Every finding on record at Columbine West Health and Rehab LLC

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication storage carts and two of two storage closets. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened;-Ensure expired medication were removed and discarded from the medication carts; and,-Ensure medications were stored in a secured area. Findings include: I. Professional reference The PharMerica (1/12/25) Abridged List of Medications with Shortened Expirations Dates, was retrieved on 6/17/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-[NAME]-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. It read in pertinent part, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product's package insert under the 'How Supplied/Storage & Handling' section. A drug product's beyond use date (BUD) is the manufacturer supplied expiration date or the shortened date after opening, whichever comes first. These in-use medications should be labeled such that the date opened is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration. The Pharmcare USA's (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 6/17/26 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/. It read in pertinent part, When medications are not disposed of correctly, they can pose serious threats to both human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death. The Highlights for Prescribing Information for Xalantan (latanoprost ophthalmic solution) 0.005%, for topical ophthalmic use (December 2022), was retrieved on 6/17/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/020597s054lbl.pdf. It read in pertinent part, Store unopened bottle(s) under refrigeration at 2 degrees celsius (C) to 8 degrees C (36 degrees fahrenheit (F) to 46 degrees F). During shipment to the patient, the bottle may be maintained at temperatures up to 40 degrees C (104 degree F) for a period not exceeding eight days. Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees C (77 degrees F) for six weeks. The Highlights of Prescribing Information for Humalog (insulin lispro) injection (May 2025), for subcutaneous or intravenous use was retrieved on 6/17/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020563s214,205747s038lbl.pdf. It read in pertinent part, Diluted Humalog for subcutaneous injection may be stored for 28 days when refrigerated at 41 degrees F (5 degrees C) and for 14 days at room temperature up to 86 degrees F (30 degrees C). When stored at room temperature, Humalog U-100 and U-200 can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time. The Highlights of Prescribing Information for Lantus (insulin glargine) injection (June 2023), for subcutaneous use (June 2023) was retrieved on 6/17/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/021081s078s079lbl.pdf. It read in pertinent part, Store unused Lantus in a refrigerator between 36 degrees F and 46 degrees F (2 degrees C and 8 degrees C). Do not freeze. The Lantus vial you are using should be thrown away after 28 days or if the expiration date has passed, even if it still has insulin left in it. The Food and Drug Administration (FDA) label for Refresh Tears (carboxymethylcellulose sodium) 0.5% (6/30/22) was retrieved on 6/17/26 from https://nctr-crs.fda.gov/fdalabel/services/spl/set-ids/329d1fe0-4432-4565-b7b1-65666bd86526/spl-doc?hl=Carboxymethylcellulose. It read in pertinent part, Discard 90 days after opening. II. Facility policy and procedure The Medication Storage policy, revised 5/16/26, was received from the nursing home administrator (NHA) on 6/16/26 at 9:00 a.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist (or designee) for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs policy. III. Observations On 6/11/26 at 4:00 p.m. the medication cart for the west hallway was observed with registered nurse (RN) #1. The following items were found: -One box of diphenhydramine (allergy medication) 25 milligrams (mg), expired May 2026; -One box of single use Genteal tears 0.1%, with two expiration dates of January 2026 and February 2026; and, -Four opened bottles of Latanoprost 0.005% with no open dates. On 6/11/26, the medication cart for the west hallway was observed with licensed practical nurse (LPN) #1. The following items were found: -Five bottles of Refresh tears eye drops (carboxymethylcellulose sodium) 0.5% with no open date; -Three bottles of Lantanoprost 0.005% with no open date; -One bottle of milk of magnesium, expired October 2025; -One bottle of magnesium oxide 400 mg with no expiration date; -One pen of Humalog insulin (short acting insulin) with no open date; and, -One pen of Lantus insulin (long acting insulin) with no open date IV. Staff interviews RN #1 was interviewed on 6/11/26 at 4:00 p.m. RN #1 said eye drops should be labeled with open dates because they were usually only good for 30 days once opened. LPN #1 was interviewed on 6/11/26 at 4:15 p.m. LPN #1 said insulin pens should always be labeled once they come out of the refrigerator with an open date. LPN #1 said he did not know that eye drops needed to be labeled with an open date. The director of nursing (DON) was interviewed on 6/16/26 at 9:12 a.m. She said the night shift nurses were responsible for auditing the medication carts during their shift. The DON said the nurses should not be administering expired medications and it was part of the five rights of medication administration to check the expiration date prior to administration. The DON said the expectation was to label medications with shortened expiration dates with an expiration date once they were opened. The DON said this was to ensure that expired medications were not being administered. IV. Additional observations The medication storage closet on the [NAME] unit was observed on 6/15/26 at 3:15 p.m. The closet was located in the main hallway next to residents' rooms. The door to the closet had a lock, however it was not locked. In the closet following items were observed: -Two baskets with ten heparin (blood thinner) syringes, one basket with five large bags of intravenous fluid (IV) solution and IV starting kits. The medication storage room on the East unit was inspected on 6/15/26 at 3:25 p.m. It was located in the hallway next to the residents' rooms and was unlocked. The storage room contained multiple wound care supplies, personal care supplies, vinegar solution, soap, disinfecting wipes, hand sanitizers, and multiple bottles of whirlpool disinfectant. V. Staff interview The DON was interviewed on 6/15/26 at 3:45 p.m. She said heparin and IV solutions were medications and should not be kept in unlocked storage. She said all medications should be kept locked and out of reach of residents. She said the storage room on the East unit should be always locked and as the room contains chemicals that should not be accessible to residents. She said she will inspect both rooms immediately and provide education to nursing staff to keep the storage room locked. The DON was interviewed again on 6/15/26 at 4:15 p.m. The DON said all medications were removed from the [NAME] closet unit and the storage room on the East side was locked.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#30) of five residents reviewed for antibiotic stewardship out of 31 sample residents. Specifically, the facility failed to ensure Resident #30's long term use antibiotic was evaluated for appropriate use.Findings include:I. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 4/27/26 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, To track how and why antibiotics are prescribed, providers perform reviews on resident medical records for new antibiotics started to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.II. Facility policy and procedureThe Antibiotic Stewardship policy, dated December 2016, was provided by the nursing home administrator (NHA) on 6/16/26 at 12:40 p.m. It read in pertinent part, Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. At least annually or per facility policy, each attending physician shall be provided feedback on their antibiotic use data in the form of a written report to improve prescribing practices and resident outcomes. Feedback may include: Clinical justification for the use of an antibiotic beyond the initial duration ordered such as a review of laboratory reports/cultures in order to determine if the antibiotic remains indicated or if adjustment to the therapy should be made.III. Resident #30A. Resident statusResident #30, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic kidney disease and history of recurrent urinary tract infections (UTIs). The 6/16/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was incontinent of bowel and bladder and was on antibiotics. B. Record reviewReview the June 2026 medication administration record (MAR) revealed the resident was receiving Cephalexin (antibiotic) 250 milligram (mg) every day for UTI prophylaxis. Starting on 1/2/26.The provider note, dated 1/2/26, documented the resident requested to be on antibiotic prophylactically that she has been on for years. The resident reported a pouch was found on last imaging in her bladder that causes recurrent bladder infection. The resident had brought the medication from home. The note documented the provider verified she took cephalexin 250 mg and placed an order for every evening. The nurse practitioner (NP) note documented on 1/2/26 by NP #1 documented Resident #31 had a history of recurrent UTIs and a bladder pouch. NP #1 documented that he educated the resident on the potential of multi drug resistant organisms (MDROs) development due to long term use of antibiotics. However, the resident refused to discontinue.IV. Staff interviewsThe infection preventionist (IP) was interviewed on 6/16/26 at 10:35 a.m. The IP said she worked in the facility part time on temporary bases until a permanent IP position was filled. She said she started in April 2026. She looked through the binder that contained antibiotic stewardship reviews for residents on antibiotics. She was not able to locate documented rationale for the long term antibiotic use for Resident #31. She said it was missed and not documented, and she did not know why the resident was on antibiotics.Registered nurse (RN) #2 was interviewed on 6/16/26 at 11:06 a.m. She said she did not know the resident was on antibiotics. She reviewed the record and confirmed that the resident was on antibiotics. She said she did not know why the resident was on antibiotics. She said the resident did not have any signs or symptoms of UTI and did not have any ongoing acute infections. She said long term use of antibiotics was not recommended as it could result in development of resistance to an antibiotic. NP #1 was interviewed on 6/16/26 at 11:36 a.m. He said to his knowledge the long term use of antibiotics was prescribed by a urologist. He said continuing use of antibiotics per resident's request was not appropriate. He said he believed there was a recommendation from a urologist.However, no additional documentation from urology was provided by the facility or located in the resident's electronic record.

Based on interviews and record review, the facility failed to protect and promote an environment free from resident-to-resident sexual abuse. The facility failure affected four of four residents (#1, #2, #3, and #4) out of seven sample residents and contributed to incidents of abuse by Resident #2 and #4. Residents #1 and #2 resided in the facility's secured unit. Fourteen residents resided in the secured unit: four male (including Resident #2) and 10 female (including Resident #1). Residents #3 and #4 resided in the non-secured unit. Resident #2 had a history of being verbally sexually inappropriate toward female residents and staff. On 2/5/25, staff observed Resident #2 grabbing the breast of female Resident #1 and lifting her shirt. When told to stop, Resident #2 stated, She likes it. Although Resident #2 was placed on one-to-one supervision from 2/5/25 until 2/7/25 at 9:30 a.m. when his medication was changed, interviews with staff revealed that not all staff were aware of Resident #2's inappropriate behavior toward Resident #1, were not educated on how to respond to his behavior toward female residents, and were not monitoring his behavior. Resident #4 had a history of being sexually inappropriate with female residents and staff. On 8/8/24, staff observed Resident #4 rubbing Resident #3's left breast. Although the facility updated Resident #4's care plan to read Resident #4 was to be seated next to male residents in group settings, interviews with staff on 2/25/25 revealed they had not been informed of the resident's inappropriate behavior toward female residents and on 2/26/25, Resident #4 was observed sitting at the nurses' station within arm's reach of a female resident. The facility's failure to inform and educate staff on Resident #2 and Resident #4's sexually inappropriate behaviors, monitor the residents' behaviors, and implement planned interventions created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm could occur. Cross-reference F744 - failure to ensure a resident diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Cross-reference F867- failure to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #2, who was admitted to the facility in November 2022, had a history of being verbally sexually inappropriate to staff and female residents. The facility failed to prevent Resident #2 from grabbing Resident #1's breast on 2/5/25. The facility's response to the incident on 2/5/25 was one-to-one supervision of Resident #2 until Resident #2's medical provider could see him. Once the provider saw him and ordered a medication change, one-to-one supervision was lifted on 2/7/25 at 9:30 a.m. However, based on interviews and observations, staff were not aware of Resident #2's sexually inappropriate behavior and left Resident #2 alone with female residents. Resident #4, who was admitted to the facility on [DATE], had a history of sexual behavior toward female staff. On 8/8/24, Resident #4 was observed by a staff member rubbing Resident #3's left breast. The resident's care plan, initiated on 8/8/24, revealed the resident was to sit next to other male residents in group settings to mitigate risk of inappropriate expressions towards other residents. However, on 2/26/25, Resident #4 was observed sitting at the nurses' station within arm's reach of a female resident. Staff interviews on 2/25/25 revealed that staff were unaware of the resident's inappropriate behavior and the intervention not to place him next to female residents. The facility's failure to inform and educate staff on Resident #2 and Resident #4's sexually inappropriate behaviors, monitor the residents' behaviors, and implement planned interventions created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm could occur. On 2/26/25 at 2:45 p.m., the nursing home administrator (NHA) was notified that the facility's failure to protect and promote an environment free from resident-to-resident sexual abuse created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 2/27/25 at 10:18 a.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: Immediate actions: Nursing home administrator (NHA) assigned a one-to-one staff member to ensure that Resident #1 and other residents were protected from Resident #2. The one-to-one supervision will continue until 2/27/25 then additional staff will be added to the schedule on all shifts indefinitely for the secured unit. This will help ensure that all residents on the secured unit will be safe. Beginning on 2/26/25 all staff that were currently working and all staff prior to the upcoming shift will be educated regarding the sexualized behaviors of Residents #2 and #4 and identified interventions as listed on the care plan. Education will be provided by written, verbal, and or digital means (Workday) for all resident's sexual expressions of need. All working staff were to have completed this as of 2/27/25. Starting on 2/26/25, identify other residents residing in the facility that have demonstrated sexual expressions of need (behaviors) in the past 6 (six) months and ensure that appropriate care plan interventions were in place. Starting on 2/26/25, immediate review of resident information sheets to ensure that interventions were in place for residents with inappropriate behavior. Education to be provided to clinical staff (nurses and certified nurse aides) regarding newly added expressions of need and interventions. Identification of other residents at risk: Residents at risk identified include all female residents residing in the facility. Sustainable fix: Implement a shift-to-shift report book with an emphasis on communicating expressions of need (behaviors) exhibited by residents on all units of the facility. Residents with active expressions of need will be identified in the shift-to-shift book. The oncoming shifts, both eight-hour and 12-hour shifts, will review and sign prior to the start of shift, this includes both nurses and CNAs (certified nurse aides). Events will be opened when new or changed expressions of need were noted. Events were to stay open until reviewed by the behavioral management team (BMT) and closed upon no expressions identified for 48 hours or stable with current interventions. Social services and/or nurse managers or their designee to ensure all residents demonstrating sexual expressions of need have a care plan and interventions in place. Any change in interventions or plan of care will result in an update to the resident information sheet (RIS). Monitoring: Shift-to-shift report book for all units will be monitored/reviewed by a secure unit manager, nurse manager or designee daily for one week, weekly for two weeks, monthly for two months All expressions of need events will be reviewed by the interdisciplinary team (IDT) or off-business hours designee daily for one week, then weekly per IDT BMT meeting. The event will be closed with demonstration of successful intervention and resolution of expressions of need. During the IDT BMT meeting, care plans will be audited based on the previous week events to ensure appropriate interventions were in place. Review and update the RIS will be a part of the IDT BMT review process documentation. C. Removal of immediate jeopardy On 2/27/25 at 3:20 p.m., the NHA was notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan and evidence of implementation of the measures outlined in the plan. However, deficient practice remained at an E level, a pattern with the potential for more than minimal harm. Interviews conducted on 2/27/25 verified that staff had been educated on sexual abuse and resident behaviors per the facility plan to remove the immediate jeopardy. -CNA #7 was interviewed on 2/27/25 at 10:55 a.m. He said he was assigned to provide Resident #2 with one-to-one supervision. He said that he was monitoring for any sexually inappropriate behaviors. He said that interventions were listed on the RIS. He said the RIS also gave tips on how to redirect. He also stated that there was a communication book that CNAs and nurses were supposed to use to write or check if there were any changes in resident behavior. -Licensed practical nurse (LPN) #3 was interviewed on 2/27/25 at 11:05 a.m. He said that he was updated on monitoring for any sexual behaviors for Residents #2 and #4. He said that they were supposed to keep them away from females. He also said that there was a new binder for communication for updating the next shift on any new behaviors. -CNA #5 was interviewed on 2/27/25 at 11:10 a.m. She said Resident #4 was known to be sexually inappropriate with female residents and female care providers. CNA #5 said Resident #4 should only be cared for by a male CNA or two female CNAs. CNA #5 said she had worked the hall four days ago and noticed the RIS had been updated for Resident #4's behaviors toward females. -CNA #4 was interviewed on 2/27/25 at 11:12 a.m. She said that she was educated on Resident #2 and how to monitor for his sexually inappropriate behaviors, who to report them to, new interventions on the RIS, and about the new communication binder for nurses and CNAs. She said that she worked only on the secured unit. -RN #1 was interviewed on 2/27/25 at 11:15 a.m. She said she had been educated on Resident #4's behaviors and that he should not be seated next to female residents due to inappropriate behaviors towards them. RN #1 said a new communication book was implemented for any staff member to document behaviors, and as the assigned floor nurse, she was required to review them. -CNA #2 was interviewed on 2/27/25 at 11:15 a.m. She said that she was educated on both Resident #2 and Resident #4, about their sexually inappropriate behaviors, who to report to, and to use the communication book to update the next shift. She said that they were also to refer to the residents' RIS for any updates. -Dietary aide (DA) #1 was interviewed on 2/27/25 at 2:11 p.m. She said that she was educated on both Resident #2 and Resident #4. She said that she was taught how to redirect them when they were sexually inappropriate and, if that behavior did happen, to report it to the charge nurse or the director of nursing ( DON). -Director of therapy (DOT) was interviewed on 2/27/25 at 2:34 p.m. The DOT said that her entire department was educated together on both Resident #2 and Resident #4. She said they were educated on their sexually inappropriate behaviors. She said that if either of the residents had any of those behaviors, they would let the charge nurse know. II. Facility abuse policy The Abuse Prevention policy, revised on 1/18/24, was received from the NHA on 2/25/25 at 2:02 p.m. It read in pertinent part: The facility does not condone resident abuse. Residents must not be subjected to by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends or other individuals. The facility has developed a staff screening, orientation, education and policy and procedure to prevent physical, mental, verbal abuse, or misappropriation of resident funds and possessions. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. All employees must immediately report to the administrator or their supervisor any suspected, observed or reported incident of a crime, whether by staff members, family members, or any other persons. The facility will conduct an internal investigation. That investigation includes interviewing any staff members, residents or family members/responsible party who might have knowledge of the crime. In each case of suspected or alleged abuse, the resident will be protected from any further abuse. Actions, as deemed necessary by the administrator or designee, will be implemented immediately. Upon completion of the investigation, the administrator or designee will prepare a written summary. The facility assesses each potential resident prior to admission. This assessment includes behavioral history. Persons with significant history or high risk of violent behavior were not knowingly admitted to the facility. If a resident experiences a behavior change resulting in aggression toward other residents the facility arranges for a psychiatric evaluation of the resident. The resident's care plan was revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization , can then be implemented. Incidents were considered for the QAPI (quality assurance and performance improvement) program and investigations were monitored quarterly by the quality improvement committee. III. Incident on 2/5/25- Sexual abuse of Resident #1 by Resident #2. A. Resident #2 - assailant 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), the resident's diagnoses included unspecified dementia severe, cognitive communication deficit, and depression. The 1/7/25 minimum data set (MDS) assessment revealed that Resident #2 was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. The assessment revealed that he needed partial to moderate assistance with most of his activities of daily living (ADL). The MDS assessment further revealed that Resident #2 did not have any verbal behaviors directed towards others. However, interviews with staff and record review indicated otherwise (see below). 2. Record review Record review revealed documentation of Resident #2's sexually inappropriate comments. The expressions of need (behavior) care plan, last reviewed on 1/22/25, documented that Resident #2 had inappropriate comments evidenced by making sexual or rude comments about people's physical appearance. Interventions listed were: redirect Resident #2's attention following adverse interaction, ensure Resident #2 was part of group conversation and one-to-one conversation when his interactions were appropriate, assess whether the aggression endangered Resident #2 or other residents, intervene if necessary, seat Resident #2 where constant or near constant observation if possible, and maintain a calm environment. The record revealed a nursing note dated 2/5/25 at 2:36 p.m. that documented a staff member reported Resident #2 inappropriately touched a female resident. It documented that an event was opened and that the family and provider were notified. The record revealed a nursing note dated 2/5/25 at 10:13 p.m. that documented a staff member reported Resident #2 had made sexually inappropriate comments toward staff while assisting the resident with his shower. The resident was noted to have attempted to kiss the staff member when the staff member was assisting the resident with shaving. No further sexual comments or behaviors were noted during the shift. Expressions of need charting (behavior monitoring and charting) was initiated by the facility on 2/5/25 after the incident with a female resident and discontinued on 2/19/25. However, there was no documentation showing what discussions were held and what factors were considered for discontinuing behavior monitoring and charting on 2/19/25. The record further revealed that Resident #2's care plan, which read the resident made inappropriate sexual or rude comments (see above), was not updated to include Resident #2's behavior of touching female residents. B. Resident #1 -victim of sexual abuse 1. Resident status Resident #1, age 81, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Alzheimer's disease, stage two kidney disease, depression, and anxiety disorder. The 11/28/24 MDS assessment revealed that Resident #1 was unable to complete the brief interview for mental status assessment. The staff assessment revealed that she had short-term and long-term memory deficits. The staff assessment further revealed that she was moderately impaired in her daily decision-making. The MDS assessment revealed that Resident #1 wandered and ambulated without assistance and needed moderate to partial assistance with most of her ADLs. 2. Record review There were no progress notes in the electronic medical record (EMR) for Resident #1 concerning the incident on 2/5/25. Expression of needs progress notes (behavior monitoring and charting) were initiated on 2/5/25 and were discontinued on 2/19/25. However, there was no documentation showing what discussions were held and what factors were considered for discontinuing behavior monitoring and charting on 2/19/25. The comprehensive care plan documented Resident #1 had physical aggression, such as hitting and swearing at others. She also had a history of verbal aggression toward staff and other residents (initiated on 11/27/24). There was no reference to the incident with Resident #2 on her care plan. 3. Resident representative interview Resident #1's responsible party was interviewed on 2/27/25 at 9:30 a.m. She said her mother had dementia, but if she was in her right mind, she would have been enraged by being touched by someone inappropriately. C. Facility response to the incident on 2/5/25 involving Resident #1 and Resident #2 1. Facility incident report The 2/5/25 facility incident report revealed that a staff member working on the secured unit witnessed Resident #2 grabbing Resident #1's breast and, when told to stop, the resident said, She likes it. The report further read: - The facility staff separated the residents and notified social services, APS (adult protective services), the police, the ombudsman, and Resident #2's provider. - Immediate interventions included one-to-one supervision of Resident #2 until he was seen by his provider and monitoring for any sexual behaviors toward female residents. 2. Facility investigation The facility investigation on 2/5/25 of the incident involving Resident #2 and Resident #1 revealed that Resident #1 and #2 resided in the secured unit, and both residents were interviewed. Resident #1 was interviewed on 2/5/25 but had no verbal response to the incident. Resident #2 was not interviewed until 2/7/25 (two days later) and did not recall the incident. The investigation further revealed that Resident #2 was seen by the nurse practitioner (NP) on 2/7/25, and a medication change occurred. The NP put the resident on 5 mg (milligrams) of methimazole, an antithyroid medication, for agitation and hypersexual behaviors. D. Failures in facility response 1. See above; Expressions of need charting (behavior monitoring and charting) for Resident #2 and #1 was initiated by the facility on 2/5/25 after the incident with a female resident and discontinued on 2/19/25. There was no documentation showing what discussions were held and what factors were considered for discontinuing behavior monitoring on 2/19/25. 2. See above; Resident #2 started a new medication on 2/7/25 to address agitation and hypersexual behaviors. There was no documentation that staff was monitoring the medication for effectiveness. Further, as of 2/25/25 (during the survey), the provider had not seen the resident to assess the resident's behavior and the effectiveness of the medication. 3. See above; neither Resident #2 nor Resident #1's care plan was updated to reference and address the incident on 2/5/25 to prevent a recurrence. A review of the record revealed that Resident #2's care plan had not been updated with his inappropriate touching of female residents, and no new interventions were put in place. A review of the record revealed that Resident #1's care plan had not been updated to document the 2/5/25 incident and to monitor her for a potential psychosocial response. 3. See below; staff interviews revealed not all staff were aware of Resident #2's sexually inappropriate behavior. E. Observations On 2/25/25 at approximately 10:20 a.m., it was observed that the secured unit was separated from the rest of the facility by doors that were locked. A code was needed to enter and leave the unit. It was noted that the nurse who cared for the secured unit was assigned part of the non-secured hallway, too, and was not constantly on the secured unit. On 2/25/25 at 10:32 a.m., Resident #1 was observed in the common area, bent over, wiping furniture, doors, and windows with a yellow grippy sock. Resident #2 was observed in his room in his bed. On 2/25/25 at 10:39 a.m., the activities staff was seen entering the common area and inviting residents to listen to him read the Daily Chronicle. Resident #1 was still in the common area bending over and touching chairs and pulling open drawers and wandering around in the common area. Resident #2 was present in the common area for the activity. On 2/25/25 at 11:15 a.m., the activities staff was reading the Daily Chronicle in the common area. Both CNAs were in different rooms, providing care with the doors closed. The nurse was not on the unit. Resident #1 was still in the common area bending over and touching objects in close vicinity of Resident #2. Residents #1 and #2 were not in constant or near-constant observation by staff. On 2/25/25 at 11:28 a.m., the registered nurse (RN) entered the unit to pass medications to other residents. On 2/25/25 at 11:40 a.m., both Resident #1 and Resident #2 were in the common area, sitting at different tables but still very close to each other. One CNA, often with her back to Residents #1 and #2, was passing drinks. The other CNA was gathering residents to come to the common area in preparation for lunch. On 2/25/25 at 1:22 p.m., Resident #1 was observed sleeping in a double occupancy male room on the bed that was currently open. CNAs were observed walking past the room and not waking her to move to her own bed. On 2/25/25 at 1:36 p.m., both CNAs were in different rooms providing care with the doors closed. There were seven residents in the common area, and the RN was not on the unit. Resident #2 was in his room with the door open, and Resident #1 was wandering the common area and hallways. On 2/25/25 at 4:03 p.m., Resident #2 was in the common area eating a snack. Resident #1 was wandering around the common area. The CNAs were not consistently in the area, entering and leaving frequently to assist other residents. The nurse was not on the unit. On 2/25/25 at 4:04 p.m., Resident #1 was walking around the common area, bent over touching different items in close proximity to Resident #2. The CNAs were not consistently in the area, entering and leaving frequently to assist other residents. The nurse was not on the unit. On 2/25/25 at approximately 6:00 p.m., Resident #2 was put on a one-to-one supervision. F. Staff interviews Staff interviews revealed that not all staff were aware of Resident #2's inappropriate sexual behavior toward female residents. 1. CNA #4, who worked on the secured unit, was interviewed on 2/25/25 at 1:41 p.m. CNA #4 said that if there was a situation between residents, she would try to de-escalate the residents and then go and tell the nurse. If the residents were on any kind of behavior precautions, she said she would get that information from the nurse and through report. CNA #4 said she would also look for any open events in the electronic medical record (EMR). She said the charge nurse usually did rounds on the secured unit about every two hours if they were not too busy. CNA #4 said that she was unaware of any sexual situation that had happened between Resident #1 and #2 and was unaware of any behavior monitoring for Resident #2. 2. RN #2, who worked as a floor nurse and was assigned to the secured unit and a non-secured hallway, was interviewed on 2/25/25 at 1:45 p.m. He said that the CNAs working the secured unit let him know if any behaviors had happened. He said he did medication pass around 7:00 a.m. or 8:00 a.m. on the secured unit, and it took him about two hours to complete the medication pass. He said that if the CNAs needed anything on the secured unit, they had a walkie-talkie that they could use to call the charge nurse over. He said they really relied on the CNAs to communicate anything concerning that they saw or heard. He said that he had heard about the incident between Residents #1 and #2 and that they were charting on both residents' expressions of need while the event was open. He said he had observed Resident #2 reaching for Resident #1's breast on a different day, but he had not made physical contact. He said that if the resident had made contact, he would have reported it to social services (SS) or the director of nursing (DON) and then filled out a report. 3. CNA #3, who worked on the secured unit, was interviewed on 2/25/25 at 4:04 p.m. She said she learned of any behaviors through report. She said there was normally a clipboard on the podium (located just outside the common area in the secured unit) that would give them information. She said that if there was a change in a resident's care plan, there was a piece of paper that staff had to sign to show they had read the updated care plan in the report room. She said she did not think that staff was monitoring Resident #2 for anything except for self-transferring. She said that she was unaware of any sexually inappropriate incident between Residents #1 and #2. 4. LPN #1, who worked on the secured unit, was interviewed on 2/25/25 at 4:19 p.m. She was working the floor as a CNA. She said she got new information from the verbal shift report. She said she also looked at open events. She said they monitored residents for behaviors every day by keeping eyes on all the residents. She said that she had heard about the incident between Residents #1 and #2 and said she had asked the CNAs if there were any behaviors exhibited by either of the residents when the event was open. 5. LPN #2, who worked on the secured unit, was interviewed on 2/25/25 at 4:26 p.m. She said that they really relied on the CNAs to communicate with the nurses. She said she had heard about the incident between Residents #1 and #2. She said that they were monitoring Resident #2's expressions of needs when the event was open. However, progress notes for Resident #2 revealed the interdisciplinary team (IDT) closed the 2/5/25 event on 2/19/25, and sexually inappropriate behavior monitoring stopped, except for one submission on 2/20/25 from the night shift nurse who charted at 6:30 a.m. at the end of her shift. 6. The DON was interviewed on 2/25/25 at 4:54 p.m. She said that if an event was being opened for a resident, nursing staff documented on the event. She said there was a chart that the nurses followed that determined how often they had to chart on that particular event. She said that behaviors should be charted on every shift and the nurse was to chart in the EMR under event charting. She said that if the event was a new type of event for the resident, there should be a prepopulated template for the care plan. If there was not a template, then the MDS coordinator would review the event the next business day. She said care plans were reviewed on admission and then quarterly, and anyone who had access to the EMR had access to the care plans. CNAs did not have access to the care plan; they got their information from the Resident Information Sheet (RIS) and from the preference binders that were found in each report room. She said staff were notified of new interventions and what to monitor for on education sheets that were placed in report rooms, and the staff development coordinator (SDC) monitored to ensure staff had read the education sheet. She said that there were 14 residents in the secured unit; four residents were male, and 10 residents were female. She said that she did not have any staffing concerns for the secured unit. She said agency staff was trained by going through orientation if they had never worked in one of their facilities before. Behavior and care concerns were reported to agency staff through verbal reports and by what was on the RIS. She said that her expectations for the nurse assigned to the secured unit to monitor both the secured and non-secured unit was to use the secured unit as their home base. The nurse should be doing their charting on the secured unit. The only time they should be off the secured unit was when they were providing care to the residents on the non-secured unit. She said that they were in the process of implementing a walkie-talkie system. She said that at night, the CNA should have the walkie-talkie on them at all times, but the day shift could use it as well. She said that CNAs charted in a separate system, but she was not as familiar with what or where the CNAs charted. She said that the incident report for the 2/5/25 event was filled out by the social services director (SSD). She said that the interventions were to keep Resident #2 separate from Resident #1, and staff were to monitor Resident #2. She said that there were no audits done on the monitoring of Resident #2. She said that the event was closed based on the IDT notes. However, see above; IDT notes about the closing of the event were not found in the EMR. 7. The NHA was interviewed on 2/25/25 at 5:32 p.m. She said new behaviors caused an event to be opened, and they had an IDT meeting where they discussed behavior monitoring and if interventions were meeting the resident's needs. The NHA said that floor staff did a small huddle where they met and discussed interventions put in place for a resident. 8. The SSD was interviewed on 2/26/25 at 9:24 a.m. The SSD said the nurse notified her on 2/5/25 about the incident involving Residents #1 and #2. The SSD said that nursing provided the assessment for Resident #1. The SSD said that she then interviewed three other residents who resided in the secured unit on the day of the incident. The SSD said she also interviewed the staff members who witnessed the incident. She said she did not interview Resident #2 the same day as the incident because she was more concerned about Resident #1. She said that since Resident #2 was on one-to-one supervision, he did not have access to Resident #1. However, see above; Resident #2's one-to-one supervision was removed on 2/7/25. 9. The NHA was interviewed again on 2/26/25 at 9:43 a.m. She said that there was not any formal education provided to the staff regarding the 2/5/25 incident. She said that education was completed verbally. The NHA said that CNAs did not document resident behaviors but were to verbalize the behaviors to the nurse, who in turn was to document the behaviors in the EMR. The NHA said they would now be initiating a communication binder for CNAs, starting 2/26/25. The NHA said the facility closed the event for Resident #2 because he had not shown any behaviors, and it seemed that the medication regime had returned him to his baseline. However, see above; Resident #2 had not been seen by the provider for an effective response to the new medication started on 2/7/25 (see below). 10. The nurse practitioner (NP) was interviewed on 2/26/25 at 10:54 a.m. She said Resident #2 was prescribed Methimazole due to low thyroid level, and low l[TRUNCATED]

