Every finding on record at Bent County Healthcare Center

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, entrance to the dish room and the dish receiving room were identified and corrected in a timely manner. Findings include: I. Facility policies and procedures The Floors policy, revised December 2009, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:51 a.m. The policy revealed all floors should be mopped, cleaned and or vacuumed daily in accordance with the facility's established procedures. The environmental services director (ESD) maintained floor-cleaning procedures. Inquiries concerning floor care should be directed to the director of housekeeping services. The Maintenance Service policy, revised December 2009, was provided by the NHA on 5/1/25 at 11:45 a.m., the policy revealed maintenance services should be provided to all areas of the facility, ground and equipment. The maintenance department was responsible for maintaining the facility, grounds, and equipment in a safe and operable manner at all times. The department should maintain the facility in good repair and free from hazards. The department should routinely schedule maintenance services to all areas of the facility. The ESD was responsible for developing and maintaining a schedule of maintenance services to assure that the facility, grounds, and equipment were maintained in a safe and operable manner. The ESD was responsible for maintaining work order requests and maintenance schedules. II. Observations An environmental tour of the kitchen and dish washing room was conducted on 4/28/25 at 9:30 a.m. Observations revealed multiple rags were on the floor under the three compartment sink and there were multiple rags wrapped around two of the feet attached to the steamer unit.There were several cut marks on the linoleum floor in the dishwashing room and one hole in the linoleum floor under the reach in freezer. A second environmental tour of the kitchen and dish room was conducted on 4/28/25 3:46 p.m. The rear entrance room to the dishwashing room revealed bubbled paint on two of the walls and there was separation of the seam in the linoleum floor. There was also a corner of the room where the cove base was not caulked. There was debris in the corner of the room.There was approximately four inches of linoleum floor adjacent to the room's cove base that was discolored. The transition strip was missing at the rear entrance to the dishwashing room. The dishwashing room had several cut marks in the linoleum floor. There were multiple brown spots on the ceiling and an unfinished sheet rock area on one wall. There was debris in the corners of the room and there was separation of the cove base along one room wall. There was approximately four inches of soiled/discolored linoleum floor adjacent to the room's cove base. There was a hole in the wall above the cove base on one wall, lint/debris on the white plastic water drain pipes, and torn/separated linoleum floor adjacent to the floor drain. There was an approximately four inch hole in the wall near the dishwashing unit and standing water under the dishwashing unit. There were four missing wall tiles, black discoloration with lint in the stainless steel hood exhaust vent over the dishwashing machine and black discoloration in multiple areas in the stainless steel hood over the dishwashing machine. There was approximately eight feet of brown/black discolored caulk at the interface of the stainless steel and the wall tile along the entrance to the dishwashing machine. The dish receiving room that was adjacent to the dishwashing room had several cut marks in the linoleum floor. There was sheet rock damage on the ceiling, three six-inch black discoloration circles on the ceiling and multiple brown discoloration stains on the ceiling. The grout had brown stains on it. There was an approximately four inch hole in the linoleum floor and brown/black discoloration on the 3/4 inch grout at the end of the stainless steel dishwasher discharge table. A third environmental tour was conducted 4/29/25 at 8:45 a.m. Kitchen observations revealed sheet rock damage with cove base separation on one wall and debris on the floor under the three-compartment sink. There was missing cove base under the second hand-washing sink located under the kitchen windows. There was debris on the floor behind the steamer unit and the spice rack. There was sheet rock damage under the fire extinguisher. III. Staff interviews and observations On 5/1/25 at 3:23 p.m., a fourth environment tour was conducted with the dietary manager (DM) and the ESD. They observed and documented each of the above items. The ESD said he did not have any work orders in the last six months of the items observed. The ESD said that staff filled out work orders on a tri-carbon form and placed them in a box on the wall outside his office. The ESD said he reviewed this box several times a day. He said the staff could also call him for any environmental issues. The DM said the kitchen staff deep cleaned the kitchen, dish room and the dish receiving room each month. She said by the above observations, the staff were not cleaning all the way up to the baseboard in these areas. She said the deep cleaning should include all of the floor and the baseboards.

Based on observations, record review and interviews, the facility failed to ensure four (#29, #32, #35 and #36) out of 14 received activities to meet the needs and interests of the residents out of 20 sample residents. Specifically, the facility failed to: -Provide person-centered activities for Resident #29, Resident #32, Resident #35 and Resident #36; and, -Ensure Resident #32 and Resident #36 were assisted to a group activity when they requested to attend. Findings include: I. Facility policy and procedure The Activities policy, revised June 2018, was provided by the nursing home administrator (NHA) on 5/1/25 at 5:29 p.m. It read in pertinent part, Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review. Attendance records are used when completing residents' progress notes to determine their participation as it relates to their activity plan. Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental, and emotional needs. Activities calenders are posted in high-visibility and high-traffic areas in the facility at a height that is readable from a wheelchair. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities program provides individualized activities consistent with the overall goals of an effective activities program. Individualized activities are reflective of the resident's activity interests, as identified in the activity assessment, progress notes and the resident's comprehensive care plan. Activities for residents with behavioral or emotional problems who cannot participate in group activities include: uncomplicated activities that can be adapted to the level of the individual's behavioral or attention function, activities requiring short periods of of concentration to reduce frustration, and activities tailored to address specific underlying causes of the individual's behavioral or attention limitations. Residents who choose not to attend group activities are encouraged to participate in independent activities. It is the responsibility of the facility and activity staff to make regular contact with residents who choose to pursue independent activities, maintain appropriate records, and offer supplies, as needed. II. Posted activities calendar The daily activities posting was observed hanging on the wall in a plastic wall sign holder in the special care unit. The posting was changed daily by the activities director (AD). The daily calendar documented the following activities: On 4/29/25: -10:00 a.m. Strawberry Crunch cookies -12:00 p.m. Daily Devotion in the main dining room -2:00 p.m. Stuck in the Mud On 4/30/25: -10:00 a.m. Butterflies -12:00 p.m. Daily Devotion in the main dining room -2:00 p.m. Bingo On 5/1/25: -10:00 a.m. May Day Coloring -12:00 p.m. Daily Devotion in the main dining room -2:30 p.m. Bible Study -3:15 p.m. May Day III. Resident #29 A. Resident status Resident #29, age 74, was admitted on [DATE]. According to the May 2025 computerized physician's orders (CPO), diagnoses included unspecified dementia, type two diabetes, age-related cognitive decline and generalized anxiety disorder. The 4/1/25 minimum data set (MDS) assessment revealed Resident #29 was unable to complete the brief interview for mental status (BIMS). The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment further revealed she was severely impaired in her daily decision-making. The MDS assessment revealed Resident #29 required partial to moderate assistance when wheeling in her wheelchair and needed substantial to maximal assistance with most of her activities of daily living (ADL). The 12/30/24 MDS assessment revealed Resident #29 was rarely/never understood. The staff assessment documented Resident #29 preferred reading books, newspapers or magazines, listening to music, being around animals, doing things with groups of people, participating in her favorite activities and participating in religious activities. B. Observations On 4/28/25 at 11:05 a.m. Resident #29, who resided on the special care unit, was sleeping at the table in the common room. The television was playing country music. There were no other activities going on. Observations of the unit revealed there were no individual activities available such as books or magazines, puzzles. During a continuous observation on 4/29/25, beginning at 11:15 and ending at 2:19 p.m., the following was observed: At 11:15 a.m. Resident #29 was sitting in the common area with other residents. No activities were being conducted. At approximately 1:30 p.m. Resident #29 was assisted to her recliner after lunch. At 2:19 p.m. Resident #29 continued to sit in the recliner. She was not invited to the activity that started at 2:00 p.m. per the posted activities calendar (see calendar above). During a continuous observation on 4/30/25, beginning at 9:09 a.m. an ending at 1:30 p.m., the following was observed: At 9:09 a.m. the AD was in the special care unit and told the staff that she was going to do the butterfly activity (craft) on the special care unit. She switched the activities schedule to the correct date. At 9:17 a.m. the AD entered Resident #29's room. She did not invite Resident #29 to the butterflies activity. At approximately 1:30 p.m. Resident #29 was assisted to her recliner after lunch. The AD was inviting residents on the special care unit to Bingo, she did not invite Resident #29. C. Record review The activities care plan, initiated on 4/3/25 and revised on 4/28/25, revealed Resident #29 liked pizza, enchiladas, card games, drawing, painting, old western movies and black and white movies. She enjoyed reading biographies and true stories. She enjoyed listening to blue grass and Spanish music. Pertinent interventions were providing the resident with independent activities of interest when requested, inviting and providing assistance to activities of interest, helping the resident turn on the television when requested. The care plan documented the activities staff would provide one-on-one social conversation if she chooses to stay in her room. According to the activity participation logs for February 2025 (2/1/25 to 2/28/25) March 2025 (3/1/25 to 3/31/25) and April 2025 (4/1/25 to 4/30/25), Resident #29 participated in activities several days a week. IV. Resident # 32 A. Resident status Resident #32, age 86, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified dementia, type two diabetes, other depressive episodes and other anxiety disorders. The 2/6/25 MDS assessment revealed the resident was unable to complete the BIMS assessment. The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment revealed she was moderately impaired in her daily decision-making. The assessment revealed Resident #32 needed partial to moderate assistance with most of her ADL and needed supervision or touching assistance when wheeling in her wheelchair. The 11/6/24 MDS assessment revealed the resident preferred reading books, magazines and newspapers, listening to music, being around animals, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. B. Observations During a continuous observation on 4/30/25, beginning at 8:49 a.m. and ending at 2:22 p.m., the following was observed: At 8:49 a.m. Resident #32 was in the common area. An unidentified CNA was sitting with the resident. The unidentified CNA was assisting the resident with drinking an oral nutritional supplement. The unidentified CNA was not talking to the resident. At 9:24 a.m. the AD engaged in a short conversation with Resident #32 and told her about the butterfly activity while she changed the television station to 50's music. At 10:12 a.m. Resident #32 was sleeping through the butterfly activity, she was cued by the AD once but fell back to sleep. At 2:22 p.m. the AD invited Resident #32 to attend Bingo. Resident #32 said she wanted to go. -However, Resident #32 was not assisted to Bingo. C. Record review Resident #32's quarterly activities assessment, dated 2/4/25 documented Resident #32 enjoyed visits with family, watching television and listening to music as her independent activities. The assessment documented Resident #32 required reminding of activities and needed assistance going to activities as well as with her independent activities. Resident #32's activity care plan, initiated on 2/4/25 and revised on 4/28/25, revealed Resident #32 enjoyed board games, card games and gardening before her cognitive decline. She enjoyed balloon activities. She enjoyed watching the Denver Broncos, classic television shows and listening to classic country music. She also enjoyed doing activities with children. Pertinent interventions included providing the resident assistance to activities of interest, providing the resident with independent activities of interest, redirecting the resident on days that she might be having a bad day and having the activities department provide visits. Review of the April 2025 (4/1/25 to 4/30/25) activity participation log revealed Resident #32 was actively passive during arts and crafts on 4/30/25. -However, observations revealed she slept through the craft on 4/30/25 (see observations above). Further review of the April 2025 activity participation log revealed Resident #32 refused to go to Bingo on 4/30/25. -However, observations revealed Resident #32 did want to go to Bingo, but the staff did not take her. V. Resident #35 A. Resident status Resident #35, age 72, was admitted on [DATE]. According to the May2025 CPO, diagnoses included Parkinson's disease (disease that causes tremors), psychotic disorder and neurocognitive disorder with Lewy Bodies (type of dementia). The 4/18/25 MDS assessment revealed Resident #35 was unable to complete the BIMS assessment. The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment revealed she was severely impaired in her daily decision-making. The assessment revealed Resident #35 needed partial to moderate assistance with the majority of her ADL as well as with her wheelchair mobility. The 10/16/24 MDS revealed it was somewhat important for Resident #35 to have books, magazines and newspapers to read, to do things with groups of people and to go outside when the weather was good. B. Observations During a continuous observation on 4/30/25, beginning at 8:49 a.m. and ending at 2:22 p.m., the following was observed: At 2:17 p.m., Resident #35 was sleeping in the dining area with potato chips and a soda in front of her. She was not asked if she wanted to go to Bingo. C. Record review The activity care plan, initiated on 4/15/25 and revised 4/28/2,5 revealed Resident #35 enjoyed listening to pop music, reading the daily newspaper, watching the Denver Broncos, being around cats and dogs and having her hair curled. The April 2025 (4/1/25 to 4/30/25) activity participation log revealed Resident #35 refused to go to Bingo on 4/30/25. -However, observations revealed that staff did not invite Resident #35 to go to Bingo (see observations above). VI. Resident #36 A. Resident status Resident #36, age greater than 65, admitted on [DATE]. According to the May 2025 CPO diagnoses, included Alzheimer's disease, dysphasia (difficulty swallowing), gastro-esophageal reflux disease and depression. The 2/5/25 MDS assessment revealed Resident #36 had moderate cognitive impairments with a BIMS score of nine out of 15. The MDS assessment revealed she required partial to moderate assistance with her ADLs. The assessment revealed it was very important for Resident #36 to be around animals, to do her favorite activities and to go outside when the weather was nice. B. Observations During a continuous observation on 4/30/25 beginning at 8:49 a.m. and ending at 2:50 p.m., the following was observed: At 2:43 p.m. the AD invited Resident #36 to go to Bingo, she told the AD that she wanted to go. The staff did not assist her to Bingo. Resident #36 was trying to get up out of the recliner and was calling out. CNA #11 continued to tell her to sit back down and to lie back. He did not offer her any other activities. C. Record review The activities care plan, initiated on 4/28/25, revealed Resident #36 enjoyed listening to short stories, watching football, listening to Hawaiian and country music. She also enjoyed activities that involved children and animals. Pertinent included providing the resident assistance to activities of interest, providing independent activities of interest and providing one one-on-one social conversation through the activities department if the resident chose to stay in her room. -However, observations revealed that staff did not provide assistance to activities of interest. The April 2025 (4/1/25 to 4/30/25) activity participation log documented that Resident #36 refused to go to Bingo on 4/30/25. -However, observations revealed Resident #36 did want to go to Bingo, but the staff did not assist her to the activity (see observations above). VII. Staff interviews CNA #10 was interviewed on 5/1/25 at 9:26 a.m., CNA #10 said the AD would come around and let the staff know what activities were going on that day. She said the AD and the CNAs would invite the residents to the different activities. She said if the residents did not want to go to the activity, they would just hang out on the unit in the common area. SShe said movies were played for the residents between activities and the staff would sometimes take the residents outside. She said puzzles, magazines, books and coloring materials were not kept in the special care unit. She said all the residents were able to use those materials. She said the staff would get the residents on the special care unit those materials if they requested them. CNA #4 was interviewed on 5/1/25 at 9:57 a.m. CNA #4 said the AD hung up the daily schedule and hung the monthly calendar in the residents' rooms. She said the AD invited the residents to the activities. She said the staff would put out coloring sheets between activities. She said the staff would also put on music and style the resident's hair between scheduled group activities. The AD was interviewed on 5/1/25 at 4:00 p.m. She said nursing staff would help with the time in between activities by doing manicures, arm massages and putting on movies for the residents. She said some of the activities were more focused for the residents who had dementia, such as aroma therapy, arm massage, trivia, old-time magazines and old-time music. She said she individualized activities by getting to know the residents and adapting to their needs. She said the staff should have gotten Residents #36 and Resident #32 up and assisted them to Bingo as requested. She said she tried to communicate with staff when a resident wanted to join in the activity. The director of nursing (DON) was interviewed on 5/1/25 at 4:18 p.m. The DON said it was important for the residents on the special care unit to have activities that enrich their lives.

Based on observations, record review, and interviews, the facility failed to ensure one (#36) out of one of 20 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure Resident #36 received nectar thick liquids per physician's orders. Findings include: I. Manufacture's recommendations The Simply Thick Easy Mix packet was provided by the director of nursing (DON) on 5/1/25 at 11:05 a.m., the directions read: add to four fluid ounces (oz) (120 milliliters - ml) of liquid. Stir briskly for 30 seconds. II. Facility policy and procedure The Dysphagia Clinical Protocol was provided by the nursing home administrator (NHA) on 5/1/25 at 2:14 p.m. It read in pertinent part, The staff and physician will identify individual with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food. If a swallowing problem is identified or suspected, a healthcare practitioner, in conjunction with nursing and the speech pathologist (SLP) will identify and document pertinent information: level of consciousness, ability to swallow three ounces of water without drooling, coughing, or choking, previous and recent history of swallowing capability and difficulty. The staff and physician will first try to identify and implement simple interventions to manage the situation for example: cutting food into smaller pieces, allowing the resident to eat more slowly. If a modified consistency diet or other restrictions are indicated, nursing will obtain an order for such restrictions from the physician. II. Resident #36 A. Resident status Resident #36, age greater than 65, admitted on [DATE]. According to the May 2025 computerized physician order (CPO) diagnoses, included Alzheimer's disease, dysphasia (difficulty swallowing), gastro-esophageal reflux disease (GERD) and depression. The 2/5/25 MDS assessment revealed Resident #36 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15.The MDS assessment documented she required partial to moderate assistance activities of daily living (ADLs). The MDS assessment documented Resident #36 did not have a swallowing disorder but was on a mechanically altered diet. B. Observations During a continuous observation on 4/28/25 beginning at 11:34 a.m. and ending at 11:45 a.m. the following was observed: At 11:34 a.m. an unidentified certified nurse aide (CNA) gave Resident #36 juice and water at the dining room table for lunch. The unidentified CNA filled the eight ounce (oz) cups to the top . The unidentified CNA added one package of a liquid thickener to each beverage and then stirred each glass for approximately five seconds. -The unidentified CNA failed to follow the manufacturer's recommendations (see observations above). At approximately 11:45 a.m. the unidentified CNA gave Resident #36 a sip of her beverage. The thickener had settled at the bottom of the glass and the liquid at the top was thin. The unidentified CNA did not stir the beverage again. Resident #36 was holding her chin up in the air with her head tilted back and took a sip of her drink. She then coughed five times, the unidentified CNA reminded her to put her chin down. On 4/29/25 at 11:37 a.m. an unidentified CNA added one packet of powdered thickener to Resident #36's lemonade and one packet of liquid thickener to her water and stirred each drink for approximately five seconds. The cups were filled to the top of the eight oz cup. On 4/29/25 at 12:10 p.m., an unidentified CNA gave Resident #36 a sip of each of her drinks. The unidentified CNA did not stir the drink again. Both drinks had been sitting since being served. The thickener had settled to the bottom of the glasses. The liquid at the top of her drink was thin like regular liquid. On 4/29/25 at 12:39 p.m, an unidentified dietary aide (DA) poured Resident #26's leftover beverages out. The consistency was thin. On 4/30/25 at 11:27 a.m. CNA #10 filled two eight oz glasses and added one packet of liquid thickener to her red juice and one packet of liquid thickener to her water. She stirred the drinks for approximately five seconds. On 4/30/25 at 12:30 p.m., an unidentified CNA offered to assist Resident #36 with her drinks, Resident #36 took a sip of her juice and coughed twice. On 4/30/25 at 1:00 p.m., the water pitcher in Resident #36's room was regular thin water. C. Record review Review of the May 2025 CPO indicated the resident was prescribed a pureed diet texture and nectar thick liquids, ordered on 3/24/25. The nutritional care plan, initiated on 2/14/25 and revised on 4/15/25, revealed Resident #36 was at increased nutritional risk due to poor intake. Interventions included following swallow precautions, providing assistance with meals, serving meals with appropriate sauces on the side for starch foods, alternating foods and liquids, checking the resident's mouth for pocketing intermittently during meals and providing and serving the residents diet as ordered (mechanical soft consistency, regular fluids and fortified foods). -However, the care plan was not updated when the resident's diet was downgraded to a pureed diet with nectar thick liquids until 4/30/25 (during the survey) The 3/16/25 nursing progress note documented the nurse had spoken to Resident #36's family when they had come in to visit her. The note documented on 3/14/25 during dinner Resident #36 had coughed and had emesis (threw up) and on 3/15/25 she had coughed with emesis during evening medication pass while swallowing her medications with water. Family members sat down with Resident #36 and began to assist her with her meal. They gave her mashed potatoes and Resident #36 demonstrated a similar cough with emesis. The note documented the nurse recommended a bedside swallow screen and the family was supportive of the concept and was willing to support the diet and liquids per rehabilitation orders. The 3/22/25 nursing progress note documented Resident #36 was doing much better since she started on a three day diet trial . The note documented she had not had any coughing since the downgrade of diet and liquids The 3/23/25 nursing progress note documented Resident #36 oral intake had increased since her diet was changed to pureed and nectar thick liquids. She had not had any coughing. III. Staff interviews CNA #10 was interviewed on 4/30/25 at 11:30 a.m. CNA #10 said she used one packet of the instant liquid food thickener per glass. She said Resident #36 had been drinking a lot more since she was placed on thickened liquids. CNA #10 was interviewed again on 4/30/25 at 1:00 p.m. CNA #10 said when she discarded the resident's water glass, the water towards the top was thinner like regular thin liquid and she said it was thicker towards the bottom of the glass. She said it probably separated because it sat too long. She said if they did not stir the thickener for long enough, the drink became lumpy at the bottom. She said the water in Resident #36's room should be thickened as well. She said when she went to Resident #36's room, she said her water was not thickened, but it should have been. She said the glasses used in the dining room were 240 ml and the water bottles in the rooms were 350 ml. She said after reading the instructions on the back of the thickener packet, she said the packet was for four ounces (120 ml). She said the instructions indicated to stir the drink for 30 seconds and the liquid should be nectar thick. She said she only got a quick training on thickened liquids on the day that Resident #36 was switched. She said if Resident #36 were to get thin liquids, she could cough or choke. CNA #11 was interviewed on 4/30/25 at 3:30 p.m. He said the hydration aide had not come by that shift to change Resident #36's water bottle in her room. He said that he had added two packets of thickener to her water bottle. He said at dinner they used one packet of thickener per glass and the drinks should be stirred for 30 seconds. CNA #4 was interviewed on 5/1/25 at 9:57 a.m. She said the nurse let the CNAs know if someone was on thickened liquids or had had any type of diet change. She said she did not know how long to stir a beverage when she added the thickener into a beverage. She said she was able to look at the drink to know when to stop stirring. She said she got a quick walk-through training when Resident #36 was switched to nectar thick liquids. She said if Resident #36 got regular liquids she could cough and it would take her a long time to stop coughing. Registered nurse (RN) #4 was interviewed on 5/1/25 at 10:20 a.m. She said the nurses got the orders for thickened liquids or diet changes from the speech therapist, dietary staff,and the physician. She said it had been a while since she had made thickened liquids. She said she would stir the beverage until she got the consistency she was looking for. She said if Resident #36 got thin liquids it could put her at risk for aspiration, choking and she could get pneumonia. The DON was interviewed on 5/1/25 at 11:05 a.m. She said Resident #36 was prescribed thickened liquids on 3/23/25 and before that was put on a three-day trial, which was initiated by nursing staff due to the resident not eating well and coughing to the point of vomiting. She said since the change, she had not seen the resident coughing. She said speech therapy did not see Resident #36 because she was on hospice, which was why they did the three-day trial. She said the diet downgrade was discussed by nursing staff and her physician. She said the CNAs should be using two packets in each eight-ounce glasses and stirring for 30 seconds. She said the water bottle in her room should be thickened as well. She said the staff working on the floor have been educated on the proper steps of using the thickener packets. CNA #6 was interviewed on 5/1/25 at 4:05 p.m. She said she had only been at the facility since March of 2025 and had not been trained on thickened liquids. She said there was a container of powdered thickener in the main kitchen that she used. She said she would use the scoop and pour a little in and stir until it was nectar thick. She said she had not heard of the packets until someone had trained her that day. She said she was to use two packets for an eight-ounce glass and stir for 30 seconds. CNA #12 was interviewed on 5/1/25 at 4:10 p.m. She said she had worked at the facility for two years and was unaware of any thickening packets. She said she used the thickening powder from the kitchen. She said she would add the powder and then check the thickness. She said the care plan had all of the dietary requirements for each resident and should indicate if they need nectar thick liquids. She said she was shown the packets and trained on them that day (5/1/25). DA #3 was interviewed on 5/1/25 at 4:42 p.m. He was observed pointing to a black container on the counter in the kitchen preparation area labeled thickener for liquids. He said there were no instructions for thickening on the container. The dietary manager (DM) was interviewed on 5/1/25 at 4:48 p.m. She said she ordered pre-bottled nectar thick water, nectar thick lemon flavored water and a nectar thick kiwi strawberry flavored water. She said she also ordered nectar thick packets as well as a thickening pump that had instructions for how many pumps to add to liquids for nectar thick, honey thick and pudding thick liquids. She said this was what the CNAs should be using when they were making drinks for the residents who were on thickened liquids. She said the CNAs should be using the pre-bottled nectar thick drinks unless the resident wanted a different flavor or a different drink then they should be using the pump or the packets. She said she did not know why they had been using the powder in the kitchen because that was for cooking. She said she had told the CNAs that she had put the pre-bottled nectar thick drinks in the refrigerator that morning (5/1/25). The dietary consultant (DC) was interviewed on 5/1/25 at approximately 5:00 p.m. The DC said Resident #36 was an aspiration risk which was why the three day diet trial was done. He said it was very important that the CNAs prepared her drinks correctly because if the drinks were too thin or too diluted she could choke. He said he was not involved with training the CNAs on thickened liquids or how to prepare the thickened liquids. The DON was interviewed again on 5/1/25 at 5:14 p.m. The DON said all of the nursing should use the pre-bottled nectar thick liquids when possible. She said if they were not able to use the pre-bottled, they should use the pump provided by the DM or use the packets and they should follow the directions on the pump and the packets. She said the CNAs should not be using the thickening powder in the kitchen to thicken liquids.

