the hospital, administered any other medications or monitored. RN #1 said she would also need to assess the resident's vital signs, notify the unit manager and the DON about the medication error and monitor the resident for any changes in condition or abnormalities.Licensed practical nurse (LPN) #1 was interviewed on 10/8/25 at 12:50 p.m. LPN #1 said she worked for an outside agency contracted by the facility, but had worked at the facility several times in the past. LPN #1 said for medication administration, she gathered medications according to what was marked as due in the resident's MAR. LPN #1 said when administering medications, she checked the resident's photo and asked the resident to tell her their name in order to verify their identity, or had another nursing staff member identify the resident if they were unable to do so themselves, in order to avoid a medication error. LPN #1 said it was important to ensure the right resident was taking the right medications to avoid medication errors. LPN #1 said if a medication error did occur, she would immediately notify the DON, the unit nurse and the resident's physician, monitor the resident's vital signs and monitor the resident for any changes.The DON was interviewed on 10/8/25 at 2:48 p.m. The DON said when nurses did their medication administrations, the DON's expectation would be that the nurse would have the resident's MAR in front of them on their computer, and would look to see what medications were due. The DON said the nurses would then verify to ensure the resident was receiving the right medication for the right resident, the right dose, the right time and the right route. The DON said nurses should verify they were administering medications to the right resident by asking the resident their name or date of birth and by verifying the resident's photo matched the resident in front of them. The DON said the nurses would then tell the resident what medications they were administering to them, watch the resident take the medications and ensure the medications were administered, then mark the medications as administered in the resident's MAR. The DON said as soon as a nurse was aware of a medication error, they should assess the resident right away and notify the resident's physician. She said once the resident was safe and stable, the nurse should notify the facility managers and the resident's representatives. For Resident #19, the DON said the facility was notified about the medication error by the hospital after the resident was sent out for her change in condition. The DON said the hospital had called the nurse on duty that evening and informed her Resident #19 told the hospital staff she thought she had been administered the wrong medications, as her medication cup said the name of a different resident. The DON said the nurse who had administered medications that day should not have pre-poured medications. The DON called the nurse who had been working that day and interviewed her on the course of events that day. The DON said the nurse said she had administered the correct medications to the correct residents, and it was her understanding Resident #19 had a change of condition.The DON said the facility began investigating the potential medication error the following morning (8/22/25) based on what the hospital reported, and began to get statements from Resident #19, her roommate, and pertinent staff. The DON said when they interviewed Resident #19's roommate she was concerned, as Resident #19 had told her the medication cup she was given had the wrong name on it, and the resident encouraged Resident #19 to talk with her nurse. Based on their investigation, the facility staff assumed Resident #19 received Resident #26's medications.The DON said Resident #19 had not had any adverse effects from the medication error. The DON said the hospital provided Resident #19 with monitoring and intravenous fluids before discharging her back to the facility the following day.The DON said the facility immediately began educating the nursing staff on medication administration, and the agency nurse who initiated the medication error was not permitted to return to the facility. The DON said the resident's photos in their EMRs were updated as a result of the medication error and would be updated at least annually going forward.The DON said it was important for residents to receive their medications as ordered to avoid the residents having any adverse medical reactions to medications given in error, and so they were treated therapeutically for whatever diagnoses the medications were ordered for by their physicians.The NHA and the ADON were interviewed together on 10/8/25 at 4:07 p.m. The NHA said whenever she signed a new contract with an outside nursing agency, she ensured the agency's requirements met or exceeded the facility's requirements. The NHA said for Resident #19's medication error, the facility assumed the resident had been administered Resident #26's medications, but they were not able to verify this information. She said the facility immediately reported the nurse to her outside nursing agency, and the nurse was suspended from the agency services. The NHA said she initiated a performance improvement plan at that time for medication administration.The ADON said she initiated medication administration observations and medication cart audits after the 8/21/25 medication error. The ADON said she also began updating all of the resident's pictures in their EMRs. VI. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included malnutrition, hypertensive heart disease and personal history of traumatic brain injury.The 8/8/25 MDS assessment indicated the resident was cognitively intact with a BIMS score of 13 out of 15. The assessment documented the resident needed substantial assistance from staff for most ADLs.B. Resident representative interviewResident #18's representative was interviewed on 10/8/25 at 9:01 a.m. The resident's representative said Resident #18 had an incident in which he and his roommate had agreed to switch sides of their room, and Resident #18 ended up getting his roommate's (Resident #16) medications. The resident's representative said Resident #18 slept most of the day on 9/21/25 but was fine the following day. The resident's representative said she had met with the DON to find out what they were going to put into place to keep the incident from happening again. The resident's representative said the DON had interviewed every staff member and resident pertinent to the investigation and had everything in place before she met with the representative. C. Record reviewThe October 2025 CPO revealed Resident #18 had physician's orders for the following daily scheduled medications: furosemide (used to treat edema) 20 mg, lactase (used to treat loose stools) 3000 units, vitamin D supplement 1000 units, Senna Plus (used to treat constipation) 50 mg, acetaminophen 1000 mg and morphine sulfate (an opioid pain medication) 0.25 milliliters.A progress note, dated 9/21/25 at 2:06 p.m., revealed a facility nurse called Resident #18's hospice nurse to alert them of a change in condition for the resident. Resident #18 had been asleep most of the morning of 9/21/25 and was unable to fully arouse. Resident #18 was able to take his medications that morning (on 9/21/25) and that afternoon but needed a lot of cueing from the nurse. Resident #18 at one point put his hand over his mouth and said his medications tasted horrible when they were crushed and put in his pudding, but the resident did swallow his medications successfully. Resident #18 was assisted into his bed after lunch for a nap. Resident #18's vital signs were assessed at that time, at which point his blood pressure measured 143/105 mmHg and his pulse was 54 beats per minute (BPM) using a vital signs machine. The nurse assessed Resident #18's blood pressure manually and found his blood pressure was 130/65 mmHg and his pulse was approximately 60 BPM. A certified nurse aide (CNA) said Resident #18's behavior was normal for him as he was usually out of bed and self-propelling around the unit in his wheelchair. Resident #18 appeared to be very lethargic. During an assessment, the nurse asked Resident #18 to squeeze her hand and the resident did not follow the verbal command. Resident #18 was not responsive when the nurse asked him if he was in any pain. The hospice nurse said a nurse from the hospice agency would go out to the facility to evaluate the resident.A progress note, dated 9/21/25 at 3:20 p.m., revealed during shift change on 9/21/25 it was reported to the incoming nurse that Resident #18 was not listed to be in the correct bed the night prior in the EMR. The other nurse told the nurse documenting the progress note that the issue of Resident #18 being in the wrong bed almost caused her to make a medication error, but she caught it in time. The nurse documenting the note said she knew the residents on the unit, including Resident #18, therefore she knew the residents received their correct medications for the morning and afternoon medication administration times on 9/21/25.As the nurse was in Resident #18's room following up on his suspected change in condition, the resident's roommate (Resident #16) approached the nurse and told her he thought she should know Resident #18 may have gotten Resident #16's medications the night prior on accident. Resident #16 told the nurse that the nurse on duty the night prior had attempted to give Resident #16 morphine, to which the resident replied he did not take that medication. The nurse repeatedly asked Resident #16 if he was refusing to take the medication she was trying to give him, and he repeatedly answered yes, as he did not take those medications. Resident #16 told the nurse Resident #18 took the medications which were administered to him, and Resident #16 overheard Resident #18 say there were a lot of medications in his cup.The nurse alerted the DON immediately and contacted Resident #18's physician and family. The nurse updated the EMR to reflect the new bed arrangement for both Resident #18 and Resident #16.A progress note, dated 9/21/25 at 4:13 p.m., revealed Resident #18 was resting in bed. Resident #18 remained lethargic but his vital signs were stable, with the exception of his body temperature measuring 96.4 degrees Fahrenheit. Resident #18's blood pressure was assessed to be 137/78 mmHg, and his pulse was 70 BPM. Resident #18 responded to verbal stimuli and touch but promptly went back to sleep. The hospice nurse arrived at the facility and assessed Resident #18.A progress note, dated 9/21/25 at 6:03 p.m., revealed Resident #18 started to arouse. Resident #18 was adjusting his blankets when a nurse entered his room to check on him. Resident #18 said he was tired and was not hungry for his dinner, and said he was going to go back to sleep. Resident #18's hospice nurse submitted a new physician's order for the resident (see hospice note below).Hospice notes, dated 9/21/25, revealed a physician's order from Resident #18's hospice provider to hold all medications for 24 hours or until Resident #18 was awake and alert, resulting from a suspected medication error on 9/20/25. The facility was to assess Resident #18's vital signs every two hours through 12:00 a.m. on 9/22/25. A progress note, dated 9/22/25 at 1:58 p.m., revealed Resident #18 was more energetic and was out of bed as of that morning (9/22/25). Resident #18 ate his lunch and was up in his wheelchair.A progress note, dated 9/23/25 at 9:58 a.m., revealed education on the medication error was provided to facility staff, and medication observations and an investigation into the error were completed and reviewed by the interdisciplinary (IDT) team.The facility investigation, dated 9/22/25, was provided by the NHA on 10/8/25 at 10:26 a.m. and revealed the following:A medication error report, dated 9/22/25, revealed Resident #18 was given another resident's medications. A description of the error documented there was a potential medication error due to Resident #18 switching which side of the room he used with his roommate without having it changed in the EMR. Resident #18's hospice provider was notified of the incident on 9/21/25 at 3:20 p.m., and provided physician's orders to hold all further medications and to begin checking the resident's vital signs every two hours. Resident #18's representative was notified of the error on 9/21/25 at 3:20 p.m. The corrective action the facility took included relieving the nurse who caused the medication error of her duties and educating the entire nursing staff.On 9/22/25 at 8:30 a.m. the DON spoke with the nurse who was on duty the evening of 9/20/25 (RN #3). The DON explained to RN #3 that an investigation had been initiated involving a potential significant medication error that occurred on 9/20/25. The DON explained a resident had reported a nurse attempted to administer morphine to him when the resident was not ordered to have morphine. The resident then reported he believed his roommate had accidentally received his medications in error. RN #3 said she noticed Resident #18 and Resident #16 were in the wrong beds in their EMR. RN #3 said she verified the residents by their names before administering their medications. RN #3 said Resident #18 was administered morphine and his other medications as ordered, and Resident #16 had refused his medications because she was administering them too late in the evening. RN #3 said she did not note any change in condition of Resident #18 during her shift.A statement from a nursing staff member, dated 9/22/25, revealed Resident #16 called the staff member into his room around midnight on 9/20/25, as he thought RN #3 had tried to give Resident #18 his medications in error. The staff member said he got RN #3 to go back into Resident #16 and Resident #18's room, but she only briefly went into the room before leaving again.A statement from Resident #16, dated 9/22/25 at 11:30 a.m., revealed Resident #16 had already planned to refuse his medications that evening as he felt they were being administered too late. Resident #16 said he heard Resident #18 say he had a lot of pills to take in his medication cup and needed to sit up so he could take them. RN #3 then approached Resident #16 and asked him if he wanted to take his morphine. Resident #16 told RN #3 he did not take morphine, and RN #3 left the room abruptly afterward. Resident #16 called another staff member into his room and told him what occurred with RN #3 and asked him what to do, to which the staff member told Resident #16 he needed to contact one of the facility's management team. RN #3 entered the room shortly thereafter and asked Resident #16 if he needed to speak with her. Resident #16 said he asked RN #3 if she gave Resident #18 his medications, and the nurse said no and told him about some issue with her computer.D. Resident #16's interviewResident #16 was interviewed on 10/7/25 at 3:05 p.m. Resident #16 said there was an instance in which his roommate (Resident #18) received his (Resident #16) medications and became really sick. Resident #16 said a nurse gave Resident #18 his medications and the process sounded different than usual. Resident #16 said he heard Resident #18 say That is a lot of pills, which Resident #16 thought was odd because he (Resident #16) took a lot of medications but knew Resident #18 did not. Resident #16 said he heard Resident #18 having a hard time swallowing all of the medications that evening. Resident #16 said when the nurse finished administering Resident #18's medications, she approached him (Resident #16) and tried to give him his medications. Resident #16 said when he refused his medications, the nurse asked him if he was sure he did not want to take his morphine. Resident #16 said he told the nurse he did not take morphine. Resident #16 said Resident #18 slept for a few days after the medication error incident but had been fine since then.Resident #16 said he and Resident #18 had agreed to switch their sides of the room that day (9/20/25). Resident #16 said he often got too hot on his side of the room and Resident #18 was too cold on his side of the room, so they switched sides so Resident #16 could be closer to the air conditioning unit. Resident #16 said he was not sure how the nurse was able to mix up himself and Resident #18, as the residents were of different ethnicities and age groups. Resident #16 said the nurse should have at least looked at the photos of the residents in the computer before giving them their medications.E. Staff interviewsThe DON was interviewed on 10/8/25 at 2:48 p.m. The DON said the ADON conducted the investigation for Resident #18's medication error. The DON said she was notified of a potential medication error, as Resident #16 was concerned and thought Resident #18 may have received his (Resident #16) medications prior to Resident #18 having a change in condition. The DON said Resident #18 was usually up and active, but had not wanted to get out of bed the morning of 9/21/25. Resident #18 was being monitored by hospice services at the time. The DON said she tried to reach

Based on observation, record review and interviews, the facility failed to prevent an accident for one (#12) of six residents out of 22 sample residents. Specifically, the facility failed to ensure certified nurse aide (CNA) #4 transferred Resident #12 appropriately, which resulted in a fall for the resident.Findings include:I. Facility policy and procedureThe Fall Risk Assessment and Management policy, revised 9/24/25, was provided by the nursing home administrator (NHA) on 10/8/25 at 3:00 p.m. The policy read in pertinent part, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.II. Resident #12A. Resident statusResident #12, age [AGE], was admitted on [DATE] and re-admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), wedge compression fracture of the first lumbar vertebrae, displaced fracture of the lateral malleolus of the right fibula, age-related osteoporosis, dementia with mood disturbance, left hemiplegia and diabetes mellitus type 2. The 7/18/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required a Sara lift (mechanical lift) with two-person assistance for transfers, assistance on and off the toilet, and with clothing management, and she turned side to side in bed with staff assistance.B. Record reviewThe 8/5/25 incident report documented Resident #12 was being transferred from her bed to a wheelchair by CNA #4, who was unable to complete the transfer, which caused the resident to fall. As a result of the incident, Resident #12 sustained a 7 centimeter (cm) skin tear to the left lower leg, with active bleeding noted at the time of assessment. According to the incident report, a predisposing factor was gait imbalance, and CNA #4 was unaware that the resident needed a Hoyer lift and assistance from an extra person for transfers.The 8/8/25 recapitulation of events revealed that Resident #12 refused to be transferred with the Sara lift and requested a stand pivot transfer. CNA #4 performed the stand pivot transfer which led to the fall.The activities of daily living care plan, initiated 2/16/21, documented Resident #12 had impaired physical mobility due to left-sided hemiplegia and contracture of the left hand following a stroke. She required a Sara lift and two-person assistance for transfers and used a wheelchair for mobility. The 8/5/25 progress note, documented after the incident, revealed Resident #12 sustained an approximately 7 cm skin tear located on the anterior left lower leg with active bleeding noted at the time of assessment. The surrounding skin was thin and bruised. Resident #12 was oriented and denied pain or dizziness. The nurse on duty assessed the wound, and the staff reported the incident to the resident's physician and family, as well as to the unit manager.III. Staff interviewsCNA #5 was interviewed on 10/7/25 at 4:22 p.m. CNA #5 said the staff were sup the resident with two people using the Hoyer lift. CNA #5 said after the fall on 8/5/25, Resident #12 got a skin tear. CNA #5 said the NHA regularly organized meetings with staff to discuss accident prevention. CNA #4 was interviewed via phone on 10/8/25 at 12:40 p.m. CNA #4 said she was a new employee and before the incident with Resident #12, a registered nurse (RN) told her that Resident #12 was a one-person assistance and was able to stand up and pivot.CNA #4 said she tried to stand-pivot Resident #12 but the resident fell. CNA #4 said after the incident, two staff members came to help, and they put the resident in bed using a Hoyer lift. She said the RN took care of the bleeding on the resident's left leg. CNA #4 said she did not know anything about Resident #12 prior to transferring the resident and she did not take care of the resident after the incident on 8/5/25.RN #2 was interviewed on 10/8/25 at 10:05 a.m. RN #2 said she did not remember anything else about Resident #12's fall because it happened months ago. She said nurses should communicate changes in care plans and transfer statuses to CNAs during rounds.The director of nursing (DON) was interviewed on 10/8/25 at 3:20 p.m. The DON said the best way to determine how to transfer a resident was a multidisciplinary decision between previous facilities' orders, physical therapy (PT) and nursing. The DON said that the statuses for transfers and mechanical lift assistance were in the residents' care plans; however, CNAs did not have access to the entire care plan. She said CNAs could see what they needed to know for resident care or ask a nurse if they needed further information on a resident's transfer status. The DON said CNA #4 transferred Resident #12 by herself because the resident refused the mechanical lift, which caused the resident to fall and sustain a skin tear. The DON said CNA #4 did not ask the nurse how to perform the resident's transfer. The DON said she did not know that an RN told CNA #4 that Resident #1 was a one-person assist for transfers and was able to stand up and pivot. The DON said after the incident, personalized education was provided to CNA #4.The NHA was interviewed on 10/8/25 at 4:30 p.m. The NHA said CNA #4 and the RN on duty at the time of the incident received safe transfer education after the incident. The NHA said she told CNA #4 and the RN that if a resident refused to use a mechanical lift, they needed to communicate with PT because PTs were the only ones allowed to transfer residents without using a Hoyer lift if the resident required a mechanical lift.

Based on record review and interviews, the facility failed to ensure two (#4 and #2) of three residents reviewed for abuse were kept free from sexual abuse out of five sample residents. Specifically, the facility failed to: -Protect Resident #4 from sexual abuse by Resident #3; and, -Protect Resident #2 from sexual abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse policy, dated 1/30/25, was provided by the nursing home administrator (NHA) on 6/23/25 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Identifying physical or psychosocial indicators of abuse (including injuries from an unknown source), neglect, exploitation, and misappropriation of resident property from situations of verbal, mental, sexual or physical abuse. The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have the knowledge of individual care needs. In cases of abuse, the quality assurance committee will review the circumstances of the abuse to determine if changes in policies and procedures are necessary to provide further preventative measures. II. Incident of sexual abuse towards Resident #4 by Resident #3 on 5/2/25 A. Facility investigation The 5/2/25 facility investigation was provided by the NHA on 6/23/25 at 4:00 p.m. The investigation revealed Resident #3 grabbed Resident #4's shirt and upper chest area. The investigation revealed the NHA interviewed Resident #4 on 5/2/25 at 10:15 a.m. Resident #4 said she went to talk to Resident #3. Resident #1 said Resident #3 shook her hand and with his other hand tried to reach down her shirt. Resident #4 said Resident #3 touched her skin and grazed her breast while holding her other hand. Resident #4 said Resident #3 shook her hand with his right hand and touched her breast with his left hand. Resident #4 said she did not welcome the touch, but was alright. Resident #4 said she felt safe because the nurse saw it and stopped it right away. Resident #4 said she did not feel totally safe because she was unsure what Resident #3 was up to and she did not want him on her unit. Resident #4 said she was not in pain. The investigation documented the director of nursing (DON) interviewed certified nurse aide (CNA) #4 on 5/2/25 at 10:40 a.m. regarding the incident between Resident #3 and Resident #4. CNA #1 said around 10:00 a.m. he was walking from the dining room on the second floor. CNA #1 said he saw Resident #3 near the nurses' station with his hand out towards Resident #4. He said he then saw Resident #3's hand pull at Resident #4's shirt by the collar. CNA #1 said he told Resident #3 that he could not do that. CNA #1 said he alerted one of the three CNAs sitting at the nurses' station. CNA #1 said one of the CNAs immediately took Resident #3 back to the third floor. CNA #1 said Resident #4 told him that Resident #3 was trying to touch her. CNA #1 said when he first saw Resident #3 reaching towards Resident #4 and pulling at her shirt, Resident #4 did not appear to have any reaction. CNA #1 said he immediately reported what happened to the nurse assigned to Resident #4. The assistant nursing home administrator (ANHA) and the DON interviewed a dietary aide (DA) on 5/2/25 at 4:30 p.m. The DA said she was in the dining room taking meal orders. She said Resident #4 was by the ice machine. The DA said she started walking out of the dining room and saw Resident #3 near Resident #4 with his hand on her shirt at the top. The DA said a CNA went to Resident #4 and Resident #3 right away and separated them. The DA said the CNA told Resident #3 that he could not touch other residents. The DA said Resident #4 did not appear to be upset. The DA said the CNA asked if Resident #4 was alright. The DA said Resident #4 said she was fine. The NHA interviewed CNA #1 again on 5/2/25 at 4:36 p.m. CNA #1 said Resident #3 had his hands on Resident #4's breast and her shirt area. The interview said CNA #1 did not specify if Resident #3's hands were in Resident #4's shirt or outside, just that his hands were placed near her breasts. The investigation documented the facility substantiated sexual abuse by Resident #3 towards Resident #4. B. Resident #3 (assailant) 1. Resident status Resident #3, age less than 65, was admitted on [DATE] and discharged to another facility on 6/20/25. According to the June 2025 computerized physician orders (CPO), diagnoses including severe traumatic brain injury (TBI). The 6/11/25 minimum data set (MDS) assessment revealed, through staff assessment, the resident required modified independence in cognitive decisions. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Record review The behavior care plan, revised 5/2/25, revealed Resident #3 had a history of sexually inappropriate behaviors. Pertinent interventions included providing one-to-one staff monitoring, providing frequent checks, providing redirection and maintaining the resident's personal space. C. Resident #4 (victim) 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses including moderate intellectual disabilities, delusional disorders, insomnia, generalized anxiety disorder and depression. The 6/13/25 MDS assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. 2. Resident interview Resident #4 was interviewed on 6/23/25 at 10:45 a.m. Resident #4 said she approached Resident #3 to shake his hand. She said in the process, he attempted to reach out and grab her breast. Resident #4 said a staff member intervened and stopped Resident #3 before he could succeed. She said after the incident, Resident #3 returned to the third floor. III. Incident of physical abuse of Resident #2 by Resident #3 on 5/20/25 A. Facility investigation The 5/20/25 facility investigation was provided by the NHA on 6/30/25 at 4:00 p.m. The investigation documented on 5/20/25 at approximately 11:00 a.m., Resident #2 reported an incident involving Resident #3 to the NHA. Resident #2 said after offering Resident #3 a spoonful of pudding, Resident #3 touched her breast twice. Resident #2 said she wanted to avoid Resident #3. The investigation documented later that day (5/20/25) at 11:35 a.m., the NHA and the DON interviewed Resident #3 about the incident. Resident #3 admitted to grabbing Resident #2's breast and stated he was horny. The investigation documented on 5/20/25 at 12:15 p.m. that the NHA interviewed staff members. The staff members reported observing nothing specific, but noted that Resident #2 had assisted Resident #3 with pudding, during which Resident #3 touched Resident #2's breast. The NHA interviewed another resident on 5/22/25 at 12:43 p.m. The resident said they did not witness the event and only saw officers enter Resident #3's room. The resident said she was not afraid of Resident #3 and said Resident #3 was no longer funny. The investigation concluded abuse occurred. Resident #3 was placed on a one-to-one caregiver indefinitely. B. Resident #2 (victim) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses including anxiety, dementia without behavioral disturbance, psychotic disturbance and mood disturbance. The 6/11/25 MDS assessment revealed Resident #2 had severe cognitive impairments with a BIMS score of seven out of 15. 2. Resident interview Resident #2 was interviewed on 6/23/25 at 11:30 a.m. Resident #2 said Resident #3 reached over and grabbed her breast while she was giving him a bite of ice cream in the dining room area on the third floor. She said after the incident, a staff member separated Resident #3 from Resident #2. IV. Staff interviews CNA #1 was interviewed on 6/23/25 at 1:15 p.m. CNA #1 said on 5/2/25 Resident #3 was in the third floor dining room and appeared to be feeling down. CNA #1 said Resident #4 approached Resident #3 to offer comfort and was touched by Resident #3. CNA #1 said he heard about the incident between Resident #2 and Resident #3 within five minutes of the incident occurring on 5/20/25. CNA #1 said a one-to-one caregiver was implemented following this event. Licensed practical nurse (LPN) #1 was interviewed on 6/23/25 at 2:00 p.m. LPN #1 said Resident #4 told her that Resident #3 grabbed her shirt. LPN #1 said both Resident #4 and Resident #3 were separated. LPN #1 said after the incident with Resident #2 and Resident #3, staff members were assigned to Resident #3 to ensure no other appropriate interactions would occur. The NHA was interviewed on 6/23/25 at 4:00 p.m. The NHA said Resident #3 had a history of sexual behaviors and that the facility had implemented a one-on-one caregiver. She said the facility was aware of Resident #3's history of inappropriate behaviors but had not implemented more restrictive interventions for him before the 5/20/25 incident. The NHA and the DON said they were not aware of Resident #3's sexually aggressive behavior before the incidents.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in five of five nourishment refrigerators. Specifically, the facility failed to ensure safe and appropriate storage of food items in the nourishment refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, ([DATE]), retrieved on [DATE], read in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (Chapter ,d+[DATE]). The Hormel Handling Information product guide, (2025), retrieved on [DATE], read in pertinent part: For Med-Pass products: Shelf life is up to four days refrigerated after opening. (Page 5) II. Facility policy and procedure The Safe Handling of Foods From Visitors policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 1:00 p.m. The policy read in pertinent part, Facility staff will request that visitors bringing in food, and or residents that received food, must notify a member of the nursing or activities departments. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. When food items are intended for later consumption, the responsible facility staff member will. Ensure that the food is stored separate or easily distinguishable from the facility food in a unit refrigerator/freezer or resident's personal regenerator in their room and labeled with the resident name and current date. Refrigerators/freezer storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperatures monitors daily for refrigerators equal to or less than 41 degrees fahrenheit and equal to or less than ten degrees fahrenheit; daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more three or more days; and cleaned weekly. III. Observations On [DATE] at 9:52 a.m. a refrigerator was observed on the first floor behind the nurses station. The refrigerator contained a container of Med-Pass (liquid supplement) approximately a quarter full and an unopened Monster energy drink. A sticky light brown substance with long black hair was in the bottom of the refrigerator. -The facility failed to label the Med-Pass with an opened or expiration date according to the product's handling instructions (see recommendations above) and the Monster energy drink was not labeled with a resident's information to differentiate it from the staff's food. On [DATE] at 10:04 a.m. a refrigerator was observed in the second floor dining room. The refrigerator contained a container of Med-Pass approximately a quarter full. -The facility failed to label the Med-Pass with an opened or expiration date according to the products' handling instructions (see recommendations above). On [DATE] at 10:09 a.m. a refrigerator was observed on the third floor. The refrigerator contained three Nestle Boost supplements with a use by date of [DATE]. On [DATE] at 10:22 a.m. in the first floor secure unit freezer, there was a clear plastic one ounce (oz) medication cup with a frozen white substance in the cup. There were small light pink pieces on top of the white substance with a small white spoon frozen inside the cup. The cup was not labeled or covered. On [DATE] at 10:35 a.m. a refrigerator was observed on the third floor secure unit. The refrigerator contained the following: -A container of Med-Pass approximately a quarter full and the facility failed to label the Med-Pass with an opened or expiration date according to the product's handling instructions (see recommendations above). -A clear plastic container topped with a red lid that contained fresh blueberries was not labeled with a resident's name or date on the container. -An opened, two quart container of coffee mate creamer that was not labeled with a resident's name or expiration date on the container. -One 16 ounce pump bottle of hand sanitizer. -A clear, two quart plastic container of salsa with no resident's name or expiration date on the container. -A disposable Starbucks cup with a sticker dated [DATE] at 9:11 a.m. with no residents name on the cup -One can of unopened Red Bull that was not labeled to differentiate it from the staff's food. A typed sign was posted on the refrigerator that read in pertinent part: Residents only. All items must have a resident name and date. All employee items will be removed. IV. Staff interviews Dietary aide (DA) #1 was interviewed on [DATE] at 10:05 a.m. DA #1 said a resident's family member could bring and keep a resident's food in the nourishment refrigerator. DA#1 said she asked the family to put the resident's name, room number and date on the item. DA #1 said the nurses used Med-Pass and should label the Med-Pass container upon opening it. Certified nurse aide (CNA) #5 was interviewed on [DATE] at 1:00 p.m. CNA #5 said if a resident's family brought in food and asked facility staff to store the food, CNA #5 labeled the container with the date food was brought to the facility and then placed the food in the resident's refrigerator. CNA #5 said if a family brought in food that was placed in a nourishment refrigerator at the nurses station she would label the item with the resident's name also. The NHA and the director of nursing (DON) were interviewed together on [DATE] at 11:30 a.m. The NHA said the dietary staff monitored temperatures of the nourishment refrigerators and checked for expired products . The NHA said the nursing staff used the refrigerators as well. The NHA said the nursing staff and the dietary staff could remove expired items from the refrigerators. The DON said the Med-Pass was not a widely used supplement but the containers were usually placed in the refrigerators after being opened. The NHA said a staff drink or food in a resident refrigerator would be discarded because the nourishments refrigerators were for resident food only.