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement Plan (QAPI) policy and procedure, reviewed April 2022, was received from the nursing home administrator (NHA) on 2/27/25 at 6:39 p.m. It revealed in pertinent part, The purpose of QAPI is to take a proactive approach to continuously improving the way we care for and interact with our residents, caregivers, and family members/responsible parties so we are able to realize our vision to provide quality health care services to our residents while promoting individual choice, resident satisfaction and employee retention. To do this, all employees will participate in ongoing QAPI efforts which support our mission and vision. QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals. The facility makes decisions based on data, which includes the input and experience of caregivers, residents, health care practitioners, families, and other stakeholders. The QAPI Steering Committee and facility QAPI teams will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in the daily life of our residents. This will be achieved by utilizing the current evidence (data, national benchmarks, published best practices, clinical guidelines) and benchmarks. Clinical Care: Levels of care: post-acute care/rehabilitation, chronic care management, dementia care and services, end of life/hospice care, social services, dietary, nursing services, MDS (minimum data set assessments), medication management, infection prevention, wound care, assistance with activities of daily living and restorative care. Data shall be collected from multiple sources to monitor the care and service areas defined above, including the following: input from caregivers, residents, families, and others, adverse events, performance indicators, survey findings and complaints. Data is collected and analyzed at both the facility and corporate level. The facility QAPI team reviews the data and compares against available benchmarks and/or established targets, then uses the information to charter facility level Performance Improvement Projects (PIPs). II. Review of the facility's regulatory record revealed it failed to operate a QA (quality assurance) program in a manner to prevent repeat deficiencies and initiate a plan to correct F600 Free from abuse and neglect During the recertification survey on 4/11/24, F600 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the abbreviated survey on 2/27/25, F600 was cited at a J scope and severity, immediate jeopardy to resident health or safety, isolated. III. Cross-reference citations Cross-reference F600: The facility failed to ensure residents were protected from resident-to-resident sexual abuse. The facility's failure to protect residents from resident-to-resident sexual abuse put residents in a situation where a serious outcome occurred and created an immediate jeopardy situation. IV. Staff interviews The NHA was interviewed on 2/27/25 at 6:05 p.m. The NHA said the QAPI committee consisted of the medical director, the director of nursing (DON), the staffing coordinator, the medical records director, the infection preventionist, the wound care/restorative nurse, the dietician, the pharmacist and the NHA. The NHA said the QAPI committee met monthly and would discuss any concerns that had been identified from current issues in the facility, such as events/occurrences and infections. The NHA said the facility did not have a PIP for abuse in place since they were put back into compliance from the last recertification survey (April 2024). -The facility had not previously identified any concerns related to abuse, despite the facility being cited for abuse on their last recertification in April 2024.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of one resident who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being out of seven sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #1. Cross reference F600: failure to protect Resident #1 from abuse. Findings include: I. Facility policy and procedure The Dementia Care policy, dated 7/1/24, was provided by the nursing home administrator (NHA) on 2/27/25 at 4:20 p.m. it read in pertinent part, Each resident who displays or is diagnosed with dementia will receive the appropriate treatment and services to attain or maintain his or her hightest practicable physical, mental and psychosocial well-being. An individualized, person-centered care plan will be developed for each resident through an interdisciplinary team (IDT) approach, which includes input from the resident and/or their representative. All approaches to care are monitored for efficacy, risks, benefits, harm and revised as necessary. Specialized support and services will be provided as necessary. Expressions of need may represent a resident's attempt to communicate. Use of the Dementia Tool is encouraged, which includes communication techniques. The Expression of Need Management policy, revised 3/7/24, was proved by the NHA on 2/27/25 at 4:20 p.m. It read in pertinent part, Expression(s) of need (previously known as behaviors) will be handled in a professional and caring manner in order to not endanger either the resident or others. Necessary care and services will be provided with a person-centered approach that reflect the resident's goals, while maximizing the resident's quality of life. The IDT team shall monitor residents on-going for expression(s) of need. If a resident has a history of expressions of need that have been care planned, the plan of care will be followed to reduce, eliminate, or manage the expressions. Upon identification of a new or worsening expression of need, interventions will be implemented immediately and an event (incident) will be opened. Expressions of need will be reviewed by the IDT team. The care plan will be reviewed and revised or implement individualized approaches, including involvement in meaningful activities. The Dementia Tool, undated, was provided by the NHA on 2/27/25 at 4:20 p.m. It read in pertinent part: -Things that work in every situation, slow down (move slowly, talk slowly); -Approach from the front so the resident can see you; -Reduce stimulation; -Approach again later; -Do not scold, confront or become angry with the resident; -Use written reminders; and, -Use non-threatening approach II. Resident #1 A. Resident status Resident #1, age 81 was admitted on [DATE]. According to the February 2025 computerized physician's orders (CPO), diagnosis included Alzheimer's disease, stage two kidney disease, depression, and anxiety disorder. The 11/28/24 minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status. The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment further revealed she was moderately impaired in her daily decision-making. The MDS assessment revealed Resident #1 wandered and ambulated without assistance. She needed moderate to partial assistance with most of her activities of daily living (ADL). B. Observations On 2/25/25 at 10:32 a.m. Resident #1 was in the common area bent over wiping furniture, doors and windows with a yellow sock. On 2/25/25 at 10:39 a.m. the assistant activities director (AAD) entered the common area and began inviting residents to listen to him read the daily chronicle. Resident #1 was still in the common area bending over and touching chairs and pulling open drawers and wandering around in the common area. Resident #1 was not invited to the activity. On 2/25/25 at 11:15 a.m. The AAD was reading the daily chronicle in the common area. Both certified nurse aides (CNA) were providing care to residents in their rooms with the doors closed. The nurse was not on the unit. Resident #1 was still in the common area bending over and touching objects. -Resident #1 was not in the direct line of sight of a staff member as directed on the resident's plan of care (see record review below). On 2/25/25 at 1:22 p.m. Resident #1 was sleeping on a bed in a double occupancy male room. CNA #2 and CNA #4 walked past the room and did not encourage Resident #1 to return to her bed. On 2/26/25 at 12:17 p.m. Resident #1 was walking up and down the secured unit hallway. She was pushing another resident's wheelchair trying to get them to move faster. The staff did not redirect her. On 2/27/25 at 2:16 p.m. Resident #1 was sitting on a love seat at the end of the hallway, alone. Staff was at the front of the unit conversing with each other while an activity was being run in the common area. -Resident #1 was not in the staff's near-constant observation, per the resident's plan of care (see record review below). C. Record review The activities care plan, revised on 12/5/24, revealed the resident was very pleasant and at times spoke in nonsensical sentences. The care plan documented that Resident #1 was interested in holding and caring for a baby doll, spending time outdoors, listening to music and her religion. Interventions included offering one-to-one visits for social interactions, offering walks and going outdoors, encouraging Resident #1 to join group activities of possible interest and offering material needed for activities of interest such as a baby doll. The expressions of need care plan, revised on 2/19/25, revealed Resident #1 experienced physical aggression such as hitting or swearing at others. Interventions included giving her a baby doll or other items of comfort, separating her from the other residents, assisting Resident #1 to sit where constant or near-constant observation was possible. -However, observations revealed the resident was not always in near-constant supervision of sight of staff and was not offered her baby doll (see observations above). The 11/25/24 nursing progress note documented Resident #1 was wandering and going from room to room. The note revealed this was not a new behavior. The 11/26/24 nursing progress note documented Resident #1 remained restless and ambulated around the secured unit touching other residents. -Review of the resident's electronic medical record (EMR) did not reveal the staff tried any interventions to prevent Resident #1 from touching other residents. The 11/28/24 nursing progress note documented Resident #1 had agitation and aggression. She was attempting to pull food away from other residents. She was also entering other resident's bedrooms and trying to pull their blankets away from them. She was attempting to hit and pinch staff. -Review of the EMR revealed that the staff administered Ativan (antianxiety medication), but it was not always effective and the floor staff tried to provide supervision and redirection but, it was not always effective. The 12/1/24 nursing progress note documented Resident #1 was wandering and touching other residents. The 12/3/24 nursing progress note documented Resident #1 was showing signs of aggression towards a male resident. The 12/4/24 nursing progress note documented Resident #1 was wandering, going from room to room and was touching other residents. The note documented this was not a new behavior. The 2/12/25 nursing progress note documented Resident #1 continued to wander the secured unit and she was not always careful or aware of her surroundings. The 2/13/25 nursing progress note documented Resident #1 wandered from room to room on the secured unit. The 2/14/25 nursing progress note documented Resident #1 was wandering from room to room with her head down. The 2/17/25 nursing progress note documented Resident #1 was wandering from room to room. The 2/19/25 nursing progress note documented Resident #1 was up and wandering the secured unit. She was in and out of other rooms and beds. Review of the January 2025 and February 2025 activity participation sheets revealed Resident #1 had two social visits (one-on-one) with activities during the month of January 2025. According to the participation sheet for February 2025 (2/1/25 to 2/26/25), Resident #1 had not had any social visits. The participation sheet documented during most of the activities during the months of January 2025 and February 2025 Resident #1 was walking or was given water by a staff member. The resident information sheet (staff directive tool) for Resident #1 documented that the resident need to be in line of sight due to being a high fall risk. III. Staff interviews The NHA was interviewed on 2/25/25 at 5:32 p.m. The NHA said that all staff members received dementia training upon hire. CNA #5 was interviewed on 2/26/25 at 12:09 p.m. CNA #5 said Resident #1 wandered all day and would go in other resident's rooms and get into other resident's space. She said Resident #1 annoyed some of the other residents by wandering into their rooms or by getting into their personal space. She said the staff would intervene before the situations got physical. She said Resident #1 did not attend activities because she wandered too much and would not stay still. She said Resident #1 was not able to engage in the activities. CNA #6 was interviewed on 2/26/25 at 12:17 p.m. CNA #6 said Resident #1 wandered most of the time. CNA #1 said Resident #1 liked to touch and feel everything. He said she went into other residents'rooms and that annoyed the other residents. He said she did not do things to purposefully harm or annoy the other residents. He said Resident #1 had not been in any recent altercations with any of the residents. He said she was mostly the victim in the altercations with the other residents. He said it was hard to engage Resident #1 in activities because she will not sit in one place for very long. He said giving her a baby doll would sometimes help with her wandering. He said Resident #1 enjoyed warm baths to calm her down Registered nurse (RN) #2 was interviewed on 2/26/25 at 12:22 p.m. RN #2 said Resident #1 was alert and oriented to herself. He said she self-ambulateed and grabbed objects and other residents. He said she was easily redirectable. He said he did not know if there was anything that would keep her from entering into other resident's rooms. The assistant activities director (AAD) was interviewed on 2/26/25 at 12:26 p.m. The AAD said the activities staff tried to do one-on-one visits with Resident #1. He said if they happened to see her enter the room while they were doing an activity they would invite her over to join. CNA #8 was interviewed on 2/27/25 at 10:55 a.m. CNA #8 said that the activities department were going to try to add additional activities on the secured unit. He said they currently only had two activities that happen on the unit. He said it might help keep the behaviors down on the secured unit. The AAD was interviewed again on 2/27/25 at 3:25 p.m. The AAD said there was a binder in the activities office where they would track to see if a resident came to the activity. He said that there was also a special care book that was resident-specific. He said that they tried to do one-on-one visits with Resident #1. He said she would join current events or reminisce groups. He said that one-on-one visits happened one to two times a week. -However, the activity participation log revealed Resident #1 had two one-on-one visits in January 2025 and did not have any in the month of February 2025. The director of nursing (DON) was interviewed on 2/27/25 at 5:15 p.m. The DON said the staff on the secured unit should utilize the dementia tool (see facility policy and procedures above). She said Resident #1 typically wandered and the staff should redirect her. She said that Resident #1 wandered into other resident's rooms and laid in open beds. She said Resident #1 did not understand that the bed or the room was not hers She said the staff needed to redirect Resident #1 by offering her comfort items such as a baby doll to hold while walking. She said if Resident #1 was sleeping in a bed that was not hers, the staff should let her be if she was not affecting other residents. She said that there was a potential for another resident not liking that Resident #1 was sleeping in their bed. She said Resident #1 had been involved in several resident to resident altercations recently. She said Resident #1 was primarily the victim. She said a resident that wandered was at increased risk of altercations with other residents. The NHA was interviewed again on 2/27/25 at 5:30 p.m. The [NAME] said the staff were aware of which residents wandered. She said the staff should redirect residents who do not understand personal space, especially if they were in a dangerous situation. She said a resident laying in another resident's bed could be a dangerous situation.

Based on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents who resided in 13 of 15 rooms out of a sample of 70 resident rooms. Specifically, the facility failed to ensure resident rooms had safe, comfortable temperatures that did not exceed 81 degrees Fahrenheit (F). Findings include: I. Facility policy and procedure The Indoor Climate Control policy, reviewed on 8/15/23, was provided by the nursing home administration (NHA) on 8/5/24 at 12:52 p.m. The policy revealed the following considerations were made to ensure that the facility remained cool during the late spring and summer months: The facility had four rooftop air conditioning (AC) units to cool the facility's corridors. The AC units do not serve individual resident rooms. The facility team adopts other methods to help maintain resident room temperatures at comfortable and safe levels. These AC units were supported by the facility system maintenance team and serviced by contracted third-party vendors, as appropriate. The maintenance team would ensure that the units were in working order during the spring and would conduct regular maintenance checks during the summer months. In addition, the facility had one window AC unit installed on the secure unit to help maintain temperatures in the common sitting area. Throughout its operating history, the facility discovered that an effective way to maintain cool temperatures was to ensure windows were shut before the heat of the day increased (approximately 10:00 a.m.). Therefore, the staff was tasked with ensuring that resident room windows were closed and that client room doors remained open. This kept the warm outside air from entering the room and allowed the cooled corridor air to enter. The resident might choose to keep their window open, but the staff would advise that they keep their door closed, to lessen the warm air entering the facility. Residents might use a personal fan in their room to help with air movement and cooling. The social services and business office teams would work with residents/families to facilitate acquiring a fan, and the maintenance team would assist with installation. The facility's maintenance team directed the effort of frequently auditing resident room and common area temperatures throughout the facility. Any temperatures outside the regulated limits were noted for further investigation and potential repairs. II. Resident council minutes The resident council minutes, dated 4/5/24, revealed one resident said it got hot in the facility and asked if there was any way to get a better air conditioning system. The NHA said she would talk with the chief executive officer (CEO) of the company. The resident council minutes, dated 6/5/24, revealed the activity director (AD) reminded everyone that as it got warmer, the only way to keep the facility cool was to keep the windows closed during the day. The AD said if the residents wanted their room window open, then the room entrance door to the hallway needed to be closed. Residents were to let staff know if they needed a fan. The resident council minutes, dated 7/3/24, revealed the maintenance supervisor (MS) reminded the residents to keep their windows closed after 10:30 a.m. to help keep their rooms cooler. He said fans could be made available if rooms were really hot. He said, if the residents wanted their room window open, then the room entrance door to the hallway needed to be shut. III. Maintenance temperature log The July 2024 temperature log was provided by the MS on 8/5/24 at 3:51 p.m. The temperature log revealed the MS took temperatures on 7/11/24 for six resident rooms and the common area on the East hall. The temperatures ranged between 70 to 80 degrees F. No other temperatures were taken for the month of July 2024. IV. Resident room observations and interviews A. Resident #6 Resident #6 resided in room #East 107-2. The 6/26/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview mental status (BIMS) score of four out of 15. On 8/5 24 at 12:22 p.m. Resident #6 was seated in a wheelchair in her room watching television. She said she liked it warm in her room. A digital thermometer was placed in the room at this time. -At 12:49 p.m. the temperature in Resident #6's was 84 degrees F. B. Resident #7 Resident #7 resided in room #West 100-2. The 6/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. On 8/5/24 at 12:25 p.m. the resident was lying in her bed. A fan was blowing on the resident. She said sometimes in the afternoon it was very hot in her room. The door to the room was open only a few inches. A digital thermometer was placed in the room. -At 12:55 p.m. the temperature in Resident #7's room was 84 degrees F. On 8/6/24 at 9:16 a.m. Resident #7 was sitting in her room in a wheelchair and a fan was blowing on the resident. Her power of attorney (POA) was sitting on the resident's bed. The resident said she could only sleep at night when the fan was blowing on her. She said at times it was sticky hot and she sweated. The POA said at times the room was unbearable due to the heat and humidity and it was hard to breathe. The POA said the resident had told her at times, it was too hot in her room. The POA said she visited the resident often. C. Resident #20 On 8/5/12 at 12:58 p.m. Resident #20 was not in their room [ROOM NUMBER]-2, located in the special care unit. A digital thermometer was placed in the room. -At 1:47 p.m. the temperature in Resident #20's room was 84 degrees F. At 1:50 p.m. the unit manager (UM) of the special care unit observed the digital thermometer temperature reading and agreed on the room temperature. D. Resident #19 On 8/5/24 at 12:59 p.m. Resident #19 was not in their room [ROOM NUMBER]-1 located in the special care unit. A digital thermometer was placed in the room. -At 1:47 p.m. the temperature in Resident #19's room was 84 degrees F. At 1:50 p.m. the UM of the secure unit observed the digital thermometer temperature reading and agreed on the room temperature. E. Resident #18 On 8/5/12 at 1:01 p.m. Resident #18 was not in their room [ROOM NUMBER]-1 located in the special care unit. A digital thermometer was placed in the room. -At 1:49 p.m. the temperature in Resident #18's room was 84 degrees F. At 1:50 p.m. the UM of the secure unit observed the digital thermometer temperature reading and agreed on the room temperature. F. Resident #17 On 8/5/24 at 1:02 p.m. Resident #17 was not in their room [ROOM NUMBER]-1 located in the special care unit. A digital thermometer was placed in the room. -At 1:49 p.m. the temperature in Resident #17's room was 84 degrees F. At 1:50 p.m. the UM of the secure unit observed the digital thermometer temperature reading and agreed on the room temperature. G. Resident #16 On 8/5/24 at 2:27 p.m. Resident #16 was not in their room #West 128-1. A digital thermometer was placed in the room. -At 3:06 p.m. the temperature in Resident #16's room was 84 degrees F. H. Resident #8 Resident #8 resided in room #West 131-2. The 6/26/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. On 8/5/24 at 2:28 p.m. the resident was sitting on her bed and said it was often very warm in her room. A digital thermometer was placed in the room. -At 3:07 p.m. the temperature in Resident #8's room was 84 degrees F. On 8/6/24 at 9:22 a.m. Resident #8 said it was already hot in her room and when it was too hot she was sticky and uncomfortable. I. Resident #9 Resident #9 resided in room #West 127-1. The 7/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15 with no behaviors. On 8/5/24 at 2:32 p.m. Resident #9 was not in their room. A digital thermometer was placed in the room. -At 3:08 p.m. the temperature in Resident #9's room was 84 degrees F. Resident #9, who had returned to her room, said it was excessively hot in her room and she was not used to the heat. She said she had always had air conditioning in her home and in the previous assisted living facility. J. Resident #15 On 8/5/24 at 2:33 p.m. Resident #15 was not in their room #West 109-1. A digital thermometer was placed in the room. -At 3:49 p.m. the temperature in Resident #15's room was 84 degrees F. K. Resident #14 Resident #14 resided in room [ROOM NUMBER]-1 on the special care unit. The 5/28/24 MDS assessment revealed the resident had both short and long term memory problems with no behaviors. On 8/5/24 at 4:30 p.m. Resident #14 was sitting on the bed in her room. Her daughter was sitting on the bed beside her. -The resident's daughter had placed a digital thermometer on the bedside table and it was 90 degrees F in the room. Resident #14's daughter said she came to the facility almost every day around 2:30 p.m. and often stayed until 8:00 p.m. She said often her mother was unable to sleep at night because it was too hot in the room. She said the room was stuffy, uncomfortable and excessively hot for her mother. She said her mother was unable to communicate that it was too hot. Resident #14's daughter said, at times, she had difficulty breathing in the room from the heat. She said her mother had been in assisted living facilities before coming to this facility and the other places had air conditioning. L. Resident #12 Resident #12 resided in room #East 135-2 The 6/27/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. On 8/6/24 at 10:02 a.m. Resident #12 said it often was very hot on her side of the room. She said it often got excessively hot around 4:00 p.m. and it made her feel miserable. M. Resident #13 Resident #13 resided in room #East 135-1. The 5/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. On 8/6/24 at 10:12 a.m. she said her side of the room could really get hot, humid and sticky. She said she felt uncomfortable with the hot temperatures in the room. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/5/24 at 12:37 p.m. CNA #1 said one or two residents had told her that it was too hot in the facility. She said she thought it was too hot in the facility at times. CNA #2 was interviewed on 8/5/24 at 1:05 p.m. CNA #2 said a family member had told her the previous week that it was excessively hot on the secure unit. CNA #3 was interviewed on 8/5/24 at 1:14 p.m. CNA #3 said, at times during the middle of the day, it was excessively hot on the secure unit. CNA #4 and CNA #5 were interviewed together on 8/5/24 at 1:35 p.m. CNA #4 and CNA #5 said residents and family members had said it was excessively hot in the facility. Both CNAs felt that at times it was too hot in the facility, usually around 4:00 p.m. The MS was interviewed on 8/5/24 at 3:51 p.m. The MS said there were 70 resident rooms in the facility. He said the thermostat located at the East nurse's station controlled the temperature on the secure unit. He said the facility air conditioning system delivered cool air to the hallways and not into resident rooms. He said residents were informed to keep their room entrance doors open to get cool air from the hallway, into their rooms. He said all of the air conditioning units were functional and were integrated into the backup power generator system, if an electrical outage occurred. The MS said he took random air temperatures in the facility. He said for the month of July 2024, he took resident room temperatures only on one day. He said he took six resident room temperatures and one common sitting area room temperature on 7/11/24. The MS completed a walk through of the East nurse station and said the thermostat was set at 72 degrees Fahrenheit and the air temperature was 79 degrees Fahrenheit. He said the [NAME] nurse station revealed the thermostat was set at 70 degrees Fahrenheit and the air temperature was 81 degrees Fahrenheit. -However, observations of several rooms revealed digital thermometer readings above 81 degrees (see observations above). The NHA was interviewed on 8/5/24 at 4:53 p.m. The NHA said she was not aware the MS had only taken resident room temperatures on 7/11/24 and not more frequently. She agreed with the July 2024 resident room temperature log. She said the MS had not told her that there were hot temperatures in the facility. She said it was hot in the facility around mid-July 2024. She said when the staff told her it was too hot in the facility, she purchased neck fans for them. Licensed practical nurse (LPN) #1 was interviewed on 8/6/24 at 10:32 a.m. LPN #1 said the residents and their families had told her it was too hot in the facility at times. She said there had been times she observed temperatures in the facility about 81 degrees Fahrenheit. LPN #2 was interviewed on 8/6/24 at 10:45 a.m. LPN #2 said the residents and their families had said to her it was too hot in the facility and it made the residents feel tired. The NHA was interviewed again on 8/6/24 at 11:30 a.m. The NHA said she would like temperatures taken daily in different areas of the facility or at least every other day. She said she did not know there were temperatures over 81 degrees in the facility. She said the staff and the MS should let her know if there were hot temperatures in the residents' rooms. She said she did speak with the CEO regarding the 4/5/24 resident council minutes regarding hot temperatures in the facility.

