Every finding on record at Fountain View Rehabilitation and Nursing LLC

Based on record review and interviews, the facility failed to ensure residents received adequate supervision and intervention to prevent physical abuse for one (#4) of four residents reviewed for abuse out of nine sample residents. Specifically the facility failed to protect Resident #4 from physical abuse by Resident #3. Findings include: I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 1/28/26 at 1:04 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Prevention of Abuse, Neglect and Exploitation the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.II. Incident of physical abuse of Resident #4 by Resident #3 on 12/1/25The facility's investigation, dated 12/2/25, was provided by the NHA on 1/28/26 at 9:58 a.m. The investigation revealed the following: Resident #3 and Resident #4 were seated at a table in the dining room together. During mealtime Resident #4 reached out and took Resident #3's dessert. Resident #3 slammed his hands on the table and then hit Resident #4 in the chest while calling Resident #4 names. Resident #3 and Resident #4 were separated immediately with no injuries, and the police were notified. The facility initiated their investigation. One of five staff members interviewed witnessed the incident. On 12/1/25 at 1:00 p.m. certified nursing aide (CNA) #3 saw Resident #4 take Resident #3's dessert. Resident #3 slammed his hands on the table and then hit Resident #4's chest, and was calling him names. -Staff interviews (see below) during the survey revealed facility staff were aware of Resident #4's behavior of frequently grabbing out for desserts. Facility staff were also aware that Resident #3 was territorial about his belongings and had a history of becoming aggressive. The facility investigation identified both Resident #3 and Resident #4 had severe cognitive impairment with behaviors. The facilities investigation concluded the physical abuse was substantiated. B. Resident #4 (victim) 1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), the diagnoses included cognitive social or emotional deficit following cerebral infarction, mood disorder due to known physiological condition with depressive features, generalized muscle weakness, and contractures to the left and right lower legs.The 1/22/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. He required maximum assistance with all activities of daily living (ADL). The MDS assessment indicated the resident did not display behaviors. 2. Record ReviewThe comprehensive care plan, initiated on 1/7/25, revealed Resident #4 exhibited impaired cognitive function/ impaired thought process related to a history of cerebrovascular accident (CVA) with residual cognitive social and emotional deficit. The interventions included using the resident's preferred name, identifying yourself at each interaction, facing the resident when speaking and making eye contact, reducing any distractions- turn off the television (TV), radio, close door etc. The care plan documented the resident understood consistent, simple, directive sentences. Additional interventions included providing the resident with necessary cues- stop and return if agitated and cueing the resident.The IDT progress note dated 12/9/25 revealed Resident #4 was involved in a resident-to-resident altercation on 12/1/25 during the lunch meal. He grabbed his tablemate's dessert and his tablemate (Resident #3) then slammed his hands on the table and hit him in his chest and began calling him names. Resident #3 and Resident #4 were immediately separated. Resident #4 was assessed for injuries and none were noted. Resident #4 was offered an alternate seating arrangement away from Resident #3 moving forward to prevent further altercations.Social services will follow up.C. Resident #3 (assailant)1. Resident statusResident #3, greater than 65, was admitted on [DATE]. According to the January 2026 CPO, the diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 12/18/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of five out of 15. He required substantial assistance with all ADLs.2. Record Review The comprehensive care plan, revised on 8/20/24, revealed Resident #3 has impaired cognitive function related to dementia diagnosis. The care plan documented the resident presented with confusion and forgetfulness. The care plan documented the resident needed redirection and cueing. The care plan documented the resident lacked orientation resulting in delusional thought processes at times redirectable. Pertinent interventions, revised on 8/20/25 included, use Resident #3's preferred name, identifying yourself at each interaction, facing the resident when speaking and making eye contact, reducing any distractions (turn off TV, radio, close the door). The care plan documented the resident understood consistent, simple, directive sentences. Additional interventions included providing the resident with necessary cues stop and return if agitated.The comprehensive care plan, revised on 11/6/24, revealed Resident #3 had a suspected history of trauma related to chronic homeless lifestyle, per family, that may contribute to problematic behaviors such as possessiveness of space, lack of trust and reactive responses. Resident #4 appeared stable, content, and adjusted. Resident #4 does have impaired cognition resulting in delusional thought processes at times. Facility staff will observe for any triggers and anticipate Resident #3's needs as indicated. Pertinent interventions revised on 8/20/24 included assessing Resident #3's need for additional services and