Every finding on record at Casper Mountain Rehabilitation and Care Center

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure timely incontinence care for 1 out of 4 residents (#1) reviewed for ADL care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 12 out of 15 which, indicated the resident had moderate cognitive impairment, and diagnoses which included heart failure, hypertension, renal insufficiency, renal failure, or end-stage renal disease, chronic obstructive pulmonary disease (COPD) with exacerbation, and aneurysm of the ascending aorta, without rupture. Further review showed the resident required partial to moderate assistance for toilet transfers, and was dependent for toilet hygiene. The following concerns were identified: a. Observation on 7/7/26 starting at 11:20 AM on Hall 4 showed resident #1 yelled for help from his/her room. Continued observation showed the resident's call light was not in reach, and the resident yelled out, I pooped my pants! At 11:34 AM a laundry aide entered the resident's room with clean laundry and left the room without providing assistance to the resident. The resident continued to intermittently yell for help. At 12:30 PM a CNA entered the room with the resident's lunch tray, stated Oh my, exited the room without leaving the lunch tray, and retrieved a second CNA to assist the resident. b. Review of the care plan initiated on 2/25/26 and revised on 3/27/26 showed the resident was at risk for falls related to impaired mobility and weakness, with interventions which included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Further review showed the resident had urinary incontinence, with a goal to remain free from skin breakdown due to incontinence. 2. Interview with the DON on 7/7/26 at 4:38 PM revealed she expected the CNAs to complete rounds of the residents' rooms, and she expected the call lights to be within reach. 3. Review of the policy titled Activities of Daily Living (ADLS) last revised 1/1/26 showed .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting; .

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure call lights were accessible for 2 of 4 sample residents (#1, #2) reviewed for call lights within reach. The findings were: 1. Review of the care plan initiated on 2/25/26 and revised on 3/27/26 showed resident #1 was at risk for falls related to impaired mobility and weakness, with interventions which included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Further review showed the resident had urinary incontinence, with a goal to remain free from skin breakdown due to incontinence. The following concerns were identified: a. Observation on 7/7/26 starting at 11:20 AM on Hall 4 showed resident #1 yelled for help from his/her room. Continued observation showed the resident's call light was not in reach, and the resident yelled out, I pooped my pants! At 11:34 AM a laundry aide entered the resident's room with clean laundry and left the room without providing assistance to the resident. The resident continued to intermittently yell for help. At 12:30 PM a CNA entered the room with the resident's lunch tray, stated Oh my, exited the room without leaving the lunch tray, and retrieved a second CNA to assist the resident. 2. Review of the care plan initiated on 7/4/26 and last revised on 4/29/26 showed resident #2 was at a risk for falls related to impaired mobility, devices attached to the resident, and anti-anxiety medication, with interventions which included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The following concerns were identified: a. Observation on 7/7/26 starting at 11:28 AM showed resident #2 sat in a wheelchair with his/her call light activated. An unidentified staff member entered the room, stated, I told nursing and exited the room without turning off the call light. The call light remained on for 22 minutes before 2 CNAs entered the room with a mechanical lift. Observation on 7/7/26 at 12:25 PM showed the resident had been transferred to bed, and his/her call light was on the bedside table and out of reach. b. Interview with resident on 7/7/26 at 12:25 PM revealed s/he had waited an hour and a half for staff to initially respond to the call light, and then s/he was unable to reach the call light after being transferred to bed because it had been left out of reach on the bedside table. 3. Interview with the DON on 7/7/26 at 4:38 PM revealed she expected call lights to be within the residents' reach. 4. Review of the policy titled Call lights: Accessibility and Timely Response last revised 1/1/26 showed .5. Staff will ensure the call light is within reach of resident and secured, as needed .6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .

Based on medical record review, staff interview, medical records request log review, and policy review, the facility failed to ensure the right to secure and confidential medical records in 1 of 3 sample residents (#4) reviewed. The findings were: 1. Review of of the medical records request log showed medical records had been requested for resident #3 on 2/2/26. Review of a progress note dated 5/11/26 and timed 1:57 PM showed resident #3's representative had been notified of missing documentation from the medical record request, and picked up copies of all documents from the request on 5/11/26. The following concerns were identified: a. Review of the medical records that had been received by the resident's representative showed the request included medical records from resident #4. b. Interview with the medical records director on 7/8/26 at 9:57 AM revealed she had been unaware resident #4 records had been included in the request with resident #3. Further interview revealed I guess they could have been there. 2. Review of the facility policy titled Authorization for Release of Protected Health Information (PHI) last updated 4/2026 showed .Purpose To ensure: .Protection of resident rights and confidentiality .

Based on resident representative and staff interview, medical record review, medical records request log, and policy review, the facility failed to provide a complete copy of medical records after they were requested for 1 of 3 sample residents (#1) reviewed. The census was 82. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 admitted to the facility on [DATE]. Further medical record review showed the resident discharged to the hospital on 1/4/26. The resident did not return to the facility following the hospitalization. 2. Review of the medical record request log showed the resident's representative requested the resident's medical records on 2/2/26, which included progress notes, lab results, imaging, results from diagnostic testing, nursing notes, and clinical summaries with the date range of 10/31/25 through 1/4/26. Further review of the records that had been provided to the resident's representative showed progress notes were provided through 12/27/25.3. Interview with the resident's representative on 4/22/26 at 10 AM revealed she had requested the resident's medical records, and after 1 month, had been given the resident's hospital records only. She reported it took another week and a half to get the resident's records from the facility, and the records were missing 1/1/26 -1/4/26. She reported she had been unable to get any further response to receive the complete set of records. 4. Interview with the medical records director on 4/22/26 at 12:40 PM revealed the resident's representative had requested the records before she had been the resident's power of attorney (POA). She stated the representative became POA on 2/26/26, and the documents were picked up that day. 5. Interview with the NHA on 4/23/26 at 11:05 AM confirmed there was no reason the resident representative couldn't get all of the records. 6. Review of the facility policy titled Authorization for Release of Protected Health Information (PHI) showed .Staff must confirm: .Date range is accurate .

Based on medical record review, and staff interview, the facility failed to ensure the comprehensive care plan was implemented for 1 of 3 sample residents (#5) reviewed for care plans. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #5 had a BIMS score of 15 out of 15, which indicated intact cognition, and diagnoses which included septicemia, diabetes mellitus, and cellulitis of the left lower limb. Further review showed the resident was dependent for all transfers. Review of the resident's care plan initiated on 2/9/26 and revised on 3/8/26 showed ADL: [name] has an ADL self-care performance deficit and is dependent with self care tasks to include: bathing, transfers, personal hygiene tasks, bed mobility, dressing, eating, toilet use, ambulation and locomotion r/t [related to] obesity, infection, and wounds. The following concerns were identified: a. Review of the care plan initiated on 2/10/26 and last revised on 3/23/26 showed BATHING PREFERENCE: Resident prefers (specify: showers/bed baths on (specify: days of week/shift?) and (has no preference of care giver type) prefers assistance with bathing to be provided by a (Specify: male/female)b. Review of the care plan initiated on 2/9/26 and last revised on 3/23/26 showed BATHING/SHOWERING: The resident requires (specify: supervision, limited, extensive, dependent) with __ person assist with bathingc. Review of the care plan initiated on 2/10/26 and last revised on 3/23/26 showed BED MOBILITY: The resident requires (SPECIFY: supervision, limited extensive, dependent) with __ person assist to turn and reposition in bedd. Review of the care plan initiated on 3/23/26 showed DRESSING: The resident requires (SPECIFY what assistance) with __ person assist for dressinge. Review of the care plan initiated on 3/23/26 showed TRANSFER: The resident requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as necessary.2. Interview with the MDS nurse on 4/23/26 at 11:44 AM confirmed the care plan was incomplete and it was not patient-centered.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure a safe environment during mechanical lift transfers for 1 of 3 sample residents (#5) reviewed. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #5 had a BIMS score of 15 out of 15, which indicated intact cognition, and diagnoses which included septicemia, diabetes mellitus, and cellulitis of the left lower limb. Further review showed the resident was dependent for all transfers. Review of the resident's care plan last revised on 3/8/26 showed ADL: [name] has an ADL self-care performance deficit and is dependent with self care tasks to include: bathing, transfers, personal hygiene tasks, bed mobility, dressing, eating, toilet use, ambulation and locomotion r/t obesity, infection, and wounds. The following concerns were identified:a. Observation on 4/22/26 at 4:08 PM showed CNA #1 was in the room of resident #5, and transferred the resident from his/her wheelchair to the bed using a full body mechanical lift. Further observation showed the CNA performed the transfer without the assistance of another staff member.b. Interview with the resident on 4/23/26 at 9:26 AM revealed that s/he does not get into his/her wheelchair every day because Some days there isn't enough staff. c. Interview with the DON on 4/22/26 at 4:19 PM revealed there should be two staff members to perform transfers when using the full body mechanical lift.d. Interview with the administrator on 4/23/26 at 11:06 AM revealed he had not heard that there were residents staying in bed due to lack of staff to use 2 people with the Hoyer lift. It is a teamwork issue. Even the nurses are available to help. e. Review of the facility policy titled Safe Resident Handling/Transfers dated 1/1/26 showed, .#8 Compliance guideline: Two staff members must be utilized when transferring residents with mechanical lift .

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure infection prevention practices, including personal protective equipment (PPE), was used during wound care for 2 of 3 sample residents (#2, #26) reviewed for enhanced barrier protection (EBP). The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #2 had a BIMS score of 15 out of 15, which indicated intact cognition, and diagnoses which included chronic venous hypertension with ulcer and inflammation of bilateral lower extremities. Further review showed the resident had 4 venous/arterial ulcers present. Review of the resident's care plan last revised on 4/6/26 showed Wound management [name] has a left anterior lower leg wound x [times] 2 and a left lateral malleolus wound and left medial calf wound. The following concerns were identified:b. Observation on 4/21/26 at 3:43 PM showed wound nurse applied an unna boot dressing to the resident's left lower leg. The Nurse wore gloves but did not wear a gown.a. Review of the medical record showed a photograph of the resident's left lower leg wound which had dimensions of length 4.12 cm, width 2.56 cm, depth 00.2 cm, area 6.29 cm [squared] and wound moderate exudate [drainage], serous clear watery fluid which is separated from solid elements.2. Review of the admission MDS assessment dated [DATE] showed resident #26 had a BIMS score of 15 out of 15, which indicated intact cognition, and diagnoses which included unspecified abdominal hernia with obstruction, without gangrene. Review of the resident's care plan last revised on 2/27/26 showed Wound management post-surgical, midline surgical incision to abdomen. The following concerns were identified:a. Observation on 4/22/26 at 10:30 AM showed the wound nurse changed a dressing located on the resident's upper quadrant of his/her abdomen. Further observation showed the nurse did not wear a gown. 3. Interview with the wound nurse on 4/22/26 at 11 AM confirmed she had not been using a gown when doing wound care. When asked what her expectations for enhanced barrier precautions was, she stated, gloves and hand hygiene.4. Interview with the infection control nurse on 4/22/26 at 11:05 AM revealed she expected enhanced barrier precautions to be used when changing ostomy bags, G-tubes [gastronomy tubes], and foley catheters. Further interview revealed she was in the process of writing a new policy.5. Review of the policy titled Infection Prevention and Control Program last updated 2018 showed no guidance on Enhanced Barrier precautions.

This requirement was not met as evidenced by: Based on medical record review, and staff, and resident interview, the facility failed to evaluate hazards and risks or identify and implement measures to reduce the hazards/risks as much as possible for 1 (#15) of 6 sample residents. The findings were: Review of the 9/22/25 quarterly MDS assessment showed resident #15 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included diabetes mellitus, morbid obesity, muscle weakness, and gout. Further review showed the resident had functional limitations of the lower extremities, and required the use of an electric wheelchair (w/c). The following concerns were identified:1.Interview with the resident on 12/29/25 at 3:33 PM revealed that s/he had caught his/her leg in the courtyard doorway at the facility while in his/her wheelchair in June 2025 and sustained a fractured leg. a. Review of the orthopedic physician's note dated 6/26/25 showed the resident had reported right ankle and leg pain after getting his/her foot caught on the facility door. b. Review of the resident's X-ray results of his/her right tibia and fibula dated 7/1/25 showed.1. An acute, nondisplaced oblique fracture through the distal tibial diaphysis.2. Review of a skin injury note dated 10/28/25 and timed 12:30 PM showed the resident had sustained a large bruise to his/her left calf after bumping his/her leg into a bed. Interview with the resident on 12/29/25 at 3:33 PM confirmed that s/he had hit his/her leg on his/her bed in October while in an electric wheelchair.3. Interview with the Physical and Occupational Therapy Director on 12/30/25 at 1:35 PM revealed there was not a wheelchair skill, or safety assessment completed on the resident, following the right leg fracture in June 2025, or after bumping his/her left leg on 10/28/25.4. Review of the care plan dated 11/6/25 showed the resident mobilized independently in a motorized w/c. An intervention to educate the resident on the proper use of mobility devices was initiated on 5/29/25. There were no additional interventions to address w/c safety.5. Interview with RN # 8 on 12/29/25 at 3 PM confirmed that safety assessments should have been completed on all residents who required power wheelchairs.

Based on resident representative and staff interview, and medical record review, the facility failed to provide services to prevent, treat, and heal pressure ulcers for 1 of 4 sampled residents (#98) reviewed for pressure ulcers. This failure resulted in actual harm to resident #98 who developed pressure ulcers. The findings were: 1. Review of the admission MDS assessment, dated 5/18/25, showed resident (#98) had a BIMS score of 3 out of 15, which indicated s/he had severe cognitive impairment, and diagnoses which include type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure. Further review showed no wounds were present upon admission and the resident was at risk for pressure ulcers / injuries. The following concerns were identified: a. Review of a physician note, dated 5/15/25, showed the resident had a nickel sized unstageable pressure ulcer located on his/her right buttocks with orders for wound care and monitoring. Review of the medical record showed no treatment orders for wound care or monitoring.b. Review of the skilled nursing evaluation, dated 5/21/25 and timed 1:30 PM, showed the resident had an abraded area noted to the buttocks and cream was applied by RN #1. c. Review of the skilled nursing evaluation, dated 5/22/25 and timed 11:25 PM showed new pressure ulcers were present to the right and left heels, left medial calf, and an abrasion to the coccyx. Further review showed RN #1 notified the DON of the new ulcers, the DON observed pressure areas, and the DON planned to discuss the new ulcers with the certified wound nurse regarding treatment options. d. Review of a physician note dated 5/25/25 showed the resident had prevalon boots and orders to continue with wound care until completely healed. Review of the resident's medical record showed no evidence the prevalon boots, or wound care was added to the orders until 5/27/25. e. Interview with the resident's representative on 8/27/25 at 5:12 PM revealed the resident had been sent to the emergency room for another matter on 5/26/25 and the physician found concerning pressure ulcers on the resident's heels and buttocks. The resident did not return to the facility following the emergency room visit.f. Interview with the interim DON on 8/27/25 at 5:30 PM confirmed there were no wound care orders or documentation the facility was treating the resident's pressure ulcers prior to 5/27/25, after the resident had discharged .

Based on observation, staff interview, review of the facility Outbreak Investigation Tool, State Licensing incident database review, and policy and procedure review, the facility failed to implement a water management program to prevent, detect, and control the risk of water-borne pathogens, failed to report an outbreak of infectious disease involving 14 residents, and failed to ensure effective infection control practices were followed during 2 random observations. The census was 82. The findings were: 1. Observation on 8/24/25 at 5:08 PM showed resident #84 was in bed and his/her catheter bag was lying flat on the floor. Interview with CNA #1 at that time revealed the bed did not have a place to hang the bag so it was put on the floor. Observation on 8/25/25 at 9:25 AM showed resident #84 was in bed and his/her catheter bag was placed in a dignity bag and lying flat on the floor. Interview with the interim DON and the ADON on 8/26/25 at 3:14 PM confirmed catheter bags should not be placed directly on the floor. 2. Review of the Legionella Water Safety Program policy, dated 7/29/25 showed control measures had been identified and the facility was to Maintain logs for each control measure, including corrective actions taken for out-of-range values. Review data monthly to detect trends or deficiencies. Interview with the NHA on 8/27/25 at 2:15 PM revealed the water management plan for Legionella had not been implemented. 3. Observation on 8/24/25 at 1 PM showed several residents had been confined to their room due to a gastrointestinal outbreak with symptoms of nausea, diarrhea, and vomiting. Review of the Outbreak Investigation Tool showed the outbreak began on 8/22/25 and involved 14 residents. Review of the state licensing agency incident data base showed no evidence the facility had reported an infectious disease outbreak. Interview with the interim DON on 8/27/2025 at 3:41 PM revealed she was unaware of the requirement.

Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to include residents in the care planning process for 3 of 5 sample residents (#12, #30, #84) reviewed. The findings were: 1. Review of the 7/17/25 annual MDS assessment showed resident #12 was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15 (cognitively intact). Further review showed the resident had a quarterly MDS assessment completed on 9/30/24, 12/31/24, and 4/2/25. The following concerns were identified: a. Interview with the resident on 8/24/25 at 3:47 PM revealed s/he did not recall being invited to a care conference meeting. b. Review of the resident's medical record showed the last documented care conference was held on 5/9/23. 2. Review of the quarterly MDS assessment showed resident #84 was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15 (cognitively intact). The following concerns were identified: a. Interview with the resident on 8/25/25 at 9:27 AM revealed s/he had not been invited to a care conference meeting. b. Review of the resident's medical record showed the last documented care conference was held on 3/25/25. c. Review of the resident's care plan showed it was last revised on 6/30/25. 3. Review of the review of the comprehensive MDS assessment dated [DATE] showed resident #30 was initially admitted to the facility on [DATE], with the most recent reentry date of 8/26/23. Further review showed the resident had a BIMS score of 15 out of 15 (cognitively intact). The following concerns were identified: a. Interview with the resident on 8/25/25 at 9:50 AM revealed s/he recalled only being invited to one care conference meeting. b. Review of the resident's medical record showed the last 2 documented care conferences were held on 8/20/24 and 5/14/25. c. Review of the resident's care plan showed it was last revised on 7/24/25. 4. Interview with the interim DON on 8/26/25 at 5:42 PM revealed care conferences were held on a quarterly basis. Further interview revealed there was no evidence the residents participated in the planning process. 5. Review of the Care Planning-Resident Participation policy and procedure showed .The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to provide a notice of transfer prior to a facility-initiated hospital transfer and provide written information on the bed-hold policy to the resident or the resident's representative for 3 of 5 sample residents (#6, #89, #94) reviewed for facility-initiated transfers. In addition, the facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. The findings were: 1. Review of the medical record showed resident #6 was transferred to the hospital on 7/16/25. Further review showed no evidence the facility had issued a written transfer notice and written information on the bed-hold policy to the resident and/or the resident representative. There was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. 2. Review of the medical record showed resident #89 was transferred to the hospital on 7/18/25. Further review showed the Notice of Transfer/Discharge was not signed by the facility representative, and there was no verification of receipt of notice by the resident or responsible party. 3. Review of the medical record showed resident #94 was transferred to the hospital on 8/4/25. Further review showed no evidence the facility had issued a written transfer notice and written information on the bed-hold policy to the resident and/or the resident representative. There was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. In addition, the resident was transferred to the hospital on 8/24/25. The facility provided a written transfer notice to the surveyor; however, it was not signed by the administrator/administrative officer or the resident/resident's representative. 4. Interview with the NHA on 8/27/25 at 3:29 PM confirmed there was no record the notices were provided to the resident or resident representative or sent to the Ombudsmen. 5. Interview with the NHA on 8/27/25 at 3:29 PM confirmed no further documentation was available and was unable to locate documentation the Ombudsman had been notified of the transfers. 6. Review of the Bed Hold Notice policy showed It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave .1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies . 2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. 3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record . 7. Review of the Transfer and Discharge (including AMA) policy showed .10. Emergency Transfer to Acute Care .g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices .

Based on observation and staff interview, the facility failed to ensure a sanitary environment in 1 of 1 food preparation area. The census was 82. The findings were: 1. Observation on 8/24/25 at 1:10 PM showed an upright fan was blowing on a food preparation area located in front of the 3-compartment sink. On the food preparation counter was a cutting board and knife. The fan was darkened and soiled with debris. Further observation showed a rack used to store clean utensils and cookware was located directly behind the hooded gas cooking area. Between the grill/oven area and the storage rack were pipes that were visibly dirty and soiled.2. Observation on 8/26/25 at 9:04 AM showed the upright fan was blowing on the same food preparation area where dietary aide #1 was preparing individual syrup cups for residents. Interview with the dietary manager and cook #1 at that time confirmed the fan was not clean. [NAME] #1 immediately disconnected the fan and took it apart to clean it. The area behind the grill/oven remained the same.3. Interview with the dietary manager on 8/26/25 at 12:15 PM confirmed the area behind the grill/oven area was not clean and was not included on the cleaning schedule.

Based on observation and staff interview, the facility failed to employ a sufficient number of staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. The census was 82. The findings were: 1. Observation on 8/26/25 starting at 11:30 AM showed dietary aide #1 and cook #1 began the noon meal service by first preparing plates for the residents which required assistance with eating and were served in the Sunflower dining room. The meals were served on dinnerware with the exception of residents who required special utensils and plates. At 11:40 AM dietary aide #1 and cook #1 prepared room trays using dinnerware to serve the meal. Service to the main dining room began at 11:45 AM and approximately three quarters of the way through service the dinnerware was switched to black foam disposable plates. 2. Interview with cook #1 on 8/26/25 at 12:01 PM revealed the facility did not have enough clean dinnerware for all of the residents and had to switch to disposable plates. [NAME] #1 stated this happened more often than it should. 3. Interview with the dietary manager on 8/26/25 at 12:15 PM revealed if the facility had 2 dietary aides during the day, the aides were responsible for retrieving the room trays and washing the dishes before the next meal service; however, if the kitchen was short a dietary aide it was up to the CNAs to return the room trays to the kitchen. The dietary manager stated when the CNAs were responsible the room trays would trickle in and this did not always leave enough time to wash the dishes.

Based on medical record review, staff interview, and review of policy and procedures, the facility failed to have a system in place to maintain documentation residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination and documentation of the consent or refusal of the immunization for 4 of 4 sample residents (#9, #10, #59, #84) reviewed for immunizations. The findings were: 1. Review of the 7/28/25 quarterly MDS assessment for resident #9 showed s/he was admitted to the facility on [DATE] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 2. Review of the 8/8/25 quarterly MDS assessment for resident #10 showed s/he was admitted to the facility on [DATE] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 3. Review of the 8/8/25 annual MDS assessment for resident #59 showed s/he was admitted to the facility on [DATE] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 4. Review of the 6/22/25 quarterly MDS assessment fore resident #84 showed s/he was admitted to the facility on [DATE] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 5. Interview with the interim DON and ADON on 8/26/25 at 3:14 PM confirmed no further documentation was available. 6. Review of the Coronavirus Disease (COVID-19) - Vaccination of Residents policy showed Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. 1. Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. 2. The resident (or resident representative) can accept or refuse a COVID-19 vaccine and can change his/her decision. 3. COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee .6. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine .10. Residents must sign a consent to vaccinate form prior to receiving the vaccine. The form is provided to the resident in a language and format understood by the resident or representative

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure the advanced directive was formulated and accurate for 2 of 28 sample residents (#84, #93) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #84 was listed as do not resuscitate (DNR). Further review of the medical record showed no evidence the resident had signed and dated an advance directive. Interview with the interim DON and MDS coordinator on [DATE] at 5:37 PM confirmed there was no evidence the resident had elected a DNR status. 2. Review of the EMR showed resident #93 was listed as a full code status. Review of a cardiopulmonary resuscitation (CPR) designation form provided by the interim DON on [DATE] at 4:48 PM was initialed No, do not administer CPR and signed and dated by the resident on [DATE]. Interview with the interim DON on [DATE] at 4:48 PM confirmed the EHR did not match the most recent election of no CPR. 3. Review of the Advance Directive policy showed . 7. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive .

Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications for 2 of 5 residents (#9, #20) reviewed for unnecessary medications. The findings were: 1. Review of the 3/10/25 quarterly MDS assessment showed resident #9 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. The resident was coded as receiving antipsychotic, antianxiety, and antidepressant medications during the 7-day look-back period. The last attempted gradual dose reduction (GDR) was documented as occurring on 12/31/24. The following concerns were identified: a. Review of the 8/24/25 Psychotropic Medication Utilization Report showed the resident was prescribed quetiapine fumarate (antipsychotic) and buspirone hydrochloride (an antianxiety medication), for paranoid schizophrenia with the last risk-benefit statement completed on 9/17/24; however, the facility was unable to locate the risk-benefit statement signed by the resident's physician or documentation to support the 12/31/24 GDR as noted on the 3/10/25 quarterly MDS assessment. b. Review of the physician orders showed the resident was prescribed 1 milligram (mg) of lorazepam (an antianxiety medication) every 8 hours as needed (PRN) on 8/1/25 for comfort focused care; however, no stop date was indicated. Review of the August 2025 medication administration record showed the resident had not been administered a PRN dose of lorazepam during the month. c. Interview with the interim DON on 8/27/25 at 12:56 PM confirmed the physician order for PRN lorazepam did not have a stop date. In addition, the interim DON revealed she was currently working on organizing the psychotropic medication review process. An additional interview with the interim DON at 3:15 PM confirmed the GDR documentation for resident #9 could not be located. 2. Review of the 6/26/25 quarterly MDS assessment showed resident #98 was admitted to the facility on [DATE] and had a diagnosis of depression. The resident was coded as receiving antipsychotics and antidepressants during the 7-day look-back period. The MDS showed no GDR was attempted or documented as being clinically contraindicated. The following concerns were identified: a. Review of the physician orders showed that the resident was prescribed 100 mg of Sertraline daily for depression on 1/23/24. b. Review of the 10/28/24 Medication Regimen Review, signed by the physician, showed that no reduction of Sertraline was ordered at that time, and no clinical rationale was documented. c. Interview with the interim DON on 8/27/25 at 11:30 AM confirmed that no GDR was attempted and no rationale was documented for the resident.

Based on medical record review and staff interview, the facility failed to ensure an environment was free from accident hazards for 2 of 3 residents (#7, #9) reviewed for smoking. The findings were:1. Review of the quarterly MDS assessment, dated 7/29/25, showed resident #7 had a BIMS score of 14 out of 15 (cognitively intact). The following concerns were identified:a. Observation on 8/25/25 at 3:59 PM showed the resident smoked in the courtyard during the scheduled smoking time.b. Review of the resident's medical record showed the last safe smoking evaluation was dated 3/10/25. Review of the resident's care plan, last updated 6/12/25, did not address smoking.2. Review of the 12/8/24 annual MDS assessment for resident #9 showed s/he was admitted to the facility on [DATE], had a BIMS score of 13 out of 15 (cognitively intact), and had diagnoses which included schizophrenia, respiratory failure, and COPD (chronic obstructive pulmonary disease). Review of the resident's care plan, dated 3/31/23, showed the resident was a smoker/uses tobacco products and was to be reevaluated via safe smoking evaluation quarterly and as needed. Review of the Resident Smoking policy showed .6. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. 7. If a resident who smokes experiences any decline in condition or cognition, he/she will be reassessed for ability to smoke independently and/or to evaluate whether any additional safety measures are indicated .The following concerns were identified:a. Review of the resident's medical record showed the last documented Smoking and Safety evaluation was completed on 1/28/25.3. Interview with the interim DON and MDS coordinator on 8/26/25 at 5:43 PM confirmed there was no additional documentation available and smoking should be addressed in the care plan and assessed quarterly. 4. Review of the policy and procedure titled Resident Smoking showed .8. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan .

Based on medical record review, staff interview, and review of the MDS RAI manual, the facility failed to ensure MDS assessments were accurate for 3 of 28 sample residents (#10, #12, #55). The findings were: 1. Review of the 2/9/22 Wyoming PASRR (pre-admission screening and resident review) Level II Determination Summary Report showed resident #12 had psychiatric diagnoses which included bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror. Further review showed the resident met the state definition of mental illness. The following concerns were identified: a. Review of the 7/1/25 annual MDS assessment showed section A1500 was marked no to the question if the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability. b. Interview on 8/26/25 at 2:38 PM with the MDS coordinator confirmed section A1500 was marked inaccurately. 2. Review of the 4/18/25 annual MDS assessment for resident #55 showed section GG (used to assess functional abilities and goals) was marked as not assessed. Interview on 8/26/25 at 2:38 PM with the MDS coordinator revealed the facility did not have staff available at that time to perform the assessment so section GG was dashed out. 3. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual version 1.19.11 last revised October 2024 showed .A1500: Preadmission Screening and Resident Review (PASRR) .code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1520, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Section GG of the RAI manual showed the intent of this section included items focused on prior function, admission and discharge performance, discharge goals, performance throughout a resident's stay, mobility device use, and range of motion. Functional status was assessed based on the resident's need for assistance when performing self-care and mobility activities.

Based on medical record review, staff interview, and review of the MDS RAI manual, the facility failed to ensure a significant change MDS assessment was completed for 1 of 28 sample residents (#10). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 0 out of 15 which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain injury, alcoholic cirrhosis of the liver, non-Alzheimer's dementia, and depression. Further review showed the resident was coded as being on hospice care. The following concerns were identified: a. Review of the resident's medical record showed a Discharge Summary from hospice with a discharge effective date of 5/9/25 due to lack of decline. b. Interview with the interim DON on 8/26/25 at 5:53 PM confirmed the resident was discharged from hospice on 5/2/25 and revealed the facility was not notified of the discharge by hospice until 7/7/25. c. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual version 1.19.11 last revised October 2024 showed .An SCSA (Significant Change in Status Assessment) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD [Assessment Reference Date] must be within 14 days from one of the following: 10 the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 20 the expiration date of the certification of terminal illness; or 30 the date of the physician's or medical director's order stating the resident is no longer terminally ill .

