Every finding on record at Casey's Pond Senior Living

Based on record review and interviews, the facility failed to identify a change of condition and notify the physician when needed for one (#59) of three residents reviewed for change of condition out of 25 sample residents.Resident #59 was admitted to the facility on [DATE] with a history of acute and chronic respiratory failure, systemic inflammatory response syndrome, and heart failure.On 7/12/25, Resident #59 completed and signed a Colorado Medical Orders for Scope of Treatment (MOST) form. The MOST form documented Resident #59 desired no cardiopulmonary resuscitation (CPR) with selective treatment, that included transfer to the hospital if indicated.On 2/21/26 at 4:43 p.m. registered nurse (RN) #3 documented that Resident #59 was not feeling well, had had no food intake, minimal fluid intake, was not talking, and had greenish/yellow mucus coming out of her mouth and nose. On 2/22/26 at 5:01 a.m. licensed practical nurse (LPN) #2, who had relieved RN #3, for the overnight shift, documented Resident #59 had refused medications and had a high fever, a fast heart rate, and elevated blood pressure. The progress note did not indicate the resident's physician had been notified of the resident's change in condition. On 2/22/26 at 10:45 a.m. RN #3 documented that Resident #59 was found deceased .Specifically, the facility failed to identify a significant change in Resident #59's condition and notify the physician timely for appropriate treatment.Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #59's change in condition prior to the onsite investigation on 7/12/26 to 7/15/26, which resulted in the deficiency being cited as past non-compliance with a correction date of 3/16/26.I. Situation of serious [NAME] 2/21/26 at 4:43 p.m. RN #3 documented that Resident #59 was not feeling well, had had no food intake, minimal fluid intake, was not talking, and had greenish/yellow mucus coming out of her mouth and nose.At 5:39 p.m. RN #3 again documented Resident #59 had had no food intake and had taken minimal fluids.On 2/22/26 at 5:01 a.m. LPN #2 documented Resident #59 was shivering, had a high fever, an elevated blood pressure, and a fast heart rate. The progress note did not indicate Resident #59's physician had been notified of her decline in condition until she was found deceased less than 24 hours after her initial documented decline.The facility's failure to recognize Resident #59's change in condition caused a lack of timely communication to the resident's physician, which resulted in the physician not being able to provide timely interventions for Resident #59's treatment and care.Lack of timely communication to the resident's physician and prompt interventions likely contributed to the resident's death.II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #59's change of condition and death incident on 2/22/26 was provided by the director of nursing (DON) on 7/15/26 at 11:29 a.m.The plan read: The facility became aware of the issue on 2/22/26 and developed a performance improvement plan (PIP) in response to Resident #59's change in condition and death. The facility terminated LPN #2's employment on 2/22/26 and provided education to RN #3 on 2/23/26 that included changes in cardiovascular, respiratory, neurological, infection/sepsis, medication related concerns, and behavioral/cognitive changes. RN #3 resigned a few weeks following the incident.On 2/27/26 the facility provided education to the nursing staff, including RN #3. The education included identifying a significant change of condition, abnormal vital signs, physician notification, and notification to the facility's on-call manager.The facility continued to audit resident changes in condition daily from 2/25/26 through 6/9/26 with no further non-compliance identified. III. Facility policy and procedureThe Change of Condition policy, dated 6/10/25, was provided by the nursing home administrator (NHA) on 7/16/26 at 11:27 a.m. The policy read in pertinent part, Significant changes in a resident's condition require accurate and timely communication, documentation, and implementation of care interventions. When a resident has a significant change in condition, provisions to communicate and care for the resident need to be updated. Significant change of condition is defined as a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting', impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision of care plan. At the time of change of condition, immediately notify the practitioner, legal representative, applicable interdisciplinary team (IDT) members, and care partners. Documentation in the medical record will include notifications, new interventions and provided support, assessment findings, resident's response to changes and resident/family communication.IV. Resident #59A. Resident statusResident #59, age [AGE], was admitted on [DATE] and passed away at the facility on 2/22/26. According to the February 2026 computerized physician orders (CPO), diagnoses included acute respiratory failure, heart failure, systemic inflammatory response syndrome (SIRS - an intense, body-wide inflammatory reaction triggered by severe physical trauma, major surgery, burns, or, when caused by an infection, sepsis), type 2 diabetes mellitus, moderate protein-calorie malnutrition, hypertensive chronic kidney disease, and fluid/electrolyte imbalance.The 1/3/26 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. B. Record reviewReview of RN #3's vital signs documentation on 2/21/26 at 11:10 a.m. indicated Resident #59 had a temperature of 99.5 degrees Fahrenheit (F), a blood pressure of 110/77 mmHg (millimeters of mercury), and a pulse of 95 beats per minute. -Despite Resident #59 having a SIRS diagnosis where an elevated temperature and heart rate would be indicative of physician notification, RN #3 failed to notify the physician of the resident's elevated vital signs.The progress note, dated 2/21/26 at 4:43 p.m. and written by RN #3, indicated Resident #59 was not feeling well, was lethargic, not talking, and had greenish/yellow mucus coming out of her mouth and nose. The resident refused to get out of her recliner and declined any food. She drank a minimal amount of fluid. RN #3 documented that lung sounds were clear to auscultation (listening) bilaterally and her vital signs were within normal limits. -However, the vital signs were not documented in the progress note. RN #3 performed influenza and COVID-19 testing on the resident and documented that both tests were negative. RN #3 notified Resident #59's responsible party but failed to notify the physician of the resident's condition.On 2/21/26 at 9:10 p.m. LPN #2 documented that Resident #59 had refused all medications three times. -However, LPN #2 failed to notify the resident's physician of the medication refusals.On 2/22/26 at 4:20 a.m. LPN #2 documented the administration of acetaminophen 1000 milligram (mg) to Resident #59 for a high temperature of 101 degrees F. However, the acetaminophen order was for 500 mg every six hours as needed for generalized pain.-LPN #2 failed to notify the resident's physician of the resident's elevated temperature. On 2/22/26 at 5:01 a.m. LPN #2 entered a progress note that indicated Resident #59 presented with a high temperature of 101 degrees F, a blood pressure of 149/95 mmHg and a pulse of 150 beats per minute. The resident was also shivering. LPN #2 administered 1000 mg of acetaminophen, then covered the resident in warm blankets. -LPN #2 again failed to notify the physician of the resident's condition and abnormal vital signs.On 2/22/26 at 5:38 a.m. LPN #2 documented that Resident #59's vital signs were taken. Her temperature was 99 degrees F, her blood pressure was 114/77 mmHg, and her pulse was 104 beats per minute. -There was no documentation that indicated Resident #59's physician had been notified of the events with the resident during the night.-There was no further nursing progress note documentation in Resident #59's electronic medical record (EMR) until 11:38 a.m. on 2/22/26, when RN #3 documented that Resident #59 had passed away that morning (2/22/26). On 2/22/26 at 3:09 p.m. RN #3 documented that during shift report that morning (2/22/26) from LPN #2, Resident #59 was shivering, had a fever of 101 degrees, and her other vital signs were out of range. According to the note, LPN #2 had administered acetaminophen, which brought the resident's vital signs down to normal. The resident declined to get up that morning and declined to eat. RN #3 went into the resident's room at 10:45 a.m., removed the blanket and tried to awaken the resident. The resident did not respond. RN #3 listened to the resident's chest with a stethoscope for a heart beat and felt for a pulse; however, neither was found. A second nurse confirmed that there were no signs of life for Resident #59. The physician was not notified until after Resident #59 had passed away. V. Staff interviewsRN #1 was interviewed on 7/14/26 at 2:45 p.m. RN #1 said if a resident had a change of condition from their normal baseline, she would obtain vital signs, observe for any change in cognition or pain and if there are abnormalities, she would reach out to the physician or the on-call provider for physician's orders. She said she would notify the charge nurse, and if there was trouble getting in touch with a physician, she would reach out to the medical director for physician's orders. She said there would always be a physician, nurse practitioner, or physician's assistant available for nursing staff to contact for a change in a resident's condition that needed to be addressed.The medical director, who was also Resident #59's primary care physician, was interviewed on 7/14/26 at 2:54 p.m. The medical director said he was Resident #59's primary care physician and he was very familiar with her. He said he was also the on-call physician on the weekend of 2/21/26 and 2/22/26. He said he was very concerned that he was not notified of Resident #59's fever and change in condition. He said he did not know that the staff had tested the resident for influenza and COVID-19. He said he had no idea that anything was going on with Resident #59 and he was not notified until after the resident had passed away. The medical director said Resident #59's MOST form indicated the resident wished to have selective treatment, which included hospitalization if necessary. He said he should have been notified of the resident's change in condition in order to have the opportunity to address the situation and have a discussion with her responsible party for treatment options. He said he was not provided the opportunity to address the resident's condition that ultimately likely resulted in a negative outcome for the resident. He said he signed the resident's death certificate but did not recall what the resident's cause of death was.The DON was interviewed on 7/14/26 at 3:41 p.m. The DON said the death of Resident #59 was very concerning. She said both nurses involved (RN #3 and LPN #2) should have notified the physician with the resident's change in condition. She said if they were unable to contact the primary care physician, then an on-call provider should have been notified regarding the resident's condition in order for the resident to receive in-house treatment physician's orders or a hospital transfer if indicated. She said the management team could have been notified as well to help facilitate notifications. She said nurses should be empowered to notify a provider themselves and not rely on management to handle a situation for them. She said nurses were to follow the physician's medication orders as they were written, and if they needed a different medication order for a fever, then they were to contact the physician. LPN #1 was interviewed on 7/15/26 at 11:20 a.m. LPN #1 said she was a travel nurse and had worked at the facility for five weeks. She said if a resident had a change of condition, she would assess their vital signs, ask about pain, and report her findings to the RN supervisor so the RN supervisor could call the provider. She said to notify the RN supervisor, she would text them first and ask if she could call them. She said after she notified them of her concerns she would wait to hear back from them and if 30 minutes went by without receiving a response, she would reach out to them again to see if they were able to talk with the provider. She said she generally did not call a provider herself, but would reach out to the RN supervisors to do so.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of one medication storage rooms and two of three medication storage carts.Specifically, the facility failed to:-Ensure expired medications were disposed of; and,-Ensure medications were contained in the original packaging.Findings include:I. Facility policy and procedureThe Medication Storage policy and procedure, dated 6/30/25, was provided by the nursing home administrator (NHA) on 7/16/26 at 11:27 a.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy.II. Observations On 7/14/26 at 9:00 a.m. the medication storage room was observed with licensed practical nurse (LPN) #3. The following item was found:-One bottle of glucosamine sulfate 500 milligram (mg) that expired June 2026.On 7/14/26 at 9:10 a.m. the medication cart on the Pond Side unit was observed with registered nurse (RN) #2. The following items were found: -One foil medication card containing four omeprazole 20 mg tablets was in the top drawer of the medication cart and was not contained in the original packaging;-One nearly full bottle of aspirin 325 mg tablets that expired March 2026;-One half full bottle of simethicone 80 mg tablets that expired February 2026;-One half full bottle of lutein 20 mg tablets that expired June 2026; and,-One foil medication card containing twelve guaifenesin 1200 mg tablets was in the bottom drawer of the medication cart and was not contained in the original packaging.On 7/14/26 at 9:34 a.m. the medication cart on the Mountain Side unit was observed with RN #1. The following items were found:-One nearly empty tube of diclofenac sodium 1% gel that expired April 2026; and,-One bottle of iron 45 mg tablets that expired May 2026.III. Staff interviewsRN #2 was interviewed on 7/14/26 at 9:10 a.m. RN #2 said all nurses were responsible for reviewing the medication carts for expired and correctly labeled medications. She said the pharmacy routinely sent someone to review the medication carts and the emergency medication machine for expired medications, but she did not know when they had last been at the facility.The director of nursing (DON) was interviewed on 7/15/26 at 9:02 a.m. The DON said all nurses were responsible for reviewing the medication carts for expired and properly labeled medications. She said that she and the assistant director of nursing (ADON) also routinely reviewed the medication carts and the medication storage room for expired medications. She said the pharmacist and a pharmacy representative made monthly visits to review the medication carts and to maintain the emergency medication machine. She said audits of the medication carts were performed in May 2026 and June 2026, but they were not completed during the pharmacist's last visit in July 2026. The DON said nurses were expected to follow competency guidelines that included labeling/dating medications and checking for expiration dates during all medication passes.

Based on observations, record review and interviews, the facility failed to ensure residents received person-centered dementia care that met the needs for one (#36) of six residents reviewed for dementia care out of 25 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for wandering and dementia care for Resident #36.Findings include: I. Facility policy and procedure The Dementia Care policy, revised 6/30/25, was provided by the nursing home administrator (NHA) on 7/16/26 at 11:27 a.m. It read in pertinent part, The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintenance of the expected stable rate of decline associated with dementia and dementia-like illnesses. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. II. Resident #36A. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included dementia with psychotic disturbances, heart failure, chronic kidney disease, depression and hypertension (high blood pressure). According to the 6/9/26 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She was independent with eating and personal hygiene. She required set up assistance with oral hygiene and toileting. She required supervision with showering. The assessment revealed the resident wandered four to six days but less than daily during the assessment look-back period. B. Resident observation During a continuous observation of Resident #36 on 7/12/26, beginning at 3:32 p.m. and ending at 4:58 p.m., the following observations were made in the Pond unit dining area and living room area: At 3:44 p.m. Resident #36 opened the door of room [ROOM NUMBER]. An unidentified nurse informed Resident #36 to walk with her. At 3:49 p.m. Resident #36 walked into room [ROOM NUMBER] and then room [ROOM NUMBER]. No staff members redirected the resident. At 4:04 p.m. Resident #36 was observed going into room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. No staff members redirected the resident. On 7/13/26 at 4:27 p.m. Resident #36 was observed walking outside to the patio on the side of the Pond unit. An alarm was heard as the door opened. Certified nurse aide (CNA) #1 asked registered nurse (RN) #2 the code to exit the door. CNA #1 walked outside and held Resident #36's hand. RN #2 was observing the resident by the door. By 4:30 p.m. Resident #36 was back in the building. RN #2 said hello to the resident and the resident said hello and said the CNA helped her in and she was there for half a day. She said she did not understand what was going on and asked where her spouse was. CNA #1 and RN #2 redirected the resident to the dining room area.-However, CNA #1 and RN #2 did not provide the resident with any meaningful activity or other distraction to redirect the resident's wandering. On 7/15/26 at 12:29 p.m., Resident #36 was observed walking into room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. An unidentified staff member sitting at the dining room table told Resident #36, from the table, to not go into the rooms and that it was her old room.-However, the unidentified staff member did not attempt to get up from the table or provide the resident with any meaningful activity or other distraction to redirect the resident's wandering into other resident's rooms.C. Resident group interview A group interview was conducted on 7/15/26 at 1:00 p.m. with four residents (#6, #13, #17, and #53), who were identified as interviewable through facility and assessment. All of the residents said there were other residents who wandered into their rooms, other resident's rooms and throughout the building. All of the residents said Resident #36 was one of the residents who wandered into their rooms or other residents' rooms. Resident #13 said in the last week, Resident #36 went into his room at around 4:00 a.m. Resident #13 said he did not know what the facility could do to stop it. Resident #53 and Resident #17 said they did not know what the facility could do to prevent other residents from going into their rooms. D. Record review The elopement and wander care plan, initiated 6/6/25, revealed Resident #36 was at risk of harm or injury to herself. She had some attempts to leave the facility unattended when she wanted to make sure her spouse was okay when he left the building in the afternoon and evening. She experienced impaired safety awareness and cognitive deficits. Interventions included distracting the resident by offering pleasant diversions, structured activities, walking to the door with her to see that her spouse departed, reassurance, food, conversation, television, and books. She preferred to be engaged in a life enrichment activity and to be with other residents or staff. Review of Resident #36's behavior monitoring and intervention task response history revealed there were no behaviors observed from 6/16/26 to 7/15/26.-However, observations on 7/12/26, 7/13/26 and 7/15/26 revealed Resident #36 wandering into other residents' rooms and out the locked door onto the patio (see observations above). Review of Resident #36's July 2026 CPO revealed the following physician's orders: Monitor for the following depressive and psychotic behaviors: biting, hitting, striking out, continuous crying, continuous screaming, yelling, continuous pacing, wandering or elopement, danger to self, danger to others, extreme fear, hallucinations, delusions, paranoia, repetitive anxious verbalizations and isolation. Record every day and night shift. Record behavior and number of episodes in supplemental documentation, ordered 3/10/25. The 6/18/26 behavior note revealed Resident #36 went to walk into room [ROOM NUMBER] and spoke to the resident in a raised voice and then exited the room. Repeated attempts to redirect, assess for pain, distraction and offering of food and fluids were unsuccessful. The resident wandered into another unit and was escorted back by staff to the room.-However, the note did not indicate what interventions were attempted for distraction. The 6/22/26 nursing note revealed the resident required consistent supervision throughout the day with one-on-one cares. Her spouse took her out to dinner and reported she was argumentative throughout their visit. When the spouse left, she made multiple exit attempts.-However, the note did not indicate what interventions were attempted to distract the resident from her multiple exit attempts. The 6/29/26 behavior note revealed after her spouse left for the day, Resident #36 became very agitated. She packed clothes, paced and opened other residents' doors. She was not easily redirected. One-on-one care was provided, along with redirection and reorientation. She exited doors in the unit two times. A CNA walked the resident a short distance the second time then brought her back in. She asked for her spouse and her children multiple times. The oncoming nurse was notified of behaviors.-However, the note did not indicate what interventions were attempted for distraction. The 7/12/26 behavior note revealed the resident had been extremely paranoid since the previous evening. She accused staff of trying to kill people and animals. Resident #36 constantly hovered over other residents when they were in the dining room. Resident #36 has been very hard to redirect. She sat with a dog for a couple of hours in the morning, which was helpful.-However, the note did not indicate what other interventions were attempted for distraction and observations revealed staff were not consistently attempting to redirect the resident's wandering with meaningful activity (see observations above). III. Staff interviews CNA #2 and CNA #3 were interviewed together on 7/15/26 at 2:55 p.m. CNA #2 and CNA #3 said they knew a resident's behavior by developing a rapport with the resident to see what escalated the resident. CNA #2 and CNA #3 said the interventions they used were redirecting, such as offering coffee, offering to play a game or an activity.CNA #2 said if she had a new resident, she tried to find something to talk about, such as something they were wearing or something they had in their room. CNA #3 said knowing who the resident was was important because if a resident said they needed to get their truck and she knew the resident had a spouse, she distracted the resident from looking for the truck by telling the resident their spouse had the truck right now and then offering another activity. CNA #3 said she was familiar with Resident #36. She said the resident wandered and tried to leave the building. CNA #3 said interventions that worked for her were working on a puzzle together. CNA #2 and CNA #3 said Resident #36 liked to help and did not like to sit still. CNA #2 and CNA #3 said she liked cleaning, cooking and laundry, so one intervention was to give her some dish towels for her to fold while they did other tasks.-However, observations revealed staff were not attempting to provide the resident with the tasks described by the CNAs and review of the care plan did not reveal documentation of these interventions (see observations and record review above). Licensed practical nurse (LPN) #1 was interviewed on 7/15/26 at 10:35 a.m. LPN #1 said typical interventions to keep a resident from wandering and eloping was redirecting, offering an activity, watching television, offering something to drink and sometimes one-on-one supervision. She said she documented what intervention was used to prevent wandering and elopement and if the intervention was effective. LPN #1 said she was familiar with Resident #36. She said interventions to prevent the resident from wandering into other rooms and outside were providing one-on-one supervision, redirecting and sitting with her.-However, observations revealed staff members were not consistently redirecting the resident, providing one-on-one supervision or sitting with the resident when she was wandering (see observations above). The director of nursing (DON) was interviewed on 7/15/26 at 4:35 p.m. The DON said staff knew what interventions to use when a resident wandered by looking at the care plan. The DON said the nurse was responsible for documenting what interventions were used and if the interventions were effective. The DON said if all interventions were used and were not effective, the nurse should call the physician and the family. The DON said the family could provide ideas on what could help the resident and the physician could provide direction on the clinical side. The DON said she was familiar with Resident #36. She said she knew the resident wandered into other residents' rooms and tried to leave the building. She said the interventions CNA #2 and CNA #3 provided were all good interventions that would be helpful for all staff to know to help manage the resident's wandering. The DON said consulting with a dementia expert might be helpful to determine interventions that could be effective for Resident #36 and other residents who wandered.

Based on observations, record review and interviews, the facility failed to ensure two (#3 and #4) of three residents out of 25 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure the manufacturer's recommendations were followed for Resident #3's air mattress; and, -Ensure the manufacturer's recommendations were followed for Resident #4's wander guard (a wearable safety device).Findings include: I. Failed to ensure the manufacturer's recommendations were followed for Resident #3's air mattressA. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers and Injuries ([DATE]), retrieved on [DATE] from https://www.guidelinecentral.com/guideline/23835, It is good practice for organizations to maintain an inventory of, or access to, a range of full body support surfaces appropriate to the clinical context. The inventory should be maintained, stored and used in accordance with manufacturer recommendations. It is good practice to use a full body support surface or integrated bed system that appropriately accommodates the weight, height, size and body mass distribution of the individual. B. Facility policy and procedure The Use of Support Services policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:27 a.m. It read in pertinent part, Support surfaces will be utilized in accordance with manufacturer recommendations including considerations for contraindications. The director of nursing (DON) will maintain a list of support surfaces used in the facility, including product specifications. A schedule for inspection and replacement will be established accordingly. C. Manufacturer's recommendations According to the Panacea Air Ease Bariatric Mattress, owner's manual, pp 6-7, retrieved on [DATE] from https://content.directsupplycdn.com/files/pdf/DS138_Manual_214_jp5Ccbw2CzKp6es5rc9kq_J1GmGyuasCiaARMAPpcCQ, Pressure adjustment: Press [+] to increase pressure. Press [-] to decrease pressure. The liquid crystal (LCD) display shows recommended settings based on user weight. Pressure setting increments (pounds - lbs.): 60, 120, 180, 240, 300, 360, 420, 480, 540, 600. Adjust firmness as necessary for resident comfort, support, and immersion into the mattress for optimal pressure redistribution. A common method for sizing an air mattress is to check to see if suitable pressure is selected by sliding one hand between the bottom mattress cover and the air base under the resident's buttocks. Users should be able to feel the space between their hand and the resident's buttocks with the acceptable range being 25 to 40 mm (one inch to one and a half inches). This hand check procedure is issued by the Agency for Health Care Policy and Research (AHCPR). Adjust the firmness with the [+] and [-] buttons: Press [-] for more immersion (if too much space during hand check, too firm) or [+] for less immersion (not enough space during hand check, too soft).D. Resident #31. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO) diagnoses included chronic heart failure, type 2 diabetes mellitus, acquired absence of left leg above knee, polyosteoarthritis, and polyneuropathy. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He used a wheelchair and had a limb prosthesis. He was independent with eating, oral hygiene and personal hygiene. He was dependent on toileting. He required substantial assistance with showering. 2. Resident interview Resident #3 was interviewed on [DATE] at 3:11 p.m. Resident #3 said he had a hard time adjusting his air mattress and it was too firm. He said the setting was supposed to be set at 60 and last week it was set at 300 plus. He said the mattress was new and the staff did not know how to use the mattress or how to maintain it. 3. Resident observation On [DATE] at 3:19 p.m. Resident #3's air mattress was observed. The air mattress was labeled Direct Supply Panacea Air Ease Bariatric Mattress. The air mattress had a control which included a digital display screen with a positive (+) symbol and negative (-) symbol on the right side. The display screen said 60. On the right side of the display screen, there was a cycle time area with the option of 10, 15, 20 or 25. The number 25 was lit up. There were green indicators labeled normal pressure and low pressure. Normal pressure was illuminated. -However, Resident #3's vital signs record revealed that on [DATE] at 1:40 p.m. he weighed 179 pounds (see record review below). 4. Record review Review of Resident #3's [DATE] CPO revealed the following physician's order: Mattress with pump for pressure distribution. Check function and setting every shift, ordered [DATE]. -However, the physician's order did not indicate what settings the mattress should be set on. The [DATE] note revealed Resident #3's mattress was currently not functioning. The [DATE] note revealed the resident's mattress was deflated despite being plugged in. The note documented there had been a work order placed for the mattress on [DATE] and [DATE]. The [DATE] note revealed Resident #3's air mattress was being repaired and the resident currently had a regular mattress. The [DATE] behavior note revealed Resident #3 was heard yelling out multiple times during the shift saying This hurts. The nurse assessed the resident each time and the resident repeatedly verbalized pain and discomfort due to his mattress. The resident was repositioned and pillows were placed for comfort. Medication was given but the interventions were ineffective. The [DATE] nurse note revealed the nurse heard a beeping sound coming from Resident #3's room. The nurse inspected the resident's air mattress and noted a red light indicating low pressure. The nurse informed the resident the settings had to be readjusted and the resident told the nurse she needed to listen to him because the mattress had been fixed the previous day ([DATE]) and it was right where he wanted it. The resident instructed the nurse not to touch his bed. The nurse attempted to educate the resident that due to the air leak, the bed would be deflated, and the resident would be able to feel metal bars from the bed. The resident declined and said to leave it alone. The [DATE] nurse note revealed Resident #3t was heard yelling Help, help, help. The nurse and a certified nurse aide (CNA) entered his room and the resident said the bed was hard as rocks and he wanted the staff to fix it. The nurse instructed the resident he would need to sit in the motorized wheelchair so the air mattress could inflate, and the resident agreed. Upon inspection of the mattress, the cardiopulmonary arrest (CPR) tab was noted to not be in place, causing an air leak. The resident was instructed about the use of the air mattress and the importance of leaving the settings and tabs in place to prevent air leakage. -However, a review of Resident #3's electronic medical record (EMR) did not reveal an assessment or documentation of what the air mattress settings should be for Resident #3's mattress. 5. Staff interviews CNA #2 and CNA #3 were interviewed together on [DATE] at 2:55 p.m. CNA #3 said she knew a resident had an air mattress because she was told during the report when a resident was first admitted . She said it was important to know that a resident had an air mattress because staff had to use a flat sheet instead of a fitted sheet when making the resident's bed if the resident had an air mattress. CNA #2 and CNA #3 said the nurses were responsible for knowing what the setting should be for the residents' air mattresses. CNA #2 and CNA #3 said they were familiar with Resident #3. CNA #2 and CNA #3 said the resident had an air mattress because he had a spot on his buttocks that hurt, as well as it was his preference to have an air mattress. CNA #2 said Resident #3 had issues with his mattress and it had been switched for a different mattress a couple times. CNA #3 said Resident #3 would blame the nights he did not sleep well on his mattress. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 10:35 a.m. LPN #1 said she had worked at the facility for six weeks. LPN #1 said she knew a resident had an air mattress because there was a physician's order and she checked the mattress every shift. She said residents had air mattresses to help with wound healing. She said it was important to check the setting on air mattresses in order to make sure the mattress was not deflated or on the improper setting. She said if there was an issue with an air mattress, she notified her manager. LPN #1 said she was familiar with Resident #3 and she was not aware if he had any issues with his mattress. The DON was interviewed on [DATE] at 4:49 p.m. The DON said staff should know a resident had an air mattress because there was a physician's order to check the settings of the air mattress. She said all residents in the facility with an air mattress, except one resident, had the same air mattress. The DON said the air mattress settings for the air mattresses that all residents had was based on the resident's weight. She said the nurses should check the resident's weight in their EMR and then confirm the setting on the resident's air mattress. The DON said she was familiar with Resident #3. She said he was very particular about his air mattress and he had an air mattress more for comfort than for wound care. The DON said the previous NHA had worked closely with Resident #3 on finding the right air mattress and the right setting because he took up a lot of the staff's time trying to troubleshoot his mattress. The DON said the NHA purchased two new air mattresses and one of the mattresses was provided to Resident #3. The DON said staff were not trained on Resident #3's new air mattress and how to check the settings. II. Failed to ensure the manufacturer's recommendations were followed for Resident #4's wander guard A. Facility policy and procedure The Resident Alarms policy and procedure, revised [DATE], was provided by the NHA on [DATE] at 11:27 a.m. It read in pertinent part, The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary.B. Manufacturer's recommendations According to the Code Alert In-service orientation manual, chapter 3 pg 1, The bracelets are made of heavy fiber-reinforced plastic, that is tear and stretch resistant to inhibit the removal of bracelets from residents. When wrist placement is used, we recommend that the bracelet be fastened to the resident's dominant wrist. For example, fasten the bracelet to the right wrist of right-handed people. This deters residents from trying to pull off bracelets. C. Resident #41. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease, anxiety, and unsteadiness on feet. According to the [DATE] MDS assessment, the resident was severely cognitively impaired with a BIMS score of three out of 15. She required setup assistance with eating, oral hygiene and showering. She was independent with toileting. She required supervision with showeringThe assessment revealed a wander and elopement alarm was used daily and the resident wandered daily. 2. Observation On [DATE] at 9:30 a.m. registered nurse (RN) #2 had multiple plastic wristbands in different colors in her hand. RN #2 brought Resident #4 to the long dining table in the kitchen in the Pond's unit. RN #2 showed Resident #4 the wristbands and asked the resident which color she wanted to put on her wrist. Resident #4 picked a color that matched her clothes and RN #2 placed the wander guard on her wrist. 3. Record reviewReview of the [DATE] CPO revealed the following physician's order:Safety device: wander guard to the right wrist. Check placement every shift, every day and night shift. Monitor placement and location, started [DATE] and stopped [DATE].Safety device: wander guard to the right ankle. Check placement every shift, every day and night shift. Monitor placement and location, started [DATE] and stopped [DATE]. Safety device: wander guard to the left ankle. Check placement every shift every day and night shift. Monitor placement and location, start [DATE] and stopped [DATE]. Safety device: wander guard to the left wrist. Check placement every shift, every day and night shift. Monitor placement and location, started [DATE] and stopped [DATE]. Safety device: wander guard to right ankle. Check placement every shift, every day and night shift. Monitor placement and location, started [DATE] and stopped [DATE]. Safety device: wander guard to the right wrist. Check placement every shift, every day and night shift. Monitor placement and location, started [DATE]. The [DATE] day nurse note revealed a CNA reported to the nurse that Resident #4 removed the wander guard that was on her wrist. The CNA was able to find the device. The nurse placed the wander guard on the resident's right ankle to see if the resident was able to tolerate it better. The physician's order was updated in the resident's EMR to reflect the new location. The [DATE] evening nurse note revealed the resident removed the wander guard this evening ([DATE]). The staff found the device in the resident's dresser drawer. The wander guard was placed back on the resident's left ankle and the physician's order was updated. The [DATE] nurse note revealed Resident #4 removed the wander guard. The staff found a wander guard on top of the resident's dresser and replaced it to the resident's right wrist. Another wander guard was found in the resident's room and was taken to the nurses' station. The [DATE] nurse note revealed Resident #4 removed the wander guard and staff replaced the wander guard on the resident's right wrist. -However, there was no documentation to indicate that the placement of the resident's wander guard was assessed to determine why she continued to be able to remove the safety device or where the best placement of the device should be for Resident #4. D. Staff interviews CNA #2 and CNA #3 were interviewed together on [DATE] at 2:55 p.m. CNA #2 and CNA #3 said nurses were responsible for checking the placement of wander guards on residents. CNA #3 said when she showered residents, she checked the wander guard. CNA #3 said she made sure the wristband was secure enough that it could not go over the resident's hand but loose enough that it did not cause skin irritation. CNA #2 and CNA #3 said they checked to make sure that the residents' wander guards could move a little around the wrist, but not too easily. LPN #1 was interviewed on [DATE] at 10:35 a.m. LPN #1 said nurses were responsible for checking the placement of wander guards on residents. She said she checked wander guards by placing two fingers in between the wander guard wristband and the resident's forearm. She said it was important that the wander guard was loose enough that it did not cause skin irritation, but tight enough that the resident could not take it off. Registered nurse (RN) #1 was interviewed on [DATE] at 3:21 p.m. RN #1 said nurses were responsible for checking the placement of wander guards on residents. She said she checked wander guards by placing one finger in between the wander guard wristband and the resident's forearm. She said it was important that the wander guard was loose enough that it did not cause skin irritation, but tight enough that the resident could not take it off. The DON was interviewed on [DATE] at 4:35 p.m. The DON said nurses were responsible for checking the placement of wander guards on residents. She said she was not aware of the different ways CNAs, LPNs and RNs checked the placement of wander guards on residents. The DON said staff should not use their fingers as a rule of thumb for how tight or loose the wander guard should be. The DON said the way the CNAs described how they checked the placement sounded the most accurate. The DON said she was familiar with Resident #4. The DON said she did not know the resident took off her wander guard yesterday ([DATE]). She said there were a couple of residents who had wander guards who were able to take their wander guards off and she said the interdisciplinary team (IDT) tried different wristbands (instead of the wristbands supplied by the manufacturer) to see if residents were less likely to find a way to take off the wristband. The DON said she did not know the manufacturer's recommendation for the type of wander guards the facility used was to place the wristband on the resident's dominant hand. The DON said she needed to ensure all staff were trained on how to check the wander guard placement in order to determine the reason residents were able to take wander guards off their wrists and ankles. She said it was important to determine how a resident was consistently removing their wander guard because residents who had wander guards had them because they were an elopement risk.