Based on record review and interviews, the facility failed to ensure six (#98, #16, #127, #106, #116 and #67) of 33 residents reviewed for abuse out of 53 sample residents were free from abuse. Specifically, the facility failed to: -Prevent resident to resident physical abuse between Resident #98 and Resident #16, who had a history of physically and verbally aggressive behaviors towards other residents and staff; -Protect Resident #67 from physical abuse from Resident #127; -Protect Resident #106 from physical abuse from Resident #127; and, -Prevent a resident to resident physical abuse altercation between Resident #116 and Resident #127. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, revised 12/17/18, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:10 p.m. It read in pertinent part, Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. Physical abuse is not limited to hitting, slapping, punching and kicking. Assess, care plan and monitor residents exhibiting needs and behaviors that predispose them to have conflict with others or to subject them to neglect by staff (such as residents with history of aggressive behaviors; residents who enter other residents' rooms, residents with self injury behaviors; residents with communication disorders; resident requiring extensive or total nursing care). II. Incident of physical abuse between Resident #98 and Resident #16 on 1/6/25 A. Facility investigation The 1/6/25 abuse investigation documented a witnessed resident-to-resident physical altercation between Resident #98 and Resident #16. The staff observed Resident #98 entering the third floor dining room and Resident #16 exiting the third floor dining room. Their wheelchairs bumped together when passing each other. Resident #98 reached over and slapped Resident #16 in the face. The staff separated the two residents. Resident #16 said that Resident #98 had slapped him. Resident #98 denied slapping Resident #16 and said Resident #16 had yelled at him. Resident #98 said he had slapped Resident #16 a long time ago because Resident #16 had made him angry. The investigation indicated the two residents were separated and placed on 15-minute checks. The on-duty nurse performed skin and pain assessments on both residents and neurological checks were initiated for Resident #16. It indicated that Resident #16 had denied pain or being afraid of Resident #98. The facility investigation unsubstantiated the allegation of physical abuse at the conclusion of the investigation due to Resident #98's poor impulse control and therefore the slap was unintentional and there was no observed pain, injury or animosity from either Resident #98 or Resident #16. -However, abuse occurred as Resident #98 slapped Resident #16. B. Resident #98 - assailant 1. Resident status Resident #98, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI) and dementia. The 11/25/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of ten out of 15. He was dependent with toileting, personal hygiene, bed mobility, transfers and required substantial/maximal assistance with eating. The assessment indicated the resident exhibited verbal behaviors towards others. The assessment did not indicate the resident exhibited physical behaviors towards others. 2. Resident observation and interview On 1/13/25 at 10:00 a.m. Resident #98 declined to be interviewed with difficult to understand speech. On 1/13/25 at 1:04 p.m. Resident #98 was sitting at a table in the dining room. He was sitting alone at a table, feeding himself and cursing, which was not directed to anyone. 3. Record review The behavior care plan, initiated 5/18/21 and revised 11/12/24, indicated Resident #98 had behaviors of being physically and verbally combative with staff, invading other residents' personal space, taking food off of other residents' plates, inappropriate behaviors toward females and poor impulse control related to his TBI. Interventions included trying different activities to increase resident engagement, initiating a behavior chart and reward program, offering to take Resident #98 to his room if his behavior was agitating other residents, encouraging the resident to develop more appropriate methods of coping and interacting, reviewing diet regimen to address his food seeking behaviors and intervening as necessary to protect the rights and safety of others. The 8/13/24 resident to resident physical altercation care plan, initiated 9/5/24, documented a female resident had reported that Resident #98 had hit her. Interventions included separating residents and initiating 15-minute checks with one-to-one support given until calm, moving resident to another floor for decreased stimulation and calmer environment with more activity involvement, following up with behavioral health services, reviewing bowel and pain regimen evaluating for neurology follow up, ruling out a medical cause, during checks noting location, environment and people surrounding him remove him from a highly stimulated, loud or crowded area and assisting as needed. The 1/6/25 resident to resident physical altercation care plan, initiated 1/6/25, indicated that Resident #98 had a resident to resident physical altercation while he was trying to enter the dining area and another resident was exiting the dining area when their wheelchairs bumped. Interventions included separating residents and initiating 15-minute checks, adding a pureed snack at 10:00 a.m. and increasing portions to double portions to reduce behavior of seeking other residents left over food in the dining area, placing a sign at the end of the steam table for staff not to park the hot food holding tower in the dining room entry to prevent resident collisions and reviewing resident mood and behavior with the psych interdisciplinary team (IDT). The facility daily behavior monitoring, from 9/14/24 to 1/14/25, documented Resident #98's physically aggressive behaviors including kicking/hitting, grabbing and pinching/scratching/spitting on 9/23/24, 10/31/24, 11/23/24, 11/24/24, 12/20/24, 12/30/24, 1/5/25, 1/6/25, 1/12/25 and 1/14/25. The 8/31/24 nursing progress note documented Resident #98 and another resident were found with wheelchair wheels entangled in the entrance way of the dining room. The other resident stated that they had been hit by Resident #98. The residents were separated and 15-minute checks were initiated. The 9/11/24 nursing progress note documented Resident #98 was swearing at the nurse on two separate occasions because he was upset that the nurse was not listening to him. The 9/12/24 social services progress note documented Resident #98 could be verbally and physically abusive toward others and that Resident #98 had a recent altercation with another resident. Resident #98 had been moved to another floor which was smaller with more activity involvement. The 12/16/24 behavior progress note documented Resident #98 had been yelling, wandering and exit seeking during the shift. The 12/25/24 behavior progress note documented Resident #98 had been yelling and cursing at staff and other residents. He was assisted out of the dining room and started to attempt to make himself vomit. The 12/25/24 behavior progress note documented Resident #98 was swearing at staff during bedtime care. Resident #98 was also swearing and trying to strike staff when he was in the middle of the hallway and staff asked him to move. The 12/31/24 behavior progress note documented Resident #98 became verbally aggressive with staff when asked to move his wheelchair and kicked staff in the shin twice. He was observed later to be verbally aggressive toward another resident and backed up his wheelchair into the other resident's wheelchair. The 1/3/25 behavior progress note documented Resident #98 attempted to hit staff when he was assisted with bedtime care. The 1/5/25 behavior progress note documented Resident #98 started eating food off of other residents' plates. A certified nurse aide (CNA) attempted to redirect the resident and he kicked her in the shin and spit food out at her. The 1/6/25 nurse progress note documented Resident #98 passed another resident and Resident #98 reached up and slapped them. Resident #98 denied slapping the other resident and said the other resident had yelled at him. He then said he had slapped the other resident a long time ago because he had made him angry. The 1/13/25 social services progress note documented the social worker spoke to Resident #98 regarding the physical altercation with another resident. Resident #98 was asked not to target or approach the other resident and not have any negative interactions with the other resident. C. Resident #16 1. Resident status Resident #16, age 81, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included dementia and post traumatic stress disorder (PTSD). The 10/29/24 MDS assessment revealed the resident had severe cognitive impairments with deficits in short and long term memory per staff assessment. He was dependent with toileting, substantial/maximal assistance with personal hygiene, transfers, partial/moderate assistance with bed mobility and set up assistance with eating. The assessment indicated the resident exhibited physical and verbal behaviors towards others. 2. Record review The post traumatic stress disorder (PTSD) care plan, initiated 7/26/24 and revised 9/24/24, documented Resident #16 had a history of PTSD related to his experiences and being wounded as a [NAME] in the Vietnam war. It indicated his triggers might be from lights at night or flood lights. Interventions included administering medications as ordered, encouraging responsible party in plan of care, facilitation referrals to community resources, monitoring resident mood and behaviors. The 12/17/24 resident to resident physical altercation care plan, initiated 12/17/24, documented Resident #16 was a victim in a resident to resident altercation. Resident #16 was being held by the wrist by another resident while the other resident was swinging a hat hitting him in his left shoulder. Interventions included assessing the resident head to toe and keeping the resident in line of sight. The 1/6/25 resident to resident physical altercation care plan, initiated 1/6/25, documented Resident #16 was slapped by another resident when their wheelchairs bumped into each other at the entrance of the dining room. Interventions included placing residents on monitoring, separating and assessing residents every 15 minutes and decongesting the entrance to the dining room. -A review of Resident #16's comprehensive care plan did not reveal personalized interventions to prevent further abuse from aggression by other residents. The 1/6/25 nursing progress note documented Resident #16 was slapped by Resident #98 while they were passing each other in the entry of the dining room. Redness was noted on the left side of his face but he denied pain or being fearful. D. Staff interviews CNA #6 was interviewed on 1/15/25 at 10:27 a.m. CNA #6 said Resident #98 would lash out towards others when he was unable to articulate or make his needs known. He said Resident #98 could get verbally and physically aggressive at times. He said Resident #16 also had difficulties communicating. He said since the recent resident to resident altercation between Resident #98 and Resident #16, Resident #16 did not seem comfortable around Resident #98. He said both residents used to get along but now Resident #16 seemed to want nothing to do with Resident #98. He said when Resident #16 saw Resident #98 he would often shake his finger at Resident #98 and say you, you. He said staff would keep Resident #98 and Resident #16 apart, especially during meals and sat them at different tables. Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 9:30 a.m. LPN #3 said Resident #98 was very attention seeking. He said he was not aware of any recent resident to resident physical altercations but Resident #98 was on 15-minute checks for his behaviors and would be summarized and documented in the medical record as a behavior note for each shift. He said Resident #98 did have a previous resident to resident physical altercation on another floor and had been moved to the current floor because of behaviors with another resident. He said if Resident #98 was unable to communicate he would lash out. He said he was unaware of any special interventions that were in place from a recent alteration with another resident. He said when there was a resident to resident physical altercation, staff would immediately separate the residents, placed them on 15-minute monitoring, notified administration and the police. Unit manager (UM) #2 was interviewed on 1/16/25 at 10:20 a.m. UM #2 said Resident #98 had a history of a TBI and had a speech impediment and difficulty in communicating. She said he was originally on another floor and had been moved to the current floor because of behavior issues with others. She said the current floor was a calmer environment for him. She said Resident #98 had a recent physical altercation with Resident #16. She said Resident #98 had reached over and slapped Resident #16 in the face when their wheelchairs bumped at the entrance of the dining room. She said Resident #98 was very impulsive. She said the staff discussed his behaviors once a week in IDT. She said Resident #16 had reacted to Resident #98 by calling out and Resident #98 had come to her office and been upset by this. She said Resident #98 had been told by staff that Resident #16 called out and not to take it personally. She said Resident #98 had been on 15-minute checks continuously for his behaviors. She said the staff had tried to decongest the entry of the dining room to prevent this from happening again. The director of nursing (DON) and the NHA were interviewed together on 1/16/25 at 1:51 p.m. The DON said Resident #98 had a long history of behaviors and physical aggression towards others. She said Resident #98 had been on another floor and had been moved to the current floor for less stimulation. The DON said there had been multiple referrals for Resident #98 for more appropriate placement, including a TBI center. She said Resident #98 was also being followed by psychiatric staff. The DON said both Resident #98 and Resident #16 had their ups and downs. She said both residents had a tendency to call out. She said Resident #98's behavior had improved while on the current floor. She said Resident #98's behaviors seemed to have escalated over the holidays. The DON said the nursing staff notified the provider, obtained a urinalysis, reviewed his chart, checked his bowel and bladder program, limited his caffeinated beverages, reviewed his medications, reviewed his pain levels, obtained a neurology referral and reviewed his diet. The DON said the nursing staff were still trying to regiment Resident #98's day and were looking into a behavioral reward system. The DON said she was not aware of any behavior changes or ongoing tension between Resident #98 and Resident #16 since the altercation. She said CNA #6 worked with Resident #98 and Resident #16 consistently and knew the residents well. She said if CNA #6 had identified there was a behavior change by Resident #16 towards Resident #98 after the physical altercation, he would know. She said if Resident #16 was no longer comfortable around Resident #98 and no longer wanting to interact with Resident #98 since the altercation, that would substantiate the allegation of physical abuse. She said she would do further research into the behavior changes between the two residents. 51710 III. Incident of physical abuse between Resident #67 and Resident #127 on 9/23/24 A. Facility investigation The 9/23/24 facility investigation documented Resident #67 was in the dining room yelling obscenities at staff members who were around the corner. Resident #127 became agitated from the obscenities and struck Resident #67. It documented Resident #67 then swung his arms trying to hit Resident #127 back before the staff could intervene. Resident #67 sustained a skin laceration above his right eyebrow, which was treated with normal saline and steri-strips. The investigation documented the residents were separated, staff and residents were interviewed, the resident's care plans were reviewed, and pain/medication reviews were conducted. Fifteen minute checks were initiated and behavioral health services were contacted. Resident #67 was interviewed and said he went to the table that Resident #127 was sitting at and asked him for help opening something. He said Resident #127 initially agreed, but then got mad and hit Resident #67 across the face. He said he hit Resident #127 back three times, but not as hard as Resident #127 hit him. Resident #67 said he felt safe as long as Resident #127 was not around. Resident #127 was interviewed and said Resident #67 was yelling at staff members then came after him. He said he told Resident #67 to stop, which made Resident #67 mad. Resident #127 said he did not physically touch or throw objects near Resident #67. Resident #127 was unable to complete the interview. The investigation documented Resident #127 appeared overstimulated by the environment and kept looking around worried. The investigation documented the staff witnessed Resident #67 and Resident #127 physically fighting each other. Resident #67 was in the dining room angry about his coffee, and started screaming obscenities. The staff member passed him and went into the kitchen. It documented the staff member heard a commotion and witnessed Resident #67 throwing a glass of juice and Resident #127 standing next to him with his right fist drawn back. It documented Resident #127 stated Resident #67 went after him for no reason, and Resident #67 should not be allowed to talk that way. The investigation documented Resident #67 was sent to the hospital days after the altercation due to low oxygen levels and lethargy. It documented a CT scan of the head and cervical spine and a chest x-ray were conducted, all negative for any findings. The results of the investigation documented that abuse was unsubstantiated as both elements of physical abuse were not met. It documented that even though Resident #67 obtained a skin tear, there was a lack of evidence proving Resident #127 intended to harm Resident #67 instead of Resident #127 reacting negatively after becoming overstimulated. Additionally, the conclusion documented although Resident #67 obtained a laceration to his eyebrow, no serious bodily injury occurred. -However, Resident #67 and Resident #127 were witnessed fighting each other and Resident #67 said he was hit by Resident #127. B. Resident #67 - victim 1. Resident status Resident #67, age 82, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, anxiety disorder and moderate and recurrent major depressive disorder. The 11/20/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. He required substantial assistance with toileting/personal hygiene and dressing. He was dependent on staff for transfers and locomotion via wheelchair. The assessment indicated the resident exhibited wandering behavior. 2. Record review A behavior care plan, initiated on 5/24/24 and revised on 1/13/25, revealed Resident #67 could be verbally and physically aggressive towards others related to his diagnosis of dementia The resident had a history of delusions and hallucinations. It documented Resident #67 had previously thrown things, wandered into other resident's rooms, made inappropriate sexual comments to others and made inappropriate jokes about being mad at or harming others. Interventions included scheduling pain medication, increasing supervision of Resident #67 through various methods, assessing for verbal and non-verbal signs of pain and offering Resident #67 tasks/activities that focused his attention. A behavioral symptoms care plan, initiated on 9/24/24, revealed Resident #67 could affect others by directing negative physical and verbal behaviors towards them. Interventions included assessing for physiological causes of aggressive behavior, a pain regimen review, providing redirection and/or one-to-one supervision as needed and intervening when Resident #67 exhibited negative behaviors towards others. A nurse progress note, dated 9/23/24 at 6:55 p.m., revealed Resident #67 was in the dining room angry about his coffee when he started screaming obscenities. It documented the nurse heard a commotion and observed Resident #67 throwing a cup of juice. It documented Resident #127 was standing next to Resident #67 with his right fist drawn back. It documented Resident #67 sustained a one and a half centimeter (cm) laceration above his right eyebrow. It documented the laceration was cleansed with normal saline and steri-strips were applied. It documented Resident #67's provider and power of attorney (POA) were notified. C. Resident #127 - assailant 1. Resident status Resident #127, age 73, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease, delusional disorders, post-traumatic stress disorder (PTSD), and mild dementia , in other diseases, with other behavioral disturbance. The 12/26/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of six out of 15. He required supervision with ambulation, transfers, and personal hygiene. He required substantial assistance with toileting hygiene and showering. He experienced hallucinations and delusions. The MDS assessment indicated the resident had symptoms of negative physical and verbal behaviors towards others, and negative behaviors not directed towards others. 2. Record review An altercation care plan, initiated on 9/24/24, revealed Resident #127 was involved in a resident to resident altercation on 9/23/24. It documented Resident #127 could be triggered by overstimulation and direct negative physical and verbal behaviors towards others. Interventions included encouraging a low stimulation dining location, assessing for physiological causes of aggression and providing redirection and/or one to one supervision as needed. The behavior care plan, initiated on 11/4/23 and revised on 1/6/25, revealed Resident #127 was physically and verbally aggressive related to his dementia with paranoia, delusion and PTSD. It documented Resident #127 became overstimulated at times and would strike out at others who made noises or touched him. Interventions included providing a calm environment, administering medications as ordered, keeping the resident near a staff member when at group activities to redirect if he had increased agitation, analyzing triggers and what deescalated the resident's behavior and staff to intervene before the agitation escalated. A nurse progress note, dated 9/23/24 at 7:11 p.m., revealed the nurse overheard Resident #67 scream an obscenity. The nurse entered the dining room and saw Resident #127 standing next to Resident #67 with his right hand raised. It documented Resident #127 said Resident #67 should not be allowed to talk that way. It documented Resident #67 sustained a laceration. It documented Resident #127 sustained no injuries, and his provider and POA were notified. IV. Incident of physical abuse between Resident #106 and Resident #127 on 12/20/24 A. Facility investigation The 12/20/24 facility investigation documented screaming was heard from Resident #127's room. When the staff approached, Resident #106 was on the floor facing into Resident #127's room, indicating she wandered in. It documented Resident #127 was standing over Resident #106. Resident #106 was attempting to kick Resident #127, however no contact was made. The investigation documented no injuries were observed on either resident. The investigation documented the residents were separated, the staff and residents involved were interviewed, and the resident's care plans were reviewed. Fifteen minute checks were initiated and a stop sign was placed on the outside of Resident #127's room to deter wandering residents from entering. The investigation documented laboratory (lab) work was requested for Resident #127. -Stop sign was in place, but was not hung up due to Resident #127 being under one-to-one supervision. His door was closed to deter other residents from entering his room. Resident #106 was interviewed and talked nonsensically when asked about the altercation. She was unable to verbalize the events and she appeared angry. Resident #127 was interviewed and said Resident #106 went into his room. Resident #127 said she did all the time. He said she was not allowed to be in there and she got in his face. He said he went to close his room door and pushed Resident #106 to the ground. -The investigation documented Resident #127 had previously been physically aggressive towards others if he felt they were invading his space and his room door was closed when Resident #106 entered. The results of the investigation documented that abuse was unsubstantiated as it did not meet all of the requirements elements of abuse criteria, even though there was evidence of intent to harm. It documented neither resident sustained physical injuries, reported any pain, or exhibited signs and symptoms of fear or emotional distress. -However, Resident #127 said he pushed #106 and Resident #106 was found lying on the floor attempting to kick Resident #127. B. Resident #106 - victim 1. Resident status Resident #106, age 77, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included dementia in other diseases, severity unspecified, with agitation, anxiety disorder and recurrent major depressive disorder. The 12/6/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. She was independent with eating, ambulating and transfers. The assessment exhibited wandering behavior. 2. Record review An altercation care plan, initiated on 12/20/24 and revised on 12/26/24, revealed Resident #106 was involved in a resident to resident altercation on 12/20/24. She went into another resident's room, which agitated him, and prompted him to push Resident #106 to the ground. Interventions included one-on-one supervision, conducting an activity review and implementing personalized activities and removing the resident to a calm/safe environment to de-escalate as necessary. A behavior care plan, initiated on 1/22/22 and revised on 8/1/24, revealed Resident #106 would often attempt to offer unsolicited help to other residents, and would lean in close to them if they did not respond to her. Interventions included redirecting residents behavior, administering medications as ordered and offering activities that diverted her attention. A nurse progress note, dated 12/20/24 at 2:03 p.m., revealed screaming was heard from Resident #127's room. It documented when the nurse approached, Resident #106 was lying on the floor attempting to kick Resident #127, who was standing over her. It documented Resident #106 was temporarily removed from the unit to calm down, 15-minute checks were initiated on Resident #106. The provider and her POA were notified. C. Resident #127 - assailant 1. Record review An altercation care plan, initiated on 12/20/24 and revised on 12/30/24, revealed Resident #127 had territorial behaviors related to dementia and PTSD and would become aggressive towards others if he felt they were invading his space. Interventions included placing a stop sign and door alarm on Resident #127's door, lab work, administering medications as ordered and intervening as necessary to protect the safety of others. A nurse progress note, dated 12/20/24 at 1:41 p.m., revealed the nurse heard screaming from Resident #127's room and found him standing over Resident #106. It documented Resident #106 appeared to have entered Resident #127's room and she was lying on the floor attempting to kick Resident #127. It documented both residents were immediately separated and 15-minute checks were initiated on Resident #127. It documented Resident #127's provider was notified and lab work was ordered. It documented a voicemail was left for Resident #127's power of attorney. III. Incident of physical abuse between Resident #116 and Resident #127 on 1/3/25 A. Facility investigation The 1/3/25 facility investigation documented Resident #116 was observed falling backwards and landing on his buttocks. When the staff approached Resident #116, Resident #127 was standing over him. The investigation documented Resident #116 did not hit his head. The investigation documented Resident #127 had finger indentations and scratches on his right arm. Resident #127 had full range of motion to the extremity and had no reports of pain. Resident #127 said he was just standing there when Resident #116 grabbed his arm and twisted it trying to push him out of the way. Resident #127 said he had to push Resident #116 to the ground so he would not fall. He said he had to defend himself. The investigation documented the residents were separated, the staff within the vicinity of the incident were interviewed, the residents were interviewed, the resident's care plans were reviewed and behavioral health services was contacted. Fifteen-minute safety checks were initiated. The investigation documented lab work and a urinary analysis (UA) was requested. Resident #116 was interviewed and said he was just standing there and was pushed down. The investigation documented the staff witnessed Resident #116 falling from around the corner. It was unclear which resident pushed first based on the interviews and the altercation being unwitnessed. Resident #127 did have finger indentations and superficial scratches on his arm aligning with the claim of Resident #116 grabbing Resident #127's arm. The results of the investigation documented that abuse was unsubstantiated as it did not meet all of the requirements of abuse because there was no intent to harm, the reddened area to the arm was resolved moments after the event occurred, there were no further injuries and neither resident showed signs of distress. -However, Resident #127 said he pushed Resident #116 and said Resident #116 grabbed his arm. B. Resident #116 - assailant Resident #116, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 CPO, diagnoses included unspecified Alzheimer's disease, schizoaffective disorder (mental disorder), and dementia, in other diseases, with other behavioral disturbance. The 11/27/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. He was independent with ambulation, bed mobility, and transfers. He exhibited wandering behavior. 2. Record review An altercation care plan, initiated on 1/3/25, revealed Resident #116 was involved in a physical altercation with another resident. Interventions included 15-minute monitoring, encouraging the resident to participate in meaningful activities, ordering lab work and referring the resident to behavioral health services for medication review. A behavior care plan, initiated on 6/4/24 and revised on 6/19/24, rev[TRUNCATED]

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of three floors. Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 1/21/25 read in pertinent part: Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (Chapter 3-28). II. Facility policy and procedure The Safe Handling of Foods From Visitors policy, undated, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:00 p.m. The policy read in pertinent part, Facility staff will request that visitors bringing in food, and or residents that received food, must notify a member of the nursing or activities departments. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. When food items are intended for later consumption, the responsible facility staff member will: Ensure that the food is stored separate or easily distinguishable from the facility food in a unit refrigerator/freezer or resident's personal regenerator (sic) in their room and labeled with the resident name and current date. Refrigerators/freezer storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperatures monitors daily for refrigerators equal to or less than 41 degrees fahrenheit and equal to or less than ten degrees fahrenheit; daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more three or more days; and cleaned weekly. III. Observations On 1/13/25 at 11:00 a.m. the following observations were made in room [ROOM NUMBER]: Two personal refrigerators each belonging to the residents who resided in room [ROOM NUMBER] were inspected. One refrigerator contained two packages of cheese and two containers of meat were stored in the refrigerator. The refrigerator did not have an internal thermometer. A resident who resided in room [ROOM NUMBER] was interviewed and said facility staff did not check the temperature of her refrigerator but her husband checked the refrigerator daily and kept it clean. The second personal refrigerator in room [ROOM NUMBER] was inspected and did not have an internal thermometer. On 1/13/25 at 1:40 p.m. the personal refrigerator in room [ROOM NUMBER] far was inspected and did not have an internal thermometer. IV. Record review Personal refrigerator monitoring logs from December 2024 (12/1/24 to 12/31/24) and January 2025 (1/1/25 to 1/13/25) were reviewed. On 12/23/25, there were no temperatures recorded for refrigerators in room [ROOM NUMBER], #131, #133, #134, #135, #137, #138 or the two refrigerators in room [ROOM NUMBER]. Temperatures were recorded once daily each day on 12/5, 12/26, and 12/27/25 for residents personal refrigerators and were as follows: A refrigerator in room [ROOM NUMBER] was documented as having temperatures of 42 F, 42 F, and 44 F. A refrigerator in room [ROOM NUMBER] was documented as having a temperature of 42F, 45, and 41 F. A refrigerator in room [ROOM NUMBER] was documented as having temperatures of 41 F, 45 F and 44 F. A refrigerator in room [ROOM NUMBER] was documented as having temperatures of 41 F, 43 F, and 43 F. A second refrigerator in room [ROOM NUMBER] was documented as having temperatures of 42 F, 41 F, and 44 F. -However, neither refrigerator in room [ROOM NUMBER] was labeled to indicate which resident's refrigerator was being monitored or what corrective actions were taken when the temperatures were out of range. Temperature logs for 1/13/25 through 1/16/25 revealed the following: A refrigerator in room [ROOM NUMBER] was documented once daily as having a temperature of 45 F, 45 F, 45 F and 45 F each day. A refrigerator in room [ROOM NUMBER] was documented once daily as having a temperature of 43 F, 43 F, 43 F, 43 F each day. -However, corrective actions were not indicated for the refrigerators in rooms #355 and #358 when they were documented as having temperatures out of the acceptable range. V. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said she was not sure who monitored the temperatures of the resident's personal refrigerators. CNA #5 said if a resident's family brought in food and asked facility staff to store the food, she labeled the container with the date food was brought to the facility and then placed the food in the resident's refrigerator. The NHA was interviewed on 1/16/25 at 11:00 a.m. The NHA said the housekeeping staff monitored and recorded the temperatures of resident's personal refrigerators when the rooms were cleaned. The NHA said the housekeeping staff kept a binder of all temperature logs for the residents personal refrigerators. The NHA said she was unsure if the facility staff provided education to the residents or their representatives regarding the food from outside sources policy. The NHA said she talked to the residents and families about the appropriate plugs and placement of the refrigerators. The environmental services director (ESD) and the NHA were interviewed together on 1/16/25 at 1:00 p.m. The ESD said each housekeeper brought a refrigerator monitoring log with them when they cleaned the resident's room. The ESD said there was a monitoring log for each hallway and when a housekeeper cleaned a resident's room, the personal refrigerator was checked and the temperature of the resident's personal refrigerator was recorded on the log. The ESD said if the temperature was above 40 degrees fahrenheit on the thermometer, that meant the refrigerator's temperature was out of range and the housekeeping staff should inform her. The ESD said she recently ordered thermometers and gave them to housekeeping staff on 1/15/25 to replace any refrigerators that needed them. The ESD said housekeeping staff carried extra thermometers with them. The NHA said if a resident's personal refrigerator was out of temperature range the facility would replace the refrigerator and discard the perishable food from the room. 51710 VI. Resident interviews and observations The resident who resided in room [ROOM NUMBER] was interviewed on 1/13/25 at 10:29 a.m. The resident said she had lived in the facility for two years and her refrigerator had not been cleaned since she moved in. The refrigerator in room [ROOM NUMBER] was observed. The refrigerator had a small amount of food spills that were red and brown in color and the freezer was half-full of packed ice crystals. A thermometer was found inside that read 40 degrees. Temperature logs were not seen in Resident #66's room. room [ROOM NUMBER]'s refrigerator was observed again on 1/15/25 at 8:09 a.m. The refrigerator had one wrapped, undated, dessert inside. The refrigerator had a small amount of food spills that were red and brown in color and the freezer was half-full of packed ice crystals. The thermometer inside read 42 degrees. The refrigerator in room [ROOM NUMBER] was observed on 1/13/25 at 10:15 a.m. The refrigerator did not have a thermometer inside. There were two open, undated, cups of fluids inside the refrigerator. The refrigerator had a small amount of food spots that were brown in color and had some built up ice-crystals present. The refrigerator in room [ROOM NUMBER] was observed again on 1/15/25 at 8:19 a.m. The refrigerator had a small amount of food spots that were brown in color. There was not a thermometer inside the refrigerator. The freezer had some built-up ice crystals present.

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident dementia abuse prevention. Specifically the facility failed to: -Provide annual resident abuse prevention training/education to 46 out of 212 staff members; and, -Provide annual dementia management education/training for 42 out of 212 staff members. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, revised 12/17/18 was received from the nursing home administrator (NHA) on 1/13/25 at 1:10 p.m. It revealed in pertinent part, It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Educating staff on factors related to dementia care and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, they may be perceived as challenging behaviors to staff and could increase the risk of resident abuse and neglect. II. Staff training records A request was made for the facility's annual abuse and dementia training records for all active staff members on 1/14/25. On 1/15/25 at 3:32 p.m. the staff development coordinator (SDC) provided the records for all active staff members who had completed annual abuse and dementia training. The records revealed 46 out of 212 staff members had not completed the facility's annual abuse training. Additionally, the records revealed 38 out of 212 staff members had not completed the facility's annual dementia training. On 1/16/25 at 2:35 p.m. the NHA provided a revised copy of all active staff members training records for annual abuse and dementia training (see NHA interview below). The revised records revealed 42 (not 38) of 212 staff members had not completed the facility's annual dementia training. -The facility failed to ensure all active staff members completed the annual training for abuse and dementia. III. Staff interviews The NHA was interviewed on 1/15/25 at 3:13 p.m. The NHA said the facility had acquired a new SDC in May 2024 who was also the infection preventionist (IP) due to the facility identifying issues with training completion. The NHA said the facility put a performance improvement plan (PIP) in place for human resources. However, the NHA said the PIP did not include annual abuse and dementia education. The NHA said the electronic education platform previously used by the facility was not being completed by staff and they had opted into a new training platform that was started on 1/1/25. The NHA said it was important to ensure all staff members were able to provide care and be aware of signs of abuse and dementia care. The NHA was interviewed a second time on 1/16/25 at 12:45 p.m. The NHA said the staff were reviewing employee files to ensure accurate counts for training were given. She said the facility would not be able to provide documentation for all staff members for abuse and dementia training. The NHA said moving forward the SDC would be responsible for auditing and ensuring all abuse and dementia training was completed on hire and annually and it was to be added to the new hire checklist. On 1/16/25 at 3:20 p.m. the director of nursing (DON) was interviewed. The DON said abuse and dementia training for all employees was important for safety and knowledge of how to handle resident situations that could arise, especially with dementia residents in the facility.

Based on observations, record review and interviews, the facility failed to ensure care for residents in a manager and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one of four residents out of 53 sample residents reviewed for respect and dignity. Specifically, the facility failed to ensure a resident was provided privacy while using the restroom. Findings include: I. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included schizophrenia, post traumatic stress disorder (PTSD) and history of falls. The 12/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was dependent on total assistance from staff for toileting hygiene, transfers, and lower body dressing. He needed substantial to maximal assistance with bed mobility and bathing, and needed set up help only with eating, oral and personal hygiene. II. Record review Resident #7's activities of daily living (ADL) care plan documented Resident #7 haD an ADL self-care performance deficit due to impaired balance, muscle weakness, decreased endurance, poor trunk control, cognitive impairments and decreased motivation to perform tasks. Pertinent interventions included Resident #7 needed assistance from two people for transferring. Resident #7 had incontinent episodes of bowel and bladder and required assistance with incontinence care and clothing management after an episode. Resident #7 transferred onto the toilet for bowel movements occasionally. III. Observations On 1/14/25 at 5:15 p.m. Resident #7 was sitting on the toilet in his room. The door to Resident #7's room and bathroom were both open, and the bathroom was immediately to the left of the room entrance. The bathroom door was opened at an angle so Resident #7 was visible from the hallway. Resident #7 was seated on the toilet, his pants were around his legs and he was holding a grab bar on the wall of the bathroom. Resident #7 grunted loudly twice and then yelled' here it comes' while seated on the toilet. An unidentified certified nurse aide (CNA) walked past Resident #7's room while Resident #7 was on the toilet with the door open, looked at the doors and continued to walk down the hallway. The unidentified CNA did not check on the resident or close the door to the room while the resident was using the restroom and was exposed to the facility hallway. Immediately after the unidentified CNA passed Resident #7's room, CNA #4 exited Resident #7's room with a clear bag of trash in her hand while Resident #7 was still in the bathroom and exposed to the facility hallway. She did not close the door to Resident #7's room, walked across the hallway and placed the clear trash bag inside a refuse container. CNA #4 walked back toward Resident #7's room and closed the door to the room. IV. Staff interviews CNA #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said if a resident was able to independently sit in the bathroom without assistance either the bathroom door or room door should be closed for privacy. CNA #5 said she was trained to ensure the residents' room doors were closed for privacy unless the resident was claustrophobic and needed the door open. CNA #5 said if a resident needed the door open, the resident should still be shielded for privacy. CNA #4 was interviewed on 1/16/25 at 2:15 p.m. CNA #4 said she thought she was in Resident #7's room with his roommate on 1/15/25. CNA #4 said sometimes Resident #7 did use the bathroom himself with the bathroom door open so he could call someone when he needed help. CNA #4 said if a resident wanted the bathroom door open while they used the bathroom then the door to the resident's room should be closed or the resident should be provided another form of privacy. The director of nursing (DON) was interviewed on 1/16/25 at 10:15 a.m. The DON said Resident #7 was fine with his bathroom door open unless his roommate's family or visitors were in the room and then he would want the door closed.

Based on observations, record review, and interviews, the facility failed to honor a resident's choice for laundry services, for one (#113) out of 33 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #113's laundry was consistently saved and stored for his wife to launder due to his multiple allergies. Findings include: I. Facility policy and procedure The facility's Promoting/Maintaining Resident Self-Determination policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 10:53 a.m. It read in pertinent part, It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. Policy compliance guidelines included: -All staff members involved in providing care to residents will promote and facilitate resident self-determination; -Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -All aspects of care and services will be discussed in the care plan meeting and documented as such; -The care plan will reflect resident choices when applicable; and, -The facility will accommodate the resident's preferences to the extent possible and as agreed upon by the resident's sponsor and physician. II. Resident #113 A. Resident status Resident #113, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral/psychotic/mood disturbance and anxiety, post-traumatic stress disorder (PTSD) and gout (a type of arthritis). The 11/11/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of two out of 15. He was independent with bed mobility, transfers and locomotion. He required partial assistance with oral/toileting hygiene and showering, and supervision with dressing. B. Resident representative interview and observations Resident #113's representative was interviewed on 1/13/25 at 2:28 p.m.The representative said a bunch of Resident #113's clothes were previously missing and she was working with one of the facility's social workers regarding the issue. She said Resident #113 was previously exposed to Agent Orange (tactical herbicide) which caused him to develop a lot of allergies. The representative said Resident #113 had gotten rashes in the past if the wrong soap or laundry detergent was used. She said she had requested Resident #113's dirty laundry to be stored and saved for her to launder due to his allergy to most commercial laundry products. She said there was a lot of turnover with the nurses and the certified nurse aides (CNA) in the facility, so she felt like she had to micromanage his care. She said she did not understand why it was so difficult for the facility's staff to ensure his laundry was in his closet for her to collect. There was a sign taped to Resident #113's bathroom door stating he was allergic to aloe and to only use the shampoo that was in his closet. Another laminated sign was taped to Resident #113's closet door stating his wife wanted to do his laundry and facility staff should store his dirty laundry in the laundry basket inside the closet. A laundry basket was inside his closet. C. Record review A grievance form, dated 12/23/24, revealed Resident #113's wife reported the resident was missing pants, pajama pants and multiple shirts. She reported often finding other resident's clothing in Resident #113's room and not his clothing. An investigation was conducted by a facility administrator on 12/23/24, and five pairs of pants and five shirts were found in his closet. The administrator left a voicemail for Resident #113's wife on 12/27/24. The facility administrator reported his clothes were located in the facility laundry and other resident's clothing were removed from Resident #113's room. A review of Resident #113's electronic medical record (EMR) documented he had allergies to hydrocodone (pain medication), valproic acid (seizure medication, penicillins (antibiotics), milk and milk products, pork, aloe, corn and lavender. A skin integrity care plan, initiated on 9/7/22 and revised on 8/6/24, revealed Resident #113 was at risk for impaired skin integrity due to anticoagulant (blood thinner) use. He had fragile skin and poor safety awareness. Interventions included encouraging good nutrition and hydration to promote healthier skin, assessing his risk of skin breakdown quarterly and as needed, and completing skin assessments weekly. -Review of Resident #113's EMR did not reveal documentation addressing his allergies, skin issues with topical products and detergents, or laundry preferences. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/16/25 at 9:34 a.m. CNA #1 said Resident #113's wife did his laundry. She said he was frequently incontinent and would sometimes go through all of his clean clothes, so his clothes would be sent to the facility's laundry room. She said the laundry department was aware of Resident #113's allergies and did his laundry different from the other residents. Licensed practical nurse (LPN) #2 was interviewed on 1/16/25 at 9:48 a.m. LPN #2 said Resident #113's wife did his laundry. She said his wife did allow the facility to do his laundry when she was sick, but otherwise she wanted to primarily do it. She said she would ask Resident #113's wife to bring additional clothing in for him due to his incontinence. The director of nursing (DON) was interviewed on 1/16/25 at 1:51 p.m. The DON said if a resident's family asked to do their laundry, the facility had signs posted for staff to place on their closet and laundry bins they could put inside the closet. She said it was important to follow a resident's request because it was their right and the facility should honor their preferences, especially if they affect their health. The DON was interviewed again on 1/16/25 at approximately 5:45 p.m The DON said the facility had begun providing education with the facility's staff to discuss the resident's laundry and laundry preferences.

Based on observations, record review and interviews the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the residents'status based on the criteria outlined in the resident assessment instrument (RAI) for one (#83) of 18 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #83's MDS accurately indicated the resident was receiving hospice services. Findings include: I. Facility policy and procedure The Documentation of Medical Record policy and procedure, undated, was received from the nursing home administrator (NHA) on 1/16/25 at 1:47 p.m. It revealed in pertinent part, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. II. Resident #83 A. Resident status Resident #83, age 66, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. The 11/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent with toileting, personal hygiene, bed mobility and required set up assistance with eating. The assessment indicated Resident #83 was receiving hospice care. -However, review of Resident #83's EMR did not reveal the resident was receiving hospice services (see record review below). B. Record review A comprehensive review of the EMR failed to reveal a physician's order for hospice, progress notes of hospice services or care planned interventions of hospice services being provided. III. Staff interview The NHA was interviewed by email communication on 1/15/25 at 1:20 p.m. She said the hospice services coded for Resident #83 on the MDS assessment was incorrect and would be corrected. The minimum data set coordinator (MDSC) was interviewed on 1/16/25 at 2:15 p.m. The MDSC said she was responsible for completing the MDS assessments for the residents. The MDSC said she would assess a resident in their room and speak with staff about resident cares to complete the MDS assessment. The MDSC said she double checked the MDS assessment and read through alerts at the end prior to signing it. The MDSC said alerts could come from a new change on the MDS assessment that was different from the previous MDS assessment if it was available. She said if an alert came up, she could change the response at that time. The MSDC said the MDS assessment could be modified at any time if an error was found. The MDSC said Resident #83 was not on hospice services and that was coded in error. The MDSC said that the MDS assessment for Resident #83 had been corrected when it was brought to her attention (during the survey). The MDSC said she planned to slow down when reading through the alerts in the future to ensure that MDS assessments were coded correctly.

Based on observations, record review and interviews, the facility failed to ensure two (#45 and and #95) of five residents who required respiratory care received the care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Implement a routine cleaning schedule for the care of Resident #45's continuous positive airway pressure (CPAP) machine; -Ensure a care plan was in place and implemented for Resident #45's CPAP machine to include route of administration, oxygen supplementation, storage, cleaning and machine settings; and, -Ensure a functional continuous positive airway pressure (CPAP) machine was available, cleansed, stored, and maintained for Resident #45 and Resident #95. Findings include: I. Professional reference The Legionella Toolkit (12/26/24) retrieved on 1/22/25 from the Centers for Disease Control (CDC) https://www.cdc.gov/control-legionella/php/toolkit/control-toolkit.html. It read in pertinent part, In the absence of control, Legionella can grow in almost any system or equipment containing non sterile water, such as tap water, at temperatures favorable to Legionella growth. Devices that may grow Legionella in the absence of control include the following: dental and medical equipment such as scalers, CPAP, bronchoscopes, and heater-cooler units. Dental and medical equipment should be cleaned regularly per manufacturer recommendations and use distilled water in respiratory equipment such as CPAP machines, heater-cooler units, and bronchoscopes (page 8). II. Facility policy and procedure The CPAP policy, revised November 2021, was provided by the nursing home administrator (NHA) on 1/16/25 at 1:47 p.m. The policy read in pertinent part, A CPAP or BiPAP's purpose is to improve oxygenation, assist in reducing pulmonary edema, decrease the work of breathing and for use with residents who do not require assistance in maintaining adequate minute volume. Cleaning the CPAP and BiPAP machines: wash the mask daily in fragrance-free soap, mild and warm water or with designated sanitation wipes, then rinse in warm water and air dry. The frame of the mask should be cleaned weekly in warm soapy water or with a designated sanitation wipe. The CPAP/BiPAP humidifier uses distilled water only and should be emptied and refilled daily. The humidification chamber should be washed daily using mild soap and warm water and air dried. III. Resident #45 A. Resident status Resident #45, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes, chronic respiratory failure with hypoxia, chronic kidney disease stage 2 and dependence on supplemental oxygen. The 12/3/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on assistance with transfers and bed mobility and needed substantial assistance with bathing. He needed set up help with upper body dressing and oral hygiene and was independent at meal time. The MDS assessment documented the resident used a non-invasive mechanical ventilator. B. Resident interview and observation Resident #45 was interviewed on 1/13/25 at 11:05 a.m. Resident #45 said his CPAP machine did not get cleaned at the facility and he used his CPAP every night. Resident #45 said he cleaned his own CPAP machine himself. Resident #45's CPAP mask and tubing were on his nightstand during the interview on 1/13/25. C. Record review A review of Resident #45's January 2025 CPO revealed a physician's order to apply the CPAP at bedtime for sleep with two liters of oxygen bled in, one time a day starting 4/23/23. A review of Resident #45's care plan documented he had altered respiratory status and difficulty breathing related to sleep apnea and had coronary heart failure. Pertinent interventions included the use of the CPAP machine as ordered. -However, further review of the resident's electronic medical record (EMR) revealed Resident #45 did not have a physician's order that included the storage of the machine and/or settings of the device. Additionally, review of the resident's EMR revealed Resident #45 did not have a physician's order for cleaning his CPAP machine. -The use of a CPAP machine was not on Resident #45's care plan as an active problem area, and the care plan did not have goals and interventions listed for the CPAP machine, to include route of administration, frequency, oxygen supplementation, storage and/or settings and a cleaning schedule. IV. Resident #95 A. Resident status Resident #95, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 CPO, diagnoses included obstructive sleep apnea (OSA), primary pulmonary hypertension (high lung pressure) and chronic obstructive pulmonary disease (COPD). The 12/3/24 MDS assessment revealed the resident was cognitively intact with a BIMSscore of 15 out of 15. She required partial assistance with bed mobility. She was dependent on staff for toileting hygiene, lower body dressing, applying/removing footwear, transfers, and locomotion. The assessment indicated the resident used a non-invasive mechanical ventilator. B. Observations On 1/13/25 at 10:26 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor. On 1/14/25 at 9:39 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor with a floor fan on top of the mask's two straps. On 1/15/25 at 8:10 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor with a floor fan on top of one of the mask's straps. On 1/16/25 at 10:38 a.m. Resident 95's CPAP mask was stored in a plastic bag hanging on the resident's bed rail. C. Resident interviews Resident #95 was interviewed on 1/15/25 at 8:10 a.m. Resident #95 said she had not used her CPAP machine in two to three years. She said her CPAP machine was not functional and the power cord had been lost when she moved to a different room in the facility. She said the unit manager (UM) ordered a new power cord one month ago (December 2024) and she was still waiting for it to arrive. Resident #95 was interviewed on 1/15/25 at 9:05 a.m. Resident #95 said her CPAP mask and machine had not been cleaned since she moved in. Resident #95 was interviewed a second time on 1/16/25 at 10:38 a.m. Resident #95 said she contacted her service provider about the power cord for her CPAP machine and she was told they would provide an update at her next appointment. She said she did not use her CPAP machine the previous night (1/15/25) and she thought the UM stored it in a bag on 1/15/25 after he was looking at her machine. D. Record review A physician's order, dated 11/12/24, revealed staff should cleanse Resident #95's CPAP every night with provided cleansing wipes. A physician's order, dated 10/25/24, revealed staff should bleed in two liters of oxygen, then assist Resident #95 with her CPAP machine at bedtime for OSA. The respiratory care plan, initiated on 6/27/23 and revised on 11/4/24, revealed Resident #95 was at risk of respiratory distress due to COPD and OSA. It documented Resident #95 had a CPAP machine and often declined to use it. Interventions included a mask fitting, on 11/5/24, to promote CPAP compliance, administering medications/inhalers as ordered, cleansing and sanitizing Resident #95's CPAP machine with CPAP wipes as directed and monitoring for signs and symptoms of respiratory distress. A nurse progress note, dated 11/5/24 at 4:22 p.m., revealed Resident #95's provider was notified she was not using her CPAP machine due to mask fit. It documented a new mask was on order and should come soon. -Review of Resident #95's EMR failed to reveal documentation to indicate the facility had addressed the resident's non-functional CPAP machine or what interventions were put in place to repair/replace it. V. Staff interviews Registered nurse (RN) #1 was interviewed on 1/15/25 at 9:42 a.m. RN #1 said the night nurse was responsible for cleaning and storing the CPAP machines/masks for residents. She said she was unsure how CPAP masks should be stored or how often the tubing should be changed. She said she would find the answer by asking the facility's infection control nurse, respiratory therapist, and/or the UM. The respiratory vendor (RV) was interviewed on 1/15/25 at 10:18 a.m. The RV said the respiratory company provided respiratory equipment for residents' needs. He said he came weekly to the facility to service equipment and replace supplies per schedule or as needed. He said if a resident/family used their personal respiratory equipment, the company would service them upon request and bill whoever initiated the request. The RV said the CPAP mask and tubing should be changed every three months. He said the mask should be stored in a bag or a resident's top nightstand drawer. He said it was important to keep it off of the ground. He said the respiratory company recommended CPAP machine supplies to be cleansed daily. UM #1 was interviewed on 1/16/25 at 11:56 a.m. UM #1 said the night shift nurses were responsible for cleaning residents' CPAP masks daily. He said he needed to check the facility's policy and procedure to verify how often CPAP machines should be cleansed. He said CPAP masks should be stored in plastic bags hung at the resident's bedside and the tubing should be draped over the bed rail. He said he requested a power cord for Resident #95's CPAP machine the previous month (December 2024) during a meeting with her care provider. He said he had left multiple voicemails, without a response or update, and advised Resident #95 to ask her care provider for an update. He said he was unsure if the CPAP mask and tubing in the plastic bag at Resident #95's bedside were new. UM #1 said he would discard the mask and tubing at Resident #95's bedside and replace it. -On 11/16/25 at 12:20 p.m., UM #1 was observed in Resident #95's room. He discarded the CPAP mask and tubing at her bedside. He said he would replace supplies with those from the facility's stock and order additional supplies from Resident #95's care provider. The director of nursing (DON) was interviewed on 1/16/25 at 1:51 p.m. The DON said the night nurses were historically responsible for cleansing CPAP supplies, however, the facility had recently given the UMs the ability to adjust the time cleansing occurred. She said the facility bulk-ordered wipes specifically used to cleanse respiratory supplies. She said the cleansing/maintenance schedule and orders/machine settings were resident-specific, and should be documented in the resident's orders and care plan. The DON said she was not sure how often CPAP machines/masks should be cleansed and how often the tubing should be replaced. She said CPAP masks should be stored in a plastic bag hung at the resident's bedside or in a bag in the top drawer of the resident's nightstand. She said she was unaware Resident #95's CPAP machine was non-functional and did not know the length of time since it was last used. The DON said cardiac issues were a potential risk for a resident not using the CPAP machine as ordered and respiratory illnesses were a risk if CPAP masks/machines were not stored and cleansed correctly. 51710

