Every finding on record at Canon Lodge Care Center

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of infectious disease.Specifically the facility failed to:-Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms;-Ensure housekeeping staff changed the mop head in a multiple resident room; and,-Ensure enhanced barrier precautions (EBP) were followed. Findings include: I. Housekeeping failures A. Facility policy and procedure The Daily Room Cleaning policy, revised 2/24/22, was provided by the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It read in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean and sanitary environment and reduce the potential for nosocomial infections. B. Observations During a continuous observation on 8/13/25, beginning at 9:01 a.m. and ending at 9:53 a.m., the following was observed: At 9:02 a.m. the housekeeping director (HKD) used hand sanitizer and donned (put on) gloves. The HKD entered a single occupancy room. The HKD sprayed a cloth with Virex II 256, wiped the sink and wiped the area around the sink. She placed the dirty cloth in the bag on the cart and grabbed a new cloth, without changing gloves or performing hand hygiene. She cleaned the surfaces of the bedroom furniture, bed frames, lights, shelves, tray table, call lights and remotes. She cleaned the window sill and blinds. She exited the room and grabbed the toilet brush and comet, without changing gloves or performing hand hygiene. She scrubbed the inside of the toilet and then flushed the toilet when done. The HKD mopped the room and the bathroom with two separate mop heads, without performing hand hygiene or changing her gloves after touching the dirty one and before touching the clean one. When she was finished cleaning the room at 9:16 a.m., she removed her gloves and performed hand hygiene. -The HKD failed to change her gloves between cleaning the room and bathroom. At 9:16 a.m. the HKD donned gloves and entered room [ROOM NUMBER], where three residents resided in. The HKD sprayed her clean cloth with Virex II 256, wiped the sink and wiped the area around the sink. She placed the dirty cloth in the bag on the cart and grabbed a new cloth, without changing gloves or performing hand hygiene. She cleaned the surfaces of the bedroom furniture, bed frames, lights, shelves, tray table, call lights and remotes. She cleaned the window sill and blinds. She disposed of the dirty cloths and then took out two mop heads from the bucket and placed them on the floor. She did not perform hand hygiene or change her gloves after touching the dirty cloths and before touching the clean mop heads. She mopped the whole room using one mop head. She used the second mop head to clean the bathroom. At 9:53 a.m. the HKD exited room [ROOM NUMBER] and removed her gloves and sanitized her hands. -The HKD failed to use new mop heads for each resident area and failed to change gloves after touching a contaminated item and before touching a clean item. C. Staff interviews The HKD was interviewed on 8/13/25 at 9:55 a.m. The HKD said she used the bleach or Virex II 256 for the mop heads. The HKD said the blue cloths were for cleaning the rooms and the yellow cloths were used for the bathrooms. The HKD said the mop heads were set up the same way. The maintenance director (MTD) was interviewed on 8/13/25 at 10:13 a.m. The MTD said the housekeepers were trained upon hire through orientation and ongoing training was completed on a regular basis. The MTD said after removing gloves the staff member should always perform hand hygiene before putting clean gloves on. The MTD said the housekeepers should change their gloves after cleaning the room and after cleaning the bathroom. He said he would immediately provide education to the housekeeping staff on the correct room cleaning procedure and hand hygiene. II. EBP failures A. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 8/20/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised 4/22/25, was provided by the NHA on 8/14/25 at 1:15 p.m. It read in pertinent part, The facility should use enhanced barrier precautions (EBP) as an additional multidrug-resistant organisms (MDRO) mitigation strategy for residents that meet the following criteria, during high-contact resident care activities. EBP are indicated for residents with indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheostomies. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contract resident care activities. High contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, medical device care or use and wound care. Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross transmission. C. Observations On 8/11/25 at 2:41 p.m. Resident #2's room was observed to have a sign on the door identifying the room required EBP. There was a container of PPE to the right of the door. Resident #2 was sitting in his wheelchair. Two unidentified staff members entered Resident #2's room with the Hoyer lift (mechanical lift). The two unidentified staff members entered the room without donning PPE. When the two unidentified staff members exited the resident's room they used hand sanitizer. Resident #2 was observed lying down in his bed. D. Resident interview Resident #2 was interviewed on 8/12/25 at 3:40 p.m. Resident #2 said he had a catheter. He said when the staff transferred him from his wheelchair to his bed, the staff did not put on gloves or a gown on. E. Staff interviews The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 8/13/25 at 5:12 p.m. The IP said the facility currently had residents who required [NAME]. The IP said she was responsible for ensuring there was an isolation cart with PPE for the staff to use and a sign in place to notify the staff that the resident was on EBP She said staff should be wearing PPE when transferring a resident who was on enhanced barrier precautions. She said she would provide education to staff on when to use PPE. F. Additional observations On 8/11/25 CNA #1 entered Resident #4's room. There was a PPE container outside of the resident's room. CNA #1 applied gloves and pulled the curtain. She provided foley catheter care to Resident #4. CNA #1 then opened the curtain, while wearing the same gloves used to drain the foley bag. She removed her gloves and performed hand hygiene with an alcohol based hand rub upon exiting the resident's room. -CNA #1 failed to put on a gown prior to providing care to a resident who was on EBP. E. Additional staff interviews CNA #1 was interviewed on 8/13/25 at 9:36 a.m. She said the staff should wear PPE when performing any catheter care to a resident who has a catheter. CNA #1 said PPE should be worn even when emptying the bag to protect from splashing. CNA #1 said she was not sure why she did not wear a gown when emptying the resident's catheter. RN #1 was interviewed on 8/13/25 at 10:47 a.m. She said staff were to apply PPE when providing care to a resident with a catheter or open area to the body. RN #1 said Resident #4 was on EBP and staff should be applying gloves and gowns while providing care. The DON was interviewed on 8/13/25 at 4:17 p.m. She said the staff needed to wear PPE when emptying catheter bags because they were to be on EBP. The DON said there should be a sign on the door indicating what type of precautions were to be taken when proving certain cares, she was unaware there was no sign on the door. The DON said they had a new infection preventionist starting next week. The DON said wearing PPE was important to help prevent infections.

Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medication for one (#26) of five residents reviewed for unnecessary medications out of 28 sample residents. Specifically, the facility failed to ensure Resident #26's responsible party was informed of an increase to psychotropic medications. Findings include: I. Facility policy and procedureThe Resident Rights facility policy and procedure, revised November 2016, was provided by the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, A facility must immediately inform the resident; consult with the resident`s physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment.II. Resident #26A. Resident statusResident #26, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnosis included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depression and cognitive communication deficit. According to the 4/17/25 minimum data set (MDS) assessment the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. B. Record reviewA review of Resident #26's electronic medical record (EMR) revealed consent forms were signed by the resident's representative for the following medications:-Seroquel (antipsychotic) 50 milligrams (mg), signed on 4/21/25;-Escitalopram Oxalate (antidepressant), signed on 5/31/25; and,-Haloperidol (antipsychotic) 1 mg, signed on 4/17/25.Review of the August 2025 CPO revealed the following medication dosage changes:-Seroquel oral tablet was increased to 25 mg three times a day on 7/8/25; -Escitalopram Oxalate tablet was increased to10 mg a day on 7/9/25; and-Haldol 2 mg was decreased to 0.5 mg two times a day on 7/10/25.The 7/8/25 psychotropic medication review documented the interdisciplinary team (IDT) determined to increase the dosage of Seroquel, Lexapro and to decrease Haldol.The July 2025 medication administration record (MAR) documented Resident #26 was administered the increased doses of Seroquel starting on 7/8/25, Lexapro starting on 7/9/25 and decreased dose of Haldol on 7/10/25.A review of the resident's EMR did not reveal documentation Resident #26's responsible party had been notified of the changes to the psychotropic medications until 7/23/25 (15 days after the Seroquel was increased and 14 days after the Lexapro was increased) during the care conference when all medications were documented as reviewed. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/13/25 at 2:29 p.m. LPN #1 said it was the nurses responsibility to notify the resident and/or family with any medication changes. She said the nurse should call the resident`s power of attorney (POA) or designated contact to obtain a verbal and/or written consent. She said the call should be documented in the progress notes. LPN #1 said Resident #26 was enrolled in hospice care during the psychotropic medication increases. She said there was confusion at that time whether the facility or the hospice should have notified the family.The director of nursing (DON) was interviewed on 8/13/25 at 3:04 p.m. The DON said she notified Resident #26`s POA verbally regarding the psychotropic medication increase, but did not document it in the resident's medical record. She said the facility did not have the resident's POA sign a consent form, which was their process.

Based on record review and interviews, the facility failed to ensure one (#8) of three residents reviewed for abuse out of 28 sample residents were free from abuse.Specifically, the facility failed to protect Resident #8 from physical abuse by Resident #22.Findings include:I. Facility policy and procedureThe Abuse Prevention policy, reviewed on 5/6/25, was received from the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as verbally aggressive behavior, physically aggressive behavior, sexually aggressive behavior, taking, touching, or rummaging through other's property, wandering into others' rooms/space, residents with a history of self-injurious behaviors, residents with communication disorders or who speak a different language, and residents that require extensive nursing care and/or are totally dependent on staff for the provision of care.II. Physical abuse of Resident #8 by Resident #22 on 7/1/25A. Facility investigationThe facility investigation was provided by the NHA on 8/12/25 at 9:03 a.m.The investigation documented that on 7/1/25 at 7:56 a.m., in the main dining room, certified nurse aide (CNA) #1 asked Resident #22 if she could move him in order to make room for Resident #8 to get to a table in the dining room. When Resident #22 was moved, he turned himself around in his wheelchair and placed both hands on Resident #8 chest, pushing him backwards. Resident #8 left the dining room and went to his room. Staff assessed Resident #8 for injuries and none were observed. Resident #22 was placed on one-to-one monitoring following the event while an investigation was being completed. CNA #1's eyewitness statement, dated 7/1/25, documented that CNA #1 had asked Resident #22 if she could move him to allow Resident #8 access to a table in the dining room. Resident #22 told CNA #2 sure go ahead and try while laughing. CNA #2 moved Resident #2 to the side and when she went to move Resident #8, Resident #22 had turned around towards Resident #8 and put both hands on Resident #8's chest, slamming him backwards in his wheelchair. Resident #8's wheelchair rolled backwards and Resident #8 was heard yelling no and took off out of the dining room.CNA #1 said Resident #22 hollered Do not be moving me! CNA #1 informed Resident #22 she had asked his permission prior to moving him and that no one had touched him other than her. Resident #22 responded that if anyone touched him, he would make them regret it.CNA #1 said she found Resident #8 in his room and he had two hand prints on his chest. Resident #8 returned to the dining room but was shaking and scanning the dining room for Resident #22.Resident #22 was taken to a table in the corner of the dining room away from Resident #8.The social services director (SSD) attempted to interview Resident #8 but he had no response and left the room.Resident #22 was interviewed by social services and he had no recollection of the event. The facility completed staff, resident and family representative interviews and no other abuse concerns were identified. The police, the physicians, the ombudsman and the family representatives were all informed of the incident. Resident #22 remained on-one-to one monitoring for 72-hours until the interdisciplinary team (IDT) met and concluded one-to-one monitoring was no longer needed as Resident #22 had not exhibited any other behaviors.The facility substantiated the abuse allegation as it was witnessed by staff. B. Resident #8 (victim)1. Resident statusResident #8, age greater than 65 was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included neurocognitive disorder (decline in cognitive function, including memory, thinking, and reasoning), dementia and rhabdomyolysis (damaged muscle tissue breakdown).The 6/16/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. The resident had unclear speech, was sometimes understood and sometimes understood others. The MDS assessment indicated the resident had no behaviors.2. Record reviewThe comprehensive care plan, initiated 6/16/25, documented Resident #8 had a behavior problem of wandering, trying to look out windows and not being aware of others' personal space related to frontal temporal lobe dementia. The goal was that Resident #8 would not experience behaviors that were harmful to himself or others. Interventions included administering medications as needed, anticipating the resident's needs, redirecting the resident away from other residents' rooms, intervening as necessary to protect the rights and safety of others by approaching/speaking in a calm manner to divert attention and removing the resident from the situation and taking him to alternative locations as needed.An event note, dated 7/1/25 at 1:03 p.m., documented another resident (Resident #22) placed both hands on Resident #8's chest and pushed him backwards in his wheelchair, causing the wheelchair to roll backwards. Resident #22 stated Do not be moving me. If anyone touches me they will regret it. Resident #8 left the dining room and went to his room. No injuries were noted and the family was notified.An alert note, dated 7/1/25 at 11:59 p.m., documented Resident #8 did not have any signs of latent injuries from the event on 7/1/25.An alert note, dated 7/2/25 at 12:16 p.m., documented Resident #8 had no signs of latent injuries to the upper body/chest post-incident on 7/1/25. He had no signs of pain or discomfort. The resident had no crying, groaning or facial grimacing.A skin integrity assessment completed on 7/1/25 revealed no changes in Resident #8's skin post-incident.C. Resident # 22 (assailant) 1. Resident statusResident #22, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, hypertension (high blood pressure) and dysphagia (difficulty swallowing). The 6/24/25 MDS assessment revealed the resident had long-term and short-term memory problems. The MDS assessment indicated the resident had physical and verbal behaviors directed towards others. 2. Record reviewThe comprehensive care plan, initiated 12/29/22, revealed Resident #22 had dementia with agitation and could exhibit impulsive behaviors, agitation/restlessness, not sleeping, verbal aggression wandering and rummaging. Identified goals were for Resident #22 to have fewer behavioral episodes. Interventions included administering medications, decreasing stimulation, offering calm environments, encouraging participation in activities, offering choices, explaining tasks, monitoring wandering behaviors, escorting the resident to an appropriate location, one-to-one supervision from 7/1/25 to 7/4/25 and redirecting the resident when he was agitated or when other residents were agitated in his vicinity.The comprehensive care plan further documented Resident #22 had the potential to be physically aggressive, including hitting, grabbing and pushing, related to dementia. Interventions included assessing and anticipating the resident's needs, providing physical and verbal cues to alleviate anxiety by giving positive feedback, assisting the resident with verbalization of sources of agitation and assisting the resident to set goals for more pleasant behaviors. Resident #22's triggers for physical aggression were related to incontinence, poor approach, elevated voice and close proximity of his personal space. A behavior note, dated 7/1/25 at 12:41 p.m. revealed CNA #1 informed the nurse that during breakfast in the dining room, she had asked Resident #22 if she could move him to make room at the table and after the resident was moved, he turned around in his wheelchair and put both hands on Resident #8's chest, pushing him backwards in his wheelchair, causing the wheelchair to roll backwards. Resident #22 stated Do not be moving me. If anyone touches me they will regret it. Resident #22 was moved to a separate table away from other residents to complete the meal. A one-to-one monitor was initiated. III. Staff interviewsCNA #1 was interviewed on 8/13/25 at 9:45 a.m. CNA #1 said Resident #8 kept to himself and was not very talkative. She said he would sometimes mumble and groan, causing other residents to become frustrated as he could not speak. CNA #1 said in July 2025 another resident, Resident #22, was in a grumpy mood and pushed Resident #8 in the chest. CNA #1 said for a while, Resident #8 avoided Resident #22 but now the two residents seemed to be okay with each other, as if they forgot it happened due to their dementia. CNA #1 said Resident #22 became aggressive if someone talked to him the wrong way or bumped into him the wrong way. She said he would get verbally aggressive and sometimes physically aggressive towards others. CNA #1 said he had behaviors throughout the day. CNA #1 said she had received online training and in-services on dementia and how to care for residents with different approaches. CNA #1 said it was good to have refresher training as the facility had new staff and all staff needed to know how to handle situations and residents. Registered nurse (RN) #1 was interviewed on 8/13/25 at 10:52 a.m. RN #1 said Resident #8 liked to roam from his room into the room across the hall, which was empty, to look out the windows. RN #1 said Resident #8 was a victim in a resident-to-resident altercation with Resident #22 in July 2025. She said Resident #22 had pushed Resident #8 in the chest. RN #1 said Resident #8 seemed to be at baseline and had not shown fear of Resident #22 since the incident.CNA #4 was interviewed on 8/13/25 at 10:54 a.m. CNA #4 said Resident #22 had aggressive behaviors related to Alzheimer's disease. She said the resident would shove people or staff away. CNA #4 said when he acted like that, staff had to divert his behaviors for safety reasons. CNA #4 said she received yearly training on abuse and how to approach dementia residents, along with training on verbal altercations and how to report a situation following the chain of command.The SSD was interviewed on 8/13/25 at 3:42 p.m. The SSD said Resident #8 had no aggressive behaviors. She said he just liked to go from his room to the room across the hallway to look out the window. The SSD said Resident #8 and Resident #22 had an altercation in the dining room on 7/1/25 where Resident #22 pushed Resident #8 in the chest. The SSD said both residents were cognitively impaired and Resident #8 got into Resident #22's personal space. The SSD said Resident #8 did not seem frightened or scared after the event and he resumed his normal activities. The SSD said Resident #8 was observed for behaviors via his body language for how he was coping post-incident, because he did not speak. The director of nursing (DON) was interviewed on 8/13/25 at 3:55 p.m. The DON said Resident #22 had dementia and if he was out and about and someone messed with something of his, he was going to fight. She said Resident #22 was physical towards staff and these were not new behaviors for him. She said Resident #22 had had a few incidents with residents. The DON said Resident #8 liked to wander from his room to the room across the hall to look out the window. The DON said Resident #8 was in the dining room (on 7/1/25) when Resident #22 pushed him with both hands on his chest. She said Resident #8 was shocked by the initial push and left the dining room and went to his room. She said Resident #8 left the dining room and when asked about the incident, he was unable to verbalize the incident due to his cognitive impairment. The DON said Resident #8 was not observed to have any behavior changed post-incident and he resumed his daily activities once he returned to the dining room. The DON said Resident #8 and Resident #22 were separated immediately and Resident #22 was placed on one-to-one monitoring for 72-hours.

