Every finding on record at Eben Ezer Lutheran Care Center

Based on and observations, record review and interviews, the facility failed to ensure six (#1, #2, #3, #4, #5 and #6) of seven residents out of seven sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #2, Resident #3 and Resident #5 were kept free from physical abuse from Resident #1; -Ensure Resident #1 and Resident #4 were kept free from abuse towards each other; and,-Ensure Resident #6 was kept free from physical abuse by Resident #7.Findings include:I. Facility policy and procedureThe Abuse policy and procedure, revised 9/13/23, was provided by the nursing home administrator (NHA) on 12/3/25 at 5:58 p.m. It revealed in pertinent part, Each resident will be free from abuse. Abuse can include verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. It is the policy of this community that all team members monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching and kicking.II. Incidents of physical abuse involving Resident #1A. Incident of physical abuse on 9/22/25 between Resident #1 and Resident #2The facility abuse investigation was provided by the NHA on 12/3/25 at 4:09 p.m. The abuse investigation documented Resident #2 said something to Resident #1 while leaving the dining room. Resident #1 then responded by hitting Resident #2. Resident #2 raised his hand to respond, when Resident #1's daughter yelled, hey at Resident #2, to get him to stop. Staff intervened and Resident #1 and her daughter continued to walk down the hallway. Both residents were separated and assessed with no injuries observed. The incident was witnessed by facility staff and Resident #1's daughter. Resident #2 and Resident #1 were interviewed and unable to recall the incident. The investigation conclusion indicated physical abuse was not substantiated because no injuries were sustained and the assailant had severe cognitive impairment and was unable to understand that her actions could result in a violation of a criminal statute. -However, abuse occurred because Resident #1 willfully struck Resident #2 after he made a comment to her. B. Incident of physical abuse on 10/2/25 between Resident #1 and Resident #2The facility abuse investigation was provided by the NHA on 12/3/25 at 4:09 p.m. The abuse investigation documented the nursing staff witnessed Resident #1 yelling at Resident #2 to give her money back. Resident #1 then hit Resident #2 on the left arm and the head. Both residents were separated and Resident #2 grabbed his walker and walked away. Resident #1 had a history of delusions and believing others were taking her money. Resident #2 was assessed with no injury observed. Resident #2 said he did not get along with Resident #1 but could not recall the incident. The resident was interviewed two days after the incident occurred. The investigation conclusion indicated physical abuse was not substantiated because no injuries were sustained, the assailant had severe cognitive impairment and did not understand her action could result in a violation of a criminal statute. -However, abuse occurred because Resident #1 willfully struck Resident #2 because she thought he stole her money. C. Incident of physical abuse on 10/3/25 between Resident #1 and Resident #3The facility abuse investigation was provided by the NHA on 12/3/25 at 4:09 p.m.The abuse investigation documented Resident #1 did not enjoy the meal which was served at lunch. Resident #1 got up from the table, walked over to Resident #3, picked up Resident #3's arm and hit her on the wrist. The investigation conclusion indicated physical abuse was not substantiated because no injuries were sustained, the assailant had severe cognitive impairment and did not understand her action could result in a violation of a criminal statute. -However, abuse occurred because Resident #1 willfully got up from her chair, walked over to Resident #3, picked up her arm and struck Resident #3 on the wrist. D. Incident of physical abuse on 10/31/25 between Resident #1 and Resident #4 The facility abuse investigation was provided by the NHA on 12/3/25 at 4:09 p.m. The abuse investigation documented Resident #1 entered Resident #4's room to use the bathroom by mistake. Resident #4 grabbed Resident #1's hands and twisted them, telling her that was not her room. Resident #1 pulled her arms away and struck Resident #4. The residents were separated and assessed with no injuries observed. Resident #4 was interviewed and said she did not recall the incident, however said people kept coming into her room. She said she felt they were trying to take her belongings. The investigation conclusion indicated physical abuse was not substantiated because no injuries were sustained, the assailant had severe cognitive impairment and did not understand her action could result in a violation of a criminal statute.-However, abuse occurred because Resident #4 willfully grabbed Resident #1's wrist and twisted because she had entered her room and Resident #1 willfully hit Resident #4 in retaliation. E. Incident of physical abuse on 11/6/25 between Resident #1 and Resident #5 The facility abuse investigation was provided by the NHA on 12/3/25 at 4:09 p.m. The abuse investigation documented Resident #5 was wheeling herself around the unit aimlessly, which was her usual behavior. Resident #1 did not like it and pushed her walker into Resident #5's legs. The certified nurse aide (CNA) was close by and witnessed the incident, however the CNA was unable to stop the walker from being pushed by Resident #1 into Resident #5.The CNA reported Resident #1, prior to the incident, was bothered by another resident who sat on the armrest of her recliner chair.Both residents were separated and assessed with no injury observed.The conclusion indicated physical abuse was not substantiated because no injuries were sustained, the assailant had severe cognitive impairment and did not understand her action could result in a violation of a criminal statute. -However, abuse occurred because Resident #1 willfully pushed her walker into Resident #5's legs because she did not like her wandering down the hallway. III. Incident of physical abuse between Resident #7 and Resident #6The facility abuse investigation was provided by the NHA on 12/3/25 at 4:09 p.m. The abuse investigation documented the nurse heard Resident #6 and Resident #7 arguing down the hallway. Resident #6 was in the hall outside Resident #7's door. Resident #7 was observed telling Resident #6 it was not her room, while she was trying to enter. Resident #6 touched Resident #7 on the head with one finger. Resident #7 slapped Resident #6 on the chest. The nurse separated both residents and conducted assessments with no injuries observed. Resident #6 said she did not know it was Resident #7's room. The interventions included identifying Resident #6 wandered into other residents' space and may have put herself at risk. Staff should assist Resident #6 away from other residents if she was in their personal space.The investigation conclusion indicated that physical abuse was not substantiated because the assailant (Resident #7) did not have intent to harm the victim (Resident #6); she was trying to prevent her from entering the room, and there was no pain or harm to the victim. -However, abuse occurred because Resident #7 willfully struck Resident #6 in the chest because she attempted to enter the room and touched her on the head. IV. Resident informationA. Resident #1 (assailant and victim)1. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, insomnia and depression. The 11/19/25 minimum data set (MDS) assessment revealed the resident had short term and long term memory impairment and severe impairment in making decisions regarding tasks of daily life. She was independent with ambulation, bed mobility and eating and required moderate assistance with dressing and bathing. The MDS assessment documented the resident did not exhibit physical behavioral symptoms, however did exhibit verbal behavior symptoms directed toward others one to three days during the assessment period. 2. Record reviewThe wandering care plan, initiated 1/13/25 and revised 1/14/25, documented Resident #1 was at risk for wandering and elopement due to confusion and new surroundings. The intervention documented engaging the resident in purposeful activity.The activity of daily living (ADL) care plan, initiated 1/23/25, documented Resident #1 had a self-care performance deficit related to a diagnosis of dementia. The care plan indicated the resident was able to transfer herself independently with a walker, toilet herself independently and was independent with bed mobility.The secured neighborhood residence care plan, initiated 1/13/25 and revised 8/11/25, documented Resident #1 resided on the secured unit due to her risk of elopement, safety awareness impairment and history of trauma that motivated the resident to find a safe neighborhood. The interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and a book, identifying a pattern of the resident's wandering; monitoring fatigue and weight loss and verifying placement and working condition of the wander alert system.The behavioral care plan, initiated 1/13/25 and revised 10/6/25, documented Resident #1 had the potential to be verbally expressive and cautious of others due to a history of trauma. Resident #1 had a history of making accusations of others, specifically males raping her related to past trauma and believing someone was stealing from her. The resident's delusions caused increased agitation toward other residents and/or staff. The interventions included analyzing key times, places, circumstances, triggers, determining what de-escalated her behavior, assessing and anticipating the resident's needs, assessing the resident's coping skills and support system, calling the family for a trial with a wander guard system on another neighborhood and offering pain interventions when the resident appeared irritable or in pain.The physically aggressive care plan, initiated 2/17/25 and revised 11/11/25, documented Resident #1 had a history of physically aggressive behavior related to poor impulse control, frustration, being smacked by another person and becoming reactive and striking back and delusions regarding someone stealing her money. The interventions included creating signage for the resident's room, assessing and anticipating the resident's needs, assessing for restlessness and facial grimacing, treating the resident for pain, assessing for clinical conditions through lab work, providing physical and verbal cueing to alleviate anxiety, giving positive feedback, assisting in the verbalization of the source of the resident's agitation, assisting in setting goals for more pleasant behavior, encouraging the resident to seek out a staff member when agitated, encouraging the resident to sit where she had her own personal space, providing frequent checks to ensure her safety and the safety of others, giving the resident as many choices as possible about care and activities, redirecting the resident away from others and providing redirection when the hallway was congested.The 9/10/25 nursing progress note documented Resident #1 was irritable and talked negatively when speaking with staff and other residents.The 9/14/25 nursing progress note documented Resident #1 had not slept that night and was up several times crying. The resident remained awake and wandering throughout the unit, entering other residents' rooms and turning on the lights.The 9/18/25 nursing progress note documented Resident #1 was up at 10:00 p.m. until 1:30 a.m. wandering in and out of other residents' rooms, sitting in the lounge, pacing and playing with light switches.The 9/22/25 nursing progress note documented Resident #1 walked out of the dining room with her daughter and passed another resident (Resident #2). While she passed by, she hit Resident #2.The 10/3/25 nursing progress note documented Resident #1 hit another resident (Resident #2) on the left arm and head, while yelling at him to give her money back.The 10/7/25 nursing progress note documented the facility attempted a trial of placing Resident #1 off the secured unit.The 10/7/25 nursing progress note documented Resident #1 attempted to exit the facility and opened the door to leave. The watch mate was activated and an alarm sounded. She said she did not know where she was going. The nurse redirected Resident #1 back to the facility and into the dining room for a snack and coffee.A 10/7/25 at 4:24 p.m. nursing progress note documented Resident #1 was found wandering in the sun room and brought back by facility staff multiple times throughout the day. The resident attempted to leave the facility and the watch mate set off the alarm.The 10/8/25 nursing progress note documented Resident #1 wandered often throughout multiple units at the facility and into the courtyard. She attempted to leave the facility at 2:40 p.m., saying she was trying to get back home. The resident was redirected back to the unit she resided in. It was determined the resident should return back to the secured unit as she had a safety impairment, short-term and long-term memory loss and exhibited behaviors that affected herself and others negatively. She was returned back to residing in the secured unit.The 10/12/25 physician progress notes documented Resident #1 had increased behaviors and aggression toward another resident. She was tried on a non-secured unit, however that trial failed because she was constantly wandering, including outside of the facility. She was returned to the secured unit.The 10/19/25 nursing progress note documented Resident #1 had increased behaviors for several days, using foul language, increased negative talks and complaints and was very agitated toward staff and other residents.The 10/30/25 incident progress note documented Resident #1 entered another resident's room (Resident #4) by accident to use the bathroom. Resident #4 grabbed her by the hands and twisted them, telling her to get out of her room. Resident #1 pulled away and hit Resident #4. Resident #1's responsible party suggested putting up a sign so she did not go into another room by accident.The 11/2/25 nursing progress note documented Resident #1 hallucinated that she was [AGE] years old and was looking for her father. She got up and told another resident she was going to kill them because they hurt her father. Resident #1 was redirected by facility staff to her room.The 11/10/25 nursing progress not documented Resident #1 was worked up and was mean toward residents and staff.The 11/16/25 nursing progress note documented Resident #1 was heard saying bang, bang, bang, he's next toward another resident. The certified nurse aide (CNA) tried to encourage the resident to be nice, however Resident #1 continued with the behavior.The 11/21/25 nursing progress note documented Resident #1 had an altercation with another resident. Resident #1 hit another resident in the shoulder after telling her to move.B. Resident #2 (victim)1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia with behavioral disturbance, anxiety and depression.The 11/17/25 MDS assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding tasks of daily life. He was independent in ambulation, bed mobility and transfers, required moderate assistance with showering and toileting and supervision with dressing and personal hygiene. The MDS assessment documented the resident did not exhibit verbal or physical behavioral symptoms toward others during the assessment period. 2. Record reviewThe 9/8/25 nursing progress notes documented Resident #2 hit another resident and then the other resident hit him back. The residents were separated and provided redirection.The 9/19/25 nursing progress notes documented Resident #2 was restless, roaming the hallways, asking the staff to check his catheter bag every couple of minutes and got mad when he was informed the bag was not full. The resident was yelling and cursing at facility staff.The 9/22/25 nursing progress note documented the activity staff member witnessed Resident #2 being hit by Resident #1 and yelled at by Resident #1's daughter. No injuries were observed.The 10/2/25 nursing progress note documented Resident #2 was hit by Resident #1. The other resident yelled at Resident #2 telling him to give her money back. Resident #2 got up and walked away from Resident #1. No injuries were observed.C. Resident #3 (victim)1. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia without behavioral disturbance and depression. The 10/22/25 MDS assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding tasks of daily life. She was independent with ambulation, personal hygiene, transfers, bed mobility and toileting, needed supervision with dressing and required maximum assistance with bathing. The MDS assessment documented the resident did not exhibit verbal or behavioral symptoms toward others during the assessment period. 2. Record reviewThe 10/3/25 nursing progress note documented Resident #3 was struck in the chest by Resident #1. Resident #3 informed the staff that Resident #1 had smacked her. Both residents were immediately separated.D. Resident #4 (victim and assailant)1. Resident statusResident #4, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia without behavioral disturbance and depression. The 10/2/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She was independent with eating and toileting. The MDS assessment documented the resident did not exhibit physical or verbal behavioral symptoms toward others during the assessment period. 2. Record reviewThe 10/30/25 nursing progress note documented Resident #1 entered Resident #4's room, thinking it was hers to use the bathroom. Resident #4 grabbed Resident #1 by the wrist and twisted. Resident #4 yelled at Resident #1 to get out of her room. Resident #1 then hit Resident #4. Resident #4 told staff, That woman came in my room and I tried to get her to leave and she attacked me. Both residents were separated and staff had them eat dinner at separate tables. No injuries were observed. E. Resident #5 (victim)1. Resident status Resident #5, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia without behavioral disturbance, anxiety disorder and Alzheimer's disease. The 10/10/25 MDS assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding tasks of daily life. She required maximum assistance with eating and oral hygiene, toileting, bathing, dressing, bed mobility and transfers. She ambulated with the use of a wheelchair. The MDS assessment documented the resident did not exhibit physical or verbal behavioral symptoms toward others during the assessment period 2. Record review The 11/6/25 nursing progress note documented Resident #5 was placed on 15-minute safety checks due to a resident-to-resident altercation. No other information was documented. F. Resident #6 (victim)1. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia without behavioral disturbance.The 11/4/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. She was independent with ambulation, bed mobility and transfers, supervision with eating and dressing and required moderate assistance with personal hygiene, toileting and bathing. The MDS assessment documented the resident did not exhibit physical or verbal behavioral symptoms toward others during the assessment period. 2. Record review The 9/12/25 nursing progress note documented the nurse heard residents arguing down the hallway. Resident #6 was sitting in the hallway outside Resident #7's room. Resident #7 told Resident #6 that was not her room. Resident #6 touched Resident #7 on the head and then Resident #7 slapped Resident #6 in the chest. No injuries were observed. G. Resident #7 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia with behavioral disturbance The 11/19/25 MDS assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding tasks of daily life. She required maximum assistance with toileting, dressing, personal hygiene, bed mobility and transfers. She used a wheelchair for mobility. The MDS assessment documented the resident did not exhibit physical or verbal behavioral symptoms toward others during the assessment period. 2. Record review The behavioral care plan, initiated 4/14/25 and revised 9/16/25, documented Resident #7 had a history of hitting out at another resident when they ran over her toes with their wheelchair. Resident #7 had the potential to strike out at other residents if they were in her space or arguing with her. The interventions included analyzing times of day, places, circumstances, triggers and de-escalation techniques, assessing and addressing any contributing sensory deficits, assessing and anticipating the resident's needs, directing the resident away from other residents' rooms, intervening when she was arguing with another resident and providing frequent checks. The 8/16/25 nursing progress note documented Resident #7 hit another resident with an open hand on the right arm after the other resident ran over her left foot. The other resident was trying to approach the recliner in the common area and did not leave room between herself and Resident #7. No injuries observed. The 8/17/25 nursing progress notes documented Resident #7 was irritable and was packing the hallways between 8:00 p.m. to 10:30 p.m. Resident #7 was observed grabbing other residents' chairs, pushing chairs out of her way and got upset when she felt another resident took her chair. She refused assistance from facility staff until 10:30 p.m. when she allowed them to assist her back to bed. The 9/4/25 nursing progress note documented Resident #7 was sitting in her wheelchair in the hallway. Another resident grabbed the wheel on her wheelchair, lifted it and tipped it over. Resident #7 remained in the wheelchair, lying on her left side. No injuries were observed. The 9/12/25 nursing progress note documented Resident #7 was sitting in the doorway of her room when Resident #6 approached. Resident #7 told Resident #6 it was not her room. Resident #6 touched her on the head, which led to Resident #7 slapping Resident #6 on her chest. No injuries were observed. The 10/14/25 nursing progress note documented Resident #7 crowded around the medication cart in the evenings asking about her mother and wanting to leave and go to Kansas. She refused to go to the dining room because of the green exit sign. V. Staff interviews Certified nurse aide with medication authority (CNA-Med)) #1 was interviewed on 12/3/25 at 3:27 p.m. CNA-Med #1 said she was a CNA with medication authority. She said Resident #1 had a history of being easily irritated and striking out at other residents. She said the facility staff tried to entertain Resident #1 as much as possible to keep her busy and away from the other residents in the secured unit. CNA-Med #1 said Resident #1 and Resident #2 did not get along and the facility staff tried to keep them away from each other as much as possible. She said Resident #1 was easily triggered into physical aggression when it involved Resident #2. She said she did not know why the two residents did not get along, but they had a clear dislike for one another. CNA-Med #1 said Resident #1 wandering throughout the secured unit and into other residents' rooms. She said the night shift reported she would be up all night, wandering into other rooms and turning on the lights. She said it was difficult to constantly redirect her away from other residents to ensure she did not become physically aggressive. CNA-Med #1 said she was aware of all the incidents involving Resident #1. She said she did not have any doubt Resident #1 was willful in being physically aggressive with other residents on the secured unit. She said she considered all of the incidents with Resident #1 physical abuse. CNA-Med #1 said the incident between Resident #6 and Resident #7 was physical abuse. She said Resident #6 was pleasantly confused and wandered throughout the unit, but Resident #7 did not like when people entered her room. She said Resident #6 touching Resident #7's head was not physically aggressive, but Resident #7's response of hitting was considered physical abuse.CNA-Med #1 said the secured unit had a lot of residents who wandered constantly and there was always a lot going on. She said the unit could use some more supervision in the common area when care was being provided or meals were being served. The NHA and the director of nursing (DON) were interviewed together on 12/3/25 at 5:03 p.m. The NHA said Resident #1 had a history of physical aggression. She said Resident #1 did not like other residents entering her space and would sometimes strike out. She said Resident #1 was a grumpy lady and it was difficult to identify all of her triggers. The NHA said the facility had tried Resident #1 off the secured unit because of all the wandering that took place on the unit, however Resident #1 was not safe and attempted to leave multiple times during the trial. She said Resident #1 currently did not have a roommate to ensure she had her own space away from other residents, for the time being. The NHA said she was aware Resident #1 and Resident #2 did not get along but was not sure the reason. She said the facility staff tried to keep them away from one another. The NHA said the definition of physical abuse included willful action. She said even though she understood the definition of willful, she did not think residents with cognitive impairment could commit physical abuse because they did not understand their actions could implicate criminal charges. The NHA said she did not feel a resident with dementia could be willful in their actions.The NHA said she did not feel the incident between Resident #6 and Resident #7 was considered physical abuse because Resident #7 had a diagnosis of dementia.