therapeutic support or specialists from the community,along with offering referrals periodically and as needed. III. Staff interviewsCNA #1 was interviewed on 1/28/26 at 9:15 a.m. CNA #1 said Resident #4 was non-compliant, and would grunt, make noises, or ball up his fists. CNA #1 said Resident #4 got agitated during care and had a history of smacking and punching staff. CNA #1 said these behaviors were documented and reported to the nurse on duty. CNA #1 said during mealtimes Resident #4 should be sat with specific residents who did not exhibit aggressive behaviors. CNA #2 was interviewed on 1/28/26 at 9:28 a.m. CNA #2 said Resident #3 had a history of sundowning by packing his belongings into his suitcase and trying to leave the facility. CNA #2 said Resident #3 had been aggressive towards staff when he did not want to get up in the morning or take a shower. CNA #2 said Resident #3 was territorial over his belongingsLicensed practical nurse (LPN) #2 was interviewed on 1/28/26 at 9:47 a.m. LPN #2 said Resident #3 did not like loud environments She said when Resident #3 was in the dining room, he would become aggressive if someone took his food LPN #2 said Resident #3 was known to shout at other residents he was upset with. She said Resident #3 had a history of making verbal threats of hurting other residents, however Resident #3 was wheelchair bound and unable to get to another resident if they were far away. LPN #2 said if Resident #3 was close enough to another resident, he would try to hit, grab, or swing. She said Resident #3 was aggressive toward staff in the morning when waking him up. LPN #2 said both Resident #3 and Resident #4 had dementia and did not recall the event. She said on 12/1/25, Resident #3 hit Resident #4 when he took his desert. LPN #2 said Resident #4 liked sweets and that is why he would reach for desserts of other residents. The NHA was interviewed on 1/28/26 at 12:13 p.m. The NHA said Resident #4's plan of care did not document Resident #4's history of reaching for other resident deserts in the dining room. She said Resident #4 should not have been seated next to Resident #3, especially since Resident #3 had a history of territorial behaviors.

Based on observations and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.Specifically, the facility failed to maintain residents' dignity and ensure call lights were answered timely.Findings include:I. Facility policy and procedureThe Call Lights: Accessibility and Timely Response policy and procedure, dated 4/11/25, was provided by the nursing home administrator (NHA) on 12/11/25 at 9:17 a.m. It read in pertinent part, All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.II. Resident interviewsResident #10 was interviewed on 12/10/25 at 11:25 a.m. Resident #10 said the staff sometimes took a while to respond to her call light. Resident #10 said the average response time when she activated her call light was about two hours, but sometimes the staff took up to three hours to get to her. Resident #13 was interviewed on 12/10/25 at 3:30 p.m. Resident #13 said the staff's response times to call lights ranged from five minutes to fifty minutes, and varied a lot. Resident #13 said he was worried about the residents who were in their rooms alone and what would happen to them if they needed help and staff took that long to respond. Resident #13 said the night shift staff were the slower shift when responding to call lights. Resident #5 was interviewed on 12/11/25 at 9:57 a.m. Resident #5 said the facility staff took a long time to answer his call lights, especially at night. Resident #5 said he felt like the staff on duty were too overtasked, and there were not enough certified nurse aides (CNA) to help everyone. Resident #5 said he had waited up to two hours for someone to answer his call light. Resident #5 said the resident council had brought up the issue of call lights the day prior (12/10/25) and the facility management said they were working on call light response times. Resident #5 said he used his call light to get out of bed or get out of his wheelchair.Resident #17 was interviewed on 12/11/25 at 12:03 p.m. Resident #17 said the staff took a long time to answer his call lights. Resident #17 said the facility staff took anywhere from thirty minutes to one hour to answer his call light, and took longer at night. Resident #17 said he experienced a fall one time and the staff took thirty minutes to come in and assist him back up. Resident #17 said he had filed a grievance about the issue six weeks prior, and a staff member had come to talk to him about the grievance yesterday (12/10/25) and told him they were getting more staff to help with the issue. Resident #17 said he used his call light to ask for help getting out of bed and to have his urinal emptied.Resident #16 was interviewed on 12/11/25 at 1:00 p.m. Resident #16 said he was frustrated with the length of time it took staff to answer his call lights. Resident #16 said the weekend prior (12/6/25) he had sat for almost two hours soaking in diarrhea in his bed, and again for an additional hour later the same day. Resident #16 said in the first instance, he activated his call light after he soiled himself, and a nurse checked on him 30 minutes later to see what he needed. Resident #16 said the nurse left to find a CNA to help Resident #16 change his brief, however no one showed up for another hour. Resident #16 said later that day he had another bout of diarrhea and activated his call light again. Resident #16 said after 30 minutes he called the front desk to ask for help. Resident #16 said a similar