Based on record review and interviews, the facility failed to assess, arrange, and document discharge services for one (#32) of one resident reviewed for discharges out of 28 sample residents.Specifically the facility failed to provide Resident #32 with a bed hold policy at the time of the resident's transfer to the hospital.Findings include:I. Facility policy and procedureThe Area of Focus: Discharge Process and Bed Holds policy and procedure, revised 11/19/24, was received from the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, Transfers or discharges include movement of a resident to a bed outside of the certified facility. Bed hold: holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. Notice before transfer: before the facility transfers the resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies the duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility, the reserve bed payment policy in the state plan,if any, the nursing facility's policies regarding bed hold periods, which may be consistent with the transfer and discharge policy, permitting a resident to return and the information specified in the transfer and discharge policy. Bed hold policies will be provided and explained to the resident or responsible party upon admission and explained to the patient before each temporary absence. Before the resident is transferred to a hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident or responsible party that specifies the duration of the bed hold policy, during which the resident is permitted to return and resume residence in the nursing facility, the reserved bed payment policy in the state plan, if any, the facility's policy regarding bed hold. In cases of emergency transfers, notice at the time of transfer means that the family, surrogate, or responsible party are provided with written notification within 24 hours of the transfer. II. Resident #32A. Resident statusResident #32, age greater than 65, was admitted on [DATE], readmitted on [DATE] and discharged on 5/30/25 to the hospital. According to the May 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic obstructive pulmonary disease (COPD - ineffective oxygen exchange in the lungs), dysphagia (difficulty swallowing) and hypertension (high blood pressure).The 3/19/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required partial/moderate staff assistance with dressing, personal hygiene and transfers. Set up assistance was needed for eating and toileting. B. Record reviewReview of the discharge care plan, initiated 3/15/25, revealed Resident #32 wished to remain in the facility for long-term care due to his 24-hour care needs.An event note, dated 5/30/25 at 7:42 p.m. documented the staff heard a loud thud coming from the hallway followed by a scream. Resident #32 was found on the floor outside of the nurses' station lying on his stomach with his wheelchair behind him. Resident #32 was not awake and when stimulated he opened his eyes.The resident had a golf ball-sized red area to his right forehead just above the eye with a small amount of bleeding observed. A registered nurse (RN) called an ambulance to have the resident taken to the hospital.-There was no documentation in Resident #32's electronic medical record (EMR) to indicate the resident or his representative were provided with a bed hold policy at the time of his transfer to the hospital.The NHA provided a bed hold policy signed by Resident #32 on 8/13/25 at 3:54 p.m. The signed bed hold policy indicated the resident signed the bed hold policy on 7/28/23, which was the resident's initial admission date to the facility.-The facility was unable to provide a bed hold policy that was signed by the resident or the resident's representative at the time of Resident #32's transfer to the hospital on 5/30/25. III. Staff interviewsRN #1 was interviewed on 8/13/25 at 10:50 a.m. RN #1 said it was the responsibility of the nurse who sent the resident out to the hospital to provide the bed hold policy to the resident or the resident's representative. RN #1 said it was a requirement to complete the bed hold. RN #1 said the resident or the resident's representative did not have to sign the form, but they had to be provided with the form. RN #1 said it was important residents had the bed hold policy information to ensure they would have a bed for them to return to if they chose to return to the facility. The director of nursing (DON) was interviewed on 4/13/25 at 4:23 p.m. The DON said the nurse sending the resident to the hospital was responsible for giving the resident or the resident's representative the bed hold policy at the time of the transfer to the hospital. The DON said the facility provided a bed hold policy for Resident #32 (on 5/30/25), however, she said the dates did not match. The DON said she called the nurse (during the survey) who had sent the resident to the hospital on 5/30/25 and the nurse informed her the number five on the form looked like the number seven. She said the nurse told her it was just her hand writing but the number seven should be a number five. -However, the date on the form provided by the facility on 8/13/25 (see record review above) was written as 7/28/23 and did not match up with the resident's transfer date of 5/30/25.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for one (#14) of two residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure a safe transfer was performed with Resident #14 who was dependent on staff. Findings include: I. Facility policy and procedureThe Activities of Daily Living policy and procedure, revised 2/12/24 was provided by the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It read in pertinent part, Utilize appropriate safety measures and any necessary equipment to maintain resident safety.The Limited Lift Program policy and procedure, revised 2/20/24, was provided by the NHA on 8/14/25 at 1:15 p.m. It read in pertinent part, The facility will assess residents for the need for assistance with transfer activities, mobility or repositioning utilizing a validated mobility assessment by either nursing or therapy. Manual lifting of all residents who are unable to bear weight will be minimized. II. Resident #14A. Resident statusResident #14, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs), a history of traumatic brain injury and injury of cervical spinal cord. The 5/22/25 minimum data set (MDS) assessment revealed Resident #14 was unable to complete the brief interview for mental status. The staff assessment revealed he had short-term and long-term memory deficits. The staff assessment further revealed he was severely impaired in his daily decision-making. The MDS assessment revealed Resident #14 was fully dependent on staff for all of his ADLs. B. ObservationsDuring a continuous observation on 8/12/25, beginning at 9:36 a.m. and ending at 9:59 a.m. the following was observed:At 9:36 a.m. certified nurse aide (CNA) #2 entered Resident #14's room with the shower chair. A second unidentified CNA entered the room without a Hoyer lift (full body mechanical lift). Resident #14 was in his Geri-chair (a specialized wheelchair that reclines) in his room. At approximately 9:40 a.m. the two CNAs assisted Resident #14 into the shower room, the unknown CNA left the shower room. Resident #14 was in the shower chair.At approximately 9:41 a.m. the Hoyer lift was not inside of Resident #14's room. At 9:48 a.m. Resident #14 returned to his room in the shower chair.At 9:50 a.m. an unidentified CNA entered Resident #14's room without the Hoyer lift. At 9:59 a.m. two CNAs left Resident #14's room. Resident #14 was in his Geri-chair (a specialized wheelchair that can recline) The Hoyer lift was not in the room. -Resident #14 was transferred without using the Hoyer lift as recommended . C. Record reviewThe ADL care plan, revised on 6/3/25, documented Resident #14 had a self-care performance deficit related to his quadriplegia and was dependent on one to two staff for all of his ADL. The care plan documented Resident #14 was totally dependent on two staff for transferring using the Hoyer lift only. The functional goal care plan, revised 7/7/25, documented Resident #14 had limited physical mobility related to his contractures on his left hand and both lower extremities. The care plan documented that staff were to assist with all transfers using the Hoyer lift. The nursing admission assessment, dated 5/19/25 documented Resident #14 required maximum assistance with two staff using the Hoyer lift for transfers. The assessment documented Resident #14 was unable to standD. Staff interviewsCNA #1 was interviewed on 8/13/25 at 9:20 a.m. She said Resident #14 required a Hoyer lift or an extensive two-person lift when he was transferred. Registered nurse (RN) #1 was interviewed on 8/13/25 at 9:40 a.m. RN #1 said Resident #14 was a two-person Hoyer lift for transfers. She said the CNAs used the Hoyer lift every time he was transferred. CNA #2 was interviewed on 8/13/25 at 10:05 a.m. She said Resident #14 was a two-person Hoyer lift except for when he was super agitated. She said when he got agitated, they would use two or three people to transfer him without the Hoyer lift.Physical therapist assistant (PTA) #1 was interviewed on 8/13/25 at 10:17 a.m. She said Resident #14 was a two-person Hoyer lift for all of his transfers. The director of rehabilitation (DOR) was interviewed on 8/13/25 at 10:20 a.m. He said he did not do the assessment for the Hoyer lift. He said Resident #14 came from another facility with the recommendation to use the Hoyer lift for transfers. He said the Hoyer lift should be used all the time. He said if staff did not use the Hoyer lift, then there would be the potential for the staff or the resident to become injured. The director of nursing (DON) was interviewed on 8/13/25 at 11:46 a.m. She said Resident #14 should be transferred with the Hoyer lift every time. She said she was unaware of anyone transferring Resident #14 without the Hoyer lift. She said that if staff were not using the Hoyer lift, there was the risk of the staff or the resident to become injured. CNA #2 was interviewed again on 8/13/25 at 2:13 p.m. She said they did a three-person transfer on 8/12/25 with Resident #14 because the resident had grabbed the Hoyer lift earlier in the morning. She said the way they performed the three-person lift was one person was behind the lifting under his arm pits and one person on each of his legs lifting. She said Resident #14's behavior of grabbing the lift had increased and if someone were to mention it to the DON then she would have him reevaluated. CNA #2 was interviewed a third time on 8/13/25 at 2:20 p.m. She said she had just spoken to the DON and said there was miscommunication. She said the CNAs thought therapy had already reevaluated Resident #14 and had given the go ahead to the two-person transfer. The DOR was interviewed again on 8/13/25 at 2:33 p.m. He said the correct way to do a two-person transfer was to put the gait belt around their waist, then have one employee in the front to do the stand-pivot-transfer and the second employee would be in back to help guide the resident. He said for a person who could not bear weight, it was not recommended to do a two-person transfer. He said Resident #14 could not bear weight and he would not recommend a two-person transfer for Resident #14. The DON was interviewed again on 8/13/25 at 2:51 p.m. She said the CNAs should not be transferring Resident #14 without the Hoyer lift. She said she began re-educating the staff and would continue to re-educate the staff until all of the CNAs and nurses have had the training. She said she was informed about Resident #14 grabbing the lift she said she would have therapy reassess him to see what they could do about his transfers.

Based on record review and interviews, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for two (#2 and #14) of three residents reviewed for restorative services out of 28 sample residents.Specifically, the facility failed to:-Ensure Resident #2 and Resident #14 were offered and provided with a restorative nursing program to maintain and/or prevent deterioration of their current levels of function and mobility; and,-Ensure Resident #14 was provided with a splint, palm guard or a rolled wash cloth in his left hand to prevent potential worsening of his hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).Findings include: I. Facility policy and procedure The Area of Focus: Restorative Nursing policy and procedure, revised 1/3/25, was received by the nursing home administrator (NHA) on 8/15/25 at 1:15 p.m. It read in pertinent part, Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. The restorative nursing program is based on the resident assessment instrument (RAI) user's manual. Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record. Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity. Other staff or volunteers who are trained may be assigned to work with specific residents. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Restorative nursing functions can be within one of the following categories: -Range of motion (active and passive); -Splint or brace assistance; -Bed mobility; -Transfers; -Walking; -Dressing and/or grooming; -Eating and/or swallowing; -Amputation/prosthesis care; -Communication; -Toileting program; and, -Bladder retraining. The trained certified nurse aide (CNA) will document provided techniques per the restorative care plan in the medical record. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included central cord syndrome at an unspecified level of cervical spinal cord and Parkinson's disease. The 5/22/25 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented Resident #2 was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, sitting to lying and chair/bed to chair transfers. B. Resident interview Resident #2 was interviewed on 8/10/25 at 7:10 p.m. Resident #2 said he was supposed to start getting restorative services at the beginning of August 2025. He said he had not received any restorative services. He said he would like to receive restorative services to help with his mobility. C. Record review The ADL care plan, revised 12/5/24, documented Resident #2 had self care performance deficits related to central spinal cord syndrome, tetraplegia (the function or loss of motor and/or sensory function in the cervical area of the spinal cord), Parkinson's disease and neuralgia (symptom of severe nerve pain) and neuritis (inflammation of a nerve). Interventions included providing extensive one to two-person assistance for bed mobility to turn and reposition the resident in bed and providing total two-person staff assistance for transferring Resident #2 using a Hoyer lift (mechanical lift). The functional goal care plan, revised 11/27/24, documented Resident #2 had limited physical mobility. Interventions included providing gentle ROM as tolerated, providing a nursing rehab/restorative active range of motion (AROM) program, which included AROM to the upper extremities for 10-20 repetitions times two sets using Theraband (a brand of elastic resistance bands used for physical therapy, rehabilitation, and exercise), incorporating one to two pound weights as tolerated, gentle upward and outward 10-15 second stretches to the left upper extremity three to four times and providing a nursing rehab/restorative passive range of motion (PROM) program, which included PROM to both lower extremities for five to 10 repetitions times two sets as tolerated and gentle stretching. The nursing restorative program evaluation, dated 1/11/25, documented Resident #2 was provided restorative nursing services for PROM for transfers. The nursing restorative program evaluation, dated 2/14/25, documented Resident #2 was provided restorative nursing services for AROM related to decreased mobility and self care deficits due to weakness. Resident #2 additionally received PROM to maintain flexibility and prevent contractures to bilateral lower extremities (BLE). The nursing restorative program note, dated 3/3/25, documented stretching exercises for lower upper extremities were added to Resident #2's restorative program routine and added to his plan of care. The nursing restorative program evaluation, dated 3/24/25, documented Resident #2 was provided restorative nursing services for AROM due to decreased mobility and self care deficits due to weakness. Resident #2 additionally received PROM to maintain flexibility and prevent contractures to BLE. The nursing restorative program evaluation, dated 7/3/25, documented Resident #2 was provided restorative nursing services for AROM related to decreased mobility and self care deficits due to weakness. Resident #2 received PROM to maintain flexibility and prevent contractures to BLE. -Review of Resident #2's electronic medical record (EMR) revealed there were no nursing restorative program evaluations for the months of April 2025, May 2025, June 2025 or August 2025. -Review of Resident #2's EMR failed to reveal progress notes or other documentation to indicate the resident had received restorative program services for the months of April 2025, May 2025, June 2025 or August 2025. -A review of Resident #2's August 2025 CPO did not reveal a physician's orders for restorative program services. D. Staff interviews CNA #1 was interviewed on 8/13/25 at 1:26 p.m. CNA #1 said she did not know if staff was providing ROM for Resident #2. She said the facility was working on getting restorative staff hired. She said there had not been a restorative aide in the facility for two or more weeks. CNA #3 was interviewed on 8/13/25 at 1:50 p.m. CNA #3 said she did not know how long there had been no restorative aide in the facility. CNA #3 said the facility had hired someone for the position who would be starting soon. CNA #3 said restorative care was important for residents because it helped with maintaining and keeping their mobility. Licensed practical nurse (LPN) #1 was interviewed on 8/13/25 at 2:03 p.m. LPN #1 said CNAs were responsible for providing restorative services to residents. LPN #1 said Resident #2 had not been receiving restorative services, but he had received restorative services in the past. She said there had been no restorative aides in the facility for six weeks. She said the facility had a staff member in mind to train for the restorative aide role and that staff member would be starting soon. The director of rehabilitation (DOR) was interviewed on 8/13/25 at 3:00 p.m. The DOR said Resident #2 was not currently receiving physical therapy. The DOR said he did not know if Resident #2 was receiving restorative services. The DOR said he was familiar with Resident #2 and said he could benefit from restorative services. The DOR said restorative services had not been consistent for residents for the last couple of months. He said the facility had hired someone to fill the role who would be starting on 8/18/25. The MDS coordinator was interviewed on 8/13/25 at 3:25 p.m. The MDS coordinator said there had not been a consistent restorative aide in the facility since the last one left a couple of months ago. The MDS coordinator said staffing was short, so there was no one to help with restorative services. The MDS coordinator said a new restorative aide was starting on 8/18/25. The MDS coordinator said Resident #2 was placed on a restorative program shortly after he was admitted to the facility. She said she tried to get him on restorative services quickly. She said Resident #2 benefited from getting restorative services. She said Resident #2 was not currently receiving restorative services. The director of nursing (DON) was interviewed on 8/13/25 at 3:36 p.m. The DON said when a resident was coming off physical therapy services, a physician's order would be written for continued restorative services. The DON said it was important for residents to continue with restorative services so that residents did not lose strength or endurance. The DON said the facility had not had a restorative services program for six weeks. She said the facility had just hired a restorative aide and would now be able to start a complete restorative services program. She said the facility's restorative services program was currently being set up and the facility would soon be able to offer restorative services again. The DON said Resident #2 would benefit from restorative services. The DON said Resident #2 would be receiving restorative services three to five times a week. She said Resident #2 needed to have restorative services for ROM because of him being bed-bound. III. Resident #14 A. Resident status Resident #14, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included quadriplegia (paralysis of all four limbs), a history of traumatic brain injury, and injury of the cervical spinal cord. The 5/22/25 MDS assessment revealed Resident #14 was unable to complete the BIMS assessment. The staff assessment for mental status revealed he had short-term and long-term memory deficits. The staff assessment further revealed he was severely impaired in his daily decision-making skills. The MDS assessment revealed Resident #14 was fully dependent on staff for all of his ADLs and had ROM on both sides of his upper and lower extremities. B. Observations On 8/10/25 at 4:55 p.m. Resident #14 was in the dining room. His left hand was contracted and the tips of his fingers were touching the palm of his hand. He did not have a splint, palm guard or a rolled washcloth in his hand. During a continuous observation on 8/11/25, beginning at 9:08 a.m. and ending at 11:47 a.m., the following was observed: At 9:08 a.m. Resident #14 was brought to his room from the dining room in his Geri-chair (specialized wheelchair that can recline). He did not have a splint, palm guard or a rolled washcloth in his left hand. At 10:23 a.m. Resident #14 was still in his room. An unidentified certified nurse aide (CNA) entered the room to answer his roommate's call light. At 10:45 a.m. the unidentified CNA left the room after assisting Resident #14's roommate. The unidentified CNA did not offer to apply a splint, palm guard or a rolled washcloth to Resident #14's left hand or offer to perform any ROM exercises with him. At 10:51 a.m. another unidentified CNA went into Resident #14's room and talked to him, however, she did not do any ROM exercises with him and did not apply a splint, palm guard or a rolled washcloth to his left hand. At 11:24 a.m. Resident #14 continued to sit in his chair in his room. No staff members offered to do ROM exercises with the resident or apply a splint, palm guard or a rolled washcloth to his left hand. At 11:47 a.m. Resident #14 was taken to the dining room for lunch. The resident's left hand did not have a splint, palm guard or a rolled washcloth applied. During a continuous observation on 8/11/25, beginning at 2:10 p.m. and ending at 4:50 p.m., the following was observed: At 2:10 p.m. Resident #14 was in his room in his Geri-chair. The resident's left hand did not have a splint, palm guard or a rolled washcloth applied. At 2:49 p.m. registered nurse (RN) #1 entered Resident #14's room and administered medications to the resident. She did not apply a splint, palm guard or a rolled washcloth to his left hand. At 3:22 p.m. Resident #14 remained in his room in his Geri-chair. His left hand did not have a splint, palm guard or a rolled washcloth applied and ROM exercises had not been performed. At 3:55 p.m. Resident #14 was still in his room in his Geri-chair. The resident's left hand did not have a splint, palm guard or a rolled washcloth applied and ROM exercises had not been performed. At 4:11 p.m. RN #1 entered Resident #14's room again and administered additional medications to the resident. She did not apply a splint, palm guard or a rolled washcloth to his hand. At 4:50 p.m. an unknown CNA took Resident #14 to the dining room for dinner The resident did not have a splint, palm guard or a rolled washcloth in his left hand and ROM had not been performed. C. Resident representative interview Resident #14's representative was interviewed on 8/11/25 at 12:25 p.m. The representative said she was unsure if Resident #14 was getting any restorative care for his contractures. She said the facility was going to have a care conference for him in a couple of weeks and she would find out then. D. Record review The ADL care plan, revised 6/3/25 documented Resident #14 had a self-care performance deficit related to his quadriplegia. Interventions included a nursing restorative program using a splint or brace and washing his left hand with soap and warm water, drying the left hand thoroughly, inspecting the hand for redness and skin breakdown and placing a rolled washcloth into his hand. The functional goal care plan, revised 7/7/25, documented Resident #14 had limited physical mobility related to the contracture of his left hand and both lower extremities. Interventions included a nursing restorative program of passive ROM on both his upper and lower extremities and performing gentle 15-20 second stretches to every joint for three to five repetitions. The restorative program evaluation, dated 6/28/25, documented the passive range of motion (PROM) restorative program was implemented for Resident #14 due to his decreased mobility related to his neurologic dysfunction and head trauma and the contracture of his left hand. The splint or brace program was also implemented because of the contracture of his left hand. -However, there was no documentation in Resident #14's EMR to indicate the resident had received a PROM restorative program from 6/28/25 to 8/11/25. E. Staff interviews CNA #1 was interviewed on 8/13/25 at 9:20 a.m. CNA #1 said Resident #14 was not receiving restorative programming. She said she did not know why. She said CNAs tried to do ROM with him when they were getting him dressed. She said she thought he might not be getting any restorative programming because he might be too hard for them to work with because he could become really aggressive. RN #1 was interviewed on 8/13/25 at 9:40 a.m. RN #1 said Resident #14 was receiving restorative services when he first got to the facility. She said the facility did not have the staff for the restorative program at that time. She said once the facility had the staff for the program, Resident #14 would be back on the program. CNA #2 was interviewed on 8/13/25 at 10:05 a.m. CNA #2 said she did not think Resident #14 received any kind of therapy. She said he did have a contracture of his left hand, but she thought it was permanent. Physical therapy assistant (PTA) #1 was interviewed on 8/13/25 at 10:17 a.m. PTA #1 said Resident #14 was not receiving any restorative services because the program had not started yet. She said the program would start the week of August 18th. The MDS coordinator was interviewed on 8/13/25 at 10:47 a.m. The MDS coordinator said the facility had Resident #14 on a restorative program but it was really inconsistent because of CNAs leaving or being moved to the floor. She said she had hired a CNA to work six days a week to do restorative programs and she would be starting the week of August 18th. She said the facility did not have anyone to provide the restorative services in the interim. The director of nursing (DON) was interviewed on 8/13/25 at 11:46 a.m. The DON said Resident #14 was on a restorative program but because of staffing, the facility had to pause the program. She said he had started the program sometime in June 2025and the program was paused sometime in July 2025. She said the program would start again the week of August 18th. She said some of the floor CNAs were trained to do restorative programs. The DON said when those CNAs who were trained to do restorative programs were working, they should be doing ROM and putting the washcloth in Resident #14's left hand.

Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one residents (#10) out of 28 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Resident #10. Findings include:I. Professional referenceAccording to the Lantus (insulin Glargine) How to use your pen retrieved on 8/18/25 from https://www.lantus.com/dam/jcr:2cfa1d37-1b5d-445d-83cd-8eaaeaeef48b/lantus-quick-reference-patient-brochure.pdf It revealed in pertinent part, Step 3 perform a safety test. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that the insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times if there is still no insulin coming out, use a new needle and do the safety test again. The most common side effect of insulin, including Lantus (glargine) is low blood sugar (hypoglycemia) which may be serious and life threatening.II. Facility policy and procedureThe Administering of Medication policy, reviewed 9/16/24, was received from the nursing home administrator (NHA) on 8/14/25 at 1:15 p.m. It revealed in pertinent part, The facility will ensure medications are administered safely and appropriately per physician orders to address the residents diagnoses and signs and symptoms. Medication error, means the observed or identified preparation or administration of medication or biologics which is not in accordance with: the prescribers order; manufactures specification regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principals include the various practices regulations in each State, and current commonly accepted health standards established by national organizations, boards and councils. Significant medication, means one which causes the resident discomfort or jeopardizes his or her health and safety. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. High alert medications include, but not limited to: Anticoagulants, chemotherapeutic agents, hypoglycemics, insulins, parenteral nutrition preparations and opioids.The Insulin Pen Administration policy, revised on 5/27/25, was received from the NHA on 8/14/25 at 1:14 p.m. It revealed in pertinent part, The facility will ensure residents with ordered for insulin administration through the use of pen delivery device is performed in accordance with current standards or practice and manufacturer's guidance. The insulin pen should be primed for each use (in accordance with manufacturer's guidelines) to prevent the collection of air in the insulin reservoir. General guidance on priming insulin pen in the absence of manufactures guidance. Dial 2 units by turning the dose selector clockwise, with the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of needle., If not repeat this procedure until at least one drop of insulin appears. III. Observations and staff interviewRegistered nurse (RN) #2 was observed on 8/10/25 at 7:14 p.m. preparing and administering medication to Resident #10. The physician's order read Glargine insulin inject 26 units subcutaneously two times a day for diabetes, ordered on 8/4/25.RN #2 collected the insulin pen, cleansed the top off with an alcohol swab and applied a new needle to the tip of the pen. She dialed the pen to 26 units at the medication cart. RN #2 took all medications prepared for Resident #10 including the insulin pen into the resident's room after donning (putting on) personal protective equipment (gown and gloves). Resident #10 took the oral medication whole with water. RN #2 then prepped the injection site with an alcohol swab, as RN #2 went to inject the insulin she was stopped and asked if she needed to prime the insulin pen. RN #2 said the type of pen and needle used did not require her to prime the insulin pen. RN #2 then continued to administer the insulin into the resident's right posterior upper arm. -RN #2 failed to prime the insulin pen (see professional reference above).IV. Additional staff interviewsThe director of nursing (DON) was interviewed on 8/13/25 at 4:32 p.m. She said the nurses were to follow the seven rights of medication administration to ensure the correct medication was administered per physician orders. The DON said the nurses were to cleanse the top of an insulin pen with an alcohol swab and prime the needle with one unit. The DON said if the needle was not primed it could cause the wrong dose of insulin to be administered leading to hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose levels).