Based on observations, record review and interviews, the facility failed to ensure that a consent and a safety bed rail evaluation was in place for one (#151) of five residents with bed rails out of 53 residents. Specifically, the facility failed to: -Ensure a signed consent was obtained from Resident #151 or the resident's representative prior to the initiation of side rails; -Ensure a physical therapy or occupational therapy (PT/OT) safety evaluation was conducted for Resident #151 prior to the use of half bed rails on a new bed; -Ensure the least restrictive alternatives were tried and documented prior to the use of half rails; and, -Ensure a physician's order was obtained for Resident #151 prior to the use of bed rails. Findings include: I. Professional reference According to the U. S. Food and Drug Administration (FDA) (2023), Recommendations for Health Care Providers Using Adult Portable Bed Rails, retrieved on 1/22/25 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Physical Restraint policy and procedure, revised December 2019, was provided by the nursing home administrator (NHA) on 1/16/25 at 3:12 p.m. It read in pertinent part, Physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident can not easily remove and that restricts freedom of movement or normal access to his/her body part. Does a resident have a device that can be considered a restraint? If yes, complete a physical restraint evaluation form, complete the physical restraint elimination usage form if the resident is a candidate for restraint reduction, elimination or usage. Physical therapy/Occupational therapy (PT/OT) consultation for least restrictive physical restraint. Obtain physician's order for restraint including medical symptoms for restraint usage, type of restraint, time of use and duration. Discuss restraint alternatives, risks and benefits with resident or legal representative upon initiation and annually. Complete physical restraint evaluation upon initial use and quarterly or with significant change. Document on care plan. III. Resident #151 A. Resident status Resident #151, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs) and pressure ulcers. The 10/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff with toileting, personal hygiene, bed mobility, transfers and required substantial/maximal assistance with eating. The assessment indicated physical restraints, including bed rails were not used. B. Observations and resident interview On 1/13/25 at 2:29 p.m. Resident #151 was lying in bed with two half rails in the up position on the bed. On 1/15/25 at 3:04 p.m. Resident #151 was lying in bed with two half rails in the up position on the bed. On 1/16/25 at 9:22 a.m. Resident #151 was lying in bed with two half rails in the up position on the bed. Resident #151 was interviewed on 1/16/25 at 9:23 a.m. Resident #151 said the nursing staff used the half rails when they were doing wound care in the mornings to prevent him from rolling out and put them down after they were done using them. He said he was able to use the controls on the bed rails to put his head up and down. He said he was not mobile enough to be able to get trapped between the bed rails and the bed. C. Record review The January 2025 CPO revealed a physician's order to put opposite rail for legs up when turning resident in bed and have two people to do any care that required turning in bed, ordered 10/10/24. -However, the physician's order did not indicate that the resident's bed rails were to be in the up position when staff was not repositioning the resident. The 10/30/24 nursing physical restraint evaluation identified the use of half rails needed for positioning and to promote independence. It documented the side rails were not a restraint because the resident was paralyzed. It documented the use of half rails was requested by nursing staff and the resident. -However, Resident #151 was totally dependent on staff for bed mobility and therefore was unable to use the bed rails independently. -However, the evaluation failed to document if a PT/OT screening had been done for the bed rails to assess for safety. The 10/30/24 nursing physical restraint elimination/usage evaluation documented a score of 19 out of 20, which indicated the potential elimination of the restraint and to attempt alternatives for restraint. -However, a comprehensive review of the nursing physical restraint elimination evaluation and Resident #151's electronic medical record (EMR) did not document that potential alternatives to the bed rails had been attempted by the facility or that discussion had taken place regarding the potential elimination of the side rails. The activities of daily living (ADL) care plan, initiated on 10/7/24, indicated Resident #151 was dependent with bed mobility. Interventions included using bed canes to promote independence for repositioning and turning in bed. -However, Resident #151 was totally dependent on staff for bed mobility and therefore was unable to use the bed rails independently. -A comprehensive review of the care plan failed to reveal documentation of the use of bed rails or other least restrictive alternatives. A comprehensive review of Resident #151's EMR failed to reveal documentation of a signed consent, a physical restraint evaluation, a physical restraint elimination evaluation, a PT/OT safety screening or a physician's order prior to the implementation of a new bed and initiation of the half side rails. IV. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 9:30 a.m. LPN #3 said bed rails were a physical restraint and should have an evaluation for risk versus benefit. He said the bed rails should be assessed for proper functioning. He said prior to initiating any physical restraint, a consent needed to be obtained and a physician's order. He said Resident #151 had side rails to help prevent falls out of bed during repositioning. He said Resident #151 also used side rails for safety because he had seizures. -However, there was no documentation in Resident #151's EMR to indicate the resident used the bed rails due to seizures. The NHA was interviewed on 1/15/25 at 3:00 p.m. The NHA said Resident #151 should not have half bed rails up on his bed. She said the bed he was using should have the bed rails zip locked down to prevent their use. She said she was not aware that bed rails were being used for Resident #151. Unit manager (UM) #2 was interviewed on 1/16/25 at 10:20 a.m. UM #2 said she was new to the physical restraint evaluation process. She said before bed rails were used, nursing staff should evaluate the need for them, obtain a consent and a physician's order. She said the nursing staff obtained a consent for the use of Resident #151's bed rails on 1/15/25 (during the survey) on the new bed from the resident. She said Resident #151 had been on a different bed with a dolphin mattress (a pressure redistribution specialty air mattress used to treat pressure wounds) and had recently switched to the current hospital type bed with the half bed rails. She said nursing staff used the bed rails to help with repositioning the resident. She said the resident was able to use the control on the bed rails himself. The director of nursing (DON) was interviewed on 1/16/25 at 3:00 p.m. The DON said that any potential restraint should be assessed to determine if it was a true restraint. She said PT/OT was involved in evaluating bed rails. She said there was a restraint assessment done when Resident #151 was admitted to the facility for his bed rails on the old bed. The DON said therapy had determined there was no benefit to having the side rails up and Resident #151 had agreed to having the side rails zip locked down so they could not be used. The DON said there were other things the facility could try for repositioning the resident, including bolsters, that were not bed rails. She said Resident #151's old bed had a dolphin mattress which he did not like. She said it was discovered, during survey, that Resident #151 had arranged for a new bed from the veterans administration (VA) and had it delivered to the facility. She said she and the NHA had not been aware Resident #151 had a new bed delivered and had been using it since approximately November 2024 or December 2024. The DON said therapy had done an evaluation on the new bed for the bed rails, after it was brought to their attention, during the survey. She said it was not a practice of the facility to use bed rails. She said medical equipment, such as hospital beds, should not be brought into the facility and used by staff and residents without notifying the DON and the NHA.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs in one of five dining rooms. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to the resident's diet orders of mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diet Orders policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:55 p.m. It read in pertinent part, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. A mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: inadequate nutrition, nutritional deficits, weight loss, medical conditions such as diabetes, renal disease, or heart disease and swallowing difficulty. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. II. Meal service observations Meal Service was continuously observed on 1/15/25 from 4:30 p.m. to 6:00 p.m. The posted menu documented the dinner meal as quiche, zucchini and onions, oven roasted potatoes, an apple cinnamon muffin and a fruit cup. At 5:20 p.m. meal tray assembly started for the long hall. A meal ticket indicated a resident was prescribed a mechanical soft diet order. The plate was assembled with a soft shell taco and ground beef, zucchini and potato wedges. The potato wedges served had skin on the potato. The meal tray was placed in the room delivery cart for service. At 5:45 p.m. a meal was assembled for a resident who's meal ticketed documented a mechanical soft diet. Written on the meal ticket was soft taco and sides. The plate was assembled with a soft shell taco and ground beef and potatoes wedges. The potato wedges served had skin on the potato and the plate was delivered to the resident in the dining room. -However, according to the diet manual description (see below) potato skins were restricted for residents prescribed a mechanically alerted diet. Both plates contained potatoes with the skin on the potatoes. At 5:52 p.m. the human resources director (HRD), who was the previous dietary manager was notified the oven roasted potatoes contained skins and were served to residents on a mechanical soft diet. The HRD said residents on mechanical soft diets should not have potato skins. III. Record review The fall/winter 2024-2025 diet spreadsheets were provided by the NHA on 1/13/25 at 1:00 p.m. The spreadsheet for dinner on 1/15/25 documented oven roasted potatoes could be served to a resident on a mechanical soft diet. -However, according to the diet manual description (see below) potato skins were restricted for residents prescribed a mechanically alerted diet. Both plates contained potatoes with the skin on the potatoes. The Dysphagia Mechanically Altered Diet Consistency Alteration Diet Manual , undated, was provided by the NHA on 1/16/25 at 1:30 p.m. It read in pertinent part, Avoid dry tough meats, or any other whole pieces of meat, cheese slices or cues, peanut butter sandwiches or pizza, potato chips, skins, fried or french fried potatoes. Please pay close attention to the menu extensions provided. Be sure that all planned foods are prepared. It is imperative to post a copy of the current day's menu extension on the tray line for easy reference during meal service. (page 71). The recipe for red fresh oven roasted potatoes, dated 11/7/23, was provided by the NHA on 1/16/25 at 1:30 p.m. The recipe instructions documented the following production steps: 1. Cut the red potatoes into quarters and steam or boil until tender. Drain off the excess liquid. 2. Melt the margarine with garlic and salt and toss the potatoes with seasoned margarine. Bake in the oven at 400 degrees fahrenheit (F) for 35 to 40 minutes or until lightly browned and tender. Hold or serve hot food at or above 135 degrees F. -The recipe did not include any further instructions on how to modify red fresh oven roasted potatoes for mechanically altered diets. IV. Staff interviews The HRD was interviewed on 1/15/25 at 5:56 p.m. The HRD said she was not sure what happened but the potatoes sent and served to the other dining rooms in the building all had potatoes without skins. She said she brought the potatoes without skins to the first floor dining room for service and removed the roasted potatoes with skin from the steam table. The dietary manager (DM) and the NHA were interviewed together on 1/16/25 at 11:30 a.m. The DM said the speech therapy department reviewed food items the residents could or could not have. The NHA said she spoke to the speech therapist for the facility. The NHA said she asked the speech therapist if they had reviewed the recipe for the oven roasted potatoes, and the speech therapist replied to the NHA that residents on a mechanical soft diet could have potato skins. The NHA said she requested a resource from the speech therapist that indicated a resident on a mechanical soft diet was able to have potato skins. -However according to the facility's diet manual (see above) potato skins were restricted from the mechanical soft diet.

Based on record review and interviews, the facility failed to maintain accurately documented medical records for one (#114) of four residents out of 53 sample residents. Specifically, the facility failed to ensure Resident #114's wound orders and treatment records were accurate. Findings include: I. Facility policy and procedure The Documentation of Medical Record policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:30 p.m. It read in pertinent part, Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy. Documentation may be performed manually or as per the facility's specific electronic medical record software program. Principles of documentation include but are not limited to: Documentation shall be factual, objective and resident centered; documentation shall be accurate, relevant and complete, containing sufficient details about the residents' care and/or responses to care; documentation shall be timely and in chronological order. Record date and time of entry. When documentation occurs after the fact, outside of acceptable time limits, the entry shall be clearly indicated as' late entry.' Corrections to a medical record shall be made to clarify inaccurate information. Contradictory information may be clarified by a new entry in the medical record. II. Resident status Resident #114, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included post surgical aftercare of the skin and subcutaneous tissue and multiple pressure ulcers. The 11/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was dependent on total assistance from staff for toileting hygiene and lower body dressing, needed substantial assistance with bed mobility and bathing, supervision with personal hygiene and set up help only for eating. The MDS assessment documented the resident had one or more pressure ulcers. III. Record review A review of Resident #114's electronic medical record (EMR) revealed the following: A 12/11/24 admission nursing data collection documented in the skin assessment section documented to See wound note. A corresponding note in the resident's EMR documented a skin assessment was completed by the wound nurse, see wound note. -However a skin/wound was not documented until 12/17/24 (see below). A skin/wound note documented on 12/17/24 revealed wound assessments were completed for Resident #114 on 12/13/24, upon admission. The note documented a right upper buttock unstageable pressure injury. A skin/wound note documented on 12/19/24 revealed a left buttock unstageable pressure injury (corrected from previously documented right buttock). A review of Resident #114's treatment administration record (TAR) revealed treatment orders for a right upper buttock pressure ulcer started 12/12/24 and discontinued 1/13/25. The treatment administration record documented treatment was administered or attempted to be administered as ordered on the right buttock during this time. -However, the facility failed to update Resident #114's wound treatment orders until 1/13/25 (during the survey) to indicate Resident #114 had a left buttock wound instead of a right buttock wound. Resident #114's admission wound location chart was provided by the NHA on 1/14/25 at 1:38 p.m. The wound location chart documented Resident #114 had a wound on his right buttock and no wound on his left buttock. The wound location chart was not dated. -However, the resident's wound was on his left buttock (see interview below). IV. Staff interviews The director of nursing (DON) was interviewed on 1/16/25. The DON said she talked to the two nurses who primarily performed Resident #114's wound treatments. The DON said both nurses knew Resident #114's wound was on his left buttock and not his right buttock. The DON said the nurses did not recognize Resident #114's wound treatment orders were incorrect. The DON said she did provide education to the assistant director of nursing (during the survey) on correct wound documentation in the resident's EMR.

Based on interviews, observation and record review, the facility failed to ensure one (#156) out of 71 sample residents were free from significant medication errors. Specifically, the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. The facility's failure to administer the anticoagulant therapy, as was indicated by the hospital discharge records, led to the resident's change of condition and ultimately, his death, from cardiac arrest due to a pulmonary embolism. The failure to ensure the accurate transcription of physician's orders placed residents at risk for serious harm or death if not corrected immediately. Findings include: I. Immediate Jeopardy A. Situation of immediate jeopardy The facility failed to ensure the transcription of medications from the hospital records for Resident #156 were accurate upon his admission to the facility. This resulted in the facility's failure to ensure Resident #156 received anticoagulant therapy, as indicated by the hospital discharge physician. Resident #156 had been recently hospitalized for an acute embolism and was a high risk for DVT. The facility's failure led to Resident #156 developing a pulmonary embolism, resulting in cardiac arrest, and ultimately, his death. B. Imposition of immediate jeopardy On 8/4/23 at 9:11 a.m., the nursing home administrator (NHA) and director of nursing (DON) were notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #156 received anticoagulant therapy. C. Facility plan to remove immediate jeopardy On 8/4/23 at 12:15 p.m., the facility submitted a plan for the immediate jeopardy. The plan read: 1. Corrective action The interdisciplinary team will conduct an audit of all new admissions and readmissions discharge orders that have been admitted to the facility within the past 30 days from today's date. The audit will be headed by the assistant director of nursing/designee. This audit will be completed by 8/7/23. 2. Identification of others The discharge orders from the hospital will be initially reviewed by the admitting nurse. The admitting nurse will then verify the continuation of the discharge orders from the discharging facility with the admissions primary care physician or mid-level provider. The admitting nurse will have a second nurse verify the orders. The second nurse and the admitting nurse will sign off on the admitting orders together. The unit manager/designee will review both nurses and verify that the orders that are in place are the correct and most appropriate orders for the admitted resident and the unit manager/designee will make changes as needed. 3. Systemic changes For all medication order changes, a second nurse will verify that medication changes to ensure that the new order (s) have been received and transcribed correctly for accurate administration of medication. This process will be reviewed five days a week by way of the order listing report during clinical meetings. Each member of the interdisciplinary team will initial off on this report to ensure compliance with this new process. Education will be provided to all licensed/registered nurses who are on duty today (8/4/23), and a continuing education will be provided to all licensed.registered nurses by 8/7/23 and all new nurses and agency staff prior to their first shift. Education will be provided by the DON (director of nursing)/designee. 3. Monitoring Results of this systemic change will be presented to the quality assurance improvement committee monthly, and as needed to ensure compliance with the new process. If a break in this process is identified, an immediate form of corrective action will be applied and a formal response will be completed. D. Removal of the immediate jeopardy The above plan was accepted on 8/4/23 at 12:34 p.m. and the immediate jeopardy removed. However, record review and interviews revealed deficient practice remained at a G level, actual harm that was isolated. II. Failure to ensure anticoagulant medication was administered according to physician's orders A. Resident #156 status Resident #156, age 77, was admitted on [DATE] and discharged to the hospital on 6/2/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included pulmonary embolism (blockage in heart arteries) and acute embolism and thrombosis of right femoral vein (blood clot in the vein in the leg). The 5/16/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with one person assistance with all activities of daily living. It indicated the resident had medically complex conditions, pulmonary embolism, DVT, PE (pulmonary embolism) or PTE (pulmonary thromboendarterectomy: surgery to remove blood clots and scar tissue from the arteries in the lungs). B. Record review The anticoagulant therapy care plan, initiated and revised on 5/22/23, documented the resident received anticoagulant therapy due to a bilateral PE. The interventions included administering anticoagulant medications as ordered by the physician; monitoring for side effects and effectiveness; following up with the physician regarding medication dosing, lab draw scheduling and abnormal test results as ordered. The 5/10/23 admission summary documented the resident was admitted to the facility due to an acute pulmonary embolism. The 5/10/23 physician history and physical documented on 5/4/23, the resident was sent to the hospital with acute complaints of chest pain and shortness of breath. The resident was found to have bilateral pulmonary artery thrombus and subsequently underwent bilateral pulmonary artery thrombectomy with the majority of the thrombus cleared from the right and a partial thrombus cleared from the left. -The physician's assessment and plan included anticoagulant therapy to include Eliquis 10 MG twice daily through 5/16/23, then Eliquis 5 MG twice daily and to monitor for any acute respiratory complications. 1. Resident #156's history of acute embolism The 5/5/23 hospital interventional radiology inpatient progress notes documented the resident was admitted to the hospital on 5/4/23 with a history of PE in 2022 and presenting with chest pain in the center of his chest and difficulty breathing as if someone were on top of him. The resident was found to be tachypneic (rapid, shallow breathing) and mildly hypoxic (low oxygen level). The CTA (computed tomography angiography with contrast) indicated the resident had a large bilateral pulmonary embolus with image evidence of a right heart strain. Due to the resident's intermediate high risk of PE, the resident was recommended for a thrombectomy. On 5/4/23, a bilateral pulmonary artery thrombectomy with majority of thrombus cleared from right and partial thrombus cleared from the left. Following the procedure, it was recommended the resident receive continued anticoagulation. The 5/10/23 discharge physician orders documented the following: -Apixaban (Eliquis) 5 MG (milligram)-take two tablets (10 MG) twice daily for seven days (5/9/23-5/16/23) followed by one tab (5 MG) twice daily thereafter. 2. Failure of the facility to ensure Resident #156 received the correct anticoagulant therapy The 5/10/23 physician's order note documented the following order was entered into the resident's electronic medical record: Eliquis Oral Tablet 5 MG-give 10 mg by mouth two times a day for PE until 5/16/23 and give 5 MG by mouth two times a day. -The CPO from the hospital (documented above) indicated the resident should receive 10 MG twice per day until 5/16/23 and then 5 MG twice per day thereafter, not receive 10 MG and 5 MG. The 5/11/23 physician's order note documented that the order was clarified to read: Eliquis 5 MG-give 10 MG by mouth two times a day for PE until 5/18/23. -However, the resident was still not receiving the correct dosage of Eliquis according to the 5/10/23 physician notes and the hospital discharge orders. According to the May 2023 MAR (medication administration record), the resident did not receive any anticoagulant therapy after 5/18/23. -The hospital discharge orders indicate the resident should receive long term anticoagulant therapy with a dose of Eliquis 5 MG twice per day, with no stop date indicated. 3. Resident #156's change of condition The 6/2/23 nursing progress note documented a certified nurse aide (CNA) altered the nursing at 12:15 p.m. the resident was slumped over in the wheelchair, drool coming from his mouth, his pupils dilated, was slurring his speech and was diaphoretic (sweating heavily). The resident displayed seizure activity for 30 seconds with convulsing. The resident had a blood pressure of 74/42 (with normal being 120/80) and had an oxygen saturation of 82% (percent) on room air (normal range 95 to 100 %). The resident was placed on a non-re-breather at 15 LPM (liters per minute) which brought the resident to 88% oxygen saturation. The resident was sent to the hospital via 911 ambulance. The 6/2/23 emergency room notes documented the resident was brought into the emergency room unresponsive. The resuscitation efforts were not successful and were terminated at 1:12 p.m. It indicated Resident #156 had a life threatening clotting disease and upon his arrival to the hospital from the facility, the medication list showed no use of anticoagulants. According to the hospital notes, the coroner determined that the resident suffered from cardiac arrest due to a pulmonary embolism from a lack of anticoagulation. The 6/27/23 certificate of death documented the resident's cause of death was cardiac arrest due to a pulmonary embolism. The facility failed to ensure the medications indicated on the hospital discharge list were properly transcribed to the resident's medical record. This failure led to the resident's lack of anticoagulant therapy, which ultimately, caused a pulmonary embolism which resulted in Resident #156's death. C. Staff interviews Registered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said anticoagulant therapy assisted in preventing DVTs and PEs. She said blood clots could travel throughout the body and cause serious health problems, even death. She said the nurse on duty was responsible for reviewing the discharge orders for an admitting resident. She said that the nurse was responsible to read over the medications, inform the attending physician at the facility and transcribe the medications into the resident's medical record. She said she was not aware of a system in place at the facility where the facility double checked the discharge orders from the hospital and the orders transcribed into the resident's medical record. She said if a resident was a high risk for PE, then not receiving anticoagulant therapy could cause the resident to suffer from an acute PE. The director of nursing (DON) was interviewed on 7/25/23 at 3:29 p.m. She said each resident who was admitted to the facility from the hospital had their medication reviewed by two nurses and the physician. She said the nurse would contact the physician to verify the medications. She said the admitting nurse was responsible for entering the medications into the resident's electronic medical record. She said the interdisciplinary team, which consisted of nursing management, did not review the admission orders to ensure the medications had been entered into the resident's medical record correctly. She said she remembered Resident #156's change of condition and being sent to the hospital but she could not remember the circumstances surrounding the change of condition. She acknowledged the orders from the hospital documented the resident should have been taking Eliquis 10 MG twice per day until 5/16/23 and then 5 MG twice per day thereafter. She confirmed the orders from the hospital were input incorrectly into the resident's medical record. She confirmed that the resident did not receive any anticoagulant therapy after 5/18/23. She confirmed the resident was a high risk for embolism and DVT. She said a lack of anticoagulant therapy could cause the resident to throw another PE and lead to serious health complications, such as death. The pharmacist and the physician were unavailable for an interview during the survey process.

Based on interviews, observations and record review, the facility failed to ensure residents had the right to a dignified experience. The facility failed to ensure Resident #113 did not experience feeling humiliation during an episode of incontinence. The facility failed to treat Resident #127 with respect and dignity when the staff used foul language toward him and told him to clean his own bathroom. Additionally, the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect. Findings include: I. Facility policy and procedure The Resident Rights and Facility Responsibilities policy and procedure, undated, was provided by the administrator in training (AIT) on 7/26/23 at 1:30 p.m. It revealed, in pertinent part, It is the facility's policy to abide by all resident rights, and to communicate these rights to residents and their designated representative in a language that they can understand. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. II. Failure to ensure Resident #113 did not experience humiliation during an incontinence episode A. Resident status Resident #113, age 63, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included lung cancer, schizoaffective disorder, anxiety and insomnia. The 6/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He was independent with all activities of daily living. It indicated the resident had mild depression with a score of six out of 27 on the PHQ-9 (patient health questionnaire for depression). B. Resident interview Resident #113 was interviewed on 7/20/23 at 12:09 p.m. He said when he was first admitted , he had walked into the hallway to ask the nurse for pain medication. He said while he was walking back to his room, he realized he had an episode of diarrhea and it had run up his back and down his legs. He said he walked into his room, activated the call light and then walked into the bathroom. He said a certified nurse aide (CNA) entered his room and gasped. He said she looked horrified and disgusted. He said he was already embarrassed but that made him feel humiliated. He said he asked her to help him and she just stood there and stared at him. He said he told her if she was not going to help then to please grab him some towels out of the wardrobe but she left the room instead. He said he yelled at her because she was refusing to help him when it was her job. He said he did not know her name because the staff at the facility did not wear name tags. He said the CNA got the nurse and the nurse came to assist him in getting cleaned up. He said the social worker had talked to him about the incident, however he felt the facility had not done anything about it and was still very upset. C. Record review The behavior care plan, initiated and revised on 7/6/23, documented Resident #113 tended to perseverate on things due to a diagnosis of anxiety and schizoaffective disorder. The interventions included anticipating the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express feelings appropriately, explaining all procedures to the resident and allowing time to adjust and monitoring behavioral episodes and attempting to determine the underlying cause. The 6/9/23 nursing progress notes documented at approximately 2:30 a.m. the resident said he was walking with the walker out of his room and became incontinent of bowel. The nurse noted she had observed bowel incontinence. The resident needed assistance getting cleaned up and provided supervision while the resident showered. It indicated the resident said he was angry and very embarrassed. The 6/9/23 satisfaction and concern form documented that the resident had been admitted to the facility and said his needs had not been taken care of and wanted to file a formal complaint. The resident reported he felt like he was ignored by the CNA and felt it was a dereliction (abandonment) of duty. He said the CNA told him that it was too early to help him, left the room and did not assist him when he had an episode of diarrhea. He said the nurse assisted him but the CNA ignored him the rest of the day and did not offer him an apology. It indicated that the nurse was spoken with and obtained a timeline, however did not indicate that the CNA had been spoken with or what was done to rectify the situation with the resident. The 6/21/23 care conference note documented the resident was still upset about the incident in the shower. Social services staff offered to talk to the director of nursing (DON), however the resident declined saying, no, I am not going to do that. What would that do. D. Staff interviews The DON was interviewed on 7/25/23 at 3:29 p.m. She said she was unaware of the situation with Resident #113. She said she was unaware if the CNA had been identified or spoken with regarding the resident's concerns. She said she was unsure why it indicated the resident was happy with the resolution when the grievance did not document a resolution. Social worker (SW) #1 was interviewed on 7/25/23 at 4:50 p.m. She said she was the social worker for Resident #113. She said the resident was very nice, upfront and knew what he was talking about. She said he was very social and walked around the facility interacting with the staff and other residents. She said she was not at the facility during the incident with the CNA. She said she was aware he was upset about the situation. She said she had suggestions to ensure this instance did not happen again, however she was unable to provide those suggestions. She said she was unsure if the CNA was talked to about the resident's concern. She said she thought the director of social services (DSS) met with the resident. The DSS was interviewed on 7/25/23 at 6:32 p.m. She said she was just the keeper of the grievances but did not actually read them. She said she never met with Resident #113 following the incident he reported. III. Failure to ensure Resident #127 was treat with respect and dignity A. Resident status Resident #127, age 79 was admitted on [DATE]. According to the July 2023 CPO, diagnoses included anxiety, depressive episodes and malignant neoplasm (cancer) of the colon. The 6/8/23 MDS assessment indicated the resident had moderate cognitive impairment with a score of nine out of 15 for the BIMS. The resident was primarily independent with activities of daily living and required setup help by staff. B. Observations and interview On 7/19/23 at 9:05 a.m., housekeeper (HSKP) #1 was observed upon entry to the third floor memory care unit. HSKP #1 said, It's this (explicit word) guy again. Resident #127 was interviewed on 7/19/23 at approximately 11:00 a.m. He said housekeeping staff in particular use foul language in his room which makes him feel disrespected. Resident #127 said they even brought him cleaning supplies and left them in the resident's room and told him you should clean the (explicit word) in the toilet yourself and you should clean your room yourself. The resident said housekeeping staff utilized a fork to scrape off dried feces in the toilet bowl and left the fork in the resident's bathroom in order for him to scrape off dried feces himself because housekeeping staff were sick of cleaning his room. At approximately 11:00 a.m. a fork with dried fecal matter on top of a three drawer plastic cart was observed in the resident's bathroom. Cross-reference F880 infection control for failure to appropriately clean the resident's room. The resident's bathroom was observed with streaks of brown hardened substance stuck to the outside of the toilet bowl. The inside of the toilet bowl contained dried fecal matter. The resident's room contained Scrubbing Bubbles (bathroom cleaner) and Ajax (all purpose powder cleaner). Cross-reference F689 accident/hazards for having unsecured chemicals. C. Staff interviews Social worker (SW) #1 was interviewed on 7/19/23 at 3:15 p.m. She said foul language should not be used in the facility, because the facility was a resident's home and the use of foul language was disrespectful. Registered nurse unit manager (RNUM) #1 was interviewed on 7/19/23 at 3:22 p.m. She said foul language should not be used in the resident's home because it could create a negative environment for a resident. The use of profanity could negatively impact a resident which could make them feel unsafe in their own home. The DON was interviewed on 7/19/23 at approximately 3:30 p.m. The DON said foul language in the care area was not professional and should not be used in the workplace by staff. IV. Failure to create a culture and environment that promoted treating residents with dignity and respect A. Resident interviews Resident #130's family member was interviewed on 7/19/23 at 3:55 p.m. He said the facility had been using agency staff members for a while and he felt they did not treat the residents at the facility with dignity and respect. He said he was assisting his mother one day when an agency staff member told him to stop and leave. He said she was argumentative with him while he was just trying to help because his mother became [NAME] with staff members she did not know. He said he worried about his mom all night long that night. Resident #75 was interviewed on 7/20/23 at 9:39 a.m. Resident #75 stated that staff talked down to her and other residents at least twice a day. She said, They talk to us like we are children and it makes me very angry and I cannot do anything about it. Resident #48 was interviewed on 7/20/23 at 1:40 p.m. Resident #48 said the administration did not treat residents nicely. She said the NHA told her don't you want to move to another facility. She said she became very upset when the NHA told her that. Resident #48 said other residents have needed help and staff have told them they needed to wait and the residents had to wait a long time, sometimes up to an hour before being helped. Resident #7 was interviewed on 7/20/23 at 10:39 a.m. She said she felt the facility staff were not respectful. She said the staff were quick to come into her room, complete their task and leave without speaking. She said she felt like they did not care and felt like a bother to them. Resident #86 was interviewed on 7/20/23 at 12:09 p.m. He said he felt the staff did not think the residents at the facility were a priority. He said they would enter the room, take care of the task and then leave. He said oftentimes staff would enter his room and ask, What do you want now? He said the facility staff would often enter his room without knocking. He said he felt it was rude for staff to walk into his home without knocking and receiving permission to enter. Resident #113 was interviewed on 7/24/23 at 3:35 p.m. He said he felt the facility staff had an attitude. He said it was like pulling teeth to get them to help. He said the staff will talk on their cell phones instead of answering the call lights. He said he felt like the staff did not care for them and was just there to get a paycheck. He said they do not have a sense of urgency and just meander down the hallway. Resident #75 was interviewed on 7/24/23 at 4:48 p.m. She said the certified nurse aide (CNA) #7 yelled at her while using the sink in her room. She said CNA #7 told her she needed to move because her roommate was getting ready to get a sponge bath. Resident #75 said she was upset that CNA #7 yelled at her. B. Observations On 7/20/23 at 10:18 a.m. an unidentified CNA exited Resident #128's room with used incontinence supplies. A loud noise was observed and the unidentified CNA returned to Resident #128's room. The CNA asked the resident, what do you want now? Resident #128 said he wanted to stand up. The CNA said, why do you want to stand up, you don't need to stand up. Resident #128 said, I need to go. The CNA responded, You aren't going anywhere and you need to calm down. The CNA then wheeled Resident #128 out to the nursing station and then left him to go into the break room. At 12:58 p.m. an unidentified CNA entered resident room [ROOM NUMBER] carrying a meal tray. She did not knock prior to entering the room, delivered the meal tray and left the room. She did not talk to the resident or set up the meal for the resident. C. Record review The March 2023 resident council minutes documented the residents felt their needs were not taken seriously. The April 2023 resident council minutes documented the resident would like the administrator to be more involved and would like more of the management team represented in the meetings. The June 2023 resident council minutes documented one resident overheard some CNAs state the residents treat them badly and that was why the staff did not stay. The residents voiced concerns the CNAs should be professional and had concerns regarding agency staff. The July 2023 resident council minutes documented residents had concerns regarding communication around the facility, call lights not being put within reach when their beds and CNAs complained they did not have time. IV. Staff interviews CNA #17 was interviewed on 7/25/23 at 3:10 p.m. She said all residents should be treated with dignity and respect. She said all staff were responsible for the care needs of each resident. The DON was interviewed on 7/25/23 at 3:29 p.m. She said facility staff should treat all residents with respect and dignity. She said each concern should be addressed with the resident who had the concern and all staff members involved. She said she had a nurse manager in the facility seven days per week to assist in handling any resident or family concerns. She said any concerns should be brought to the unit manager and with the social worker, work to resolve each resident's concerns. She said the nursing management had been pushing customer service and trying to have positive interactions with residents. 48113 48114

Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to significant medications errors that rose to the level of immediate jeopardy and residents were provided respect and dignity by staff that caused a pattern of psychosocial harm. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the director of nursing (DON) on 8/8/23 at 2:30 p.m. It revealed, in pertinent part, Purpose: to evaluate facility quality indicators, identify quality issues, develop corrective action plans and evaluate any action plans for continuous quality improvement. Any concerns, trends or clusters identified should be listed on the QA Concerns List. Document the concern, goal and approaches and interventions to correct the concern on the QA Concern Action Plan. Review monthly any ongoing concerns until resolved. Develop new interventions as needed. II. Cross-reference citations Cross reference F760: the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. The facility's failure to administer the anticoagulant therapy, as was indicated by the hospital discharge records, led to the resident's change of condition and ultimately, his death, from cardiac arrest due to a pulmonary embolism. The failure to ensure the accurate transcription of physician's orders placed residents at risk for serious harm or death if it was not immediately corrected. Cross reference F550: the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect. Several residents reported psychosocial harm of feeling humiliated, disrespected and treated like children. These concerns were reported in resident council meetings. III. Staff interviews The director of nursing (DON) was interviewed on 7/25/23 at 8:15 p.m. She said the QAPI meetings were only required to be held every quarter, but the facility held them monthly. She said the nursing home administrator (NHA,) herself, assistant director of nursing (ADON), unit managers, social services, dietary manager, pharmacist and other members of the interdisciplinary team attended the meeting. She said each department presented a scheduled set of reports at each meeting and the facility attempted to identify the issues throughout the facility and discover trends. The DON said if new areas of concern were identified, performance improvement plans (PIP) would be developed and discussed during the next QAPI meeting. The DON said she remembered Resident #156's change of condition and being sent to the hospital but she could not remember the circumstances surrounding the change of condition. She said the facility had not identified that the facility's failure to transcribe the hospital discharge orders correctly directly related to Resident #156's change of condition and ultimately, his death. The DON said she was unaware many residents had concerns that staff did not treat them with dignity and respect. She said she was not aware residents had brought up the concerns during resident council. She said she had nurse managers on duty seven days per week to address concerns, but was not aware that the program had not been successful based on multiple resident interviews. The DON said the concerns identified during the survey process had not been previously identified by the facility staff and brought to the QAPI meeting.

Based on record review, observations, and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required per their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to consistently provide adequate nursing staff given the acuity and diagnoses of the facility's population, resident census, and the residents' daily need for care and services. Cross-reference citations: -F677 for the failure to provide timely incontinence care and reposition to residents; -F686 for the failure to provide repositioning for residents with pressure injuries; -F689 for the failure to ensure two staff were utilized when transferring residents with mechanical lifts; and, -F692 for the failure to provide timely eating assistance and consistently provide fluids to residents between meals. Findings include: I. Resident census and conditions According to the 7/19/23 Resident Census and Conditions of Residents report, the resident census was 158 and the following care needs were identified: -110 residents needed assistance of one or two staff members for bathing and 37 residents were dependent;11 residents were independent. -135 residents needed assistance of one or two staff members for dressing and seven residents were dependent;16 residents were independent. -134 residents needed assistance of one or two staff members for transferring and no residents were dependent; 24 residents were independent. -129 residents needed assistance of one or two staff members for toilet use and 11 residents were dependent; 18 residents were independent. -60 residents needed assistance of one or two staff members for eating and six residents were dependent; 92 residents were independent. II. Staff requirements for each floor/unit A. 1st Floor rehab- 18 residents Two licensed nurses for 12 hours for the day shift and four certified nurse aides (CNAs); The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and three CNAs. B. 2nd Floor - 25 residents Two licensed nurses 12 hours for the day shift and five CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and three CNAs. The unit had a CNA medication aide who worked from 6:00 p.m. to 6:00 a.m. C. 3rd Floor - 23 residents Two licensed nurses 12 hours for the day shift and three CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. D. 3rd Floor Memory Care - 12 residents One licensed nurse 12 hours for the day shift and one CNA; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and one CNA. E. Memory unit- 27 residents One licensed nurse 12 hours for the day shift and three CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. III. Resident Council minutes The Resident Council minutes were reviewed on 7/24/23 at 4:42 p.m. A. Resident Council minutes dated 2/8/23 revealed residents complained staff said showers were being skipped because the staff did not have time. B. Resident Council minutes dated 5/10/23 revealed residents miss their old CNAs and have mixed reviews on agency staff; it was discussed the whole country was in a CNA shortage. C. Resident Council minutes dated 7/12/23 revealed residents complained about staff administering wrong medications or not receiving their medications and the nurses do not want to double check or they do not have time; the nurses just drop off the medications and leave them on the table where they are not seen, and therefore, are not being taken. The minutes further read, showering schedules were a mess. Residents complained the facility would not pay overtime for reliable CNAs but will pay for agency staff who leave early. IV. Observations A. Resident #130 was observed on 7/19/23 at 4:44 p.m. According to the comprehensive care plan, the resident needs more attention as she was not able to make her needs known. She cannot use the call light as she did not know what it is. B. Resident #25 was observed continuously on 7/24/23 from 1:10 p.m. to 3:00 p.m. -At 1:15 p.m. Resident #25 engaged the call light and requested for her husband (Resident #110) to be transferred from his wheelchair to his recliner. -At 1:18 p.m. CNA #12 responded and said she would be back in 10 minutes. The CNA turned off the call light; she did not address the resident's request. -At 2:15 p.m. Resident # 25 engaged the call light, 60 minutes later. Her husband continued to sit in his wheelchair and Resident #25 again requested for her husband to be moved from his wheelchair to the recliner. Staff turned off the call light and at time transferred Resident #25's husband to his recliner. V. Resident interviews Resident interviews revealed delays, from 20 minutes to over an hour, in staff providing them requested assistance. A. Resident #127 was interviewed on 7/19/23 at 11:13 a.m. According to computerized physician's orders (CPO), the resident admitted on [DATE] and assessed on 6/8/23 as moderately impaired. The resident said he had to wait 45 minutes for his call light to be answered when there were fewer staff working. He said around 4:00 p.m. or 5:00 p.m. there were not a lot of staff working on the floor He said the evening and middle of the afternoon and weekends were the worst. B. Resident #43 was interviewed on 7/19/23 at 12:06 p.m. According to CPO, the resident was admitted on [DATE] and assessed on 6/21/23 as cognitively intact. She said during the evening shift, if you push your call light, you can wait a long time, anywhere from 30-45 minutes. She said this happened often and mainly in the evening. C. Resident #104 was interviewed on 7/19/23 at 1:16 p.m. According to CPO, the resident was admitted on [DATE] and assessed on 4/9/23 as cognitively intact. He said there was not enough staff here. He said he had had to fill his own cups with ice every day as staff did not offer to do so. D. Resident #98 was interviewed on 7/19/23 at 1:20 p.m. According to CPO, the resident was admitted on [DATE] and assessed on 5/29/23 as cognitively intact. He said he had never waited less than an hour for help when pushing the call light. E. Resident #130 was interviewed on 7/19/23 at 4:44 p.m. According to CPO, the resident was admitted [DATE] and assessed on 5/29/23 as moderately impaired. She said this past Monday her sister pushed the call button and no one came for an hour and 15 minutes. F. Resident #7 was interviewed on 7/20/23 at 10:44 a.m. According to CPO, the resident was admitted [DATE] and assessed on 5/15/23 as cognitively intact. She said she requires assistance from two staff with toileting, transfers, and bed mobility, and sometimes there was only one staff working the hallway and it was hard to get the care she needed. She said she had had to wait around 20 minutes to get help. She said two CNAs worked the hallway and she required a two person assist. She said sometimes they only have one CNA and it was hard for her to get the care she needs. G. Resident #85 was interviewed on 7/25/23 at 2:00 p.m. Record review revealed the resident was admitted [DATE] and assessed on 6/26/23 as cognitively intact. She requires, per MDS, extensive assistance with toileting. She said she had had to wait over an hour at times to get assistance to use the restroom for a bowel movement and she believed it was due to a lack of available staff. VI. Staff interviews Staff interviews indicated staffing expectations (see above) were not being consistently met. Staff reported they had too many duties and it was difficult to keep an eye on all the residents. A. CNA #9 was interviewed on 7/23/23 at 5:47 p.m. She said she had been employed at the facility since 4/12/19 and usually worked the weekends. She said every weekend and especially on Sundays, the facility was very, very short-staffed. She said most of the time, the facility did not have enough staff coverage, so the facility had been working with agency staff most of the time, call-off. CNA #9 said this morning, they only had two CNAs for the second floor. She said at 10:00 a.m. a third CNA came in but she was a shower aide. B. CNA #11 was interviewed on 7/23/23 at 5:50 p.m. She said she had been employed at the facility since 7/2/13 and usually worked weekdays. She said due to staffing shortages, the residents do not get the care they need. She said the facility had only one Sara lift on the second floor and the majority of the residents on the second floor require a Sara lift. C. CNA #7 was interviewed on 7/24/23 at 9:55 a.m. She said she had been employed at the facility since 1/21/22 and usually worked weekdays. She said staffing issues were horrible and the weekends were the worst. She said the weekend supervisor did not tell anyone anything. She said this morning there were three CNAs because a CNA picked up an extra shift. She said there used to be five CNAs on the second floor and now, because the census was low, they pulled the fifth CNA and there were only four CNAs on the first shift. She said when the facility changed the schedule, reducing the number of CNAs each shift, a lot of staff left. She said the facility was using a lot of agency staff. D. CNA #12 was interviewed on 7/24/23 at 3:36 p.m. She said she had been employed at the facility since 6/5/23 and usually worked weekdays. She said the third floor Memory Care usually had three CNAs and two registered nurses (RNs) who worked the floor and it was not enough staff. She said it was difficult to keep an eye on all the residents in Memory Care, especially those with wandering behaviors and were a fall risk. She said sometimes the RN will help her with transfers but some of the other staff would not help. She said she could not provide the appropriate care with the amount of staff they currently have. She said since the survey began, there had been more staff help but after the survey, staff would get the help they need and the facility will be short-staffed again. She said she had never seen the director of nursing (DON) in the Memory Care unit except when the survey was going on. E. CNA #2 was interviewed on 7/24/23 at 3:47 p.m. She said she had been employed at the facility since 6/5/23 and usually worked weekdays. She said they usually have three CNAs and two RNs a shift who sometimes help her out. She said sometimes there was not enough staff, especially when two CNAs were helping a resident out, leaving one CNA to attend to the other residents. G. CNA #1 was interviewed on 7/24/23 at 3:59 p.m. She said she had been employed at the facility since 1/13/22 and usually worked weekdays. She said there were three CNAs and two RNs on her shift. She said depending on the day and how many requests the residents have, it would be helpful to have an extra CNA. She said when there were too few facility staff, the facility had agency staff come in to fill in for staffing shortages. H. CNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she had turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she was always providing care for someone else. Cross-reference F686. I. An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. J. The DON was interviewed on 7/25/23 at 7:52 p.m. She said she had been employed at the facility since February 2023. She said the facility did not have a shortage of staff because the facility uses agency staff to supplement staffing. She said, on the first floor, they have three to four CNAs and two RNs and on the second floor, they have two RNs and anywhere from four to six CNAs. She said on the third floor, they have two RNs and three to four CNAs. She said every floor had a nurse manager. She said the nursing home administrator (NHA), DON, and scheduler were responsible for staffing concerns. She said she and the scheduler meet daily to discuss staffing concerns or issues. She said they staff according to the census, acuity level and medical necessity. The DON said if the acuity requires three-person assistance, then they would add another staff aide or nurse to make sure there was enough staff. The DON said if there was not enough staff to address residents' needs, then their needs would not be addressed. She said they try to staff as adequately as they can, but there was nobody jumping into health care and everyone was tired of doing this kind of work. She said they have tried to put out bonuses and did not work. She said they were competitive in their salaries and no one was jumping at the opportunity. She said they offered to pay training for new CNAs and no one had applied. K. The scheduler was interviewed on 8/8/23 at 2:30 p.m. She said she had received a directive from management to staff the units by census or she will get in trouble. She staffing should be as follows: The first floor should have three CNAs for day shift and night shift, two nurses on day shift and from 6:00 p.m. to 10:00 p.m. and 6:00 p.m. to 6:00 a.m., one nurse. The second floor should have four CNAs and two nurses. The first floor Memory Care unit should have one nurse and three CNAs. The third floor should have three CNAs and two nurses on day shift and from 6:00 p.m. to 10 :00 p.m., one nurse and two CNAs. The third floor Memory Care should have one CNA and one nurse on day shift. She said on the night shift, one nurse floats back and forth. The scheduler was interviewed again on 8/8/23 at 3:00 p.m. She said they have several CNA and nurse positions open. She said: -The first floor had open positions of three morning CNAs and one CNA at night. There was one full time nurse position open. -The second floor had six CNA positions open, one on day shift, two on night shift and two-part time CNAs. There were three nurse positions on day shift and two full time nurse positions open on night shift. -The third floor had one morning and one night CNA position open. There are three nurse positions open on day shift and two nurse positions open on night shift. The Memory Care unit on the third floor had two CNA positions open for an eight hour shift and one-part time CNA needed. There was one nurse position open for the night shift. She said the facility was not offering any hiring bonus. She said the facility would pay for new CNAs included $1500.00 toward training classes. The scheduler said they used to have PRN as needed when staff called off but she said staff do not answer their phones, so she said she stopped calling them. She said she had increased the bonus to $15.00 an hour for CNAs and $60.00 an hour for nurses. She said she was not supposed to increase the bonus as the bonuses need to be approved by the NHA. She said when there was a call-off, she would put a message to staff in care communication and it went out to all the staff. She said the call-offs vary on the weekdays, but there were more call-offs on the weekends. She said they changed the staff's schedule so staff rotate every other weekend off and every weekend on. She said they use agency staff to fill the gaps in open positions. She said if the agency staff called off they were suspended from care for seven days. She said she gave staff three chances to call-ff and if they continue to call-off she took them off the schedule and off the list for rehire. VII. Additional information The facility staffing policy was received on 8/8/23 at 2:35 p.m. It read, in pertinent part, it was the goal of the facility to operate at the optimal level to meet the standards of care for our residents. The facility's daily staffing HPPD (hours per patient day) changes routinely, however, the facility will never operate below a minimum of 2.0 HPPD. The state of Colorado had no minimum staffing ratio for long-term care. However, the facility adhered to all state and federal regulations related to staffing and the guidance provided by such entities. The facility will adjust its staffing as needed based on census, acuity and the needs of the residents. The AIT was interviewed on 8/8/23 at 2:36 p.m. She said the policy was given to her by the DON and printed off by the DON today. The scheduler was interviewed on 8/8/23 at 2:45 p.m. She said she did not recognize the staffing policy when shown. The AIT was interviewed on 8/8/23 at 3:00 p.m. She said when she was not able to find a policy she would go to the DON and provide the copy. She said the policy that was provided was what the DON had printed off. 38185 48113