instance had happened the weekend before that (11/29/25) in which he sat in a urine-soaked brief for an hour and 55 minutes before someone came to help him. Resident #16 said he had called the front desk three different times to have someone come help him that day. Resident #16 said the skin on his scrotum was burned because he was left soaking in urine and diarrhea for extended periods. Resident #16 said when the nurse cleaned him up that day, his scrotum was blistered and he cried because it hurt so badly. Resident #16 said he was upset because his scrotum had previously been irritated but was just starting to heal when these incontinence episodes occurred. Resident #16 said he felt terrible, anxious and stressed out waiting for the staff to come help him change his brief.III. Frequent visitor interviewA frequent visitor to the facility was interviewed on 12/11/25 at 9:07 a.m. The frequent visitor said there had been concerns from residents about long call wait times since the end of October 2025. The frequent visitor said one resident had fallen and waited 45 minutes for someone to answer his call light and assist him back up. The frequent visitor said multiple residents had shared with her that they waited up to two hours for their call lights to be answered, and the facility had not responded to their grievance forms they had filled out.IV. Record reviewFacility grievances pertaining to call lights were provided by the NHA on 12/11/25 at 9:17 a.m. and revealed the following:A grievance from Resident #16, dated 12/10/25, revealed Resident #16 reported he experienced long call light wait times after incontinence episodes on 12/6/25 and 12/7/25. Resident #16's skin in his peri-area was observed on 12/10/25 with no open areas identified. The grievance documented the facility was unable to confirm the time frame of Resident #16's call light wait times. Interventions put in place included offering Resident #16 a room change, initiating a regular toileting schedule, giving the resident the director of nursing's (DON) personal cellphone number, and the DON frequently following up with the resident. The grievance was finalized and signed on 12/11/25.A grievance from a resident, dated 12/9/25, revealed the resident said they experienced long call light wait times during a call light audit. -The call light grievance was not signed and no interventions were listed.A grievance from Resident #9, undated, revealed that on 8/26/25 the resident put her call light on at 7:00 p.m. and a CNA did not respond to her call light until 9:10 p.m. The resident documented the CNA walked past her room several times during the period and did not acknowledge her call light. The grievance form documented the facility management spoke with the CNA who was on duty that day, and the CNA told them she had answered the call light timely and told the resident she needed to charge a battery for the mechanical lift. The CNA said she returned to Resident #9 and assisted her into bed at 9:00 p.m. that night. Interventions put into place included educating the CNA to keep the resident updated of situations as they arise. The grievance was finalized and signed on 8/29/25.A grievance from Resident #17, dated 11/4/25, revealed that a frequent visitor to the facility reported Resident #17 said his call lights were not answered timely. The grievance form documented the management team spoke with Resident #17, as the visitor had mentioned the resident wanted a room change, and the resident denied wanting a room change. Interventions included staff education on call light accessibility and timely response. The grievance was finalized and signed on 11/12/25.A call light education sign-in sheet, dated 11/12/25, was attached to Resident #17's grievance. The sign in sheet was signed by 12 staff members on 12/9/25, and three additional staff members on 12/11/25 (almost one month after the grievance was submitted by Resident #17).Call light audits, dated 10/1/25 through 12/9/25, were received from the NHA on 12/11/25 at 5:46 p.m. and revealed the following:The call light audit consisted of interviewing five residents to see if they felt their call lights were being answered timely, activating five call lights to see whether they were answered in five minutes, and determining whether the call lights were functioning properly and accessible to the resident. For resident interviews, residents indicated their call lights were not answered timely on 11 out of 48 possible opportunities.The audit documented call lights were not answered timely when activated on five of 48 possible opportunities.The audits were timestamped every weekday at times ranging from 10:00 a.m. to 4:40 p.m.-However, no audits during the 10/1/25 to 12/9/25 time period were conducted at night, in the early morning, or on a weekend date, which is when multiple residents indicated the longest call light wait times occurred.V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 12/11/25 at 2:27 p.m. LPN #1 said she felt like she had enough staff to help her complete her tasks each shift if everyone showed up, but the staff were strained if anyone called out. LPN #1 said her call light response times depended on whether or not the nursing staff were in other residents' rooms providing care when the light went on. LPN #1 said call light wait times ranged from 15 to 20 minutes if not longer. LPN #1 said she had heard complaints from residents about call light times, mostly from one specific resident who was concerned about long wait times on the weekends and at night.Registered nurse (RN) #1 was interviewed on 12/11/25 at 2:47 