Based on interviews and record reviews, the facility failed to ensure an effective discharge planning process for three (#8, #6 and #7) out of four residents reviewed out of 14 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documented in Resident #8, Resident #6 and Resident #7's medical record; and, -Ensure the interdisciplinary team was involved in the discharge planning process for Resident #8, Resident #6 and Resident #7. Findings include: I. Resident #8 A. Resident status Resident #8, age 76, was admitted on [DATE] and discharged home on 9/4/24. According to the September 2024 CPO diagnoses included retention of urine, hypertension, type 2 diabetes without complications and muscle weakness. The 6/3/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. The resident required supervision or touch assistance with activities of daily living. The MDS assessment indicated the resident did not have an active discharge plan. B. Record review The baseline care plan, dated 5/30/24, documented the resident wished to return home. The goal was to develop and follow a full discharge plan. The discharge care plan, initiated on 5/30/24, revealed the resident's discharge plan was to remain at the facility for long term care. Pertinent interventions included reviewing the discharge plan quarterly and as requested. The initial discharge plan evaluation dated 5/31/24 showed the resident and family were not sure of the resident's discharge plan at that time. The initial physical therapy evaluation and plan dated 5/31/24 showed the goal was for the resident to return home. -A review of Resident #8's EMR did not reveal documentation indicating the discharge planning process was discussed with the IDT team during the resident's stay at the facility. The discharge summary dated 8/28/24 revealed the resident was recommended to have outpatient rehab services after discharge. -However, review of Resident #8's EMR did not reveal documentation that home health services were established. II. Resident #6 A. Resident status Resident #6, age 77, was admitted on [DATE] and is still admitted to the facility. According to the November 2024 CPO, diagnoses included methicillin susceptible staphylococcus Aureus infection bacteremia, hypertension, Chronic obstructive pulmonary disease, oxygen dependence and muscle weakness. The 11/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required assistance with activities of daily living due to oxygen dependence and weakness. The MDS assessment documented the residents overall discharge goal was to return to the community and that there were no active discharge planning occurring. B. Record review The baseline care plan dated 11/13/24 documented the resident wished to return home. The goal was to develop and follow a full discharge plan. The discharge care plan, initiated on 11/13/24, revealed the resident's discharge plan was to discharge home with home health services. Pertinent interventions included reviewing the residents discharge plan quarterly and as requested. The initial discharge plan evaluation, dated 11/15/24, revealed the resident and the resident's family were not sure at that time which home health services agency they wanted. -A review of the resident's EMR did not reveal documentation regarding the resident's discharge plan or documentation indicating the IDT team was involved in the resident's discharge planning. 51916 III. Resident #7 A. Resident status Resident #7, age 80, was admitted on [DATE] and discharged home on 8/21/24 According to the August 2024 computerized physician orders (CPO), diagnoses included bilateral hip osteoarthritis, and bilateral total hip replacement. B. Record review The care plan, initiated on 8/20/24, revealed the resident desired to return home. The goal was for Resident #7 to understand the discharge plan. Pertinent interventions included establishing a pre discharge plan with the resident and family, evaluating the resident's motivation to return to the community, evaluating her abilities and strengths and determining gaps in her abilities which would affect discharge and make post discharge community resources to support independence. The 8/8/24 occupational therapy initial note documented the resident's goal was for the resident to return home and would like to have some assistance with higher level cleaning tasks. The 8/8/24 physical therapy initial note documented the resident's goal was to return home. In the initial discharge planning evaluation, dated 8/13/24, documented that the resident would likely require assistance when discharged from the facility due to concerns about safety, assistive device needs and caregiver support. The discharge summary information dated 8/20/24 failed to address if the resident still needed rehabilitation services after discharge. The summary documented the resident was recommended to have home health services at discharge. -However, there was no indication that home health services were established upon discharge. -The initial discharge planning showed the resident had requested community resources after discharge, however, there was no evidence to show it was provided. A review of the resident's electronic medical record (EMR) did not reveal any documentation indicating the resident's discharge planning process was reviewed with the IDT team during the resident's stay at the facility. The 8/21/24 progress note documented the resident was discharged with medications, and all belongings. -A review of the resident's EMR did not reveal documentation indicating if the resident was referred to home health services as mentioned in the initial discharge planning. IV. Staff interviews The social services director (SSD) was interviewed on 12/4/24 at 12:41 p.m. The SSD said the baseline care plan was when the discharge plan began, she said the nurse would find out what the plan was for discharge. The SSD said she then held an initial care conference with the resident and family and discharge was discussed. The SSD said she kept notes on a paper document, and then the paper document would be scanned into the electronic medical record. The SSD was interviewed on 12/4/24 at 4:43 p.m. The SSD said she was responsible for coordinating the discharge planning process. She said the facility usually had a care conference upon admission to address the initial discharge planning evaluation. She reviewed the medical record and could not locate the care conference notes which she said they had discussed the plan. The SSD was interviewed on 12/4/24 at 5:34 p.m. The SSD said she was unable to locate any care conference notes for Resident #7, Resident #6 or Resident #8. She said she completed them on paper, then they would get scanned into the EMR. She said Resident #7 was discharged to her daughters house. She said she reviewed the records for Resident #8, Resident #6 and Resident #7 and confirmed the records showed no documentation for discharge planning. The regional nurse consultant (RNC) was interviewed on 12/4/24 at 5:52 p.m. The RNC said the discharge planning and the care conference notes needed to be electronic and that she would provide education to the SSD.

Based on observations, record review and interviews, the facility failed to provide care and services for an activity of daily living (ADL) for four (#13, #5, #9 and #14) out of five residents reviewed out of 14 sample residents. Specifically, the facility failed to ensure meal assistance was provided for Resident #5, Resident #9, Resident #13 and Resident #14, who required physical assistance and encouragement with food intake. Findings include: I. Resident #13 A. Resident status Resident #13, age 77, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses include [NAME] Syndrome (absence of one X chromosome in females, symptoms include certain learning disabilities), dementia, mixed incontinence and gastro-esophageal reflux disease (GERD) with esophagitis, with bleeding. The 10/17/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. She required set-up assistance during meals. B. Observations During a continuous observation of the dinner meal on 12/2/24, beginning at 5:05 p.m. and ending at 5:34 p.m., the following was observed: At 5:34 p.m. the resident received her meal. She picked up the fork and began to eat. At 5:14 p.m. the resident was picking at her meal. At 5:20 p.m. she was not eating her meal. The staff did not provide cueing or assistance. At 5:34 p.m. the resident was asked by an unidentified certified nurse aide (CNA) if she was ready to watch television. The resident had only eaten approximately 50% of her meal. The CNA assisted her away from the table. She was not encouraged to eat more of her meal. During a continuous observation of the lunch meal on 12/3/24, beginning at 12:19 p.m. and ending at 12:46 p.m. the following was observed: At 12:19 p.m. the resident received her meal which consisted of a sandwich. At 12:29 p.m. CNA #1 asked if she would like her sandwich cut, as it was not cut. The resident had not touched the egg salad sandwich. At 12:32 p.m. the resident was eating the sandwich, after it was cut into quarters. At 12:46 p.m. LPN #1 said to the resident that she had not eaten much and asked the resident if she was ready to lay down. LPN #1 did not provide encouragement or cueing to the resident. The resident left the table with eating one quarter of the sandwich. During a continuous observation of the dinner meal on 12/3/24, beginning at 5:10 p.m. and ending at 5:20 p.m. the following was observed: At 5:10 p.m. the resident had her meal. She received a sandwich and Jello. At 5:17 p.m. the resident was asked by CNA #2 if she was done eating, the resident had only eaten half of her sandwich and not touched her Jello. The resident was not provided an alternative, cueing or encouragement. At 5:20 p.m. she was assisted from the table. C. Record review The ADL care plan, revised on 7/29/24, revealed Resident #13 had an ADL self-care performance deficit related to dementia, generalized weakness, unsteady gait and history of falls. Pertinent interventions included providing one on one supervision, cueing and set-up assistance at meals. D. Staff interviews CNA #2 was interviewed on 12/4/24 at 2:20 p.m. CNA #2 said Resident #13 responded well to cueing at meals. She said she assisted Resident #13 with her meal that morning (12/4/24) because she was more tired than normal. She said the staff offered her different options and that large meals intimidated her. She said Resident #13 normally consumed 50 to 75% of small portioned meals. II. Resident #5 A. Resident status Resident #5, age 88, was admitted on [DATE] and readmitted on [DATE].According to the December 2024 CPO, diagnoses included altered mental status,other symptoms and signs involving cognitive functions and awareness, cognitive communication deficit, unspecified dementia (unspecified severity) with agitation and dysphagia (difficulty swallowing). The 10/28/24 MDS assessment revealed Resident #5 had a severe cognitive impairment with a BIMS score of two out of 15. She required hands-on assistance and supervision during meals. B. Observations During a continuous observation of the dinner meal on 12/2/24, beginning at 5:00 p.m. and ending at 5:38 p.m., the following was observed: At 5:00 p.m. Resident #5 was sitting in the dining room waiting for her meal tray. She had half a glass of water in front of her. At 5:08 p.m. Resident #5 called for help which alerted a staff member she wanted something else to drink. At 5:10 p.m. the resident was given another glass of water and chocolate milk. At 5:13 p.m. an unidentified CNA gave Resident #5 her meal tray then walked away. The unidentified CNA did not help the resident set-up her meal or provide cueing. At 5:18 p.m. Resident #5 had taken small bites of her food, spitting some out at times. She ate a few bites of her dessert and 75% of her chocolate milk. The staff had not offered cueing or assistance. At 5:25 p.m. Resident #5 continued to pick at food, taking a few bites. No cueing or encouragement was provided. At 5:32 p.m. Resident #5 was not eating. She had a sip of water. The staff had not encouraged her to eat more. At 5:38 p.m. Resident #5 was assisted back to her room. She had eaten 25% of her meal. She was not encouraged to eat more nor was she offered something else. During a continuous observation of the dinner meal on 12/3/24, beginning at 5:05 p.m. and ending at 5:35 p.m., the following was observed: At 5:05 p.m. the resident had her meal in front of her. The resident was not eating. The staff did not offer cueing or assistance to the resident. At 5:10 p.m. the resident picked up her fork and ate a few bites. She had a glass of milk, but had not touched it. The staff did not offer cueing or assistance to the resident. At 5:35 p.m. CNA #1 asked the resident if she was done with her meal. The resident shook her head yes. She consumed less than 25% of her meal. She was not offered assistance or encouragement or an alternative prior to leaving the dining room. C. Record review The care plan, revised on 8/13/24, revealed Resident #5 has an ADL self-care performance deficit related to dementia and fatigue. Pertinent interventions included providing supervision and set up assistance by one staff member to eat. D. Staff interviews CNA #2 was interviewed on 12/4/24 at 2:20 p.m. CNA #2 said Resident #5 required cueing when eating and that she got anxious in the dining room. She said Resident #5 required assistance with feeding at times and preferred a bland diet. She said Resident #5 would spit out food she did not like. CNA #2 said when this behavior was observed, the staff offered the resident other options. The director of nursing (DON) was interviewed on 12/4/24 at 2:38 p.m. The DON said she provided education to the staff regarding meals and meal assistance today (12/4/24). 52045 III. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted to the facility on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included Alzheimer's disease, and dysphagia (difficulty swallowing). The 9/4/24 minimum data set (MDS) assessment revealed the resident had short-term and long term memory deficits and was severely cognitively impaired per staff assessment. She required supervision and touching assistance with meals. B. Observations During a continuous observation of the lunch meal on 12/3/24, beginning at 12:14 p.m. and ending at 12:56 p.m., the following was observed: At 12:14 p.m Resident #9 received his meal and a glass of chocolate milk. At 12:22 p.m Resident #9 picked at his food. The staff did not provide the resident encouragement. At 12:26 p.m CNA #1 sat next to Resident #9 at the table. CNA #1 provided assistance to another resident at the table, but did not provide cueing or encouragement to to Resident #9. Resident #9 continued sitting at the table with his eyes closed and was not eating. At 12:37 p.m Resident #9 had not received any cueing or encouragement. At 12:43 p.m Resident #9 was not eating his meal. He had not received any encouragement. At 12:56 p.m CNA #4 said to CNA #1 that Resident #9 did not eat. CNA #1 said he ate good at breakfast. The staff did not offer any meal substitutes to the resident or provide encouragement before he was assisted away from the table. During a continuous observation of the dinner meal on 12/3/24, beginning at 5:24 p.m and ending at 5:30 p.m., the following was observed: At 5:24 p.m. Resident #9 sitting at the table not eating his evening meal with no encouragement or assistance from staff At 5:30 p.m CNA #1 sat next to Resident #9 to help another resident but she did not provide any encouragement to Resident #9. He ate approximately 50% of his meal with no encouragement offered of an alternative meal. C. Record review The care plan, revised on 9/23/24, revealed Resident #9 had an ADL self-care performance deficit related to Alzheimer's and history of fractures. Pertinent interventions included providing set up of his meal and supervision and assistance. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/4/24 at 10:05 a.m. LPN #1 said Resident #9 needed supervision assistance with meals. IV. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted to the facility on [DATE]. According to the December 2024 CPO, diagnoses include altered mental status, dementia, unspecified hearing loss, muscle weakness and dysphasia. The 10/10/24 MDS assessment revealed Resident #14 had severe cognitive impairments with a BIMS score of three out of 15. Resident #14 required set up and feeding assistance with meals. B. Observations During a continuous observation of the dinner meal on 12/2/24, beginning at 5:15 p.m. and ending at 5:34 p.m., the following was observed: At 5:15 p.m. Resident #14 received her meal with no set up assistance provided. At 5:20 p.m Resident #14 remained in the dining room and was not eating her meal. The staff had not offered any assistance or cueing to the resident. At 5:34 p.m. Resident #14 had not eaten any of her meal. CNA #1 assisted Resident #24 from the table. Resident #14 was not offered any cueing or assistance during the meal. C. Record Review The care plan, revised on 10/11/24 revealed Resident #14 had an ADL self-care performance deficit related to confusion and dementia. Pertinent interventions included Resident #14 was able to feed self but required cueing, reminders and set up assistance for meals. D. Staff interviews CNA #4 was interviewed on 12/4/24 at 2:30 p.m. CNA #4 said Resident #14 sometimes did not eat all of her meals. CNA #4 said when the resident did not eat all of their meal, the staff were supposed to offer another meal choice. CNA #4 did not state why Resident #14 was not offered another meal. CNA #4 said sometimes there was only one CNA in the dining room to help multiple residents eat at meal times.

Based on record review and interviews, the facility failed to ensure the discharge summary was complete for two (#7 and #8) of three residents reviewed for discharge out of 14 sampled residents. Specifically, the facility failed to ensure completed discharge summaries were completed and included a recapitulation of the resident's stay for Resident #7 and Resident #8. Findings include: I. Resident #7 A. Resident status Resident #7, age 80, was admitted on [DATE] and discharged home on 8/21/24 According to the August 2024 computerized physician orders (CPO), diagnoses included bilateral hip osteoarthritis and bilateral total hip replacement. Based on a health status note on 8/8/24 and a skilled nursing progress note from 8/19/24, Resident#7 was aware of surroundings and able to make needs known. B. Record review The discharge summary, dated 8/20/24, documented the resident was discharged home. The discharge summary failed to show that all areas on the form were completed. The following were missing: -Physical and mental functional status including activities of daily living (ADLs); -Continence; -Communication; -Special treatment and procedures; -Resident needs, strengths and goals; -Resident's customary routine; -Summary information on and additional areas assessed; -Pertinent lab test results; -Rehabilitation follow up or potential; -Recapitulation of stay specifically social service and activities; and, -Whether the resident required outpatient rehabilitation services after discharge. The form instructed the resident to follow up with the physician, however, there was no number or name of the physician provided. C. Staff interviews The social service director (SSD) and the regional nurse consultant (RNC) were interviewed together on 12/4/24 at 5:34 p.m. The SSD said she opened the discharge assessment. The SSD said different members of the interdisciplinary team filled out their designated section of the assessment. The SSD said the form was to be completed in entirety and provided to the resident upon discharge. She said the licensed nurse who was discharging the resident was responsible to ensure the form was completed prior to the resident's discharge. She said she reviewed the discharge summaries for both Resident #7 and Resident #8 and confirmed they were not completely filled out. The RNC said discharge summaries were an area which needed improvement. The director of nursing (DON) was interviewed on 12/4/24 at 4:43 p.m. The DON said the discharge summary was a group effort. She said the discharge summary needed to be completed prior to discharge and agreed the discharging nurse was responsible to ensure it was completed. 52045 II. Resident #8 A. Resident status Resident #8, age 76, was admitted on [DATE] and discharged on [DATE]. According to the August 2024 CPO, diagnoses included deep tissue injury of the right heel and diabetes. The 6/3/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. The resident required supervision or touch assistance with activities of daily living. B. Record review The discharge summary, dated 8/28/24, documented the resident was discharged home. The discharge summary failed to show that all areas on the form were completed. The following were missing: -Physical and mental functional status including ADLs; -Skin condition; -Special treatment and procedures; -Resident needs, strengths and goals; -Resident's customary routine; -Summary information on and additional areas; -Pertinent lab test results; -Rehabilitation follow up or potential; and, -Recapitulation of stay, specifically social service and activities. C. Staff interview The SSD was interviewed on 12/4/24 at 5:34 p.m. The SSD said she was unable to locate any care conference notes which documented discharge planning for Resident #8. The SSD said it was her responsibility to make sure the discharge process was completed.

Based on record review and interviews, the facility failed to manage pain in the manner consistent with professional standards of practice for one (#11) of four residents reviewed for pain out of 14 sample residents. Specifically, the facility failed to ensure Resident #11's pain was managed appropriately and consistently to meet the resident's stated level of acceptable pain. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, reviewed 9/5/24, was received from the nursing home administrator (NHA) on 12/4/24 at 1:01 p.m., read in pertinent part, Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. A resident will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. An individualized pain management care plan will be developed and initiated when pain indicators are identified. The care plan will be reviewed and revised by the interdisciplinary team (IDT) upon completion of each MDS (minimum data set) assessment and as needed. A pain goal is set; alert and oriented residents state an acceptable level of pain on an intensity scale where zero is no pain and ten is the worst pain imaginable, according to the Numeric Pain Intensity Scale rating from the Medication Administration Record (MAR) and a comprehensive pain management care plan is initiated and implemented based on initial and ongoing pain assessments. Approaches are modified as necessary. II. Resident #11 A. Resident status Resident #11, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included history of low back pain unspecified, polyneuropathy (a disease that damages the peripheral nerves, causing weakness, numbness, and burning pain), peripheral vascular disease (PVD) resulting in right lower extremity amputation below the knee secondary to a necrotic (dead tissue) wound with osteomyelitis (infection of bone tissue), phantom limb syndrome with pain (a condition where a person feels like an amputated limb is still there, and may experience pain or other sensations in that limb), limb ischemia (a condition that occurs when blood flow to an extremity is severely reduced or blocked, leading to pain, sores, and other complications), pain to an unspecified joint and pain to an unspecified hip. The 11/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was able to self-propel in his manual wheelchair and perform most activities of daily living independently. The MDS assessment documented the resident had pain almost constantly which affected his sleep and frequently affected his day to day activity. The resident received both scheduled and as needed (PRN) pain medications and non-pharmacological pain interventions. The MDS assessment indicated Resident #11's pain rating upon the completion of the assessment was a 10 on a numeric pain scale of 1-10. B. Resident interview Resident #11 was interviewed on 12/4/24 at 1:35 p.m. Resident #11 said his pain was not being controlled. He said he had been having increased pain to his left leg after a surgical procedure two weeks ago which involved a surgical incision from his left groin to his mid-calf. He said he would rate his pain level as a score of 37 if he could, but he said the pain scale only went to a 10. He said the facility finally increased his pain medication and his first dose of the new medication would be administered that evening (12/4/24). C. Record review Resident #11's quarterly pain assessment from 10/4/24 documented the resident's pain level was a 10 out of 10, generalized pain. The assessment indicated the resident's acceptable pain level was a 5 out of 10. -Review of Resident #11's electronic medical record (EMR) revealed there was no pain assessment documented upon the resident's readmission to the facility on [DATE]. The 11/20/24 care plan report identified Resident #11 had expressed pain/discomfort related to aftercare following surgical amputation of his right leg below the knee, back pain related to intervertebral disc disorders and left hip related to bursitis and polyneuropathy. The care plan indicate the resident's acceptable pain level goal was a 5 out of 10. Interventions included trying non-pharmacological interventions before offering medication, including rest, reposition, elevation, and distraction. -The care plan failed to include Resident #11's pain related to his post-operative surgical incision. Review of Resident #11's November 2024 CPO revealed the following physician's orders for pain management: Resident #11's pain level is assessed every shift (day and night). His acceptable level of pain is set at 5 out of 10 on the numeric scale (0-10). Pain locations include right below knee amputation, shoulders and back. Non-pharmacological interventions include rest, reposition, elevation and distraction. Do not rouse resident from sleep and do not exceed 3,000 mg (milligrams) of Tylenol in a 24-hour period, ordered 4/4/24. The physician's order for the daily pain assessments failed to include the resident's new location of pain to his left lower extremity. Lidocaine external gel 4%: apply to left lower extremity topically four times a day for acute on chronic pain, avoid incision; ordered 11/27/24 and discontinued on 11/29/24. Lidocaine external patch 4% (Lidocaine). Apply to the left lower extremity topically one time a day for pain and remove at bedtime, ordered 11/29/24. Lyrica oral capsule 75 mg (Pregabalin). Give one capsule by mouth three times a day for chronic pain, ordered 8/5/24. Robaxin 750 mg oral tablet (Methocarbamol). Give one tablet by mouth one time a day and at bedtime for pain, ordered 4/12/24. Tylenol oral tablet 325 mg (Acetaminophen). Give 650 mg by mouth four times a day for pain, ordered 8/28/24. Oxycodone HCl oral tablet 5 mg. Give one tablet every 8 hours for pain, ordered 5/29/24 and discontinued on 11/20/24. Xtampza ER (oxycodone) oral capsule 12-hour abuse deterrent 9 mg. Give one capsule by mouth every 12 hours for pain with a start date of 11/20/24. Oxycodone HCl oral tablet 2.5 mg every eight hours as needed for severe pain levels of 8 to 10, ordered 7/12/24 and discontinued on 11/15/24. Oxycodone HCl oral tablet 5 mg. Give one tablet by mouth every six hours as needed for moderate pain levels of 3 to 7. Give two tablets by mouth every six hours as needed for severe pain levels of 8 to 10, ordered 11/15/24. Order administration notes from the November 2024 and December 2024 medication administration records (MAR) for PRN (as needed) Oxycodone indicated the resident's acceptable pain level was 5 out of 10. An alert progress note from 11/19/24 at 12:45 p.m. documented Resident #11 refused wound care services from the wound doctor. He had received one Oxycodone 5 mg tablet PRN at 11:29 a.m. with no pain level indicated upon administration. His follow-up pain level at 2:20 p.m. was 6 out of 10 and the nurse documented the pain medication was effective. -Although the nurse documented the pain medication was effective, the resident's pain level was still above his stated acceptable pain level of 5 out of 10. An Oxycodone administration note in progress notes from 11/22/24 at 12:51 p.m. revealed the resident was unable to work with physical therapy (PT) due to a pain level of 10 out of 10 and facial grimacing. Review of Resident #11's November 2024 MAR revealed the following: On 11/16/24 at 10:17 a.m., the resident was administered one tablet of Oxycodone 5 mg PRN for a pain level of 9 out of 10. He refused to take two tablets due to fear of constipation. Upon reassessment for pain medication effectiveness at 12:30 p.m., almost two hours after the administration of the medication, Resident #11 rated his pain at an 8 out of 10. The nurse documented the intervention as ineffective. -However, there was no follow-up note indicating further intervention was attempted or that a physician was notified. On 11/17/24 at 9:38 a.m., the resident was administered two tablets of Oxycodone 5 mg PRN for a pain level of 9 out of 10. Upon reassessment for pain medication effectiveness at 12:17 p.m., almost three hours after the administration of the medication, Resident #11 rated his pain at an 8 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 8 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/19/24 at 11:29 a.m., the resident was administered one tablet of Oxycodone 5 mg PRN, his pain level and non-pharmacological interventions were not documented upon administration. Upon reassessment for pain medication effectiveness at 2:20 p.m., almost three hours after the administration of the medication, Resident #11 rated his pain level at 6 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 6 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/22/24 at 12:51 p.m., the resident was administered two tablets of Oxycodone 5 mg PRN for a pain level of 10 out of 10. Resident #11 was unable to participate with PT due to his pain and facial grimacing was observed in the note. Upon reassessment for pain medication effectiveness at 4:20 p.m., almost four hours after the administration of the medication, the resident rated his pain level at an 8 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 8 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/24/24 at 2:14 p.m., the resident was administered two tablets of Oxycodone 5 mg PRN for a pain level of 8 out of 10. Upon reassessment for pain medication effectiveness at 3:43 p.m., Resident #11 rated his pain level at 7 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 7 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/24/24 at 10:10 p.m., the resident was administered two tablets of Oxycodone 5 mg PRN for a pain level of 10 out of 10, the note stated that repositioning was ineffective. Upon reassessment for pain medication effectiveness at 11:43 p.m., Resident #11 rated his pain level at 6 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 6 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/27/24 at 9:05 a.m., the resident was administered one tablet of Oxycodone 5 mg PRN for a pain level of 8 out of 10. Upon reassessment for pain medication effectiveness at 11:56 a.m., almost three hours after the administration of the medication, Resident #11 rated his pain level at 8 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 8 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/28/24 at 8:20 a.m., the resident was administered one tablet of Oxycodone 5 mg PRN for a pain level of 7 out of 10. Upon reassessment for pain medication effectiveness at 11:13 a.m., almost three hours after the administration of the medication, Resident #11 rated his pain level at 7 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 7 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/28/24 at 9:49 p.m., the resident was administered two tablets of Oxycodone 5 mg PRN for a pain level of 10 out of 10. A progress note indicated that repositioning and distraction were ineffective. Upon reassessment for pain medication effectiveness at 10:51 p.m., Resident #11 rated his pain level at 6 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 6 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. On 11/30/24 at 3:10 p.m., the resident was administered two tablets of Oxycodone 5 mg PRN for a pain level of 10 out of 10. A progress note indicated that repositioning and distraction were ineffective. Upon reassessment for pain medication effectiveness at 4:46 p.m., Resident #11 rated his pain level at 7 out of 10. The nurse documented the pain medication was effective. -However, Resident #11's pain level of 7 out of 10 was still above the resident's stated acceptable pain level of 5 out of 10. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/4/24 at 1:50 p.m. LPN #1 said Resident #11 had a surgical procedure two weeks prior. She said despite medication changes made to the resident's pain regimen since his return to the facility, his pain had been difficult to manage. She said the physician increased his Xtampza from 9 mg every 12 hours to 12 mg every 12 hours on 12/4/24 (during the survey) and the facility was waiting for the new dose of the medication to arrive. The director of nursing (DON) was interviewed on 12/4/24 at 2:38 p.m. She said care plans for pain were reviewed with the IDT and suggestions were given. She said pain meetings began at the end of August 2024. The DON said at the meetings, the IDT evaluated residents' pain medications and MDS assessment pain levels, how often the residents' pain was being addressed and what was being done to treat residents' pain. The DON said pain assessments should be done upon admission and readmission, quarterly, every shift and with changes in condition. She said a pain assessment should have been completed for Resident #11 upon his readmission to the facility on [DATE].