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to implement treatment to maintain or improve conditions for 1 of 4 sample residents (#1) reviewed with non-pressure wound care. This failure resulted in actually harm to resident #1 who was transferred to the hospital and treated for an infection related to the wound. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 admitted to the facility on [DATE] and had a BIMS score of 15 out 15, which indicated the resident was cognitively intact. The resident had diagnoses which included congestive heart failure, hypertension, renal insufficiency, benign prostatic hyperplasia, and encephalopathy. Further review showed the resident was at risk of pressure injury development with no pressure injuries present and no wounds, venous ulcers, or arterial ulcers present. The following concerns were identified: a. Review of a physician note dated 3/27/25 showed the resident was seen for an initial evaluation of multiple wounds to his/her bilateral lower extremities. The wound assessment showed .1. RLE [right lower extremity] lateral non-pressure ulceration stage 2-onset 3/27/25 -16.0cm x [by] 8.0cm x 0.2cm - cluster of open areas with + [positive] slough, minimal granulation. Large amount of SS [serosanguious] drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 2. RLE [right lower extremity] anterior non-pressure ulceration - stage 2 - onset 3/27/25 -3.5cm x 2.5cm x 0.1cm - cluster of open areas with + slough, minimal granulation. Large amount of SS drainage, no odor, no erythema, no s/s [signs or symptoms] of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 3. RLE posterior non-pressure ulceration - stage 2 - onset 3/27/25 - 4.5cm x 1.0cm x 0.1cm - cluster of open areas with + slough, minimal granulation. Large amount of SS drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 4. LLE [left lower extremity] anterior non-pressure ulceration - stage 2 - onset 3/27/25 -0.6cm x 0.8cm x 0.1cm - 1 small open area with +slough, minimal granulation. Large amount of SS drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 5. L 5th toe -stage 2 - onset 3/27/25 - 0.8cm x 0.5cm x 0.1cm - 1 small punched out appearing open area with m+ [sic] slough, no drainage. No odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are well-defined . b. Review of a physician note dated 4/22/25 showed the resident was seen to evaluate the chronic BLE [bilateral lower extremities] venous ulcerations. The wound assessment showed .1. RLE lateral non-pressure ulceration - stage 2 - onset 3/27/25 -10.3cm x 7.5cm x 0.1cm - cluster of open areas with + slough, minimal granulation. Large amount of SS drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 2. RLE anterior non-pressure ulceration - stage 2 - onset 3/27/25 -18.0cm x 13.0cm x 0.1cm - cluster of open areas with + slough, moderate granulation. Large amount of SS drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 3. RLE posterior non-pressure ulceration - stage 2 - onset 3/27/25 -11.4cm x 9.0cm x 0.1cm - cluster of open areas with + slough, moderate granulation. Large amount of SS drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 4. LLE anterior non-pressure ulceration - stage 2 - onset 3/27/25 -17.0cm x 15.0cm x 0.1cm - 1 small open area with + slough, moderate granulation. Large amount of SS drainage, no odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are not well-defined. 5. L 5th toe -stage 2 - onset 3/27/25 - 0.8cm x 0.5cm x 0.1cm - 1 small punched out appearing open area with m+ slough, no drainage. No odor, no erythema, no s/s of elevated bacterial burden. Peri-wound pink/edematous/moist. Wound edges are well-defined. 6. L Great toenail - the nail is only attached at the root. See below procedure. 7. R Great toe - stage 2 - onset 4/22/25 - 1.6cm x 3.2cm x 0.1cm - new onset circular open area d/t increased moisture exposure from large amount of drainage from BLE - +slough, light SS drainage, no erythema, no s/s of infection. 8. R foot 2nd toe - stage 2 - onset 4/22/25 - 3.0cm x 2.5cm x 0.1cm - small circular open area with +slough, light SS drainage, no erythema, no s/s of infection . The procedure indicated the resident's left great toenail was cut back to the root, betadine painted and wrapped with kerlix . c. Review of a wound picture of the resident's left foot 5th toe dated 3/27/25 showed a yellow area near the toenail which measured 0.8 cm by 0.5 cm by 0.1 cm. Further review showed the resident's surrounding skin on his/her foot was pink in color, which was normal for him/her, with slight edema and there were no additional wounds observed at that time, the 5th toenail was light yellow; however, the other nails appeared normal in color. d. Review of wound picture of the resident's left foot 5th toe dated 4/22/25 showed a yellow/brown area near the toenails which measured 0.8 cm by 0.5 cm by 0.1 cm. The review showed the resident's foot appeared darker in color with more edema present and the resident's 5th toenail was dark yellow. Further review showed open areas to the 3rd toe and great toe and a discoloration present on the 4th toe which was red, yellow, orange, and brown in color. Review of a wound picture for the resident left foot 3rd toe dated 4/22/25 showed the open area had a light pink wound bed which appeared wet, the edges appeared to be rolled up and were white with some yellow discoloration noted. The wound measured 1.5 cm by 2.3 cm by 0.1 cm. The review showed an open area on the 2nd toe near the nail bed and an open area on the nail bed of the great toe where a large portion of the nail had been removed. Further review showed discoloration to 2nd toenail with a dark area near the cuticle and large dark discoloration on the tip of the great toe. Review of a picture of the resident's left foot 2nd toe showed the open area measured 1.9 cm by 1.0 cm by 0.1 cm. Further review of the resident's medical record showed no evidence the open area to the resident's great toe, where the toenail was missing, was measured. e. Review of a wound picture of the resident's right lateral leg dated 3/27/25 showed scattered areas which varied in color including yellow, red, and pink. The yellow areas were located near the resident's ankle and the surrounding tissue appeared normal in color for the resident. Further review showed the area measured 16.0 cm by 8.0 cm by 0.2 cm. Review of a wound picture of the resident's right anterior leg dated 3/27/25 showed an area which had scattered open areas and the wound beds were red in color. Further review showed the area measured 3.5 cm by 2.5 cm by 0.1 cm and the surrounding skin was normal for the resident. Review of a wound picture of the resident's right posterior leg showed an area with some light brown discoloration and the area measured 4.5 cm by 1.0 cm by 0.1 cm. Further review showed the surrounding skin was normal for the resident. f. Review of a wound picture of the resident's right lateral leg dated 4/22/25 showed a large open area with a bright red wound bed. There were small scattered areas that appeared pink with yellow edges and some with white tissue. Further review showed the wound appeared wet and measured 18 cm by 13 cm by 0.1 cm. Review of a wound picture of the resident's right posterior leg dated 4/22/25 showed the wound bed bright red with area of shiny white tissue. The wound bed appeared wet and draining. Further review showed the wound measured 11.4 cm by 9.8 cm by 0.1 cm. g. Review of a wound picture of the resident's left anterior leg dated 3/27/25 showed an open area with a wound bed that was yellow and slightly tan in color. Further review showed the area measured 0.6 cm by 0.8 cm by 0.1 cm. h. Review of a wound picture of the resident's left anterior leg dated 4/22/25 showed a large open area that was bright red and dark red in color. There were other areas of intact tissue in the wound bed that had yellow and white color. The wound appeared wet with drainage noted and measured 17.0 cm by 15.0 cm by 0.1 cm. i. Review of a wound picture of the resident's right 2nd toe showed the resident's toenail was dark yellow in color and there was an open area which had a white wound bed. The surrounding tissue was darker in color and the wound appeared to be draining fluid. Further review showed the wound measured 3.0 cm by 2.5 cm by 0.1 cm. There were no previous pictures of the right 2nd toe wound in the medical record. j. Review of a wound picture of the resident's right great toe dated 4/22/25 showed the toenail was very thick and yellow with some black areas noted to the lateral nail fold. Further review showed an open area on the top of the foot with a slightly yellow wound bed and white tissue surrounding the wound and an area on the later toe which was white and yellow in color. The tip of the resident's toe was bright red in color. Further review showed the wound measure 1.6 cm by 3.2 cm by 0.1 cm. There was no previous picture of the right great toe in the medical record. k. Review of the progress notes showed no evidence of wound monitoring or identification of new wounds. j. Review of the TAR for April 2025 showed resident #1 had an order for .Saturate Kerlix with Vashe and wrap R leg and L leg for 15min followed by light scrub. Pat dry. [NAME] Lotion to legs. K2 Lite [compression wraps] to both legs starting at base of toes to below knee. one time a day every Fri for wound care which began on 4/3/25. The review showed treatments on 4/4 and 4/18 were performed by a MA-C and no treatment was performed on 4/11 or 4/25. Further review showed no evidence of as needed dressing changes, refusals of dressing changes, or dressing changes performed by the wound team. l. Interview with MA-C #1 on 5/16/25 at 10:38 AM revealed she was not able to perform wound measurements or assessment because she was not a nurse. Further interview revealed the wound team measured and assessed wounds on Tuesdays. Interview with MA-C #1 on 5/16/25 at 11:43 AM revealed the resident's wounds had gotten worse during his/her stay and as needed dressing changes and refusals of dressing changes should be documented on the treatment administration record. m. Review of a hospital history and physical note dated 4/25/25 and timed 9:46 PM showed the resident arrived to the hospital in very poor condition and his/her dressing to the bilateral lower extremities were saturated. The resident reported increasing leg pain with his/her right leg being worse than the left. The note showed .On arrival [s/he] was noted to be covered in feces, [s/he] had dressings on [his/her] lower extremities that were feces soaked as well. Patient is supposed to have wound care changes every Tuesday but [s/he] is unclear when [his/her] last change was . The physical exam showed .[his/her] lower extremities have wounds from the knees down, skin is sloughed off, [his/her] right lower extremity is erythematous up to med thigh, [s/he] has wounds on [his/her] toes. No heel wounds . The Assessment/Plan showed .Sepsis (WBC, HR) Right lower extremity cellulitis. Likely secondary to multiple lower extremity wounds. Follow-up blood cultures. Wound care consult for wounds. Continue vancomycin and ceftriaxone . 2. Interview with the infection preventionist/staff development coordinator on 5/16/25 at 1:22 PM revealed if wound care was not performed or if additional PRN [as needed] dressings were performed, the nurse should document the care in the progress notes or in a note on the TAR. She revealed she was not able to oversee wound care in the facility and the facility did not have a staff performing oversight for the wound program. Further interview confirmed both residents experienced wound deterioration. 3. Review of the facility policy titled Wound Treatment Management dated 2024 showed .8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. lack of progression towards healing. b. Changes in characteristics of the wound .

Based on medical record review, and resident interview and staff interview, the facility failed to ensure residents were free from physical abuse for 1 of 5 residents (#2) reviewed for behavioral symptoms. This failure resulted in harm to resident #2, who was punched in the face by another resident, and sustained bruises to the face and wrist. The findings were: 1. Review of the 5/4/22 quarterly MDS assessment for resident #1 showed the resident was admitted on [DATE] with diagnoses which included unspecified dementia with behavioral disturbance. The resident had severe cognitive impairment with a BIMS score of 4 out of 15. The resident also had physical and verbal behavioral symptoms on 1 to 3 days during the look back period. Review of the 4/21/22 annual MDS assessment for resident #2 showed the resident had diagnoses which included dementia and anxiety. The resident had a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Review of the Medication Regimen Review for resident #1, dated 12/21/21, showed a recommendation signed by the physician that read, .continue the prn Haldol [an antipsychotic medication], still necessary to prevent harm to others . Review of the quarterly Psychotropic Medication Management Review dated 3/15/22 showed the following recommendations: .dangerous behaviors less frequent only 1 time use of prn Haldol this month. Review of the progress note dated 4/20/22 and timed 12:22 PM showed the resident was given Haldol due to agitation, yelling and accusing the laundry of stealing his/her clothes. Further review showed staff tried to redirect him/her, however s/he continued to yell at other residents about the laundry. Review of the progress note dated 4/26/22 and timed 4:04 PM showed resident #1 was upset about his/her roommate, resident #2. Resident #1 stated resident #2 turned off his/her television without permission. Further review showed the resident was yelling and showed aggression toward the staff by pushing a bedside table through the room-dividing curtain towards the staff. Review of the progress note dated 4/29/22 and timed 2:58 PM showed resident #1 was very agitated about his/her roommate and the television. Further review showed while maintenance was providing resident #1 with a different television remote, resident #1 called his/her roommate a b*tch. The note further showed when resident #1 was returning to his/her room and saw the roommate in a common area, s/he yelled at the roommate calling him/her a b*tch. Staff were able to prevent resident #1 from approaching the roommate at that time. The following concerns were identified: a. Review of the progress note for resident #1 dated 5/3/22 and timed 1:45 PM showed the writer .heard screaming from room, CNA noted resident hitting [his/her] roommate in the face and [his/her] arm. Immediately intervened, resident swinging at the CNA also, resident assisted to stationary chair and roommate removed from room to safety .roommate and belongings removed from room, resident is on 15 minute checks. b. Review of the SBAR Summary dated 5/3/22 and timed 1:45 PM showed resident #2 was in his/her room watching television when resident #1 came in the room, hit him/her, knocked his/her glasses off, and hit his/her right arm. Further review showed resident #2 had a bruise to the face and right wrist, and interventions included ice application to right cheek, and moving resident #2 to another room. Review of the Treatment Administration Record for May 2022 showed an order to monitor the bruising to resident #2's right cheek and right wrist until resolved. c. Interview with CNA #1 on 5/17/22 at 4:20 PM revealed on 5/3/22 resident #1 was agitated and threatening to kill his/her roommate. The CNA stated resident #1 came out to the common area. The CNA thought resident #1 had calmed down and saw the resident walk to to his/her room. The CNA stated resident #2 was in the room watching television. The CNA stated she heard screaming and yelling from the room and when she got to the room resident #1 stated s/he hit the f*cking b*tch. The CNA stated she got between the residents and resident #1 hit her. She further stated the nurse came to the room and they immediately removed resident #2 from the room. d. Interview on 5/17/22 at 1:00 PM with resident #2 revealed s/he had a previous roommate (resident #1) who was upset with her over the television remote control. S/he said they were both able to change each other's channel and didn't know it. S/he stated resident #1 got angry and hit him/her, and this upset resident #2. e. Interview on 5/17/22 at 4:25 PM with RN #1 revealed resident #1 had been agitated over the television remote and maintenance had changed the television and remote for resident #2. She stated resident #1 and resident #2 had been roommates for a short time. Resident #1 did not like having roommates, and was territorial. She further stated when the altercation occurred she and CNA #1 immediately removed resident #2 from the room. Resident #2 had a bruise on his/her face and on his/her wrist. She also stated they kept resident #2 at the nurse's station while they moved his/her belongings to another room. f. Review of the care plan for resident #1, with a revision date of 5/9/22, showed the resident displayed behaviors such as hitting staff, suicidal ideation, and resisting cares. Interventions included .observe behavior episodes and attempt to determine underlying cause .document behavior and potential causes . The care plan failed to show resident-specific non-pharmacological interventions for identifying and preventing an escalation of behaviors. 2. Interview on 5/18/22 at 12:24 PM with the DON revealed resident #1 had roommates in the past and there was not a problem. She stated resident #1 used to live in the main area, however s/he had violent behaviors towards staff and tried to elope. She stated they tried to transfer him/her to the psychiatric hospital, however they refused to take him/her. She stated since resident #1 had been in the secure unit his/her behaviors had diminished, s/he participated in activities, ate meals in the common area, and had a friend. She stated when resident #2 returned to the facility from the hospital, they placed him/her in the secure unit and the only available room was with resident #1. She further stated after the 5/3/22 incident, she talked to resident #1 who told her s/he did not want any roommates and s/he would hurt any further roommates. The DON also stated after the incident they initiated 15 minute checks, but as soon as resident #2 was transferred to another room, resident #1 was happy and had not displayed any agitation since.