Based on observations, record review and interviews the facility failed to maintain an effective pest control program so the facility was free from pests and cockroaches, in one of one kitchen and one of two dining rooms. Specifically, the facility failed to: -Ensure an effective pest control program that eliminated the presence of live and dead cockroaches in the kitchen and dining room, food preparation area, storage area, serving and eating areas; -Ensure dead and decaying roaches were removed from the dining room lower cupboard space; and, -Ensure heavily occupied sticky pest traps, containing a large amount of trapped dead and decaying cockroaches were removed timely and when the traps were full. Findings include: I. Professional references According to the Colorado Department of Public Health and Environment, Colorado Retail Food Establishment Regulations, effective 3/16/24, was retrieved on 9/25/24 from https://cdphe.colorado.gov/dehs Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: routinely inspecting incoming shipments of food and supplies; routinely inspecting the premises for evidence of pests; using methods, if pests are found, such as trapping devices or other means of pest control; eliminating harborage conditions; and, removing dead or trapped insects and other pests. Dead or trapped insects and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. According to the National Pest Management Association (NPMA) The Truth About Cockroaches and Health, 2024, was retrieved on 9/25/24 from https://www.pestworld.org/news-hub/pest-health-hub/the-truth-about-cockroaches-and-health/# Cockroaches have many negative consequences for human health because certain proteins (called allergens) found in cockroach feces, saliva and body parts can cause allergic reactions or trigger asthma symptoms. Cockroaches can also passively transport microbes on their body surfaces including pathogens that are potentially dangerous to humans. Cockroaches have been implicated in the spread 33 kinds of bacteria, including E. coli and Salmonella species, six parasitic worms and more than seven other types of human pathogens. E. coli and Salmonella are classic causes of food poisoning or gastroenteritis. Common symptoms include belly pain, severe stomach cramps and tenderness, diarrhea which can sometimes be bloody, nausea and vomiting. Some people can experience severe diarrhea, which will cause dehydration and may require hospitalization . In rare cases, the bacteria can spread to the bloodstream and cause life threatening infections. According to Terminix What to do if you find dead roaches, 2024, was retrieved in 9/25/24, from: https://www.terminix.com/cockroaches/why-cockroaches-die-on-their-backs/#:~:text=Dead%20cockroaches%20are%20typically%20not,contaminate%20surfaces%20near%20food%20areas. Dead cockroaches are typically not directly harmful but can pose risks. Their body parts, droppings, and shed exoskeletons can trigger allergies and asthma. They may also carry bacteria and pathogens that contaminate surfaces near food areas. Additionally, a dead cockroach can attract more roaches because they are scavengers. II. Facility policy and procedure The Pest Control policy, revised May 2008, was provided by the nursing home administrator (NHA) on 9/20/24 at 11:30 a.m. It read in pertinent part: Our facility shall maintain an effective pest control program. Maintenance services assist, when appropriate and necessary, in providing pest control services. III. Observations and interview On 9/19/24 at 2:38 p.m. the kitchen and main resident dining room were observed. The kitchen had several pest control sticky traps on the floor underneath and behind the counters and kitchen equipment. All of the traps were full of cockroaches and other insects. There was a live cockroach underneath the shelving in the dry storage room and one on the wall. All of the cupboards in the main dining room underneath the counters where dinnerware, condiments, snacks and drinks were stored and set up were full of several dead and live cockroaches. The dead cockroaches were in different stages of decay. There was one live cockroach observed on the wall behind the drink machine next to the lemonade dispenser. The dietary manager (DM) said the facility had eliminated the mice but were still dealing with cockroaches and flies. The DM said the facility had to increase the frequency of pest control from once a week to twice a week to try to get the problem under control. The DM said she had extra sticky traps so that she could replace the full traps in the kitchen. She said she had to replace the traps almost daily. The DM said they had the light-up traps to manage the flies but they still had flies in the kitchen. The cook and the serving staff had to monitor the uncovered foods so that flies would not land on the food. VI. Record review Pest control records were reviewed on 9/19/24. The documents revealed the facility had received services for pest management twice a month from March 2024 through the month of the survey (September 2024). The pest control company treated the facility for ongoing problems with German roaches, oriental roaches and a few other insect pests. The consistent monthly pest control treatment provided was to treat the presence of German roaches. Areas treated included the kitchen, the resident dining room, resident rooms (bathrooms and closets), the facility entrance, offices and the facility exterior. The treatments provided varied depending on the provider's recommendations. The most focused areas targeted for pest control treatment were the kitchen and the resident dining room. The last day of treatment was on 9/18/24, the day before the survey started (9/19/24). The pest control provider replaced six glue board stick traps. -However, all the stick glue traps observed during the survey on 9/19/24 were full of cockroaches. -There were no sticky (glue) traps placed in the cupboards under the service area counters in the resident dining room. V. Staff interviews The NHA was interviewed on 9/19/24 at 4:58 p.m. The NHA said the facility increased the frequency of pest control visits to twice a month to address the ongoing issues with insect presence. She said the pest control provider was in the building yesterday (9/18/24). The NHA said she just observed the stick traps and did not think they had been changed in a while due to the amount of bugs in the trap and she was not sure if the maintenance department or the DM changed the traps in between pest control visits. The NHA said the usual pest control treatment was for the provider to spray the facility with the prescribed pest control product and place stick traps throughout the building where problems were identified. She said did not know the details of the products used. The NHA was not aware of the presence of cockroaches in the cabinets under the serving areas in the resident's dining room. The NHA said she provided staff training on keeping all areas of the dining room clean and free of cockroach remains.

Based on observations, record review and interviews, the facility failed to ensure one (#105) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. During the 4/28/23 visit, the surgeon removed the sutures and staples from the surgical site on both sides of the right ankle. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The order also noted to keep the boot on except for baths. The resident had complaints of pain to the right lower extremity on 5/11/23. The nurse assessed the area and found the ankle surgical sites had opened. The facility had not assessed or monitored the ankle for 12 days. Cross-reference F686, failure to prevent an unstageable pressure injury to the resident's heel. Findings include: I. Resident status Resident #105, age 85, was admitted on [DATE], readmitted [DATE], and discharged [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included fracture of right lower leg, subsequent encounter for closed fracture with routine healing, multiple sclerosis, and acute respiratory failure with hypoxia. The 5/24/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was identified having a scar over a bony prominence, a surgical wound, and surgical wound care. II. Record review The progress note dated 4/9/23 included, This nurse was alerted by power of attorney (POA)/daughter that while out of facility with her, she got her foot trapped between the strap and her chair that loads her into families personal vehicle. Elder (Resident #105) has severe bruising and swelling around right inner ankle and small abrasion to top of right foot. Pedal pulse palpable elder moving foot around with no resistance or facial grimacing of pain/discomfort. Daughter stated that they offered to take elder to the hospital prior to coming back to the facility and elder refused .It has been approximately two hours since elder arrived back to facility and is having complaints of pain to right lower extremity (RLE). As needed (PRN) tylenol (APAP) given to increase comfort. Elder continues to refuse going to the emergency room (ER) for a possible fracture (XR). The progress note dated 4/10/23 included, Elder leaving facility at 9:00 a.m. with facility transport to get an x-ray and labs drawn. While on the way to the hospital, elders daughter wanted elder to be taken to the ER instead. Daughters assisted elder in the ER along with transport. Elder has fractures to RLE and waiting on official results. Elder is being admitted to hospital .primary stating that possibly surgery tomorrow with surgeon 4/11/23. The progress note dated 4/13/23 included, Elder readmitted to facility at 3:15 p.m. from the hospital .Elder is alert and oriented times three and is able to make her needs known to staff. Elder is non-weight bearing and Hoyer (mechanical lift) lift used for transfers with two person assist. Elder transported in wheelchair with one assist. Elder transported in wheelchair with one assist. Ace bandage present to RLE and bandage is to be in place until next appointment with the surgeon .Oncoming nurse to perform skin assessment. The progress note dated 4/28/23 included, Elder returning to facility at 1:00 p.m. by private vehicle .Report received from surgeon. Report: follow-up open reduction and internal fixation (ORIF) right ankle. No complaints. Minimal sensation. Splint removed. Staples and stitches removed. Placed in boot. Non-weight bearing, keep soft padding around ankle. OK to remove for shower. RECOMMENDATION: 1) Follow up in four weeks with x-ray of right ankle. 2) Boot on except for bathing. Will continue to monitor. The progress note dated 5/11/23 at 8:30 p.m. included, Called to elder's room by certified nurse aides (CNAs) .Elder at this time complaining of right heel hurting. Upon inspection found wrinkled up ace wrap covering ankle incisions with dried drainage on it. Ace had foul smell to it. Upon carefully removing ace wrap using sterile saline to loosen ace from ankle I found right outer ankle with dehisced incision with redness circling the entire wound. Several loose steri-strips removed with sterile saline and gauze cleaning. Inner ankle incision dehisced with hardware obvious. This incision also cleaned with sterile saline and gauze. A loose suture and several steri-strips that were no longer intact were removed. Area surrounding this incision also redeemed. Wounds very tender to touch. After cleaning both wounds they were covered with telfa .then secured with conforming gauze wrap. Spoke with elder regarding findings and wants to see the surgeon in the morning. Medicated for pain per suggestion and request. Director of nursing (DON) and wound care aware of findings. The progress note by the wound nurse dated 5/11/23 at 10:39 p.m. included, Registered nurse (RN) #5 notifying this nurse via phone of .lateral ankle surgical incision with complete dehiscence (a partial or total separation of previously closed wound edges, due to a failure of proper wound healing) with orthopedic hardware visible .medial ankle wound, possibly surgical incision site, with extensive depth and wound bed mixture of granulation, slough, and eschar (forms of dead skin) tissue, peri-wound (skin surrounding the wound) red as well as surrounding skin .This nurse notifying DON and strongly recommended to RN #5, DON, and nursing home administrator (NHA) that elder be sent to emergency room . The progress note dated 5/12/23 included, Call placed to primary answering service at 6:10 a.m.Primary calling back this nurse and provided order to send to hospital emergency room to treat and evaluate right foot. Elder with two open post surgical areas .POA called and updated. Elder transported to hospital via facility transportation to hospital at 7:30 a.m. The progress note dated 5/12/23 included, Elder returned to facility from the hospital at 1:30 p.m. via facility transportation. Elder diagnosed with wound dehiscence .New orders obtained for wet to dry dressings after removing old dressings and cleaning with normal saline .Areas assessed upon return. Bandages removed and pictures sent to wound nurse. The progress note by the wound nurse dated 5/14/23 included, Elder came back from ER after the surgeon and the primary consult with orders to do wet to dry dressings, however, at that time wound appeared crater like (sore on the skin) with orthopedic hardware showing, and significant depth to the wound. Today found with large wet to dry dressing doubled over wound bed as well as intact/healthy skin surrounding wound .Wet to dry dressing on this wound is not appropriate. Changed to clean with normal saline wash, dry with 4X4 gauze. Skin prep peri wound. Apply nickel thick layer of Santyl (wound gel treatment) on to wound bed leaving no Santyl on wound edges, nor on health per wound/skin. Cover with a composite dressing .this nurse continues to recommend antibiotics and this nurse continues to feel that wet to dry dressing is not the best wound care choice for this area, and feel even wound vac (vacuum) (a closed system device to promote wound healing) would wound be appropriate. This nurse to send concerns to both primary and surgeon. Expressed to floor nurse a need for antibiotics and more appropriate wound orders. The progress note dated 5/15/23 included, This nurse alerted by staff that elder had a temp (temperature) of 101.5 and 102.2. Elder was given tylenol at 1:30 p.m. earlier today for an elevated temp of 99.9 .Provider's office was called x four and went straight to voice mail. Medical director given telephone order to send elder to ER for change of condition .Called for an ambulance, leaving the facility at 4:52 p.m. Primary called back at 5:05 p.m. and updated on elders condition. The progress note dated 5/16/23 included, Received call from the hospital with an update on Resident #105. Elder was given Levaquin (an antibiotic) and a chest x-ray was obtained with the results of suggested pneumonia. The progress note dated 5/18/23 included, Elder readmitted to facility at 1:10 p.m. via facility transportation. readmitted from hospital with diagnosis of COVID, pneumonia, and wound dehiscence .Orders for wound vac discussed with primary and surgeon. Machine to be set at 120 on continuous. Skin cleaned with normal saline and patted dry. Skin prep applied to periwound and drape applied to skin prior to foam being applied. Foam cut to area and wound vac on suctioning well. POA in room upon return and was updated on condition. The progress noted dated 5/19/23 included, Wound vac intact on right ankle. The progress note dated 5/20/23 included, Wound care on right inner ankle and outer ankle done per orders on treatment administration record. Wound vac patent. The progress note by the wound nurse dated 5/21/23 included, Weekly wound note: Right medial ankle wound s/p dehiscence .wound bed is 100% yellow and brown slough, no depth or hardware seen. Slough is thick but moist .Right lateral ankle wound s/p incision dehiscence with wound vac in place. Vac appears patent at this time. Will assess wound tomorrow with scheduled vac change. The progress note by the wound nurse dated 5/22/23 included, Dehisced surgical incision right lateral ankle with continued orthopedic hardware visible, the entire length of the wound. Small serosanguinous ( a mix of blood serum -clear fluid, and blood) drainage in wound vac canister noted. Wound bed with 90% red granulation (new pink tissue) tissue, 10% yellow slough, present around hardware, proximal, distal, and posterior edges of wound bed .Site was cleaned thoroughly with NS (normal saline) wash and 4 x 4 gauze used to dry. Skin prep thoroughly applied to peri wound and on skin that wound contact vac drape. Periwound and skin was draped with vac drape. Black vac foam cut to fit and placed in to wound bed, covered with vac drape. [NAME] pad was placed mid wound and secured with vac drape along edges. Wound vac patent at 120 mmHg as ordered. The progress noted dated 5/26/23 included, Elder having shower this AM and wound vac intact. Canister with dark red/brown drainage .Outer left ankle with 75% slough (yellow/white) surrounding tissue intact with no maceration noted. The progress note by the wound nurse dated 5/28/23 included, Weekly wound note: Right medial ankle wound bed is 80% yellow slough, 20% interspersed granulation tissue. No major depth or hardware seen .Right lateral ankle wound appears to be granulating over orthopedic hardware nicely in middle of wound bed. Wound bed 90% red granulation tissue, 10% yellow slough around distal hardware and posterior wound edge .Wound being treated with wound vac therapy. The progress note by the wound nurse dated 6/4/23 included, Weekly wound note: Right medial ankle wound bed is 80% red granulation tissue, 20% yellow slough, wound bed appeared to be hypergranulation. Right lateral ankle wound appears to be granulating over orthopedic hardware nicely in middle and proximal area of wound bed. Wound bed 100% red granulation tissue. Peri wound is intact, but reddened. Wound being treated with wound vac therapy continuous at 120 mm/hg. Wound vac may not be needed for much longer. The progress note dated 6/5/23 included, Elder has an x-ray done to right ankle on 5/28/23. Impression: 1. Medial malleolus hardware noted. Near complete healing. 2. Lateral plate and screw fixation hardware right distal fibula. Near complete healing. Primary aware of results. -The facility did not have assessments/monitoring of the surgical area to the right ankle from 4/28/23, when the surgeon removed the staples/sutures, until 5/11/23. III. Interviews Certified nurse aide (CNA) #2 was interviewed on 8/22/23 at 9:24 a.m. She said if any skin changes were noted, she would report to the nurse. She said CNAs look at every resident's skin during showers. She said aides complete a shower skin assessment form after each shower. CNA #3 was interviewed on 8/22/23 at 9:30 a.m. She said with all cares including toileting the aides looked at the skin of the residents. She said if there were anything new/different she was to report the finding to the nurse right away. Registered nurse (RN) #1 was interviewed on 8/22/23 at 9:37 a.m. She said if the facility admitted or readmitted a resident and an order was unclear, the admitting staff should call for a clarification to the order. She said skin was assessed weekly and the facility had a wound nurse who would assess wounds weekly. She said if a skin concern was reported by an aide, an assessment would be completed. The director of nursing (DON) was interviewed on 8/23/23 at 11:00 a.m. She acknowledged Resident #105 did not have an assessment or monitoring to her right ankle after return from the surgeon when the staples/sutures were removed for 12 days. She said the resident had an order to remove the boot for showers, but had discovered upon investigation that the aides were not removing the boot during showers. She said after the wound openings were discovered, re-education was completed with the aides to remove boots/splints and dressings for all showers unless an order explicitly says not to, and with nurses to monitor surgical sites more. After the wounds were found, orders were put in to check to see if the dressings were dry/intact every shift and wound care completed as ordered. She said the area was reported to the wound nurse who began weekly assessments as well. The DON said after the wound opened, education/training was provided to all nurses on the implementation, use, and troubleshooting the wound vac. She said the facility also implemented shower skin sheets to reinforce skin inspections during showers and removal of dressings. She said going forward all new surgical sites would be reported to the wound nurse for weekly monitoring as well. She said if any skin issues were identified, the wound nurse would be notified.

Based on observations, record review and interviews, the facility failed to ensure for one (#1) of two residents reviewed for pressure injuries received care consistent with professional standards of practice. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The orders also noted to keep the boot on except for baths. The resident had complaints of pain to the right lower extremity on 5/11/23. The nurse assessed the area and found the resident had developed an unstageable pressure injury to the right heel. The facility had not assessed or monitored the ankle for 12 days. Cross-reference F684, quality of care, regarding failure to assess and monitor surgical sites. Findings include: I. Resident status Resident #105, age 85, was admitted on [DATE], readmitted [DATE], and discharged [DATE] According to the July 2023 computerized physician orders (CPO), the diagnoses included fracture of right lower leg, subsequent encounter for closed fracture with routine healing; multiple sclerosis, and acute respiratory failure with hypoxia. The 5/30/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was identified having an unstageable pressure injury. II. Record review The progress note dated 4/9/23 included, This nurse was alerted by power of attorney (POA)/daughter that while out of facility with her, she got her foot trapped between the strap and her chair that loads her into families personal vehicle. Elder (Resident #105) has severe bruising and swelling around right inner ankle and small abrasion to top of right foot. Pedal pulse palpable elder moving foot around with no resistance or facial grimacing of pain/discomfort. Daughter stated that they offered to take elder to the hospital prior to coming back to the facility and elder refused .It has been approximately two hours since elder arrived back to facility and is having complaints of pain to right lower extremity (RLE). As needed (PRN) tylenol (APAP) given to increase comfort. Elder continues to refuse going to the emergency room (ER) for a possible fracture (XR). The progress note dated 4/10/23 included, Elder leaving facility at 9:00 a.m. with facility transport to get an x-ray and labs drawn. While on the way to the hospital, elders daughter wanted elder to be taken to the ER instead. Daughters assisted elder in the ER along with transport. Elder has fractures to RLE and waiting on official results. Elder is being admitted to hospital .primary stating that possibly surgery tomorrow with surgeon 4/11/23. The progress note dated 4/13/23 included, Elder readmitted to facility at 3:15 p.m. from the hospital .Elder is alert and oriented times three and is able to make her needs known to staff. Elder is non-weight bearing and Hoyer (mechanical lift) lift used for transfers with two person assist. Elder transported in wheelchair with one assist. Elder transported in wheelchair with one assist. Ace bandage present to RLE and bandage is to be in place until next appointment with the surgeon .Oncoming nurse to perform skin assessment. The progress note dated 4/28/23 included, Elder returning to facility at 1:00 p.m. by private vehicle .Report received from surgeon. Report: follow-up open reduction and internal fixation (ORIF) right ankle. No complaints. Minimal sensation. Splint removed. Staples and stitches removed. Placed in boot. Non-weight bearing, keep soft padding around ankle. OK to remove for shower. RECOMMENDATION: 1) Follow up in four weeks with x-ray of right ankle. 2) Boot on except for bathing. Will continue to monitor. The progress note dated 5/11/23 at 8:30 p.m. included, Called to elder's room by certified nurse aides (CNAs) .Elder at this time complaining of right heel hurting. Upon inspection found an area approximately the size of a 50 cent piece of necrotic tissue. No draining obvious .Heel floated using pillow and small rolled blanket. Spoke with elder regarding findings and wants to see the surgeon on the morning. Medicated for pain per suggestion and request. Director of nursing (DON) and wound care aware of findings. The progress note by the wound nurse dated 5/11/23 at 10:39 p.m. included, Registered nurse (RN) #5 notifying this nurse via phone of large unstageable pressure injury to right heel, 100% black eschar tissue appearing very unstable, site inflamed and swollen as well as surrounding skin, including redness .This nurse notifying DON and strongly recommended to RN #5, DON, and nursing home administrator (NHA) that elder be sent to emergency room . The progress note dated 5/12/23 included, Call placed to primary answering service at 6:10 a.m.Primary calling back this nurse and provided order to send to hospital emergency room to treat and evaluate right foot. Elder with eschar tissue to heel .POA called and updated. Elder transported to hospital via facility transportation to hospital at 7:30 a.m. The progress note dated 5/12/23 included, Elder returned to facility from the hospital at 1:30 p.m. via facility transportation .(Right) 2.8 X 3.4 heel, 100% intact eschar tissue .Left heel assessed with no redness. Areas assessed upon return. Bandages removed and pictures sent to wound nurse. The progress note by the wound nurse dated 5/14/23 included, Unstageable pressure injury to right heel found 5/11/23. Site measuring 3.2 X 5 X unable to determine (UTD), site is 100% black eschar (dead) tissue, eschar stable is unstable, especially at wound edges. Elder came back from emergency room (ER) after primary and surgeon consult with no specific wound care orders. Unknown at this time how aggressive primary wants wound care to be. Order put in to apply Betadine in the morning and wrap with Kerlix until specifics can be obtained from the physicians. The progress note dated 5/15/23 included, This nurse alerted by staff that elder had a temp(temperature) of 101.5 and 102.2 Elder was given tylenol at 1:30 p.m. earlier today for an elevated temp of 99.9 .Provider's office was called x four and went straight to voice mail. Medical director given telephone order to send elder to ER for change of condition .Called for an ambulance, leaving the facility at 4:52 p.m. Primary called back at 5:05 p.m. and updated on elders condition. The progress note dated 5/16/23 included, Received call from the hospital with an update on Resident #105. Elder was given Levaquin (an antibiotic) and a chest x-ray was obtained with the results of suggested pneumonia. The progress note dated 5/18/23 included, Elder readmitted to facility at 1:10 p.m. via facility transportation. readmitted from hospital with diagnosis of COVID, pneumonia .Heel with intact eschar tissue and inner ankle with eschar, granulation, and slough. POA in room upon return and was updated on condition. The progress noted dated 5/19/23 included, Heel continues to be intact with eschar tissue. The progress note dated 5/20/23 included, Treatment nurse providing treatment to right heel/ankle. Heel protectors on at all times. Elder sitting up in bed with call light in place. Will continue to monitor. The progress note by the wound nurse dated 5/21/23 included, Unstageable pressure injury to right heel found 5/11/23. Site measuring 4.2 x 5 x UTD, site is 100% black eschar tissue, eschar stable is unstable, especially at wound edges and border. Peri wound (skin around the wound site) is red, inflamed. Primary agreeing to treatment order: clean with normal saline and 4 x 4 gauze, skin prep peri wound, apply Betadine in the morning and wrap with Kerlix. The progress note dated 5/22/23 included, Heel/foot/ankle was wrapped with kerlix gauze The progress note dated 5/24/23 included, Right heel continues with 100% eschar tissue. No drainage and area treated as ordered. The progress note dated 5/25/23 included, Heel: Betadine applied and heel wrapped. Surrounding skin peeling. The progress note dated 5/26/23 included, (Hospital) wound clinic specialist called and scheduled an appointment 6/7/23. Daughter notified. The progress note dated 5/27/23 included, Wound on right heel continues with eschar tissue, scant serosanguinous drainage noted. The progress note by the wound nurse dated 5/28/23 included, Unstageable pressure injury to right heel found 5/11/23. Site measuring 3.5 x 5 x UTD, site is 100% black eschar tissue, eschar stable is unstable, especially at wound edges and border. Peri wound is red, inflamed. Treatment order: clean with normal saline and 4 X 4 gauze, skin prep peri wound, apply Betadine in the morning and wrap with kerlix. The progress note dated 6/1/23 included, Heel with intact eschar tissue and no drainage noted. The progress note dated 6/2/23 included, Heel intact eschar tissue. Wound care performed as ordered. The progress note dated 6/3/23 included, Right heel continues with eschar tissue. The wound specialist treatment orders from the 6/7/23 visit included, Right heel ulcer- Santyl, betadine paint periwound, moleskin donut (cushioned dressing), calcium alginate, abdominal pad, Kerlix, and ace wrap. The wound specialist visit note dated 6/21/23 included, Right foot ulcer, there are no signs of infection, Stage 2, the wound was debrided (mechanical procedure to remove dead/unhealthy skin) .The wound dressed with clean dressings according to the orders. Patient will return in two weeks for follow-up. The wound specialist note dated 7/19/23 included, To right heel: apply silvercel to wound bed, betadine paint to periwound then moleskin donut, calcium alginate, gauze, and abdominal pad. Wrap entire foot with cast padding and coban (bandage). III. Interviews Certified nurse aide (CNA) #2 was interviewed on 8/22/23 at 9:24 a.m. She said if any skin changes were noted, she would report to the nurse. She said CNAs looked at every resident's skin during showers. She said aides completed a shower skin assessment form after each shower. CNA #3 was interviewed on 8/22/23 at 9:30 a.m. She said with all cares including toileting the aides looked at the skin of the residents. She said if there were anything new/different she was to report the finding to the nurse right away. Registered nurse (RN) #1 was interviewed on 8/22/23 at 9:37 a.m. She said if the facility admitted or readmitted a resident and an order was unclear, the admitting staff should call for a clarification to the order. She said skin was assessed weekly and the facility had a wound nurse who would assess wounds weekly. She said if a skin concern was reported by an aide, an assessment would be completed. The director of nursing (DON) was interviewed on 8/23/23 at 11:00 a.m. She acknowledged Resident #105 did not have an assessment or monitoring to her lower right extremity after return from the surgeon for 12 days. She said the resident had an order to remove the boot for showers, but had discovered upon investigation that the aides were not removing the boot during showers. She said after the pressure injury was discovered, re-education was completed with the aides to remove boots/splints and dressings for all showers unless an order explicitly says not to, and with nurses to monitor surgical sites more. After the pressure injury was found, orders were put in to check to monitor the eschar and surrounding skin every shift and wound care completed as ordered. She said the area was reported to the wound nurse who began weekly assessments as well. The DON said after the pressure injury developed, education/training on pressure injuries was reinforced to all nurses. She said the facility also implemented shower skin sheets to reinforce skin inspections during showers. She said going forward all new skin issues would be reported to the wound nurse for weekly monitoring as well. She said if any skin issues were identified, the wound nurse would be notified.