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 two of four hallways. Specifically, the facility failed to: -Ensure housekeeping completed proper hand hygiene when cleaning resident rooms; and, -Ensure nursing followed proper standards of practice during wound care and followed enhanced barrier precautions appropriately. Findings include: I. Failure to ensure housekeeping completed proper hand hygiene when cleaning resident rooms A. Facility policy and procedure The Hand Hygiene policy, revised 5/6/21, was received from the nursing home administrator (NHA) on 8/15/24 at 10:18 a.m. It documented in pertinent part, All staff will perform proper hand hygiene to prevent the spread of infection to other personnel, neighbors and visitors. This applies to all working staff in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. B. Observations During a continuous observation on 8/13/24, beginning at 11:21 a.m. and ending at 11:50 a.m., the following was observed: Housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER]. She started with donning (putting on) clean gloves. -HSKP #1 did not perform hand hygiene prior to donning the clean gloves. HSKP #1 removed the bedroom and bathroom trash. She grabbed a towel out of a bucket filled with cleaning solution. She did not know what kind of solution it was. She wiped down the bedroom door handles, closet door handles, light switches, bedside tables and the dresser. She took the towel into the bathroom and wiped down the sink, grab bars and toilet. She disposed of the soiled towel. She started to mop the floor of the bedroom and brought it into the bathroom. She mopped the bathroom and then finished mopping the bedroom with the same mop head. -HSKP #1 did not change the mop head when she went from the bathroom to the bedroom. -HSKP #1 did not change her gloves or perform hand hygiene after cleaning the bathroom prior to mopping the floor. HSKP #1 removed her gloves, threw them away and wiped her hands on a dry towel. She wiped her hands on her scrub pants. She donned a clean pair of gloves. -HSKP #1 did not perform hand hygiene after removing the gloves or prior to donning clean gloves. HSKP #1 moved the housekeeping cart to room [ROOM NUMBER]. She checked the trash in the bedroom and in the bathroom. She grabbed a towel from out of a bucket filled with cleaning solution. She wiped down the bedroom door handles, closet door handles, light switches, bedside tables and the dresser. She took the towel into the bathroom and wiped down the sink, grab bars, and the toilet. She disposed of the soiled towel. She started to mop the floor of the bedroom and brought it into the bathroom. She mopped the bathroom and then finished mopping the bedroom with the same mop head. -HSKP #1 did not change the mop head from the bathroom to the bedroom. -HSKP #1 did not change her gloves or perform hand hygiene after cleaning the bathroom prior to mopping the floor. HSKP #1 removed her gloves, threw them away and wiped her hands on the same dry towel from earlier. She wiped her hands on her scrub pants. She donned a clean pair of gloves. -HSKP #1 did not perform hand hygiene after removing the gloves or prior to donning clean gloves. C. Staff interviews The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 8/15/24 at 10:00 a.m. The DON said hand hygiene should be performed prior to donning gloves and after removal of gloves. She said housekeepers should change gloves after completing a room before moving to the next room. She said they should change gloves when moving from the bathroom to the bedroom to clean. She said the housekeepers should dispose of a dirty towel and use a new one when moving from room to room. She said the bedroom and bathroom should be treated as two separate rooms. 50690 II. Failure to ensure nursing followed proper standards of practice during wound care and followed enhanced barrier precautions appropriately A. Professional reference Centers for Disease Control and Prevention (4/2/24), Implementation of Personal Protective Equipment (PPE) - Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), was retrieved on 8/19/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds, regardless of MDRO colonization status. B. Facility policy and procedure The Wound Care policy, revised 12/29/23, was provided by the DON on 8/15/24 at 10:18 a.m. It read in pertinent part, Use disposable cloth to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Place a disposable cloth under the wound to serve as a barrier to protect the bed linen and other body sites. Wipe reusable supplies with alcohol as indicated (supplies that were outside of containers and touched by unclean hands such as scissors. C. Observations On 8/13/24 at 3:30 p.m., licensed practical nurse (LPN) #1 was observed during a dressing change for a resident's heel wound. LPN #1 entered the resident's room with her supplies and placed them on the bedside table. LPN #1 opened the supplies containers and took a pair of scissors from her pocket to cut the ace bandage that covered the resident's current dressing. -LPN #1 failed to wear a gown for high contact care with a resident who was on enhanced barrier precautions (EBP). -LPN #1 failed to use a disposable cloth to establish a clean field on top of the resident's bedside table. -LPN #1 failed to sanitize the pair of scissors she removed from her pocket prior to cutting off the ace bandage. LPN #1 removed the resident's old dressing. She cleansed the wound and placed the resident's heel back onto the bed. -LPN #1 failed to protect the cleansed wound by placing a clean disposable cloth underneath the resident's heel before resting it on the bed. LPN #1 applied the new dressings and wrapped a clean bandage around the resident's foot to cover the dressings. She cut the bandage with the same pair of scissors. -LPN #1 failed to change gloves and perform hand hygiene prior to applying the new dressing. -LPN #1 failed to disinfect the dirty scissors before using them to cut the clean bandage. D. Staff interviews LPN #1 was interviewed on 8/13/24 at 3:30 p.m. LPN #1 said she did not think the resident was on any enhanced barrier precautions. LPN #1 said, after seeing the EBP sign outside the resident's door, that for a resident who was on EBP, dirty trash was put in a red bag and dirty clothes were put in a yellow bag. She said that if she were to do resident care, such as providing feeding assistance or giving medications, she would wear a disposable gown and gloves. -LPN #1 failed to identify that she should have worn a disposable gown while performing the resident's wound care. LPN #1 was interviewed again on 8/15/24 at 9:10 a.m. LPN #1 said on 8/13/24 during the wound dressing change, she forgot to wear the proper personal protective equipment (PPE). LPN #1 said she should have worn a gown when she was doing the dressing change because the resident was on EBP. She said she probably should have put something under the resident's heel to keep the bottom of the heel from contacting the resident's bed sheets while doing the dressing change. The DON was interviewed on 8/15/24 at 3:18 p.m. The DON said the residents who were on EBP had a tag on their door to indicate the need for PPE. She said that gloves and a gown should be worn to do wound dressing changes and most residents had their own supplies in the bathroom, including PPE gowns. The DON said before a dressing change, a clean disposable cloth should be put on top of the resident's tray table and the wound supplies should be placed on top of the cloth. She said, depending on where the wound was located, a clean disposable cloth should be positioned so that the wound and the resident's bed were kept clean during the wound care process. She said the nurses usually had their own scissors, but scissors should be sanitized in between dirty and clean stages and in between residents.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of four kitchenettes. Specifically, the facility failed to: -Ensure food was labeled, dated and discarded in a timely manner; -Ensure staff performed hand hygiene before donning (putting on) gloves to serve ready-to-eat food; and, -Ensure food was reheated to the appropriate temperature. I. Failed to ensure food was labeled, dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/21/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, A date marking system that meets the criteria 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 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 and interviews On 8/12/24 at 9:13 a.m., during the initial kitchen tour, there were 24 avocados in a cardboard box in the large refrigerator in the main kitchen. The avocados were dark and had a mushy texture. The registered dietitian (RD) said the avocados needed to be thrown away and she threw them away in the trash. In the large freezer, there was a large sheet pan on the top shelf that had a red pureed item that was not labeled and was uncovered. There was a large cookie sheet with red cake and white frosting that was not labeled and was uncovered. On 8/14/24 at 11:19 a.m. there were three cartons of liquid thickener in the East [NAME] unit refrigerator. Two of the cartons were apple and lemon flavored that were opened and did not have an opened date. The third carton was orange juice and was dated 7/20. The label on the carton said the thickener was good for seven days once it was opened. On 8/15/24 at 10:09 a.m. the refrigerator on the Somerly unit had one carton of orange flavored thickener that was opened and dated 6/18. C. Staff interview The dietary manager (DM) was interviewed on 8/15/24 at 10:51 a.m. The DM said the avocados should have been discarded prior to the avocados rotting. The DM said the pureed frozen food and the cake should have been covered. II. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/21/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles, and after touching bare human body parts other than clean hands and clean, exposed portions of arms; and during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands. Except when washing fruits and vegetables as specified, food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. B. Observations During a continuous observation on 8/14/24, beginning at 11:46 a.m. and ending at 12:15 p.m. the following was observed in the Elim/Deaconess dining unit: Dietary aide (DA) #3 served multiple residents their meals. DA #3 had disposable gloves on her hands. At 11:59 a.m. DA #3 placed two slices of bread in the toaster with her gloved hands and touched the toaster button to toast the bread. DA #3 plated another resident's lunch. During this time she touched serving utensils. DA #3 used the same gloved hands to take the toast from the toaster to a plate. She took two pads of butter and an individual size jam for the toast. She touched the toast with her same gloved hands and used a knife to butter and jam the toast. She took off her gloves and put them into the trash and then put on new gloves without performing hand hygiene. At 12:15 p.m. DA #3 took a baked sweet potato out of the unit's oven with the same gloved hands. She unwrapped the plastic wrap from the potato. DA #3 used her gloved hands to take the skin off the sweet potato. She disposed of the plastic gloves in the trash and then put on new gloves without performing hand hygiene. C. Staff interview The DM was interviewed on 8/15/24 at 10:51 a.m. The DM said staff should wash their hands between every task and after changing their gloves. The DM said it was important for staff to wash their hands between tasks to avoid cross-contamination and food borne illnesses. III. Failed to ensure food was reheated properly A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/21/24 from:https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, Food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius (C) (165 degrees Fahrenheit (F)) for 15 seconds. Food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. B. Observation and interview During a continuous observation on 8/14/24, beginning at 11:46 a.m. and ending at 12:15 p.m., the following was observed on the Elim/Deaconess dining unit: At 11:56 a.m. DA #3 opened a single-serve-size can of tomato soup and poured the soup into a plastic soup bowl. DA #3 placed the soup in the microwave. DA #3 took the soup out of the microwave and placed the soup on a meal tray for the server to deliver the soup. DA #3 said she reheated the soup for 30 seconds. -DA #3 did not take the temperature of the soup to ensure it reached the correct internal temperature. C. Staff interview The DM was interviewed on 8/15/24 at 10:51 a.m. The DM said food should be reheated long enough so the food reached the temperature of 165 degrees F for 10 seconds. The DM said it was important to reheat food correctly to kill any bacteria.

Based on observations, record review and interviews, the facility failed to ensure one (#26) of six out of 32 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure the physician's orders for Resident #26 contained the dose of the medication the nurse was to administer to the resident. Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 8/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect dosage is a prevalent modality of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication and the patient's identity is verified, without first checking to ensure it is the correct strength for the patient. According to the National Institutes of Health (NIH), National Library of Medicine, Lidocaine 4% cream. (January 2019), retrieved on 8/21/24 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=a3216e25-82bb-4905-ac0b-b2ef4aa32ea0&type=display, Apply externally to the affected area up to three to four times a day. According to the National Institutes of Health (NIH), National Library of Medicine, Silver Sulfadiazine (January 2023), retrieved on 8/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK556054/, A layer one sixteenth of an inch should be applied to entirely cover the cleaned area. According to the National Institutes of Health (NIH), National Library of Medicine, Triamcinolone (February 2024), retrieved on 8/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK544309/, Instructions are to apply a thin layer to the affected area and rub gently. According to IcyHot, retrieved on 8/21/24 from https://www.icyhot.com/en-us/products/creams-rubs/lidocaine-cream, Apply a thin layer to affected area every six to eight hours, not more than three to four times daily. Massage until thoroughly absorbed into the skin. II. Facility policy and procedure The Nursing Medication Administration policy, revised 7/10/24, was received from the nursing home administrator (NHA) on 8/15/24 at 4:05 p.m. It read in pertinent part, Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, right documentation. III. Resident #26 A. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic neuropathy (nerves damaged in the feet, organs or muscles), open wound on right lower leg and left lower leg, dependent on supplemental oxygen, venous insufficiency (the veins in the legs had trouble pumping blood back to the heart) and hypertension (high blood pressure). The 7/3/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15.The resident was independent with eating, oral hygiene, toileting, dressing and personal hygiene. The resident required substantial assistance from staff with showering. The assessment revealed the resident had one venous ulcer (an open sore on the skin when there are problems with blood flow in the veins). The resident was treated with an application of nonsurgical dressings and ointments. B. Resident interview and observation Resident #26 was interviewed on 8/12/24 at 2:03 p.m. Resident #26 had a white bandage approximately five to seven inches long that was covering half of each of her lower extremities. Resident #26's lower extremities had a white substance surrounding the bandages. The resident said she had bandages because she had a sore on each of her legs. She said she had pain surrounding her sores. She said the facility gave her medication to treat the sores and for the pain. C. Record review Review of the August 2024 CPO revealed Resident #26 had the following physician's orders: Lidocaine 4% cream, apply to the right lower leg ulcer topically two times a day every other day for wound pain, ordered on 8/5/24. -The physician's order did not include a dose to direct the nursing staff how much medication to administer to the resident. Silver sulfadiazine 1% cream, apply to the right lower leg stasis ulcer (a venous ulcer when valves in the leg veins can not stop blood from being pulled down by gravity), ordered on 8/5/24. -The physician's order did not include a dose to direct the nursing staff how much medication to administer to the resident. Silver sulfadiazine 1% cream, apply to the right lower leg stasis ulcer every eight hours as needed for the right lower leg stasis ulcer, ordered on 8/5/24. -The physician's order did not include a dose to direct the nursing staff how much medication to administer to the resident. Icy hot lidocaine 4% cream, apply to the neck every four hours as needed for pain, ordered on 9/1/22. -The physician's order did not include a dose to direct the nursing staff how much medication to administer to the resident. Triamcinolone acetonide 0.5% cream, apply to itchy areas due to rash topically every twelve hours as needed for rash to bilateral arms, legs, back and abdomen, ordered on 10/3/23. -The physician's order did not include a dose to direct the nursing staff how much medication to administer to the resident. IV. Staff interviews Certified nurse assistant with medication aide authority (CNA-Med) #1 was interviewed on 8/15/24 at 12:44 p.m. CNA-Med #1said some of the key components of a prescription were the right resident's name, the right birthdate, the right dose, the right route and the right frequency. She said if the provider left a component out of the prescription, she did not give the medication until the order was clarified. CNA-Med #1 said the medication administration order (MAR) and the medication container should direct how much cream to dispense. CNA-Med #1 said the different creams in her medication cart had a label attached to the creams that indicated how much cream to use during the skin treatment. CNA-Med #1 said the creams were kept in a locked cabinet in the residents' room. CNA-Med #1 said the creams located in the cabinet in Resident #26's room did not say how much cream to use during treatment. Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 2:07 p.m. LPN #1 said some of the key components of a prescription were the right route, the right resident and the right dose. She said if the provider left a component out of the prescription, she contacted the provider to clarify the order. LPN #1 said she did not give the medication until the order was clarified. She said she knew how much cream to use because the physician's order would include how much of the medication was to be given. She said she was not familiar with Resident #26. She said she reviewed the different physcian's orders for cream medications for Resident #26. LPN #1 said she did not see the dose for the creams on the physician's orders. She said it was important to know how much to apply because one of the creams was for a wound. LPN #1 said it should be a sufficient amount to cover the wound but not so much that the wound would be smothered. The director of nursing (DON) was interviewed on 8/15/24 at 3:08 p.m The DON said some of the key components of a prescription were the right route, the right resident and the right frequency. She said if the provider left a component out of the prescription, the nurse should contact the provider to clarify the order. The DON said the nurse should not administer the medication until the nurse obtained a clarification. She said was not aware Resident #26's prescription creams did not say how much for the nurse to administer. V. Facility follow up The NHA provided additional information on 8/16/24 at 2:27 p.m. The following physician's order was updated on 8/16/24: Silver sulfadiazine 1% cream. Apply to the right lower leg stasis ulcer topically two times a day for right lower leg stasis ulcer. Apply one sixteenth inch or 120 cubic centimeters (cc) layer to the right lower extremity; and, apply to the right lower leg stasis ulcer topically every eight hours as needed for the right lower leg stasis ulcer. Apply one sixteenth inch or 120 cc layer to the right lower extremity.

Based on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#55) of four residents reviewed for accidents and hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure identified interventions were implemented consistently and monitored for effectiveness; and, -Update and revise Resident #55's care plan with new interventions after each skin injury. Findings include: I. Resident #55 A. Resident status Resident #55, age 79, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia, abdominal aortic aneurysm, acute kidney disease, localized edema and history of falling. The 7/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. He required total assistance with toileting and dressing. He required setup assistance for oral hygiene and he was independent for eating. The assessment revealed the resident did not have skin tears. B. Resident observations On 8/12/24 at 12:15 p.m. Resident #55 was observed in the hallway in front of his room. Resident #55 did not have protection sleeves on either of his arms. C. Resident interview Resident #55 was interviewed on 8/13/24 at 9:30 a.m. He had protection sleeves on both of his arms. Resident #55 said he bled easily. He said he wore protection sleeves most of the time. Resident #55 said the staff did not remind him to wear the sleeves and he asked for assistance when needed. During the interview, the resident's room was observed. Resident #55's bathroom had an additional pair of protection sleeves hanging on a towel rack. Resident #55 had a white dressing on the back of his right hand. D. Record review Resident #55's wound management skin care plan, revised 7/7/24, revealed the resident had bruising to bilateral upper extremities, right hip, left calf and abrasions to bilateral elbows. Interventions included notifying providers of no signs of improvement and providing wound care per treatment. Resident 55's skin breakdown care plan, revised 3/15/24, revealed the resident had potential for pressure ulcer development or skin breakdown due to history of ulcers and excoriation to buttocks. Interventions included administer treatments as ordered, apply geri sleeves (protection sleeves) and encourage the resident to wear sleeves to protect his arms. -The intervention to apply protection sleeves was not added to the care plan until 8/14/24, during the survey (see director of nursing (DON) interview below). Resident #55's activities of daily living self care performance deficit care plan, revised 3/15/24, revealed the resident had a deficit due to kidney failure and weakness. Interventions included using a bell to call for assistance, offering night light to the resident, and physical therapy and occupational therapy evaluation and treatment. The 6/24/24 nurse progress note revealed the resident was found in his room sitting on the floor with his back against the wall under his window. The resident was bleeding from both elbows. The resident had a skin tear on the left inner elbow and on the right elbow. The 6/24/24 fall committee progress note revealed the new interventions were to provide a night light and physical therapy. The 6/28/24 nurse progress note revealed the resident had a new bruise that was dark purple in color to the left elbow and to the right wrist. The resident said he had no idea what happened. The 7/1/24 nurse progress note revealed the resident had a new bruise on the right posterior thigh. -The progress note failed to identify any new intervention put into place to prevent further skin injuries. The 7/2/24 nurse progress note revealed the resident had a u shaped skin tear to the right elbow. -The progress note failed to reveal any new interventions put into place to prevent further skin injuries. The 7/3/24 nurse progress note revealed the resident had a skin tear on the back of his right hand. Resident #55 said he hit the back of his hand on the sit to stand mechanical assistance when he adjusted his pants. -The progress note failed to reveal any new interventions put into place to prevent further skin injuries. The 7/9/24 nurse progress note revealed arm sleeves were offered for both arms. -However, the intervention was not added to the care plan until 8/14/24, during the survey (see DON interview below). The 7/20/24 nurse progress note revealed the resident had a skin tear on his left forearm. The resident went to the dining room to show the nurse the new skin tear. The nurse asked what happened and the resident said he was messed up everywhere while pointing to both arms. -The progress note failed to reveal any new interventions put into place to prevent further skin injuries. The 8/1/24 nurse progress note revealed the resident had a new dark purple bruising proximal to his left antecubital (a small depression on the front of the elbow). The resident said he did not know what happened. The 8/9/24 nurse progress note revealed the resident had a new dark purple bruising on his right elbow. The resident did not know what happened. The 8/10/24 nurse progress note revealed the resident had a new skin tear with dark purple bruising on his left hand. The resident said he needed help because he bumped his elbow on the side table and he was bleeding. -The progress note failed to reveal any new interventions put into place to prevent further skin injuries. A request for the incident reports for Resident #55's skin injuries (from 6/24/24 through 8/10/24) was made to the nursing home administrator (NHA) on 8/13/24. A verbal description of the incidents was provided by the NHA on 8/14/24 (see NHA interview below). II. Staff interviews The NHA was interviewed on 8/14/24 at 1:30 p.m. The NHA said the 6/28/24 skin incident (bruises) was due to the resident's fall on 6/24/24. She said the interventions were offering a night light, physical and occupational therapy and offering a new recliner. The NHA said the 7/1/24 skin incident report revealed the resident's bruising was from the 6/24/24 fall. The NHA said the 7/2/24 skin incident report revealed the resident's skin was rubbed on the recliner during a transfer. She said the interventions were to help him transfer, anticipate his needs, use the call light and gain strength through physical therapy and occupational therapy. The NHA said protection sleeves were offered but the sleeves were not added as an intervention in the resident's care plan and were not communicated to the care team. The NHA said the 8/2/24 skin incident report revealed Resident #55 did not remember what happened. He said the resident had his protection sleeves on while he was riding the therapy bike in the therapy room. The NHA said an unidentified certified nurse aide (CNA) was interviewed and said the day after his skin injury, the resident was not wearing the protection sleeves. The NHA said the skin incident report revealed the intervention was to wear protection sleeves. -The interventions listed on the skin incident reports were not added to Resident #55's care plan (see record review above). Certified nurse aide with medication aide authority (CNA-Med) #1 was interviewed on 8/15/24 at 12:44 pm. CNA-Med #1 said if she saw a new skin condition she told the charge nurse, the assistant director of nursing (ADON) or director of nursing (DON). She said she documented new skin injuries under a task to monitor for skin injury. She would tell the next CNA at shift change. She said she knew if a resident was at risk for skin injury and what interventions to use to prevent skin injuries because it should be on the resident's care plan. Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 2:07 p.m. LPN #1 said if she saw a new skin condition, she documented the condition on an incident report and communicated to the family, provider, wound nurse and other staff. LPN #1 said she completed a skin assessment. She said she told the provider about the skin condition so new orders could be obtained to review if there were signs of infection. LPN #1 said Resident #55 had sustained several skin injuries since he was admitted to the facility. She said interventions used to prevent skin injuries were for the resident to wear protective sleeves and be careful to avoid bumping his arms on hard surfaces. The DON was interviewed on 8/15/24 at 3:08 p.m. The DON said if a nurse saw a new skin condition, the nurse completed an incident report that included the details of what happened, skin assessment, and notified the family and the provider. She said the nurse documented what contributed to the injury and identified an immediate intervention to prevent further injuries. The DON said the nurse documented in the incident report and sometimes as a progress note. She said some interventions to prevent skin injuries included padding hard surfaces and positioning pillows. She said social services, nursing and medical records were responsible for updating the residents' care plans and care plans were updated at care conferences, quarterly and as needed. The DON said Resident #55 had been at risk for skin injury since his admission to the facility. She said interventions to prevent future skin injury were protection sleeves for both of his arms and CNAs were to monitor his skin. She said the protection sleeves were added as an intervention on 8/14/24 (during the survey) but the intervention was put into place in July 2024. III. Facility follow up The NHA provided a timeline of interventions added after each skin injury on 8/16/24 at 3:13 p.m. (after the survey). The intervention information provided included the following: The intervention added after the 7/1/24 incident was an x-ray to rule out injury, environment assessment, education on call light and changed pain medication from as needed to scheduled. The interventions added after the 7/1/24 incident were environment assessment, occupational therapy, treatment orders from the provider, temperature adjusted in the resident's room, tested for COVID-19, warm blanket and pillow offered. The interventions added after the 7/3/24 incident were physical therapy, medical management, lab monitoring, treatment orders and education to the resident on hand placement using the lift. The interventions added after the 8/2/24 incident were protection sleeves for both arms, continued physical therapy and occupational therapy, lab monitoring, medical management, fluid restriction, daily nursing assessment and education on the use of protection sleeves. The interventions added after the 8/9/24 incident were medical management, education on protection sleeves, physical therapy, occupational therapy, fluid restriction, lab monitoring, daily nursing assessment and resident declined protection sleeves. The interventions added after the 8/10/24 incident was medical management, education on protecting arms, physical therapy, occupational therapy, lab monitoring, fluid restriction and daily nursing assessment. The resident refused to have his side table moved or padded. -However, the interventions provided by the NHA had not been updated on the resident's care plan prior to the survey.