Based on observations, record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for pressure injuries out of 36 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Resident #30 was admitted on [DATE] for long term care. At the time of the admission, the resident was identified as being at risk for developing pressure injuries. Upon admission, the resident's skin was intact and she did not have any pressure injuries. Resident #30 attended dialysis three times a week. On 10/7/23, a nurse documented Resident #30 developed a deep tissue injury (DTI) on her right heel. Preventative measures to protect the resident's heels were not implemented until after the development of the DTI on 10/7/23. On 10/12/23, the wound care physician classified the resident's wound as an unstageable pressure injury. Due to the facility's failure to implement effective pressure injury prevention interventions in a timely manner, Resident #30 developed a facility-acquired DTI to her right heel. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 4/17/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin Protection and Wound Prevention policy, revised 6/29/23, was received from the nursing home administrator (NHA) on 4/11/24 at 1:45 p.m. It read in pertinent part, Most residents admitted to the facility are considered at risk for developing wounds, although the level of risk may vary. Staff at the facility take an aggressive approach to wound prevention and will implement the following protocol upon admission on all residents. Procedure: skin assessments will be completed upon admission, within one to two weeks of admission, quarterly, and with a significant change of condition. Nursing assessment of skin condition will be completed at least weekly and documented in medical record. Care of residents with decreased mobility includes: off-loading heels with a pillow if resident is unable to reposition their lower extremities, turning or repositioning at least every two hours or more frequently, use of pillows or other positioning device to keep bony prominences from direct contact with one another. All residents with braces, splints, casts, or other mechanical devices will have skin closely monitored for breakdown. III. Resident #30 A. Resident status Resident #30, age 73, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included diabetes mellitus (high blood sugar), end stage kidney disease (kidneys can no longer support body's needs) with hemodialysis (process where a machine filters and cleans the body's blood) and dementia. According to the 4/6/24 minimum data set (MDS) assessment, Resident #30 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required touching assistance for rolling left to right and most transfers. She required substantial/maximal assistance for lower body dressing and putting on/taking off footwear. The assessment documented the resident was at risk of developing pressure ulcers and one unstageable pressure ulcer due to coverage of the wound bed with slough (soft, dead tissue, usually cream or yellow in color) and/or eschar (firm, dry dead tissue, usually black in color) which was not present upon admission. According to the 9/24/23 admission MDS assessment, the resident was at risk of developing pressure injuries but had no current pressure injuries present at admission. B. Wound observation and interview On 4/9/24 at 3:56 p.m. a wound observation was completed in the presence of registered nurse (RN) #1. Resident #30 was positioned on the recliner with heels floating off the recliner. The resident was wearing soft blue foam booties. With consent from the resident, RN #1 removed the dressing to the resident's right heel. Moderate yellow discharge was observed on the dressing. The wound on the resident's heel was oblong in shape extending to both sides of the heel. The wound bed was pink in color with multiple areas of yellow tissue (slough) obstructing the wound. RN #1 said there was some yellow slough covering the wound bed. She said the pressure injury developed after admission and she believed it was from the resident sitting in the dialysis chair for extended periods of time without wearing pressure reducing boots. C. Record review The 9/18/23 admission nursing assessment documented this resident's only skin conditions on admission included a right lower extremity surgical wound and bilateral (right and left sides) lower extremities were dry and scaly. The skin integrity care plan, initiated 9/19/23 and revised 4/9/24, identified Resident #30 was at risk for skin breakdown due to age, limited mobility, occasional incontinence and diagnosis of diabetes. Interventions included encouraging the resident to wear long sleeves/long pants, use a pressure reducing mattress, use pillows or off-loading devices to relieve pressure on heels, use a cushion in a chair, keep linens clean, dry and wrinkle free, reposition the resident, encourage physical activity, use lift device to avoid shearing, assess and monitor risk factors, apply lotion to lower extremities, keep resident clean and dry, and encourage adequate intake of nutritional foods. -However, review of the September 2023 and October 2023 treatment administration records (TAR) revealed there was no documentation to indicate the resident had heel protection in place and staff were monitoring for the heel protection until 10/16/23, after the development of the right heel wound. A progress note documented by an RN on 10/7/23 revealed there was a new deep tissue injury (DTI) to the resident's right heel. The note documented new interventions for the wound included a dressing and heel protector boots. The wound care registered nurse (WCRN) documented an initial note on 10/9/23. It revealed the right heel had eschar surrounded by slough and maceration (soft skin, when skin is in contact with moisture for too long). A wound care physician note from 10/12/23 documented the resident was being evaluated for an unstageable pressure injury on the right heel. The injury obscured full thickness and tissue loss, had moderate serous (clear, watery plasma) drainage and 100% eschar. Orders included right heel wound care orders, specialty mattress, offloading heels, wheelchair cushion, nutritional supplements, turn and repositioning resident and monitor for signs of infection. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/9/24 at 1:49 p.m. CNA #1 said Resident #30 required assistance of one person for walking, transferring, showering and repositioning. She said she helped the resident put off-loading boots on before she went to dialysis, when she was in bed and up in her wheelchair. RN #2 was interviewed on 4/9/24 at 2:10 p.m. RN #2 said the resident required one person to assist her for care. She said the resident wore pressure reducing boots to dialysis, when she was seated in her wheelchair and when she was in bed. She said the WCRN was responsible for her right heel wound since it was a pressure injury but RN #2 said she would replace the dressing as needed if the WCRN was not in the building. The WCRN was interviewed on 4/10/24 at 3:00 p.m. The WCRN said she saw the resident for the first time once the right heel wound had already developed on 10/9/23. She said the first time she saw the wound there was slough and eschar. She said she notified the wound care physician, painted the wound with betadine, elevated the resident's legs, put pressure off-loading boots on both feet and encouraged the resident not to wear shoes. She said the wound was unstageable. She said on 10/10/23, she noticed the wound had a foul odor, the resident's pain was worse, and there was more drainage from the wound. The resident was put on antibiotics for possible infection. She said the resident would have benefited from elevating her legs and wearing the pressure off-loading boots upon admission. The WCRN said she had not participated in the admission of Resident #30 and therefore it was the responsibility of the admitting nurse to implement any preventive measures upon admission. She said she provided care to the residents in the facility only after they developed wounds. The wound care physician (WCP) was interviewed on 4/11/24 at 10:00 a.m. The WCP said Resident #30 had an unstageable pressure ulcer to her right heel when she began seeing the resident for wound care. She said if interventions, such as offloading the heels and elevating legs on admission had been done, the wound would have likely been prevented. The assistant director of nursing (ADON) was interviewed on 4/11/24 at 2:15 p.m. The ADON said it was likely Resident #30 developed the pressure injury on her heel by sitting for a long time in dialysis. He said the protective booties were not implemented until after the development of the wound. He said since it likely occurred at the dialysis clinic, it was beyond the facility's control to implement any measures while resident at the dialysis. He said the facility did communicate with dialysis prior to every session of the dialysis and could have implemented protective booties for the resident prior to her visits to dialysis.

Based on observation and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, information on how to file a complaint with the State Agency. Specifically, the group interview revealed the facility failed to ensure residents knew where the required posting on how to file a complaint with the State Agency was located and that residents were able to easily access and read the information on the posting. Findings include: I. Resident group interview The resident group interview was conducted on 4/10/24 at 1:10 p.m. with eight residents (#1, #44, #146, #7, #35, #61, #8 and #21) who routinely attended monthly resident council meetings and were deemed interviewable by the facility and assessment. All eight residents said they did not know how to file a complaint with the State Agency and were not aware the information was posted in the facility. Resident #1 said whenever he had a concern and told a certified nurse aide (CNA) about it, the concern was never followed up on by the facility. II. Observation On 4/11/24 at 9:53 a.m. the required posting with the State Agency information on it was observed in the corner of the lobby. The information on how to file a grievance was posted above the eyeline for a resident in a wheelchair and was written in a small font. III. Staff interview The social services director (SSD) was interviewed on 4/11/24 at 9:46 a.m. The SSD was not sure where the State Agency information was posted and said he needed to ask someone. After asking someone, the SSD said the posting was located in the corner of the facility lobby. The SSD said the posting might not be visible to residents, depending on their level of visual impairment, but he said the residents felt comfortable asking staff members for help if they could not see the posting.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen and one of two nourishment rooms. Specifically, the facility failed to: -Ensure holding temperatures were at appropriate temperatures; and, -Ensure food was labeled, dated and disposed of in a timely manner. I. Failure to ensure holding temperatures were at appropriate temperatures. A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, ([DATE]) were retrieved on [DATE] from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view and read in pertinent part, The food shall have an initial temperature of 41 F (fahrenheit) or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. B. Observations During a continuous observation of the kitchen on [DATE], beginning at 11:30 a.m. and ending at 12:20 p.m., tartar sauce was observed on a cart next to the oven and stove.The tartar sauce was portioned into two ounce (oz) to four oz sized plastic cups. The cups were on a cookie sheet. There was no mechanism to keep it cold. At 12:20 p.m. cook (CK) #1 took the temperature of the tartar sauce. CK #1 said the tartar sauce contained mayonnaise and lemon juice. -The temperature of the tartar sauce read 62 degrees F, which was above the appropriate cold holding temperature of 41 degrees F. CK #1 spoke to the dietary manager (DM) to confirm she was to discard the tartar sauce. The tartar sauce was discarded in the trash. C. Interviews The registered dietician (RD) was interviewed on [DATE] at 11:52 a.m. The RD said the tartar sauce needed to be discarded if it was not kept at a cold holding temperature of 41 degrees F or below in order to avoid the danger zone for potential food-borne illnesses. The dietary manager (DM) was interviewed on [DATE] at 2:02 p.m. The DM said there should be a cooling mechanism to keep the tartar sauce at the appropriate holding temperature. She said the tartar sauce should remain below 41 degrees F below for cold foods. II. Failure to ensure food was labeled, dated and disposed of in a timely manner A. Professional reference The Colorado Retail Food Establishment Rules and Regulations ([DATE]), retrieved on [DATE] from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, read in pertinent part, A date marking system that meets the criteria stated in one (1) and two (2) of this section may include: Using a method approved by the department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine, marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded, marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. B. Observations On [DATE] at 9:40 a.m. an observation of the main refrigerator in the kitchen revealed the following:. There was an eight ounce plastic cup covered with aluminum foil in the refrigerator. The foil was labeled with a resident's name and indicated the cup contained a chocolate milkshake. -The foil was labeled with date [DATE] (10 days earlier). -There was an opened almond milk carton without a discard date on it. On [DATE] at 10:34 a.m. observations of the refrigerator in the west unit's nourishment room revealed the following: There was one opened Pedialyte (a liquid product to replace fluids and minerals) plastic carton. The manufacturer label said to discard if not used within 48 hours. -There was no date to indicate when the Pedialyte carton was opened. There was one Magic Cup nutritional supplement in the refrigerator. The manufacturer label said to use it within five days if thawed for pudding-like texture. -There was no date on the Magic Cup to indicate when the supplement was thawed. C. Staff interviews The RD and the nursing home administrator (NHA) were interviewed on [DATE] at 11:52 a.m. The RD said milkshakes that are poured into a plastic cup and covered with aluminum foil expired within the same date the cups were labeled. The NHA said the resident's personal chocolate milkshake, opened almond milk carton, Pedialyte carton and the Magic Cup should have had a used by date on them. The DM was interviewed on [DATE] at 2:02 p.m. The DM said the opened containers should have an opened on and use by date. She said the opened items in the main kitchen refrigerator and the west unit's nourishment room should have had a used by date on them.

Based on observations, record review, and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on three of five units. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices; and, -Ensure staff used appropriate personal protective equipment (PPE) when entering the room of a COVID-19 positive resident. Findings include: I. PPE failures for EBP A. Facility policy The Infection Prevention and Control Program policy, revised January 2023, was received by the nursing home administrator (NHA) on 4/9/24 at 10:38 a.m. The policy read in pertinent part, Multi-drug resistant organisms (MDRO) are defined as microorganisms that are resistant to one or more cases or antimicrobial agents. Enhanced barrier precautions (EBP) may be indicated for residents with any of the following, as directed by the infection preventionist and/or provider: wounds or indwelling medical devices, regardless of MDRO colonization status or infection or colonization with an MDRO. EBP include the use of gloves and gown during a high-contact care activities such as: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) or wound care for any open skin requiring a dressing. B. Resident #9 observations Resident #9 was observed on 4/8/24 at 2:01 p.m. He was inside the room seated in a wheelchair and had an indwelling catheter bag hanging from his wheelchair. Resident #9 was observed on 4/10/24 at 2:00 p.m. An unidentified certified nursing aide (CNA) and registered nurse (RN) #1 went into the resident's room to transfer the resident from the recliner chair to his bed for a wound dressing change. -The unidentified CNA and RN #1 did not put on gloves or gowns before they initiated the transfer. The wound care registered nurse (WCRN) entered the resident's room once he was in bed. -The WCRN did not put on a gown prior to completing the wound care dressing change for the resident. C. Resident #30 observations Resident #30 was observed on 4/8/24 at 1:49 p.m. Resident #30 was seated in a wheelchair in her room. An unidentified CNA went into her room to provide care. -The CNA did not put on a gown or gloves while transferring the resident from her wheelchair to the recliner chair. Resident #30 was observed on 4/9/24 at 3:56 p.m. RN #1 went into the resident's room to look at her pressure ulcers on both heels. She peeled back the resident's wound dressings to look at the wounds and put the dressings back into place. -RN #1 did not put on a gown while completing the resident's wound care. D. Staff interviews The infection preventionist (IP) and corporate nurse consultant (CNC) #1 were interviewed on 4/11/24 at 10:40 a.m. The IP said the facility currently did not have EBP in place for residents without MDROs who had indwelling medical devices or wounds. She said placing residents on EBP had not been done yet due to the lengthy process that was involved. She said the process involved educating residents, resident representatives and staff on the procedure. The IP said the facility had adequate PPE, such as gloves, gowns, eye protection, and masks in order to place all residents with indwelling devices/wounds on EBP. CNC #1 said they were aware of new requirements for EBP and were planning to implement it next week (week of 4/15/24). 37166 II. PPE Failures for COVID-19 positive room A. Professional reference According to the Center for Disease Control and Prevention (CDC) Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 (6/3/2020), retrieved on 4/17/24 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/communication/print-resources/A_FS_HCP_COVID19_PPE_card.pdf, PPE must be donned correctly before entering the patient area (for example, isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (for example, retying gown, adjusting respirator/face mask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. B. Observations On 4/10/24 at 12:11 p.m. CNA #4 was observed delivering a lunch tray to room [ROOM NUMBER]. The sign on the door indicated staff were to wear PPE, including a gown, gloves, N95 mask and face shield. CNA #4 donned a yellow gown, placed a N95 mask on top of the surgical mask he was wearing, put on a face shield and gloves and entered the room. CNA #4 exited the room at 12:15 p.m. wearing a surgical mask. On 4/10/24 at 12:22 p.m. CNA #3 entered room [ROOM NUMBER]. -CNA #3 donned a gown, face shield and gloves prior to entering the resident's room, however, he failed to remove his surgical mask and put on a N95 mask. CNA #3 entered the room wearing a surgical mask. C. Staff interviews CNA #3 was interviewed on 4/10/24 at 12:39 p.m. CNA #3 said he should have been wearing a N95 mask but he forgot. The infection preventionist (IP) was interviewed on 4/10/24 at 1:20 p.m. The IP said the resident in room [ROOM NUMBER] tested positive for COVID-19. She said appropriate PPE for the room was a N95 mask, gown, gloves and face shield. The IP said a N95 mask should not be worn on top of a surgical mask. She said having a surgical mask under a N95 mask compromised the seal of the N95 mask and did not provide adequate protection.

Based on record review and interviews, the facility failed to take steps to ensure the 15 residents, including Resident #39, who resided in the secure unit were free from potential sexual abuse by Resident #43. Record review revealed Resident #43 had a documented history of sexually inappropriate behavior toward male residents. Record review and interview revealed the facility failed to take timely steps to minimize the potential risks to other residents related to her behavior. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised 1/19/23, was received from the nursing home administrator (NHA) on 4/8/24 at 11:34 a.m. It read in pertinent parts: The facility does not condone resident abuse, neglect, exploitation or misappropriation of resident property by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or any other individual. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, or deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. III. Residents A. Resident #43 Resident #43, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), the resident's diagnoses included vascular dementia, anxiety, bilateral age-related macular degeneration (an eye disorder that causes blurred vision or a blind spot), congestive heart failure, chronic respiratory failure, and reduced mobility. The 2/7/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The 10/24/23 care plan identified the resident had dementia with behavioral disturbances. She may make inappropriate statements or gestures towards others. Interventions included administering Aricept and Seroquel, monitoring for adverse side effects, allowing the resident to have as much independence with personal care as safely possible, providing choices, and building a rapport with the resident at the beginning of the shift to facilitate trust. B. Resident #39 Resident #39, age greater than 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses include Alzheimer's disease, reduced mobility, anxiety disorder, repeated falls, and unsteadiness on feet. The 1/31/24 MDS assessment revealed he did not have a BIMS assessment completed due to severe cognitive impairment. The resident's 7/10/23 care plan revealed he had impaired cognitive status related to Alzheimer's dementia. Interventions included reminding the resident of the location of his room, time for meals, etc. The 10/17/23 care plan revealed the resident had cognitive loss and communication deficits related to dementia. He may not understand what was said to him and was unable to make his needs known. Interventions included monitoring for signs and symptoms of restlessness. The 11/16/23 care plan revealed the resident had a diagnosis of anxiety disorder. Interventions included administering Gabapentin and Paxil as ordered, monitoring for adverse effects, and notifying the provider. Also, to provide emotional support and if the resident was irritable, ask for sources of discomfort and attempt to remedy. III. Incident of potential sexual abuse Interviews revealed an incident of potential sexual abuse involving Resident #43 and Resident #39. The incident was also documented in the facility's investigation conducted during the survey on 4/10/24, eight days after the incident occurred. A. The social services director (SSD), in an interview on 4/9/24 at 2:02 p.m., said Resident #43 had placed male Resident #39's hand underneath her shirt and his hand touched her breast. The SSD said her immediate intervention was to tell Resident #43 that Resident #39 was married. Resident #43 then removed her (and Resident #39's) hand. The SSD said she told the nursing home administrator (NHA) what happened and the NHA said the incident was not reportable. She did not remember the exact date but said it was in the past two weeks. B. A review of the facility investigation of the incident conducted during the survey and dated 4/10/24, revealed the incident occurred on 4/2/24. The facility investigation read in part: -On 4/2/24, the social services director (SSD) noted the hand of Resident #39, who had a diagnosis of Alzheimer's disease, was placed on the breast of a female resident, Resident #43, by the female resident. Resident #39 did not move his hand when it was upon her breast and did not appear to be in any distress. The SSD sat in between both residents and took Resident #39's hand away from the female resident's breast. The SSD told the female resident (Resident #43) that Resident #39 was married and his wife would not appreciate what she did. Staff sat the female resident at another table. The SSD asked Resident #39 if he was ok, to which he responded yes. Upon further interviewing, the SSD also asked Resident #39 if a situation like this was to happen again would he be upset, and he said no. -On 4/3/24 at 10:04 a.m., the SSD reported the incident to the NHA. The NHA asked the SSD to follow up the next morning to assess if there were any changes in Resident #39's previous response. The NHA said that based on Resident #39 response and lack of any nonverbal expressions that would indicate distress, an incident report was not appropriate and their interaction was consensual. The facility investigation further read: - On 4/2/24 and 4/3/24, Resident #39 was interviewed by the SSD. Resident #39 did not have a brief interview for mental status (BIMS) assessment completed due to severe cognitive impairment. He was asked if he remembered the incident and he said no. He was asked if the scenario were to happen to him if he would be upset and he said no. The SSD said that based on this interview, she concluded it was not a reportable incident because he did not recall it. He was not in distress after this interaction. -On 4/10/24 at 2:00 p.m., Resident #43 was re-interviewed. Her BIMS assessment was three out of 15 which indicated she had severe cognitive impairment. She reported she was happy. She was sad, did not feel safe, and did not enjoy living at the facility because My babies aren't here. She said she likes the residents in the unit and she did not recall the incident. -On 4/10/24 at 2:00 p.m., Resident #39 was re-interviewed. His BIMS assessment was not completed due to severe cognitive impairment. He reported he was happy and enjoyed living at the facility. He was not sad. He did not respond when asked if he felt safe and if he got along with the residents. He did not recall the incident. C. On 4/9/24 at 2:30 p.m., there was no documentation that the facility had reported the incident to the state as potential sexual abuse. IV. Facility failures A. Facility failure to respond to respond to Resident #43's inappropriate behaviors before 4/2/24. Record review revealed facility knowledge of Resident #43's inappropriate sexual behavior before 4/2/24. -A social services progress note on 2/29/24 by the SSD revealed the resident touched another male resident in the groin area. A certified nurse aide (CNA) tried to take the resident's hand away from the male resident. The SSD told the resident that the man was married and his wife would not appreciate that. Resident #43 asked if the SSD was married to the male resident, she said yes and the resident let go of his hand. The CNA then told the SSD that the resident kissed the male resident earlier. The male resident did not appear to be in any distress. The resident was moved away from the male resident and staff encouraged the resident to eat in her room that evening. -Further record review revealed the facility opened an expression of need (EON) event, a form to document resident behaviors, from 3/1/24 through 3/10/24. A review of the EON revealed it was opened to document resident sexual comments or actions. However, there was no evidence Resident #43's care plan was revised to identify and address the potential risk of abuse to other residents related to Resident #43's sexual comments or actions. B. Facility failure address promptly and comprehensively the incident on 4/2/24. A review of the facility investigation of the incident conducted during the survey and dated 4/10/24 (see above), revealed the SSD did not report the incident involving Resident #43 and #39 until the next day. While the facility investigation documented steps taken by the facility, there was no documentation of these steps until 4/10/24 during the survey. Further, while the facility investigation indicated neither Resident #43 nor #39 recalled, was upset, or remembered the incident on 4/2/24, there was insufficient documentation that the residents'ability to consent to sexual contact was thoroughly assessed. -There was no indication Resident #39 understood the scenario posed by the SSD and the consequences of his answer when asked if the scenario described would upset him. -There was no indication Resident #39 understood the consequences of his answer to the NHA when asked if the incident with Resident #43 was consensual and he said yes, even though this was a factor, in part, in the determination that the incident was not considered potential abuse. A review of Resident #43 and #39's progress notes revealed no documentation regarding the incident on 4/2/24 and no evidence of a plan to monitor the residents'well-being following the incident. Finally, although the 4/2/24 incident represented a second incident of inappropriate sexual behavior toward a male resident, there was no evidence Resident #43's care plan was revised to identify and address the potential risk of abuse to other residents related to Resident #43's sexual comments or actions. 3. Facility failures after the incident 4/2/24 Record review revealed documentation that Resident #43 continued to exhibit inappropriate sexual behavior after the incident on 4/2/24. -Another EON event was opened on 4/3/24 to document any sexually inappropriate actions or language. A social services progress note also dated 4/3/24, revealed the resident using sexually inappropriate language and actions toward other male residents and male staff. She asked the staff if they would like to go to bed and would like to cuddle and kiss. The note read that although this was not a new expression, it seemed to increase, the event opened to monitor. -A nurse progress note on 4/4/24 revealed the resident asked the nurse to go to bed with her. It was not a new expression. Interventions included a calm environment, avoiding overstimulation, calm, slow understandable approach, redirection, distraction, safety of resident, ensure comfort. The interventions were effective. -A nurse progress note on 4/5/24 revealed the resident asked multiple staff members to go to bed with her. She asked another resident to go to bed with her. The CNA relayed to the nurse that the resident was hallucinating this evening, saw a boy/male in her room, and did not want the CNA to leave her alone. -A nurse progress note on 4/7/24 revealed the resident was agitated and tried to touch a male's resident personal area. The male resident was moved away from the area where the resident was sitting. The resident started to yell and asked to bring the resident back. The resident was redirected to watch television in her room in an effort to calm her down. -A nurse progress note on 4/8/24 revealed the resident asked a male resident to go to bed with her. Interventions included music or television, a calm environment and avoiding overstimulation, redirection, distraction, and the safety of the resident maintained. The interventions were somewhat effective. Although the nurse progress notes referenced interventions to address Resident #43's inappropriate behaviors which were sometimes effective, these interventions were not placed on the resident's care plan for consistent implementation until 4/8/24, during the survey. 4. Interviews with staff revealed not all staff were aware of planned interventions to ensure they were implemented consistently. A care plan, initiated on 4/8/24, identified that the resident made sexual comments or approaches toward staff and other residents at times. Interventions included if the resident experienced hypersexual behaviors or actions, try to remove the resident from the staff or resident or remove the resident from crowded areas with male residents, behavior management team to review as needed and according to facility protocol, and staff to have heightened awareness of resident's whereabouts. If the resident approached a male resident in the hall or dining room, observe and redirect if she attempts physical contact with the resident. CNA #5, interviewed on 4/9/24 at 4:52 p.m., said he knew to be careful with Resident #43 because she could be handsy with someone. He said when she exhibited these behaviors, he would try to distract and redirect her. He said her behaviors were consistent throughout the day. He said she varied on how handsy she would be and said he had not seen her act like that with male residents. -The CNA did not mention for staff to have heightened awareness of the resident's whereabouts. Licensed practical nurse (LPN) #2, interviewed on 4/9/24 at 4:50 p.m., said he was familiar with Resident #43. He said the resident exhibited sexual behaviors to males. He said she bounced between being funny and sweet to being super grabby with male residents. She made comments like take off your pants, come to my bed, and come to my room. He said redirection helped the resident. If three male residents were sitting at a table, he would redirect the resident to sit in a different direction. He said out of sight out of mind helped the resident's behavior. -The LPN did not mention for staff to have heightened awareness of the resident's whereabouts. Registered nurse (RN) #5, interviewed on 4/9/24 at 4:55 p.m., said she did not receive training on how to handle Resident #43. She used redirection when the resident had behaviors. The RN said when the resident exhibited behaviors she would make a joke to redirect her. If her behavior affected other residents, RN #5 would intervene and would redirect her. -The RN did not mention for staff to have heightened awareness of the resident's whereabouts. V. Additional steps taken by the facility during the survey and facility follow-up after the survey regarding the facility's determination that the incident on 4/2/24 did not represent potential abuse as it was consensual. The NHA was interviewed on 4/10/24 at 9:17 a.m. She said Resident #43 had a one-on-one sitter as of 4/10/24 and for the foreseeable future. She said Resident #43's care plan was updated with interventions that worked for the resident. Resident #43's provider visited on 4/10/24 to review her medications. The NHA said the provider told her that Sertraline could cause an increase in sexual behaviors. The NHA also reported the incident to the state. She said it was better to err on the side of caution. She said she contacted the ombudsman to conduct additional training. The NHA provided a copy of an in-service training class for one-on-one care for Resident #43 on 4/10/24 at 4:00 p.m. The training class took place on 4/10/24. It revealed good interventions were transitional conversations, coffee or beverage of choice, talking about her sons, offering meaningful activities, offering baby doll, offer therapy or other comfort items. The NHA emailed the following statement on 4/12/24 at 8:41 a.m. explaining that review of the incident which occurred promptly as well as a review of the regulations, the incident was determined to not meet reportable criteria as the element for Consent Not Given was not present; the alleged victim in this situation engaged in the act with the alleged perpetrator with no signs of distress or action to stop the act. The facility acted in good faith and timely to review and respond to this incident. The medical director (MD) provided a letter on 4/12/24 that indicated it is misleading to assume that dementia residents could not participate in their decision-making as they routinely do in a long-term care setting and based on the SSD's report of the incident, Resident #39 did not withdraw from Resident #43's attempt at intimate touch. He did not verbalize no and did not physically push away. The staff had to physically separate him as he did not choose to do so on his own. The MD said Resident #39 showed in the past that he is capable of verbalizing needs and dislikes. He demonstrated this by prior refusals of care in the setting of intimate personal care delivered by facility staff. The resident did not express concern or distress with the incident. He said he was okay with similar engagement with female residents in the future. The MD said Resident #43 had advanced dementia and she did not understand her expressions were inappropriate, especially in public space, and that her verbal expressions were not welcomed by male staff. -However, the facility failed to consider and address Resident #43's known inappropriate behaviors before and after the 4/2/24 incident to ensure the protection of residents in the secure unit from future potential sexual abuse.