Based on medical record review, resident and staff interview, and review of the facility's investigation, the facility failed to ensure residents were free from abuse for 1 of 6 sample residents (#1) with allegations of abuse. This failure resulted in actual harm to resident #1 who suffered pain, bruising, and emotional trauma resulting from assault by a staff member. Corrective measures were implemented by the facility and compliance was determined to be met on 10/4/21. The findings were: 1. Review of the 8/7/21 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had a BIMS score of 15 out of 15 (indicating the resident was cognitively intact), did not exhibit hallucinations or delusions; and required supervision for all ADLs except for bathing which was coded as dependent with the physical assist of 1 staff member. Review of a Head to Toe Skin Check dated 9/24/21 and timed 7 AM showed the resident had Intact Skin. Review of the facility's Suspected Abuse Investigation form showed an investigation was started on 9/25/21 at 10:15 PM following an allegation of sexual abuse. The following concerns were identified: a. Interview with the resident on 10/14/21 at 2 PM revealed on the evening of 9/25/21 s/he was in bed for the night when CNA #1 came into the room with a flashlight, sat down in the recliner next to the bed, reached out with his hand and then squeezed the resident's left breast so hard it hurt and left the room. The resident stated s/he was angry and followed CNA #1 out of the room and into a room across the hall where s/he yelled at CNA #1 and called him a bastard. Further, the resident stated s/he was so scared by the incident s/he had pulled the tubing from his/her oxygen concentrator so hard the humidifier bottle full of water had fallen out. The resident stated the police had come the following day and photographs of his/her breast had been taken. b. Interview with resident #2 on 10/14/21 at 2:20 PM, who resided in a room across the hall from resident #1, revealed on 9/25/21 CNA #1 was in his/her room when resident #1 came in very upset and stated CNA #1 had touched him/her. c. Interview with LPN #1 on 10/14/21 at 6:35 PM revealed on 9/25/21 she had finished passing medications on hall 2 and was coming into hall 1, when the resident, who appeared anxious and very upset, indicated s/he needed to talk to her. LPN #1 stated the resident told her he squeezed me and indicated his/her left breast. A skin assessment was done at that time with no findings noted. LPN #1 then notified the night supervisor of the allegation. LPN #1 stated the resident was cognitively intact and well aware of everything that goes on and his/her main problem was anxiety. d. Interview with the night supervisor (LPN #2) on 10/14/21 at 6:50 PM revealed CNA #1 had told her he had been taking vital signs when the resident followed him into the next room and called him a bastard. LPN #2 removed CNA #1 from his duties and notified the manager on call of the allegation. In addition, LPN #2 stated the resident was very upset, informed her CNA #1 had grabbed his/her breast so hard it hurt, and did not want CNA #1 in his/her room. LPN #2 stated the resident was cognitively intact and she thought the resident was very truthful. e. Interview with the ADON on 10/14/21 at 2:22 PM revealed she was the manager on call on 9/25/21 and had been notified of an allegation of abuse from the night supervisor. The ADON stated CNA #1 had told her he had been in the resident's room taking vitals and when he took off the blood pressure cuff he had bumped [the resident's] breast. In addition, the ADON stated CNA #1 asked if he could listen at the door when the resident was interviewed. The ADON instructed CNA #1 he could finish his charting in the breakroom and then instructed him to vacate the facility; however when she exited the resident's room after the interview, CNA #1 was standing in the hallway. The ADON stated when she woke up the resident for an interview the resident asked Are you here because of the man that came in with the flashlight, sat in the recliner, and grabbed my breast? f. Review of the skin assessment dated [DATE] and timed 11 AM (approximately 12 hours after the incident) showed the resident had Bruising to left breast. Blue/purple circular bruise with smaller circular bruises that are darker. No other skin issues noted. Assessed breast last night at approx 2230 [10:30 PM] and no bruising was noted. Today bruising to left breast is visible. Review of the skin assessments dated 10/3/21 and 10/10/21 noted the bruises were resolving and were light purple and yellowish in color. g. Interview with LPN #3 on 10/14/21 at 2:10 PM revealed the resident was adamant that CNA #1 had grabbed his/her breast on purpose because it hurt a lot. LPN #3 stated she had taken photographs of the bruising with the police camera the day after the incident and the bruises were still visible now. Further LPN #3 stated the resident was cognitive enough to describe what happened to him/her and remembers from day to day. h. Telephone interview on 10/15/21 at 10:24 AM with CNA #1 revealed he obtained vital signs on the resident in bed A and then approached resident #1 who was awake and sitting in a recliner watching television. CNA #1 stated he always obtained vital signs in the same order starting with the resident's oxygen saturation level and pulse, body temperature, respirations per minute, and ended with blood pressure using a manual cuff. CNA #1 stated after he had completed the resident's vital signs, s/he followed him into a room across the hall and called him a sick man and a sick bastard. Further, CNA #1 stated the facility told him to complete his charting and leave the facility. CNA #1 denied grabbing the resident's breast. i. Review of the 9/25/21 Hall 1 Vital Signs worksheet showed CNA #1 had documented he had obtained vital signs on 11 residents on hall 1, however interview with resident #1 on 10/14/21 at 2 PM revealed CNA #1 had not obtained his/her vital signs. Interview with the ADON on 10/14/21 at 2:22 PM revealed the cognitive residents on hall 1 were interviewed with 100% of them stating their vital signs had not been taken by CNA #1. Interview with the NHA on 10/15/21 at 12:20 PM confirmed 10 cognitive residents on hall 1 had been interviewed and all of them reported their vital signs had not been obtained by CNA #1. j. Review of the facility's investigation showed the resident followed CNA #1 out of his/her room on 9/25/21 at 10:15 PM visibly upset, and confronted him saying the he had inappropriately touched him/her. The investigation included interviews with staff and cognitive residents, and skin assessments on all non-cognitive residents on hall 1. Interviews with the cognitive residents on hall 1 revealed CNA #1 had not obtained vital signs on the evening of 9/25/21. The facility substantiated the allegation of abuse and false documentation as verified by bruising on Lt [left] breast of resident consistent in size and shape of finger prints, and multiple statements from residents that the CNA did not obtain their vitals which he had documented in the medical record. CNA #1's employment with the facility was terminated. 2. Review of the facility's corrective measures showed the following: a. The facility terminated CNA #1's employment on 9/25/21. b. A skin assessment was completed on all non-cognitive residents. c. Education was provided to all employees on 10/4/21 which included the types of abuse, suspicious behaviors or signs of abuse a resident might demonstrate, reporting requirements, false documentation, and grievances and concerns. Review of the personnel roster showed 100 of 113 employees had been provided the education. Interview with the NHA on 10/15/21 at 12:20 PM revealed the remaining staff members were PRN employees and were required to complete the education prior to working their next shift.

Based on medical record review, hospital medical record review, staff interview, and professional standard review, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being were provided for 1 of 4 sample residents (#110) whose change in condition required immediate medical care. This failure resulted in actual harm for the resident, who was not transported to the hospital until a minimum of 3 hours and 26 minutes after staff were aware of the resident's symptoms of a [MEDICAL CONDITION] (MI). The findings were: Medical record review showed resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review showed the resident was transferred to a local hospital emergency department on 1/21/17 with a significant change in condition. At the hospital emergency room (ER) the resident was found to have had an MI ([MEDICAL CONDITION]) and the hospital STEMI protocol (ST elevation MI, or [MEDICAL CONDITION]) was initiated to address the resident's critical condition. Review of the resident's blood pressure (BP) readings prior to 1/21/17 included the following measurements: On 12/22/16 the reading was 127/80; on 12/23/16 the reading was 128/66; on 12/28/16 the reading was 147/67; on 1/4/17 the reading was 118/64; on 1/11/17 the reading was 115/63; on 1/16/17 the reading was 115/63, and on 1/18/17 the reading was 135/71. The following concerns were identified: 1. The facility failed to ensure a timely and ongoing comprehensive assessment concerning a significant change in condition for resident #110 as evidenced by the following: a. Review of a 1/21/17 note written at 6:45 AM by LPN #1 revealed the following: CNA notified LPN that resident not acting like (himself/herself). VS (vital signs) obtained, WNL (within normal limits) with exception of BP of 64/48, rechecked several times. Resident able to respond verbally, denied any pain, NAD (no acute distress), lung sounds clear in upper fields, diminished in lower bilaterally, pedal pulses palpable, no [MEDICAL CONDITION] noted, able to follow simple commands. Resident cooperative with AM cares, will pass information on to oncoming RN for further observation. No additional documentation was in the medical record until 1/21/17 at 10:11 AM (3 hours and 26 minutes later), written by RN #3 as follows: Vital Signs: BP 78/48-1/21/17 10:17 (AM) Position: Sitting L/arm, P 78-1/21/17 10:19 (AM) Pulse Type: Regular, R 20-1/21/17 10:19 (AM) Route: W 159.6 lb-1/15/17 11:13 (AM) Scale: Chair Scale, O2 95.0%-1/18/2017 01:05 (AM) Method: Room air. RN Assessment/LPN Appearance of resident-What I think is going on with the resident is: concerns w/difficulty breathing and moist sounding R lobes. Additional Nursing Notes as applicable: Family/Health Care Agent Notified: Own responsible party, at 01/21/2017 10:00 AM. Primary Care Clinician Notified (via phone call): Dr. (physician's name) at 01/21/2017 10:00 AM. Review of the 1/21/17 SBAR Communication Form and Progress Note at 10:11 AM by RN #3 confirmed the nursing notes and had no additional information. b. Review of the 1/21/17, timed at 7:27 PM, note written by RN #3 showed the following interventions for resident #110 with no timeline documented (resident was at a local hospital when this note was written): Resident sent to ER this a.m. for evaluation per Dr. (physician's name). Received in report this a.m. that resident's BP was 62/48 in L (left) arm and 54/48 in R (right) arm. Unsure what time these BPs were obtained. Aides immediately began taking VS upon a.m. shift w/resulting BP of 78/48. Fluids were immediately encouraged and provided w/no resistance from resident. O2 sat (saturation) was 96% at this time but when rechecked by this nurse, O2 sat was 82%. Provided breathing tx (treatment) per order w/resulting in O2 sat 84%. Began supplemental O2 at 2 lpm (liters per minute) via NC (nasal cannula) which increased O2 sat to 95%. Then lowered O2 to 1.5% w/resulting O2 of 91%. Resident appeared to be doing better, however, shortly thereafter, (s/he) became pale and lung sounds became moist. Called Dr. (physician's name) and received order to send to ER. This nurse checked BP prior to transport which resulted in 88/54 and pulse was 78. Resident was sent to ER via facility van w/facility transport staff. c. Interview with RN #3 on 2/9/17 at 10:25 AM confirmed the documentation for the significant change regarding resident #110 on 1/21/17 was not consistent because she felt the resident was improving. d. Interview with the DON on 2/9/17 at 1:10 PM confirmed his expectation for the change in condition for resident #110 on 1/21/17 would have been for nursing staff to have notified the physician when the resident became hypotensive, hypoxic, and was not acting like himself/herself, for staff to have followed physician orders, and for staff to have continued a timely and comprehensive assessment. 2. The facility failed to ensure an appropriate and timely transfer for resident #110 concerning a significant change in condition as evidenced by the following: a. Review of the nursing documentation on 1/21/17 at 6:45 AM showed the resident had a change in condition related to [MEDICAL CONDITIONS], and not acting like himself/herself. The notes showed these issues continued; however, the facility failed to notify the physician until 1/21/17 at 10:00 AM (3 hours and 15 minutes later), when a physician order [REDACTED]. At that time the facility failed to ensure an appropriate transfer via emergency medical services, and instead transported the resident to the local emergency room via facility van with one staff member, a CNA, who was the driver. b. Review of the local emergency department documentation showed resident #110 arrived at theER on [DATE] at 11:41 AM via facility van with the van driver stating, I think (s/he) has pneumonia or something, (s/he) isn't acting right and (s/he's) wheezing. The documentation showed the resident was usually on RA (room air), and ER staff placed (him/her) on 0.25 l NC (0.25 liters per minute via nasal cannula), BP noted to be 71/53 in triage, pt. (patient) unable to answer most questions. Review of an ER Admission Report from ER physician #1 written on 1/21/17 at 5:17 PM showed resident #110's chief complaint upon admission to the ER was being confused and having trouble breathing. The documentation showed the resident was confused and was poorly responsive. The documentation noted a 78 systolic BP and indicated the resident was markedly hypotensive in triage. The Assessment area of the ER documentation completed by ER physician #1 showed, Acute ST elevation [MEDICAL CONDITION] infarction (MI), possibly subacute as the patient does have Q-waves in V2 and V3 and his troponin is markedly elevated. This process has been going on for some time. [MEDICAL CONDITION] and [MEDICAL CONDITION] with cardiogenic shock and poor perfusion. Marked lactic acidosis due to hypoperfusion and end-organ dysfunction. Marked lactic acidosis due to hypoperfusion and end-organ dysfunction. Acute kidney injury, likely associated with cardiogenic shock and poor kidney perfusion. Markedly elevated BNP (brain natriuretic peptide) and findings consistent with [MEDICAL CONDITIONS], volume overload, and acute hypoxemic [MEDICAL CONDITION] associated with cardiogenic shock. Review of discharge documentation on 1/21/17 signed by physician #2 at 10:05 PM and physician #3 at 10:32 PM confirmed the following: Called by Dr. (physician's name) after nursing notified him of need to see patient regarding unresponsiveness for likely death. The patient was found to be breathless, pulseless, and without heart sounds, blood pressure, and corneal reflexes. The patient was pronounced dead at 1941 (7:41 PM) on January 21, 2017 . c. Interview with RN #3 on 2/9/17 at 10:25 AM confirmed that in hindsight she should have sent resident #110 to the local emergency department by utilizing emergency medical services (911) instead of the facility van with one staff member, a CNA, who was the driver. d. Interview with the DON on 2/9/17 at 1:10 PM confirmed his expectation for the change in condition for resident #110 on 1/21/17 would have been for staff to have notified the physician and contacted emergency medical services, not the facility van, for transport. e. According to the americanheartassociation.org website, accessed 2/14/17, Under Catch the signs early, the instructions include, Don't wait to get help if you experience any of these [MEDICAL CONDITION] warning signs. Although some [MEDICAL CONDITION] are sudden and intense, most start slowly, with mild pain or discomfort. Pay attention to your body-and call 911 if you feel .shortness of breath with or without chest pain. According to the website http://www.heart.org/HEARTORG/Professional/Mission-Lifeline/MissionLifeline-Heart-Attack-101_UCM_ 0_Article.jsp#.WLCy1zhRpBs, accessed on 2/14/17, at Mission: Lifeline [MEDICAL CONDITION] 101, .In instances where a patient cannot access a PCI hospital within the golden 90-minute window, the best avenue of treatment might then be for the local hospital to administer clot-busting medicine.

Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided to maintain/attain the highest practicable physical well-being for 1 of 7 sample residents (#7). This failure resulted in a negative outcome for the resident who developed multi-location skin breakdown. The findings were: Review of the 10/25/16 annual MDS assessment showed resident #7 required extensive assistance for ADLs, and was at risk for pressure ulcers. Further review showed the resident did not have any pressure ulcers at the time of the assessment. Review of the pressure ulcer CAA showed chronic health conditions such as incontinence, inability to perform ADLs without significant physical assistance, existing pressure ulcer(s), and extrinsic risk factors (pressure) contributed to the problem. Review of the care plan related to skin issues showed it was initiated on 2/1/16. The resident had risk factors related to impaired mobility, incontinence, use of assistive devices (wheelchair), and a history of open areas. Interventions included an air mattress with an initiation date of 5/13/16. The following concerns were identified: a. Confidential interview with staff #1 on 12/14/16 revealed the 500 hallway where resident #7 lived was cold due to problems with the heat system. The staff stated the problem had been ongoing since Saturday 12/10/16, and the temperatures were so cold resident #7 was brought out of his/her room and into the main area to sleep on a mattress on the floor for 2 nights (12/10/16 and 12/11/16) and be warmed up. b. Confidential interview with staff #2 on 12/14/16 revealed residents on the secured unit had been uncomfortable and complaining of the cold temperatures. The staff member reported the temperatures were uncomfortably cold on Friday 12/9/16, Saturday 12/10/16, and Sunday 12/11/16, and resident #7 was brought into the milieu to sleep on a mattress on the floor Saturday and Sunday due to the resident's room being so cold and the resident freezing. c. Confidential interview with staff #3 on 12/14/16 revealed on the afternoon of 12/10/16, the resident was so cold in his/her room they were unable to get a temperature to register on the resident with a forehead temperature strip. She stated the resident was brought out of the room to be warmed up, and they placed the resident in a recliner and covered him/her with blankets. She further stated once the resident had warmed up a temperature was taken and she remembered it was about 95 degrees F. d. Review of the progress note dated 11/23/16 and timed at 2 AM showed the resident had an open wound to lower spinal area approximately 1 cm circular over bony prominence and the resident .continues to be on an air mattress. Review of the progress note dated 12/6/16 and timed at 3:10 PM showed area resolved 11/31. The next progress note was dated 12/11/16 at 2:44 PM and showed Resident not eating or drinking well. Skin cool to touch. Warm blankets placed on resident to warm (him/her) SAO2 (oxygen saturation level) low? Accuracy d/t (due to) fingers cold, Resident noted with increased lethargy. Review of the SBAR (situational background assessment recommendation) note dated 12/12/16 at 7:33 PM showed the resident had developed a new open area on his/her buttocks. According to the 12/13/16 SBAR note, the open area to the coccyx/buttocks .appeared to be a Kennedy ulcer (a type of ulcer associated with end of life) and has sdti's (suspected deep tissue injuries) to the back, scapula, bilateral feet, and a sheared blister to the right buttock, resident is declining in the last 48 hrs (hours). There were no notes in the clinical record related to the resident sleeping on the mattress outside of his/her room, and no vital signs documented between 11/30/16 and 12/11/16. e. Review of the progress note dated 12/13/16 and timed at 10:37 AM showed the resident had .Kennedy ulcer coccyx 9 x 7 iliac crest 1.5 x 3, lumbar spine 0.6 x 1, 1 x 0.4, 0.7 x 0.4, right scapula 0.4 x 1, left foot 1.5 x 1.8, right foot 2 x 2, left great toe 0.3 x 0.3. Multiple red areas that are blanching left second toe 0.5 x 0.7 left inner ankle 2 x 3, 2 x 2 left front ankle, medial left foot near arch 0.5 x 0.5, 1 x 1, right second toe 0.8 x 1.3, top of right foot 4.5 x 1, lateral right foot 1 x 0.7, scratch along right hip 3 x 0.2 . f. Interview with the DON on 12/15/16 at 10:25 AM verified the resident slept on a mattress on the floor for 2 nights. The DON stated he was not aware of this situation until 12/12/16. The resident's plan of care was not followed those 2 nights s/he was placed on the mattress outside of the room because the mattress was not an air mattress. The DON further verified information related to this situation was not documented in the clinical record and there was no other documentation related to the incident. g. Interview with the administrator on 12/15/16 at 11:21 AM verified he became aware of this situation on 12/12/16 when he arrived at the facility and saw the mattress on the floor in the secured unit milieu. He was concerned and stated the staff should have notified himself or the DON of the situation. He verified there was no documentation related to this instance. The administrator stated the staff should have relocated the resident's entire bed, with the air mattress. h. Observation of the resident's skin on 12/15/16 at 11:42 AM with the medical director showed the resident had multiple closed wounds to the back, bilateral lower legs, bilateral feet, right hip, and a large open wound to the coccyx/buttock bilateral region.