Based on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on a hose in the biohazard room sink, west shower room and the south shower room, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 8/23/23 at 2:24 p.m. revealed backflow prevention devices were not installed on the hose in the biohazard room, west shower and south shower room hand held shower. The hose in the biohazard room was utilized to rinse soiled items. The hose was sitting inside the rinse sink which had standing water on the bottom of the sink. The hand held showers in the west and south shower rooms were long enough for the nozzle end to be submerged beneath the level of the drain threshold. II. Staff Interview The maintenance supervisor (MTCE) was interviewed on 8/24/23 at 9:30 a.m. He said the hose in the biohazard room was used to rinse soiled clothing and other facility items, and it did not have a backflow prevention valve installed. He said the west and south shower room did not have a functioning backflow preventer valve on the hand held shower head. He said he would place the backflow valves on them immediately.

Based on record review and interviews, the facility failed to provide response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity. Findings include: I. Facility policy and procedure The Grievance policy, undated, was provided by the nursing home administrator (NHA) on 8/23/23. It read it pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance. The resident, or person filing the grievance on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and any actions that will be taken to correct any identified problems. II. Resident interview The resident council president, Resident #8, was interviewed on 8/22/23 at 3:32 p.m. He stated the social services director (SSD) was supposed to handle the grievances brought up in the council meeting. Resident #8 said the grievance system was like a brain bleed. The council did not get a resolution brought back after a grievance was aired the system did not function well. Because of this, residents had stopped bringing up grievances. III. Record review A review of the resident council meeting minutes dated 7/7/23 revealed group grievances concerning certified nurse aides (CNA) having conversations with each other in the dining room pertaining to patient care and using the resident's names. The CNAs were using personal cell phones in the dining room while assisting residents. And once residents in the dining room received the meal tray, the CNAs did not follow up with the residents to inquire if anything else was needed. A review of the resident council meeting minutes dated 8/1/23 revealed the same group grievances from the previous meeting concerning CNAs having conversations with each other in the dining room pertaining to patient care and using the resident's names. The CNAs were using personal cell phones in the dining room while assisting residents. And once residents in the dining room received the meal tray, the CNAs did not follow up with the residents to inquire if anything else was needed. The meeting minutes did not reveal a resolution had been brought back to the resident council. A review of a resident council response form dated 7/7/23 revealed the director of nursing (DON) had a meeting with the CNAs to address the resident council grievance on 7/7/23. The form included the agendia but no staff roster of attendance. There was no follow up with the resident council documented on the response form. A review of a resident council response form dated 8/7/23 revealed the DON had a meeting with the CNAs to address the resident council grievance on 8/10/23. The form included the agendia and a staff roster of attendance. There was no follow up with the resident council documented on the response form. IV. Staff interviews The SSD was interviewed on 8/23/23 at 2:07 p.m. She said she handled individual grievances and not the resident council grievances. The activities director (AD) ran the resident council meeting and the other managers only went if the council invited the manager. The AD filled out the grievance form and gave it to the responsible department manager to resolve. The SSD did not know where the grievance form went after it was resolved or who was responsible for following up with the residents. The AD was interviewed on 8/24/23 at 8:55 a.m. She said she facilitated the resident council meeting with the residents. When a grievance was brought up, she filled out the grievance form and gave it to the department manager who needed to follow up. The department manager took it to the NHA once it had been resolved for approval. Then the NHA would return it to the AD to file. The AD would provide the resident council with the resolution. The director of nursing (DON) and NHA were interviewed on 8/24/23 at 11:00 a.m. The NHA stated after a resident council grievance had been addressed, a resolution was taken back to the resident council meeting. The SSD was the grievance official and the NHA did not know why the resident council grievances were not addressed by the SSD like the individual grievances were. The DON could not explain why the CNAs received the same in-service training two months in a row for the same grievance or why the problem continued after the first in-service training.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 13 of 32 resident rooms in three hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment were conducted on 8/23/23 at 2:24 p.m. revealed: room [ROOM NUMBER]: The wall next to the window had three dime sized holes. The baseboard cove next to room [ROOM NUMBER] was missing a section approximately five inches long by four inches high. room [ROOM NUMBER]: The wall next to the sink had a plastic corner piece which was broken with a sharp edge approximately three inches long. The wall in the bathroom had deep scratches from the wheelchair hitting the wall. room [ROOM NUMBER]: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. The wall in the bathroom had an area approximately six inches wide by 14 inches long which had rough and unfinished plaster, and the wall next to the toilet had an unfinished painted area approximately eight inches in circumference. The wood edge next to the television in the common area had a missing piece approximately five inches long by three inches wide and had exposed sharp corners. The wall in the biohazard room had an area at the bottom of the sink which had water damage approximately eight inches wide by 13 inches long. room [ROOM NUMBER]: had a plastic cover missing approximately four inches wide by four inches long which had sharp edges. The wall next to the resident's bed had approximately 14 areas of painted patch work which had not been completed. room [ROOM NUMBER]: The wall next to the resident's bed had four dime sized holes. The wall had approximately 10 areas of painted patch work which had not been completed. room [ROOM NUMBER]: The window next to the resident's bed had two missing curtain brackets approximately three inches by three inches. The wall above the resident's bed had two large white unpainted areas. room [ROOM NUMBER]: The wooden door had an area approximately two feet long by nine inches wide with peeling and splintering edges. room [ROOM NUMBER]: The wall next to the resident's bed had an area approximately six inches in circumference of painted patch work which had not been completed. The wall next to the television in the south hall had chipped and peeling paint approximately five inches wide by seven inches long. The shower room on the south hall had the outline of a soap dispenser which had been removed with five dime sized holes. room [ROOM NUMBER]: The wood railing was falling off the wall next to the window with damaged sheetrock approximately six inches wide by five inches long. room [ROOM NUMBER]: The wall behind the recliner had two damaged areas from the recliner hitting the wall. The damage was approximately six inches long by three inches wide and seven inches long by two inches wide. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance director (MTCE) on 8/24/23 at 9:30 a.m. The above detailed observations were reviewed. The MTCE documented the environmental concerns. The MTCE said the facility utilized work orders as well as a computer system to identify environmental issues. The MTCE said he did not have work orders for the damage identified during the environmental tour. The MTCE said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure safe water temperatures. Findings include: I. Water temperature observations 8/21/23: -At 9:02 a.m., the temperature of the tap water was obtained in room [ROOM NUMBER]. The water was found to be 139 degrees Fahrenheit (F); -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; The [NAME] shower room [ROOM NUMBER].4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F. -At 10:09 a.m., certified nurse aide (CNA) #1 observed the temperature of the resident's water in room [ROOM NUMBER]. The temperature was 139.4 degrees F. CNA #1 said the thermometer reading was 139.4 degrees F. CNA #1 was unsure what the water temperature was supposed to be kept at. -At 10:13 a.m., the maintenance director (MTCE) observed the water temperature in room [ROOM NUMBER]. The temperature was 139.4 degrees F. II. Staff interviews The maintenance supervisor MTCE was interviewed on 8/21/23 at 10:33 p.m. He stated the facility immediately purged all the hot water from the lines. The MTCE said the boiler had recently been replaced. The MTCE said the water had been holding at 116 degrees F. The MTCE said the water mixing valve may have been the issue and he was currently checking to see if it was functioning correctly. The MTCE said the facility monitored the water temperatures weekly and would provide the temperature logs. The nursing home administrator (NHA) was interviewed on 8/21/23 at 10:45 a.m. The NHA was informed of the observations above. The NHA said there had not been any residents burned by the water. She said the water temperature should be at or around 117 degrees F. Certified nurse aide (CNA) #8 was interviewed on 8/21/23 at 11:00 a.m. CNA #8 provided showers to the residents. She said she checked the water temperature on her wrist to ensure the water temperature was not too hot. She said if the resident was cognitively alert she would ask the resident to tell her as well but would constantly check the water temperature.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for four of five certified nurse aides (CNAs), one of one licensed practical nurses (LPNs) and four of four registered nurses (RNs). Specifically, the facility: -Failed to complete competencies as identified in the facility assessment for CNAs #1, #2, #4, and #5; -Failed to complete competencies as identified in the facility assessment for LPN #1; and -Failed to complete competencies as identified in the facility assessment for RNs #1, #3, #4, and #5. Findings include: I. Facility assessment The facility assessment, reviewed 6/7/23, identified the staff training topics provided by the facility to meet the needs of the residents, which read in pertinent part: Facility training topics are conducted at hire, annually, and as needed. -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of elders as determined by the facility staff. -Identification of elder changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. II. Census and conditions The census and condition form, provided by the nursing home administrator on 8/23/23, identified: 45 residents needed the assistance of one or two staff for bathing; -40 residents needed the assistance of one or two staff for dressing; -47 residents needed the assistance of one to two staff with transferring; -38 residents needed the assistance of one to two staff with toilet use; and -48 residents needed the assistance of one to two staff with eating. III. Training records The training records were requested on 8/23/23 at 10:01 a.m. The facility was not able to provide competencies for CNAs #1, #2, #4, and #5; LPN #1; and RNs #1, #3, #4, and #5 as identified in the facility assessment. IV. Interviews The staff development coordinator (SDC) was interviewed on 8/23/23 at 1:10 p.m. She said she was responsible for nurse aide training, and the director of nursing (DON) was responsible for the nursing staff training/competencies. She said there had not been annual training completed for the nurse aides, that the only time competencies were completed were on hire. She said annually there were specific topics identified that the facility would conduct competencies on. She said it would be important to ensure the aides were providing cares safely and correctly. The director of nursing (DON) was interviewed on 8/24/23 at 10:23 a m. She said the facility had not completed competencies as outlined in the facility assessment. She said she would be responsible for the nurses and the SDC would be responsible for the aides. She said competencies would ensure the correct cares for the overall best practices for the elders in the facility. She said it would help support the staff and reinforce best practices.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for four of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #1, CNA #2, CNA #4 and CNA #5. Findings include: I. Record review CNAs #1, #2, #4, and #5 did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interviews The staff development coordinator (SDC) was interviewed on 8/23/23 at 1:10 p.m. She said she was not aware nurse aide performance reviews were required annually. She said going forward there would be performance reviews completed. The director of nursing (DON) was interviewed on 8/24/23 at 10:23 a m. She said the facility had not completed any annual performance reviews. She said it would help support the aides and reinforce best practices.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Food was stored and labeled properly. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36, Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 8/23/23 at 9:55 a.m., dietary aide (DA) #1 had just completed preparing minced moist mechanical soft meals of chicken tarragon. DA #1 placed the minced moist mechanical soft chicken into a metal pan and proceeded to wrap it with aluminum foil. DA #1 was asked what the temperature of the mechanical altered chicken tarragon was. DA #1 stated the temperature of the chicken tarragon was 114 degrees F. She then wrapped the metal container and placed it into the warming oven. DA #1 proceeded to complete the same process for pureed chicken tarragon. She then placed seven large pieces of chicken into the blender and proceeded to puree the chicken. After getting it to the correct consistency she grabbed another metal pan and poured the pureed chicken into the pan. She placed it on the counter and took the temperature, which was 113 degrees F. She wrapped it with aluminum foil and placed it into the oven. -At 10:12 a.m., the DA #1 was asked if she checked the temperature of the minced moist foods and pureed food after pureeing them. The DA #1 said, No, I do not, but I would take the temperatures before serving them and they should be at 160 degrees F. -At 11:40 a.m., DA #1 again took the temperature of all items listed above. The chicken tarragon minced meat mechanical soft was at 162 degrees F and the pureed tarragon chicken was at 164 degrees F. C. Additional interview The DM was interviewed on 8/23/23 at 2:00 p.m. She said she was aware that the temperatures of the modified food dropped at times. She said, It's my expectation that the food was ok as long as it reached 165 degrees F before serving. She said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 8/21/23 at 8:40 a.m. revealed three large cutting boards. There were green, blue, and brown cutting boards. All cutting boards were heavily scored and stained. On 8/21/23 at 8:47 a.m., DA#1 was cutting toast on the green cutting board. On 8/23/23 at 1:54 p.m. during kitchen observations DA #3 was cutting raw pork on a brown cutting board. C. Staff Interview The DM was interviewed on 8/23/23 2:00 p.m. The DM was told of the observations of the cutting boards in the kitchen. She acknowledged the cutting boards were visibly stained and showed wear. She said he would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Labeling food A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 3-701, 4 a-d. pg. 104, 4 a-d. It read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. B. Observations and interviews On 8/21/23 at 7:40 a.m. during the initial tour of the kitchen items stored in the walk-in freezer that were not labeled included: a chocolate cream pie, pastry pie shells, peach bites, mixed vegetables, corn on the cob, hamburger patties, corn dogs, country steak, and chicken nuggets. The mixed vegetables, corn on the cob, hamburger patties, country steak, and corn dogs were not sealed in the bag. On 8/23/23 at 1:45 p.m., during the kitchen tour the unlabeled bags listed above had not been dated or labeled when they were opened. The dietary manager was shown the items mentioned. C. Staff interview The dietary manager (DM) was interviewed on 8/23/23 at 2:00 p.m. She said all food should have been labeled to include the item and date. She said by doing so, it identified the product, so staff knew what they were grabbing and it was the correct product. She said it was important to date the items so the staff knew when to discard them. She said the potential risk of not labeling or sealing the bags was serving an incorrect food item and serving food which had freezer burn due to it being left open. She said a negative outcome would be serving residents food which had lost its flavor or nutrient value due to not having a date of when it was opened.

Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies. Findings include: I. Professional references A. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. B. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019, pp. 95-96: -Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects should be kept out of all areas of a health-care facility. -From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Excluding pests from entering the indoor environment and -Applying pesticides as needed. II. Main kitchen observations and interviews On 8/21/23 at 8:56 a.m., during the initial tour of the main kitchen, two staff members were observed working in the kitchen preparing food, and were observed swatting away flies. Flies were observed in all food preparation areas. Two staff members were observed utilizing their hands to clear flies from the area. Several flies were observed on walls, clean dishes, scoops and tongs, and the dishwashing machine. Dietary aide (DA) #2 was interviewed on 8/22/23 at 8:58 a.m. DA #2 said the flies had been especially bad recently and they were everywhere. On 8/23/23 at 8:45 a.m., during the morning kitchen tour one staff member was making toast with the flies flying and landing on the bread. On 8/23/23 at 10:09 a.m., flies were observed on chicken which was being prepared for the afternoon meal. The dietary manager was interviewed on 8/23/23 2:00 p.m. She said the flies in the kitchen had been getting worse and she really did not know what to use to get rid of the flies. She said, I know I cannot use sticky fly traps but I have to do something about the flies. She said a negative outcome with the flies was the flies could be carriers of bacteria and just a plain nuisance. III. Resident interviews Resident #9 was interviewed on 8/22/23 at 2:30 p.m. She said the flies were so bad that she did not eat in the dining room, and she said they were just as bad in her room. She said, Isn't there anything that can be done? Resident #6 was interviewed on 8/22/23 at 2:46 p.m. She said the flies were so bad in herroom. The resident had a fly swatter on her bed. She said, I have to cover my food with a napkin when I am eating in the dining room. Resident #36 was interviewed on 8/22/23 at 3:14 p.m. She said that the flies were terrible this year. She said they were just a bother. Resident #20 was interviewed on 8/23/23 at 9:19 a.m. She said, These flies are crazy because they are everywhere. They seem to follow you everywhere you go, especially in the dining room. I can't eat in the dining room. Resident #19 was interviewed on 8/23/23 at 1:12 p.m. He said the flies were not too bad in his room but were worse in the dining room. IV. Staff interviews The maintenance supervisor (MTCE) was interviewed on 8/23/23 at 9:30 a.m. The MTCE was told of the observations and resident interviews. The MTCE said he had not heard of any problems with flies in the kitchen, dining room or in residents' rooms. The MTCE said they had a contract with a local pest control company who came in monthly or as needed. He said he would contact him immediately to see what the facility's alternatives were. The nursing home administrator (NHA) was interviewed on 8/24/23 at 10:35 a.m. The NHA was told of the observations above. The NHA said she had just heard about the problem with flies with the residents this past Tuesday. She said we had one complaint from one particular resident and the facility got her a fly swatter.

Based on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#8) of four residents reviewed for PASRR out of 24 sampled residents. Specifically, the facility failed to notify the State Mental Health Agency when recommendations had not been met for Resident #8. Findings include: I. Facility expectations Pre-Admission Screen and Resident Review training provided to the social services director (SSD) on 3/29/22 was provided by the nursing home administrator (NHA) on 8/23/23. It read in pertinent part: Specialized services: If a nursing facility cannot arrange or provide specialized services, it must transfer the resident to an appropriate nursing home. Psychiatric case consultation is defined as the addition of a psychiatrist or psychiatric prescriber to a resident's medication review treatment team, quarterly when stable and monthly when not stable. II. Resident status Resident #8, age 82, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included major depressive disorder and dementia. The 6/23/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. III. Pre-Admission Screen and Resident Review (PASRR) level II notice of determination for MI (mental illness) evaluation and facility failures: The PASRR level II, provided to the facility on [DATE], included the evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of major depressive disorder. MI was ruled out, however specialized services were recommended. The resident was to receive psychiatric case consultation. IV. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was either unavailable or sleeping. V. Record review The mood care plan, revised 6/29/22, revealed the resident used antidepressant medication related to major depressive disorder. She had a psychosocial well-being problem related to admission. The resident was in assisted living and required a higher level of care. The interventions were for staff to anticipate and respond to needs promptly. The resident was to receive a familiar routine with monitoring for changes in mood, depression, or behaviors. The August 2023 CPO revealed the following physician orders: -Duloxetine (Cymbalta) 20 MG (milligrams)-give one tablet by mouth one time a day for depression - ordered on 5/17/23. A review of progress notes dated 8/22/23 revealed: -Social service progress notes dated 8/22/22 documented the social worker discussed the recommendations with the resident from the PASRR evaluation. The resident declined but agreed to allow the facility to schedule if she felt more depressed. No further social services notes were located regarding PASRR or recommendations. No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the recommendations were located. VI. Staff interviews The SSD was interviewed on 8/23/23 at 11:53 a.m. She did not recall the PASRR recommendations for Resident #8. She stated psychiatric case consultation was the same as individual therapy services. She said there was not a psychiatrist available in the area. The SSD had not notified the State Mental Health Agency the recommendations made for Resident #8 were not provided. The NHA was interviewed on 8/23/23 at 12:38 p.m. Her expectations of the SSD included completing PASRRs and following through on PASRR recommendations. The NHA said there was a psychiatrist available in the area to satisfy PASRR recommendations for psychiatric case consultations.