Based on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and person-centered care for one (#56) of six residents out of 36 sample residents. Specifically, the facility failed to revise Resident #56's care plan to address the resident's pattern of repeated refusals of three physician ordered pain medications. I. Resident #56 A. Resident status Resident #56, age 78, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease, psychotic disturbance, mood disturbance, anxiety, hallucinations, post traumatic stress disorder, depression, pain in right and left knee, stiffness of left knee and chronic pain syndrome. The 1/2/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment indicated the resident had moderate pain frequently which interfered with her day to day activities. B. Record review The pain risk care plan, revised 4/5/24, revealed the resident was at risk due to her knee pain related to arthritis, headaches, jaw pain, and diagnoses of chronic pain syndrome neurologia. The resident was able to express her pain to staff. She voiced complaints of muscle spasms. Interventions included administering pain medications as ordered and monitoring effects,pain medications included acetaminophen, biofreeze gel and gabapentin. -The pain care plan failed to document Resident #56 frequently refused her pain medications or interventions to try to get her to take her medications. The April 2024 CPO revealed the following physician orders: Acetaminophen 500 mg (milligrams). Take two tablets three times a day for arthritic pain. Start date 2/23/24. Biofreeze gel 4%. Apply a thin layer to the right knee three times a day for arthritic pain. Start date 10/27/22. Gabapentin 400 mg. Take one capsule three times a day for pain. Start date 6/1/22. Resident #56's January 2024 medication administration record (MAR) revealed the following: Biofreeze gel 4% was not administered due to the resident's refusal on: -1/5/24 at 7:00 a.m. and 12:00 p.m; -1/8/24 at 12:00 p.m; -1/9/24 at 7:00 a.m., 12:00 p.m. and 5:00 p.m; -1/13/24 at 12:00 p.m; -1/14/24 at 5:00 p.m; -1/18/24 at 7:00 a.m., 12:00 p.m. and 5:00 p.m; -1/21/24 at 12:00 p.m; -1/26/24 at 12:00 p.m; and, -1/31/24 at 7:00 a.m. Resident #56's February 2024 MAR revealed the following: Biofreeze gel 4% was not administered due to the resident's refusal on: -2/8/24 at 7:00 a.m. and 12:00 p.m; -2/10/24 at 7:00 a.m. and 12:00 p.m; -2/19/24 at 7:00 a.m; -2/22/24 at 7:00 a.m. and 12:00 p.m; and, -2/23/24 at 12:00 p.m. Resident #56's March 2024 MAR revealed the following: Acetaminophen 500 mg, two tablets was not administered due to the resident's refusal on: -3/1/24 at 5:00 p.m; -3/8/24 at 5:00 p.m; -3/16/24 at 5:00 p.m; -3/17/24 at 6:30 a.m; -3/20/24 at 5:00 p.m; and, -3/25/24 at 12:00 p.m. Biofreeze gel 4% was not administered due to the resident's refusal on: -3/1/24 at 7:00 a.m. and 5:00 p.m -3/6/24 at 7:00 a.m. and 5:00 p.m; -3/8/24 at 5:00 p.m; -3/13/24 at 5:00 p.m; -3/14/24 at 5:00 p.m; -3/16/24 at 5:00 p.m; -3/17/24 at 7:00 a.m. and 5:00 p.m; -3/19/24 at 5:00 p.m; -3/20/24 at 5:00 p.m; -3/21/24 at 5:00 p.m; -3/22/24 at 7:00 a.m. and 5:00 p.m; -3/25/24 at 12:00 p.m. and 5:00 p.m; -3/26/24 at 5:00 p.m; and, -3/31/24 at 5:00 p.m. Gabapentin 400 mg was not administered due to the resident's refusal on: -3/8/24 at 5:00 p.m; -3/16/24 at 5:00 p.m; -3/17/24 at 7:00 a.m; and, -3/25/24 at 12:00 p.m. Resident #56's April 2024 MAR revealed the following: Acetaminophen 500 mg, two tablets was not administered due to the resident's refusal on: -4/6/24 at 12:00 p.m; and, -4/7/24 at 6:30 a.m. Biofreeze gel 4% was not administered due to the resident's refusal on: -4/2/24 at 12:00 p.m; -4/3/24 at 5:00 p.m; -4/4/24 at 7:00 a.m. and 12:00 p.m; -4/5/24 at 5:00 p.m; -4/6/24 at 12:00 p.m; and, -4/7/24 at 7:00 a.m. Gabapentin 400 mg was not administered due to the resident's refusal on: -4/6/24 at 12:00 p.m; and, -4/7/24 at 7:00 a.m. -There was no documentation in Resident #56's electronic medical record (EMR) to indicate the facility had attempted to address the resident's repeated pattern of pain medication refusals or update the resident's care plan. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/11/24 at 11:36 a.m. LPN #1 said if a resident refused medications it was the resident's right to refuse. He said he tried to educate residents why they should take their medication. He said there was a trend of medication refusals, the provider and family should be notified. He said the provider should be notified because the provider could see what other medication options were available for the resident. LPN #1 said the residents ' family should be notified because they might know other ways that helped get the resident take the medication. LPN #1 said he was familiar with Resident #56 and she never refused medications from him. He said he built a rapport with her and thought she did better with male nurses and aides. LPN #1 said it was important to figure out how to approach Resident #56 so she did not refuse her medications. Nurse manager (NM) #1 was interviewed on 4/11/24 at 11:03 a.m. NM #1 said every resident had a right to refuse medications. She said nurses should educate the residents why they should take the medication. She said the nurse should reattempt a couple times before the nurse documented the refusal in a progress note. NM #1 said if a resident refused medications for a couple of days the facility should try to see what was going on and if there was something that triggered the refusals. She said she would collaborate with the provider or hospice. She said Resident #56's refusals could be due to her receiving too many medications at once. She said the family should be notified when there was a trend and asked for input on what might work to ensure the resident took their medications NM #1 was interviewed again on 4/11/24 at 12:19 p.m. NM #1 said she reviewed Resident #56's chart and she saw the resident had multiple refusals of her pain medications. She said the Biofreeze gel was cold to the touch which could be why Resident #56 was refusing the medication. She said she would talk with the nurse to find out what might be causing the resident to refuse her medications. NM #1 said she saw a trend with a specific nurse who documented the resident refused medications frequently. She said this might be a training opportunity for that specific nurse on how to approach the resident and what to do when the resident refused medications. The assistant director of nursing (ADON) was interviewed on 4/11/24 at 1:01 p.m. The ADON said if a resident refused medications the nurse should reapproach a couple times. He said if the resident still refused, the nurse should go to the charge nurse because they might have tips on how to approach the resident for medication administration. He said if there was a trend, the provider and family should be notified. An event in the resident's electronic medical chart should be opened and the trend should be discussed in the morning nurse's meeting to identify a plan to address the refusals. The ADON said he was familiar with Resident #56. He said he knew she refused medications but did not know or could not remember why she refused.

Based on observations, interviews and record review, the facility failed to ensure residents received person-centered dementia care that met their needs for one (#43) of five residents reviewed for dementia care out of 36 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #43 in order to provide the resident with her highest practicable quality of life and care. Findings include: I. Facility policy A dementia policy was requested from the facility on 4/11/24, however, one was not provided A Dementia Tools document, which was undated, was received from the nursing home administrator (NHA) on 4/11/24 at 12:58 p.m. It read in pertinent part: Meal tips - food and fluids. Let them eat what sounds good, even if it was not good for them. A dementia training document, which was undated, was received from the NHA on 4/11/24 at 12:58 p.m. It read in pertinent part: Provide remarkable individualized care. Build meaningful relationships that enrich lives in a stimulating and supportive environment. The Expression of Need Management policy, revised 3/7/24, was received from the NHA on 4/11/24 at 12:58 p.m. It read in pertinent part: Necessary care and services will be provided with a person-centered approach that reflects the resident's goals while maximizing the resident's quality of life. II. Resident #43 A. Resident status Resident #43, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician order (CPO), diagnoses included vascular dementia, anxiety, bilateral age related macular degeneration (eye disorder that causes blurred vision or a blind spot), congestive heart failure, chronic respiratory failure and reduced mobility. The 2/7/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment indicated the resident wandered daily and her behavior remained the same from the previous assessment. The resident did not refuse care. B. Resident representative interview The resident's representative was interviewed on 4/8/24 at 2:09 p.m. He said that Resident #43 struggled emotionally and he wished he understood the resident. He said her dementia caused her to be excited. He said she had lost her independence which caused her some frustration. He thought Resident #43 wished she had free range mobility and that her friends visited her. He said the secured unit tempered her ability to move as she wished, however, he said it was important for the facility to keep a close eye on her because she wandered and said she wanted to go outside to her children and grandchildren. C. Observations On 4/9/24, during a continuous observation beginning at 10:57 a.m and ending at 11:57 a.m., the following observations were made: At 10:57 a.m. Resident #43 was sitting in the community area of the secured unit. She sat at a table by herself facing a wall of cabinets and a small refrigerator. She had animal graham crackers and a cup of liquid. -There was no staff interacting with her. At 10:59 a.m. the resident asked for food. An unidentified staff member reminded the resident she had crackers on the table. Resident #43 said she wanted something other than crackers. The unidentified staff member offered yogurt, pudding or applesauce. The resident said she wanted all of the options. -The unidentified staff member gave the resident yogurt, but did not provide her with the other two options that had been mentioned. -The unidentified staff member made no attempt to engage the resident in conversation or provide any other interaction other than to give the resident yogurt. At 11:05 a.m., another resident was escorted to the same table as Resident #43. At 11:09 a.m. an unidentified nurse walked by and Resident #43 said she wanted food. The nurse said lunch was coming. -The nurse did not interact further with Resident #43 or provide the resident with any other type of activity in an attempt to distract the resident from her repetitive requests for food. At 11:15 a.m. Resident #43 said she wanted coffee. The other resident at her table agreed and said they needed coffee. At 11:20 a.m. Resident #43 asked about food again. -None of the staff who were nearby getting drinks for residents acknowledged Resident #43's question about food. At 11:26 a.m. Resident #43 again asked about lunch. Certified nurse aide (CNA #1) said lunch was coming in four minutes. -CNA #1 did not interact further with Resident #43 or provide the resident with any other type of activity in an attempt to distract the resident from her repetitive requests for food. At 11:28 a.m. Resident #43 asked the other resident at her table about food. The other resident said she had to wait. At 11:30 a.m. Resident #43 told the other resident at her table there were two minutes until lunch and she wondered what was for lunch. At 11:41 a.m. the other resident's lunch arrived at the table. At 11:42 a.m. the other resident told an unidentified staff member to give Resident #43 her lunch. At 11:44 a.m. Resident #43's lunch arrived. At 11:53 a.m. Resident #43 said she wanted dessert. -None of the staff acknowledged the resident's request for dessert. On 4/10/24, during a continuous observation beginning at 2:40 p.m and ending at 3:40 p.m., the following observations were made: Resident #43 had a one-to-one staff member sitting next to her in the community room in the secured unit. Resident #43 was in a wheelchair. -At 2:40 p.m. Resident #43 said she wanted breakfast. She was near several unidentified staff members, including the one-to-one staff member. One unidentified staff member asked her what she wanted besides breakfast because the kitchen was closed. Another staff member told her the kitchen was closed and they did not have breakfast. -Neither of the unidentified staff members made an attempt to get Resident #43 something to eat. At 2:53 p.m. the resident again asked for breakfast. The one-to-one staff member told her what time it was and that dinner was soon. -The one-to-one staff member did not attempt to get the resident something to eat or engage her in any type of meaningful activity to distract her from her repeated request for breakfast. From 2:53 p.m. until 3:00 p.m. the one-to-one staff member pushed Resident #43 up and down the hallway of the secure unit in her wheelchair in an attempt to distract the resident. At 3:00 p.m. the one-to-one staff member returned to the community room with Resident #43. At 3:03 p.m. Resident #43 asked when she could eat. The one-to-one staff member said it was a couple hours until dinner. The resident said she did not want dinner, she wanted breakfast. The staff member said let's go to your room and see what was there. -The one-to-one staff member did not offer Resident #43 anything to eat or attempt to engage the resident in any type of meaningful activity to distract her from her repeated request for breakfast. -At 3:05 p.m. the one-to-one staff member asked CNA #2 where snacks were located. CNA #2 told her where the snacks were. -The one-to-one staff member did not offer the resident any snacks despite having just been told where the snacks were located. -From 3:05 p.m. to 3:40 p.m. the one-to-one staff member proceeded to push Resident #43 up and down the hallway of the secure unit. During the 35 minute timeframe, Resident #43 said four different times that she wanted to get out of here (the secure unit). One time she was asked where she wanted to go and she pointed to the door to leave the secure unit. -The one-to-one staff member did not attempt to interact with or engage Resident #43 in a more meaningful activity than being pushed up and down the hallway of the secure unit. D. Record review The 10/24/23 dementia care plan identified the resident had dementia with behavioral disturbances. Interventions included administering aricept and seroquel and monitoring for adverse side effects, allowing the resident to have as much independence with personal care as safely possible, providing choices and building a rapport with the resident at the beginning of the shift to facilitate trust. -The care plan failed to include the resident's repetitive requests for food, especially breakfast, or any interventions to address the resident's need. The 10/19/23 activities care plan revealed the resident was pleasant and engaged in conversation easily. Barrier to leisure activity was tolerance. Interventions included offering one on one visits for increased social interaction, inviting the resident to activities of interest, staff to introduce resident to other residents during group activities, invite theresident to spiritual programs, set up independent activities as desired and staff to refocus on tasks at hand when distracted. The 3/11/24 care plan identified the resident was at risk for wandering and exit seeking. Interventions included developing a plan of care and recommendations in caring for the resident, maintaining door closures, frequent rounding to ensure the resident was in the facility, providing redirection as appropriate and determining reasons and triggers for wandering. Review of Resident #43's electronic medical record (EMR) revealed the following progress notes: On 2/7/24, the nurse progress note said the resident was shouting and calling out asking for staff to stay with her prior to dinner. On 2/8/24, the nurse progress note said the resident called out to staff, needed company and wanted to talk. The resident thought another resident was her boyfriend and she wanted to feed him. On 2/9/24, the nurse progress note revealed Resident #43 did not feel safe in the room alone. She was brought to the community room. She felt safer with other people around her. She was put into bed and the resident reported she was very anxious and wanted a staff member to stay with her until she fell asleep. Resident #43 calmed down and fell asleep. On 2/14/24, the social worker's progress note revealed the resident had moments of sadness. On 4/5/24, the nurse progress note revealed the resident asked another resident to go to bed with her. Resident was hallucinating. She saw a boy/male in her room and did not want the staff to leave her alone. The resident talked about dying. III. Staff interviews The nurse manager (NM) #1 was interviewed on 4/11/24 at 11:03 a.m. NM #1 said if a resident had dementia and they asked for food, the staff should give them food. She said if a resident said they were hungry, the staff should not withhold a snack. She said it was important to offer food with dementia residents because it was hard to determine if the resident's satiety (fullness) was reached with the meals provided. NM #1 said she was familiar with Resident #43. She said she used to be the night nurse for the unit Resident #43 lived in. She said if a resident was hungry, she would not withhold a snack. She said she was not aware Resident #43 asked for meals and snacks and that staff said the kitchen was closed and it was not breakfast time and did not offer snacks. She said she would educate the staff. The assistant director of nursing (ADON) and corporate nurse consultant (CNC) #2 were interviewed on 4/11/24 at 1:01 p.m. The ADON and CNC #2 said they were not familiar with Resident #43. The ADON said snacks should be offered to a resident regardless if the resident recently ate something. The resident might have been hungry and the staff should have found a snack. CNC #2 said it was important to offer a resident food that was specific to what they were asking for. If a resident asked for breakfast the staff should offer some breakfast food. CNC #2 said it was not effective telling a resident with dementia that it was not time for breakfast or dinner. CNC #2 said residents with dementia were hard to redirect and if the resident was focusing on food that was the subject of the moment for the resident. CNC #2 said maybe the resident was hungry. The ADON and CNC #2 said they needed to work to train the staff on dementia care.

Based on record review and interview, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (# 66) of five residents reviewed for unnecessary medications out of 36 sample residents. Specifically, the facility failed to track and monitor behaviors for Resident #66 who was on four different psychotropic medications. Findings include: I. Facility policy The Psychotropic Medication policy, revised February 2024, was provided by the nursing home administrator (NHA) on 4/11/24. It documented in pertinent part, An event will be opened to document target symptoms prior to initiation of antipsychotics and will remain open until the resident stabilizes as determined by IDT (interdisciplinary team). Residents are continually monitored for adverse side effects. If noted, an event will be opened and the provider will be notified. Residents taking antidepressant may have target symptoms monitored as recommended by the IDT. If a new hypnotic medication is ordered or recommended, the IDT will open an event to determine the sleep patterns of the resident, and review with consideration on non-medication based approaches to encourage the resident's sleep. II. Resident status Resident #66, age above 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and depression. The 2/28/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score (BIMS) score of nine out of 15. The assessment indicated the resident did not display or feel little interest or pleasure in doing things and was not feeling down, depressed or hopeless. He did not display any signs of social isolation. The assessment indicated the resident was not physically or verbally aggressive towards others and he did not reject the care. The assessment indicated Resident #66 was receiving antipsychotic and antidepressant medications. III. Record review The care plan for psychotropic medications, initiated 1/15/24 and revised 3/11/24, documented the resident was at risk for side effects related to the use of antidepressant medications. Interventions included administering mirtazapine (an antidepressant medication), sertraline (an antidepressant medication) and trazodone (an antidepressant medication) as ordered, monitoring for potential side effects such as headache, tremor, dizziness, insomnia, somnolence, fatigue or allergic reactions and notifying the physician if appropriate. The care plan for cognition, initiated 2/29/24 and revised 3/6/24, revealed the resident had impaired cognitive status related to diagnosis of dementia. Interventions included to provide assistance and verbal cues with activities of daily living (ADL) as needed. -The care plan did not mention the resident's use of psychotropic medication for dementia and specific behaviors the resident displayed. The April 2024 CPO documented Resident #66 was receiving the following medications: Mirtazapine tablet 15 milligrams (mg) orally at bedtime for depression. Start date 2/28/24. Olanzapine (an antipsychotic medication) tablet 2.5 mg orally twice a day for dementia with associated behavior. Start date 2/28/24. -The physician's order did not indicate what associated behavior the medication was used for. Sertraline tablet 200 mg orally, once in the morning, for depression. Start date 2/28/24. Trazodone tablet 25 mg orally at bedtime. Start date 3/8/24. -There was no diagnosis documented for the use of the medication. -The April 2024 CPO did not include daily monitoring for side effects of the psychotropic medications and/or monitoring of targeted behavior related to the use of the medications. -Review of Resident #66's progress notes revealed no documented behaviors. -Review of Resident #66's monitoring events demonstrated no active events for the documentation of targeted behaviors for psychotropic medications. IV. Staff interviews The social services director (SSD) was interviewed on 4/11/24 at 11:30 a.m. The SSD said he participated in psychotropic review meetings but he did not recall discussing any specifics about Resident #66's medications. He was not sure why the resident was on three different antidepressants. The SSD was interviewed again on 4/11/24 at 12:15 p.m. The SSD said he clarified medications with the resident's physician and trazodone was administered for insomnia, not depression. He said he was still uncertain why the resident was on two other antidepressants and he was not able to locate a physician statement which documented a rationale for the use of two antidepressants. The SSD said he did not know what specific behaviors the resident displayed to justify the use of the olanzapine antipsychotic medication for dementia. Certified nurse aide (CNA) # 2 was interviewed on 4/11/24 at 1:30 p.m. CNA #2 said the resident did not have any aggressive behaviors. He said the resident would occasionally raise his voice when he needed help from staff. He said all of the resident's requests were reasonable and related to care. CNA #2 said the resident did not use the call light but preferred to yell to help when needed. Registered nurse (RN) #3 was interviewed on 4/11/23 at 2:05 p.m. RN #3 said the resident did not have any aggressive behaviors and he did not usually refuse care. She said the resident would occasionally get upset with care provided in the middle of the night. She said the resident used to live in assisted living and he was not accustomed to the call light system. She said the resident did not use the call light and often yelled for help. RN #3 said all the resident's requests were reasonable and pertinent to the care he needed. She said the resident had several hospitalization s during his stay in the facility and every time after his return he was more agitated and would yell for help. Once settled and adjusted to the routine he would not yell as much. RN #3 said if Resident #66 had behaviors they would be documented under progress notes. She said if the behavior was new and acute in onset, the event task would be started and behaviors would be monitored daily. RN #3 said for residents who were started on medications for insomnia, hours of sleep should be documented to ensure the medication was effective. She said Resident #66 was admitted with the medication for insomnia and she was not sure how and when tracking of hours of sleep should have been started. The assistant director of nursing (ADON) was interviewed on 4/11/23 at 2:45 p.m. The ADON said behavior tracking was usually documented under events. He said assessments for side effects of psychotropic medications should be documented under progress notes. He said resident's medication administration records did not include daily behavior tracking.