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure 1 of 8 recently admitted sample residents (#76) received appropriate treatment and services related to psychosocial adjustment issues. This failure resulted in a negative psychosocial outcome to resident #76. The findings were: Review of the 11/9/15 admission MDS assessment for resident #76 revealed [DIAGNOSES REDACTED]. Continued review of the assessment showed the resident triggered for further assessment of communication and psychosocial well-being. Review of the communication CAA revealed the resident was .resistant to Long Term Care and a move to this facility, (s/he) has a Dx (diagnosis) of anxiousness . Review of the psychosocial well-being CAA revealed the resident reported .mood issues which could be attributed to (his/her) new admission in the facility and may take time for adjustment to (his/her) new environment. The following concerns were identified: a. Review of the progress note dated 11/9/15 and timed 7:39 PM revealed the resident told a staff member s/he would not take .the pills because (s/he) wants to die . b. Review of the progress note dated 11/16/15 and timed 1:58 PM showed the resident had been moved out of the facility by family. Review of MDS data showed the resident was readmitted to the facility on [DATE]. c. Interview with the administrator on 1/15/16 at 12 PM revealed the resident was removed from the facility by family members who did not have the authority to do so, and the resident's relative who did hold power of attorney ensured the resident's return to the facility and restricted the other family member's ability to contact the resident. d. Review of the progress note dated 11/21/15 and timed 2:43 PM revealed the resident looked .down and depressed, not smiling and frequently with a frown on (his/her) face . e. Review of a social service note dated 11/25/15 and timed 3:47 PM showed (Resident name) is alert and oriented to person, place, although (s/he) can be confused with time or date. Daily decision making is currently moderately impaired. Depression features are noted with (resident name) as being down at times overall. A history of behavioral symptoms include being paranoid at times and trying to elope from the facility . f. Observation of the resident on 1/11/16 at 2 PM showed his/her room was located on the secure (locked) dementia unit. The resident was seated in a chair in his/her room. The resident was awake, but was not engaged in any activity. The room was dark; no lights were on and the window blinds were closed. Interview with the resident at that time revealed the blinds didn't work, and couldn't be adjusted, So they stay that way all of the time. The resident then began to weep, and stated, I'm terribly, terribly unhappy! g. Further review of the medical record failed to show any social service notes after 11/25/15. h. Interview with the social services director on 1/15/16 at 4:45 PM revealed the resident did have an understanding of the situation with his/her family members and was distressed by it. He noted the resident was angry at times, and suffered anxiety. He further stated a care plan to address the resident's distress had been developed just that day.

Based on medical record review and staff interview, the facility failed to consult with the resident's physician after a change in condition for 4 of 7 sample residents (#20, #52, #85, #116) with a change in condition. This failure resulted in harm to residents (#20, #116). The findings were: 1. Review of the 5/12/15 interdisciplinary team note showed resident #116 was admitted to the facility for rehabilitation after lumbar surgery, and infection of the surgical wound. The following concerns were identified: a. Review of the nursing note dated 5/27/15 and untimed showed Resident crying out this am, very drowsy from pain meds (medications) earlier & [MEDICATION NAME] (a muscle relaxant), c/o (complains of) that (s/he) couldn't feel (his/her) legs, difficulty sitting up @ (at) bedside, very adamant that (s/he) wanted to lay in bed . b. Review of the 5/28/15, untimed, late entry for 5/27/15 nursing note showed Request to get resident in to see (physician name) @ (clinic name) d/t (due to) increased pain and difficulty moving (his/her) legs. (S/he) was rescheduled with an appt. (appointment) for 29th. Incision noted to be without s/sx (signs/symptoms) infection and resident was ext X 1 asst (extensive assist of 1 person) with transfer to recliner with nurse. c. Further review of the medical record showed no evidence the physician was contacted directly about the resident's increased pain and inability to feel his/her legs. d. Review of the 5/29/15 nurse's note timed at 11:50 PM indicated the resident had an appointment at the clinic, and returned with new orders. Notes from this appointment were requested from the facility, and were not available. e. Review of the 5/31/15 SBAR Communication Form and Progress Note timed at 9 PM showed Increased lumbar pain unrelieved by medications, no feeling in either leg. Demands to go to (clinic name) for eval (evaluation) by (his/her) surgeon (physician name) . The note further showed the resident was transferred to the hospital via non-emergent ambulance, and subsequently taken to a Denver, Colorado hospital via emergency air transport. f. Review of the 6/1/15, untimed, nurse's note showed the resident was sent to a Denver hospital related to L4 & L5 (lumbar vertebrae) disintegrating due to infection. g. Interview with the DON, ADON and corporate nurse on 1/15/16 beginning at 2:05 PM confirmed the facility could provide no evidence the resident's physician was consulted about the change in condition on 5/27/15. 2. Review of the medical record showed resident #20 required daily medication for Diabetes Mellitus. Review of the January 2016 medication review form showed the physician ordered blood sugar levels before meals and at bedtime and sliding scale insulin based on the results of the blood sugar levels, [MEDICATION NAME] 40 units at bedtime, and [MEDICATION NAME] 500 mg pills twice daily. Further review of the medication review form showed the parameters for the sliding scale insulin administration addressed blood sugar levels up to 350 (this number is milligrams of glucose per deciliter of blood), but failed to address blood sugar levels above 350. The following concerns were identified: a. Review of the January 2016 MAR indicated [REDACTED]. This review showed the resident did not receive the sliding scale insulin for the following documented blood sugar levels: 464 at 1 PM and 387 at 9 PM on 1/4/16; 572 at 1 PM and 472 at 5 PM on 1/5/16; 486 at 1 PM on 1/6/16; 499 at 5 PM on 1/7/16; and 499 at 9 AM on 1/8/16. b. Review of the nursing progress notes and documented communication with the physician showed staff did not report their inability to obtain the blood sugar levels as ordered, elevated blood sugar levels above 350, and omitted insulin doses to the physician. c. Interview with the DON on 1/11/16 at 2:05 PM revealed the resident was transported to the hospital on [DATE] and his/her blood sugar level was 800. Interview with the ADON on 1/14/16 at 8:45 AM revealed staff should have reported the elevated blood sugar levels and lack of insulin administration to the physician. He further stated the physician's orders [REDACTED]. 3. Review of the 11/12/15 admission MDS assessment showed resident #52 was admitted with a surgical wound, and was receiving surgical wound care. Further, the resident required the extensive assistance of 2 or more persons for most ADLs. Review of the resident's care plan for skin issues showed an intervention dated 11/16/15, Observe wound healing and maintain wound vac (vacuum) as dressing . Review of physician orders [REDACTED]. Wound vac maintenance daily with dressing change on MON (Monday), WED (Wednesday) and FRI (Friday) every day and night shift . The following concerns were identified: a. Review of the 12/27/15 late entry for 12/26/15 progress note showed .was going to change wound vac to right buttock area, no wound canisters were found . b. Review of the 12/27/15, timed 6:27 PM, progress noted showed wound continues to be without wound vac . c. Further review of the medical record showed the order for the wound vac was not discontinued until 12/30/15. d. Interview with the DON, ADON and corporate RN on 1/15/16 beginning at 2:05 PM confirmed the resident's wound vac was not changed according to the physician's orders [REDACTED]. Further, the DON confirmed the physician was not contacted regarding the facility's inability to apply the wound vac until 12/30/15. 4. Review of the 1/6/16 quarterly MDS assessment showed resident #85 had [DIAGNOSES REDACTED]. Review of the SBAR (situation, background, assessment, recommendation) form dated 12/20/15 showed the resident complained of increased discomfort to the left lower extremity. A soft raised area behind left knee was also identified by the nurse completing the assessment. Further review of the SBAR form showed an area to indicate the date and time the physician was notified; however, this area was left blank. Interview with the DON, ADON, and corporate RN on 1/15/16 at 2:15 PM confirmed the SBAR form did not indicate the physician was notified of the resident's complaint. Interview with the DON on 1/15/16 at 8 PM verified there was no additional documentation to show the physician was notified.

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure medically-related social services issues were addressed for 2 of 7 sample residents (#31, #76) with these types of needs. The failure resulted in a negative psychosocial outcome to resident #76. The findings were: 1. Review of the 11/9/15 admission MDS assessment for resident #76 revealed [DIAGNOSES REDACTED]. Continued review of the assessment showed the resident triggered for further assessment of communication and psychosocial well-being. Review of the communication CAA revealed the resident was .resistant to Long Term Care and a move to this facility, (s/he) has a Dx (diagnosis) of anxiousness . Review of the psychosocial well-being CAA revealed the resident reported .mood issues which could be attributed to (his/her) new admission in the facility and may take time for adjustment to (his/her) new environment. The following concerns were identified: a. Review of the progress note dated 11/9/15 and timed 7:39 PM revealed the resident told a staff member s/he would not take .the pills because (s/he) wants to die . b. Review of the progress note dated 11/16/15 and timed 1:58 PM showed the resident had been moved out of the facility by family. Review of MDS data showed the resident was readmitted to the facility on [DATE]. c. Interview with the administrator on 1/15/16 at 12 PM revealed the resident was removed from the facility by family members who did not have the authority to do so, and the resident's relative who did hold power of attorney ensured the resident's return to the facility and restricted the other family member's ability to contact the resident. d. Review of the progress note dated 11/21/15 and timed 2:43 PM revealed the resident looked .down and depressed, not smiling and frequently with a frown on (his/her) face . e. Review of a social service note dated 11/25/15 and timed 3:47 PM showed (Resident name) is alert and oriented to person, place, although (s/he) can be confused with time or date. Daily decision making is currently moderately impaired. Depression features are noted with (resident name) as being down at times overall. A history of behavioral symptoms include being paranoid at times and trying to elope from the facility . f. Observation of the resident on 1/11/16 at 2 PM showed his/her room was located on the secure (locked) dementia unit. The resident was seated in a chair in his/her room. The resident was awake, but was not engaged in any activity. The room was dark; no lights were on and the window blinds were closed. Interview with the resident at that time revealed the blinds didn't work, and couldn't be adjusted, So they stay that way all of the time. The resident then began to weep, and stated, I'm terribly, terribly unhappy! g. Further review of the medical record failed to show any social service notes after 11/25/15. h. Interview with the social services director on 1/15/16 at 4:45 PM revealed the resident did have an understanding of the situation with his/her family members and was distressed by it. He noted the resident was angry at times, and suffered anxiety. He further stated a care plan to address the resident's distress had been developed just that day. 2. Review of the medical record for resident #31 revealed s/he was admitted on [DATE] after a stroke. This review showed the stroke affected the resident's balance, vision, and cognitive ability. According to the care plan, revised 12/27/15, staff were directed to administer antidepressant medications and observe/document/report adverse reactions and effectiveness. Observations on 1/11/16 revealed the resident was awake in bed from 4:30 PM to 5:45 PM. At 5:45 PM s/he ate in the dining room and returned to his/her bed at 6:15 PM. On 1/12/16 the resident was observed in bed from 9:20 AM to 11:30 AM. The following concerns were identified: a. During an interview on 1/12/16 at 9:45 AM the resident sobbed and stated s/he was depressed because something was making him/her sleep all the time, his/her vision was limited due to the stroke and cataracts on both eyes, family was far away and could not visit often, and there was nothing to do all day at the facility. b. During a second interview on 1/14/16 at 5 PM, the resident revealed s/he continued to feel sad, and it was hard to keep from feeling depressed. c. Interview with the social services director on 1/14/16 at 6:30 PM revealed a social services admission assessment had not been completed for the resident. At that time the social services director stated he was not aware of the resident's depressed feelings. d. Interview on 1/15/15 at 7:30 AM with CNA #5 revealed the resident liked to stay in his/her room and usually got up for breakfast then returned to bed. e. Interview with the social services director on 1/15/16 at 8:15 AM revealed he talked with the resident after talking with the surveyor, and determined additional and revised interventions were needed to address the resident's depression.