Based on observations, record review and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one (#57) of 15 residents reviewed for bed rails out of 32 sample residents. Specifically, for Resident #57, the facility failed to: -Assess and review what interventions were attempted prior to the use of side rails; -Ensure the resident's comprehensive care plan was person centered; -Ensure assessments of the resident's use of the bed rails were completed regularly after they were installed; and, -Obtain consent that included the risks and benefits for using bed rails from the resident and/or the resident's representative before the bed rail installation. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Clinical Guidance for the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, (2/27/23) was retrieved on 8/19/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines. It read in pertinent part, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Nursing Proper Use of Positioning Bars policy, undated, was provided by the nursing home administrator (NHA) on 8/15/24 at 4:05 p.m. It revealed in pertinent part, An assessment will be made to determine the resident's symptoms or reason for using positioning bars. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility and the ability to transfer between positions, to and from bed or chair, to stand and toilet. The use of positioning bars as an assistive device will be addressed in the resident's care plan. Informed consent for the use of less restrictive devices will be obtained from the resident or legal representative per facility protocol. Less restrictive interventions that will be incorporated in care planning include providing restorative care to enhance abilities to stand safely and to walk; a trapeze to increase bed mobility; placing the bed lower to the floor and surrounding the bed with a soft mat; equipping the resident with a device that monitors attempts to arise; providing frequent staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom and furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend this information. Documentation will indicate if less restrictive approaches are not successful and orders to apply and monitor the use of positioning bars for a specific time frame. III. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following cerebral infarction (an ischemic stroke), myocardial infarction (heart attack), chronic kidney disease, dementia, mood disturbance, anxiety and depression. The 7/1/24 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. The resident had an impairment on one side of her upper and lower extremities and used a wheelchair. The resident was dependent on staff assistance for toileting, showering and dressing. The resident required partial assistance with personal hygiene and oral hygiene. The assessment revealed the resident did not use bed rails or physical restraints. B. Resident interview and observations Resident #57 was interviewed on 8/12/24 at 2:53 p.m. Resident #57 was in her reclining chair in her room. Her bed was to the left of her recliner. There was a bed rail on the right side of her bed near the head of the bed. Resident #57 said she did not know what the bed rail was used for and she did not remember when she last used the bed rail. On 8/13/24 at 9:47 a.m. the bed rail was attached to the right side of the resident's bed. On 8/14/24 at 1:16 p.m. the bed rail was attached to the right side of the resident's bed. C. Record review The fall care plan, revised 10/31/23, revealed Resident #57 was at risk for falls due to a cerebral vascular accident with right-sided weakness. The pertinent intervention included positioning bars to assist with transfer and mobility. -The comprehensive care plan failed to include a reason for the use of the bed rail. The August 2024 CPO revealed Resident #57 had a physician's order for positioning bars to assist with transfers, mobility and fall prevention, ordered on 3/13/24. -The physician's order did not specify if the bed rail was to be placed on both sides of the bed or one side of the bed. The 3/12/24 safety device assessment revealed the resident required the assistance of two staff members with transfers using a gait belt and a front-wheel walker. The safety device recommended was positioning bars on bed. The assessment revealed the resident's representative provided consent for the bed rail on 3/12/24. -The assessment did not specify if the bed rail was on the left side, right side or both sides of the bed. -The assessment did not reveal why the bed rail was recommended. -The assessment did not reveal what actions were attempted prior to the use of the bed rail. -The assessment did not indicate the risks and benefits to use a bed rail and what alternatives were tried and failed prior to the use of a bed rail were reviewed with the resident's representative prior to providing consent on 3/12/24. The 3/12/24 nursing progress note revealed the resident's representative gave consent for use of bed rails. -The progress note failed to identify what was tried and failed prior to the use of bed rails and the risks and benefits to the use of bed rails. The 4/24/24 social services note revealed a care conference was held. The resident's care plan was reviewed and updated. -The social services note failed to identify the use of the bed rails were reviewed. III. Staff interviews Certified nurse assistant with medication aide authority (CNA-Med) #1 was interviewed on 8/15/24 at 12:44 p.m. CNA-Med #1 said she knew if a resident was supposed to have a bed rail by looking at the care plan, through a verbal report at shift change and if there was a sticker on the resident's door. Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 2:07 p.m. LPN #1 said if a resident had a bed rail, the nurse contacted the physician for an order. She said she informed maintenance so the bed rail could be installed and restorative nursing was notified. LPN #1 said restorative nursing was responsible for completing the bed rail assessment. She said the nursing staff or the restorative staff obtained consent from the resident or the resident's representative for the bed rail. LPN #1 said the risk and benefits of using a bed rail were reviewed with the resident or the resident's representative when consent was obtained. She said the consent form was documented in the assessment and in a progress note. The director of nursing (DON) was interviewed on 8/15/24 at 3:08 p.m. The DON said the use of bed rails was evaluated quarterly when the care plan was reviewed by the interdisciplinary team (IDT). -However, record review did not reveal a quarterly evaluation had been completed after the bed rail was installed in March 2024 (see record review above). The DON said Resident #57 used the bed rail to help with positioning. The DON said sometimes the staff helped the resident with repositioning and sometimes the resident used the bed rail for self-positioning. The DON said she was not aware the risks and benefits were not documented in Resident #57's electronic medical record (EMR) and the assessment was incomplete. The DON said she did not know the assessment was missing information regarding the placement of the bed rail, why the bed rail was recommended and what actions were attempted before the use of the bed rail.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for one of five certified nurse aides (CNA) reviewed. Specifically, the facility did not provide regular in-service education based on the outcome of the annual performance review for CNA #5. Findings include: I. Record review CNA #5 (hired before 8/14/23) had an annual performance review on 10/1/23. The performance review indicated CNA #5 scored a 50% in the areas of complaints and grievances, environment, quality improvement, workplace violence and sexual harassment. -CNA #5 did not have an in-service education plan based on the outcome of the annual performance review. II. Staff interview The director of nursing (DON) was interviewed on 8/15/24 at 1:52 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of the reviews. The DON said if a CNA scored 50% on a test, the score indicated the CNA did not meet the expectations. She said CNA #5 worked per diem (as needed) and had worked at the facility for at least a year. She said an annual performance review should be completed for all CNAs. She said if there was an area of improvement, she met with the CNA one-on-one to provide education and training.

Based on record review and staff interviews, the facility failed to ensure two (#58 and #48) of four residents out of 25 sample residents reviewed for abuse were kept free from abuse. Resident #48, with a diagnosis of dementia, had known aggressive and impulsive behaviors to other residents. Resident #48 was walking down the hallway and Resident #58 was walking towards her. Resident #48 pushed Resident #58 and she lost her balance. Resident #58 fell to the ground and fractured her right hip. The facility failed to protect Resident #58 from Resident #48's aggressive behaviors. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/26/23 to 3/2/23, resulting in the deficiency being cited at past non-compliance with a correction date of 1/14/23. I. Facility policy The Abuse policy, revised 7/10/22, was provided by the nursing home administrator (NHA) on 2/27/23 at 2:15 p.m. It read in pertinent part: It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility would strive to educate team members and other applicable individuals in techniques to protect all parties. Every resident was unique and may be subject to 'abuse' based on a variety of circumstances, including community physical plant, environment, the resident's health, behavior or cognitive level. a. Before admission, prospective residents would be screened to help determine suitable placement within the community. b. Upon admission and periodically after that, each resident would have an assessment completed which identified potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns. c. The interdisciplinary team would identify the vulnerabilities and interventions on the resident care plan. II. Resident altercation The 1/14/23 health status note revealed Resident #58 was physically abused by Resident #48 (perpetrator). It reported that at approximately 3:00 p.m. Resident #48 was leaving the shower room and walking down the hall when Resident #58 walked towards her. Resident #48 pushed Resident #58 causing her to fall. Resident #58 sustained a right hip fracture related to the fall. Both residents lived in the memory care neighborhood and were non interviewable. Resident #48 was accompanied by a certified nurse aide at the time of the incident. III. Resident #48 A. Resident status Resident #48, age 74, was admitted on [DATE] and readmitted [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included Parkinson's disease, unspecified dementia, history of falling, and anxiety. The 12/6/22 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status score (BIMS). She had short and long term memory problems, and her cognitive skills for daily living were severely impaired. She required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. She required supervision while walking independently in the corridor. She had inattention and disorganized thinking. She had physical symptoms towards others one to three days out of the seven day look back period. She received an antipsychotic and an antidepressant daily. B. Record review The behavior care plan, initiated 8/26/22 and revised 2/27/23, revealed the resident had the potential to be physically aggressive related to her impulsivity and dementia. Interventions included: -Care partners to provide reassurance to the resident when walking. -Care partners would conduct frequent checks to be aware where the resident was for safety. -Resident resided on the west side of the memory care neighborhood related to preference of a lower stimulated environment that assists in the prevention of other residents entering into her proximity and preventing her from reacting in a physically aggressive way towards them. -Motion monitor in her room. -Offer and encourage engagement with personalized sensory box. -Review and monitor psychotropic medication regimen as needed by pharmacy consultant, primary care physician, and psychotropic committee. The activities care plan, initiated 8/26/22 and revised 12/22/22, revealed the resident participated in one to one programming of her desired activities. She was invited to a smaller group of activities of her choosing. Interventions included: -Care partners to offer resident's simple pleasures such as: soda, rice krispies treats, and snacks, especially chocolate. -Encourage resident to go into the living area next to her room where her coloring and drawing table as well as supplies were. -Invite and encourage resident to participate in desired activity as tolerated. The 1/14/23 health status note documented the altercation. The resident was immediately escorted to her room. IV. Resident #58 A. Resident status Resident #58, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the February 2023 CPO, the diagnoses included unspecified dementia, unspecified fracture of the right femur, major depressive disorder, anxiety disorder, unsteadiness on her feet, other abnormalities of gait and mobility, and age-related osteoporosis. The 12/6/22 MDS revealed, the resident was unable to complete a BIMS. She had short and long term memory problems, and her cognitive skills for daily living were severely impaired. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required supervision with transfers and walking in room and corridor. She had inattention and disorganized thinking. She wandered one to three days out of seven look back days. The behavior care plan, initiated 9/2/22 and revised 2/27/23, revealed the resident's behavior may impact others because of her dementia. She had a history of becoming confused, tearful, and believed that others in her room and/or previous roommates were strangers and did not belong in her room. Interventions included: -Resident would not have a roommate at the time. -Encourage resident to express her feelings and validate if needed. -Frequent checks. -Staff would intervene if the resident got upset with other residents. -Stop sign and creative name design placed across the residents door to deter other residents from wandering into her room. The activities care plan, initiated 9/2/22 and revised 1/23/23, revealed the resident loved to read about anything and also enjoyed reading her bible. She liked to listen to music and gospel. She liked to attend social gatherings. Interventions included: -Keep the resident's family involved in discussion about her care. -Participate in meaningful engagements independently (read and watch TV). -Participate in socials, group music events, and movies. The 1/14/23 health status note documented the resident had been walking down the hall independently when she was pushed by another resident and hit the handrail before falling to the ground. The resident was complaining of right hip pain and was unable to move as well as yelling out in pain. The resident was sent to the emergency room for evaluation and treatment. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 3/1/23 at 9:55 a.m. She said Resident #48 was moody and could get angry. She said the resident hit staff and other residents. She said when Resident #48 left her room, staff walked with her to keep other residents safe, since they never knew when she would strike out. She said Resident #48 liked to go into other resident rooms. She said Resident #58 cried a lot for no reason which aggravated other residents. She said when there was an altercation between residents, staff would immediately separate them. CNA #2 was interviewed on 3/1/23 at 10:05 a.m. She said Resident #48 wandered and would not wait for help. She said Resident #48 did not like big groups and liked to be alone. She said Resident #48 would hit others if she did not know them, especially new people, and struck out without warning. She said if she left her room, staff were required to be one-on-one with her. She said Resident #48 had a motion sensor in her room to notify staff she was being active, and also had a door knob safety cover on her door on the outside to prevent residents from wandering into the room. She said Resident #58 cried most of the time and aggravated Resident #48. She said Resident #48 could not handle annoying or loud sounds. She said when there was an altercation between residents, staff would immediately separate them. Licensed practical nurse (LPN) #3 was interviewed on 3/1/23 at 10:47 a.m. She said Resident #48 could be resistive to care. She said when Resident #48 went into the hallway and someone was in her view, she would reach out for them. She said she could lash out and hit without warning. She said she had a motion sensor in her room and when activated staff would immediately check on her. She said staff tried to keep other residents from her hallway. She said if residents did walk down Resident #48's hallway, they would watch to make sure they were kept safe. She said the staff tried to keep the residents in the common area so they could be monitored. She said staff tried to keep the residents engaged so they did not wander. She said Resident #58 did not have any behaviors, but cried a lot, had repetitive words, and wandered. She said Resident #58 no longer resided in the memory care neighborhood. The NHA was interviewed on 3/1/23 at 1:26 p.m. She said Resident #48 was leaving the shower room and walking down the hall with a CNA. She said Resident #58 was coming towards them and Resident #48 reached out and pushed her. She said Resident #58 lost her balance and fell to the ground. She said Resident #48 was immediately taken to her room and Resident #58 was assessed for injuries. She said Resident #58 was sent to the emergency room for evaluation and treatment. VI. Facility interventions On 1/14/23 the facility placed a motion monitor in Resident #48's room and required staff to be with her one-on-one staff supervision when she left her room. Following the incident the facility: -Held an in-service for all staff on dementia and abuse. -The facility completed a full audit of the memory care neighborhood and identified three residents with aggressive behaviors. Individualized interventions were put into place for each of the three identified residents. Resident #58 no longer resided in the memory care neighborhood. When she was readmitted from the hospital, she resided in a different neighborhood within the facility. Resident #48 was not involved in any further resident to resident altercations.

Based on observations, record review and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#29 and #4) of nine residents reviewed for accidents/hazards out of 25 sample residents. Resident #29 had three falls since admission, had severe cognitive impairment, used a wheelchair for ambulation, and required supervision with transfers. Between 9/21/22 and 11/27/22, Resident #29 experienced three falls: one witnessed and two unwitnessed. After the 11/18/22 fall, the resident sustained a left hip fracture. On admission the resident fall risk was 15. The facility failed to initiate a fall care plan with effective interventions to prevent repeated falls. Furthermore, the facility's failure to timely develop appropriate interventions, and effectively anticipate cognitively impaired resident's needs, resulted in two unwitnessed falls within 10 days, contributing to Resident #4's pelvic fracture and decline in activities of daily living. Findings include: I. Facility policy The Fall Prevention policy, revised 12/21/22, was provided by the nursing home administrator (NHA) on 3/1/23 at 3:45 p.m. It read in pertinent part: Each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (resident pushes a resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse indicate in the assessment the resident's fall risk and initiate interventions on the baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's High Risk or Low/Moderate Risk Protocols. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Indicate transfer status on door name plate. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Medication regimen review iv. Low bed v. Alternate call system access vi. Scheduled ambulation or toileting assistance vii. Family/caregiver or resident education viii. Restorative nursing program ix. Therapy services referral 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program and the interdisciplinary team will review fall interventions as necessary. 8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete an incident report. c. Notify the physician and family. d. Review the resident's care plan and update as indicated. e. Document all assessments and actions. f. Obtain witness statements in the case of injury. II. Resident #29 A. Resident status Resident #29, age 73, was admitted on [DATE]. According to the February 2023 computerized physicians orders (CPO), the diagnoses included multiple sclerosis, unspecified dementia, anxiety, and a fracture of the ischium (hip). The 12/2/22 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status score (BIMS). She had short and long term memory problems, and her cognitive skills for daily living were severely impaired. She required extensive assistance with toilet use, dressing, and personal hygiene. She required supervision with transfers and walking in the room and corridor. She had impairment to one side of her lower extremities. She used a wheelchair and had a fracture related to a fall. She had two or more falls with injury since admission, and one fall with a major injury. B. Record review Care plan The left ischium fracture care plan, initiated 11/16/22, revealed the resident sustained a hip fracture related to a fall. The interventions included: -Anticipate and meet needs. -Be sure the call light was within reach and respond promptly to all requests for assistance. -Float heels while in bed. -Care team to consider physical therapy (PT) and occupational therapy (OT) evaluation if needed and if resident and family wishes too. -Follow physician orders for weight bearing status. -Modify environment as needed to current needs: non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills, clutter, and glare free light. -Monitor, document, and report as needed signs and symptoms of hip fracture complications. The fall risk care plan, initiated 3/1/23 (during survey), revealed the resident had a potential for falls related to multiple sclerosis and history of falls. The interventions included: -The resident would frequently ambulate behind her wheelchair and transfer chair to chair throughout the day. -The resident had shoes and may need assistance with putting them on. -The residents' room would be arranged to promote safe mobility with the wheelchair. -The resident transfers independently. -The resident used a wheelchair for mobility. -The resident would like personal items within reach. C. Observations 1. Call light observations The call light in the residents room was not within her reach. The call light cord hung over the call light house attached to the wall which was observed on 2/27/23 at 11:20 a.m., 2/28/23 at 10:58 a.m. and 3/1/23 at 12:34 p.m. Making the call light unavailable if the resident returned to her room. 2. Resident #29 observations On 2/28/23 at 9:56 a.m. Resident #29 was observed sitting in a recliner in the common area watching the bowling activity. She transferred herself from the recliner to her wheelchair to take her turn at bowling. On 2/28/23 at 11:02 a.m. following the bowling activity, Resident #28 transferred herself from her wheelchair into a recliner in the common area. On 3/1/23 Resident #29 was observed continuously from 10:33 a.m. to 11:45 a.m. She self transferred herself from her wheelchair to a recliner and vice versa 13 times. At 11:45 a.m she stood up from a recliner and abandoned her wheelchair. She used an overbed table as a walker and pushed it to a chair across the room and sat down. She declined to go to the dining room for lunch. Lunch was brought to her and placed on the overbed table. With all the resident's transfers, the resident's wheelchair brakes were not engaged and the wheelchair rolled backwards as she sat. Falls The fall investigations were requested from the NHA on 2/28/23. The NHA stated that fall investigations were part of the facility's quality assurance performance improvement (QAPI) process and they were not provided. 1. According to the 9/24/22 health status note, at 4:19 a.m., the resident recalled falling in the shower. She stated she hit her head indicating along the lower hairline behind her ear. There were no reddened areas or tender spots. Her neurological status (neuros) were intact. -No fall care plan was initiated with implemented interventions. 2. According to the 11/18/22 incident note, at 9:14 a.m., the nurse was in the dining room helping another resident and heard yelling. She saw Resident #29 laying on her left side beside the window in the lounge. She attempted to assess the resident but she would not turn over onto her back and continued crying and yelling out. The supervisor asked the resident if she wanted to go to the hospital which she declined. X Rays revealed the resident sustained a left ischium fracture. A left ischium fracture care plan was initiated. However, a fall care plan was not in place with effective interventions. 3. According to the 11/27/22 post fall evaluation, at 2:14 a.m., the resident had an unwitnessed fall at her bedside. Activity at the time of fall was probably the resident transferring between wheelchair and the recliner. There was no injury. -No new interventions were implemented and the fracture care plan was not revised. -There were no IDT review notes for any of the above falls. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 3/1/23 at 9:55 a.m. She said Resident #29 was independent and a stand by assist with transfers, but mostly transferred herself. She said staff did stand by assist with transfers to the toilet, bed, and recliner. She said she did not know what interventions were in place to prevent falls because she worked all of the units. She said staff tried to keep the resident in the common area. She Resident #29 could not remember how to use her call light and yelled out. CNA #2 was interviewed on 3/1/23 at 10:05 a.m. She said Resident #29 was one assist with transfers and could bear weight. She said the resident was not able to recall how to use the call light. She said the resident was on frequent checks since she wandered. She said staff tried to keep her in the common area so they could monitor her. She said Resident #29 frequently transferred herself and would not wait for help. Licensed practical nurse (LPN) #3 was interviewed on 3/1/23 at 10:47 a.m. She said Resident #29 was independent with transfers. She said since the resident's past falls, the resident continued to transfer independently per her choice. She said no interventions were in place to reduce her falls. She said the resident was not able to use her call light. -However, the MDS assessment indicated the resident required supervision from staff for transfers and walking. The NHA was interviewed on 3/1/23 at 1:00 p.m. She said the fall on 9/21/22 was a result of Resident #29's history of trauma and striking out at staff. She said the staff was giving her a shower when she became agitated when the water was turned. The resident stood up from the shower chair and swung at the staff and fell . She said the physician speculated that the resident was having a flare up related to her multiple sclerosis and was having increased spasms and pain. The resident was offered to be sent to the hospital but refused. The NHA said the fall on 11/18/22 was caused by a rolling stool that was next to a chair. She said Resident #29 frequently transferred herself from her wheelchair to a chair. She said the intervention was to remove the stool from the common area. She said the physician said the resident became hypoxic (low blood oxygen level) from refusing to wear her oxygen. She said the resident refused to go to the hospital for x-rays until the family was able to take her. The x-ray resulted in a hip fracture. The NHA said the 11/27/23 fall was unwitnessed in her room. She said as an intervention the facility added purposeful rounding and to offer assistance with toilet use. She said PT/OT was not offered. The restorative nursing program director (RNPD) was interviewed on 3/1/23 at 1:15 p.m. She said Resident #29 should have been a one person assist or stand by assist for transfers. She said the resident was not on a restorative program because she did not retain information. She said she would immediately initiate a fall care plan with an appropriate plan of care. E. Facility follow-up The NHA was interviewed again on 3/2/23 at 11:37 a.m. She said the facility did a root cause and analysis and the falls had declined since October 2022. She said the facility had fall rounds every Thursday. She said going forward the facility would create a profile for each high risk fall resident and put a plan of correction in place. She said the facility pharmacist would do an additional review for residents who were a high fall risk as well. She said starting the following week, in the fall meeting the facility would review falls and the pharmacist would review medications. -However, based on Resident #29's fall risk, falls with injury and observations, the facility did not implement effective measures to prevent falls. 31229 III. Resident #4 A. Resident status Resident #4, age above 65, was admitted on [DATE]. According to the February 2023 clinical physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic neuropathy, Alzheimer's disease, osteoarthritis and history of falling. The diagnosis of fracture of left pubis was added on 2/16/23. The 12/14/22 MDS assessment revealed the resident had impaired cognition including short and long-term memory problems. No behaviors or rejection of care were noted. She required limited assistance with bed mobility and transfers, extensive assistance with dressing, toilet use and personal hygiene, and supervision with eating. No falls or falls history were noted. B. Record review The comprehensive care plan revealed the following: -Fall: The resident is moderate risk for falls r/t (related to) use of walker, hx (history of) of tremor and poor vision (dated 9/26/22). Interventions included: Assist of 2 (two) and gait belt for transfers (dated 3/1/23). (Resident) will remain free of injury. Start: 4/19/21. Neighbor has floor lamp next to bed to use when the room is dark due to poor eyesight. Restorative program in place for AROM (active range of motion), strength, ambulation. (Resident) will be provided with non-skid socks at night d/t (due to) fall. (Resident) uses a w/c (wheelchair) for mobility. Purposeful rounding during the day, evening, and night. Start: 11/30/21. Has push pad call light. Start: 12/13/21. Motion monitor in room to alert staff when (resident) is getting up. Start: 12/27/21 (revision on 2/20/23). -ADL (activities of daily living): The resident has an ADL self-care performance deficit r/t (related to) dementia, fatigue. New pelvic fx (fracture) 2/16/23 (dated 2/17/23). Interventions included: Encourage the resident to use bell to call for assistance (dated 9/26/22). -Cognition: (Resident) has impaired cognitive function/dementia or impaired thought processes r/t (related to) dementia, impaired decision making, long term memory loss (dated 9/26/22). -Risk for Falls (dated 2/5/23). Interventions included: If fall occurs, alert provider. If resident is a fall risk, initiate fall risk precautions. -The fall care plan did not specify frequency of purposeful rounding. -The cognition care plan did not address resident's ability to use a call light. -The facility failed to monitor the effectiveness of Resident #4's care planned interventions and implement effective interventions. C. Nursing notes On 2/5/23 a nurse documented: This writer heard neighbor (referred to as resident) calling for help and when writer walked into room, writer noticed neighbor was on her knees leaning against bed (like praying) and blankets were on the floor. This writer asked neighbor what happened and neighbor states 'I slid out of bed.' Neighbor does complain of knees and legs hurting. The bed was lower and staff used sling to assist neighbor to bed. Notified (name/son) at 2043 (8:43 p.m.) and informed him of incident. Fax was sent to (physician). Fall protocol started. Neighbor was given routine Tramadol (pain medication) around 2100 (9:00 p.m.). Neighbor has been resting in bed and has not had any further complaints of pain. On 2/16/23 at 5:10 p.m. a nurse documented: This nurse was informed at 1710 (5:10 p.m.) that the neighbor was on the floor in between the bathroom and bedroom doorway with her walker in front of her. 'My hip hurt.' Head-to-toe assessment done with complaints of pain to the left hip, stopped moving neighbor and sent to (hospital) via ambulance at 1749 (5:49 p.m.), son (name) was notified at 1726 (5:26 p.m.), called 911 at 1728 (5:28 p.m.) and EMTs (emergency medical technicians) arrived at 1735 (5:35 p.m.). Neuro (neurological) checks were initiated with elevated blood pressure, and blood sugar 162. On 2/16/23 at 8:51 p.m. a nurse documented: Called son and updated him that (Resident) will be returning from (emergency room ) with a closed pelvic fracture that is non-surgical and non-displaced, was given Morphine 2 mg at 1842 (6:42 p.m.). The 2/16/23 hospital record, x-ray report revealed the following: Nondisplaced fractures of the superior and inferior ramus of the left ischium (two fractures in the pelvic ring bone). On 2/16/23 a nurse documented: The neighbor returned from ER (emergency room ) at 2134 (9:34 p.m.) with new orders . may ambulate and weight bear light toe touch on her left leg, and assist as needed with transfers and weight bearing. Diagnosis of closed pelvic non-surgical, non-displaced left hip fracture. Son (name) has been notified and updated. The neighbor is eating a snack in the dining room and the fall protocol continues. On 2/17/23 a nurse documented: Neighbor in w/c (wheelchair) in DR (dining room) eating snack at the beginning of the night. Neighbor assisted to bathroom and then to bed x 2 (with two) staff. Neighbor c/o (complaint of) pain to inner left groin/hip area, insisted she wanted to go to BR (bedroom). Positioned on her right side in bed. Continue on neuros. Neighbor able to move all extremities, lifts left leg well only c/o of pain with extra movements . On 2/17/23 restorative program manager documented: Assessed transfer with stand pivot transfers and neighbor is not able to maintain toe touch weight bearing. Discussed with therapy and we both agreed total lift is most appropriate for transfers. D. Staff interviews CNA #4 was interviewed on 3/1/23 at 5:02 p.m. He said the resident was most of the time independent with all transfers, sometimes required supervision. He said when staff were busy with a resident it was not possible to respond immediately to an alarm from another resident's room. CNA #3 was interviewed on 3/2/23 at 11:10 a.m. She said Resident #4 was not able to use her call light. She said prior to her falls, the resident transferred with staff supervision, however she did not wait for staff. She said the resident had a monitor in her room that would sound on the hallway when she tried to transfer herself from the bed and put her feet on the floor. She said when staff were busy with another resident they did not come right away. She said she was not aware the resident's assessment (MDS assessment 12/14/22) documented required limited assistance with transfers and extensive assistance with toilet use. LPN #1 was interviewed on 3/2/23 at 11:20 a.m. He said he was aware Resident #4 required frequent staff checks as she did not remember to use the call light and always transferred herself. The restorative nursing program director was interviewed on 3/2/23 at 12:33 p.m. She said the resident's care included purposeful rounding, and after the fall on 2/16/23, was added in the task and nursing aides have to chart on it in the resident's record. She said the care plan should specify rounding every two hours.

Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for one of three medication storage rooms and one of three medication carts. Specifically, the facility failed to discard expired medications and to lock a medication cart, when left unattended. Findings include: I. Facility policy The Medication Storage, dated January 2023, was requested and received on 3/2/23. The policy documented in pertinent part: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication; -Outdated medications and containers are immediately removed from stock, disposed of according to medication disposal procedures; -Medication storage conditions were monitored on a regular basis as a random quality assurance check. II. Observations and interviews A. Medication cart -On 2/26/23 at 4:30 p.m., the Deaconess medication cart was observed to be unlocked and unattended for greater than five minutes. There were three residents sitting near the medication cart and two residents self-propelling in their wheelchair in the hallway and around the medication cart. Licensed practical nurse (LPN) #1 was interviewed immediately after the observation and he stated that he had been administering medications to another resident. He stated he was aware the medication cart should be locked when unattended to prevent unauthorized access to medications and supplies. B. Medication room On 2/28/23 at 10:45 a.m., the Deaconess medication room was observed with LPN #2. LPN #2 verified the medication room had expired items: -Sunmark 12 hour mucous relief nasal spray, one each, expired September 2021, 525 days prior; -Nestle Arginaid Extra, Arginine-Intensive supplement drink, 10 each, use by date September 2022, 151 days prior. LPN #2 was interviewed immediately after the observation and stated the night shift staff were responsible for verifying expiration dates and removing expired items from supply. She stated using expired medications could expose the resident to a risk for infection and/or receiving ineffective medications. She immediately removed the nasal spray and supplemental drinks from supply for proper disposal. III. Interview The director of nursing (DON) was interviewed on 3/1/23 at 1:30 p.m. The DON was unaware there were expired items in the medication room. She said it was the responsibility of the night shift nursing staff to identify and remove expired medications from the medication rooms and carts but all staff should remove expired items immediately upon discovery.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) out of three sample residents. Resident #1 was admitted to the facility on [DATE] and was at risk for falls due to weakness, impaired balance and dementia. The facility failed to properly transfer the resident to prevent injury on 7/19/22, which resulted in displaced left femur (hip) bone fracture, hospitalization and surgery. The resident was assessed by staff after complaints of left knee and hip pain and was noted to have edema of the left knee and thigh. The staff informed the resident's physician, x-rays were ordered and the resident was sent to a hospital on 7/19/22. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/28/22 to 10/6/22, resulting in the deficiency being cited as past noncompliance with a correction date of 7/29/22. I. Facility action The facility designed a performance improvement plan on 7/20/22 with emphasis on all staff re-training on appropriate transfers for all residents who required assistance with transfers in the facility. Care plans were updated for all residents who required assistance with transfers. New staff orientation was updated to ensure all residents' transfer status was appropriately informed. The Residents Safe Transfers policy was reviewed and updated on 7/25/22. The policy was approved and signed by the medical director on 7/28/22. All nursing and therapy staff were re-educated on 7/26/22 on transfer techniques and included demonstrations, and final competency test on proper transfers techniques and mechanical lifts transfers utilized in the facility. Audits were completed daily to assess all three shifts in the facility for safe transfers with randomly chosen residents until 7/29/22. II. Resident #1 Resident status Resident #1, age 87, was admitted on [DATE] and readmitted on [DATE] after hospitalization on [DATE]. According to the Profile Face Sheet, diagnoses included displaced oblique fracture shaft of left femur, spinal stenosis, osteoporosis, dementia and history of falling. The 6/10/22 minimum data set (MDS) assessment revealed the resident had impaired cognition with short and long term memory problems, and hallucinations were noted. She required extensive assistance of two staff with bed mobility, dressing, and personal hygiene. She was totally dependent on two staff with transfers and toilet use, and required extensive assistance with one staff for eating. She was always incontinent. Her weight was 122 pounds with no weight loss. She had no pressure injuries. She received an antipsychotic medication and opioid daily. B. Record review The resident's comprehensive care plan for falls, dated 9/29/19, revealed, Transfers with assist of 2 (two persons) and [NAME] lift. A nursing note on 7/19/22 at 8:13 a.m., documented, CNA (certified nurse aide) reports left knee and thigh swollen. Does appear swollen like arthritis but is not red nor warm to touch. On 7/19/22 at 10:10 a.m., a nurse documented, Physician in facility, ordered X-ray, resident complained left knee and hip pain. Resident sent out to a hospital. The hospital admission records revealed the following, Patient is nonverbal, AOX1 (alert and oriented to self), and unable to provide any history. She is grimacing in pain. She cannot answer any yes/no questions. Information obtained from chart at bedside, as well as ER (emergency room ) providers who got signout from EMS (emergency medical services). Per chart review patient lives at a nursing facility and is wheelchair bound at baseline. Staff found her laying in her bed with obvious left thigh deformity this morning, and EMS was called. There is no history of fall, patient has been wheelchair bound and cannot get out of bed on her own power or back into bed .XR (x-ray) pelvis showed displaced rotated angulated distal femur diaphysis fracture. III. Staff interviews The NHA was interviewed with the director of nursing (DON) on 10/5/22 at 1:57 p.m. The NHA said she and the DON initiated the investigation immediately after the resident was sent out to the hospital on 7/19/22 for injury of unknown origin. She said two certified nursing aides (CNAs) who transferred the resident early that morning were suspended immediately pending the investigation and interviewed. She said one of the two CNAs said the resident was transferred with a sit to stand [NAME] (mechanical) lift, while the other CNA said they transferred the resident from bed to wheelchair stand-pivot arm to arm. She said both CNAs were terminated after the investigation was completed on 7/20/22. The DON said all residents who required assistance with transfers, care plans were reviewed to ensure appropriate transfers status was listed. She said if the resident required two staff assistance with transfers they had to use a mechanical lift, it was the facility policy. The NHA said stickers with residents' transfer status were placed on each resident room name plate for staff to ensure the transfer status was known. The DON said all nursing staff received mandatory re-training on safe transfers' techniques. The NHA said 20 residents were interviewed for how staff assisting with transfers, is the transfer correct, is it comfortable, does it cause pain, is pain addressed by staff. CNA #1 was interviewed on 10/5/22 at 4:17 p.m. She said the entire staff was trained on safe transfers on 7/26/22. She said each resident's transfer status sticker was placed on the name plate at the entrance door of the resident's room. She said all residents who required mechanical lift transfers needed two staff assistance. Registered nurse (RN) #1 was interviewed on 10/5/22 at 4:28 p.m. She said she participated in the mandatory safe transfers techniques training in July (2022). She said all residents who required a mechanical lift were to transfer with two staff assistance. She said the residents were not to transfer stand-pivot when their care plan documented extensive assistance. She said two person stand-pivot transfers were not allowed in the facility. Licensed practical nurse (LPN) #1 was interviewed on 10/5/22 at 4:35 p.m. He said all staff were to attend the mandatory training on safe transfers techniques in July (2022). He said all nursing staff should be aware which resident required mechanical lift and who was just one person assistance. He said two staff were to assist the resident who required a mechanic lift with transfers.

Based on observations, interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#54 and #2) of six residents reviewed for falls, out of 32 sample residents. Specifically, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #54 and Resident #2, and falls that resulted in multiple injuries to Resident #54. The lack of supervision and effective interventions resulted in seven unwitnessed falls and one witnessed fall since 1/5/21 that caused multiple fractures and injuries to Resident #54's pelvis, right wrist, left hip, left elbow, left hand and head that caused her extreme pain, required trips to the emergency department and resulted in limited mobility. Findings include: I. Facility policy The Fall Prevention policy and procedure, dated 12/16/19, provided by the nursing home administrator (NHA) on 11/18/21 at 11:38 a.m. read in part: -Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. -A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. -The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. -High risk protocols include: Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status and provide additional interventions as directed by the resident's assessment, including but not limited to: Assistive devices, increased frequency of rounds, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education, restorative nursing program, therapy services referral. -When any resident experiences a fall, the facility will: Assess the resident, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments and actions, obtain witness statements in the case of injury. II. Resident #54 A. Resident status Resident #54, age 92, was admitted [DATE] and readmitted [DATE]. According to the November 2021 computerized physician orders (CPO) diagnoses included unspecified fracture of left acetabulum (hip socket), muscle weakness, difficulty in walking, unspecified fracture of pubis (pelvis), abnormalities of gait and mobility, history of falling and unspecified fracture on the lower end of the right radius (wrist). The 8/31/21 minimum data set (MDS) assessment indicated Resident #54 had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. She was positive for wandering and required limited assistance of one staff member for bed mobility, dressing and personal hygiene. She required limited assistance of two staff members for transfers. She was not steady and was only able to stabilize with staff assistance when moving from seated to a standing position, when walking, when moving on and off the toilet and with surface to surface transfers. She had impairment of one side of her lower extremity. She was occasionally incontinent of bladder, always continent of bowel and was not on a toileting program. She received scheduled pain medication. She was positive for falls with injury and one with major injury. B. Daughter interview and observations Resident #54's daughter was interviewed on 11/15/21 at 11:29 a.m. She said the resident was admitted to the memory care unit in January 2021. She fell while on that unit and broke her pelvis. She moved off the memory care unit and to her current room in March 2021. She has fallen multiple times since moving and has broken multiple bones. She has broken her pelvis twice and her right wrist. She said there was a motion sensor near her bathroom door that was supposed to alert staff if she was up and moving around but she was not sure it was working because when I am here and walking near it no one comes to see if everything is ok. At this time the motion sensor was positioned at the bottom of the door frame on the outside of the bathroom door. The resident was seated on the side of her bed, which had a lipped mattress. She was able to position herself to the edge of the bed with her feet touching the floor. No staff entered the room when the resident or her daughter moved within range of the motion sensor. Her bed was not in its lowest position. On 11/16/21 at 2:50 p.m. Resident #54 was seen seated alone at a table in the dining area on [NAME] hall. On 11/17/21 at 12:00 p.m. the door to Resident #54's room was closed and she was not in the common area. On 11/18/21 at 8:10 a.m. Resident #54 was in her room with the door closed. Upon entry to the room, the motion sensor that had been by the bathroom door, had been moved to underneath her bed facing toward the bathroom door. She had the box call light system, that was normally mounted to the wall, lying on her overbed table next to her bed. C. Record review The care plan initiated 1/8/21, revised 1/20, 2/24, 3/8, 4/9, 8/22, 8/24, 9/9, 10/13, 10/24 and 11/16/21 indicated Resident #54 had a potential for falls related to confusion with a history of falls and a recent fall with fracture of her pelvis. Staff were to assist her routinely, conduct purposeful rounding every two hours. If she was unable to get up they were to check and change her and do bed checks at night. She used a bedside commode for toileting. On 1/20/21 staff were to offer routine assistance to the bathroom as she did not always use her call light. She used a wheelchair for mobility and required the assistance of two staff members for non weight bearing transfers. She needed verbal cueing for weight bearing restrictions due to poor cognition. She was to wear non-skid footwear when out of bed. Her bed was to be locked and kept in the lowest position. On 3/8/21 Resident #54 was to transfer with stand by assistance with a front wheeled walker and she used a wheelchair for long distance mobility. However, the care plan also indicated she transferred independently. A lipped mattress was applied to her bed. She had the potential for pain related to a left pelvic fracture. Staff were to provide analgesics as ordered and report uncontrolled pain to provider. On 4/9/21 Resident #54 was to have a touch call bell. However, throughout the survey she did not have the touch call bell. On 8/22/21 staff were to monitor for pain related to a fractured right wrist and encourage Resident #54 to keep a splint on her right wrist. No new interventions were added. On 8/24/21 staff were to rest Resident #54's right arm on a pillow to help relieve discomfort, two days after the fracture. On 9/9/21 a motion monitor was placed in Resident #54's room, related to recent falls with fractures, to alert staff when she was getting out of bed. Staff were to encourage her to sit in the living area so they could keep a better eye on her. On 10/13/21 Resident #54 had a fall with a laceration to the back of her head with a hematoma. Staff were to assess for pain and monitor for healing. No new interventions were added. On 10/24/21 Resident #54 had a fall in the hallway and fractured her pelvis again. Staff were to orient to room features, bed function, call light use and remind the resident to use call light for assistance with transfers and toileting. Pain medication was ordered for three days. No new interventions were added. On 11/16/21 the care plan indicated Resident #54 was non-compliant with non-weight bearing status and she had a touch call bell, however throughout the survey she did not have the touch call bell at her bedside. Review of the fall risk assessments, that indicated a score greater than 10 was considered a high fall risk, revealed the following: -1/8/21-a score of 14, high risk -4/15/21-a score of 15, high risk -7/2/21-a score of 9, low risk -11/8/21-a score of 19, high risk No new fall risk assessments were completed after the falls in August, September and October 2021. All pain assessments were requested and the NHA said there had been no quarterly pain assessments completed since her admission to the secure unit in January 2021. Medication administration record (MAR) documentation for routine nursing pain assessments was also requested but was not provided. Therapy documentation was requested for all falls and the only documentation received was related to the fall on 1/5/21 and 10/24/21. The incident reports for each fall were requested but were not provided. D. Falls Fall #1, 1/5/21 unwitnessed fall: The 1/5/21 nursing event note documented by licensed practical nurse (LPN) #4 at 8:04 a.m. read: Resident had been up all night walking. At 5:00 a.m., heard resident hollering and found on floor at room doorway, laying on left side and complaining of pain to left side. Also sustained 1 centimeter (cm) U shaped skin tear to elbow. Dressed skin tear with steri strips. Neuro (neurologic) checks were started and vital signs (VS). About 7:00 a.m., physician was here doing rounds and saw resident and gave orders to send to emergency room (ER) for x-rays. Left in ambulance at 7:50 a.m. Family was notified of fall and being sent to hospital.Was also on 15 minute checks due to altercation with another resident. -No documentation was provided for the 15 minute checks staff were to have conducted prior to this fall. The 8:13 a.m. nursing note documented by registered nurse (RN) #2 read in part: Was notified by charge nurse that resident had fall this am at 5:00 and at 7:24 a.m. resident having severe pain to left hip/pelvic area. Physician here informed her that resident having severe pain to left hip/pelvic area received telephone order (T.O.) to send resident to ER for evaluation. At 7:50 a.m. left via ambulance. The 1:30 p.m. nursing note documented by RN #2 read: Was informed by RN at hospital that resident fractured left hip, that she will be admitted . All departments notified. The 1/5/21 ER computed tomography (CT) pelvis scan indicated Resident #54 had a fall with a comminuted (bone broken into more than two pieces) fracture of the left acetabulum (socket of the hip bone) consistent with impaction injury. Adjacent pelvic sidewall hematoma is present. The 1/5/21 ER physician documentation at 8:25 a.m. indicated the patient had an unwitnessed ground-level fall at the nursing home. At baseline the patient ambulates with a walker. Patient brought in unable to bear weight on the left leg. Only complaint is pain in the left leg. Pain is moderate. Patient needs 3 months of touchdown weight bearing on the left lower extremity. Acute pain control as needed. At this time the patient has a catheter inserted because of her inability to move without severe pain. -The 12:52 p.m. physician history and physical documentation read in part: She presented to the emergency room after a fall with severe pain and could not ambulate or move. She was brought by emergency medical services (EMS) to the emergency room department where she was found to have a comminuted minimally displaced acetabular fracture to the left hip. After discussions with the orthopedic team in the emergency room it was felt that this was a nonsurgical injury and that the patient was going to need to be treated for pain and then started on a program of minimal weight bearing or toe-touch weightbearing. In my estimation this patient is going to require greater than 48 hours of hospitalization for the appropriate management and care of the presented issues. Patient has significant pain to the left hip region whenever she moves at all. I have inadequate pain control at this juncture she is going to require intravenous (IV) opioid therapy. The oral opioids that she was given in the emergency room have done nothing to really help her when she tries to move. The 1/7/21 physician progress note read in part: I anticipate this patient being able to be discharged back to the nursing home tomorrow where it is going to be a very long arduous path back to a baseline because of this acetabular fracture. The 1/8/21 hospital discharge summary read in part: The patient was placed on toe-touch weight bearing only. Because of patient's severe dementia she is unable to grasp the concept of limited weightbearing and physical therapy (PT) occupational therapy (OT) have recommended that this patient be in a wheelchair for locomotion purposes until there is some more healing. She still has significant pain when trying to lift the left lower extremity. She is unable to do so yet. -No pain assessment was completed after this fall and the intervention for the staff to offer routine assistance to the bathroom was not added to the care plan until 1/20/21. The 1/6/21 OT evaluation documented the following: Per patient's (pt's) daughter report, the pt has been a resident of the nursing home for a period of time. The daughter states that the pt had been ambulating with a front wheeled walker (FWW), but did need occasional cues for safety. The patient was also able to dress herself, but needed cues to do so. She also needed cues to toilet. Not oriented to place, not oriented to situation, not oriented to time. Due to pt's decreased short term memory (STM), pt requires consistent cueing to maintain toe touch weight bearing (TTWBing) at this point in time as she does not have the ability to remember her weight bearing precautions. Due to her impaired STM, she will continue to require extensive physical assist with mobility in order to maintain TTWBing and to allow for healing of her acetabular fracture. The 1/8/21 therapy evaluation documented the following: Upon PT arrival to client's room, she is seated edge of bed (EOB) and very impulsive and displays moderate confusion. During rest, client denies pain throughout the left lower extremity (LLE) and hip; upon standing and attempted transfers with FWW, client reports ouch!, though is unable to rate her pain level numerically. RN reports that client has been very confused and impulsive. RN present during evaluation. PT recommends to RN for nursing staff to use assist x 2 for transfer from bed to chair so additional staff can assist with client maintaining LLE TTWB status. PT does not recommend use of stand aide as it is unlikely that LLE TTWB can be maintained with the use of standing aide. Client has significant dementia and displays decrease in functional safety awareness. Fall #2, #3 and #4, 8/21, 8/22/21-(two falls) all unwitnessed The 8/21/21 nursing documentation completed by LPN #5 at 5:26 a.m. read: 4:00 a.m. neighbor (resident) yelled out for help, sitting on floor by side of bed, sheet to bed on floor. No injury noted, neighbor is able to move all extremities, no complaints of pain or discomfort. Neighbor was getting up from floor by herself, did not want to wait for lift. Staff x 2 assisted neighbor with sitting on side of bed. When neighbor went to stand up with walker she complained of right wrist pain. Neighbor is moving wrist with full range of motion (ROM), refused ice pack, did accept as needed (PRN) Tylenol. 4:45 a.m. neighbor walked out of room with walker, then standing in hall holding on to walker with only left hand, went to use left hand to adjust hair and almost fell backwards, this nurse was within reach and caught neighbor. Assisted neighbor back to room and to recliner. Fall protocol started, neuro's remain within normal limits (WNL). Physician faxed, will notify oncoming shift to call daughter in the morning. The 9:26 a.m. nursing note documented by LPN #2 read: Called and spoke to daughter regarding fall at 4:00 a.m., updated her that neighbor is moving all extremities, also informed daughter that neighbor has stated that she ' broke her right wrist. ' Right wrist has no swelling, no signs of pain or discomfort and is able to move wrist with no problems. Daughter stated to let her know if anything changes. The 8/22/21 nursing note documented by RN #4 at 12:32 p.m. read in part: Called from nurse on unit, neighbor had fallen at 11:00 a.m., right wrist swollen and painful, neighbor not able to bend wrist. Neighbor agreed to go to ER (emergency room ). Called on call physician and spoke directly to the nurse practitioner (NP) received new orders to send to ER for x-ray of right wrist evaluate and treatment for possible fracture. Notified on call transportation for pick up. Called ER nurse to give report but no answer. Neighbor sent out with a staff member. The 1:54 p.m. nursing note documented by LPN #2 read: Neighbor had just been weighed, when certified nurse aide (CNA) left the room and then neighbor had fallen. When this nurse got to the room neighbor was naked from the waist down with a pair of pants lying on neighbor's legs, back and head were against the wall across from the closet. Neighbor stated ' I fell and my head hurts ' head to toe assessment done, no bleeding or a bump to the back of head, right wrist was swollen, red, warm and tender to the touch. Assisted neighbor to get up and in wheelchair and CNA helped neighbor get dressed. Neuro checks started and sent neighbor to hospital ER for evaluation and treatment with an x-ray. Physician notified via fax and spoke with daughter. Received call from the ER that right wrist is fractured and a splint was placed on the right wrist, with orders to follow up with primary doctor. The 10:20 p.m. nursing documentation completed by RN #5 read in part: Resident on fall protocol. She slept much of the evening, ate in her room, took the right wrist splint off, states her right wrist hurts. The 8/22/21 ER physician documentation at 1:02 p.m. read in part: Chief complaint right wrist pain after fall this am. Wrist x-ray findings: Distal radius does show a fracture. She was placed in a prefabricated wrist splint. The 8/24/21 physician note read in part: Over the weekend patient fell and sustained a right distal radial fracture. She was sent home in a brace which she keeps removing it because of her dementia. She keeps removing her splint so it is difficult to immobilize the joint so that the fracture can heal correctly. The 8/25/21 orthopedic consultation note read in part: Patient has dementia and decided she did not want to cooperate with any type of casting. She felt that she did not need to have anything done. -Staff were to check on the resident more throughout the day and anticipate her needs but there was no documentation of more frequent checks after this fall. Purposeful rounding (every two hours) was not started until 8/24/21. Fall #5, 9/8/21 unwitnessed fall On 9/8/21 at 11:29 p.m. nursing note documented by RN #6 read in part: At approximately 7:47 p.m. neighbor was shouting ' someone help ' and I had found her on the floor near her bed. Neighbor states she had gone to the restroom and when finished she decided she was too weak to get up so she crawled to her bed. Neighbor states when she got near her bed she was too weak to get up on her own so she started to yell for help. Upon assessment findings include a skin tear on left arm below elbow measuring 0.5 cm x 0.5 cm, red/purple in color, scant blood, surrounding skin intact. Skin condition was treated per standing order, cleaned with normal saline and applied steri-strip. Neighbor states ' I don't hurt any different than what I did before ' . Neuros were started and indicate no abnormal findings. Family was notified about the incident and had no questions but did ask to reach out with any changes. Towards the end of my shift neighbor transferred self from her bed to the recliner and was encouraged to use call light. All personal items and call light are within reach. -The motion sensor was added on 9/9/21 after this fall, but only after she had sustained three prior falls with two fractures. Staff were to try and keep the resident in the lounge area so they could watch her. Fall #6, 10/5/21 unwitnessed fall The 10/5/21 nursing note, documented by RN #7 at 11:57 p.m., read: At approximately 7:00 p.m. CNA on duty notified this nurse that neighbor was sitting on the floor in front of her recliner. Transferred to bed x2 assist and gait belt. Denies pain. No injuries noted. ROM to all extremities per her normal. Denies hitting head. Alert and oriented x3. Fall protocol started. Neuro checks WNL. Refused vital signs being taken multiple times. Stated ' I'm fine I'm fine. ' Remained in bed watching TV for the rest of the evening. -No new interventions were put in place after this fall. Staff were to be educated again on motion monitor, to make sure it was not being turned off. Fall #7, 10/13/21 unwitnessed fall The 10/13/21 nursing note, documented by LPN #2 at 9:08 a.m., read: This nurse was informed by CNA that neighbor had told her that she had fallen this morning and had hit her head. ' I fell this morning and hit my head, I think that I stumbled and hit my head on the floor. I seem to be doing that a lot, must be because I am getting old. ' Head to toe assessment done and found a 0.25 cm cut with a hematoma to the back of head. Cleaned and left open to air. Neighbor got self up off of the floor and was back in bed when neighbor told CNA of the fall, Neuro checks started. Physician and power of attorney (POA) notified and updated. -No new interventions were added after this fall. Fall #8, 10/24/21 witnessed fall The 10/24/21 nursing note documented by RN #2 at 12:22 p.m., read: At 11:45 notified by charge nurse that resident had tripped over vital sign kart by CNA station and that the CNA had caught her and eased her to the floor. At 11:48 a.m. resident laying in bed supine position with legs in bent position. Asked resident if she could extend her legs and she did slowly without any difficulty. No abnormal internal or external rotation noted, no shortening of left leg noted. Complains of left groin pain 10/10. Paged on call physician. NP returned call informed him that resident had tripped was caught and eased to the floor and that she complains of left groin pain 10/10. Informed him no abnormal external, internal or shortening of leg noted. Told him resident is requesting X-ray to be done. Received T.O. (telephone order) for resident to go to ER for evaluation via facility bus. Called hospital spoke with ER nurse informed her of above information and that resident will be transported by facility bus. The 10/24/21 nursing note documented by LPN #6 as a late entry at 1:23 p.m, read: Incident time: 10:05 a.m. CNA called writer to CNA station, noted resident laying on floor on left side. CNA stated resident had tripped over the vital signs cart, she caught resident and lowered her to the floor. States resident did not hit her head. Resident stated she had tripped. Resident checked for injuries, noted skin tear left hand 1.2 cm. ROM WNL. No complaints of pain or discomfort at this time. Resident assisted up off floor with 2 staff assist and put into wheelchair and taken to room. Put into recliner per request. Skin tear cleansed with normal saline and approximated with steri strips. The 10/24/21 hip/pelvis x-ray report revealed the following: Interval fracture of the left ischium (lower and back part of the hip bone) with mild displacement. Fracture lines appear acute. The 10/24/21 ER physician note documented at 1:03 p.m. indicated the following: She has mild tenderness in the left hip but more with palpation of the left ischial tuberosity (curved bone that makes up the bottom of the pelvis). X-ray of left hip and pelvis shows a nondisplaced pubic rami (at the front of the pelvis) and ischial tuberosity fracture. CT scan confirms the above findings with minimal hematoma. Previously noted acetabular fracture line still present. The 10/28/21 therapy notes documented the following: Patient has bedrest orders from the physician, however, nursing staff report patient is getting herself out of bed and ambulating with a FWW to dining room independently several times per day. It was determined she is not appropriate for skilled PT services at this time and has limited to no rehab potential due to her advanced dementia affecting her ability to participate in or carry over any education or training provided by therapist to facilitate independence and mobility. After this fall she was placed on routine pain medication and staff were to check on her frequently. -However, there was no documentation provided that frequent checks were completed. She was to have a push-pad call light on her bed so staff would be alerted if she was getting up. However, she did not have a push-pad call light on her bed throughout the survey. E. Staff interviews CNA #11 was interviewed on 11/18/21 at 8:20 a.m. She said she had worked at the facility for 10 months and she was familiar with Resident #54. She said the resident would get up on her own and often did not remember to use the call light. She said the motion sensor under her bed would send an alert vibration to a box the CNAs carried in their pocket to let them know the resident had placed her feet on the floor. She said if she would go on a break she would give the nurse the box so she would know if the resident was getting up. She said when she worked she tried to check on the resident often, roughly every 30 minutes or so but those checks were not documented. She said Resident #54 was not supposed to be walking because of a recent fracture but she would still get up on her own and walk. She said the resident had not had one-to-one supervision after any of the falls. LPN #2 was interviewed on 11/18/21 at 8:35 a.m. She said she had worked with Resident #54 since March 2021 and was aware of the many falls she had had. She said the motion sensor was added to her care plan on 9/9/21. She said when the resident pushed her call light the nurses and CNAs would be alerted through a pager that she needed help. She said the resident often did not understand and would forget to use her call light when she needed help. She said she did not carry one of the boxes that was connected to the motion sensor. She said the resident had not had one to one supervision after any fall occurrence. The restorative manager (RM) was interviewed on 11/18/21 at 12:01 p.m. She said she was involved in all fall occurrences. She said she would meet during the morning meetings with the NHA and the director of nurses (DON) and every Friday they discussed any residents that had falls and they would try to come up with different interventions to prevent falls. She said Resident #54 had been impulsive and would get up on her own, unfortunately resulting in multiple falls with injuries. She said the motion sensor was added as an intervention in September 2021 but there have been no new interventions added since then although the resident had fallen three more times in October (2021). F. DON interview The DON was interviewed on 11/18/21 at 11:36 a.m. She said Resident #54 usually would not call for assistance prior to getting herself up. She said she was supposed to have a soft call light that activated with a mild touch. However, she was unaware the call light the resident had at her bedside was the hard box type that was removed from the wall and placed on her bedside table. The resident would have to push a blue button in the center of the box to activate the call light. She said she had also placed a sign within the resident's sight that reminded her to use the call light. She said the sign had an arrow pointing to the call light next to her. However, she was unaware there was no sign in the resident's room. She said they had not used one-to-one supervision as an intervention after any of her falls. She said when she fell in January 2021on the secure unit they allowed her daughter to stay with her for a while but no one has stayed with her after any of the falls since January 2021. She did not offer any recommendations on how to prevent future falls for Resident #54. III. Resident #2 A. Resident status Resident #2, age 90, was admitted on [DATE] with diagnoses of [CONDITION(S)] ([CONDITION(S)]), depression, [CONDITION(S)] and chronic kidney disease (CKD). The 11/1/21 minimum data set (MDS) assessment revealed severely impaired cognition with a brief interview for mental status (BIMS) score five out of 15. No rejection of care was documented. The resident was independent with bed mobility, transfers, dressing, toilet use and personal hygiene. He required supervision with eating. He received an antidepressant and opioid medications daily. B. Record review 1. Care plan: -Cognitive loss/dementia: (Resident) has difficulty with comprehension. BIMS score 5. Approaches included: remind, supervise or assist as needed. -Falls: (Resident) has potential for falls related to weakness, balance problems. Approaches included: floors free from spills and clutter. Provide adequate, glare free lighting. Personal items within reach. Assist to wear non-skid footwear. (Dated 4/28/21); Rolater walker, independently ambulate and assist prn (as needed). Transfers independently. (Dated 5/10/21). Non-skid strips by bed. Provided (Resident) a pendant call bell. (Dated 9/2/21). Provided (Resident) with a reacher. Encourage (Resident) to use walker instead of cane due to 2 (two) recent falls. (Dated 11/1/21). 2. Falls Nursing notes review and provided by the nursing home administrator (NHA) records revealed the following: -9/1/21, Neighbor was found sitting on the floor with his back against the bed frame with no injuries noted. He said he was getting up to go to the bathroom and slipped. He said he did not hit his head. Head to toe assessment done, he was able to move all extremities, no signs of injuries or bruising noted. POA (power of attorney) and MD (physician) notified. Restorative put nonskid strips on floor beside bed and provides him with a pendant call bell. -9/27/21, Noted a decline in strength, endurance and ambulation and also memory issues. PT (physical therapy), ST (speech therapy), OT (occupational therapy) evaluation and treatment standing orders written. -10/30/21, Nurse saw a bruise on neighbor's R (right) elbow and neighbor said he fell before lunch. He said he was coming out of the bathroom and lost his balance. Assessed neighbor for injuries and found 10x5cm dark purple bruise to R (right) elbow. Able to move all extremities. Denies pain. Neuros WNL (within normal limits) for neighbor. Neighbor refused VS (vital signs) to be checked. Neighbor was encouraged to use walker instead of cane. Blood pressure is dropping when standing. MD (physician) notified. -10/31/21, CNA (certified nurse aide) reported to this nurse that neighbor was on the floor in his room. He was lying on the floor next to his bed near the closet wearing his slippers. His cane beside him. He said he just fell but did not remember what he was doing. Nurse found a 3x1.7cm rectangular skin tear to L (left) elbow. Able to move all extremities. Denies pain. Neuros WNL (within normal limits) for neighbor. He was provided a reacher. -11/12/21, CNA (certified nurse aide) found neighbor lying on the floor leaned up against the chair. He stated he was coming out of the restroom and went to sit in his chair and missed the seat and slid down the chair. Head to toe assessment was done, able to move all extremities, no signs of injuries or bruising noted. Assist of two to get neighbor up off the floor into his chair. Nuero checks started, POA (power of attorney) and MD ([TRUNCATED]