Based on record review and interviews, the facility failed to provide services by qualified persons for two (#4 and #7) of five residents out of 10 sample residents. Specifically, the facility failed to: -Ensure an assessment was conducted by a registered nurse (RN) after Resident #4 sustained a fall with major injury prior to moving the resident to her bed; and, -Ensure an assessment was conducted by a RN on two occasions after Resident #7 sustained falls without injury. Findings include: I. Professional references The Colorado Department of Regulatory Agencies, Board of Nursing: Practice Act and Laws, Colorado Revised Statutes, (2021), Title 12 Healthcare Professions and Occupations. Article 255 Nurses and Nurse Aides, retrieved from https://www.colorado.gov/pacific/dora/Nursing_Laws on 3/30/22, read in pertinent part, Practical nurse or licensed practical nurse means a person who holds a license to practice as a licensed practical nurse in this state with the right to use the title 'licensed practical nurse' and its abbreviation 'LPN.' 'Practice of practical nursing' means the performance, under the supervision of a licensed health care provider authorized to practice in this state, of those services requiring the education, training, and experience, as evidenced by knowledge, abilities, and skills in: Caring for the ill, injured, or infirm; teaching and promoting preventive health measures; acting to safeguard life and health; administering treatments and medications prescribed by a licensed healthcare provider; or participating in the assessment, planning, implementation, and evaluation of the delivery of patient care services that is commensurate with the practical nurse's education. 'Practice of practical nursing' includes the performance of acts within the practical nurse's educational background and using procedures leading to predictable outcomes. Registered nurse or registered professional nurse means a professional nurse, and only a person who holds a license to practice professional nursing in this state may use the title 'registered nurse' and its abbreviation, 'RN.' 'Practice of professional nursing' means the delivery of independent and collaborative nursing care to individuals of all ages, families, groups, and communities, whether sick or well, in all settings. The functions include the initiation and performance of nursing care through health promotion, supportive or restorative care, disease prevention, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 'practice of professional nursing' includes the performance of such services as: evaluating health status through the collection and assessment of health data; health teaching and health counseling; providing therapy and treatment that is supportive and restorative to life and well-being either directly to the patient or indirectly through consultation with, delegation to, supervision of, or teaching of others; executing delegated medical functions and delegated patient care functions; referring to medical or community agencies those patients who need further evaluation or treatment; and reviewing and monitoring therapy and treatment plans. II. Facility policy and procedures The Fall Management policy, revised 1/13/22, was provided by the director of nursing (DON) on 3/29/22 at 11:37 a.m. It read in pertinent part, Residents have the right to a safe environment, while maximizing their independence. Fall prevention seeks to balance residents' safety from falls while respecting individual rights and preservation of dignity. It is the facility's goal to reduce falls and injury related to falls. Protocol in the event of a fall: nurse to conduct a physical assessment. Provide emergency care as appropriate. Assist the resident off the floor via mechanical lift once a nurse deems it safe to do so. -The policy failed to specify that a registered nurse (RN), not a licensed practical nurse (LPN), must conduct post fall assessments. III. Resident #4 A. Resident status Resident #4, age 76, was admitted on [DATE], and readmitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/13/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of nine out of 15. She required supervision of one staff person for bed mobility and transfers. She required supervision with set up help only for ambulation, dressing, toilet use, and personal hygiene. She had one fall with injury (minor) since her admission on 10/8/21. B. Record review Review of Resident #4's care plan, initiated 10/9/21 and revised 3/15/22, revealed the resident was at risk for falls related to history of falls, decreased mobility, decreased balance, decreased cognition, and medications associated with fall risks. Pertinent interventions included educating staff to monitor for side effects to new medications, educating the resident to use call light when in need of assistance, assuring the resident 's floor was free of glare, liquids, and foreign objects, providing assistance as needed for activities of daily living (ADLs) and mobility, giving the resident verbal reminders not to ambulate/transfer without assistance, encouraging the resident to assume a standing position slowly, and providing the resident with a walker for safety. A progress note written by LPN #1 on 2/27/22 at 9:10 a.m. documented the following, in pertinent part: Resident noted laying on the floor, on her right side, between bedside dresser and bathroom door. Resident states, 'I was cleaning water off of the floor.' Complaints of severe pain to right hip, skin tear noted to right forearm and redness to right forehead. Transferred with the assistance of two people via mechanical lift to bed. Positioned to comfort, vital signs within normal limits and neurological assessment at baseline. Charge nurse (RN) notified and fall protocol initiated per facility protocol. -The progress note indicated LPN #1 evaluated the resident and the resident was transferred to the bed with a mechanical lift prior to Resident #4 being assessed by a RN. A progress note written by RN #6 on 2/27/22 at 12:23 p.m. documented the following, in pertinent part, Notified about resident fall after 9:00 a.m. Resident reports significant right hip pain. Per report (from LPN), the resident fell in her room on her right side, transferred to bed via lift. Resident reports she does not want to move her right leg due to pain, and states it hurts worse than when she broke her left hip. Contacted on-call nurse practitioner (NP), who stated that if resident could not/would not bear weight on leg she should be sent to the emergency department for evaluation. The resident expressed she was okay with this. After discussion with the resident, a non-emergent ambulance was requested. -The progress note indicates RN #6 did not assess the resident following the fall until after she had been moved to the bed. A Fall Event assessment was completed by RN #5 on 2/27/22 at 9:29 a.m. The assessment documented Resident #4 sustained a fall in her room while attempting to clean up a spill on the floor. The assessment further documented the resident had painful/limited range of motion in her right lower extremity with no rotation/deformity/shortening noted, and she was complaining of severe pain (7/10) in her right hip. -Despite RN #5 completing the Fall Event assessment, she did not assess Resident #4 prior to the resident being moved from the floor to her bed (see RN #5's interview below). A nurse practitioner's note on 2/27/22 documented the following, in pertinent part, [AGE] year old patient with history of left hip fracture, cognitive impairment, [CONDITION(S)]. Nursing called this morning to report the patient sustained an unwitnessed fall about a half hour ago, staff thinks she hit her head and she is complaining of acute right hip pain. They used a lift to get her back into bed. Nursing reports no obvious limb length discrepancy or anatomic deformity but she is complaining of significant pain to her right hip area. I asked the nurse if she had been able to bear weight after fall - they were not sure - RN did additional assessment of patient and reported her pain is too severe to attempt weight bearing and she declined to try. Nursing has been in contact with the family who is open to emergency department evaluation. In the setting that she is unable to bear weight and now complains of severe pain, I recommend emergency department evaluation for suspicion of fracture. On review this afternoon, 2/27/22, hip x-ray reporting acute oblique intertrochanteric fracture of the right femur with mild lateral displacement and impaction of the distal fracture fragment. I suspect she will be admitted for surgical correction of her hip fracture. C. Interviews RN #5 was interviewed on 3/28/22 at 2:03 p.m. RN #5 said she was working as the ward clerk on 2/27/22 when Resident #4 fell and sustained her right hip fracture. She said she went into the resident's room after the fall to see if LPN #1 needed assistance. RN #5 said when she entered the room, LPN #1 had already assessed the resident and directed staff to transfer the resident to her bed using a mechanical lift. She said Resident #4 was lying in her bed and stated she was having pain in her right leg. RN #5 said when she tried to gently move the resident's right leg, the resident was in significant pain. She said LPN #1 went and got RN #6, who was the charge nurse on duty on 2/27/22, and he came and assessed the resident and then contacted the nurse practitioner (NP). She said Resident #4 was then transferred to the hospital for further evaluation. RN #5 said if a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it did not matter whether a LPN or a RN conduct the assessment of the resident. RN #6 was interviewed on 3/28/22 at 2:20 p.m. RN #6 said he was the charge nurse on duty on 2/27/22 when Resident #4 fell and broke her hip. He said LPN #1 was the resident's nurse on that date. He said LPN #1 came to get him a few minutes after 9:00 a.m. and told him Resident #4 had fallen. RN #6 said LPN #1 told him she had assessed the resident and had the staff transfer her to her bed using the mechanical lift. He said LPN #1 told him the resident was complaining of severe pain in her right hip. RN #6 said he went to Resident #4's room to assess her. He said the resident had no noticeable rotation or deformity in her right leg, however she was in quite a bit of pain. He said he called the NP who gave him an order to have the resident transferred to the hospital for further evaluation. RN #6 said if he had gotten to the resident first, he might have left her on the floor until the provider was notified because her significant pain was a good indicator that she might have broken her hip. He said LPN #1 was a very competent nurse. He said since Resident #4's leg was not rotated or obviously deformed and she was very uncomfortable on the floor, he felt that was why the resident was transferred back to the bed prior to him being notified of the fall. RN #6 said he thought any nurse could assess a resident. He said it did not necessarily need to be a RN who conducted the assessment. LPN #1 was interviewed on 3/28/22 at 5:04 p.m. LPN #1 said she was Resident #4's nurse when the resident fell and broke her hip on 2/27/22. She said a certified nurse aide (CNA) came and told her the resident had fallen. She said when she went into the resident's room, the resident was lying on the floor and told her that she had been walking back from the bathroom and was trying to clean up a water spill on the floor when she fell . LPN #1 said she did not have a RN come and conduct the initial assessment on the resident. She said she assessed the resident and determined that there was nothing out of the ordinary for her right leg. She said there was no obvious rotation or deformity when she compared the resident's right leg to her left leg. LPN #1 said Resident #4 did complain of severe pain to her right hip, however she was also extremely uncomfortable lying on the floor and requested to get off the floor as soon as possible. LPN #1 said she directed staff to transfer the resident to her bed using the mechanical lift, per facility protocol. She said as soon as the resident was settled into her bed, she went and notified RN #6 and he came to assess her. She said after RN #6 assessed the resident, he called the NP and the resident was transferred to the hospital for further evaluation. LPN #1 said if there had been something noticeably wrong with Resident #4's leg, she would not have directed staff to move the resident. She said LPNs were allowed to assess the resident in order to provide their report of the situation to the RN. The DON was interviewed, with the nursing home administrator (NHA) present, on 3/29/22 at 1:10 p.m. The DON said LPN #1 assessed Resident #4 when she fell and sustained her fractured hip on 2/27/22. She said after assessing the resident, LPN #1 directed staff to transfer the resident to the bed using the mechanical lift, which was the facility's policy for transferring residents after a fall. The DON said Resident #4 was very uncomfortable on the floor and LPN #1 did not observe any rotation or deformity of her right hip, therefore she made a decision, based on her nursing judgement, to transfer the resident to a more comfortable location prior to notifying RN #6. The DON said the facility followed the scope of practice as stated by the state board of nursing (BON) for LPNs and RNs. She said the BON did not specify that a LPN could not conduct an assessment of a resident. III. Resident #7 A. Resident status Resident #7, age 88, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/28/22 minimum data set (MDS) assessment revealed the resident had both short and long term memory problems. The resident was severely impaired with cognitive skills for daily decision making with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, toileting, and personal hygiene. The resident did not have any functional impairments in his ranges of motion. The resident had experienced two or more falls since he was admitted to the facility. B. Resident observations The resident sat on a couch in the secure unit common area on 3/8/22 at 12:42 p.m. He appeared well groomed and wore the appropriate clothing. He wore white socks and shoes on both feet. There was a pillow behind his back. He had his legs crossed and the calf area of both legs were draped over the right armrest of his wheelchair. The resident sat in his wheelchair in the secure unit common area on 3/28/22 at 2:50 p.m. He appeared well groomed and wore the appropriate clothing. He wore white socks and shoes on both feet. He was using his feet to ambulate his wheelchair around in the common area. The resident sat in his wheelchair in his room with the door closed on 3/29/22 at 10:45 a.m. The social worker (SW) and the surveyor entered the room. The resident had his pants pulled down and they were positioned on top of his shoes that were on the floor. The front part of his brief was pulled downward, but it was not off the resident. He was pulling at the brief with his hands. The resident had no odors and appeared well groomed. The SW talked with the resident and left the room to summon a certified nurse aide (CNA). The CNA came immediately and closed the door to the room as she talked with the resident. C. Record review The care plan for being at risk for falls related to a history of falls, decreased mobility, decreased balance, incontinence, self-transferring and medications that were associated with fall was initiated on 4/28/21 and revised on 3/28/22. The resident was observed to remove his footwear that included gripper socks. Some of the interventions were to ensure the resident wore gripper socks as tolerated. Staff were to assist the resident between 6:00 a.m. and 6:30 a.m., out of bed. The resident would be encouraged to come to the secure unit common area and offered a snack (before breakfast). Staff were to offer to assist the resident in his wheelchair if he arose early in the morning. Staff were to offer assistance when the resident was looking for a place to sit and to offer to help the resident to lay down as needed. Staff were to provide an activity or a snack during shift change. Staff were to open an event to monitor the resident for more frequent urination and/or restlessness. Staff were to provide the resident with an activity after lunch to keep the resident occupied. Staff were to provide prompt toileting in the morning and if the resident refused, staff were to reproach frequently. Staff were to perform frequent rounding to observe the resident while in bed for safety. Staff were to be educated to toilet the resident right before he went to bed. Staff were to ensure the resident's floor was free from glare, liquids and foreign objects. Staff were to encourage the resident to use environmental devices such as hand grips, handrails, etc. Staff were to provide the resident with verbal reminders not to transfer without assistance and encourage him to assume a standing position slowly. Staff were to provide the resident with a safety device/appliance (wheelchair) as directed per this current resident information sheet (RIS). Staff were to provide the resident with proper, well maintained footwear. Staff were to analyze any falls the resident had to determine a pattern and/or trend. Staff were to keep the resident's call light, personal items and frequently used items with his reach. Staff were to occupy the resident with meaningful distractions: (e.g., music, companion, crafts, etc.). A fall risk assessment dated [DATE] at 4:55 p.m., revealed the resident had a score of 80 or greater. The resident had one or more falls in the past six months. The resident was incontinent and was administered two or more high fall risk medications. The resident had altered awareness of his immediate physical environment and was impulsive. The resident lacked the understanding of his physical and cognitive limitations. D. Fall One 12/30/21 at 10:45 p.m. The post fall information sheet dated 12/30/21 at 10:45 p.m., by a licensed practical nurse (LPN) revealed the five whys (reasons) of this fall were that the resident was awakened by another resident, the resident frequently self-transferred, the resident had no safety awareness, the resident frequently wanted to use the bathroom when awake per his baseline and the resident had cognitive deficits. The resident was observed in bed with his eyes closed at 10:00 p.m. The resident said prior to the fall he wanted to get up and use the bathroom, I was getting up. The post fall review dated 12/30/21 at 10:45 p.m., by a LPN revealed the resident's call light was on and this LPN went to check on the resident. The resident was sitting on the floor and there was another resident in the room. The resident performed an unassisted transfer. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was toileted at 10:00 p.m. and was dry. The resident had gripper socks on. The resident had a skin tear to his right forearm near the elbow. The immediate intervention was to assist the resident up from the floor and to the bathroom. The nurse practitioner (NP) was called on 12/31/21 (not timed) and the family was notified on 12/31/21 at 8:30 a.m. The interdisciplinary team ( IDT) recommendation was to arrange the room for easy access to the trash for the resident to expel excessive sputum. -A RN assessment of the resident was not performed prior to moving the resident from off the floor. An event details note dated 12/30/21 at 10:45 p.m., by a LPN revealed the resident's call light was on and the LPN went to check on the resident. The resident was sitting on the floor and his wheelchair was away from his bed. Observations revealed there was another resident in the room at this time. The resident had been in his bed with his eyes closed and his wheelchair was close to the bed. This was reported from the evening shift at 10:00 p.m. The resident was in his bed prior to the fall in his room. The resident did not complain of any pain and the resident did not have any injuries. Safety measures that were in place at the time of the fall were; low bed, call light within reach, use of shoes/non-skid socks and a wheelchair. The new interventions that were implemented were the IDT would start an investigation to determine the root cause of the fall. If the resident had previous falls; those falls would be reviewed for trends or patterns. Staff were to complete neurological assessments per the facility's protocol. Staff were to educate the resident on the importance of using the call light. Staff were to monitor the resident for signs of pain, administer analgesics as needed and utilize non-pharmacological pain relief measures. Staff were to continue the interventions contained in the resident's fall risk care plan. The neurological assessments were started on 12/30/21 at 10:45 p.m., and were completed according to the specified frequency. A nurse note dated 12/31/21 at 5:33 a.m., by a licensed practical nurse (LPN) revealed the call light came on and this LPN went to check on the resident. The resident was sitting on the floor and his wheelchair was away from his bed. Observations revealed there was another resident in the room at this time. The resident had been in his bed with his eyes closed and his wheelchair was close to the bed. This was reported from the evening shift at 10:00 p.m. The resident received a long thin skin tear to the right forearm near the elbow and there was scant blood to the area. The IDT note dated 1/3/22 at 11:47 a.m., by a RN revealed, the committee met to discuss current interventions and care plans for the unwitnessed fall on 12/30/21 at 10:45 p.m. The resident's call light was on and staff went to check on the resident. The resident was sitting on the floor and the resident received a skin tear to his right forearm near the elbow. There was also another resident in the room. An intervention was to arrange the room for easy access to the trash for the resident to expel excessive sputum. E. Fall Two on 3/19/22 at 7:00 a.m. A fall note dated 3/19/22 at 7:00 a.m., by a LPN revealed the resident had previously been observed resting on his bed. The resident was now observed sitting on the floor with his right upper extremity on the bed and his left upper extremity on his wheelchair that was placed at a 90-degree angle beside his bed. The locks on the wheelchair were engaged and the call light was activated. The resident had gripper socks on. He denied any pain and his ranges of motion were at his baseline. The resident was laughing and talking with staff while he was assisted from the floor with a mechanical Hoyer lift. The resident's vital signs and neurological assessments were at his baseline. -There was no RN assessment of the resident before he was lifted off the floor. The post fall investigation for the fall on 3/19/22 at 7:00 a.m., by a LPN revealed the resident's call light was activated. New or changed interventions by the IDT were for staff to assist with getting the resident up for the day between 6:00 a.m. and 6:30 a.m. Staff were to encourage the resident to go to the common area and to offer the resident a snack (before breakfast). The post fall information sheet, by a certified nurse aide (CNA) revealed the resident had a fall on 3/19/22 at 7:00 a.m. The five whys related to the fall were; the resident had cognitive deficits, the resident's wheelchair was next to his bed, the resident was unable to understand using the call light and the resident's transfers were sometimes weak/unstable. The resident was asleep in bed before the fall. The resident was trying to get up and move into his wheelchair that was next to the bed at the time of the fall. The resident was unable to answer/comprehend any questions. The resident's call light was in place and he had yellow (non-skid) socks on. The event details note on a fall on 3/19/22 at 7:00 a.m., was written by a LPN. The resident was unable to make a lucid statement. The resident had been resting in bed before the fall. The resident was now observed sitting on the floor with his right upper extremity on the bed and his left upper extremity on his wheelchair that was placed at a 90-degree angle beside his bed. The locks on the wheelchair were engaged and the call light was activated. The fall occurred in the resident's room. The resident did not complain of any pain and no injuries were observed. The resident had a mental status of times one. The safety measures in place at the time of the fall were the call light was in reach, frequent safety checks and/or purposeful rounding program, low bed, shoes/non-skid socks and wheelchair. The implemented interventions were for the IDT to start an investigation to determine the root cause of the fall. If the resident had previous falls; those falls would be reviewed for trends or patterns. Staff were to involve the resident in activities of interest. Staff were to continue the interventions on the resident's fall risk care plan. The neurological assessments were started on 3/19/22 at 7:00 a.m., and were completed according to the facility's schedule. A fall note dated 3/19/22 at 10:41 p.m., by a LPN revealed the resident had no additional falls this shift. The resident's neurological assessments and vital signs were within normal limits. The resident did not have any complaints of pain. The resident did not use his call light. Staff were to provide interventions such as use of a low bed, ensure the use of appropriate footwear and/or grippy socks and place the resident's bed against the wall to reduce room obstacles. A fall IDT committee note dated 3/21/22 at 10:27 a.m., by a RN revealed, this committee met to discuss the current interventions and care plan related to an unwitnessed fall on 3/19/22. The resident was observed sitting on the floor on the open side of his bed. The resident had his right upper extremity resting on his bed and his left upper extremity resting on his wheelchair. The resident's wheelchair was alongside this bed at a 90-degree angle with the wheelchair brakes in the locked position. The resident was wearing gripper socks and the call light was activated. The resident did not have any injuries. The new interventions were for staff to assist the resident to get up for the day between 6:00 a.m. and 6:30 a.m. Staff were to encourage the resident to go to the common area and to offer the resident a snack. A fall note dated 3/21/22 at 2:01 a.m., by a RN revealed the resident had no additional falls this shift. The resident's neurological assessments and vital signs were within normal limits. The resident did not complain of any pain. The resident did not use the call light. The interventions for this shift were for staff to ensure his bed was against the wall to reduce rom obstacles, place his bed in the low position and ensure the resident wore the appropriate footwear and/or grippy socks. F. Staff interviews and email The social worker (SW) was interviewed on 3/28/22 at 2:55 p.m. The SW office was located on the secure unit. She said the resident had several falls. She said the Resident #7 was unsteady and self-transferred himself. She said he was headstrong and did what he wanted to do. She said he was impulsive and could not understand he had to wait for staff to help him. She said when he wanted to get up and go, he just got up and went. She said staff would try to reach him quickly or talk with him, but he was impulsive. She said sometimes he was redirectable and other times he was not. She said staff did frequent rounds to observe the resident. She said staff tried to always keep an eye on him. She said he had not had any injuries from the two falls previously mentioned. She said they did not use a fall mat on the floor when the resident was in bed because of his reliance on his wheelchair; it was decided not to create an additional fall mechanism with the mat beside his bed. She said the resident liked to keep the wheel chair close to his bed at all times. She said the facility trended his falls and he often fell between 1 a.m., and 6:00 a.m. She said staff tried to make sure the resident was up at 6:00 a.m., to use the toilet and assist the resident to the common area where he was visible to the staff. The staff provided him with a toileting program every two hours. The NHA, DON and the regional services manager (RSM) were interviewed on 3/29/22 at 1:33 p.m. The DON said regarding the fall on 12/30/21 at 10:45 p.m., the LPN did the assessment on the resident before the resident was moved. The DON said the event information was completed by the nurse (LPN) that opened the event. The DON said the IDT meets daily, but not on the weekends, to discuss any issues/concerns. The DON said the resident had a skin tear and was evaluated to see if any of his medications caused the fall. The DON said staff were trying to anticipate his needs as best as they could. The staff reviewed his sleep schedule to see if it had changed. She said staff had increased activities on the secure unit, provided the resident with individual activities, and the secure unit had more staffing that were able to visualize the resident more. The DON said when the resident got up early, the staff took the resident to the common area and gave him snacks before breakfast. An email dated 3/29/22 at 1:38 p.m., by the CSM revealed From LPN scope of practice: The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the RN or MD for further or full assessment. Practice of practical nursing includes: Participating in the assessment, planning, implementation, and evaluation of the delivery of patient care services that is commensurate with the practical nurse's education. The DON was interviewed on 3/29/22 at 2:01 p.m. She said there was no RN assessment for the resident's fall on 3/19/22 at 7:00 a.m., because the resident did not experience a change of condition. She said the resident did not have any injuries or pain. She said the resident's safety measures and interventions were in place at the time of the fall. She said it was her understanding that if there was no change in a resident's baseline; a RN assessment was not necessary. She said if a LPN performed an assessment on a resident after a fall; the LPN would then report information to the charge nurse (RN) and to the resident's provider.

Based on observations, record review and interviews, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#2) of four out of 11 sample residents. Specifically, Resident #2 was admitted to the facility on [DATE] with a known history of falls and weakness before being admitted to the facility. The resident was identified as being high risk based on the facility fall risk assessment dated [DATE]. The admission minimum data set (MDS) assessment dated [DATE] revealed the resident required extensive two plus staff assistance for transfers and toileting. The MDS assessment and the resident information sheet used by nursing staff as a directive for care were not the same regarding transfers/toileting requirements. Findings include: I. Professional reference The Physiopedia Numeric Pain Rating Scale, updated 2021, retrieved on 4/26/21 from https://www.physio-pedia.com/Numeric Pain Rating Scale, revealed a resident selected a whole number from 0 to 10 integers (whole number) that best reflects the intensity of his/her pain level. Zero represented no pain, five represented moderate pain and ten represented worse pain possible. This numerical pain rating was a valid and reliable scale to measure pain intensity. II. Facility policies and procedures The Fall Reduction Program policy, revised on 11/13/19, was provided by the nursing home administrator on 4/22/21 at approximately 11:00 a.m. The policy revealed residents have the right to a safe environment, while maximizing their independence. The policy also revealed fall prevention sought to balance resident's safety from falls while respecting individual rights and preservation of dignity. It was the facility's goal to reduce falls and injuries related to falls. -The admitting nurse would complete the Fall Risk Observation upon admission. Individualized interventions would be implemented to minimize the potential for a fall occurrence dependent on the resident's risk. -A root cause analysis would be completed after each fall. This may include information related to the resident's current status (cognition, toileting patterns, mobility, current illness, vital signs, current medications, ect.) and details surrounding the event. -Once a root cause analysis was completed, a discussion of new interventions would be conducted. The Falls Committee and/or nurse designee would recommend new interventions and safety measures to reduce recurrent falls and maintain the highest level of mobility. III. Resident #2 A. Resident status Resident #2, age 78, was admitted on [DATE] and discharged on [DATE] to another facility. According to the November 2020 computerized physician orders (CPO), diagnoses included non-displaced fracture of the lateral malleolus of the left fibula (ankle fracture), stiffness of left ankle, spastic hemiplagea (muscles on one side of the body being in a constant state of contraction) affecting left non-dominate side, muscle weakness, unsteadkness on feet and lack of coordination. The 10/21/2020 minimum data set (MDS) assessment, revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive two plus staff assistance for transfers and toileting. IV. Record review The Point of Care Activities of Daily Living Category Report for the dates of 10/15/2020 through 10/28/2020 was provided by the minimum data set coordinator (MDSC) on 4/22/21 at 9:40 a.m. The report revealed the resident required extensive assistance from two staff for transfers and toileting. The nurse practitioner (NP) note dated 10/15/2020 at 2:41 p.m., revealed the resident had recurrent falls and had impaired functional mobility, gait, balance and endurance. The resident had left [CONDITION(S)] and continued to be a high fall risk due to debility, and a history of falls at previous facilities. The care plan for falls, started on 10/15/2020 (revised on 11/13/2020), revealed the resident was at high risk related to a history of falls, inability to stand unassisted, over the age of 70 and the use of medications that were associated with a fall risk. Some of the approaches were to provide assistance as needed with activities of daily living and mobility (refer to the resident information sheet for details). The staff were to provide assistance (refer to the toileting plan if applicable). -This care plan did not reveal the resident required extensive assistance from two staff for transfers and toileting as indicated on the 10/24/2020 MDS above. The care plan for activities of daily living/rehabilitation potential, started on 10/15/2020 (revised on 11/13/2020), revealed the resident had experienced a decline in function from baseline due to increased weakness and deconditioning with functional limitations due to a recent history of an ankle fracture and previous diagnosis of [CONDITION(S)]. Some of the approaches were to enforce weight bearing restrictions as ordered (refer to the resident instruction sheet and current orders for specifics), provide assistance for activities of daily living, mobility as needed and refer to the resident instruction sheet for specifics. -This care plan did not reveal the resident required extensive assistance from two staff for transfers and toileting The care plan for pain, started on 10/15/2020 (revised on 11/13/2020), revealed the resident complained of pain related to a recent history of ankle fracture, diabetic [CONDITION(S)], history of a lumbar compression fracture and a [CONDITION(S)]. Some of the approaches were to administer routine medications as ordered. Monitor for and report adverse consequences, such as falling, constipation, loss of appetite and excessive drowsiness. Monitor and record any non-verbal signs of pain such as crying, grading, moaning, restlessness, grimacing, diaphoresis (excessive abnormal sweating), and withdrawal, ect (et cetera). Assess the resident for pain if observed and offer as needed pain medications as ordered per the current medication administration record or the treatment administration record as indicated and monitor for effects. The Fall Risk assessment dated [DATE] at 1:31 p.m., noted a score of 28 or high risk. Some of the risk score calculation specifics were the resident had an age of between 70 to 79, had a history of one or more falls in the past six months, received two or more high risk fall medications and required assistance or supervision for mobility, transfers or ambulation. The resident information sheet dated 10/21/2020 was provided by the minimum data set coordinator (MDSC) on 4/22/21 at 9:40 a.m. The transfer section revealed the resident was a minimum to moderate assistance of two staff with a transfer pole and grab bar. The second staff person as needed to get out of bed until the pole was placed. -The toileting section of the sheet did not reveal the number of staff that were required for this activity of daily living. A therapy note dated 10/23/2020 at 3:04 p.m., by the director of therapies (DOT) revealed the resident assessed as being a high fall risk due to a history of falls in the past six months, the resident was incontinent and took high fall risk medications. The resident required assistance with mobility, and presented with cognitive limitations. The resident currently had physical therapy and occupational therapy orders in place to address her strength, balance, functional mobility, activities of daily living, and safety deficits. The resident transferred with two staff members and required staff to be within arms length for assistance with toileting. Nurse note dated 10/24/2020 at 7:45 a.m., by registered nurse (RN) #3 revealed the resident sustained a witnessed fall attempting to transfer to commode. A certified nurse aide (CNA) was present when the fall occurred. The CNA reported the resident did not hit her head. A mechanical lift was used to return the resident to her bed. The resident reported mild pain of 3 out of 10 on the numeric pain scale with no [CONDITION(S)] or injury noted. There was no change in the resident's baseline (normal) ranges of motion. The Post Incident Falls Accident Follow form revealed the resident had a fall on 10/24/2020 at 7:45 a.m. A CNA was in the bathroom assisting the resident with toileting. When the resident attempted to stand up, the resident experienced leg weakness and the resident was slid to the floor. The resident was using the grab bar at the time. The resident said she had leg weakness and her legs were unable to hold her up. The resident denied hitting her head. The Falls Committee Investigation, signed by the NHA on 10/26/2020 (not timed) revealed the root cause of the fall was the resident's legs gave out and was slid down to the floor by the CNA that was assisting the resident while toileting. The resident was using the grab bar at the time. The section on current fall interventions with transfers revealed minimum to moderate assistance with two staff members with a transfer pole and a grab bar. Staff were to be within arms length for toileting. -However, according to her therapy note on 10/24/2020 the resident transferred with two staff members and required staff to be within arms length for assistance with toileting.(see above). The Event Report for Falls revealed the resident had a fall on 10/24/2020 at 7:45 a.m. A CNA was assisting the resident to the bathroom. When the resident tried to stand up from her wheelchair to the commode, her legs buckled and she slid to the floor. The resident said she had pain in her left ankle with a numeric pain scale of 3 out of 10. The resident had no pain or limitations in ranges of motion for all four extremities. There was no rotation/deformity or shortening noted in her extremities. The resident was an assist of one staff member with/without a device. Nurse note dated 10/25/2020 at 8:49 p.m., by an RN revealed the resident complained of a dull ache pain in her left ankle with a numeric pain scale of 6 out of 10. As needed pain medication was administered at 8:49 p.m., and at 9:30 p.m., the resident was sleeping comfortably. Nurse note dated 10/25/2020 at 2:42 p.m., by RN #3 revealed the resident was reporting increased pain to her left ankle due to the fall on 10/24/2020. A compression stocking was removed from the left ankle. Trace [CONDITION(S)] and light bruising to the lateral aspect of the ankle were observed. The resident reported pain with passive ranges of motion. The charge nurse was notified, the resident was administered as needed pain medication and an elastic wrap was applied as requested by the resident. Nurse note date 10/26/2020 at 11:27 a.m. by an RN revealed this was a Fall Committee Interdisciplinary Team Review (IDT) note. The fall on 10/24/2020 was the resident's first fall. The fall was discussed in the morning IDT meeting and in the fall committee IDT meeting. Prior to this witnessed fall, the resident was in the bathroom with a CNA who was assisting the resident with toileting. The resident said her legs gave out and was unable to keep from sliding to the floor. A grab bar was in use at the time. Currently the resident was a minimum to moderate assist with two staff members with the use of a grab bar. The staff were to be within arm's length of the resident during toileting. Nurse note dated 10/26/2020 at 2:54 p.m., by RN #3 revealed the resident reported a numeric pain scale of 8 out of 10 in her left ankle. Bruising was noted to the lateral aspect of the left ankle. As needed pain medication was administered with good effect. The NP note dated 10/26/2020 at 2:54 p.m., revealed this was a follow up visit related to a fall with left ankle pain. The resident had a fall on 10/24/2020 in the bathroom and now had increased [CONDITION(S)], bruising, increased pain and limited ranges of motion to the left ankle. The resident stated she had pain and an inability to move the left ankle. The resident stated she had pain on the dorsal and medial side of the foot. The resident was worried that she broke her foot during the fall on 10/24/2020. The resident had lower extremity +2 [CONDITION(S)] from the foot to the ankle and was unable to wear a shoe related to swelling. A bruise was noted on the posterior and medial ankle. The resident was unable to perform passive ranges of motion without pain. The resident's pain, [CONDITION(S)], loss of range of motion and bruising suggest an injury and a two view ankle x-ray was ordered. The Radiology Order dated 10/26/2020 at 4:14 p.m., by the NP for x-rays of the left foot and left ankle. Nurse note dated 10/26/2020 at 5:46 p.m., by an RN revealed the resident complaint of pain to the left ankle with a numeric pain scale of 6 out of 10. The pain was not radiating. As needed pain medication was administered at 5:46 p.m. At 6:46 p.m. the resident rated the pain as a 3 out of 10 on the numeric pain scale. Nurse note dated 10/26/2020 at 6:30 p.m., by a licensed practical nurse (LPN) revealed the resident complaint of pain in the left ankle with a numeric pain scale score of 10 out of 10 with movement. The resident said the ankle was okay when the ankle was not touched. As needed pain medication was administered and was effective. Nurse note dated 10/27/2020 at 2:51 a.m., by an RN revealed the resident had an x-ray and the results were a non-displaced fracture of the lateral malleolus. The resident said she absolutely did not want to go to the hospital at this time. The plan at this time was for the resident to see a foot specialist instead. The resident was aware and treated for pain with [MEDICATION(S)] Acetaminophen (narcotic) effectively and water-circulating heating pad (kpad) to the site. The care plan for bowel and bladder, started after the fall on 10/27/2020 (revised on 11/13/2020), revealed the resident had occasional episodes of incontinence related to decreased mobility. Some of the interventions were that the resident required staff assistance for toileting and transfers. Staff were to remain at arm's length for toileting safety. V. Staff interviews On 4/22/21 at 9:40 a.m., the MDSC acknowledged the MDS dated [DATE] revealed the transfer and toileting sections noted that the resident required extensive assistance with two plus staff. The MDSC said the CNAs document their participation with a resident in transfers and toileting in the facility's named computerized documentation system. She said she reviewed their documentation, reviewed nursing progress notes, CNA progress notes, physical therapy/occupation therapy notes and observed the resident to make the determination for the coding in the MDS assessment. The MDSC said the resident information sheet provided information to the CNAs for them to know the amount of help to provide to a resident during their activities of daily living interactions. She provided and agreed to the information on the 10/21/2020 resident information sheet. She said the information on the resident information sheet could be updated almost on a daily basis. RN #3 was interviewed by a telephone conference call on 4/22/21 at 10:02 a.m. She said a CNA reported to her of a witnessed fall in the bathroom while the CNA was transferring the resident according to the information on the resident information system (which revealed the resident was two staff with a transfer pole and grab bar). The CNA told her the resident's legs gave out and the CNA did what she could to guide the resident as she fell to the floor. RN #3 did a full assessment of the resident and there were no outward signs or symptoms of injury at this time. RN #3 and one CNA picked the resident off the floor using a mechanical lift. The resident was placed in bed. RN #3 said the resident did not complain of any pain at this time. She said later in the shift, the resident did complain of soreness to her left ankle. She reported this concern to the charge nurse and left a voicemail to the family member first listed on the face sheet as the point of contact. The DOT was interviewed on 4/22/21 at 11:09 a.m. She reviewed the Fall Risk assessment dated [DATE] at 1:31 p.m., by an RN. She said the assessment revealed the resident had a score of 28 or a high risk. The DOT said physical therapy was started on 10/23/2020 and the resident was able to safely transfer from her bed to and from a wheelchair that required moderate (50% resident and 50% staff) assistance. She said this meant that staff would have their hands on the resident. She said this information would also equate to transfers during toileting. She said her interpretation of the resident information sheet was that the resident could use the grab bar for toileting with the assistance of one staff member. -However, this would contradict the recommendations from the DOT note written on 10/23/2020, which revealed The resident transferred with two staff members and required staff to be within arms length for assistance with toileting. RN #5 was interviewed on 4/22/21 at 11:44 a.m. She said there was one CNA in the bathroom with the resident during the toileting process. She said the resdient's legs gave out and the CNA helped slide the resident to the floor. She said the resident information sheet could change several times a day. CNA #1 was interviewed on 4/22/21 at 12:15 p.m. She said that CNAs refer to the resident information sheet to know the ADL status of the residents. She reviewed the resident information sheet dated 10/21/2020 for this resident. She said this resident required minimum to moderate two staff assistance for transfers. She said two staff had to provide some physical strength to help transfer the resident. She said she was unsure how the transfer section correlated to the toileting section of this resident information sheet. She said for this resident's information sheet, she would have had to go ask a nurse for guidance on toileting. RN #1 and RN #4 were interviewed on 4/22/21 at 12:22 p.m. They both reviewed this resident's information sheet dated 10/21/2020. Both agreed the transfer section revealed minimum to moderate two staff assistance with transfer pole and grab bar; the second person as needed to get out of bed until the pole was placed. They both agreed the toileting section of the resident information sheet did not reveal how many staff were needed to safely perform this ADL. At 1:36 p.m., RN #4 said she felt that the facility had sufficient staff in the bathroom for the resident's safety at the time of the fall. The director of nursing (DON) was interviewed on 4/22/21 at 2:35 p.m. She said it was reported to her the resident had fallen in the bathroom with one CNA present. An RN was alerted and did the assessment. The RN noted there were no injuries and a mechanical lift was used to remove the resident from the floor to her bed. She said it was later in the day when the resident said she had some pain in the ankle area. She said a mobile radiological service unit came to the facility and took x-rays on 10/26/2020.