p.m. RN #1 said she heard a lot of complaints about call light times from the residents. RN #1 said she mostly heard about issues with call light times at night and on the weekends. RN #1 said it was difficult, as she felt like she had enough staff to help her with her tasks if everyone showed up, but there were often call-outs.The DON was interviewed on 12/11/25 at 4:05 p.m. The DON said the facility performed weekly call light audits and angel rounds, during which time the management team checked with a list of residents to ask about their care and call light response times. The DON said the maintenance staff did the call light audits. The DON said the facility had struggled with call light response times. The DON said the layout of the facility was funky, so if a CNA sat down at the nurse's station to chart, they could not see the hallway or any call lights which were activated. The DON said she had ordered tablets and stools for the CNAs so they could chart while sitting in the hallways. The DON said she had also just moved her office to a different location so she could offer more support to the staff. The DON said she had recently changed the CNA shift schedule so there were two CNAs for each hallway. She said now when one CNA had to help provide supervision for mealtimes or smoke breaks, there would be someone else on the hallway to watch the call lights. The DON said they had adjusted the nursing schedule so there were now seven CNAs working during the days and evenings. The DON said the facility had not been able to adjust the night shift schedule as there were not enough staff members who were able to work that shift. The DON said the new staffing changes were initiated 12/10/25 in response to Resident #17's grievance form. The DON said call lights were an ongoing issue prior to Resident #17's grievance. The DON said if a staff member called out, the staffing coordinator tried to back-fill the open shift with as-needed staff, offer bonuses, or otherwise rearrange the nursing staff's schedule so they could offer support when needed. The DON said the staffing coordinator also worked on the floor as needed. The DON said there were times when the facility was not successful in back-filling a shift after someone called out, but nothing consistent.The NHA and the DON were interviewed together on 12/11/25 at 5:12 p.m. The NHA said the facility staff did a daily call light audit and daily angel rounds. The NHA said angel rounds were done by all of the management team, and involved a list of residents the management team members saw daily and asked them about their care. The NHA said whether or not the residents' call lights were being answered timely was not on the list of questions the management team asked, but they would be adding it to the list.The NHA said she and the DON had put an action plan in place just prior to the survey being conducted on 12/10/25. The NHA said the plan included interventions such as moving the DON's office and purchasing tablets for the CNAs so they could watch for call lights while they charted. The NHA said the facility had also changed their schedule so the CNAs could work as partners on their respective hallways. The NHA said the DON would also begin doing daily call light audits and spot education as needed.The NHA said the facility had been conducting call light audits over the last year. The NHA said call light audits involved the staff member seeing how long it took for the nursing staff to answer the call light and seeing if the call light was within the resident's reach. The NHA said the maintenance staff conducted these call light audits on day shifts and weekend shifts. The NHA said the facility had not conducted any call light audits on the night shift. The DON said the facility would be adding a designated charge nurse on the night shifts who would do call light audits at night.The NHA said call light wait times had been noted as a concern prior to 12/10/25, and frequent visitors had brought the issue to their attention. The NHA said after the facility received Resident #17's grievance form, the staff decided to put a formal plan in place to address call light wait times.The DON said the facility had conducted education with the staff on addressing call lights during their all-staff meeting on 12/9/25.The NHA said the facility had also conducted education on the date listed on the education sign-in sheet (see record review above) and on 12/9/25, but she was not sure why the dates were listed together.VI. Additional documentationA call light performance improvement plan, dated 12/10/25, was received from the NHA on 12/15/25 at 9:16 a.m., after the survey exit. The root cause was identified as call lights not being responded to in a timely fashion. The community policy was for call lights to be responded to within seven minutes. The action plan included the following interventions:-The DON would begin call light education with all nursing staff, starting 12/12/25;-The DON would audit a minimum of five call lights per day for response time, and follow with spot-education if call lights were not responded to timely;-The DON would adjust staff assignments, completed 12/12/25;-The DON would move her office to a different hallway to ensure call lights were answered timely, completed 12/12/25;-The DON would order tablets for the CNAs to use for documentation so they could remain in their assigned hallways, completed 12/11/25; and,-The social services director or designee would interview two residents per week to inquire about call light response times and report their findings to the DON and NHA.