Based on observations, record review and interviews, the facility failed to ensure that residents requiring treatments and services for mental disorders or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being for two (#2 and #4) of four residents reviewed out of 14 sample residents. Specifically, the facility failed to provide mental health counseling services for Resident #2 and Resident #4. Findings include: I. Facility policy and procedure The Behavioral Health Services policy, reviewed on 9/6/24, was received from the nursing home administrator (NHA) on 12/4/24 at 1:02 p.m. The policy read in pertinent part, The facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meets each resident's needs and includes individualized approaches to care. The nursing assessment and social services assessment are completed upon admission/readmission, quarterly and as needed with change of condition. Through this assessment, the facility should identify residents who develop decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, and may have made verbalizations indicating psychosocial adjustment difficulty. If a determined need is present, the facility should consult with the attending physician to make a referral to a mental health professional for assessment and potential for ongoing follow-up. The facility must determine through its facility assessment what types of behavioral health services it may be able to provide. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included opioid dependence, chronic pain syndrome, osteoarthritis (difficulty walking), depression and anxiety. The 10/22/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident had felt down, depressed or hopeless nearly every day over the seven day look back period. The resident had a score of 15 out of 27 on the Patient Health Questionnaire-9 (PHQ-9 - a screening tool used for depression), which indicated she had moderately severe depression. B. Observations On 12/3/24 at 8:15 a.m. Resident #2 was observed crying in her room alone. On 12/4/24 at 9:30 a.m. Resident #2 was in the hallway speaking to the social services director (SSD). The resident was crying as she spoke to the SSD. C. Resident interview Resident #2 was interviewed on 12/3/24 at 8:10 a.m. Resident #2 said she could not stop crying. Resident #2 said she had felt depressed ever since she was admitted to the facility because she felt like no one was listening to her when she had a complaint about her pain. Resident #2 said she had been asking for counseling services but she had not received any. Resident #2 said her depression had increased and she cried often. D. Record review Review of the behavior care plan, revised 11/1/24, revealed Resident #2 had a behavior problem including making false accusations and using profanity towards staff, manipulation and repeatedly asking for scheduled and PRN pain medications to be given together, related to panic and anxiety disorder. Interventions included assisting the resident to develop more appropriate methods of coping and interacting. A review of Resident #2's December 2024 CPO revealed a physician's order for a referral for mental health services, ordered 11/19/24. -Review of Resident #2's EMR failed to reveal documentation to indicate the resident had received any mental health services or refused when mental health services were offered to her. E. Staff interview The SSD was interviewed on 12/4/24 at 1:10 p.m. The SSD said Resident #2 was referred to a mental health services agency on 8/29/24 and Resident #2 refused. The SSD said she called the mental health services agency again on 9/27/24 and Resident #2 refused counseling services again. -However, there was no documentation in Resident #2's EMR to indicate counseling services had been offered and she refused (see record review above). 51916 III. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 CPO, diagnoses included major depressive disorder (MDD), recurrent, severe with psychotic symptoms, paranoid schizophrenia, insomnia, unspecified and cognitive communication deficit. The 9/26/24 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. The resident was independent with most activities of daily living (ADLs) requiring minimal assistance due to dizziness and gait imbalance. The MDS assessment indicated the resident had felt down, depressed or hopeless for half or more of the days over the seven day look back period. B. Resident interview Resident #4 was interviewed on 12/4/24 at 8:00 a.m. Resident #4 said he was having a hard time with his depression lately because his sister was actively dying and her prognosis was poor. The resident said he had not had counseling services for a while. He said he would like to have counseling services via telehealth (service provided through a video conference) as he did not want to leave the building. C. Record review A 9/26/24 psychosocial progress note documented Resident #4 had agreed to receive services from the new mental health services agency via telehealth. -However, there was no documentation in Resident #4's EMR to indicate the dates the resident received counseling services via telehealth between 9/26/24 and 12/4/24 or documentation to indicate the resident had refused counseling services (see SSD interview below). Review of Resident #4's December 2024 CPO revealed a physician's order for the resident to receive mental health services with the new agency, ordered 11/19/24. -However, there was no documentation in the resident's EMR to indicate the new mental health services agency had been contacted to begin providing counseling services for Resident #4. -There was no documentation in Resident #4's EMR to indicate the resident had refused counseling services. The trauma-informed care plan, revised 10/1/24, revealed Resident #4 required trauma-informed care due to having experienced several traumatic/stressful events throughout life, such as natural disaster, auto accident, exposure to a toxic substance, physical assault, assault with a weapon, sexual assault and a sudden accidental death. The resident would, at times, have repeated/disturbing/unwanted memories and dreams related to these events and feelings of the events happening again. He avoided memories related to the events and was jumpy/easily startled. Pertinent interventions include the SSD was to offer and arrange counseling services as tolerated (initiated 2/5/2020) and referral to a mental health services agency for counseling services (initiated 10/1/24). The pre-admission screening and resident review (PASRR) Level II care plan, revised 7/22/24, revealed Resident #4 had PASRR Level II with the primary diagnosis of paranoid schizophrenia as well as major depressive disorder, recurrent, severe with psychotic symptoms. Based on the PASRR Level II evaluation findings, it was recommended for Resident #4 to receive individual therapy three times a month. Pertinent interventions included providing ongoing documentation and evaluation of the resident's mood, the resident participating in treatments, cares, medication management and psychiatric stability and reporting significant changes to his physician, psychiatrist and PASSR,if necessary, for further evaluation. D. Staff interviews The SSD was interviewed on 12/4/24 at 11:50 a.m. The SSD said the facility's mental health services agency had recently changed. She said the previous mental health agency stopped providing services for the facility in June 2024 or July 2024, as the therapist had retired and there the agency did not have a replacement therapist. The SSD said the facility recently contracted with a new mental health services agency in September 2024. However, to this date Resident #4 and one other are the only ones that will start services. The SSD said she was unable to provide documentation of the dates Resident #4 was provided with counseling services. The director of nursing (DON) was interviewed on 12/4/24 at 12:06 p.m. The DON said Resident #4's first counseling session with the new mental health services contract agency was scheduled for tomorrow (12/5/24). She said it was the responsibility of the SSD to offer and arrange counseling services for residents. She said Resident #4 had a physician's order to receive counseling services that was obtained on 11/19/24. She said the SSD had called the mental health services agency back today (12/4/24) to follow up on the referral. The SSD was interviewed a second time on 12/4/24 at 1:10 p.m. The SSD said Resident #4 refused telehealth counseling services on 9/25/24. She said after talking to the new mental health agency (during the survey), she found out the agency had called Resident #4's private cell phone and he had declined their services on 9/25/24. She said she was not aware the company had contacted the resident and she had not followed up on the physician's referral for the resident to have counseling services.

Based on observations, interviews and record review, the facility failed to store, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure stored kitchen equipment were clean and sanitary; and, -Ensure systems were in place to prevent compromised food safety through proper staff training. Findings include: I. Failure to ensure stored kitchen equipment were clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Non food-contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues (Retrieved 10/5/23). B. Observations Observations on 9/24/23 at 2:45 p.m. revealed: -Three stacks of steam table pans on a shelf were wet in between the pans. -The green (vegetable) and red (meat) cutting boards were extremely scored. -The chrome kitchen shelving holding table pans, baking sheets and other equipment used to prepare and serve food, were covered with the accumulation of dust, dirt and debris. -Serving trays on the chrome kitchen shelves used to hold drinking cups for residents were covered in debris. Several cups were stacked directly on the chrome kitchen shelving. Observations on 9/25/23 at 9:01 a.m. revealed: -The chrome kitchen shelving holding table pans, baking sheets and other equipment used to prepare and serve food, was covered with the accumulation of dust, dirt and debris. -Serving trays on the chrome kitchen shelves used to hold drinking cups for residents were covered in debris. -The drawer in dining room containing resident drinking cups stacked together had debris and food residue. C. Staff interviews Dietary aide (DA) #2 was interviewed on 9/25/23 at 9:01 a.m. He stated the kitchen manager had been out on leave since 6/26/23 and the kitchen staff had not had a cleaning schedule since then. Kitchen shelving was part of the surfaces required to be cleaned by the kitchen staff. Steam table pans should be completely dry before stacking with no moisture. Cups should not be stacked directly on the chrome shelving and the trays the cups were stacked on should be clean. The dietary manager (DM) was interviewed on 9/25/23 at 9:45 a.m. The cutting boards had been replaced. He stated the cups in the drawer were for the staff to use when serving juice in the dining room. The kitchen staff and nursing staff were supposed to keep the drawer clean. He looked into the drawer and stated it was not clean. The clinical registered dietitian (CRD) was interviewed on 9/25/23 at 10:00 a.m. After inspecting the chrome kitchen shelving and trays used to hold drinking cups inside the kitchen, she stated the trays and shelving were not clean. Steam table pans should be completely dry before stacking with no moisture. Cups should not be stacked directly on the chrome shelving and the trays the cups were stacked on should be clean. She would provide records of staff training. The CRD was interviewed again on 9/25/23 at 3:09 p.m. She stated she was unable to locate staff training. II. Failure to ensure systems were in place to prevent compromised food safety through proper staff training. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The designated person in charge shall ensure that: -Food employees are properly trained in food safety. (Retrieved 10/5/23) B. Observations DA #1 was observed on 9/24/23 at 3:00 p.m. using the chlorine test strip that was used for the dishwasher on the red sanitation bucket. The reading on the strip was blank so DA #1 changed out the water and the solution. She did not retest. DA #3 was observed on 9/25/23 at 9:01 a.m. using the chlorine test strip that was used for the dishwasher on the red sanitation bucket. The reading on the strip was blank. The DM was observed on 9/25/23 at 9:30 a.m. He showed DA #3 the quat test strip for use with the sanitation concentration. C. Staff interviews DA #1 was interviewed on 9/24/23 at 3:00 p.m. After testing the sanitation concentration in the red sanitation bucket with the incorrect strip, she stated the bucket only had water in it and no chemical. She was not aware of the parts per million (ppm) that should be present in the concentration. DA #3 was interviewed on 9/25/23 at 9:01 a.m. After testing sanitation concentration in the red sanitation bucket with the incorrect strip, she could not explain why the strip was blank indicating no chemicals present. She was not aware of the ppm required in the concentration. The CRD was interviewed on 9/25/23 at 10:00 a.m. She said she would provide training records for the kitchen staff on sanitization. The CRD was interviewed again on 9/25/23 at 3:09 p.m. She stated she was unable to locate staff training. III. Facility follow-up The CRD provided staff inservice on 9/27/23 dated 9/27/23. The agenda for the inservice was as follows: -Air drying processes for preventing moisture on pans. -Usage of a drying rack in the dining room for the beverage station instead of placing cups inside the drawer. -Deep cleaning of racks, wall shelving, and floors to be added to the cleaning schedule. -Training for staff on how to use chemical concentration strips for dishwasher and sanitation buckets was not included.

Based on record review and interviews, the facility failed to ensure views, grievances and recommendations were considered for resident council members. Specifically, the facility failed to: -Effectively address, resolve and demonstrate the facility's response to grievances brought up in resident council; and, -Ensure resident council meetings were meeting the views and agendia desired by the resident council members. Findings include: I. Facility policy and procedure The Resident Council policy, revised 10/6/22, was provided by the nursing home administrator (NHA) on 9/26/23. It read it pertinent part, A resident group is defined as a group of residents that meet regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. The activities director or social services will facilitate follow up on all complaints, suggestions and ideas presented at the council meeting and will report results at the next meeting for the residents' information. This information will be included in the minutes. The activities director or social services will encourage maximum resident participation, leadership and development. Administrative policies, procedures and ideas will be presented to the council for discussion and approval. II. Resident interviews The resident council president, Resident #1, was interviewed on 9/27/23 at 2:50 p.m. She stated the resident council meeting did not provide relevant information for the residents attending. The department heads attended and went through what each department did and it sounded like the department heads were reading job descriptions. The same information was provided each meeting. If the residents had a grievance from the previous month, a resolution was not provided. Resident #4 was interviewed on 9/27/23 at 2:55 p.m. He stated the resident council meetings provided the residents with the same information each month and were repetitive. He stated some residents did not attend anymore because of this. III. Record review A review of the resident council meeting minutes dated 6/28/23 through 8/23/23 revealed the following: For all three months, the same information was provided for each department regarding qualifications, job duties, locations in the facility to find information and facility processes. A review of a resident council meeting minutes dated 7/26/23 revealed the only new information provided at the meeting was the facility had a performance improvement plan for showers, call lights and hydration. A concern was brought up regarding the facility serving too much chicken but no residents were identified. A review of a resident council meeting minutes dated 8/23/23 revealed new concerns brought up were residents wanting more trash cans with lids under the sinks and an unidentified resident was missing clothing. -There was no mention of the concern brought up in the previous meeting. A review of resident council grievances provided by the NHA on 9/27/23 at 3:10 p.m. revealed a resident grievance regarding a staff member which was not documented in the meeting minutes. -Grievances brought up in the months of July and August 2023 regarding too much chicken being served and needing trash cans did not have grievance forms completed. IV. Staff interviews The activities director (AD) was interviewed with the NHA on 9/27/23 at 2:00 p.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 NHA. The NHA would provide the grievance to the department manager responsible and would file the grievance after it was resolved. Grievances were reviewed every morning in the morning meeting to ensure the grievance was returned and resolved timely. The AD would provide the resident council with the resolution. The NHA stated after reading the resident council meeting minutes, the meeting minutes were repetitive and not reflective of residents' participation. She said she would complete an education with the AD on how to conduct resident council meetings and document. V. Facility follow-up The NHA provided resident council education conducted with the AD, undated, on 9/28/23 at 9:50 a.m. It read it pertinent part, Minutes should indicate interactions of residents in the resident council. Minutes should include follow-up of old business to include detailed information. Minutes should include details of new business and blue cards for concerns to be followed up. Minutes are to include the residents' interactions such as questions by resident and response from departments asked or follow-up. Included was the facility policy on Resident Council signed by the AD, undated.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews for four of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular inservice education based on the outcome of the reviews for CNA #1, #2, #3 and #4. Findings include: I. Record review CNA #1 (hired 9/27/22), CNA #2 (hired 1/31/22), CNA #3 (hired 9/18/2020) and CNA #4 (hired 12/26/2000) did not have an annual performance review completed. The CNAs did not have an inservice education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 9/27/23 at 10:40 a.m. She said the facility had not completed any annual performance reviews. She said the facility would develop a plan to complete the performance reviews going forward.

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. Specifically, the facility failed to develop a facility assessment which included staff education and staff competencies. Findings include: I. Facility assessment The facility assessment, provided by the nursing home administrator (NHA) on 9/25/23 at 12:40 p.m. had been updated on 2/13/23 and reviewed by the quality assurance performance improvement committee on 2/14/23. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population. The facility census and conditions provided on 9/25/23 identified the following: -Three catheters in the facility. -Four contractures. -Two pressure injuries. -14 residents receiving respiratory care. -One resident receiving suction. -Four residents receiving injections. II. Staff interviews The NHA was interviewed on 9/27/23 at 10:20 a.m. The NHA said the previous NHA and the interdisciplinary team developed the facility assessment. The NHA said she had not reviewed the facility assessment since starting a couple of months previously. The NHA reviewed the facility assessment and said the assessment did not have specific training staff needed to help the residents at the facility. She said the facility assessment should reflect the needs of the residents. The NHA said the interdisciplinary team and herself would review the facility assessment and create a new one. The NHA said the current facility assessment was missing staff training and competencies necessary for the care of the residents and would be updated to ensure the training and education programs would cover the residents' needs.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#4, #24, #16 and #12) of six residents reviewed for vaccinations out of 18 sample residents. Specifically, the facility failed to ensure Residents #4, #24, #16 and #12 were offered and/or received pneumococcal immunization. Findings include: I. Professional reference According to Center for Disease Control and Prevention, reviewed 11/21/22, retrieved on 2/14/23 from https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged [AGE] years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October. Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present. Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March. According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2023, retrieved on 2/13/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part, The pneumococcal vaccine was to be administered to immunocompetent adults aged [AGE] years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals age 19-[AGE] years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23. II. Facility policy The Resident Vaccine policy, revised 12/1/22, was provided by the nursing home administrator (NHA) on 9/28/23 at 11:48 a.m. the policy included, The facility must develop policies and procedures to ensure that - 1. Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization. 2. Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. 3. The resident or the resident's representative has the opportunity to refuse immunization; and the resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. On admission the facility should determine the vaccination history of the resident and if the the resident has previously been vaccinated with one or both of the Pneumococcal vaccines. If the resident has previously received one or the other vaccine prior to admission or after admission, the facility should consult with the primary provider to determine if a second vaccination is needed and which vaccine that should be. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. III. Residents A. Resident #4, age under [AGE] years was admitted on [DATE]. The medical record revealed the resident had received the first dose of his pneumococcal vaccination 6/8/22 and his pneumococcal vaccination was not up-to-date. According to the minimum data set (MDS) dated [DATE], the resident's influenza and pneumococcal vaccines were up to date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine after 6/8/22. B. Resident #24, age [AGE] years was admitted on [DATE]. The medical record revealed the resident had received the first dose of his pneumococcal vaccination outside of the facility on 9/21/21 and his pneumococcal vaccination was not up-to-date. According to the MDS dated [DATE], the resident's influenza and pneumococcal vaccines were up to date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine after admission. C. Resident #16, age 84 was admitted on [DATE]. The medical record revealed the resident had received the first dose of his pneumococcal vaccination on 6/27/19 his pneumococcal vaccination was not up-to-date. According to the MDS dated [DATE], the resident had refused the influenza vaccine and pneumococcal vaccine was up to date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine after 6/27/19. D. Resident #12 Resident #12, age under [AGE] years was admitted on [DATE]. The medical record failed to reveal the resident had received or refused her pneumococcal vaccination. According to the MDS dated [DATE], the resident had received the influenza vaccine outside of the facility and pneumococcal vaccine was up to date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Interview The director of nursing (DON) was interviewed on 9/26/23 at 4:15 p.m. with the clinical nurse consultant (CNR) present. The DON stated residents were offered immunizations at admission. The residents identified (see above) were reviewed by the DON and the CNR. The residents did not have consents or refusals on file. The residents had not been offered the vaccines yearly. The DON said the facility would work with the provider and ensure residents were up to date or had received education regarding refusals.