Based on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections for one out four units. Specifically, the facility failed to: -Don and doff personal protective equipment (PPE) and perform hand hygiene appropriately between tasks; -Wear, store and disinfect the appropriate PPE for the task determined by the COVID-19 status of the facility; -Clean resident rooms in a systematic manner like clean to dirty areas; -Prevent clothing of housekeeper from being contaminated by cleaning the floors by lying on the floors and cleaning on hands and knees; -Use a clean rag between tasks; -Perform glove change and hand hygiene prior to touching resident personal items; -Clean bottles of solution that were on the floor prior to storing in the houskeeping cart; and -Educate and receive a return demonstration about the housekeeping process following infection control practices for the housekeeper (HSK) to ensure understanding of training. Findings include: I. Facility policy and procedure The nursing home administrator (NHA) on 12/1/2020 at 12:17 p.m., provided a printed copy of the Standard Precautions policy revised in July 2020. It read in pertinent part, -Cleaning should proceed from clean to dirty areas of the room and from high to low vertically. -The bathrooms should be cleaned last after completing the room. -The toilet should be the last item cleaned in the bathroom. -Decontaminate cleaning cloths regularly to prevent cross-contamination. -Use a new cleaning cloth when moving from the resident room to the bathroom to clean. The housekeeping director (HSKD) on 12/1/2020 at 9:43 a.m., provided the housekeeping audit checklist which read in pertinent part, Always clean from a clean area to a dirty area and the bathroom should always be cleaned last. In double occupancy rooms, change gloves and perform hand hygiene from one side of the room to the other side of the room. Always change gloves and perform hand hygiene when moving from one side of the room to the other and from one task to another. A. Observations On 11/30/2020 at 2:00 p.m. observation of the housekeeper cleaning a resident room revealed: The housekeeper (HSK) was standing in front of a cleaning cart on the East 100's hallway outside room [ROOM NUMBER]. He gathered cleaning rags and spray bottles to enter the double occupancy resident room. HSK hung his mask off of his right ear in the hallway to drink water from his water bottle. He took his left forefinger and rubbed it back and forth six times under his nostrils as he sucked in mucous. He did not perform hand hygiene before putting on his face shield or gloves. He then went into the resident's bathroom with two bottles of spray cleaner and a cleaning rag. HSK held both bottles in his hand then used one of the bottles to spray cleaning solution on the toilet. He wiped off the toilet from the top of the toilet tank, sides, front of the toilet tank, the top of the toilet seat, then lifted the toilet seat, wiped underneath the toilet seat, the rim of the toilet bowl, then the base with a rag. Both cleaning solution spray bottles were placed on the floor in front of the toilet and the cleaning rag was placed on top of one of the spray bottles. They remained in this position until he finished cleaning the entire room. The HSK started cleaning the resident's bathroom, a dirty area then moved into the resident living area of the room versus starting in the clean area and ending in the dirty area. HSK went to the hallway to get a rag and wore the same pair of gloves. He had cleaned the toilet and bathroom with those same gloves. There was a bucket of clean water, per the housekeeper, that he put the rag into and rang out before going back into the resident's room. He got down on the floor on his hands and knees, and washed the floor starting where it met the wall, past the bed and he continued to wash the floor to the resident hallway door. He hung the floor rag on the inside door knob of the resident's hallway door. HSK did not change his gloves or do hand hygiene after cleaning the floor by hand and went to the housekeeping cart to get a new rag. He took a clean rag from the supply cart, placed it in the clean water bucket on top of the housekeeping cart, which contained no cleaning solution and returned to cleaning the floor. He removed his face shield and placed it face down on the resident's bed, which left him without the appropriate PPE for the outbreak status of the building, see Facility COVID-19 status below. He then alternated between lying on his back and his left side, on the floor next to the resident's bed while he cleaned the floor. He got up on his knees and put his face shield on which was on the resident's bed. He failed to do hand hygiene prior to donning and doffing the face shield. He stored the face shield in a resident care area, the resident's bed and did not do appropriate sanitizing of the face shield, or clean the resident's bed. HSK did not change his gloves and perform hand hygiene and used the same rag which was used to clean the floor under the bed to wipe down the resident's dresser. He then took out the window screen and wiped it down with the same rag, followed by the window sill, then wiped down the resident's bed side table and the resident's personal radio. The resident asked the HSK to assist with the function of the two television remotes as she handed them to him. With the same gloved hands and the rag in his hand, he assisted with the function of the television through the remotes then handed the remotes to the resident. He did not clean the remotes prior to handing them to the resident. Using the same rag and gloved hands the HSK walked over to the shared resident sink. He wiped down the top of the mirror with that rag, opened the medicine chest and wiped the inside, the side walls adjacent to the sink, the counter and sink basin. He collected the rags from the spray bottles, the bottles from the bathroom floor and the rag from the door knob and went to the housekeeping cart. HSK took the two spray bottles of cleaning supplies from the bathroom floor and placed them back on top of his cart without sanitizing the outside of the bottles. He placed the dirty rags in the plastic bag attached to the cart. The housekeeping director (HSKD) approached the HSK at the housekeeping cart and demanded the employee to change his gloves and perform hand hygiene. The HSK at this time took off his gloves, performed hand hygiene and put on a new pair of gloves. B. Staff interviews The housekeeper (HSK) was interviewed on 11/30/2020 at 2:15 p.m. He said he only wore one pair of gloves for the entire room and did not change between tasks. He said he did not need to use hand sanitizer before putting on gloves because the gloves protected his hands. He said he often washed the entire floor on his hands and knees because the floor got a better cleaning. He said he tried to remember to change rags between tasks but sometimes forgot. The housekeeping director (HSKD) was interviewed on 12/1/2020 at 9:30 a.m. She said the expectations for housekeeping would be to follow the checklist provided on the cleaning carts. She said each housekeeper would change gloves two to four times while cleaning rooms and perform hand hygiene between glove changes. She said each side of a room would require at least three clean rags to be used, the toilet would be cleaned last, and it was expected cleaning began at the cleanest part of the room and ended with the dirtiest. She said floors should not be cleaned on a persons ' hands and knees except to clean a tough stain. She said a mop with a clean mop head should be used to clean the floor. She said this employee has been trained to clean according to the checklist for cleaning many times. The director of nursing (DON) was interviewed on 12/1/2020 at 10:00 a.m. She said the housekeeping staff were to keep their face shields on while they cleaned a room, use different pairs of gloves between tasks, switch rags between tasks, and to use proper hand hygiene. The nursing home administrator (NHA) was interviewed on 12/1/2020 at 10:20 a.m. She said the housekeeper did not clean properly. She said she was working with the human resource department as to the specific course of action needed to be taken with this employee. C. Facility COVID-19 status The NHA was interviewed on 12/1/2020 at 10:30 a.m. She said the facility had 17 COVID-19 positive residents on the COVID-19 unit, and seven COVID-19 positive staff. The facility was working with the Colorado Department of Health and Environment, and the county health department.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to properly clean resident rooms, and follow proper hand hygiene procedures while cleaning resident rooms. Findings include: I. Facility policies The Infection Prevention and Control policy and procedure, last revised February 2020, provided by the nursing home administrator (NHA) on 4/14/2020 at 12:47 p.m. read in pertinent part: Standard Precautions: Standard precautions shall be used routinely during the care and interactions of all residents regardless of their [DIAGNOSES REDACTED]. Hand Hygiene: Healthcare workers must perform hand hygiene (even if gloves are used): -After contact with inanimate objects in the resident's room, especially those in the immediate vicinity of the resident; and -After removing gloves. Use of PPE: Gloves: Wear gloves with fit and durability appropriate to the task: Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment. II. Failure to properly clean resident rooms and follow proper hand hygiene procedures A. Observations On 4/14/2020 at 10:04 a.m. a housekeeper (HK) was observed entering an unidentified double occupancy resident room. The HK did not perform hand hygiene prior to entering the room, she removed a bottle of cleaner from her housekeeping cart and entered the room. The HK was observed lifting personal pictures and items in the resident room with her bare hands, in order to spray the residents shelf with the cleaning product. -10:05 a.m., the HK entered the resident bathroom, and lifted the raised toilet seat with her ungloved hands. The HK did not perform hand hygiene. -10:07 a.m. the HK was observed wiping one of the residents' bedside table, while picking up the resident's television remote and her oxygen incentive spirometer with her ungloved hand. -10:09 a.m., the HK was observed holding the resident's call light in her ungloved hand and wiping the residents' call light. -10:12 a.m. the HK went into the resident bathroom, she did not perform hand hygiene, she removed a pair of gloves and put them on. -10:13 a.m., the HK cleaned the sink and toilet in the resident bathroom with her gloved hands, when she finished with the bathroom she emptied the resident trash can and wiped the trash can with a rag. She removed her gloves, and did not perform hand hygiene. -10:14 a.m., the HK picked up the toilet riser with her bare hands and placed it back over the resident's toilet. -10:14 a.m. the HK performed hand hygiene in the resident's bathroom sink, for 10 seconds, and used her bare hand to turn off the faucet. -10:15 a.m., the HK removed the trash from the room, and stated that she needed to go to the housekeeping closet for additional mop heads. -10:17 a.m., the HK returned with several mop heads, she placed one on her mop, and used her bare hands to get the mop head wet in the bucket of mop water. -10:18 a.m. the HK began mopping the residents room, while mopping the floor, she was observed using her bare hands to move both the resident's wheelchair and walkers. The HK touched the handles multiple times with her bare hands. -10:20 a.m. the HK was observed picking up one of the resident's oxygen tubing from the floor and placing it onto the resident's bed in order to mop the floor. -10:22 a.m. the HK mopped the bathroom floor, and removed the soiled mop head with her bare hand. -10:23 a.m., the HK placed the soiled mop head in her housekeeping cart, and reentered the residents bathroom to wash her hands. The HK washed her hands for less than 10 seconds, and used her bare hand to turn off the water. B. Interviews The HK was interviewed on 4/14/2020 at 10:24 a.m. She said she had not had much training regarding COVID-19 and did not think anything had changed as far as how to clean. She said the only difference was that she was now required to wear a mask. The HK said wearing gloves was a personal preference, and she only wore them when she cleaned the bathroom. The HK said she did not wash her hands or use alcohol based hand hand rub (ABHR) everytime she changed gloves or switched tasks because she washed her hands when she finished a room. The environmental service director (ESD) was interviewed on 4/14/2020 at 10:33 a.m., she said she and the other managers had done several trainings and hands on demonstrations over the past month regarding COVID-19, how to properly clean and what chemicals to use, as well as how to correctly use personal protective equipment (PPE). The ESD said the facility was not currently low on gloves, and the housekeepers should be using disposable gloves the entire time they are cleaning resident rooms. The ESD said each housekeeper had heavy-duty reusable gloves they could also use while cleaning the bathroom, they just needed to be sanitized between rooms. The ESD said hand hygiene needed to be performed before putting gloves on and after gloves had been removed. The ESD said the dirty mop head should never be touched with bare hands. The NHA, director of nursing (DON), and infection preventionist/unit manager (IP) were interviewed on 4/14/2020 at 11:45 a.m. The NHA said all of the staff in the building, including all of the housekeeping staff had multiple training sessions including training on COVID-19, proper PPE use, as well as how to properly don (put on) and doff (remove) PPE including gloves. The IP said gloves needed to be worn the entire time a housekeeping staff was cleaning a resident room, and needed to be changed when the housekeeper changed tasks. The DON said anytime gloves are removed, hand hygiene should be performed either by washing hands, or using ABHR. The IP said she would make sure the room and the resident's personal items were recleaned using proper cleaning procedures. The NHA reviewed the training the housekeeper had attended and stated she had training on 3/11/2020, 3/12/2020, 3/13/2020, 3/16/2020, 3/20/2020, 3/24/2020 and 4/13/2020. The NHA said the housekeeper did hands on training on 4/2/2020, where the housekeeper did a return demonstration on properly donning and doffing PPE, which included donning and doffing gloves, and proper hand hygiene.

Based on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in two of three dining rooms. Specifically, the facility failed to: -Prevent potential cross contamination during meal service and meal delivery; -Ensure drink stations were free of contamination; and -Use proper hand hygiene during meal delivery. Findings include: I. Facility policy The Food Safety and Sanitation policy and procedure manual, revised 2019, was provided by the nursing home administrator (NHA) on 12/18/19 at 1:50 p.m. The policy read in pertinent part: All local state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department . All staff will be in good health, will have clean personal habits, and will use safe food handling practices . The Hand Washing policy and procedure manual, revised 2019, was provided by the nursing home administrator (NHA) on 12/18/19 at 1:50 p.m. The policy read in pertinent part: Employees will wash handing as frequently as needed throughout the day using proper hand washing procedures . If chemical sanitizing are used, staff must wash hands . Staff will be educated on the importance of hand washing . II. Observations [NAME] Cross contamination related to the delivery of ready to eat food and improper hand hygiene. The lunch meal was observed in the secured unit dining room on 12/16/19 from 11:30 p.m. to 12:35 p.m. Prepared meal plates arrived in the unit at 12:48 p.m. Certified nurse aide (CNA) #1 and licensed practical nurse (LPN) #2 delivered the plated food to the residents in the dining room. During observations CNA #1 did not wash her hands prior to serving plated ready-to-eat food to the residents. CNA #1 did not sanitize her hands before or during meal service. LPN #1 was observed to use safe food handling practices. Between 12:49 p.m. and 12:55 p.m., CNA #1 served seven residents in the dining room. Out of those seven residents, she placed her thumb on the eating surface of the three plates and inside the rim of a divided plate, when transporting and serving the plated food. B. Contamination of the drink station during meal service. During the lunch service on 12/18/19, the drink station was used in a manner that contaminated the station's beverage delivery equipment. -At 12:12 p.m., a community student volunteer was observed standing in front of the drink station in the dining room. She held a disposable plastic water bottle in her hand. The bottle had a small portion of water covering the inside bottom surface of the disposal bottle. The volunteer refilled the bottle by placing the beverage spout inside the opening at the top of the bottle. III. Staff interviews The dietary manager (DM) and the NHA were interviewed on 12/19/19 at 9:40 a.m. The DM said she and the facility were responsible for providing training opportunities so her dietary staff understood how to prevent cross-contamination. The DM said staff should practice good personal hygiene and safe food handling procedures. She said the registered dietitian would be conducting and incorporating more training in January. She said all staff including CNAs needed to practice hand hygiene when serving meals. DM said her staff routinely wiped down the drink station after each meal service but not after each use during the service. The NHA said the drink station contamination concern would be followed up regarding the student volunteer. The NHA said all identified concerns would be immediately corrected to ensure safe food handling practices and limit the risk of cross contamination. The job coach responsible for supervising the community student volunteer was interviewed on 12/19/19 at 11:05 a.m. She said she nor her student was trained on facility rules that included guidelines for safe, sanitary practices. She said they had not been provided any guidance on facility expectations.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for two (#82 and #18) of six residents reviewed for non-pressure related skin conditions and physician orders [REDACTED]. Specifically, the facility failed to: -Monitor bruising for healing after a fall for Resident #82; and -Follow blood pressure medication physician orders [REDACTED]. Findings include: I. Bruising after a fall [NAME] Facility policy and procedure The facility Skin Monitoring Protocol was provided by the nursing home administrator (NHA) on 12/8/19 at 4:40 p.m. It read, in pertinent part, Any new bruise identified after admission should be monitored for 7 days by the day shift. The assessment should include location, size, and appearance of bruise; presence of any new bruises; presence of pain, condition of resident's skin (if fragile, if bruises easily, if on anticoagulants, etc.) Assessment of extremity or body part where bruise is located; range of motion, strength, pain, and comparison with baseline. B. Resident #82 status Resident #82, age below 90, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/22/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. She required extensive two person assistance for activities of daily living (ADLs) and she used a wheelchair for mobility. She had a stage two pressure injury and received hospice and oxygen therapy. C. Record review The comprehensive care plan, revised 4/2/18, revealed the resident was at risk of bleeding or bruising due to routine aspirin use. Interventions included monitor for signs or symptoms of bleeding such as bruising, dark stools, hematuria, etc. The 11/18/19 event report, completed by registered nurse (RN) #2, revealed Resident #82 sustained an unwitnessed fall in her bathroom. She sustained injury to the right side of her back with sheared skin and bruising. The nurse failed to assess the location, size, and appearance of the bruise, as indicated in the facility policy and procedure. The nurses failed to monitor the healing of the bruising from the resident's fall in follow up skin assessments. D. Interviews RN #2 was interviewed on 12/19/19 at 9:53 a.m. She said after a fall occurred an investigation into the fall was opened by the nurse. She said nurses should open a separate event to monitor injuries sustained from a fall to monitor for healing. She said Resident #82's bruising should have been monitored after the fall in a separate event by the nurse who initially assessed the resident's injury. The director of nursing (DON) was interviewed on 12/18/19 at 4:17 p.m. She said skin tears should be monitored for at least 72 hours and more severe bruising should be monitored until they are healed. She said the facility policy was to monitor the bruise appearance for at least seven days to ensure the bruise was healing. II. Blood pressure medication per physician orders [REDACTED]. Resident #18 status Resident #18, age 86, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/24/19 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS identified the resident required supervision with most activities of daily living (ADLs). B. Record review According to the CPOs for (MONTH) 2019, the resident received: -Losartan 75 milligrams (mg) once a day in the morning for hypertension, hold the medication for systolic blood pressure below 110 millimeters of mercury (mmHg). -[MEDICATION NAME] tablet 0.1 mg once a day, as needed for systolic blood pressure above or equal to 180 mmHg. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Losartan medication was marked as administered. On 11/15/19, Resident #18's systolic blood pressure was 182 mmHg. [MEDICATION NAME] was not administered on that day. Review of the (MONTH) 2019 MAR indicated [REDACTED]. [MEDICATION NAME] was not administered to the resident on those days. Review of the blood pressure record for (MONTH) and (MONTH) 2019 revealed the resident had systolic blood pressure above 180 mmHg on: -12/18/19, 186/92 mmHg taken at 6:00 a.m., retaken in five minutes with reading 142/84; -12/15/19, 182/83 mmHg taken at 11:47 a.m., no further retakes of blood pressure for the day; -12/6/19, 202/81 mmHg taken at 6:59 a.m., retaken at 8:38 a.m. with reading 121/75; -12/4/19, 185/85 mmHg at 7:51 a.m., no further retakes of blood pressure for the day. The progress notes did not provide any clarifications why Losartan medication was administered when the resident's systolic blood pressure was below 110 mmHg, and/or why [MEDICATION NAME] medication was not given to the resident when her systolic blood pressure was above 180 mmHg as ordered by the physician. C. Interviews Registered nurse (RN) #1 was interviewed on 12/18/19 at 4:31 p.m. She said she checked the resident's blood pressure every morning before breakfast and only after administering all medications. She reviewed the MAR for (MONTH) 2019 and said that she was the nurse who worked on 11/1 and 11/5/19. She said she recalled checking the resident's blood pressure in the morning, and she did not administer Losartan on those days because the resident's systolic blood pressure was too low. She said it was marked on the MAR indicated [REDACTED]. She said she was aware that there was a way to mark that medication was not given, but she did not do it correctly on those days. The corporate nurse consultant (CNC) was interviewed on 12/19/19 10:22 a.m. He said it was a technical error in documentation for 11/1 and 11/5/19. He said all nurses were reeducated on proper documentation. Regarding the [MEDICATION NAME] medication that was not given to the resident when her blood pressure was above 180 mmHg, he said that on some days the resident's blood pressure was rechecked and the systolic value was below 180 mmHg. On other days it was not rechecked and nurses were expected to recheck the blood pressure and if it was above 180 mmHg, [MEDICATION NAME] should have been administered. He said his expectation was to check the resident's blood pressure in the morning before breakfast, and if the systolic reading was above 180 mmHg, to administer scheduled Losartan medication and recheck the blood pressure within one hour (the time when Losartan would become effective). If the systolic blood pressure would not drop below 180 mmHg within one hour, the nurses were expected to administer [MEDICATION NAME] medication. He said the MAR indicated [REDACTED]. He said the order read to administer [MEDICATION NAME] if systolic blood pressure was above 180 mmHg. He said moving forward they would clarify orders with the physician and educate nurses on proper documentation. The director of nursing (DON) was interviewed on 12/19/19 at 12:45 p.m. She said she agreed with the corporate nurse consultant, that nurses should recheck blood pressure after the first medication within one hour and only after administering the second medication. She said the current order did not call for waiting one hour and rechecking blood pressure. She said the plan moving forward was to clarify the order with the physician.