Based on interviews and record review, the facility failed to ensure each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for two (#12 and #24) of five residents reviewed out of 24 sample residents. Specifically the failed failed to: -Obtain a level I screening for Resident #12 who suffered from mental illness (MI) prior to admission so a level II evaluation and determination could be completed by the State Mental Health Agency; -Notify the State Mental Health Agency Resident #24 had exceeded the 30 day provisional preadmission screening and resident review (PASRR) period; and -Submit a new PASRR to the State Mental Health Agency for Resident #24 to determine if a level II evaluation was needed. Findings include: I. Resident #24 A. Resident status Resident #24, age 78, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 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. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. B. PASRR level II notice of determination for MI (mental illness) evaluation and facility failures The resident's pre-admission level I PASRR dated 4/19/23 revealed the resident was approved under a provisional admission. The PASRR included the definition of a provisional admission. It documented a provisional admission resident as one who had either a known or suspected mental illness or related condition. The facility was responsible to submit a new level I screen if the resident was anticipated to remain in the facility past 30 days. There were no additional level I PASRR screens in the resident's chart to indicate the State Mental Health Agency was notified the resident had resided in the facility for four months. This failure resulted in the resident not being screened for a level II PASRR and not being identified for any specialized services. C. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated he struggled with depression and adjustment issues at the facility. After returning from the Vietnam war, he coped with drugs and alcohol and isolated himself from his family. He stated he attempted suicide seven times in his life, the last time being ten years ago. He denied current thoughts of self harm. His post traumatic stress disorder (PTSD) gave him flashbacks and hallucinations of things he saw and did when in Vietnam. He said he was still trying to process those feelings. Some of his triggers were when people came up behind him and not having a safe place to go to process. D. Record review The comprehensive care plan, initiated on 5/10/23, revealed the resident had PTSD with nightmares related to military service. Interventions included to reorient the resident, allow him to verbalize his feelings and anticipate the resident's needs. The resident had the potential to be verbally aggressive related to mental and emotional illness. Interventions included analyzing triggers, monitor effectiveness of medications, anticipate needs, give the resident choices, provide positive reinforcement for good behavior, and ensure the resident had independent activities he enjoyed The resident took antidepressant medications related to depression and PTSD. The resident took anti psychotics related to PTSD, nightmares, and flashbacks. Interventions included administering medications as ordered, monitor for adverse reactions, and educate the resident on risks/benefits and side effects of medications. The August 2023 CPO revealed the following physician orders: -Abilify (Aripiprazole, an antipsychotic medication) 10 milligrams (MG)- give one tablet by mouth one time a day for PTSD- ordered on 6/7/23. -Trazodone (antidepressant) 100 MG- give one tablet by mouth for depression- ordered on 4/20/23. -Venlafaxine (Effexor, antidepressant) 75 MG- give three capsules by mouth two times a day for PTSD- ordered on 4/27/23. Progress notes reviewed from 4/22/23 to 8/24/23 revealed no social service notes were located documenting a new PASRR had been submitted. II. Resident #12 A. Resident status Resident #12, age 70, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included bipolar, depression, and anxiety. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. No behaviors were indicated. The resident was marked as having a PASRR level II condition of mental illness on the MDS. B. PASRR level II notice of determination for MI evaluation and facility failures A pre-admission level I PASRR was not located. Additionally, there was no evidence the facility had received a level II PASRR, level II evaluation or notice of determination. This failure resulted in the resident not being screened for appropriateness of placement setting and possible required recommendations for the facility to provide. C. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was sleeping each time. D. Record review The comprehensive care plan, revised on 7/11/21, revealed the resident had bipolar disorder with anxiety. The resident had been stable over the past year and no longer required services from the mental health provider. Interventions included to keep the physician, mental health provider, and family informed of any changes in mood, depression, and behaviors. The resident would maintain a daily routine, be provided with calm environments if conflicts arose, and be encouraged to participate in activities of choice. The resident took Lithium (a psychiatric mood stabilizer) and Cymbalta (an antidepressant) for depression. Interventions included monitoring for behaviors and adverse reactions. Provide activities of choice and provide a safe environment. The resident took Risperdal (an antipsychotic) for bipolar as evident by inappropriate verbal comments and resistance to care. Interventions included monitoring for behaviors and adverse reactions. When manic, the resident would display excessive talking, seeking out men, wandering, expressing a desire to smoke, and decreased sleeping. Staff to assist with distractions and encourage participation in activities. The August 2023 CPO revealed the following physician orders: -Cymbalta (antidepressant) 30 MG- give one by mouth once a day for bipolar- ordered on 4/8/21. -Lithium carbonate (mood stabilizer)150 MG- give one by mouth once a day for bipolar- ordered on 5/7/21. -Risperdal (antipsychotic) 1 MG- give one by mouth once a day for dementia with behaviors- ordered on 12/21/22. -Lorazepam (Ativan, anti-anxiety) 0.5 MG- give one tablet by mouth at bedtime for other specified anxiety disorders- ordered on 7/18/23. -Lorazepam 0/25 MG- give one tablet two times a day for anxiety- ordered on 7/19/23. Progress notes reviewed from 12/31/22 to 8/24/23 revealed no social service notes were located documenting a pre-admission PASRR had been requested or a level II evaluation request had been submitted. III. Staff interviews The SSD was interviewed on 8/23/23 at 11:53 a.m. She did not know the timeframe for a provisional PASRR for Resident #24. She stated she had been sending in status change PASRRs for Resident #12 and was told there was nothing else she needed to do. She was not aware of what was needed regarding a new admission with MI and the importance of the level II PASRR process. She did not have a preadmission screen level I, a level II evaluation or letter of determination with mental health recommendations for Resident #12. The nursing home administrator (NHA) was interviewed on 8/23/23 at 12:38 p.m. Her expectations of the SSD included completing PASRRs and following through on PASRRs ensuring the resident's medical records had complete PASRRs. IV. Facility follow up On 8/23/23 at 3:00 p.m. (during the survey), the NHA provided documentation the SSD submitted an updated PASRR for Resident #24 to the State Mental Health Agency.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#27 and #28) of two residents reviewed for supplemental oxygen use out of 24 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #27 and 28. Findings include: I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/23/23 at 2:47 p.m. by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. II. Resident # 27 A. Resident status Resident #27, age 76, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included schizophrenia, heart failure, left bundle-branch block, schizoaffective disorder, and hypoxia. According to the 7/31/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident had verbal symptoms directed toward others. She required limited assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Record review The resident did not have a care plan addressing the titration or monitoring of Resident #27's needs. The August 2023 CPO included an order dated 3/27/23 to titrate oxygen via nasal cannula to keep SaO2 (oxygen saturation levels) above 89% for congestive heart failure (CHF). C. Observation On 8/21/23 at 12:54 p.m. Resident #27 was lying down in bed sleeping. Resident #27 had her oxygen cannula on the side of her face. The resident's oxygen concentrator was set on three liters per minute (LPM). On 8/22/23 at 10:04 a.m. Resident #27 was in her room sitting in her wheelchair, she did not have her oxygen on. The resident's oxygen concentrator was set on three LPM. The activity director entered Resident #27's room and asked Resident #27 how she was doing. The activity director exited the resident's room and did not remind Resident #27 to put on her oxygen. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/22/23 at 10:10 a.m. She said oxygen was a medication. She said the resident was supposed to be on two LPM continuously. LPN #1 went to the resident's room and stated the resident was not wearing her oxygen cannula correctly as it was on the side of her face. LPN #1 helped Resident #27 put on her cannula and exited the resident's room. She said she would have to check Resident #27's order to see what the physician's orders stated on LPM. LPN #1 was shown Resident #27's order. She said she would contact Resident #27's provider because the order was not clear on where to start with LPM and when and how long titration was required. She said a negative outcome could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream). The DON was interviewed on 8/22/23 at 3:42 p.m. The DON said oxygen was a medication. The DON was told of the observation above. She said Resident #27's order should have been clarified with the physician to show what the initial LPM was to be and how titration was to be monitored. She said the facility needs to consult with the physician to get the order changed. III. Resident #40 A. Resident status Resident #28, age 66, was admitted on [DATE] and readmitted [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety, depression, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. According to the 7/4/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen (02) therapy. B. Record Review The resident did not have a care plan for his oxygen use. The August 2023 CPO included an order dated 6/11/23 oxygen five LPM via nasal cannula, may titrate to keep oxygen saturation above 90%. C. Observation and interview On 8/21/23 at 2:10 p.m., the resident was sitting in his recliner in his room. His room concentrator was set to three LPM and he was wearing his oxygen cannula. On 8/22/23 at 3:00 p.m., the resident was sitting in his recliner and was not wearing his oxygen. Certified nurse aide (CNA) #6 walked into Resident #28's room to check his vitals. CNA #6 was asked to check the resident's oxygen saturation. CNA #6 placed the resident's oxygen cannula on the resident and checked his oxygen saturation, which was 84%. CNA #6 had Resident #28 take in several deep breaths and continued to have Resident #28 take deep breaths. Resident #28 was able to get his oxygen saturation up to 92%. CNA #6 reeducated Resident #28 to always have his oxygen cannula on. CNA #6 was asked to check LPM on the room concentrator which was set to three LPM. D. Staff interview CNA #6 was interviewed on 8/22/23 at 3:09 a.m. CNA #6 said Resident #28 had been wearing oxygen ever since she started working at the facility, which had been approximately one year. The DON was interviewed on 8/22/23 at 3:42 p.m. She said oxygen was a medication. She said Resident #28's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls, and hypoxic events and could have put the residents in respiratory distress.

Based on record review and interviews, the facility failed to ensure residents were provided medically related social services to attain and maintain the highest practicable mental and psychosocial wellbeing for three (#24, #12, and #9) of five residents reviewed out of 24 sample residents. Specifically, the facility failed to ensure: -Social services was providing and arranging needed mental and psychosocial counseling services for Residents #24 and #9; -Social services was meeting the needs of residents who were having difficulty with change, loss, and adjustment for Residents #24, #12 and #9; and -Social services was meeting the need for emotional support for residents suffering from suicidal ideations and changes in mental health symptoms for Residents #24 and #12. Findings include: I. Facility description of medically related social services The resident services director (social services director) job description signed by the social services director (SSD) on 10/6/2010 was provided by the nursing home administrator (NHA) on 8/24/23. It read in pertinent part: The primary purpose of this position is to plan, organize, and direct the operation of psychosocial programs for elders including social services. To include: Assure the coordination of outside services of outside agencies occur, assisting residents with financial and legal matters, and assure counseling and support for elders (residents) and families occur. II. Resident #24 A. Resident status Resident #24, age 78, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 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. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. C. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated it was difficult for him to adjust to people younger than him providing personal care when he first admitted to the facility. He said he knew he gave the nurses and certified nursing aides (CNAs) hell. When he struggled with depression and adjustment issues, he would talk to his nurses. The SSD did not come to talk to him. He stated he attempted suicide seven times in his life, the last time being ten years ago. He denied current thoughts of self harm. His post traumatic stress disorder (PTSD) gave him flashbacks and hallucinations of things he saw and did when in Vietnam. He said he was still trying to process those feelings. Some of his triggers were when people came up behind him and not having a safe place to go to process. Resident #24 was interviewed again on 8/22/23 at 1:23 p.m. He stated he had thoughts he would be better off dead in the last thirty days but he tried to stay positive. He had requested a mental health appointment through the Veterans Administration (VA) but it was canceled for some reason. He was not sure if the SSD was making him a new appointment or if he was expected to make the appointment himself. The SSD had not talked to him about it. He said he received psychosocial support from the nurses when he was having flashbacks and was distressed. D. Record review The comprehensive care plan, initiated on 5/10/23, revealed the resident had PTSD with nightmares related to military service. Interventions included to reorient the resident, allow him to verbalize his feelings and anticipate his needs. The resident had the potential to be verbally aggressive related to mental and emotional illness. Interventions included analyzing triggers, monitoring effectiveness of medications, anticipating needs, giving the resident choices, providing positive reinforcement for good behavior, and ensuring the resident has independent activities he enjoys. The resident took antidepressant medications related to depression and PTSD. The resident took antipsychotics related to PTSD, nightmares, and flashbacks. Interventions included administering medications as ordered, monitor for adverse reactions, and educate the resident on risks/benefits and side effects of medications. The August 2023 CPO revealed the following physician orders: -Abilify (Aripiprazole, antipsychotic) 10 milligram (MG)- give one tablet by mouth one time a day for PTSD- ordered on 6/7/23. -Trazodone (antidepressant) 100 MG- give one tablet by mouth for depression- ordered on 4/20/23. -Venlafaxine (Effexor, antidepressant) 75 MG- give three capsules by mouth two times a day for PTSD- ordered on 4/27/23. Progress notes reviewed from 4/21/23 to 8/24/23 revealed: -Nursing progress notes dated 4/21/23 at 3:48 p.m. revealed the resident displayed agitation when having physical difficulty feeding himself. He became angry and threw his plate on the floor. The resident stated he was leaving the facility and wanted staff to find his scooter so he could leave. The resident eventually went to sleep. -Behavior notes dated 4/22/23 at 3:29 p.m. revealed the resident had been uncooperative with care and stated he was going to leave the facility to return home. He again asked the facility to get his electric scooter for him (this was not at the facility). When the nurse tried to explain this, the resident stated his property had been stolen and he was going to call the Los Angeles police department. -Behavior notes dated 4/22/23 at 4:05 p.m. revealed the resident had escalated to screaming continuously. He again demanded the staff help him to discharge home and retrieve his scooter. The registered nurse (RN) supervisor had to calm the resident down. -Nursing progress notes dated 4/22/23 at 5:03 p.m. revealed nursing placed a call to the local mental health provider to have the resident assessed for suicidal ideations due to making verbal threats of self harm. The mental health provider informed the facility the resident required medical clearance first. -Nursing notes dated 4/22/23 at 6:48 p.m. revealed nursing placed a call to the resident's primary care provider to inform the provider of the resident's behaviors. -Order administration notes dated 4/23/23 at 10:09 p.m. revealed the resident was experiencing delusions the staff had not showered him with despite having been showered. The resident became agitated and verbally aggressive. -Nursing notes dated 4/23/23 at 3:09 p.m. revealed the resident stated to the nurse he wanted to return home but understood he was in the facility for therapy. -Order administration notes dated 4/24/23 at 2:21 p.m. revealed the resident had been yelling at his family during their visit. He told his family he was unhappy and to take him home. -Order administration notes dated 4/25/23 at 2:33 p.m. revealed the resident had become withdrawn and remained agitated. -Nutrition dietary notes dated 4/26/23 at 10:26 a.m. revealed the resident had not been adjusting well to placement and wanted to return home. -Order administration notes dated 4/26/23 at 3:29 p.m. revealed the resident was resistant to care and wanting to leave the facility. -Social services progress notes dated 4/27/23 at 3:15 p.m. revealed the social services director (SSD) met with the resident to complete the MDS and social history. The resident scored a 2 on his depression screen indicating no depressive symptoms. The note did not indicate the SSD had followed up with the resident regarding his behaviors, suicidal ideations, or demands to discharge. -Behavior notes dated 4/28/23 at 1:02 a.m. revealed the resident continuously was found to be crawling across his floor. When staff tried to educate him on using his call light and not crawling out of bed, he became belligerent. He yelled obscenities at the CNAs and woke up other residents. The other residents began to yell obscenities at him, and it went back and forth until the CNAs got him to return to bed. -Nursing progress notes dated 4/28/23 at 4:12 p.m. revealed the resident was screaming and using obscenities. The resident stripped off all of his clothing and was pulling on his catheter tubing. The tubing was adjusted and the resident eventually calmed down. -Nursing notes dated 4/28/23 at 7:12 p.m. revealed the resident's son had brought in his electric scooter but was told by the nurse the resident could not keep it. The resident became agitated and threatened to get into his scooter and leave. The son left with the scooter. -Order administration notes dated 4/28/23 at 9:03 p.m. revealed the resident was experiencing delusions he had lost four phones in four days. -Behavior notes dated 4/29/23 at 3:49 a.m. revealed the resident was experiencing visual hallucinations of people in a kitchen within his room. The resident had been yelling out for help. -Order administration notes dated 4/30/23 revealed the resident had been yelling throughout the day and was irritable. -Nursing notes dated 5/2/23 at 7:27 p.m. revealed the resident was experiencing visual hallucinations of a woman in his room trying to kidnap him. The resident had been yelling out for help. He claimed the woman was trying to kidnap him and make him use drugs. -Nursing notes dated 5/2/23 at 9:29 p.m. revealed the resident was experiencing visual hallucinations and speaking to someone in his room who was not there. -Incident notes on 5/3/23 at 3:20 a.m. revealed the resident had crawled out of bed and pulled out his catheter. He refused to allow staff to reinsert it. He was experiencing hallucinations of men in his room yelling at him. -Order administration notes dated 5/3/23 at 1:09 p.m. revealed the resident was experiencing delusions he had his sister's car at the facility and needed to return it to her. -Order administration notes dated 5/3/23 at 3:29 p.m. revealed the resident was experiencing delusions he had his sister's car at the facility and needed to return it to her. -Behavior notes dated 5/4/23 at 3:31 p.m. revealed the resident was yelling for staff assistance. He had ripped his call light from the wall and tried to self transfer so he could have a bowel movement. The resident ended up having a bowel movement in his bed. He also had thrown his water on the floor and nursing was unable to redirect his behaviors. -Behavior notes dated 5/6/23 at 4:06 p.m. revealed the resident had pulled his call light from the wall and was yelling for staff. He was refusing to use his urinal and instead used cups, his trash can, or the floor. The resident poured his water on the floor twice and stripped his clothes off twice. -Order administration notes dated 5/10/23 at 2:31 p.m. revealed the resident was experiencing confusion and agitation with increased anxiety. -Order administration notes dated 5/11/23 at 8:46 p.m. revealed the resident was experiencing delusions and hallucinations he was instructing troops he said who were not following his instructions. -Order administration notes dated 5/21/23 at 2:03 a.m. revealed the resident was experiencing delusions and hallucinations. He said there were sheriffs outside his window and he had been talking to a sergeant. -Order administration notes dated 5/22/23 at 12:51 a.m. revealed the resident was experiencing delusions asking the staff when chow was. He had become withdrawn with increased agitation. -Nursing progress notes dated 5/29/23 at 1:25 p.m. revealed the resident was experiencing delusions telling the nurse he had magical powers and his daughter had once brought him a dead baby with a hole in its skull. His daughter visited him by coming through the walls. -Order administration notes dated 6/2/23 at 11:03 p.m. revealed the resident was experiencing anxiety and came to the nurse stating he was going crazy. He was aware some of the things he saw were not real and expressed interest in seeing a psychiatrist. -Social services progress notes dated 6/6/23 at 10:09 a.m. revealed the physician had ordered mental health consultation for the resident. The SSD was attempting to schedule it through the resident's insurance. The note did not indicate the SSD had followed up with the resident regarding his behaviors, hallucinations, or delusions. -Behavior notes dated 6/9/23 at 8:26 p.m. revealed the resident had been found in his room yelling and swinging suspenders around the room. The resident was experiencing delusions and hallucinations where someone else was in the room. -Nursing progress notes dated 6/9/23 at 8:33 p.m. revealed the resident was to be referred to the mental health provider for counseling. -Nursing notes dated 6/26/23 at 7:22 p.m. revealed the resident had been out of the facility for his mental health appointment but when he arrived, the appointment had been canceled. The resident was to have a rescheduled appointment. -Social services progress notes dated 7/14/23 at 10:41 a.m. revealed the resident's MDS was completed. His depression score had increased to 14, indicating moderate depression. He had negative thoughts about himself and thoughts he would be better off dead but said he would not harm himself. The SSD had not been able to reschedule his mental health appointment yet. No suicidal ideation screen was conducted and the note did not indicate the SSD discussed with the resident his behaviors and hallucinations. -Behavior notes dated 7/24/23 at 7:50 p.m. revealed the resident was tearful and talked to the nurse about having to serve his son with eviction papers to leave his home. He stated his son hated him. -Order administration notes dated 7/25/23 at 2:23 a.m. revealed the resident had expressed depression related to the situation with his son. -Order administration notes dated 7/29/23 at 5:54 p.m. revealed the resident was having behaviors of yelling, using obscene language, anxiety, and irritability. -Medical appointment scheduling notes written by the business office assistant (BOA) dated 8/23/23 at 2:11 p.m. (during survey) revealed the BOA was notified by the SSD the resident needed a mental health appointment scheduled. A message was left with the VA. From 4/21/23 to 8/23/23, eighteen progress notes were documented concerning aggressive, depressive, or adjustment related behaviors. Fourteen progress notes were documented concerning hallucinations, delusions, and flashbacks. There were only two social service progress notes in this time frame and neither reflected the SSD addressed with the resident directly his behaviors or adjustment issues. II. Resident #12 A. Resident status Resident #12, age 70, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included bipolar, depression, and anxiety. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. No behaviors were indicated. The resident was marked as having a PASRR level II condition of mental illness on the MDS. B. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was sleeping each time. C. Record review The comprehensive care plan, revised on 7/11/21, revealed the resident had bipolar disorder with anxiety. The resident had been stable over the past year and no longer required services from the mental health provider. Interventions included to keep the physician, mental health provider, and family informed of any changes in mood, depression, and behaviors. The resident would maintain a daily routine, be provided with calm environments if conflicts arose, and be encouraged to participate in activities of choice. The resident took Lithium (a psychiatric mood stabilizer) and Cymbalta (an antidepressant) for depression. Interventions included monitoring for behaviors and adverse reactions. Provide activities of choice and provide a safe environment. The resident took Risperdal (an antipsychotic) for bipolar as evident by inappropriate verbal comments and resistance to care. Interventions included monitoring for behaviors and adverse reactions. When manic, the resident would display excessive talking, seeking out men, wandering, expressing a desire to smoke, and decreased sleeping. Staff to assist with distractions and encouraging participation in activities. The August 2023 CPO revealed the following physician orders: -Cymbalta 30 MG- give one by mouth once a day for bipolar- ordered on 4/8/21. -Lithium carbonate 150 MG- give one by mouth once a day for bipolar- ordered on 5/7/21. -Risperdal 1 MG- give one by mouth once a day for dementia with behaviors- ordered on 12/21/22. -Lorazepam (Ativan) 0.5 MG- give one tablet by mouth at bedtime for other specified anxiety disorders- ordered on 7/18/23. -Lorazepam 0/25 MG- give one tablet two times a day for anxiety- ordered on 7/19/23. Progress notes reviewed from 12/31/22 to 8/24/23 revealed: -Nursing notes dated 6/20/23 at 7:07 p.m. revealed the resident had a fall in her bathroom and was unable to move her left leg and complained of pain in her leg and hip. An ambulance was called to take the resident to the hospital. -Nursing notes dated 6/20/23 at 8:27 p.m. revealed the resident was admitted to the hospital with a left hip fracture. -Nursing notes dated 6/22/23 at 5:30 p.m. revealed the resident was readmitted to the facility post surgery for a left hip fracture. -Social services progress notes dated 7/5/23 at 11:56 a.m. revealed the resident's MDS was completed. -Nursing progress notes dated 7/6/23 at 3:49 p.m. revealed the resident stated to the nurse the prior day's storm had made her feel nervous and voiced increased anxiety before and after the storm. Twice during the shift, the resident had attempted to transfer and ambulate herself, needing to be reminded to call for assistance. The daughter was contacted and the daughter informed the nurses the resident had sounded confused and had slurred speech when on the phone. The physician was notified. -Nursing progress notes dated 7/8/23 at 2:04 p.m. revealed the resident alerted nursing she was feeling anxious and wanted to lie down. -Nursing progress notes dated 7/9/23 at 12:29 p.m. revealed the resident continued to show confusion with pacing back and forth in her wheelchair. -Nursing progress notes dated 7/10/23 at 7:43 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. The resident stated she did not know why she was there, she was confused, and did not know where she was. She expressed her confusion and forgetfulness was making her feel anxious. The resident had also begun to not recall when to use her call light for assistance and would instead yell for staff. -Order administration notes dated 7/11/23 at 2:37 p.m. revealed the resident expressed frustration related to her onset of confusion and desired to isolate in her room. -Nursing progress notes dated 7/11/23 at 3:27 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. Nursing documented the resident had become less talkative and presented as sad. -Order administration notes dated 7/12/23 at 7:26 a.m. revealed the resident had increased anxiety. -Nursing progress notes dated 7/12/23 at 2:37 p.m. revealed the resident continued to tell nursing staff she felt anxious and nervous. The resident would exit her room after being taken there by staff to roam the hallways. -Nursing progress notes dated 7/12/23 at 8:52 p.m. revealed the resident continued to show confusion. She would request to use the bathroom when she did not need to. After being laid down in bed, the resident would attempt to get out of bed unassisted. -Nursing progress notes dated 7/13/23 at 3:36 p.m. revealed the resident continued to show increased anxiety and restlessness. -Nursing progress notes dated 7/13/23 at 7:08 p.m. revealed the resident asked to be laid down and then frequently asked staff to get her up and lay her down again. -Nursing progress notes dated 7/14/23 at 6:59 a.m. revealed the resident had been restless throughout the night, requesting the staff not leave her alone. She frequently asked the staff to get her up and lay her down again stating she could not sleep. The note documented the behavior had been occurring for the last several nights. -Nursing progress notes dated 7/14/23 at 3:09 p.m. revealed nursing contacted the nurse practitioner regarding the resident's increased restlessness, anxiety, and fears of being left alone by the staff. The resident was refusing to lie down or stay in her room. Nursing requested the addition of Ativan from the nurse practitioner. -Order administration notes dated 7/15/23 at 12:29 p.m. revealed the resident displayed restlessness, anxiety, and self isolating in her room. -Nursing progress notes dated 7/15/23 at 12:31 p.m. revealed the resident was given an Ativan for restlessness and anxiety. The medication was ineffective. The resident continued to ask to get up and lay down frequently. The resident continued to pace the hallways seeking staff and requested to stay with them. She expressed wanting the staff to sit with her and hold her hand. -Nursing progress notes dated 7/15/23 at 9:10 p.m. revealed the resident continued to display restlessness, anxiety, pacing, and requests to be put to bed and then gotten out of bed. -Nursing progress notes dated 7/16/23 at 3:24 p.m. revealed the resident continued to display restlessness and requested the staff to sit with her. Ativan was ineffective. -Order administration notes dated 7/17/23 at 1:34 a.m. revealed the resident displayed anxiety. -Order administration notes dated 7/17/23 at 7:43 p.m. revealed the resident stated she was feeling anxiety. -Order administration notes dated 7/18/23 at 1:48 a.m. revealed the resident displayed anxiety. -Nursing progress notes dated 7/18/23 at 4:16 p.m revealed the provider was contacted and the Ativan was increased for continued anxiety. -Behavior notes dated 7/22/23 at 8:04 p.m. revealed after agreeing to take a shower, the resident refused once inside the shower. -Nursing progress notes dated 7/24/23 at 11:28 a.m. revealed the resident continued to display anxiety and agitation. Calling for staff when they walked past her room and showing forgetfulness. -Nursing progress notes dated 7/25/23 at 10:39 a.m. revealed the resident continued to display confusion. -Nursing progress notes dated 7/25/23 at 10:47 a.m. revealed the resident had a telehealth appointment with the mental health provider by request of her nephrologist (kidney doctor) to determine if lithium could be discontinued. The resident became agitated by the questions and refused to continue with the appointment. -Social services notes dated 7/25/23 at 11:02 a.m. revealed the SSD was advised by the mental health provider of the outcome of the appointment. -Nursing progress notes dated 7/25/23 at 12:50 p.m. revealed the resident continued to display irritability. -Nursing progress notes dated 7/26/23 at 2:50 p.m. revealed the resident continued to display anxiety. -Nursing progress notes dated 7/27/23 at 4:50 p.m. revealed nursing contacted the nurse practitioner regarding increasing the resident's Ativan again as the current dose was not effective. The nurse practitioner declined as the provider had recently increased it. The provider was questioning if hospice/comfort care needed to be considered. -Nursing progress notes dated 7/29/23 at 2:29 p.m. revealed nursing contacted the daughter to discuss possible hospice/comfort care. The daughter declined. -Nursing progress notes dated 8/4/23 at 9:52 p.m. revealed the resident continued with anxiety and restlessness. -Nursing progress notes dated 8/6/23 at 2:44 p.m. revealed the resident continued to attempt to self transfer. The resident had refused her shower the prior day and wanted to reschedule it for 8/6/23. While staff came to take the resident for her shower, she refused three times and called the staff inappropriate names. From 6/20/23 to 8/24/23, twenty six progress notes were documented concerning anxiety, distress, and confusion. From 7/6/23 to 8/6/23, the resident also displayed behaviors consistent with her care plan as indicators of bipolar episodes: decreased sleeping, inappropriate comments, wandering, and resistance to care. According to the resident's medical record, from 12/31/22 until 7/6/23, the resident's behaviors had been stable. There was only one social service progress note in the time frame and it did not reflect the SSD addressed with the resident her behaviors or increased anxiety. III. Resident #9 A. Resident status Resident #9, age 74, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included recurrent depressive disorder and insomnia. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Resident interview The resident was interviewed on 8/22/23 at 2:01 p.m. The resident stated she had requested information from the facility to contact the state health department regarding flies in the facility but was never given the information. She said she had episodes of depression since coming to the facility but no one had asked her if she would like to see a psychologist for depression or adjustment issues. When she was upset, the nurses would come and talk to her sometimes. C. Record review The comprehensive care plan revised on 6/29/23 revealed the resident had anxiety and adjustment issues related to nursing home placement. Interventions included encouraging the resident to participate in activities, providing her with choices, providing consistency of care, praising good behavior, and if possible schedule times for ADL care with the resident. The resident was taking an antidepressant medication related to depression manifesting as tearfulness, lashing out at staff, and being argumentative. Interventions were to monitor the resident's behaviors. The August 2023 CPO revealed the following physician orders: -Prozac (antidepressant) 10 MG- give three capsules by mouth one time a day for recurrent depressive disorder- ordered on 6/12/23. Progress notes reviewed from 6/13/23 to 8/24/23 revealed: -Order administration notes dated 6/13/23 at 9:27 p.m. revealed the resident expressed to nursing staff distress with her roommate for not turning off her television or lights when she went to bed. The resident stated she had been unable to sleep for two nights as a result. -Order administration notes dated 6/14/23 at 1:12 a.m. revealed the resident expressed frustration to the nurses regarding her roommate. The resident was yelling and touching her roommate's television, complaining about the roommate's light being on. -Nursing progress notes dated 6/14/23 at 4:09 a.m. revealed the resident expressed to nursing staff she could not sleep because there was a light on in her room. The resident came out of her room several times to complain to staff about the light. The resident was arguing with her roommate and attempting to turn her roommate's television off. The resident was yelling at staff stating she could not take this anymore and wanted to leave. -Nursing progress notes dated 6/14/23 at 2:20 p.m. revealed the resident expressed to the nurses being unhappy with her roommate. Nursing advised the social services director of the situation. -Social service progress notes dated 6/14/23 at 3:12 p.m. revealed the behavior committee reviewed the resident's chart and no changes were recommended due to the resident being a new admission. The note did not indicate the SSD followed up with the resident on her distress or concerns. -Order administration notes dated 6/14/23 at 8:04 p.m. revealed the resident displayed behaviors of frequently calling the staff into her room to address superficial needs in order to have someone in the room with her. -Order administration notes dated 6/19/23 at 1:34 p.m. revealed the resident had been tearful when nursing was communicating with her due to feeling frustration. The staff brought her coffee in a facility cup and not in her personal coffee cup as per her preference. -Order administration notes dated 6/20/23 at 8:03 p.m. revealed the resident displayed behaviors of anger and distress regarding the dinner served. She expressed dinner being disgusting and then expressed anxiety regarding a potential new roommate she was going to get. She was concerned the roommate would also leave a light on. -Behavior notes dated 6/21/23 at 8:07 p.m. revealed the resident expressed anger and distress to nursing regarding her new roommate and the door being cracked open in the evening so the nurses could check on the roommate. The resident was upset about the light coming into her room and disrupting her sleep. -Order administration notes dated 6/23/23 at 8:49 p.m. revealed the resident expressed tearfulness and frustration to nursing staff but no further details were provided in the note. -Nursing progress notes dated 6/23/23 at 9:46 p.m. revealed the resident expressed distress and frustration to the nursing staff stating the situation with the roommate had been handled poorly. The resident demanded to speak to someone in upper management. Nursing advised her the director of nursing would be notified. -Nursing progress notes dated 6/24/23 at 3:41 p.m. revealed the resident expressed distress to nursing regarding needing her room to be rearranged and needing an extension cord in order to use her stereo. -Social service notes dated 6/26/23 at 10:29 a.m. revealed the SSD had a conversation with the resident's daughter. The conversation pertained to items the resident was missing from her previous facility. The SSD was aware of the resident's behaviors and informed the daughter of the behaviors. However, progress notes did not indicate the SSD had met with the resident to discuss her behaviors, distress, challenges adjusting, or desire to express grievances. -Social service notes dated 6/26/23 at 4:44 p.m. revealed the SSD completed the resident's MDS and was aware the resident was unhappy with her roommates. -Order administration notes dated 6/26/23 at 8:36 p.m. revealed the resident did not receive her dinner in her room as she requested and was upset she had been forgotten. -Order administration notes dated 6/28/23 at 3:08 p.m. revealed the resident expressed tearfulness and frustration to nursing staff regarding her iced tea not being strong enough. She lashed out at staff accusing them of not knowing what they were doing and not being able to do anything right for her. -Order administration notes dated 7/3/23 at 12:42 p.m. revealed the resident had been tearful every time the staff went into her room but could not explain what she was tearful about. -Order administration notes dated 7/3/23 at 8:54 p.m. revealed the resident had been calling staff frequently to her room for superficial requests like moving a table or closing her blinds. -Order administration notes dated 7/4/23 at 1:31 p.m. revealed the resident had been tearful. The resident denied physical discomfort and attempted to express her emotional distress to the staff regarding feeling her previous facility had been better. -Social service progress notes dated 7/6/23 at 11:44 a.m. revealed the resident had come to the SSD's office to request discharge back to her prior facility. The resident felt the current facility was charging her for her incontinence supplies. The SSD called the prior facility and left a message. No further conversation was documented reflecting the SSD addressed the resident's grievance. -Nursing progress notes dated 7/7/23 at 11:48 a.m. revealed the resident had an appointment in the morning and had been upset about leaving the facility for the appointment. She had been upset about her incontinent pads and oxygen tubing. -Order administration notes dated 7/8/23 3:10 p.m. revealed the resident expressed frustration and was argumentative with nurs