Based on interviews and record review, the facility failed to ensure one (#17) out of 18 sample residents were kept free from sexual abuse. Specifically, the facility failed to prevent sexual abuse to Resident #17 from Resident #16. Findings include: I. Facility policy and procedure The Abuse Policy, reviewed 7/18/23, provided by the nursing home administrator (NHA) on 9/25/23 at 12:40 p.m., included in part: It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Procedure: Establishing a safe environment that supports, to the extent possible, a resident's consentual sexual relationship and by establishing policies and protocols for preventing sexual abuse. II. Witnessed incident on 8/12/23 A. Resident #16 progress note On 8/12/23 at 5:05 a.m. the progress note documented, Resident found in roommates bed touching roommate inappropriately. Taken back to his own bed. B. Resident #17 progress note On 8/12/23 at 11:41p.m. the progress note documented, Late entry for 8/12/23 at 5:10 a.m. Checked on resident after CNA (certified nurse aide) reported roommate had been lying in his bed and touching him inappropriately. Resident was visibly upset. Voicing concerns about episode that just happened. No apparent injury noted. Call made to the director of nursing (DON) at 6:36 a.m. Message left to return the call. C. Facility investigation The facility investigation was reviewed on 9/26/23. The investigation included: On 8/12/23 at 8:43 a.m. it was reported to the nursing home administrator (NHA) that at 5:05 a.m. the CNA heard the victim (Resident #17) shouting for help. When the CNA entered the room, the alleged assailant (Resident #16) was found in the victim's bed inappropriately touching the victim's intimate parts. Immediate actions taken by the facility: The alleged assailant (Resident #16) was moved to a private room, a one to one (1:1) sitter was assigned during investigation. The victims (Resident #17) skin assessment was at baseline, no injuries (found) related to this event. The victim (Resident #17) verbalized he is not fearful. The facility summary of the investigation included: The victim (Resident #17) stated that the alleged assailant (Resident #16) got into his bed and was touching his intimate parts. III. Resident #16 A. Resident status Resident #16, over the age of 80, was admitted on [DATE]. According to the September 2023 computerized physicians orders (CPO), diagnoses included Alzheimer's disease and dementia. The 8/1/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired and unable to complete a brief interview for mental status (BIMS). He displayed physical behavioral symptoms one time and other behavioral symptoms not directed toward others one time during the assessment period. B. Record review The care plan, initiated 8/12/23, identified Resident #16 would at times exhibit sexual behaviors. Interventions included: -Medication review as needed. -Offer a body pillow. -Offer counseling. -Psychological consult as needed. -Resident placed in an independent room. IV. Resident #17 A. Resident status Resident #17, over the age of 80, was admitted on [DATE]. According to the September 2023 computerized physicians orders (CPO), diagnoses included cellulitis and osteomyelitis. The 8/4/23 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He displayed no behaviors during the assessment period. V. Interviews CNA #1 was interviewed on 9/26/23 at 9:15 a.m. She said Resident #16 did not display sexual behaviors. She said she knew he was inappropriate with Resident #17 once and had a room change and medication change after that episode. She said he did not have another episode after the incident with Resident #17. The NHA was interviewed on 9/26/23 at 11:00 a.m. She said she was the abuse coordinator. She said she was informed by the DON of the incident between Resident #16 and Resident #17. She said Resident #16 was removed to a single room and immediately put on a one-to-one staff supervision. She said she started interviewing staff about the situation. She said a skin and pain assessment was completed on Resident #17. She said the facility called the provider for a medication review for Resident #16 and received a referral for psychiatric services. She said the necessary notifications were made. She said the incident was substantiated. She stated the facility had been sending out referrals for Resident #16 to be transferred to a more appropriate facility, however, all the facilities stated they were not accepting new admissions at the time. She said the room change and medication changes helped Resident #16's behavior and he had not climbed into another resident's bed.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for two (#4 and #11) of 12 residents reviewed for activities of daily living (ADL) of 18 sample residents. Specifically, the facility failed revised the ADL care plan to include person-centered, resident-specific refusal of bathing/showers for Residdent #4 amd Resident #11. Findings include: I. Resident #4 A. Resident status Resident #4, age under [AGE] years, was admitted on [DATE]. According to the September 2023 CPO, the diagnoses included paranoid schizophrenia, and chronic fatigue. The 9/1/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident did not have behaviors of rejecting evaluations or care. The resident was independent in his ADLs, only requiring set up and supervision with bathing. B. Record review The comprehensive care plan, revised on 3/19/19, revealed the resident had an ADL self care deficit related to diagnosis of schizophrenia, impaired balance, and limited mobility. Interventions included to provide extensive assistance with transferring into the shower room. The resident could shower with staff supervision in the shower room. His preferred shower days on Mondays, Wednesdays and as necessary. -The care plan did not reveal the resident's staff preferences, the reason for the preference or approaches to use. CNA task follow up reports for bathing from 7/1/23 through 9/27/23 provided by the NHA on 9/29/23 at 5:30 p.m. revealed: For the month of July 2023, the resident received six showers and refused twelve. For the month of August 2023, the resident received five showers and refused eight. For the month of September 2023, the resident received seven showers and refused three. Progress notes reviewed from 7/1/23 to 9/28/23 revealed: -Alert note dated 7/12/23 documented the nurse spoke to the resident regarding his refusal to take a shower. The resident told the nurse he would take one the following day. The refusal had been passed on to the CNA. -Health status note dated 7/16/23 documented the nurse spoke to the resident regarding his refusal to shower. Alternative staff offered and the resident declined. -Alert note dated 7/19/23 documented the resident continued to refuse to take a shower and staff were to monitor him. -Alert note dated 7/26/23 documented the resident refused his shower stating he felt too weak. -Alert note dated 8/9/23 documented the resident declined a shower. -Alert note dated 8/17/23 documented the resident had refused his shower the prior evening and wanted to take a shower in the morning. -Alert note dated 8/20/23 documented the nurse spoke with the resident regarding his refusals to shower. The resident explained he felt uncomfortable with younger CNAs giving him showers and would feel more comfortable with someone his own age. He expressed he was shy and did not like young girls showering him. The nurse informed him there were no CNAs his age and offered him a bed bath. The resident stated he would consider it. The resident was approached later on and refused. -No additional documentation in the resident's progress notes pertaining to refusals to shower, accommodations for his preference for an older CNA to shower him or follow-up from the director of nursing (DON) regarding the continued refusals. C. Staff interviews CNA #1 was interviewed on 9/24/23 at 1:39 p.m. Resident #4 did not have behaviors of refusing care. Licensed practical nurse (LPN) #3 was interviewed on 9/25/23 at 10:05 a.m. LPN #3 stated Resident #4 wanted things to be as he expected, very routine and structured. He would refuse showers at times if not meeting his routine. LPN #2 was interviewed on 9/28/23 at 10:40 a.m. Resident #4 would refuse showers if he could not have a certain staff member showering him. The resident's shower schedule had been modified around the preferred CNAs schedule. LPN #2 did not know why the resident preferred this particular staff member. CNA #6 was interviewed on 9/28/23 at 11:00 a.m. Resident #4 had refused showers but no longer refused as long as he could have his preferred staff member showering him. The DON was interviewed on 9/28/23 at 11:56 a.m. Residents were scheduled for showers twice a week according to the resident's preferred days of the week. It was identified in March 2023 preferences and schedules were not being put into the care plans and CNA tasks properly and it had been corrected. Resident care plans were updated to reflect the resident's shower schedule and preferences. Preferences like staff gender or if a particular staff member was preferred (without using the staff's name) were to be identified in the resident's care plan under interventions. The CNAs and nurses were using bathing sheets to document baths/showers, refusals, and approaches. If a resident refused, the staff should re-approach twice and if unsuccessful, the nurse should approach the resident. Nurses were to document in the progress notes alternatives offered (bed baths, different staff) and document refusals. If the resident continued to refuse, the nurse needed to notify the DON. Resident #4 had behaviors of refusing showers unless certain staff offered. His shower days were scheduled around the schedule of the CNA he was comfortable receiving showers from and this preference should be in the resident's care plan. 31820 II. Resident #11 A. Resident status Resident #11, over the age of 80, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included dementia, cognitive deficit and difficulty walking. The 4/17/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with no brief interview for mental status (BIMS) completed. The MDS assessment identified the resident needed extensive assistance with personal hygiene. Bathing did not occur. The resident had no behaviors of refusing care. B. Record review -Review of the comprehesive care plan revealed the ADL care plan failed to include his refusal of baths/showers and approaches to encouragements to achieve the bath/shower (see staff interviews). C. Staff nterviews CNA #4 was interviewed on 9/27/23 at 3:30 p.m. She said when a resident refused a shower she would re-approach on a few. If the resident continued to refuse, she would report the refusal to the nurse. She said the nurse would talk to the resident as well as therapy. She said if the resident continues to refuse, the director of nursing (DON) would get involved. Licensed practical nurse (LPN) #3 was interviewed on 9/27/23 at 3:45 p.m. She said Resident #11 had several refusals. She said sometimes she would tell Resident #11 that he would get a cold beer after the shower. She said that would work sometimes. She said he was difficult to get into the shower. She said he refused often. She said she would write a progress note after several attempts have failed. The DON was interviewed on 9/28/23 at 11:56 a.m. She said Resident #11 isolated himself in his room often. She said if he refused she wanted staff to offer him a beer afterward to help encourage him. She said there should have been a care plan with person centered approaches for Resident #11.

Based on record review and interviews, the facility failed to ensure 12 hour in-service training for certified nurse aides (CNAs). Specifically, the facility failed to ensure CNAs received 12 hours annually training for two of five CNAs. Findings include: I. Training review Five CNAs were reviewed for the annual required 12 hours training. Training records revealed CNA #2 (hired 1/31/22) and CNA #3 (hired 9/18/2020) of the five CNAs reviewed did not have the required 12 hour annual training. II. Interview The director of nursing (DON) was interviewed on 9/27/23 at 10:40 a.m. She said she was not aware there were CNAs that did not have the 12 hours required annual training. She said the required 12 annual training included continuing education and changes. She said systems would be improved to ensure CNA training was completed as required.

Based on observations, interviews and record review, the facility failed to keep one of eight sample residents (#1) free from physical abuse and/or mistreatment. Specifically, the facility physically restrained the resident in order to deliver medication and perform treatments. Staff members failed to recognize this action as abusive, failed to report it, failed to investigate it and failed to intervene. Repeat incidents occurred, contributing to resident #1 emotional distress and psychological decline. Cross-reference F155, F222, F225, F319, F490 and F501. The findings include: I. Immediate Jeopardy A. Failure Record review revealed the facility physically restrained resident #1 in order to deliver medication and perform treatments. Staff members failed to recognize this action as abusive, failed to report it, failed to investigate it and failed to intervene. Repeat incidents occurred, contributing to resident #1 emotional distress and psychological decline. The facility's failures above created a situation of immediate jeopardy for serious harm. B. Imposition of Immediate Jeopardy On 8/21/13 at 4:15 p.m., the facility was notified by the Health Facilities and Emergency Medical Service Division (HFEMSD) of the State Health Department that the failure to protect resident #1 from physical and emotional abuse created a situation of Immediate Jeopardy for serious potential harm. On 8/22/13 at 3:42 p.m., the facility presented a revised plan to HFEMSD to remove the Immediate Jeopardy situation. The plan implemented by the facility concurrently, included the following: August 21, 2013 The following is a plan of abatement for (name of facility), dated 8/21/13 regarding alleged immediate jeopardy F223 and F225 involving one resident (name) and how the facility will safeguard all other residents. The definition of abuse is defined by the State of Colorado as: 'Any occurrence involving physical abuse of a patient or resident, as described in section 18-3-202, 18-3-203, and 18-3-204..C.R.S. by another patient or resident, an employee of the facility, or a visitor to the facility." 25-1-124 (d) C.R.S. 2 Elements are Needed: -Intent OR knowingly OR recklessly -Bodily injury and/or serious bodily injury -and/or Unreasonable confinement or restraint (26-3.1-101 (4)(a)(11) C.R.S. Note: serious bodily injury is defined as "bodily injury, which involved a substantial risk of death, a substantial risk of serious permanent disfigurement, or a substantial risk of protracted loss or impairment of any part of organ of the body." 18-1-901 (3)(p). C.R.S. The facility must conduct a preliminary investigation to determine if the elements of abuse are present. If the injury could be the result of abuse, and the facility is unable to rule out abuse, the incident must be reported. Below is a summary of action items the facility has taken to abate the immediate jeopardy: -On 8/21/13 at approximately 5:25 p.m. the Director of Nursing and Executive Director were both suspended and the facility oversight and management is now directed by the Regional and Divisional teams of the company until further notice. -All current in house residents, 8/21/13, will be interviewed to determine if anyone has experienced abuse or is fearful of abuse. -All staff currently on duty on the evening shift on 8/21/13 will be inserviced on what is abuse, how to report alleged abuse and to report alleged abuse immediately to their direct supervisor, including regional and divisional staff and the importance of investigating all alleged/potential abuse. -All remaining nursing staff will be inserviced prior to their next shift on abuse. -Staff on vacation and PRN staff will be contacted and inserviced on abuse, prior to working their next shift. -Nursing staff on the evening shift on 8/21/13 were provided contact information for the Regional and Divisional teams. -The Regional Director of Clinical Services will remain onsite for the completion of the abatement plan until totally implemented. -System Change - The nurse/supervisor contacts the DON/Executive Director/Regional Director of Clinical Services/Divisional Director of Clinical Services and they will direct the investigation. All suspected abuse allegations will be reported to the State Health Department within 24 hours and the investigation will be completed and submitted within 5 days. -Nurse/supervisor will attempt to determine if there is an alleged assailant, if none can be identified at the time, the investigation serves as a protective measure for the resident(s). -If an alleged assailant can be identified, then that individual is suspended if it is an associate or asked to leave if it is a visitor, if it is a resident then the nurse must protect the other residents (i.e. 1:1 or separate). -The nurse/supervisor will initiate interviews of the incident (it is imperative that nursing does not investigate nursing). -In the absence of witnesses to the incident, "Incident Data Archive interview statements" should be initiated. a. Remember these are each person's individual statement, it is not an interview, allow each person to express themselves without being guided. -The individual directing the investigation should begin completing the 'Facility Abuse Investigation form." -The person directing the investigation (will) not only take statements from individuals, but (be expected) to conduct a focused interview with them as well. -Once the investigation data collection has been completed, the interdisciplinary team comprised of the Executive Director, Director of Nursing and Social Services at a minimum, will review the data and together attempt to determine cause of the abuse/injury. The conclusion of the investigation will be documented on the abuse investigation form and may be shared with the state health department and local law enforcement. -Documents associated with the investigation will be maintained in a file in the Executive Director's office. C. Removal of Immediate Jeopardy On 8/22/13 at approximately 3:45 p.m., the facility was informed that Immediate Jeopardy was removed based on the review and the facility's implementation of their plan as described above. After the removal of Immediate Jeopardy, deficient practice remained at a G level, representing actual harm that is isolated. II. Failure to Keep Resident #1 Free From Abuse A. Facility Policy The facility policy, titled "Protection from Abuse" last revised 6/17/08, read in pertinent part: -All residents in the facility are to be free from verbal, physical and mental abuse. -The social services are bound by acceptable standards of practice to intervene when abuse is suspected. -All allegations of abuse are reported immediately to the executive director. The facility policy for "Reporting Alleged Abuse" no date read in pertinent part: -This facility does not condone resident abuse and/or neglect by anyone. -The person observing an incident of resident abuse or suspecting resident abuse will immediately report such incidents to their immediate supervisor and the charge nurse. Facility policy defined 'Abuse' as verbal, sexual, physical, and mental abuse, neglect, corporal punishment, and involuntary seclusion. B. Resident #1 Resident #1, age 79, was admitted to the facility on [DATE] with diagnoses including [MEDICAL CONDITIONS], diabetes and major depressive affective disorder, severe degree and specified as with psychotic behaviors. The resident also had a [DIAGNOSES REDACTED]. 1. Resident Status a. Minimum Data Set (MDS) According to the resident's 8/6/13 quarterly MDS, resident #1 had a BIMS (cognitive status) score of 9, indicating she was moderately cognitively impaired. Her mood assessment noted she had "little interest or pleasure in doing things," was "feeling down, depressed or hopeless," Her mood severity score was noted as 2, indicating depression. She had no physical behavioral symptoms; however, she rejected cares 1 of 3 days in the reporting period. -She needed extensive assist for activities of daily living and limited assist with ambulation. She had a urinary catheter. -She was receiving scheduled pain medication, anti-depressant and anti-anxiety scheduled medications. Triggered care areas included psychosocial well-being, [MEDICAL CONDITION] drug use, pain, and cognitive/dementia issues. b. Physician Orders The computerized physician orders [REDACTED]. The resident's ancillary orders included to check the resident's oxygen level if she complains of shortness of breath, give nebulizer treatment. If still having symptoms and oxygen reading is greater than 92% give sublingual [MEDICATION NAME]. The resident's oxygen orders read as follows: oxygen at 1.5 liters per nasal cannula. Record review revealed the resident had a urinary catheter for [MEDICAL CONDITION] bladder that was inserted on 11/9/12 and changed monthly per the physician orders. c. Care plan Review of the resident's comprehensive care plan revealed the care plan included plans for behaviors and activities. -The behavior care plan (dated 11/9/12 - no updates) documented the resident struggled to accept the fact that she could no longer be at home with significant other. Approaches included administering and observing the effectiveness of medications as ordered; staff to anticipate the resident's needs before she got stressed; educate on the casual factors of behavior and planned intervention and investigate/observe the need for psychiatric support. -The resident's activities care plan (updated 8/14/13) read the resident was put on 1:1 monitoring for suicide watch. Approaches included in pertinent part, room and clothing searches, and the removal of cords and potentially harmful objects. 2. Resident Interview and Observations Resident #1 was interviewed in her room on 8/20/13 beginning at 10:15 a.m. She said she had no choices regarding her health care, life and routine in the facility, but whatever they did for her was fine. She said nothing mattered to her since her husband was terminal. At approximately 10:20 a.m. the facility charge nurse and a facility certified nurse aide (CNA) entered the room to assist the resident out of bed. -The resident began crying and became extremely agitated. The resident was observed to look frightened and her speech became very rapid. The resident was observed to become short of breath as she accused staff of taking her to the hospital for not taking her medicine. The resident sobbed and requested her oxygen be turned up. The resident stated to the charge nurse, "I always take my medicine when I am supposing to, just like you (pointing at the nurse) tell me to. You sent me to the hospital because you want me to go away to the state hospital." The nurse aide did not respond to the resident. The staff nurse offered the resident medication and re-assured that is not why the resident was sent to the emergency room . -The resident then stopped sobbing and became calm. Staff assisted her in getting out of bed. The resident then leaned in toward the surveyor and said, "They are all lying don't believe them," looking toward the staff in the room. Resident #1 was interviewed again when she approached the surveyor in the hallway by the dining room on 8/20/13 at approximately 11:30 a.m. The resident said, "You still want talk to me." Asked if there was anything she would like to add, she said, "Only that I am going to die soon." The resident began sobbing and said she wanted to go to her room. Resident #1 was interviewed a third time at 3:45 p.m. on 8/20/13. She said, spontaneously, that she always took the medications the facility gave her. She said she had bad breathing problems and hurt. 3. Resident Complaint Review of a "Concern and Comment" form dated 6/2013, submitted by the resident to facility administration, was reviewed. The form included the resident's name and read, "I want the DON (Director of Nurses) and staff nurses to stop holding me down and forcing medicine in my mouth and not replacing my catheter." 4. Record review and Interview - Failure to Report and Prevent Potential Abuse and/or Mistreatment of [REDACTED]. Review of witness statements, progress notes, type-written statements, and interview with the Social Services Director (SSD) revealed observed incidents on 5/5/13, 5/31/13, 6/1/13, 6/10/13 when staff held the resident down and attempted to replace the resident's urinary catheter and/or administer medications in the presence of the resident's expressed refusals and resistance. None of these incidents were reported or comprehensively investigated as possible abuse and/or mistreatment. a. 5/5/13 The social services director (SSD) was interviewed on 8/22/13 at approximately 3:51 p.m. She said she observed the resident exhibiting behaviors on 5/5/13 while the nurses were working with her in her room; the resident had pulled out her catheter and was having a psychotic episode. The SSD said, "I watched the nurses trying to put liquid medicine in her mouth for chest pain. The medication was [MEDICATION NAME]. The DON (director of nurses) held her legs down while she was trying to re-connect the urinary catheter. The SSD said she is aware of resident rights, specifically the right to refuse treatment or medication, as well as the obligation to report suspected abuse. The SSD said she did not report her observations to anyone in the facility. The SSD stated that she did not think the nurse's actions were abusive; the resident had a history of [REDACTED]. b. 5/31/13 On 5/31/13 at 4:14 p.m., review of nurses' notes revealed the resident was sent to the hospital for evaluation of behaviors and was working herself into a 'maniac moment.' Review of witness statements and a SSD progress note dated 5/31/13 revealed the following documentation about the events preceding the resident's transfer. Witness Statement #1, dated 5/31/13, and signed by a facility nurse read in pertinent part: The resident was observed by the nurse at approximately 8:45 a.m., attempting to pull out her urinary catheter and having increased agitation and verbally yelling, "I just want to die." The facility DON and SSD were asked to come to the resident's room to assist the nurse. After the arrival of the DON and SSD, the DON held the resident's legs down. Another staff nurse was asked to fill the [MEDICATION NAME] in the syringe and squirt in the resident's mouth. The resident then spit the medication out and all over the nursing staff. Witness statement #2, dated 5/31/13 at 2:30 p.m. and signed by a facility nurse, read in pertinent part: The nurse was informed through verbal communication from the previous shift that the resident was agitated and had pulled her urinary catheter out and the DON was in the room with another nurse replacing the catheter. The DON asked the nurse when she entered the resident's room to call the doctor and get a stat (immediate) order for [MEDICATION NAME] (antipsychotic) IM (intramuscular injection). Review of a progress note, dated 5/31/13 at 4:19 p.m. and signed by the SSD, read in pertinent part: When arriving to work the SSD went directly into (resident #1's) room after receiving verbal information from other staff members that the resident had refused all medications, pulled out her urinary catheter and remov(ed) her oxygen. The SSD documented that she would like to see the resident evaluated by a psychiatrist and that it was time to discharge the resident to another facility to pursue furthering the resident's mental health needs. Neither the 5/31/13 witness statements above nor the 5/31/13 SSD progress note revealed the events above were reported as potential abuse and/or mistreatment to anyone in the facility. c. 6/1/13 A type-written plain piece of copy paper dated 6/1/13 and not signed by the author, a facility staff nurse identified by the name typed on the document, read in pertinent part: The nurse entered the resident's room and the resident was observed to be combative and pulling the urinary catheter out yelling, 'I just want to die.' The DON re-inflated the balloon (on the catheter) and reinserted the urinary catheter while the resident was yelling. The author of the document indicated that the resident was flailing and attempting to throw herself off the bed and the nurse put her knee on the edge of the mattress to keep the resident from hurting the nurse. Neither of the type-written statements by staff above revealed the events 6/1/13 were reported as potential abuse and/or mistreatment to anyone in the facility. d. 6/10/13 Witness statement #3, dated 6/10/13 at 10:00 a.m. and signed by a facility nursing aide, documented in pertinent part: When she entered resident #1's room, the nursing staff was positioned with one on each side of the bed. The DON was observed holding the resident's arms down and attempting to give her medication while the resident was turning her head and spitting out the medication. The witness statement by the nursing aide did not indicate the observations were reported as potential abuse and/or mistreatment to anyone in the facility. 5. Resident's Current Status Observations of the resident's status on 8/19/13 conflicted with documentation regarding the resident's behavior, although generally consistent with an emergency department report later that evening. a. Observations 8/19/13 -At approximately 9:00 a.m. the resident was observed sleeping in her bed. The resident was observed in no acute distress. The oxygen was applied to her nasal area per provider order. No signs or symptoms of [MEDICAL CONDITION] or behaviors were observed. -At approximately 11:00 a.m., the resident was observed sitting in her wheelchair in the hallway by the facility cafe socializing with another resident. No symptoms of [MEDICAL CONDITION] or behaviors were observed. -At approximately 4:45 p.m. the resident was observed sitting in her wheelchair in her room and was in no acute distress. -At 5:00 p.m. the resident was observed assisted to the dining room for the dinner meal. The staff was observed providing full assist with locomotion of the resident's wheelchair. b. Record Review and Interview Review of nurses' notes revealed documentation at 2:54 p.m. that read, "(Resident #1) is having [MEDICAL CONDITION] and psychotic behaviors. She is hitting herself and has bruising on her chest and a skin tear to the right wrist." She verbalized she wanted to die and was going to kill herself multiple times." A telephone order was obtained at 2:54 p.m. to give the resident [MEDICATION NAME] 0.5 mg p.o. if resident has no effect from current dose. Sixteen minutes later, at 3:10 p.m., another telephone order was received for [MEDICATION NAME] 1 mg orally "now" for agitation. In an interview with the SSD on 8/22/13 at approximately 3:51 p.m. revealed the resident was in the shower in the morning and stated that she wanted to die. The resident then began to play her history back and then had meltdown, and grabbed the shower head and tried to get the hose and tried to choke herself. Review of nurses' notes revealed the resident returned to the facility on [DATE] at 10:10 p.m., three hours after displaying behaviors and requiring multiple telephone orders for a controlled anti-anxiety medication (see above). The resident was diagnosed with [REDACTED]. There was no [DIAGNOSES REDACTED]. 6. Cross reference F225 - Failure to Report and Thoroughly Investigate Potential Abuse and/or Mistreatment. a. See above resident complaint documented on the facility "Concern and Comment" form dated 6/2013 regarding forced medications and treatments. Per documentation submitted by the Nursing Home Administrator (NHA) while interviewed on 8/21/13 at approximately 2:33 p.m., the NHA replied to the resident using a document titled, "Facility investigation and Response." This document was undated and read, "all statements were consistent, Resident was upset and trying to pull catheter out. Resident also resisted taking medication, but several nurses tried. Talked with resident." The investigations of the above incidents were not thorough. Specifically, the investigations, kept in a folder labeled "[MEDICATION NAME]," included only the witness statements above, taken on the day of the incidents; no further investigations were conducted. The investigation of the above incidents did not include steps to prevent the resident from further incidents of abuse and/or mistreatment. Specifically, there was no documentation that staff members involved in the incidents were suspended during the investigation or educated about resident rights and caring for residents with behavioral symptoms. There was no evidence the incidents 5/5/13, 5/31/13, 6/1/13 and 6/10/13 were reported to the State or to the facility's corporate office. 7. Staff Interviews The DON was unavailable for interview 8/19/13 - 8/22/13. She was no longer present at the facility. Interview with a facility staff nurse on 8/20/13 at approximately 10:00 a.m. revealed resident #1 was not hard to re-direct. The nurse re-directed the resident by taking her hand and holding it then sitting down beside her and talking or listening to the resident. However, she said some nurses medicate the resident by putting the [MEDICATION NAME] in the resident's nebulizer treatment and telling the resident it was to help her with her breathing. The nurse said she does not do that as the resident usually does not need to be medicated. She was not aware of any reports of alleged or suspected abuse and said she had not made any such reports regarding what she knew about resident #1 and staff interactions. Interview with the NHA on 8/21/13 at 2:33 p.m. revealed she was aware of resident's concerns with forced medications and reinsertion of her catheter. The NHA said she had not reported the complaint to the State or the facility's corporate regional nurse consultant (CRNC). Interview with the CRNC on 8/21/13 at 2:03 p.m. revealed the facility should have reported the alleged abuse and/or mistreatment to the State and to the corporate office. The CRNC said it is not acceptable to restrain anyone to give medications or treatments. The CRNC said the DON named in the incidents (see above) as holding a resident down to administer meds, that are not court ordered, should not be currently working in the facility. Interview with the medical director on 8/24/13 at approximately 10:00 a.m. revealed he was not aware of any abuse investigation related to allegations of abuse and physical restraint by the facility staff.