Based on observations and interviews, the facility failed to prepare and serve food in a sanitary manner. Specifically, the facility failed to have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher. Findings include: I. Professional reference According to the Food and Drug Administration Food Code (2022) accessed on 8/16/23 from https://www.fda.gov/media/164194/download?attachment read in pertinent part, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160 F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160 ). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160 F. II. Observations On 7/19/23 at 8:53 p.m. an unidentified dietary aide put a load of dishes through the dishwasher. She said the dishwasher was high temperature and indicated that the external display read 180 degrees F (Fahrenheit). She said she did not know how to check the internal temperature of the dishwasher to ensure the outside display was correct. She said the facility did not keep a log of the temperature of the dishwasher. III. Record review The facility was unable to provide documentation that the internal temperature of the dishwasher was being monitored to ensure functionality. IV. Staff interviews The dietary manager was interviewed on 7/19/23 at 11:35 p.m. He said the facility did not have a way to check the internal temperature of the dishwashing machine. He said the outside gauge was sufficient. He said he would not know how to begin to check the internal temperature of a dishwasher. He said he did not have a waterproof thermometer and had never heard of temperature testing strips. He said he could not be certain the outside gauge was correct, but felt it probably was fine. He said he did not understand why he needed to ensure the internal temperature and the outside gage matched, when he felt as though it most likely did match. He said he did not have a policy on the dishwasher. He said he would not know where to look to even obtain a policy on the use of the dishwasher.

Based on observations and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in multiple areas of the facility. Specifically, the facility failed to ensure resident rooms and facility hallways. Findings include: I. Initial observations The following was observed during the initial walkthrough of entering the facility on [DATE] at 9:00 a.m. until [DATE] at 4:00 p.m. The third floor memory care was observed to have bugs (deceased ) in multiple ceiling light fixtures throughout the unit. room [ROOM NUMBER] and #17: The window blinds were observed to be broken, bent and missing. room [ROOM NUMBER]: The electrical outlet on wall behind head of bed was observed to be dislodged from wall and unusable. room [ROOM NUMBER]: Multiple holes and tears, ranging from approximately one inch to four inches were observed in the screen to the window. room [ROOM NUMBER]: Two vertical holes, approximately three inches in length and half an inch wide were observed in the wall behind the head of the bed; pieces of drywall and dust was observed on the floor below the holes. room [ROOM NUMBER]: Ants were observed on the floor nearest the window. II. Environmental tour and staff interview The environmental tour was conducted on [DATE] at 3:21 p.m. with the maintenance director (MTD). The above observations were reviewed and documented by the MTD. He said he did not know if it was the responsibility of the maintenance or housekeeping department to clean bugs from light fixtures on the ceiling, he said he would discuss with the housekeeping department. He said he was aware of the damaged blinds in room [ROOM NUMBER] and #17 and was awaiting delivery of more blinds. He said he was unaware of the damaged electrical outlet in room [ROOM NUMBER]. He said he was unaware of the damage to the screen window in room [ROOM NUMBER] and suspected it was [NAME] damage from a recent storm. He said he was unaware of the damage to the wall in room [ROOM NUMBER] but was familiar with the problem. He said it occurred with the bariatric beds and the design when the residents raise and lower the head of the bed. He said he was aware of the ants in room [ROOM NUMBER] and the problem has been resolved. He said the staff submitted work tickets through a web-based communication system to inform the maintenance department of needed repairs. He said the same system was used to track and complete general maintenance rounds in the facility. He said he would attend to repairs as soon as possible.

Based on record review and interviews, the facility failed to ensure one (#4) of six residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Resident #4 sustained head trauma (concussion) and extensive bruising to her legs, face and scalp when she was transferred by staff with a Hoyer (mechanical) lift. The facility staff did not assess the resident after the incident. Right after the incident, the resident was sent to her scheduled appointment with a cardiologist. The resident developed a headache, blurred vision and nausea where she was sent to the emergency room (ER) by a cardiologist and diagnosed with a concussion and scalp hematoma. Findings include: I. Facility policies and procedures The Falls Prevention and Management policy, revised 7/21/17, was provided on 5/30/23 by the director of nursing (DON). -The policy read did not include any information on injuries caused by the equipment. -The policy on accidents related to the equipment was requested at the time of the survey, however was not provided at the time of the survey with exit on 5/30/23 or 24 hours after the exit. II. Resident status Resident #4, age 78, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), hypertension and bipolar disorder. The 2/28/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident required extensive assistance of two people with transfers, dressing, toileting and personal hygiene. The fall section revealed the resident did not have a fall in the last six months. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. III. Resident interview and observation Resident #4 was interviewed on 5/30/23 at 1:30 p.m. She said last Monday (5/22/23) she had a scheduled appointment with a cardiologist. Before the appointment, two certified nurse aides (CNAs) were transferring her using a Hoyer lift from the bed to the wheelchair. At the time of the transfer, when she was in the sling of the Hoyer in midair, something went wrong and the lift tilted. She landed abruptly into her wheelchair and the top metal bar of the Hoyer lift hit her on the head. Resident #4 stated she felt sudden pain in her head and back of her thighs. She said her pain at the time of the incident was 8 to 9 on the scale of 10 (with 10 being the worst pain on the scale). Both CNAs stated that Hoyer wheels did not turn properly and it caused the lift to tilt. She said right after the incident she was taken to the cardiology appointment and the nurse at the facility did not assess her for injuries. Resident #4 stated her headache got worse, she had blurred vision, felt lightheaded and nauseous by the time she arrived at her appointment. She reported her symptoms and incident to the cardiologist who sent her to the ER for evaluation. At the time of the interview, the resident was observed in her bed. On her left forehead she had four to five centimeters (cm) bruise that was black to yellow in color. Another bruise, dark red to black in color was observed at the top of the resident's head. The bruise was about one by two cm., with an elevated surface. Resident #4 parted her hair and pointed to the bruise. She said this was where the top bar of Hoyer lift hit her. She said she had bruises on both of her upper legs. She said she continued to have headaches and was fearful of transfers. She said she did not refuse any transfers as it was the only way for her to get out of the bed. Resident #4 said after she returned from the ER, unit manager (UM) #1 and her nurse (licensed practical nurse #1) told her the CNAs did not observe the lift touching or hitting her. She said they ignored her statement that she got hurt and called me a liar. She said when bruises became visible a few days later, the nurses at the facility did not monitor them and did nothing about it. IV. Skin assessment The resident's skin on her legs was inspected on 5/30/23 at 2:40 p.m. in the presence of licensed practical nurse (LPN) #2. A large blue to gray to yellow bruise was observed on the resident's left upper inner and back thigh. The bruise located slightly above the knee joint and extended to about two thirds of the resident's upper and inner thigh. The left thigh had a small red to blue bruise, approximately one cm by two cm. Both bruises appear to be healing. The resident stated that bruises on her thighs, face and head were the result of the Hoyer incident that took place several days ago. V. Record review The comprehensive care plan, initiated on 5/19/21 and revised on 2/17/22, revealed the resident was using Hoyer lift for transfers and assistance of two people. The care plan for skin integrity, initiated on 6/20/21 and revised on 8/16/22, documented the resident was at risk for skin integrity due to multiple comorbidities including the use of anticoagulation medication (Coumadin). Interventions included to monitor her skin weekly and to report any abnormalities to the physician. -The skin integrity care plan was not updated with skin injuries the resident sustained on 5/23/23 during the transfer. The medication administration record (MAR) for May 2023 revealed that resident was receiving an anticoagulant medication: Coumadin four milligrams (mg) by mouth in the afternoon every Monday, Wednesday for atrial fibrillation. Start date 4/3/23. -The May 2023 MAR did not include any evidence that the resident was monitored for bleeding and bruising due to the use of anticoagulant. The cardiology report dated 5/23/23 documented the resident complained of nausea and jaw pain after the incident in the facility. The cardiologist sent the resident to the ER for a head scan and evaluation. The ER discharge summary dated 5/23/23 around 3:00 p.m. revealed the resident was admitted for nausea, headache and lightheadedness. Her head scan was negative for any acute findings and she was discharged back to the facility with a diagnosis of concussion and scalp hematoma. The initial progress note in resident's electronic medical record regarding the incident was documented on 5/23/23 at 3:03 p.m. documenting the resident reported an incident that occurred during the Hoyer transfer (before going) to the cardiologist and based on her symptoms such as nausea, headache and jaw pain, she was sent to the ER. -The note did not mention who communicated the message to the facility staff and what actions were taken after the resident returned from the ER. -The progress notes did not include the resident's assessment by a registered nurse and did not document the resident's vital signs at the time of her return. The incident report was provided by the assistant director of nursing (ADON) on 5/30/23 at 3:50 p.m. and included following information: An incident report dated 5/23/23 at 12:38 p.m., read the resident was transferred from bed to her wheelchair with the Hoyer lift, but the lift was not turning around and all wheels raised and she fell on her chair and the Hoyer fell on the arms of both CNAs. Resident went to a doctor's appointment right after the incident. Further the note by the nurse read, as immediate actions taken the resident was assessed at the doctors office. Under injuries, it was documented a bruise on top of the scalp. -Per interview with the ADON (see below), she added bruises later to the report. A handwritten note dated 5/23/23, with no time, by UM #1 read: I spoke to (resident) who stated she hit her head when the Hoyer tipped over. (Head scan) was completed and the hospital and at the time of incident had no bruising to her head. -The note did not include the assessment of the resident's legs or her vital signs. A handwritten note with no initials, dated 5/23/23, with no time, mentioned CNA #1 and CNA #2 were interviewed at the same time. The note read: We were transferring the resident off bed to the chair and the Hoyer did not want to turn around and all the wheels were raised and she fell on the chair and the Hoyer on the arms of (CNA #1) and (CNA #2). The resident did not hit anything nothing touched her. -The note did not include the signature or initials of the writer and it was unclear who wrote the note. Per interview with the ADON (see below) she said the note was most likely written by LPN #1, who was a treating nurse for Resident #4 at the time of the incident. A CT scan results showed no acute findings; A progress note by UM #1 on 5/23/23 at 3:16 p.m. (already mentioned above); and A note by the LPN #1 who worked with a resident on that date was completed 5/23/23 at 5:52 p.m. The note was identical to the note in the incident report (see above). -The note did not document if the resident was assessed by LPN #1 before she was sent to her appointment with the cardiologist or after she returned from the ER. -The incident report did not include the interview with Resident #4 who was alert and oriented to time, place and person and was able to provide a detailed recollection of events. -The incident report did not include a summary of findings or the conclusion. It did not specify what caused the lift to tilt, improper use or malfunction. The report did not specify what immediate actions were taken on 5/23/23 to ensure the lift was not used until inspected (the inspection was completed on 5/24/23, see under facility follow-up). -The CNAs that were involved in this incident were not checked for their competency and knowledge of Hoyer lift use, they were not provided additional education after the incident. The neurological checks were provided by ADON and revealed the resident's vital signs were first taken after the incident on 5/24/23 at 2:30 p.m. -The neurological checks were almost 24 hours after she returned from theER on [DATE] around 3:30 p.m. The skin assessment on 5/24/23 (a day after the incident) documented the resident had discolorations on both of her arms and surgical dressing on the neck. -The skin assessment did not mention the resident's legs, face and scalp bruises. The skin assessment on 5/30/23 (completed at the time of the survey) documented that the resident had bruises on the left knee, right knee, right thigh and top of her scalp. The note read: bruising occurred during back to bed transfer, back of both legs, forehead and scalp. -There was no evidence that bruises were monitored after the incident. VI. Staff interviews LPN #2 was interviewed on 5/30/23 at 2:40 p.m. He said he was familiar with the resident and he was not aware of any recent falls. He said the resident had bruises on her head from the transfer a few days ago. He said he learned about her bruises today but he had no time to document that in the resident's progress notes. He said the resident was alert and oriented and was able to make needs known. CNA #3 was interviewed on 5/30/23 at 2:45 p.m. She said she knew the resident well, but was not working with her today. She said the resident was a Hoyer lift transfer with two person assistance all the time. She said she heard about the incident with the lift from the resident herself, but she did not work with her at the time of the incident or after. She said the resident was cooperative with care, alert, oriented and did not have refusals or other types of behaviors. She said she never had any accidents with Hoyer lifts with any residents in the building. CNA #1, CNA #2 and LPN #1 were not available for an interview at the time of the survey. UM #1 was interviewed on 5/30/23 at 2:48 p.m. She said she initially learned about the incident from the driver who was transporting the resident to the cardiologist appointment. She said the driver reported the resident was taken to the ER right from the appointment. UM #1 said she briefly spoke with both CNAs (CNA #1 and CNA #2) on 5/23/23 and they both told her the resident was not hurt during the transfer. She said she talked to LPN #1 and told her to start the incident report for the resident. The ADON was first interviewed on 5/30/23 at 3:22 p.m. She said she was aware of the Hoyer lift incident with the resident. She did not recall from whom she initially learned about it, but she remembered discussing it with the interdisciplinary team (IDT) team. She said she did not know if LPN #1 was or was not notified by CNAs about the incident before resident left for an appointment and she could not say if resident was or was not assessed by LPN #1. She said her role was to make sure the investigation was complete. She said the Hoyer lift was inspected by the maintenance director (MTD), but she was not sure when. She said she was gathering the investigation information and could answer questions later when she gets it together. The MTD was interviewed on 5/30/23 at 4:10 p.m. He said he usually got reports about equipment from staff through the electronic system the facility was utilizing. He reviewed the records on his phone and stated he could not locate the exact time and date when he received the request to inspect the Hoyer lift. He said he would ask the NHA for assistance. He said when staff sent requests for inspection they did not specify which lift was involved, they would just say which floor the lift was on. He said he recalled getting the request to inspect the lift on the second floor a few days ago. He said he inspected all the lifts that were present on the second floor and they all were functioning appropriately. The ADON was interviewed a second time on 5/30/23 at 4:44 p.m. She said she gathered the report and provided it in the folder. She said the resident was sent to ER for the evaluation and her head scan revealed no acute findings. She said the neurological assessments were started late, on 5/24/23 because they could not decide if it was necessary since her head scan looked good. She said the handwritten note in the investigation folder was most likely completed by LPN #1. She said the incident report was completed by LPN #1 and she later added bruising to the incident report section. She said she was not aware the resident was diagnosed with concussion (as documented on hospital discharge summary). The DON was interviewed on 5/30/23 at 6:04 p.m. She said she was aware of the incident with the lift involving Resident #4. She said the incident was investigated and it was inconclusive what happened. She said the resident should be assessed as soon as staff become aware of the incident. She said she did not know about the incident until the resident returned from the ER. She said she did not know if CNAs notified LPN #1 about the incident before the resident left for an appointment. She said the investigation did not determine the CNAs, who operated the lift on 5/23/23,required competency check or additional training. She said the lift was inspected by MTD and was functioning properly. VII. Facility follow-up On 5/30/23 at the time of the survey, the NHA submitted an email with a copy of work order #16449, dated 5/24/23 for 2-nd floor common area Hoyer lift. The note under comments read all lifts were checked and were in working condition. -The date on the work order indicated that Hoyer lift that tilted during transfer with Resident #4 was still used by staff on 5/23/23.

Based on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident individuality for three (#2, #4 and #6) residents of six residents reviewed out of eight sample residents and 54 residents on the second floor. Specifically, the facility failed to answer the residents' call light and provide services in a timely manner, which caused the residents to feel ignored, anxious and scared at times. Cross-reference F725 Sufficient Staffing. Findings include: I. Resident #2 Resident #2, age 68, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia, history of COVID-19, hydrocephalus (water on the brain), depressive episodes, type 2 diabetes mellitus, atherosclerotic heart disease, history of transient ischemic attack and cerebral infarction (stroke) and chronic kidney disease. The 11/10/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of one staff with mobility and activities of daily living (ADLs) with the exception of eating. Resident #2 was interviewed on 12/5/22 at 2:24 p.m. He stated the call lights had been taking a very long time to answer, sometimes close to an hour at night when there were only two certified nurse aides (CNAs) at night. He stated the facility was frequently short staffed and it made him upset and feel forgotten or worthless when the call light took a long time. He stated the staff worked hard and tried, but there just were not enough of them to care for all of the people on the floor. He stated he was not only concerned for himself and his care, but for the other residents on the floor who needed more help than he did. II. Resident #4 Resident #4, age 79, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included malignant neoplasm (cancer) of lung and uterus, morbid obesity, obstructive sleep apnea, venous insufficiency and type 2 diabetes mellitus. The 9/23/22 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 11 out of 15. She required supervision to limited assistance of one staff member with her mobility and ADLs. Resident #4 was interviewed on 12/7/22 at 8:32 a.m. She stated the facility was short staffed regularly, especially at night. She stated the CNAs on the second floor work very hard and treat the residents well but they can only do so much when there are two of them at night. She stated she had to wait for 30 minutes to an hour for her call light to be answered at night and had got herself out of bed on more than one occasion to go out in the hall to look for someone and it took 45 minutes to see any staff come by her room. She stated she frequently heard other residents on the hall calling out for help and waiting for a long time to receive assistance. She stated the long wait times make her feel afraid that she would not receive assistance if something bad happened to her or if she fell . III. Resident #6 Resident #6, age 70, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included heart failure, shortness of breath, anemia, chronic pain, chronic obstructive pulmonary disease, type 2 diabetes mellitus, dependence on supplemental oxygen, and cachexia. The 10/26/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required supervision assistance of one staff with mobility and ADLs. Resident #6 was interviewed on 12/7/22 at 9:30 a.m. She stated the facility did not have enough staff. She stated the call lights and cares took a long time because there was not always enough staff on the floor to get to everyone. She stated there were a lot of people who needed a lot of help on the unit and she worried they were not getting the help they needed timely. IV. Record review Resident council minutes were reviewed for November 2022. One of the residents in attendance complained that her call light was not being answered, and that she called out for the nurse by name who did not come in and help her. The notes revealed the resident reported feeling very sad and scared when this happened. One resident stated she was given a bell for emergencies to add to the call light but did not receive a prompt response. Another resident stated that CNAs say wait a minute and do not return. A resident stated that she understands the building has been short staffed and that CNAs have a lot of people to get to. Another resident stated she was told they were short staffed on a day they were fully staffed. Grievances for September 2022, October 2022, November 2022 and December 2022 to date were reviewed, and five grievances were filed related to long call light times. Follow up from the facility was to educate staff regarding timely call light response and to complete call light audits. The call light audits were requested, though were not provided and residents continued to experience long call light response times (see above). V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/8/22 at 12:15 p.m. She stated there was not always enough staff on the floor and it was difficult to get everything done when the facility was short staffed. She stated the resident call lights should be answered within five minutes, though this was very difficult to accomplish, especially when the facility was not fully staffed, and during meal times and shift changes. LPN #2 was interviewed on 12/9/22 at 1:25 p.m. She stated there was not enough staff to answer call lights timely for the residents. She stated they tried, though call lights were often longer during the day when there were four CNAs caring for all the residents on the unit. She stated the CNAs and nurses had difficulty getting to all the residents timely when multiple staff were caring for those residents who needed two or more staff for care tasks. CNA #1 was interviewed on 12/9/22 at 1:35 p.m. She stated four staff was the very minimum the unit could have to care for residents during the day and evening. She stated it was difficult to get to all resident call lights timely when multiple staff were providing care for residents who required two-person assistance. She stated she had worked the night shift on many occasions and two CNAs were not enough to provide timely care to the residents. CNA #2 was interviewed on 12/9/22 at 1:40 p.m. She stated she always worked day shift and it was difficult to provide timely care to all residents and answer the call lights timely when there were only four CNAs. She stated when there were only two CNAs on night shift, the morning shift could be chaotic, because the night shift staff could not get to everything and everyone the night before. The director of nursing (DON) was interviewed on 12/9/22 at 3:02 p.m. She stated call lights should be answered within three to five minutes ideally, and anything over 15 minutes would be excessive and residents start to worry. She stated long call light response times could become a dignity issue if residents were having to wait a long time to be assisted to the bathroom and residents could get scared if no staff came to answer their call light.

Based on observation, interviews and record review, the facility failed to ensure four of 39 sample residents (#4, #7, #27 and #28) were protected from inappropriate sexual behavior by staff. Certified nurse aide (CNA) #1, employed by the facility since 1/13, had a history of [REDACTED].#28, and #4, all of whom resided on restorative unit, in 3/13, 5/13 and 7/13. No steps were taken by the facility to ensure residents were protected from further inappropriate sexual behavior by CNA #1. CNA #1 continued to provide direct resident care without restriction or oversight on the same resident unit (restorative) after these incidents and until 8/14/13, when resident #7 alleged she was sexually assaulted by CNA #1 on 8/14/13. Review of facility staff records during the recertification revisit and abbreviated survey 8/19/13 to 8/27/13, revealed the facility failed to take steps after 8/15/13 to ensure staff members were thoroughly screened and fit to serve. Out of 45 staff files reviewed, 22 lacked information to confirm staff was fit to serve prior to hire. Cross-reference F225. The facility's failure to ensure residents were protected from inappropriate sexual behavior by staff after 3/13, and failure to ensure staff was fit to serve, created a situation of immediate jeopardy for serious resident harm. The findings include: I. Imposition of Immediate Jeopardy On 8/21/13 at approximately 1:40 p.m., the nursing home administrator (NHA), the director of nursing (DON), regional nurse consultant (RNC), the outgoing regional vice president (RVP) and incoming RVP were informed by CDPHE that repeated allegations of inappropriate sexual behavior by CNA #1, the facility's knowledge of these allegations, the facility's failure to ensure residents were protected, and the facility's continued failure to ensure staff was fit to serve created a situation of immediate jeopardy. II. Facility Response and Removal of the Immediate Jeopardy On 8/22/13 at 9:00 a.m., the following plan (draft #3) was submitted by the facility to CDPHE to remove the immediate jeopardy. The plan read: 1. Currently doing a house wide employee file audit for required background checks, reference checks, abuse training and license verification. No one will work until being declared fit for duty by the outcomes of these checks. Future new hire files will be reviewed by the payroll clerk for required documents before the employee can begin providing resident care. The Administrator will sign off completed new hire files to validate that required documents are present. 2. We will continue our search for a Human Resource Manager who will focus on the aspects of employee files from hiring (onboarding) to separation, including hiring practices, disciplinary practices, training and maintenance of the employee files. The Goal is to have someone in place by September 10th, 2013. In the meantime the current HR Manager will receive training and support from the Home Office Human Resource Director who is PHR certified. 3. Home Office Director of Human Resources will develop a hiring practices process for the facility to follow by 8/23/13. 4. The Home Office has signed the facility up for a nationwide background check company (Metro data) which will include national, district, state, OIG, national sex offenders, E-Verify, license verification. 5. The Home Office Human Resource Director is currently reviewing the employees we sent through the system this week to ensure no outstanding employee issues exist. Currently the Director of Human Resources is here providing support however the VP of Clinical services or Operations Consultant will provide the ongoing support until a stable system is in place. 6. Staff who have had recent discipline in their files related to resident care issues will receive additional training and documented oversight related to the discipline. The additional oversight will continue for a maximum of 30 days or until the employee can demonstrate consistent acceptable provision of care. If the employee fails to demonstrate acceptable care provision, they will be separated from employment. The unit manager and interim DON will document progress weekly. 7. Allegations of abuse in all areas will receive direct oversight from the home office to ensure process is followed. (see attached investigation process to be implemented). Identified employees will be suspended. If an allegation of sexual abuse is made the resident will be sent to the emergency room for sexual abuse assessment and treatment immediately. 8. If the police are involved, the employee will not return to work without written documentation from the Police department that the case is closed and unfounded and/or guidance from the VP of Clinical Services or designee if the Police are not involved. 9. VP of Clinical Services will be present in the facility and be involved in abuse investigations and will review final conclusion to ensure the Facility follows the processes and systems. 10. VP of Clinical Services provided training to the Interim DON and Unit Managers on identification of injuries of unknown origin assessment and investigation requirements. 11. DON candidates have been screened and interviewed, recruitment will continue. The plan is to have the DON offer accepted by September 15, 2013. 12. Residents currently in house will have a skin assessment completed today to identify any injuries of unknown origin to include bruises, skin tears, abrasions etc. Issues that cannot be explained will be investigated to rule out abuse. If abuse is suspected required state agency notifications will be made within 24 hours and the investigation report will be filed within 5 days. 13. Abuse Training was initiated 8/15/13. Currently over 90% have received the training. Currently 100% of staff working on the floor have received this training. 14. The Home Office Compliance Officer provided training on the Resident Protection System to include abuse, investigation and reporting requirements to the Consultant staff and the Administrator on 8/16/13. 15. Licensed Nurses will receive training by VP of Clinical Services on Physical Assessment, head to toe assessment and documentation, and reporting beginning 8/22/13. Education will be completed by 8/28/13. 16. Abuse Guideline will be reviewed and revised by VP of Clinical Services on 8/21/13 to include more comprehensive guide to abuse identification. To be completed by 8/23/13. On 8/22/13 at 11:00 a.m., the facility was notified immediate jeopardy was removed; however, deficient practice remained at a G level, actual harm. III. Resident Protection System - Preventing Abuse and Neglect A. Expectations of the facility's "Resident Protection System" On 8/20/13 at approximately 12:23 p.m., the facility's Operations Consultant (OC) provided an Employee Guidelines packet that included a document titled, "A Resource Guide for Resident Protection System (Preventing Abuse and Neglect) - A Partnership in Caring for Our Residents." The undated document read in pertinent part: 1. Statement of Commitment (pertinent part) -The facility educates all employees on resident protection processes to ensure our residents are protected from abuse or neglect upon hire and thereafter annually. -Instructions for reporting allegations of abuse and neglect are made available to all residents, visitors and staff. -Comprehensive and thorough investigations will be completed on any allegations of abuse and neglect. The facility will take immediate and appropriate actions to protect our residents. -The facility will notify any outside entities, including regulatory agencies, the ombudsman, protective services and legal investigators (e.g. police etc,) as appropriate to the situation. -The Seven key components for successfully maintaining safe environments for our residents are: screening, training, prevention, identification, investigation, protection and reporting/response. -Our facility is committed to protecting all residents who reside here from abuse and neglect. 2. CMS Federal Regulations -F223 - The resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. -F224 and F226 - Staff treatment of [REDACTED]. -F225 - The facility must not employ individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law or have a finding entered into the state nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. -Abuse can occur by various means and degrees; however the facility's immediate response is the same regardless of the nature of the suspected abuse. 3. Staff Responsibilities Employees are required to report any occurrence of potential mistreatment they observe, hear about or suspect to a supervisor, whose obligation it is to report to the Resident Protection System Coordinator (Administrator) and/or the Director of Nursing. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. 4. Identifying Abuse Any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. 5. Types of Abuse Verbal, sexual, physical, mental, involuntary seclusion, neglect, injuries of unknown origin and misappropriation of resident property. 6. Reporting An employee who witnesses abuse or crime, or receives an allegation of abuse or crime is required to report as follows; all employees must inform their immediate supervisor, supervisors must immediately inform the Resident Protection System Coordinator (Administrator) and/or Director of Nursing, the Director of Nursing must immediately inform the Administrator. 7. Definitions As defined by CMS in the States Operational Manual --Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. --Sexual Abuse: Includes but not limited to sexual harassment, sexual coercion and sexual assault. --Physical Abuse: Includes but not limited to hitting, slapping, pinching, kicking and attempts at controlling behavior through corporal punishment. --Injuries of Unknown Origins: An injury should be classified as an injury of unknown source when both of the following are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury or the location of the injury, e.g., the injury was located in an area not generally vulnerable to trauma or the incidence of injuries over time. 8. Prevention Consists of maintaining systems which detect, identify, correct and prevent the occurrence of abuse ...The Administrator is designated as the Resident Protection System Coordinator (RPC) and will manage and evaluate the Resident Protection System within the facility. The Administrator will ensure there is evidence that processes are in place and operationalized to prevent abuse. The RPC (Administrator) is responsible for the investigating, reporting, and coordinating of the investigation process or any alleged or suspected abuse regardless of the source of the concern. Employee education on the Resident Protection System will occur upon hire, annually thereafter and as needed. Other tools or processes that may be utilized to help identify and prevent abuse include but are not limited to: family, staff, resident interviews, clinical rounds/observations, resident record reviews, clinical and/or stand up meetings, resident council meetings, concern forms, incident reports, care line calls and grievance committee. 9. Investigation (Occurrence) Allegations of abuse and neglect will be thoroughly investigated using the occurrence investigation process. This investigation process includes but is not limited to: reporting of the allegation/occurrence/suspicion; notification of local and state authorities per regulations, establishing the facts by asking who, what, when, where, why; conduct interviews, make observations, include others that may have been affected, review information for trends and/or inconsistencies, validate information, develop a summary of findings and complete necessary facility specific as well as state required forms (when indicated). It is important that any and all allegations are reported immediately, that immediate action is taken and that the investigation process is started as soon as the allegation is received. If an employee is identified as the person who is allegedly responsible for the abuse/neglect, the employee is asked to provide a statement if this is possible and then the employee is suspended until the results of the investigation are obtained. If the staff member is unable to be interviewed immediately, the staff member is suspended and will be contacted by the RPC or lead investigator to obtain his/her statement. 10. Protection It is the facility's responsibility to protect residents, family members and staff from harm during an investigation of alleged abuse. In Staff To Resident (Reported or Suspected): Attend to the resident's immediate needs, if the accused is known and still in the facility do not leave resident alone, notify your supervisor immediately, if your supervisor does not respond immediately notify the RPC. 11. Reporting CMS Regulations require that any and all allegations of abuse, mistreatment, neglect including injuries of unknown origin and misappropriation of residents personal property be reported immediately to the Administrator (RPC) of the facility and other officials in accordance with state law. If there is not a shorter time frame requirement, CMS defines "immediately" to mean as soon as possible, but no more than 24 hours after discovery of the incident. When an allegation becomes known, your initial report to the Administrator, state agency and other required officials in accordance with state law must be made within 24 hours. The results of the investigation must be reported to the Administrator, State agency, and other officials in accordance with state laws within five working days of the incident, or per regulation if it is more stringent. Reasonable Suspicion of a Crime: If a staff member suspects a crime has been committed against a resident, a report must be filed with the local law enforcement agency (city police, county deputy etc,.) according to the following guidelines; serious bodily injury must be reported within two hours. A serious bodily injury is an injury involving extreme physical pain, substantial risk of death, protracted loss or impairment of function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation. No serious bodily injury must be reported within twenty-four hours. 12. Response The findings of the investigation will determine the facility's response and what actions will be taken. What the facility does in response to the outcome of the investigation is crucial to preventing further incidents. Actions taken should be appropriate to the situation and may include education, disciplinary action up to termination, resident room moves, resident schedule change and behavior management as a few examples. B. Definition of Sexual Harassment On 8/20/13 at 12:23 p.m., the facility's Operations Consultant (OC) provided an Employee Guidelines packet. On page 3 Section 2, it read (in pertinent part): Definition of Sexual Harassment: For the purpose of this policy, sexual harassment is defined as: Unwelcome sexual advances, requests for sexual favors, sexual jokes or inferences and other verbal or physical conduct of a sexual nature when. . . . Examples of sexual harassment may include but are not limited to: unwanted sexual advances, demands for sexual favors in exchange for favorable treatment or continued employment, repeated sexual jokes, flirtations, advances or propositions, verbal abuse of a sexual nature, graphic or verbal commentary about an individual's body, sexual prowess or sexual deficiencies, leering, [MEDICATION NAME], touching, pinching, assault, coerced sexual acts or suggestive insulting, obscene comments or gestures, and displays in the workplace of sexually suggestive objects or pictures. IV. Failure to Protect Residents from Sexual Abuse A. CNA #1 1. Review of CNA #1's file revealed the CNA was hired by the facility in January of 2013 (1/10/13) as a certified nurse aide. He generally worked the evening shift and always worked on the restorative unit. -CNA #1's file contained a printed document titled "National Sex Offender Search." The results showed the search included all states, territories and Indian Country for the first and last name like the name of CNA #1, and that two records were located. -A handwritten note at the top of the form read, "Not our applicant." There was no additional information found in the file to show how the facility determined neither of the two records found were CNA #1. On 8/20/13 at 9:25 a.m., the Nursing Home Administrator (NHA) stated he did not know how Human Resources (HR) had determined according to the National Sex Offender Search that CNA #1 was not the individual the facility had hired. 2. Review of facility incident/investigation reports revealed the facility documented four allegations of inappropriate sexual behavior by CNA #1 toward facility residents 3/13, 5/13, 7/13 and 8/13. See details below. 3. Review of facility staff records, incident investigations, disciplinary actions and interview with VPSC on 8/26/13 at 3:26 p.m. revealed: -Documentation of disciplinary action against CNA #1, an oral reprimand, dated 3/26/13 following an allegation on 3/26/13 involving resident #28. The CNA was not suspended. See further details below. -Suspension of CNA #1 on part of 5/18/13 and all of 5/19/13, following an allegation on 5/18/13 involving resident #27. CNA #1 was paid for the suspension time and upon his return, continued to work on the same unit (restorative). No disciplinary action was taken. See further details below. -No documentation of disciplinary action following allegation 7/13/13 involving resident #4. However, file review showed a "Time off Request" form documented the CNA was suspended 7/23, 7/24, 7/26, 7/27, 7/29, 7/30, and 7/31/13 pending an investigation. See further details below. 4. On 8/19/13, the CDPHE received a complaint that the facility failed to keep resident #7 free from employee to resident sexual abuse. Specifically, on 8/15/13, the resident informed a CNA during her shower, that she had been sexually assaulted by CNA #1 the night before. On 8/21/13 at 12:20 p.m., the police detective on the case was interviewed in person at the facility. He stated CNA #1 was contacted by police on 8/15/13 and taken into custody (jail), where he currently resides, after he confessed to sexual assault of resident #7 and a previous assault of resident #4. The police detective stated he had asked the previous NHA why CNA #1 was not pulled off the working schedule and the floor since there was still the active investigation going on. The detective stated this had been an active case since 7/19/13. B. Inappropriate Sexual Behavior by CNA #1 1. Resident #7 - Allegation 8/14/13 Resident #7, a [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Primary [DIAGNOSES REDACTED]. a. Resident Status Review of the most recent (admission) minimum data assessment (MDS), dated [DATE], revealed the resident scored a 10 out of 15 on the brief interview for mental status (BIMS); indicating some cognitive impairment. She exhibited no behaviors. She required extensive assistance of one staff with mobility and transfers on and off the toilet. b. Documented Rape Allegation Review of facility documentation revealed statements from staff related to the 8/14/13 allegation. -The CNA who provided resident #7 a shower the day after the incident on 8/15/13 around 9:00 a.m., reported that during the shower, the resident exhibited a facial expression. At that time the CNA asked the resident if everything was okay. The resident initially responded everything was okay, however, when the CNA noted her facial expression did not change the CNA repeated the question. The resident then responded that she had been raped the night before. -At 10:41 a.m., a head to toe assessment was completed by the unit manager registered nurse (RN). Documentation showed the resident's "Skin warm, dry and intact to entire torso, no bruising, red marks, or open areas noted to chest, back, posterior and anterior thighs, several areas of faded greenish/yellow areas to lower abdomen noted, skin intact, non tender. As I touched the resident's back, resident stated, 'That's where he put the board up against me, so he wouldn't leave any finger prints or marks, right around the kidney area.' No redness, no scratches, no discoloration or open areas noted, no evidence of pain when palpated, no flinching, peri area clean, no evidence of bleeding. Patient denies pain or discomfort." -At 1:45 p.m., "Patient transferred to (name) hospital for a SANE (examination by a sexual assault nurse examiner) via ambulance accompanied by 2 EMTs. MD notified, family notified by case worker. Police present prior to transfer." -At 11:43 p.m., notes documented, "Resident returned from hospital at 7:00 p.m. Resident was transferred to decliner (sic) with 1 assist. This nurse checked in on her and resident denied any pain or discomfort. Resident was offered a snack and it was accepted. Resident has been resting comfortable for the duration of this shift." c. Hospital Records Review of the emergency department report documented the "patient claims she was sexually assaulted by worker last night at facility. The patient is claiming that sometime last night, a male staff member, raped her with a board. The patient allegedly complained of some back pain earlier, this time denies any back pain." The physical examination documented, in part, the patient was alert and oriented x 2. There was no obvious external trauma and no outward signs of physical trauma; will await sexual assault nurse evaluation. Further record review revealed the resident signed the consent forms for examination. SANE Examination Results: Mental Status was cooperative and calm, alert and oriented x 4. Date and time of the assault was 8/14/13 about 11:00 p.m., inside the resident's bathroom off her own room. The resident's description was, "I was sitting on the commode and he helped me to get up which was not out of the ordinary. And then suddenly as I am grabbing ahold of the stand up bar, he kind of gave me a kick in the back and then, how shall I say this correctly, he pushed me up against the wall and the grab bar and very quickly he had something in his hand and he forced it against my back. He kept pushing (patient motions with her hands a pushing motion) this tool that he had into my back. (SANE nurse clarifies by asking patient to point to what she means by "back" and patient points to lower back.) SANE nurse asks if he put this tool into her butt or her vagina? Patient reports, well the end of it might have gone in my hynie. SANE nurse asked to clarify what hynie is, 'my rump'. SANE nurse asks if anything went into her vagina, 'no but happened so fast I guess I have to say no. It appeared he was attacking my rearend." Regarding evidence of digital penetration, unknown, although resident stated "he might of when he used the tool." Regarding use of a foreign body, "lower back and my rump, pushing. I determined the tool was like a board." Body Surface Examination revealed the resident had lower back bruising where she reported being pushed with "tool." Review of the female body diagram showed documented bruising to the lower back a 2 x 2 centimeter blue bruise, purple and blue bruising to bilateral shins, to bilateral forearms, and multiple red, purple bruises across the abdomen. The summary of the assessment documented, "Tool pushed into patient's lower back and possibly 'in my hynie;' no genital trauma noted. Bruise to lower back above buttocks present." On 8/15/13 at 7:15 p.m., the resident was transported back to the facility. d. Observations and Interviews On 8/21/13 at 10:30 a.m., the unit manager registered nurse (RN) who completed the head to toe assessment for resident #7 on 8/15/13 was interviewed. -She stated she remembered some old bruising on the resident's abdomen; yellow green in color. She did not see any bruises to the resident's back after the resident claimed a board was placed up against her back. She complained of no pain although she described the area on her where the board was placed. The RN reiterated there were no red areas to her back, however, her assessment focused on the resident's [MEDICATION NAME] area. -She said, "I have to believe what the patient tells me. Cognitively, resident #7 has some short-term memory (problems) but she's very lucid. She said that following the assault, the resident was moved to a different room. She felt the resident was doing well, however, the resident stated to her, 'I don't know if I want to go into that bathroom again.' -The RN was unable to explain how her assessment revealed no bruising to the resident's lower back, legs and arms when the SANE examination identified the bruising (except for the abdominal area.) On 8/21/13 at 11:45 a.m., resident #7 was observed seated in a wheelchair in her room. During an interview at the time she said she may be okay talking, however, then stated, "I have been questioned so much, when is it going to end? It keeps popping up in my mind and I've accepted it, but it will probably never go away." e. Record Review On 8/12/13, prior to resident #7's assault, the facility had received a letter from the local police department stating their investigation of CNA #1's (previous) sexual assault of another facility resident (see below, involving resident #4's allegation) was still open. The letter instructed the facility to not let CNA #1 know of the request. Even though the facility was informed the sexual assault investigation of CNA #1 was open and ongoing, the facility continued to allow CNA #1 to provide direct care staff to residents residing on the restorative unit. The facility's failure to protect the residents resulted in the assault of resident #7. C. Previous Allegations of Inappropriate Sexual Behavior by CNA #1 - Facility Failure to Implement Resident Protection System to Ensure Resident Safety. Record review and interviews revealed the facility became aware of allegations of inappropriate sexual behavior toward residents by CNA #1 in 3/13. The facility repeatedly failed to respond in a manner to ensure residents were protected from further incidents of inappropriate sexual behavior by staff. 1. Resident #28 - Allegation 3/26/13 Resident #28's clinical record was reviewed on 8/24/13 at 9:00 a.m. Resident #28, age 86, was admitted to the facility on [DATE]. She was readmitted on [DATE]. The face sheet documented the resident [DIAGNOSES REDACTED]. a. Resident Status The MDS Significant Change dated 8/4/13 documented the resident had a BIMS (cognition) score of 01 indicating severe impairment. The resident required extensive assistance from staff (one person physical assist) for bed mobility, transfers, dressing, toileting and personal hygiene. The resident also required physical help in part of bathing activity. Physician orders [REDACTED]. The Care Plan (CP) dated 9/5/13 (goal time) documented the resident had a problem with self care deficit needs related to lack of motivation, Alzheimer's/Dementia and disease progression. The Approaches Section (AS) documented the Certified Nurse Aide (CNA) was to assist the resident with activities of daily living (ADLs), oral hygiene, grooming, bathing, toileting, transfers, repositioning and encourage rest periods. The AS also documented the resident required extensive assistance for bed mobility, transfers and toileting. The AS further documented the CNA should introduce self, their role, draw on old memory/connections and do not argue or quiz. The Care Plan (CP) dated 11/7/13 (goal time) documented the resident had short-term memory impairment and needs assistance with decision-making due to Alzheimer's/dementia manifested by lack of verbalization (slow to find words). The Approaches Section (AS) documented the Certified Nurse Aide (CNA) was to redirect/reorient resident when needed, speak slowly/clearly, give resident time to respond, praise accomplishments, offer conversation, allow resident to set pace, explain procedures/cares when provided and provide one-to-one with resident. The CP also documented to demonstrate tasks slowly, encourage expression of feelings, offer verbal/non-verbal cues, and administer [MEDICATION NAME] for dementia as physician ordered. b. Investigation form 3/26/13 On 3/26/13 an Investigation form was completed with resident #28 by Social Services (SS). -The resident was documented as having stated CNA #1 comes and kisses me all the time on the mouth: the resident was documented as (stating) it's alright. -The SS employee asked the resident were the kisses romantic and the resident replied "no." -The SS employee asked the resident were the kisses more like a motherly kiss and she replied "yes." -The SS employee asked do you feel safe here "uh hu." -The SS employee asked has it happened with anyone else "no just my daughter." -The SS employee asked has he done anything other than kiss you, "no." -There were eight separate residents interviewed per documentation provided and none had been kissed or received/perceived inappropriate attentions from staff members. c. Facility Response to 3/26/13 Allegation (1) Record Review On 8/22/13 at 4:02 p.m., the NHA provided a copy of a First Offense - Oral Reprimand dated 3/26/13. The Violation documented actions meant in kindness were perceived as romantic by resident. -The box NO was checked in the section of the form which detailed had this concern/violation been previously discussed with this employee. -The Violation Summation documented the resident stated to staff "Named Individual kisses me on the lips every night." The resident did not feel the kisses were romantic in any way - more of motherly. -Expected Level of Performance documented as a staff member it is never OK to kiss residents. This may come off as abuse. -The Plan of Correction was education/counseling. -The Employee Comments documented I (named) understand my [MEDICATION NAME] for the resident may be perceived differently and my actions were not romantically. -The form was signed by CNA #1, a witness, a supervisor and a department manager. The form was not signed by the NHA. (2) Interview On 8/26/13 at 11:48 a.m., the current NHA stated he was the Guardian Angel for the resident. The NHA stated he interviewed the resident the day after the event (3/26/13) and she told him she was "OK." The NHA stated the resident wanted the CNA #1 to come back to work on the unit. The NHA stated the resident told him she liked the CNA #1 kissing her and again stated she wanted him back on the unit. The NHA stated the resident told him she was not afraid of CNA #1 or any other staff members. The NHA stated when subsequent allegations involving CNA #1 were publicized, he had another talk with the resident and she stated everything was fine; she was not afraid of anyone. c. Failures in Facility Response (1) Record Review -There was no evidence in the disciplinary action or investigat