Based on observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#39) of five residents reviewed for unnecessary medications. Specifically, the facility failed to ensure the ordered antibiotic was effective to treat the resident. Findings include: I. Resident status Resident #39, age 90, was admitted on [DATE] and readmitted [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and urinary tract infections. The 5/8/23 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status (BIMS) due to severe cognitive decline. During the look back period, she had received an antibiotic seven out of seven days. II. Record review The August 2023 CPO included an order for Keflex 250 mg (cephalexin). Give one capsule by mouth at bedtime for recurrent urinary tract infections (UTIs). The order started 8/23/21. The hospital discharge paperwork dated 7/14/23 included: -Page four listed the discharge medications to include cephalexin 250 mg, take one capsule by mouth nightly at bedtime. -Page seven noted, antibiotic resistance to cephalosporins. III. Interviews The director of nursing (DON) was interviewed on 8/23/23 at 2:00 p.m. She said she was not aware the resident had developed a resistance to Keflex. She said the facility went by the discharge orders and did not see the notation of resistance. She said going forward she would review the discharge instructions more closely and would contact the primary to discontinue the Keflex.

Based on record review and interviews, the facility failed to ensure three (#24, #12, and #9) of five residents reviewed were free from unnecessary psychotropic medications out of 24 sample residents. Specifically, the facility failed to monitor targeted behaviors and provide non-pharmacological interventions for psychotropic medications for Residents #24, #12 and #9. Findings include: I. Resident #24 A. Resident status Resident #24, age 78, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 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. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. B. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated he suffered from post traumatic stress disorder (PTSD), flashbacks, and hallucinations. The flashbacks and hallucinations were disturbing to him at times, and consisted of things he saw and did when in Vietnam. He said he was still trying to process those feelings. Some of his triggers were when people came up behind him and not having a safe place to go to process. He said interventions that worked for him were listening to his music, playing on his phone, smoking cigarettes, and one-to-one visits with staff. D. Record review The comprehensive care plan, initiated on 5/10/23, revealed the resident had PTSD with nightmares related to military service. The resident had the potential to be verbally aggressive related to mental and emotional illness. The resident took antidepressant medications related to depression and PTSD. The resident took antipsychotics related to PTSD, nightmares, and flashbacks. Interventions included administering medications as ordered, monitor for adverse reactions, and educate the resident on risks/benefits and side effects of medications. Interventions for the resident's psychotropic medications did not include non-pharmacological approaches. The August 2023 CPO revealed the following physician orders: -Monitor for signs and symptoms of depression: withdrawn, tearful, resistive with care. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions- ordered on 4/20/23. No specific medication was indicated. -Monitor for signs and symptoms of mood swings: withdrawal, depression, anxiety, flashbacks, irritability. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions- ordered on 4/20/23. No specific medication was indicated. -Abilify (Aripiprazole, antipsychotic) 10 milligrams (MG)- give one tablet by mouth one time a day for PTSD- ordered on 6/7/23. -Trazodone (antidepressant) 100 MG- give one tablet by mouth for depression- ordered on 4/20/23. -Venlafaxine (Effexor, antidepressant) 75 MG- give three capsules by mouth two times a day for PTSD- ordered on 4/27/23. Behavior monitoring dated 5/1/23 to 8/23/23 revealed: -May 2023 monitoring documented behaviors of mood swings on 5/2/23-5/4/23, 5/10/23, 5/11/23, 5/20/23, 5/22/23, 5/27/23, 5/29/23, and 5/30/23. -May 2023 monitoring documented behaviors of depression on 5/3/23, 5/4/23, 5/6/23, 5/10/23, 5/11/23, 5/17/23, 5/20/23, and 5/27/23. -June 2023 monitoring documented behaviors of mood swings on 6/2/23 and 6/25/23. -June 2023 monitoring documented behaviors of depression on 6/2/23. -July 2023 monitoring documented behaviors of mood swings on 7/24/23 and 7/29/23. -July 2023 monitoring documented no behaviors of depression. -August 2023 monitoring documented no behaviors of mood swings. -August 2023 monitoring documented behaviors of depression on 8/14/23. Progress notes reviewed from 5/1/23 to 8/24/23 revealed: -Incident notes on 5/3/23 at 3:20 a.m. revealed the resident had crawled out of bed and pulled out his catheter. He refused to allow staff to reinsert it. He was experiencing hallucinations of men in his room yelling at him. No non-pharmacological interventions were documented. -Order administration notes dated 5/3/23 at 3:29 p.m. revealed the resident was experiencing delusions he had his sister's car at the facility and needed to return it to her. No non-pharmacological interventions were documented. -Order administration notes dated 5/4/23 at 12:57 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 5/6/23 at 11:56 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 5/10/23 at 2:31 p.m. revealed the resident was experiencing confusion and agitation with increased anxiety. No non-pharmacological interventions were documented. -Order administration notes dated 5/11/23 at 12:07 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 5/17/23 at 8:23 p.m. revealed the resident refused his shower. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 5/21/23 at 2:03 a.m. revealed the resident had experienced delusions and hallucinations. He said there were sheriffs outside his window and he had been talking to a sergeant. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 5/23/23 at 5:48 a.m. documented a behavior was observed: yes. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 5/28/23 at 1:28 a.m. documented a behavior was observed: yes. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Behavior notes dated 6/9/23 at 8:26 p.m. revealed the resident had been found in his room yelling and swinging suspenders around the room. The resident was experiencing delusions and hallucinations where someone else was in the room. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 6/25/23 at 7:34 p.m. documented a behavior was observed: yes. No other information included in the note. -Social services progress notes dated 7/14/23 at 10:41 a.m. revealed while the SSD was conducting a depression screen with the resident he stated he had lost interest in activities he enjoyed, had been feeling down, had trouble sleeping due to nightmares, felt bad about himself and had thoughts he would be better off dead. He denied a plan to harm himself. Those indicators of depression were not documented on his behavior tracker and the depression behavior tracker was not modified to include suicidal ideations. No non-pharmacological interventions were documented. -Order administration notes dated 7/25/23 at 2:23 a.m. revealed the resident had expressed depression related to the situation with his son. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/29/23 at 5:54 p.m. revealed the resident had behaviors of yelling, using obscene language, anxiety, and irritability. No non-pharmacological interventions were documented. -Order administration notes dated 8/15/23 at 1:57 a.m. documented a behavior was observed: yes. No other information included in the note. The behavior episode had not been documented on the behavior tracker. No progress note was located for the behavior documented on the August 2023 tracker for 8/14/23. II. Resident #12 A. Resident status Resident #12, age 70, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included bipolar, depression, and anxiety. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. No behaviors were indicated. B. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was sleeping each time. C. Record review The comprehensive care plan, revised on 7/11/21, revealed the resident had bipolar disorder with anxiety. The resident took Lithium (a psychiatric mood stabilizer) and Cymbalta (an antidepressant) for depression. Interventions included monitoring for behaviors and adverse reactions. Provide activities of choice and provide a safe environment. The resident took Risperdal (an antipsychotic) for bipolar as evident by inappropriate verbal comments and resistance to care. Interventions included monitoring for behaviors and adverse reactions. When manic, the resident would display excessive talking, seeking out men, wandering, expressing a desire to smoke, and decreased sleeping. Non-pharmacological interventions included; snacks from nurses station, call daughter, puzzles, Bingo, personal comfort food (Mexican food), and games. The August 2023 CPO revealed the following physician orders: -Monitor for signs and symptoms of depression: sad expression, irritability or frustration, isolating self in room. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions for use of Cymbalta- ordered on 5/5/2020. -Lithium carbonate (mood stabilizer) 150 MG- give one by mouth once a day for bipolar- ordered on 5/7/21. -Monitor for signs and symptoms of mood swings: inappropriate verbal comments to staff and elders (residents) and resistance to care. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions for use of Risperdal- ordered on 9/30/21. -Cymbalta (antidepressant) 30 MG- give one by mouth once a day for bipolar- ordered on 4/8/21 (original start date 11/15/2020). -Risperdal (antipsychotic) 1 MG- give one by mouth once a day for dementia with behaviors- ordered on 12/21/22 (original start date 1/29/2020). -Lorazepam (Ativan, anti-anxiety) 0.5 MG- give one tablet by mouth at bedtime for other specified anxiety disorders- ordered on 7/18/23. -Lorazepam 0/25 MG- give one tablet two times a day for anxiety- ordered on 7/19/23. No behavior trackers for Lithium or Lorazepam were located in physician orders. Behavior monitoring dated 5/1/23 to 8/23/23 revealed: -May 2023 monitoring documented no behaviors of mood swings. -May 2023 monitoring documented behaviors of depression on 5/15/23 and 5/29/23. -June 2023 monitoring documented no behaviors of mood swings. -June 2023 monitoring documented no behaviors of depression. -July 2023 monitoring documented no behaviors of mood swings. -July 2023 monitoring documented behaviors of depression on 7/11/23, 7/13/23, 7/15/23, 7/17/23, 7/21/23, 7/25/23, and 7/27/23. -August 2023 monitoring documented no behaviors of mood swings. -August 2023 monitoring documented no behaviors of depression. Progress notes reviewed from 5/1/23 to 8/24/23 revealed: -Order administration notes dated 5/29/23 at 1:20 p.m. documented the resident had a sad expression. No other information included in the note. -Nursing progress notes dated 7/6/23 at 3:49 p.m. revealed the resident stated to the nurse the prior day's storm had made her feel nervous and voiced increased anxiety before and after the storm. Twice during the shift, the resident had attempted to transfer and ambulate herself, needing to be reminded to call for assistance. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/8/23 at 2:04 p.m. revealed the resident alerted nursing she was feeling anxious and wanted to lie down. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/9/23 at 12:29 p.m. revealed the resident continued to show confusion with pacing back and forth in her wheelchair. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/10/23 at 7:43 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. The resident stated she did not know why she was there, she was confused, and did not know where she was. She expressed her confusion and forgetfulness was making her feel anxious. The resident had also begun to not recall when to use her call light for assistance and would instead yell for staff. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/11/23 at 2:37 p.m. revealed the resident expressed frustration related to her onset of confusion and desired to isolate in her room. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/11/23 at 3:27 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. Nursing documents the resident had become less talkative and presented as sad. No non-pharmacological interventions were documented. -Order administration notes dated 7/12/23 at 7:26 a.m. revealed the resident had increased anxiety. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/12/23 at 2:37 p.m. revealed the resident continued to tell nursing staff she felt anxious and nervous. The resident would exit her room after being taken there by staff to roam the hallways. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/12/23 at 8:52 p.m. revealed the resident continued to show confusion. She would request to use the bathroom when she did not need to. After being laid down in bed, the resident would attempt to get out of bed unassisted. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/13/23 at 3:36 p.m. revealed the resident continued to show increased anxiety and restlessness. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/14/23 at 6:59 a.m. revealed the resident had been restless throughout the night, requesting the staff not leave her alone. She frequently asked the staff to get her up and lay her down again stating she could not sleep. The note documented the behavior had been occurring for the last several nights. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/14/23 at 3:09 p.m. revealed nursing contacted the nurse practitioner regarding the resident's increased restlessness, anxiety, and fears of being left alone by the staff. The resident was refusing to lie down or stay in her room. Nursing requested the addition of Ativan from the nurse practitioner. -Order administration notes dated 7/15/23 at 12:29 p.m. revealed the resident displayed restlessness, anxiety, and self isolating in her room. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/15/23 at 9:10 p.m. revealed the resident continued to display restlessness, anxiety, pacing, and requests to be put to bed and then gotten out of bed. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/16/23 at 3:24 p.m. revealed the resident continued to display restlessness and requested the staff to sit with her. Ativan was ineffective. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/17/23 at 1:34 a.m. revealed the resident displayed anxiety. No other information included in the note. -Order administration notes dated 7/17/23 at 7:43 p.m. revealed the resident stated she was feeling anxiety. No other information included in the note. -Order administration notes dated 7/18/23 at 1:48 a.m. revealed the resident displayed anxiety. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Behavior notes dated 7/22/23 at 8:04 p.m. revealed after agreeing to take a shower, the resident refused once inside the shower. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/24/23 at 3:04 a.m. revealed the resident had an unwitnessed fall and was sent out to the hospital. The progress note was marked as a behavior associated with mood swings. -Nursing progress notes dated 7/25/23 at 12:50 p.m. revealed the resident continued to display irritability. No other information included in the note. -Nursing progress notes dated 7/26/23 at 2:50 p.m. revealed the resident continued to display anxiety and staff contacted the provider per the resident's request. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 8/4/23 at 9:52 p.m. revealed the resident continued with anxiety and restlessness. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 8/6/23 at 2:44 p.m. revealed the resident continued to attempt to self transfer. The resident had refused her shower the prior day and wanted to reschedule it for 8/6/23. While staff came to take the resident for her shower, she refused three times and called the staff inappropriate names. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. No progress note was located for the behavior documented on the May 2023 tracker for 5/15/23. III. Resident #9 A. Resident status Resident #9, age 74, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included recurrent depressive disorder and insomnia. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Resident interview The resident was interviewed on 8/22/23 at 2:01 p.m. She said she had episodes of depression since coming to the facility but no one had asked her if she would like to see a psychologist for depression or adjustment issues. When she was upset, the nurses would come and talk to her sometimes. C. Record review The comprehensive care plan, revised on 6/29/23 revealed the resident had anxiety and adjustment issues related to nursing home placement. The resident was taking an antidepressant medication related to depression manifesting as tearfulness, lashing out at staff, and being argumentative. Interventions were to monitor the resident's behaviors. Interventions for the resident's psychotropic medication did not include non-pharmacological approaches. The August 2023 CPO revealed the following physician orders: -Prozac (antidepressant) 10 MG- give three capsules by mouth one time a day for recurrent depressive disorder- ordered on 6/12/23. -Monitor for signs and symptoms of depression: tearful, frustrated, statements of feeling sad, argumentative, lashing out at staff. If behaviors observed document the behavior episode, interventions used and effectiveness. No specific medication indicated- ordered on 6/26/23. Behavior monitoring dated 6/12/23 to 8/23/23 revealed: -June 2023 monitoring documented behaviors of depression on 6/26/23 and 6/27/23. -July 2023 monitoring documented behaviors of depression on 7/3/23-7/6/23, 7/8/23, 7/9/23, 7/11/23-7/13/23, 7/17/23- 7/20/23, 7/24/23- 7/27/23, and 7/31/23. -August 2023 monitoring documented behaviors of depression on 8/3/23, 8/6/23-8/17/23, 8/19/23, 8/22/23-8/24/23, 8/27/23, and 8/28/23. Progress notes from 6/26/23 to 8/24/23 revealed: -Order administration notes dated 6/28/23 at 3:08 p.m. revealed the resident expressed tearfulness and frustration to nursing staff regarding her iced tea not being strong enough. She lashed out at staff accusing them of not knowing what they were doing and not being able to do anything right for her. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/3/23 at 12:42 p.m. revealed the resident had been tearful every time the staff went into her room but could not explain what she was tearful about. No non-pharmacological interventions were documented. -Order administration notes dated 7/3/23 at 8:54 p.m. revealed the resident had been calling staff frequently to her room for superficial requests like moving a table or closing her blinds. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 7/4/23 at 1:31 p.m. revealed the resident had been tearful. The resident denied physical discomfort and attempted to express her emotional distress to the staff regarding feeling her previous facility had been better. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 7/5/23 at 10:42 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/6/23 at 2:03 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/6/23 at 9:53 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/8/23 3:10 p.m. revealed the resident expressed frustration, was argumentative with nursing staff and threatened to start throwing things. No non-pharmacological interventions were documented. -Order administration notes dated 7/9/23 at 11:32 a.m. revealed the resident expressed frustration, complaints, and was argumentative with nursing staff but no further details were provided in the note. -Order administration notes dated 7/11/23 at 1:36 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/12/23 at 1:02 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/13/23 at 12:33 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/17/23 at 7:41 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/19/23 at 1:50 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/20/23 at 1:28 p.m. revealed the resident expressed tearfulness towards nursing staff stating she could not do this anymore, was frustrated, and felt exhausted. No non-pharmacological interventions were documented. -Order administration notes dated 7/24/23 at 2:21 p.m. revealed the resident expressed frustration and was screaming because she could not get her oxygen on her face correctly. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 7/25/23 at 12:49 p.m. revealed the resident expressed frustration to nursing but no further details were provided in the note. -Order administration notes dated 7/26/23 at 1:24 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/31/23 at 12:50 p.m. revealed the resident expressed tearfulness and frustration to nursing staff but no further details were provided in the note. -Order administration notes dated 8/3/23 at 12:38 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/6/23 at 5:21 p.m. revealed the resident expressed frustration to nursing staff but no further details were provided in the note. -Order administration notes dated 8/7/23 at 1:12 p.m. revealed the resident expressed frustration, was argumentative, and lashing out at staff but no further details were provided in the note. -Order administration notes dated 8/8/23 at 1:34 p.m. revealed the resident expressed frustration, was argumentative, and lashing out at staff but no further details were provided in the note. -Order administration notes dated 8/9/23 at 2:15 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/9/23 at 3:03 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/10/23 at 12:47 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/10/23 at 8:14 p.m. revealed the resident expressed she was upset the staff had promised her sheets on the bed would be changed to her own personal sheets she had brought per her preference but it had not been done. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 8/11/23 at 10:28 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/12/23 at 4:56 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/13/23 at 11:32 a.m. revealed the resident expressed frustration, lashing out at staff, and was argumentative but no further details were provided in the note. -Order administration notes dated 8/14/23 at 10:43 a.m. revealed the resident expressed frustration and was argumentative but no further details were provided in the note. -Order administration notes dated 8/15/23 at 11:11 a.m. revealed the resident expressed frustration and was argumentative but no further details were provided in the note. -Order administration notes dated 8/16/23 at 9:05 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/17/23 at 1:17 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/19/23 at 1:43 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/22/23 at 1:46 revealed the resident expressed frustration and was argumentative but no further details were provided in the note. -Order administration notes dated 8/23/23 at 2:26 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/23/23 at 2:34 p.m. revealed the resident expressed frustration and was argumentative but no further details were provided in the note. III. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 8/22/23 at 2:30 p.m. She stated Resident #9 had forgetfulness but no other behaviors. Resident #24 had forgetfulness. She had not been told he had PTSD or what his triggers were. Resident #12 had no behaviors, just slept a lot. CNA #8 said the SSD and DON did not let them know resident specific behaviors; the staff had to read the care plan. The target behaviors and interventions were in the care plans. The CNAs reported behaviors to the nurses and the nurses documented in the resident's chart. Registered nurse (RN) #1 was interviewed on 8/23/23 at 9:59 a.m. She stated Resident #24 did not have behaviors anymore; he used to self-isolate. He had PTSD, nightmares, and sometimes he heard voices. RN #1 was not aware of specific triggers or interventions for Resident #24. Resident #12 currently had behaviors of flat affect, isolating, resisting care and refusing therapies. She had been getting paranoid and had decreased sleep for the last few months. Resident #9 had quite a few behaviors. She got easily frustrated when things did not happen the way she expected. She got angry and tearful; the adjustment to placement had been hard for her. Doing her art and listening to her stereo were really important to her. If a resident was having behaviors, the nurse would visit with the resident and make a progress note. The behavior would also be marked on the resident's behavior tracker. The behavior tracker popped up like the MAR and prompted the nurse to make a progress note after a behavior was indicated. The progress note should include the behavior, the intervention tried, and whether or not the behavior intervention was effective. The SSD was interviewed on 8/23/23 at 11:53 a.m. She said Resident #24 initially refused care when he first arrived. She did not know what his PTSD triggers were or effective interventions; she said she could go and ask him. Resident #12 did not have behaviors. The SSD did not know if the resident had changes in behavior or mental cognition since her fall on /20/23; the SSD would have to look into it. Resident #9 did have behaviors, the resident could be demanding and attention seeking. Behavior tracking was entered as an order. Nursing entered those orders and did not include her in the conversation regarding the content. During the psychotropic drug review meeting, the physician would review the resident's behavior in the chart to decide if medication was still needed. The SSD did not know every element required in the behavior note. When a resident was having behavioral issues, nursing staff did not contact the SSD. Behaviors were reviewed in the morning management meeting the SSD attended. The NHA was interviewed on 8/23/23 at 12:38 p.m. The NHA said the MDS manager reviewed the resident's history to find target behaviors to include in the behavior tracking order. The NHA did not know where in the resident's chart the MDS manager found the target behaviors. The MDS manager did not work in the building; it was a remote position. The director of nursing (DON) and NHA were interviewed on 8/24/23 at 11:00 a.m. The DON stated when behavior trackers were established, part of the process included looking at the medication the resident was taking and the signs and symptoms of the diagnosis associated with the medication. When a behavior occurred, the nurses documented the behavior, the interventions tried, and if the interventions were effective or ineffective. When the nurse made a behavior tracking progress note, it should not say yes for a behavior indicated with no further information. The behavior tracking was used to provide the physician with information on whether a medication was effective or ineffective. The physician would use the information to decide on discontinuing medication, increasing medication, or starting a dose reduction. Monitoring was important to determine the overall safety of the resident. The SSD tracked the resident behaviors and was able to run a report in the medical records system. In the morning management meeting, behaviors were discussed from the prior twenty four hours and the SSD was expected to follow up with the residents.