Based on interviews and review of the facility Dietary Manager job qualifications, the facility failed to have a Certified Dietary Manager and/or full time Dietitian oversight to perform the functions of the kitchen and nutrition services for all 83 residents receiving food from the kitchen. This failure increased the potential that the residents would not be provided the diets specific to their needs and basic kitchen sanitation would not be maintained. Findings include: During the initial tour of the kitchen on 09/16/24 at 9:40 AM, the Dietary Manager (DM) stated that he had started working as the dietary manager about a week ago. When asked if he was certified as a dietary manager, the DM stated that he was enrolled in an online Certified Dietary Manager (CDM) course and had finished about 40 hours out of a 120 - hour course. Further interview with the DM on 09/16/24 at 9:40 AM revealed that the facility's Registered Dietitian (RD) came to the facility twice a week for consultation with the DM. On 09/19/24, the facility Administrator provided the job descriptions signed by the DM and verification that the DM was not certified and did not have current ServSafe certification but was enrolled in a CDM course and a ServSafe Food Protection Manager Certification Exam. Review of the job descriptions provided by the Administrator revealed a job description for a cook position, signed by the DM and the Administrator on 09/01/24. Further review revealed a job description for a DM, signed by the DM and the Administrator on 09/07/24. During an interview on 09/19/24 at 2:05 PM, the Administrator stated that the DM was originally hired as a cook but then was hired as the DM a week later. The Administrator verified that the DM was not certified and that the RD did not work full time at the facility but came to the facility twice a week to oversee the kitchen and to perform nutritional assessments and develop plans of care for the residents. Review of the Job Description: Director of Food and Nutrition Services, signed by the DM and the Administrator on 09/07/24, revealed, . the primary purpose of the director of food and nutrition services is to plan, organize, develop, and direct the overall operation of the dietary department in collaboration with the facility's contracted Registered Dietitian . to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner . Further review of the Job Description: Director of Food and Nutrition Services, signed by the DM and the Administrator on 09/07/24, revealed, . 1. Must have one or more of the following certifications/qualifications: certified dietary manager, certified food service manager . 2. Must have and maintain an active food handler's permit/ServSafe certification . Supervise and assist in food preparation, following appropriate menus . ensure cooks and dietary sides have the necessary information and equipment to carry out their job functions including . cleaning schedules and checklists, temperature logs . Supervise staff to ensure the kitchen is clean and sanitary at all times . Cross Reference: F803D Menus Meet Resident Needs and F812 Food Procurement-Sanitation.

Based on observations, interviews, and policy review, the facility failed to maintain the kitchen in a sanitary condition and failed to maintain temperature and sanitizer logs for the dish machine. This failure increased the risk of contamination of food served to all 83 residents who received food from the kitchen. Findings include: Review of the policy, Dietary Sanitization, adopted 12/19/16, revealed, The food service area shall be maintained in a clean and sanitary manner . All utensils, counters, shelves and equipment shall be kept clean . All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils . Dishwashing machines must be operated in accordance with manufacturer's instructions . Low-Temperature Dishwasher (Chemical Sanitization) wash temperature 120 degrees. Final rinse with 50 parts per million (ppm) with hypochlorite (chlorine) for at least 10 seconds . Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent an accumulation of grime. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. During the initial kitchen tour on 09/16/24 at 9:40 AM, the following observations were made with the Dietary Manager (DM): Two plastic three-shelf carts holding clean dishes had food debris, dust, and water splatter marks on all three shelves, the wheels, and the handles of the cart. A plastic three-shelf cart used for condiments such as sugar, salt, and pepper packets had dust and splatter marks on the shelves, the wheels, and the handles of the cart. The bottom shelves of the two prep tables were observed with dust and splatter marks on the shelves and on the items stored on the shelves, including a meat slicer. Clean oven trays were observed stored on the bottom shelf of one of the prep tables. The meat slicer was uncovered and had dust, dried food debris, and a cookie wrapper on it. The reach-in refrigerator had juice spilled on the bottom shelf. The reach-in freezer had unidentifiable spills on the bottom shelf. The outside of the doors of the reach-in