Based on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for two (#58 and #45) of six residents out of 25 sample residents. Specifically, the facility failed to: -Ensure Resident #58 and Resident #45 were offered non-pharmacological interventions prior to administering as-needed (PRN) antipsychotic medications; and, -Ensure Resident #58's representative consented to increasing the dose of an antipsychotic medication.Findings include: I. Facility policy and procedure The Psychotropic Medication Management policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:27 a.m. It read in pertinent part, Residents and representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions. If antipsychotic medications are prescribed, documentation must show indication for the antipsychotic medication; multiple attempts to implement care planned, non-pharmacological approaches; ongoing evaluation of the effectiveness of the interventions with rationale for decisions; and adequate monitoring for adverse consequences and medication side effects. Resident, family member or PRN (as needed) orders for psychotropic medications are limited to 14 days and excluding antipsychotics, may only be extended if the practitioner documents the rationale for the extended time in the medical record and indicates a specific duration of time. PRNs for antipsychotics require assessment and a new order by the practitioner every 14 days. PRN medications are to treat emergencies or address acute or intermittent symptoms and must be used to treat a diagnosed specific condition. The practitioner must directly examine the resident and assess the resident's current condition and progress to determine if the PRN antipsychotic medication is still needed and document the following is the antipsychotic medication still needed on a PRN basis; what is the benefit of the medication to the resident; have the resident's expressions or indications of distress improved because of the PRN medication.II. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE] and discharged on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included Alzheimer's disease, insomnia, depression, anxiety, restlessness, agitation and hostility. According to the [DATE] minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on staff assistance for oral hygiene and toileting. She required substantial assistance with showering and partial assistance with personal hygiene. The assessment revealed she did not have physical or verbal symptoms directed towards others and she wandered daily, based on the 14-day assessment look back period. The assessment revealed the resident received antipsychotic medications on a routine basis.B. Resident's representative interview Resident #58's representative was interviewed on [DATE] at 2:35 p.m. The representative said a short time after Resident #58 was admitted to the facility ([DATE]), the facility called him to see if he was okay with them administering medications to help mellow the resident. He said the facility told him she was agitated and the behavior was uncontrolled. He said he agreed to let them administer the medication because the facility explained it was temporary. The representative said the resident was not big on taking scheduled medications but he thought the resident would be okay taking medications for a short period of time. The representative said when it came time to transfer the resident to another facility ([DATE]), he found out Resident #58 was on several psychotropic medications that were scheduled for daily use. The representative said he was never told the medications changed from as needed use back in [DATE] to scheduled use on a daily basis. The representative said Resident #58 would not have wanted to be on psychotropic medications on a regular basis. The representative said Resident #58 was now at another nursing facility. He said she was not receiving any scheduled psychotropic medications at the new facility and her behavior was managed. C. Record review Review of Resident #58's [DATE] CPO revealed the following physician's orders: Lorazepam (an antianxiety medication) 1 milligram (mg). Take 0.5 mg by mouth one time only for agitation and safety issues until [DATE], ordered [DATE]. Lorazepam 1 mg. Take 0.5 mg by mouth one time only for aggression until [DATE], ordered [DATE]. Lorazepam 0.5 mg. Take one tablet by mouth every 12 hours as needed for agitation and aggression for 14 days. Use of hydroxyzine dose if ineffective, ordered [DATE]. Olanzapine (an antipsychotic medication) 15 mg. Take one tablet by mouth one time a day for psychotic behavior and behavioral disturbance, ordered on [DATE] and discontinued on [DATE].Olanzapine 5 mg. Take one tablet by mouth one time a day for Alzheimer's with agitation, ordered on [DATE] and stopped on [DATE]. Olanzapine 20 mg. Take one tablet by mouth one time a day for psychosis. Administer at 3:00 p.m, ordered on [DATE]. Seroquel (an antipsychotic medication) 25 mg. Take one tablet by mouth every eight hours as needed for agitation until [DATE], ordered [DATE] and stopped on [DATE]. Seroquel 25 mg. Take one tablet by mouth every 12 hours as needed for agitation. Try non-pharmacological interventions and redirection prior to using, ordered [DATE] and stopped [DATE]. Review of Resident #58's [DATE] medication administration record (MAR) revealed the following medications were administered to the resident: Lorazepam 1 mg was administered on [DATE] and [DATE]. Olanzapine 15mg was administered on [DATE] and [DATE]. Olanzapine 5 mg was administered on [DATE], [DATE], [DATE] and [DATE]. Review of Resident #58's [DATE], [DATE], [DATE], [DATE] and [DATE] MARs revealed Olanzapine 20 mg was administered to the resident once daily. Review of Resident #58's consents for use of psychoactive medication revealed the following: The olanzapine consent was obtained via phone from the resident's representative on [DATE]. - However, there was no documentation regarding what dose of the medication was discussed with the representative. The olanzapine consent from [DATE] revealed the resident's representative refused to sign on [DATE]. -However, the consent from [DATE] was over three months after the first dose of olanzapine was administered to the resident, despite the Olanzapine having been increased on [DATE] from 15 mg daily to 20 mg daily. There was no documentation indicating the representative authorized the increase of the medication. The [DATE] nurse note revealed the representative was called to inform him on the use of Lorazepam for Resident #58. The nurse called the physician and received an order for a one-time dose of lorazepam for safety issues. -However, there was no documentation the nurse explained to the representative the options, the risks, the benefits, side effects, alternatives and how long the medication would be used for the resident. The [DATE] behavior note revealed the resident was given a PRN (as needed) dose of Seroquel and a PRN dose of lorazepam. The note documented neither of the medications were effective. -However, there was no documentation regarding what non-pharmacological interventions were attempted and if the interventions were effective before the seroquel and lorazepam were administered to the resident. The [DATE] behavior note revealed Resident #58 attempted to exit the unit once. One display of anxious behavior was observed as well. Lorazepam was administered and care was ongoing. -However, there was no documentation regarding what non-pharmacological interventions were attempted and if the interventions were effective before the lorazepam was administered to the resident. III. Resident #45A. Resident status Resident #45, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included vascular dementia with behavioral disturbances, anxiety, chronic respiratory failure with hypoxia (unable to receive enough oxygen), transient ischemic attack (TIA or mini stroke) and cerebral infarction (an ischemic stroke when blood flow is blocked to a part of the brain). The [DATE] MDS assessment revealed the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. She used a walker and a wheelchair. She required partial assistance with eating and personal hygiene. She was dependent on oral hygiene, toileting, and showering. The assessment revealed she had behavioral symptoms not directed toward others daily during the assessment look-back period. The assessment revealed the behavior significantly interfered with the resident's participation in activities and social interactions. The behavior significantly intruded on the privacy or activities of others and disrupted the care or living environment. The assessment revealed the resident received antipsychotic medications, antianxiety medications and antidepressant medications. B. Resident's representative interview Resident #45's representative was interviewed on [DATE] at 9:34 a.m. The representative said Resident #45 took lorazepam as needed because the facility told him she sometimes had behaviors that affected others. The representative said she made loud noises that were a disruption to other residents. He said he visited the resident and if she made noises when he was there, he would talk to her in Italian because that was her first language. He said another intervention that helped the resident was to turn the television on so she could watch any type of sports. He said he thought the facility administered lorazepam to Resident #45 about two times per week. C. Observation During a continuous observation on [DATE], beginning at 3:32 p.m. and ending at 4:58 p.m., the following observations were made in the Pond unit dining area and living room area: Resident #45 was in her room with the door closed with an unidentified certified nurse aide (CNA). At 3:32 p.m. a resident was yelling, which could be heard upon entering the unit. The yelling was identified as coming from Resident #45's room. At 3:41 p.m. an unidentified resident went to Resident #45's room. The unidentified resident said there was a child in Resident #45's room as she stood at the closed door. At 3:44 p.m. Resident #36 opened the door of Resident #45's room. Resident #36 asked if Resident #45 was okay. At 3:47 p.m. Resident #45 came out of her room in a wheelchair with an unidentified CNA. The CNA pushed the resident to a dining room table. At 3:50 p.m. an unidentified resident told the nurse Resident #45's yelling was disturbing. From 3:32 p.m. to 3:50 p.m. Resident #45 was heard saying oh no multiple times. From 3:50 p.m. to 4:12 p.m. Resident #45 was observed with her eyes closed. From 4:12 p.m. to 4:58 p.m. Resident #45 was observed eating and drinking. D. Record Review The [DATE] social services assessment revealed the resident had advanced dementia. She loved television and socialization. She would self-soothe by yelling out. Staff would determine if she needed to be in her recliner, have something to eat or to drink. She was very hard of hearing. Review of Resident #45's July CPO revealed the following physician's order: Lorazepam 0.5 mg. Take 0.5 mg tablet by mouth every 24 hours as needed for severe agitation and vocalization related to vascular dementia with behavioral disturbances for 14 days, ordered [DATE]. Lorazepam 0.5 mg. Take 0.5 mg tablet by mouth every 24 hours as needed for severe agitation and vocalization related to vascular dementia with behavioral disturbances for 14 days, ordered [DATE]. Lorazepam 0.5 mg. Take 0.5 mg tablet by mouth every 24 hours as needed for severe agitation and vocalization related to vascular dementia with behavioral disturbances for 14 days, ordered [DATE]. Lorazepam 0.5 mg. Take 0.5 mg tablet by mouth every 24 hours as needed for severe agitation and vocalization related to vascular dementia with behavioral disturbances for 14 days, ordered [DATE]. Lorazepam 0.5 mg. Take 0.5 mg tablet by mouth every 24 hours as needed for severe agitation and vocalization related to vascular dementia with behavioral disturbances for 14 days, ordered [DATE]. Lorazepam 0.5 mg. Take 0.5 mg tablet by mouth every 24 hours as needed for severe agitation and vocalization related to vascular dementia with behavioral disturbances for 14 days, ordered [DATE].Review of Resident #45's [DATE] MAR revealed lorazepam was administered to the resident on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #45's [DATE] MAR revealed lorazepam was administered to the resident on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #45's [DATE] MAR revealed lorazepam was administered to the resident on [DATE], [DATE], [DATE] and [DATE]. Review of Resident #45 electronic medical record (EMR) revealed no documentation indicating non-pharmacological interventions were offered and if they were effective before the lorazepam was administered to the resident.IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 10:35 a.m. LPN #1 said she had worked at the facility for six weeks. LPN #1 said she was not sure who explained the risks versus benefits when a resident started a psychotropic medication. LPN #1 said if she were to get an order from a physician for a new psychotropic medication, she would ask her on-call manager about consent. LPN #1 said she assumed if there was a physician's order for a psychotropic medication, consent was obtained prior to the order being placed. She said the consent included the risks versus benefits, the side effects and alternatives. She said the name of the medication, the dose and duration would be explained to the resident or the resident's representative. She said if there was an increase in the dose of a psychotropic medication, the resident or the resident's representative needed to be notified and consent obtained for the increase in the dose. She said if the medication was PRN, she could administer the medication for the timeframe explained to the resident or the resident's representative. She said if the same medication was ordered after the timeframe expired, the resident or the resident's representative needed to be notified. LPN #1 said if a psychotropic medication was given, a non-pharmacological intervention should be attempted prior to the medication being given. LPN #1 said the non-pharmacological interventions were documented as a progress note or on the MAR. She said she should document if the intervention was effective or ineffective. LPN #1 said she did not work here when Resident #58 was in the facility and she was not familiar with Resident #45. She said she usually did not work in Resident #45's unit. Registered nurse (RN) #1 was interviewed on [DATE] at 3:21 p.m. RN #1 said she had worked at the facility for over a year. RN #1 said the charge nurse was responsible for explaining the risks versus benefits when a resident started a psychotropic medication. RN #1 said the name of the medication, the dose and the duration of using the medication was explained to the resident or the resident's representative. She said if there was an increase in the dose of the medication, the resident or the resident's representative needed to be notified and consent obtained for the increase in the dose. She said the consent was documented on the consent form. RN #1 said if the medication was PRN, she could administer the medication for the timeframe explained to the resident or the resident's representative. RN #1 said if a psychotropic medication was given, a non-pharmacological intervention should be attempted prior to the medication being given. RN #1 said the non-pharmacological interventions were documented as a progress note or on the MAR. She said she would document if the intervention was effective or ineffective. RN #1 said she was familiar with Resident #58. She said every day around 3:00 p.m., the resident would be restless, hallucinate and hear voices. She said effective interventions were having the resident sit in the corner recliner in the living room in her unit. RN #1 said other effective interventions were walking with her, talking to her in a calm voice, giving her a drink in a special cup, and giving her a blanket that was special to her. RN #1 said she had seen behaviors occur when Resident #58 needed toileting assistance. RN #1 said she was not familiar with Resident #45. The director of nursing (DON) was interviewed on [DATE] at 4:35 p.m. The DON said the charge nurse verified physician's orders for newly admitted residents and reviewed the risks versus the benefits of the medication, including the name of the medication, the dose and how long the medication would be used for. She said if there was an increase in a dose of a psychotropic medication, the resident or the resident's representative needed to consent to the increase. The DON said the consent was documented on the consent form or as a progress note by the physician or a nurse. The DON said when a PRN medication was administered, a non-pharmacological intervention should be attempted prior to the medication being administered. The DON said the interventions should be documented in the same progress note that indicated the PRN medication was administered. The DON said she was familiar with Resident #58 and Resident #45. The DON said she thought there was consent for the psychotropic medications that Resident #58 was administered, including when there was an increase in the dose of her olanzapine. The DON said it was not clear if non-pharmacological interventions were attempted for Resident #45 prior to administering PRN lorazepam to the resident.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator. Findings include: I. Observations On 3/18/24 at 11:09 a.m., the medication refrigerator was observed with the registered nurse liaison (RNL). A vial of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) was in a storage box. -The storage box was not permanently affixed to the inside of the refrigerator. II. Staff interviews The RNL was interviewed on 3/18/24 at 11:11 a.m. The RNL said she was new to the facility and still in training. She said she was not aware that controlled medications were required to be in a permanently affixed locked compartment in the refrigerator. She said she understood anyone with access to the refrigerator could just take the controlled medication boxes out of the refrigerator. The director of nursing (DON) was interviewed on 3/20/24 at 1:10 p.m. The DON said she was not aware that refrigerated controlled medications were required to be in a permanently affixed locked compartment, however, the maintenance department had attached the storage box to the inside of the refrigerator (during the survey).

Based on record review and interviews, the facility failed to ensure residents were free from abuse for one (#26) of two residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to protect Resident #22 from sexual abuse by Resident #26. Findings include: I. Facility policy and procedure The Abuse Non-Tolerance policy, dated October 2022, was provided by the nursing home administrator (NHA) on 3/18/24. It read in pertinent part, Residents and clients must be free from abuse by anyone, including associates, other residents or clients, consultants or volunteers, family members or legal guardians, friends or other individuals. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Capacity and consent: Residents and clients have the right to engage in consensual sexual activity. However, if the community has reason to suspect that a resident may not have the capacity to consent to sexual activity, the community must take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity. Protection of the person who may have been a victim of abuse: -Changing caregiver assignments; -Restricting visitors; -Frequent monitoring of the resident; -Relocating the resident to a more visible area; -Utilizing a companion or sitter to stay with the resident; and, -Have the resident leave the community as appropriate and if desired with friends or family. II. Facility investigation The facility investigation, dated 2/5/24, documented the following information in pertinent part, (Resident #22) and (Resident #26) were sharing transportation to church. (Resident #22) reports that they were holding hands in church and it was consensual. On the bus ride back to the community, they were also holding hands. (Resident #22) reports that she let go and when she did (Resident #26) did not remove his hand from her person and that his hand lingered on her clothing over her breast. She did not say anything and he removed his hand. (Resident #22) reported the incident to a nurse after returning to the community. Nurse provided information to DON (director of nursing) and Social Worker via email, which was read the following day just prior to submission of report. (Resident #22) denies feeling unsafe with (Resident #26), and states 'we are friends, he is a boob man, he's not aggressive.' (Resident #22) would like to continue to share the bus to church on Sundays. No physical redness, bruising. Resident is relaxed in body language and denies feeling unsafe. No physical harm, (Resident #22) did not provide consent, also wishes to continue to have interactions with alleged assailant (Resident #26). Every 30 minute observations of alleged assailant (Resident #26). Behavior monitoring updated in treatment administration record (TAR) to be more individualized to (Resident #26) specific behaviors of concern. Continue observation monitoring when resident is out of room. Additional education provided to nursing staff regarding behaviors, interventions and documentation. Place next to male or out of reach of females when possible during activities and transportation. Consider alternative living arrangement. Resident and POA (power of attorney), notified of concern regarding pattern of behavior and inability to retain education or control impulses secondary to TBI (traumatic brain injury). Social services will assist family in looking for alternate living options. If the behaviors continue (Resident #26) may be facing involuntary discharge. Review of the State Agency portal revealed the facility reported the incident on 2/5/24. III. Resident #26 (assailant) A. Resident status Resident #26, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included personal history of traumatic brain injury, hemiplegia (paralysis), unspecified, affecting left non-dominant side, mild cognitive impairment, psychophysiologic insomnia, personality change due to known physiological condition and other sexual dysfunction not due to a substance or known physiological condition. The 1/29/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score 14 out of 15. No behaviors were documented. He required set-up assistance with toileting, moderate assistance with bathing and maximal assistance with lower body dressing. He was independent with transfers. B. Resident interview Resident #26 was interviewed on 3/17/24 at 4:42 p.m. Resident #26 said he had lived at the facility for four years. He said he stayed in his room most of the time and kept himself busy watching movies on his television (TV) and computer, reading and writing emails and people could visit with him if they wanted. He said he did not want to leave his room because he was accused of touching a female resident. He said when he was in his twenties, he spent many years living and working in Brazil as a model. He said he wrote a book about that time but it was not published yet. C. Record review A review of Resident #26's comprehensive care plan, initiated 1/30/2020, revealed the resident had a diagnosis of a traumatic brain injury (TBI) and had impulse control issues. The resident had hypersexuality and watched pornography at times. Interventions included: Be aware of any behaviors that put the resident or others at risk and report this to the DON , nurse manager or social service director (SSD), initiated 5/4/2020; If the resident was inappropriate in anyway staff was to directly tell him in the moment that what he was doing was not alright; If the resident was confused, staff was to tell him what behaviors were appropriate, if the resident was masturbating in front of others, staff was to tell him it was not an appropriate time to do that, and allow him to have some privacy in his room, initiated 1/30/2020; If the resident was out of his room, staff was to supervise him so he did not put himself and others at risk, if the resident's zipper was down and he was exposing himself, staff were to let him know and either take him back to his room or ask him to return to his room, initiated 11/16/2020; the resident required two certified nurse aides (CNAs) to provide personal care and bathing at all times; If the resident made inappropriate sexual comments or began to masturbate while being showered, staff was to tell him to stop and tell him it was inappropriate, initiated 6/12/23; The resident was to be placed/encouraged to sit next to males or out of reach of females during events or during transportation, initiated 2/9/24. -The care plan did not address the need for the resident to have close staff supervision when Resident #26 was outside of his room. The life enrichment (activities) care plan, initiated 2/4/2020, revealed Resident #26 shared interest in going out to church services on Sundays. All arrangements were made to help with transportation, initiated: 9/13/21. \ -The care plan failed to address appropriate supervision when Resident #26 was outside of the facility. Review of Resident #26's electronic medical record (EMR) revealed the following progress notes: On 9/13/23, a nurse documented in pertinent part, Resident was seen touching another resident in an inappropriate manner. Resident was made aware that his behavior was inappropriate and separated from other resident. Physician assistant and DON informed. Orders received to increase resident's Sertraline (antidepressant) in order to control his behaviors. On 9/13/23, a physician documented in pertinent part, Hemiparesis, left. Due to TBI. Wheelchair dependent. Cognitive and neurobehavioral dysfunction following brain injury. Cognitive and behavioral problems with executive dysfunction, impaired decision-making, disinhibition, lack of safety awareness, impulsivity, irritability, and inappropriate sexual behaviors. He tends to have unrealistic expectations, and poor insight into the limitations of his impairments. Inappropriate behaviors involving female residents, risk of harm, will increase Zoloft (antidepressant) to 75 mg (milligrams) qd (daily). On 9/20/23, a nurse documented in pertinent part, CNA reported that resident was behaving in a way that was sexually inappropriate. She stated that he was in his doorway with his penis in his hands while the housekeepers were mopping. Resident was told to go into his room and not to expose himself in the hallway. On 10/24/23, a social worker documented in pertinent part, Resident #26 is a long term care resident who resides in a private room in the (name) neighborhood at the (facility). Resident #26 experienced a TBI as a young adult. His only daughter, (name), lives in (town). Resident #26 does not engage in many activities or socialization, preferring to stay in his room and watch TV. His room is covered in pictures of himself pre-TBI and family members. Occasionally he will attend an activity, especially if it involves food. Resident #26 has also attended a photography activity before, which he enjoyed. Even if he does not want to attend many group activities, Resident #26 enjoys it if you stop by him and engage in conversation 1:1 (one-on-one). He enjoys listening to stories about others' lives, and telling you about his life. He has written a book about his life, and sometimes asks for help in getting it published. [NAME] can sometimes make inappropriate sexual comments, if this happens it is important to tell him that it was inappropriate. Resident #26 enjoys attending church services at the Christian church on Sundays when there is a driver available. On 2/5/24, the DON documented in pertinent part, Interview with Resident #26 regarding allegation of sexual misconduct by another resident. (Name of social worker), LSW (licensed social worker) present. Resident #26 acknowledges that he was holding hands with another resident, denies touching breast or lingering hand states 'I didn't do that .she's old .On the bus? I was here and she was over there. We were closer at church.' On 2/9/24, the DON documented in pertinent part, Spoke with resident regarding the investigation of sexual misconduct. (Name of social worker), LSW present. Resident #26 reports that as he has considered our previous conversation. He recalls when Resident #22 removed her hand and his remained on her body and said 'but her (breasts) are huge, they're down to here, so what am I supposed to do, plus she never said anything, she could've moved my hand.' The vulnerability of the surrounding population, likelihood of cognitive impairment and inability to know other individuals medical history was reviewed. Resident informed of requirement and importance of not touching other residents. Discussed an established pattern of behavior and need to seek alternate living arrangement if the behaviors persist. Resident said 'I won't, these people are all old around here, I don't get off touching old ladies.' Resident acknowledges his understanding. Resident is aware of notification to POA (power of attorney). -Despite the facility's awareness of Resident #26's hypersexual behaviors and history of inappropriately touching a female resident, the facility allowed the resident to travel next to a female resident in a van (see facility investigation above). -The facility failed to protect Resident #22 from being inappropriately touched by Resident #26. IV. Resident #22 (victim) A. Resident status Resident #22, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, post-traumatic stress disorder, alcohol dependence with alcohol-induced persisting dementia and major depressive disorder. The 1/21/24 MDS assessment revealed the resident had intact cognition with a BIMS score of 13 out of 15. The resident had no hallucinations, delusions or behaviors. She had a range of motion impairment on one side of both the upper and lower extremity. She required substantial/maximal assistance with toileting, bathing and dressing and partial/moderate assistance with transfers. B. Resident interview Resident #22 was interviewed on 3/20/24 at 12:42 p.m. Resident #22 said she had experienced inappropriate touching in the past. She said one evening Resident #26 was sitting at the computer desk on her unit when she went down to use the computer. She said he moved over and let her use the computer and started telling her about his time in Brazil and how he loved the women there because they did not wear shirts and the men could touch and kiss the women's breasts. She said when she was finished on the computer she bent over causing her breast to fall with gravity and Resident #26 touched her right breast. She said she told him this isn't Brazil and we aren't going to be doing that. She said she did not wear a bra. She said she was not afraid of Resident #26 and did not feel uncomfortable around him because she knew how to take care of herself. She said after the computer incident, Resident #26 was banned from going down to her unit and was even banned from being around her for a while. C. Record review A review of Resident #22's comprehensive care plan, initiated 6/20/19, revealed the resident had impaired cognitive function/dementia or impaired thought processes. She did not have safety awareness and was often impulsive. Interventions included: Reminding the resident of goals she had set such as not over eating and focusing on keeping her weight low, providing gentle reminders if staff saw her doing anything unsafe or making poor decisions, providing the resident with simple instructions and reminders when needed and staff was to remember, due to the resident's cognitive impairments, she would l often have the same conversation over again. The mood care plan, initiated on 6/20/19, revealed the resident struggled with alcohol addiction in the past and used alcohol to treat her depression and get to sleep. The resident would overeat because she thought it would make her feel better and she was often down which would present as irregular sleep patterns, irritability and overeating. The resident saw a therapist but due to her dementia, insight work was sometimes difficult. Interventions included: Arranging for psychological consultation and follow up as indicated, assisting the resident with developing/providing her with a program of activities that was meaningful and of interest, Encouraging and providing opportunities for exercise and physical activity, discussing with the resident, her family and caregivers any concerns, fears or issues regarding health or other subjects as they occur, encouraging the resident to express her feelings and giving her time to talk., avoiding challenging her behavior as she did not respond well and showing the resident care and gentleness. -The care plan failed to address Resident #22's vulnerability and risks for being a victim of sexual abuse. -Review of Resident #22's EMR did not reveal documentation that she was inappropriately touched by Resident #26. V. Staff interviews The SSD was interviewed on 3/18/24 at 11:25 a.m. The SSD said Resident #26 was sexually and verbally inappropriate towards staff and would ask for sexual favors. She said the resident was observed by staff placing his hand on a female resident's leg while she was playing piano. The residents were immediately separated. She said the facility investigated an incident when a female resident reported that Resident #26 touched her breast while on a bus trip to church on 2/4/24. She said the female resident was not upset or afraid of Resident #26, she said the residents were still friends. She said Resident #26 was always accompanied/supervised by staff when he wished to leave his room and join any group activities. Certified nurse aide (CNA) #5 was interviewed on 3/19/24 at 9:30 a.m. CNA #5 said she was aware of Resident #26 being sexually inappropriate towards staff. She said the resident's behaviors were documented in the care plan. She said she had not experienced any inappropriate situations with Resident #26. She said she worked mostly night shifts and the resident was always respectful when she was assisting him with activities of daily living (ADL). Licensed practical nurse (LPN) #2 was interviewed on 3/19/24 at 9:36 a.m. LPN #2 said she was aware of Resident #26's inappropriate sexual behaviors towards staff and female residents. She said she witnessed the incident when Resident #26 placed his hand on a female resident's leg. She said staff immediately separated both residents. She said she was aware of Resident #26 exposing his lower body parts to some staff, mostly housekeepers as the housekeeping closet was across the hall from the resident's room. She said Resident #26 was easy to redirect. She said once a staff member observed his inappropriate behavior, the resident would apologize. VI. Facility follow-up Resident #26's care plan was updated on 3/20/24 (during the survey) to include the following intervention: I enjoy attending church on Sundays. Please place me in my w/c (wheelchair) out of reach of any other residents when riding the bus.