Based on observations, record review and interviews, the facility failed to ensure assistance, supervision, and an environment free of accident hazards for one (#27) of five sample residents out of 25 sample residents. The facility failures to observe, supervise, anticipate the needs and implement appropriate person centered fall prevention measures for Resident #27, who had a [DIAGNOSES REDACTED].#27's fall. Resident #27 was found on the floor on 1/16/2021 at 11:40 p.m. Resident #27 had an unwitnessed fall and sustained two lacerations to the left side of her head, requiring sutures, and a dislocated shoulder. She was sent to the emergency room for evaluation and treatment. Furthermore, the facility failed to ensure the fall care plan was updated for Resident #27, and appropriate consistent interventions were implemented, to ensure the resident received two person assistance with transfers and ambulation. Findings include: I. Facility policies The falls policies were emailed by the nursing home administrator (NHA) on 3/12/2021 documented in pertinent part: a. Falls-clinical protocol, last revised March 2018, in pertinent part: The staff and physician will monitor and document the individual'ss response to interventions intended to reduce falling or the consequences of falling. b. Fall risk assessment, last revised March 2018, 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. II. Resident #27 A. Resident status Resident #27, over the age of 80, was admitted on [DATE]. According to the March 2021 computerized physician orders [REDACTED]. According to the 1/25/2021 significant change minimum data set (MDS) assessment, the resident had severe cognitive impairment with no score noted with the brief interview for mental status (BIMS) score. The resident suffered one fall with major injury since admission or prior assessment. She required extensive assistance from two people for bed mobility, transfer, walking in room, walking in corridor, locomotion on and off the unit, dressing, and toileting. The resident was not steady and only able to stabilize with human assistance to move from a seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and surface to surface transfer. The resident required a walker or wheelchair for mobility. B. Record review The care plan for falls, initiated 12/9/2020 without revision, stated the resident was high risk for falls related to confusion, deconditioning, and unaware of safety needs. She had a history of [REDACTED]. light was within reach, and encourage her to use it for assistance as needed; and, she needed a safe environment with even floors, free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, and personal items within reach. The care plan for ADL self-care performance deficit related to dementia and postural kyphosis, initiated on 12/9/2020, was last revised on 2/12/2021. Interventions included set up with her walker; she required supervision on mobility while using her walker; she required supervision with transfers using her walker; she required supervision with bed mobility; and as needed safety, she was a fall risk, anticipate her needs and encourage her to use her call light. -The MDS and the care plan did not have matching documentation to coordinate efforts regarding transferring and ambulation status of the resident for safety concerns. C. Resident observations and interviews On 3/9/2021 at 8:40 a.m. the resident was observed sitting in a bedside high-back chair. She had a wheeled bedside table pushed up in front of her. The resident had her call light button on the bed next to her. The resident'ss walker was observed across the room, about 10 feet away, near the sink. The resident was observed slowly scooting forward in her chair, pushing her table away from her. She said she needed to get up and go to the bathroom. She refused to push her call light button, and said she did not need the help. She would not engage in conversation, and continued to get into an upright position. The resident said she would get her walker, and go to the bathroom by herself. The call light button was pushed on behalf of the resident, as she reached her walker, and attempted to take herself to the bathroom. A staff member entered the room, and told the resident she would assist her. On 3/9/2021 at 3:05 p.m. the resident was observed sitting in her high-back bedside chair. Her walker was observed in the hallway, outside of her room. She was observed sitting in the chair with her wheeled bedside table in front of her. Her call light was on the bed beside her. The larger table top was placed on top of the table, so the resident could work on her jigsaw puzzle. On 3/10/2021 at 5:30 p.m. the resident'ss walker was observed placed next to her high-back bedside chair, in close enough proximity to reach it from her chair. Her call light was on the bed beside her. She was eating dinner from her wheeled bedside table. She said that the staff usually had the walker placed outside of her room, in the hallway. She said she usually had to push the call light button, so someone could bring her walker to her, if it was in the hallway. On 3/10/2021 at 6:05 p.m. the resident said that her walker was in her room, so she could get it herself if she wanted to use it. Her call light was on the bed beside her. The walker was observed across the room from her, next to her sink, an estimate of about 10 feet away. She currently had the jigsaw puzzle table top in front of her, as she sat in her high-back bedside chair. The facility failed to establish consistent approaches, walker placement, to prevent resident'ss falls. D. Fall investigation On 1/16/2021 at 11:40 p.m. the staff heard a loud thud, and upon entering the resident'ss room, found the resident was lying on the floor on her left side. The resident had active bleeding from the left side of her head, which were two lacerations present on the left side of her head, adjacent to her left eyebrow, which required sutures in the emergency room . The resident stated she was attempting to go to the bathroom, and had fallen on the floor. The resident was assessed, a neurological assessment was started, and the lacerations to her forehead were dressed. The resident was observed guarding and moaning in pain of her left arm/shoulder. The physician ordered the resident sent to the emergency room for 2 view x-rays to her left shoulder. Upon return to the facility, the resident'ss arm was in a sling, and the staff was informed the resident'ss left shoulder was dislocated, and had reduction in the emergency room . The fall investigation determined that a predisposing environmental factor included poor lighting. A predisposing physiological factor included impaired memory. A predisposing situation factor included a recent room change. The resident was found to have no lighting in her room at the time of the incident. The resident may have tripped over her bedside table, due to the darkness. The resident was alert and oriented times two, and stated she was attempting to go to the restroom. Identified interventions included neurological checks, physical therapy screen, ortho consult, physical and occupation therapy, hemi-walker, and education with the staff on the use of her light. This was signed by staff in medical records, a registered nurse (RN), social services, and the staff development coordinator (SDC). The rehabilitation screening was completed on 1/18/2021, and identified the resident'ss injury as a non-displaced humeral fracture. Therapy orders received. In-service training report completed on 1/18/2021 documented that staff would make sure to keep the light on over the resident'ss sink at all times during the night. Also, the staff was to keep the resident'ss bedside table away from the bed, and out of the resident'ss path to the bathroom, to prevent a tripping hazard. The physician consultation on 1/19/2021 documented that the resident had dislocated her left shoulder, and it was reduced in the emergency room . She was sent home with a sling immobilizer. The recommendation was to use the arm sling for four weeks, and it was ok to use the arm for walking if she could tolerate it with assistance. E. Record review Progress note on 1/17/2021 documented that after the resident'ss return from the emergency room , the resident had been attempting to get up and ambulate and transfer on her own, redirecting her often. A post-fall Morse Fall Scale was completed on 1/17/2021 and indicated a score of 80, high risk for falling. Progress note on 1/18/2021 documented that the resident was able to stand with transfers, but was unsteady and required two person assistance. Progress note on 1/23/2021 documented that the resident had taken herself to the bathroom. Social service note on 1/29/2021 documented that the resident was unable to understand what she was asking and she was trying to get up, and stated she needed to use the bathroom. A physician follow-up visit on 2/16/2021 documented that the left shoulder pain was improving, and it was ok for her to use the walker. Physical therapy progress note, signed 2/16/2021, documented the resident was able to ambulate to the restroom with caregiver assistance and maximum verbal cueing secondary to dementia. III. Staff interviews The director of nursing (DON) was interviewed on 3/9/2021 at 2:15 p.m., while reviewing the facility'ss fall investigation for Resident #27. She said that after every fall, they have an interdisciplinary team (IDT) that investigates the fall, what caused it, interventions, and any education that was needed. She said the staff that makes up the IDT can change according to the situation, and who was available. She said that after Resident #27'ss fall, the medical records, an RN, social services, and the SDC had made up the IDT for the investigation. The IDT would then follow-up with educating the interventions to the staff. In-service training was completed on 1/18/2021. The training identified that staff was to keep Resident #27'ss pathway to the bathroom, inside her bedroom, clear of any tripping hazards. This in-service also identified that the resident'ss bedside table was to be kept away from her bed. The staff was also in-serviced to make sure that Resident #27'ss sink light was to be on at all times during the night, so she would have a better view of any tripping hazards. Restorative certified nurse aide (RCNA) was interviewed on 3/9/2021 at 3:00 p.m. She said residents that were fall risks were checked on regularly. She said that Resident #27 was able to stand up on her own, but that she required the use of her walker to get around. She said since her fall, they had to watch her very carefully. Certified nurse aide (CNA #1) was interviewed on 3/10/2021 at 5:05 p.m. He said that he was not working when Resident #27 fell . He said that he understood that the resident was trying to go to the bathroom at night. He said that he was told that she had tripped on her wheeled bedside table while trying to independently ambulate. He said she had a large table top that was placed on top of her wheeled bedside table when she wanted to work on her jigsaw puzzle. He said that when she sat in her bedside chair, he would place the table in front of her. He said that at the end of the day he would place the table in an area of the room near the privacy curtain, out of the way, so she would not trip again. He said that she was compliant about using her call light button for assistance, and would not stand up without help. He said he kept her walker outside of her room, by the door, or right next to her chair. He said she was good about using the call light, and he would then bring her the walker. He said she required standby assistance. Licensed practical nurse (LPN #1) was interviewed on 3/10/2021 at 6:30 p.m. LPN #1 said that Resident #27 was pretty good about using her call light. She said that since her fall, they were putting her walker in the hallway. She said that since her fall, they wanted to have her walker out of her way. LPN #1 looked down the resident hallway, and stated that she currently did not observe the resident'ss walker in the hallway. LPN #1 entered the resident'ss room, and observed the resident was in her bedside chair, with the jigsaw table pushed up close to her. The walker was observed in the resident room, about 10 feet away, against the resident'ss sink. LPN #1 said that since the resident had last fallen, the walker was allowed to be next to her chair, only if she was sitting in the chair, and the table was not pushed up next to her. This was to prevent the temptation for her to get up independently again, and accidently trip over the table on the way to get her walker. LPN #1 said that the walker should not be by the sink. She moved the walker to the hallway, since she said the table was still in front of the resident. Staff development coordinator (SDC), was interviewed on 3/10/2021 at 7:55 p.m. She said that the resident was a high fall risk, and that she had fallen a couple months ago. She said that the resident required assistance with walking, and used a walker. The SDC said she was not aware that there had been observations of the resident walking independently, without the walker, to try and go to the bathroom. She was not aware that the resident had been observed not using the call light for assistance. The SDC said that there had been some inconsistencies with the walker'ss use, where it should be placed, and how the fall and ADL interventions had been implemented for Resident #27. She agreed that it would need to be reviewed.

Based on record review and interview, the facility failed to ensure that two (#4 and #2) of four sample residents received appropriate transfer assistance for residents with foley catheters and failed to ensure one (#4) of four sample residents received appropriate care and treatment of [REDACTED]. -provide transfer assistance in an appropriate manner to protect Resident #4 from pain and trauma to the catheter site and to prevent the potential for injury for Resident #2. -follow fundamentals of nursing care for the care and treatment of [REDACTED]. Cross-reference F323. Source: Taylor et al, Fundamentals of Nursing: The Art and Science of Nursing Care, 6th Ed. 2008, Lippincott, Williams and Wilkins, pg 1514-1515, in pertinent part: Hazards of Urethral Catheterization Sepsis and trauma are the two major hazards of introducing an instrument such as a catheter into the bladder. The male urethra is especially vulnerable to injury because of its longer length. The mucous membrane lining the urethra is delicate and easily damaged. Caring for a patient with an Indwelling Catheter Note the volume and character of the urine and record observations carefully. Report signs and symptoms of infection promptly. Change catheter only as necessary based on clinical symptoms: leakage, bleeding, associated infections. The catheter must be properly secured to prevent injury or friction. Proper attachment prevents trauma to the urethra and meatus from tension on the tubing. Source: Brunner and Suddarth, Textbook of Medical Surgical Nursing, 12th Ed. 2010 Lippincott, Williams and Wilkins, Pg 1374, in pertinent part: Never irrigate the catheter routinely. Avoid unnecessary handling or manipulation of the catheter by the patient or staff. The findings include: 1. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE]. The Resident Admission Record listed [DIAGNOSES REDACTED]. The facility Discharge and Transfer-Discharge Summary revealed the resident was discharged to the hospital emergency department on 12/9/11 for evaluation of indwelling catheter retention and hematuria. physician's orders [REDACTED]. There was no order noted to irrigate (flush) the catheter as needed. The resident's interdisciplinary care plan, dated 7/14/11, (ICP) read, "Problem - the resident was occasionally incontinent of bladder. The resident wears attends". There was no update for the indwelling foley catheter order, dated 10/28/11, to include interventions for care of the catheter. An Acute/Temporary Care Plan, dated 10/28/11, read, "Foley cath removed, failure to void, 1100 cc (cubic centimeters) retained. #16 French cath placed. Monitor for drainage". The information on the acute/temporary care plan was lined through, indicating it was no longer current. There was no update for the care of the catheter, to include irrigation (flushing) of the catheter as needed. The ICP, dated 7/14/11, also contained a care plan for transfers for the resident using an (EZ) lift assist with two staff persons and the resident needed assistance with set up for all activities of daily living. A physician progress notes [REDACTED]. Nurses' notes revealed the following: - 11/30/11 (in) p.m. - head of penis sore with open scab. Area cleaned and repair cream applied. - 12/6/11 4:34 p.m. - tip of penis continued with large open sore getting worse with current tx (treatment). New tx order. Elder with very severe pain when cleaning penis. Elder with tears in eyes and crying. Did provide with Perc ([MEDICATION NAME]) at that time. - 12/7/11 7:01 p.m. - wound care provided to penis, continues with purulent drainage. New tx applied. - 12/9/11 10:00 a.m. CNA reported was transferring elder from bed to wheelchair. Upon transferring indwelling catheter tubing bag got stuck to lift and was pulled. This nurse completed assessment at 10:05 a.m., catheter appeared patent and intact. Complained of penile pain 8/10 (pain scale of 1 to 10, 10 being the worst pain imaginable). Administered one tablet [MEDICATION NAME] at 10:15 a.m.. Elder stated pain pill helped. Pain 6/10 at 11:00 a.m. After lunch, elder was laid down to bed to re-assess foley. Output less than 150 milliliters (mL). Rechecked balloon, flushed foley, and manipulated foley slightly, noted elder grimacing, heavy frank bloody discharge oozed down foley, approximately 100 cc. Placed call to doctor. Doctor stated to reinsert foley at 1:45 p.m., and monitor output, that trauma from having a catheter pulled out would have frank blood discharge. When re-inserting indwelling foley cath, no urine returned. This writer and CNA spoke with Nursing Home Administrator (NHA) to possibly have elder checked out by ER. NHA spoke with doctor and new order obtained at 2:15 p.m. to transport to ER for evaluation. 2. Resident #2, according to the facility admission record, was admitted on [DATE] with [DIAGNOSES REDACTED]. She was totally dependent on staff for bed mobility and transfer. She had an indwelling catheter. Observations: On 1/10/12 at 5:00 p.m., a lift transfer was observed for resident #2. Two CNAs and the Restorative CNA (RCNA) participated in the transfer. The foley bag was observed placed on the lower extremity transfer straps. One CNA stated the facility had two different kinds of lifts, a Hoyer lift and a sit to stand (EZ) lift. Both lifts require two staff. He wasn't sure why the RCNA was present. She usually left with the previous shift. On 1/10/12 at 6:06 p.m., the RCNA stated, "I often supervise transfers to make sure two people do the lift. I watch positioning so limbs aren't injured." Interviews: On 1/10/12 at 3:45 p.m., Resident #2 was interviewed. She stated that, "There are times I am transferred with the lift with just one staff and my catheter bag usually falls down on the lift". She went on to say, "The lifts were not made for catheters". On 1/11/12 at 8:55 a.m., the NHA, Director of Nursing (DON), and Staff Development Coordinator (SDC) were interviewed. The SDC stated after the incident with the catheter getting caught on the lift, there was an in-service done by the Physical Therapy Assistant (PTA) and the Rehabilitation CNA on proper transfers when a resident had a catheter. The DON stated the expectation was for two persons to use the lift, one spotter and one to do the mechanics of the lift. With a spotter, the catheter tubing being caught and pulled may possibly have been avoided. The Licensed Practical Nurse (LPN) who provided care for the resident on 12/9/11 was interviewed by phone 1/11/12 in the a.m. He stated he flushed the foley catheter after it had gotten pulled and was not draining properly. He also stated he used a foley insertion kit with a 30 cc syringe. On 1/11/12 at 10:10 a.m., the DON was interviewed. She stated, during the investigation, she had not asked the LPN how the catheter was irrigated or what supplies were used to irrigate the catheter. She expected that the catheter irrigation kit would be used. It had a 60 cc syringe with a catheter tip. She stated, "I would not expect that the catheter insertion kit would be used." The DON acknowledged the catheter insertion kit had a 30 cc syringe that would be used to inflate the balloon inside the bladder to hold the catheter inside the bladder and it was not the same syringe provided in the catheter irrigation kit. She also acknowledged the catheter irrigation kit provided a 60 cc syringe with a catheter tip as a larger syringe should be used to avoid too much pressure when flushing the catheter.

Based on record review, observations and interview, the facility failed to ensure that two (#4 & #2) of four sample residents received adequate supervision and assistance with assistive devices (mechanical lifts) to prevent accidents. Specifically the facility failed to: - provide safe transfer assistance for Resident #4 resulting in his catheter being pulled causing pain and trauma to the catheter site. - provide safe transfer assistance for Resident #2 resulting in the potential for injury The findings include: 1. Resident #4, according to the facility Resident Admission Record, was admitted to the facility, on 4/12/10 and readmitted on [DATE], with [DIAGNOSES REDACTED]. The facility Discharge and Transfer-Discharge Summary revealed the resident was discharged to the hospital emergency department on 12/9/11 for evaluation of indwelling catheter retention and hematuria. physician's orders [REDACTED]. There was no order noted to irrigate (flush) the catheter as needed. The resident's interdisciplinary care plan (ICP), dated 7/14/11, read, "Problem - resident was occasionally incontinent of bladder. Resident wears attends". There was no update for the indwelling foley catheter ordered 10/28/11. The ICP, dated 7/14/11, read, "Resident requires two person and sit to stand (EZ) lift assist for transfer. Approaches included the resident needed set up of all activities of daily living with two person and sit to stand (EZ) lift for transfer type tasks." physician progress notes [REDACTED]. He also had fractured his second toe and sustained a laceration to the bottom of the toe which required sutures about 2 weeks ago. Orders (were) written to remove sutures. Nurses' notes revealed the following: - 10/13/11 at 2:32 a.m., 24 hour chart check complete. No new orders. The Certified Nurse Aid (CNA) notified this nurse, elder being transferred with mechanical lift at bedtime and legs gave out underneath him. This nurse found elder at edge of bed and mechanical sling around him properly. (The resident) required assistance of 4 people to be pulled onto bed. During this time elder cut his right foot. Laceration (was) between 2nd and 3rd toe which was bleeding profusely. Cleaned area and noticed laceration very deep that apparently was going to need stitches. Informed night nurse and notified Primary Care Provider. Elder transported to ER at the medical center via facility transportation at 1:27 a.m. - 10/13/11 at 7:35 a.m. elder (was) lying in bed. Elder dressing to right foot soaked through with blood. Dressing removed and laceration continues to bleed. While cleaning toe, noticed white fragments. Dressing applied to toe. Elder sent back to ER for re-evaluation of toe per doctor's orders. Nurses notes for 12/9/11 revealed the CNA reported he/she was transferring elder from the bed to wheelchair and upon transferring the indwelling catheter tubing bag got stuck to the lift and was pulled. The nurses notes went on to read in pertinent part, "Completed an assessment at 10:05 a.m. and the catheter appeared patent and intact. Complained of penile pain 8/10 (pain scale of 1 to 10, 10 being the worst pain imaginable). The nurse administered one tablet Percocet at 10:15 a.m.. and the Elder stated the pain pill helped. Pain 6/10 at 11:00 a.m. After lunch, elder was laid down to bed to re-assess foley. Output less than 150 milliliters (mL). Rechecked balloon, flushed foley, and manipulated foley slightly, noted elder grimacing, heavy frank bloody discharge oozed down foley, approximately 100 cc. Placed call to doctor. Doctor stated to reinsert foley at 1:45 p.m., and monitor output, that trauma from having a catheter pulled out would have frank blood discharge. When re-inserting indwelling foley cath, no urine returned. This writer and CNA spoke with Nursing Home Administrator (NHA) to possibly have elder checked out by ER. NHA spoke with doctor and new order obtained at 2:15 p.m. to transport to ER for evaluation. 2. Resident #2, according to the facility admission record, was admitted on [DATE] with [DIAGNOSES REDACTED]. She was totally dependent on staff for bed mobility and transfer. She had an indwelling catheter. Observations: On 1/10/12 at 5:00 p.m., a lift transfer was observed for resident #2. Two CNAs and the Restorative CNA (RCNA) participated in the transfer. The foley bag was observed placed on the lower extremity transfer straps. One CNA stated the facility had two different kinds of lifts, a Hoyer lift and a sit to stand (EZ) lift. Both lifts require two staff. He wasn't sure why the RCNA was present. She usually left with the previous shift. On 1/10/12 at 6:06 p.m., the RCNA stated, "I often supervise transfers to make sure two people do the lift. I watch positioning so limbs aren't injured". Interviews: On 1/10/12 at 3:45 p.m., Resident #2 was interviewed. She stated that there were times she was transferred with the lift with just one staff. She stated the catheter bag usually fell down on the lift. The lifts were not made for catheters. On 1/11/12 at 8:55 a.m., the NHA, Director of Nursing (DON), and Staff Development Coordinator (SDC) were interviewed. The NHA stated, with the investigation, the incident was ruled an accident, and no one was at fault. The SCD stated after the incident with the catheter and the lift, there was an in-service done by the Physical Therapy Assistant (PTA) and the RCNA. When a new lift was purchased, the manufacturer would do an in-service. The DON stated the expectation was for two persons to use the lift, one spotter and one to do the mechanics of the lift. The DON stated with the facility investigation of the pulled catheter, only one CNA performed the lift. The CNA stated the resident wanted to lay down, and he didn't want to wait for help. He just didn't wait for help. With the investigation, the CNA wasn't asked how much of a wait it might have been for help. She stated with the investigation, other staff members on duty that shift were not interviewed regarding where they were. She stated, even if staff needed to wait, her expectation was that the procedure of using two staff for a mechanical lift was followed. On 1/11/12 in the a.m., the Licensed Practical Nurse (LPN) who provided care for the resident, on 12/9/11, was interviewed by phone. He stated he had assumed that two staff transferred the resident using the mechanical lift. On 1/11/12 at 10:10 a.m., the DON brought the disciplinary action form for the CNA. The action was to re-educate and do a competency checklist. The checklist was completed by the RCNA. She agreed that the checklist was not specific to always have two staff perform the lift, nor how to place the catheter bag for residents who have catheters. She stated there was no employee response or comments on the form because they were considered optional. On 1/11/12 at 10:15 a.m., the CNA who provided care for the resident on 12/9/11 was interviewed. He stated the resident wanted to go to bed. He looked around for help, and waited 10-15 minutes. He stated the LPN said to get him lying down, and he was busy. He knew he was supposed to always have two persons for using the lifts. The tubing got caught during the move, and pulled. On 1/11/12 at 11:10 a.m., the SDC stated the CNA care plans should include the location of the catheter bag during transfers by lift. Upon review of the CNA care plan the DON acknowledged this was not included but the process should be the same for each person who was lifted by a mechanical lift. The SDC stated she wasn't sure what the PTA and RCNA taught regarding placement of catheter bags on the lifts. On 1/11/12 at 1:20 p.m., the incident/accident investigation for the toe fracture and laceration for Resident #4 was reviewed. The investigation stated the incident happened, on 10/12/11 at 10:00 p.m. The investigation was not dated. The form did not include additional staff interviews. The form indicated only one CNA was involved in the transfer. The CNA statement read, "resident's toe got caught on the bed frame during the transfer."