Based on medical record review and staff interview, the facility failed to ensure adequate care and/or timely response to a change of condition for 5 of 35 sample residents (#20, #25, #52, #88, #116). This failure resulted in actual harm for 2 residents (#20, #116) who were transported to the hospital for acute care. The findings were: 1. Review of the 5/12/15 interdisciplinary team note showed resident #116 was admitted to the facility for rehabilitation after lumbar surgery, and infection of the surgical wound. The following concerns were identified: a. Review of the nursing note dated 5/27/15 and untimed showed Resident crying out this am, very drowsy from pain meds (medications) earlier & [MEDICATION NAME] (a muscle relaxant), c/o (complains of) that (s/he) couldn't feel (his/her) legs, difficulty sitting up @ (at) bedside, very adamant that (s/he) wanted to lay in bed . b. Review of the 5/28/15, untimed, late entry for 5/27/15 nursing note showed Request to get resident in to see (physician name) @ (clinic name) d/t (due to) increased pain and difficulty moving (his/her) legs. (S/he) was rescheduled with an appt. (appointment) for 29th. Incision noted to be without s/sx (signs/symptoms) infection and resident was ext X 1 asst (extensive assist of 1 person) with transfer to recliner with nurse. c. Further review of the medical record showed no evidence the physician was contacted directly about the resident's increased pain and inability to feel his/her legs. d. Review of the 5/29/15 nurse's note timed at 11:50 PM indicated the resident had an appointment at the clinic, and returned with new orders. Notes from this appointment were requested from the facility, and were not available. e. Review of the 5/31/15 SBAR Communication Form and Progress Note timed at 9 PM showed Increased lumbar pain unrelieved by medications, no feeling in either leg. Demands to go to (clinic name) for eval (evaluation) by (his/her) surgeon (physician name) . The note further showed the resident was transferred to the hospital via non-emergent ambulance, and subsequently taken to a Denver, Colorado hospital via emergency air transport. f. Review of the 6/1/15, untimed, nurse's note showed the resident was sent to a Denver hospital related to L4 & L5 (lumbar vertebrae) disintegrating due to infection. g. Interview with the DON, ADON and corporate nurse on 1/15/16 beginning at 2:05 PM confirmed the facility could provide no evidence the resident's physician was consulted about the change in condition on 5/27/15. 2. Review of the medical record showed resident #20 required daily medication for Diabetes Mellitus. Review of the January 2016 medication review form showed the physician ordered blood sugar levels before meals and at bedtime and sliding scale insulin based on the results of the blood sugar levels, [MEDICATION NAME] 40 units at bedtime, and [MEDICATION NAME] 500 mg pills twice daily. Further review of the medication review form showed the parameters for the sliding scale insulin administration addressed blood sugar levels up to 350 (this number is milligrams of glucose per deciliter of blood), but failed to address blood sugar levels above 350. The following concerns were identified: a. Review of the January 2016 MAR indicated [REDACTED]. This review showed the resident did not receive the sliding scale insulin for the following documented blood sugar levels: 464 at 1 PM and 387 at 9 PM on 1/4/16; 572 at 1 PM and 472 at 5 PM on 1/5/16; 486 at 1 PM on 1/6/16; 499 at 5 PM on 1/7/16; and 499 at 9 AM on 1/8/16. b. Review of the nursing progress notes and documented communication with the physician showed staff did not report their inability to obtain the blood sugar levels as ordered, the elevated blood sugar levels, and omitted insulin doses to the physician. c. Interview with the DON on 1/11/16 at 2:05 PM revealed the resident was transported to the hospital on [DATE] and his/her blood sugar level was 800. Interview with the ADON on 1/14/16 at 8:45 AM revealed staff should have reported the elevated blood sugar levels and lack of insulin administration to the physician. He further stated the physician's orders [REDACTED]. 3. Review of the 11/12/15 admission MDS assessment showed resident #52 was admitted with a surgical wound, and was receiving surgical wound care. Further, the resident required the extensive assistance of 2 or more persons for most ADLs. Review of the resident's care plan for skin issues showed an intervention dated 11/16/15, Observe wound healing and maintain wound vac (vacuum) as dressing . Review of physician orders [REDACTED]. Wound vac maintenance daily with dressing change on MON (Monday), WED (Wednesday) and FRI (Friday) every day and night shift . The following concerns were identified: a. Review of the 12/27/15 late entry for 12/26/15 progress note showed .was going to change wound vac to right buttock area, no wound canisters were found . b. Review of the 12/27/15, timed 6:27 PM, progress noted showed wound continues to be without wound vac . c. Further review of the medical record showed the order for the wound vac was not discontinued until 12/30/15. d. Interview with the DON, ADON and corporate RN on 1/15/16 beginning at 2:05 PM confirmed the resident's wound vac was not changed according to the physician's orders [REDACTED]. Further, the DON confirmed the physician was not contacted regarding the facility's inability to apply the wound vac until 12/30/15. 4. Review of the December 2015 and January 2016 MARs showed resident #25 had orders related to his/her [DIAGNOSES REDACTED]. Hold if systolic blood pressure (BP) less than 100 and [MEDICATION NAME] tablet 25 mg, give 0.5 tablet by mouth 2 times per day. Hold if systolic BP less than 110 or heart rate less than 60. Further review of these MARs showed the resident received these medications daily except on 1/3/16 when both medications were shown to be held due to the resident being hospitalized . Also on 1/2/16, 1/8/16, and 1/9/16 the 9 PM dose of [MEDICATION NAME] was held due to condition. The following concerns were identified: a. Review of the MARs and the medical record failed to show the BP or heart rate was taken prior to the medications being administered. In addition, the progress notes failed to show the resident was out of the facility on 1/3/16, or why the medication was held on the other dates. b. Review of the vital sign documentation in the chart showed in December 2015 the resident's heart rate was taken only 18 times with no values less than 60. On 1/13/16 the January vital signs for heart rate were reviewed, and there were only two times when these values were recorded, with none below 60. c. Review of the December 2015 BP documentation showed only 18 times when the values were recorded. On 12/10/15 at 6:51 PM the value was 89/60, and the [MEDICATION NAME] was administered at 9 PM according to the MAR. d. Review of the January 2016 documentation for BP showed only 5 times when the value was recorded. e. Interview with the DON on 1/15/16 at 5:30 PM verified she was unable to find any additional documentation of vital signs and confirmed they should be taken prior to administration of these medications. 5. Review of the 11/12/15 quarterly MDS assessment showed resident #88 had [DIAGNOSES REDACTED]. Review of the January 2016 MAR indicated [REDACTED] a. There was no evidence the resident's blood sugar was checked or the insulin administered prior to 10 meals between 1/1/16 and 1/14/16. b. The resident was administered insulin on 3 occasions when the blood sugar was indicated to be below the specified parameter of 150. c. The resident was administered insulin 11 times with no documented blood sugar. d. Interview with the DON, ADON, and corporate RN on 1/15/16 at 2:15 PM confirmed the MAR indicated [REDACTED]. Interview with the DON on 1/15/16 at 8 PM revealed there was no additional documentation to provide related to the resident's insulin administration.

Based on observation, medical record review, review of facility incident/accident logs, policy and procedure review and staff interview, the facility failed to thoroughly investigate falls, and develop and implement interventions to prevent future falls for 2 of 12 sample residents (#68, #108) and 1 non sample resident (#98) with falls. This failure resulted in significant injury to resident #68. The findings were: 1. Review of the 12/3/15 quarterly MDS assessment for resident #68 showed the resident required the extensive physical assistance of 1 person for bed mobility and transfers. Review of MDS assessments from 4/10/15 to 12/3/15 showed the resident had 1 fall with no injury in that 8 month period. The following concerns were identified: a. Review of a progress note dated 12/11/15 and timed 10:42 AM showed the resident was found on the floor in his/her room. According to the note, the resident tried to self-transfer from wheelchair to bed. No injuries were found. b. Review of the Interdisciplinary Post Fall Review for the 12/11/15 fall showed the interdisciplinary team summarized Resident noted to have a tabs monitor in place, anti-rollbacks to w/c (wheelchair), cushion to w/c, low bed in place, and has a hx (history) of non-compliance with self transferring. The review further showed the resident's care plan should be revised, but failed to indicate what revisions should be made to the care plan to reduce the resident's risk for further falls. c. Review of a progress note dated 12/15/15 and timed 7:34 AM showed the resident had fallen and was complaining of left thigh pain, and long time stomach pain. Review of the 12/15/15 SBAR Communication Form and Progress Note showed the resident had fallen, and things that made the condition or symptom worse were transferring on my own without calling for help. Things that made the condition or symptom better were watch closer. d. Review of the Interdisciplinary Post Fall Review for the 12/15/15 fall showed the resident was found on the floor in his/her room at 7:30 AM, and the resident stated s/he fell trying to go to bed. The review further showed the resident's care plan should be revised, but failed to indicate what revisions should be made to the care plan to reduce the resident's risk for further falls, and recommended equipment be used. The equipment to be used was described as bed monitor, comfort measures. e. Review of the resident's care plan for falls showed the following interventions: i. Anti-rollbacks on WC (wheelchair) in past, re-evaluated and removed for time being. This intervention was initiated on 12/10/15 and revised on 1/12/16. ii. Initiate safety checks as indicated. This intervention was initiated on 12/2/15. iii. Low bed. This intervention was initiated on 12/15/15. iv. Observed for placement and function of devices per facility protocols, assure that call bell is within (the resident's) reach at bedtime. This intervention was initiated on 12/2/15. v. Pressure sensor pad while in bed. This intervention was initiated on 1/5/16. vi. Resident is a 2 person transfer. This intervention was initiated on 1/7/16. vii. Tabs monitor while in WC. This intervention was initiated on 1/5/16. f. Review of the 12/22/15 Incident/Accident Investigation Follow-Up showed the following Description of Incident/Accident : Resident had 2 falls on 12/11 & 12/15 both were unwitnessed self-transfers from w/c (wheelchair) to (his/her) bed. Resident denied need to utilize BR (bathroom) and was continent at the time. Up with hoyer, MAE (moves all extremities), no increased c/o (complaints of) discomfort & VS (vital signs) stable, hypotension noted. g. Continued review of the 12/22/15 Incident/Accident Investigation Follow-Up showed the following Summary of Investigation (Reasonable Conclusion): Attempted self transfer after breakfast. Resident self propels in w/c and took self back to (his/her) room. Resident wanted to lay down after (his/her) meal. Resident with cognitive deficits, but can demonstrate utilization of call light, easily irritable with staff and non-compliant. i. Recommendations/New interventions included pressure sensor pad placed in bed, OT (occupational therapy) to eval (evaluate) & tx (treat) with w/c positioning and safety for transfers. ii. Review of the resident's care plan showed no interventions were added to the care plan as a result of this follow-up, and no interventions in the care plan addressed the resident's desire to go to bed after breakfast. h. Review of the 12/20/15 SBAR Communication Form and Progress Note showed the Resident c/o left groin pain. Had c/o left leg pain to off going shift, stating that she thought her leg was broke. No report of incident with resident during previous shift. Resident states that (s/he) fell , hitting (his/her) head on (his/her) nightstand this morning, although resident is not a reliable historian. Resident noted with raised reddened area to left buttock & reddened area to left side of head. ROM (range of motion) to Left leg guarded d/t (due to) c/o left groin pain. Denies headache. i. Further review of the 12/20/15 SBAR Communication Form and Progress Note showed the author Spoke with RCS (resident care specialist) .who assisted the resident last night. Resident was having difficulty standing to transfer in to shower chair after having a loose BM (bowel movement) early this morning and was lowered to the floor. j. Review of the facility's Fall Management policy, revised August 2012, showed An episode where a resident lost balance and would have fallen were it not for staff intervention is a fall. In other words, an interrupted fall is still a fall. k. Review of facility incident logs showed no fall was logged for this resident on 12/20/15. l. Further review of the medical record showed no assessment of the resident was completed after the 12/20/15 fall, and no investigation was made into the fall. m. Review of the 12/22/15 progress note timed at 2 PM showed Resident complaining of increased pain when sitting up in (his/her) wheelchair for lunch, call to (physician name) received orders we may send (him/her) in for Xray if (s/he) agrees. Resident agreed call to non emergent transport . n. Review of the 12/22/15 progress note timed at 7 PM showed Dr. called back reported Resident did have a fracture to left hip not a surgical candidate . o. Interview with the DON, ADON, and corporate nurse on 1/15/16 beginning at 2:05 PM confirmed the resident often liked to return to bed after breakfast and a meaningful intervention to prevent falls should address that desire. The DON revealed she did not know how the resident broke his/her hip, but there had been no investigation of an injury of unknown origin. Further, the DON revealed she was unaware of the resident's fall on 12/20/15, and confirmed no investigation of the fall had been completed. 2. Review of the 11/11/15 quarterly MDS assessment for resident #98 showed cognitive skills for daily decision making were severely impaired. The resident required the extensive assistance of 1 person for most ADLs. Further review of 11/11/15 quarterly MDS assessment in addition to review of the 8/25/15 quarterly MDS assessment, and the 6/8/15 quarterly MDS assessment showed the resident had 4 no injury falls and 2 falls with injury in the time period covered by those assessments. The following concerns were identified: a. Observation on 1/12/16 at 11:48 AM showed the resident was up in a wheelchair with a chair alarm attached to the wheelchair. The chair alarm had a long cord that was clipped to the back of the resident's clothing. During continued observation, the resident stood up out of the wheelchair. The cord for the alarm was so long, the alarm did not sound when the resident stood up. b. Observation on 1/14/16 at 4:55 PM showed the resident was up in a wheelchair with a chair alarm attached to the wheelchair. The resident stood up out of the wheelchair, and the alarm did not sound due to the length of the cord. Staff in the area did not notice the resident standing. c. Observation on 1/14/16 at 5:08 PM and 5:25 PM showed the resident again stood up out of the wheelchair, and the alarm did not sound. d. Interview with the DON, ADON, and corporate nurse on 1/15/16 beginning at 2:05 PM confirmed a chair alarm with a cord that is too long to alert when the resident stands up out of the wheelchair is not an effective fall intervention. 3. Review of the 12/28/15 care plan interventions showed resident #108 required assistance with transfers. Review of the transfer evaluation, completed on 12/18/15, showed the resident was non-ambulatory, non-weight bearing, and unable to follow directions. Further review of this evaluation showed a mechanical lift (total body/sling or stand assist as appropriate) should be used for all transfers. On 1/12/16 at 6:50 AM CNAs #3 and #4 were observed as they transferred the resident from the bed to the wheelchair using a sit-to-stand mechanical lift. Observation later that day at 11:50 AM revealed the bath aides #1 and #2 used the sit-to-stand mechanical lift to transfer the resident from wheelchair to the shower chair. During the observations the following concerns were identified: a. The sling was positioned beneath the underarms, around the upper chest and above the resident's mid back area, instead of the lower back area. b. The resident did not bear weight during the transfers, causing his/her body weight to be supported totally by the sling. c. The resident told the staff the sling hurt and called out, no, no as s/he was being transferred. d. Staff did not instruct the resident to bear weight, nor did they implement measures that increased body support and decreased pain and discomfort. e. Interview with the DON on 1/15/16 at 2:45 PM revealed the resident was able to bear weight, but staff had to tell him/her to do it. She further stated an assessment by the therapist might be needed to determine whether using the sit-to-stand mechanical lift was appropriate for this resident.

Based on observation, staff interview, and medical record review, the facility failed to provide appropriate skin care assessments, monitoring, and treatments for 2 of 6 sample residents (#2, #10) with wounds. This failure resulted in actual harm for resident #2 who required inpatient hospitalization for wound care. The findings were: 1. Review of the 1/7/15 quarterly MDS assessment showed [DIAGNOSES REDACTED]. This review showed the resident was totally dependent on staff for repositioning, transfers, and incontinent care; and s/he did not have wounds, pressure ulcers, arterial ulcers or venous ulcers. The following concerns were identified: a. Review of the care plan for resident #2 showed staff were directed to observe skin weekly and document findings as indicated. Review of the February and March 2015 nursing notes, bath records, and weekly skin assessments showed no evidence a skin assessment was done from 2/24/15 to 3/5/15 (9 days). b. Review of the skin assessments dated 2/3/15, 2/10/15, 2/17/15, and 2/24/15 showed staff identified redness on the buttocks on 2/3/15 and redness on the coccyx on 2/24/15. This review showed no documented findings of more than redness at any other time. c. Interview with CNA #1 on 3/17/15 at 2:30 PM revealed there were red and open areas on the resident's buttocks for over a week before the resident was transported to the hospital and the nurses put a cream on it. She further stated the sores on the resident's buttocks and swollen red areas on the resident's legs continued to worsen. d. Review of the nursing notes showed the resident was transported to the hospital on [DATE] due to wounds and [MEDICAL CONDITION] that were first noted on 3/5/15. Review of the hospital physician's note, dated 3/6/15, revealed the resident had multiple ulcerated skin areas and right leg [MEDICAL CONDITION]. Further review of this physician's note showed the resident was admitted with the following wounds: "...deep tissue injury" mostly on the left sacral area, right leg swelling with increased redness and warmth on the foot up to the mid shin, an area of redness centered around necrotic tissue over the lateral aspect of the right knee, a necrotic ulcer facing the lateral aspect of the distal part of the fifth toe, and an ulceration on the left foot. Review of the hospital records showed the resident returned to the facility on [DATE] with orders for continued intravenous antibiotic therapy and treatments for the wounds. e. Observation of the resident with the DON on 3/16/15 at 7:30 PM revealed a dark purple area on the sacrum, both buttocks and coccyx surrounded a 4.4 centimeters (cm) by 5.5 cm open yellow area. This open area had serosanguineous drainage. There were additional wounds on both feet, legs, and right knee and necrotic tissue was observed on the edges of the wounds on the feet and right knee. Interview with the DON at that time revealed the wounds were present before the resident went to the hospital. She further stated the wound on the sacrum, buttocks and coccyx was an IAD caused by diarrhea from a [MEDICAL CONDITION]; and the wounds on both legs were due to [MEDICAL CONDITION]. Review of the bowel records and interview with the infection control nurse on 3/17/15 at 7:10 PM revealed the resident did not have diarrhea episodes after the 2/24/15 skin assessment which showed only redness. In addition, review of the Medication Administration Record [REDACTED]." f. Review of the skin care monitoring system on 3/17/15 revealed the facility had not implemented a system for ensuring the resident received incontinent care in a timely manner to prevent worsening of the existing IAD and prevent development of IAD. During an interview on 3/18/15 at 2:55 PM the DON acknowledged the lack of a system for monitoring for IAD. She further verified there were problems with the skin monitoring system and she was working to resolve those problems. g. During an interview on 3/16/15 at 7:30 PM, the DON stated the wounds on the resident's feet were due to circulatory problems. Review of the hospital and facility physicians' documentation revealed no evidence of a physician's determination that these wounds were unavoidable due to circulatory problems. In an interview on 3/18/15 at 2:55 PM, the DON verified the lack of this evidence. 2. Review of the 11/25/14 admission nursing assessment showed resident #10 was admitted to the facility with venous stasis ulcers on the legs. Review of the 2/19/15 quarterly MDS assessment showed [DIAGNOSES REDACTED]. Further review showed the resident was alert and oriented, and required extensive assistance with most ADLs. Review of the care plan, updated 3/18/15, showed the resident was bedridden due to a cervical fracture. Further review of the care plan showed staff were to provide wound care as ordered for a chronic venous stasis ulcer on the left leg. Review of the 3/2/15 and 3/9/15 weekly skin assessments showed the venous stasis ulcer on the left leg measured 15 cm x 12 cm x .2 cm, had macerated edges, and was red with serosanguineous drainage. The following concerns were identified: a. Review of the weekly skin assessments and treatment records from 11/25/14 to 3/6/15 showed no evidence staff had obtained treatment orders for the venous stasis ulcer. b. Review of the skin assessments, treatment records, and nurses' notes from 11/25/14 to 3/6/15 revealed wound care was provided, but it was unclear what that care entailed and the frequency it was provided. c. Review of the physician's progress note, dated 3/6/15, revealed the nursing staff had not monitored the area and they had been changing the dressings "from time to time." Further review showed the physician ordered an antibiotic and [MEDICATION NAME] (an external antimicrobial cream) with daily dressing changes to remove the "necrotic tissue." d. In an interview on 3/18/15 at 2:55 PM, the DON confirmed the lack of monitoring and treatment orders. During the interview the DON did not identify a system that had been implemented to prevent reoccurring incidents of staff failure to obtain prescribed treatments for venous/stasis ulcers.