Based on interviews and record review, the facility failed to thoroughly investigate and report to appropriate authorities a complaint by one of eight sample residents (#1) alleging physical abuse. Cross-reference F223; abuse. The facility physically restrained resident #1 in order to deliver medication and perform treatments. Staff members failed to recognize this action as abusive, failed to report it, failed to investigate it and failed to intervene. Repeat incidents occurred, contributing to resident #1's emotional distress and psychological decline. The findings include: I. Immediate Jeopardy A. Failure Record review revealed the facility physically restrained resident #1 in order to deliver medication and perform treatments. Staff members failed to recognize this action as abusive, failed to report it, failed to investigate it and failed to intervene. Repeat incidents occurred, contributing to resident #1's emotional distress and psychological decline. The facility's failures above created a situation of immediate jeopardy for serious harm. B. Imposition of Immediate Jeopardy On 8/21/13 at 4:15 p.m., the facility was notified by the Health Facilities and Emergency Medical Service Division (HFEMSD) of the State Health Department that the failure to protect resident #1 from physical and emotional abuse created a situation of Immediate Jeopardy for serious potential harm. On 8/22/13 at 3:42 p.m., the facility presented a revised plan to HFEMSD to remove the Immediate Jeopardy situation. The plan implemented by the facility concurrently, included the following: August 21, 2013 The following is a plan of abatement for (name of facility), dated 8/21/13 regarding alleged immediate jeopardy F223 and F225 involving one resident (name) and how the facility will safeguard all other residents. The definition of abuse is defined by the State of Colorado as: 'Any occurrence involving physical abuse of a patient or resident, as described in section 18-3-202, 18-3-203, and 18-3-204..C.R.S. by another patient or resident, an employee of the facility, or a visitor to the facility.' 25-1-124 (d) C.R.S. 2 Elements are Needed: -Intent OR knowingly OR recklessly -Bodily injury and/or serious bodily injury -and/or Unreasonable confinement or restraint (26-3.1-101 (4)(a)(11) C.R.S. Note: serious bodily injury is defined as "bodily injury, which involved a substantial risk of death, a substantial risk of serious permanent disfigurement, or a substantial risk of protracted loss or impairment of any part of organ of the body." 18-1-901 (3)(p). C.R.S. The facility must conduct a preliminary investigation to determine if the elements of abuse are present. If the injury could be the result of abuse, and the facility is unable to rule out abuse, the incident must be reported. Below is a summary of action items the facility has taken to abate the immediate jeopardy: -On 8/21/13 at approximately 5:25 p.m. the Director of Nursing and Executive Director were both suspended and the facility oversight and management is now directed by the Regional and Divisional teams of the company until further notice. -All current in house residents, 8/21/13, will be interviewed to determine if anyone has experienced abuse or is fearful of abuse. -All staff currently on duty on the evening shift on 8/21/13 will be inserviced on what is abuse, how to report alleged abuse and to report alleged abuse immediately to their direct supervisor, including regional and divisional staff and the importance of investigating all alleged/potential abuse. -All remaining nursing staff will be inserviced prior to their next shift on abuse. -Staff on vacation and PRN staff will be contacted and inserviced on abuse, prior to working their next shift. -Nursing staff on the evening shift on 8/21/13 were provided contact information for the Regional and Divisional teams. -The Regional Director of Clinical Services will remain onsite for the completion of the abatement plan until totally implemented. -System Change - The nurse/supervisor contacts the DON/Executive Director/Regional Director of Clinical Services/Divisional Director of Clinical Services and they will direct the investigation. All suspected abuse allegations will be reported to the State Health Department within 24 hours and the investigation will be completed and submitted within 5 days. -Nurse/supervisor will attempt to determine if there is an alleged assailant, if none can be identified at the time, the investigation serves as a protective measure for the resident(s). -If an alleged assailant can be identified, then that individual is suspended if it is an associate or asked to leave if it is a visitor, if it is a resident then the nurse must protect the other residents (i.e. 1:1 or separate). -The nurse/supervisor will initiate interviews of the incident (it is imperative that nursing does not investigate nursing). -In the absence of witnesses to the incident, "Incident Data Archive interview statements" should be initiated. a. Remember these are each person's individual statement, it is not an interview, allow each person to express themselves without being guided. -The individual directing the investigation should begin completing the 'Facility Abuse Investigation form." -The person directing the investigation (will) not only take statements from individuals, but (be expected) to conduct a focused interview with them as well. -Once the investigation data collection has been completed, the interdisciplinary team comprised of the Executive Director, Director of Nursing and Social Services at a minimum, will review the data and together attempt to determine cause of the abuse/injury. The conclusion of the investigation will be documented on the abuse investigation form and may be shared with the state health department and local law enforcement. -Documents associated with the investigation will be maintained in a file in the Executive Director's office. C. Removal of Immediate Jeopardy On 8/22/13 at approximately 3:45 p.m., the facility was informed that Immediate Jeopardy was removed based on the review and the facility's implementation of their plan as described above. After the removal of Immediate Jeopardy, deficient practice remained at a G level, representing actual harm that is isolated. II. Facility Failure to Thoroughly Investigate and Report a Complaint of Abuse. A. Facility Policy The facility policy regarding the investigation and reporting of alleged abuse (undated) read in pertinent part: -All reports of abuse will be promptly investigated. -The investigation will include a written summary including a review of the incident, an interview with the person reporting the abuse, interview with the witness, a review for the resident's medical record and a review of the employee files named in the incident. -If the accused individual is an employee they will be placed on suspension pending the investigation. -The person investigating the alleged abuse will keep the resident informed of the progress of the investigation. -Federal requirements mandate that facilities must ensure all allegations of abuse are reported immediately to their state survey agencies. -Facilities must satisfy the federal requirement to report the results of an investigation within 5 working days from the date of the incident. Any report after that time will be considered out of compliance. B. Facility corporate policy regarding abuse The Corporate Regional Nurse Consultant (CRNC) was interviewed on 8/21/13 at 2:03 p.m. -The CRNC said the corporate policy for abuse complaints is as follows: Once the facility does an investigation, the Nursing Home Administrator (NHA) along with the clinical team develop a plan of action to keep the residents safe and free from abuse. The NHA should take direction in developing questions and in dispersing and assigning the team to go throughout the facility and get information. When the information comes back it is reviewed by the Social Services Director (SSD). After the NHA reviews the information, witness statements, and interviews, the NHA should document a summary statement prior to closing out the case. -The CRNC said it is not "okay" to sign off on a complaint involving resident abuse and not report it to the corporate office. The NHA is supposed to fill out a corporation document showing that staff was suspended and forward to corporate human resources, documenting that the staff member is suspended without pay. The CRNC said in most cases all staff named in the complaint are suspended until the investigation is complete. C. Resident #1 (Cross-reference F223) Resident #1, age 79, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had a [DIAGNOSES REDACTED]. 1. Resident Status a. Minimum Data Set (MDS) According to the resident's 8/6/13 quarterly Minimum Data Set (MDS), resident #1 had a BIMS (cognitive status) score of 9, indicating she was moderately cognitively impaired. Her mood assessment noted she had "little interest or pleasure in doing things," was "feeling down, depressed or hopeless," Her mood severity score was noted as 2, indicating depression. She had no physical behavioral symptoms; however, she rejected cares 1 of 3 days in the reporting period. -She needed extensive assist for activities of daily living and limited assist with ambulation. She had a urinary catheter. -She was receiving scheduled pain medication, anti-depressant and anti-anxiety scheduled medications. Triggered care areas included psychosocial well-being, [MEDICAL CONDITION] drug use, pain, and cognitive/dementia issues. b. Physician Orders The computerized physician orders [REDACTED]. The resident's ancillary orders included to check the resident's oxygen level if she complains of shortness of breath, give nebulizer treatment. If still having symptoms and oxygen reading is greater than 92% give sublingual [MEDICATION NAME]. The oxygen orders read: Oxygen 1.5 liters via nasal cannula continuous. Record review revealed the resident had a urinary catheter for the [MEDICAL CONDITION] bladder that was inserted on 11/9/12 and changed monthly per the physician orders. c. Care plan Review of the resident's comprehensive care plan revealed the care plan included plans for behaviors and activities. -The behavior care plan (dated 11/9/12 - no updates) documented the resident struggled to accept the fact that she could no longer be at home with significant other. Approaches included administering and observing the effectiveness of medications as ordered; staff to anticipate the resident's needs before she got stressed; educate on the casual factors of behavior and planned intervention and investigate/observe the need for psychiatric support. -The resident's activities care plan (updated 8/14/13) read the resident was put on 1:1 monitoring for suicide watch. Approaches included in pertinent part, room and clothing searches, and the removal of cords and potentially harmful objects. 2. Resident Complaint Review of a "Concern and Comment" form dated 6/2013 submitted by the resident to facility administration was reviewed. The form included the resident's name and read, "I want the DON (director of nursing) and staff nurses to stop holding me down and forcing medicine in my mouth and not replacing my catheter." 3. Record review and Interview - Observed Incidents of Physical Abuse Review of witness statements, progress notes, type-written statements, and interview with the Social Services Director (SSD) revealed observed incidents on 5/5/13, 5/31/13, 6/1/13, 6/10/13 when staff held the resident down and attempted to replace the resident's urinary catheter and/or administer medications in the presence of the resident's express refusals and resistance. a. 5/5/13 The social services director (SSD) was interviewed on 8/22/13 at approximately 3:51 p.m. She said she observed the resident exhibiting behaviors on 5/5/13 while the nurses were working with her in her room; the resident had pulled out her catheter and was having a psychotic episode. The SSD said, "I watched the nurses trying to put liquid medicine in her mouth for chest pain. The medication was [MEDICATION NAME]. The DON (director of nurses) held her legs down while she was trying to re-connect the urinary catheter." The SSD said she is aware of resident rights, specifically the right to refuse treatment or medication, as well as the obligation to report suspected abuse. The SSD said she did not report her observations to anyone in the facility. The SSD stated that she did not think the nurse's actions were abusive; the resident had a history of [REDACTED]. b. 5/31/13 On 5/31/13 at 4:14 p.m., review of nurses' notes revealed the resident was sent to the hospital for evaluation of behaviors and was working herself into a 'maniac moment.' Review of witness statements and a SSD progress note dated 5/31/13 revealed the following documentation about the events preceding the resident's transfer: Witness Statement #1, dated 5/31/13, and signed by a facility nurse read in pertinent part: The resident was observed by the nurse at approximately 8:45 a.m., attempting to pull out her urinary catheter and having increased agitation and verbally yelling, "I just want to die." The facility DON and SSD were asked to come to the resident's room to assist the nurse. After the arrival of the DON and SSD, the DON held the resident's legs down. Another staff nurse was asked to fill the [MEDICATION NAME] in the syringe and squirt in the resident's mouth. The resident then spit the medication out and all over the nursing staff. Witness statement #2, dated 5/31/13 at 2:30 p.m. and signed by a facility nurse, read in pertinent part: The nurse was informed through verbal communication from the previous shift that the resident was agitated and had pulled her urinary catheter out and the DON was in the room with another nurse replacing the catheter. The DON asked the nurse when she entered the resident's room to call the doctor and get a stat (immediate) order for [MEDICATION NAME] (antipsychotic) IM (intramuscular injection). Review of a progress note, dated 5/31/13 at 4:19 p.m. and signed by the SSD, read in pertinent part: When arriving to work the SSD went directly into (resident #1's) room after receiving verbal information from other staff members that the resident had refused all medications, pulled out her urinary catheter and removed her oxygen. The SSD documented that she would like to see the resident evaluated by a psychiatrist and that it was time to discharge the resident to another facility to pursue furthering the resident's mental health needs. c. 6/1/13 A type-written plain piece of copy paper dated 6/1/13 and not signed by the author, a facility staff nurse identified by the name typed on the document, read in pertinent part: The nurse entered the resident's room and the resident was observed to be combative and pulling the urinary catheter out yelling, 'I just want to die.' The DON re-inflated the balloon (on the catheter) and reinserted the urinary catheter while the resident was yelling. The author of the document indicated that the resident was flailing and attempting to throw herself off the bed and the nurse put her knee on the edge of the mattress to keep the resident from hurting the nurse. d. 6/10/13 Witness statement #3, dated 6/10/13 at 10:00 a.m. and signed by a facility nursing aide, documented in pertinent part: When she entered resident #1's room, the nursing staff was positioned with one on each side of the bed. The DON was observed holding the resident's arms down and attempting to give her medication while the resident was turning her head and spitting out the medication. 4. Resident Observations and Interviews Resident #1 was interviewed in her room on 8/20/13 beginning at 10:15 a.m. She said she had no choices regarding her health care, life and routine in the facility, but whatever they did for her was fine. She said nothing mattered to her since her husband was terminal. At approximately 10:20 a.m. the facility charge nurse and a facility certified nurse aide (CNA) entered the room to assist the resident out of bed. -The resident began crying and became extremely agitated. The resident sobbed and requested her oxygen be turned up. The resident stated to the charge nurse, " I always take my medicine when I am supposing to, just like you (pointing at the nurse) tell me to. You sent me to the hospital because you want me to go away to the state hospital." The nurse's aide did not respond to the resident. The staff nurse offered the resident medication and re-assured that is not why the resident was sent to the emergency room . -The resident then stopped sobbing and became calm. Staff assisted her in getting out of bed. The resident then leaned in toward the surveyor and said, "They are all lying don't believe them," looking toward the staff in the room. Resident #1 was interviewed again when she approached the surveyor in the hallway by the dining room on 8/20/13 at approximately 11:30 a.m. The resident said, "You still want talk to me." Asked if there was anything she would like to add, she said, "Only that I am going to die soon." The resident began sobbing and said she wanted to go to her room. Resident #1 was interviewed again at 3:45 p.m. on 8/20/13. She said, spontaneously, that she always took the medications the facility gave her. She said she had bad breathing problems and hurt. 5. Failures in Facility's Response to Resident #1's 6/2013 Complaint of Abuse Review of the facility's documentation investigating resident #1's complaint (see above) and staff and corporate interviews revealed the facility failed to thoroughly investigate and report the resident's complaint of abuse. a. The NHA was interviewed on 8/21/13 at approximately 2:33 p.m. The interview revealed the following: -The NHA was aware of resident #1's concerns of abuse and forced medication by the facility staff in June 2013. The NHA said the incident and witness statements (see above) were kept in a folder labeled "[MEDICATION NAME]." -The NHA had not reported the alleged abuse to the state health department, the local authorities or the CRNC as required by state law, federal regulations and facility policy. -The entire investigation of resident #1's complaint was on the comment card. The documentation that was returned to the resident read, "All statements were consistent, Resident was upset and trying to pull catheter out. Resident also resisted taking medication, but several nurses tried. I talked with resident." This was the end of the facility's investigation. The witness statements were obtained on the day of the incident(s) and the NHA did not feel the need to investigate further. -There were no suspensions or counseling with any of the staff including the DON and the other staff involved in the documented incidents (see above). -No report of the resident's complaint was made to the corporate office and neither an incident report nor a summary of the investigation was completed as outlined in corporate policy. b. The CRNC was interviewed on 8/21/13 at 2:03 p.m. after reviewing the incidents for the resident contained in the folder marked "[MEDICATION NAME]." -The CRNC said it was not acceptable to restrain anyone to give medications or treatments and State guidelines required the incidents in the file be reported to the State and corporate office. -The CRNC said the time frame for reporting was two hours and the facility had 24 hours to complete their investigation and make proper notification to law enforcement and the State. The CRNC said this was not done. -The CRNC said the facility did not comply with corporate policy (see above) for reporting, investigating, and suspending staff involved in an allegation of abuse. c. The DON was unavailable for interview 8/19/13 - 8/22/13. She was no longer present at the facility. d. The facility Medical Director was interviewed on 8/24/13 at approximately 10:00 a.m. and he was not aware of any abuse investigation related to allegations of abuse and physical restraint by facility staff.