Based on observation, record review and interviews the facility failed to ensure that one (#66) of five residents reviewed out of 32 sample residents were free from unnecessary [CONDITION(S)] medications. The facility's failed to document and evaluate the effectiveness of non pharmacological behavioral interventions for Resident #66, a person with dementia; alternatively [CONDITION(S)] medications were prescribed which lead to over-sedation of the resident. The resident resided in a secured memory care unit with other residents and had an alarm system on her door to alert staff when the door opened. The facility failed to demonstrate how non-pharmacological interventions were attempted and failed prior to initiating medication changes and prescribing [CONDITION(S)] medications which posed risk to the resident's health, safety and highest practicable physical, mental and psychosocial well-being. The resident was prescribed duplicate medication therapies to target behavioral symptoms of dementia with [CONDITION(S)] which had sedative effects. (cross-reference to F744 failed to ensure resident with dementia received appropriate treatment and care) Findings include: I. Facility policy The Use of [CONDITION(S)] Drugs policy, dated 1/1/18, was provided by the nursing home administrator (NHA) on 11/28/21 at 11:28 a.m. It read in pertinent part, Residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). A [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior. [CONDITION(S)] drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. The indications for initiating, withdrawing, or withholding medications(s), as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. For [CONDITION(S)] drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. [CONDITION(S)] medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents who use [CONDITION(S)] drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. Residents who use [CONDITION(S)] drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the [CONDITION(S)] drugs. II. Observations of side effects of duplicate medication therapy Numerous observations were made of Resident #66 between 11/14/21 and 11/18/21. The following observations were made: -On 11/15/21 at 12:25 p.m., the resident was observed laying in bed. She did not lift her head or respond to her name. Her lunch meal tray sat on her bed, uneaten. -On 11/15/21 at 5:05 p.m.the resident was observed laying in bed. -On 11/16/21 at 9:16 a.m. the resident was observed laying in bed. -On 11/16/21 at 12:47 p.m., the resident was observed laying in bed. Her lunch meal tray was next to her on a bedside tray table, mostly uneaten. A cooked brussel sprout was tucked under the pillow she was resting her head on. The resident slightly shook her head yes when asked if she was hungry. She then attempted to lift her head and then laid back down. -On 11/16/21 at 4:10 p.m. the resident was observed to be laying in bed. -On 11/17/21 at 9:22 a.m., the resident was observed laying in bed. -On 11/17/21 at 4:45 p.m. the resident was observed to be out of her room and coming down the hallway with the assistance of three staff people: one staff person supporting each of her arms with weight bearing assistance and one staff person behind her. Staff escorted the resident to the shower room. -On 11/18/21 at 9:15 a.m. the resident was observed in her bed with her breakfast meal tray on the bedside table. III. Psychiatrist interview The facility psychiatrist (PSY) was interviewed 11/17/21 at 10:38 a.m. He said he was concerned about the resident's [CONDITION(S)] medication regimen and he felt the facility staff were quick to ask for medication adjustments without attempting non-pharmacological interventions. He said the resident would respond to internal stimuli and could act out unprovoked. He said a different environment better suited to the resident's needs would be more appropriate, however, the resident representative was not in favor of moving the resident. He said he did not feel the current regimen was safe and if others could not be safe around her when she was not sedated; it was not an appropriate placement. He said that he would want to know what was attempted prior and what circumstances could have contributed to behaviors prior to making medication changes. He said requests for consultation on medication adjustments came from facility staff and not from the resident's physician. He said the primary care physician (PCP) would receive recommendations but ultimately make the decision of which medications were prescribed. He said that he was concerned that medications were being requested and added as a convenience for staff. He said the resident was in a controlled environment living on a secured unit and the facility staff were alerted when the resident left the room. He said he felt the request of the facility for additional medication was for the purpose of sedating the resident. He said over-sedating a resident posed risks to their safety and impacted their quality of life. IV. Resident #66 A. Resident status Resident #66, age 72, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), pertinent diagnoses included dementia with behavioral disturbance and [CONDITION(S)], [CONDITION(S)], anxiety disorder and dementia. The 10/8/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and a brief interview for mental status (BIMS) could not be conducted because the resident was rarely/never understood. The resident required extensive assistance from two staff members to perform bed mobility, personal hygiene, toilet use and dressing. She required limited assistance from one staff member to perform bathing. She required supervision with eating, transfers and walking in her room and on the unit. The resident had one instance of exhibiting aggressive behavior during the seven day assessment period. V. Record review Intake documentation from an outside facility dated 6/13/18 indicated that the resident history/previous diagnosis of paranoid [CONDITION(S)] with visual hallucinations and unspecified [CONDITION(S)] not due to a substance or known physiological condition. The [CONDITION(S)] medication review committee, which included the facility pharmacist (PH), medical director, NHA, director of nursing (DON), social services director (SSD), social worker (SW) and other members of the resident care team, met monthly or as needed and documented recommendations of the committee. The facility psychiatrist (PSY) provided recommendations to the committee. The committee met on 4/11/2021 after the resident returned from an outside behavioral health facility. She returned with prescriptions for [MEDICATION(S)] 10 milligrams (mg) once daily, [MEDICATION(S)] 100 mg in the morning, 50 mg at noon and 100 mg at hour of sleep related to diagnosis of dementia with [CONDITION(S)] [MEDICATION(S)] 100 mg in the morning related to major neurocognitive disorder with behavioral disturbance and Oxcarbazine 150 mg twice daily related to dementia with [CONDITION(S)]. A physician order dated 4/11/21 ordered that every shift, staff document behaviors of hallucinations that cause anxiety, fear or distress and offer interventions including; one to one staff assistance, provide an activity, time alone, provide needed care, assess cause, change environment, distraction, offer a PRN (as needed) medication, offer snack, toilet resident or walk with with the resident. Interventions were numbered and should be documented as to which intervention was offered when behaviors were present. A physician order dated 4/11/21 prescribed 150 mg of [MEDICATION(S)] (an anti-[CONDITION(S)] medication) twice daily at 8:00 a.m. and 8:00 p.m. related to dementia with [CONDITION(S)]. The resident was admitted to the facility with this prescription. The resident care plan initiated on 4/11/21, included the resident had the potential for pushing or hitting others if they get too close to her/invading her personal space. The resident had a history of pushing or hitting others if they were in her way. Interventions included: -Staff were to assist the resident to sit in a recliner when in the living room (not the couch) so other residents won't sit beside her; and -Staff to monitor and intervene if other residents got too close to the resident. The [CONDITION(S)] medications review committee met on 4/23/21; the note read that the resident attempted to pull another resident out the resident's bed. The nurse was able to stop this. The PSY recommended prescribing [MEDICATION(S)] 12.5 mg three times daily related to neurocognitive with behavior disorder. The committee notes indicated that staff should observe for over sedation or changes in her vitals. A physician order dated 4/23/21 prescribed Trazadone (an antidepressant medication) 12.5 mg three times daily at 8:00 a.m., 12:00 p.m. and 8:00 p.m. A consent for the use of Trazadone was signed by the resident's representative on 4/27/21. The consent included, There are many potential risks associated with the use of [CONDITION(S)] medications. These potential risks include risk of falls, altered level of consciousness, increased confusion, loss of balance and various other side effects which can differ depending on the medications. In addition, the Food and Drug Administration (FDA) gave a 'Black Box' warning that 'Elderly patients with dementia are at increased risk of death, heart failure or sudden death. The consent also included that non-pharmacological interventions attempted had been one-to-one visits with the resident, aroma therapy, chaplin services, massage, music and to go outdoors. On 4/29/21 the care plan was updated to include that the Resident's emotional well-being is impacted by her dementia with [CONDITION(S)], paranoia, being over-stimulated by others around her and her physical aggression towards others. The resident will have improved emotional well-being as observed by behaviors that indicate she is comfortable in her environment. The resident will color or do puzzles in her room. Her family stated she used to do puzzles a lot; she does not always get the puzzle right but she enjoys it. The [CONDITION(S)] medication committee met on 5/26/21; the note read the resident had continued to exhibit aggressive behaviors. Recommendation was made that [MEDICATION(S)] 12.5 mg could also be used as an as needed medication. The PSY did not feel one day with incidents required a large medication change from him. He did not feel comfortable making adjustments. The committee note indicated that the resident would benefit from a small neighborhood, however, the resident representative was not in favor of having the resident moved. The note read the psychiatrist stated it was in the best interest of the resident not to snow her (over sedate). On 5/29/21 additional interventions were implemented on the care plan to include: -A sign with the resident's name in large letters placed on her door to help the resident find her room; -Staff perform safety checks every 15 minutes to be aware of her location; -Staff to encourage the resident to eat in the living room or her room where there is less stimulation. If she insists in eating in the dining room, staff will escort her out when she is done; -Staff to help the resident find her room after supper. On 6/28/21 a nurses note read that the resident slapped another resident. No injuries occurred; Resident #66 was redirected and walked back to her room by staff. On 6/30/21 the committee met for review; the note read that the resident was exhibiting a baseline of difficulty with redirection when disinhibited and having agitation towards others which for the most part were unanticipated per staff. It was reported that the resident was having episodes of exhibiting aggression. Given physical agitation and reports of requiring frequent redirection from entering other residents' rooms; the team recommended increasing [MEDICATION(S)] dosage from 12.5 mg to 25 mg. On 9/14/21 a nurse's note read that the resident had taken a rice crispy treat away from another resident and ate it. Staff redirected her away from the other resident and back into her room. On 9/24/21 additional interventions implemented to the resident's care plan which included: -To offer weighted blanket or baby doll for comfort; -Chaplin to deliver large print devotional books; -Offer audio books. On 9/16/21 a nurses note read that the resident had grabbed onto another resident's forearm and then released and went down the hallway. No injuries were documented. On 9/28/21 the [CONDITION(S)] medications committee reviewed the resident's medications and behaviors; the committee note read that it had reported by another resident on the memory care unit that the resident may have hit a peer, but it was not witnessed. Resident #66 was reported to be restless, agitated and hard to redirect. Her [MEDICATION(S)] was increased by her primary care physician (PCP) from 25 mg to 50 mg three times daily. -Trazedone was increased three times in three months; from 12.5 mg three times daily to 25 mg three times daily to 50 mg three times daily, however, documentation of behaviors and intervention offered every shift was not completed as ordered by the physician on 4/11/21. The September 2021 medication administration record (MAR) had no documented behaviors or non-pharmacological interventions offered. A physician order dated 9/29/21 increased prescribed Trazedone to 50 mg three times daily related to behavioral disturbance. On 10/4/21 the committee met for review; the note read that they reviewed use of [MEDICATION(S)] and if it's use had been beneficial to reducing behaviors. [MEDICATION(S)] was increased from 100 mg in the morning, 50 mg in the afternoon and 100 mg at hour of sleep to 100 mg in the morning, 200 mg in the afternoon and 100 mg at hour of sleep. The committee note read that more behaviors were occurring in the afternoon. Her [MEDICATION(S)] was reduced a total of 50 mg to 100 mg in the morning and 200 mg in the afternoon and 100 mg at hour of sleep. The note indicated the committee would review use of [MEDICATION(S)]. -This was an increase in [MEDICATION(S)] not a reduction. A physician order dated 10/4/21 ordered [MEDICATION(S)] (an antipsychotic medication) be administered three times daily: 100 milligrams (mg) at 8:00 a.m., 200 mg at 2:00 p.m. and 100 mg at hour of sleep related to dementia with [CONDITION(S)]. On 10/8/21 a nurses note read that the resident was trying to get into another resident's room and they were both in the doorway. The resident shoved the other resident to try to get by. She was taken back to her room. On 10/8/21, the [CONDITION(S)] medication committee met for review; the note read that it was recommended that [MEDICATION(S)] be increased to 15 mg daily, initiate [MEDICATION(S)] one mg daily (the resident should be observed for increased fall risk and blood pressure monitored), [MEDICATION(S)] be increased to 100 mg (this change to be held for one week after other medication changes were made). -The care plan was not updated with new interventions. The facility decided to increase the residents' medication instead. A physician order dated 10/8/21 prescribed 15 mg of [MEDICATION(S)] (an antipsychotic medication) daily in the morning related to neurocognitive with behavior disorder. A physician order dated 10/8/21 prescribed [MEDICATION(S)] (an [NAME]-hypertensive medication) one mg twice daily related to dementia with [CONDITION(S)]. A consent for the use of [MEDICATION(S)] was signed by the resident representative on 10/11/21. The consent included, There are many potential risks associated with the use of [CONDITION(S)] medications. These potential risks include risk of falls, altered level of consciousness, increased confusion, loss of balance and various other side effects which can differ depending on the medications. In addition, the Food and Drug Administration (FDA) gave a 'Black Box' warning that 'Elderly patients with dementia are at increased risk of death, heart failure or sudden death. The consent also included that non-pharmacological interventions attempted had been one-to-one visits with the resident, aroma therapy, chaplin services, massage, music and to go outdoors. A consent for the use of Prosazin was signed by the resident representative on 10/11/21. The consent included, There are many potential risks associated with the use of [CONDITION(S)] medications. These potential risks include risk of falls, altered level of consciousness, increased confusion, loss of balance and various other side effects which can differ depending on the medications. In addition, the FDA gives a 'Black Box' warning that 'Elderly patients with dementia are at increased risk of death, heart failure or sudden death. The consent also included that non-pharmacological interventions attempted had been one to one visits with the resident, offer simple pleasures, anticipate needs, activity and change the environment. The care plan was updated on 10/12/21 to include that the resident had sensory impairment secondary to dementia with [CONDITION(S)]. Interventions included: -To assist the resident in daily decision making. Staff were to identify/eliminate factors causing acute confusional state; -Avoid frustrating the resident by quizzing with orientation questions that cannot be answered; and, -Provide a low-stimulation environment and when speaking to her, give her time to respond. On 10/13/21 the care plan was updated to include a door alert system placed on her door to alert staff when the door to her room was opened. On 10/15/21, the [CONDITION(S)] medication committee met. The resident's prescription to [MEDICATION(S)] was increased from 150 mg to 200 mg per day for depression as recommended by the psychiatrist and ordered by the PCP. Daily charting for behaviors was completed by facility staff. Review of the behavior charting from 10/17/21 to 11/17/21 revealed that the resident had documented behavioral symptoms of aggression on 10/19/21 and 10/20/21. -There was no corresponding narrative documentation of what the behavior exhibited was, where it took place and if a non pharmacological intervention was attempted and whether it was effective. No other behaviors were documented during this period. A physician order dated 10/27/21 ordered the resident's doorbell alarm to be checked every shift to ensure it was working. Place a work order if not functioning after troubleshooting. Assign one to one staff supervision of the resident. Every shift staff keeps the resident's door closed at all times while she is in her room and the doorbell will function properly. When the resident is out of her room; staff were to accompany her at all times for safety. A risk versus benefit analysis document dated 11/1/21 for the use of [MEDICATION(S)] read that no changes were recommended by the [CONDITION(S)] medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the resident was doing well on the medication. A risk versus benefit analysis document dated 11/1/21 for the use of [MEDICATION(S)] read that no changes were recommended by the [CONDITION(S)] medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the resident was doing well on the medication. A risk versus benefit analysis document dated 11/1/21 for the use of [MEDICATION(S)] read that no changes were recommended by the [CONDITION(S)] medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the resident was doing well on the medication. A risk versus benefit analysis document dated 11/1/21 for the use of [MEDICATION(S)] read that no changes were recommended by the [CONDITION(S)] medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the patient was doing well on the medication. A risk versus benefit analysis document dated 11/9/21 for the use of [MEDICATION(S)] read that no changes were recommended by the [CONDITION(S)] medication review committee. The medication should be continued despite potential side effects because the risk outweighs the benefit. The document stated that The physician must elaborate as to why. The physician documented that the patient was doing well on the medication. -No clarification was documented as to what resident/patient doing well on medication meant; the response was vague and did not elaborate on the justification for the use of duplicate medication therapies. The facility completed and documented checks of the resident every 15 minutes. Review of the recorded checks on the resident from 11/9/21 to 11/16/21 revealed she was documented to be in bed, sleeping or in her room at all hours of the day and night: -On 11/9/21 at 8:15 a.m. the resident was documented as being out of her room and was back to her room by 8:30 a.m. The resident was in bed from 1:00 p.m. until midnight. -On 11/10/21, the resident was documented to be in her bed or room all day. -On 11/11/21, the resident was documented to be eating lunch at 12:00 p.m. and was out of her room at 4:15 p.m.; the remainder of the day she was documented as being in her bed/room. -On 11/12/21, the resident was documented as being in her room the entire day. At 6:15 p.m. the documentation indicated that she was eating in her room. -On 11/13/21, the resident was documented as being in her room/ bed until she was sent to the emergency at 1:30 p.m. and returned at 3:45 p.m. where she was documented as being in her bed for the rest of the day. -On 11/14/21, the resident was documented as being in her room the entire day. She ate breakfast at 4:45 a.m. and ate lunch at 12:00 p.m. and was otherwise documented as laying in bed. -On 11/15/21, the resident was documented as being in her bed or room every 15 minutes with the exception of 4:45 p.m. to 5:15 p.m. when she was sitting in her chair in her room. -On 11/16/21, the resident was documented as wandering from 12:00 p.m. to 12:30 p.m. She was documented as being in her room or bed for the rest of the day. Review of the record did not reveal what non-pharmacological interventions were attempted or implemented when the resident exhibited behaviors. VI. Staff interviews The NHA was interviewed on 11/17/21 at 8:39 a.m. She said that Resident #66 had exhibited aggressive behaviorstowards staff and other residents at the facility. She said the resident had not had behaviors in a while. She said the resident had been sent to an outside behavioral health facility in April of 2021 where she had done well with a lower staff to resident ratio. She said that the resident returned to the facility and her provider team felt she would be better served in a more supervised setting with less people and where she could get behavioral supports; she said the resident's representative did not want the resident to move and preferred that she be sedated if it meant having her remain in the facility rather than be moved to another facility. Certified nurse aide (CNA) #9 was interviewed on 11/17/21 at 9:44 a.m. She said that the resident was in her room most of the time but would wander into other resident rooms and had a history of acting aggressive towards others. She said she would make sure the resident was clean and her hair was brushed. She said that the resident had an alarm on her door that would go off at the nurse's station to alert staff if she was leaving her room or if someone else was entering her room. She said staff would observe the resident when she was out of her room. She said the resident would not often sit at the table or close to other residents but staff knew to observe for behaviors if she was in common spaces. She said the resident was not typically aggressive but could swing her arms or act out unprovoked and in a way that was hard to predict. Licenced practical nurse (LPN) #2 was interviewed on 11/17/21 at 9:53 a.m. She said Resident #66 was often sleepy and often preferred to be in bed. She said the resident was not prescribed medications that caused sedation. She then reviewed the resident's electronic medical record and after reviewing the resident's physician orders; she said the resident was on multiple medications that caused sedation. She said the resident had a silent door alarm which alerted the staff at the nursing station when her door opened. She said that the purpose of the alarm was alert staff should keep an eye out for her and make sure she and other residents were safe. She said the [CONDITION(S)] medication committee met regularly and would make changes to the resident's medications as needed. The SW was interviewed on 11/17/21 at 2:26 p.m. She said she had been involved in the [CONDITION(S)] medication committee that reviewed the resident's medication regimen monthly. She said the resident had exhibited aggressive behaviors towards staff and other residents and her medications had been adjusted to reduce behaviors. She said the committee had identified the use of audio books such as the bible, a weighted blanket and aromatherapy as non pharmacological interventions for the resident. She said the interventions were individual to the resident, however, could not recall whether the effectiveness of interventions were discussed. The resident's PCP was interviewed on 11/18/21 at 8:53 a.m. She said the resident's medications were recommended by a psychiatrist, though her name was on the medication orders. She said, due to the resident's history of wandering and aggressive behaviors, medication changes had been made numerous times to target behaviors. She said that the resident had a silent alarm on her door to alert staff when the door to her room opened as a preventive intervention. She said due to the resident's size, she had the potential to harm others if she were to become aggressive. She said that she felt the resident's medication regimen did have cause for concern due to the potential negative side effects for the resident. The DON was interviewed on 11/18/21 at 11:44 a.m. She said Resident #66 did not communicate verbally, but staff would try to anticipate her needs. She said sometimes the staff would attempt to do activities with her. She said the facility had implemented calming person centered interventions such as playing bible scripture on audio books for her. She said the resident had paranoia and fear in her eyes at times and may be responding to internal stimuli. She said that the resident was prescribed medications for behaviors and psychiatric symptoms which had a sedating effect. She said it was unethical to overly sedate a resident but that it was also the responsibility of the facility to ensure the safety of other residents and that was a fine line at times. She said having the silent alarm on the resident's door was helpful because staff could know to be aware and provide supervision if she left her room. She said the resident used to constantly be exiting her room and attempting to go into the rooms of other residents. She said there were times when staff were busy with other residents that they would not be able to be as attentive to Resident #66. She said she felt it was time the committee looked at reducing her medications since she was not coming out of her room as often and was sleeping more. The SSD was interviewed on 11/22/21 at 12:04 p.m. She said the [CONDITION(S)] medication committee reviewed all residents prescribed [CONDITION(S)] medications monthly as well as quarterly. She said the consulting psychiatrist (CP) would make recommendations to the facility and the PCP. She said the CP would provide options to the PCP and she would then make medication changes. She said the facility would take into consideration the risk versus benefit of prescribing [CONDITION(S)] medications. She said the PSY had recommended a smaller situation. She said the alarm on the resident's door was helpful to alert staff when she may be leaving her room or others may be entering her room. She said the PSY had previously prescribed medication but had transitioned to consulting and making recommendations as needed. She said she could not recall what interventions had been attempted with the resident, however, due to the history of aggressive behaviors and the potential of aggression; her medications had been adjusted numerous times. The PH was interviewed on 11/22/21 at 12:16 p.m. He said that nursing home residents should be on the lowest possible amount of [CONDITION(S)] medications due to the risks associated with their use. He said [CONDITION(S)] medications should be monitored closely and evaluated for effectiveness because different individuals had different reactions to medications and some may not be as effective for some than others. He said the facility had a psychotic medication review committee that met on a regular basis (at least monthly). He said that Resident #66 had been prescribed Oxcarbazine, an anti [CONDITION(S)] medication, which potentially had a sedative effect for behaviors. He said that the resident was prescribed Prosazin, an antihypertensive medication, because it was found to help control behaviors due to blocking the body's alpha one receptor which boosts arousal. He said that [MEDICATION(S)], Trazadone and [MEDICATION(S)] had sedative effects. He said he felt the next step should be to try a reduction of either [MEDICATION(S)] or [MEDICATION(S)]. He said that the resident had a medication regimen which could include risk to the resident. He said that the facility initiated a reduction of the resident's prescription to Trazedone from 50 mg three times daily to 25 mg on 11/18/21. VI. Facility follow-up A new physician order was entered on 11/18/21 which reduced the resident's Trazadone from 50 mg three times to 25 mg in the morning and 50 mg at noon and hour of sleep. -This would be a reduction of one medication by 25 mg per day.