Based on record review, interview and observations, the facility failed to ensure resident #1 received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment and plan of care. Specifically: The facility failed to monitor and evaluate the resident's response to preventive efforts and treatments, and revise the approaches as appropriate. The facility failed to involve patient in the development of plans and goals and offer alternate interventions when current interventions were ineffective. The facility also failed to follow their plan of correction (POC) for the citation of F309, on March 23, 2011, cited at a "G (harm)." The findings include: 1. Resident #1 a. Resident status Review of the face sheet reviewed revealed sample resident #1, an [AGE] year-old male, was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), diarrhea, [MEDICAL CONDITION], senile dementia, joint pain, chronic sinusitis, chronic pain, vitamin deficiency and [MEDICAL CONDITION] (on his scalp). Review of the most recent quarterly annual Minimum Data Assessment (MDS), dated [DATE], revealed resident #1 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), and was independent with mobility. Review of the resident's care plan revealed the resident was care planned with occasional shoulder pain, and having the occasional headache as well as phantom leg pain. The resident's care plan regarding comfort revealed the resident had a goal of 'four' on a scale of 0 to 10 (10 indicating severe pain), five days a week. b. Review of the medication administration record (MAR) revealed the nurse failed to monitor and evaluate the resident's response to preventive efforts regarding pain as evidenced by the absence of documentation and follow-up on the administration of [MEDICATION NAME], a pain medication prescribed as needed (prn) every four hours for pain. Specifically: --Review of the narcotic record revealed that on 4/29/11 at 8:00 p.m., 4/30/11 at 10:00 a.m., 5/1/11 at 2:00 p.m., 5/2/11 at 7:30 p.m., 5/2/11 at 7:30 p.m., [MEDICATION NAME] was administered, but was not reflected on the MAR. --On 4/23/11, 4/24/11, 4/25/11, 4/28/11, 5/5/11 [MEDICATION NAME] was documented on the front of the MAR but not noted on the back under nurse's medication notes. --On nurse's medication notes on 5/6/11, [MEDICATION NAME] was documented as given at 9:00 a.m. for pain described as 10 out of 10, with no documented effectiveness or follow-up assessment. An interview with a nurse on 5/10/11 at 9:30 a.m. revealed resident #1 had increased pain during transfers, and his pain is often a 10 out of 10; and the best she could achieve for the resident was a six out of 10; or maybe eight out of 10. When asked what interventions she had used, she stated she used [MEDICATION NAME] if the resident was having phantom leg pain, peppermint oil for shoulder pain; but more regularly, she had used distraction as a pain intervention. When asked if she documented the results of the non-pharmacological interventions, she stated she had not. She stated she knew she should document the results of pain interventions but did not have the time. An interview conducted on 5/10/2011 at 1:30 p.m. with the Nursing Home Administrator (NHA) and Director of nursing (DON), where both were asked if they were aware the MAR and the narcotic log for resident #1 did not match, specifically, the log showing medication had been signed out on various dates without any reflection on the MAR, both stated they were not aware of this. The NHA further commented that she would have to look into it, because they were supposed to match. When asked if they were aware of the effectiveness of prn pain medication not being consistently documented, they stated they were not. c. Resident #'1s goal of having pain of less than four on a scale of one to 10 had not been achieved by the goal date of 5/3/11, and there was no evidence of the facility's attempts to involve the patient in the development of new plans and goals, nor was there evidence of the facility offering alternate interventions when current interventions were ineffective. Specifically: Record review of resident #1 revealed the care plan stated the resident's pain goal is less than four on a scale of 0 to 10 for five days a week with a start date of 2/3/2011 and a goal target date of 5/3/11. This goal was not accomplished as evidenced by only 20 out of 57 pain assessments in the treatment record rating pain below a four from 4/21/11 to 5/9/11. An interview with resident #1 on 5/10/11 at 8:45 a.m. revealed the resident would like his pain medication reviewed, and also have his left arm looked at to see if there was any way to decrease the amount of movement he made in the arm that was causing pain. When he was asked if he had met with anyone at the facility to discuss pain management, he stated he had not. In an interview with the DON and the NHA on 5/10/11 at 1:30 p.m., they were asked if they were aware of the interventions the resident would like to try. The DON stated she had met with the patient about a month ago to discuss his pain and he had stated as long as he did not have a decline in function, he would not want his pain medication increased. When asked if she had met with him recently to review his goals, she stated she had not and would have to approach him again. An interview with resident #1 on 5/10/11 at 8:45 a.m. revealed that when asked if he took his prn medication that morning, he stated he had, and could not have another medication until three and a half hours after his morning pill. Resident #1 rated a 10 out of 10 pain. When asked if he would want a pill immediately if he could have it, he replied he would. The DON was asked if resident #1 had received his prn [MEDICATION NAME] that morning. She said she would check with the nurse. When the nurse was asked in an interview on 5/10/11 at 9:30 a.m. if resident #1 had received his prn medication that morning, she stated he had not. Observation on 5/9/11 at 4:15 p.m. and on 5/10/11 at 8:45 a.m. revealed resident #1 did not have any adaptive equipment present that would decrease his need to use his predominant hand as he had suggested (see above). An interview with the NHA and the DON on 5/10/11 at 1:30 p.m. revealed they had not evaluated the resident's need for adaptive equipment. d. The facility also failed to follow their plan of correction (POC) for the citation of F309 on March 23, 2011, cited at a "G". Specifically: The plan of correction for F309 on March 23, 2011 stated, "Beginning 4/5/11 pain interviews/observations were completed for all elders. These interviews will be repeated a minimum of weekly and as needed until pain management goals are met,"..."If an elder is continuing to have complaints or signs of pain and no resolution has been achieved with the elder's primary care provider, then the medical director is to be contacted immediately to consult on the elder and address any pain issues. MDS coordinator/designee will conduct a weekly pain committee meeting with the IDT and management staff including the DON to monitor elders who have not reached their pain goals. Results of this meeting will be shared with the primary care provider and/or medical director for adjustment in care plan by the next business day following the IDT meeting." The plan of correction further stated, "MDS coordinator/designee will conduct a weekly pain committee meeting with the management staff including the DON, to monitor elders who have not reached their pain goals. Results of this meeting will be shared with the primary care provider and/or medical director for adjustment in care plan by the next business day."..."Based on the content of reports, additional interventions will be implemented." Record review of the weekly pain interviews the week of 4/29/11-5/5/11 were missing for resident #1. Review of the record of the weekly pain committee meeting revealed the facility had included patient #1 in May 2, 2011 and May 9, 2011 but did not include him on April 24-30, 2011. Review of record for resident #1 revealed the resident had been assessed with [REDACTED]. The resident had a pain goal of less than 4 on his care plan; and a pain goal of 2 on his treatment administration record (TAR). The care plan for resident #1 was not updated from 2/3/11 under the heading of Comfort as of 5/10/11. The acute care plan addressed the resident's pain on 4/13/11 with new intervention of "1) continue current meds per order 2) continue non-pharm interventions 3) Dates for surgery." These interventions had hash marks across them and date resolved was blank. An Interview with the DON and the NHA on 5/10/11 at 1:30 p.m. revealed what the hash marks indicated on the temporary care plan. The NHA stated they meant the issue was resolved or it was moved to the permanent care plan. When asked if any of the issues on the 4/13/11 acute care plan were resolved or moved to the permanent care plan, she stated they were not and she would have to update them. An interview with the DON and NHA on 5/9/2011 at 4:00 p.m. occurred in which the DON was asked if any new interventions had been implemented since 4/5/11 for resident #1. She stated they were waiting on the Veterans Administration to authorize a surgery for [REDACTED]. When asked if the peppermint oil or any current interventions were relieving the resident's pain, she stated the resident was not getting pain relief from the current interventions.

Based on record review, and staff and family interviews, the facility failed to ensure one (#1) of five sample residents received appropriate care and services to attain and/or maintain her highest practicable physical well-being. Resident #1 experienced unnecessary pain due to the following systemic facility failures: -Lack of adequate pain assessments; -Lack of physician notification that the ordered scheduled pain medication caused nausea; -Lack of physician notification that the ordered scheduled pain medication was being refused due to nausea; -Lack of implementation of the interventions to address pain before therapy sessions and dressing changes; -Lack of monitoring and documentation of the effectiveness of pain medications. The findings include: A. PROFESSIONAL REFERENCE -McCaffery, Margo and Pasero, Chris, Pain: Clinical Manual, 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36, reads in pertinent part relative to pain assessment/pain management: "Clearly, for many years clinicians have been placed in a challenging situation...they had no standards for (pain) assessment and treatment...Critical to correcting this is establishing a standard for assessing the existence and intensity (of pain)...if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently...the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain. Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management." -According to the Clinical Practice Guideline, a Quick Reference Guide for Clinicians for the prevention and treatment of [REDACTED].S. Department of Health and Human Services, pressure ulcers can cause the resident to experience pain and discomfort from tissue damage, wound cleaning, or dressing changes. B. FACILITY POLICY The facility policy on "Pain Assessment" was received per request on 6/28/10, from the Director of Nursing (DON). The policy read in pertinent part: "General: The purpose of this procedure is to assess the Elders pain level and provide optimal comfort through pain control plan which is mutually established with the elder, family and members of the healthcare team. I. General Guidelines. . . B. A comprehensive pain assessment will be completed as part of the initial nursing assessment with development of a pain management program as indicated. . . E. Pain will be assessed and documented at regular intervals, as necessary, and in accordance with pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the elder will occur within two hours of administration. . . III. Steps in the Procedure C. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes and accompanying signs/symptoms. D. Determine appropriate type of pain medication as ordered by the physician. . . G. Do follow-up assessment within two hours after administration of medication. H. Evaluate effectiveness of non-pharmacological interventions, i.e., repositioning elder, turning light off, warm cloth, etc. I. If pain is not relieved, give further medication as ordered by the physician. If there are no orders, notify the physician and obtained an order. . . V. Reporting. . . B. Notify the physician of any unrelieved pain." C. FACILITY FAILURES 1. Record Review a. Resident Status Closed record review revealed resident #1, [AGE] years old, was admitted to the facility on [DATE], from the hospital for a 14 day rehabilitation (rehab) stay for a [MEDICAL CONDITION]. The resident's other [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident had short-term memory impairment and had modified independence in the cognitive skills needed for daily decision-making. -The resident was coded as needing extensive assistance of a staff member for all activities of daily living, except eating. -The resident was coded as being occasionally incontinent of bowel and incontinent of bladder. -The resident had moderate pain daily, and was 66 inches tall and weighed 159 pounds. -The resident had a stage III pressure ulcer. 2. Pain management plan a. Care Plan The acute/temporary care plans dated: -5/3/10, revealed the resident's problems of a right [MEDICAL CONDITION] repair, risk for falls, and skin breakdown of the coccyx in the gluteal fold and three blisters on the heels. Interventions included: -Monitor sites for drainage and signs and symptoms of infection, -Notify the physician if signs and symptoms of infection appear, and -[MEDICATION NAME] (narcotic [MEDICATION NAME]) as needed for pain. Another problem was documented as "pain not controlled." The goal was to have the pain to be less than 2/10 on the 1 to 10 pain scale for 48 hours. Some of the interventions listed were: -[MEDICATION NAME](narcotic [MEDICATION NAME]) per order, -[MEDICATION NAME] as needed, -Obtain a routine stool softener/laxative, -[MEDICATION NAME] per order, and -Assure that BMs (bowel movements) are being documented. -5/13/10, two of the three entries added to the acute/temporary care plan included that the resident was refusing the [MEDICATION NAME] that the resident was to be discharged on Monday, May 17, 2010. b. Physician Orders The admission physician's orders [REDACTED]. On 5/10/10, [MEDICATION NAME] mg. orally, was ordered to be given twice a day. The 5/10 Medication Administration Record (MAR) indicated the medication was scheduled at AM and HS. c. Pain Assessment The resident's pain assessment was requested on 6/28 and again on 10/5/10. The resident's "Pain Management" Assessment, dated 5/4/10, revealed the following (a typed check-mark indicated the documented choice): -Indicate all [DIAGNOSES REDACTED]. -Describe, if necessary. Right [MEDICAL CONDITION] with repair was documented. -Pain site (if pain is present, check all sites that apply in last seven days). Hip pain was checked. -Describe other pain site, if necessary-no documentation. -Pain symptoms (Code the highest level of pain present in the last seven days) a. Frequency of pain - pain daily was checked. (Choices were no pain, pain less than daily, or pain daily.) b. Intensity of pain-moderate pain was checked. (Choices were mild pain, moderate pain, or times when pain is horrible or excruciating.) -Character of pain-how does resident described pain? Aching was documented. (Choices included: pain is constant/persistent, pain comes and goes, breakthrough pain-pain management place but pain exceeding measures, new pain-resident has not experienced this pain before, other, and no pain.) -On a scale of 0-10, how does the resident rate intensity of pain? (Zero indicated no pain, 4 indicated moderate pain-distressing/miserable, 7 indicated severe pain, and 10 indicated excruciating pain). Number 4 was checked, indicating moderate pain-distressing/miserable. -Duration of pain- Pain comes and goes was checked. -Onset of pain-afternoon was checked. -Other expressions of pain (Choices were agitation, anxiety, crying, calling out, frowning/grimacing, hitting/pushing away, holding/splinting/guarding, irritability, moaning, refusing to eat, resistiveness, wincing, other and none of above.) None of the above was checked. -Accompanying symptoms-Does resident exhibit or complain of any of the following? (Choices were behavioral changes during pain episode, decreased physical activity, emotional outbursts, impaired concentration, inability to perform ADLs (activities of daily living), loss of appetite, nausea/vomiting, sleep disturbances, other, and none of the above) None of the above was checked. -Interventions-indicate pain management measures taken. (Choices were [MEDICATION NAME], cold, eating, elastic bandage/support binder, elevate the [MEDICAL CONDITION]/affected extremity, exercise, heat, immobilize/splint area, massage, other medications, relaxation techniques/biofeedback, rest, other, none of above.) [MEDICATION NAME], cold, and the rest were checked. -Outcome of pharmacological measures used. (Choices included [MEDICATION NAME] effective, described below if necessary; [MEDICATION NAME] somewhat effective, described below; [MEDICATION NAME] ineffective, described below; and no [MEDICATION NAME] necessary.) [MEDICATION NAME] effective, described below if necessary was checked. -Outcome of non-pharmacological measures used. (Choices included interventions effective, described below if necessary; interventions somewhat effective, described below; interventions ineffective, described below; and no interventions necessary.) Interventions effective, described below if necessary was checked. -Indicate other measures taken (Choices included activities, clergy, nursing, rehab, occupational therapy, pain clinic, pharmacist drug review, physical therapy, physician/NP/PA update, psychotherapy, social service, therapeutic recreation, other, and none of above.) Occupational therapy and physical therapy were checked. -Indicate what referrals may be appropriate. No referrals necessary was checked. There was no documentation describing how effective "cold," "rest," and "[MEDICATION NAME]" were in relieving the resident's pain, what activity increased the resident's pain, and what the resident's acceptable pain level was. Review of the 5/10 MAR and the Narcotic sign-out record revealed resident #1 used [MEDICATION NAME] 5/500 as follows on: ? 5/4-one tablet at 3:45 p.m. ? 5/5-one tablet at 9:30 a.m., 10:30 a.m., and 4:30 p.m. and two tablets at 11:00 p.m. ? 5/6-one tablet at 5:15 a.m., 10:40 a.m., and at 2:20 p.m. ? 5/7-two tablets at 7:00 a.m., and at 3:30 p.m. ? 5/8-two tablets at 12:30 a.m., 8:00 a.m., and at 8:00 p.m. ? 5/9-two tablets at 9:15 a.m., 3:15 p.m., and at 22:12 p.m.(10:12 p.m.) ? 5/10-one tablet at 7:50 a.m., 10:00 a.m., 2:15 p.m., and at 8:15 p.m. ? 5/11-no pain medications were documented as given. ? 5/12-one tablet at 10:30 a.m. ? 5/13-one tablet at 12:00 p.m. and at 4:30 p.m. ? 5/14-one tablet at 8:30 a.m., 10:00 p.m., and at 11:00 p.m. See orders above; there was no guidance when the resident should receive one versus two [MEDICATION NAME] tablets for pain. [MEDICATION NAME] mg. (ordered on [DATE] to be given twice a day) was documented as given on: ? 5/10 at 8:00 p.m. ? 5/11 at 6:40 a.m. (refused the HS dose) ? 5/12 at 7:00 a.m. (refused the HS dose) ? 5/13 at 8:30 a.m. (refused the HS dose) ? 5/14 at 8:30 a.m. (refused the HS dose) ? 5/15 at 7:00 a.m. and at 8:45 p.m. ? 5/16 at 6:40 a.m. (refused the HS dose) ? 5/17 at 7:10 a.m. Pain was to be assessed each shift on a scale of 0-10 and documented. Review of the 5/10 Treatment Administration Record (TAR) revealed inconsistent documentation of the resident's pain. -There was no documentation of a pain level on the 2 p.m.-10 p.m. and 10 p.m.-6 a.m. shifts on 5/5 and on 5/16. -There was no documentation of a pain level on the 10 p.m. to 6 a.m. shift on 5/11, and on the 6 a.m. to 2 p.m. shift on 5/17/10, the day the resident was discharged and admitted to the hospital. The resident's pain level was documented as ranging from zero (no pain) to 8/10. The resident's pain was documented as an 8/10 even after the scheduled [MEDICATION NAME] ordered. (on the 6 a.m.-2 p.m. shift on 5/12 and 5/13/10). 3. Documentation of repeated complaints of moderate, severe, and excruciating pain - discharge 5/17/10 - hospitalization for debridement of infected ulcer. a. Review of some of "Resident Progress Notes" revealed the following: -5/3/10 at 7:10 p.m. the resident was admitted to the facility. -5/5/10 at 1:20 p.m. A nurse documented the resident complained of pain in the right hip (7/10), and received [MEDICATION NAME] with minimum relief and received a second [MEDICATION NAME] with more pain relief noted. -5/5/10 at 5:16 p.m. the physical therapist documented the resident complained of pain at a level of 6/10 prior to the treatment and after the treatment. The therapist requested pain medications from the nurse. -5/5/10 at 5:30 p.m. a nurse documented the resident's pain had decreased to a 6/10 level. -5/6/10 at 12:25 p.m. the physical therapist documented the resident, "complains that she is having difficulty controlling her pain at times secondary to having to ask for her pain meds. Discussed with the patient possibility of getting her on a schedule for her pain meds to allow her pain to be controlled. This patient was discussed in Medicare meeting this day. This writer requested that patient be put on a schedule for her pain medications to allow her to better manage her pain. Discharge plans were also discussed for this patient secondary to her payer source." -5/7/10 at 8:25 p.m. a nurse documented a dressing change was completed to the coccyx. "Wound continues to have foul smell with increased amount of brown drainage. Resident with some pain upon cleansing wound. Continuing to wait from PCP (primary care physician) regarding recommendations for wound care." -5/9/10 at 10:42 a.m. a nurse documented the resident complained of pain to the right hip and generalized pain. Two [MEDICATION NAME] were given and the resident stated it was effective. -5/10/10 at 1:36 p.m. a nurse documented the resident complained of severe pain with pressure and received [MEDICATION NAME] with some relief. -5/10/10 at 2:56 p.m. the physical therapist documented the resident complained of pain in her gluteal area. -5/10/10 at 5:39 p.m. a physical therapy aide documented the resident complained of pain in the area of a pressure wound. At 8:10 p.m. the occupational therapist documented the resident complained of pain in the area of the wound. -5/10/10 at 9 p.m. a registered nurse (RN) documented the wound measurements as 5.0 cm times 3.5 cm times 0.3 cm with large amount of yellow/white slough noted and no new skin growth noted. The nurse documented the resident was at a 10 pain level earlier in the evening (at hard stool removed manually) and now stated the pain was at a 6 to 8 pain level. -5/11/10 at 2:56 p.m. a nurse documented wound care was "provided to the coccyx with contin. (uous) foul odor, purulent drainage in moderate amounts. New wound orders started. Pain better controlled with [MEDICATION NAME] relief of constipation. . ." -5/12/10 at 3:22 p.m. a nurse documented the resident had requested [MEDICATION NAME] in addition to the routine MS Contin. The resident had also required [MEDICATION NAME] for an upset stomach and nausea. -5/13/10 at 7:18 a.m. a nurse documented the resident had not complained of nausea throughout the night however had refused the [MEDICATION NAME] the evening. -5/13/10 at 8:45 p.m. a nurse documented that routine [MEDICATION NAME] given as directed for pain. The nurse also documented the resident stated, "It makes my mouth feel funny and it makes me nauseous. Explained to resident medication was for pain and if needed resident could have prn (as needed) [MEDICATION NAME] ([MEDICATION NAME])." The resident stated she liked the other one better ([MEDICATION NAME] as needed). The nurse documented the resident continued to have pain with wound dressing changes. -5/13/10 at 12:10 p.m. the physical therapist documented the resident complained of pain in the area of her wound. At 4:42 p.m. the physical therapy aide documented, "Continued training as tolerated. Continue to notify nursing of rx (treatment) time) for pain pre-medication." -5/16/10 at 1:13 p.m. a nurse documented that the dressing change was done (there was no description of the wound). In addition the nurse documented the resident complained of nausea and [MEDICATION NAME] was given at approximately 11 a.m. At 9:30 p.m. a nurse documented that the dressing was changed. "Wound bed with yellow/green foul-smelling wound bed, red raised skin around the perimeter of wound bed with increased raised area on right side of wound bed towards right hip area. Noted increased redness to skin around wound areas of abrasion was some bleeding noted. Res did c/o pain with dressing change & stated the area really hurt. Res refused [MEDICATION NAME] HS stating she didn't want to take it and only had pain when someone is touching her wound. Res family in with res. at this time." b. Discharge and hospitalization Review of nurses's notes/physician's orders [REDACTED]. by the family. From there, the resident was referred to the hospital emergency room . -Review of a 5/18/10 hospital pre-surgery consult described the wound as gangrenous with a foul odor. The consult in addition, read, "The patient reportedly yesterday was discharged from the nursing home and told that the nursing home could not take care of the sacral decubitus ulcer and that she needed inpatient care. The patient subsequently saw her primary care physician who is subsequently referring her to this ER (emergency room ). -Review of the hospital surgery consult and surgery report, dated 5/18/10, indicated a stage IV pressure ulcer that was debrided of skin, subcutaneous, tissue, muscle, fascia and coccyx bone. 4. Facility Failures - Failure to care plan, assess, inform and address the resident's pain. a. There was no evidence the facility developed an acute care plan for the pain resulting from the pressure ulcer. There was no documentation of a plan to ensure pain medication was offered prior to therapies and dressing changes, even though pain was documented as being associated with these procedures. b. There was no documentation that the physician was notified when (1) the resident's pain was documented as reaching levels of "severe" (7/10) and "excruciating," (10) and (2) when the scheduled MS Contin, per the nurses' documentation, caused the resident nausea and was refused by the resident. (Cross-reference F157) c. There was no evidence that the resident's pain was assessed daily with regard to location of pain, intensity of pain, and identification of contributing factors (Cross-reference F314 for effects of incontinence and constipation on resident's pain). d. There was no documentation that the resident's pain and pain management plan was comprehensively reassessed as the resident's wound deteriorated and staff documented her pain as "severe" and "excruciating" pain increased. The sole pain assessment located in the medical record was the admission pain assessment documenting the pain from the [MEDICAL CONDITION] and not pain resulting from the infected pressure ulcer. There was no evidence the resident was timely assessed to receive additional pain management for the intense pain from the pressure sore. 5. Interviews a. A family member was interviewed on 10/6/10 at 7:30 a.m. and again on 10/11/10 at 10:45 a.m. (after survey exit). -The family member stated the physician never physically observed the resident's pressure wound until the resident was discharged from the facility (5/17/10). -The family member went on to say the resident suffered with pain from the pressure wound and could not tolerate the pain medications ordered, yet the pain medications were not changed. The family member stated the resident saw things in the air and did not know what she was doing or where she was when on some of the pain medications. -The family member stated the resident's unmanaged pain and worsening pressure ulcer delayed her therapy progress and her recovery. b. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were interviewed on 10/6/10 at 9:56 a.m. and again at 11:15 a.m. No comments were made when the resident's pain issues and lack of intervention were discussed.