Based on observations, interviews and record reviews the facility failed to honor one of eight sample residents (#1) right to refuse treatment and medications. Specifically: The facility failed to obtain the resident's consent for medications and physical restraints for resident #1 in order to deliver medication as well as perform treatments. Repeat incidents occurred, contributing to resident #1's emotional distress and psychological decline. Cross-reference F223 The findings include: A. Facility Expectations A facility document called resident rights and posted throughout the facility read in part: -Our residents are our highest priority and all residents will be treated with kindness, respect and dignity. -Federal and state laws guarantee certain rights to all residents of this facility. -The facility will make effort to assist each resident in exercising his/rights. -Each staff member has the duty to read and learn the resident's rights and violations of any resident's rights may result in disciplinary action. B. Resident #1 Resident #1, age 79, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was her own responsible party per the face sheet documentation on the admission page dated 11/9/12. 1. Resident Status a. Minimum Data Set (MDS) According to the resident's 8/6/13 quarterly MDS, resident #1 had a BIMS (cognitive status) score of 9, indicating she was moderately cognitively impaired. Her mood assessment noted she had "little interest or pleasure in doing things," was "feeling down, depressed or hopeless." Her mood severity score was noted as 2, indicating depression. She had no physical behavioral symptoms; however, she rejected cares 1 of 3 days in the reporting period. -She needed extensive assist for activities of daily living and limited assist with ambulation. She had a urinary catheter. -She was receiving scheduled pain medication, anti-depressant and anti-anxiety scheduled medications. Triggered care areas included psychosocial well-being, [MEDICAL CONDITION] drug use, pain, and cognitive/dementia issues. b. Physician Orders The computerized physician orders [REDACTED]. The resident's ancillary orders included to check the resident's oxygen level if she complains of shortness of breath, give nebulizer treatment. If still having symptoms and oxygen reading is greater than 92% give sublingual [MEDICATION NAME]. Oxygen 1.5 liters via nasal cannula continually. Record review revealed the resident had a urinary catheter for the [MEDICAL CONDITION] bladder that was inserted on 11/9/12 and changed monthly per the physician orders. c. Care plan Review of the resident's comprehensive care plan revealed the care plan included plans for behaviors and activities. -The behavior care plan (dated 11/9/12 - no updates) documented the resident struggled to accept the fact that she could no longer be at home with significant other. Approaches included administering and observing the effectiveness of medications as ordered; staff to anticipate the resident's needs before she got stressed; educate on the casual factors of behavior and planned intervention and investigate/observe the need for psychiatric support. -The resident's activities care plan (updated 8/14/13) read the resident was put on 1:1 monitoring for suicide watch. Approaches included in pertinent part, room and clothing searches, and the removal of cords and potentially harmful objects. d. Consent forms The resident's 'Psychoactive Medication Informed Consent,' dated 11/10/12 for the use of an anti-depressant medication was not consented to for use by the resident who signed the document but did not indicate consent or the date. No consents were in the medical record for the use of the current medications in the classes of anti-psychotic, anti-anxiety and anti-depressant medications as ordered in the CPO. No documentation was provided by the facility that indicated the resident/family was provided and educated with information about the psychopharmacological medications the resident was receiving, such as the side effects of the medications, the indication for use of the medications, the expected time frame of use and the expected outcome. 2. Resident Complaint Review of a "Concern and Comment" form dated 6/2013 submitted by the resident to facility administration was reviewed. The form included the resident's name and read, "I want the DON (director of nursing) and staff nurses to stop holding me down and forcing medicine in my mouth and not replacing my catheter." 3. Record Review and Interview - Observed Incidents of Medications and Treatment against the Resident's Refusals and Resistance Review of witness statements, progress notes, type-written statements, and interview with the Social Services Director (SSD) revealed observed incidents on 5/5/13, 5/31/13, 6/1/13, 6/10/13 when staff held the resident down and attempted to replace the resident's urinary catheter and/or administer medications in the presence of the resident's express refusals and resistance. a. 5/5/13 The social services director (SSD) was interviewed on 8/22/13 at approximately 3:51 p.m. She said she observed the resident exhibiting behaviors on 5/5/13 while the nurses were working with her in her room; the resident had pulled out her catheter and was having a psychotic episode. The SSD said, "I watched the nurses trying to put liquid medicine in her mouth for chest pain. The medication was [MEDICATION NAME]. The DON held her legs down while she was trying to re-connect the urinary catheter. b. 5/31/13 On 5/31/13 at 4:14 p.m., review of nurses' notes revealed the resident was sent to the hospital for evaluation of behaviors and was working herself into a 'maniac moment.' Review of witness statements and a SSD progress note dated 5/31/13 revealed the following documentation about the events preceding the resident's transfer: Witness Statement #1, dated 5/31/13, and signed by a facility nurse read in pertinent part: The resident was observed by the nurse at approximately 8:45 a.m., attempting to pull out her urinary catheter and having increased agitation and verbally yelling, "I just want to die." The facility DON and SSD were asked to come to the resident's room to assist the nurse. After the arrival of the DON and SSD, the DON held the resident's legs down. Another staff nurse was asked to fill the [MEDICATION NAME] in the syringe and squirt in the resident's mouth. The resident then spit the medication out and all over the nursing staff. Witness Statement #2, dated 5/31/13 at 2:30 p.m., and signed by a facility nurse, read in pertinent part: The nurse was informed through verbal communication from the previous shift that the resident was agitated and had pulled her urinary catheter out and the DON was in the room with another nurse replacing the catheter. The DON asked the nurse when she entered the resident's room to call the doctor and get a stat (immediate) order for [MEDICATION NAME] (antipsychotic) IM (intramuscular injection). Review of a progress note, dated 5/31/13 at 4:19 p.m. and signed by the SSD, read in pertinent part: When arriving to work the SSD went directly into (resident #1's) room after receiving verbal information from other staff members that the resident had refused all medications, pulled out her urinary catheter and removed her oxygen. c. 6/1/13 A type-written plain piece of copy paper dated 6/1/13 and not signed by the author, a facility staff nurse identified by the name typed on the document, read in pertinent part: The nurse entered the resident's room and the resident was observed to be combative and pulling the urinary catheter out yelling, 'I just want to die.' The DON re-inflated the balloon (on the catheter) and reinserted the urinary catheter while the resident was yelling. d. 6/10/13 Witness Statement #3, dated 6/10/13 at 10:00 a.m., and signed by a facility nursing aide, documented in pertinent part: When she entered resident #1's room, the nursing staff was positioned with one on each side of the bed. The DON was observed holding the resident's arms down and attempting to give her medication while the resident was turning her head and spitting out the medication. 4. Resident Observations and Interview Resident #1 was interviewed in her room on 8/20/13 beginning at 10:15 a.m. She said she had no choices regarding her health care, life and routine in the facility, but whatever they did for her was fine. She said nothing mattered to her since her husband was terminal. At approximately 10:20 a.m., the facility charge nurse and a facility certified nurse aide (CNA) entered the room to assist the resident out of bed. -The resident began crying and became extremely agitated. The resident was observed to look frightened and her speech became very rapid. The resident was observed to become short of breath as she accused staff of taking her to the hospital for not taking her medicine. The resident sobbed and requested her oxygen be turned up. The resident stated to the charge nurse, "I always take my medicine when I am supposing to, just like you (pointing at the nurse) tell me to. You sent me to the hospital because you want me to go away to the state hospital." The nurse aide did not respond to the resident. -The staff nurse offered the resident medication and re-assured her that was not why the resident was sent to the emergency room . The resident sobbed and requested her oxygen be turned up. -The resident then stopped sobbing and became calm. Staff assisted her in getting out of bed. The resident then leaned in toward the surveyor and said, "They are all lying don't believe them," looking toward the staff in the room. Resident #1 was interviewed again at 3:45 p.m. on 8/20/13. She said, spontaneously, that she always took the medications the facility gave her. She said she had bad breathing problems and hurt. 5. Staff Interviews a. The SSD was interview on 8/22/13 at 3:51 p.m. The SSD said she is aware of resident rights, specifically the right to refuse treatment or medication. However, she did not report her observations (see above) to anyone in the facility. b. A facility staff nurse was interviewed on 8/20/13 at approximately 10:00 a.m. -She said the resident was not hard to re-direct. The nurse re-directed the resident by taking her hand and holding it then sitting down beside her and talking or listening to the resident. -She said some nurses medicate the resident by putting the [MEDICATION NAME] in the resident's nebulizer treatment and telling the resident it was to help her with her breathing. She said she doesn't do that as the resident usually does not need to be medicated. -She said she is aware of the resident right to refuse medications or treatments. c. The DON was unavailable for interview 8/19/13 - 8/22/13. She was no longer present at the facility. d. The unit medication nurse was interviewed on 8/21/13 at 3:14 p.m. The nurse stated: -If a resident refuses a medication, the nurse would note it by circling the medication on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. -Resident #1 declines by not responding to you and when she does that, they would mark declined. Resident #1 had declined medication about once a month and usually it is due to her sleeping; when she wakes up, she asks for her medication. She stated that if residents were refusing medications, nurses need to find other ways or just have to wait it out. She said she could go to her charge nurse to see what to do to keep them calm but usually it was a waiting thing. -Resident #1 was usually given [MEDICATION NAME] for pain and she accepted that fine. However, the resident was under the impression that the [MEDICATION NAME] ([MEDICATION NAME]) was bad for her because it made her feel weird and she thought staff were trying to poison her. The nurse stated there was no reason to have the [MEDICATION NAME] because the resident did not want it, but she knew some nurses were still giving the [MEDICATION NAME] to the resident by putting it in her nebulizer treatments. She said she did not do this. -Last time (8/19/13 when resident #1 refused medication and treatment), they had to send her to the emergency room . The physician wanted them to give her [MEDICATION NAME], but she sat one-on-one with the resident in the shower room and calmed her down. -If the resident was trying to pull her catheter out, she said they would try to take it out. The only time she would replace the catheter would be after the resident had calmed down, and she would never have anyone hold her down for that.

Based on interview and record review, the facility failed to keep sample resident #1 free from chemical restraint. Specifically, the facility medicated the resident without any medical symptoms in order to address the resident's resistance to medication and treatments. This contributed to resident #1's emotional distress and psychological decline. Cross-reference F155, F223, F501. The findings include: Resident #1, age 79, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Resident status Minimum Data Set (MDS): According to the resident's 8/6/13 quarterly MDS, resident #1 had a BIMS (cognitive status) score of 9, indicating she was moderately cognitively impaired. -Her mood assessment noted she had "little interest or pleasure in doing things;" was "feeling down, depressed or hopeless," Her mood severity score was noted as 2. She had no physical behavioral symptoms. -She rejected cares 1 of 3 days in the reporting period. -She needed extensive assist for activities of daily living and limited assist with ambulation. -She was receiving scheduled pain medication, anti-depressant and anti-anxiety scheduled medications. -Triggered care areas included psychosocial well-being, the use of [MEDICAL CONDITION] drugs and cognitive/dementia issues. Orders: The computerized physician orders [REDACTED]. Ancillary orders under the section of oxygen in the CPO indicated that if the resident complained of shortness of breath, the nursing staff was to check the resident's pulse oximetry or oxygen levels. If the resident's oxygen level was below 92%, the resident was to have her oxygen increased. If the resident complained of shortness of breath the facility was to give her a nebulizer treatment then re-check the oxygen level. If the oxygen level was 92 or greater, and the resident still complained of shortness of breath then give [MEDICATION NAME] sublingual. Care plan: Review of the resident's comprehensive care plan revealed the care plan included plans for behaviors and activities. -The behavior care plan (dated 11/9/12 - no updates) documented the resident struggled to accept the fact that she could no longer be at home with significant other. Approaches included administering and observing the effectiveness of medications as ordered; staff to anticipate the resident's needs before she got stressed; educate on the casual factors of behavior and planned intervention and investigate/observe the need for psychiatric support. -The resident's activities care plan (updated 8/14/13) read the resident was put on 1:1 monitoring for suicide watch. Approaches included in pertinent part, room and clothing searches, and the removal of cords and potentially harmful objects." -The resident had no care plan for the use of as needed medications. (See above orders for as needed [MEDICATION NAME] sulfate) 2. Resident Complaint Review of a "Concern and Comment" form dated 6/2013 submitted by the resident to facility administration was reviewed. The form included the resident's name and read in pertinent part, "I want the DON (director of nursing) and staff nurses to stop holding me down and forcing medicine in my mouth ... " 3. Record Review and Interview a. Review of witness statements, progress notes, type-written statements, and interview with the Social Services Director (SSD) revealed observed incidents on 5/5/13, 5/31/13, and 6/10/13, when staff held the resident down and attempted to administer medications to address the resident's resistance to medication and treatments. 5/5/13: The social services director (SSD) was interviewed on 8/22/13 at approximately 3:51 p.m. She said she observed the resident exhibiting behaviors on 5/5/13 while the nurses were working with her in her room; the resident had pulled out her catheter and was having a psychotic episode. The SSD said, "I watched the nurses trying to put liquid medicine in her mouth for chest pain. The medication was [MEDICATION NAME]. The DON held her legs down while she was trying to re-connect the urinary catheter. There was no indication from the SSD that the resident was short of breath or experiencing chest pain to explain the administration of [MEDICATION NAME]. 5/31/13: On 5/31/13 at 4:14 p.m., review of nurses' notes revealed the resident was sent to the hospital for evaluation of behaviors and was working herself into a 'maniac moment.' Review of witness statements and a SSD progress note dated 5/31/13 revealed the following documentation about the events preceding the resident's transfer. Witness Statement #1, dated 5/31/13, and signed by a facility nurse read in pertinent part: The resident was observed by the nurse at approximately 8:45 a.m., attempting to pull out her urinary catheter and having increased agitation and verbally yelling, "I just want to die." The facility DON and SSD were asked to come to the resident's room to assist the nurse. After the arrival of the DON and SSD, the DON held the resident's legs down. Another staff nurse was asked to fill the [MEDICATION NAME] in the syringe and squirt in the resident's mouth. The resident then spit the medication out and all over the nursing staff. Witness Statement #2, dated 5/31/13 at 2:30 p.m., and signed by a facility nurse, read in pertinent part: The nurse was informed through verbal communication from the previous shift that the resident was agitated and had pulled her urinary catheter out and the DON was in the room with another nurse replacing the catheter. The DON asked the nurse when she entered the resident's room to call the doctor and get a stat (immediate) order for [MEDICATION NAME] (antipsychotic) IM (intramuscular injection). Review of a progress note, dated 5/31/13 at 4:19 p.m. and signed by the SSD, read in pertinent part: When arriving to work the SSD went directly into (resident #1's) room after receiving verbal information from other staff members that the resident had refused all medications, pulled out her urinary catheter and removed her oxygen. There was no documentation in the documentation above that the resident was experiencing chest pain or shortness of breath when staff attempted to administer the [MEDICATION NAME] above. Moreover, there was no indication that the resident's behaviors, while resistive, presented risk for serious harm when the [MEDICATION NAME] order was requested. There was no documentation in the progress notes explaining why staff believed the resident was experiencing a psychotic episode with her statement "I just want to die." 6/10/13: Witness Statement #3, dated 6/10/13 at 10:00 a.m., and signed by a facility nursing aide, documented in pertinent part: When she entered resident #1's room, the nursing staff was positioned with one on each side of the bed. The DON was observed holding the resident's arms down and attempting to give her medication while the resident was turning her head and spitting out the medication. Neither the above statement nor progress notes identified the medication staff was attempting to administer against the resident's refusal. 8/19/13: Interview with the SSD on 8/22/13 at approximately 3:51 p.m. revealed the resident was in the shower in the morning and stated that she wanted to die. The resident then began to play her history back and then had meltdown, and grabbed the shower head and tried to get the hose and tried to choke herself. A nurses' note on 8/19/13 at 7:13 p.m., "this nurse contacted doctor and received order for [MEDICATION NAME] 1mg- an anti- anxiety medication because the resident stated she wanted to die." b. Review of facility narcotic count sheets for the months of May 2013, June 2013, July 2013 and August 2013 revealed the administration of [MEDICATION NAME] to resident #1. May 2013 During the month of May, the resident received [MEDICATION NAME] 0.5ml for shortness of breath six times. No breathing assessments were documented in the nursing notes pre and post medication as ordered by the physician. There was no documentation in the resident's medical record that the resident was having increased difficulty with shortness of breath and that this information was conveyed to the medical provider. The resident's [MEDICATION NAME] count was adjusted by a facility nurse. The previous count of [MEDICATION NAME] on 5/22/13 was 15.57 ml and on 5/31/13 (see above incident regarding the resident forced medications via a syringe) the narcotic count was adjusted by .75mls of [MEDICATION NAME] by a facility nurse. The nurse did not get a second witness to the wasting of the medication. June 2013 The resident received four additional doses of [MEDICATION NAME] for shortness of breath. The resident's medical record contained no nursing documentation of an assessment done on the resident for shortness of breath. There was no documentation regarding the effectiveness of the medication on the resident's shortness of breath. July 2013 The resident received [MEDICATION NAME] sulfate 0.5ml with syringe via the nebulizer indicated for shortness of breath nine times in the month of July 2013. The same nurse signed out and administered seven of the nine doses to the resident for shortness of breath. There were no assessments as ordered by the physician for shortness of breath or effectiveness of the use of the medication. August 2013 The resident received [MEDICATION NAME] sulfate 0.5ml with syringe via the nebulizer indicated for shortness of breath three times in the month of August 2013. c. Performance Improvement (PI) committee meeting minutes documented: -For June 2013 - a topic that was re-addressed was the inappropriate use and indications of resident medications. -For July 2013 - the topics included chemical restraints and incidents. 4. Resident Interview and Observations Resident #1 was interviewed in her room on 8/20/13 beginning at 10:15 a.m. She said she had no choices regarding her health care, life and routine in the facility, but whatever they did for her was fine. She said nothing mattered to her since her husband was terminal. At approximately 10:20 a.m. the facility charge nurse and a facility certified nurse aide (CNA) entered the room to assist the resident out of bed. -The resident began crying and became extremely agitated. The resident was observed to look frightened and her speech became very rapid. The resident was observed to become short of breath as she accused staff of taking her to the hospital for not taking her medicine. The resident sobbed and requested her oxygen be turned up. The resident stated to the charge nurse, "I always take my medicine when I am supposing to, just like you (pointing at the nurse) tell me to. You sent me to the hospital because you want me to go away to the state hospital." The nurse aide did not respond to the resident. -The staff nurse offered the resident medication and re-assured her that was not why the resident was sent to the emergency room . The resident sobbed and requested her oxygen be turned up. The resident stated to the charge nurse, "I always take my medicine when I am supposing to, just like you (pointing at the nurse) tell me to. You sent me to the hospital because you want me to go away to the state hospital." -The resident then stopped sobbing and became calm. Staff assisted her in getting out of bed. The resident then leaned in toward the surveyor and said, "They are all lying don't believe them," looking toward the staff in the room. Resident #1 was interviewed again when she approached the surveyor in the hallway by the dining room on 8/20/13 at approximately 11:30 a.m. The resident said, "You still want talk to me." Asked if there was anything she would like to add, she said, "Only that I am going to die soon." The resident began sobbing and said she wanted to go to her room. Resident #1 was interviewed a third time on 8/20/13 at 3:45 p.m. on 8/20/13. She said, spontaneously, that she always took the medications the facility gave her. She said she had bad breathing problems and hurt. 5. Interviews On 8/22/13 at approximately 4:45 p.m. an interview was conducted with the facility charge nurse. The nurse said resident #1's [MEDICATION NAME] use was for shortness of breath. The nurse stated some nurses put the [MEDICATION NAME] in the resident's breathing treatment and don't tell her and the reason they do this is because it calms the resident down. The nurse further stated that most of the time the resident just "needs someone to sit with her and reassure her." On 8/24/13 at approximately 10:00 a.m. an interview with medical director was conducted by phone. -The medical director indicated in the 7/25/13 Performance Improvement (PI) committee meeting, a number of residents were identified as chemically restrained because their hypnotic or sedative medications were not properly indicated or used per the FDA indication. He thought the number was in error. -The medical director said he was not aware of the concern documented in the June PI meeting (see above) regarding the residents' medications not matching the indications for the medication. He stated that the "pharmacy was monitoring that." Although he said he did recall at the July 2013 PI meeting that topics discussed at the meeting included chemical restraints, narcotic count inconsistencies, improper medication dosing and indications and behavior tracking. (Cross reference F501 for further details on medical director interview) The Director of Nurses was unavailable for interview 8/19/13 - 8/22/13.