Based on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to follow accepted standards of practice for medication administration by pre-pouring medications prior to confirming the resident was ready and available for medication administration. Findings include: I. Professional references Nursing rights of medication administration, updated on 9/5/22, was retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 3/22/24 at 9:00 a.m. It read in pertinent part: 'Right time'-administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. Long Term Care Nursing: Medication Pass, updated on 1/24/24, was retrieved from https://ceufast.com/course/long-term-care-nursing-medication-pass on 3/22/24. It read in pertinent part: Medication errors are serious and can cause resident harm or even death. It is human nature to want to simplify things when there is much to be done. In an attempt to do this, sometimes shortcuts are made. However, this is not good practice. Especially when it comes to medications. Do not take shortcuts. More specifically, do not, under any circumstances, try to pre-pour medications to save time. Pre-pouring medications are against regulations. In addition, it increases the risk of making mistakes. II. Facility policy and procedure The Medication Storage policy, version one 2024, was provided by the director of nursing (DON) on 3/21/24 at 8:49 a.m. It read in the pertinent part, Medications are administered at the time they are prepared. Medications are not pre-poured. III. Observations On 3/19/24 at 8:36 a.m., the medication pass on the Mountainside unit was observed with the registered nurse (RN) #1. At 9:06 a.m., RN #1 prepared medications for Resident #44. RN #1 walked to the resident's room and found the resident was not in her room. RN #1 returned to the medication cart, wrote the resident's name on the medication cup and put it in the top drawer. RN #1 began preparing medications for the next resident. -RN #1 did not destroy the dispensed medications. -The dispensed medications were not administered to the resident until 10:14 a.m., over an hour after RN #1 prepared them. At 9:11 a.m., RN #1 prepared medications for Resident #50. She dispensed four of the ordered medications into a medication cup for the resident and then stopped. She put the medication cup in the top drawer of the medication cart and locked the cart. RN #1 did not label the medication cup with the resident' sname. She left the medication cart and went to another resident's room to finish flushing a foley catheter. -RN #1 did not destroy the dispensed medications. At 9:27 a.m., RN #1 returned to the medication cart, removed the medication cup for Resident #50 and continued to dispense the remaining medications. At 9:30 a.m. RN #1 took the medication cup to the resident's room and the resident was asleep. She returned to the medication cart, placed the medication cup back in the top drawer and began preparing medications for the next resident. -RN #1 did not destroy the dispensed medications. -The dispensed medications were not administered to the resident until 10:26 a.m., almost an hour after RN #1 prepared them. IV. Staff interviews RN #1 was interviewed on 3/19/24 at 9:11 a.m. RN #1 said she realized she was not supposed to put dispensed medications in the top drawer of the medication cart but she did not know what she should have done because she needed to flush a foley catheter. The DON was interviewed on 3/20/24 at 1:05 p.m. The DON said storing dispensed medications in a medication cup in the top drawer of the medication cart was not safe practice and was not permitted in the facility. The DON said the nurse should have destroyed the medications and dispensed them again when the resident was ready for administration.

Based on observations, record review and interviews, the facility failed to ensure two (#7 and #49) of four residents out of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility failed to: -Ensure Resident #7's portable oxygen concentrator was turned on while she was out of the building at an appointment; and, -Ensure Resident #49 was assisted with removing her cervical collar (c-collar) during meal times. Findings include: I. Resident #7 A. Resident status Resident #7, age 82, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic respiratory failure (shortness of breath) and chronic obstructive pulmonary disease (COPD) ( airflow blockage and breathing related problems). The 2/1/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with transferring, dressing and personal hygiene. B. Resident observation and interviews On 3/19/24 at 9:21 a.m., Resident #7 returned to the facility from an outside appointment. She said she left the building at 8:15 a.m. via facility transportation for the appointment but when she arrived at the appointment was told she did not have an appointment scheduled. The dial of Resident #7's portable oxygen tank was positioned on zero. Resident #7 said she received 2 liters per minute (LPM) of oxygen. She said she was unable to tell if oxygen was flowing through the nasal cannula. At 9:25 a.m. licensed practical nurse (LPN) #1 approached Resident #7 and asked about the appointment. LPN #1 said Resident #7 required 2 LPM of oxygen. LPN #1 turned the dial on the portable oxygen tank to 2 LPM. LPN #1 said Resident #7 had cold hands and proceeded to warm Resident #7's hands up using friction from her own hands prior to placing a pulse oximeter (a non-invasive device which measures the level of oxygen in the blood) on Resident #7's finger. The pulse oximeter indicated Resident #7 had an oxygen saturation level (SpO2) of 87 percent (%). After being on 2 LPM of oxygen for just under two minutes, Resident #7's SpO2 increased to 92%. LPN#1 said the certified nurse aides (CNA) were supposed to ensure the resident's portable oxygen tank was turned on once she was positioned in her wheelchair. She said the CNAs must have forgotten to turn the oxygen tank on before Resident #7 left for her appointment. C. Record review The March 2024 CPO revealed the following physician's order: -Oxygen 2 LPM via nasal cannula (NC) every day and 3 LPM via NC every night. Check pulse oximeter on day and evening shift, ordered 9/11/23. The oxygen therapy care plan,initiated on 6/20/19, revealed Resident #7 utilized oxygen. Pertinent interventions included monitoring for signs and symptoms of respiratory distress and the oxygen flow rate was 2 LPM at night. -The care plan failed to include an oxygen flow rate for day time use. -The care plan failed to reflect the correct oxygen flow rate of 3 LPM at night. The 3/19/24 progress note (during the survey) revealed nursing staff had spoken to the CNA who had assisted Resident #7 out of bed. The CNA told the nursing staff she turned the portable oxygen tank off to fill it and must have forgotten to turn it back on. D. Facility follow up On 3/19/24 at 10:30 a.m. (during the survey), the director of nursing (DON) began providing facility staff education on portable oxygen tank expectations. The education revealed in pertinent parts: When a resident requires supplemental oxygen, please ensure the following: nasal cannula is in their nose, portable oxygen is set to their ordered amount, tank has enough oxygen in it to provide resident with their needed amount for the needed time before a refill is needed. When transferring residents between surfaces please ensure oxygen tubing is hooked up to the appropriate source and the source is turned on to ordered flow rate. The DON also provided written follow up revealing in pertinent: An audit was conducted of all residents with portable tanks on their wheelchairs to ensure that portable oxygen tanks were turned on to the appropriate amount. No additional issues were noted. an education was provided to nursing team members working on 3/19/24, including team members who were working with the above noted resident. Nursing team members not working on 3/19/24 will also be educated. An audit was created for the nursing leadership team (or designees) to monitor random residents from each neighborhood two times per week. This audit will be brought to the community's GO (QAPI) meeting and reported to ensure substantial compliance. -However, the facility's corrective actions began after the concern with the portable oxygen tank was brought to the facility's attention. II. Resident #49 A. Resident status Resident #49, age 75, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included fracture of the neck and muscle weakness. The 2/20/24 minimum data set MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance with bathing, dressing, toileting, limited assistance with personal hygiene and set up / clean up for eating. B. Resident observation and interview On 3/17/24 at 5:00 p.m., Resident #49 was sitting in the main dining room at a table eating soup. The resident was wearing a cervical collar (c-collar) ( a collar used to support and limit movement of neck and head). Resident #49 had awkward movements while eating as she had to bring the eating utensil to eye level and then to her mouth while eating. Resident #49 was interviewed on 3/18/24 at 9:00 a.m. Resident #49 was sitting in her wheelchair in her room eating breakfast with the c-collar on. The resident said she was at the facility receiving therapy after she fell at home in January 2024. She said she fractured her right hip and her neck. Resident #49 said she was doing better than when she first admitted to the facility and was told the c-collar could be removed during meals. Resident #49 said she was unsure who was allowed to remove the c-collar and thought only certain staff were trained on this because only some of the staff would offer to remove the c-collar during meals. Resident #49 said the c-collar was uncomfortable and made eating difficult. She said eating foods containing a lot of liquid, such as yogurt, soup or hot and cold cereals, presented the most difficulty with spilling. Resident #49 said if she could not stab food with her fork or the food did not stick to her spoon she usually spilled food on herself Resident #49's c-collar had multiple small dark circular stains on the padding where her chin was resting. On 3/18/24 a 12:09 p.m., Resident #49 was sitting in her room eating lunch wearing the c-collar. Resident #49 was interviewed again on 3/19/24 at 9:20 a.m. Resident #49 was sitting in her wheelchair in her room eating breakfast wearing the c-collar. She said staff had not offered to remove the c-collar while she was eating. On 3/19/24 at 1:00 p.m., LPN #1 was assisting Resident #49 in her room with a scheduled treatment. LPN #1 said the c-collar could be removed by any nurse or CNA and should be removed at meals. She said the c-collar was removed and reapplied by two velcro straps. LPN #1 said Resident #49 could adjust the velcro on her own if she wanted to. Resident #49 said she was unaware she could do this and did not think she had enough strength in her arms after therapy to adjust the c-collar on her own. On 3/20/24 at 12:15 p.m., Resident #49 was sitting up in her wheelchair in her room eating lunch without her c-collar on. She said someone offered to remove the c-collar while she was eating. On 3/21/24 at 9:30 a.m. Resident #49 was sitting in her wheelchair in her room eating breakfast wearing the c-collar again. The breakfast consisted of fruit mixed with yogurt. She said staff had not offered to remove the c-collar while she was eating. C. Record review -Review of Resident #49's comprehensive care plan, initiated 2/12/24, did not reveal a care plan focus for the resident's c-collar. The March 2024 CPO revealed the following physician's order: -Every day and night shift keep the c-collar in place at all times except when eating, ordered 2/26/24. C. Additional interviews CNA #3 was interviewed on 3/20/24 at 10:00 a.m. CNA #3 said Resident #49's c-collar could be removed when she was eating. She said CNAs could assist the resident with removing the c-collar. CNA #3 said she assisted Resident #49 if she asked for help and offered to help the resident remove the collar sometimes. CNA #4 was interviewed on 3/20/24 at 10:00 a.m. CNA #4 said Resident #49's c-collar could be removed while she was eating. She said CNAs and nurses could assist the resident with removing the c-collar. She said she offered to assist the resident remove the c-collar when she worked with her. The DON and LPN #1 were interviewed on 3/20/24 at 10:20 a.m. LPN #1 said she observed Resident #49 eating that morning (3/20/24) without her c-collar. LPN #1 said she was unsure if the resident had her c-collar removed for all meals. The DON said the physician's order would be clarified to instruct staff to assist Resident #49 with removing the collar at all meals. D. Facility follow up On 3/20/24, the DON began providing staff education it read in pertinent: Please assist Resident #49 to remove her neck brace at meals. It is difficult for her to feed herself with it on and she may not remember every time to ask. On 3/20/24, the March 2024 CPO revealed the revised order: Please encourage and assist me to wear my c-collar when I am not eating and assist me to remove at meals, if I decline please educate me on reasons and benefits. -However, the facility's corrective actions began after the concern with Resident #49's c-collar was brought to the facility's attention. -The facility failed to include updating the care plan to include the c-collar as part of facility follow up.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19 in two of three resident neighborhoods. Specifically, the facility failed to ensure residents were offered, encouraged and provided hand hygiene prior to eating their meals. Findings include: I. Professional reference According to CDC guidance, How to protect yourself and others, updated 11/4/2020; retrieved 1/7/21 from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html Everyone should wash your hands often, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing. It is especially important to wash: Before eating or preparing food. Before touching your face. After using the restroom. After leaving a public place. After blowing your nose, coughing, or sneezing. After handling your mask. Everyone should wear a mask in public settings and when around people who don't live in your household, especially when other social distancing measures are difficult to maintain. II. Facility policy and procedures A policy related to encouraging or providing hand hygiene to residents prior to eating was requested from the nursing home administrator (NHA) and director of nursing (DON) on 1/6/21 at approximately 4:00 p.m. The NHA replied via email on 1/7/21 at 3:11 p.m. He responded that he confirmed there was no specific language in any of their policies related to encouraging resident hand hygiene. He said that issue would fall within general standards of practice. III. Observations The Mountainside neighborhood meal pass was observed on 1/5/21 from 11:50 a.m. through 12:22 p.m. The following was observed: -At 11:50 a.m., certified nurse aide (CNA) #2 was observed not providing or offering hand hygiene to the resident in room [ROOM NUMBER] prior to the resident eating lunch. -At 11:53 a.m., the cook was observed delivering lunch to a female resident in the Mountainside dining room, who was seated in a high-backed wheelchair. He was not observed offering the resident any type of hand hygiene prior to eating her lunch. -At 11:55 a.m., CNA #2 was observed delivering another lunch tray to a resident in their room on the Mountainside hall. Again, the CNA did not encourage the resident to practice any type of hand hygiene prior to eating lunch. No assistance was provided to assist the resident to the sink in their room to wash their hands nor was any other type of alcohol-based hand sanitizer offered to the resident. -At 12:25 p.m., registered nurse (RN) #2 was observed delivering a lunch tray to one of the residents in an isolation room on the Mountainside hall. She was not observed offering the resident encouragement to sanitize their hands prior to eating nor was she observed to provide the resident a method to do so. Both Mountainside and Pondside neighborhoods were observed on 1/6/21 from 11:35 a.m. through 12:12 p.m. consistently. The following was observed: -At 11:55 a.m., CNA #3 was observed serving the resident in room [ROOM NUMBER] their lunch tray. No hand hygiene was performed or offered to the resident prior to eating. -At 12:00 p.m., the nurse aide (NA) was observed serving the resident in room [ROOM NUMBER] their lunch tray. No hand hygiene was performed or offered to the resident prior to eating. -At 12:07 p.m., the NA was observed serving the resident in room [ROOM NUMBER] their lunch tray. No hand hygiene was performed or offered to the resident prior to eating. IV. Staff interview The NHA and the DON were interviewed together on 1/6/21 at approximately 4:00 p.m. They both said they would have expected to see staff encouraging the residents to practice some type of hand sanitization prior to eating. The NHA, DON and the corporate compliance officer (CCC) were interviewed via a zoom meeting on 1/7/21 at 4:00 p.m. The CCC confirmed the parent corporation did not have any type of policy related to offering residents hand hygiene prior to eating. The CCC said, although the facility had no policy, she agreed it was best practice to encourage and offer residents some type of method to practice hand hygiene prior to eating. The DON said she began an all-staff inservice to address this issue on 1/6/21, which continued on 1/7/21. She said the facility would also be monitoring meal services to observe if staff were offering hand hygiene to residents prior to eating. V. Facility COVID- 19 status The director of nursing (DON) was interviewed on 1/5/21 at 8:45 p.m. She said they had no COVID-19 positive residents and one COVID-19 positive staff. She said there was one presumptive positive COVID-19 resident and 32 pending COVID-19 tests for staff.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility production kitchen. Specifically, the facility failed to minimize the risk for potential foodborne illness in an at risk population. The facility failed to ensure: -Appropriate hand washing; -Safe storage of cold foods; and -Food and non-food contact surfaces were maintained in a clean and sanitary manner. Findings include: I. Hand hygiene [NAME] Professional references According to the Food and Drug Administration (FDA) Food Code (2017), pp. 48-50, foodservice staff shall use the following handwashing procedures: -Rinse under clean, running warm water; -Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; -Rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails and creating friction on the surfaces of the hands and arms fingertips, and areas between the fingers; -Thoroughly rinse under clean, running warm water; and -Immediately follow the cleaning procedure with thorough drying using individual disposable towels, a continuous towel system that supplies the user with a clean towel, or a heated-air hand drying device. The FDA Food Code (2017) pp. 49-50, detailed the following instances when foodservice staff should wash their hands: -Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and -After engaging in other activities that contaminate the hands. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised (MONTH) 2019 was provided by the nursing home administrator (NHA) on 10/30/19. The policy revealed all associates associated with food handling shall wash their hands at the following times: -Before handling clean utensils, dishes or equipment; -After handling soiled silverware or utensils; -After touching hair, skin or clothing; and -After any other activity that may contaminate the hands. C. Observations The initial tour of the kitchen was on 10/28/19 from 2:05 p.m. through 2:35 p.m. The observations included: -The paper towel dispenser above the handwashing sink adjacent to the food preparation sink did not have paper towels and there was no trash receptacle near the sink; and -The paper towel dispenser above the handwashing sink adjacent to the electric slicer was inoperable and there was no trash receptacle. The paper towel dispenser was not marked as out of service on repeat observations on 10/29, 10/30 and 10/31/19 respectively. Food service utility (FSU) #1 worker was observed on 10/29/19 at approximately 4:00 p.m. He entered the kitchen through the rear entry door and removed his hat with his right hand and scratched his head with his left hand. He entered the dish room and pulled a clean rack of dishes from the dish washing machine. He did not wash his hands after they were contaminated or before he handled clean kitchenware. FSU worker #2 was observed in the dishwashing room on 10/31/19 at approximately 10:00 a.m. He loaded two racks of soiled plates and utensils on the dirty side of the dish machine and slid one into the dishwashing machine. He moved to the clean-side drain board and removed clean cups and other utensils and placed them on a rolling utility cart. He did not wash his hands between touching soiled and clean kitchenware. II. Safe cold food storage [NAME] Facility policy and procedure The Cold Storage Temperatures policy and procedure, revised (MONTH) 2019, was provided by the NHA on 10/30/19. The policy read in pertinent part: -Each refrigerated storage unit shall have an independent thermometer in addition to a built in thermometer; and -The temperature of each unit shall be recorded and initialed each morning at opening and in the evening at closing on the monthly refrigerator/freezer log sheet. B. Observations The initial tour of the kitchen was on 10/28/19 from 2:05 p.m. through 2:35 p.m. On the wall to the right of the walk-in refrigerator there was an incomplete temperature recording log. There were no internal thermometers in the compact freezer next to the deep fat fryer or within the reach-in refrigerator next to the serving line. On 10/30/19 at approximately 4:00 p.m. there was an uncovered and unlabeled three gallon container of marinara sauce in the walk-in refrigerator. There was a defrosted ice-paddle partially submerged in the red sauce and the outside of the container was warm to the touch. The dining services manager (DSM) checked the temperature with his thermometer and it read 71 degrees Fahrenheit (F). He said he did not know when it had been placed in the refrigerator and he placed it in the dish washing room to be discarded. C. Record review The Kitchen Coolers and Freezer temperature logs for (MONTH) 2019 and (MONTH) 2019 were provided by the DSM on 10/28/19 at 2:23 p.m. The month of (MONTH) had no recorded temperatures for 11 out of 30 days. The month of (MONTH) 2019 temperature log had last recorded data on the morning of 10/15/19 and only two out of a possible 27 evening temperatures recorded. III. Clean and sanitary work surfaces [NAME] Professional reference According to the Food Code (YEAR) Recommendations of the United States Public Health Service Food and Drug Administration, page 149: Non-food contact surfaces of equipment should be kept free of dirt, food residue and other debris. Food contact surfaces should be clean to sight and touch. B. Facility policy and procedures The Cleaning of Food and Non-Food Contact Surfaces policy and procedure was provided by the NHA on 10/30/19. The policy revealed utensils and equipment used to serve potentially hazardous foods (PHF) were cleaned and sanitized after each use and non-food contact surfaces of equipment shall be cleaned as often as necessary to keep the equipment free of dust, dirt, food particles and other debris. C. Observations The initial tour of the kitchen was on 10/28/19 from 2:05 p.m. through 2:35 p.m. The observations included: -There was a large plastic bin beneath the top shelf of a rolling stainless steel table at the end of the long rectangular food preparation table. Along the interior sides and bottom of the bin there were large pieces of dried food, white and yellow food splatter and dried brown-colored liquid stains; -The inside of the utensil drawer on the right-sided end of the service table had chunks of food debris and a blackish-brown dust and greasy grime build up along the inside edges and corners; -The tops of the bulk sugar and flour containers stored beneath the drainboard of the three compartment sink had loose pieces of food debris and food splatter. These observations were repeated on 10/29, 10/30 and 10/31/19 respectively. -The floor behind and beneath the rolling bulk food containers had black build up of grime, multiple pieces of paper, a wadded up paper towel and loose food debris. The electric slicer was observed on 10/29/19 at approximately 3:00 p.m. The slicer was covered with a large plastic bag. There was build-up of dried meat between the slicer blade and blade sharpening tool mounted on the slicer. The slicer tray beneath had dried pieces of brown food in multiple areas. D. Record review The facility Kitchen Cleaning List was provided by the DSM on 10/31/19. There were no cleaning log sheets from 9/29/19 through 10/19/19. E. Staff interview The DSM was interviewed on 10/31/19 at approximately 10:30 a.m. He said staff should wash their hands before they touched any clean utensils. He said ongoing education would be provided to all food service associates related to proper hand washing. He said the automatic paper towel dispenser should be tagged out of service and there should be a covered trash receptacle at each hand washing sink. He said there had been a lapse in procedures for ensuring appropriate cold food storage. He said he had purchased additional internal thermometers and re-educated staff on temperature controls and the facility policy for recording cold storage unit temperatures. He said the cleaning schedule had not been followed until the most recent days. He said he and the executive chef would direct overdue and current cleaning responsibilities immediately.

Based on observation and interviews, the facility failed to treat one (#27) of two residents reviewed for dignity of 39 sample residents with respect and dignity and provide care for the resident in a manner that enhanced her quality of life. Specifically, the facility failed to: -Assist Resident #27 with dining while being seated at the resident's eye level; and -Interact with Resident #27 while assisting the resident with dining. Findings include: I. Facility policy and procedure The Dignity and Respect policy, revised 10/11/18, revealed the purpose of the policy was to identify ways staff would maintain residents' dignity while providing care. Staff should display respect for residents when speaking with, caring for or talking about them, as constant affirmation of their individuality and dignity as human beings. The Feeding Assistance checklist, dated (MONTH) 2019, documented staff assisting residents with dining should always treat residents with dignity and respect. Staff should sit at the same level as the resident and within the resident's line of vision. Staff should converse with the resident, if able, and should not talk to others while assisting the resident. II. Resident #27 status Resident #27, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/28/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) cognition score, but documented the resident had both short-term and long-term memory deficits. The resident required supervision of one for eating. The MDS dated [DATE], which was in progress, documented the resident required limited assistance of one of eating. III. Resident observations Resident #27 was observed during dinner in the Pondside dining room on 10/28/19 at 5:27 p.m. The resident was seated in her high-backed wheelchair and was positioned at a table for residents who required assistance with their meals. The resident was being assisted with her meal by certified nurse aide (CNA) #3 and the CNA was observed to be standing over Resident #27 while assisting the resident. -At 5:31 p.m., Resident #27 was observed to give CNA #3 a somewhat angry look and refused the bite that the CNA was offering the resident. -At 5:32 p.m., CNA #3 was observed to be interacting with other staff rather than interacting with Resident #27, until 5:36 p.m. CNA #3 had the resident's food on a spoon during the four-minute observation. -At 5:36 p.m., CNA #3 was observed standing with her left hand on her hip while feeding Resident #27. She was observed to smile at the resident, but not to verbally interact with the resident. The CNA kept offering Resident #27 repeated spoonfuls of food and not speaking to the resident. -At 5:38 p.m., CNA #3 continued to stand over Resident #27 while offering the resident drinks out of a sippy cup. There were two other staff members seated at this assist table who were assisting other residents at the residents' eye level. Resident #27 was observed at her table in the Pondside dining room on 10/29/19 at 5:33 p.m. CNA #3 was again assisting Resident #27 with her meal. During this observation, the CNA was seated on a high wooden counter stool, which placed the CNA above the resident's line of sight. The CNA said she had been working in the facility since the end of (MONTH) 2019. IV. Staff interviews CNA #6 was interviewed on 10/30/19 at 12:29 p.m. She said Resident #27 should be positioned at a 90-degree angle with staff seated on her left side in order to have staff visible to the resident. She said staff should not be standing over a resident while assisting them with their meals. CNA #8 was interviewed on 10/30/19 at 1:55 p.m. She said staff should be seated next to the resident, at the resident's eye level, when assisting them with their meals. She said it was not appropriate to stand over a resident while helping them eat their meal. She said it was also not appropriate to sit on a high counter stool and be elevated above the resident while assisting them. CNA #7 was interviewed on 10/30/19 at 2:14 p.m. She said, when assisting a resident with their meal, staff should sit beside the resident eye-to-eye so the resident could see the staff. She said staff should never stand over a resident when assisting with their meal. She said having staff seated on a high counter stool would not be appropriate either. CNA #2 was interviewed on 10/30/19 at 2:18 p.m. She said, when assisting a resident with their meal, staff should face the resident as directly as they could while continuing to maintain direct eye contact. She said it would overpower the resident if staff were above them. She said staff should not stand or sit on a tall counter chair when assisting residents with their meals. Licensed practical nurse (LPN) #1 was interviewed on 10/30/19 at 2:21 p.m. He said, when assisting a resident with their meal, staff should position themselves on the side of the resident that gave the resident the most comfort and feeling of independence. He said staff should be seated at the same level as the resident or staff would assert dominance over the resident, which would be disconcerting to them. He said it was not appropriate for staff to stand over a resident while assisting them with their meal. He said the counter stools would be too high for an average sized CNA to assist residents at an appropriate height and that would be a dignity issue for the residents. Social services coordinator (SSC) #1 was interviewed on 10/30/19 at 4:25 p.m. She said staff should be seated next to the resident and verbally interacting with the resident while assisting a resident with their meal. She said the above observations constituted a dignity issue and a perfect chance for staff education about how to interact with residents who required assistance with their meals. The interim director of nursing (DON) was interviewed on 10/30/19 at 4:32 p.m. She said staff should sit next to a resident when assisting with their meals, while communicating with and verbally engaging the resident. She said she also observed the interaction between Resident #27 and CNA #3 the evening of 10/28/19. She said she felt CNA #3 was inappropriately positioned to assist Resident #27 with her meal and asked CNA #3 to stop bopping around and sit down. She said the CNA's response to that request was to tell the interim DON that she did not like that rule, and she did not sit down. She said she notified CNA #3's supervisor and said she was disappointed in CNA #3's response to her request. The corporate nurse consultant (CNC) was interviewed on 10/30/19 at 5:59 p.m. She said she essentially felt the same about the observations of CNA #3's assistance with Resident 27's meals on 10/28/19 and 10/29/19 as the interim DON felt. CNA #3 was unavailable for an interview regarding dining assistance, in that she was not scheduled to work on either 10/30/19 or 10/31/19.

Based on observations, record review, and interviews, the facility failed to ensure one (#36) of one resident reviewed for bathing and grooming received the necessary assistance with activities of daily living (ADLs) of 39 sample residents. Specifically, the facility failed to ensure Resident #36 received timely assistance with eye and facial cleanliness. Findings include: I. Facility policy and procedure The Resident Observations policy and procedure, dated (MONTH) (YEAR), was provided by the corporate nurse consultant (CNC) on 10/31/19 at 12:05 p.m. It listed the expectations for residents' grooming and cleanliness, which included the following: staff were to check to ensure their skin was clean and there was not food on their face or hands, their hair was combed and clean, their eyes were not matted, and their mouth did not contain debris or odor. II. Resident #36 status Resident #36, age 91, was admitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/16/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with dressing, eating, and personal hygiene, and was totally dependent for bed mobility, toilet use, and transfers. She had functional limitation in range of motion in both of her upper and lower extremities bilaterally. III. Observations On 10/29/19 at 9:19 a.m., Resident #36 was sitting in her wheelchair in the sunroom in the Mountainside neighborhood. She was awake and alert and was watching TV. There was a string of drool, approximately three inches long, coming out the left side of her mouth. Her eyes were soiled with thick crusted debris accumulation on both the upper and lower lashes, and there were dried brown food stains on her chin and around the corners of her mouth. On 10/30/19 at 10:00 a.m., Resident #36 was sitting in her wheelchair in the sunroom picking at the left side of her head with her left index finger. The skin on her eyebrows was dry and flaking off in pieces and there was thick crusted tan debris accumulation on her upper and lower eyelashes. There was brown, dried debris on her chin. There was a large accumulation of white dandruff flakes on the sling behind her head. On 10/30/19 at 12:03 p.m., Resident #36 was returned to the Mountainside neighborhood by a community life staff member and was placed at a dining table. Her eyes and eyelashes remained crusted with tan debris. CNA #10 fed the resident her lunch without offering to wash her hands or her face. On 10/31/19 at 8:57 a.m., Resident #36 was sitting in her wheelchair in the Mountainside sunroom. She had dry, crusted tan debris on her upper and lower eyelashes bilaterally. IV. Record review The care plan, initiated 6/26/19 and not revised since, identified an ADL self-care performance deficit related to her disease process and contractures. The approaches documented she was dependent on staff for bathing, showering, personal hygiene and oral care. The bathing records were reviewed from 8/1/19 through 10/31/19 and documented the following: -8/10/19 = bathed (10 days since last bathed) -8/24/19 = bathed (10 days since last bathed) -10/3/19 = bathed (five days since last bathed) -10/10/19 = bathed (five days since last bathed) -10/30/19 = bathed (seven days since last bathed) The documentation did not include any refusals of care by the resident. V. Staff interviews CNA #11 was interviewed on 10/31/19 at 8:57 a.m., and she confirmed she routinely worked with Resident #36. She said it was not unusual to see sleepies in her eyes and on her eyelashes in the mornings and stated, In the mornings we need to really wipe them out. CNA #12 was interviewed on 10/31/19 at 10:00 a.m., and she confirmed she routinely worked with Resident #36. She said the resident was totally dependent on staff for all of her ADL needs because she was unable to provide them herself. She said after residents ate their meals, they would have their hands sprayed with hand sanitizer or a wet towel would be used to wipe their hands and face if needed. She said she provided routine morning ADL care for Resident #36 that included combing her hair and washing her face, and she had not noticed flaky skin on her scalp or dandruff. She said the resident refused care sometimes, but if they waited for a few minutes and re-approached her, she was agreeable. The CNA confirmed she had noticed Resident #36's eyelashes to be crusted with debris and said she used a wet paper towel with warm water to clean them. Registered nurse (RN) #4 was interviewed on 10/31/19 at 10:28 a.m., and she confirmed she routinely worked with Resident #36. She said she had noticed crusted debris in the resident's eyes in the past and said she did not have an eye infection. She stated, I think she just needs her face washed. The director of nurses (DON) and CNC were interviewed on 10/31/19 at 10:50 a.m. The DON said the routine morning ADL care provided to residents who were unable to provide it for themselves included changing into clean clothes, washing their face, brushing their teeth, getting anything out of their eyes, provide toileting, and allowing them to pick what they wanted to wear. She said if a resident had food or debris on their face after a meal, the staff should address it by taking them into their room and using a washcloth to clean them up. She said Resident #36 did not have an eye infection and she had not noticed the crusted debris in her eyes or excessive flaking dandruff. She said she would talk to the resident's nurse for more details and look in the chart. The DON and CNC said residents should be clean and well groomed.