Based on record review and interviews, the facility failed to ensure residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#66) out of three residents reviewed out of 32 sample residents. Specifically, the facility failed to implement identified person centered interventions for Resident #66, a person with dementia and behavioral disturbances; alternatively the resident was given multiple medications which caused sedation. (cross reference to F758: use of unnecessary [CONDITION(S)] medications) Findings include: I. Facility policy Per the nursing home administrator (NHA), the facility did not have an official policy related to dementia care, however, did require training of their staff. The following was provided on 11/21/21 at 2:09 p.m. by the NHA, We have required the Hand in Hand training in the past as well as the [NAME] Alternative curriculum Reframing Dementia which both focus on person-directed care. Reframing Dementia draws primarily on the ideas behind Principles One through Five of the [NAME] Alternative to: -Convey the fundamental role of sensitivity, awareness, and presence in identifying the needs of those living with dementia in long-term care communities. -Demonstrates how relying on our assumptions weakens the care partnership. -Provide the opportunity to see dementia and those living with it through different eyes. -Explore the impact of loneliness, helplessness and boredom on those living with dementia. -Apply practical approaches to relieving these Three Plagues that draw on the development of deep connections with people who live with dementia; and -Identify how we benefit from the unique gifts people living with dementia have to offer. The facility provided dementia training through an online curriculum to every newly hired employee. Staff were assigned training modules to complete. II. Resident #66 A. Resident status Resident #66, age 72, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/8/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and a brief interview for mental status (BIMS) could not be conducted because the resident was rarely/never understood. The resident required extensive assistance from two staff members to perform bed mobility, personal hygiene, toilet use and dressing. She required limited assistance from one staff member to perform bathing. She required supervision with eating, transfers and walking in her room and on the unit. The resident had one instance of exhibiting aggressive behavior during the seven day assessment period. B. Observations On 11/15/21 at 12:25 p.m., the resident was observed laying in bed. She did not lift her head or respond to her name. Her lunch meal tray sat on her bed, uneaten. -On 11/15/21 at 5:05 p.m. the resident was observed laying in bed. -On 11/16/21 at 9:16 a.m. the resident was observed laying in bed. -On 11/16/21 at 12:47 p.m., the resident was observed laying in bed. Her lunch meal tray was next to her on a bedside tray table, mostly uneaten. A cooked brussel sprout was tucked under the pillow she was resting her head on. The resident slightly shook her head yes when asked if she was hungry. She then attempted to lift her head and then laid back down. -On 11/16/21 at 4:10 p.m. the resident was observed to be laying in bed. On 11/17/21 at 9:22 a.m., the resident was observed laying in bed. -On 11/17/21 at 4:45 p.m. the resident was observed to be out of her room and coming down the hallway with the assistance of three staff people: one staff person supporting each of her arms with weight bearing assistance and one staff person behind her. Staff escorted the resident to the shower room. -On 11/18/21 at 9:15 a.m. the resident was observed in her bed with her breakfast meal tray on the bedside table. C. Record review The resident care plan initiated on 4/11/21, included the resident had the potential for pushing or hitting others if they get too close to her/ invading her personal space. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: -Staff were to assist the resident to sit in a recliner when in the living room (not the couch) so other residents won't sit beside her; and -Staff to monitor and intervene if other residents got too close to the resident. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/29/21 additional interventions were implemented on the care plan to include: -A sign with the resident's name in large letters placed on her door to help the resident find her room; -Staff perform safety checks every 15 minutes to be aware of her location; -Staff to encourage the resident to eat in the living room or her room where there is less stimulation. If she insists in eating in the dining room, staff will escort her out when she is done; -Staff to help the resident find her room after supper. On 9/24/21 additional interventions implemented to the resident's care plan which included: -To offer weighted blanket or baby doll for comfort; -Chaplin to deliver large print devotional books; -Offer audio books. The October 2021 and November 2021 (11/1/21 through 11/17/21) Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Daily charting for behaviors was completed by certified nurse aides (CNA). Review of the behavior charting from 10/17/21 to 11/17/21 revealed that the resident had documented behavioral symptoms of aggression on 10/19/21 and 10/20/21. -There was no corresponding narrative documentation of what the behavior exhibited was, where it took place and if a non pharmacological intervention was attempted and whether it was effective. No other behaviors were documented during this period. The resident had a doorbell alarm which alerted staff if the door to her room was opened. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read to place a work order if not functioning after troubleshooting. Assign one to one staff supervision of the resident. Every shift staff keeps the resident's door closed at all times while she is in her room and the doorbell will function properly. When the resident is out of her room; staff were to accompany her at all times for safety. Facility staff completed checks on the resident every 15 minutes. Review of the documentation of checks on the resident from 11/9/21 to 11/16/21 revealed the resident was most often in bed or in her room: On 11/9/21 at 8:15 a.m. the resident was documented as being out of her room and was back to her room by 8:30 a.m. The resident was in bed from 1:00 p.m. until midnight. -On 11/10/21, the resident was documented to be in her bed or room all day. -On 11/11/21, the resident was documented to be eating lunch at 12:00 p.m. and was out of her room at 4:15 p.m.; the remainder of the day she was documented as being in her bed/room. -On 11/12/21, the resident was documented as being in her room the entire day. At 6:15 p.m. the documentation indicated that she was eating in her room. -On 11/13/21, the resident was documented as being in her room/ bed until she was sent to the emergency at 1:30 p.m. and returned at 3:45 p.m. where she was documented as being in her bed for the rest of the day. -On 11/14/21, the resident was documented as being in her room the entire day. She ate breakfast at 4:45 a.m. and ate lunch at 12:00 p.m. and was otherwise documented as laying in bed. -On 11/15/21, the resident was documented as being in her bed or room every 15 minutes with the exception of 4:45 p.m. to 5:15 p.m. when she was sitting in her chair in her room. The record indicated that person-centered interventions were identified but there was no documentation or observation of the staff implementing or utilizing interventions passively or with staff. Alternatively, when the resident exhibited behaviors, medications were added or adjusted. (cross reference to F758: use of unnecessary [CONDITION(S)] medications) III. Staff interview Certified nurse aide (CNA) #9 was interviewed on 11/17/21 at 9:44 a.m. She said that she received training on dementia care when she started her position. She said that the resident was in her room most of the time but would wander into other resident rooms and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that the resident had an alarm on her door that would go off at the nurse's station to alert staff if she was leaving her room or if someone else was entering her room. She said staff would observe the resident when she was out of her room. She said the resident would not often sit at the table or close to other residents but staff knew to observe for behaviors if she was in common spaces. She said that staff would check on the resident every 15 minutes. She said the resident was not typically aggressive but could swing her arms or act out unprovoked and in a way that was hard to predict. Licenced practical nurse (LPN) #2 was interviewed on 11/17/21 at 9:53 a.m. She said Resident #66 was often sleepy and often preferred to be in bed. She said the resident had a silent door alarm which alerted the staff at the nursing station when her door opened. She said that the purpose of the alarm was alert staff should keep an eye out for her and make sure she and other residents were safe. She said the [CONDITION(S)] medication committee met regularly and would make changes to the resident's medications as needed. The social worker (SW) was interviewed on 11/17/21 at 2:26 p.m. She said the resident had dementia with behaviors, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident was non verbal and could not communicate her needs. She said the resident's care team had identified interventions to help soothe the resident; staff would offer the resident a weighted blanket and the bible on an audio book. The director of nursing (DON) was interviewed on 11/18/21 at 11:44 a.m. She said all staff received dementia training at time of hire and annually. She said Resident #66 did not communicate verbally, but staff would try to anticipate her needs. She said sometimes the staff would attempt to do activities with her. She said the facility had implemented calming person centered interventions such as playing bible scripture on audio books for her. She said the resident had a silent doorbell alarm which alerted staff when the door to her room was opened. The facility established interventions for dementia care for the resident, however, failed to show how they implemented and measured the effectiveness of the interventions; alternatively when the resident exhibited behaviors, the facility adjusted her [CONDITION(S)] medications and the resident was sedated. (cross reference to F758: unnecessary [CONDITION(S)] medications).