Based on medical record review and staff interview, the facility failed to ensure effective interventions and/or post-fall assessments were implemented to prevent falls for 2 of 3 sample residents (#5, #8) identified at risk for falls. The lack of effective interventions resulted in harm for resident #5. The findings were: 1. Review of the medical record showed resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission notes dated 12/3/14 and timed at 5 PM showed the resident was "very unsteady on feet" and had poor balance. In addition, it was noted the resident required extensive assistance with transfers and locomotion. Review of the 7 PM to 7 AM shift nursing notes dated 12/3/14 showed the resident was confused, had an unsteady gait, wandered about, and kept removing the safety alarm that was placed for safety. It was also noted the resident was weak and required extensive assistance with mobility and transfers. Review of the next nursing notes dated 12/4/14 and timed at 5 PM showed the resident was alert but restless, was incontinent, had an unsteady gait and was weak. The nursing notes written on 12/5/14 for the 7 PM to 7 AM shift showed the resident was bed/chair bound, weak, and required total assistance with cares. Review of the nursing notes written at 5 PM on 12/6/14 revealed physical therapy (PT) had reported the resident was having trouble bearing weight on the left leg that morning and s/he complained of pain. Interview with the DON on 1/16/15 at 2:10 PM revealed the physician was faxed this information at noon on 12/6/14. Further review of the nursing notes showed PT recommended using the sit-to-stand lift to assist with transfers with 2 persons. Interview with the DON on 1/16/15 at 2:10 PM verified when the physician was faxed about the fall he was asked to approve the recommendation for sit-to-stand lift and did so at that time. Review of the SBAR (Situation Background Assessment/Appearance/ Request) communication form and progress note dated 12/6/14 and timed at 5 PM showed the resident was having difficulty bearing weight on the left leg and complained of pain in the left hip. Continued review of the SBAR showed the resident was unsafe to bear weight on the left leg. Normally the resident was able to stand with the assist of one and a gait belt. Review of the 12/6/14 SBAR timed at 6:30 PM showed the resident had an unwitnessed fall. The resident was found in the dining room lying on his/her left side. The report showed the resident had blood on the forehead and left eye lid. The resident was transported to the emergency room for evaluation. The following concerns with fall prevention were identified: a. Review of the initial care plan completed on 12/4/14 showed the resident had a history of [REDACTED]. The only intervention recommended on the initial care plan was to place a "wander guard, or other electronic safety devices as deemed necessary by assessment." This care plan was not specific or individualized for the resident. The staff placed an alarm on the resident. However, it was noted in the 12/3/14 nursing notes timed from 7 PM to 7 AM the resident removed the alarm which rendered this intervention ineffective. b. The resident was transported to the emergency roiagnom on [DATE] after the fall. Review of the history and physical performed on 12/6/14 showed x-ray of the left hip revealed dislocation of the left acetabular component without fracture. The dislocation was reduced in the emergency room . Upon re-admission to the facility on [DATE] (2 day hospital stay) the resident required a left knee and thigh brace according to the nursing note dated 12/8/14 and timed at 2 PM. Review of the fall risk evaluation performed on 12/8/14 showed the resident scored 21; a score of 10 or greater indicates high fall risk. Review of the transfer evaluation performed on 12/8/14 showed the resident required the use of a mechanical lift for transfers. Review of the medical record showed the care plan after the resident's re-admission was completed on 12/30/14, 22 days after re-admission and this care plan did not note the use of a brace or the sit-to-stand lift with assistance of two staff. c. According to the physician's telephone order on 12/12/14 timed at 4:45 AM, the resident had another fall with a head injury and required transport to the emergency room . Review of the emergency room notes verified the resident was seen for an evaluation of a fall on 12/12/14. Review of the nursing notes for 12/12/14 showed no documentation of the fall. 2. Medical record review showed resident #8 was re-admitted to the facility on [DATE] at 3 PM due to general decline after having been discharged to his/her home on 9/5/14. Review of the 8/18/14 admission MDS assessment showed staff were required to transfer the resident from a sitting to a standing position, on and off of the toilet, and for surface to surface transfers. Review of the 8/28/14 and 12/6/14 fall risk evaluations showed the resident was at high risk for falls. Review of the 12/3/14 nursing notes showed the resident fell at 4 PM while being transferred to a recliner chair by a family member. Review of the entire medical record showed the facility failed to complete a review of the fall to determine if any additional measures were required to lower the risk for falls. Review of the care plan, last updated on 9/2/14, showed family members were not addressed as being appropriate for transferring the resident, and review of the entire medical record showed the facility failed to provide education to the resident's family members regarding safe transfers. 3. Interview with the administrator on 12/31/14 at 6:40 PM confirmed the facility had identified an ongoing staff shortage. He further acknowledged this staffing shortage had the potential to affect resident safety; which would include fall risk. .

Based on medical record review, family interview, and staff interview, the facility failed to address pain in a timely manner for 1 of 1 sample resident (#13) who had increased pain. The findings were: 1. Medical record review showed resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing note review revealed a 7/25/14 note (no time documented) which stated, "Resident c/o (complaint of) leg cramps, tenderness, weakness in bilat (both) lower ext. (extremities) over the last couple of days (as reported by staff). Resident refusing to bear wt. (weight) MD notified." Review of a prior note dated 7/18/14 (no time documented) revealed, "Resident holding left leg and complaint of pain. Review of a nursing note dated 8/4/14 at 1600 (4 PM) revealed, "Returned from appt. Progress note + left femoral neck fracture." Review of a 7/28/14 physician note revealed, "...(The resident) is mostly non-verbal. Is in obvious amount of pain. Nursing notes comment on leg pain. (The resident) will not ambulate. Localized at left femur above knee. Acute increase in pain." Review of physician orders [REDACTED]. The following concerns were identified: a. Review of the July 2014 Medication Administration Record [REDACTED]. b. Interview with the resident's POA on 8/14/14 at 7:45 PM revealed the POA's spouse visited the resident between 7/11/14 and 7/28/14 (date uncertain) and notified staff that the resident appeared in pain any time s/he was moved. The POA visited the resident between 7/11/14 and 7/28/14 after the POA's spouse visited, and notified staff the resident would not/could not bear weight on his/her legs and was in pain. The POA stated this was different for the resident. c. Interview with the DON on 8/14/14 at 1 PM confirmed the facility had [MEDICATION NAME] in their emergency kit available for use at the time of the order, and confirmed the facility failed to administer the medication until 7/30/14.

Based on observation, medical record review, and staff interview, the facility failed to prevent the development of an avoidable pressure ulcer for 1 of 2 sample residents (#15) who entered the facility without a pressure ulcer. The failure to prevent the development of a stage IV pressure ulcer resulted in actual harm to this resident. The findings were: Medical record review showed resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 1/7/14 admission MDS assessment showed the resident had no pressure ulcers. Review of a 2/20/14 communication to the physician revealed an elliptical shaped eschar surrounding pink subcutaneous tissue wound at the left buttock/thigh fold, and a 4/4/14 physician progress notes [REDACTED]. Review of the 4/4/14 quarterly MDS assessment revealed the resident had a stage IV pressure ulcer which measured 1.3 centimeters (cm) long by 5 cm wide by 5 cm deep. According to the weekly pressure ulcer log on 8/11/14 the pressure ulcer measured 0.2 cm by 1.8 cm by 2.5 cm of tunneling. On 8/13/14 at 9:50 AM the wound care nurse was observed providing pressure ulcer care for the resident. During the observation the nurse removed and replaced the packing in the tunneled stage IV pressure ulcer. The following concerns were identified: a. Review of a 12/2/13 prescription for DME (specialized bed) for a [DIAGNOSES REDACTED]. is not very mobile. (The resident) is limited wt. (weight) bearing on left side. New bed needed for better care and avoidance of complications." Review of a 1/6/14 physician order [REDACTED]." However, medical record review showed the facility failed to complete a comprehensive pressure ulcer risk assessment until 4/2/14 (41 days after the pressure ulcer was identified), which identified the resident as high risk using the Braden scale. b. Review of the 2/24/14 physician orders [REDACTED]." Review of the 3/3/14 physician orders [REDACTED]. Review of a 3/30/14 communication with the physician stated, "...Pt. still not being adequately hydrated." Review of the corresponding 3/31/14 physician order [REDACTED]. needs 16 ounces at least between meals-PUSH FLUIDS all times." Further review showed a pressure ulcer care plan was initiated on 1/5/14. However, review of the care plan showed the facility failed, with the exception of the pressure relief bed, to add the physician orders [REDACTED]. c. Interview with the DON on 8/15/14 at 10:30 AM confirmed the facility failed to complete a comprehensive pressure ulcer risk assessment until 4/2/14 (41 days after the pressure ulcer was identified). She further acknowledged the facility failed to monitor the fluid intake of the resident, the frequency of repositioning in bed, and the timeframe the resident was left in his/her wheelchair. Facility failure to timely assess pressure ulcer risk and adequately intervene before a pressure ulcer occurred resulted in the likelihood the resident's pressure ulcer was avoidable. In addition, facility failure to ensure physician orders [REDACTED].

Based on observation, medical record review, and staff interview, the facility failed to ensure effective interventions were implemented to prevent falls for 3 of 7 sample residents (#7, #12, #13) identified at risk for falls. In addition, staff failed to provide timely medical and nursing care for 1 resident (#13) who had assessed changes in health status following multiple falls. This failure resulted in actual harm for 1 resident (#13) and was evidence of the facility's inability to sustain compliance with their PoC and proposed 6/24/14 DoC. The findings were: 1. Medical record review showed resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed the resident had 16 falls which occurred on 3/20/14, 3/30/14, 4/3/14, 4/18/14, 5/7/14, 5/19/14, 5/21/14, 6/7/14, 6/18/14 twice, 6/23/14, 6/27/14, 7/2/14, 7/8/14, 7/11/14, and 7/14/14. The following concerns were identified: a. Review of Interdisciplinary Post Fall Reviews dated 4/4/14, 5/13/14, 5/21/14, 6/9/14, 6/21/14, 7/3/14, 7/9/14, and 7/11/14 showed one of the recommendations of the team that signed the reviews was to revise the care plan. However, review of the care plan showed the plan concerning falls was initiated on 3/31/14 and was only reviewed and/or revised on 4/4/14, 7/11/14, and 7/22/14 (3 times for 16 falls). The facility failed to review and/or revise the care plan on 5/13/14, 5/21/14, 6/9/14, 6/21/14, and 7/3/14 as recommended, and failed to document a rationale for why the care plan was not revised. b. Review of nursing notes showed the following: On 5/10/14, "Resident ambulating about with walker with slow, steady gait. On 6/20/14, "Was ambulated to room..." On 6/21/14, "Able to move all extremities. Continues to have some difficulty ambulating." On 6/22/14, "Able to move all extremities." The following changes were documented after the 7/11/14 fall: On 7/11/14 at 6 PM, "Wheelchair for mobility." On 7/18/14, "Resident holding left leg and complaint of pain." On 7/25/14, "Resident complained of leg cramps, tenderness, weakness in bilat (both) lower extremities over the last couple of days (as reported by staff). Resident refusing to bear weight." On 7/29/14, "WFP-physician visit-1. Ankle brace/index on left leg if pt. able to cooperate. 2. X-ray left knee complete for leg pain. 3. X-ray pelvis for left leg pain. 4. x-ray left femur 2 views for leg pain...Norco (narcotic pain medication) 5/325 1/2 tab BID (twice a day). On 8/4/14, "Return from appt. Progress note + left femoral neck fx (fracture). MD called and discussed recommendations with family/RP (resident's physician?)-Resident to be NWB (no weight bearing) left leg. Surgery scheduled for Thursday. X-rays for tomorrow were canceled....Resident has not been bearing weight-Staff have been using the lift to transfer." c. Interview with the resident's POA on 8/14/14 at 7:45 PM revealed the POA's spouse visited the resident between 7/11/14 and 7/28/14 (date uncertain) and notified staff that the resident appeared in pain any time s/he was moved. The POA visited the resident between 7/11/14 and 7/28/14 after the POA's spouse visited, and notified staff the resident would not/could not bear weight on his/her legs and was in pain. The POA stated this was different for the resident. The POA stated he notified the MD after his visit and was told he could get a second opinion if he wished. The POA stated he then set-up the appointment that resulted in the resident's Orthopedic visit with x-rays, followed by "total hip surgery." d. Interview with the DON on 8/15/14 at 10:30 AM confirmed the facility did not always update the care plan or provide a rationale as to why the facility failed to do so. She further confirmed the facility failed to obtain a specialist appointment for the resident concerning his/her change in ambulatory status after the 7/11/14 fall until after the resident's POA intervened and scheduled the Orthopedic visit with x-rays that resulted in finding the fracture. This finding resulted in the resident undergoing a left hip hemiarthroplasty on 8/7/14. 2. Review of the 7/14/14 nursing admission assessment showed resident #12 was admitted from the hospital after leg amputation surgery. This review also showed the resident was alert and oriented and required supervision with transfers. According to the medial record the facility van was used to transport the resident from the facility to the wound clinic for care of the amputation surgical wound. The following concerns were identified regarding unsafe practices during resident transport: a. Interview with the resident on 8/14/14 at 12:20 PM revealed the following information: on 7/28/14 s/he was transported by the facility van from the facility to the wound clinic for care of his/her surgical wound. The van driver stopped to pick up another resident before taking resident #12 to the clinic. When the driver left the van to assist the other resident, resident #12 was left alone on the van with van door opened and motor running. The driver was "gone for about 45 minutes", it was hot, and the heat made the resident feel "awful". S/he then moved out of the wheelchair, supported his/her weight with one leg and grasped the seats and support poles to aide his/her departure from the van. S/he turned the ignition off and positioned himself/herself through the opened door on the steps of the bus. b. During an interview on 8/14/14 at 3:15 PM the van driver verified the incident occurred as described by resident #12, except the van driver was unsure of how long she had left the resident alone. During the interview the van driver also stated she now realized how unsafe it is to leave a resident unsupervised on a van with the engine running and the door opened for prolonged periods of time. c. Interview on 8/14/14 at 1:20 PM with the DON and administrator revealed they had not investigated the incident or implemented measures to prevent reoccurrence because they were not aware of the incident. 3. Review of the 6/17/14 quarterly MDS assessment showed resident #7 was wheelchair dependent, had cognitive impairment, required extensive assistance with toileting and transfers and had multiple non-injury falls. Review of the 6/17/14 care plan showed interventions for fall prevention included: remind resident to use call light, attach a chair alarm when up, provide scheduled toileting assistance, and observe for potential patterns of fall to identify possible causes. Further review revealed the resident did not consistently use the call light or call for assistance and frequently removed the chair alarm. Observation on 8/13/14 from 1:50 PM to 2:25 PM revealed the resident sat in his/her room with the chair alarm detached. Continued observation revealed the chair alarm was not reattached until the ADON responded to the roommates call light at 2:25 PM. At that time the ADON stated the chair alarm should be attached at all times.