Based on observations, record review and interviews, the facility failed to ensure one (#35) of one residents reviewed out of 40 total sample residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated the ulcers were unavoidable; and a resident having pressure sores received necessary treatment and services to promote healing, and prevent new sores from developing. Specifically; the facility failed to provide the appropriate pressure relieving device (mattress or overlay) or other devices to the resident's bed in a timely manner to prevent the development of a stage III coccyx wound, a stage II to the left coccyx, and a stage II to the right medial gluteal region. The findings include: 1. Professional Standards The 'National Pressure Ulcer Advisory Panel, "NPUAP Pressure Ulcer Stages/Categories," 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ (January 2015). International NPUAP-EPUAP Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure Ulcer Stages/Categories Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. 2. Facility Polices The Decubitus Ulcer and Wound Documentation (revised 1/1/2015) -Policy: Wounds and decubitus ulcers will be assessed and monitored in order to prevent their occurrence and to evaluate the healing process when they are present. --4. Pressure-relieving devices may be used when a resident has a pressure ulcer. This determination will be based on assessment and recommendation by the facility Wound Care Team. --8. Pressure ulcers will be followed at least weekly by the facility Wound Care Team. - The policy for Braden Scales with Moderate Risk (addendum to pressure ulcer policy start date 1/16/15) --Pressure- relieving mattress or A/P overlay mattress. 3. Resident #35 a. Resident Status On 12/11/14 this [AGE] year old resident was admitted to the facility. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Admission assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating he was cognitively intact. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was frequently incontinent of both bowel and bladder. The MDS documented the resident utilized a pressure reducing device for his bed and wheel chair. The MDS did not document the resident had any skin conditions or pressure ulcers. b. Record Review The hospital History and Physical (H&P) dated 12/8/14 documented the resident had [MEDICAL CONDITION], pneumonia, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The H&P did not document the resident had any current pressure ulcers to his coccyx or gluteal regions. The Care Plan (CP) dated 12/11/14 for skin protection/wound prevention documented the resident was at risk of skin breakdown due to limited mobility, incontinence and advanced age. The resident reported he had a history of [REDACTED]. The resident had a [DIAGNOSES REDACTED]. The approaches documented the resident had been educated on the importance of side lying positions when in bed. The resident reported he slept on his side. Staff was to inspect his skin weekly for red or open areas. Staff was to document any such areas noted and consult a physician or nurse practioner as needed for treatment orders. The resident had a pressure reducing mattress on his bed and pressure reducing cushion on his wheel chair. Staff was to provide assistance with peri care after each toileting or incontinent episode. The CP dated 12/20/14 (nine days after admission) documented the resident had wounds to his coccyx and left medial gluteal region. The approaches documented the resident stated he typically slept on his sides and was able to move independently in bed. Occupational Therapy (OT) was to provide wheelchair positioning. The facility was to provide a pressure relieving wheel chair cushion and a pressure reducing mattress to his bed. Staff was to provide topical treatments as ordered. The CP dated 12/30/14 documented the resident had a wound to his coccyx. The approaches documented to provide an Air Pressure (A/P) overlay mattress to the resident's bed and a pressure relieving cushion to his wheelchair and recliner. The resident stated he typically slept on his sides and was able to move independently in bed. OT was to provide wheelchair positioning. Staff was to provide topical treatments as ordered. The Physician order [REDACTED]. -Weekly head to toe skin assessments once a day on Saturday. Perform a full head to toe skin assessment and open an event in Matrix for each skin alteration identified starting on 12/11/14. -Nutritional supplement 4 ounces (chocolate) by mouth twice a day between meals for weight loss since admission starting on 1/2/15. -Encourage and assist the resident to lay down in his bed with side lying positions as he accepts every shift starting on 1/13/15. -Magic cup with dinner orally once a day starting on 1/16/15. -Juven (agrinine, gluatime, calcium beta-[MEDICATION NAME]-beta-[MEDICATION NAME]) power in a packet 7-7-1.5 gram orally, twice a day between meals, mixed in 6-8 ounces of water and stir according to package directions for wound healing starting on 1/20/15. -Coccyx wound cleanse with wound cleanser, cut Puracol to fit the wound and apply cover with foam dressing ([MEDICATION NAME]). Change every two weeks and as needed. Change following the resident's bath as needed starting on 1/20/15. -Air Pressure A/P mattress to the resident's bed every shift starting on 1/21/15. The Braden Skin assessment dated [DATE] at 12:31 p.m., documented the resident had a preliminary score of 15: at risk. When the resident's advanced age (greater than 65) was added as an additional risk factor his final risk level was 13-14: moderate risk. The interventions documented were to apply a pressure reducing mattress or overlay for his bed and a pressure reducing device for chair/wheelchair. He was not noted as having skin breakdown or pressure ulcers. The dietary note (DN) dated 12/12/14 at 5:55 p.m., documented the initial nutritional assessment had been completed and a nutrition concern event was opened for the resident being at high nutritional risk related to a [DIAGNOSES REDACTED]. The resident was on the restorative dining program and needed assistance with his meals. Staff was to offer snacks between meals and offer the resident assistance as needed. The Registered Dietician (RD) was to monitor his weight trends and determine his need for additional nutrition interventions. The DN did not document the resident had any pressure ulcers. The nursing notes (NN) dated 12/13/14 at 10:27 p.m. indicated the resident's skin was warm, dry and intact. The NN documented there was no new skin issues noted at this time. The NN dated 12/15/14 at 1:45 p.m., documented the resident had a callous (tough skin which has become somewhat thick and hard in response to repeated friction, irritation or pressure) area measuring 1 centimeter (cm) by 1 cm on his coccyx. The area was not open and the resident did not complain of pain or discomfort. Nutrashield (skin protectant) was applied to the callous area. A message was left for the nurse practioner and a phone message was left for the resident's family. The NN documented the Wound Care Team (WCT) were verbally notified. (See notes and interview below: The WCT did not assess the resident until 12/30/14, and did not order additional pressure preventions until 1/20/15.) The NN dated 12/16/14 at 2:14 p.m., documented the callous area to the resident's coccyx was still present and there were no open areas noted. The NN documented the author would continue to monitor. The NN dated 12/17/14 at 5:00 p.m., documented the pain interview had been completed. The resident reported he frequently had moderate pain to his buttocks usually relieved with medication. The NN documented the charge nurse was notified, the nurse practioner was notified by the communication book, a pain event was opened, and the resident's wife was notified by phone. The OT notes dated 12/17/14 at 6:22 p.m., documented the resident stated he needed a different cushion because the one he had was not very comfortable. The resident's standard wheelchair cushion (foam with gel overlay) was upgraded to a pressure relieving Equagel cushion. The NN dated 12/18/14 at 2:16 p.m., documented the resident remained in the skilled nursing facility for a [DIAGNOSES REDACTED]. The resident reported he had occasional severe prickly pain to his buttocks. The NN documented the resident did not have a callous to his coccyx area and there was no apparent redness to the skin in this area. The NN dated 12/18/14 at 2:58 p.m., documented the resident reported he had mild to moderate intensity pain to his buttocks twice during this shift. The resident refused as needed [MEDICATION NAME]. The resident was encouraged to offload his buttocks and change positions frequently to decrease pain. The NN dated 12/22/14 at 10:42 p.m., documented the resident did not complain of pain to his bottom this shift. The NN dated 12/23/14 at 1:39 a.m., documented the resident denied pain to his buttock during the night. The Physical Therapy (PT) note dated 12/24/14 at 4:08 p.m., documented the resident stated the tilt in space wheelchair with a pressure relieving cushion felt better on his bottom. The OT note dated 12/26/14 at 2:50 p.m., documented the resident stated he was glad to have his wheelchair from home because when he tilted back his bottom hurt less. The OT note also documented the care staff were educated about safety with the tilt in space wheelchair including the positioning of the chair was to be no more than 90 degrees upright to reduce the potential for the resident to fall forwards out of his wheelchair. The note also documented to position the resident with his hips back after reclining to provide optimal wheelchair positioning and pressure release. The NN dated 12/27/14 at 9:33 p.m., documented the resident's skin was warm, dry and intact. The resident continued to have a callous area to his coccyx. The NN documented no new skin issues were noted and no open areas or redness was noted. The facility barrier cream was applied. The NN dated 12/27/14 at 10:51 p.m., documented the resident continued with a callous to his coccyx. The callous was noted to be white and non-blanchable. There were no signs or symptoms of infection and a treatment was applied per orders. The NN documented the resident denied any pain to the area. The Wound Care Team note dated 12/30/14 at 7:00 a.m., documented the resident had a coccyx wound measuring 0.8 cm x 0.3 cm x 0.2 cm (stage III) with a 100% smooth red wound bed. In addition, a second wound on the resident's left coccyx measured 0.3 cm x 0.3 cm. The resident's right medial gluteal region also had an area of intact skin that was non-blanchable redness measuring 0.1 cm x 0.1 cm. The resident reported he has had this type of skin concerns for the past months. He stated the areas opened and healed with his wife putting ointment on the areas. The resident had a pressure relieving type wheelchair cushion in place. The WCT would notify the resident's physician for further treatment orders including a request for a nutritional supplement. The note also documented the author would discuss wheelchair positioning with therapy. The NN dated 12/30/14 at 7:07 a.m., documented facility barrier cream was applied to the calloused area at the coccyx per orders. The NN dated 12/31/14 at 11:07 p.m., documented the resident's coccyx wound had a white, raised, hard area surrounding by a small red open area. The area was cleansed, skin prep and a foam dressing was ordered. The resident was offloaded in bed. The NN dated 1/1/15 at 2:30 p.m., documented the resident remained in the facility for pneumonia. The resident was alert and oriented times four and was able to make his needs known. The resident was up for meals in the main dining room. The resident utilized the SARA (Standing and Raising Aide) lift for transfers. The resident offloaded his coccyx this shift. The NN note dated 1/2/15 at 10:17 a.m., documented the resident remained in the facility for pneumonia. The resident was alert and oriented times four and was able to make his needs known. The resident was up for meals in the main dining room. The resident was afebrile this shift and the resident utilized a SARA lift for all transfers. The resident had red areas noted to the top of his head. The resident denied any discomfort to these areas. The resident offloaded his coccyx this shift. The DN dated 1/2/15 at 2:19 p.m., documented the resident had a weight loss of 4.8% in 16 days. The resident had a current weight of 151.5 lbs on 12/27/14. The resident was discussed in the skin and weight committee meeting for pressure areas to his coccyx and non-blanching redness to his buttock. The resident agreed to try a chocolate nutritional supplement drink, 4 ounces twice a day. The DN documented to continue with the resident's current diet as ordered and continue with the nutrition concern event. The RD was to monitor the resident's weight trends weekly. The NN dated 1/3/15 at 11:14 p.m., documented the resident continued with a coccyx wound at this time. The resident was noted with a 2-3 cm in diameter white/macerated wound on his coccyx. There was an additional wound noted to be open at 4 o'clock to the initial wound. The dressing was changed per orders. The weekly skin assessment dated [DATE] at 3:04 p.m., documented the resident's skin was warm, dry and intact with no new skin issues. The coccyx wound continued with white macerated areas surrounding the wound with a smaller (approximately 1 cm in diameter) open area at 4 o'clock. The dressing was changed per orders at this time. The NN dated 1/5/15 at 2:28 p.m., documented the resident remained in the facility for a [DIAGNOSES REDACTED]. The coccyx wound remained open and red with white flaky skin surrounding the wound. The WCT note dated 1/6/15 at 7:00 a.m., documented the resident had a coccyx wound measuring 0.3 cm x 0.2 cm x 0.1 cm (stage III) with a 100% pink wound bed. The surrounding wound was noted with a white callous. In addition, there was an open area of skin to the left gluteal region measuring 0.1 cm x 0.1 cm. The resident reported he slept on his side when he was in bed. The team would continue with the pressure relieving wheelchair cushion and the pressure reducing mattress. The treatments would continue as ordered as well as the nutritional supplements. The right gluteal non-blanching area was now resolved. The OT note dated 1/7/15 at 6:53 p.m., documented the resident stated he liked the new wheelchair cushion and it was comfortable. The note documented the resident had an upgraded cushion to a higher grade pressure relieving cushion system. The resident was educated on offloading techniques to promote healing of his current wound and to prevent further skin breakdown. The NN dated 1/8/15 at 12:25 a.m., documented the coccyx wound had an open area at its center with thick, white, and raised surrounding tissue. The coccyx was noted with redness all over. A dressing was applied per orders. The resident turned side to side while in his bed. The NN dated 1/8/15 at 2:43 p.m., documented a pain assessment had been completed and the resident reported occasional moderate pain to his bottom. The DN dated 1/9/15 at 3:25 p.m., documented the resident had triggered for an 8.3% weight loss in the past 23 days with a current weight of 146 pounds. The resident currently had pneumonia with a decrease in his meal intake. The resident had a current diet for dysphagia with a mechanical soft diet and honey thick liquids. The resident had a drink supplement ordered at four ounces twice a day. The RD would consider ordering a supplement pudding related to a honey thick liquid order. The resident had an intake record of 1-50% for breakfast, 1-25% for lunch and 1-25% for dinner over the past several days. The resident had a skin event for a coccyx wound and a gluteal wound. The note documented to continue to assist the resident with his meals and encourage intake. Staff was to offer snacks/supplements between meals. The RD was to monitor weight trends weekly. The NN dated 1/10/15 at 12:18 a.m., documented the resident's dressing was changed to his coccyx area per orders. The NN documented there was a small open area noted and the skin inferior to the wound was irritated with a scant amount of bleeding. The NN dated 1/11/15 at 12:09 a.m., documented the resident's dressing was changed to his coccyx wound. The NN documented the wound had a small open area with redness to the surrounding area. The note also documented there was some tenderness present. The NN dated 1/11/15 at 11:55 p.m., documented the resident's dressing was changed to his coccyx area. The NN documented the resident had a small open area with thick white surrounding tissue. The NN dated 1/13/15 at 1:43 p.m., documented the resident's dressing was changed to his coccyx wound per orders. The NN documented the resident had a small open area with white surround tissue. The WCT note dated 1/13/15 at 7:00 a.m., documented the resident had a coccyx wound measuring 0.6 cm x 0.4 cm x 0.6 cm (stage III) with undermining extending 0.4 cm between the 1-6 o'clock region of the wound bed. The wound was noted with a 100% smooth wound bed and callous edges. The resident also had a wound on his left gluteal fold measuring 0.1 cm x 0.1 cm (stage II) with surrounding blanching redness. A staff member of OT was present during this observation. The note documented to continue therapies as ordered and to educate the resident on the importance of lying down in bed on his sides during the day to offload. The resident stated he was in agreement with the plan. The nurse practioner would be notified of the current findings. The NN dated 1/14/15 at 3:28 p.m., documented the resident explained he had pain when sitting in his wheelchair and also sitting in his recliner. The resident stated he was comfortable sitting on his bed leaning back against a pillow on the wall. The wound to the resident's coccyx was observed and nearly healed. The resident stated the pain was not at the wound site but at his tailbone. The NN dated 1/15/15 at 11:37 p.m., documented the coccyx wound remained unchanged. The wound was left OTA (open to air) with Z-guard (skin protectant paste) applied per orders. There was redness to the resident's coccyx area and he was encouraged to turn and offload in bed. The NN note dated 1/16/15 at 4:32 a.m., documented the resident had an open area approximately one cm in diameter with macerated skin on the perimeter. The area was cleansed and facility barrier cream was applied per orders. The NN documented there was no dressing orders at this time so the area remained OTA. The NN dated 1/16/15 at 11:37 p.m., documented Z-guard was applied to the wound on the resident's buttocks, to the surrounding red area and to his gluteal wound. The NN documented the area remained unchanged. The DN dated 1/16/15 at 11:53 a.m., documented the resident had a recent decrease in weight from 140.5 pounds on 1/10/15 down to 136.2 pounds on 1/13/15. The resident's diet continued with the mechanical soft diet with honey thick liquids and a nutritional supplement twice a day between meals. The resident was moved to the restorative table in the dining room on 1/13/15 to provide additional assistance. The resident's meal intake had been variable ranging between 25-75% of most meals. The resident's food preferences were reviewed and yogurt was added to his breakfast, fruit at lunch and a Magic Cup with his dinner for additional calories and protein. The nutrition event would remain open until his weight had stabilized. The DN documented the resident had open areas to his skin on his coccyx and left gluteal area. The NN dated 1/17/15 at 3:00 p.m., documented a weekly skin assessment had been completed in the bath house with a CNA present. The NN documented no new skin issues were noted. The open wound remained with no drainage or signs or symptoms of infection to the resident's coccyx. The NN documented a very small open area was noted to the left of the resident's open wound. The NN documented Z-guard was applied per order. The resident's skin was warm and intact. The rash to the resident's back and sternum was resolved. The NN dated 1/18/15 at 10:39 p.m., documented Z-guard was applied to the resident's coccyx per orders. The NN documented the area remained slightly open with a small open area to the left side of the resident's coccyx. The resident offloaded as tolerated. The NN dated 1/19/15 at 11:45 p.m., documented Z guard was applied per orders. The resident was instructed to offload on his sides. The WCT note dated 1/20/15 at 7:00 a.m., documented a floor Registered Nurse (RN) was present during the observation of the resident's coccyx wound. The wound measured 1.0 cm x 0.6 cm x 0.4 cm (stage III) with undermining extending to 0.4 cm at all edges. The note documented to continue with the pressure-relieving wheelchair cushion and ensure the cushion was placed in his recliner when in use. The note documented the nurse practioner would be notified for changes in treatment if indicated. The note further documented the left gluteal region wound has resolved. The Wound Care Team note dated 1/20/15 at 7:14 a.m., documented there was no further open areas of skin noted to the left gluteal region at this time. The surrounding skin was noted with blanching redness. The note documented to continue to encourage the resident to rest on his sides when in bed. The note also documented to continue with the pressure relieving cushion to his wheelchair and also to his recliner. The NN dated 1/21/15 at 10:05 p.m., documented the PRN (as needed) dressing of Puracol and [MEDICATION NAME] (foam dressings) were applied to the resident's coccyx wound per orders. The NN dated 1/23/15 at 11:21 p.m., documented the resident was in his recliner in his room for the first half of the shift. The resident was transferred to his bed at that time. The NN documented throughout the shift the resident was offloaded to the right side. The NN also noted the resident was compliant with all positioning requests. The OT note dated 1/21/15 at 8:56 a.m., documented the resident stated his bottom hurt in reference to his complaint of pain while seated in his wheelchair. The note also documented the resident had an upgraded cushion to a higher grade pressure relieving cushion system. The resident would be educated about the correct pelvic positioning and offloading techniques to promote healing of his current wound and to prevent further skin breakdown. The note documented to continue to provide education to the resident, family and care staff regarding the resident sitting at 90 degrees at meals with an upright posture. The NN dated 1/23/15 at 11:22 p.m., documented the resident continued with a wound to his coccyx. The dressing to the resident's wound was changed per orders this shift as needed. The resident denied any pain to the area and there were no signs or symptoms of infection noted. The NN dated 1/24/15 at 10:57 p.m., documented the resident remained in his bed throughout this shift. The NN documented there were no issues with positioning in his wheelchair. The NN dated 1/24/15 at 10:59 p.m., documented the resident had a dressing change to his coccyx this shift. The resident tolerated the procedure well. The NN documented the resident's skin surrounding the perimeter of his wound was irritated in the square of the [MEDICATION NAME]. The NN documented a note to the Wound Care Team to assess whether the use of something other than [MEDICATION NAME] would be preferred. The NN dated 1/25/15 at 10:42 a.m., documented the resident remained at the facility with [DIAGNOSES REDACTED]. The resident utilized the a mechanical lift for all transfers. The resident ate his meals in the main dining room with some assistance. The resident was alert and orientated to his self and to the city. The resident was noted with a red groin this shift. The resident used a pressure relieving cushion this shift and off loaded in his bed and recliner. The NN dated 1/25/15 at 9:23 p.m., documented the resident remained in his bed throughout this shift. The NN documented the resident tolerated frequent repositioning to offload from his coccyx wound. The NN dated 1/25/15 at 9:36 p.m., documented the dressing to the resident's coccyx wound was changed PRN this shift due to soiling. The resident tolerated the procedure well. c. Observations On 1/21/15 at 3:00 p.m., resident was observed lying in his bed with his eyes closed. The head of his bed was elevated and he had a pillow under his head. A second pillow was between him and the wall. The resident was lying on his back at this time. On 1/22/15 at 2:00 p.m., and 3:00 p.m., the resident was observed lying in bed on his right side buttock. The head of his bed was elevated and a pillow was under his head. On 1/23/15 at 10:45 a.m., the resident was sitting in a recliner in his room. He was reading the paper and the television was on. He stated he could not remember if he had the pressure ulcers to his bottom when he was at home. He stated he tried to shift his weight frequently form one side to the other as he sat. He stated the facility changed out his mattresses and put an Alternating Pressure (AP) overlay on the bed. He stated he slept better with the overlay on his bed. He stated he was satisfied with his care at the facility and with the care he received for his pressure ulcers. He stated the facility did educate him to offload off of his pressure ulcers. The resident was seated on his right side buttock. On 1/23/15 at 3:45 p.m., the resident was observed sitting in his recliner on his right side buttock. The resident had his eyes closed and had his glasses on. On 1/26/15 at 9:23 a.m., the resident was observed lying in his bed with the head of the bed elevated. He had his glasses on and he stated he was doing well. The resident was lying on his right side buttock. The AP overlay mattress was on the bed. d. Staff Interviews On 1/23/15 at 4:00 p.m., the Director of Nursing (DON) and the Clinical Coordinator (CC) were interviewed. The CC stated she had called the resident's wife and she stated the coccyx wound was a pre-existing issue. The wife confirmed he had open areas on his coccyx previously for the past year. The wife stated the area around the coccyx had opened and closed in the past. The DON stated the nurse who made the measurements on 1/3/15 and 1/16/15 was not trained as a wound nurse and was not part of the facility wound team. The CC stated the resident had a pressure redistribution mattress on his bed. On 1/26/15 7:55 a.m., the DON provided the manufacture's description of the pressure redistribution mattress the resident utilized. The DON agreed on the model (named) of the mattress. The mattress was documented as designed for residents up to a stage II pressure ulcer. On 1/26/15 at 8:50 a.m., the Restorative Nurse Director (RND) reviewed the manufacture's description of the pressure redistribution mattress the resident utilized. The RND agreed on the model (named) of the mattress. She also agreed the mattress was documented as designed for residents up to a stage II pressure ulcer. The RND stated this was the mattress the resident was currently utilizing with an overlay. On 1/26/15 at 10:20 a.m., the CC agreed the resident acquired the pressure ulcer in the facility on 12/30/14 and the AP overlay was put on his bed on 1/20/15 (a day prior to the order) (NN above stated the wound team was to be notified of an identified skin isssue on 12/15/14.). The CC stated on 12/30/14 (initial assessment) the resident had a stage III pressure on his coccyx, a stage I to his right medial gluteal area and a stage II to the left side of his coccyx. The CC stated on 1/6/15 the resident had a stage III pressure ulcer to his coccyx, the right medial gluteal area had resolved and a stage II to the left side of his coccyx. The CC stated on 1/13/15 the resident had a stage III pressure ulcer to his coccyx and a stage II to the left side of his coccyx. The CC stated on 1/20/15 the resident had a stage III pressure ulcer to his coccyx and the ulcer to the left side of his coccyx had resolved. On 1/26/15 at 10:47 a.m., the Assistant Director of Clinical Services stated she expected nursing staff to follow facility policies. E. Conclusion The facility was aware the resident had a history of [REDACTED]. When the resident was admitted to the facility he did not have any pressure ulcers. The resident was provided a standard facility mattress designed to be utilized with residents with up to a stage II pressure ulcer. On 12/30/14 the resident developed a coccyx wound measuring 0.8 cm x 0.3 cm x 0.2 cm (stage III), a second wound on the resident's left coccyx measured 0.3 cm x 0.3 cm and a third wound on his right medial gluteal region measuring 0.1 cm x 0.1. The facility provided the AP overlay to the resident's bed on 1/20/15 (21 days after the resident developed his pressure ulcers).

Based on observations, record review and staff interviews, the facility failed to provide adequate supervision for one of five sample residents (#1). Specifically, one staff member transferred resident #1 without using the appropriate transfer technique; the resident fell sustaining a hematoma to the left side. Two days after the fall, the resident was hospitalized secondary to a critical high white blood cell count and hypotension. The hospital [DIAGNOSES REDACTED]. Seven days after the fall, in the hospital, the hematoma ruptured and surgery was required. The findings include: Facility Policy Fall Prevention Program (revised 10/9/09) Residents at the facility (named) have the right to a safe environment, while maximizing their independence. "All alternatives for preventing falls such as treating health problems and making environmental modifications must be explored." -Procedure 2c: assess assistive devices for proper fit and use. Provide instruction as needed. -Procedure 3b: document fall risk measures in the care plan and monitor the effectiveness of the program. -Procedure 3c: obtain consults as appropriate - Physical Therapy, Occupational Therapy, Dietary, Restorative, and Activities, etc. Facility Policy Transferring, Lifting and Repositioning Residents (Gait Belts and Mechanical Lifts) (no date) -Transfers and Lifting: Upon admission or change of condition, residents will be evaluated for safe transfer. Resident who requires assistance in transferring are transferred using a gait belt or with a mechanical lift. All members of the nursing staff are responsible for using proper body mechanics, knowing the proper procedures, and correctly operating assistive devices. No staff member is to use the mechanical lift devices until educated on its use. -Utilize the Mechanical Lift: Anyone requiring maximum assistance of two people for transfer. Those who are unpredictable with the amount of assistance they require. -Use a Gait Belt for: All residents will be transferred using a gait belt unless contraindicated for the resident, i.e. abdominal or chest wound, mandatory lift etc. Record Review On 8/23/13 at 2:18 p.m., resident #1 ([AGE] years old) was admitted to the facility. The resident transferred from the hospital to the facility for continued treatment of [REDACTED]. On 8/27/13 the resident was sent to the hospital for a critical white blood count and hypotension. The resident returned to the facility on [DATE]. On 9/8/13 the resident was sent to the hospital as the wound dehisced (wound dehiscense occurs when surgical wound closures reopen) and returned on the same day. An appointment was made for the resident to see the surgeon the following day for further assessment. On 9/8/13, the resident's readmission record documented the resident had the following Diagnoses: [REDACTED]./embolism. The Minimum Data Set (MDS) 5-day dated 8/27/13 documented the resident required extensive assistance with two plus person physical assist for toileting. Physician order [REDACTED]. On 8/24/13, the physician ordered Physical Therapy and Occupational Therapy to evaluate and treat the resident. The resident utilized Coumadin (a blood thinner) 2 milligrams (mg) by mouth each day at 5:00 p.m. (8/24/13). I. Transfer/Mobility Assessments identified the resident was a high fall risk and required a mechanical lift for all transfer needs: Admission - Nursing Admission Assessment On 8/23/13 at 3:43 p.m., an assessment was conducted. The assessment documented in pertinent part: -Transfers: extensive assistance (resident involved in activity, staff provide weight bearing support), and -Fall Risk - accident in last 180 days (resident considered a High Risk; initiate fall prevention problem on Plan of Care). Occupational Therapy Initial Evaluation On 8/23/13 at 4:22 p.m., an evaluation was conducted. The evaluation documented in pertinent part: Functional Limitations the resident did require a moderate-maximum assist times two on initial stand from wheelchair this date. Recommendation staffs use the Standing and Raising Aide (SARA) lift with resident at this time. The resident understood and agreed with this recommendation. Once resident was standing she required Contact Guard Assist (CGA) for ambulation and transfers using the front wheeled walker. Physical Therapy Initial Evaluation On 8/23/13 at 4:31 p.m., an evaluation was conducted. The evaluation documented in pertinent part: Functional Limitations transfers; sit - stand equals maximum assist times two at wheelchair level. Moderate assist from elevated bed; Stand Pivot Transfer (SPT) = CGA with front wheeled walker. Care Plans (CP) CP dated 8/24/13 resident required assist with Activities of Daily Living (ADL) due to weakness and impaired mobility following recent surgery and hospitalization . Approaches documented provide assist of one with dressing, grooming/hygiene and oral care. Encourage resident to participate as much as she was able. Provide verbal cues during ADL activities as needed. See also any additional directions per Certified Nurse Aide (CNA) report sheet. Provide assist of 1-2 with bed mobility, transfers and toileting, or as directed per CNA report sheet. Provide assist with bathing. Physical Therapy and Occupational Therapy to evaluate and treat as ordered. Clinical Notes - Fall in bathroom two days after admission (on this initial note it did not state the CNA transferred the resident alone, did not use a gait belt and did not use a mechanical lift as therapy recommended on 8/24/13 - (see typed interview from CNA below). On 8/25/13 at 10:00 p.m., a Nurse Note by a Registered Nurse (named) documented she was called into resident's room by Certified Nurse Aide (CNA named) who reported he witnessed resident falling in bathroom. Resident assessed and noted stable then transferred from floor to bed using Vander Lift. An additional Registered Nurse (named) assisted with assessment and transfer. Resident reported pain rating 10/10 in left hip but no abnormal positioning or shortening of leg. Large purple-black bruise measuring 12 x 6 centimeters (cm) with raised "goose egg" noted to left hip. Ice applied to bruise and swelling. Scheduled Dilaudid (pain medication) administered for pain. Resident reported interventions to be helpful in reducing pain to 7/10. Three small superficial skin tears noted to left shin: these were cleansed, Triple Antibiotic Ointment (TAO) applied and covered with gauze and Hypafix. Vital signs and neurological assessments were within normal limits. On 8/25/13 at 11:55 p.m., Safety Event - Fall documented an event occurred on 8/25/13 at 10:00 p.m. The event details documented the resident had a fall in the bathroom witnessed by a Certified Nurse Aide (named). What was the resident doing just prior to the fall; attempting to go to the bathroom. Does the resident exhibit or complain of pain related to the fall; yes in the left hip, swelling and bruising. Also resident has left skin tears. On a scale of 1-10 how does the resident rate the intensity of the pain; 10 - excruciating pain (worse possible). Body assessment the resident received a superficial injury to the left hip and shin. The resident had ranges of motion times four without pain/limitations. The position of the extremities did not demonstrate any rotation/deformity/shortening noted. The resident did not exhibit any changes in her mental status of new onset. The resident was administered two tabs of Hydrocodone Bitartrate and Acetaminophen (Norco) 5/325 approximately one hour prior to the event. The resident's usual ambulatory status was assist of one with/without device. The resident experienced discomfort/pain prior to the fall. The safety measures/adaptive equipment in use at the time of the fall were call light in reach, frequent safety checks, shoes/non-slip socks and the CNA was in room assisting with toileting. The immediate interventions taken were to administer analgesics. The description of the measures were bruise and swelling to left hip assessed with [REDACTED]. Notifications were faxed to physician 8/25/13 at 11:44 p.m., and family notified on 8/26/13 at 10:26 a.m. Vital signs were taken and documented. On 8/26/13 at 12:30 p.m., a Physician Telephone Order (PTO) documented to obtain x-ray of left hip and pelvis with a [DIAGNOSES REDACTED]. On 8/26/13 at 1:42 a.m., a Skilled Nurse Note by a (named) Registered Nurse documented resident at skilled nursing facility for a [DIAGNOSES REDACTED]. Ambulates Stand by Assist (SBA) using SARA lift and wheelchair. Resident had witnessed fall this shift resulting in bruising to left hip and skin tear to left shin. Vital signs are within normal limits. Resident able to make needs known and call light within reach. On 8/26/13 at 1:31 p.m., a Nurse Note by the Director of Nursing (DON) documented Falls Committee: Witnessed fall on 8/25/13 at 10:00 p.m., resident witnessed falling to the floor in bathroom with a bruise noted on left hip after fall. No falls since admission. Resident was currently being followed by Physical Therapy/Occupational Therapy for strengthening and to address Activities of Daily Living (ADL's). Resident admitted to facility on 8/23/13. Care plan updated, CNA worksheet reviewed. Medications and vitals reviewed: will continue with Physical Therapy and Occupational Therapy services. CP dated 8/26/13 resident at risk for fall related to weakness, pain, impaired balance, and a history of falls. Approaches documented to orient the resident to use and location of the call light. Remind and encourage resident to call for assist with transfers or ambulation. Provide assist with transfers and/or ambulation as recommended per therapies or as noted on Certified Nurse Aide (CNA) instruction sheet. CP dated 8/26/13 Activities of Daily Living (ADL) functional/rehabilitation potential. Resident has bruise to left hip. See witnessed fall event for location/description. Approaches documented to handle resident with care during direct care. Use ice to reduce trauma/damage to the skin surface. Post Incident (Falls) Accident Follow-Up The time of the incident was 8/25/13 at 2200 (10:00 p.m.). The Registered Nurse (RN) documented CNA (named) witnessed resident falling following standing up after toileting. Two RNs (named) arrived and immediately assessed the resident. Resident noted on the floor in front of the toilet with brief down and feces present on buttocks. Resident complained of pain and scrape to left hip. The resident's statement documented "I just fell when I was using the toilet." Post Incident/Accident Follow-Up (Skin) The time of the incident was 8/25/13 at 2200 (10:00 p.m.) The incident occurred in the resident's bathroom. The resident had a bruise measuring 12 x 6 centimeters (cm) on the left hip. The description documented a purple-black bruise; tender, swelling noted "goose egg" raised 3 cm. The resident's statement documented, "I fell " and "I scraped my hip on the wall." The Summary Statement documented ice was applied to the area and effective in reducing swelling after ten minutes: scheduled opioid analgesic administered for pain. Director of Nursing's (DON) typed Interviews about the event - CNA did not use the appropriate transfer technique with the resident on 8/25/13: On 8/26/13 (no time) the DON called the (named) Registered Nurse (RN) who worked the evening shift on the hall where the fall occurred. The RN stated the CNA (named) called her to the room and when she went to the room the resident was on the floor in the bathroom. The CNA stated the resident was standing to go to the bathroom and then fell . The resident was assessed by two RNs and then assisted off the floor with the Vander lift. On 8/26/13 (no time) an interview was conducted with the DON and the CNA (named) involved with the resident's fall on 8/25/13. The CNA stated the resident was in the wheelchair and needed to use the toilet. The CNA performed a one person transfer (resident refused the gait belt). The resident was getting ready to stand from the toilet and she fell forward and then to the ground. The CNA stated on Friday when the resident was admitted to the facility and he was working he thought he remembered the resident was a one person transfer. On 8/26/13 (no time) a brief interview was conducted with resident #1. The resident stated the CNA helped her stand to go to the bathroom and her knees felt weak and she fell to the floor. When asked about the use of a mechanical lift, the resident stated they had used the lift the day before however, that evening (8/25/13) they had not been using the lift. The resident stated the CNA (named) had done a one person transfer twice that evening (8/25/13) with no problems. The resident was not fearful and did not request the SARA lift. On 8/26/13 (no time) interview with the Restorative Nursing Supervisor (RNS) who stated on admission 8/23/13 she put the resident (named) was a SARA lift transfer on the CNA/Nurse worksheet. This statement was also confirmed by the (named) Charge Nurse. On 8/26/13 (no time) a second interview was conducted with the (named) RN who was working the evening shift of the incident. She stated the CNA/Nurse worksheet said the resident (named) was a SARA lift. Disciplinary Action A Disciplinary Notice, 8/29/13, documented the named CNA was given a written warning for transferring a resident without using the transfer stated on the CNA/Nurse worksheet. This was a careless action which endangered the safety of the resident and yourself. This was a violation of the correct transfer status which was on the CNA/Nurse worksheet and was to be utilized as such for the safety and well being of the resident and the staff. Check your CNA/Nurse worksheet on a daily basis for any changes and follow the correct transfers' status for all residents. Summation of Injury On 8/27/13, according to the nurses' notes and hospital records, the resident was transferred to the hospital secondary to a critical white blood cell count and hypotension (low blood pressure). The 8/27/13 - 9/5/13 hospital report was reviewed, "Shock secondary to hemorrhage and hypovolemia (hypovolemic shock is an emergency condition in which severe blood and fluid loss make the heart unable to pump enough blood to the body). Left flank hematoma - a CT scan on admit showed a large left flank and left pelvic subcutaneous hematoma. No acute fracture." On 9/2/13, the hematoma spontaneously ruptured. The resident was taken to operating room on 9/2/13 for debridement of necrotic skin and closure. After the surgery and transfusions, the resident was stabilized and returned to the facility on [DATE]. Interviews On 10/30/13 at 1:00 p.m., a meeting was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated the CNA/Nurse worksheet stated to use a SARA (mechanical) lift which was a one staff person lift for toileting. The DON stated the CNA did not use the SARA lift. The DON stated the CNA performed a one person transfer in the bathroom. The DON stated the CNA did not use a gait belt for the one person transfer because the resident requested the gait belt not be used. The DON stated with the use of a SARA (mechanical) lift, a gait belt would not have had to be used. The DON stated the CNA should have used the SARA lift. The DON stated the CNA received a written reprimand for not using the correct transfer methodology (SARA lift) for this resident. The DON stated the CNA stated he did not look at the CNA/Nurse worksheet at the beginning of his shift or prior to his interactions with residents. The DON stated it was her expectation nursing staffs review the CNA/Nurse worksheet when they come on their shifts and prior to working with the residents. The DON stated it was her expectation nursing staffs use the Physical Therapy recommended mechanical lift for the specified resident. The DON stated it was her expectation nursing staffs follow facility policies and procedures. The DON stated she did not do an in-service to all CNAs however; she posted a flyer in the report rooms (The flyer documented the following information: (8/27/13) All Nursing Staff! Do the Correct Transfer! It is very imperative that every day and shift that you work you must check your report sheet for current transfer status. When you give report both parties must talk through the residents' transfers - each and every one. Even if you worked the same hall yesterday you must review the report sheet to make sure the transfer status has not changed. This is updated every day and can change very quickly). On 10/30/13 at 1:10 p.m., the NHA stated it was her expectation nursing staffs review the CNA/Nurse worksheet when they come on their shifts and prior to working with the residents. The NHA stated it was her expectation nursing staffs use the Physical Therapy recommended mechanical lift for the specified resident. The NHA stated it was her expectation nursing staffs follow facility policies and procedures. On 10/30/13 at 1:44 p.m., the RN who assessed the resident after the fall was interviewed. The RN stated the resident was wedged between the side of the toilet and the wall. The RN stated the CNA told her the resident had fallen. The RN stated the resident told her I am hurt but it is minor; I think I just scraped my skin. The RN stated the resident wanted to get into bed. The RN stated the resident complained of pain 10/10 on the pain scale. The RN stated she did not witness any abnormal positioning of the limbs. The RN stated after the event she and the CNA reviewed the CNA/Nurse worksheet and it documented to use the SARA (mechanical) lift for toileting. The RN stated the CNA admitted to her he transferred the resident improperly. The RN stated it was her expectation nursing staffs follow the CNA/Nurse worksheets in their interactions with residents. On 10/30/13 at 2:15 p.m., the CNA (named) involved with the fall was interviewed. He stated he did not review the CNA/Nurse worksheet prior to working with the resident on that shift unfortunately. He stated the resident was just getting ready to sit on the toilet, she had her hands on the grab bars and he had his hand on the back of the resident's pants. He stated suddenly the resident fell forward onto her knees and onto the floor in the bathroom. He stated he did not use his gait belt for the transfer because the resident stated she did not want him to use the gait belt. He stated he was not aware the resident required a mechanical lift during toileting at that time. He stated after the event he and an RN reviewed the CNA/Nurse worksheet: the sheet documented to use a SARA (mechanical) lift.