Based on observations, interviews and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as Coronavirus disease (COVID-19). Specifically, the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines to: -Ensure two of three screening stations utilized as an access point by dietary, environmental, maintenance and transportation staff was manned and that the screening forms were audited to ascertain that staff did not answer a yes to any of the questions contained in the screening form (questionnaire); -Ensure staff consistently perform hand hygiene before and after contact with residents and potentially contaminated items; -Ensure residents were offered, encouraged and assisted to perform hand hygiene before eating their meals; and, -Ensure staff wore medically approved face masks while in resident care areas. Findings include: On 6/24/2020 at approximately 4:45 p.m., the nursing home administrator (NHA) said throughout the past three months, the facility had experienced in excess of 20 cases of positive COVID-19. She said the infection control policy had been updated numerous times and the facility was constantly educating staff on infection control. She said the facility had been COVID free for the past 28 days. Although the facility was COVID-19 free, the facility continued to experience breaks in infection control. I. Failed to ensure active screeing at all stations were monitored A. Professional reference According to the Centers for Disease Control and Prevention (CDC) updated 4/15/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, included the following recommendations: -Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility. B. Observation On 6/24/2020 at 4:39 p.m. and on 6/25/2020 at 11:15 p.m., the dining services building was observed, the building had two screening stations. One of the stations was designated for vendors who brought food supplies and other necessities to the facility while the other screening station was designated for the dietary staff. The dietary staff were however observed utilizing both screening stations to enter and exit the building. Whilst the vendor screening entrance was manned with a staff who screened the vendors by asking pertinent questions related to COVID 19. Specifically, the screening questionnaire included a COVID-19 specific screening questions which asked about whether or not the individual completing the questionnaire had travelled to counties, states and international countries where COVID-19 had been reported. It also asked the question of any symptom consistent with COVID-19 which included fever, chills, cough, sore throats, difficulty breathing etc. The dietary staff screening entrance was not manned, although it had the same questionnaire in place, alongside a thermometer and an alcohol based hand rub (ABHR). The Dietary staff screening station also had piles of screening forms which dated back to May 2020. C. Interview On 6/25/2020 at12:45 p.m., dietary aide (DA) #1 was interviewed. She said she came into the facility through the service building. She said when she arrived at the facility, she answered no to the questions asked in the screening form. She said she took her temperature by herself. She said she was supposed to have another co-worker verify her temperature, she however verified that she does not get to do that. Specifically, DA #1 said It's a waste of time to be waiting on another employee to verify my temperature, I just want to get to work straight away. She also reported that there was no section of the screening form that recorded temperatures. DA #2 was interviewed on 6/25/2020 at 12:52 p.m. She said the service building was recently built and had its own primary access that was not the facility's main entry. She said when she arrived at the beginning of her shift, she was required to screen herself into the service building. She said she was required to fill out the screening questionnaire and to also take her temperature. She verified that the questionnaire did not have a section to document temperatures. In addition, DA #2 said when she was last to arrive at the service building, she was unable to have a co-worker verify her temperature. She said she would take her temperature and resumed her duties. She said she did not know the temperature threshold that would raise a red flag (hinder her from resuming work). On 6/25/2020 at 12:15 p.m., the executive assistant (EA) was interviewed. She said the facility was not allowing visitors which included staff and resident family into the facility. She said few essential vendors were allowed into the facility. She said dietary staff were not screened through the main entrance. Specifically, the EA said the kitchen was located in the service building which had its own screening station and it was where dietary, environmental, maintenance and transportation staff got screened. She said the screening station was not manned and that she does not know who reviewed the screening forms to identify when a dietary staff answered a yes to any of the questions within the screening form. On 6/25/2020 at 1:22 p.m. the nursing home administrator (NHA) and the director of nursing (DON) were interviewed. The DON said there was three different screening points across the facility. She clarified that of the three screening points, only the main entry screening point was manned. She said staff had been trained to screen themselves. The DON said four members of the administration reviewed the screening forms to ensure no staff had answered a yes to any of the pertinent screening questions. She listed herself (DON), the NHA, the chief executive officer (CEO) and maintenance director (MD) as the individuals who reviewed the screening forms. The DON and NHA however verified that they only reviewed the screening forms from the main entry. Specifically, the DON and the NHA said none of the administrative members listed above reviewed the screening forms from other entry points. They also verified that dietary staff went across the facility and were not restricted to the service building alone. On 6/25/2020 at 1:39 p.m., the CEO was interviewed. She verified that she only reviewed the screening forms from the main entry. On 6/25/2020 at 1:51 p.m. The dining director (DD) was interviewed. The DD said she does not know what to do with the screening forms. She said she guesses she would be reviewing them going forward. On 6/25/2020 at 1:57 p.m. The maintenance director (MD) was interviewed. He said he was just made aware (on survey day) that he would be auditing the screening forms. He said going forward, the backlogs of the screening forms in the service building would be taken to the main entry where they would be audited alongside the screening forms across the building. II. Improper hand hygiene during meals A. Facility policy and procedure The Novel Coronavirus Prevention and Response policy dated 3/13/2020, was provided by the nursing home administrator (NHA) on 6/25/2020 at 10:43 a.m., it read in pertinent part: The facility will follow any recommendations from the CDC. Frequent hand washing or use of alcohol based hand sanitizer after resident contact. The Infection Control, Standard Precautions policy was provided by the NHA on 6/25/2020 at 10:43 a.m., it read in pertinent part: Handwashing: -Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. -Wash hands immediately .between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. -Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. The Nursing Infection Control policy was provided by the NHA on 6/25/2020 at 10:43 a.m., it read in pertinent part: Hands shall be washed thoroughly before and after caring for each resident, before serving meals .after handling a patient's articles or supplies . - Handwashing is the single most important procedure for the prevention of infection. Indications for handwashing: Before preparing or serving food, passing fresh water, giving medications, and before eating. Before and after .assisting residents .even when gloves are used. -To be effective, alcohol based hand rub (ABHR) must cover the entire surface of the hands and then be allowed to evaporate from the skin. None of the policies provided by the facility contained guidance for resident hand hygiene. B. Professional standard According to the CDC, Hand Hygiene Guidance, last updated 1/30/2020: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following: -Immediately before touching a patient, -Before moving from work on a soiled body site to a clean body site on the same patient, -After touching a patient or the patient's immediate environment, -After contact with blood, body fluids, or contaminated surfaces, -Immediately after glove removal. -Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. Retrieved 6/26/2020 from https://www.cdc.gov/handhygiene/providers/guideline.html. According to the CDC Hand Hygiene in Healthcare Settings: Patients guidance, last updated 3/15/16: Clean Hands Count for Patients. Patients should clean their hands: Before preparing or eating food. Before touching eyes, nose, or mouth. After using the restroom. After blowing their nose, coughing, or sneezing. After touching facility surfaces. Retrieved 6/26/2020 from: https://www.cdc.gov/handhygiene/patients/index.html C. Observations and interviews during meal service of improper hand hygiene Observations on the Bethany and Immanuel neighborhoods were conducted on 6/24/20 between 4:30 and 4:45 p.m. Observations did not reveal resident hand hygiene was performed before meal service. -At 4:45 p.m., four residents were assisted out of their rooms and into the assisted dining room. Residents were not offered hand hygiene as they entered the dining room. -Between 4:52 p.m. and 5:00 p.m., the residents in the assisted dining room were served their meal. Hand hygiene was not provided to the resident's before they ate their meal. On 6/24/2020 at 4:42 p.m., certified nurse aide (CNA) #1 was observed, in the common area of the secured unit, bringing a male resident, his walker and a cloth facemask. After assisting the male resident put on his cloth facemask, she approached a female resident who had called the CNA over to ask a question. CNA #1 touched the female resident hand and shoulder while consoling the female resident. Immediately following CNA #1 touched the shoulder of a second female resident as she passed by. CNA #1 then stopped to talk to the third female resident and assist the female resident who was in a wheelchair to the bathroom. The CNA did not perform any hand hygiene between contacts with any of the four residents that she provided physical hand on assistance too. On 6/24/2020 between 4:42 p.m. and 5:03 p.m., there were several more observations of CNA #1 touching potentially contaminated surfaces (tables in the common area, resident wheelchairs and walkers, rolling tray tables, the counter at the nurses station, resident hands/bodies and resident masks without performing hand hygiene in between contact with those surfaces and residents. On 6/24/2020 from 4:42 p.m. to 5:04 p.m., residents were observed waiting in the common area for their dinner. The residents were socializing with each other, touching potentially contaminated surfaces in the common area, touching their faces and facemasks, wandering the hall touching the handrails, coloring with shared [MEDICATION NAME] and watching television. No hand hygiene was provided. The dinner trays arrived in the common area at 5:04 p.m. None of the residents eating in the common area of the secured unit were offered, encouraged or assisted to perform hand hygiene before they were served and started to eat their dinner. CNA #1 and #2 were observed physically assisting residents to the common area dining tables to eat. The CNAs assisted some residents to the table in their wheelchair, assisted one resident to transfer from her wheelchair to a dining chair and physically guided others to sit safely in dining chairs. The CNA served dinner trays, removed plastic wrap and lids from the cups and plates, unwrapped eating utensils, handed the residents napkins and cut up food. Neither CNA #1 or #2 performed hand hygiene on themselves before or after each resident contact during the dinner services. On 6/24/2020 at 5:07 p.m., two female residents were observed waiting in the common area of the secured unit for their meal. CNA #1 assisted the residents from the common room and the back dining room to eat dinner. Neither resident was offered, encouraged or assisted to perform hand hygiene before they were served and started to eat their dinner. CNA #2 was interviewed on 6/25/2020 at 5:20 p.m. CNA #2 said most residents use the bathroom before meal time and washed their hands then. There was no sink in the common room or in the dining room for residents to wash their hands. Observations were conducted during the dinner meal on 6/24/20 between 5:25 p.m. and 5:39 p.m. CNA #8 fed two residents at the same table in the dependent dining room. The CNA alternated between feeding the two residents. During the observation, CNA #8 touched multiple potentially contaminated items such as the bottom of the stool he sat on, and both residents ' utensils, bowls and cups. He did not perform hand hygiene between feeding each resident or after he touched the stool. On 6/26/2020 at 12:35 p.m. lunch service on the secured unit was observed. CNA #3 was delivering resident meals in the common area. The CNA delivered lunch to a male resident who had been sitting in the common area of the unit. The CNA did not offer, encourage or assist the resident to perform any type of hand hygiene before serving his meal or before he started to eat. The CNA did not perform hand hygiene on herself before or after serving and setting up the meal for the resident. The CNA served another resident without performing hand hygiene. She handled a rolling table tray; positioned it in front of the resident; removed plastic wrap from the plates and cups and poured drinks; then continued to serve four other residents without offering the residents ' hand hygiene or performing hand hygiene on herself between resident contacts. CNA #3 was observed physically assisting residents into alternative seating, brushed the hair out of one resident's face with her hand, and cut up the residents food items without any hand hygiene in-between residents' contact. CNA #4 was interviewed on 6/25/2020 at 12:04 p.m. CNA #4 said she was trained to clean her hand frequently, including after touching contaminated equipment and in-between each resident contact. She said she mostly used ABHR, but washed with soap and water after assisting residents in the bathroom. The NHA was interviewed on 6/25/2020 at 1:22 p.m. The NHA said staff were to perform some type of hand hygiene after each resident contact, after touching potentially contaminated surfaces, and prior to and in-between serving the resident meals. Staff assist residents with hand hygiene first thing in the morning, at bedtime, after they used the bathroom and before they left their rooms for meals. They do not have a sink in the dining rooms so it would be challenging to wash the residents ' hands in the dining room and other residents would not understand how to use ABHR. The NHA acknowledges the facility could offer ABHR or hand wipes in the dining room and in common areas for residents who were not brought to the dining room from their rooms. Staff would have to assist those who did not understand how to use ABHR and wipes. The NHA said according to the management team, hand hygiene should have been performed between residents to prevent the potential spread of transmission [MEDICAL CONDITION] and infections. III. Improper use of alcohol based hand rub A. Manufacturer's instructions for use The Mystic Mountain hand sanitizer (ABHR) instructions for use, undated, was provided by the NHA on 6/29/20 via email. According to the instructions, the ABHR should cover all surfaces of the hands. The hands should be rubbed together until dry. B. Observations On 6/25/20 at 11:44 a.m., AC #1 placed a clothing protector on a resident in the assisted dining room in the Bethany neighborhood. AC #1 touched his neck and back of his shirt as she placed the clothing protector on the resident. She retrieved a bottle of alcohol based hand rub (ABHR) from her pocket and sprayed it on the palms of her hands. She did not spray the ABHR to cover all surfaces of her hands. The AC quickly rubbed together the palms of her hands for two to three seconds and exited the dining room. -At 11:55 a.m., AC #2 removed a meal tray from the meal cart outside of the assisted dining room in the Bethany neighborhood. The AC placed the meal in front of the resident. She uncovered the plate, drinking cup and bowls. She touched his utensils as she cut up his meal in bit sized pieces. AC #2 sprayed a ABHR on the back side and palms of her hands and waved her hands in the air to dry. She did not rub the ABHR over the surfaces on her hands till they were dry. C. Staff interview CNA #7 was interviewed on 6/25/20 at 1:10 p.m. According to the CNA, most staff used the Mystic Mountain hand sanitizer. She said the ABHR sanitizer needed to cover the hands and be rubbed together till dry for proper use. The nursing home administrator (NHA) was interviewed with the director of nursing (DON) and was interviewed on 6/22/20 at 1:22 p.m. According to the DON, ABHR should have been applied to all surfaces of the hands and the rubbed together to dry for effective use. IV. Improper hand hygiene when donning and doffing gloves A. Professional standards The Centers for Disease Control and Prevention (CDC) Using PPE, last updated 4/3/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html. According to CDC recommendations for how to put on (don) PPE gear included identifying and gathering the proper PPE to don and perform hand hygiene before putting on gloves. B. Facility policy and procedure The Infection Control Standards Precautions policy, undated, was provided by the facility on 6/25/20. The policy read in pertinent part: Wash hands immediately after gloves are removed, between resident contacts, and otherwise indicated to avoid transfer of microorganisms to other residents and environments Wear gloves (clean, non sterile) when touching blood, body fluids, secretions, excretions, and contaminated items Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents and environments. C. Observations Housekeeper (HK) #1 was observed on 6/25/20 at 10:25 a.m. cleaning room [ROOM NUMBER]. The HK donned a pair of gloves from her pocket. She did not perform hand hygiene before donning the gloves. HK #1 entered the resident room and removed a bag of trash from the waste bin next to the resident's bed. She set the trash bag off the floor and placed a new bag inside the waste bin. The HK spoke to the resident laying in bed as HK #1 touched the top surface of the resident's book on the bed side table and picked up a figurine with her gloved hands. As the resident spoke, she produced a slight cough. The HK picked up the trash bag and exited the room. HK #1 set the trash in her cart and doffed her gloves. She did not perform hand hygiene after doffing her gloves. HK #1 retrieved a push broom from her cart, touching the handle with her ungloved hands. She began to sweep under the furniture and around the room. She paused, removed a pair of gloves from her pocket, donned the gloves without hand hygiene and continued to sweep. The HK set aside the broom, exited the room, and doffed the gloves. She retrieved the mop from the mop bucket. Touching the mop handle with her bare hands. She slid the TV stand away from the wall, touching the stand with her hands. She mopped behind the stand and replaced it against the wall. HK #1 exited the room, and returned the mop to the mop bucket. She did not perform hand hygiene. With her bare hands, she touched her housekeeping cart keys, opened the cart, removed clean cloths and a cleaning bottle caddy from the cart, and returned the keys to her pocket. HK #1 entered the room, placed the items in the bathroom and proceeded to wipe down the surface of the resident's bedside table without gloves. HK #1 paused, removed a pair of gloves from her pocket and donned a new pair of gloves before entering the bathroom. HK #1 cleaned the bathroom. After cleaning the bathroom, HK #1 exited the room with a balled pair of gloves in her right hand. She threw gloves away in the cart. She did not perform hand hygiene touching the balled gloves. HK #1 reentered the resident's room with a broom. She did not wear gloves as she touched the broom handle. She completed sweeping the room and bathroom. She exited the room without hand hygiene, emptied the contents of her dust pan, retrieved the mop from the bucket, touching the handle of the mop and entered the room. She did not perform hand hygiene when entering the room, she did not don gloves and she moped the rest of the room and bathroom. The HK mopped the corner of the room behind the resident's entrance door. As she cleaned behind the door, she touched the outer surface of the door frame with her hand. HK #1 exited the room without hand hygiene, placed the mob in the bucket and moved her cleaning cart the outside of the neighboring resident room [ROOM NUMBER]. HK #1 donned a pair of gloves without hand hygiene and entered room [ROOM NUMBER]. She collected the trash and proceeded to clean room [ROOM NUMBER]. On 6/24/20 at 4:50 p.m., a meal cart with plated and covered meals arrived outside the assisted dining room. Four residents sat in the assisted dining room, waiting for their meals. -At 4:52 p.m., CNA #5 removed a pair of gloves from her pocket. She donned the gloves over her hands. She did not perform hand hygiene before she donned the gloves. CNA #5 pulled the first tray from the meal cart and placed it in front of the first resident. CNA #5 removed the plastic wrap of the plate and cup. She removed the lids of the bowls and pulled the top of a prepackaged pat of butter and placed his utensils next to his plate. She doffed her gloves by using her right hand to pull the fingertips of the left glove away from her left hand. CNA #5 used her ungloved left hand to doff the right hand. When the CNA removed the glove, she touched the outer surface of the glove with her left hand when she quickly pulled the glove off from the wrist. She balled both gloves in her left and before disposing of them. CNA#5 did not perform hand hygiene after inappropriately doffing the gloves. CNA #5 returned to the meal cart and retrieved another set of gloves from her pocket. She donned the gloves without performing hand hygiene. CNA #5 proceeded to serve the three remaining residents. During each meal delivery, she continued to not perform hand hygiene before and after donning and doffing gloves. During each meal delivery she failed to appropriately doff gloves by touching the outer surface of each glove after she served and set up the resident's meals. D. Staff interview The maintenance director (MD) was interviewed on 6/25/20 at 12:32 p.m. The MD said he oversaw the housekeeping department. According to the MD housekeepers are trained during the new hire department orientation on appropriate housekeeping practices. He said all staff receive infection control during new hire orientation. The MD said that a couple of months ago, each staff member including the housekeeping staff, received one on one training on infection control. He said the training included hand hygiene and appropriate donning and doffing of personal protective equipment (PPE). He said he also personally performed routine observation audits of housekeeping practices pertaining to cleaning and infection control. The MD stated that he felt his staff was well trained and performed safe and effective cleaning to prevent the spread of infections [MEDICAL CONDITION]. HK #1 was interviewed on 6/25/20 at 12:55 p.m. According to HK #1 hand hygiene should be performed before donning and after doffing of gloves. She said she kept alcohol based hand rub (ABHR), inside her housekeeping cart. She said an ABHR pump was located next to the door inside each resident's room. The HK said she should have worn gloves when providing each task and change the gloves after each task was completed. The nursing home administrator (NHA) and the director of nursing (DON) was interviewed on 6/25/20 at 1:22 p.m. According to management, staff has received extensive training on appropriate use of personal protective equipment (PPE), to include how to don and doff PPE correctly and the importance of hand hygiene before and after donning and doffing of gloves. V. Staff hand hygiene after touching potentially contaminated surfaces A. Observations On 6/24/20 at 4:47 p.m. A resident in the assisted dining room removed his mask as he waited for his meal. CNA #6 encouraged the resident to put his face mask back on over his face. She picked up the mask from the table, touching the inside and outside of the mask as she adjusted it to cover his nose and mouth. CNA #6 did not perform hand hygiene after she replaced the mask on the resident. The CNA entered a resident room directly across from the dining room. She did not perform hand hygiene when entering the resident's room. CNA #6 spoke to the resident inside the room and touched the resident's bedside table with her un-sanitized hands. She closed the entrance door to the resident's room, touching the inside of the door. On 6/25/20 at 12:02 p.m., activity coordinator (AC) #1, was observed as she physically fed a dependent resident in the main dining room outside of the Bethany neighborhood/unit. A bottle of alcohol based hand rub (ABHR) was placed in the center of the table near the AC. -At 12:09 p.m., AC #1 scratched the top of her right shoulder with her left hand. AC #1 then placed her left palm over the resident's beverage cup, gripping the top edge of the cup with her fingers as she moved it towards the back side of the plate. AC #1 did not provide hand hygiene after scratching her shoulder and before she placed her palm and fingers directly over the resident's cup. The AC did not perform hand hygiene with the available ABHR before she proceeded to feed the resident after scratching her shoulder. On 6/25/20 at 12:13 p.m., Housekeeper (HK) #2 was observed feeding a resident in the assisted dining room in the Bethany neighborhood. She handled the resident's cup, plate, and utensils as she physically fed the resident. -At 12:15 p.m., HK #2 put her hand over her shoulder and under the backside of her uniform top. She scratched her shoulder blade and then proceeded to feed the resident. She did not use hand hygiene after she scratched her back and before she continued to feed the resident. B. Staff interview HK #2 was interviewed on 6/25/20 at 1:05 p.m. According to HK #2, she was a paid feeding assistant. She said she was provided a two day training class to learn how to feed residents. She said the infection control preventionist provided her the training. According to the HK, appropriate hand hygiene when feeding residents was part of the training to feed residents. AC #1 was interviewed on 6/25/20 at 1:18 p.m. AC #1 said she was a paid feeding assistant. According to the AC, she was trained to not touch the eating or drinking surface of resident cups, plates or utensils. She said placing her hand over the resident's cup, gripping it around the drinking surface of the cup, would not have been an appropriate infection control technique. She said she was also trained to perform hand hygiene anytime she touched a potentially contaminated surface, especially when feeding residents. VI. PPE use A. Facility policy and procedure The Mask Procedure, dated 6/5/2020, was provided by the NHA on 6/29/2020 at 12;12 p.m., it read in pertinent part: If the unit you are assigned to has no cases of COVID 19 ., you can wear a procedure mask or an KN95 mask as a procedure mask- it is your choice. Procedure masks will be made available at the desk where you sign in for the day. B. Professional standard According to the Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of Facemasks, last updated 4/3/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html#contingency-capacity: In settings where facemasks are not available, HCP (healthcare personal) might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. Retrieved 6/26/2020 C. Observations and interview On 6/25/20 at 12:14 p.m. the transportation coordinator (TC) wore a cloth mask as she entered the Bethany neighborhood (unit), a resident care area. She walked down the hall passing resident rooms with open doors. The TC entered the assisted dining room in the center of the unit. Still wearing her cloth mask she spoke to a resident eating in the dining room. On 6/26/2020 from 4:32 p.m. to 5:50 p.m., CNA #1 was observed wearing a homemade cloth face mask while working with residents on the secured unit. The CNA was not wearing any other type of medically grade FDA approved mask under the homemade cloth mask. The TC was interviewed on 6/25/20 at 12:19 p.m. According to the TC, she could wear a cloth mask in the facility as long as she was not providing patient care. She said she would wear a procedure face mask if she would have been providing care. The NHA was interviewed on 6/25/2020 at 1:22 p.m. The NHA said only medical records and administrative staff were permitted to wear a cloth mask, because they do not work in residents' care areas. All other staff were trained that they needed to wear a surgical mask when in the resident care areas or when they were with residents. The facility has N95 masks available for staff if they choose to wear the N95 mask in place of a surgical mask by their choice or when working with resident's on droplet precautions. The

Based on observations, interviews, and record reviews, the facility failed to ensure staff were following the precautions to prohibit the transmission of communicable diseases. Specifically, staff were not donning PPE (Personal Protective Equipment) in the sequence that prevents the transmission of infectious diseases and signage detailing what PPE to use in isolation rooms was not available for staff in certain rooms. These failures place residents and staff at risk for acquiring infectious diseases. 1. Findings include: Isolation Policy page 43, given by the CEO (Chief Executive Officer), on the third paragraph reads in pertinent part, The facility will utilize procedures recommended by the Centers for Disease Control and Prevention (CDC) if isolation is needed;. The sequence for putting on PPE by the CDC lists donning gown first, followed by mask or respirator, then goggles, and then gloves. This sign was present on the doors of the isolation rooms in Immanuel hall. An observation on 4/15/20 at 11:50 AM revealed Nursing Student 1 (NS1) in the Immanuel hall prior to going into a room where a droplet precaution sign was on the door. NS1 donned gloves without performing hand hygiene, then donned shoe coverings, followed by a gown. NS1 was wearing the mask prior to donning the gloves. When NS1 was asked about the lack of hand hygiene prior to donning gloves, NS1 replied Oh I forgot. When asked about the sequence she used for donning PPE, NS1 looked at the sign posted on the door and acknowledged she should have donned the gown before the gloves. An observation on 4/15/20 at 12:00 PM evidenced Certified Nurse Aide 1 (CNA1) donning gloves followed by donning a gown prior to going into an isolation room with a droplet precaution sign on the door. When CNA1 was asked why she donned the gown after the gloves, CNA1 replied I forgot. Then CNA1 removed the gown and gloves, and donned the gown before donning the gloves. On 4/17/20 at 3:13 PM during an interview via conference call with the Administrator, the CEO, and the Infection Prevention and Control (IPC) - Nurse (RN), the above observations were mentioned. The CEO replied NS1 has had training on the proper sequence of PPE and sent the documentation via email from NS1's school of nursing, and CNA1 said she was nervous. When the signs illustrating the sequence on the doors were mentioned, the IPC-RN reported yes that is why we have them, and it is our expectation that they follow the sequence, since then they have been educated on donning (PPE) and hand hygiene. 2. Findings include: Isolation policy page 43, given by the CEO, on the third paragraph reads in pertinent part, In the event that isolation precautions are necessary, a sign requesting that visitors check with the nurses station prior to entering the resident's room will be posted on the resident's door. An observation on 4/15/20 at 12:10 PM in the Elim hall revealed a couple of rooms that had signage stating, Droplet Precautions to prevent the spread of infections, anyone entering this room must wear: surgical mask. Below the first sign, a CDC postage title How to safely remove personal protective equipment (PPE) Example 2. No gloves or gowns are listed as a precaution to prevent the spread of infection on the sign on the resident's door. On 4/15/20 at 12:40 PM in an interview with the CEO and the Environmental Services Supervisor, when shown a picture of the signs in Elim hall, the CEO replied, I was unaware of inconsistency of the signage. The CEO further stated droplet precautions should include mask, gloves, and gowns. On 4/17/20 at 3:17 PM in an interview via conference call with the Administrator, the CEO, and the IPC-RN, when the observation of the inconsistency of the signage was mentioned, the IPC-RN, replied yes, we fixed that.