Based on observations, record review, and interviews, the facility failed to administer medications according to professional standards of quality for two (#39 and #30) of 11 residents reviewed for medication administration of 39 sample residents. Specifically, the facility failed to ensure: -Resident #39's and Resident #30's medications were not left at the bedside; -Residents #39 and #30 were evaluated and assessed to self-administer their own medications in a timely manner; and -Physician orders [REDACTED].#39 and #30 to self-administer their own medications. Findings include: I. Facility policy and procedure The corporate nurse consultant (CNC) provided the Safe Medication Preparation policy and procedure, dated (YEAR), on 10/31/19 at 12:05 p.m. It documented prior to administering medications, a physical assessment should be performed that would reveal physical findings for any indications or contraindications for medication therapy. Be sure to assess the resident's sensory, motor, and cognitive functions. By assessing the resident's level of knowledge, you determine the need for teaching. Complete appropriate assessments, which may include vital signs, laboratory data, and the nature and severity of symptoms. Nursing interventions focus on safe and effective drug administration. This includes careful medication preparation, accurate and timely administration, and patient education. Follow the six rights of medication administration (right person, right route, right dose, right time, right medication, and right documentation). Stay with the resident until the medication is taken. Provide help as necessary. Do not leave medication at the bedside without a health care provider's order. II. Resident #39 [NAME] Resident status Resident #39, age 90, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/17/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Mood symptoms present included feeling down, depressed or hopeless, feeling tired or having little energy, and moving or speaking so slowly that other people could have noticed occurred once during the lookback period. Behaviors of [MEDICAL CONDITION] that were present included delusions. She required extensive assistance with bed mobility, dressing, and personal hygiene, and supervision with eating. B. Observation and resident interview On 10/29/19 at 10:21 a.m., Resident #39 was lying in bed in her room and there was an empty paper soufflé medication cup and a plastic soufflé cup with multiple pills in it sitting on her bedside table. Licensed practical nurse (LPN) #1 entered the room at 10:22 a.m., and explained the resident preferred he left the medications at her bedside so she could take them at her own pace. He turned to leave the room and stated, Make sure she takes her pills. After LPN #1 left the room, Resident #39 said, They usually leave them next to the bedside. They are not supposed to, but (LPN #1) knows me. She said the medications were routinely left on her bedside table by the nursing staff and she confirmed one of the pills in the plastic soufflé cup was a narcotic. She explained she was slow in taking her pills and liked to have a little bit of rest time in between taking each medication. She said most of the time she did not have any problems swallowing them, but sometimes the broken potassium tablet would scratch down my food pipe and I definitely have to wait for a little bit in between pills. There were seven pills in the plastic medication cup and she swallowed them all together at 10:26 a.m. C. LPN #1 interviews LPN #1 was interviewed on 10/29/19 at 10:40 a.m., and he confirmed he routinely worked with Resident #39. He said he usually left her morning medications at her bedside for her to take at her leisure. He said if he stayed in her room during the medication pass and waited for her to take the pills, She will just talk and talk and I've been stuck in there for 30 minutes before. He stated, I just have to walk away or else I would be in there forever. He confirmed he routinely left her medications at her bedside and would go back into her room later and check on her to make sure she had taken them. LPN #1 was interviewed a second time on 10/29/19 at 5:28 p.m. He confirmed there were seven pills in the soufflé cup at the resident's bedside that morning and identified them as the following: [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (antiulcer), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (opioid [MEDICATION NAME]) and two [MEDICATION NAME] (diuretic). He said Resident #39 also received a potassium pill in the mornings, which he would break in half and place it in a separate paper soufflé cup, which she would normally take first. He said he was currently responsible for 30 residents and said if he stayed in Resident #39's room and waited for her to take her pills, I would be in there for 30 minutes, and I do not have that amount of time in my day. D. Record review The care plan, initiated 6/25/19 and not revised since, identified the resident had impaired cognitive function/dementia or impaired thought processes and needed verbal and visual cues to help with recall, orientation and tasks of daily life. She required approaches that would maximize her involvement in daily decision-making and activity by limiting her choices, using cueing, task segmentation, written lists, and instructions. She should be cued, reoriented and supervised as needed. She had been diagnosed with [REDACTED]. She knew her name and at times her caregivers, but was not aware of where she was or her situation. The care plan, initiated 6/20/19 and not revised since, identified the resident was at potential nutrition and hydration risk related to a history of swallowing difficulty and use of diuretics. The approaches documented she had complained of difficulty swallowing in the past and should be monitored for signs and symptoms of aspiration, and allowed to drink and eat at her own pace. The Monthly Nursing Observations assessment, dated 10/25/19, documented the resident's orientation included short- and long-term memory impairment and impaired decision-making ability. The CPO for (MONTH) 2019 included the medications listed above, but did not include an order that the resident could administer her own medications. The clinical record was reviewed in its entirety and there was no assessment for self-administration of medications present. On 10/30/19, the director of nurses (DON) and CNC were asked to provide the most recent assessment for self-administration of medications for Resident #39. A Medication Self-Administration Safety Screen, dated 10/30/19 (same day), was provided. It included the following instructions: Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. The form provided space for up to 10 different medications to be listed, and each should include the provider's order, the reason for use, and the side effects. Under the space for medication #1, the form listed see orders, and the remaining nine medications were void of documentation. The evaluation revealed the resident was completely capable of correctly reading medication labels, and could correctly state the time, frequency, and dosage for the medications to be taken. However, she required assistance opening containers and correctly stating what each medication was used for. The section on the form titled Approvals, was void of documentation as to whether or not the resident agreed to the terms and policies for self-administration, but was dated 10/30/19. The section on the form titled, Physician, documented the resident may self-administer medications unsupervised once prepared by staff and may be left at the bedside with the resident. The physician's orders [REDACTED]. Registered nurse (RN) #1 completed the form. A progress note dated 10/30/19 was written by a physician's assistant that read, (MONTH) leave pills at bedside with resident once prepared by staff. On 10/31/19 at 10:00 a.m., the MDS coordinator provided a list of residents in the facility that included their BIMS scores and who were independently able to ambulate or propel themselves in their wheelchairs. There were a total of three residents who were severely impaired and five residents who were moderately impaired but were able to navigate independently. E. Additional staff interviews Certified nurse aide (CNA) #12 was interviewed on 10/31/19 at 10:00 a.m., and she confirmed she routinely worked with resident #39. She said she was confused at times, and other times she was able to have a good conversation with her. The CNA said she saw her medications left at her bedside every morning and stated, Because she likes to take her time taking them. RN #1 was interviewed on 10/30/19 at 6:05 p.m., and she confirmed she was the nurse who completed the medication self-administration assessment for Resident #39 earlier that day. She said she received no training or guidance on how to complete the form or do the assessment, and had never completed one before. She said she did not speak to Resident #39 personally, but rather, she interviewed LPN #1 instead. She said the assessment needed to re-done and would clarify with the DON who should complete it. The DON and CNC were interviewed on 10/31/19 at 10:50 a.m. The CNC confirmed if a resident was deemed safe to administer their own medications, there should be an order from their provider stating that. The DON said Resident #39's mental clarity varied, and on some days, she was very clear and on other days, she was a little less clear. She explained the resident often refused to keep her oxygen on, so when she woke up in the mornings she was more confused. They were not aware of any swallowing difficulties Resident #39 had and were unable to speak to the impaired decision-making ability, memory impairment, and dementia with impaired thought processes care plans. The CNC said the self-administration of medication assessment was used as a guide for staff to make a recommendation and decide as a team to allow it or not. She said the assessment that was performed for Resident #39 revealed she was okay to be unsupervised and then they obtained an order to support that. She confirmed Resident #39 had not had any previous self-administration of medication assessments performed prior to the one completed 10/30/19, and explained the facility staff were not doing those assessments, but instead would follow a physician's orders [REDACTED]. The CNC said if medications were left at a resident's bedside, the safety of the other residents in the facility would be ensured because on the following medication round, the nurse would determine if the medication had been consumed. She said if they had reports that residents were in the habit of hoarding or keeping pills or not taking them appropriately, that would cause a reassessment. III. Resident #30 [NAME] Resident status Resident #30, age 61, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the most recent MDS assessment completed 9/2/19, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident experienced delusions and exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, cursing at others, screaming at others). B. Observation During medication pass with LPN #1 on 10/29/19 at 3:19 p.m., the nurse was observed taking medications into Resident #30's room, including [MEDICATION NAME] (medication for overactive bladder), [MEDICATION NAME] (opioid narcotic), and [MEDICATION NAME] (antipsychotic). LPN #1 handed the medications to the resident along with a cup of pudding and left the resident's room. The nurse did not stay with the resident to ensure the medications were taken. C. Record review The resident medication self-administration safety screen, completed 10/30/19 (during survey and after medication pass observation), showed the resident was capable of self-administering medications. However, the screen was not completed prior to allowing the resident to administer her own medications. The CPO showed an order added 10/30/19 (during survey and after medication pass observation) which read resident may have medications at bedside. However, the order was not obtained prior to leaving the medications at the resident's bedside.

Based on record review, observations, and interviews, the facility failed to ensure infection control standards of practice for three (#15, #5 and #13) of three residents reviewed for blood glucose monitoring of 34 sample residents. Specifically, the facility failed to: -Properly disinfect and store personal blood glucose monitoring devices after use for Residents #15, #5, and #13; -Dispose of contaminated materials properly after blood glucose testing; and -Wear appropriate personal protective equipment (PPE) while performing blood glucose testing. Findings include: I. Facility policy and procedure According to the Blood Sugar Glucometer Testing policy, revised (MONTH) (YEAR), provided by corporate nurse consultant (CNC) on 10/31/19 at 8:30 a.m., staff were to provide privacy, apply gloves, and clean the glucometer with disinfectant wipes (or manufacturer's recommendations) after each use. II. Observations During medication pass with licensed practical nurse (LPN) #1 on 10/29/19 at 3:30 p.m., the LPN was observed performing a blood sugar test on Resident #13. Upon completion the LPN returned the blood glucose monitoring (BGM) device to the carrying pouch while wearing contaminated gloves and set the pouch on the counter at the nursing station. The BGM device was returned to the storage cabinet without being disinfected after use. The LPN was also observed to walk across the resident hallway with a contaminated glove on, carrying the lancet device, and disposed of the lancet in the sharps container on the medication cart. During medication pass with LPN #1 on 10/30/19 at 3:29 p.m., the LPN was observed performing a fingerstick blood glucose test on Resident #15. After completion of the test the LPN was observed returning the BGM device to the carrying pouch with contaminated gloves and returned the pouch to a storage cabinet at the nursing station without disinfecting the device. The LPN was also observed wearing a contaminated glove while holding the lancet device in the hallway and disposed of it in the sharps container on the medication cart. During medication pass with LPN #1 on 10/30/19 at 4:00 p.m., the LPN was observed performing a fingerstick blood glucose test on Resident #5. After the completion of the blood glucose test the LPN was observed returning the BGM device to the carrying pouch with contaminated gloves and placing the pouch on the medication cart at the nursing station without disinfecting the device after use. LPN #1 was observed walking in the resident hallway with a contaminated glove holding the lancet device to dispose of it at the sharps container on the medication cart. Registered nurse (RN) #4 was observed performing a blood glucose fingerstick test on an unknown resident while in the Pondside resident dining room on 10/30/19 at 4:40 p.m. The RN was observed not wearing gloves while performing the fingerstick blood glucose test. III. Record review Skills checklists for blood sugar glucometer testing for LPN #1 and RN #4 were provided by the facility. On 11/21/18 LPN #1 completed the skills checklist which included to disinfect the glucometer with disinfectant wipes after each use. RN #4 completed her skills checklist on 9/1/19, which included to apply gloves while performing the test. According to the manufacturer's instructions for the BGM device provided by the facility, to disinfect your meter, clean the meter with a validated disinfecting wipe or other EPA registered wipe. IV. Interviews LPN #1 was interviewed on 10/30/19 at 5:17 p.m. He said all nurses were to disinfect the BGM devices after each use using a disinfectant wipe, then document they were disinfected in the electronic medical record. He said his process was to disinfect them in the morning, but some residents had several blood glucose tests a day so he would clean at the end of the day and not after each use. He said it was ok for staff to walk in the hallway with contaminated gloves and materials as long as it was with only one glove. He said there were sharps containers in each resident's restroom and he would probably start using those. RN #4 was interviewed on 10/31/19 at 10:22 a.m. She said nurses were to clean BGM devices before and after every use. She also said nurses should be wearing gloves during BGM tests, and she should have had gloves on while performing the observed BGM test on the unknown resident. The CNC and director of nursing (DON) were interviewed on 10/31/19 at 10:09 a.m. The DON said nurses should be disinfecting the BGM devices before and after use with a disinfectant wipe. She said nurses should wear gloves while performing a BGM test. She said nurses should dispose of contaminated materials in the nearest sharps container, and staff should not walk through residential areas or hallways with dirty gloves or contaminated materials.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility kitchen and one of three resident dining room refrigerators. Specifically, the facility failed to minimize potential risks for foodborne illness in a highly susceptible population as evidenced by: -Inadequate hand washing; -Insufficient sanitation of work surfaces; and -Failure to monitor, identify and correct improper refrigerator temperatures in the Creekside dining area. Findings include: I. Inappropriate hand hygiene A. Professional references According to the Food and Drug Administration (FDA) (YEAR) Food Code pp. 48-50: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils. In addition hands shall be washed: - After handling soiled utensils or equipment; - During food preparation as often as necessary to remove soil and contamination; - After engaging in other activities that contaminate the hands; and - Before donning gloves to initiate a task that involves working with food. The following cleaning procedures shall be used: -Rinse under clean, running warm water; -Apply hand washing soap; -Thoroughly rinse under clean, running warm water; and -Immediately follow the cleaning procedure with thorough drying of the cleaned hands. B. Facility policy and procedures The Hand Hygiene policy revised 1/18, provided by the director of nursing (DON) on 11/14/18 at approximately 4:00 p.m., read in pertinent part: All associates involved in the handling of food shall wash their hands with soap and water at the following times: -Before handling food or clean utensils, dishes or equipment -Before putting on gloves -After handling soiled utensils -After removing gloves. In addition, procedures for effective hand washing stipulated hand washing sinks and supplies should be easily accessible, include a covered trash receptacle, and provide hot water at 100 degrees Fahrenheit (F) within one minute. C. Observations On 11/12/18 at approximately 12:30 p.m. there was no trash can near the hand washing sink located to the right of the food preparation table. A dietary staff member moved a table-height, uncovered trash container being used for food waste during preparation to the side of the hand sink to discard paper towels. approximately 20 feet which was used on the other side of the preparation table to the side of the hand washing sink. On subsequent visits to the kitchen on 11/12/18, 11/13/18, 11/14/18 and 11/15/18 there was no trash receptacle near the hand washing sink to the right of the preparation table. On 11/14/18 at approximately 12:24 p.m., Cook #3 was observed loading soiled utensils into the dish machine. He was wearing green, elbow-length dishwashing gloves. He removed the green dishwashing gloves which were covering a pair of clear single-use gloves, and removed clean utensils from the dish room. He returned to the dishroom, donned the green dishwashing gloves over the single-use gloves and continued to wash dishes. On 11/15/18 at 8:05 a.m, the soap dispenser above the hand washing sink to the right of the preparation table did not dispense soap. On 11/15/18 at 8:08 a.m., Cook #2 approached the hand washing sink to the right of the food preparation table he pushed the bar of the dispenser and no soap was dispensed. He rubbed his hands beneath the water and dried them with a paper towel. On 11/15/18 at 8:18 a.m., Server #3 pressed the dispense bar of the soap dispenser and no soap was dispensed. She retrieved a refill container of a blue colored soap and refilled the soap dispenser with a container of blue colored antimicrobial hand washing soap. She held her hands under running water for approximately two minutes, and said the water did not get warm. She then used the hand washing sink at the far left of the cooks line. On 11/15/18 at 8:55 a.m. the hand washing sink water was 61 degrees F after two minutes. D. Staff interviews Server #3 was interviewed on 8/15/18 at approximately 8:20 a.m. She said she changed the soap dispenser because it was empty and all dietary staff should know where to find the soap and how to refill the dispenser. She said the water felt really cold and it would not warm up. Cook #3 was interviewed on 11/15/18 at approximately 9:30 a.m. He said he wore the green dishwashing gloves to prevent the clear single-use gloves from getting dirty. He said he had not received kitchen sanitation training. The interim food service director (FSD) was interviewed on 11/15/18 at 8:59 a.m. She said the water in the hand washing sink was too cold and she would put in a work order. The interim FSD and registered dietitian (RD) were interviewed jointly on 11/15/18 at 11:05 a.m. They said dietary staff should wash their hands anytime they changed gloves. They said dishwashing gloves should not be worn over other gloves. They said maintenance was working to fix the mixing valve for hot water and the sink would be taken out of service until hot water was restored. The FSD said a foot operated trash can would be found to place near the hand washing sink. II. Failure to adequately sanitize kitchenware and equipment A. Professional references 1. According to the Food Code (YEAR) Recommendations of the United States Public Health Service Food and Drug Administration, page 149: Non-food contact surfaces of equipment should be kept free of dirt, food residue and other debris. Food contact surfaces should be clean to sight and touch. 2. According to the Colorado Retail Food Establishment Rules and Regulations (effective 3/1/13), page 67: Equipment food-contact surfaces and utensils shall be clean to sight and touch. Utensils and food-contact surfaces of equipment shall be cleaned and sanitized at any time during the operation when contamination may have occurred; and after final use each day. 3. According to the Colorado Retail Food Establishment Rules and Regulations (effective 3/1/13) pg. 36: Cloths used for wiping food spills or cleaning on food-contact surfaces shall be cleaned and rinsed frequently. These cloths should be held between uses in a clean, chemical sanitizer solution at the proper concentration. B. Facility policy and procedures 1. The Sanitizing Food Contact Surfaces policy and procedure, revised (MONTH) (YEAR), provided by the DON on 11/14/18 at 5:25 p.m., read each work area shall be equipped with sanitizing solution. Quaternary ammonia sanitizing solution used in red buckets must be between 200 to 400 parts per million (ppm). 2. The Cleaning of Food and Non-food Contact Surfaces policy, revised (MONTH) (YEAR), provided by the DON on 11/14/18 at 5:25 p.m. read in part: All in-use wiping cloths must be kept in sanitizing solution between uses regardless of their intended use. C. Observations During the initial tour of the kitchen on 11/12/18 from 12:30 p.m. to 1:05 p.m., there was an inverted red sanitizing bucket and a wet cloth in the sink directly across from the preparation table. A dietary staff member used the cloth to wipe the preparation table. He placed the cloth back in the sink basin and placed two white cutting boards on the table. He did not sanitize the table and the cloth was not stored in a sanitizing solution. On 11/14/18 at 12:24 p.m. Cook #3 was cutting melon and pineapple at the food preparation table. He removed a cloth from a red sanitizing bucket and wiped fruit juice from around the cutting board and the blade of the knife. He continued to cut fruit with the soiled and non-sanitary knife. On 11/15/18 at 9:20 a.m, the interim FSD used a test strip from a white cylinder-shaped container stored above the preparation sink. She verified the solution had been prepared and checked with the same strips by Cook #4 at approximately 9:10 a.m. She said the strip read 200 parts per million (ppm) of sanitizer. -The strip container read, Antimicrobial Fruit and Vegetable Treatment Test Strip and had a color coded chart of eight colors ranging from royal blue to pale green. Each color indicated the amount of water in relation to the product expressed as a ratio. D. Staff interviews Cook #4 was interviewed on 11/15/18 at approximately 9:20 a.m. He said the green color on the strip container indicated the sanitizer solution concentration and he typically used these strips. Cook #1 was interviewed on 11/15/18 at approximately 9:30 a.m. He said he used the same container of strips earlier in the morning to check the sanitizer solution and maybe the color was off because it needed to be changed. The RD and interim FSD were interviewed on 11/15/18 at 11:05 a.m. They provided the content and roster of an in-service done that morning will all dietary staff on site. They said all staff must know what chemicals were used to sanitize and now to ensure the concentration is at the appropriate concentration. III. Failure to ensure cold foods stored at appropriate temperatures A. Professional references According to the Food and Drug Administration (FDA) website, www.fsis.usda.gov, downloadable document, Refrigeration and Food Safety, last modified 1/23/15, bacteria grow most rapidly in the range of temperatures between 40 and 140 degrees F, the Danger Zone. A refrigerator set at 40 °F or below will protect most foods. B. Observations On 11/13/18 at 2:40 p.m and 5:53 p.m., the South (Creekside) dining room below-counter refrigerator thermometer read 50 degrees F. The refrigerator contents included pudding, yogurt, applesauce, milk, and juice. On 11/14/18 at the Creekside room refrigerator temperature was 45 degrees F. On 11/15/18, at approximately 11:55 a.m., the temperature of the Creekside refrigerator was 48 degrees F. C. Record review The facility Refrigeration Temperature Record sheets, last revised (MONTH) (YEAR), stipulated the standards of a minimum refrigerator temperature of 34 degrees F and a maximum temperature of 41 degrees F. All entries were to be initialed by the staff person who recorded the temperature with a notation of the corrective action taken for any reading outside the standard range. Creekside refrigerator temperature logs provided by the RD on 11/15/18 at approximately 3:00 p.m. revealed the notation previous log destroyed by water written diagonally across the top one-third of the form. There were no entries 11/1/18 through 11/11/18. The dates 11/12/18 through 11/14/18 had p.m. readings only. D. Staff interviews and facility follow-up The interim FSD and RD were interviewed on 11/15/18 at 11:05 a.m. They said the refrigerator in the Creekside dining area remained in use despite the area being utilized for activities. They said they were not aware of any refrigerator temperatures above 40 degrees F. They said they would evaluate the Creekside refrigerator and provide follow-up. A text message from the RD on 1/15/18 at 12:48 p.m., stated the contents of the Creekside refrigerator had been discarded and the refrigerator was now cooling properly.

Based on interviews, observations and record review, the facility failed to employ sufficient dietary support staff to carry out the functions of the food and nutrition services department in two of two facility dining rooms. Specifically, insufficient numbers of adequately trained food and nutrition staff contributed to prolonged wait times for meals and overall decreased resident satisfaction with dining. Findings include: I. Food production and service The facility had one production kitchen and two functioning serving kitchens. There was a serving kitchen with adjacent dining area in the Pondside and Mountainside neighborhoods. Meals for the neighborhood dining rooms and for in-room dining were prepared in the production kitchen and transported to the neighborhoods for service to residents. Certified nursing aides (CNAs) took orders and delivered trays for in-room meals. There was one dietary server assigned to each neighborhood kitchen and dining area. Meal times were breakfast 8:00 a.m., lunch 12:00 p.m. and supper 5:00 p.m. II. Resident interviews Interviews with residents who, per facility assessment were cognitively intact and interviewable, revealed the following comments. Resident #22 was interviewed on 11/12/18 at 3:56 p.m. She said she ordered a room tray and often received cold pancakes in the mornings. She said the facility had fancy-sounding names for food and she was often uncertain what she was ordering. She said the staff who she ordered the meals from could not tell her what some of the dishes were. Resident #28 was interviewed on 11/13/18 at 9:45 a.m. Regarding food service, Resident #28 said, A lot of times the food is cold; they don't have enough people to work in the kitchen. A lot of times the CNAs help serve depending on who's here. Last night I got there just a tiny bit after 5:00 p.m. and didn't leave till 6:30 because I never got my main dish. I was the last one served for some reason. The resident said staff usually brought menu items from the kitchen far away to our little kitchen. If they ran out of food, they had to call the main kitchen and get them to prepare it, then staff had to go get it. Not a very good system I don't think. She said residents could order eggs any style, hot dogs, hamburgers, etc. from the anytime menu if they didn't like the main menu items. But then you have to sit and wait for it because they have to send down to (the main kitchen) to get it. I don't know how they could design a worse system. III. Family member interview Resident #51's family member was interviewed on 11/12/18 at 3:10 p.m. She said, Meal wait times can be an hour: 15 minutes in between soup, meal and dessert service. Because the middle kitchen is closed. There is usually one person serving every single tray. If they don't know the resident it's a struggle. One lunch (Resident #51) waited from 11:30 a.m. to 12:55 or 1:00 p.m. IV. Dining observations A. Dinner on 11/12/18 Continuous dinner service observations on 11/12/18, from 5:00 to 5:50 p.m., revealed the following: Residents were seated in the dining room at 5:00 p.m. Two long tables and one short table were available in the dining room: the long bar table in front of the kitchen, a long table in the center of the dining room, and directly behind it a three-top assistance table against the wall. -At 5:27 p.m. a nurse served a room tray. Resident orders were being taken. Two or three residents were eating cauliflower-cheese soup, but some declined soup when offered. One resident at the bar table, who had soup, was just served his entree. Glasses of water were on the tables, and hot beverages were now being served. -At 5:29 p.m. only one resident at the bar table by the kitchen had been served. Two other residents were sitting at the bar table with him but not yet served. The other residents had not been served. -At 5:31 p.m. the same resident at the bar table was served a second plate of food. At 5:32 p.m. the second resident at the bar table (Resident #48) was served his plate. At 5:33 p.m., a staff person wheeled a resident into the dining room and took the resident's order. Two of the three residents at the bar table were eating their meals, but the third resident still had no entrée. -At 5:37 p.m. Resident #41, who was sitting at the head of the long table, was served her entrée. The six other residents at her table had drinks but no food. At 5:40 p.m., the third resident at the bar table was served, 11 minutes after the first resident was served. -At 5:41 p.m., the resident to the right of Resident #41 was served her plate. Five others at the table were not yet served. At 5:46 p.m., a third resident at the long table was served. Four residents at the table were still without food and waiting. At 5:47 p.m., the resident who was brought in later was served her soup. The male resident at the far end of the table (opposite Resident #41) was served a bowl of soup. -At 5:50 p.m., a fourth male resident wheeled up to the bar table, and the first resident was served at the three-top table at the far wall behind the long table. Dinner was scheduled for 5:00 p.m., and most residents had been waiting in the dining room since then, but several residents had still not been served at 5:50 p.m., some of whom sat at the same table with those who were already eating their meals. B. Dinner on 11/13/18 Continuous dinner service observations on 11/13/18, from 5:00 to 5:51 p.m., revealed the following: -At 5:32 p.m., residents had been in the dining room since 5:00 p.m. The three residents at the bar table were eating together. Only two residents at the long table had been served their entrée and the rest were waiting. One resident was still eating her soup. The male resident at the end of the table was served his meal, picked up his adaptive fork and was slowly trying to pick up a bite of food. -At 5:41 p.m., Resident #41, at the opposite end of the long table, said to her tablemates, I don't think I'm going to get any food anyway. -At 5:42 p.m., a nurse delivered a room tray to Resident #51. -At 5:49 p.m., Resident #41 and her three remaining tablemates were served their entrees after at least a 49-minute wait. The residents at the assist table still had not been served. C. Lunch on 11/14/18 Continuous observations from 12:15 to 12:40 p.m. on 11/14/18 revealed the following: -At 12:15 p.m., four entrees were delivered to residents at the long table. All three residents at the bar table had been served. Resident #28 just seated herself at the long table. Six other residents at the long table were not yet served and were waiting. -At 12:17 p.m., Resident #43 was wheeled up to the bar table by staff to join the three who were already eating. Resident #41 at the head of the long table was served her entrée. -At 12:22 p.m., Resident #51's and Resident #106 at the long table were served. Resident #43 was eating soup at the bar table with his three tablemates who were eating their entrees. -At 12:23 p.m., Resident #28 at the long table was served her entrée. -At 12:26 p.m., the last resident at the long table was served her meal, 11 minutes after the first resident at the same table was served. A CNA asked all the residents if they needed anything. -At 12:27 p.m., Resident #17 at the small assist table was served by kitchen staff. Two of the three residents at the assist table had no food yet. A CNA said they were getting soup now, and added, We always start with soup. -At 12:34 p.m., Resident #17 was slowly eating soup with an adaptive spoon. Her two tablemates and everyone else in the dining room had been served and were eating something. -At 12:36 p.m., CNA #7 stood over Resident #17, placed a straw in a cup and held it to her mouth, then walked away toward the kitchen, saying tomato soup was all she wanted to eat for lunch that day. -At 12:40 p.m., CNA #7 was asking Resident #17 if she was done, and asking other residents at the assist table if they were done, although they had only been served a few minutes before. Residents at the long table were not served together. Residents at the assist table were served last and were asked if they were finished after seven minutes. V. Record review Facility assessment The facility assessment, last updated 10/21/18, indicated 38 of 51 residents would be considered to require assistance of one to two staff or fully dependent on staff for eating. B. Resident council meeting minutes The Neighborhood Council Minutes were reviewed from 1/2018 through 10/2018 and revealed the following comments and discussions: 1/11/18: One resident said she was consistently hearing just a moment please from both servers and nursing staff in the dining room. 3/8/18: One resident said he was told individual packets of salad dressing or steak sauce were not available in the neighborhoods. The food service director responded those items were available and the servers had to go to the main kitchen to get them. 6/14/18: The culinary director suggested residents order their evening meal at lunch when ordering a la carte so they would not have to wait so long at the evening meal. -One resident said ordering that far in advance was difficult due to last minute changes from dietary. -One resident said if the item is broadcast on the television screen it should be available at meal time. -Two residents said they had very long waits for meals. One had waited over 45 minutes and the other over an hour before saying forget it it ' s too late. 9/13/18: One resident said she had to wait a long time for dinner sometimes. One resident asked if the cooks were well trained or do they just take anyone. 10/11/18: Residents were informed there would be no menu modifications while the culinary director was away to keep it stable. -The DON announced the Creekside dining area was going to become the new Community Life room for group activities. C. Dining service handbook The Morrison Community Living (MCL) Dining Handbook, undated, was provided by the registered dietitian (RD) on 11/15/18 at 1:44 p.m. She said this was the training tool used throughout the past summer at monthly department meetings and new employees were given a copy. Steps for quality table service included (pp.7-9): -Greeting each resident within two minutes of being seated; -Deliver beverages immediately, serving females first; -Clear dishes after everyone has finished the first course; and, -Detailed instructions for which side of the resident and with which hand meal courses and beverages are served and cleared. VI. Staff interviews CNA #6 was interviewed on 11/13/18 at 9:46 p.m. She said it was her opinion that the dietary department should serve the room trays first due to resident's food getting cold. She said, in the past eight weeks she had worked in the facility, she had had several complaints of this nature from the residents. Server #4 was interviewed on 11/14/18 at approximately 8:25 a.m. She said she was always busy and often has worked double shifts. She said there were times she felt like she needed help but the residents understand and do not hold it against her. She said it was not uncommon for meals from the kitchen to take over 30 minutes, especially at lunch. The interim food service director (FSD) and registered dietitian (RD) were interviewed on 11/15/18 at 11:05 a.m. and the findings above discussed. They said the facility tried to give everyone five star service, so all staff knew the proper way to serve, although different team members worked and organized differently. They said it could be overwhelming for some staff, and some were just more efficient naturally. They said there was one server assigned to each neighborhood. Residents should have their order taken in 10 minutes or less and some items could take up to 30 minutes with preparation and travel time. They said in-room meals were last to be served unless the dining room was slow and the server had time. They said items ordered from the a la carte menu were phoned to the kitchen by the neighborhood server and delivered to the neighborhoods when ready. They said resident meals phoned in were put in line behind any orders ahead from the assisted living and bistro. They said tablet computers had been ordered to communicate directly with the kitchen. They said there were no dietary staff reassigned to Mountainside or Pondside as an additional server. They said the position of a runner was created to help facilitate prompt service by decreasing the travel time back and forth to the production kitchen. They said there was one person in the position who was scheduled five days per week. They said there was no part-time runner position and staff would let them know when help was needed. The RD said they offered staff training, but one on one training was something they would like to do. It needs to be a more scheduled training we can work on. They said they were taking orders a table at a time, and if one resident sat at a table later, it could affect meal service times, depending on the day and the meal. They said they attempted to accommodate resident needs, but the size of the kitchen was a challenge. The director of nursing (DON) was interviewed on 11/15/18 at approximately 12:30 p.m. She said nine to 12 residents were now served from the other two neighborhood kitchens. She said she felt meal service times had decreased. She said 20 minutes would be a reasonable wait for a meal unless it was an item requiring longer preparation time. She said wait times greater than 20 minutes for on-menu items were excessive.