refrigerator and freezer were streaked with spilled food debris and fingerprints. The kitchen floor was dirty with food debris. The DM was observed running the dish machine. When asked where the temperature gauge was located, the DM showed this surveyor that the gauge was under the machine and turned so that the face of the gauge could not be read. The DM stated that the temperatures of the wash and final rinse were to be above 120 degrees and were taken with a thermometer. The DM demonstrated taking the temperatures of the water during the wash and the rinse. The wash temperature was 118 degrees and the final rinse was 123 degrees. The DM stated that the dish machine was a low temp machine. When asked how the level of the sanitizer was measured, the DM stated with test strips. When asked what the sanitizer measured at, the DM stated, Haven't done that yet today, although the dish machine was being used for the breakfast dishes. The DM was asked where the temperature and sanitizer logs were maintained. The DM responded that the logs were taped to the outside of the reach-in refrigerator door. Observation with the DM revealed there were no temperature or sanitizer logs for the dish machine. A return tour of the kitchen on 09/16/24 at 2:55 PM revealed the same observations as above. Review of the ECOLAB ES-400 Dish machine manufacturer's information, provided by the Administrator, revealed a minimum wash and rinse temperatures of 120 degrees. Further review of the ECOLAB ES-400 Dish machine manufacturer's information revealed that the chlorine sanitizer was to be between 50 and 100 ppm. During an interview on 09/19/24 at 10:34 AM, the Administrator verified that temperature/sanitizer logs were not being maintained since initiating new temperature log forms on 09/01/24. The Administrator stated that the temperature/sanitizer logs were to be maintained with each wash at least three times a day. During a follow up tour of the kitchen on 09/19/24 at 11:30 AM, the sanitation concerns seen on 09/16/24 had been corrected. During an interview on 09/19/24 at 11:42 AM, the DM verified that temperature and sanitizer logs for the dish machine had not been initiated until with the dinner meal on 09/16/24. During continued interview on 09/19/24 at 11:47 AM, the DM stated that cleaning the kitchen was on my list of things to do but I spent my first week [as DM] meeting with the residents. The DM did verify that the sanitation observations on 09/16/24 were not due to the kitchen not being cleaned for one week and that the kitchen staff should be able to identify and correct to maintain a sanitary kitchen.

Based on record review, interview, and facility policy review, the facility failed to 1.) develop care plans with measurable goals for seven of 23 sampled residents (Resident (R) 8, 9, 14, 37, 57, 69, 286) and 2.) failed to develop care plans to address vision and hearing and/or dental status for two of 23 sampled residents (R286 and R9). This had the potential for the residents to have unmet care needs. Findings include: Review of the facility's Care Plans, Comprehensive and Revisions policy, adopted 12/19/16 revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: Include measurable objectives and timeframes . 1. Review of R8's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anxiety, sleep apnea, abnormalities of gait and mobility, hypothyroidism, and type two diabetes. Review of R8's Care Plans, located under the Care Plan tab of the EMR, indicated a Care Plan developed to address R8's hypothyroidism contained a goal of I will be free of s/s [signs and symptoms] of hypothyroidism through the review date. A Care Plan developed to address her risk for falls contained a goal of My risks and injury potential will be minimized through the next review date. A Care Plan developed to address R8's use of oxygen due to poor gas exchange and sleep apnea contained a goal of I will have no s/sx [signs or symptoms] of poor oxygen absorption through the review date. 2. Review of R9's Admission Record, located in the Profile tab of the EMR, revealed R9 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, history of falling, and personal history of TBI (traumatic brain injury). Review of R9's Care Plans, located under the Care Plan tab of the EMR, revealed a care plan developed to address R9's risk for falls related to his TBI contained a goal of My risks and injury potential will be minimized through the next review date. A Care Plan developed to address R9's cognitive deficit related to the TBI contained a goal of R9 will be able to communicate basic needs daily through the review date. There was no Care Plan developed to address R9's dental status. 