Based on resident and staff interview and record review, the facility failed to ensure two of eight sample residents (#1, #5) who displayed mental and/or psychological adjustment difficulty, received appropriate treatment and services in a timely manner to address the problem. Specifically: - For resident #1, the facility failed to assess resident psychosocial and adjustment needs, assess the lethality of resident [MEDICAL CONDITION] and ensure the resident was safe. In addition, the facility failed to provide mental health services and emotional support in a timely manner, including physician and mental health involvement for the resident's depression. These failures contributed to the resident's psychosocial distress and suicidal expressions. -For resident #5, the facility failed to promptly follow up on the resident's request to see a mental health professional to address her psychological needs and decrease her medication use. Cross-reference F155, F222 and F223 The findings included: 1. Resident #1, age 79, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status Minimum Data Set (MDS) Assessments: (1) According to the 5/10/13 quarterly MDS, resident #1 had a BIMS (cognitive status) score of 10, indicating she was moderately cognitively impaired. -Her mood assessment noted she had "little interest or pleasure in doing things;" was "feeling down, depressed or hopeless," and "feeling bad about yourself, that you have let yourself or family down." Her mood severity score was noted as 4, indicating depression. She had physical behavioral symptoms that did not affect self or others on 1 of 3 days. -She needed extensive assist for activities of daily living. -She was receiving scheduled pain medication, anti-depressant and anti-anxiety scheduled medications. -Triggered care areas included psychosocial well-being, [MEDICAL CONDITION] drug use, pain, and cognitive/dementia issues. (2) According to the resident's 8/6/13 quarterly MDS, resident #1 had a BIMS (cognitive status) score of 9, indicating she was moderately cognitively impaired. - Her mood assessment noted she had "little interest or pleasure in doing things;" was "feeling down, depressed or hopeless," Her mood severity score was noted as 2 indicating that her mood assessment had gotten better. She had no physical behavioral symptoms. -She rejected cares 1 of 3 days in the reporting period. -She needed extensive assist for activities of daily living and limited assist with ambulation. -She was receiving scheduled pain medication, anti-depressant and anti-anxiety scheduled medications. -Triggered care areas included psychosocial well-being, [MEDICAL CONDITION] drug use, pain, and cognitive/dementia issues. Care Plan: Review of the resident's comprehensive care plan revealed she was care planned for behaviors on admission (11/9/12). The behavior care plan documented the resident struggled to accept the fact that she could no longer be at home with significant other. Approaches included administering and observing the effectiveness of medications as ordered; staff to anticipate the resident's needs before she got stressed; educate on the casual factors of behavior and planned intervention and investigate/observe the need for psychiatric support. b. Resident Interview - Expressions of psychological distress and losses (1) Resident #1 was interviewed on 8/20/13 at 10:15 a.m. When asked about choices regarding her health care and life and routine in the facility, the resident said she had no choices, but whatever they did for her was fine. She said nothing mattered to her since her husband was terminal. The interview was suspended when the resident began crying and the facility staff came in to assist her. (2) Resident #1 was interviewed again when she approached the surveyor in the hallway by the dining room on 8/20/13 at approximately 11:30 a.m. The resident said, "You still want talk to me." Asked if there was anything she would like to add, she said, "Only that I am going to die soon." The resident began sobbing and said she wanted to go to her room. (3) Resident #1 was interviewed again on 8/20/13 at 3:45 p.m. She said, spontaneously, that she always took her medications the facility gave her. She said she had bad breathing problems and she was going to die soon and wanted to be with her husband, who recently shared that he had a terminal [DIAGNOSES REDACTED]. Asked if she had seen a psychiatrist or psychologist to discuss how she was feeling, she said no. Asked if she had regular visits from the social worker, she said there was a lady who worked at the facility who met with her sometimes, but she wasn't sure if it was the social worker. She said she was unaware of a psychiatric evaluation or any other visits for support and with whom she could talk about her spouse's illness or about her own health. c. Facility knowledge of the resident's depression and suicidal thoughts - facility response - failures in facility response (1) Knowledge of the resident's depression and suicidal thoughts Review of the nurses' notes revealed staff was aware of the resident's suicidal ideation and losses and of her depression. The notes stated in pertinent part: -On 5/20/13 at 4:53 a.m., "the resident struggles with her placements and wishes she could of stayed with her husband. She has depressive and crying episodes over this often." -On 5/31/13 at 4:14 p.m., the resident was sent to the hospital for evaluation of behaviors and was working herself into a maniac moment. (The facility anticipated a psychiatric evaluation but this did not happen.) - On 6/3/13 at 11 p.m., "Resident needs reassurance consistently related to high anxiety and end stage [MEDICAL CONDITION]." -On 6/5/13 at 7:06 p.m., "resident called 911 tonight and was upset related to her husband." She then called 911 again." Per nurses' notes, a police officer was sent to the facility to check on the resident. - On 6/14/13 at 1:50 p.m., "(Resident) refused medications, meals and refused to speak or answer questions. Will only open eyes briefly." (2) Nurses' notes and care plan review showed an escalation in resident's expressions of despair in August. Care plan review revealed the resident's activities care plan was updated 8/14/13. The activities care plan identified the resident was put on 1:1 monitoring for suicide watch until cleared by someone on the interdisciplinary team (IDT) mental health consult, social service department, physician or DON (Director of Nurses) as safe, noting the resident was a danger to self and possibly others. Approach included in pertinent part, room and clothing searches, and the removal of cords and potentially harmful objects. Nurses' notes on 8/19/13 documented the following; -At 2:25 p.m. "Resident stated I want to die." -At 2:54 p.m., "she is having [MEDICAL CONDITION] and psychotic behaviors. She is hitting herself and has bruising on her chest and a skin tear to the right wrist." She verbalized she wanted to die and was going to kill herself multiple times." Spoke with the DON at 3:00 p.m. and the resident will be sent to the hospital for mental health evaluation. -At 7:13 p.m., "this nurse contacted doctor and received order for [MEDICATION NAME]- an anti-anxiety medication. After talking with the resident, she is upset about her husband having terminal diagnosis." I then called the provider and asked for an order to transport for a psychiatric evaluation." Interview with the social services director (SSD) on 8/22/13 at approximately 3:51 p.m. revealed the resident was in the shower in the morning and stated that she wanted to die. The resident then began to play her history back and then had meltdown, and grabbed the shower head and tried to get the hose and tried to choke herself. d. Failures in facility response to resident #1's depression and suicidal thoughts before and on 8/19/13. (1) Review of the resident's comprehensive care plan revealed: The behavior care plan (see above) failed to identify the specific behaviors the resident exhibited, their severity, their triggers, or the facility's planned interventions. Moreover, there was no evidence this care plan had been updated since admission, even though the progress notes (see above) indicated the resident had been transferred to the hospital several times since admission for psychotic symptoms. The comprehensive care plan included had no care plan specific to the resident's depression, including her symptoms, approaches to relieve her distress and plans for emotional psychological support to address her depression and losses, even though the resident's [DIAGNOSES REDACTED]." (2) Further record revealed no psychiatric/mental health support. Although the behavioral care plan (see above) directed staff to investigate and observe the resident's need for psychiatric support, record review revealed no recent evaluations by a psychologist or on-going psychosocial support in August 2013. The resident had been evaluated on 6/11/13, 7/2/13 and 7/30/13. The psychologist wrote on all three occasions that supportive treatment and suggestions would be the plan of action for the resident. e. Failures in facility response to resident #1's depression and suicidal thoughts on and after 8/19/13. (1) Review of the nurses' notes (see above) revealed no documentation on 8/19/13 that the resident's suicidal statements were assessed for lethality. Further, there was no documentation the resident's physician was notified of the above information until five hours after the resident initially expressed suicidal thoughts. (2) Review of the document, "Q 15 minute checks-suicide/bx watch," revealed the 15-minute checks had documentation on 8/19/13 at 5:30 p.m. that the resident was on the phone. See above care plan for suicide ideation and the removal of all cords. This documentation indicated that this was one hour before the resident was sent to hospital for emergent psychiatric treatment. (3) Although record review revealed the resident did not receive a psychiatric evaluation after transport to the hospital as she was not medically cleared, there was no evidence that upon the resident's return, suicide watches and monitoring were consistently implemented or psychological support was planned. The resident was not evaluated by a physician or any member of the IDT team for removal of the suicide precautions. While the physician visited 8/20/13 and acknowledged that after a visit from her spouse the resident became anxious and depressed "expressing wish to die," there was no documentation the IDT met to discuss how to address the resident's psychosocial needs and safety. (4) The activities care plan was not updated after the resident exhibited additional suicidal expressions 8/19/13 for which she was transported to the hospital. There was no documentation evidencing whether 1:1 monitoring continued after her return. (5) Further review of the 15-Minute Check Documentation, that read, "Start eve 8/19/13 until tomorrow 8/20/13 per (DON)" revealed omissions. Specifically: -No staff checks were documented on 8/19/13 for 30 minutes between 5:30 p.m. and 6:00 p.m. -No staff checks were documented on 8/20/13 between the hours of 8:30 p.m. and 10:00 p.m. No comments were noted, and the checks included nothing but unidentified staff initials, the date and the resident's name and room number. f. Staff Interviews Staff interview revealed staff failed to assess, evaluate, communicate and comprehensively address suicidal ideation as well as failed to provide emotional support. Interview with social services director (SSD) on 8/22/13 at approximately 3:51 p.m. revealed the following: -The resident does not have a [DIAGNOSES REDACTED]. -The resident did not receive any mental health evaluation when she was sent to the hospital after trying to hurt herself on 8/19/13 because she had a urinary tract infection. -The SSD stated that she had contacted the psychologist for the facility. The resident was seen in house until the psychologist could see the resident. The last date of a visit by the psychiatrist was documented on 7/30/13 indicating that the resident had not yet been assessed after being on suicide watch and an emergency transport for mental evaluation on 8/19/13. -The reason the facility did not put any interventions in place when the resident returned from the hospital without a psychiatric evaluation was because "the resident stated that she felt okay and wasn't going to do anything. We were looking to the medication review done by the doctor when he came in." 2. Resident #5, a [AGE] year old female, was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On 7/25/13 the Admission Minimum Data Set (MDS) documented that the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. No behavior or mood issues were identified. Record Review: The following copies of documents, unless otherwise specified, had been received on 8/22/13 at 8:45 a.m. from the Health Information Management Director: On 7/25/13 the Telephone Orders (TO) documented the order for the discontinuation of [MEDICATION NAME] 25 milligrams (mg) at bedtime and to begin [MEDICATION NAME] 12.5 mg at bedtime for anxiety. According to www.drugs.com <http://www.drugs.com>. "[MEDICATION NAME] (quetiapine) is an antipsychotic medicine. It works by changing the actions of chemicals in the brain. [MEDICATION NAME] is used to treat [MEDICAL CONDITION] in adults... [MEDICATION NAME] is used to treat [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]) in adults ..." On 8/13 the Medication Administration Records (MARs) documented that the resident was currently taking [MEDICATION NAME] 12.5 mg by mouth (p.o.) at bedtime for anxiety. On 7/25/13 the Psychoactive Medication Informed Consent form documented that the resident was taking [MEDICATION NAME] 12.5 milligrams (mg) at bedtime for anxiety. The documented expected benefit was relaxation. On 7/25/13 the AIMS (abnormal involuntary movement scale) was completed and the resident had no abnormal body movements identified. On 8/1/13 (last reviewed) the [MEDICAL CONDITION] Medication Care Plan documented that the resident was taking psychoactive medications for management of depression and anxiety. The following approaches included: - " ...Psychiatry/psychology services PRN ..." On 8/22/13 at 7:13 p.m. the Social Service Director (SSD) provided a copy of the Psychosocial Well - Being Care Plan which documented that it was initiated on 7/18/13. The care plan documented that the "Resident displays a psychosocial well being problem as evidenced by self isolation, anxiety, extreme worrying or fear, continuous crying, and lack of interest to pursue relations, or interaction with others, and [DIAGNOSES REDACTED]. Her cat lives with her in her room which has made her adjustment to the facility more comfortable." The approaches included the following: -"Give positive re-inforcement as initiative/involvement improves/attempts to solve conflicts. - Invite, encourage, remind, escort to activity programs consistent with resident's interests. - Observe need for psychological/psychiatric services. Provide for these services if agreed upon by resident/responsible party and ordered by physician." On 8/2/13 the Social Service Assessment which had been completed as the resident's initial assessment documented the resident would like to meet with a Psychologist. Failures: No documentation was found in the resident's medical records that she was offered a consultation with a Mental Health Professional. No physician documentation indicated he/she was contacted regarding the resident's request for Mental Health professional evaluation. Resident Interview/Observations: On 8/21/13 at 5:10 p.m. the resident said she had problems with feeling really anxious and had a feeling of wanting to run and hide. She stated she had not been offered a consultation with a Mental Health Professional and she would like to see someone so she could get rid of some of her medications. Facility Follow up During Survey: On 8/22/13 at 5:00 p.m. the copy of the Behavior Monitoring Form from the Social Service Director (SSD) documented that the targeted behaviors were "extreme worry, extreme fear, and continuous crying." The interventions included the following: " ...Consultation..." On 8/22/13 at 5:14 p.m. the SSD reported that she was the person who would be responsible for setting up the Mental Health consultation for any resident who required the services. She reported that this resident was a candidate for mental health services. She reported that she was not sure if she could get a Mental Health consultation in the short time that the resident was expected to be in the facility. She reported that she did not have a specified time that would be acceptable to not arrange the Mental Health services.

Based on interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Record review and interviews revealed staff members repeatedly failed to recognize actions taken by staff - forcing medications, administering medication without clinical support, and physically restraining a resident to complete treatment - was abusive, chemically restraining and against the resident's rights. Failure to address staff's interactions contributed to emotional and psychological harm to one of eight sample residents (#1). Cross-reference F155, F222, F223, F225, F250, F309, F315, F319, F329, F425, F431, F441, F501, F514, and F520. The findings include: 1. Seventeen deficiencies were cited during the complaint investigation exiting 8/22/13 in the areas of resident rights, resident behavior and facility practice, quality of care, pharmacy services, infection control and administration. The deficiencies included: a. Resident rights - Cross reference F155: The facility failed to ensure residents had the right to refuse treatment. Cited at actual harm that is isolated. b. Resident behavior and facility practice - Cross reference F222: The facility failed to ensure the residents were free from chemical restraints. Cited at actual harm that is isolated. - Cross reference F223: The facility failed to ensure residents were free from abuse. Cited at immediate jeopardy for serious harm that is isolated. Record review revealed the facility physically restrained resident #1 in order to deliver medication and perform treatments. Staff members failed to recognize this action as abusive, failed to report it, failed to investigate it and failed to intervene. Repeat incidents occurred, contributing to resident #1's emotional distress and psychological decline. See F223 for further details. -Cross reference F225: The facility failed to have evidence that allegations of abuse were thoroughly investigated and reported. Cited at immediate jeopardy for serious harm that is isolated. Review of witness statements, progress notes, type-written statements, and interview with the Social Services Director (SSD) revealed observed incidents on 5/5/13, 5/31/13, 6/1/13, 6/10/13 when staff held resident #1 down and attempted to replace the resident's urinary catheter and/or administer medications in the presence of the resident's express refusals and resistance. The NHA was interviewed on 8/21/13 at approximately 2:33 p.m. The interview revealed the following: -The NHA was aware of resident #1's concerns of abuse and forced medication by the facility staff in June 2013. The NHA said the incident and witness statements (see above) were kept in a folder labeled "[MEDICATION NAME]." -The NHA had not reported the alleged abuse to the state health department, the local authorities or the CRNC as required by state law, federal regulations and facility policy. -The entire investigation of resident #1's complaint was on the comment card. The documentation that was returned to the resident read, "All statements were consistent, Resident was upset and trying to pull catheter out. Resident also resisted taking medication, but several nurses tried. I talked with resident." This was the end of the facility's investigation. The witness statements were obtained on the day of the incident(s) and the NHA did not feel the need to investigate further. -There were no suspensions or counseling with any of the staff including the DON and the other staff involved in the documented incidents. See F225 for further details. c. Quality of care -Cross reference F309: The facility failed to provide necessary services and care to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for residents. -Cross reference F315: The facility failed to provide catheter care and maintenance. -Cross reference F319: The facility failed to provide care and services to assist the resident to reach and maintain the highest level of mental and psychosocial functioning. Cited at actual harm that is isolated. -Cross reference F329: The facility failed to ensure residents medication regimens were free from unnecessary drugs. d. Pharmacy services -Cross reference F425: The facility failed to ensure the licensed pharmacist collaborated with the facility to identify and address pharmaceutical concerns. -Cross reference F431: The facility failed to ensure controlled medications were properly stored, labeled and accounted for. e. Infection control -Cross reference F441: The facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. f. Administration - Cross reference F501: The facility failed to ensure the medical director coordinated medical care in the facility and provided clinical guidance and oversight. Cited at actual harm that is isolated. - Cross reference F514: The facility failed to ensure resident clinical records were complete and accurate. - Cross reference F520: The facility failed to implement an effective quality assurance program. 2. Preventing Abuse and Abuse Reporting a. Interviews On 8/20/13 at approximately 10:00 a.m. the director of nursing (DON) was interviewed. The interview revealed that as the director of nursing she is responsible for the resident care staff. She further stated that it was her responsibility to report any resident injuries whether the origin was known or not. The charge nurse on duty, the DON and the Nursing Home Administrator (NHA) were to be notified via telephone of any possible abuse investigations. On 8/20/13 at approximately 10:10 a.m. the Assistant Director of Nurses (ADON) stated the facility had a no tolerance policy on any type of abuse. She further stated that it was her expectation that the facility staff report any occurrences of abuse according to the facilities abuse prohibition policy. The NHA was interviewed on 8/21/13 beginning at approximately 4:45 p.m. and ending at 5:05 p.m. The Regional Nurse consult was present for the interview. -The NHA stated her role in the facility was providing direct oversight of the staff and the care delivered in the facility. -When told of the findings under F223 and F225 (see these deficiencies for further details), the NHA stated that she did not know what the specific citations were indicative of. She further stated that she did not know F223 and F225 were areas of resident abuse and abuse investigation. -The NHA, when asked to provide the facility's criteria for reporting abuse to the state, stated that she was not sure where that was. She said she was aware of current residents with bruises of unknown injuries and/or residents with current fractures of unknown origin. b. Records During the complaint investigation exiting 8/22/13, the facility did not provide any documentation to support any type of staff education regarding the identifying of potential/actual resident abuse and reporting. On 8/21/13 at approximately 4:40 p.m., in an interview with the NHA, director of nursing (DON), the regional nursing consultant (RNC) regarding sample resident #1, the NHA offered no information regarding the alleged abuse and left the room during the state's notice of immediate jeopardy of serious harm (F223J and F225J). After 8/21/13, the NHA was no longer present in the facility or in charge of administering its resources to ensure each resident attained or maintained their highest practicable level of well being.

Based on staff and medical director interviews and record review, it was determine the facility failed to ensure the medical director provided clinical guidance and oversight of resident care policies and coordinated facility-wide medical care. Specifically: -The medical director failed to identify, evaluate and address quality of life and quality of care issues. Record review and interviews revealed staff members repeatedly failed to recognize actions taken by staff - forcing medications, administering medication without clinical support, and physically restraining a resident to complete treatment - was abusive, chemically restraining and against the resident's rights. Failure to address staff's interactions contributed to emotional and psychological harm to one of eight sample residents (#1). -The medical director failed to ensure issues identified and discussed in Performance Improvement meetings were addressed in a timely manner. Findings include: A. Expectations A review of the 'Medical Director Agreement' dated 5/18/10 and signed by the facility medical director revealed the following: -The medical director's duties included full compliance of Title 42, Section 483.75(i) of the Code of Federal Regulations, Appendix PP and guidance for long term care facilities. -The medical director will assist in coordinating medical care in the facility and to ensure that adequate and appropriate medical services are provided to the residents in the facility. -The medical director will evaluate the adequacy of nursing care furnished to facility residents and assist with implementing resident care policies and coordinate medical care in the facility. B. Issues raised in Performance Improvement (PI) meetings regarding the care and services provided to facility residents. (1) The May, June and July 2013 PI meeting minutes indicated the medical director was in attendance at all the meetings. a) The May 2013 PI meeting minutes included the topics of behavior tracking, residents with injuries of unknown origin and falls including fractures. The quality assurance and performance improvement plan was left blank and contained no action plans for the issues addressed at the May 2013 PI meeting. The medical director and NHA had signed off on the meeting minutes. b) The June 2013 PI meeting minutes documented addressed topics including late survey results, resident falls and residents with bruising of unknown origin. A topic that was re-addressed was the inappropriate use and indications of resident medications. The quality assurance and performance improvement plan was left blank and contained no action plans for the issues addressed at the June 2013 PI meeting. The medical director and NHA had signed off on the meeting minutes. c) The July 2013 PI meeting minutes included the topics of chemical restraints and incidents. The incidents discussed included behavior tracking, medical consents for the use of [MEDICAL CONDITION] medications and counting narcotics. Seven residents were noted as chemically restrained. (2) Review of the oversight document (per medical director interview below, this was the form for documenting concerns from the issues raised at the meeting), completed by the medical director and attached to the meeting minutes for 5/2013, 6/2013 and 7/2013 PI meetings revealed no concerns. C. Record review and interviews revealed the following deficient practice during the complaint investigation exiting 8/22/13: -F155; the facility failed to respect the resident's right to refuse medications and treatment, contributing to resident harm. -F222; the facility failed to ensure residents were free from chemical restraints -F223; the facility failed to protect one resident from physical abuse, creating the potential for immediate and serious harm. -F225; the facility failed to report and comprehensively investigate allegations and observed incidents of physical abuse, creating the potential for immediate and serious harm. -F329; unnecessary medications -F431; storage, labeling and accounting of controlled medications D. Interview On 8/24/13 at approximately 10:00 a.m., the facility medical director was interviewed by telephone. The interview revealed: -The physician had been the medical director of the facility for approximately three and half years and visits the facility "maybe twice weekly." -The physician had not been made aware of the immediate jeopardy (IJ) imposed by the state on 8/21/13 until 8/23/13, three days after the imposition of IJ. He was not aware of the number of citations or the areas of citation. He had not heard of allegations of abuse being reported or observed (Cross reference F155, F223, F225). -He stated the PI meetings are held monthly and the last time he attended and participated was in 7/2013. The topics included chemical restraints, narcotic count inconsistencies, improper medication dosing and indications and behavior tracking. He did not indicate he had reviewed facility policies and procedures on resident care to address the issues discussed. Likewise he had not developed any plans to address the issues, thinking the DON and/or Nursing Home Administrator (NHA) would follow up. He stated he and the NHA consult frequently, and "we may need to document that." -The medical director indicated that he had never provided any medical in-services or education to the facility or any of the staff at the facility in the three years that he had been the facility medical director. "I have made myself available for the facility; however, they have not asked for any education. I was not really aware of any major issues until now." -The medical director said he had provided no guidance or teaching after the last federal survey in (2/13) with the citation of seven deficiencies. The citations included behavior monitoring, unnecessary medication and resident care areas. He said he was not aware that behaviors were not being monitored and remembered discussing alternative therapies to address behaviors. -Regarding the 5/2013 meeting minutes and the topic of resident with injuries of unknown origin, the medical director indicated that he thought "the NHA and the staff were following up with that." -In the same meeting (5/2013), the topic of nursing staff auditing other nursing staff for medication administration was brought forward by the facility pharmacist. The medical director indicated that he remembered the topic and "it cause me to raise my eyebrows and raised a red flag." He stated that he thought the NHA and the DON (Director of Nurses) would follow up on the topic. -Behavior monitoring not being documented or tracked by the facility staff was another topic of the 5/2013 PI meeting. The medical director stated he was in attendance at the meeting and remembers "talking about the behavior monitoring but cannot recall who was going to take charge of the issue." -The medical director said he was made aware during the 6/2013 PI meeting that there had been an increase in resident falls. Another topic that was brought forward was a concern from nursing about destruction of resident medications and the cost associated with destruction. The medical director stated "that raised my eyebrows ... and I thought the NHA was taking care of the situation." He further stated that the topic had been brought up by the facility pharmacy as well. -The medical director stated he was not aware of the concern documented in the 6/2013 PI meeting regarding the resident medications not matching the indications for the medication. He stated that the "pharmacy was monitoring that." -The medical director said he attends the pharmaceutical reviews held by the facility pharmacist. The NHA and the DON were also in attendance at those meetings. The medical director was aware the pharmacy had concern about frequent observations of the unlocked narcotics and the discrepancies around the narcotic counts; "This raised a red flag in my book." He said he thought the DON and the pharmacist were following up with this issue. -He said he was not aware of any behavior tracking problems even though the topic had been addressed in recent PI meetings (see above) when he was in attendance. The plan of action was to have the pharmacy and the nursing departments follow up. He said the NHA was in attendance at the meetings and took hand written notes during the meeting. He said "I am not sure why she did not document when we needed plans of action. I left the plans of action up to her." He said he has not addressed anything specifically with the DON or the nursing staff. -Regarding the 7/2013 PI meeting, the medical director indicated the number seven as indicated in the July 2013 minutes of residents chemically restrained was incorrect and the number of residents chemically restrained as of the date of the meeting (7/25/13) was actually five. He said, "I don't know where that number came from. That sounds high to me. I think that if there were seven residents on chemical restraints that would raise a red flag for me." He further stated that the number of restraints was from the number of hypnotic or sedative medications that were not properly indicated or used per the FDA indication on the facilities residents. -He said if he had concerns or issues with a problem identified by a department at the PI meeting, he would have documented it in the PI minutes and in the medical oversight document, attached to the meeting minutes. Both of those documents are completed at the end of the PI meeting.