Based on observations, record review, and interviews, the facility failed to ensure the resident's call light system was functioning in its entirety. Specifically, the facility failed to ensure call light requests for assistance were not dismissed prior to the resident receiving the help they needed. Cross-reference F725 sufficient nursing staff Findings include: I. Professional standard According to Potter, Perry, Stockert, and Hall (copyright (YEAR)), Fundamentals of Nursing (ninth edition), page 390: Nurses are responsible for making a patient's bedside safe. Explain and demonstrate to patients how to use the call light or intercom system and always place the call device close to the patient at the conclusion of every nurse-patient interaction. Respond quickly to call lights. II. Facility layout The facility had three neighborhoods with one long hallway that connected all three: Mountain Side, Creek Side, and Pond Side. The resident call light system alerted staff by sending notifications to IPods carried by the certified nurse aides (CNA) and licensed nursing staff. In addition, each neighborhood had an electronic digital display that would light up with the resident's room number, whether it was the main room or bathroom where the assistance was needed, and the number of tries that had occurred since the resident first pushed the call button. III. Resident interviews Resident #3 was interviewed on 11/12/18 at 1:17 p.m. She said approximately one week prior, the battery in her call light was not working and it had to be replaced. She said after the battery was replaced, her call lights were answered more timely. Resident #25 was interviewed on 11/12/18 at 1:43 p.m. She said she had lengthy call light response times in the past and had not made it to the bathroom in time on one occasion. She said recently the battery in her call light was not functioning properly and needed to be replaced. Resident #28 was interviewed on 11/12/18 at 1:59 p.m., and she said she had to wait too long for the bathroom at night and That's not good. She said one of her worries was having a fall and the call light response time has been a problem. She stated, It's a problem about twice a week; they come eventually but sometimes that's too late. She asked, What if you fall and can't reach the call light and they don't come, then what? There you are on the floor for hours again. She said it concerned her because the night prior, a CNA went to get her a bandage and never came back. She said one night, a couple weeks ago, she had wet her pajamas and could not reach a dry adult incontinence brief and stated, There I was. It was a long time. She said she pushed the call light and no one responded and she finally took off the wet pajamas herself. She said a nurse checked on her later and she told him she had been incontinent of urine, and he told her she should have used the call light to ask for help. She clarified she had pushed the call light but no one responded. Resident #1 was interviewed on 11/13/18 at 9:19 a.m. He said sometimes after he pushed his call light he had to wait as long as an hour for help when they got busy. He said it usually occurred during the day shift and stated, It doesn't do any good to say anything. Resident #51's daughter was interviewed on 11/12/18 at 3:10 p.m., and she said the resident had waited 15-30 minutes for a call light response. She stated, Twice now I've been with Mom, watched it and timed it, and personally went down to get someone at the nurses' station. IV. Record review The call light history and response time was reviewed for the following residents from 9/1/18 through 11/14/18, and the following was documented: 1. The call light history and response time was reviewed for Resident #25 from 9/1/18 through 11/14/18, and the following dates revealed the call light was pushed and the alert was never responded to: -9/1/18 at 1:30 and 6:44 a.m.,9/2/18 at 4:56 p.m.,9/5/18 at 6:25 p.m.,9/8/18 at 5:15 and 5:34 a.m.,9/9/18 at 6:28 a.m., 9/12/18 at 3:26 p.m., 9/13/18 at 6:24 a.m., 9/18/18 at 6:57 a.m.and 4:24 p.m., -9/21/18 at 6:21 a.m., 9/22/18 at 5:09 a.m., 9/26/18 at 6:41 p.m., 9/27/18 at 7:04 p.m., 10/1/18 at 9:27 p.m., 10/3/18 at 3:56 p.m., 10/16/18 at 6:25 a.m., 10/29/18 at 6:25 and 6:45 a.m., 10/31/18 at 6:53 a.m. 2. The call light history and response time was reviewed for Resident #28 from 9/1/18 through 11/14/18, and the following dates revealed the call light was pushed and the alert was never responded to: -9/1/18 at 8:14 p.m. and 9:31 p.m., 9/4/18 at 7:31 a.m., 9/8/18 at 11:33 a.m., 9/10/18 at 10:31 p.m., 9/12/18 at 10:51 p.m., 9/13/18 at 11:13 p.m., 9/18/18 at 1:30 a.m., 9/21/18 at 2:13 a.m., 9/23/18 at 5:04 a.m., 8:35 a.m., 9:55 p.m., and 11:14 p.m., 9/26/18 at 12:07 a.m., 9/28/18 at 7:53 a.m., 9/30/18 at 11:23 a.m. and 11:32 a.m., 10/1/18 at 11:22 a.m., 10/5/18 at 1:39 a.m., 10/6/18 at 3:54 a.m., 10/12/18 at 11:13 a.m., 10/13/18 at 7:30 a.m., 10/14/18 at 9:35 a.m., 10/16/18 at 9:29 a.m., 10/17/18 at 8:10 a.m., 2:10 p.m., and 10:46 p.m., 10/22/18 at 8:46 p.m., and 9:30 p.m., and 11/3/18 at 8:56 p.m. 3.The call light history and response time was reviewed for Resident #1 from 9/1/18 through 11/14/18, and the following date revealed the call light was pushed and the alert was never responded to: -10/6/18 at 7:02 a.m. 4. The call light history and response time was reviewed for Resident #51 from 9/1/18 through 11/14/18, and the following dates revealed the call light was pushed and the alert was never responded to: -9/1/18 at 6:54 a.m. and 10:19 a.m., 9/2/18 at 12:37 p.m., 9/4/18 at 1:49 p.m., 9/7/18 at 8:59 p.m, 9/9/18 at 4:28 a.m., 9/10/18 at 5:08 a.m., 9/12/18 at 2:24 p.m. and 4:08 p.m., 9/13/18 at 3:53 p.m., 9/17/18 at 5:57 p.m., 9/21/18 at 6:38 p.m., 9/22/18 at 9:23 a.m., 9/23/18 at 7:12 p.m., 9/24/18 at 11:44 a.m., 9/30/18 at 10:45 a.m., 10/13/18 at 10:11 a.m., 10/16/18 at 4:57 p.m., 10/26/18 at 5:47 p.m. and 6:11 p.m., 10/28/18 at 4:04 p.m., and 11/1/18 at 2:42 p.m. 5. The call light history and response time was reviewed for Resident #3 from 9/1/18 through 11/14/18, and the following date revealed the call light was pushed and the alert was never responded to: -9/10/18 at 4:21 p.m. V. Staff interviews: RN #1 was interviewed on 11/13/18 at 9:13 p.m., and said if a call light was pulled out of the wall it might not alarm. She said earlier that day, she entered room [ROOM NUMBER] and noticed the call light was not connected to the wall, was lying on the floor, and was not alarming. She plugged the call light back into the wall and instructed the resident to walk out to the nurses' station if that happened again and she did not receive a response to her call light. RN #3 was interviewed on 11/13/18 at 9:32 p.m. and said she was carrying a CNA IPod for call light notifications because they were short one CNA on her neighborhood. She explained the call light system was initiated when the resident first pushed the call button for help, and that alert was sent to the CNAs working in the neighborhood. That occurred every two minutes, and she called them Try one, try two, and try three. She said try four would be eight minutes after the call light was initially pushed, and then the system would then notify every nurse working in every neighborhood as well as all of the CNAs. The RN was asked if the call light ever timed out after a certain number of tries and she stated, Try nine is considered an unanswered call and that goes to (nursing home administrator/NHA) and (DON), and said, That is when it would drop off. RN #5 was interviewed on 11/13/18 at 10:27 p.m., and she confirmed she was the charge nurse working that night. She said she could not confirm that call lights were dropped after try nine without assistance being provided. She said she thought it was try six when an actual phone call occurred to the NHA, so they tried very hard to answer them before it got to that. The information technologist (IT) was interviewed on 11/15/18 at 8:46 a.m. He said there was a bed call light and bathroom call light in each resident's room. If they needed assistance, they pressed the button, or pulled the string if they were in the bathroom, and that sent a signal out to a wallboard and to a portable IPod device that signaled to the CNA that a resident in room X needed assistance. The CNA would go and help the resident and pressed the reset button when they were finished, and then the process started all over again. He said there were groupings of emails set up for notification when the call lights were alarming for a certain amount of time with no response. He explained the notifications were Level 1, Level 2, and Level 3, which escalated to include more staff were notified the longer the alarm remained unanswered. He said Level 1 alerted the CNAs working in the particular neighborhood where the call light was initiated. Level 2 escalated to all CNAs and nurses in the building who were working the floor. Then Level 3 went out to all of them again, including the director of nurses (DON) and nurse manager (NM). The IT said he was occasionally made aware of call lights not functioning properly by staff or residents, which could be made through a work order, email, phone call, or verbal requests. He said he performed random audits and do call light testing in all of the rooms. If he saw a call light not operating correctly, or a cord that was frayed, or if he was pressing it and nothing was happening, he would replace them. He said it was rare for the call light to be pushed and not send an alarm, but they were mechanical devices and required troubleshooting. He said more often than not, it was user error and they were working the way they should be. He said he was not aware of the call light in room [ROOM NUMBER] not alarming when it was pulled out of the wall and clarified that when they were removed from the wall, it triggered a spring to be released that would then set off the call light. He looked at his most recent call light audit for room [ROOM NUMBER], dated 10/31/18, and said he had changed the bed cord at that time, and would investigate further. The IT said the call light system included a way to look at the battery life remaining in the wall-mounted units and stated, But personally, I don't trust it. He said checking the batteries was not currently on a routine schedule, but he knew the facility had changed every call light battery within the whole system within the past year. He explained if a resident pressed the call light more often, the battery would wear down faster. The DON was interviewed on 11/14/18 at 3:14 p.m. She said she had not been aware that the call lights dropped off after try nine until the night before, when she received a phone call from RN #5. She said she had a conversation with the IT that morning and had been told in the past that this was the company's functionality, the try nines. She said the functionality had been increased that morning to 100, which was equivalent to 200 minutes. Meaning, if the call light alert was tried every two minutes for 100 times, it would take 200 minutes before the call light would drop off. She said they were happy with the increase and the change had already been made on the nursing staff's IPods, which is what they received the call light notifications on. She confirmed the facility did not currently have a system in place to routinely check the call light batteries and said their maintenance director and IT would change them if they were notified to do so. She said in the event a call light was not functioning properly, they had bells they could provide to the residents to use in the meantime, and the call light could be changed out very quickly. The DON said if a call light was pulled out of the wall, she did not know if it would alarm and keep alarming or not. She said the nursing staff did hourly rounding in their assigned zones, and if for some reason, a call light was broken, she felt it would be identified quickly. She said sometimes the CNAs or nurses entered a resident's room to answer a call light and forgot to reset it. She said in the past when a resident or family complained of a lack of timeliness answering the call lights, they had a video surveillance system in the building they could review. She said she would check that camera system based on that complaint to explain to the family staff had been in the resident's room. She said the longest wait time she was aware of was 21 minutes, and said that was a long time, however, that is a rarity. She said she trusted the staff and thought they just forgot to turn the call lights off. VI. Additional observations On 11/14/18 at 3:35 p.m., the DON entered room [ROOM NUMBER] and pulled the call light out of the wall. It initiated a call light notification through the system properly. At 3:40 p.m., the DON tested the call light in room [ROOM NUMBER], and it initiated the call light system appropriately. VII. Facility follow up The DON provided additional documentation via email on 11/19/18 at 3:02 p.m. She said their video footage was deleted regularly based on the volume allowed per camera, and the systems rebooted sporadically. She said Resident #1's room did not have video footage until 9/12/18 when she had requested the camera be relocated so she could see the nurses' station, which also gave access to his room. In addition, Resident #25's room did not currently have video access to view her room, but she would ask for a camera angle to be relocated so she could view her room in the future. The additional documentation did not address the video footage for Resident #25, Resident #28, or Resident #51.

Based on observations, record review and interviews, the facility failed to provide oxygen services as prescribed by the physician. Specifically, the facility failed to ensure oxygen therapy was administered as ordered by the physician for four (#2, #12, #13 and #35) of four residents reviewed for oxygen therapy of 35 sample residents. Findings include: I. Facility policy and procedure The Oxygen Therapy Monitoring policy, revised 10/11/18, provided by the director of nursing (DON) on 11/14/18 at 1:57 p.m., stated in purpose that oxygen therapy was considered a vital treatment, and monitoring its correct usage was the responsibility of all nursing staff. The policy statement read that regularly scheduled checks of each oxygen dependent resident would be done to ensure that residents were receiving the correct liter flow, attached to an adequate supply source, and had a nasal cannula or mask in place and all tubing intact. Compliance with these expectations would be monitored by the nursing manager and any pattern of errors would be addressed. II. Resident #2 A. Resident status Resident #2, age 61, was admitted on [DATE]. The computerized physician orders [REDACTED]. The most recent minimum data set (MDS) assessment completed 8/1/18, included a brief interview for mental status (BIMS) score of 15 of 15 indicating a cognitively intact status. MDS [DIAGNOSES REDACTED]. The resident was listed as receiving oxygen therapy while a resident. B. Observations -On 11/12/18 at 1:59 p.m. Resident #2 was observed in her room on the in room stationary oxygen concentrator set at 3.5 liters per minute (LPM). The resident stated that her setting should be set at 2.5 liters. -On 11/13/18 at 1:12 p.m. the resident was observed on 3.5 LPM on her stationary concentrator in her room. -On 11/14/18 at 1:12 p.m. while doing wound care with the wound care nurse practitioner (NP) the resident was observed on her in room stationary concentrator set at 3.5 LPM. This flow rate was confirmed with the NP. -On 11/15/18 at 11:19 a.m. the resident was observed on 3.5 LPM on her in room stationary concentrator; this flow rate was confirmed with registered nurse (RN) #4. RN #4 stated it was the responsibility of the nurses to check and confirm oxygen flow rates every shift. C. Record Review The physician order [REDACTED].#2 read for oxygen at 2.5 LPM nasal cannula at all times. The care plan initiated on 5/8/18 for the problem of oxygen therapy included an approach to administer oxygen at 2.5 LPM via nasal cannula at all times per physician orders. Point of care history charting for the order to administer oxygen at 2.5 LPM via nasal cannula indicated that from 11/12/18 through 11/14/18 (during survey) the resident was being documented as receiving 2.5 LPM despite the observations of 3.5 LPM listed prior. D. Interviews The DON and nurse manager (NM) were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the resident should be on 2.5 LPM as ordered by the physician and that the resident was on the wrong oxygen flow settings. The DON and NM both confirmed that nursing staff had been entering wrong LPM documentation in the point of care history documentation for oxygen administration. III. Resident #13 A. Resident status Resident #13, age 82, was originally admitted [DATE] with the most recent return admission on 8/26/16. CPOs included the [DIAGNOSES REDACTED]. The most recent MDS assessment completed on 8/30/18, included a BIMS score of two of 15 indicating severe cognitive impairment. The resident was listed as receiving oxygen therapy while a resident, and [DIAGNOSES REDACTED]. B. Observations -On 11/12/18 at 2:39 p.m. the resident was observed in the activities area in her wheelchair not wearing her nasal cannula. The resident was holding the oxygen tubing in her hand. -On 11/13/18 at 8:23 a.m. the resident was observed on her in room stationary concentrator at 2.5 LPM resting in bed. -On 11/14/18 at 8:34 a.m. the resident was observed on her in room stationary concentrator set at 2.5 LPM while asleep in bed. At 3:06 p.m. the resident was observed in the hallway on her portable oxygen device set at 2.5 LPM, the setting was confirmed with RN # 2. RN #2 was unaware why the oxygen was set at 2.5 liters despite confirming the order for 3 LPM. At this same time the stationary in room concentrator was observed as well, and was also confirmed to be still set at 2.5 LPM. The RN was unsure of why both the stationary in room and portable devices were both set to 2.5 LPM and acknowledged that both were wrong in comparison of the order flow rate of 3 LPM. -On 11/15/18 at 9:11 a.m. the resident was again observed on 2.5 LPM on the in room stationary concentrator while resting in bed. C. Record review The physician orders [REDACTED]. The care plan for oxygen therapy was last edited on 4/30/18. The care plan read to administer oxygen at 3 LPM via nasal cannula. Point of care history charting for the order to administer oxygen at 3 LPM via nasal cannula indicated that from 11/12/18 through 11/15/18 (during survey) the resident was being documented as receiving 3 LPM despite the observations of 2.5 LPM listed prior. D. Interviews The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the resident should be on 3 LPM as ordered by the physician and that the resident was on the wrong oxygen flow settings. The DON and NM both confirmed that nursing staff had been entering wrong LPM documentation in the point of care history documentation for oxygen administration. IV. Resident #12 A. Resident status Resident #12, age 82, was originally admitted on [DATE] with the latest return admission on 8/30/18. The resident face sheet [DIAGNOSES REDACTED]. The most current MDS assessment dated [DATE] listed a BIMS score of 13 out of 15 indicating a cognitively intact mental status. MDS [DIAGNOSES REDACTED]. The resident was identified as receiving oxygen therapy while a resident. B. Observations -On 11/13/18 at 9:14 a.m. the resident was observed on his in room concentrator at 5.5 LPM; the resident was unsure of his correct oxygen settings. -On 11/13/18 at 12:03 p.m. the resident was observed in the hallway reading the paper while sitting in the sun. The flow rate on his portable oxygen device was set to 6 LPM. -On 11/13/18 at 3:05 p.m. the resident was observed in bed on 6 LPM from his portable oxygen device hanging off his wheelchair. The oxygen device gauge was reading low and in the red indicating it was nearly empty. This was confirmed with RN #4 who switched the resident to the in room stationary condenser and set the flow rate at 5 LPM. The RN confirmed that there would have been no alarms if the portable oxygen device ran empty or if the resident's oxygen saturation would have fallen below normal limits due to the device running out of oxygen. C. Record review The computerized physician orders [REDACTED]. The care plan last edited on 8/2/18 read to administer the resident's oxygen at 5 LPM via nasal cannula continuously. Point of care history reports for the order to administer oxygen at 5 LPM via nasal cannula indicated that from 11/12/18 through 11/15/18 (during survey) the resident was documented as receiving 5 LPM. D. Interview The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members confirmed that the resident should be on 5 LPM as ordered by the physician and that the resident was on the wrong oxygen flow settings during listed observations. The DON and NM both confirmed that nursing staff had been entering wrong LPM documentation in the point of care history documentation for oxygen administration. The DON confirmed that it was the nurse's responsibility to confirm both flow rates and the tank capacity during hourly rounding, and that it is the CNA's responsibility for filling portable oxygen devices. V. Resident #35 A. Resident status Resident #35, age 89, was originally admitted [DATE] with the most recent return admission on 8/2/17. The CPO listed [DIAGNOSES REDACTED]. According to the most recent MDS assessment on 9/27/18 the resident had a BIMS score of five out of 15 indicating severe cognitive impairment. MDS [DIAGNOSES REDACTED]. B. Observations -On 11/13/18 at 08:36 a.m. the resident was observed in bed not wearing her nasal cannula for oxygen administration; the stationary in room oxygen concentrator was set to 4.5 LPM. LPN #2 stated that the resident regularly removed her oxygen and was unsure how long the resident was without her oxygen. -On 11/13/18 at 3:25 p.m. the resident was observed in bed with her nasal cannula falling off and not secured properly. -On 11/14/18 at 12:25 p.m. the resident was observed not wearing her nasal cannula. -On 11/14/18 at 1:28 p.m. the resident was again observed not wearing her nasal cannula. C. Record review The (MONTH) (YEAR) CPO read for oxygen via nasal cannula 4 LPM in daytime and 5 LPM at night for every shift day, evening, and night. The care plan was initiated for the problem of oxygen therapy on 8/3/17. The approach of administering oxygen via nasal cannula at 4 LPM in the daytime and 5 LPM at night via nasal cannula as ordered was last edited on 4/24/18. Another approach -- listed as I often remove my oxygen tubing and forget to replace it. Please ensure my nasal cannula is in place each time we meet -- was created on 11/14/18 (during survey). A nursing progress note by LPN #2 on 8/5/18 at 4:45 p.m. read in pertinent part that the resident was on oxygen via nasal cannula which the resident frequently took off causing some changes in mental status that resumed to normal when the resident put oxygen back on. D. Interview The DON and NM were interviewed on 11/15/18 at 12:30 p.m. Both staff members stated that it was the nursing staff's responsibility to be ensuring that residents were both wearing oxygen and that oxygen flow rates were set to the prescribed rates, and that this should have been done upon hourly rounding. The DON and NM stated that per the care plan wording of ensure my nasal cannula is in place each time we meet was in reference and would be done during the hourly rounding. The DON acknowledged that nursing staff had identified and documented the resident did get more confused when removing her oxygen and that her confusion improved when the oxygen was reapplied. The DON and NM both agreed that changes in mental status such as an increased level of confusion was an early sign of [MEDICAL CONDITION]. The DON also stated that the care plan interventions for this resident to ensure she was receiving her oxygen administration were effective. The DON and NM stated that a new process was initiated in the last two weeks in response to identified issues with ensuring oxygen flow rates. They said it was now the nurse's responsibility to verify oxygen flow rates for all residents receiving oxygen therapy in the facility, and that these checks should be done hourly. The DON stated that there was no policy for nurses to titrate oxygen flow rates either up or down, and that all changes to a resident's oxygen flow rate required a physician order. The DON and NM stated that there was no reason for any resident's oxygen settings to have deviated from the prescribed oxygen settings. The DON and NM both stated that the new process initiated two weeks ago of having the nurses ensure oxygen flow rates were consistent with the prescribed flow rates during hourly rounding, had not been effective.