Based on record review and staff interviews, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: The facility failure to use its resources effectively contributed to a failure to protect residents from inappropriate sexual behavior by CNA #1. Cross reference F223; abuse. The facility failure to use its resources effectively contributed to a failure correct deficiencies cited in recertification survey 6/24/13. Cross-reference: F225, F250, F281, F309, F353, F431, F441 and F514. The facility failure to use its resources effectively contributed to additional citations during the revisit and abbreviated survey 8/27/13. Cross reference F387, F497, F516, and F520. The findings include: I. Nursing Home Administrator Expectations A. Administrator Job Description/Evaluation (undated) On 8/27/13 at 9:17 a.m., the Vice President of Clinical Services (VPCS) provided the facility Job Description/Evaluation (JDE) for the position of Administrator of the facility. The JDE documented in pertinent part in the Responsibilities section: -Operates the facility in accordance with established policies and procedures of the governing body. -Act as liaison with the governing body, medical/nursing staff and other professional and supervisory staff through regular meetings and periodic reporting. -Prepares and forwards on time to proper authorities all reports such as staffing, census, etc., and any special reports required by management. -Write definite policies regarding duties and activities of the staff, which will assure health care and safety of the residents and others, and explain these policies so that the aim and purpose of the facility may be achieved by cooperative effort. -Recruits, employs and releases all staff. Works with the Director of Nursing (DON) in hiring personnel and assure there are adequate numbers of aides and orderlies to meet the needs of the residents on a twenty-four hour basis. -Interpret the lines of authority to each employee so that each will have a clear understanding of the person to whom he is immediately responsible. -Write personnel policies and individual duties and see that all employees know them, and delegate the authority required for the performance of their jobs to the department head. -Notify licensing agency of any changes in key personnel. -Use diplomacy but firmness in settling any disputes, complaints, etc., concerning personnel or residents or families. -Supervises all department heads, including office staff. Supervise by regular rounds and conferences, the work of all responsible personnel. Check with department heads daily. -Evaluate the performance of each employee periodically with the department head, discuss the evaluation with the employee. -Work with the department heads in providing opportunities and material for regular staff meetings and in-service education pertaining to the job. -Assist the department heads in dismissing from employment any person whose work is not satisfactory. -Give honest appraisal of an employee's work and behavior to succeeding employers. -Work with nursing director in providing a safe place for storing current and closed resident records. -Maintain as much personal contact as possible with the resident and his family or guardian in order to continue good relationship and to determine changing conditions and needs. Letter writing is excellent. -Ascertain that the necessary food and other supplies needed for the operation of the facility are purchased and on hand. -Responsible that all equipment is in operating order. -Study and keep current with the changes in regulatory agencies. -Is an active member of all committees, where applicable and set meeting dates and directs that copies of the minutes and reports of these meetings are kept and sent to the proper officials. -Establishes standard operating procedures for physician practices in the facility in coordination with the nursing director. -Reviews and evaluates all reports and documenting disposition of recommendations and implementation from the facility's committees and consultants. B. On 8/26/13 at 1:35 p.m., a review of the facility's Quality Assurance (QA) committee process was conducted with the Nursing Home Administrator (NHA) and the Operations Consultant (OC). The OC stated the NHA provided leadership for the facility and was a member of the QA committee. II: Failure to Administer Resources Effectively and Efficiently to Maintain Compliance with Regulatory Requirements A. Failure to ensure QA committee action plans were consistently implemented to address a resident's right to be free from verbal, sexual, physical and mental abuse, cross reference F223 (K): Abuse - the facility was cited at a "K" level, indicating substandard quality of care and resulting in an imposition of immediate jeopardy due to the facility failure to prevent multiple residents from physical and sexual abuse. Record review and interviews revealed: Certified nurse aide (CNA) #1, employed by the facility since 1/13, had a history of [REDACTED].#28, and #4, all of whom resided on restorative unit, in 3/13, 5/13 and 7/13. No steps were taken by the facility to ensure residents were protected from further inappropriate sexual behavior by CNA #1. CNA #1 continued to provide direct resident care without restriction or oversight on the same resident unit (restorative) after these incidents. On 8/15/13, resident #7 informed a CNA during her shower that she had been sexually assaulted by CNA #1 the night before. On 8/21/13 at 12:20 p.m., the police detective stated CNA #1 was contacted by police on 8/15/13 and taken into custody (jail), where he currently resides, after he confessed to sexual assault of resident #7 and a previous assault of resident #4. B. Failure to Address Previously Cited Deficiencies and New Areas of Deficient Practice 1. Repeat Citation of Deficiencies from last survey dated 6/24/13. Observations, record review and interviews conducted during the revisit survey exiting 8/27/13 revealed the facility failed to develop and implement plans to correct the following deficiencies cited during the recertification survey 6/24/13: F225: "Not employ individuals who have been found guilty of abuse" was recited at a "G" level, indicating a widespread potential for more than minimal harm. This represented an increase in the scope of deficient practice from a scope of "D," potential for more than minimal harm that is isolated. F250: "Social Services" was recited at a "D" level, indicating an isolated potential for more than minimal harm. This deficiency was previously cited at a "D" level, indicating an isolated potential for more than minimal harm. F281: "Professional Standards" was recited at a "D" level, indicating an isolated potential for more than minimal harm. This deficiency was previously cited at a "D" level, indicating an isolated potential for more than minimal harm. F309: "Quality of Care" was recited at a "G" level, indicating actual harm is isolated. This deficiency was previously cited at a "G" level. F353: "Sufficient Nursing Staff" was recited at an "E" level, indicating a potential for more than minimal harm at a pattern. This deficiency was previously at an "E" level. F431: "Labeling of Drugs" was recited at an "E" level, indicating a potential for more than minimal harm at a pattern. This deficiency was previously cited at an "E" level. F441: "Infection Control Program" was recited at an "E" level. This deficiency was previously cited at an "E" level, indicating a potential for more than minimal harm at a pattern. F514: "Resident Clinical Record Accuracy" recited at a "D" level, indicating potential for more than minimal harm that is isolated. This deficiency was previously cited at a "D" level. C. New Deficiencies Cited During Revisit and Abbreviated Survey F223: "Abuse" was newly cited at a "K" level, resulting in substandard quality of care and the imposition of immediate jeopardy, due to the facility's failed to prevent multiple residents from physical and sexual abuse. F387: "Frequency and Timeliness of Physician Visits" was cited at an "E" level, indicating a potential for more than minimal harm at a pattern, due to the facility failed to ensure physician visits were timely. F490: "Facility Administrated Effectively" was cited at a "G" level, actual harm that is isolated, due to the facility's failure to employ a Nursing Home Administrator who followed all of the components of their job description, provided leadership for the facility and managed the facility in a safe effective manner. F497: "Regular In-Service Education" was cited at an "E" level, indicating a potential for more than minimal harm at a pattern due to the facility failed to ensure nurse aide performance reviews were completed and in-services were provided to nurse aides to ensure continued competence. F516: "Facility Safeguards Clinical Records" was cited at an "E" level, indicating a potential for more than minimal harm at a pattern due to the facility failure to implement appropriate interventions to prevent unauthorized use (easily accessible) of resident clinical records. F520: "Facility Maintains a Quality Assurance Committee" was cited at an "F" level, indicating a widespread potential for more than minimal harm due to the facility failure to ensure QA action plans were consistently implemented to address identified areas of concerns. III. Staff Interviews On 8/27/13 at 9:05 a.m., the Vice President of Clinical Services (VPCS) stated the Nursing Home Administrator (NHA) was the leadership in the facility and was responsible to follow the policies and procedures of the facility. At 9:17 a.m., the VPCS stated it was her expectation the NHA of the facility adhere to the 35 responsibilities detailed in the JDE for Administrator and the NHA had not done so and this NHA (previous NHA) was no longer at the facility. (According to the facility, the previous NHA's tenure ended 8/18/13.) On 8/27/13 at 10:16 a.m., the Operations Consultant (OC) stated it was his expectation the NHA of the facility adhere to the 35 responsibilities detailed in the JDE for Administrator. At 10:36 a.m., the OC stated the previous NHA did not perform his duties as described in the JDE for Administrator. The OC stated the facility received repeated deficiencies due to a lack of administrative leadership. On 8/27/13 at 10:31 a.m., the current Nursing Home Administrator (NHA) stated it was his expectation the administrator of the facility follow the responsibilities criteria documented in the Administrator Job Description/Evaluation form.

Based on observation, interviews and record review, the facility failed to ensure four of 39 sample residents (#4, #7, #27 and #28) were protected from inappropriate sexual behavior by staff. Certified nurse aide (CNA) #1, employed by the facility since 1/13, had a history of [REDACTED].#27, #28, and #4, all of whom resided on restorative unit, in 3/13, 5/13 and 7/13. No steps were taken by the facility to ensure residents were protected from further inappropriate sexual behavior by CNA #1. CNA #1 continued to provide direct resident care without restriction or oversight on the same resident unit (restorative) after these incidents and until 8/14/13, when resident #7 alleged she was sexually assaulted by CNA #1 on 8/14/13. Review of facility staff records during the recertification revisit and abbreviated survey 8/19/13 to 8/27/13, revealed the facility failed to take steps after 8/15/13 to ensure staff members were thoroughly screened and fit to serve. Out of 45 staff files reviewed, 22 lacked information to confirm staff was fit to serve prior to hire. Cross-reference F225. The facility's failure to ensure residents were protected from inappropriate sexual behavior by staff after 3/13, and failure to ensure staff was fit to serve, created a situation of immediate jeopardy for serious resident harm. The findings include: I. Imposition of Immediate Jeopardy On 8/21/13 at approximately 1:40 p.m., the nursing home administrator (NHA), the director of nursing (DON), regional nurse consultant (RNC), the outgoing regional vice president (RVP) and incoming RVP were informed by CDPHE that repeated allegations of inappropriate sexual behavior by CNA #1, the facility's knowledge of these allegations, the facility's failure to ensure residents were protected, and the facility's continued failure to ensure staff was fit to serve created a situation of immediate jeopardy. II. Facility Response and Removal of the Immediate Jeopardy On 8/22/13 at 9:00 a.m., the following plan (draft #3) was submitted by the facility to CDPHE to remove the immediate jeopardy. The plan read: 1. Currently doing a house wide employee file audit for required background checks, reference checks, abuse training and license verification. No one will work until being declared fit for duty by the outcomes of these checks. Future new hire files will be reviewed by the payroll clerk for required documents before the employee can begin providing resident care. The Administrator will sign off completed new hire files to validate that required documents are present. 2. We will continue our search for a Human Resource Manager who will focus on the aspects of employee files from hiring (onboarding) to separation, including hiring practices, disciplinary practices, training and maintenance of the employee files. The Goal is to have someone in place by September 10th, 2013. In the meantime the current HR Manager will receive training and support from the Home Office Human Resource Director who is PHR certified. 3. Home Office Director of Human Resources will develop a hiring practices process for the facility to follow by 8/23/13. 4. The Home Office has signed the facility up for a nationwide background check company (Metro data) which will include national, district, state, OIG, national sex offenders, E-Verify, license verification. 5. The Home Office Human Resource Director is currently reviewing the employees we sent through the system this week to ensure no outstanding employee issues exist. Currently the Director of Human Resources is here providing support however the VP of Clinical services or Operations Consultant will provide the ongoing support until a stable system is in place. 6. Staff who have had recent discipline in their files related to resident care issues will receive additional training and documented oversight related to the discipline. The additional oversight will continue for a maximum of 30 days or until the employee can demonstrate consistent acceptable provision of care. If the employee fails to demonstrate acceptable care provision, they will be separated from employment. The unit manager and interim DON will document progress weekly. 7. Allegations of abuse in all areas will receive direct oversight from the home office to ensure process is followed. (see attached investigation process to be implemented). Identified employees will be suspended. If an allegation of sexual abuse is made the resident will be sent to the emergency room for sexual abuse assessment and treatment immediately. 8. If the police are involved, the employee will not return to work without written documentation from the Police department that the case is closed and unfounded and/or guidance from the VP of Clinical Services or designee if the Police are not involved. 9. VP of Clinical Services will be present in the facility and be involved in abuse investigations and will review final conclusion to ensure the Facility follows the processes and systems. 10. VP of Clinical Services provided training to the Interim DON and Unit Managers on identification of injuries of unknown origin assessment and investigation requirements. 11. DON candidates have been screened and interviewed, recruitment will continue. The plan is to have the DON offer accepted by September 15, 2013. 12. Residents currently in house will have a skin assessment completed today to identify any injuries of unknown origin to include bruises, skin tears, abrasions etc. Issues that cannot be explained will be investigated to rule out abuse. If abuse is suspected required state agency notifications will be made within 24 hours and the investigation report will be filed within 5 days. 13. Abuse Training was initiated 8/15/13. Currently over 90% have received the training. Currently 100% of staff working on the floor have received this training. 14. The Home Office Compliance Officer provided training on the Resident Protection System to include abuse, investigation and reporting requirements to the Consultant staff and the Administrator on 8/16/13. 15. Licensed Nurses will receive training by VP of Clinical Services on Physical Assessment, head to toe assessment and documentation, and reporting beginning 8/22/13. Education will be completed by 8/28/13. 16. Abuse Guideline will be reviewed and revised by VP of Clinical Services on 8/21/13 to include more comprehensive guide to abuse identification. To be completed by 8/23/13. On 8/22/13 at 11:00 a.m., the facility was notified immediate jeopardy was removed; however, deficient practice remained at a G level, actual harm. III. Resident Protection System - Preventing Abuse and Neglect A. Expectations of the facility's Resident Protection System On 8/20/13 at approximately 12:23 p.m., the facility's Operations Consultant (OC) provided an Employee Guidelines packet that included a document titled, A Resource Guide for Resident Protection System (Preventing Abuse and Neglect) - A Partnership in Caring for Our Residents. The undated document read in pertinent part: 1. Statement of Commitment (pertinent part) -The facility educates all employees on resident protection processes to ensure our residents are protected from abuse or neglect upon hire and thereafter annually. -Instructions for reporting allegations of abuse and neglect are made available to all residents, visitors and staff. -Comprehensive and thorough investigations will be completed on any allegations of abuse and neglect. The facility will take immediate and appropriate actions to protect our residents. -The facility will notify any outside entities, including regulatory agencies, the ombudsman, protective services and legal investigators (e.g. police etc,) as appropriate to the situation. -The Seven key components for successfully maintaining safe environments for our residents are: screening, training, prevention, identification, investigation, protection and reporting/response. -Our facility is committed to protecting all residents who reside here from abuse and neglect. 2. CMS Federal Regulations -F223 - The resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. -F224 and F226 - Staff treatment of [REDACTED]. -F225 - The facility must not employ individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law or have a finding entered into the state nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. -Abuse can occur by various means and degrees; however the facility's immediate response is the same regardless of the nature of the suspected abuse. 3. Staff Responsibilities Employees are required to report any occurrence of potential mistreatment they observe, hear about or suspect to a supervisor, whose obligation it is to report to the Resident Protection System Coordinator (Administrator) and/or the Director of Nursing. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. 4. Identifying Abuse Any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. 5. Types of Abuse Verbal, sexual, physical, mental, involuntary seclusion, neglect, injuries of unknown origin and misappropriation of resident property. 6. Reporting An employee who witnesses abuse or crime, or receives an allegation of abuse or crime is required to report as follows; all employees must inform their immediate supervisor, supervisors must immediately inform the Resident Protection System Coordinator (Administrator) and/or Director of Nursing, the Director of Nursing must immediately inform the Administrator. 7. Definitions As defined by CMS in the States Operational Manual --Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. --Sexual Abuse: Includes but not limited to sexual harassment, sexual coercion and sexual assault. --Physical Abuse: Includes but not limited to hitting, slapping, pinching, kicking and attempts at controlling behavior through corporal punishment. --Injuries of Unknown Origins: An injury should be classified as an injury of unknown source when both of the following are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of the extent of the injury or the location of the injury, e.g., the injury was located in an area not generally vulnerable to trauma or the incidence of injuries over time. 8. Prevention Consists of maintaining systems which detect, identify, correct and prevent the occurrence of abuse .The Administrator is designated as the Resident Protection System Coordinator (RPC) and will manage and evaluate the Resident Protection System within the facility. The Administrator will ensure there is evidence that processes are in place and operationalized to prevent abuse. The RPC (Administrator) is responsible for the investigating, reporting, and coordinating of the investigation process or any alleged or suspected abuse regardless of the source of the concern. Employee education on the Resident Protection System will occur upon hire, annually thereafter and as needed. Other tools or processes that may be utilized to help identify and prevent abuse include but are not limited to: family, staff, resident interviews, clinical rounds/observations, resident record reviews, clinical and/or stand up meetings, resident council meetings, concern forms, incident reports, care line calls and grievance committee. 9. Investigation (Occurrence) Allegations of abuse and neglect will be thoroughly investigated using the occurrence investigation process. This investigation process includes but is not limited to: reporting of the allegation/occurrence/suspicion; notification of local and state authorities per regulations, establishing the facts by asking who, what, when, where, why; conduct interviews, make observations, include others that may have been affected, review information for trends and/or inconsistencies, validate information, develop a summary of findings and complete necessary facility specific as well as state required forms (when indicated). It is important that any and all allegations are reported immediately, that immediate action is taken and that the investigation process is started as soon as the allegation is received. If an employee is identified as the person who is allegedly responsible for the abuse/neglect, the employee is asked to provide a statement if this is possible and then the employee is suspended until the results of the investigation are obtained. If the staff member is unable to be interviewed immediately, the staff member is suspended and will be contacted by the RPC or lead investigator to obtain his/her statement. 10. Protection It is the facility's responsibility to protect residents, family members and staff from harm during an investigation of alleged abuse. In Staff To Resident (Reported or Suspected): Attend to the resident's immediate needs, if the accused is known and still in the facility do not leave resident alone, notify your supervisor immediately, if your supervisor does not respond immediately notify the RPC. 11. Reporting CMS Regulations require that any and all allegations of abuse, mistreatment, neglect including injuries of unknown origin and misappropriation of residents personal property be reported immediately to the Administrator (RPC) of the facility and other officials in accordance with state law. If there is not a shorter time frame requirement, CMS defines immediately to mean as soon as possible, but no more than 24 hours after discovery of the incident. When an allegation becomes known, your initial report to the Administrator, state agency and other required officials in accordance with state law must be made within 24 hours. The results of the investigation must be reported to the Administrator, State agency, and other officials in accordance with state laws within five working days of the incident, or per regulation if it is more stringent. Reasonable Suspicion of a Crime: If a staff member suspects a crime has been committed against a resident, a report must be filed with the local law enforcement agency (city police, county deputy etc,.) according to the following guidelines; serious bodily injury must be reported within two hours. A serious bodily injury is an injury involving extreme physical pain, substantial risk of death, protracted loss or impairment of function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation. No serious bodily injury must be reported within twenty-four hours. 12. Response The findings of the investigation will determine the facility's response and what actions will be taken. What the facility does in response to the outcome of the investigation is crucial to preventing further incidents. Actions taken should be appropriate to the situation and may include education, disciplinary action up to termination, resident room moves, resident schedule change and behavior management as a few examples. B. Definition of Sexual Harassment On 8/20/13 at 12:23 p.m., the facility's Operations Consultant (OC) provided an Employee Guidelines packet. On page 3 Section 2, it read (in pertinent part): Definition of Sexual Harassment: For the purpose of this policy, sexual harassment is defined as: Unwelcome sexual advances, requests for sexual favors, sexual jokes or inferences and other verbal or physical conduct of a sexual nature when. Examples of sexual harassment may include but are not limited to: unwanted sexual advances, demands for sexual favors in exchange for favorable treatment or continued employment, repeated sexual jokes, flirtations, advances or propositions, verbal abuse of a sexual nature, graphic or verbal commentary about an individual's body, sexual prowess or sexual deficiencies, leering, [MEDICATION NAME], touching, pinching, assault, coerced sexual acts or suggestive insulting, obscene comments or gestures, and displays in the workplace of sexually suggestive objects or pictures. IV. Failure to Protect Residents from Sexual Abuse A. CNA #1 1. Review of CNA #1's file revealed the CNA was hired by the facility in January of 2013 (1/10/13) as a certified nurse aide. He generally worked the evening shift and always worked on the restorative unit. -CNA #1's file contained a printed document titled National Sex Offender Search. The results showed the search included all states, territories and Indian Country for the first and last name like the name of CNA #1, and that two records were located. -A handwritten note at the top of the form read, Not our applicant. There was no additional information found in the file to show how the facility determined neither of the two records found were CNA #1. On 8/20/13 at 9:25 a.m., the Nursing Home Administrator (NHA) stated he did not know how Human Resources (HR) had determined according to the National Sex Offender Search that CNA #1 was not the individual the facility had hired. 2. Review of facility incident/investigation reports revealed the facility documented four allegations of inappropriate sexual behavior by CNA #1 toward facility residents 3/13, 5/13, 7/13 and 8/13. See details below. 3. Review of facility staff records, incident investigations, disciplinary actions and interview with VPSC on 8/26/13 at 3:26 p.m. revealed: -Documentation of disciplinary action against CNA #1, an oral reprimand, dated 3/26/13 following an allegation on 3/26/13 involving resident #28. The CNA was not suspended. See further details below. -Suspension of CNA #1 on part of 5/18/13 and all of 5/19/13, following an allegation on 5/18/13 involving resident #27. CNA #1 was paid for the suspension time and upon his return, continued to work on the same unit (restorative). No disciplinary action was taken. See further details below. -No documentation of disciplinary action following allegation 7/13/13 involving resident #4. However, file review showed a Time off Request form documented the CNA was suspended 7/23, 7/24, 7/26, 7/27, 7/29, 7/30, and 7/31/13 pending an investigation. See further details below. 4. On 8/19/13, the CDPHE received a complaint that the facility failed to keep resident #7 free from employee to resident sexual abuse. Specifically, on 8/15/13, the resident informed a CNA during her shower, that she had been sexually assaulted by CNA #1 the night before. On 8/21/13 at 12:20 p.m., the police detective on the case was interviewed in person at the facility. He stated CNA #1 was contacted by police on 8/15/13 and taken into custody (jail), where he currently resides, after he confessed to sexual assault of resident #7 and a previous assault of resident #4. The police detective stated he had asked the previous NHA why CNA #1 was not pulled off the working schedule and the floor since there was still the active investigation going on. The detective stated this had been an active case since 7/19/13. B. Inappropriate Sexual Behavior by CNA #1 1. Resident #7 - Allegation 8/14/13 Resident #7, a [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Primary [DIAGNOSES REDACTED]. a. Resident Status Review of the most recent (admission) minimum data assessment (MDS), dated [DATE], revealed the resident scored a 10 out of 15 on the brief interview for mental status (BIMS); indicating some cognitive impairment. She exhibited no behaviors. She required extensive assistance of one staff with mobility and transfers on and off the toilet. b. Documented Rape Allegation Review of facility documentation revealed statements from staff related to the 8/14/13 allegation. -The CNA who provided resident #7 a shower the day after the incident on 8/15/13 around 9:00 a.m., reported that during the shower, the resident exhibited a facial expression. At that time the CNA asked the resident if everything was okay. The resident initially responded everything was okay, however, when the CNA noted her facial expression did not change the CNA repeated the question. The resident then responded that she had been raped the night before. -At 10:41 a.m., a head to toe assessment was completed by the unit manager registered nurse (RN). Documentation showed the resident's Skin warm, dry and intact to entire torso, no bruising, red marks, or open areas noted to chest, back, posterior and anterior thighs, several areas of faded greenish/yellow areas to lower abdomen noted, skin intact, non tender. As I touched the resident's back, resident stated, 'That's where he put the board up against me, so he wouldn't leave any finger prints or marks, right around the kidney area.' No redness, no scratches, no discoloration or open areas noted, no evidence of pain when palpated, no flinching, peri area clean, no evidence of bleeding. Patient denies pain or discomfort. -At 1:45 p.m., Patient transferred to (name) hospital for a SANE (examination by a sexual assault nurse examiner) via ambulance accompanied by 2 EMTs. MD notified, family notified by case worker. Police present prior to transfer. -At 11:43 p.m., notes documented, Resident returned from hospital at 7:00 p.m. Resident was transferred to decliner (sic) with 1 assist. This nurse checked in on her and resident denied any pain or discomfort. Resident was offered a snack and it was accepted. Resident has been resting comfortable for the duration of this shift. c. Hospital Records Review of the emergency department report documented the patient claims she was sexually assaulted by worker last night at facility. The patient is claiming that sometime last night, a male staff member, raped her with a board. The patient allegedly complained of some back pain earlier, this time denies any back pain. The physical examination documented, in part, the patient was alert and oriented x 2. There was no obvious external trauma and no outward signs of physical trauma; will await sexual assault nurse evaluation. Further record review revealed the resident signed the consent forms for examination. SANE Examination Results: Mental Status was cooperative and calm, alert and oriented x 4. Date and time of the assault was 8/14/13 about 11:00 p.m., inside the resident's bathroom off her own room. The resident's description was, I was sitting on the commode and he helped me to get up which was not out of the ordinary. And then suddenly as I am grabbing ahold of the stand up bar, he kind of gave me a kick in the back and then, how shall I say this correctly, he pushed me up against the wall and the grab bar and very quickly he had something in his hand and he forced it against my back. He kept pushing (patient motions with her hands a pushing motion) this tool that he had into my back. (SANE nurse clarifies by asking patient to point to what she means by back and patient points to lower back.) SANE nurse asks if he put this tool into her butt or her vagina? Patient reports, well the end of it might have gone in my hynie. SANE nurse asked to clarify what hynie is, 'my rump'. SANE nurse asks if anything went into her vagina, 'no but happened so fast I guess I have to say no. It appeared he was attacking my rearend. Regarding evidence of digital penetration, unknown, although resident stated he might of when he used the tool. Regarding use of a foreign body, lower back and my rump, pushing. I determined the tool was like a board. Body Surface Examination revealed the resident had lower back bruising where she reported being pushed with tool. Review of the female body diagram showed documented bruising to the lower back a 2 x 2 centimeter blue bruise, purple and blue bruising to bilateral shins, to bilateral forearms, and multiple red, purple bruises across the abdomen. The summary of the assessment documented, Tool pushed into patient's lower back and possibly 'in my hynie;' no genital trauma noted. Bruise to lower back above buttocks present. On 8/15/13 at 7:15 p.m., the resident was transported back to the facility. d. Observations and Interviews On 8/21/13 at 10:30 a.m., the unit manager registered nurse (RN) who completed the head to toe assessment for resident #7 on 8/15/13 was interviewed. -She stated she remembered some old bruising on the resident's abdomen; yellow green in color. She did not see any bruises to the resident's back after the resident claimed a board was placed up against her back. She complained of no pain although she described the area on her where the board was placed. The RN reiterated there were no red areas to her back, however, her assessment focused on the resident's [MEDICATION NAME] area. -She said, I have to believe what the patient tells me. Cognitively, resident #7 has some short-term memory (problems) but she's very lucid. She said that following the assault, the resident was moved to a different room. She felt the resident was doing well, however, the resident stated to her, 'I don't know if I want to go into that bathroom again.' -The RN was unable to explain how her assessment revealed no bruising to the resident's lower back, legs and arms when the SANE examination identified the bruising (except for the abdominal area.) On 8/21/13 at 11:45 a.m., resident #7 was observed seated in a wheelchair in her room. During an interview at the time she said she may be okay talking, however, then stated, I have been questioned so much, when is it going to end? It keeps popping up in my mind and I've accepted it, but it will probably never go away. e. Record Review On 8/12/13, prior to resident #7's assault, the facility had received a letter from the local police department stating their investigation of CNA #1's (previous) sexual assault of another facility resident (see below, involving resident #4's allegation) was still open. The letter instructed the facility to not let CNA #1 know of the request. Even though the facility was informed the sexual assault investigation of CNA #1 was open and ongoing, the facility continued to allow CNA #1 to provide direct care staff to residents residing on the restorative unit. The facility's failure to protect the residents resulted in the assault of resident #7. C. Previous Allegations of Inappropriate Sexual Behavior by CNA #1 - Facility Failure to Implement Resident Protection System to Ensure Resident Safety. Record review and interviews revealed the facility became aware of allegations of inappropriate sexual behavior toward residents by CNA #1 in 3/13. The facility repeatedly failed to respond in a manner to ensure residents were protected from further incidents of inappropriate sexual behavior by staff. 1. Resident #28 - Allegation 3/26/13 Resident #28's clinical record was reviewed on 8/24/13 at 9:00 a.m. Resident #28, age 86, was admitted to the facility on [DATE]. She was readmitted on [DATE]. The face sheet documented the resident [DIAGNOSES REDACTED]. a. Resident Status The MDS Significant Change dated 8/4/13 documented the resident had a BIMS (cognition) score of 01 indicating severe impairment. The resident required extensive assistance from staff (one person physical assist) for bed mobility, transfers, dressing, toileting and personal hygiene. The resident also required physical help in part of bathing activity. Physician orders [REDACTED]. The Care Plan (CP) dated 9/5/13 (goal time) documented the resident had a problem with self care deficit needs related to lack of motivation, Alzheimer's/Dementia and disease progression. The Approaches Section (AS) documented the Certified Nurse Aide (CNA) was to assist the resident with activities of daily living (ADLs), oral hygiene, grooming, bathing, toileting, transfers, repositioning and encourage rest periods. The AS also documented the resident required extensive assistance for bed mobility, transfers and toileting. The AS further documented the CNA should introduce self, their role, draw on old memory/connections and do not argue or quiz. The Care Plan (CP) dated 11/7/13 (goal time) documented the resident had short-term memory impairment and needs assistance with decision-making due to Alzheimer's/dementia manifested by lack of verbalization (slow to find words). The Approaches Section (AS) documented the Certified Nurse Aide (CNA) was to redirect/reorient resident when needed, speak slowly/clearly, give resident time to respond, praise accomplishments, offer conversation, allow resident to set pace, explain procedures/cares when provided and provide one-to-one with resident. The CP also documented to demonstrate tasks slowly, encourage expression of feelings, offer verbal/non-verbal cues, and administer [MEDICATION NAME] for dementia as physician ordered. b. Investigation form 3/26/13 On 3/26/13 an Investigation form was completed with resident #28 by Social Services (SS). -The resident was documented as having stated CNA #1 comes and kisses me all the time on the mouth: the resident was documented as (stating) it's alright. -The SS employee asked the resident were the kisses romantic and the resident replied no. -The SS employee asked the resident were the kisses more like a motherly kiss and she replied yes. -The SS employee asked do you feel safe here uh hu. -The SS employee asked has it happened with anyone else no just my daughter. -The SS employee asked has he done anything other than kiss you, no. -There were eight separate residents interviewed per documentation provided and none had been kissed or received/perceived inappropriate attentions from staff members. c. Facility Response to 3/26/13 Allegation (1) Record Review On 8/22/13 at 4:02 p.m., the NHA provided a copy of a First Offense - Oral Reprimand dated 3/26/13. The Violation documented actions meant in kindness were perceived as romantic by resident. -The box NO was checked in the section of the form which detailed had this concern/violation been previously discussed with this employee. -The Violation Summation documented the resident stated to staff Named Individual kisses me on the lips every night. The resident did not feel the kisses were romantic in any way - more of motherly. -Expected Level of Performance documented as a staff member it is never OK to kiss residents. This may come off as abuse. -The Plan of Correction was education/counseling. -The Employee Comments documented I (named) understand my [MEDICATION NAME] for the resident may be perceived differently and my actions were not romantically. -The form was signed by CNA #1, a witness, a supervisor and a department manager. The form was not signed by the NHA. (2) Interview On 8/26/13 at 11:48 a.m., the current NHA stated he was the Guardian

Based on record review and staff interview, the facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Specifically, 1. One of five recently-hired employees did not have any references checked, and 2. One of five recently-hired employees did not demonstrate abuse training. The findings include: 1. Facility Policy: Review of the undated "Resident Protection System" showed the following: "The 7 key components for successfully maintaining a safe environment for our residents are screening, training, prevention, identification, investigation, protection, and reporting/response." The system went on to show "Every prospective employee is screened for a history of abuse, neglect or misappropriation of resident property prior to being hired. This is accomplished through several methods: Criminal background checks, State licensing boards and registries and previous and current employers." Under training was the following: "Employees will receive abuse prevention and reporting education on following the 7 key components upon hire, annually, and thereafter as needed." 2. Failures: Review of recently hired employee files was conducted 6/24/13 at 1:15 p.m. Five new employees were chosen for review. -Two of five files were found lacking in required elements: a. One file for a Registered Nurse showed no evidence of attempt(s) to contact previous employers for references prior to her start date of 3/20/13. The potential employee had completed information on a reference check form, but there was no information written on the form where the Hiring Manager was to document the contact. b. One file for a Housekeeper failed to show conclusive evidence of abuse training prior to or on her start date of 5/12/13. The employee had worked in the facility prior to this time. The only evidence of abuse training was an abuse in-service post-test dated 11/2/11. 3. Interviews: -In interview on 6/24/13 at approximately 1:15 p.m., the Director of Human Resources said she was in her position for approximately two months. She confirmed there should be written evidence of reference checks, including the date of contact. (Provided during survey) A mandatory all-staff meeting was conducted 5/1/13. The newly rehired housekeeper had not been hired at that time. There was no evidence of any individualized training for this newly-hired employee when she resumed employment with the facility. -In interview on 6/24/13 at approximately 1:15 p.m., the Housekeeping Director provided a sign-in sheet of an employee training attended by this employment during her previous period of employment, but there was no evidence the employee received any abuse training after 11/2/11 or with the recent re-hire to the facility.