Based on closed record review and staff and family interviews, the facility failed to ensure one (#1) of five sample residents was given the necessary care and services to prevent further skin breakdown and/or recurrent/new pressure sores development. Specifically, resident #1, who was admitted with documented skin breakdown and who was assessed at high risk for skin breakdown, was admitted from the hospital to the facility on [DATE] for a 14 day rehabilitation (rehab) stay for a [MEDICAL CONDITION]. -There was no evidence the resident was timely assessed to receive additional nutritional intervention, or that the physician was kept informed of the deteriorating condition of the pressure wound in order to change treatments, prescribe antibiotics, and/or order debridement in a timely fashion. -The resident was discharged home on [DATE], but taken from there to the physician's office that same day by her family. She was immediately readmitted to the hospital with [REDACTED]. The findings include: 1. Standards - risk factors and preventative interventions -According to the Clinical Practice Guideline, a Quick Reference Guide for Clinicians for the Prevention and treatment of [REDACTED].S. Department of Health and Human Services, pressure ulcers can cause the resident to experience pain and discomfort from tissue damage, wound cleaning, or dressing changes. Thorough resident assessments must be conducted to identify the residents who are at risk to develop pressure sores. All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. -According to "Clinical Practice Guidelines," "Written repositioning schedules should be developed even when patients are using a pressure-reducing support surface. These surfaces serve only as adjuncts to strategies for positioning and careful monitoring. Reposition the sitting individual so points under pressure are shifted at least every hour." -According to the U.S. Department of Health and Human Services, "Clinical Practice Guidelines" Number 3, "Pressure Ulcers in Adults: Prediction and Prevention," and Number 15 "treatment of [REDACTED]. -All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. -Residents who have developed a pressure sore are at a higher risk to develop additional pressure sores. Preventive measures include the following: Identify the at-risk residents who need the preventive measures, ensure the resident's nutritional and water intake is adequate to maintain the skin's tolerance to pressure, and protect the skin from damage from external pressure by utilizing frequent position changes and pressure-relieving devices; e.g., cushions or special mattresses. Pressure ulcers should be assessed for classification or stage, location, size, and condition of the pressure ulcer and surrounding tissue. -According to Pressure Ulcers in Adults: Prediction and Prevention, by the U.S. Department of Health and Human Services, page 9, under the heading for Mechanical Loading and Support Surfaces, "any person at risk for developing pressure ulcers should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals." -According to the U.S. Department of Health and Human Services AHCPR Clinical Practice Guideline for treatment of [REDACTED]. . ." According to the Clinical Practice Guideline, No. 15, "treatment of [REDACTED]. -In the Consumer Guide, "Treating Pressure Sores," published by The U.S. Department of Health and Human Services on page 5: "taking pressure off the sore is the first step toward healing. Healing pressure sores depends on three principles: pressure relief, care of the sore and good nutrition." According to "Nutrition Care of the Older Adult," by Niedert & Dorner, 2nd Edition (2004), pages 120 & 423: In determining caloric needs, "an estimate of energy needs must be completed for each client ...To estimate kilocalories, calculate the (basal energy expenditure) and multiply it by the activity factor and the injury factor." Activity factors have a number assigned depending on the activity status of the client such as chair fast. Injury factors have a number range assigned depending on the injury such as wound healing. 2. Facility Policy The policy, titled "Pressure Ulcer Prevention and Management" effective date [DATE], read in pertinent part: "General: The primary purpose of the pressure ulcer management and prevention program is to reduce the occurrence of pressure ulcers. Identification, prevention, and treatments will be based on NPUAP definitions, recommendations, and practice standards. The interdisciplinary team will partner with the elder when planning and providing care. . . -II. Admission Process . . . C. A Norton skin assessment will be completed within the first eight hours of admission. . . E. Based on the elder's history, clinical status, head to toe skin assessment, and Norton risk assessment, an acute temporary care plan will be initiated per definition and policy. Interventions to promote healing may include incontinence management, a turning and repositioning plan, initial treatment(s), any other pressure relieving strategies and elder goals for treatment. . . -III. Treatment Program A. The nurse identifying a potential pressure ulcer, will obtain treatment orders, based on the (name of nursing home) Treatment Algorithm. An acute temporary care plan will be initiated, and the open area noted on the 24 hour report. Pictures will be taken at time of discovery and weekly or on a PRN (as needed) basis. B. The following people will be notified: -The physician: by the nurse obtaining the treatment order -The elder and/or responsible party -The IDT (interdisciplinary team) members, including the RD (registered dietitian), social services, activities, and therapy. A nutritional evaluation will be completed within seven days of onset. Depending on contributing factors to the pressure ulcer, a therapy, social service, and activities evaluation may also be initiated. -The IDT will be informed of in-house acquired pressure ulcers. C. Pain, pressure re-distribution, nutrition, and incontinence management (depending on the location of the pressure ulcer) will be re-evaluated as part of a potential overall change of condition when pressure ulcers are identified." 3. Facility Failures a. Resident Status Resident #1, [AGE] years old, was admitted to the facility on [DATE] from the hospital for a 14 day rehab stay for a [MEDICAL CONDITION]. The resident's other [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident had short-term memory impairment and had modified independence in the cognitive skills needed for daily decision-making. -The resident was coded as needing extensive assistance of a staff member for all activities of daily living, except eating. -The resident was coded as being occasionally incontinent of bowel and incontinent of bladder. -The resident was coded with moderate pain daily, and was 66 inches tall and weighed 159 pounds. -The resident had a stage III pressure ulcer. The facility admission skin assessment, dated [DATE], documented, among other skin issues, a black eschar 3 cm x 3 cm on the tailbone area, a 10 cm x 7 cm red breakdown with serous (?) (Illegible) drainage on the tailbone area, and a 3 cm x 2.5 cm area of pink breakdown on the lower buttocks. (Review of facility records on the tailbone/buttock - see below - revealed only documentation regarding the tailbone area with eschar.) A Norton Skin Assessment was completed on [DATE] at 6:35 a.m. (completed two days after admission). The documented score was 14. The interpretation of the score included "14 or less equals at risk for skin breakdown, over 14 equals not a risk for skin breakdown." b. Pressure Ulcer Management Plan The acute/temporary care plans revealed: -A [DATE] plan that revealed the resident's problems of a right [MEDICAL CONDITION] repair, risk for falls, and skin breakdown of the coccyx in the gluteal fold and three blisters on the heels. Pertinent interventions included: -Monitor sites for drainage and signs and symptoms of infection, -Notify the physician if signs and symptoms of infection appear, and -[MEDICATION NAME] (narcotic [MEDICATION NAME]) as needed for pain. -A [DATE] plan revealed the problem of a "new wound care to coccyx" area. The goal was documented as "FYI" (for your information). The interventions were listed as: -Dressing changed per order, -Santyl here tonight, -Measurements remain the same as when wound nurse here, and -Request Prostat from the physician. Another problem was documented as "pain not controlled." The goal was to have the pain be less than ,[DATE] on the 1 to 10 pain scale for 48 hours. Some of the interventions listed were: -[MEDICATION NAME](narcotic [MEDICATION NAME]) per order, -[MEDICATION NAME] as needed, -Obtain a routine stool softener/laxative, -[MEDICATION NAME] per order, and -Assure that BMs (bowel movements) are being documented. -On [DATE], two of the three entries added to the acute/temporary care plan included that the resident was refusing the [MEDICATION NAME] that the resident was to be discharged on Monday, [DATE]. -On [DATE], three entries were added to the acute/temporary care plan. These included (1) The resident fell on [DATE], and a discussion was held with the family about a pressure alarm. (2) The family requested x-rays of the right hip and (3) The resident was in need of a blood transfusion. c. Documentation of deteriorating wound and physical condition - failure of facility to timely respond to changes Review of some of "Resident Progress Notes" revealed the following: -[DATE] at 7:10 p.m. the resident was admitted to the facility. -[DATE] at 1:11 p.m. A nurse documented "Coccyx area necrotic tissue present no drainage noted. Did apply dressing per SO (standing order) and wound care specialist notified for consult. Heels intact without areas of redness or breakdown. . . Incontinent of bowel and bladder. . ." -[DATE] at 9:35 a.m. The physical therapy evaluation was completed and the therapist documented, "She may need to be on a regular therapy schedule with pain medication ,[DATE] minutes prior to allow her to achieve maximum benefit from therapy at this time." -[DATE] at 1:20 p.m. A nurse documented the resident complained of pain in the right hip (,[DATE]), and received [MEDICATION NAME] with minimum relief and received a second [MEDICATION NAME] with more pain relief noted. "Wound care provided to coccyx in right hip. Coccyx with purulent drainage in moderate amount with foul order noted this shift. Wound care specialist to be in this afternoon. . . Encouraged resident to stay off the coccyx except when up for meals/PT/OT (physical and occupational therapies) or special activities to help with wound healing. Will continue to monitor." -[DATE] at 5:16 p.m. the physical therapist documented the resident complained of pain at a level of ,[DATE] prior to the treatment and after the treatment. The therapist requested pain medications from the nurse. -[DATE] at 5:30 p.m. a nurse documented the resident's pain had decreased to a ,[DATE] level. -[DATE] at 12:25 p.m. the physical therapist documented the resident was discussed in Medicare meeting this day; Discharge plans (and pain management) were discussed for this patient secondary to her payer source. -[DATE] at 4:52 p.m. the physical therapist documented the resident reported pain in the anterior groin with movement. -[DATE] at 8:25 p.m. a nurse documented a dressing change was completed to the coccyx. "Wound continues to have foul smell with increased amount of brown drainage. Resident with some pain upon cleansing wound. -[DATE] at 3:43 p.m. a nurse documented that the dressing change was completed to the coccyx area and the wound had an odor and brown liquid drainage. "Encouraged to keep off coccyx as tolerated. Will continue to monitor." -[DATE] at 10:42 a.m. a nurse documented the dressing was done as ordered to the coccyx area; however, there was no description of the wound and/or drainage. -[DATE] at 1:36 p.m. a nurse documented that the coccyx area "was with full slough with foul odor with green tinge to the wound site." Also the nurse documented the resident complained of severe pain with pressure and received [MEDICATION NAME] with some relief. . ."Call out to M.D. and fax for better wound management and wound care for better debridement. Also questioned need for better routine pain management. Resident educated several times to stay off bottom at all times." There was no evidence of a wound description as the size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME]. This was the first documentation that the physician was notified of the condition of the resident's wound even though (see above), the declining condition of wound was documented as early as [DATE] to have purulent drainage. -[DATE] at 2:56 p.m. the physical therapist documented the resident complained of pain in her gluteal area, required assistance from supine to sitting position and needed minimal assistance to roll onto her right side. -[DATE] at 3:24 p.m. a note was written by the Resident Services Director (RSD) that the family had noticed issues with confusion and requiring frequent reminders and cueing in therapy and regarding other issues. -[DATE] at 3:38 p.m. (seven days after the resident has been admitted to the facility) a nurse documented the physician responded with orders for wound care. -[DATE] at 5:39 p.m. a physical therapy aide documented the resident complained of pain in the area of a pressure wound. At 8:10 p.m. an occupational therapist also documented the resident had complained of pain in the area of the pressure wound. -[DATE] at 9 p.m. a registered nurse (RN) documented the wound measurements as 5.0 cm times 3.5 cm times 0.3 cm with large amount of yellow/white slough noted and no new skin growth noted. The nurse documented the resident was at a 10 pain level earlier in the evening (as hard stool removed manually) and now stated the pain was at a 6 to 8 pain level. -[DATE] at 11:20 a.m. the dietary manager (DM) documented a note that the resident was a new admit; however, there was no mention of the pressure ulcer. At 2:56 p.m. a nurse documented wound care was "provided to the coccyx with contin. (uous) foul odor, purulent drainage in moderate amounts. New wound orders started. Pain better controlled with [MEDICATION NAME] relief of constipation. . ." -[DATE] at 3:22 p.m. a nurse documented the resident can be forgetful toward the evening and that wound care was provided to the coccyx. The wound was described as "bed black with yellow/tan excessive drainage." The physician was faxed (nine days after the resident had been admitted ) for "Prostat to aid in the healing process awaiting orders." -[DATE] at 4:47 p.m. the physical therapist aide documented the resident was helped to the bathroom and was incontinent of urine and bowel. Laboratory tests completed on [DATE] revealed low levels of [MEDICATION NAME] at 2.7 (reference range 3XXX,[DATE].1 G/DL.), of hemoglobin at 8.6 (reference range 11XXX,[DATE].9 GM/DL), of hematocrit at 26.5 (reference range 35XXX,[DATE].0%) and an elevated white blood count at 12.2 (reference range 3XXX,[DATE].8 thousands per MCL). -[DATE] at 7:18 a.m. a nurse documented the coccyx dressing was changed and the wound was described as "grayish black wound bed, odor and brown liquid drainage continues." The nurse also documented the resident had been incontinent of bowel and required assistance with transfers and with repositioning. -[DATE] at 8:45 p.m. a nurse documented that routine [MEDICATION NAME] given as directed for pain. The nurse also documented the resident stated, "It makes my mouth feel funny and it makes me nauseous. Explained to resident medication was for pain and if needed resident could have prn (as needed) [MEDICATION NAME] ([MEDICATION NAME])." The resident stated she likes the other one better ([MEDICATION NAME] as needed). The nurse documented the resident continues to have pain with wound dressing changes. The wound bed was described as "less black and gray in color this a.m. Continues with foul odor and lots of redness around the wound." -[DATE] at 10:12 a.m. Prostat was ordered (10 days after the resident was admitted and three days before the resident was to be discharged .) At 11:46 a.m. social service noted discharge planning was discussed which included wound care at home. At 12:10 p.m. the physical therapist documented the resident complained of pain in the area of her wound. At 4:42 p.m. the physical therapy aide documented, "Continued training as tolerated. Continue to notify nursing of rx (treatment) time for pain pre-medication." -[DATE] at 12 a.m. a nurse documented the resident fell going to the bathroom unattended. The resident received a 2 cm laceration to the right side of the head just above the ear, 1 cm skin tears to the right and left forearms, and a bruise/abrasion to the right wrist. -[DATE] at 11:59 a.m. the Registered Dietitian (RD) was called (11 days and almost 2 weeks after the resident was admitted to the facility) regarding the wound status. The RD documented the coccyx wound as a stage II. The RD documented according to the dietary manager the resident was eating well. The RD documented the resident needed 2160 calories, ,[DATE] g protein, and 2160 ml of fluid; her needs were mostly met with the regular diet and her good appetite. The RD recommended a multiple vitamin without minerals, 8 ounces of milk with every meal, whole wheat bread and fresh fruit twice daily and 30 ml of protein syrup twice a day. -[DATE] at 3:55 p.m. a nurse documented that "Prostat to begin on [DATE] to assist with wound healing." The resident was sent to hospital for x-rays (per the request of the family) of the right hip due to the fall and also for type and cross match for a blood transfusion that would take place on [DATE] at the hospital. At 5:04 p.m. the resident "refused physical therapy secondary to pain from the previous night's fall." -[DATE] at 11:04 p.m. a nurse documented the resident had refused to [MEDICATION NAME] supper however accepted [MEDICATION NAME] at bedtime. The "coccyx was measured, treatment was completed, skin was irritated (red and) under some of the [MEDICATION NAME]. . ." -[DATE] at 1:13 p.m. a nurse documented that coccyx wound care was completed in the wound was described as, "with severe odor, moderate purulent drainage on old bandage, slough covering 90% of wound bed with 10% granulation tissue present on the outer edges. Slight tunneling noted since Tues (day). Educated resident needing to stay off the coccyx at all times. Pain in wound site during wound care ,[DATE]. And received [MEDICATION NAME] routine. . ." The nurse documented the resident was transferred to the hospital for a blood transfusion. "Did get a call from nurse x1 with resident c/o (complained of) nausea. Also noted [MEDICATION NAME] at HS (bedtime) x3 for c/o of nausea. We'll continue to monitor." -[DATE] at 10:44 p.m. a nurse documented the wound was increasing in depth, 1.3 cm in depth at this time. Eschar black has debrided and changed to white and is starting to show some good skin growth to the edges. . . " -[DATE] at 1:13 p.m. a nurse documented that the dressing change was done; however, there was no description of the wound. In addition, the nurse documented the resident complained of nausea and [MEDICATION NAME] was given at approximately 11 a.m. "Skin and wound care specialist is to be here in regards to her coccyx at 6:30 a.m. on Monday, [DATE]." At 9:30 p.m. a nurse documented that the dressing was changed. "Wound bed with yellow/green foul-smelling wound bed, red raised skin around the perimeter of wound bed with increased raised area on right side of wound bed towards right hip area. Area cleaned with normal saline, applied Santyl, oil [MEDICATION NAME], gauze & foam to wound secured with [MEDICATION NAME] after applying skin prep to surrounding skin. Noted increased redness to skin around wound areas of abrasion with some bleeding noted. Wound care specialist to begin to see res(ident) in a.m. Res did c/o pain with dressing change & stated the area really hurt. Res refused [MEDICATION NAME] HS stating she didn't want to take it and only had pain when someone is touching her wound. Res family in with res. at this time." -[DATE] at 10:30 a.m. the dietary manager (DM) documented a note indicating the resident's intake was 50 to 100%. The DM documented the resident was receiving fortified milk of meals and was being discharged home on [DATE]. The Resident Services Director (RSD) (social services) documented at 12:09 p.m. that she was informed by the family they were taking the resident directly to the physician upon discharge and hoping to go directly to the wound clinic. At 1:26 p.m. a nurse documented that wound care was provided to the coccyx with the wound care specialist present. The nurse also documented that the wound continued with moderate amounts of purulent drainage. A phone call was made to the physician requesting the resident be seen for wound care and follow-up and to discuss wound care clinic instead of going home (per family request - see interview below). Pre-surgery hospital consult: The hospital pre-surgery consult, dated [DATE], described the wound as gangrenous with a foul odor. The consult in addition, read, "The patient reportedly yesterday was discharged from the nursing home and told that the nursing home could not take care of the sacral decubitus ulcer and that she needed inpatient care. The patient subsequently saw her primary care physician who is subsequently referring her to this ER (emergency room ). The hospital surgery consult and surgery report, dated [DATE], indicated a stage IV pressure ulcer that was debrided of skin, subcutaneous, tissue, muscle, fascia and coccyx bone. d. Other Facility failures (1) Failure to accurately assess the wound daily. -There was no evidence the wound was assessed daily for, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME]. (2) Failure to consistently monitor effectiveness of the pressure ulcer management plan. -There was no evidence of a written repositioning schedule so points under pressure were shifted at least every hour. The facility documented the resident had short-term memory and was forgetful, yet kept reminding the resident to off load. -There was no evidence of a discussion with the physician of the possible insertion of a Foley catheter to prevent further breakdown from urinary incontinence the resident was assessed for and experienced. -There was no evidence of documentation of a toileting schedule to prevent episodes of incontinence. The resident was diagnosed with [REDACTED]. -Review of the ,[DATE] Treatment Administration Record (TAR) revealed a daily dressing change beginning on ,[DATE] and ending on [DATE], that consisted of cleaning the wound with normal saline, patting dry, applying Santyl, foam, and [MEDICATION NAME]. -Review of the wound care specialist notes, dated [DATE], indicated the pressure ulcer was unstageable and measured 5 cm x 2.5 cm x 0.2 cm. The wound care specialist recommended an enzymatic debridement. The recommended treatment was to clean the wound with wound cleanser, pat dry. Apply skin prep to around the wound. Apply a thin layer of Santyl to the wound bed and cover with oil emotion, gauze, then foam; changed daily. -Review of the physician's telephone orders revealed the physician had not ordered/documented the above [DATE] specific dressing change orders until [DATE] at 4 p.m. (a week after the resident was admitted and five days after the wound care specialist's visit). The physician ordered dressing change twice a day instead of daily. There was no evidence the physician had observed the draining pressure ulcer. -Further review of the TAR revealed the BID dressing change scheduled in the a.m. and at bedtime was not completed [DATE] as evidenced by lack of initial in the dated square. -Review of the wound care specialist documentation, dated [DATE], the second documented visit and 12 days after the first visit, revealed the coccyx pressure wound was still unstageable, full thickness, and measured 6.0 cm x 4.0 cm x 0.3 cm and with undermining 0.9 cm from ,[DATE] o'clock. The wound bed was described as "suspected deep tissue injury that is [MEDICATION NAME]. Thick adherent, yellow/black slough." The peri-wound was described as [DIAGNOSES REDACTED], slightly denuded skin. The wound care specialist recommended calcium alginate absorbs excess exudate. The wound care specialist also documented that the resident should see a physician as soon as possible to discuss options as the wound clinic, surgical debridement, enzymatic debrided, [DEVICE], etc. (3) Failure to notify the RD timely with regards to nutritional interventions. -The resident was admitted on [DATE] for a pre-determined 14 day rehab stay. It was not until [DATE] RD was notified (11 days and almost 2 weeks after the resident was admitted to the facility) regarding the wound status. The RD recommended a multiple vitamin without minerals, 8 ounces of milk with every meal, whole wheat bread and fresh fruit twice daily and 30 ml of protein syrup twice a day. -Review of the telephone physician's orders [REDACTED]. -Despite Prostat not being ordered until [DATE] and a clarification order was written for Prostat 30 ml orally twice a day on [DATE], it was not offered to the resident until [DATE], two days before discharge. -There was no evidence that a multiple vitamin without minerals was administered as recommended by the RD. -There was no evidence that a multiple vitamin without minerals was ordered and/or included on the medications to be taken when discharged . (4) Failure to consistently involve the physician with changes in the pressure wound. (Cross-reference F157) -There was no evidence the physician was notified with changes in the wound as the foul odor, the purulent drainage, the increase in pain regarding the wound (and the resident's nausea with the routine pain medications) and the increase of redness around the coccyx pressure ulcer. Interviews - A family member was interviewed on [DATE] at 7:30 a.m. and again on [DATE] at 10:45 a.m. (after survey exit). The family member stated the physician never observed the resident's pressure wound until the resident was discharged from the facility. The family member stated she requested the wound care specialist on [DATE], to document the resident needed to see the physician as soon as possible. The family member also stated the resident was often incontinent of urine and laid in a wet bed for long periods of time. The family member went on to say the resident suffered with pain from the pressure wound and could not tolerate the pain medications ordered, yet the pain medications were not changed. The family member said the resident saw things in the air and did not know what she was doing when on some of the pain medications. The family member commented she was present during a dressing change completed by a RN. Observations of RN completing the dressing change on the open wound according to the family member, included the RN's two dogs present in the room and lying on the resident's bed, the RN not washing her hands or cleaning her scissors. She stated one nurse was covered in dog hair as she took care of the resident. (Cross reference F441 Infection Control) -The wound care specialist was interviewed on [DATE] at 1:30 p.m. The wound care specialist stated she usually visited the facility once a month. Wound care specialist explained she could only see residents with Medicare B coverage and provided "hands off" services. She stated she was employed by a company that sold pressure wound products and could recommend treatments and products, educate the nurses, and answer the nurses' questions about resident's wounds that she could not observe. She went on to say she could recommend low flow air mattresses and check wheelchair for the proper pressure relieving cushions. She again emphasized she provided "hands off" treatment and for only residents who had Medicare B (outpatient) coverage. -The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were interviewed on [DATE] at 9:56 a.m. The NHA explained that the standing orders for pressure ulcer treatments were approved by the medical director. The standing orders were discussed in the ,[DATE] quality assurance meeting. The NHA stated resident #1 was private pay and her insurance company would not pay for the ordered Prostat. The NHA said the pharmacy works with the physician in cases as this. According to the DON, the physician was notified "right away" about the pressure wound and the wound care specialist came to observe the wound on [DATE]. When asked about the wound care specialist, the DON verified the care specialist could only observe Medicare B residents (which resident #1 was not), recommend wound treatments/products, and provide "hands off" advice. However, the physician did not fax approval of the wound care specialist recommendations until [DATE], the DON continued. The DON stated the facility would send the resident out to physician if they had concerns about wounds or wound healing.