Based on resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 17 (#1, #2, #3, #9, #16, #22, #24, #25, #28, #31, #35, #41, #44, #47, #50, #51, #52) of 35 sample residents. Resident and staff interviews revealed the facility failed to consistently provide adequate nursing staff resulting in delayed call light response, assistance with activities of daily living, assistance to and from the toilet, and prolonged wait times before and after meals in the dining room. Findings include: Cross-reference F550 failure to provide care with dignity and respect, F695 failure to provide oxygen therapy as ordered, F744 failure to provide person-centered dementia care, F802 sufficient dietary support personnel, and F919 failure to answer call lights in a timely manner. I. Facility policy and procedure The Staffing policy and procedure, last revised 10/10/18, was provided by the director of nurses (DON) after survey exit on 11/19/18. The policy included clinical staffing would be based on census and acuity and may be adjusted up or down as needed to provide sufficient staffing. The day and evening shifts would include three licensed nurses and six certified nurse aides (CNAs); the night shift would include two licensed nurses and three CNAs. The DON, nurse manager, and minimum data set (MDS) coordinator would cover shifts that could not be replaced by regular staff members. An additional float CNA would be added when acuity required it, and all efforts should be made by the manager on call to replace call-ins to maintain the above staffing levels. II. Record review A. According to the Resident Census and Conditions of Residents report, signed by MDS coordinator on 11/12/18, the resident census was 52 and the following care needs were identified: -42 residents needed assist of one or two staff for dressing -23 residents needed assist of one or two staff for bathing -35 residents needed assist of one or two staff and nine were dependent for transfers -31 residents were occasionally or frequently incontinent of bladder -Six were bedfast all or most of the time -28 residents had dementia or [MEDICAL CONDITION] -25 received respiratory treatment -Five residents had pressure ulcers B. Resident council meeting minutes The Neighborhood Council Minutes were reviewed from 1/2018 through 10/2018 and revealed the following comments: -One resident said the nurses seem very stretched. (2/8/18) -One resident said she likes the transportation she receives to groups, but sometimes feels stranded afterwards as it can take a while to get back. (4/12/18) -Some residents felt it seemed as though the nursing department was short on staffing . they agreed it was around change of shift and meal times . the Ombudsman asked residents if their call buttons were answered in a timely manner, some said they wait at times . (8/9/18) -One resident commented that the nurse staffing seems short lately on both shifts. He said they do a great job, but need more help. One resident added that they are having a CNA class currently, so that should help with staffing . One resident asked about the traveling nurses we have lately . (9/13/18) -(DON) announced that it had been a group effort to come to the decision to use Creekside dining as the new Community Life Room for activity groups . This will start this Monday the 15th . One resident asked about now only having one nurse on each neighborhood. (DON) explained the medication nurses has shrunk to one medication nurse manager. (10/11/18) III. Resident and family interviews A. Resident group interview A resident group interview was conducted on 11/13/18 at 1:00 p.m. with eight residents who, per facility and assessment, were interviewable and four of whom regularly attended resident council meetings. Several of the residents said the facility did not have sufficient nursing staff to ensure they did not have to wait too long for the care and services they required. B. Resident and family interviews Residents who, per facility assessment were interviewable, made the following comments regarding nursing staffing. Resident #35 was interviewed on 11/12/18 at 12:59 p.m. She said CNAs in the facility needed training, and they were short staffed on Sundays and the midnight shift. Resident #3 interviewed on 11/13/18 at 12:19 p.m. She said that due to insufficient staff, she had been left on the toilet for an hour or longer just a few weeks ago. She said, by the time she got off the toilet, her bottom was numb. She was interviewed a second time on 11/12/18 at 1:17 p.m. She said approximately one week prior, the battery in her call light was not working and it had to be replaced. She said after the battery was replaced, her call lights were answered more timely. On 11/13/18 at 10:12 a.m., the resident said she felt there were times when the facility needed more CNAs and nurses on the floor. Resident #2 was interviewed on 11/12/18 at 1:24 p.m. She said the facility never had enough staff in the morning and would only have one CNA working when they were supposed to have two in each neighborhood during the 6:00 a.m. to 2:00 p.m. shift. She stated, They take 20 minutes to answer the call light. Resident #52 was interviewed on 11/12/18 at 1:30 p.m. She said she felt the facility did not have enough nurses or CNAs working to get to all the residents needs quick enough. Resident #25 was interviewed on 11/12/18 at 1:43 p.m. She said the facility could use more CNAs, more training for the CNAs, and the facility was short on staffing during the night shift. She said she had lengthy call light response times in the past and had not made it to the bathroom in time on one occasion. She said recently the battery in her call light was not functioning properly and needed to be replaced. Resident #41 was interviewed on 11/12/18 at 1:49 p.m. She said the facility was always short on CNAs, especially at night, when there was one person on duty for two hallways, and that did not work out very well. She said when she was in the bathroom and needed help, sometimes she ended up waiting for long periods and her legs got sore and would go to sleep while she was sitting on the toilet waiting. She said this had been brought up in resident council in the past, and it was usually during the night shift. Resident #47 was interviewed on 11/12/18 at 1:57 p.m. She said the facility need more nursing staff to help her lie down in a timely manner. She said it was an issue on all days and all shifts. She said she had waited up to three hours for assistance, from the time she originally asked for help, for staff to come and assist her to bed. Resident #28 was interviewed on 11/12/18 at 1:59 p.m., and she said staffing was a problem. She said she had to wait too long for the bathroom at night and That's not good. She said she had talked to the facility staff in the past about the concern during her care conferences and was told they would ensure they came in to her room at eight p.m. in the evenings and get her ready for bed. She said one of her worries was having a fall and the call light response time has been a problem. She explained her neighborhood had only one CNA after 10:00 p.m., and they had many people to take care of. She estimated one nurse and one CNA were responsible for caring for over 20 residents. She stated, It's a problem about twice a week; they come eventually but sometimes that's too late. She asked, What if you fall and can't reach the call light and they don't come, then what? There you are on the floor for hours again. She said it concerned her because the night prior, a CNA went to get her a bandage and never came back. She said one night, a couple weeks ago, she had wet her pajamas and could not reach a dry adult incontinence brief and stated, There I was. It was a long time. She said she pushed the call light and no one responded and she finally took off the wet pajamas herself. She said a nurse checked on her later and she told him she had been incontinent of urine, and he told her she should have used the call light to ask for help. She clarified she had pushed the call light but no one responded. She said the facility used a lot of traveling nursing staff who stayed for a month or two, and thought more would stay if it were not so expensive to live in the area. Resident #9 was interviewed on 11/12/18 at 2:04 p.m. She said staff did not come when she rang her call light and this had happened on more than one occasion. Resident #24 was interviewed on 11/12/18 at 2:43 p.m. She said the call light response was very slow and she had waited for over an hour for help with incontinence care at times, mostly during the night shift. She said when that happened to her, It feels like (expletive). Resident #51's daughter was interviewed on 11/12/18 at 3:10 p.m., and she said the resident had waited 15 to 30 minutes for call light response. She said her mother required two staff members for assistance to use the bathroom, and she had a fall on 9/2/18. She said two Wednesdays ago, there was one CNA for the 2:00 p.m. to 10:00 p.m. shift, which was not enough. She stated, Twice now I've been with Mom, watched it and timed it, and personally went down to get someone at the nurses' station. She said meal wait times could be an hour, and it was a 15-minute wait for soup, then another wait for the meal, and then another wait for the dessert. She said there was usually one person serving every single tray, and if the staff did not know the resident, It's a struggle. She said recently she waited for lunch from 11:30 a.m. to 1:00 p.m. before she was served. Resident #51's daughter was interviewed a second time on 11/13/18 at 10:08 a.m. She said the facility staff left her mother on the toilet, unattended, and that made the family concerned. She said the resident had sciatic pain from sitting for 15 to 30 minutes about a week ago during the weekend. Resident #22 was interviewed on 11/12/18 at 3:56 p.m. She said she felt the facility was short staffed and the staff told her every other day that there was not enough staff working. Resident #1 was interviewed on 11/13/18 at 9:19 a.m. He said sometimes after he pushed his call light he had to wait as long as an hour for help when they got busy. He said it usually occurred during the day shift and stated, It doesn't do any good to say anything. Resident #16 was interviewed on 11/13/18 at 1:14 p.m. She said sometimes her medications were given to her late, 30-40 minutes after they were due. She said the facility had a lot of nursing turnover and some new nurses who were there for 60-day intervals, and they were not used to the residents' medications. Resident #31 was interviewed on 11/13/18 at 1:20 p.m. He said the facility seemed to have a lot of nursing turnover and they were understaffed at times. Resident #44 was interviewed on 11/13/18 at 2:14 p.m. He said the facility was short of staff and would sometimes rush when providing him cares. He said it was most noticeable during the evenings between 6:00 p.m. to 7:00 p.m. when they were putting residents to bed and more people needed help. Resident #50 was interviewed on 11/13/18 at 2:20 p.m. He said the staff who were currently working in the facility were stretched out too thin. He said there were too many people to take care of with too many issues to take care of at the same time. He said 8:00 p.m. - 9:00 p.m. was when he noticed it was the worst, when they were trying to get everyone to bed. IV. Observations On 11/13/18 at 9:00 p.m., the Pond Side neighborhood was short staffed, with one nurse and one CNA working, rather than the routinely scheduled two CNAs. There was a dietary staff member working in the kitchenette and the majority of the resident room doors were closed. On 11/13/18 at 9:06 p.m., the Creek Side neighborhood was short staffed, with one nurse and one CNA working, rather than the routinely scheduled two CNAs. Resident #11 was observed sitting in her wheelchair calling out and said, Is anyone going to give me a push? I wish someone would come and give me a push. At 9:08 p.m., registered nurse (RN) #1 propelled the resident into the TV room and the resident stated, I want to go to my bedroom. The RN said she would be able to go to her room as soon as she located a staff member to help her, and then left the resident in the TV room. At 9:12 p.m., a CNA propelled the resident into her room. On 11/14/18 at 12:21 p.m., arrangements had been made with the nurse practitioner (NP) to observe Resident #35's wounds. However, the NP said the observation would not be able to be completed at that time because there was not enough staff to help. The wound observation was completed at 1:25 p.m., when assistance was available. On 11/14/18 at 12:45 p.m., Resident #2's wounds were observed with the NP. There were no CNAs available to assist, so the unit secretary (who was also a CNA) was asked to help. The call light messaging system was observed from the Mountain Side neighborhood dining room on 11/14/19. The following messages were noted: - 2:57 p.m.: Try 6 for Bed 41 - 3:25 p.m.: Try 12 for Bed 41 - 3:51 p.m.: Try 7 for Bed 33, Try 5 for Bed 41 and Try 6 for Bed 33 On 11/15/18 at 10:44 a.m., there was a Try 4 for Bed 41. This message changed to Try 5 for Bed 41 at 10:46 a.m. (Cross-reference F919 call light system) On 11/15/18 at 10:44 a.m., there were no nursing staffing observed on Mountainside neighborhood until 11:52 a.m. V. Additional record review The Daily Staffing Reports were reviewed from 9/1/18 through 11/14/18 and revealed the facility was unable to locate the reports for 10/17/18 through 10/22/18, 10/24/18 through 10/30/18 and nine days in November. The staffing sheets revealed the following nursing shortages: -September: 22 days were short CNA staff, 14 days they were short on more than one shift -October: Eight days were short CNA staff, three days they were short on more than one shift -November: one day were short CNA staff VI. Staff interviews The nurse manager (NM) was interviewed on 11/13/18 at 12:54 p.m., and she confirmed she was responsible for scheduling the nursing staff. She explained they used a nurse scheduling software that allowed staff to sign up for shifts as needed. She said the desired staffing numbers for the facility's three neighborhoods included the following: -6:00 a.m. to 2:00 p.m., three licensed nurses and six CNAs -2:00 p.m. to 10:00 p.m., three licensed nurses and six CNAs -10:00 p.m. to 6:00 a.m., three licensed nurses and six CNAs The NM said it was acceptable for a staff member to float back and forth among the units. She said at night, starting at 10:00 p.m., there were two nurses and three CNAs, so there was one staff member in each neighborhood at all times. If there was a call out, the person calling off had to notify the nurse manager, and then the nurse manager called around to find a replacement. She said nurses had worked as CNAs in the past, and started using agency nurses in (MONTH) (YEAR). She said they were trying to get away from using agency nurses but had not been able to. She said the local area was very transient due to the ski season and they had had multiple staff members leave. She said they had nursing staff who worked per diem and liked to pick up extra shifts when needed. She said when agency nurses and CNAs were first hired, they had a 12-hour training shift. After that, if they were not comfortable, they could get more and stated, But no one has ever needed additional training. She said the facility also required nurses to complete competencies that included tube feedings, abuse, skin assessments, hand hygiene, shift report, infection control, writing a telephone order, proper body mechanics, and medication administration before they were released on their own. CNA #9 was interviewed on 11/13/18 at 9:03 p.m. She said facility staffing depended on the day, but that the facility was having trouble retaining CNAs especially. She said maybe working as a CNA was not the job they expected. She said staffing had been a problem for months and it was not getting better. She said she picked up an extra shift at least every other week due to call offs. She said she had worked short-handed approximately 50% of the time. CNA #6 was interviewed on 11/13/18 at 9:46 p.m. She said she had been working in the facility for the past eight weeks as a traveling CNA and that she picked up three extra shifts just last week. She said they often worked short-handed and often had to go find help from a nurse during these times. She said she was training another traveling CNA that evening, which was slowing things down even further. She said she felt the facility could use another CNA on the Pondside neighborhood. RN #5 was interviewed on 11/13/18 at 9:12 p.m. She said the facility was not fully staffed the night she was interviewed. She said the facility had used traveling CNAs recently, but thought those CNAs were on vacation at the time. She said the facility was short one CNA on Mountainside neighborhood that evening and since she had CNA duties to perform herself, she was a bit behind schedule with passing medications and other nursing duties. She said the facility was very short of CNAs working presently. She said there were many jobs in the area, but not many workers for those positions. She said lack of CNAs affected the residents negatively, as their dinners and baths were rushed. She said the CNAs attempted to make up missed baths or showers during the night shift. She said the facility used to have a dedicated bath aide prior to the CNA shortage, but that they would not have a bath aide again until the facility was fully staffed with CNAs. She said the facility did not call the employees; they posted the opening they were short staffed and employees signed up to work. She said she signed up for extra work about three times per month. She said the night shift should have three CNAs working in the building; one per neighborhood. She said approximately three times per month, there were only two CNAs in the building from 6:00 p.m. to 10:00 p.m. She said being down one CNA during this time was very problematic due to residents finishing their meals and getting ready for bed at this time. She said that shortage of CNAs delayed residents' cares. She said showers were either postponed or turned into bed baths and that this had been happening more often the past two weeks. She said 50% of the CNAs had been newly hired within the past year. She said the longest call light she had seen going off without being answered was a Try 6. She said she thought every Try was five minutes, so a Try 6 should have been 30 minutes. She said Resident #12 had told her earlier that night that his call light had been going off for an hour. RN #1 was interviewed on 11/13/18 at 9:13 p.m., and said she worked per diem at the facility, and had picked up a four hour gap that evening shift on the Creek Side neighborhood. She said she routinely worked with one or two CNAs with her, and if there was not a second CNA, I step up and do more CNA stuff. She explained the Pond Side neighborhood where she was working had six out of 17 residents who needed to be transferred with mechanical lifts and explained those required two staff members. She said the CNA who was currently working in the neighborhood with her was an agency staff member. RN #1 was interrupted and had to go sign in a delivery of medications at the front desk. When she returned, she said she had a concern with the dining service and did not think there was enough dietary staff to get the meals served in a timely manner. She said she would prefer the residents seated at the same table received their meals all at the same time, versus how it currently was being served, when one resident was getting their soup and another was already eating their dessert. (Cross-reference F802 dietary staffing) RN #3 was interviewed on 11/13/18 at 9:32 p.m. She said the Pond Side neighborhood was currently staffed with one CNA, rather than the two routinely scheduled CNAs. She said she was busy and they were usually putting people to bed at that time of the evening and she was carrying a CNA IPod for call light notifications. She said she and the CNA were currently responsible for 19 residents, five of whom required mechanical lifts for transfers, which required two staff members. She said when that happened they tried to plan it out and rotate through the residents, prioritizing by their needs. She explained the call light system was initiated when the resident first pushed the call button for help, and that alert was sent to the CNAs working in the neighborhood. That occured every two minutes, and she called them Try one, try two, and try three. She said try four would be eight minutes after the call light was initially pushed, and would then notify every nurse working in every neighborhood as well as all of the CNAs. She stated, Try nine is considered an unanswered call and that goes to (the nursing home administrator/NHA) and (DON), and said, That is when it would drop off. CNA #3 was interviewed on 11/13/18 at 9:46 p.m. Shesaid she had worked night shift at the facility for two and a half years. She said sometimes the CNA staffing was a little short, and confirmed she was working short staffed that night on the Pond Side neighborhood, without one CNA. She said she was normally called to work extra shifts three to four times each month and had worked short-handed four times in a six-month period. She said if she needed help during her shift, she would just walk to another neighborhood and ask for it. CNA #4 was interviewed on 11/13/18 at 10:00 p.m. She said she worked for an agency and that was her first night working at the facility. She was being oriented by another agency CNA [MEDICATION NAME] and said they were teamed up so she could learn the routine. She said she had not completed any classroom orientation specific to the facility prior to starting and was not aware if she had any competencies to complete prior to working on her own. The DON was interviewed on 11/14/18 at 3:14 p.m. She said the call light system's functionality was the Try nine's, meaning the call lights did get dropped after nine 'tries,' which sent notification to staff every two minutes until it was answered, for a total of 18 minutes. After the 18 minutes, the call was not responded to, and stopped alarming. She said when this process was brought to her attention the day prior, the functionality had been increased to 100 tries, or 200 minutes. The DON and NM were interviewed on 11/15/18 at 12:28 p.m. The DON confirmed the facility was currently utilizing one agency licensed practical nurse and five CNAs. She said their community was unique in that it was rural and they had very few nurse and CNA applicants. She said they had a high cost of living, which affected the ability for people to live in their town and work. She said the town's population was small and they had the competition of the hospital there as well. The DON said the facility was currently providing CNA classes in-house and they were trying hard to recruit them and retain them when they did their training there. She said the facility recently hired a recruitment and retention staff member to begin actively recruiting CNAs. She said they were trying to think as creatively as possible to recruit nursing staff and wanted to limit their use of agency staff. She said she saw it as a benefit for current agency CNAs to orient new agency CNAs when they start working at the facility, because they knew what the differences were in each community and had worked in multiple areas. The DON confirmed two staff members were required to assist all residents when a mechanical lift was used. She said there were currently three residents in Pond Side, six in Creek Side, and four or five in Mountain Side who required a mechanical lift. She said there was currently one resident in both Pond Side and Creek Side who did not get out of bed. The DON and NM said they felt the facility had enough staff available to meet the needs of the residents.

Based on observations, record review and family and staff interviews, the facility failed to provide supervision, assistance and equipment to prevent falls and ensure safe transfers for two of five residents reviewed for falls (#76 and #60) of 48 sample residents; and failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to: -Thoroughly investigate, assess and implement timely interventions in response to multiple falls for residents #76 and #60; and -Provide supervision to prevent falls and accidents for residents #76 and #60. These failures contributed to resident #76 experiencing 16 falls over a 47 day period resulting in skin tears, hematomas, and femur fracture that caused pain and required surgical repair. The facility further failed to ensure chemicals were properly and safely stored. The findings included: I. Falls and Accidents A. Facility Policy On 5/31/16, at 4:56 p.m., the interim director of nurses (DON) provided the facility's policy and procedure titled Falls Policy, last revised 12/30/15, which included: All residents will be assessed on admission, quarterly and at change of condition to determine each individual's risk for falls. Residents who have one or more of the following criteria will be considered at high risk for falls: 1) Risk assessment score above 10; 2) Determined 'high risk' by other stated criteria by the conference team. Safety measures and all interventions and strategies will be put in place and included in the care plan and on the bedside care card .The admitting nurse will complete the interim care plan, noting if the resident is 'high risk' and identifying immediate safety measures to be implemented .The IDT (interdisciplinary team) will review the Falls Risk Assessment Safety Measures and care plan at each care conference, at a change of condition. The falls team and IDT will determine if further assessment or interventions should take place. The falls team leader will arrange Falls Team Meetings every month to review statistics and tracking information. Incident protocol will be followed when a fall occurs . B. Resident #76 Resident #76, age 85, was admitted on [DATE] and re-admitted on [DATE]. According to the 5/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 4/16/16 minimum data set (MDS) assessment, the resident had short- and long-term memory problems with severely impaired cognitive skills for daily decision making. He had no delirium, no psychosis, no verbal or physical behavioral symptoms directed towards others and no rejection of care. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. His balance was not steady moving from seated to standing, walking, turning around and facing the opposite direction, moving on and off toilet and surface to surface transfers. He used a walker and wheelchair for mobility and had an indwelling urinary catheter. The fall history on admission section was void of documentation and he'd had one fall with no injury and one fall with injury prior to his admission. He'd received five days of occupational therapy (OT) and four days of physical therapy (PT). Initial Staff Interview: On 5/24/16 at 11:11 a.m. registered nurse (RN) #37 who was caring for resident #76 was interviewed. She was asked how many falls the resident had in the last 30 days. She said the resident had eight falls, with the most recent on 5/21/16. The RN was asked if any of the falls had resulted in an injury. She said that on 5/4/16 he had an injury, and on 5/11/16 he was sent to the hospital for a femur fracture of his left leg. (However, the femur fracture was to his right leg, not his left - see below.) Family Interview: The resident's wife was interviewed on 5/23/16 at 2:40 p.m. She was asked if the resident got up in the morning according to his previous routine. She said, He gets up in the night because he has been sleeping all afternoon. He can't walk by himself. He has had six falls here. She said she was frustrated and stated, They are supposed to go around to every room and see if people are okay, and they don't. That's why people fall and nobody knows. On the third fall he fell and broke his hip and he had surgery at the hospital. And again, nobody noticed until a while had passed. I leave his door open so that they can see in when they pass by if his feet are in the bed, or on the floor. She said the fall where he broke his femur occurred approximately two weeks ago, and he still had bruising on the left side of his neck that was fading. -Resident #76's wife said, I think they need more people . Not enough nursing staff. There are some outstanding people who are CNAs (certified nurse aides) but many are not trained to do things for someone like him. If he's not eating, he's in bed. That's the treatment they have. (Cross Reference F353 Sufficient Staffing) Record Review: The care plan, initiated and last revised on 4/18/16, identified safety as a problem area, which included a recent fall in his previous assisted living home that caused fractured ribs, multiple bruises and skin tears. The interventions included assistance with his ADLs (activities of daily living), bed and chair alarms since he did attempt unsafe transfers without calling for assistance at times, shoes with adequate tread, ensuring the call light was within his reach and reminding him how to use it. The bed should be in the low position with the brakes locked and the television should be off to provide a low-stimulation environment. The interim care plan, initiated 5/15/16 and not revised, was created after the resident was readmitted to the facility. It identified the following problems and interventions: Impaired mobility status [REDACTED]. He had left hip pain and received Tramadol (an analgesic) as needed. (However, the right hip was surgically repaired, not the left.) He was at risk for falls with a score of 14 HRF (unknown abbreviation) falls. He had a history of [REDACTED]. Additionally, the interim care plan included a note: Needs constant supervision, very restless. Likes to do tasks with hands and enjoys social interaction. The computerized physician's orders [REDACTED]. -Bed/chair alarm at all times. Fun noodles and fall mat when in bed, every shift; day, evening and night, started 5/15/16 -Remeron (an antidepressant with sedative effects) 15 milligrams (MG) by mouth at hour of sleep. Document hours of sleep, started 5/15/16 -PT, speech therapy and OT to evaluate and treat, started 5/15/16 -Wound care to right hip; check drainage every shift and call MD if increasing, started 5/21/16 -Wound care to right hip surgical incision; use ABD (abdominal) dressing to cover. Change BID (twice a day) and PRN (as needed), started 5/23/16 The Fall Risk Assessment dated 4/3/16 documented a total score of 16, which indicated he was at high risk for falls. -The Fall Risk Assessment dated 5/15/16 documented a total score of 18, which indicated he was at high risk for falls. The initial physical therapy assessment, dated 4/4/16, documented that the resident was referred to physical therapy due to a recent decline in functional mobility following a fall, subdural hemorrhage, and subarachnoid hemorrhage, as well as three broken ribs. The plan of treatment included the goals to decrease his risk for falls and mobility disability and increased functional activity tolerance. The potential for achieving these goals was documented as, Good rehab potential as evidenced by high prior level of functioning and recent onset. The treatment frequency was five times per week for 57 days. He was responsive to cues, required 25% hands on assist for bed mobility, 25% hands on assist for transfers, used a front wheeled walker and gait required 15% hands on assistance. 1. Fall on 4/4/16 at 6:30 p.m. (day after admission) The progress notes dated 4/4/16 at 8:06 p.m. included, Unwitnessed fall out of recliner in room. Staff heard resident yelling out (name of wife). No visible injuries .Very confused .Unable to verbalize needs .Bed alarm was attached to shirt intact so did not sound. Attends (adult incontinence briefs) on floor and resident was pulling on catheter tubing. Frequent checks being done. Safety measures in place and will continue to assist. The fall Event Report, dated 4/4/16 documented in pertinent part: Trying to climb out of chair and yelling for (name of wife). The form documented that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall. The Drug Review section of the form requested documentation of any analgesics, anticonvulsants, antihypertensives, antipsychotics, anxiolytics, diuretics, narcoticss, sleeping medications or other medications that the resident might be taking, and documented None of above. However, at the time, the resident was currently receiving Lasix (diuretic), and Remeron (antidepressant). The immediate measures taken included placement of chair/wheelchair alarm and rest. The form documented that the falls prevention program was not initiated. 2. Fall on 4/8/16 at 12:45 a.m. The progress notes dated 4/8/16 at 3:12 a.m. included, Resident was found on hands and knees crawling towards the door by CNA. Resident assisted back to bed and nurse was notified .No complaints of pain by resident and no injuries noted by nurse . There was no documentation in the progress notes to indicated that the resident's family or physician had been notified. The fall Event Report, dated 4/8/16 documented in pertinent part: Unwitnessed fall. The form was void of documentation for the event details, pain, neurological check, possible contributing factors, or immediate measures taken. The form documented that the physician and family were not notified and the care plan was not reviewed. 3. Fall on 4/14/16 at 5:30 a.m. The progress notes dated 4/14/16 at 7:53 a.m. included, Staff responded to resident calling out for help. Found kneeling on floor mat. Two person assist back into bed .Resident restless and confused .Asking for (wife's name). Attempted to reorient but not successful. One-on-one time spent .Resident continues to attempt to climb out of bed this morning. The fall Event Report, dated 4/14/16 documented in pertinent part: Unwitnessed fall in room onto knees to floor mat. The form documented that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall. The Drug Review section of the form documented that the resident was currently taking sleeping medications but did not include Lasix and Remeron. The immediate measures taken included rest and the falls prevention program was not initiated. 4. Fall on 4/16/16 at 9:21 a.m. The progress notes dated 4/16/16 at 9:33 a.m. included, Resident was found sitting up against his night stand holding onto the back of his head. No redness or actual bruising or hematoma is observed at this time .Placing ice pack to back of his head and encouraging resident to either call out for help or use the call bell . The fall Event Report, dated 4/16/16 documented in pertinent part: Continued fall risk. Staff takes all precautions but resident continued to self transfer, does not use call light or call out for help. Resident is impulsive and gets up .Continue to have call light in place with other safety precautions. Encourage resident to use call light or call out verbally for help. Leave door open. The Drug Review section of the form documented that the resident was not currently taking any of the previously listed medications. However, he was taking Remeron at the time. The form documented that the falls prevention program was not initiated. 5. Fall on 4/17/16 at 4:01 p.m. The progress notes dated 4/17/16 at 4:17 p.m. included, Wife was in the room and staff was just entering room when resident was lowering himself to the floor. Resident continues to be weak and has an unsteady gait .Continues to be impulsive and gets up or out of bed independently and cannot remember to use his call light or call out for help .he does not seem to be oriented enough to use his call light .resident has a bed/chair alarm but it is usually too late by the time it goes off. Staff leaves door to room open but staff is tending to other residents as well . The fall Event Report, dated 4/17/16 documented in pertinent part: Witnessed resident went down onto the floor with no injuries .Fall precautions in place, including: call light within reach, bed in lowest position, fall mat in place, resident and wife educated on the need to use call light for transfers and ambulation. Hourly rounding in place. The clinical record was reviewed in its entirety and there was no documentation of hourly rounding. The form documented that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall. The Drug Review section of the form documented that the resident was not currently taking any of the previously listed medications. However, he was taking Remeron at the time. The form documented that the resident's physician and family were not notified, the care plan was not reviewed and the falls prevention program was not initiated. 6. Fall on 4/24/16 at 3:15 p.m. The progress notes dated 4/24/16 at 4:36 p.m. included, Resident had witnessed fall in bedroom at 3:15 p.m. Before fall resident was observed resting in bed. From the main nurse work station on the west end of the hall, CNA observed resident walking unassisted in room. CNA ran to resident but by the time CNA reached room resident had fallen. CNA stated, 'He fell backwards on his (bottom), hit his elbows, and then his head hit the floor Resident's right elbow with skin tear, some skin sheared off completely. Resident also presents with hematoma and large bump on the back of his head (which) has been bleeding on and off throughout shift . The fall Event Report, dated 4/24/16 documented in pertinent part: Witnessed fall in room. The Drug Review section of the form documented that the resident was not currently taking any of the previously listed medications. However, he was taking Remeron at the time. The form documented that immediate measures taken included direct pressure to his wound and first aid was given. The form documented that the physician was not notified, the falls prevention program was not initiated and the care plan was not updated. 7. Fall on 5/4/16 at 4:45 p.m. The progress notes dated 5/4/16 at 5:55 p.m. included, CNA states she was going to transfer resident to chair when she realized he needed to be changed. CNA states she left resident sitting on the side of his bed while she grabbed an (adult incontinence brief) and soft and dry wipes. Resident attempted to self transfer when CAN witnessed resident falling. Per CNA, resident did fall to his knees and bumped his head on clothing closet. Hematoma to back of right side of head and left knee with 1 CM (centimeter) x 1 CM abrasion with red perimeter (of) wound. There is no documentation that the physician or family were notified. The fall Event Report, dated 5/4/16 at 4:45 p.m. documented in pertinent part: Witnessed fall .sitting on side of bed. The form documented that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall and the immediate measures taken included placement of the chair/wheelchair alarm. The Drug Review section of the form documented that the resident was not currently taking any of the previously listed medications. However, he was taking Remeron and Zyprexa (antipsychotic) at the time. The form documented that the resident's family or physician were not notified and the care plan was not reviewed. There were no new fall precautions initiated after this fall. The progress notes dated 5/4/16 at 2:34 p.m. was written by an occupational therapist and included, [DIAGNOSES REDACTED] education completed for caregivers to decrease resident fall risk, with suggestion to increase night time supervision secondary to sleep disturbances associated with [DIAGNOSES REDACTED]. The clinical record was reviewed in its entirety and was found to be void of any documentation that showed increased supervision at night. 8. Fall on 5/5/16 at 10:37 p.m. The progress notes dated 5/5/16 at 6:50 p.m. included, Resident had another fall today; reopened the skin tear to elbow. Area cleaned with normal saline, patted dry covered with a Bandaid. The progress notes dated 5/5/16 at 7:02 p.m. included, Resident woke up agitated. Unable to redirect. Resident had an unwitnessed fall at 3:30 p.m. Resident got up out of bed on his own and fell just before his door leaving his room .Resident has a new abrasion to the left posterior shoulder .Area has existing healing scab .Call light in place, door remains open to view resident for fall precautions . The fall Event Report, dated 5/5/16 documented in pertinent part: Unwitnessed fall at 3:30 p.m Abrasion to left posterior shoulder, reopened skin tear to right elbow .bed alarm/resident removes, no alarm sounded .The Drug Review section was void of documentation and there were no additional fall precautions initiated after this fall. The form documented that the resident's physician and family member were not notified and the care plan was not reviewed. 9. Fall on 5/9/16 at 6:00 p.m. The progress notes were void of any documentation related to the fall that occurred on 5/9/16 at 6:00 p.m. The progress notes dated 5/8/16 at 3:33 p.m. included: (Resident #76) continues to self transfer and was ambulating without walker or assist. One to one was required for several hours as staff ambulated in halls with resident continuously. Resident became very frustrated and was hitting and holding his fists up towards staff with re-direction to chair or bed for rest, as resident was exhausted and staff was unable to tend to other residents at that point. Zyprexa 5 MG for severe agitation was given, not effective .At this point safety was becoming more of a concern resident putting himself and others at risk. Ativan 1 MG was given for extreme agitation and combativeness and putting himself in danger . The fall Event Report, dated 5/9/16 documented in pertinent part: Unwitnessed fall in dining room .skin tear .behaviors present at dinner and after fall. The form documented that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall and the immediate measure taken was rest, and one to one care as long as staff available. 10. Fall on 5/10/16 at 2:46 a.m. The progress notes dated 5/10/16 at 2:46 a.m. included: Resident tried to get out of dining room chair and slipped out onto the floor. Wheel came off of dining room chair. Staff found resident lying on left side .Assessment done and two person assist into different chair .Resident denies pain .Confused, restless and agitated .staff gave one to one care watching movie in sun room. Resident unable to understand staff's directions . There was no documentation to indicated that the resident's family or physician had been notified. The medical record was reviewed in its entirety and was found to be void of a fall Event Report that was completed for this fall. The progress notes dated 5/10/16 at 8:58 a.m. included an occupational therapy note that read in pertinent part: Fall assessment with nursing input to decrease falls. Suggest resident seated in wheelchair, with no footrests, shoes instead of slippers, and encourage self propelling of wheelchair with use of feet. Caregivers/nurses education to encourage. 11. Fall on 5/10/16 at 3:30 p.m. The progress notes dated 5/10/16 at 3:56 p.m., written by social services coordinator #8, included: Left a voice mail with (resident #76's) wife, (name of wife). However, I also contacted (resident #76's) daughter-in-law (name of daughter-in-law) and informed her of (resident's) falls early this morning and this afternoon. No injuries noted. (Name of daughter-in-law) asks that if there are any changes noted, that she would like (medical director) to call her. The progress notes are void of any documentation that addressed the fall the resident sustained [REDACTED].>The fall Event Report, dated 5/10/16 documented in pertinent part: Unwitnessed fall 3:30 p.m., dining room .self propelling in wheelchair. The form documented that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall and the immediate measure taken was to place the wheelchair alarm and rest. The Drug Review section of the form documented that the resident was currently taking anxiolytics and Proscar (prostatic hyperplasia agent). However, he was also taking Remeron and Zyprexa at the time. The form documented that the resident's physician and family were not notified and the care plan was not reviewed. Further, there was no documentation to show that additional interventions were put in place to prevent future falls. The occupational therapy progress notes dated 5/11/16 at 12:56 p.m. included: Resident brought to therapy room by wheelchair in a.m. for participation with sorting activity, content to attempt activity while seated looking out window. After lunch, resident returned and participated in folding and sorting activity, then said, 'I need to go now.' Therapist lifted leg to remove footrest for self propelling, with resident saying, 'Ouch!' Alerted (charge nurse), for assistance with further evaluation. Accompanied resident to hospital for further evaluation and remained with resident until family arrived. The note was written by the therapy director, #34. The progress notes dated 5/11/16 at 4:10 p.m. included in pertinent part: Resident would not weight bare on right leg with standing. Right groin area very tender to touch and right leg internally rotated . The progress notes dated 5/11/16 at 5:02 p.m. included, Resident to ER from (name of local medical center) x-ray for right femoral neck fracture . The progress notes dated 5/15/16 at 3:38 p.m. included, Resident arrived (from local medical center) .two person extensive assist for transfer from wheelchair to bed .unable to verbalize or demonstrate understanding of use of call light .Right hip incision clean, dry and intact with staples .resident restless and attempting to get out of bed . 12. Fall on 5/17/16 at 3:38 a.m. The progress notes dated 5/17/16 at 3:28 a.m. included, The resident was found on the floor mat, saying 'help.' The resident was assisted back to bed using two assist. Resident capable of offering some assistance. No injury found. Left hip dressing is intact with minor drainage .Bed alarm was clipped to resident but magnet failed to pull out of alarm device . The fall Event Report, dated 5/17/16 documented that the resident had an unwitnessed fall in his room. The bed alarm was in use at time of the fall. The Drug Review section of the form documented that the resident was not currently taking any of the previously listed medications. However, he was taking Melatonin at the time. The immediate interventions taken included placing the bed alarm on, but no additional fall precautions were initiated. Further, there was no documentation to indicate that the bed alarm was replaced or checked for proper functioning. 13. Fall on 5/18/16 at 5:05 p.m. The progress notes dated 5/18/16 at 5:05 p.m. included in pertinent part: Resident fell out of bed immediately after the CNA left the room per CNA report. CNA had attached the resident's bed alarm and the resident had unattached the alarm himself. Resident also had SCD's (sequential compression devices) attached .will assess dressing to surgical incision. Resident helped up into chair, chair alarm in place, resident under supervision in dining room. The clinical record was reviewed in its entirety and there was no fall Event Report or incident report completed for this fall. Further, there is no documentation to indicate that the resident's physician or family was notified of the fall. 14. Fall on 5/21/16 at 6:00 a.m. The progress notes dated 5/21/16 at 6:39 a.m. included in pertinent part: The resident had just been checked on .He was then found sitting on the floor beside the bed at 6:00 a.m. and appeared to have slid off onto the floor because the peri-pad had slid off with him and was still behind him. No new injuries were noted. The resident had removed his t-shirt which had the bed alarm attached to it, so the alarm did not go off . The fall Event Report, dated 5/21/16 documented that the resident had an unwitnessed fall in his room and that restraints and adaptive equipment (bed or chair alarm) were not in use at the time of the fall. The form documented that the resident's physician and family member were not notified and the care plan was not reviewed or updated. 15. Fall on 5/21/16 at 7:45 a.m. (one hour and 45 minutes after the previous fall) The progress notes dated 5/21/16 at 10:54 a.m. included in pertinent part: Resident found shortly after previous fall at 6:39 a.m. crawling on floor, was on floor mat and bed in low position .right hip incision has been bleeding. (Name of physician) was notified last night. Treatment to replace Island Telfa dressing as needed. Incision was bleeding moderately again when found on floor . The fall Event Report, dated 5/21/16 documented the identical information from the progress notes (see above), and the rest of the form was void of documentation. There were no possible contributing factors, drug review, or interventions completed and the form documented that the resident's physician and family was not notified and the care plan was not reviewed or updated. 16. Fall on 5/24/16 at 3:49 p.m The progress notes dated 5/24/16 at 4:06 p.m. were void of any documentation of the fall that had occurred at 2:07 p.m. that day. In summary, the resident had a total of 16 falls since his admission to the facility, over a 47 day period, one of which included a femur fracture that required surgical repair. Observations: On 5/23/16 at 2:22 p.m., resident #76 was observed seated in his wheelchair in his room. He was slouched down in his wheelchair and was nearing the edge of the seat cushion. At 3:00 p.m., he began to attempt to stand up on his own without assistance and the chair tab alarm was pulling tight but did not separate enough to alarm. His call light was pushed to notify staff he needed assistance and two CNAs entered the room to help him. On 5/24/16 at 1:07 p.m., resident #76 was observed seated in his wheelchair at a table in the Pond dining room. His wheelchair did not have the tab alarm in place. He was seated there alone and had two full beverage glasses in front of him. At 1:08 p.m., he stood up on his own and CNA #41 walked over to him and helped him sit back down. She asked another CNA (#16) to help her lay him down and at 1:12 p.m., the resident was propelled into his room. -At 1:26 p.m., the door to the resident's room remained closed and an attempt was made to knock and enter the room. CNA #16 explained that if someone were to go into the room it would probably disturb him, and He is one that is really difficult to get to sleep. -At 2:02 p.m., the door to the resident's room remained closed. There were no staff within sight in the Pond neighborhood. At 2:07 p.m., the rehabilitation therapy assistant (#30) noticed that the door to the room was closed, and she asked CNAs # 41 and #16 if he was doing okay in his room. They informed her that the resident was sleeping and she told them she was going to just go in and check on him. When she opened the door, the resident was laying on the floor on his left side, with his SCD stockings still connected to his legs that were connected to the foot of the bed. There was no tab alarm in sight and no audible alarm sounding. The therapy aide immediately notified CNAs #41 and #16 that he'd fallen and they informed the nurse. While waiting for help to arrive, the therapy aide returned to the resident's room and asked him if he'd hit his head, and he responded, yes, and rubbed the back of his head. On 5/24/16 at 4:32 p.m., the door to the resident's room was open and he was observed lying in bed and appeared to be asleep. There was no bed or tab alarm in place. The fall mat was on the floor next to his bed. On 5/24/16 at 5:35 p.m., the resident was observed in his wheelchair being propelled away from the dining room table and into his room by a CNA. At 5:49 p.m., the CNA was observed to exit his room and closed the door behind her. At 5:50 p.m., the therapy aide (#30) was observed to open the door to the resident's room. On 5/25/16 at 11:57 a.m., resident #76 was propelled out to the dining room table on the Pond hall by a CNA and his tab alarm was not on. At 11:59 a.m., a CNA placed his tab alarm on the back seat of his wheelchair and clipped it to his t-shirt. At 12:02 p.m., the resident tried to stand up on his own and had his left foot on the floor and was outside of the foot pedals but he was not successful. Another resident approached him and stated, He needs a push. At 12:04 p.m., the residents' wife arrived and pushed him up closer to the dining room table and locked the brakes on his wheelchair. Staff Interviews: CNA # 16 was interviewed on 5/25/16 at 4:10 p.m. and she confirmed that she routinely worked in the Pond neighborhood and was familiar with resident #76. She explained that the facility's process for updating CNAs related to resident care was usually through a care card, which she explained was posted in a plastic envelope inside the resident's closets. She said they would also receive a verbal report from the previous CNA at shift change. -The CNA said resident #76 was unable to provide any care for himself. She stated, I feel as if sometimes this isn't the facility for him. He needs someone to be a one-to-one with him. I feel like as if me caring for him takes away from my other residents who are supposed to be and should be here. I am constantly getting up to help him sit down. He falls a lot here .It is really hard to redirect him and get him to calm down when he gets wound up or frustrated. I feel like we don't have the staff to care for him here. (Cross-reference F353) -The CNA said resident #76 was unable to use his call light and stated, If he hits his call light it is because he accidently hit it or he is getting up and pulling it out of the wall. Or his wife hit it. -The CNA said the door to his room was routinely kept open but sometimes they would close it if his wife was with him because she knows to push the call light if he needed something. She stated, Yesterday a new CNA closed the door and he fell . She didn't know we needed to keep it open. But most of his falls come from him coming out of bed. On 5/25/16 at 2:23 p.m., PT #40 and therapy aide #42 were interviewed and they confirmed that they were currently working with the resident. The PT said they were trying to get him back to his prior level of functioning before he fell , which included walking with assistance. She said he was currently able to do that, so he would be discharged to the restorative program the following day (5