Based on family interview, staff interviews and record review, the facility failed to assess and timely manage pain for one (resident #61) of 56 sample residents. Specifically, -The facility failed to assess, monitor and adequately treat resident #61's immediate pain while she remained in the facility for two and a half to three hours after an un-witnessed fall with [MEDICAL CONDITION]. -The facility failed to have a Registered Nurse (RN) complete an assessment of resident #61 prior to moving her after the resident reported a fall with injury. The findings include: -Facility Policy: In pertinent part, the facility "Assessing Falls and Their Causes" section of the "Falls and Fall Risk" unit of the facility "Nursing Services Policy and Procedure Manual" revised October 2012 stated: "After a fall ...Once nursing staff rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying or standing position and then document relevant details." "After a fall ...Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings." 1. Resident #61, age [AGE] years, was admitted to the facility on [DATE], re-admitted to the facility on [DATE] and 5/27/13. According to the June 2013 Computerized physician's orders [REDACTED].#61's [DIAGNOSES REDACTED]. According to the 4/25/13 quarterly Minimum Data Set (MDS), resident #61 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status score of 11/15. Resident #61 reported experiencing severe pain almost constantly that made it hard for her to sleep at night. The pain did not limit her ability to conduct daily activities. The resident had not received routine or as needed pain medication during the MDS evaluation period. 2. Family Interview regarding the events after being notified of the "alleged fall": On 6/18/13 at 12:15 p.m., a family member that visited resident #61 at the facility frequently was interviewed about a fall that occurred on 5/24/13. The interview with the family member revealed the following: -The family member stated that resident #61 had an un-witnessed fall resulting in a fracture to the hip. -The family member stated the resident was moved into bed after the fall. -The family member stated s/he visited the resident in the facility after being notified of the fall and found resident #61 to be in pain. -The family member was unhappy that resident #61 was made to wait, in pain, while the facility attempted to reach the physician, who was in the building. -The family member expressed dissatisfaction at having resident #61 in "agony" for at least two hours while the facility waited to obtain an x-ray; permission to give a narcotic pain medication to treat the pain from the resident's broken hip; and permission to send the resident out to the hospital. -The family member stated the resident was given Aleve, an over-the-counter pain medication, to treat the pain from a broken hip and the resident remained in pain. -The family member stated resident was eventually seen by the doctor in the facility and was only then given narcotic pain medication. -The family member stated the resident was sent to the hospital by sometime before 3:00 p.m., which was more than two and a half hours after the fall with fracture. -The family member expressed he/she was upset that resident #61 was not sent out to the hospital until the physician had confirmation of the [MEDICAL CONDITION] in the form of X-ray results. 3. On 6/21/13 a review of resident #61's clinical record was conducted. The review revealed the following: An alleged fall or event occurred on 5/24/13 around 11:45 a.m. The resident reported immediate hip pain. The resident [MEDICATION NAME] 1:00 p.m., one hour after the event. -Nurse's Note dated 5/24/13 at 2:01 p.m., written by the Unit Manager (UM), who was a Licensed Practical Nurse (LPN), stated, in pertinent part, that a call had been placed to the physician for authorization to medicate the resident with an alternate pain reliever. The resident was noted to have been medicated with Tylenol [MEDICATION NAME](see below - Tylenol not signed out as given on the medication records). The note stated that resident #61 was complaining of hip pain. The resident was "yelling out in pain" when gentle range of motion was initiated. The left foot was noted to be externally rotated. The note documented that resident #61's son was notified of the fall and was "upset" that his mother had not yet been seen by the physician. - Nurse's Note dated 5/24/13 at 2:03 p.m., written by the LPN that usually served as the weekday day-shift charge nurse for resident #61 stated that resident #61 experienced an un-witnessed fall in the bathroom at approximately 11:45 a.m. Resident #61 experienced left hip pain of a 6/10 and a change in range of motion after the fall. No additional pain assessments after the fall and before the resident left for the hospital were identified in the nurse's notes. -Nurse's Note written by the UM dated 5/24/13 and timed at 2:32 p.m., stated that resident #61 was seen by the physician. The physician gave permission to send resident #61 to the emergency room to treat a possible left [MEDICAL CONDITION]. The note documented that the physician gave permission to medicate resident #61 with [MEDICATION NAME] (used for mild to moderate pain). No assessment of the resident's pain level was noted. -Nurse's Note written by the LPN charge nurse on 5/24/13 at 3:19 p.m., showed, in pertinent part, that resident #61 received one tablet of [MEDICATION NAME], with good effect, before being sent to the emergency room for evaluation and treatment of [REDACTED]. No notation of the pain level prior to or after the administration of the [MEDICATION NAME] was present in the note. -The pain scale charting for resident #61 on 5/24/13 showed the resident was assessed for pain at 12:56 a.m., and at 9:32 a.m. In both instances the resident was "0- no pain." No pain scale charting of the resident post-fall were identified in the pain scale records. 4. According to the 5/2013 Medication administration record (MAR), resident #61's pain management regimen was: --[MEDICATION NAME] 60 mg by mouth each morning. Resident #61 received this medication at 9:32 a.m. on 5/24/13. --Aspercreme applied topically to the right knee twice daily in the morning and afternoon. Resident #61 was documented to have received this medication on 5/24/13. --Tylenol 650 mg by mouth every four hours as needed for pain. Resident #61 did not receive Tylenol on 5/24/13 according to the MAR. --Aleve 220 mg by mouth as needed twice daily for pain. Resident #61 received one dose [MEDICATION NAME] 1:00 p.m., according to the MAR. The efficacy of [MEDICATION NAME] not documented on the MAR, the pain scale, or the nurse's notes. --The MAR did not demonstrate that [MEDICATION NAME] or a similar pain reliever was administered to resident #61 on 5/24/13. 5. On 6/24/13, additional review of the resident #61's clinical record was conducted. The additional review revealed: -An untimed physician's orders [REDACTED]. -The Final X-ray Report dated 5/24/13 and timed, per the fax line, at 2:33 p.m., showed that resident #61 experienced a "communicated left proximal intertrochanteric femoral fracture." The stated reason for the x-ray was "pain." -The 5/24/13 hospital admission records showed resident #61 was admitted to the hospital on [DATE] at 5:16 p.m., for surgical repair of a [MEDICAL CONDITION] femoral neck. The resident was noted to have achieved acceptable pain management from the [MEDICATION NAME] (for moderate to severe pain) administered in the emergency room . 6. Failures: -The clinical record contained no evidence that resident #61 received an assessment of her hip pain by an RN prior to the transfer from the wheelchair to bed. Correspondence with the Scope of Practice Specialist at the Colorado State Board of Nursing revealed: The Colorado Nurse Practice Act (NPA) CRS 12-38-103 (9)(a)(b) defines the Practice of Practical Nursing as ..."the performance, under the supervision of a dentist, physician, podiatrist, or professional nurse authorized to practice in this state, of those services requiring the education, training, and experience, as evidenced by knowledge, abilities, and skills required in this article for (licensure)..." Those services are "(I) Caring for the ill, injured, or infirm; (II) Teaching and promoting preventive health measures; (III) Acting to safeguard life and health; or (IV) Administering treatments and medications prescribed by: (A) A legally authorized dentist, podiatrist, or physician; or (B) Physician assistant implementing a medical plan pursuant to subsection (4) of this section. (b) "Practice of practical nursing" includes the performance of delegated medical functions." The definition does not include performing nursing assessments. Therefore, the performing nursing assessment is outside the LPN scope of practice. -The clinical record showed no evidence of resident #61 having been assessed by an RN in the interceding time between the fall at 11:45 a.m., and approximately 2:00 p.m., when the physician arrived to assess resident #61. 7. Staff Interviews: On 6/24/13 at 11:47 a.m., the LPN that served as the charge nurse for the unit where resident #61 resided was interviewed. The interview revealed the following: - LPN stated she was working as the charge nurse when resident #61 experienced the fall on 5/24/13. -The LPN stated the resident was found alone in the bathroom, in her wheelchair, calling out and complaining of left hip/leg pain around 11:45 a.m. -The LPN stated she had resident #61 placed in bed. The LPN denied having a Registered Nurse (RN) assess the resident prior to the transfer to bed. -The LPN stated she could not recall having either the charge nurse from the other unit, who was an RN or the Director of Nursing (DON) assess the resident on 5/24. -The LPN stated she attempted an assessment of the resident once in bed. The LPN noted the resident's foot had been turned a weird way. The LPN stated the resident tried to hit her when a range of motion examination was attempted (staff was attempting to move the leg). -The LPN stated she left the resident to call the physician to obtain orders for pain medication and an x-ray. The LPN stated she was having difficulty getting a call back from either the physician or the nurse practitioner. The LPN stated she had not been aware that the physician was in the building. -The LPN stated she notified the resident's son, who arrived shortly after the notification. The LPN stated the son was very angry that resident #61 was in pain and was without more potent pain relief. The LPN stated she only [MEDICATION NAME] until the physician approved the use of one tablet of [MEDICATION NAME] from the emergency kit. -The LPN stated the UM, who was also an LPN, was notified of the fall. -The LPN acknowledged that the administration of the one tablet of [MEDICATION NAME] was not documented on the MAR, though it should have been. -The LPN acknowledged that there was only one documented pain assessment completed at 11:45 a.m. The resident was transferred out of the facility by ambulance sometime around or after 2:30 p.m. On 6/24/13 at 12:16 p.m., the RN that usually worked the day shift on the other unit of the floor where resident #61 resided was interviewed. The RN stated she was working on the day when resident #61 fell and broke her hip. The RN denied assessing the resident after the un-witnessed fall in the bathroom. On 6/24/13 at 3:11 p.m., the UM for the unit where resident #61 resides was interviewed about the un-witnessed fall and respective follow up on 5/24/13. The interview with the UM revealed the following: -The UM reported she was not notified of the fall until after lunch, which she estimated to be sometime between 1:30 p.m. and 2:00 p.m. -The UM stated she would have expected earlier notification of the fall with possible injury. The UM stated she wanted to be notified of such a fall immediately. -The UM stated at the time she was notified of the fall, resident #61 still required physician orders [REDACTED]. The UM stated floor staff had been calling resident #61's physician and were unaware the physician was elsewhere in the building making rounds. -The UM reviewed the clinical record for resident #61 and pointed to the nurse's note that indicated resident #61 had received Tylenol [MEDICATION NAME] pain. The UM acknowledged that only [MEDICATION NAME] present on the MAR and was documented as being given at 1:00 p.m. -The UM stated that she assessed resident #61 and observed that her left foot was externally rotated. The UM stated that the appearance of resident #61's foot position in bed indicated the presence of a [MEDICAL CONDITION]. The UM stated that resident #61 would not allow a range of motion check of the injured left leg. -The UM stated she went to find the resident's physician and bring her to see resident #61 because she knew the physician was making rounds in the building on a different floor. -The UM was stated that resident #61's pain should have been monitored no less than every 20 minutes during the time she remained at the facility. The UM reviewed the pain documentation and found that resident #61 had one instance of pain documentation, in nursing notes, during the time in building post fall. The UM stated that if the pain monitoring was not documented, then it was not done. -The UM stated that she believed resident #61 received [MEDICATION NAME] before being sent to the hospital. The UM acknowledged the MAR did not demonstrate administration of any narcotic pain reliever prior to the resident's being sent to the hospital. The UM pointed to a nurse's note that showed the resident received [MEDICATION NAME] before going to the hospital. -The UM stated she did not know if an RN had assessed resident #61 prior to the physician being located in the building. -The UM stated that it was her preference for a resident with a suspected fracture to be sent out to the hospital for treatment within the hour of the injury. On 6/24/13 at 4:51 p.m., the Director of Nursing (DON) was interviewed in the presence of another nurse who was present to assist the DON with record review in the electronic records system. The interview revealed the following: -The DON denied assessing resident #61 after her fall. -The DON and the nurse assisting with records each stated the resident assessment must be completed by an RN because the assessment was not within the LPN scope of practice. -The DON stated an RN should have assessed resident #61 before the resident was moved. The DON stated any RN assessing the patient should have documented the assessment in the clinical record. -The nurse assisting with record review stated she was unable to locate documentation in the clinical record of an RN assessing resident #61 after the fall. -The nurse assisting with record look-up, who was an LPN and UM in another part of the facility, stated that during the day shift many RNs are available to assist an LPN with assessment. -The DON stated that she would have expected the UM and the charge nurse to observe the patient after the fall and document their respective observations. -The DON stated it was her personal practice, and not company policy, to assess residents for pain after a fall every 30 minutes to an hour and to write the assessment down for the purpose of communication. -The DON and the nurse assisting with record review stated that there was no pain scale documentation for resident #61 after the fall. -The nurse assisting with record review stated she was unable to determine the time the [MEDICATION NAME] was given because it was not documented on the MAR. -The DON stated they could check the emergency kit to determine when the medication was removed. A copy of the documentation of pharmacy authorization to remove the [MEDICATION NAME] from the emergency kit was requested during this interview. The pharmacy documentation was not furnished prior to survey exit or during the grace period following survey exit.

Based on record review and interview, the facility failed to ensure two (#9, #5) of 39 residents received the care and services necessary to attain or maintain their highest practicable level of well being. Specifically: -Resident #9 experienced low blood oxygen levels on [DATE]. When attempts to increase the oxygen levels were unsuccessful, staff failed to timely communicate with the in-house physician for further evaluation and treatment. This resulted in an untimely transfer to the hospital for the resident who was in respiratory distress. -Resident #5 experienced low blood oxygen levels on [DATE]. When attempts to increase the oxygen levels were unsuccessful, she was not transported to the hospital in a timely manner. The findings include: A. Professional Reference According to K Lawrence, MSN, RNBC (Clinical Educator II Educational Resource Center) and S Simpson Johnson (BS, RRT Manager, [MEDICAL CONDITION] Care Services), Measuring Oxygen Saturation, <http://www.favoriteplus.com/oxygen-saturation.php>: "A saturation of 97% of the total amount of hemoglobin in the body is filled with oxygen molecules. A range of 96% to 100% is generally considered normal. Anything below 90% could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (,[DATE]%) and [MEDICAL CONDITION] (usually ,[DATE]%) is narrow. If oxyhemoglobin is low (below 90%) inadequate amounts of oxygen will reach body cells." B. Resident Failures 1. Resident #9, a [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The [DATE] quarterly Minimum Data Set showed the resident was cognitively intact. She received oxygen therapy. a. Resident Status Review of the resident's care plans revealed care plans addressing the resident's respiratory needs. (1) The impaired gas exchange care plan, updated on [DATE], showed the resident had a potential for impaired gas exchange related to resident refusal to wear Bi-pap manifested by fatigue and dyspnea. Approaches included: --Assist deep breathing --Administer medications as ordered --Observe for side effects and effectiveness --Assess [MEDICAL CONDITION] status --Monitor vital signs (2) The ineffective breathing pattern care plan dated [DATE] showed the resident had an ineffective breathing pattern related to [MEDICAL CONDITIONS] and manifested by shortness of breath and anxiety. Approaches included: --Assess respiratory status --Assess breath sounds --Position to facilitate breathing and comfort --Administer oxygen as ordered --Assist with using respiratory devices as ordered --Record oxygen saturation every shift --Oxygen on at all times Review of the resident's [DATE] computerized physician orders [REDACTED]. -[MEDICATION NAME] (opioid [MEDICATION NAME]) 7XXX,[DATE] milligrams, two tabs three times daily and [MEDICATION NAME] (opiod [MEDICATION NAME]) 5 milligrams, two tabs every two hours as needed. -Continuous oxygen per nasal cannula at 3 liters per minute (start date [DATE]). -Monitor oxygen saturation every shift (start date [DATE]). The [DATE] nursing progress notes were reviewed and revealed the resident's oxygen saturation was recorded, per shift, as follows: --[DATE]: 97%, 93%, 93% --[DATE]: 97%, 96% --[DATE]: 94%, 93%, 92% --[DATE]: 96%, 94%, 94% --[DATE]: 96%, 95%, 96% --[DATE]: 94%, 96%, 95% --[DATE]: 92%, 95%, 94% --[DATE]: 92%, 96% No progress notes regarding a drop in the resident's oxygen saturation, respiratory distress, or labored breathing were documented on these dates. b. Change of Condition [DATE] Review of the nursing progress notes for [DATE] (written after midnight on [DATE] for events [DATE] but not identified as a late entry), physician orders [REDACTED].[REDACTED] At 12:32 a.m., the resident had received a nebulizer treatment at 3:30 p.m. At that time, there were no signs or symptoms of distress but the resident's voice sounded "nasaly." At 6:30 p.m., the resident placed a call to the nurse's station requesting that her air conditioner be turned off because she was cold. The nurse went into the resident's room and found the resident with labored breathing and a "pasty" appearance. The resident's oxygen saturation was taken and measured 73%. The nurse increased the resident's oxygen and contacted her supervisor. The supervisor came and assessed the resident. The supervisor then called the in-house physician who gave an order for [REDACTED]. According to drugs.com, [MEDICATION NAME] is a medication designed to reverse the effects of opioids including respiratory depression. Onset of action is generally apparent within two minutes when given IV; onset of action is slightly less rapid when it is administered IM. Following the administration of [MEDICATION NAME], the resident's oxygen saturation continued to drop and remained in the 70's. The nurse documented she then contacted the in-house physician and he came up to the unit to assess. Cylinder oxygen with a non-rebreather mask (which supplies a higher concentration of oxygen than a nasal cannula) was applied to the resident. With the non-rebreather mask applied, the resident's oxygen saturation increased to 90%, but she continued to not look well and be in distress. The in-house physician contacted the resident's daughter and an untimed order was written, "Transfer to ER (emergency room ), DX (diagnosis) respiratory distress." The nursing progress note read the decision to send the resident to the hospital was at approximately 9120 (such a time does not exist). However, review of the paramedic call sheet for [DATE] showed emergency medical services were contacted at 8:53 p.m. due to respiratory distress. c. Hospital Records The [DATE] emergency room record was reviewed and documented, in pertinent part: "(Resident) is a [AGE] year-old female who presents with acute respiratory distress from a skilled nursing facility. ... I received a call from a physician who treats her provided some information that she has been having difficulty breathing progressively worsening over the last several days. In that he noted pulse oxygenation in the 70s at the skilled nursing facility. Review of systems is largely unable to be obtained due to the respiratory distress ... This is an elderly obese lady who is a DNR (do not resuscitate) and DNI (do not intubate) and a right lower lobe pneumonia and some respiratory distress ...Final impression: pneumonia." The resident was admitted to the hospital due to her pneumonia. She expired at the hospital on [DATE]. Her cause of death was end-stage [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]. d. Staff Interview - Failure to timely communicate with physician for further evaluation and treatment On [DATE] at 12:12 p.m., the in-house physician and the resident's primary care provider (PCP) was interviewed about the evening the resident was hospitalized . He said, "She was in acute respiratory distress. When I first got called that she wasn't looking too good and was hypoxic, I asked them to increase her oxygen. She was on a lot of narcotics so we pushed the [MEDICATION NAME]. I was busy with something else and wasn't able to get there immediately. The nurse told me they were going to get (the nursing supervisors). I eventually got there and (the nursing supervisor) said she's not looking good. She's was definitely hypoxic and we put a non-rebreather on her and I called the family and said we really need to send her to the hospital." The PCP was unsure of what time the resident was sent out to the hospital. On [DATE] at 2:54 p.m., the nursing supervisor RN (NS) who worked the night the resident was hospitalized was interviewed. She said: -"I worked the night that they sent her out. They said she didn't look good and was having respiratory difficulty. I went up and looked at her and took her pulse ox. I called the doc and we gave her some [MEDICATION NAME]." She said even after the [MEDICATION NAME] was administered, the resident's oxygen saturation remained in the 70s. The NS said she believed the effects of [MEDICATION NAME] could be seen within 15 minutes. -She stated the PCP came up and an order was made to send the resident to the hospital because, "She just didn't look right and was having respiratory difficulty." -The NS said she was not sure what time the resident was sent out to the hospital. On [DATE] at 6:00 p.m., the LPN who was working the evening the resident was sent to the hospital was interviewed. She said: -"I had gone in there after dinner and she was struggling. Her pulse ox was in the 70s. I elevated her head and the supervisor came down. She had me call the doctor and he ordered to give her [MEDICATION NAME]." She said, "I've never given ([MEDICATION NAME]) before so I'm unsure of how long it takes. We gave it to her and she continued to desat. We put her on high flow oxygen and a non-rebreather mask. She came up to ,[DATE] but her look was off. She was very pasty and her eyes were rolling back. The doctor said to send her out." The LPN reviewed the documentation and said "At 8:53 p.m. the call was made and it was 2120 (9:20 p.m.) when she left." On [DATE] at 9:41 p.m., the PCP was again interviewed. He stated [MEDICATION NAME] takes between ten to 15 minutes to act. He said he was not notified the [MEDICATION NAME] did not work and improve the resident's breathing and oxygen saturation. He said, "If I would have been notified I would have moved a little faster. I was really busy that day and would have liked to be notified. They should have called me and said it did not work. -After not receiving an update, I got worried so I called (the nurse supervisor) to ask for the status of the patient. She said she was not looking good and I just moved. We got her on the non-rebreather mask and I called (the resident's daughter) and told her that she's not looking good and we need to get her to the hospital now. -The PCP said he believed there was a delay in sending the resident to the hospital. He said, "I think it's a huge system based error and we definitely need to work on response times." On [DATE] at 10:15 a.m., the interim director of nursing (IDON) said, "When someone can't breathe, that's an immediate concern. When the [MEDICATION NAME] didn't work, they should have notified the physician right away. She said the resident's respiratory distress [MEDICATION NAME] over two hours was a "long time". 2. Resident #5, an [AGE] year old female, was admitted to the facility on [DATE]. According to the facility admission record, her [DIAGNOSES REDACTED]. a. Resident Status According to the MDS (minimum Data Set), dated [DATE], the resident required extensive assist of one person for bed mobility, dressing, toilet use and personal hygiene and extensive assist of two for transfers. She was rarely to never understood. The resident did not have an order for [REDACTED]. b. Change of Condition [DATE] Review of the nursing progress note dated [DATE] at 4:10 a.m. revealed: At 11:15 p.m. (on [DATE]) the resident began rolling her head back and forth saying, "oh oh." The resident had oxygen but her oxygen saturation (PO2) was 70%. Increased oxygen flow to 3.5 liter per minute (LPM) and PO2 increased to 74% but then dropped to 67%. Resident placed on a rebreather mask and PO2 went to 60 76%. It appeared that the resident was mottling around the groin area and some around the knees and finger tips. The family was called to ask about sending the resident to the ER and which hospital they preferred. The physician was contacted and an order was received to transport the resident to the ER for respiratory distress. 911 called to transport resident quickly to ER. Resident transported at 12:17 a.m. Review of a telephone order (TO) dated [DATE] revealed an order to send the resident to the emergency room (ER). There was no time written on the TO. c. Staff Interviews - Failure to promptly transfer resident On [DATE] at 3:50 p.m., the medical director was interviewed. He said the nurses at the facility have been empowered to call 911 for residents anytime they feel it is necessary. On [DATE] at 10:16 a.m., the interim director of nursing (IDON) was interviewed. She indicated having to wait an hour was a long time when you can't breathe. She indicated that if someone can't breathe it should not take more than 30 to 45 minutes at the most to get them sent out. She indicated that she was unsure why the family had to be contacted regarding the choice of hospital prior to calling the doctor and getting an order to transport. She indicated that the nurse can call 911 and send resident to the hospital anytime they feel like they need too. On [DATE] at 2:35 p.m., the registered nurse (RN) who wrote the progress note above was interviewed. -She said after assessing resident #5, the house supervisor had come up to help her. She said the resident seemed to be having a hard time breathing. She confirmed that an hour was a long time to wait for treatment when you can't breathe. -She said that they had to get all the paperwork for transport completed before she called 911. She indicated that the delay probably came in doing the paperwork. She said that they probably should have just called 911.

Based on observations, interviews and record reviews, the facility failed to promote an environment that was free from accident hazards for two of 56 sample residents (#61, #229) and residents on the third floor. Specifically, 1. The facility failed to reassess sample resident #61's safety needs in order to implement and provide adequate supervision for fall preventions. The resident had cognitive impairments, history of falls and was identified as a high risk for falls. The resident fell twice in the facility, sustaining a hip fracture with the second fall; - The facility failed to provide adequate supervision during eating for resident #61 and swallowing precautions followed; - The facility failed to ensure chemicals were stored appropriately in resident #61's room; 2. The facility failed to ensure residents on the third floor were served coffee at a safe temperature. 3. The facility failed to ensure medications were stored safely for resident #229. The findings include: 1. Resident #61 A. Resident #61 was admitted to the facility with a history of falls on 11/27/12: Resident #61, age [AGE] years, was admitted to the facility on [DATE], re-admitted to the facility on [DATE] and 5/27/13. According to the June 2013 Computerized physician's orders [REDACTED]. 1. Resident's original admission identified the resident had a history of [REDACTED]. According to the 12/4/12 admission Minimum Data Set (MDS), resident #61 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status score of 11/15. Resident #61 required extensive assistance with transfers and toileting. Resident #61 was documented to have had a fall in the month prior to admission to the facility. Resident #61 was documented to have had falls in the two to six months prior to admission to the facility and a fracture related to falls within the six months prior to admission to the facility. Resident #61 resided on the Restore Unit during this admission to the facility (rehabilitation unit). On 6/19/13 at 10:38 a.m., a family member and regular visitor to resident #61 were interviewed by telephone. The family member stated that resident #61 had been admitted to the facility before in November 2012 for rehabilitation after a fall with arm fracture. The family member stated resident #61 improved with rehabilitation and was discharged home in January 2013. The resident was discharged home. 2. After an unsuccessful transition home and further falls, the resident returned to the facility on [DATE]. According to the 2/5/13 admission MDS, resident #61 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status score of 11/15. Resident #61 required supervision for transfers and extensive assistance of one staff for toileting. Resident #61 used a wheelchair for mobility. Resident #61 required extensive assistance for locomotion on the unit and did not leave the unit during the MDS observation period. Resident #61 was coded as being "Not steady, only able to stabilize with human assistance" for moving from seated to standing position, moving on and off the toilet, and surface to surface transfers. The MDS revealed that resident #61 had fall in the month prior to re-admission to the facility. On 6/19/13 at 10:38 a.m., a family member and regular visitor to resident #61 were interviewed by telephone. The interview revealed the following: -The family member stated resident #61 was readmitted shortly after returning home from a previous stay at the facility for rehabilitation. -According to the family member, resident #61 was readmitted to the facility because she continued to fall and was unsafe at home. -The family member stated resident #61 had cognitive impairment and did not consider her safety needs and ability level when she transferred, ambulated and toileted. A review of the resident's fall risk assessment dated [DATE] showed that resident #61 was a "high risk" for fall with a score of "greater than ten" indicated in the computerized fall risk record. Upon the resident's re-admission, a review of the care plans (conducted on 6/21/13 during survey) did not show that a fall care plan was in place even though the resident was identified at risk and had a history of [REDACTED]. On 6/24/13 at 10:46 a.m., a Physical Therapist (PT) familiar with resident #61, stated the resident had a mechanical fall (tripping fall and not from a medical issue) at home and as a result was re-admitted to the facility on [DATE]. The PT continued that due to resident #61's history of falls, cognitive impairment, and diminished safety awareness; resident #61 was at risk for additional falls. The PT stated resident #61's [DIAGNOSES REDACTED]. 3. Five days after her re-admission, the resident fell : A nurse's note dated 2/3/13 and timed at 1:36 p.m., stated that resident #61 was found on the floor of the bathroom after an un-witnessed fall. According to the note, resident #61 was self-transferring between the wheelchair and the toilet. The fall was noted to be without injury. The 2/4/13 fall risk assessment created/signed at 8:24 a.m., by the Unit Manager (UM) showed that resident scored 23 points on the fall risk scale. Per the assessment tool implemented by the facility, resident #61 was a "high risk" for falls when they scored above ten. A copy of the 2/3/13 "Incident Prevention Addendum" fall investigation was reviewed on 6/24/13. In pertinent part, the fall investigation showed: -The resident experienced an un-witnessed fall transferring between the toilet and wheelchair while alone in the bathroom. -The form noted the resident had experienced previous falls. -The form noted resident #61 required stand-by assistance for transfers. -The resident did not lock the wheelchair brakes when transferring to the toilet. -The approach that would be implemented was to remind cognitively impaired resident #61 to lock her brakes before transfers and to implement a sensory alarm to the wheel chair. -A fall care plan was initiated on 2/3/13 after the first fall: On 6/21/13 at approximately 12:00 p.m., the clinical record was reviewed with the assistance of the Medical Records Director (MRD). The MRD's assisted review of the resident's clinical record revealed that on 2/3/13 at 1:36 p.m., a care plan for the problem of "falls" was initiated for resident #61. The approaches implemented on 2/3/13 were replaced when the care plan was last updated on 2/4/13 at 9:59 a.m. Approaches for the 2/4/13 fall prevention were: -Encourage resident to ask for assistance -Assist resident to use eye glasses, dentures, hearing aides -Telephone within reach -Call light in reach -Sensory alarm to wheelchair when in wheelchair secondary to decreased safety awareness With the review of the post fall assessment and care plan, the facility failed to assess supervision needs, history of falls, fall risk or possible equipment needs. The resident was identified with impaired cognition. -On 6/19/13 at 10:38 a.m., a family member who regularly visited resident #61 at the facility was interviewed by telephone. The interview revealed the following: The family member stated that nurse aide staff on the floor was not consistent. The family member noted that resident #61 would become comfortable with a nurse aide only to have them changed to another assignment or leave. The resident complained to family that she experienced waits for toileting assistance before and after the meal time. The family member stated that s/he had observed lengthy waits for toileting assistance when the resident needed assistance before and after lunch. -A "Resident Restraint Screen Form" dated 3/6/13 (reviewed on 6/24/13) showed the following recommendations to improve resident #61's safety related to decreased safety awareness: -Low bed while in bed -Pressure alarm to bed and wheelchair -Lipped mattress Although these interventions were recommended on 3/6/13, the care plan was not updated to reflect the current safety needs of the resident. 4. Second fall occurred on 5/24/13 with injury (Cross reference to F309 for interviews and record reviews related to pain and nursing assessment after the fall with fracture on 5/24/13): From 2/4/13 through 5/24/13, there had been no revisions to the resident's fall care plan or re-assessments of safety interventions. A review of resident #61's clinical record conducted on 6/21/13 failed to locate documentation in the nursing notes, therapy notes, care plan or Cardex (nurse aide care plan) during the period prior to resident #61's second fall of a re-assessment of the pressure alarm intervention's efficacy. (See interviews below with family member on 6/18/13, Charge Nurse on 6/24/13 at 11:47 a.m., Unit Manager (UM) on 6/24/13 at 3:11 p.m., about resident #61 turning off the pressure alarm. See Investigation Reports below showing the pressure alarm was found turned off at the time of the second fall.) According to the 4/25/13 quarterly MDS, resident #61 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status score of 11/15. Resident #61 required extensive assistance of one staff for transfers and toileting. Resident #61 used a wheelchair for mobility. Resident #61 required limited assistance from staff for mobility on and off the unit. According to the MDS, resident #61 was unsteady with moving from a seated to standing position, moving on and off the toilet and with surface to surface transfers. A nurses' note dated 5/24/13 at 2:01 p.m., written by the Unit Manager (UM), who was a Licensed Practical Nurse (LPN) was reviewed. The note, in pertinent part, stated the resident's left foot was externally rotated. A nurse's note dated 5/24/13 at 2:03 p.m., written by the LPN that usually served as the weekday day-shift charge nurse for resident #61 was reviewed. In pertinent part, the note stated that resident #61 experienced an un-witnessed fall in the bathroom at approximately 11:45 a.m. A nurse's note written by the UM dated 5/24/13 and timed at 2:32 p.m., stated that resident #61 was seen by the physician, who gave permission to send resident #61 to the emergency room to treat a possible left hip fracture. A review of the "Incident Prevention Addendum" completed by the LPN/Charge Nurse dated 5/24/13. In pertinent part, the document stated that resident #61 was not compliant with fall interventions because she "turns alarm off." The document stated that resident #61 had the pressure alarm in place in her wheel chair at the time of her fall but the alarm did not sound because it was turned off. -A review of the "Nurse Manager Investigation" completed on 5/24/13 was reviewed in pertinent part: Resident #61 was not compliant with fall prevention measures because resident #61 could "turn off alarm." The sensory alarm was noted to have been in place in the wheel chair at the time of the fall but was not sounding. The causative factors for the fall stated that resident #61 lost balance while standing and trying to use a toilet plunger to remove a shirt from the shower curtain rod in her room. The resident lost balance and fell back into her wheelchair. The "new" fall prevention measures being implemented were to reinstitute sensory alarm to the wheelchair, and add low bed, floor mat and a lipped mattress. Three of the fall prevention measures were for prevention of injury falls from bed, even through the resident was not noted to have experienced such. Although staff was aware of the resident's ability to turn off her alarm prior to this second event, the safety needs of the resident had not been reassessed to address supervision with her history and risk of falls. A review of the "Risk Report" for the 5/24/13 fall was reviewed in pertinent part, the risk report stated that resident #61 experienced a fall with injury on 5/24/13 at approximately 11:45 a.m. No alarms were sounding upon discovery of the resident post fall. The resident's roommate reported hearing a noise in the bathroom. The report noted that the physician's report documented that upon examination the resident's left foot to be externally rotated. A review of the Final X-ray Report dated 5/24/13 and timed, per the fax line, at 2:33 p.m., showed that resident #61 experienced a "communicated left proximal intertrochanteric femoral fracture." The stated reason for the x-ray was "pain." A review of the available 5/24/13 hospital admission records was conducted on 6/24/13. The hospital admission records showed resident #61 was admitted to the hospital on [DATE] at 5:16 p.m., for surgical repair of a fracture of the left femoral neck. Resident #61 was discharged back to the facility for skilled nursing care on 5/27/13. -On 6/18/13 at 12:15 p.m., a family member that visited resident #61 at the facility frequently was interviewed about a fall that occurred on 5/24/13. The interview with the family member revealed the following: The family member stated that resident #61 had a fall in the bathroom while unattended in the late morning before lunch time. The family member stated that resident #61 had an alarm on her chair; however according to family member the resident was able to turn the alarm off at will. The family member stated that resident #61 was injured in the fall, breaking her hip. The family member stated that s/he felt the fall could have been prevented if staff paid attention to the whereabouts of resident #61. -On 6/19/13 at 9:40 a.m., the Licensed Practical Nurse (LPN) that served as the charge nurse for the weekday-day shift on resident #61's unit was interviewed about recent falls for resident #61. The charge nurse stated that resident #61 had an un-witnessed fall with fracture in the last 30 days. The LPN stated that resident #61 had fractured her hip while trying to retrieve a blouse that was hanging on the shower curtain rod in her bathroom in her room. The resident was attempting to use a plunger to obtain the blouse and fell backwards. On 6/24/13 at 10:57 a.m., the Therapy Manager (TM) was interviewed regarding resident #61's fall. According to the TM, the resident was alone in the bathroom trying to get a shirt off the shower curtain rod when she sat down hard into the wheelchair. Per the TM the resident was not found on the floor, but seated in her wheelchair. Per the TM, resident #61 would not have been able to assist herself from the floor to the wheelchair had she fallen to the floor. The TM related this was also the consensus of the nursing staff. On 6/24/13 at 11:47 a.m., the LPN that served as the charge nurse for the unit where resident #61 resided was interviewed. The LPN stated the resident was found alone in the bathroom, in her wheelchair, calling out and complaining of left hip/leg pain around 11:45 a.m. The sensory alarm was not sounding because the resident had turned it off. The LPN stated the resident had a history of [REDACTED]. On 6/24/13 at 3:11 p.m., the UM stated the resident had a history of [REDACTED]. The UM acknowledged the fall care plan did not address the resident's ability to disarm her alarm. The UM stated she conducted an investigation after the fall, in part because it was unusual to find a resident injured, sitting in a wheelchair when claiming there had been a fall. The UM stated that all staff denied assisting resident #61 back into her wheelchair. Resident #61 would not have been able to move herself into her wheelchair had she been on the floor. According to the UM, the roommate recalled hearing a loud sound in the bathroom before resident #61 was heard to be calling out for help. 5. Safety interventions in place after the resident's return on 5/27/13: A review of hospital discharge records dated 5/27/13 showed the resident had no weight bearing restrictions in place on return to the facility. A physician's telephone order (TO) dated 5/29/13 showed the following interventions were ordered: -Sensory alarm in bed secondary to decreased safety awareness. -Sensory alarm in wheelchair secondary to decreased safety awareness -Lipped mattress to act as a "bounds check." -Bed in low position when resident is in bed due to decreased safety awareness. -Floor mat next to bed when resident is in bed. Review of the Treatment Administration Record (TAR) (from 6/1/13 to 6/21/13) showed that staff was to document/initial each shift that they monitored the following supportive devices for resident #61: -Sensory alarm in bed when the resident was in bed due to decreased safety awareness. -Sensory alarm in wheelchair due to decreased safety awareness. The TAR did not inform staff that the resident had a history of [REDACTED]. -Lipped mattress to act as boundary. -Low bed in the lowest position when in bed due to decreased safety awareness. -Floor mat next to bed when in bed due to decreased safety awareness. Though a few holes were present, all of the above devices were signed off by staff as being present on each shift. A review of the "Restraint Screen Form" dated 5/31/13 showed the resident was evaluated for use of safety devices secondary to a fall with fracture. The following devices were evaluated to improve resident #61's safety awareness: -Low bed while in bed -Floor mat secondary to fall -Pressure alarm while in bed and wheelchair. -Lipped mattress -The form did not remark on the efficacy of the pressure alarm even though investigations into resident #61's falls showed that the resident could disarm the alarm. -The fall care plan remained unchanged since the last revision on 2/4/13. The care plan had not been updated or revised to include the new safety devices from 3/9/13 or 5/30/13. 6. Observations/Interviews: On 6/18/13 at 12:11 p.m., resident #61 was observed seated in her wheelchair in the dining room. The resident was not wearing glasses, a hearing aid or dentures (See above the 2/4/13 fall care plan approaches to assist the resident with placement of glasses, dentures and hearing aids). No anti-roll back or anti-tip type device was observed on the wheelchair. A pressure alarm was observed to be in place. No tags or "tape" was observed to be in place on the resident's wheel chair alerting staff to resident's fall risk (see interview below on falling leaf'/high risk fall program). On 6/18/13 at 2:13 p.m., resident #61's room was observed. The resident was noted to have a fall mat available at the bed side and a low bed. The resident did not have a lipped mattress in place on the bed. No falling leaf was present on the door to indicate a resident in the room was a high risk for falls. -On 6/19/13 at 10:38 a.m., a family member that frequently visited resident #61 at the facility was interviewed. The interview revealed the following: The family member stated that resident #61 had dentures but did not wear them due to ill fit. The family member stated that the resident was deaf in one ear and did not use a hearing aid in her good ear. On 6/20/13 at 9:52 a.m., resident #61 was observed seated in her wheelchair in the common area by the nurse's station. The resident did not have dentures, glasses or a hearing aid in place. The resident had a shoe on one foot and a plain sock on the other. The pressure alarm was in place on the back of the wheel chair. No tape or tag was observed on the back of the wheel chair. The following additional observations were made: -The charge nurse was heard to direct a near-by Certified Nurse Aide (CNA) to assist resident #61 back to bed. The resident stated she wished to remain up and wait for a phone call. -The charge nurse assured resident #61 that the phone would be provided to her in her room if she was in bed. -Resident #61 requested to be taken to the toilet. -Resident #61 was escorted to her room by the CNA. After having her temperature taken and protective boot placed on the sock foot, resident #61 was assisted to the toilet. -The CNA step outside the bathroom door and closed it to provide privacy at 10:02 a.m. -The CNA was observed to check resident #61 intermittently to determine if she had completed toileting. -The CNA reported she was new to the facility. The CNA stated she was waiting outside the bathroom door to provide privacy and because resident #61 would try to transfer herself when she was done. -At 10:09 a.m., the CNA was heard to remind resident #61 that she needed help to stand as she entered the bathroom to assist the resident who was attempting to transfer from the toilet. On 6/24/13 at 8:41 a.m., resident #61 was observed in bed. The bed was in low position, with the fall mat and sensory alarm in place. The resident was on an air mattress not a lipped mattress. No leaf was present on the doorway to identify resident #61 as a high risk for falls. 7. Lack of Supervision and unsafe transfer: On 6/24/13 at 8:43 a.m., a Certified Nurse Aide (CNA) brought in to assist resident up from bed was observed to transfer resident #61. The CNA did not apply a gait belt prior to transferring the resident. The CNA had the resident hold on to her as she lifted her to a standing position from the bed and pivoted her into the wheelchair. The CNA stated she should have used a gait belt but that the resident did not like it. The CNA did not attempt to place the gait belt on the resident and therefore did not receive any comment or refusal from the resident about the use of the gait belt. The CNA confirmed an air mattress, not a lipped mattress in place on the bed. -On 6/24/13 at 10:46 a.m., a Physical Therapist (PT) familiar with resident #61 was interviewed regarding current fall interventions in place for resident #61. The PT was accompanied to resident #61's room. The PT confirmed that resident #61 did not have a lipped mattress in place on the bed. The PT reviewed the resident's orders and noted the resident had an order for [REDACTED]. Regarding the interventions in place to prevent falls for resident #61 the PT stated: The interventions in place to prevent falls when up in the wheelchair remained the same - the pressure alarm and reminders to ask for assistance. The bed related fall prevention interventions were implemented proactively and not as a response to any actual falls experienced by the resident. The PT stated that the CNA should have used a gait belt to transfer resident #61 because resident had a recent fracture and remains unsteady. The PT stated that resident #61 had improved since her return from the hospital but remained less mobile than her prior baseline. -On 6/24/13 at 12:55 p.m., the bathroom call light in resident #61's room was noted to be on. Resident #61's roommate had been observed to have been sent out to the hospital earlier that morning for a scheduled procedure. Upon approach to resident #61's room, resident #61 was observed alone in the bathroom attempting to stand from the wheel chair with the aid of the grab bars. No alarm was heard to be sounding. A CNA arrived in resident #61's room almost immediately behind the surveyor. The CNA agreed that resident #61 was attempting to transfer from the wheel chair to the toilet with the aid of the grab bars. A second CNA entered the room to provide assistance. After assisting the resident, the first CNA, who usually worked as a bath aide, was interviewed. The CNA stated that she placed resident #61 in the bathroom and turned on the call light to obtain assistance for resident #61 because the resident needed to toilet. -On 6/24/13 at 12:57 p.m., the UM acknowledged the fall care plan did not address the resident's need for supervision during toileting. The UM stated the presence of the pressure alarm should have been a reminder that the resident was a fall risk. The UM viewed resident #61 at this time. The UM stated the resident did not have on glasses, a hearing aide or dentures. The UM was heard to confer with the CNA who was assisting resident #61. The UM stated that resident #61 did not use glasses or a hearing aide. The UM stated the resident's dentures were being refit. The UM stated she did not know why the resident's fall care plan, which she agreed should be individualized to the resident, stated these devices needed to be in place for fall prevention purposes. The UM was observed to remove/discontinue the care plan approaches related to glasses, hearing aid and dentures from the fall care plan. -On 6/24/13 at 3:11 p.m., the UM stated the care plan was not updated to include new approaches to prevent falls after the fall on 5/24/13. The care plan did not inform staff that resident #61 could disable her fall alarm. The resident remained a "high fall risk" with her most recent fall risk assessment showing a score of 22 on 6/6/13. -On 6/24/13 at 4:51 p.m., an interview was conducted with the Director of Nursing (DON) and with the assistance of an LPN who was present to assist the DON with review of resident #61's electronic clinical record. The interview revealed the following: The DON would expect that resident #61 not be left alone in the bathroom because of a history of falls. The DON and LPN reviewed the care plan. The DON acknowledged the care plan should be individualized to the resident and should contain all current interventions in place. The DON stated residents at high risk for falls could be place in the falling leaf program. -On 6/24/13 at 5:38 p.m., therapy staff was interviewed as a group about the high risk fall program. An Occupational Therapy Assistant (OTA) stated that tape was placed on the walker of residents to alert staff to the safety status of residents for mobility in the facility. Red tape, for example meant the resident was not safe to walk alone in the facility. Other therapy staff concurred that this was a practice on the restore unit and for other residents throughout the building on therapy service. Therapy staff acknowledged the tape could also be placed on the wheelchair of a resident that was high risk for falls when unattended. -On 6/24/13 at 5:40 p.m., an RN who worked on the second floor was interviewed. The RN stated that residents identified as a fall risk on their fall risk assessment would have a leaf on the door. Per the RN, the leaf was part of their falling leaf program that helped staff to identify what residents were at risk for falls. The RN stated that the fall risk assessments were completed upon a resident's admission to the facility, quarterly, and with any change in a resident's condition. -On 6/24/13 at 5:45 p.m., a CNA who worked on the second floor was interviewed. The CNA stated that residents that have a leaf on their door have been identified as being a fall risk. The CNA continued, adding that the leaf was used to help decrease the resident's risk of falls. The CNA stated that they should never be left alone when they are being toileted. -On 6/24/13 at 5:46 p.m., a CNA that worked on the third floor was asked about the meaning of a leaf posted on the doorjamb of a room. The CNA stated that the leaf was to remind staff that a resident was a fall risk. -On 6/24/13 at 5:47 p.m., the UM stated the falling leaf program was for any resident that had frequent falls, had falls with injury or that was a high risk for falls. At admission, resident #61 was known to be a high risk for falls and could have been included in the falling leaf program. The resident has had falls including a fall with injury since admission. The UM stated she thought the resident was in the falling leaf program. The UM stated that resident #61 should have a tag on her chair to remind staff not to leave her unattended. The UM viewed resident #61 who was seated in the television area. The UM acknowledged that resident #61 did not have the reminder on her wheelchair. The UM viewed the door to resident #61's room and stated that resident #61 did not have a leaf in place to remind staff that she was at risk for falls. B. Resident #61 Swallowing Precautions Resident #61, age [AGE] years, was admitted to the facility on [DATE], re-admitted to the facility on [DATE] and 5/27/13. According to the June 2013 Computerized physician's orders [REDACTED]. The quarterly 4/25/13 Minimum Data Set (MDS) documented that resident #61 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status score of 11/15. Resident #61 required supervision assistance with meals. Resident #61 was not documented to have signs and symptoms of swallowing disorder during the MDS evaluation period. Resident #61 was not on a mechanically altered diet. Record Review: On 6/24/13 the clinical record for resident #61 was reviewed. The review revealed the following: - 6/1/13 a physician's telephone order (TO) stating speech therapy should evaluate and treat resident #61 for three weeks related to dysphagia (difficulty swallowing). -6/1/13 a Diet Order and Communication form directed that resident #61 was to receive mechanical soft diet with ground meats due to chewing/swallowing problems. -6/14/13 TO stated resident #61 would be discontinued from speech therapy services. -6/24/13 the care plan for resident #61 was reviewed. The care plan was not inclusive of the swallowing precautions listed on the signage posted in resident #61's room (see below). Observation: On 6/20/13 at 9:52 a.m., a sign dated 6/4/13 was observed to be posted in resident #61's room. In pertinent part, the sign, which bore the resident's name, stated that resident #61 was on swallowing precautions. The resident's diet was "ground/mechanical soft" with thin liquids. Staff was directed to feed the patient with one-on-one supervision. Staff was directed to ensure that resident #61 sat upright at meals. On 6/24/13 at 8:41 a.m., resident #61 was observed reclined in bed with the bed in low position. The head of the bed was not elevated to 90 degrees and was at 10 degrees approximately. No staff was present in the room. The resident was using a fork to pick up the food from the plate that was resting on her chest. The plate contained cottage cheese, mandarin oranges and sliced banana. The over-the-bed table was at hip height, out of reach, off to the side of the bed with the room tray and beverages on top. The resident was not heard to be choking or coughing and was not seen to be pocketing the food. A nurse was immediately summoned to the room. Staff Interviews: On 6/24/13 at 8:42 a.m., the Unit Manager (UM) who was a Licensed Practical Nurse (LPN) was asked to observe the resident. The LPN stated that resident #61 should not be eating while reclined in bed. The UM stated the resident's position put her at risk for swallowing problems and aspiration. The LPN summoned a CNA to the room to assist resident #61 to an adequate position for consuming a meal. The LPN was observed to ask two different CNAs if they assisted the resident with her morning meal set-up. Both were heard to deny responsibility. On 6/24/13 at 8:52 a.m., a Registered Nurse (RN) that worked on the third floor was interviewed. The RN reviewed the swallowing precautions sign in resident #61's room. The RN stated that resident #61 should not have been left in her room to eat unattended due to her swallowing problems and precautions listed on the sign provided by therapy staff. The RN directed the CNA, who was preparing to exit the room, to remain with resident #61 until her meal was completed. On 6/24/13 at 8:59 a.m., the Speech Language Pathologist (SLP) who was also the Rehabilitation Manager (RM) was interviewed. The RM stated that it was a choking hazard for resident #61 to consume food while reclining on her back in bed. The RM stated that resident #61 should be sitting at a 90 degree angle while eating. The RM stated it was not a good idea to leave resident #61 to eat unattended in her room. On 6/24/13 at 10:17 a.m., the SLP that treated resident #61 from 6/1/13 to 6/14/13 was interviewed. The SLP stated resident #61 was seen for choking and coughing at meals and decreased intake. The SLP stated that her recommendations for care were captured on the sign posted in resident #61's room. The SLP stated staff s