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: - follow proper sanitary procedures when cleaning residents' rooms, including room with isolation precautions; and - use an appropriate disinfectant cleaner for routine cleaning of residents' rooms, including room with isolation precautions. Findings include: I. Facility policy and procedure The Environmental Services Cleaning Guidebook policies and procedure, undated, was provided by the nursing home administrator on 7/11/19 at 1:30 p.m., and read in pertinent part: Routine occupied room cleaning: - Change rag as needed to ensure saturation, no double dipping. Change rag and start with a fresh one after cleaning the bed. Move from door and sanitize all equipment, restroom to be done last. - Do not wear dirty gloves outside of the room, if you have to leave the room, remove your gloves and perform hand hygiene. Put a new pair of gloves on to resume cleaning. - Before leaving the room remove gloves and perform hand hygiene. Isolation cleaning procedures: - Follow routine cleaning. Quat (quaternary ammonium chloride compound) detergent for floor cleaning. - Wipe down all furniture surfaces with disinfectant. - Clean bathroom sink and toilet bowl with disinfectant. - Mop floor, making sure that the entire floor is mopped thoroughly with disinfectant. II. Professional reference According to The Centers for Disease Control and Prevention (CDC) (2015) Environmental Infection Control, retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/environmental/ The CDC recommendations read in pertinent part, Use a one-step process and an EPA (Environmental Protection Agency)-registered hospital disinfectant/detergent designed for general housekeeping purposes in patient-care areas when uncertainty exists as to the nature of the soil on these surfaces or uncertainty exists regarding the presence or absence of multi-drug resistant organisms on such surfaces. III. Observations Observations of cleaning a double occupancy room on secured unit on 7/10/10 at 10:00 a.m. - 10:00 a.m. housekeeper (HK) #1. was observed donning gloves without performing hand hygiene, the HK#1 removed the cleaning supplies from her housekeeping cart. With gloved hand she touched her keys, and placed them into her shirt top pocket. The HK carried a caddie of the supplies into the resident's room. - 10:01 a.m. the HK#1 removed the lid of the toilet tank and added a chemical to the toilet tank water, the HK stated the chemical was used to remove the stains caused by the hard water. - 10:04 a.m. the HK#1 refilled the paper towel dispenser in the bathroom, the HK was wearing the same gloves while handling the paper towels. - 10:06 a.m. the HK#1 poured cleaner into the bowl of the toilet and sprayed the cleaner onto a rag. The HK was observed wiping the toilet with the rag. She placed the soiled rag on the bathroom floor when she finished cleaning the toilet. She used a toilet brush to clean the inside of the toilet. - 10:10 a.m. the HK#1 began removing the resident's personal item from the medicine cabinet in the bathroom. The HK#1 continued to wear the same gloves, the HK#1 was observed picking up the resident's toothbrush with her gloved hand. The HK#1 stated she was changing out the paper towels that lined the shelves in the medicine cabinet. The HK#1 said she changed the towels several times a week because the paper towels get wet. - 10:12 a.m. the HK#1 began cleaning the resident's room, she did not change her gloves after cleaning the bathroom. The HK#1 pulled furniture polish from the cleaning supply caddie. The HK#1 was observed spraying the furniture polish onto the resident's bedside tables and dressers. The HK#1 wiped down both resident's furniture with the same rag. While wiping down the furniture the HK#1 was observed lifting both resident's personal items. - 10:17 a.m., the HK#1 went to hallway to remove the broom from the housekeeping cart, the HK#1 returned to the room, and swept the bathroom floor. - 10:18 a.m. the HK#1 used her gloved hand and raised one of the resident's bed using the bed controller, and swept under the bed. - 10:24 a.m., the HK#1 used her gloved hand and using the bed controller raised the other bed in the room. The HK#1 swept under the bed. The HK#1 pulled out a lipstick container and using her gloved hand, picked the lipstick off the floor and placed the lipstick onto the resident's dresser. - 10:25 a.m. the HK#1 went to housekeeping cart and removed the broom head with her gloved hand and placed it into the soiled bin on her cart. The HK removed the mop from her cart and stated the last thing she did was mop the room. - 10:27 a.m. the HK#1 began mopping the resident's room, beginning with the bathroom, after mopping the bathroom, the HK began mopping the resident's floor. - 10:28 a.m., the HK#1 lowered both resident beds while wearing the same gloves. - 10:30 a.m., the HK#1 turned off the lights to the room, while wearing the same gloves. She removed the gloves and did not perform hand hygiene. The HK said she was done cleaning the room. Observation of cleaning a double occupancy room on the 300 hallway on 7/10/19 at 12:36 p.m. - 12:37 p.m., HK #2 removed a housekeeping caddie from the housekeeping cart, and entered the room. The HK entered the bathroom, and donned a pair of gloves without performing hand hygiene. - 12:38 p.m., the HK#2 lifted the toilet lid and added Bio Conqueror 105 to the toilet, the HK used a toilet brush and cleaned the toilet. - 12:39 p.m., the HK#2 sprayed a rag with the Bio Conqueror 105 to a rag, the HK wiped the toilet seat and the handles in the bathroom with the same rag. -12:40 p.m., the HK#2 lifted one of resident's toothbrushes with her gloved hand, wiped the shelf where the toothbrushes were sitting, the HK picked up the other toothbrush with her gloved hand and continued to wipe the bathroom shelf. -12:42 p.m., the HK#2 sprayed the Bio Conqueror 105 onto a rag and began cleaning the resident's room. The HK was observed picking up both resident's personal items to wipe under them. The HK was wiping both resident's bedside tables and dressers with the same rag. -12:43 p.m., the HK#2 was observed picking up one of the resident's call light, the HK wiped the call light with the same rag she was using throughout the room, the HK placed the call light on the resident's bed after she wiped it with the rag. -12:45 p.m., the HK#2 removed her gloves, she did not perform hand hygiene. -12:48 p.m., the HK#2 dusted and mopped the bedroom and bathroom floor. Observation of cleaning the room with isolation precautions -1:21 p.m., HK #2 donned a gown and gloves to clean the room. The HK stated the cleaning supplies were kept in the resident's room. The HK said they used Bio Conqueror 105 to clean the entire room. -1:25 p.m., the HK#2 sprayed the toilet with the Bio Conqueror 105, the HK immediately wiped the toilet and handrails in the bathroom. -1:26 p.m., the HK#2 sprayed a rag with the Bio Conqueror 105, the HK picked up the cup holding the resident's toothbrush with her gloved hand and wiped the bathroom counter. -1:27 p.m., the HK#2 began cleaning the resident's room, she sprayed a rag with the Bio Conqueror 105 and wiped the resident's bed rails and trapeze. -1:28 p.m., the HK#2, using the same rag, wiped the resident refrigerator, with her gloved hand, the HK opened the door of the refrigerator to wipe the door. -1:29 p.m., the HK#2, using the same rag began wiping the resident's bedside table, the HK was observed picking up the resident's stethoscope and blood pressure cuff with her gloved hand. -1:30 p.m., the HK#2 stated she only had to clean the resident's floor as the final step of cleaning. The HK said the resident's bathroom and bedroom with totally carpeted, so she used a brush floor sweeper to clean the floor. The flooring in the resident's room was visibly soiled with large brown and black stains. The HK said when the floor gets really bad, they have the carpet cleaner they use to clean the floor. -1:35 p.m., the HK#2 finished sweeping the bathroom and bedroom floor. The HK removed her gown and gloves, she did not perform hand hygiene. The HK said when she finishes the room, she takes the soiled rags to the soiled utility closet. IV. Product information The label for Bio Conqueror 105 was reviewed on 7/10/19 at 2:00 p.m. The label read in pertinent part, liquid is a bioactive concentrate that eliminates the actual source of the odor. High fragrance, surfactants, and bacterial concentrations work quickly to clean and consume the source of the malodor. Bio-Conqueror 105 specially formulated to consume urine, waste, food, grease, detergent residues, drains, pet messes and dander. The label did not indicate the spray had disinfectant properties, or was to be used as a disinfectant. The label did not specify surface contact times to be followed. The label did not include an EPA (Environmental Protection Agency) registration number, which would indicate the product was evaluated and approved by the EPA for use as a disinfectant. V. Staff interviews HK #2 was interviewed on 7/10/19 at approximately 1:30 p.m., she said the only cleaner she used on a daily basis while cleaning resident rooms was the Bio Conqueror 105. She said she had a chemical in her cart that was a disinfectant, but she only used that occasionally for cleaning stains off the floor. The HK#2 said the product used in the mop water was a disinfectant, and that was used in all of the rooms with the tile flooring. The HK#2 said the rooms with carpeting were only vacuumed as part of the daily housekeeping. The housekeeping supervisor (HKS) was interviewed on 7/11/19 at 9:00 a.m., she said housekeepers needed to wash their hands or use hand sanitizer prior to putting on gloves. She said when housekeepers were cleaning double occupancy rooms, they wore the same gloves and used the same cleaning cloths for both neighbors furniture, if they were on isolation precautions they would use separate rags and gloves. The HKS said if the housekeeper began the room cleaning with the bathroom, the housekeeper would need to wash her hands and put on new gloves prior to cleaning the rest of the room. The HKS said they used the Bio-Conqueror 105 in the bathroom sink and toilet, and a chemical for hard water stains in the toilet is used weekly to remove stains. The HKS stated the facility had ordered a new product for the isolation rooms, but she was not sure if the product was on the housekeeping carts. The HKS stated she had a disinfectant that was in a spray can, and that product was used when there was a stain on the floor. She stated isolation rooms, are mopped as the final step in cleaning, and the mop head is changed after each isolation room, or the isolation room is mopped last. She said the isolation rooms with carpeting are vacuumed daily, and when the neighbor comes off of isolation, the housekeeping staff attempt to spray the carpet to clean it. HK #2 and the HKS were interviewed a second time on 7/11/19 at 10:27 a.m. The HK said the only cleaning product she used was the Bio-Conqueror 105, including in isolation rooms. The HK removed the bottle of Bio-Conqueror 105 for an isolation room, and verified that was the only product she used. The HK said the disinfectant in the spray can stripped the wax off of the floor and finish off the sink, so she only used it for stains in a small area, or stains that were dark like grape juice. The infection preventionist (IP) was interviewed on 7/11/19 at 11:55 a.m. She said the housekeepers needed to perform hand hygiene before putting on gloves and also when removing them. The IP said the bathroom and the toilet should be the last thing cleaned, and hand hygiene should be performed after moving to the next task. The IP said all rooms in the facility should be cleaned with a disinfectant, and a bio-enzymatic cleaner would not be classified as a disinfectant. The IP said she was not sure how the rooms with carpet were able to be properly disinfected, and that was something she would need to look into.

Based on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately, for three (#71, #46 and #61) of four, out of 45 sample residents. Specifically, the facility failed to: - report Resident #71's injury of unknown origin to the State Survey Agency in accordance with State law; and - report Resident #46 and #61 resident to resident altercation to the State Survey Agency in accordance with State law. Cross reference F610 - The facility failed to thoroughly investigate the injury of unknown origin. Findings include: Facility policy The Abuse Prevention policy, revised 1/9/19, was provided by the nursing home administrator (NHA) on 7/8/19 at 8:30 a.m. The policy read in pertinent part, It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or neighbor property) are reported per Federal and State Law. The facility will ensure that all violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of neighbor property, are reported immediately, but not later than two hours after the alleged allegation is made, if the event that cause the allegation results in serious bodily injury, or no later than 24 hours if the event that cause the allegation did not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a neighbor in the facility. I. Failure to report injury of unknown injury for Resident #71 A. Resident #71 Resident #71, age 88, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 5/29/19 minimum data set (MDS) assessment revealed Resident #71 had short and long term memory problems and her cognitive skills for daily decision making were severely impaired. The resident had delusions, however no other behavioral symptoms during the seven days look back period. She required extensive assistance from two (or more) persons with transfers, dressing, toilet use and personal hygiene, and limited assistance of one person with eating and bed mobility. She used a wheelchair for mobility with one person physical assistance. She had two falls since her last MDS assessment, one with no injury, and one with non-major injury. She did not receive an anticoagulant medication. Record review The 7/8/19 nursing note documented the following: This morning when she was going to the dining room staff noted that she had a hematoma to her left forehead which is four cm (centimeters) by four cm. Neuros were started. Temp(erature) 97.2. Pulse 110, respirations 24. Dr. (name) notified. The cause of the injury is unknown. The 7/9/19 nursing note documented the following: Neighbor assisted to wheelchair. Readily visible lump on head. Also noted bruise (three cm) greenish in color on right buttock and abrasion near coccyx, 1 cm by 1 cm and 1.5 cm. Skin does not appear to be broken. Son notified per TC (telephone call). Neighbor self transferred to two different neighbors beds. Unable to get to sit at table for meal. Did drink most of med pass and medications. Neuros are intact. Doctor faxed notification of skin areas. The 7/11/19 nursing note documented the following: Two bruises were reported. One was noted to left hip 2 cm in size noted to be fading. One was noted to left outer calf and is .5 cm in size and is also fading. No noted discomfort. The 7/8/19 incident report documented the nursing home administrator (NHA) and the director of nursing reviewed the incident report on 7/11/19. The report documented the investigation outcome was unsubstantiated, the State reportable question was left blank. Staff interviews A certified nurse aide (CNA)#1 was interviewed on 7/10/19 at 10:23 a.m. She said she was the CNA working with the resident when the bump and hematoma was noted on her forehead. CNA#1 said she did not know how the resident got the hematoma, but had reported it to the nurse working that morning. The director of nursing (DON) was interviewed on 7/10/19 at 4:45 p.m. The DON said the resident's hematoma was reported to her earlier today. She said they were looking into the cause of the hematoma. She said the CNA had reported it to the charge nurse and the charge nurse reported it to her. She said they were checking neuros on the resident. The DON said they were also interviewing certified nurse aides to see what happened. The DON said the resident had a history of [REDACTED]. The DON said hematoma to forehead is not a small injury. The DON said the injury was not reported to the State Survey Agency. She said the facility was going to report the hematoma after an investigation had been completed so they could determine the cause of the hematoma. The DON said the injury should have been reported to the State Survey Agency following the guidelines. The NHA was interviewed on 7/11/19 at 9:00 a.m. She said she did not report the injury to State Survey agency because she did not feel it met the criteria for reporting. II. Failure to report an altercation between Resident #46 and Resident #61: B. Resident #46 Resident #46, age 95, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 5/13/19 minimum data set (MDS) assessment revealed Resident #46 had short and long term memory problems and her cognitive skills for daily decision making were severely impaired. She required extensive assistance from two (or more) persons with dressing, toilet use and personal hygiene, and limited assistance of one person with transfers, locomotion, eating and bed mobility. She was able to walk independently on the unit. Record review The 7/4/19 nursing progress note documented the following: At 1545 (3:45 p.m.) CNA reports two neighbors met in the hall (this neighbor and peer (Resident #61) CNA reports this neighbor called out ' Ow ' . CNA stated peer hit this neighbor in the left arm then CNA turned peer around to go the other direction. This neighbor struck out at peer hitting her right shoulder back. No evidence of trauma on face. Agitated and taken to lobby to sit under warm blanket. Given Tylenol for possible discomfort. Calmed and incident forgotten within five minutes. Attempted to notify family per TC (telephone call). No answer. Message left requesting return call. Doctor faxed. C Resident #61 Resident status Resident #61, age 69, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 5/23/19 minimum data set (MDS) assessment revealed Resident #61 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance from two (or more) persons with bed mobility, transfers, dressing and personal hygiene and limited assistance of one person with locomotion and toilet use. She was able to walk independently on the unit with a walker. Record review The 7/5/19 nursing note document the following: At 1545 (3:45 p.m.) CNA reports this neighbor met peer (Resident #46) in hall and heard Resident #46 say 'Ow'. This neighbor struck Resident #46 on the left jaw. CNA turned this neighbor around to head the other way and Resident #46 struck this neighbor right shoulder back. No signs of injury and event forgotten within five minutes. TC (telephone call) to notify responsibility party and doctor faxed notification. The 7/6/19 nursing note documented the following: Neighbor no longer makes anxious complaints because cannot articulate words but remains anxious as evidence by inability to sit, follows staff around to into other neighbor rooms. Attention and reassurance seeking. Staff interviews A licensed practical nurse (LPN) #1 was interviewed on 7/10/19 at 3:30 p.m. She said she was the nurse working evening shift when the residents had their altercation. The LPN said she did not witness the incident, but the CNA working that evening was the staff member who witnessed the residents hitting each other. The LPN stated the incident had occurred on a holiday, so when the incident happened she notified the manager on call. The manager on call was the resident service director (RSD). The LPN said she spoke with the RSD who told her to place both residents on 15 minute checks. The LPN said the RSD stated she would notify the nursing home administrator (NHA). The RSD was interviewed on 7/11/19 at 8:46 a.m. The RSD said she recalled getting the call about the altercation between Resident #46 and #61. The RSD said she asked the nurse to complete a skin check for both residents and also 15 minute checks. The RSD said she had notified the NHA immediately following her conversation with the LPN. The RSD said it was not reported to the State Survey Agency because the residents did not have injuries, both residents had forgotten about the incident and had no memory of the incident, and did not demonstrate any fear, so she felt it did not meet the criteria for reporting. The NHA was interviewed on 7/11/19 at 9:00 a.m. She said she was notified of the incident by the RSD via a phone call. She said she did not report it to the State Survey Agency because she did not feel it met the criteria for abuse reporting. The NHA said the resident's had no recollection of the incident and were not injured. Facility follow-up The NHA stated she had reported the injury of unknown origin for Resident #71, and the altercation between Resident #46 and #61 to the State Survey Agency on 7/11/19 at 10:56 a.m.

Based on interviews and record review, the facility failed to have evidence all alleged violations of abuse and/or mistreatment, including injuries of unknown origin, were thoroughly investigated for one (#71) of four residents investigated for abuse out of 45 sample residents. Specifically, the facility failed to timely and thoroughly investigate an injury of unknown origin for Resident #71. Cross reference F609 - The facility failed to report an abuse allegation. Findings include: I. Facility policy The Abuse Prevention policy, revised 1/9/19, was provided by the nursing home administrator on 7/8/19 at 8:30 a.m. The policy read in pertinent part, Investigations of injuries of unknown origin or suspicious injuries: When an injury of unknown origin occurs, it must be investigated to rule out abuse. These types of injuries include, but are not limited to, bruising in an area not typically vulnerable to trauma, bruising of unusual size or shape, multiple unexplained bruises, or bruising to the inner thigh, face, chest or breast. II. Resident status Resident #71, age 88, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 5/29/19 minimum data set (MDS) assessment revealed Resident #71 had short and long term memory problems and her cognitive skills for daily decision making were severely impaired. The resident had delusions, however no other behavioral symptoms during the seven days look back period. She required extensive assistance from two (or more) persons with transfers, dressing, toilet use and personal hygiene, and limited assistance of one person with eating and bed mobility. She used a wheelchair for mobility with one person physical assistance. She had two falls since her last MDS assessment, one with no injury, and one with non-major injury. She did not receive an anticoagulant medication. III. Record review The 7/8/18 nursing note documented the following: This morning when she was going to the dining room staff noted that she had a hematoma to her left forehead which is four cm (centimeters) by four cm. Neuros were started. Temp 97.2. Pulse 110, respirations 24. Dr. (name) notified. The cause of the injury is unknown. The 7/9/19 nursing note documented the following: Neighbor assisted to wheelchair. Readily visible lump on head. Also noted bruise (three cm) greenish in color on right buttock and abrasion near coccyx, 1 cm by 1 cm and 1.5 cm. Skin does not appear to be broken. Son notified per TC (telephone call). Neighbor self transferred to two different neighbors beds. Unable to get to sit at table for meal. Did drink most of med pass and medications. Neuro's are intact. Doctor faxed notification of skin areas. The 7/11/19 nursing note documented the following: Two bruises were reported. One was noted to left hip 2 cm in size noted to be fading. One was noted to left outer calf and is .5 cm in size and is also fading. No noted discomfort. The 7/8/19 incident report documented the following: The certified nurse aide (CNA) working with the resident the night before stated she had performed a check on the resident between 3 and 4 a.m., and the resident was in her bed and no injury was noted. The registered nurse (RN) working with the resident the night before the hematoma was noted, was performing wound care on the resident at 5 a.m., and did not notice anything on the resident's forehead. The RN stated the bump on the resident's head was noticed when she was coming to breakfast. The CNA who noticed the bump on the resident's head was interviewed on 7/11/19. In that interview the CNA stated she had also noted bruising to the resident's left hip and calf when she was bathing the resident on Tuesday (7/9/19). IV. Staff interviews CNA #1 was interviewed on 7/10/19 at 10:23 a.m., she stated she had noticed the bump and hematoma was noted on the resident's forehead. The CNA said she did not know how the resident got the bump. The CNA said she reported the bump to the unit's nurse. The director of nursing (DON) was interviewed on 7/10/19 at 4:45 p.m. The DON said the resident's hematoma was reported to her earlier today. She said they were looking into the cause of the hematoma. She said the CNA had reported it to the charge nurse and the charge nurse reported it to her. She said they were checking neuros on the resident. The DON said they were also interviewing certified nurse aides to see what happened. The DON said the resident had a history of [REDACTED]. The DON said hematoma to forehead is not a small injury. The NHA was interviewed on 7/11/19 at 9:00 a.m., she said she reviewed the incident report and concluded the resident received the bump and hematoma from a fall. The NHA did not provide an investigation regarding the bruising noted on the resident's hip or calf on 7/11/19, or an investigation into the bruising noted on the right buttock on 7/9/19.

Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievance for one (#68) of one reviewed for complaints/grievances out of 45 sample residents. Specifically, the facility failed to have documentation the resident's grievance was investigated and the resident was informed of the steps taken to resolve it. Findings include: I. Grievance policy The grievance policy and procedure was provided by the resident services director (RSD) on 7/9/19 at 10:50 a.m. It read in pertinent part: Administration of (facility) will make every effort to satisfactorily and promptly resolve any complaint, concern or grievance brought to the attention of the facility. The facility respects the individual's right to: voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished .Prompt efforts by the facility to resolve grievances the resident or his/her representative may have, including those with respect to the behavior of other residents .The resident or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended within ten working days of filing of the grievance or complaint .A copy of the grievance/complaint investigation report must be attached to the grievance and complaint report and filed in the business office. II. Resident's status Resident # 68, age 66, was initially admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 physician computerized orders (CPO), pertinent [DIAGNOSES REDACTED]. The 5/27/19 minimum data set (MDS) assessment revealed the resident's cognitive skills for daily decision making were severely impaired. She had no hallucinations, delusions or rejection of care behaviors. She required extensive assistance of two persons with bed mobility, dressing and personal hygiene and was totally dependent on two staff with transfers, eating and toilet use. Family interview Resident #68's family member was interviewed in on 7/8/19 at 11:22 a.m. She said she purchased two fans for the resident. She said when the resident moved, about three months ago, to another room within the facility, one of the fans went missing. She said she reported the incident to the social worker (SW). She said no one had gotten back to her with a resolution of her concern. Staff interview and record review The SW was interviewed on 7/9/19 at 4:55 p.m. She said if a resident or family member reported a concern regarding missing property, it should be documented on the 24 hour report sheet and should be followed up within 72 hours. She said staff would search for the missing item. She said if it was not found, then, depending what the item was, the facility would replace it. She confirmed that it was reported to her the resident's fan was missing. She said staff searched for the fan and did not find it. She said she followed up with the complainant and told her that the staff did not find the fan. She said she told the complainant that the fan would be replaced. She said she did not document the investigation. She said she instructed the housekeeping department to replace the resident's fan, but did not follow up to ensure it was replaced. She said she should have documented the complaint and ensure a resolution was reached. The nursing home administrator (NHA) was interviewed on 7/10/19 at 1:03 p.m. She said the process was if a resident or family member complaint or voiced a concern of a missing property, it should be documented on the 24 hour report. She said the social worker was responsible to follow up on complaints and ensure a resolution was reached. She said the staff would search for the missing item. She said if the item was not found, then it would be replaced by the facility. She said all grievances should be documented and follow up promptly with a resolution. She said if it was not documented, then it would be difficult to follow up. She said the social worker should have documented and follow up with the grievance and ensure a resolution was reached. Facility follow-up On 7/10/19 at 12:55 a.m., the SW said she had replaced the resident's fan.