Based on resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 11 (#2, #9, #15, #16, #24, #33, #37, #41, #46, #51, #76) of 48 sample residents. Resident and staff interviews revealed the facility failed to consistently provide adequate nursing staffing resulting in delayed call light response and assistance to and from the toilet. Residents and a family member said residents had experienced falls and incontinence accidents as a result of insufficient staffing. Residents said during interviews that they felt depressed, mad, embarrassed, forgotten, helpless, disgusted and frustrated. The findings included: Cross-reference F323 accident-free environment, F309 care and services, F312 activities of daily living, and F318 restorative services. 1. Facility policy The facility policy on Staffing, revised 12/13/15, included: Purpose: To provide adequate staffing . Clinical staffing will be based on census and acuity. Day Shift: 3 Licensed Nurses, 8 Certified Nurse Aides. Evening Shift: 3 Licensed Nurses, 7 Certified Nurse Aides. Night Shift: 2 Licensed Nurses, 3 Certified Nurse Aides . All efforts should be made by the Charge Nurse to replace call-ins to maintain the above staffing levels. 2. Resident Status According to the Resident Census and Conditions of Residents report, signed by the minimum data set (MDS) coordinator on 5/24/16, the resident census was 58 and the following care needs were identified: -38 residents needed assist of one or two staff and 18 residents were dependent for bathing; -48 residents required assist of one or two staff and five were dependent for dressing; -42 residents needed assist and eight were dependent for transfers; -44 residents needed assist and eight were dependent for toilet use; -44 residents needed assist and five were dependent for eating; -34 residents were occasionally or frequently incontinent of bladder; -26 residents were occasionally or frequently incontinent of bowel; -Eight residents had catheters; -40 residents were in a chair most or all of the time; -33 residents ambulated with assistive devices; -13 residents had contractures; -38 residents had documented signs and symptoms of depression; -30 residents had dementia; -13 residents had behavioral healthcare needs; -49 residents received preventive skin care and six residents had pressure ulcers; -25 residents received rehabilitative services; -29 residents received psychoactive medications and five received antipsychotic medications; -32 residents were on pain management programs; and -Eight residents had significant weight loss. 3. Family interview Resident #76's wife was interviewed on 5/23/16 at 2:40 p.m. She was asked if the resident got up in the morning according to his previous routine. She said, He gets up in the night because he has been sleeping all afternoon. He can't walk by himself. He has had six falls here. She said she was frustrated and stated, They are supposed to go around to every room and see if people are okay, and they don't. That's why people fall and nobody knows. On the third fall he fell and broke his hip and he had surgery at the hospital. And again, nobody noticed until a while had passed. I leave his door open so that they can see in when they pass by if his feet are in the bed, or on the floor. She said the fall where he broke his femur occurred approximately two weeks ago, and he still had bruising on the left side of his neck that was fading. -Resident #76's wife said, I think they need more people . Not enough nursing staff. There are some outstanding people who are CNAs (certified nurse aides), but many are not trained to do things for someone like him. If he's not eating, he's in bed. That's the treatment they have. 4. Resident Interviews Residents, who per facility and assessment were cognitively intact and interviewable and resided throughout the facility, made the following comments when asked about sufficient nursing staffing: Resident #2 was interviewed on 5/25/16 at 3:55 p.m. She said she felt the nursing home needed more staff to address her needs in a timely manner. She said she had been left on the toilet for 20 minutes before someone returned to assist. She said she felt depressed and mad when this happened. Resident #9 was interviewed on 5/26/15 at 10:08 a.m. She said she felt that the nursing home needed more CNAs. She said she had waited 20 minutes to get out of bed in the morning on numerous occasions. She said she had held her urine for so long that once a CNA answered her call light she had an accident on the way to the bathroom. She said she had felt embarrassed when this happened. Resident #15 was interviewed on 5/25/16 at 3:42 p.m. She said the new CNAs had not been trained correctly. She said she had been left two times recently on the bedside commode without a call light within reach. She said the CNAs had forgotten about her. Resident #16 was interviewed on 5/25/16 at 4:06 p.m. She said she did not feel the facility had enough CNAs and the new CNAs had a lack of training. She said she had been left on the toilet for 30 minutes. She said she would pull the call light cord in the bathroom and the CNAs will come into the room and turn off the call light and tell her they will be right back. She said she felt helpless when they don ' t come back for a long time. Resident #24 was interviewed on 5/26/16 at 11:03 a.m. She said she did not feel the facility had sufficient nursing staff, as she routinely had to wait 30 minutes or longer especially around noon time for her call light to be answered. She said the call light had only worked part of the time due to the call light battery running low. Resident #33 was interviewed on 5/23/16 at 3:00 p.m. She said she felt her hallway could use another CNA especially in the morning time. She said she had to wait at times 20-30 minutes for assistance with activities of daily living (ADLS). Resident #37 was interviewed on 5/26/16 at 9:55 a.m. She said she did not feel the facility had enough CNAs and that getting timely assistance was difficult. She said she had to wait 15-20 minutes at times to get assistance with ADLs. Resident #41 was interviewed on 5/26/16 at 9:58 a.m. She said she had to wait up to 40 minutes to get assistance up from the toilet. She said the early afternoon sometimes can be the most difficult time to get timely assistance from the CNAs. Resident #46 was interviewed on 5/25/16 at 3:39 p.m. She said she did not feel the facility had enough CNAs because she had been left on the toilet for long periods of time. She said she pressed the call light with no response. She said she feels disgusted when the staff doesn't answer her call light in a timely manner. Resident #51 was interviewed on 5/25/16 at 3:13 p.m. She said she did not feel the facility had sufficient nursing staff, as she routinely had to wait approximately 15 to 20 minutes for her call light to be answered especially with toileting. She said she had received assistance by a CNA with toileting and the CNA did not return. She said she had to scream to get the attention of the staff because her call light went unanswered. She said a different CNA had returned to assist. She said she felt helpless and frustrated. 5. Staff Interviews Nursing staff members, who worked throughout the facility on all shifts, made the following comments when asked if the facility had sufficient nursing staffing to meet resident needs: CNA #17 was interviewed on 5/25/16 at 8:54 a.m. She said some of the new staff was not trained correctly and they were not prepared for this type of work. Registered nurse (RN) #1 was interviewed 5/25/16 at 3:55 p.m. She said the nursing facility used to staff three CNAs per neighborhood and now it's two CNAs and a floater. She said three CNAs per neighborhood was better and the staff was able to provide better care. She said the West Pond neighborhood needed more assistance because of the higher acuity of the residents. CNA #2 was interviewed on 5/26/16 at 9:23 a.m. She said the facility was often short staffed in the mornings and had quite a few call ins in the evening. She said it was challenging getting residents up in the morning, toileting them after meals and transferring them into bed after lunch with two CNAs per 30 residents. CNA #3 was interviewed on 5/26/16 at 11:28 a.m. She said call ins were a problem especially with the acuity level of the West Pond neighborhood. She said the West Pond needed more CNAs due to the acuity of the residents' needs. She said it was difficult to provide the care the residents needed with two CNAs and a floater because the one floater CNA covered the whole nursing facility. RN#39 was interviewed on 5/26/16 at 1:22 p.m. She said the west neighborhood needed more CNAs because of the higher acuity level of the residents. She said there were a couple of residents needing one to one oversight, which was difficult to do with two CNAs and a floater. RN#38 was interviewed on 5/26/16 at 1:28 p.m. She said they needed more staff on the West Pond neighborhood because some of the residents needed one to one assistance and the acuity level of the residents. She said the nurses on the West Pond neighborhood also had more charting then the other neighborhoods. CNA #5 was interviewed on 5/26/16 at 3:42 p.m. She said they needed more staff on the West Pond neighborhood due to residents needing more assistance and a couple of residents needing one to one assistance which they could not provide with two CNAs. RN#36 was interviewed on 5/26/16 at 3:57 p.m. She said they had higher acuity residents on the west neighborhood and it can be challenging to provide oversight with a couple of the residents while trying to provide care for the other residents. CNA #13 was interviewed on 5/26/16 at 4:00 p.m. She said the West Pond neighborhood needed more CNAs due to the acuity of the residents residing on that neighborhood. She said a couple of residents required one to one assistance which was difficult to provide with two CNAs. The interim director of nursing (IDON) and the nursing home administrator (NHA) were interviewed on 5/26/16 at 5:45 p.m. The IDON said her expectation was the facility to be fully staffed. NHA and IDON said their expectations were: -Day shift - three nurses, six CNAs, one float CNA and one bath aide five days a week. -Evening shift - three nurses, six CNAs and one float CNA -Night shift - two nurses and three CNAs. The IDON and NHA said they felt that their call light response times were good. They said the average call light response time was four minutes based on their call light audits. The IDON said they completed call light audits monthly and shared the results at resident council. The NHA and IDON were unaware of the residents' complaints regarding long call light times and being left on the toilet. IDON and NHA said their expectations of call light response times were five to six minutes. The IDON said her staff was trained to enter a room and turn off the call light; if they were unable to fulfill the care need of the resident, they turned the call light back on and told someone who could fulfill the need. The NHA and IDON said their expectation was that staff would return to the room when they said they would return. 6. Record Review The daily staffing sheets, reviewed from 3/21/16 through 5/21/16, showed gaps in staffing on the following days: -3/22/16: short one CNA on day, one on evening shift, and one at night shift. -3/28/16: short one CNA on evening shift and one on night shift -4/1/16: short three CNAs on evening shift -4/2/16: short one CNA on day shift -4/3/16: short one CNA on evening shift -4/10/16: short one CNA on day shift -4/11/16: short two CNAs on evening shift -4/12/16: short one CNA on day shift -4/16/16: short one CNA on evening shift -4/17/16: short one CNA on evening shift -4/22/16: short two CNAs on day shift -4/24/16: short one CNA on evening shift -4/25/16: short two CNAs on evening shift -5/1/16: short one CNA on day shift -5/6/16: short two CNAs on evening shift -5/7/16: short one CNA on evening shift -5/8/16: short one CNA on day shift and two CNAs on evening shift -5/13/16: short two CNAs on evening shift.

Based on resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 13 (#4, #7, #10, #21, #26, #32, #41, #47, #53, #59, #62, #64 and #98) of 36 sample residents. Resident and staff interviews revealed the facility failed to consistently provide adequate nursing staffing resulting in delayed call light response, assistance to and from the toilet, assistance with bathing, catheter care, and medication administration. The findings included: Cross-reference F309 highest practicable quality of care regarding pain management and timely medication administration, F312 activities of daily living, F314 pressure ulcers, F325 weight loss, and F362 sufficient dining room staffing to meet resident needs. A. Expectation The facility policy on Staffing, revised 10/28/14, read in pertinent part: Purpose: To provide adequate staffing . Clinical staffing will be based on census and acuity. Day Shift: 3 Licensed Nurses, 9 Certified Nurse Aides. Evening Shift: 2 Licensed Nurses, 8 Certified Nurse Aides. Night Shift: 2 Licensed Nurses, 3 Certified Nurse Aides . All efforts should be made by the Charge Nurse to replace call-ins to maintain the above staffing levels. B. Resident Status According to the Resident Census and Conditions of Residents report, signed by the director of nursing (DON) on 7/7/15, the resident census was 63 and the following care needs were identified: -32 residents needed assist of one or two staff and 30 residents were dependent for bathing; -56 residents required assist of one or two staff and five were dependent for dressing; -55 residents needed assist and seven were dependent for transfers; -59 residents needed assist and three were dependent for toilet use; -61 residents needed assist and one was dependent for eating; -41 residents were occasionally or frequently incontinent of bladder; -32 residents were occasionally or frequently incontinent of bowel; -Six residents had catheters; -11 residents were bedfast all or most of the time; -49 residents were in a chair most or all of the time; -28 residents ambulated with assistive devices; -17 residents had contractures; -43 residents had documented signs and symptoms of depression; -37 residents had dementia; -16 residents had behavioral healthcare needs; -57 residents received preventive skin care and nine residents had pressure ulcers; -11 residents received rehabilitative services; -38 residents received psychoactive medications and ten received antipsychotic medications; -32 residents were on pain management programs; and -13 residents had significant weight loss. B. Resident Interviews: Residents, who per facility and assessment were cognitively intact and interviewable and resided throughout the facility, made the following comments when asked about sufficient nursing staffing: Resident #7 was interviewed on 7/6/15 at 4:09 p.m. She said she did not feel the facility had enough nursing staff to address the residents' needs in a timely manner. She stated that recently she had to wait for 45 minutes for assistance off the toilet. She recalled a recent time that her call light was not answered timely. She stated, I had to go so bad, that I wet all over the floor. I kept saying I was sorry. This resident said on the day of this interview, she waited for about 15 minutes for assistance to get to the bathroom. Resident #59 was interviewed on 7/6/15 at 3:46 p.m. She stated that the facility had a problem with staffing and that staff often called off and did not come in to work. She stated that it had taken as long as an hour after pressing her call light for the staff to respond because the staff were busy with other residents. She stated that the typical response time was 20 minutes. She stated that there was a time that she had an episode of urinary incontinence while awaiting her call light to be answered. Resident #64 was interviewed on 7/6/15 at 4:41 p.m. She stated the facility tended to have a chronic staffing issue. She stated that once she had to wait an hour for staff assistance. Resident #47 was interviewed on 7/7/15 at 8:18 a.m. She stated she did not feel the facility had enough nursing staff because the certified nurse aides (CNAs) were short-handed at times. She stated the CNAs answered the call lights, turned them off, and said they would return to assist her. They would eventually return, but often it took them quite some time to return. She stated that the staff turned off her call light before her needs were met. Resident #62 was interviewed on 7/6/15 at 4:39 p.m. He stated he did not feel the facility had sufficient nursing staff, as he routinely had to wait approximately 20 minutes for his call light to be answered. He said the previous evening, there was only one nurse and one CNA for the East Mountainside neighborhood. He also said there was a new nurse on duty that evening and that his wife had to wait about three hours for her pain medications to be given to her. Resident #4 was interviewed on 7/6/15 at 2:47 p.m. She stated the facility was usually short-handed and she did not always get her scheduled baths. She said, A couple of times, I had to have a bed bath due to the facility being short staffed. She said it often took half an hour for her call light to be answered and that on a few occasions, she had fallen asleep and forgotten what she originally wanted in the time that it took her call light to be answered. -Resident #4 was interviewed a second time on 7/8/15 at 11:31 a.m. She stated there were times she had been told by staff members that if she did not take her bath as scheduled, her bath would not occur at all until her next scheduled bath time. She said she was scheduled for baths on Sundays, Tuesdays and Fridays, but that she did not always receive three baths per week as requested. She stated she needed at least three baths per week because sometimes her catheter bag got too full and overflowed. She stated that sometimes her call light was answered immediately and sometimes it took them approximately 20 minutes to answer her light. Resident #98 was interviewed on 7/7/15 at 11:26 a.m. She stated the facility did not have enough nursing staff and that getting timely assistance was difficult. She said she often had to wait lengthy periods of time while they were finishing assisting other residents and that every department in the facility could use more staff. Resident #21 was interviewed on 7/6/15 at 4:08 p.m. He stated the facility was often short-staffed on weekends. The resident was interviewed a second time on 7/9/15 at 9:40 a.m. He reiterated that he felt the facility was short-staffed, especially on weekends. He said several of the current staff were still being trained, and that the new staff were either too slow or needed more training. Resident #26 was interviewed on 7/7/15 at 9:49 a.m. She stated she did not feel the facility was sufficiently staffed because she often had to wait about 30 minutes for her call light to be answered. -Resident #26 was interviewed a second time on 7/7/15 at 2:53 p.m. She stated she felt the facility had been short staffed especially the last few months. She said the CNAs were overwhelmed and the facility needed more CNAs to help out. She said the average call response time was maybe 15 minutes and the longest time recently was half an hour. This resident stated that she had recently been left on the toilet for half an hour and that when her call light was finally answered, her bottom was numb and her legs were tingling. Resident #10 was interviewed on 7/9/15 at 11:05 a.m. She stated she recently waited a very long time for her pain medication to be given and the nurse brought her pain medication approximately three hours later than usual. She was asked if her pain level that evening was any worse than usual because she received the pain medication late, and she stated that once her pain reached the highest level, it did not get any worse. She rated her pain at the highest level on the evening in question. She said that when this occurred, only one nurse and one CNA were working, and that the nurse was very busy helping the CNA get all of her tasks done. She stated that the facility definitely needed more help. Resident #41 was interviewed on 7/8/15 at 1:30 p.m. She stated the facility did not have enough CNAs, and she felt the CNAs were overworked and needed more help. She said the longest call light response time was 15 to 20 minutes, and that getting assistance was difficult in the mornings when all the residents were waking up and wanting assistance at the same time. Resident #47 was interviewed on 7/8/15 at approximately 2:00 p.m. She said she had not received her lunch room tray that day until about 10 minutes earlier (approximately 1:50 p.m.). She said this was because the facility did not have enough help to pass room trays timely. She said she felt the facility could use more CNAs. She said she did not receive her pain medication on time some days. Resident #32 was interviewed on 7/8/15 at 2:15 p.m. She said the facility needed more nurses and CNAs. She stated, Just like this morning, about 9:30 a.m., I got my diabetic shot an hour late . We are not getting served in a timely manner for lunch and dinner. I think they need more help in the kitchen and dining room in general to make it go quicker. (Cross-reference F362 dining room staffing.) When asked, resident #32 stated an average call light response time was 15 to 20 minutes. She stated that the longest call light response times occurred on the night shift and that an unidentified nurse did not come to her room until 10:00 p.m., stating she was too busy to get there sooner. Resident #32 stated that this nurse was almost one and a half hours late passing her medications. This resident stated that she could not go to sleep until she got her shot. -Resident #32 stated she would like to have a bath daily, but that was not possible due to inadequate staffing. This resident said she felt that getting a bath every other day would not be unreasonable to ask for. -She stated that she relied on CNAs to put her TED hose on first thing every morning, but there had been times she lay in bed for lengthy periods waiting for her TED hose to be donned in order to get out of bed. Resident #32 stated that on 7/7/15, she did not make it out to the dining room until 12:30 p.m. because she was waiting for her medications and her TED hose to be donned. Family Interview: Resident #53's family member was interviewed on 7/7/15 at 11:44 a.m. She stated she felt there were a few lunch times and a few Saturdays that she thought the facility could use a few more CNAs. She said that approximately one month ago, she was in the facility visiting resident #53 and the only staff member working in the South Creekside dining room was a kitchen staff member who was not qualified to assist if a resident began choking or needed any other nursing care. The family member stated this was very concerning to her. Staff Interviews: Nursing staff members, who worked throughout the facility on all shifts, made the following comments when asked if the facility had sufficient nursing staffing to meet resident needs: CNA #17 was interviewed on 7/8/15 at 9:32 a.m. She stated the facility was often short staffed on weekends, with two CNAs and one additional CNA to float between neighborhoods. She stated there was usually enough staff on the schedule, but when people called off, there were staffing issues. She stated there were usually more problems with the evening and night shifts calling in. The CNA stated ten of 22 residents residing on East Mountainside required two-person transfers and that it was sometimes difficult to find a second person to assist in a timely manner. She stated that currently the facility only had one nurse to work one and a half neighborhoods, and this was not enough. CNA #6, who worked on the West Pond neighborhood, was interviewed on 7/8/15 at 9:47 a.m. She said the facility did not have enough nursing staff available because each of the three neighborhoods had about four residents needing extra help with eating. She said the West Pond neighborhood was supposed to have three CNAs during the day shift and nine CNAs facility wide, but the facility was short-staffed more than 50 percent of the time due to staff call-offs. -When asked how staff calling off impacted resident care, she said, When we are short staffed with 23 residents, we have to cut out tiny things like not being able to do range of motion exercises for the full 15 minutes required . Some days, we can't do it at all . It affects (the residents) greatly. -She said it was difficult to get everyone toileted every two hours. She also stated that it was difficult getting all of the residents' baths done, but they do get done eventually. -She said residents had told her they did not feel the facility had enough nursing staff. She said the CNAs were trained to not let the call lights go longer than nine minutes before being answered, and at that time the call light request would go out to all neighborhood pagers, including the nurses' pagers. She admitted that call lights did take longer than nine minutes to answer on occasion and that on East Mountainside, a call light often took longer than 12 to 15 minutes to be answered. -She stated a Try 9 call light taking longer than 24 minutes to be answered went to an unanswered alert status. As an example, she said a few days ago at about 2 p.m., a Try 9 alert went out on another neighborhood. She went to answer the call light and observed the CNAs for that neighborhood were sitting in the living area and were not answering the light. She said she found that a resident had been left on the toilet and her call light had been going off for at least 27 minutes. -The CNA said she had had to tell a resident that she could not assist them immediately, but would come back to help just as soon as she could. -The CNA said on her neighborhood, five of 23 residents required two-person assist for transfers, and that sometimes it was difficult to find a second person to assist in a timely manner, delaying resident care even further. -CNA #6 stated that due to the facility being short staffed, she was often called to work evenings. She stated that the evening shift toileted residents three times during the eight-hour shift, and that the night shift checked and changed residents twice in that eight-hour shift. CNA #3 was interviewed on 7/8/15 at 10:01 a.m. She said the facility did not have enough nursing staff to ensure that all residents had their needs met in a timely manner due to the fact that, in the past and again presently, the facility had residents who required 1:1 staff attention due to their specific needs. She stated that the facility currently did not have an extra person consistently staffed for their current resident requiring 1:1 attention. -When asked specifically how lack of staffing impacted the residents' care, she stated, Considering most of the people on my hall (have severe dementia), they need re-directing, which doesn't always occur .Most of (the residents) are wheelchair bound and are total assist with transferring and ambulating. This CNA stated, Usually after breakfast, is the catch up time for what got missed. -She stated that a resident, who no longer resided in the facility, complained to her often that she did not feel the facility had enough nursing staff. She stated that the resident moved to another facility because she was very unhappy here and talked about lack of staffing quite a bit. -CNA #3 stated that the morning of this interview, she saw a call light take longer than 15 minutes to be answered on another hall. She admitted that she had had to tell a resident that she could not assist them immediately, but would return to help them just as soon as she could. She stated that nine of 13 residents residing on her hall required two-person transfers. CNA #3 ended the interview by saying, I think we need more staff due to the numerous call-ins. Registered nurse (RN) #2 was interviewed on 7/8/15 at 10:28 a.m. She stated that being short-staffed caused medications to get passed late. She said residents had complained to her about short staffing. -This RN stated, Realistically, there have probably been some residents who were incontinent of urine while waiting for the call light to be answered. She said the facility was not adequately staffed with nurses or CNAs about once per week. When asked how she prioritized the resident's care when she did not have enough CNA assistance, she stated, I make sure everyone gets their meds as timely as possible, baths are rescheduled, some get bed baths instead of a full tub bath .also shorter baths, not spending as much TLC time with residents. -She stated there were times that she might technically miss a dose of medication due to insufficient staffing. She elaborated that no crucial medications were getting missed. She said she thought administration would be added a nursing position for both days and evenings for the South Creekside neighborhood. On 7/8/15 at 10:47 a.m. RN #10 was interviewed and stated the facility had 19 residents who required two-person transfers and five to six other residents who vacillated between requiring a one- or two-person transfer, out of 63 current residents. She stated that having over one-third of their residents needing two people to transfer was difficult. She felt that residents' basic care was being met, but that it would be nice to have additional staff for more TLC time with the residents, like taking them outside for a walk when they desired. She stated that getting all of the residents' medications passed in a timely manner was a fine balancing act. CNA #7 was interviewed on 7/8/15 at 3:11 p.m. He stated that occasional call-offs negatively impacted the residents' care due to the last second nature of call-offs. He stated that on South Creekside neighborhood, seven of the 19 residents required two-person transfers. CNA #16 was interviewed on 7/8/15 at 3:22 p.m. She stated that on most days, the facility had enough nursing staff scheduled, but had a couple of rough patches here with people calling in so much. She was asked how lack of staffing impacted the residents' care and she stated, I feel like I'm just running around and cannot speak with residents like I'd like . Only the basics are getting done. This CNA acknowledged that she had been told by residents that they felt that there was not enough nursing staff. She stated that family members notice when we are short staffed and running around. She stated that the longest it recently took a call light to be answered was possibly 12 minutes. She stated that there were eight or nine two-person transfers out of the 22 residents on her neighborhood. RN #1 was interviewed on 7/8/15 at 3:36 p.m. She stated that resident #59 (see interview above) had told her that she did not feel the facility had enough nursing staff. She stated that recently she saw a Try 7 come through on her pager, which meant the call light had been going off for at least 18 minutes, but acknowledged that this did not occur often. She stated that there had been some episodes of urinary incontinence in residents normally continent while awaiting their call lights to be answered. She stated that on the West Pondside neighborhood, five of 22 residents residing on the neighborhood required two-person transfers. She stated the facility was looking into adding an extra nurse on days and evenings so that there would be three nurses on each neighborhood and that this position addition was greatly needed. CNA # 15 was interviewed on 7/8/15 at 3:51 p.m. She stated that if everyone scheduled actually showed up, the facility absolutely had enough staff, but that this was not always the case. She stated that staffing had improved the past few months due to a new group of dedicated CNAs being hired on. She stated that lack of staff showing up impacted the residents' care because the CNAs felt that they had to rush through cares and they were not able to spend the quality time with the residents, as the residents desired. She stated that resident #41 had complained of cold food in the dining rooms because there was not an adequate number of staff assisting in the dining rooms. (Nursing staff also assisted with meal service and resident assistance in the dining rooms.) -This CNA stated that on South Creekside neighborhood, there were seven or eight residents out of 19 to 20 that required two-person transfers. She stated that there were six or seven residents out of 22 on East Mountainside that required two-person transfers. She said she was certain there was at least one episode of urinary incontinence related to lengthy call light response times, but could not recall the details. CNA # 11 was interviewed on 7/9/15 at 8:40 a.m. She stated there was not enough nursing staff to address all the residents' needs in a timely manner. She elaborated and stated that, at present, they had a resident requiring 1:1 assistance being bounced from CNA to CNA to unit secretary for coverage and that this resident had not even had her morning cares performed yet. CNA #11 stated that she would probably address this resident's cares during her break time. She stated that it really bothered her when residents did not get the care they needed. -When asked for specifics, the CNA gave an example of the day before, when two residents did not receive their scheduled baths and one of the residents had already been waiting for his bath for three days. She stated, We have to leave baths behind or we don't take our breaks . I think it's good for the residents to speak up and get more help . Water is supposed to be passed daily, but it's not being done. I did not have time to pass water yesterday . If we have a good team, we hustle. If not, it puts us into a spin. -This CNA said residents were not being toileted in a timely manner and there have been recent resident falls and incontinence of urine while residents were waiting for their call lights to be answered. -She stated that East Mountainside neighborhood probably had the longest call light response time and yesterday, she noticed a call light going off on that neighborhood for at least 12 minutes. She shared that she has had to tell a resident that she could not immediately assist them, but that she would return as soon as she could; she recalled getting back to that resident approximately 10 minutes later. -She stated that there were currently ten residents out of 19 or 20 residing on her hall that required a two-person transfer. She admitted that it was often difficult to find the second person to assist with a transfer and the longest it had taken her to find help was a very long time. She stated that sometimes she was forced to go on another hall to find assistance or grab an available nurse to assist. This CNA ended the interview by stating, I think that we really need to stress sufficient staffing so we can take care of the residents. If there was sufficient staff, there would not be staff burned out and calling off. CNA #18 was interviewed on 7/9/15 at 9:45 a.m. He said he felt the facility had some rough times with staffing occasionally and that these times were mostly due to staff calling in. He stated that the acuity on the South Creekside neighborhood was higher than on the other neighborhoods and that an extra CNA working on that neighborhood would be very nice, as it was a bit hard at times to get all resident care tasks done. He stated four or five out of 20 residents on his hall required two-person transfers. He said the average call response time was three to four minutes and the longest time he could recall was a Try 5 or 12 minutes. The assistant director of nursing (ADON) #20 was interviewed on 7/8/15 at 9:30 a.m. She said the nurses worked the following shifts: -Days: 6:30 a.m. to 3:00 p.m. -Evenings: 2:30 p.m. to 11:00 p.m. -Nights: 10:30 p.m. to 7:00 a.m. She stated that the CNA schedule was as follows: Days: 6:00 a.m. to 2:15 p.m. Evening: 2:00 p.m. to 10:15 p.m. Nights: 10:00 p.m. to 6: 15 a.m. The ADON and DON were interviewed together on 7/9/15 at 9:55 a.m. They stated that the receptionist developed the CNA schedule and the nurses signed up for their own schedules, and the DON oversaw this. The DON stated that residents and families may perceive staffing differently than in their prior building because the new building was so large and spread out. She stated that the CNAs were usually in resident's rooms and out of sight, so the residents and families may not be seeing staff out and about like they used to in the prior building with the long corridors. -She stated that the facility's expectation was to be fully staffed, but they never were allowed to be more than one position down. She stated that they were going to a different staffing pattern as of 7/19/15 in which they were going to hire another nurse so there would be a nurse for each hall. At present, each nurse was covering one and a half neighborhoods themselves or approximately 32 or 33 residents each. -The DON stated that the facility did track call light response time on the average. She stated the facility no longer had the technological capacity to track each neighborhood or specific rooms, and were only able to get averages presently. She stated that recently, the average call light response time was three minutes and 18 seconds, and that the highest recent call light response time was four minutes and 11 seconds. The nursing home administrator (NHA), DON and ADON were interviewed on 7/9/15 at 1:15 p.m. They said they felt that call light response time was good. The DON was asked if the staff were trained to leave the call light on until the resident's needs were met or when they first entered the room to check on the resident. The DON stated that she told staff to turn the call light off when first checking on the resident or otherwise the pager system would keep going off and staff would then be coming from all over the building to answer the light. The NHA stated that it was human nature for people to always assume that everyone was short staffed. He stated that census had been down recently, but was now climbing back up. The ADON stated that she thought that the poorly staffed days seem to stick in the resident's heads. Record Review: The daily staffing sheets, reviewed from 6/1/15 through 7/9/15, showed gaps in staffing on the following days: -6/1/15: Short 4.75 hours of one CNA evening shift on West Pondside -6/2/15: Short one CNA day shift on West Pondside and one nursing night shift on West Pondside -6/3/15: Short 1.5 hours of one CNA day shift on East Mountainside and one CNA evening shift on West Pondside -6/4/15: Short 4.25 hours of one CNA day shift on East Mountainside and one CNA evening shift on East Mountainside -6/5/15: The ADON stated that this date's daily staffing sheet was missing and unavailable -6/6/15: Short 4.25 hours of one CNA day shift on West Pondside -6/7/15: Short 3.25 hours of one CNA evening shift on West Pondside and one CNA night shift on West Pondside -6/8/15: Short 1.0 hour of one CNA evening shift on West Pondside -6/9/15: Short 1.25 hours of one CNA day shift on West Pondside and one CNA day shift on East Mountainside -6/10/15: Short one CNA evening shift on East Mountainside -6/12/15: Short 6.25 hours of one CNA day shift on West Pondside, 5 hours of one CNA evening shift on West Pondside and one CNA was late arriving for their night shift on West Pondside -6/13/15: Short 2 hours of one CNA day shift on East Mountainside and 5 hours of one CNA evening shift on West Pondside -6/14/15: Short 3.25 hours of one CNA evening shift on West Pondside -6/15/15: Short one CNA evening shift on South Creekside -6/16/15: Short 4 hours of one CNA day shift on South Creekside, one CNA was late for their evening shift on West Pondside and one CNA was late for their evening shift on South Creekside -6/17/15: Short one CNA evening shift on South Creekside and one CNA was late for their night shift on West Pondside -6/18/15: Short 3 hours one CNA evening shift on East Mountainside -6/19/15: Short 3 hours one CNA evening shift on East Mountainside -6/20/15: Short 1.75 hours one CNA evening shift on West Pondside, short 3 hours one CNA evening shift on East Mountainside, and one CNA was late for their night shift on West Pondside -6/21/15: Short 3 hours one CNA evening shift on East Mountainside -6/22/15: Short one CNA evening shift on East Mountainside -6/24/15: Short one CNA day shift on West Pondside and short one CNA evening shift on East Mountainside -6/25/15: Short one CNA evening shift on East Mountainside -6/26/15: Short one CNA evening shift on West Pondside -6/27/15: Short one CNA day shift on South Creekside and short 3.75 hours one CNA evening shift on West Pondside -6/28/15: Short one CNA day shift on South Creekside and short 3 hours one CNA evening shift on East Mountainside -6/30/15: Short one CNA evening shift on East Mountainside and 3.25 hours one CNA night shift on East Mountainside -7/2/15: Short 1.25 hours one CNA evening shift on East Mountainside -7/3/15: Short 0.75 hours one CNA day shift on South Creekside -7/4/15: Short one nursing evening shift on West Pondside -7/5/15: Short one CNA day shift on East Pondside, another 0.5 hour day shift on East Pondside and 3 hours one evening shift on East Mountainside -7/7/15: Short 5 hours one CNA evening shift on East Mountainside -7/8/15: One CNA day shift arrived late on West Pondside and short one CNA evening shift on West Pondside The documentation provided by the DON on 7/9/15 at approximately 11:00 a.m. showed the following information: -From 1/1/15 to 1/6/15: 19 call lights unanswered -From 1/6/15 to 1/13/15: 44 call lights unanswered -From 1/13/15 to 1/23/15: 30 call lights unanswered -From 1/23/15 to 2/5/15: 30 call lights unanswered -From 2/5/15 to 2/18/15: 47 call lights unanswered -From 2/18/15 to 3/4/15: 27 call lights unanswered -From 3/4/15 to 3/18/15: 26 call lights unanswered -From 3/18/15 to 4/2/15: 39 call lights unanswered -From 4/2/15 to 4/18/15: 36 call lights unanswered -From 4/18/15 to 5/3/15: 23 call lights unanswered -From 5/4/15 to 5/18/15: 22 call lights unanswered (Unanswered call lights - see above - meant 24 minutes or more elapsed before the call light was answered)