Based on record review and staff interviews, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: The facility failure to use its resources effectively contributed to a failure to protect residents from inappropriate sexual behavior by CNA #1. Cross reference F223; abuse. The facility failure to use its resources effectively contributed to a failure correct deficiencies cited in recertification survey 6/24/13. Cross-reference: F225, F250, F281, F309, F353, F431, F441 and F514. The facility failure to use its resources effectively contributed to additional citations during the revisit and abbreviated survey 8/27/13. Cross reference F387, F497, F516, and F520. The findings include: I. Nursing Home Administrator Expectations A. Administrator Job Description/Evaluation (undated) On 8/27/13 at 9:17 a.m., the Vice President of Clinical Services (VPCS) provided the facility Job Description/Evaluation (JDE) for the position of Administrator of the facility. The JDE documented in pertinent part in the Responsibilities section: -Operates the facility in accordance with established policies and procedures of the governing body. -Act as liaison with the governing body, medical/nursing staff and other professional and supervisory staff through regular meetings and periodic reporting. -Prepares and forwards on time to proper authorities all reports such as staffing, census, etc., and any special reports required by management. -Write definite policies regarding duties and activities of the staff, which will assure health care and safety of the residents and others, and explain these policies so that the aim and purpose of the facility may be achieved by cooperative effort. -Recruits, employs and releases all staff. Works with the Director of Nursing (DON) in hiring personnel and assure there are adequate numbers of aides and orderlies to meet the needs of the residents on a twenty-four hour basis. -Interpret the lines of authority to each employee so that each will have a clear understanding of the person to whom he is immediately responsible. -Write personnel policies and individual duties and see that all employees know them, and delegate the authority required for the performance of their jobs to the department head. -Notify licensing agency of any changes in key personnel. -Use diplomacy but firmness in settling any disputes, complaints, etc., concerning personnel or residents or families. -Supervises all department heads, including office staff. Supervise by regular rounds and conferences, the work of all responsible personnel. Check with department heads daily. -Evaluate the performance of each employee periodically with the department head, discuss the evaluation with the employee. -Work with the department heads in providing opportunities and material for regular staff meetings and in-service education pertaining to the job. -Assist the department heads in dismissing from employment any person whose work is not satisfactory. -Give honest appraisal of an employee's work and behavior to succeeding employers. -Work with nursing director in providing a safe place for storing current and closed resident records. -Maintain as much personal contact as possible with the resident and his family or guardian in order to continue good relationship and to determine changing conditions and needs. Letter writing is excellent. -Ascertain that the necessary food and other supplies needed for the operation of the facility are purchased and on hand. -Responsible that all equipment is in operating order. -Study and keep current with the changes in regulatory agencies. -Is an active member of all committees, where applicable and set meeting dates and directs that copies of the minutes and reports of these meetings are kept and sent to the proper officials. -Establishes standard operating procedures for physician practices in the facility in coordination with the nursing director. -Reviews and evaluates all reports and documenting disposition of recommendations and implementation from the facility's committees and consultants. B. On 8/26/13 at 1:35 p.m., a review of the facility's Quality Assurance (QA) committee process was conducted with the Nursing Home Administrator (NHA) and the Operations Consultant (OC). The OC stated the NHA provided leadership for the facility and was a member of the QA committee. II: Failure to Administer Resources Effectively and Efficiently to Maintain Compliance with Regulatory Requirements A. Failure to ensure QA committee action plans were consistently implemented to address a resident's right to be free from verbal, sexual, physical and mental abuse, cross reference F223 (K): Abuse - the facility was cited at a K level, indicating substandard quality of care and resulting in an imposition of immediate jeopardy due to the facility failure to prevent multiple residents from physical and sexual abuse. Record review and interviews revealed: Certified nurse aide (CNA) #1, employed by the facility since 1/13, had a history of [REDACTED].#27, #28, and #4, all of whom resided on restorative unit, in 3/13, 5/13 and 7/13. No steps were taken by the facility to ensure residents were protected from further inappropriate sexual behavior by CNA #1. CNA #1 continued to provide direct resident care without restriction or oversight on the same resident unit (restorative) after these incidents. On 8/15/13, resident #7 informed a CNA during her shower that she had been sexually assaulted by CNA #1 the night before. On 8/21/13 at 12:20 p.m., the police detective stated CNA #1 was contacted by police on 8/15/13 and taken into custody (jail), where he currently resides, after he confessed to sexual assault of resident #7 and a previous assault of resident #4. B. Failure to Address Previously Cited Deficiencies and New Areas of Deficient Practice 1. Repeat Citation of Deficiencies from last survey dated 6/24/13. Observations, record review and interviews conducted during the revisit survey exiting 8/27/13 revealed the facility failed to develop and implement plans to correct the following deficiencies cited during the recertification survey 6/24/13: F225: Not employ individuals who have been found guilty of abuse was recited at a G level, indicating a widespread potential for more than minimal harm. This represented an increase in the scope of deficient practice from a scope of D, potential for more than minimal harm that is isolated. F250: Social Services was recited at a D level, indicating an isolated potential for more than minimal harm. This deficiency was previously cited at a D level, indicating an isolated potential for more than minimal harm. F281: Professional Standards was recited at a D level, indicating an isolated potential for more than minimal harm. This deficiency was previously cited at a D level, indicating an isolated potential for more than minimal harm. F309: Quality of Care was recited at a G level, indicating actual harm is isolated. This deficiency was previously cited at a G level. F353: Sufficient Nursing Staff was recited at an E level, indicating a potential for more than minimal harm at a pattern. This deficiency was previously at an E level. F431: Labeling of Drugs was recited at an E level, indicating a potential for more than minimal harm at a pattern. This deficiency was previously cited at an E level. F441: Infection Control Program was recited at an E level. This deficiency was previously cited at an E level, indicating a potential for more than minimal harm at a pattern. F514: Resident Clinical Record Accuracy recited at a D level, indicating potential for more than minimal harm that is isolated. This deficiency was previously cited at a D level. C. New Deficiencies Cited During Revisit and Abbreviated Survey F223: Abuse was newly cited at a K level, resulting in substandard quality of care and the imposition of immediate jeopardy, due to the facility's failed to prevent multiple residents from physical and sexual abuse. F387: Frequency and Timeliness of Physician Visits was cited at an E level, indicating a potential for more than minimal harm at a pattern, due to the facility failed to ensure physician visits were timely. F490: Facility Administrated Effectively was cited at a G level, actual harm that is isolated, due to the facility's failure to employ a Nursing Home Administrator who followed all of the components of their job description, provided leadership for the facility and managed the facility in a safe effective manner. F497: Regular In-Service Education was cited at an E level, indicating a potential for more than minimal harm at a pattern due to the facility failed to ensure nurse aide performance reviews were completed and in-services were provided to nurse aides to ensure continued competence. F516: Facility Safeguards Clinical Records was cited at an E level, indicating a potential for more than minimal harm at a pattern due to the facility failure to implement appropriate interventions to prevent unauthorized use (easily accessible) of resident clinical records. F520: Facility Maintains a Quality Assurance Committee was cited at an F level, indicating a widespread potential for more than minimal harm due to the facility failure to ensure QA action plans were consistently implemented to address identified areas of concerns. III. Staff Interviews On 8/27/13 at 9:05 a.m., the Vice President of Clinical Services (VPCS) stated the Nursing Home Administrator (NHA) was the leadership in the facility and was responsible to follow the policies and procedures of the facility. At 9:17 a.m., the VPCS stated it was her expectation the NHA of the facility adhere to the 35 responsibilities detailed in the JDE for Administrator and the NHA had not done so and this NHA (previous NHA) was no longer at the facility. (According to the facility, the previous NHA's tenure ended 8/18/13.) On 8/27/13 at 10:16 a.m., the Operations Consultant (OC) stated it was his expectation the NHA of the facility adhere to the 35 responsibilities detailed in the JDE for Administrator. At 10:36 a.m., the OC stated the previous NHA did not perform his duties as described in the JDE for Administrator. The OC stated the facility received repeated deficiencies due to a lack of administrative leadership. On 8/27/13 at 10:31 a.m., the current Nursing Home Administrator (NHA) stated it was his expectation the administrator of the facility follow the responsibilities criteria documented in the Administrator Job Description/Evaluation form.

Based on record review, interview and observation, the facility failed to ensure that six (#1, 6, 7, 8, 9, and 10) out of 11 sample residents who were admitted without pressure sore remained free from pressure sores. Specifically: -Resident #1 developed several pressure sores after admission that became infected and caused pain. Resident #6 was observed with a new open area during survey that had not been identified by staff. -Residents #6, #7, and #9, although currently healed (except for resident #6 as stated above), developed pressure sores, per facility documentation, that were acquired "in-house." -Resident #10 had a pressure ulcer, the discovery of which (pre or post admission) was conflicting. -Resident #8 had multiple pressures; her non-compliance, cited by the facility as a factor in the pressure sores not healing, was not re-evaluated or interventions to address it were not comprehensively reviewed and revised. In addition, the facility lacked accurate and up-to-date information on the number of residents with pressure sores. The findings include: A. PROFESSIONAL REFERENCE: According to White-Chu and Reddy, "Wound care in short-term rehabilitation facilities and long term care: Special needs for a special population," Skin Med, Volume 10, Issue 2, March/[DATE], pp. ,[DATE]: -Pressure ulcers primarily present over bony prominences, including the sacrum, heels, hips and elbows. They can also occur anywhere that skin is damaged by excessive pressure, friction or shear, or excess moisture. -Support surfaces are important for offloading of pressure, but they do not address the other ulcer causes, such as friction, shear, and moisture. In short, nothing can replace good personal attendant care with frequent turning, incontinence care, and lifting and transfers that minimize friction and shear. B. FACILITY POLICY Facility policy titled, 'Pressure Ulcer, Prevention of,' stated in pertinent part: -All residents will be assessed upon admission then for 4 consecutive weeks using the Braden scale. - Residents will then be assessed at least quarterly thereafter. -Assessment of risk factors: Identifying Co-morbid Diagnosis, general condition of skin, circulation, drugs that affect wound healing or may increase the risk for breakdown, cognitive impairment or behaviors, nutritional status, urinary or fecal incontinence, hydration/fluid balance, terminal condition, mobility status, including bed mobility, limitation in range of motion and deformities, contractures, refusal of care or non-compliance, history of pressure ulcers. -Prevention: Any resident that is assessed as being at risk for skin breakdown will have specific preventative measures implemented and care planned, these measures will be resident specific, all residents will have a bi-weekly skin check to assess for any areas. -Procedure: Assess for risk of pressure ulcer development, keep sheets dry and free of wrinkles and debris as possible, use elbow and heel protectors as necessary, establish a turning and positioning schedule in bed and chair to meet the resident's needs, assist residents at meal time, offer fluids, position to prevent pressure from medical devices such as tubes, casts, braces, etc. -Documentation guidelines: When pressure ulcer is identified the following processes will include: Notify MD of the wound and obtain orders, chart in the clinical record the findings, notify the POA (power of attorney), if applicable, notify the wound nurse, weekly assessments and measurements to begin until healed, date, time, stage, description and treatment to pressure ulcer, (see pressure ulcer report) pressure ulcer investigation completed upon discovery, treatments as ordered, preventative and healing measures implemented, resident added to weekly PAR meeting, PUSH tool to be completed weekly, all recommendations from PAR meeting to be added to care plan, RD (registered dietitian) referral as needed. -Care plan documentation guidelines: Problem: Identify the appropriate problem under which to list the pressure ulcer care as an approach, identify and treat the underlying cause of the pressure ulcer. Goal: List measurable goals to be accomplished, target date. Approaches: List responsible discipline for each approach, list instructions unique to this resident, list necessary monitoring and observation of the underlying condition, list treatment as ordered if necessary, list pressure reducing or relieving surfaces, list frequency of positioning. C. INTERVIEW Interview with interim director of nursing (IDON), LPN (licensed practical nurse) unit manager, WLPN (wound LPN) (hire date [DATE] per her report) on [DATE] at 11:56 a.m. revealed that each unit manager and the WLPN did wound rounds weekly. -The IDON stated that they have a meeting on the wounds every Friday and all unit managers, WLPN, IDON, therapy, the dietician and nursing home administrator attend the meetings. She stated that they review wounds and the WLPN discuss supplements, therapy positioning and treatment and progress. Managers are responsible for following through on the recommendations. The IDON was responsible for taking the findings of the weekly meetings to their quality assurance (QA) meeting monthly. -When asked what the number of wounds "in house" currently was, the IDON stated that the WLPN had a tool that she used to report the number of wounds "in house" that were acquired prior to and during residents' stay at the facility. However, the IDON stated that there was some confusion with how they were recording wounds so they had just come up with a more accurate number. She stated that the facility was re-implementing the use of the report that week. At that time she stated that she believed that there were 11 or 12 wounds "in house." She did not know how many were facility acquired. Later on [DATE] at 2:17 p.m. the IDON, WLPN, and unit manager reported that there were 16 wounds "in house" with eight acquired "in house" and six residents admitted with wounds. On review of their records, they then stated that 12 residents had wounds and ten had acquired the wounds at the facility and two were acquired prior to admission. On [DATE] at 4:30 p.m. the IDON, unit manager, and WLPN were asked to provide documentation of any of the residents' wounds being unavoidable. They stated that they had looked at all documentation for the residents including their charts and meeting minutes regarding the residents and could not provide documentation on any of the 11 residents that confirmed the residents' wounds were unavoidable. On [DATE] at 9:10 a.m. the IDON was asked if there was an error in the report they had provided the previous day. She stated that the report had been incorrect and that 11 out of the 12 residents with wounds acquired wounds after admission to the facility. D. RESIDENT FAILURES 1. RESIDENT #1 (closed record) Resident #1 a [AGE] year old female, was admitted to the facility on [DATE]. She was discharged due to death on [DATE]. According to her face sheet, her [DIAGNOSES REDACTED]. The resident expired on [DATE] at the facility. On [DATE], review of the resident's certificate of death revealed it read, in pertinent part, 'Immediate cause of death: General decline and [MEDICAL CONDITION]. Other significant factors contributing to death: Bladder and [MEDICAL CONDITION], pressure ulcer with wound infection.' a. Resident Status on Admission According to her admission minimum data set ((MDS) dated [DATE], the resident was admitted with no indication of wounds. She was also noted as having no venous or arterial ulcers and not being a risk for pressure ulcers. According to her final change of condition MDS dated [DATE], the resident had two unstageable wounds and one stage one wound at her time of death that were acquired while in the care of the facility and the most severe tissue type for any pressure ulcer was documented as necrotic tissue. b. Pressure Ulcer Development After Admission Orders: According to the [DATE] computerized physician orders [REDACTED]. - "A.M. wound P.M. wound coccyx wound cleanse with (normal saline) pat dry, apply santyl to wound bed cover with Xeroform and apply bordered foam dressing. (Encourage resident to lie on side.)" - "Wound treatment: Cleanse with normal saline to it (left) heel pressure area and pat dry, apply calcium alginate to wound bed and cover with foam border A.M. wound P.M. wound prn (as needed) until resolved." Wound Documentation: When asked to provide wound documentation the facility provided wound documentation that first identified wound origin on [DATE]. All skin assessments documented prior to [DATE] stated that the resident's skin was intact. Wound documentation written by nursing staff read in pertinent part: -[DATE]- pressure ulcer acquired in house. Location: sacral. Length 13 cm, width 9 cm, unable to determine depth. Large amount of serosanguineous exudate wound base 70% black necrosis. Pressure ulcer left heel: 2.75 cm by 2.5 cm. Added to change of condition MDS where it was documented as well. -[DATE]- Pressure ulcer acquired in house sacral 12cmx 12 cm, worsening. Large amount of serosanguineous exudate. Pressure ulcer left heel 2 cm x 2 cm. -[DATE]- Pressure ulcer acquired in house sacral 12 cm x 10 cm. Large amount of serosanguineous exudate with foul odor. Worsening. Pressure ulcer Left heel, origin in house, 2 cm x 1.5 cm. -[DATE]- Pressure ulcer sacral acquired in house, 16 cm x 15 cm. Large amount of serosanguineous exudate with foul odor. Comments, " Wound is unavoidable (related to) poor nutritional status, (patient) not wanting aggressive (treatment, had MD speak with resident and nephew-discussed outcomes (patient/nephew) chose hospice, will treat with 2 (antibiotics) for 4 weeks. Pressure ulcer left heel 4 cm x 3.5 cm. (New wound) Pressure ulcer left hip 4.5 cm x 3 cm. -[DATE]- Pressure ulcer acquired in house sacral 15 cm x 14 cm, large amount of foul odor serosanguineous exudate. Comments: wound is unavoidable r/t poor nutritional status, pt not wanting aggressive tx. Left heel pressure ulcer origin in house. Right hip pressure ulcer origin in house, 3.5 cm x 2.5 cm. -[DATE]- Pressure ulcer acquired in house 14 cm x 12 cm large amount of foul odor exudate. Left heel pressure ulcer stage II, origin in house, 2 cm x 3 cm. Right hip pressure ulcer origin in house (no measurements). No further weekly wound documentation was available. On [DATE] at 4:30 p.m. the IDON, unit manager, and WLPN were asked for any documentation from a physician that indicated that the wounds acquired in house were unavoidable, the facility stated that they did not have any documentation from a qualified health care professional that could verify that the wounds were unavoidable. Pain Documentation: All documented weekly wound tracking notes (,[DATE], ,[DATE], ,[DATE], ,[DATE] (pain regimen adjusted)[DATE] (pain regimen adjusted) ,[DATE] (pain regimen adjusted)) indicated that the resident was experiencing pain due to wounds. On [DATE] it stated that the resident experienced pain daily. Pain Orders were as follows, beginning in ,[DATE]: -Resident had an order written [REDACTED]. -From [DATE]-[DATE], the resident had an order for [REDACTED]. -On [DATE], an order was written for [MEDICATION NAME][MEDICATION NAME] mg twice daily This was discontinued [DATE], and another order was written [DATE] for 20 mg [MEDICATION NAME][MEDICATION NAME] daily. (An order also was written on [DATE] for [MEDICATION NAME] 15 mg tab twice daily until [MEDICATION NAME] 20 mg arrived from pharmacy. This order was discontinued [DATE]). -On [DATE] a PRN order was written for [MEDICATION NAME] (liquid [MEDICATION NAME]) 5 mg every two hours.(the medication was administered on ,[DATE] and ,[DATE]). -On [DATE] an order was written for [MEDICATION NAME] 10 mg every hour as needed (the medication was administered ,[DATE], and ,[DATE]). -On [DATE] an order was written for [MEDICATION NAME] 20 mg every hour as needed (the medication was administered once on [DATE]). c. Interviews Interview with the DON, the WLPN, unit one nurse manager and unit three nurse manager of [DATE] at 2:17 p.m. revealed that their expectation if a resident obtained new breakdown was that they would call the physician and start interventions immediately. They stated that they only had a monthly risk assessment at the time of resident #1's skin breakdown. -When asked if they had identified what had made resident #1 who was not a risk for pressure ulcers per their report (they reviewed in computer notes which showed that the resident scored a 12 which was a high risk on [DATE]. On ,[DATE] on admission she scored 18 which was a very low risk) increase in risk level and acquire ulcers, they stated that they did not know. When asked if they did a root cause analysis of the resident's decline when the first ulcer occurred they stated that they had investigated the cause of the skin breakdown. They stated that they had initiated a new skin breakdown form in March and that having new leadership they were learning the system. -When asked if they identified what had occurred from the time of the resident's skin assessment on [DATE] which stated that the resident's skin was intact and the [DATE] note which stated that the resident had a necrotic wound, they stated that they did not know but that a wound care order had been written on [DATE] (a wound care order written on [DATE] stated, "wound to coccyx, cleanse with NS (normal saline) apply santyl to wound bed, calcium alginate, cover with bordered foam change daily and as needed."). -When asked to provide documentation of the wound from [DATE]-[DATE], they stated that there was no documentation of the wound in that timeframe other than the order (see above). -All staff in the interview agreed that there was no evidence of any of the wounds being unavoidable. 2. RESIDENT #6 Resident #6 was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of unspecified chronic [MEDICAL CONDITIONS], paralysis agitans, hypertension (HTN), [MEDICAL CONDITION] reflux, and constipation. The [DATE] significant change in status Minimum Data Set (MDS) documented the resident was usually able to make herself understood and was usually able to understand what was being said to her. She scored a ,[DATE] on the Brief Interview for Mental Status (BIMS), which signified that she was severely cognitively impaired. -Under the functional status section, it was documented that the resident needed extensive assistance with bed mobility and transfers from two staff members. Under the bladder and bowel section, it was documented that the resident was always incontinent of bowel and bladder. -Under the skin condition section, it was documented that the resident was at risk for pressure ulcers; and had a stage two pressure ulcer which was acquired on [DATE]. It was granulated tissue. Under the restraint section, it was documented that the resident had a restraint (unspecified type) which was used daily. The Braden Scale for Predicting Pressure Sore Risk from [DATE] documented the resident was a low risk for pressure sores. a. Wound Development and Facility Response Review of weekly wound skin records, nutritional notes and physician orders [REDACTED]. (1) The [DATE] weekly wound skin record documented the resident had a pressure ulcer on the right buttocks which had first been observed on [DATE]. The resident's co-morbidity factors were that she was immobile and on hospice. It was 3 cm X 0.5 cm and was superficial. The area around the wound was reddened and the wound edges were intact. The interventions were to turn and reposition, off-load pressure, incontinence care barrier cream, and a chair cushion. The physician and the family were notified of the wound on [DATE]. There was second wound that was also first observed on [DATE], acquired in-house. It was 0.2 cm X 0.2 cm and superficial. The treatment was the same as for wound one. The [DATE], un-timed physician telephone order documented an order for [REDACTED]. (2) The [DATE] weekly wound skin record documented the resident had a pressure ulcer one on her right buttock, a stage II, and was acquired in-house. It was 0.3 cm X 0.5 cm and superficial. It was reddened, intact, and improving. The second wound was a stage II pressure ulcer, acquired in-house, and was 0.1 cm X 0.1 cm. It was smaller and becoming a pin-point. She also had a third pressure ulcer, a stage II, on her right buttock. It was 0.1 cm X 0.1 cm., a pin-point area. It was improving and becoming smaller. (3) The [DATE] weekly wound skin records documented that the resident had a stage II pressure ulcer on her right buttock which was acquired in-house. It was 0.3 cm X 0.2 cm, superficial, with 100% granulation. It was intact and becoming smaller. The interventions were to cleanse with Normal Saline (NS) and apply Neutrophor cream after each incontinent episode and as needed PRN (as needed); turn and reposition off-load pressure. The second and third wounds were not referenced. (4) The [DATE] weekly wound skin records documented the resident had a 0.3 cm X 0.2 cm right buttock pressure ulcer which was acquired in-house. It was superficial with 100% granulation. Per the documentation, the other two wounds (two and three) remained closed for two weeks. (5) The [DATE] weekly wound skin records documented the resident had a 0.3 cm X 0.3 cm right buttock pressure ulcer which was in-house acquired. It was superficial with 100% granulation, per the documentation it was improving and becoming more shallow. (6) The [DATE] weekly wound skin records documented the resident had a 0.3 cm X 0.2 cm on the right buttock which was acquired in-house. It was superficial with 100% granulation. It was improving, and becoming smaller. There was no other documentation of the pressure ulcer found in the chart. (7) The [DATE] weekly skin record documented the resident had an open area to the left side of her buttocks. The [DATE], 11:00 a.m. physician telephone order documented that the resident's wound was to be dressed with Hydrogel on the right (R) side of the buttocks after cleaning it with normal saline. It was then to be covered with a bordered foam dressing. (8) The [DATE] weekly wound skin records documented that the resident had a 2.1 cm X 2 cm X <0.2 cm left buttock pressure area which was acquired in-house. It was reddened with <0.2 cm of yellow center. It was 95% granulated, serosanguinous, it had worsened over the week, becoming larger and slightly deeper. The wound treatment was changed to [MEDICATION NAME] wound gel with foam border dressing, and it was to be changed daily. She was still to be turned and repositioned, staff was to off-load pressure, provide incontinence care, barrier cream, lotion to dry skin, and a chair cushion was to be used. (9) The [DATE] weekly wound skin records documented that the resident had a 2 cm X 1.8 cm X <0.2 cm left buttock stage II pressure ulcer which was acquired in-house. It was reddened, but was improving, and becoming smaller. The monthly nutritional progress note from [DATE] documented the resident was being reviewed for her weight and skin. She ate approximately ,[DATE]% at meals. The resident had on-going wound treatments. Recommendations included a supplement with liquid PRO 30 ml two times a day. Her weight was stable; however, she had inadequate/inconsistent energy intake. (10) The [DATE] weekly wound skin records documented the resident had a 0.2 cm X 0.2 cm left buttock stage II pressure ulcer which was acquired in-house. It was 100% granulated and was improving and becoming smaller and more shallow. (11) The [DATE] weekly wound skin records documented that the resident had a 0.5 cm X 0.3 cm left buttock stage II pressure ulcer which was acquired in-house. It was 100% granulated, and was slightly larger; but was very, very superficial. The [DATE] physician telephone order documented that the current wound orders for the resident's buttocks were to be discontinued. The new orders were to apply Neutrophor cream to the wound on her left (L) buttocks every shift. (12) The [DATE] weekly wound skin records documented the resident's left buttock stage II pressure ulcer was completely healed. She was still to be turned and repositioned, staff was to off-load pressure, (provide) incontinence care, barrier cream, lotion to dry skin, and a chair cushion and air mattress were to be used. On [DATE] at 8:40 a.m. the resident's physician orders [REDACTED]. There were no wound treatments included in the orders. There was an order for [REDACTED]. There was an order for [REDACTED]. b. Observations On [DATE] at 10:21 a.m. a certified nurse aide (CNA) was observed completing the resident's peri care. No barrier cream was observed on the resident's buttocks. On [DATE] at approximately 10:25 a.m. the restorative licensed practical nurse (RLPN) and the unit manager came to the resident's room to perform a skin assessment. -The skin assessment revealed the resident's buttocks were red but blanchable when touched. There was a round, pinpoint open area on the resident's interior right buttock. The unit manager pointed out the areas of scarring from previous wounds. The RLPN pressed on the pinpoint open area and said it was blanchable. When asked if it was an open area, the RLPN stated that it was blanchable. She was asked again if the skin was opened; she would not answer. -The unit manager stated the area was open and looked like a scratch. The CNA who had done the resident's peri care was contacted and asked if he had seen the area. He stated that was the first time he had seen it. The unit manager asked him if they could get some cream for her. -The RLPN stated they would have to investigate whether the open area was due to scratching or another cause. c. Staff Interviews During an interview with the resident's nurse on [DATE] at 11:02 a.m., she stated the resident was incontinent, and was checked and changed every two hours as needed. The nurse added the resident went to bed after meals. She stated the resident's incontinence varied day by day; and sometimes she needed to go the bathroom more than other days. The resident's skin was very fragile. She tended to scratch at areas. She was turned frequently. There were no open areas on the resident at the time. She was unsure of what may have caused the open areas, as she only worked on the hall once a week. She had not observed the resident's skin that day, but when she worked with her, she usually did look at her skin. On [DATE] at 11:18 a.m., the RLPN stated the resident had orders for skin cream three times a day. On [DATE] at 3:16 p.m.,the unit manager stated the resident had developed a pressure area to her right buttock during the summer. She never had any open area on the left buttock; it was always on the right and it had resolved on [DATE]. She was incontinent and was taken to the bathroom upon arising, before and after meals, at bedtime and PRN. When she had the skin breakdown, she was being checked for incontinence more often. -She said the resident also had bolsters on her bed at one time, and when she was in bed with the bolsters, there was not a lot of room and she laid on the bolsters. When they changed to a lipped mattress, the wounds started healing better. She was lying down more often. The reason for the lipped mattress was because the resident was a fall risk at one time. -She said the barrier cream was to be placed on the resident after incontinence episodes and when lying down or getting up. 3. RESIDENT #9 Resident #9, age 84, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of muscle weakness, symptoms involving the nervous and musculoskeletal system, and rehabilitation. The [DATE] 30-day Minimum Data Set (MDS) documented that the resident was able to make himself understood and was usually able to understand what was being said to him. He scored a ,[DATE] on the Brief Interview for Mental Status (BIMS) which signified that he was severely cognitively impaired. He was totally dependent with bed mobility, transfers, and toileting. Per the MDS, the resident did not have any unhealed pressure ulcers nor did he have any healed pressure ulcers (but see below). Per the assessment, the resident had an indwelling Foley catheter. a. Status - Pressure Ulcer Interventions, Pressure Ulcers on and after Admission (1) [DATE] - Review of an un-timed Physician Telephone Order (PTO) revealed in pertinent part that the resident's heels were to be prepped bilaterally for protection, [MEDICATION NAME] was to be put on his buttocks every shift for protection, and his heels were to be floated while he was in bed at all times. (2) [DATE] - Review of the weekly skin charting revealed in pertinent part that the resident was admitted with two stage II pressure ulcers. The ulcers were behind both of his ears and were caused by his nasal cannula. -By [DATE] the facility documented that both pressure ulcers were healed. -On [DATE] both pressure ulcers were still healed. -On [DATE] the pressure ulcer to the right ear was still healed but the pressure ulcer to the left ear opened back up. It was 0.8 cm X 0.4 cm and was superficial and 100% granulated. The order was to cover with [MEDICATION NAME] and change every three days. The staff was also to ensure that there were foam covers on the 02 cannula. -On [DATE] the resident's right ear ulcer was still healed, the left was 0.3 cm X 0.4 cm. No changes were made to the orders. The pressure ulcer was not documented on [DATE], it was documented as being healed again on [DATE]. (3) Review of PTOs revealed on [DATE] (un-timed) an order for [REDACTED]. (4) [DATE] - the weekly skin charting documented that the resident had a stage II pressure ulcer to his left buttocks which was caused by pressure shearing. It was first observed [DATE] and was acquired in-house. The co-morbidity factors were: incontinence, poor mobility,[MEDICAL CONDITION](hypertension), and [MEDICAL CONDITION]. It was 2.8 cm X 2.4 cm X <0.2 cm. It was 100% granulated and was exuding light sanguineous fluid. The orders were to apply [MEDICATION NAME] every shift, turn and reposition, off-load pressure, incontinence care, barrier cream, offer fluids, chair cushion, and air mattress. -On [DATE] it was 1.6 cm X 1.4 cm X <0.2 cm, it was 90% granulated and 10% slough, and still had light sanguineous liquid exuding from it. It was improving and getting smaller. No order changes. However, on [DATE], a PTO un-timed documented that the open area to his left buttocks was to be cleansed and Calcium Alginate with silver was to placed on the open area. [MEDICATION NAME] was to be placed around the wound and a [MEDICATION NAME] dressing was to be applied and changed every ,[DATE] days. -On [DATE] it was 2 cm X 1.6 cm X <0.2 cm, it was 100% granulated, with light sanguineous liquid still exuding from it. It was improving, no slough was noted. No order changes. On [DATE] it was 1.3 cm X 0.2 cm X <0.2 cm, it was 100% granulated, with light sanguineous liquid still exuding from it. It was improving, no slough was noted, and it was getting smaller. No order changes. -On [DATE] it was documented as having resolved. b. Staff Interview During an interview with the DON, the RLPN, and the unit managers for floor two and three on [DATE] at 2:17 p.m. they stated that the interventions in place for the resident prior to [DATE] (buttocks skin breakdown - see above) were that the resident had a potential for skin integrity problems and his heels were to be floated and his skin was to be kept dry. -They stated when the doctor started [MEDICATION NAME] (diuretic), the resident started having skin breakdown, so they placed a Foley catheter (see above order [DATE]); due to the [MEDICATION NAME], the resident would have to use the bathroom every ten minutes. -Per staff, all other interventions were implemented after his skin breakdown. They said when he was up in his chair, they did not place him back in bed because he was a Sara lift. Because the resident was totally dependent, incontinent of bladder, had poor mobility and required the lift, staff had implemented an up/down schedule. They stated since he acquired the pressure ulcer, his mobility had improved and the pressure ulcer had healed. 4. RESIDENT #7 Resident #7, age 93, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of dislocation of shoulder, difficulty in walking, muscle weakness, other symptoms involving the nervous and musculoskeletal systems, and a lack of coordination. The [DATE] significant change Minimum Data Set (MDS) documented that the resident was able to understand and was able to be understood. She scored a ,[DATE] on the Brief Interview for Mental Status which signified that she was moderately cognitively impaired. Physician order [REDACTED]. a. Pressure Ulcer Development - Facility Response The skin section of the [DATE] significant change MDS documented that the resident had a stage II unhealed pressure ulcer which had first been identified on [DATE] and had granulated tissue. The pressure ulcer had not been present at the previous assessment. The [DATE], 8:40 a.m. care plan documented that the resident had an impairment of her skin integrity. The pertinent approaches included: - Assess skin condition daily and note any changes. - Measure area - Apply pressure relieving devices - Reposition every two hours - Barrier cream to peri-area as needed The [DATE] skin documentation read that the resident had a new in-house acquired pressure ulcer on her right buttock. It was 0.5 cm and circular in shape. It was superficial and the surrounding skin was pink. It was 100% granulated. There was no odor present and the wound edges were intact. The physician and the family were both notified. The treatment was to cleanse and apply Neutrophor cream. The resident was to be encouraged to lie down after meals to off-load pressure. Per the documentation, the resident was non-compliant. The [DATE] skin documentation documented that the resident's pressure ulcer was 0.4 cm and circular in shape. It was superficial and the surrounding skin was pink. It was 100% granulated. There was no odor present and the wound edges were intact. The ulcer was healing and becoming smaller. The treatment was to cleanse and apply Neutrophor cream. The [DATE] skin documentation documented that the resident's pressure ulcer was 0.3 cm X 0.3 cm. It was superficial and the surrounding skin was pink. It was 100% granulated. There was no odor present and the wound edges were intact. The ulcer was healing and becoming smaller. The treatment was to cleanse with Normal Saline (NS) and apply Neutrophor cream. The resident was to be encouraged to lie down after meals to off-load pressure. Per the documentation, staff had tried to encourage the resident to lie down between meals but the resident often refused. The risks and benefits of sitting up vs. lying down were explained to the resident and she did not want to continue the conversation. The nursing staff was going to try da