Based on observation, medical record review, staff interview, and review of facility incident reports, the facility failed to ensure resident safety concerning hot beverages for 1 (#16) of 70 residents who were known to consume hot beverages. In addition, the facility failed to promote a safe and accident-free environment in 3 resident rooms (#505, #507, #602) and 1 of 6 resident areas (secure unit). The findings were: 1. Review of an incident report concerning resident #16 showed the resident sustained [REDACTED]. The hot chocolate was served to the resident by staff. Review of the incident details showed the burn was described as a 15 millimeter (mm) by 9 mm reddened area to the left thigh, and a 15 mm by 17 mm reddened area to the right thigh. The notes showed the facility staff removed the resident's pants at the time the beverage was spilled and placed a cool compress to the reddened areas. Further review showed the physician was notified by voice mail at that time, and staff documented the plan to monitor the burn until resolved. Observation on 1/6/14 at 5:15 PM revealed RN #4 provided wound care for open areas on the resident's inner thighs. At that time the areas were bleeding. Review of physician signed orders on 1/7/14 showed "Keep clean dry...monitor until healed...burn healing...no evidence of infection." The following concerns were identified with the facility's accident prevention: a. Interview with the administrator and DON on 1/9/14 revealed after the incident the facility changed the way hot chocolate was dispensed. When the burn occurred the hot chocolate was dispensed from a machine into the cup. The change included the hot chocolate being poured into carafes prior to meals and allowed to sit prior to being poured into resident cups. In addition, a plan was developed to monitor the temperatures of the hot chocolate; however, this monitoring was not accomplished due to frequent staff changes in the dietary department. b. Review on 1/9/14 of the completed incident investigation related to the spilled hot chocolate showed the facility ordered cups with lids on 1/8/14 (15 days after the resident was burned) to secure hot beverages for 2 residents identified as needing lids for hot drinks, which included resident #16. c. On 1/7/14 at 9:40 AM a surveyor checked the temperature of a cup of coffee taken from a coffee machine in the main dining room used by residents; the temperature was 168 degrees Fahrenheit (F). Thirty minutes later the temperature of a second cup of coffee from the same machine was checked and found to be 165 degrees F. Observation on 1/7/14 at 5 PM showed the facility was installing a new coffee machine at that time. d. Interview with the regional dietary supervisor on 1/8/14 at 11:30 AM revealed the new coffee dispenser which was installed on 1/7/14 was ordered due to a change in contracts. The supervisor further revealed this machine was better because the temperature could be adjusted and controlled. When asked what temperature was appropriate the supervisor revealed they set the temperature to 150 degrees F. e. Interview on 1/9/14 at 8:30 AM with the administrator, DON, and RN #1 confirmed they had started taking and controlling temperatures of hot beverages on 1/8/14. This was based on installation of the new coffee machine and their discussion with the regional dietary supervisor. They further acknowledged the new coffee pot installed on 1/7/14 was planned due to a contract change. f. Interview on 1/8/14 at 6:45 AM showed dietary aide #1 checked the facility coffee temperature. The temperature was 125 degrees F, and at that time the aide stated any temperature above 160 degrees F was a potential hazard for residents. 2. Observation in the following areas showed heat vents with exposed metal edges that had the potential for injury: a. Observation on 1/7/14 at 10:40 AM showed the bathroom heat vent in room #507 was loose with the middle metal clamp jutting outward 13 inches revealing a 6 inch sharp edge. b. Observation on 1/7/14 at 11:40 AM revealed the secure unit sun room heat vent was loose from the wall 53 inches across with a sharp metal edge pointing outward. c. Observation on 1/7/14 at 1:45 PM showed the bathroom heat vent in room #504 was loose with the middle metal clamp jutting outward 15 inches revealing an 8 inch sharp edge. d. Observation on 1/8/14 at 11:20 AM showed the bathroom heat vent in room #602 was loose from the wall 6 feet across revealing a sharp metal edge across the entire vent. Interview with the maintenance supervisor on 1/8/14 at 2:20 PM confirmed heat vents were in disrepair. He further stated the facility planned to update the entire heating system. However, the facility failed to have a specific plan to address this issue.

Based on observation; staff interview; and review of medical records, infection control data, manufacturer's instructions, and policy and procedures, the facility failed to maintain an infection control program that ensured identification, investigation, intervention, and containment of infections. This failure resulted in harm to residents as evidenced by a significant increase in infections after initial identification of a contagious process. Therefore, this resulted in an immediate jeopardy situation for all residents of the facility. The census was 101. The findings were: On 10/11/12 the facility notified the state survey agency via fax concerning an outbreak of gastrointestinal symptoms (nausea, vomiting, diarrhea) at the facility which involved twelve residents and seven staff members at that time. The ICP was called on 10/12/12 by the survey agency, and the ICP stated the facility had notified the state epidemiologist about the outbreak. The ICP further stated the facility was attempting to obtain stool specimens to determine if the outbreak was a norovirus. The following concerns were noted: During an interview on 10/17/12 at 9:16 AM, the ICP stated that last week, around October 10th, she printed off the Wyoming Department of Health Epidemiology Section's recommendations regarding an outbreak of viral gastroenteritis. Review of "Guidelines for the Control of a Suspected or Confirmed Outbreak of Viral Gastroenteritis in a Nursing Home" showed the following recommendations: a. Isolate ill residents from others by confining them to their rooms ...group ill people together if possible ...discontinue activities where ill and well residents would be together. b. Ill staff should remain out of work for 3 days following cessation of diarrhea and/or vomiting. c. Minimize the flow of staff between sick and well residents ... d. Staff should wash their hands when entering and leaving every resident room. Hand sanitizers might serve as an effective adjunct in between proper handwashing but should not be considered a substitute for soap and water handwashing. e. Frequently disinfect areas with greatest likelihood of contamination including bathrooms, high-touch surfaces such as handrails, doorknobs, and physical/occupational therapy equipment ...environmental surfaces should be disinfected using a freshly made chlorine bleach solution or other commercially prepared product registered with the EPA as effective against norovirus ...Personnel performing environmental services should adhere to the manufacturer's instructions for dilution, application, and contact time. At the time of survey, the facility had not implemented the above recommendations. Refer to the evidence in this citation for details. The following deficiencies in the infection control program were identified on survey: a. On 10/15/12 the ICP provided a list of residents and staff with gastrointestinal signs and symptoms that had been revised since notifying the state survey agency on 10/11/12. The list contained 24 residents and 9 staff members. A review of medical records in the secure unit revealed 11 additional residents with gastrointestinal signs and symptoms (nausea, vomiting, and/or diarrhea) who had not been identified and were not included in current surveillance logs: #69, #73, #78, #80, #83, #84, #86, #90, #95, #98, and #99. In addition, review of the facility 24-hour reports revealed 6 additional residents were not included in active surveillance: #88 on 10/6, #67 on 10/2 (identified in infection control data on 10/13), #14 on 10/11, #53 on 10/10, #61 on 10/10, #54 on 10/7. During an interview with the ICP on 10/16/12 at 2 PM, she stated the facility failed to employ anyone in the infection control role from 5/12/12 until 9/27/12, and surveillance activities were not completed during that time. The ICP stated she had failed to track everyone during the outbreak because she had other duties competing for her time. The ICP was assigned to a medication cart and corresponding resident hallway at that time. The ICP stated she used 24-hour nursing reports and information discussed in the daily management meetings to enter residents and staff members into the infection control tracking data. At that time she stated her primary function was in direct care roles, and not in infection surveillance. Therefore, the ICP stated she did not review the 24-hour reports or attend management meetings daily. When asked when she last reviewed the reports and/or attended daily management meetings, the ICP said, "It has been awhile, and I do not attend meetings or review the reports daily." b. On 10/16/12 at 2 PM, the ICP confirmed the facility had failed to investigate the outbreak to determine the source. The ICP stated she called the state epidemiologist sometime during the prior week and left a voice-mail message concerning the facility outbreak, but had not received a return call. Interview with state epidemiologist #1 on 10/17/12 at 11 AM showed the state epidemiology department had no record concerning a message from the facility regarding the outbreak. Review of infection surveillance data provided on 10/18/12 showed residents affected with gastrointestinal signs and symptoms since the outbreak had risen to 41, and the staff with the signs and symptoms had risen to 18. During that time, one resident (#2) was sent to a local hospital on [DATE] with gastrointestinal signs and symptoms. The resident returned to the facility on [DATE]. According to the facility policy and procedure titled, "Outbreak Investigation" the facility should designate a staff member as the investigation coordinator. The Infection Preventionist will gather and compile data related to the infection(s) as follows: 1. Conduct case findings (review ongoing surveillance charts of other patients at risk and microbiology reports) to determine whether there have been other cases of the infection, 2. Evaluate previous facility experience with the infection, 3. Prepare a line listing of cases to include: resident, room number, date of admission, date of infection onset, site culture results, and physician, 4. Plot number of cases by date of onset (epidemic curve), 5. Review patient charts of cases and interview involved personnel for various factors that conceivably may have played a role in transmission of an infection, e.g., geographic locations of patients, specific personnel having contact with patients, medications and treatments administered, 6. Review various Infection Prevention techniques (hand hygiene, use of standard precautions, etc.) as actually practiced in the facility, and 7. Maintain surveillance for occurrence of any further infections. c. During an interview on 10/16/12 at 2 PM, the ICP further stated the facility failed to monitor staff and/or resident handwashing. Observation on 10/16/12 at 8:05 AM showed the medical records director passed water/ice to residents in the 300 hallway. The water pitchers were brought out of the rooms, filled with ice and water, and returned to the resident's rooms. She cleansed her hands with hand sanitizer, but at no time during the observation did she actually wash her hands. Observation on 10/16/12 at 10:25 AM showed CNA #6 provided personal care to resident #42 after toileting. The aide wore gloves, but failed to wash her hands or the resident's hands after removing her gloves. According to the facility policy and procedure titled, "Hand Hygiene" the purpose of hand hygiene is "To decrease the risk of transmission of infection by appropriate hand hygiene." The policy stated information which included, "Handwashing/hygiene is generally considered the most important single procedure for preventing healthcare-associated infections." Under the title, "Handwashing" the following was noted, "When hands are visibly dirty or contaminated.........after going to the bathroom, and before eating, perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water." The following concerns with a lack of disinfection were identified: The ICP stated in interview on 10/17/12 at 9:16 AM, that upon the first gastrointestinal signs and symptoms among the residents, she cleaned hall 1 doorknobs and handrails with a 10% bleach solution. No resident rooms or other areas were cleaned or disinfected with bleach. Observation on 10/16/12 at 8:05 AM showed resident room [ROOM NUMBER] was being cleaned by housekeeping staff #1. She used Ecolab A-456-II which was automatically dispensed. The surfaces were not visibly wet within 5 minutes of the application of the solution. Observations on 10/16/12 at 8:25 AM and 8:36 AM revealed housekeeping staff #2 cleaned rooms [ROOM NUMBERS]. She used the product A-456-II and the surfaces treated were not visibly wet after 5 minutes. During an interview with housekeeping staff #2 and #3 on 10/17/12 at 10:30 AM, each confirmed they did not know the difference between cleaning and disinfecting with regard to the Ecolab product A-456-II. In addition, housekeeping staff #2 stated she wiped down surfaces with a solution soaked wet cloth, then immediately used another cloth to dry the same area. Review of the manufacturer's instructions for the product showed for disinfection, the treated surfaces must remain wet for 10 minutes. During an interview with the housekeeping supervisor on 10/17/12 at 10:30 AM, she stated the Ecolab A-456-II should clean on contact. She was unaware of the manufacturer's requirement of a 10 minute contact time for disinfection. On 10/17/12 at 2:59 PM, after the facility was made aware of the 10 minute contact time, staff was observed mopping the floor outside of the dining room using the A-456-II product. The floors were not visibly wet at 3:05 PM (6 minutes later). The following concerns were identified concerning employee illness: During an interview on 10/17/12 at 9:16 AM, the ICP stated the facility's policy was that ill employees could return to work when "symptoms subside." She further stated she understood the state epidemiology section recommended ill employees did not return to work for 72 hours after the cessation of symptoms. Review of documentation provided by the facility on 10/17/12 at 5:45 PM revealed 8 employees reporting defined symptoms for acute gastroenteritis returned to work within 24 hours of their last reported symptoms and an additional 2 staff members returned within 48 hours of their last reported symptoms. Further interview with the ICP on 10/17/12 at 10:40 AM revealed when staff called in, they called the front office and the secretary would fill out an absentee report. When asked how she monitored employees who called in sick, to get further information on symptoms to look for patterns, the ICP responded that employee calls were discussed during the morning management meetings. However, she stated she was not always able to attend those meetings. The following additional concerns were identified: a. During the survey period from 10/15/12 at 2:35 PM through 10/18/12 at 12:15 PM, observations showed the facility failed to post signs in the facility to address the outbreak and instruct visitors in what to do (example: see nurse before entering room). b. Multiple observations during the survey period from 10/15/12 at 2:35 PM through 10/18/12 at 12:15 PM showed staff and residents failed to wash residents' hands. c. Observations during the evening meal on 10/15/12 and noontime meal on 10/16/12 showed the facility failed to cohort residents with symptoms during meals, or have residents eat in their rooms if they had gastrointestinal symptoms. d. Observation on 10/15/12 at 5:05 PM showed the restorative care manager and CNA #7 used a full mechanical lift to transfer resident #89 from his/her wheelchair to the resident's bed. When asked after the transfer, CNA #7 stated staff used the lift slings repeatedly with other residents and would change them out each evening or if they became visibly soiled. The sling was not cleaned before or after the transfer. An additional observation of resident #89 on 10/16/12 at 11:30 AM showed the restorative care manager and CNA #2 used a sit-to-stand lift to transfer the resident. The sling was not changed or cleaned before or after. An interview with the CNA immediately after the observation revealed the facility changed the lift sling after the evening shift, and if the sling became visibly soiled. During an observation on 10/16/12 at 11:40 AM, CNAs #2 and #3 used a full mechanical lift to transfer the resident from his/her bed to the resident's wheelchair. The lift sling was not changed or cleaned before or after the transfer. During an observation on 10/16/12 at 9:10 AM, CNA #6 transferred resident #49 from his/her chair to the bed using a sit-to-stand lift. Afterward, the aide provided incontinence care for the resident while wearing gloves. However, the aide did not wash her hands or the resident's hands after the care was provided. In addition, the aide did not clean the sling used during the transfer. During an interview immediately after the observation, the aide stated the lifts were cleaned on the night shift, and the slings were changed out at the end of each shift. On 10/17/12 at 12:14 PM, the administrator was notified of the immediate jeopardy. The facility's action plan included the following immediate changes: a. Education for housekeeping staff regarding disinfection, with use of a 1:10 bleach solution. b. Education for residents and nursing staff concerning proper hand hygiene. c. A change in policy for staff illness that included remaining out of work for 72 hours post gastrointestinal signs and symptoms. d. A change in policy and procedure regarding lift slings which included assignment to each resident a sling of their own. Also, lifts and slings will be disinfected with micro-kill disinfectant according to manufacturer's instructions. e. A change in policy and procedure to cohort residents with like signs and symptoms which included a specific dining area. f. A change in infection control monitoring to include ongoing monitoring of residents for signs and symptoms of illness and infection, and posting for visitors to include instructions to see nurses at nursing station before entering a room with an affected resident. g. Education for all staff concerning these changes. The facility action plan was accepted on 10/17/12 at 6:08 PM, and the immediate jeopardy was removed on 10/18/12 at 9:38 AM. However, deficient practice remained at a scope and severity of H (actual harm that is not immediate jeopardy). On 10/25/12 at 9 AM, state epidemiologist #1 provided the State Survey Agency with the following update received from the facility on 10/24/12: at that time 45 residents, 27 staff members, and 1 visitor had reported gastrointestinal symptoms since onset of the outbreak.