Based on observations, resident and staff interviews and record review, the facility failed to ensure five (#7, #19, #26, #32 and #59) of 36 sample residents, who was unable to carry out activities of daily living (ADLs), received the necessary assistance with toilet use, dressing, grooming and personal hygiene. These failures contributed to residents: -Experiencing incontinence accidents; -Being left on the toilet for extended periods; -Waiting extended periods for assistance to have TED hose donned; -Waiting extended periods for medications to be administered; and -Not receiving necessary grooming and hygiene assistance. The findings included: A. Facility Policy The facility policy entitled Expectations of All Staff All Shift, dated 10/28/14, read in part, Purpose: To establish expectations for nursing staff, define standards of care and incorporate the philosophy of Eden Alternative into daily routines and tasks. -Answer call lights before providing routine care. -Assisting dependent elders to toilet according to care plan and on request. -A.M. Care means to assist with, set up or perform: Washing face, hands, arm pits and applying deodorant; Combing hair. Assisting with . other devices as needed . Assisting to toilet. -H.S. (Bedtime) Care means to assist with, set up or perform: Washing face and hands . Assist to toilet. B. Failures to Provide Resident ADL Assistance 1. Resident #7 Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 6/3/15 Minimum Data Set (MDS), she had a BIMS (cognition) score of 15 out of 15 indicating she was cognitively intact. She required extensive assistance with transfers and toilet use, was occasionally incontinent of bladder and always continent of bowel. Resident #7 was interviewed on 7/6/15 at 4:09 p.m. She stated she did not feel the facility had enough nursing staff to address the residents' needs in a timely manner. She stated that recently she had to wait for 45 minutes for assistance off the toilet. She recalled a recent time that her call light was not answered timely. She stated, I had to go so bad, that I wet all over the floor. I kept saying I was sorry. This resident stated that on the day of this interview, she waited for about 15 minutes for assistance to get to the bathroom. 2. Resident #26 Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 5/20/15 MDS, she had a BIMS of 15 out of 15 indicating she was cognitively intact. She required extensive assistance for toilet use, extensive two-plus person assist for transfers and dressing, had an indwelling catheter and was occasionally incontinent of bowel. Resident #26 was interviewed on 7/7/15 at 9:49 a.m. She stated she did not feel the facility was sufficiently staffed because she often had to wait about 30 minutes for her call light to be answered. -Resident #26 was interviewed a second time on 7/7/15 at 2:53 p.m. She stated she felt the facility had been short staffed especially the last few months. She said the CNAs were overwhelmed and the facility needed more CNAs to help out. She stated that the average call response time was maybe 15 minutes and the longest time recently was half an hour. This resident stated that she had recently been left on the toilet for half an hour and that when her call light was finally answered, her bottom was numb and her legs were tingling. 3. Resident #59 Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 6/13/15 MDS, she had a BIMS score of 13/15 indicating she was cognitively independent. She required extensive assistance with toilet use, used a walker or wheelchair for ambulation, had been trialed with a toileting program but no response was noted and she was no longer on a toileting program. The resident was frequently incontinent of bowel and bladder. Resident #59 was interviewed on 7/6/15 at 3:46 p.m. She stated that the facility had a problem with staffing and that staff often called off and did not come in to work. She stated that it had taken as long as an hour after pressing her call light for the staff to respond because the staff were busy with other residents. She stated that the typical response time was 20 minutes. She stated that there was a time that she had an episode of urinary incontinence while awaiting her call light to be answered. 4. Resident #32 Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her 4/29/15 MDS, she had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. She required extensive assistance with dressing and needed assistance with part of the bathing activity. She used a walker for ambulation and was always continent. Resident #32 was interviewed on 7/8/15 at 2:15 p.m. She said the facility needed more nurses and CNAs. When asked, resident #32 stated an average call light response time was 15 to 20 minutes. She stated that the longest call light response times occurred on the night shift. Resident #32 stated she would like to have a bath daily, but that was not possible due to inadequate staffing. This resident said she felt that getting a bath every other day would not be unreasonable to ask for. She stated that she relied on CNAs to put her TED hose on first thing every morning, but there had been times she lay in bed for lengthy periods waiting for her TED hose to be donned in order to get out of bed. Resident #32 stated that on 7/7/15, she did not make it out to the dining room until 12:30 p.m. because she was waiting for her medications and her TED hose to be donned. 5. Resident #19 Resident #19, age 90-plus, was admitted to the facility on [DATE] and readmitted on [DATE] following a hospital stay. Her [DIAGNOSES REDACTED]. According to the 2/18/15 quarterly MDS, the resident's BIMS (cognition) score was five out of 15, indicating severe cognitive impairment. -According to the 5/20/15 quarterly MDS, the resident required supervision with set-up for eating; limited assistance of one for ambulating in her wheelchair; extensive assistance of one for toileting and personal hygiene; extensive assistance of two for bed mobility, transfers, and dressing; and was totally dependent with two for bathing. Resident Observations: On 7/7/15 at 9:13 a.m., resident #19 was observed seated at the dining room table with the back of her hair uncombed and disheveled. On 7/7/15 at 3:50 p.m., resident #19 was observed lying in bed, covered by a blanket. The back of her hair was not observable, but there was brownish colored debris on both sides of her mouth. On 7/8/15 at 8:08 a.m., resident #19 was observed sitting at the dining room table with her hair uncombed and disheveled. On 7/8/15 at 11:42 a.m., resident #19 was again observed sitting at the dining room table with hair uncombed and disheveled in back. On 7/8/15 at 4:13 p.m., resident #19 was sitting at the dining room table and was playing cards. Her hair remained uncombed and disheveled in back. On 7/8/15 at 5:15 p.m., resident #19 was sitting at the dining room table, eating dinner with her hair uncombed and flattened in the back. On 7/9/15 at 8:02 a.m., resident #19 was observed sitting at the dining room table, eating breakfast with her hair uncombed and disheveled. On 7/9/15 at 2:56 p.m., resident #19 was observed sitting at the dining room table, playing cards with her hair uncombed and sticking out of the back of her head. Record Review: The care plan regarding personal care, dated 11/17/13 and updated 5/28/15, read in pertinent part, Grooming: I need extensive assistance grooming. Please encourage me to do what I can for myself, but be available if I do not complete the tasks adequately. Staff Interviews: The assistant director of nursing (ADON) and director of nursing (DON) were interviewed together on 7/9/15 at approximately 1:30 p.m. The above observations of resident #19 were reviewed. The ADON described the above observations as bed head and both the ADON and DON stated it was their expectation that all residents be neatly groomed with their hair combed. They acknowledged that this was care planned for resident #19 and that this resident was not a resident who resisted cares. Certified nurse aide (CNA) #11 was interviewed on 7/9/15 at 8:30 a.m. She stated that resident #19 was not resistive to having her hair combed or her face washed. She acknowledged that resident #19's hair did look unkempt that morning. -CNA # 11 stated residents were not being toileted in a timely manner and stated that there had been recent resident falls and incontinence of urine while residents were waiting for their call lights to be answered. -She shared that she has had to tell a resident that she could not immediately assist them, but that she would return as soon as she could; she recalled getting back to that resident approximately 10 minutes later. She stated that there were currently ten residents out of 19 or 20 residing on her hall that required a two-person transfer. She admitted that it was often difficult to find the second person to assist with a transfer and the longest it had taken her to find help was a very long time. She stated that sometimes she was forced to go on another hall to find assistance or grab an available nurse to assist if need be. CNA #17 was interviewed on 7/8/15 at 9:32 a.m. The CNA stated ten of 22 residents residing on East Mountainside required two-person transfers and that it was sometimes difficult to find a second person to assist in a timely manner. She stated that currently the facility only had one nurse to work one and a half neighborhoods, and this was not enough. CNA #6, who worked on the West Pond neighborhood, was interviewed on 7/8/15 at 9:47 a.m. She said it was difficult to get everyone toileted every two hours. She also stated that it was difficult getting all of the residents' baths done, but they do get done eventually. -She said residents had told her they did not feel the facility had enough nursing staff. She said she had recently found, after answering a call light, that a resident had been left on the toilet and her call light had been going off for at least 27 minutes. -The CNA said she had had to tell a resident that she could not assist them immediately, but would come back to help just as soon as she could. -The CNA said on her neighborhood, five of 23 residents required two-person assist for transfers, and that sometimes it was difficult to find a second person to assist in a timely manner, delaying resident care even further. CNA #3 was interviewed on 7/8/15 at 10:01 a.m. She said the facility did not have enough nursing staff to ensure that all residents had their needs met in a timely manner. When asked specifically how lack of staffing impacted the resident's care, she stated, Considering most of the people on my hall (have severe dementia), they need re-directing, which doesn't always occur . Most of them (the residents) are wheelchair bound and are total assist with transferring and ambulating. CNA #3 stated that this morning she saw a call light take longer than 15 minutes to be answered on another hall. She admitted that she had had to tell a resident that she could not assist them immediately, but would return to help them just as soon as she could. She stated that nine of 13 residents residing on her hall required two-person transfers. Registered nurse (RN) #2 was interviewed on 7/8/15 at 10:28 a.m. She said, Realistically, there have probably been some residents who were incontinent of urine while waiting for the call light to be answered. She said the facility was not adequately staffed with nurses or CNAs about once per week. When asked how she prioritized the resident's care when she did not have enough CNA assistance, she stated, I make sure everyone gets their meds as timely as possible, baths are rescheduled, some get bed baths instead of a full tub bath .also shorter baths, not spending as much TLC time with residents. RN #1 was interviewed on 7/8/15 at 3:36 p.m. She stated that resident #59 had told her that she did not feel the facility had enough nursing staff working. She stated that recently she saw a Try 7 come through on her pager, which meant the call light had been going off for at least 18 minutes, but acknowledged that this did not occur often. She stated that there had been some episodes of urinary incontinence in residents normally continent while awaiting their call lights to be answered. She stated that on West Pondside neighborhood, five of 22 residents residing on the neighborhood required two-person transfers. CNA # 15 was interviewed on 7/8/15 at 3:51 p.m. This CNA stated that on South Creekside neighborhood, there were seven or eight residents out of 19-20 that required two-person transfers. She stated that there were six or seven residents out of 22 on East Mountainside that required two-person transfers. She stated that she was certain there was at least one episode of urinary incontinence related to lengthy call light response times, but could not recall the details.

Based on resident/medical director/staff interview and record review the facility failed to ensure that one (#4) of 22 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, while being transferred with the assistance of one staff member using a lift, the resident, who had extensive assistance needs, fell out of the lift onto the floor; resident #4 suffered two fractured ribs as a result. The findings include: Resident #4, an [AGE] year-old female, was admitted to facility, on 12/27/07 and readmitted , after a brief hospitalization , to the facility, on 1/29/11. Her [DIAGNOSES REDACTED]. Record Review The significant Change minimum data set (MDS) assessment, dated 2/4/11, revealed resident #4 was moderately impaired in cognition (BIMS scores = 10), required extensive assistance with bed mobility and transfers. Specifically, the MDS stated that she required one person physical assist when transferring, extensive assistance to dress, eating - setup only, extensive assistance with toileting hygiene and bathing. Her balance during transitions and walking - was not steady, she was only able to stabilize with human assistance, walking - did not occur. Functional limitation in range of motion (ROM) reported impairment, all extremities and she was checked for upper/lower impairment on both sides. In addition, the resident experienced a Cerebral Vascular Accident (CVA) and/or Transient ischemic attack (TIA) or a stroke. Her wheelchair was propelled by others and she was incontinent of bladder and bowel. Her height was 5'5'' and she weighed 171 pounds. Resident #4 was assessed to have a score of 17 on her Fall Risk Assessment, dated 1/29/11, where a score of 10 or higher represents a high risk for falls. She was placed on a Falls Prevention Program and a care plan was initiated for fall prevention. Care Conference notes, dated 2/10/11, related, "spoke at length with daughter... It has been decided by all that resident will use the Hoyer lift for all transfers . . . This information added to the care plan." Relevant plans of care included: -ADL's (Activities of daily living) - 2/10/11: "I need extensive assistance with toileting I will use bedpan until able to assist with transfers . . . I need total assistance with transfers. Use Hoyer Lift . . ." -Falls - 2/10/11: "I am at risk for falls because I need assistance with ADLS and mobility, I take antihypertensive medications. I have a history of falls and I have joint pain. I will need assistance to BR (bathroom) Q (every) 2-3 hours. Sit at side of bed monitor for s/s (signs/symptoms) of hypotension before standing. Shoe with good tread, walker and w/c (wheelchair) with foot pedals, I am in falls prevention program." The "Events" section of resident #4's medical record included the following: "3/13/11, (name) RN, Short description - Resident was being transferred from her bed to her wheelchair using total lift. She fell from the lift onto her left side. Occurred 3/13/11 4:45 p.m. Location of fall - room. Resident had requested to get out of bed for dinner, was being transferred to wheelchair from bed. Pain - yes, left shoulder, left arm left hip and left ankle - Scale 1-10 = 8, Observation - large bruise to upper left arm, 13cmX2cm. Bruise to distal upper left arm 2cm (centimeters) X6cm. Bruise to left side of neck 5X5cm. Skin tear to right hand proximal index finger knuckle 0.5X0.5cm. ROM (range of motion) painful and limited in upper and lower extremity. No rotation/deformity/shortening noted. Neuro checks. Contributing factor - orthopedic condition. Resident's left shoulder was uncomfortable in sling and she was wiggling around. To ED (emergency department) for x-rays. Transferred to slide board with minimal change in position, then lifted to stretcher for transfer to ED for x-rays." The Nurses' Notes included the following relevant entries: --"3/13/11 6:31 p.m. - (entered by) House Supervisor - Called to patient room at approx (approximately) 5:30 p.m. Pt. (patient) lying supine on floor with flexible slide board in place and (nursing facility) staff X4 in room. Pt. is calm and cooperative, states she fell on to her left side, complains of left arm pain and that 'my left breast hurts' with assessment and palpation. Pt. also states left ankle and left shoulder are tender. Pt. lifted with 5-person assist to stretcher using flexible slide board, placed on portable oxygen and taken to radiology (nursing facility is attached to the hospital) for x-ray series per (physician). Pt. tolerated x-rays well and was taken back to room and transferred to bed. Positioned for comfort - pt denies need for pain medication at this time however requests Valium for anxiety. (RN) aware and will administer as ordered. (RN) also in contact with family and update given regarding x-ray results. Orders rec'd (received) to hold Coumadin tonight." --"3/13/11 11:43 p.m. After resident's fall this evening I called her daughter. When resident returned from x-ray, resident requested her daughter's presence so I called her again. At that time we had results of x-rays and knew there were rib fractures but no other fractures. I told daughter of this over the phone. Daughter came in and was able to reassure and comfort (resident). She had some questions about how the fall happened and I asked that she speak to management tomorrow. The resident had been able to tell her that she fell from the lift while being transferred from bed to wheelchair. Call to nurse manager earlier this evening to inform her of the above." --3/14/11 5:18 a.m. Resident heard moaning from hall. Facial pain was observed as 8 (out of 10). Resident is in distressing pain while lying still and extreme pain during repositioning . . . complained of pain in lower left rib area and left shoulder . . . "(Medication was administered at this time)." The diagnostic imaging report (x-ray), dated 3/13/11, for resident #4 reported: "Examination: left shoulder two views . . . History: fall. Findings: . . .There are acute fractures antero-laterally located in the left 3rd and 4th ribs . . ." The monthly summary, dated 3/31/11, reported in pertinent part: ". . .Transfer: How resident moves between surfaces, to/from bed, chair, wheelchair, standing position - ADL support provided - two-person physical assist . . . Modes of Transfer - lifted mechanically . . ." There was no record of this fall reported on the monthly summary. Interviews 1. Resident At 9:52 a.m. on 4/6/11, resident #4 was interviewed. When asked about the fall from the sling of the lift, the resident replied, "Oh, my ribs and shoulder still hurt from that (fall from the lift) . . . the girls put hot packs on and that helps . . . The girl helping me was new, I remember that . . . it happened so fast - I was on the floor before I knew it . . . Now I know that there are four ropes that need to be hooked and I watch them (the Certified Nurse Aides placing her in the sling of the lift) very carefully . . . I still don't like that thing (the lift). To tell the truth I never did . . . I was thinking that maybe one of the ropes wasn't crossed but I am not sure . . . Since then they always have two (staff) come in and help me to my wheelchair with the lift." 2. Attending Physician/Medical Director Resident #4's attending physician was interviewed, at 2:20 p.m. on 4/5/11. The physician said that one of the nursing staff had notified him of the fall and that it was customary for the facility to call and fax him. "I don't remember the whole story (regarding how she came to fall out of the Hoyer lift). With our (medical) service, our PA's (physician assistants) respond to immediate situations." When asked how many people the facility used in transfers of residents who require Hoyer lifts, he responded that he would be guessing and that he wasn't sure. The physician said, "I think it would depend on the person - some people, if more mobile, would only need one; others like (resident #4), who need more assistance, would possible need two . . . Yes, I am the Medical Director as well . . . The QA (quality assurance) team meets monthly. We talk about falls . . . We talked about this fall and how to prevent it from happening again to this resident and to others . . . For follow up? . . . I believe they did some further training with the Certified Nurse Aides (CNAs) and lifts." 3. Staff The certified nurse aide (CNA) who assisted resident #4 with the lift transfer, on 3/13/11, was not scheduled to work and was not interviewed because "she is currently out of town" according to the director of nursing (DON). The DON submitted the requested copy of the CNA's Skills and Equipment Competencies from the CNAs orientation. Although the competencies list included Encore lifts, Hoyer lift, Sabina lift, Sara lift, Vander lift, Vera lift and Golvo lift, there was no signature verifying that the CNA had completed these competencies. The DON stated the CNA had not signed it yet because she was out of town and that she was "still in her 90 day probation period." The house supervisor who assisted in aftercare for resident #4 after her fall was interviewed, at 4:23 p.m. on 4/4/11. She stated: --"I was house supervisor. I got a phone call that there was a fall at the (nursing home) and they asked me to give a hand. When I got there she (resident #4) was still lying on the floor. We moved the back board under her and with 3 or 4 other people in the room, we lifted onto a stretcher. --She was conscious and awake - not complaining of a horrific amount of pain and answered questions appropriately. --I still don't understand it, she (the CNA) said she had put her (the resident) on the Hoyer lift like she always does. She (resident #4) said that it (the lift sling) hurt her shoulders. --The CNA said she (resident #4) rolled shoulders inward and that caused her to fall . . . --Someone told me it's (fall out of the sling attached to the lift) easy to do if you don't cross the straps. I took (resident #4) down for x-rays. --Afterwards, I sent the nursing home administrator an e-mail. I asked her to follow up with equipment check. We took the lift out of services until maintenance could check it. --It was a bad thing and really scary and I am glad that (resident #4) wasn't hurt worse than she was." During an Interview with the registered nurse (RN) who was summoned by the CNA on 3/13/11, the RN stated as follows: --"The emergency light went off. I looked down hall and could tell that it was (resident #4)'s room . . . She was on the floor, the CNA was with her. It was clear she fell out of the lift. She was laying on top the sling I think. I was worried about how she was lying on the floor - possible broken hip - a fracture . . . --I wanted to get lift away from her. My memory is really bad. We put her on a backboard. We called the house sup(ervisor); she came over and helped us lift her on the backboard to stretcher, then to get x-rays. I wanted to talk to her (the CNA) but the CNA who had transferred her had gone to eat. --When I did get to talk to her, she (the CNA) said she had no idea how it happened . . . There were some straps still hanging from the lift. How could straps come out of hook thing? I just don't see how it could happen. --Another CNA, who was working as unit secretary that evening removed one upper body strap because it was in (resident #4's) face (when she was lying on the floor). Really you know, she (the CNA) said that (resident #4) stated it (the sling) was uncomfortable on her shoulders and that she (resident #4) was wiggling; but I can't imagine that anyone could wiggle out of the sling. I remember the CNA stated, I think she fell on her shoulder." At 3:42 p.m. on 4/4/11, two CNAs were observed transferring a resident using the Hoyer lift to transfer a resident from his bed to a wheelchair. After the observation, they were both interviewed briefly. Both of the CNAs said they were trained to "always use two people" for Hoyer lifts for "stability and safety." The DON was interviewed, at 4:19 p.m. on 4/4/11. She stated: --"They called me at home to tell me that it (resident #4's fall from the Hoyer lift) had happened. The RN said that (resident #4) fell out of the lift . . . There isn't an explanation of how she fell . --The CNA was a fairly new CNA . . . No, there wasn't another CNA with her . . . You know we encourage two but if the CNA feels it's safe to use one then it's ok. --We have ten Sara and Hoyer lifts. --When asked if she counseled the CNA and if there was documentation of it, the DON replied, "There won't be anything in her file . . . --I asked her to come in the next morning and demonstrate how to use the lift for me. She did it correctly . . . --No, I just suggested that she use two people from then on. We (the CNA and I) went in and talked with (resident #4). --I and she (resident) stated she didn't think the CNA did anything wrong . . . --Inservices to other staff? . . . I didn't do them after that but everyone is inserviced when they are oriented. The last inservice on lifts was on 6/30/10." The DON continued, "I am sure that she (resident #4) is still sore . . . She said (she) didn't mind (to continue to use the lift) . . . we make sure that there are two people to lift her . . . --No, there are no other incidents (of falls from lifts) that I can recollect. We suggest that everyone gets the straps crossed. I asked her, 'Did you cross them? Were all the hooks in place?. . . --We had maintenance check it out. It is a brand new Liko Golvo lift (similar to a Hoyer). The hooks have a safety clasp like a carabineer; you have to manually open the hooks. --Since the ED is right here, we don't do transfer form unless they are admitted to the hospital. We give a verbal report to the ED staff. She actually did not go to ED - she just had x-rays and they brought her back." Policy and Procedure At 3:52 on 4/4/11, the DON stated, "We don't have a policy and procedure for lifts, we use and teach the manufacturer's instructions." The DON submitted the manufacturer's instruction guide for review. It was titled, "Liko Universal Sling" and stated in pertinent part: ". . . Lifting from the Bed: We recommend applying the sling when the patient is lying horizontally, as this is the easiest procedure . . . Insert the sling's edge under the patient with the lower edge level with the coccyx . . . Insert the leg supports under each leg . . . The leg supports can be connected in different ways . . Crossed-over leg supports - the most common way of applying the sling. One leg support loop is passed through the other before the loops are connected to the sling bar . . .Raise the head end of the bed. First connect the upper strap loops to the sling bar, then the leg support loops. Lift."