Based on record review, staff and family interview, the facility failed to ensure two of 29 sample residents (#53 and #34) received adequate supervision and assistive devices to prevent accidents. Specifically: The facility failed to provide adequate interventions to prevent further falls. Resident #53 fell multiple times, sustaining a fracture, lacerations, skin tears and bruising. The findings include: 1. Resident #53, age 91, was admitted to the facility 9/13/11. His [DIAGNOSES REDACTED]. The resident's Minimum (MDS) data set [DATE], revealed the resident was severely impaired in decision making ability, was usually understood and could usually understand. His eye sight was highly impaired. He needed extensive assist with all activities of daily living except eating. He was frequently incontinent of bowel and bladder. The resident's care plan for falls was dated 10/3/11, and was updated on 5/25/12, 10/12/12, 11/29/12 and 1/18/13. The problem was the resident was a risk for falls related to weakness, impaired cognition, impaired vision, attempts to self transfer, leaning forward in the wheelchair. The goal was free from injury from falls. The approaches were: -Consult with a neurologist. -In room an audio device to monitor periods of restlessness. -Discuss with resident's spouse regarding her concerns and requests for different fall interventions. -Provide fine motor activities. -Floor mat and noodle to bed. Resident has a low bed and is kept in lowest position. -Provide a reacher for personal items. -Remind resident of call light. -Provide assist with transfers and/or ambulation as recommended by therapies. Falls: -4/21/12 Fall with injury. The resident had a fall on 4/21/12 and sustained skin tears on the right and left elbows. -5/4/12 Fall with injury. According to the fall committee notes dated 5/4/12, the resident was found on the floor in his room. He stated, "I felt I needed to (get) up and walk." He sustained two skin tears. Interventions already in place were: the bed in a low position, floor mat in place with a bolster to prevent him from falling out of bed. The resident had restorative care, the care plan was reviewed and medications were reviewed. There were no new interventions at this time. -5/19/12 Fall with no injury. According to the fall committee notes dated 5/25/12, there was an unwitnessed fall and the resident was found on the bathroom floor. The resident had alarms, floor mat, restorative for strengthening, a reacher is available for retrieving needed items. There were no new interventions. -5/20/12 Fall with no injury. According to the fall committee notes dated 5/25/12, the resident was observed in his room on the floor. There were no new interventions at this time. -7/18/12 Fall with no injury. According to the fall committee notes dated 7/27/12, the resident was observed on the floor by his sink. He continued on restorative care for ambulation. Check and change toileting program to continue, fall mat and bolster while in bed. Medications reviewed and will request vitamin D from the physician. Care plan reviewed. -8/9/12 Fall with no injury. There were no fall committee notes. -8/30/12 Fall with injury. According to the fall committee notes dated 8/31/12, the resident was found on the floor of his room. (He) complained of right shoulder pain. The resident was sent to emergency room . The resident had a fractured humerus. There were no new interventions at this time. -10/4/12 Fall with injuries. According to the fall committee notes dated 10/12/12, the resident was found on the floor. He had been in his wheelchair prior to the fall. He had abrasions to left upper quadrant. X-rays showed no new injuries to his arm. Physical therapy and occupational therapy continue to work with the resident. No new interventions at this time. -10/16/12 Fall with no injury. According to the fall committee notes dated 10/26/12, the resident was found on the floor next to the sink. No injury noted. -10/22/12 Fall with injury. According to the fall committee notes dated 10/26/12, the resident was on the floor in his room. Carpet as well as fall mat while in bed. Continue to remind resident to call for assistance. Medications and care plan reviewed and updated. No injury noted; however, there was bruising to the bilateral upper extremities on 10/25/12. -10/26/12 Fall with injury. According to the fall committee notes dated 11/2/12, the resident was sitting in his wheelchair prior to the incident. The resident had been ill the past week and more agitated and combative. Will check with the physician for medications time changes. Care plan reviewed. Bruises to upper bilateral extremities. -11/27/12 Fall with injury. According to the fall committee notes dated 12/3/12, the resident had been sitting in the wheelchair prior to the incident. Staff instructed to recline the wheelchair. Injury noted and sent to ER for laceration on the face and a broken nose. Continue with floor mat and bolster in place, check and change for toileting and restorative care. -12/29/12 Fall with injury. According to the fall committee notes dated 1/4/13, the resident was found sitting on the floor. He had a laceration to the right temple. There were no interventions at this time. -1/8/13 Fall without injury. According to the fall committee notes dated 1/11/13, the resident was found on the floor with the wheelchair off to the side. Resident often attempts to self transfer. Continue with high back wheelchair, medications and care plan reviewed. Remind the resident to call for assistance when needed. Keep items on bedside table with in reach. -1/17/13 Fall with injury. According to the fall committee notes dated 1/18/13, the resident was found on the floor next to bed. The resident was sent to ER for staples to the back on the head. Neurology consult, will obtain a room monitor to be kept in resident's room and the nurses' station. -1/19/13 Fall with injury. According to the fall committee report dated 1/25/13, there was an unwitnessed fall in resident's room. Injury noted. Continue with all safety measures currently in place. Interviews: The resident's spouse was interviewed on 1/28/13 at approximately 4:00 p.m. She stated her husband had fallen so many times. She stated just a few days after he was admitted to the facility the resident fell and broke his hip. A week or so later the resident fell and dislocated the hip. She further stated that he had fallen and fractured the other hip and recently fractured his arm. The director of nurses (DON) was interviewed on 1/31/13 at 4:30 p.m. She was asked about the resident's falls and interventions to prevent further falls. The fall committee notes were reviewed. She stated they were a no restraint facility so restraints were not an option. She stated they updated the care plan, putting things in and took things out. She stated they had purchased a high backed wheelchair hoping to recline it and prevent the resident from rising so easily. The DON stated they had done every thing they could think of. However, the facility failed to implement available interventions to prevent the resident's repeat falls. See care plan and fall committee reports above; there was no evidence the facility had comprehensively investigated why the resident continued to self-transfer from bed and wheelchair. Although found in the bathroom or by the sink several times, there was no evidence the resident's activity of daily living needs were re-evaluated, including toileting and ambulation. Moreover, there was no indication that the facility had considered increasing supervision of the resident, even though he was well known to self transfer and had sustained fractures and lacerations from unwitnessed falls. 2. Resident #34 According to the face sheet, the resident, a [AGE] year-old male, originally was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 12/19/12 annual Minimum Data Set (MDS) showed the resident's cognition was severely impaired, scoring five out of 15 possible points on the Brief Interview of Mental Status. The resident required extensive assistance with bed mobility, transfers, walking, dressing, eating, toilet use, and personal hygiene. Record Review: The fall care plan dated 7/17/09, showed the resident was at risk for falls related to impaired mobility due to history of falls, impaired memory, and limited safety awareness. Approaches included: --Administer calcium as per MD/PA orders. --Resident has an anti-roll device on his wheelchair. --Utilize nightlight in room. --Resident often transfers without calling for assistance despite reminders from staff to call for assist. --Resident is not able to use call light reliably due to impaired memory. Perform visual checks in between meals and at night. --Provide standby assist or as needed with transfers. Remind resident not to walk/transfer unassisted. --Resident to wear gripper socks when in bed. --Transfer pole next to bed to assist with transfers. --Resident often gets up and closes his room door at night; encourage him to call for assist with adjusting door or other needs. The bowel and bladder care plan dated 6/22/12 showed the resident was continent of bowel and bladder. Approaches included: --Resident is frequently able to verbalize need to be toileted. --Resident self transfers to the bathroom. Staff to remind him to use his call light and wait for assistance. --Staff to monitor resident for calling out or physical signs such as restlessness or attempts to self transfer as signs that he needs to be toileted. --Staff to notify restorative department if changes in elimination pattern noted. The resident's progress notes were reviewed back to November 2012 and revealed the resident fell on [DATE]. The progress note documented, "Resident noted on floor by CNA (certified nurse aide). Resident states that he was trying to self transfer to go to bathroom when he slipped onto his bottom. Resident noted lying near bed. Resident c/o (complaints of) minor pain 1/10 to back. No injury noted. Resident assisted to bed via vanderlift with no problems. Daughter/POA notified. Fax out to DR. Neuro checks initiated." The fall event report dated 12/29/12 showed the resident was attempting to self transfer and slipped onto his bottom. The fall occurred in the resident's room. Immediate measures taken included neuro checks and the administration of analgesics. The event was closed on 1/4/13 and showed no new interventions were implemented. The post incident accident follow-up form dated 12/31/12 documented in pertinent part: Resident statement: "States that he was trying to self-transfer to go to the BR (bathroom) when he slipped onto his bottom." Root Cause: " ...Resident self-transfers despite reminders to call for assist." Steps Taken to Prevent Recurrence: 1. Fall occurred unwitnessed on 12/29/12 in resident room with no injury. 2. Previous fall 7/12/12. 3. Continue calcium as ordered. 4. Opened event to observe transfers at different various times of day. Will review in 1-2 weeks. 5. Continue anti-roll back device to wheelchair. A 1/4/13 fall committee note documented: "Resident had unwitnessed fall on 12/28/2012 in his room at 20:57. He stated he was trying to self transfer. No injuries noted at the time. His last fall occurred on 7/12/12. Resident does have a transfer pole in his room to assist him in transfers; staff continue to remind him to wait for assistance. Resident does have an anti-rollback device on his wheel chair. No new interventions at this time." No new interventions were implemented following the fall. Although the resident indicated he was transferring to use the toilet when he fell , there was no indication the facility considered increased staff supervision during toileting times or increased assistance with toileting. The resident's toileting abilities were last assessed on 12/19/12, ten days prior to the fall. The assessment noted, "Seven Day Voiding Diary completed for annual review. Resident had only 2 episodes of incontinence throughout the 7 days, he is observed as continuing at his baseline of continence. He continues to self toilet, although staff remind him to wait for assistance. Transfers are assessed as SBA (stand by assistance) with Transfer Pole. This nurse did observe resident transferring with his pole, he is able to maintain balance and use it appropriately. ADLs (activities of daily living) do need assistance for completion. Meals are eaten at the Restorative table in the Main Dining Room for cues as necessary. There is a Feeding Safety Program in place. Resident is able to self propel about the facility in his wheel chair; a specialty cushion and anti-rollback device are in place. A Restorative Program is in place for Active Range of Motion for Lower Extremities and Passive Range of Motion Upper Extremities; he does refuse occasionally. Will continue to monitor for needs." The resident's progress notes were reviewed back to 12/29/12 and showed the resident attempted to self-transfer from his bed. Although the transfers were documented, the reason for the transfer - for purposes of preventing self-transfers - was not consistently documented. Of the reasons documented, toileting was referenced most frequently. Specifically: --12/30/12 (3:45 a.m.): "Continues on fall follow up and noted to attempt to self transfer from bed to w/c (wheelchair) several times tonight and was reminded to use call light and did not use call light at this time ..." --1/13/13 (6:30 a.m.): "Resident calling out from room. When this nurse arrived, resident was self-transferring in to the bathroom. Resident safely assisted back into w/c and then assisted by CNA to toilet. Resident educated on importance of using the call light." --1/14/13 (2:32 p.m.): "Increased attempts to self-transfer this shift. Resident had no falls and was assisted when noted to be verbally calling out. Resident educated on importance of using call pad. Ensured call pad was functioning properly and frequently checked on resident throughout shift." --1/15/13 (12:45 p.m.): "This nurse observed resident self transfer off toilet to w/c. This nurse assisted resident with pants and transfer." --1/15/13 (12:56 p.m.): "Resident just self-transferred into bed." --1/18/13 (12:19 p.m.): "Continues to self-transfer without using call light within reach at all times. Transfer pole in proper place and W/C near bed. No falls or injuries so far this shift, will continue to monitor for safety and assist as able." --1/19/13 (9:06 p.m.): "Resident was noted self transferring one time by this nurse. The nurse explained to resident the use of the call light and it was not safe for him to transfer without assistance." --1/22/13 (11:14 p.m.): "Resident noted to attempt to self-transfer once this shift. Resident noted trying to sit up in bed to use the restroom. No other attempts to self-transfer noted this shift." --1/25/13 (1:10 p.m.): "Continues to self-transfer without using call light within reach at all times. Transfer pole in proper place and W/C near bed. No falls or injuries so far this shift, will continue to monitor for safety and assist as able." --1/28/13 (11:27 a.m.): "Resident self-transferred into bathroom, this nurse assisted resident back into w/c." --1/29/13 (1:44 p.m.): "Resident transferred self from bed to wheelchair x 1 this shift ..." Staff Interview: On 1/31/13 at 5:38 p.m., the director of nursing (DON) acknowledged the resident continued to self-transfer. "We don't want him to get up by himself but he does. He's not a frequent faller." When asked what new interventions were implemented following the resident's 12/29/12 fall, the DON said the resident's transfers were monitored and anti-roll back wheels were continued on his wheelchair. She acknowledged interventions surrounding toileting were not implemented. On 2/4/13 at 9:17 a.m., a certified nurse aide (CNA) who was assigned to the resident stated the resident was occasionally incontinent and wore protective undergarments. When asked how she knew the resident needed to go to the bathroom, the CNA said she would either ask the resident or sometimes he would let her know. On 2/4/13 at 11:04 a.m., the DON stated ideally we want him to have assistance but he calls when he remembers.

Based on record review and staff interviews, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for three (#1, #6 and #9) of 20 sample residents. Specifically, the facility failed to: -prevent a fecal impaction from developing for resident #1; -implement interventions to address constipation for resident #6; -initiate a physician-ordered laboratory test for resident #9. The findings include: I. Failure to Prevent the Development of a Fecal Impaction A. Facility Policy The facility's standard bowel protocol (BP) was as follows: 1. If no bowel movement by the end of six shifts, give 30 cc (cubic centimeters) of milk of magnesia. 2. If no result within two shifts, give one [MEDICATION NAME] 10 mg (milligram) suppository. Listen for bowel sounds and notify the MD/NP (physician/nurse practitioner) if diminished or absent, and -If no results within two shifts, give Fleets Enema and then notify MD/NP. If no results that shift, notify MD/NP. B. Resident Failure Sample resident #1, age 85, was admitted to the facility on [DATE]. His diagnoses, according to the face sheet, included [MEDICAL CONDITIONS], end stage [MEDICAL CONDITION], depression, fractured lower humerus, [MEDICAL CONDITIONS], dementia and constipation. The 10/22/10 Minimum Data Set (MDS) assessment documented the resident had short-term memory loss; but was alert and oriented to time, place and season. He was usually understood and could usually understand others. The resident was incontinent of bowel and bladder. He needed extensive assistance with the assist of two staff members for transfers, toileting and dressing. 1. Record Review A 9/28/10 care plan addressing the resident's bowel incontinence related to decreased mobility documented he was on a prompted toileting program and was encouraged to verbalize the need to go to the bathroom. A 9/28/10 care plan addressing the resident's alteration in bowel elimination due to end stage [MEDICAL CONDITION] documented the goal was to eliminate discomfort related to loose stools or constipation for the next 90 days. The approaches included: monitor and document bowel movements daily, monitor for signs and symptoms of constipation such as absence of stool for 6 shifts or longer, intervene per facility bowel protocol as ordered, monitor effects of the interventions, and administer bowel care medication ([MEDICATION NAME]) as ordered per current medication administration record (MAR). Review of the resident's 9/10 bowel record, kept with the MAR (medication administration record), documented: -The resident had no BM for four days (9/3/10 to 9/6/10). -On 9/7/10, a "0" was recorded, indicating no BM, however documentation of a BM was written over the "0". It was unclear whether the resident had a BM that day (Cross-reference F281: Professional Standards). -The resident had a small BM on 9/8/10. -There was no BM documented on 9/9/10 or the morning of the 9/10/10. The 9/10 MAR documented: -The resident received milk of magnesia on 9/5/10 and 9/8/10. -A [MEDICATION NAME] suppository was administered on 9/9/10. -On 9/10/10, the resident received Magnesium [MEDICATION NAME]. The back side of the MAR, used to document administration of as-needed medications and their effectiveness, documented milk of magnesia was administered on 9/5/10, then again on 9/8/10. On 9/9/10, the resident was administered a [MEDICATION NAME] suppository. There was no mention of the magnesium [MEDICATION NAME] (documented on the MAR as administered on 9/10/10). The 9/10 treatment flowsheet documented: -The resident received milk of magnesia twice on 9/5/10. -On 9/9/10, the resident received a [MEDICATION NAME] suppository. The information on the treatment flowsheet did not match the information documented on the MAR. A 9/7/10 nurse's note documented the resident had requested a suppository after his bath. Bowel sounds were present. Fluids were encouraged. There was no indication he received a suppository on that day, even though the resident had not had a bowel movement for five days (see bowel record, above). There were no notes concerning the resident's bowel status on 9/8/10. There was no documentation indicating bowel sounds were checked. A 9/9/10 nurse's note documented, "The resident's stomach is very distended, attempted digital disimpaction at 10:00 a.m. with no results. A fleet's enema was administered at 10:15 a.m., this also yielded no results. At 1:30 p.m. another attempt at digital disimpaction with no results. Bowel sounds heard in all four quadrants. Another fleets enema was given at 1:50 p.m. Information passed on to next shift." A 9/10/10, 6:46 a.m. nurse's note documented, "Stomach distended fleets enema administered with no results. Denies abdominal pain, cramping, nausea. Bowel sounds diminished with a high pitched tone. Resident states he was not passing gas. Reports fullness. MD (physician) paged. Asymptomatic." A 9/10/10, 8:30 a.m. nurse's note documented the nurse spoke with the MD concerning the resident's distended abdomen. The note documented the resident was in pain. The MD recommended administering 30 cc of [MEDICATION NAME] as needed. A 9/10/10, 1:16 p.m. nurse's note documented the resident's abdomen remained distended. A digital exam produced no results. The resident had decreased bowel sounds in all four quadrants. The resident requested an additional digital disimpaction attempt. Another 9/10/10 nurse's note documented, "No results from the enema given yesterday, gave magnesium [MEDICATION NAME] at 6:30 a.m. with no results. Attempted digital disimpaction at 1:30 p.m. no results. Resident had bowel sounds in all four quadrants. Resident sent to hospital at 1:40 p.m." 2. Hospital Record Review A 9/10/10 hospital note documented the resident was admitted with a chief complaint of severe constipation. The note revealed the resident was previously hospitalized in 2/10 with a large amount of stool in his sigmoid colon. He was recently noted to have increased abdominal distension and no bowel movements for several days. A CT scan revealed a very large amount of stool in the sigmoid colon with displacement of the bladder. The note documented the resident was on a bowel regimen at the facility. His family member was concerned the nursing home did not monitor the resident's bowel status closely enough. The note documented the resident's abdomen was assessed to have hyperactive bowel sounds soft and somewhat high-pitched. The abdomen was distended. There was a definite fullness in the lower abdomen, but no distinct edges to the mass, with the conclusion that the resident had severe constipation with a large amount of stool in the sigmoid colon. A 9/10/10, 9:05 p.m. physician's note documented the resident had severe chronic constipation with a fecal impaction. A 9/13/10 hospital note documented the resident received a [MEDICATION NAME] enema for a large rectal impaction with incomplete clearing from prior study. The note documented the resident had a persistent impaction of stool in a distended rectum. He received approximately six bottles of [MEDICATION NAME] enema, diluted with a similar volume of water. Partial evacuation occurred after two sessions with [MEDICATION NAME]. A 9/14/10, 6:47 a.m. physician's note documented the resident became unconscious and code was called due to [MEDICAL CONDITION] during the night. He was resuscitated and given IV fluids. A 9/14/10 physician's note documented (the resident had a) "massive fecal impaction with question of a twist in the colon. Hypotensive event last night likely secondary to dehydration now resolved." A 9/14/10 hospital note documented a flexible sigmoidoscopy exam indicated a large fecal impaction. A large amount of firm but soft stool was noted within the rectal vault. The colon appeared dilated and some what atonic. There was a large amount of liquid stool in the descending colon and sigmoid colon. The rectosigmoid colon was flushed to promote evacuation of stool. A 9/15/10 hospital discharge note documented, in pertinent part, the resident was admitted on [DATE]. He presented with increased abdominal pain and decreased appetite. A CT scan showed a massive dilated distal colon filled with stool. A GI consult was obtained and the resident was given [MEDICATION NAME] 24 mcg (micrograms) three times per day. Finally, on the fifth hospital day, he underwent a sigmoidoscopy. He was noted to have a very large rectal vault. The patient did have stool removed each and every day with tap water enemas; and ultimately enough of the stool was removed to get relief. On the fourth hospital day the patient became unconscious and hypotensive and a respiratory intervention was called. The resident was given 500 cc of normal saline and the family was summoned to the bedside. On the sixth day, the patient was stable enough to be sent back to the facility. The discharge [DIAGNOSES REDACTED]. 3. Staff Interviews The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were interviewed on 11/3/10 at approximately 3:00 p.m. Both stated they were aware the resident had a fecal impaction. II. Failure to Implement Interventions to Address Constipation A. Facility Policy See the facility's standard BP (above). B. Resident Failure Resident #6, [AGE] years old, was admitted to the facility on [DATE]. The face sheet documented the resident had the following Diagnoses: [REDACTED]. The 8/18/10 MDS assessment documented the resident was modified independent in cognitive skills for daily decision-making. The resident required limited assistance from staff (one person physical assist) for toileting, transfers, dressing, and eating. The resident was continent of bowel and had a regular pattern of bowel elimination. 1. Record Review The 6/16/10 comprehensive care plan documented the resident was continent of bowel and was frequently able to verbalize the need to be toileted. The approaches included: note changes in voiding pattern and consult MD/NP as needed. The 11/1/10 physician order [REDACTED]. The order report also documented the following four PRN (as needed) medications for bowel care/constipation: -[MEDICATION NAME] S 50 mg (milligrams) - 8.6 mg orally twice a day, -Milk of Magnesia 30 ml (milliliters) orally once a day, -Fleet Enema 19 g (grams) - 7 g rectally once a day, and -[MEDICATION NAME] laxative suppository 10 mg rectally once a day. The 11/1/10 physician order [REDACTED]. Mosby's "Nursing Drug Reference," (2004), Skidmore-Ruth, Elsevier, St. Louis, Missouri, p. 690, documented constipation as a possible side effect/adverse reaction for MS Contin. The 11/1/10 physician order [REDACTED]. The 9/10 bowel record documented the resident did not have a documented bowel movement from 9/19/10 through 9/24/10, a period of six days. The record documented the resident refused one dose of 30 ml of milk of magnesia on 9/21/10. The 9/10 treatment flowsheet documented the resident refused one dose of milk of magnesia on 9/21/10. The flowsheet did not document the resident was administered any additional bowel care/constipation interventions from 9/1/10 to 9/30/10. Nurse's notes dated 9/19/10 through 9/24/10 did not document the resident was administered any bowel care/constipation interventions, any assessment of the resident's bowel sounds, or whether the MD/NP were notified the resident had not had a bowel movement in six days. On 11/3/10 at 9:00 a.m., the NHA and the DON were both notified of the lack of documentation of bowel movements on the bowel record from 9/19/10 through 9/24/10. Further documentation was requested. The DON stated the facility Bowel Protocol (BP) was documented on the bowel record. On 11/3/10 at 3:06 p.m., the DON stated/agreed the bowel record did not contain any documentation on bowel movements from 9/19/10 through 9/24/10. The DON also agreed the treatment flowsheet did not document the resident was administered any bowel movement interventions from 9/19/10 through 9/24/10. The DON stated it was her expectation nursing staff document administered bowel management interventions on the flowsheet. The DON also stated the clinical record did not contain any documentation the resident's bowel sounds were assessed during the time period 9/19/10 through 9/24/10 as per facility protocol. The DON stated it was her expectation nursing staff follow the facility BP. III. Failure to Initiate a Physician-Ordered Laboratory Test A. Resident Failure Sample resident #9, [AGE] years old, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, including senile dementia, malignant neoplasm of the cecum, hypertension, [MEDICAL CONDITIONS], and lumbago. The quarterly MDS assessment, dated 9/1/10, documented the resident was totally dependent on staff members with bed mobility and transfers and required extensive assistance with dressing, bathing, and toilet use. He was usually continent of bowel and frequently incontinent of bladder. He was able to make himself understood and able to understand others. 1. Record Review A 10/26/10 physician's telephone order (TO) documented an order for [REDACTED]. The above order was documented on the treatment flow sheet on 10/26/10. According to the 10/10 and 11/10 bowel movement (BM) records, the resident had BM on 10/28/10 and 11/3/10; however, there was no evidence in the medical record the hemoccult tests had been done. 2. Staff Interview During the meeting on 11/2/10 at approximately 2:45 p.m., the NHA and DON were informed of the above findings. The DON stated she would follow up with the nurses regarding the ordered hemoccult tests. On 11/3/10 at 11:00 a.m., the DON stated the ordered hemoccult tests were not done while records indicated the resident had bowel movements twice since the order was written. She added in-service training on improving communication between shifts would be provided to licensed staff.