Based on observation, interview, and record review, the facility failed to ensure one of 56 sample residents (#171) was free from abuse. The resident was verbally abused and sustained multiple bruises and a skin tear when staff attempted to get him in bed against his wishes. Cross-reference F225; investigation and reporting of abuse. Staff failed to timely report and document observed verbal abuse and failed to timely investigate an allegation of physical abuse. The findings include: A. Facility Policy on Abuse "What to do: 1. Create a safe environment for all residents. 2. Assess victim for injury and intervene accordingly. 3. Report the abuse to your supervisor immediately! 4. Document the incident in as much detail as possible. 5. Assure the situation will not occur again. 1. All reports of abuse, neglect and injuries of an unknown source will be promptly and thoroughly investigated by facility management. If you suspect any form of resident abuse, you must notify your supervisor IMMEDIATELY. If you are unable to reach your supervisor, you must contact one of the following: A (Name and phone number) Nursing Home Administrator B ( Name and phone number) Director of Nursing C (Name and phone number) Social Services Manager D (Name and phone number) Risk Manager 2. Our facility will protect residents from harm during investigations of abuse allegation. a. You must make sure ALL residents are safe from harm. b. If a resident is the offender, make sure you remove them from others. c. If a staff member is the offender, have a supervisor or 'Manager on Duty' escort the employee out of the building until an investigation can be completed. d. If a family member is the offender, ask the family member to leave the facility. 3. All suspected cases of incidents of rape MUST be reported immediately to the Administrator and the Director of Nursing. 4. Our facility will not condone any form of resident abuse or neglect. 5. Failure to report abuse is the same as committing the abuse yourself and is subject to suspension, termination, loss of license, and possible criminal charges. 6. It is facility policy to contact the Ombudsman with any allegation. Moreover, the police will be contacted if the allegation is criminal in nature. FORMS OF RESIDENT ABUSE; - Verbal - Sexual - Physical - Mental - Neglect - Involuntary Seclusion - Misappropriation of Property ZERO TOLERANCE FOR ABUSE: Our facility has adopted a standard of zero tolerance towards abuse. These are the components of the abuse prevention program at (the facility): 1. A system for conducting background investigation of potential employees for a history of abuse, neglect, or mistreatment; 2. Ongoing training and orientation of employees on issues related to abuse prohibition practices; 3. Guidelines on how and to whom to report abuse as well as how to identify, correct and intervene in situations in which abuse, neglect, and/or misuse of resident property is likely to occur; 4. Guidelines to identify possible incidents or claims of abuse which need investigation; 5. Guidelines to investigate different types and claims of abuse; 6. Measures to protect our residents from harm during investigations; and 7. Methods for reporting all possible violations and verified incidents as well as our response to the findings of our investigation. WHAT YOU NEED TO KNOW: 1. You must report any case of suspected abuse to your supervisor IMMEDIATELY. 2. If you are unable to contact your supervisor, you may also contact (Name), Director of Nursing (phone number), or (Name), Administrator, at (phone number). 3. Any staff member accused of abuse will be suspended during the investigation. 4. Residents are protected from further harm during abuse investigations. 5. Failure to report abuse is same as committing the abuse yourself and will be prosecuted as so." B. Resident Failure 1. Resident #171, [AGE] years old, was admitted to the facility on [DATE] with a re-admission date of [DATE]. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. According to the physician orders [REDACTED]. According to the minimum data sets ((MDS) dated [DATE], the resident was coded as a 0 (understood) in makes self understood, a 0 (understands) ability to understand others, a 3 (three) in repetition of three words, a 2 (yes, no cue required) for two of the three words for recall and a 0 (no, could not recall) for one of the three words for recall. The resident's brief mental status exam score was 9 (moderate impairment). 2. Observations On 3/16/11 at 9:30 a.m. the resident was observed in his room sitting in his recliner chair. Multiple bruises and a skin tear were observed. -The resident had a large bruise to the inside of his left elbow. The bruise was reddish purple at the center of the elbow and fading yellow on the outside of the elbow. -The resident had a dark purple bruise approximately 3 cm x 0.5 cm on the right side of his left hand, a skin tear covered with a band-aid on the outside of his left forearm, and two dark purple, almost black bruises below and just to each side of the skin tear. The bruise closer to the hand was approximately 2 cm x 1 cm and the bruise closer to the elbow was approximately 2 cm x 2 cm. -The resident also had a red/purple horizontal bruise approximately 7 cm x 1 cm across his right wrist, starting at the inside of the wrist and ending towards the outside, and a red/purple horizontal bruise approximately 4 cm x 1 cm just above the previous bruise, starting from the outside of his right wrist and ending toward the inside of his wrist. 3. Failure to keep resident #171 free from abuse According to a written staff statement completed by a life enrichment assistant, signed and dated on 3/11/11, the resident reported he had been abused by his aide the previous day. He showed the writer some bruises and stated the aide had grabbed him around his neck as well. The resident also stated this was the second time this incident had happened with this same aide. The resident quoted the aide said to him "I don't take s**t from nobody and you're going to get up and go." He repeated this to the writer twice and continued to point to the bruise on his arm. The writer then stated that the resident was immediately taken to the conference room and the incident was reported to the resident's nurse. The nurse instructed the life enrichment assistant to notify the director of nursing (DON); the life enrichment assistant was unable to locate the DON so it was reported to the human resources director. According to a written statement completed by a certified nurse aide (CNA) signed and dated 3/11/11, on the night of 3/10/11 between 10:30 p.m. and 11:00 p.m., resident #171 was sitting by the conference room while the nurses were giving report. He was yelling help me, the night shift nurse turned around and said "stop it right now" then she got up and got in his face and told him she was "not going to take his s**t" she began to push him to his room while his feet were dragging. Resident #171 was in his wheelchair. The nurse took him to his room, closed the door and 15 minutes later came out and said he was in bed. According to a written statement completed by a licensed practical nurse (LPN) signed and dated on 3/14/11, she was giving report to the on-coming night shift nurse. At this time resident #171 was in the hallway yelling, suddenly the night shift nurse got upset and left the room. She started telling the resident she was not going to "take his s**t", that his behavior was unacceptable. She was wheeling him the down the hall taking him to his room still talking to the resident; the nurse wrote that she was unable to hear the entire conversation. 4. Interviews On 3/16/11 at 9:15 a.m. the Director of Nursing (DON) stated she had immediately suspended the night shift nurse the resident had made the allegations about. However, see below; the DON was not notified of the incident until 1:00 p.m. on 3/11/11. The night shift nurse had continued to work her shift which involved caring for resident #171. On 3/16/11 at 9:30 a.m. resident #171 was interviewed. -When asked how he got the bruise on his arms, the resident stated, "Either a certified nurse aide (CNA) or nurse, got abusive with me a couple days ago. I was supposed to go to bed and didn't want to, the nurse said, "I don't take s**t from anyone, you will go to bed." "She took me to my room and threw me down on the bed. I have had problems with her about two to three weeks ago too." -The resident said the staff member grabbed him by the collar and wrapped her arms around his waist and threw him on the bed. He stated, "I was scared because I had the encounter with her before. I told the police that I am afraid to live here. I feel fearful now." When asked what time this all took place, the resident stated about 10:00 p.m. He stated that the staff member was mean and vicious. On 3/16/11 at 2:05 p.m., a LPN, who witnessed the incident but did not provide a written statement, was interviewed. She said she was giving report in the conference room, along with the other evening shift nurse, to the on-coming night shift nurse and resident #171 was screaming in the hallway. -The LPN said the night shift nurse got up and said to the resident she wasn't going to tolerate this behavior and that she wasn't going to put up with his s**t. The night shift nurse wheeled him to his room. -The LPN indicated she couldn't see them or hear them once they went around the corner. She stated she remained in the conference room and at her medication cart until the nurse returned. She stated that the nurse did not say anything to her when she returned but she appeared frazzled. -The LPN said she did not report the incident to anyone until she was asked about it once she came into work the next day. On 3/16/11 at 2:26 p.m., the CNA who provided the written statement above dated 3/11/11 was interviewed. The CNA said she was there and witnessed the incident between resident #171 and the night shift nurse. She repeated the incident as written in her statement above. She also indicated that no one went into the room while the resident and nurse were in there. She stated she and the nurse worked together for the entire night shift and they were responsible for caring for the resident. When asked if she had reported the incident to anyone, she stated "no. She said she was asked about it and then provided a statement. She indicated she knew she was responsible for reporting and intervening with any abuse incident but she was new and was scared to say anything. On 3/16/11 at 2:50 p.m. the LPN who provided the written statement above dated 3/14/11 was interviewed. She stated she had not reported the incident and that she had received a message at home from the facility related to the incident. She stated that when she returned their call she told them what had happened (see written statement above). She was informed she would need to provide a written statement when she returned to work. She stated she had not gone into the resident's room or intervened during the incident. She indicated she was aware she was supposed to intervene and report any abuse immediately. She stated she felt like this incident was abusive and she didn't really know why she hadn't followed the proper procedure. On 3/16/11 at 4:20 p.m. the DON was interviewed. -The DON indicated she was notified about the incident by the human resources director about 1:10 p.m. on 3/11/11. She stated she interviewed the resident briefly and he stated that last night (3/10/11) he had not wanted to go to bed and one of the caregivers had gotten rough with him. -The DON said the regional nurse consultant (RNC) interviewed the resident, spoke to the family and handled the interactions with the police officer. The DON indicated she interviewed the LPNs on the evening shift; one was out sick and was interviewed over the phone. This LPN provided the written statement. -The DON had a copy of the statements and she stated the statement reflected what the LPN had told her. The DON stated she called the police on 3/11/11 at 1:30 p.m. to report the verbal abuse. -The DON said the resident is alert and oriented and a good historian, very credible. And, when the night shift nurse came into the facility to provide a statement to the police, the resident pointed her out to the DON. -The DON stated she would expect the staff to intervene and report all abuse immediately. She stated she provided a verbal warning to the two LPNs and the one CNA regarding their failure to report and intervene with abuse.

Based on observations, record review and interviews, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source involving two of 56 sample residents (#2 and #171) were reported immediately to the administrator and thoroughly investigated. Specifically: -The facility failed to immediately report observed verbal abuse directed toward resident #171, failed to timely assess the resident, failed to timely initiate an investigation and failed to take steps to keep the resident safe from further abuse. -The facility failed to thoroughly investigate an injury of unknown origin for resident #2 -The facility failed to ensure staff were fit to serve. The findings include: A. Facility Policy and Procedures on Abuse The facility policy on abuse was requested from the Nurse Consultant on 3/10/11 at 10:00 a.m. Review of the policy revealed the following information: "WHAT TO DO: 1. Create a safe environment for all residents. 2. Assess victim for injury and intervene accordingly. 3. Report the abuse to your supervisor immediately! 4. Document the incident in as much detail as possible. 5. Assure the situation will not occur again. 1. All reports of abuse, neglect and injuries of an unknown source will be promptly and thoroughly investigated by facility management. If you suspect any form of resident abuse, you must notify your supervisor IMMEDIATELY. If you are unable to reach your supervisor, you must contact on of the following: A (Name and phone number) Nursing Home Administrator B ( Name and phone number) Director of Nursing C (Name and phone number) Social Services Manager D (Name and phone number) Risk Manager 2. Our facility will protect residents from harm during investigations of abuse allegation. a. You must make sure ALL residents are safe from harm. b. If a resident is the offender, make sure you remove them form others. c. If a staff member is the offender, have a supervisor or 'Manager on Duty' escort the employee out of the building until an investigation can be completed. d. If a family member is the offender, ask the family member to leave the facility. 3. All suspected cases of incidents of rape MUST be reported immediately to the Administrator and the Director of Nursing. 4. Our facility will not condone any form of resident abuse or neglect. 5. Failure to report abuse is the same as committing the abuse yourself and is subject to suspension, termination, loss of license, and possible criminal charges. 6. It is facility policy to contact the Ombudsman will any allegation. Moreover, the police will be contacted if the allegation is criminal in nature. FORMS OF RESIDENT ABUSE; - Verbal - Sexual - Physical - Mental - Neglect - Involuntary Seclusion - Misappropriation of Property ZERO TOLERANCE FOR ABUSE: Our facility has adopted a standard of zero tolerance towards abuse. These are the components of the abuse prevention program at (the facility): 1. A system for conducting background investigation of potential employees for a history of abuse, neglect, or mistreatment; 2. Ongoing training and orientation of employees on issues related to abuse prohibition practices; 3. Guidelines on how and to whom to report abuse as well as how to identify, correct and intervene in situations in which abuse, neglect, and/or misuse of resident property is likely to occur; 4. Guidelines to identify possible incidents or claims of abuse which need investigation; 5. Guidelines to investigate different types and claims of abuse; 6. Measures to protect our residents from harm during investigations; and 7. Methods for reporting all possible violations and verified incidents as well as our response to the findings of our investigation. WHAT YOU NEED TO KNOW: 1. You must report any case of suspected abuse to your supervisor IMMEDIATELY. 2. If you are unable to contact your supervisor, you may also contact (Name), Director of Nursing (phone number), or (Name), Administrator, at (phone number). 3. Any staff member accused of abuse will be suspended during the investigation. 4. Residents are protected from further harm during abuse investigations. 5. Failure to report abuse is same as committing the abuse yourself and will be prosecuted as so." B. Facility Failures in Addressing Abuse Allegations 1. Resident #171 Resident #171, [AGE] years old, was admitted to the facility on [DATE] with a re-admission date of [DATE]. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. According to the physician orders [REDACTED]. According to the minimum data sets ((MDS) dated [DATE], the resident was coded as a 0 (understood) in makes self understood, a 0 (understands) ability to understand others, a 3 (three) in repetition of three words, a 2 (yes, no cue required) for two of the three words for recall and a 0 (no, could not recall) for one of the three word for recall. The resident's brief mental status exam score was 9 (moderate impairment). a. Observation On 3/16/11 at 9:30 a.m. the resident was observed in his room, sitting in his recliner chair. Multiple bruises and a skin tear were observed. -The resident had a large bruise to the inside of his left elbow. The bruise was reddish purple at the center of the elbow and fading yellow on the outside of the elbow. -The resident had a dark purple bruise was approximately 3 cm x 0.5 cm on the right side of his left hand, a skin tear covered with a band-aid on the outside of his left forearm, and two dark purple, almost black bruise below and just to each side of the skin tear. The bruise closer to the hand was approximately 2 cm x 1 cm and the bruise closer to the elbow was approximately 2 cm x 2 cm. -The resident also had a red/purple horizontal bruise approximately 7 cm x 1 cm across his right wrist, starting at the inside of the wrist and ending towards the outside, and a red/purple horizontal bruise approximately 4 cm x 1 cm just above the previous bruise, starting from the outside of his right wrist and ending toward the inside of his wrist. b. Abusive incident 3/10/11 On 3/16/11 at 9:30 a.m. resident #171 was interviewed. -When asked how he got the bruise on his arms, the resident stated, "Either a CNA (certified nurse aide) or nurse, got abusive with me a couple days ago. I was supposed to go to bed and didn't want too, the nurse said, "I don't take s**t from anyone, you will go to bed." "She took me to my room and threw me down on the bed. I have had problems with her about two to three weeks ago too." The resident stated the staff member grabbed him by the collar and wrapped her arms around his waist and threw him on the bed. He stated "I was scared because I had the with encounter her before. I told the police that I am afraid to live here. I feel fearful now." When asked what time this all took place the resident stated about 10:00 p.m. He stated the staff member was mean and vicious. According to a written staff statement, completed by a life enrichment assistant, signed and dated on 3/11/11, the resident reported he had been abused by his aide the previous day. He showed the writer some bruises and stated she had grabbed him around his neck as well. The resident also stated this was the second time this incident had happened with this same aide. The resident quoted the aide said to him "I don't take s**t from nobody and you're going to get up and go." He repeated this to the writer twice and continued to point to the bruise on his arm. The writer then stated that the resident was immediately taken to the conference room and the incident was reported to the resident's nurse. The nurse instructed the life enrichment assistant to notify the director of nursing (DON); the life enrichment assistant was unable to locate the DON so it was reported to the human resource director. According to a written statement completed by a certified nurse aide (CNA) signed and dated 3/11/11, on the night of 3/10/11 between 10:30 p.m. and 11:00 p.m., resident #171 was sitting by the conference room while the nurses were giving report. He was yelling help me, the night shift nurse turned around and said "stop it right now" then she got up and got in his face and told him she was "not going to take his s**t" she began to push him to his room while his feet were dragging. Resident #171 was in his wheelchair. The nurse took him to his room, closed the door and 15 minutes later came out and said he was in bed. According to a written statement completed by a licensed practical nurse (LPN) signed and dated on 3/14/11, she was giving report to the on-coming night shift nurse. At this time resident #171 was in the hallway yelling, suddenly the night shift nurse got upset and left the room. She started telling the resident that she was not going to "take his s**t", that his behavior was unacceptable. She was wheeling him the down the hall taking him to his room still talking to the resident; the nurse wrote that she was unable to hear the entire conversation. Another LPN on duty the evening of 3/10/11 did not provide a written statement. c. Failure to immediately report observed verbal abuse, timely assess resident, initiate an investigation and take steps to keep the resident safe from further abuse. (1) Record Review The medical record (review of nurses notes and progress notes from 3/10/11 to 3/16/11) revealed no documentation of the incident involving the resident and the night nurse 3/10/10 and no documentation 3/10/11 or 3/11/11 about the bruises on the resident's arms and wrists. A note 3/12/11 at 7:00 a.m. documented the resident continued with bruising to both forearms. There was no further description of the bruising. According to the skin assessment dated [DATE]-3/12/11 and 3/14/11-3/16/11, a head to toe assessment was completed and skin was intact with no redness or bruising noted with no new areas noted. On 3/13/11 the skin assessment stated no new areas noted. Review of the employee files for the two LPNs and the CNA on duty 3/10/11 revealed there was no documentation of disciplinary action or education related to the observed and reported verbal abuse of resident #171 on 3/10/11. (2) Interviews On 3/16/11 at 9:15 a.m. the Director of Nursing (DON) stated she had immediately suspended the night shift nurse the resident had made the allegations about. However, see interview below; the DON was not notified about the incident by the human resources director about 1:10 p.m. on 3/11/11. On 3/16/11 at 2:05 p.m. , an LPN who was witnessed the incident but did not provide a written statement, was interviewed. -The LPN indicated she was giving report in the conference room, along with the other evening shift nurse to the on-coming night shift nurse and resident #171 was screaming in the hallway. -The LPN said the night shift nurse got up and said to the resident she wasn't going to tolerate this behavior and that she wasn't going to put up with his s**t. The night shift nurse wheeled him to his room. -The LPN indicated she couldn't see them or hear them once they went around the corner. She stated she remained in the conference room and at her medication cart until the nurse returned. She stated that the nurse did not say anything to her when she returned but she appeared frazzled. -The LPN said she did not report the incident to anyone until she was asked about it once she came in to work the next day. On 3/16/11 at 2:10 p.m. the regional clinical consultant (RCC) indicated there were no incident reports related to resident #171's bruising. On 3/16/11 at 2:26 p.m. the CNA who provided the written statement above dated 3/11/11 was interviewed. The CNA indicated she was there and witnessed the incident. She repeated the incident as set forth in her written statement. -The CNA said no one went into the room while the resident and nurse were in there. She stated she and the nurse worked together for the entire night shift and that they were responsible for caring for the resident. -When asked if she had reported the incident to anyone she stated "no." She said she was asked about the incident and then provided a statement. She indicated she knew she was responsible for reporting and intervening with any abuse incident but she was new and was scared to say anything. On 3/16/11 at 2:45 p.m., bruising to the resident's arms and hands was observed in the presence of the regional clinical consultant (RNC). -The RNC stated the bruises on the left hand and arm were from blood draws but that she was unaware of the bruising to the right wrist. However, record review revealed the resident's most recent blood draw was on 2/24/11. -The RNC stated she would not expect to see any follow up (regarding the resident's bruising) because the resident bruises easily, he has a care plan for it and his family is aware. -The RNC was asked about the resident's skin assessments (see above). She indicated she had seen the nurse documentation stating that the resident had had head to toe assessments completed that had not noted redness or bruising. She indicated she would expect to see the bruising noted on the skin assessments completed by the nurses. On 3/16/11 at 2:50 p.m. the LPN who provided the written statement above dated 3/14/11 was interviewed. -The LPN stated she had not reported the incident and that she had received a message at home from the facility related to the incident. She stated that when she returned their call, she told them what had happened (see written statement documentation above). She said she was informed that she would need to provide a written statement when she returned to work. -The LPN stated she had not gone into the resident's room or intervened during the incident with the night nurse. She said she was aware she was supposed to intervene and report any abuse immediately. She stated she felt like this incident was abusive and she didn't really know why she hadn't followed the proper procedure. On 3/16/11 at 4:20 p.m. the DON was interviewed. -The DON said she was notified about the incident by the human resources director about 1:10 p.m. on 3/11/11. She stated she interviewed the resident briefly and he stated last night (3/10/11) he had not wanted to go to bed and one of the caregivers had gotten rough with him. -The DON said the RNC interviewed the resident, spoke to the family and handled the interactions with the police officer. -The DON said she interviewed the LPNs on the evening shift. One was out sick and was interviewed over the phone; this was the LPN who provided a written statement. The DON had a copy of the statements and she stated the statement reflected what the LPN had told her. -The DON stated she called the police on 3/11/11 at 1:30 p.m. to report the verbal abuse. -The DON said resident #171 is alert and oriented and a good historian, very credible. And, when the night shift nurse came into the facility to provide a statement to the police, the resident pointed her out to the DON. -The DON stated she would expect the staff to intervene and report all abuse immediately. She stated she provided a verbal warning to the two LPNs and the one CNA who were on duty 3/10/11, regarding their failure to report and intervene with abuse. 2. Resident #2 Resident #2, age 71, was admitted to the facility on [DATE] with diagnoses, according to the computerized physician orders, of [MEDICAL CONDITION], hypertension, dementia, and [MEDICAL CONDITION]. According to the 1/27/11 significant change minimum data set (MDS), the resident was coded as usually able to make herself understood and was usually able to understand others. The resident scored 3/15 on the brief interview for mental status (BIMS). The resident exhibited disorganized thinking and inattention; the resident did not have any mood or behavior problems documented during the assessment period. The resident required extensive assistance with bed mobility, transfers, toileting and dressing. She was incontinent of bowel and bladder. a. Complaint On 3/7/11 at 9:30 a.m. a complaint was received by the Health Facilities and Emergency Medical Services Division alleging that a staff member, who was assisting resident #2 with dressing prior to a doctor's appointment, was struggling with putting an earring in and re-pierced the resident's ear, causing a new hole (in the ear lobe). The complainant further alleged that staff struck the resident in the ear causing bruising and swelling. The complainant stated that a nurse was notified on 3/4/11 and cleaned the ear up, and that the (nursing home) administrator (NHA) was also notified of incident on Friday 3/4/11. The police were notified by the complainant to investigate on 3/6/11, as, according to the complainant, the facility had not responded to their concerns regarding suspected abuse. b. Interviews and Observations During observations and interview on 03/07/11 at 5:30 p.m., resident #2 was observed to have two holes in her left ear and one hole in the right ear. The left ear appeared to have an old, torn ear piercing measuring approximately 2 cm and an additional reddened pinpoint hole to the left of the previous piercing. The outer ear cartilage of the left ear was swollen and three additional reddened areas were observed on the outer ear cartilage as well. The resident stated that she was not sure what happened to her ear last week, but said a staff member "smacked me and I don't know why." During an interview with a family member on 3/7/11 at 5:45 p.m. she stated that the resident had just returned from the hospital on [DATE], as she had pneumonia. She stated that the swelling and redness on the resident's left ear had gone down. She said she first noticed blood on the left earlobe on 3/3/11. She said the facility was not responding to the family's concerns regarding the injury to the resident's ear or to resident #2's expressions that she "is afraid." The family member stated her sister had filed a grievance with the facility on 3/4/11, reporting the resident's injury, as well as other issues. She said she had notified the police of her concerns on 3/6/11. Resident #2 was interviewed on 3/8/11 at 1:41 p.m. Resident #2 stated, "She just yanked on my ear when I was getting dressed for my doctor's appointment." The resident was asked if it hurt her and she responded, "Sure." The resident described the staff member as, "not too tall, un-tinted hair, and she was nicely proportioned." The resident did not recall whether the staff member had worked with her before. She said her ear bled a little bit as, "She smacked me up side of the head." In response to how the resident felt regarding the incident she stated, "It made me feel bad, and I didn't respond to her at all. I was disgusted." c. Facility failure to timely initiate a thorough investigation and take steps to keep the resident safe from further potential abuse. (1) Record Review The resident's medical record (review of nurses' notes and progress notes from 3/3/11 to 3/8/11) revealed no documentation of an incident involving the resident and a staff member. Further review of nurses' notes revealed: -On 3/3/11 at 3:15 a.m. the nurse documented that a head to toe assessment was completed and the resident skin was intact, with no redness or bruising noted. -On 3/4/11 at 1:35 a.m. the nurse documented that a head to toe assessment was completed and the resident skin was intact, with no redness or bruising noted. -On 3/4/11 at 11:09 p.m. the nurse documented that the resident's (family member) was visiting this evening. The nurse documented the following in pertinent part..., "Noted 1 cm scratch to (left) earlobe. Outer area of ear appears slightly more swollen than(right) ear. Ear was cleaned and TAO was applied, though no (signs/symptoms) of infection present. Pt states her ear does not hurt..." -On 3/5/11 at 3:14 a.m. the nurse documented that a head to toe assessment was completed and the resident skin was intact, with no redness or bruising noted. -On 3/6/11 at 12:44 a.m. the nurse documented that a head to toe assessment was completed and the resident skin was intact, with no redness or bruising noted. -On 3/6/11 at 12:45 a.m. the nurse documented that a head to toe assessment was completed and the resident skin was intact, with no redness or bruising noted. (2) Director of Nursing (DON) Interview The Director of Nursing (DON) was interviewed on 3/7/11 at 5:05 p.m. -The DON stated that she had received a phone call from the Nursing Home Administrator (NHA) on 3/3/11, requesting she come to his office to discuss resident #2's family's complaints regarding, in part, that resident #2 had blood on her earring. She said the family had other complaints as well, regarding the resident's cleanliness. -The DON stated that regarding the blood on the earring, "The earring thing, that happens to a lot of people, I didn't really get concerned about that." The DON had statements which the NHA had sent by email from the two certified nurse aides (CNAs) taking care of resident #2, indicating that they had not noticed any blood on the resident's ear. -The DON indicated she had proceeded to investigate the family's other complaints over the next several days. However, she did not investigate the alleged injury to the resident's ear. She did not directly interview staff, interview the resident or interview the resident's family member after receiving the grievance on 3/4/11. -The DON stated that she came to work on 3/6/11 because she had a lot of paperwork to do and she stated, "I was up in my office around 5-6 p.m. and they called me from the floor and said (resident #2) was in the lobby with her (family member), waiting for the police. I called (the Administrator), then went down and asked her about it." -The DON said that was when the family member told her then that resident #2 had been slapped on the side of the face and had her hair pulled. The DON said, "I was 10 feet away, (I) didn't see any swelling or bruising," although the DON said there was a small red area on the resident's ear, and a small nick in her left ear (gesturing to top of left ear), -The DON, after talking to the family member on 3/6/11, said she checked with the hair dresser because she thought the resident's ear might have been nicked by scissors during a hair cut, but the hair dresser said she hadn't cut the resident's hair. The DON acknowledged that she did not interview the resident at that time, and did not try to get closer to examine the resident because "(I) didn't want them (resident #2 and her family member) to feel intimidated; they have a right to contact the police about anything they want to." -The DON said that based on resident #2's description of the staff involved (white, short brown hair, young), she had sent the staff member assigned to care for the resident home "today," (3/7/11) even though she didn't meet the resident's description. She said the CNA had told her she hadn't done anything with the resident's earring on 3/3/11; she had just gotten the resident changed and dressed. -The DON confirmed that the CNA who worked with the resident on 3/4/11 also had worked with the resident on 3/4/11 and was scheduled to work on 3/7/11. -The DON stated that today (3/7/11) in the morning, she "started investigating every single person working from Thursday to today, going through the staff to see who has short brown hair. The DON stated she was still in the progress of investigation, and she had interviewed several residents on that floor where the CNA who cared for resident #2 worked. The DON said she had talked to the resident today (3/7/11) and she had said that the CNA was trying to put the earring in for her and it was in the wrong place. The DON stated that the ear was red and you could tell there was pressure but the ear was not punctured all the way through. -The DON said that she had seen resident #2 in the facility lobby on 3/3/11, laughing, smiling, interacting with people and waiting for her ride. She said the resident had no complaints. The DON then stated, "I didn't interpret the earring thing as someone intentionally trying to hurt the resident so didn't take any action at that point." -The DON said she had requested today (3/7/11) that the social worker (SW) for the resident's floor talk to resident #2. The DON had the resident placed on 15-minute checks because of family complaints and to make sure she's was OK. -The DON stated she had reported the allegation of abuse to the state at 3:00 p.m. on 3/7/11 after finding out yesterday that police had assigned a case number. The DON stated, "Initially I was working this up as a resident concern, looking to see if I needed to go beyond that, and from everything I gathered from the physician and my staff, I didn't think we had neglect. But I was continuing the investigation." d. Additional Staff Interviews On 3/7/11 at 5:32 p.m. the second floor SW, who was familiar with resident #2, was interviewed. -The SW said that she usually speaks to the resident on a daily basis, and that she does the quarterly assessments. The SW described the resident, per assessments, as having a bit of short/long term memory loss, some hampered decision making but slight, she can make her needs known, takes her a little bit of time. The SW said she did not know if the resident could remember names, but she could remember faces. The SW said the resident may remember a face but not the date that I saw her last . -The SW stated that she had spoken to the resident's family member on 3/3/11 and 3/4/11, and the family member had not said anything on those two days about the resident being hit. The SW said she found out about that allegation this morning (3/7/11). -The SW said s/he didn't do anything at that point because DON was investigating, although she said she later interviewed neighboring residents, interviewed resident #2 about 9 a.m. after breakfast this morning (3/7/11). She said resident #2 informed her that she was slapped on the left side of the face, said the (staff) had short hair and was fairly short, couldn't remember her name. The SW stated, "(When) I asked why she didn't report it when it happened, she said she'd forgotten about it. I asked her what day it happened, she couldn't remember what day, that's about it." -The SW said she did not ask the resident if she was afraid. She said she talked to other residents in that area and none of them had anything bad to say about the CNA who was sent home. The SW stated she was instructed to ask the residents about the one particular CNA, not about any other staff. The SW said she interviewed residents she "thought this aide would have in that area. I figured she would have had about 5-6 that were able to answer questions. There was a total of about 10-11 that she would normally have taken care of, sharing with the other CNA. The SW had no other information regarding the incident. e. Time Sheet Review Review of the time revealed that on 3/3/11 and 3/4/11 the CNA who worked with resident #2 on 3/3/11, and who was suspended on 3/7/11 (see DON interview above), worked the day shift (6 a.m. to 2 p.m.) on both days. The CNA was not scheduled to work on 3/5/11 or 3/6/11, but was scheduled for the day shift on 3/7/11. C. Facility Failure to Sufficiently Screen Staff 1. Review on 3/16/11 at 11:30 a.m. of the employee record for the CNA who cared for resident #2 on 3/3/11, revealed that the last name of the CNA as written on her driver's license and social security card did not match the last name of the CNA on the CNA license. Review of the background check from the Department of Public Safety on 3/16/11 revealed that the background check was completed under the last name matching the social security card and drivers license, not the name on the CNA license. Review of the CNA's employment application revealed that no reference checks had been completed. During an interview on 3/16/11 at 1:45 p.m. with the staff development coordinator (SDC) she was asked how she knew the CNA was who she said she was, due to the different last name on the CNA license. The SDC responded that she asked the CNA if the last name was hers and she had responded yes. The SDC admitted she had not requested any documentation to verify that the CNA license belonged to the employee who had a driver's license and social security card under a different last name. She admitted that she did not believe it was possible that someone would work under a stolen license, and could not imagine that things like that happened. During an interview on 3/16/11 at 2:00 p.m. with a staff member from the Board of Nursing (BON) she stated that they did not have any record of the CNA name (current last name) under the listed names for that person's CNA license. The BON gave the surveyor the current last name and a second last name of the CNA license and neither name matched the CNA's documentation. The BON stated they required a name change be completed within 30 days. The SDC, during the interview on 3/16/11, stated there are two people verifying references, she and another employee, and he usually put a check by the reference he has contacted, and she usually documented on the form. However, there was no reference checked off or other form completed for the CNA in question to show that reference checks had been done. On 3/16/11 at 4:22 p.m. the SDC brought the facility check list for new hires prior to attending orientation and working on the floor. The facility performs two satisfactory reference checks, background check, Medicare fraud check, sex offender check, license verification, and a drug screen. During an interview on 3/16/11 at approximately 3:00 p.m. the director of nursing (DON) stated that she would have called and validated the registry, and asked for a copy of the marriage license. On 3/16/11 at approximately 4:40 p.m. the CNA provided court documents which verified her identity for current and previous names used. D. Staff Education on Abuse On 3/10/11 at 11:00 a.m., documentation of an abuse inservice was requested from the Staff Development Director (SDC). The SDC provided the agenda and the sign-in sheets for the two most recent inservices on Abuse and Neglect. -The SDC stated that on 12/1/10, the Ombudsman did a presentation on Abuse and Neglect at an All Staff meeting. -The SDC said that because not all of the staff was able to attend the Ombudsman's presentation, the facility's administrative staff did another presentation on 2/23/11, including the same information as provided by the Ombudsman. The second inservice was attended by a much greater number of staff than had attended the first inservice. On 3/16/11, at about 10:00 a.m. ( after two additional complaints of resident abuse had been received) the Nurse Consultant stated that all the staff would be inserviced on abuse the following week. The Nurse Consultant was asked for an agenda for the upcoming inservice. On 3/16/11 at 4:00 p.m., the Nurse Consultant provided a copy of the Power Point slides that were to be used for the upcoming abuse training. The slides reviewed the facility's policy on employee screening, as well as abuse and neglect.