3. Review of R14's Admission Record, located in the Profile tab of the EMR, revealed R14 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, bipolar disease, insomnia, and age-related osteoporosis. Review of R14's Care Plans, located under the Care Plan tab of the EMR, indicated a Care Plan developed to address R14's use of anti-depressant medications related to her insomnia contained a goal of R14's risk for discomfort or adverse reactions related to anti-depressant therapy will be minimized through the review date. A Care Plan developed to address R14's fall risk contained a goal of The resident's risk for injury will be minimized through the review date. A Care Plan developed to address R14's use of anti-psychotic medication for her bipolar disease contained a goal of R14 will reduce the use of psychotropic medication through the review date. 4. Review of R37's Admission Record, located in the EMR under the Profile tab, revealed R37 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, obstructive sleep apnea, type two diabetes, hypertension, right above the knee amputation, and idiopathic neuropathy. Review of R37's Care Plans, located under the Care Plan tab of the EMR, indicated a Care Plan developed to address R37's use of the medication Oxycodone (opioid pain medication) contained a goal of I will be free of any discomfort or adverse side effects from pain medication through the next review. A Care Plan developed to address R37's hypertension contained a goal of I will remain free of signs and symptoms of hypertension through the review date. 5. Review of R57's Admission Record, located in the EMR under the Profile tab, revealed R57 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), history of falling, and dependence on supplemental oxygen. Review of R57's Care Plans, located under the Care Plan tab of the EMR, indicated a Care Plan developed to address R57's high fall risk contained a goal of My risks and injury potential will be minimized through the next review date. A Care Plan developed to address R57's altered cardiovascular status contained a goal of I will be free from complications of cardiac problems through the review date. A Care Plan developed to address R57's use of pain medication contained a goal of I will be free of any discomfort or adverse side effects from pain medication through the review date. 6. Review of R69's Admission Record, located in the EMR under the Profile tab, revealed R69 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, cerebral infarction, and hereditary neuropathy. Review of R69's Care Plans, located under the Care Plan tab of the EMR, indicated a Care Plan developed to address R69's pain related to neuropathy, immobility, and osteoarthritis contained a goal of The resident's risk for side effects of analgesia will be minimized through the review date. A Care Plan developed to address R69's risk for feelings of hopelessness and passive suicidal ideation due to loss of independence, potential placement, and brain injury contained a goal of R69 will display decreased episodes of emotional crisis through the review period. 7. Review of R286's Admission Record, located in the EMR under the Profile tab, revealed R286 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease and acquired absence of right leg below the knee. Review of R286's Care Plans, located under the Care Plan tab of the EMR, indicated a Care Plan developed to address R286's risk for falls due to the right below the knee amputation contained a goal of no falls or injuries by next 90-day review. A Care Plan developed to address R286's need for Skilled Nursing Care related to a recent hospital stay for toxic encephalopathy contained a goal of R286 will return to prior function level after rehab by the review date. There was no care plan developed to address R286's hearing and vision deficit. During an interview with Registered Nurse (RN) 2 on 09/18/24 at 9:15 AM, RN2 stated the expectation was that Care Plan goals would be measurable.

Based on interview, review of the facility's Controlled Drugs Count Record/Date sheets, and policy review, the facility failed to ensure a narcotic count was consistently completed at each shift change on four of four medication carts. Failure to properly account for the narcotics had the potential to result in missing narcotic medication. Findings include: Review of the facility policy titled, Controlled Substances, adopted 12/19/16, indicated, . The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances . Nursing staff must count controlled medications at the end of each shift, The nurse coming on duty and the nurse going off duty must make the count together . Review of the Controlled Drugs Count Record/Date for four of the four medication carts used by the facility revealed the following: 1.The Controlled Drugs Count Record/Date for the Weeping [NAME] unit medication cart was missing a nurse's signature as follows: 09/18/24: oncoming for 6:00 AM to 6:00 PM During an interview on 09/18/24 at 9:11 AM, Registered Nurse (RN) 2 stated she was busy and forgot to sign the record. RN2 confirmed the Controlled Drugs Count Record/Date was supposed to be signed by both the oncoming and off going nurses at each shift change. 2. The Controlled Drug Count Record/Date for the Spring Canyon unit medication cart was missing nurse signatures as follows: 09/01/24: oncoming at 6:00 AM to 6:00 PM 09/01/24: off going at 6:00 AM to 6:00 PM 09/02/24: oncoming at 6:00 PM to 6:00 AM 09/02/24: off going at 6:00 PM to 6:00 AM 09/14/24: oncoming at 6:00 PM to 6:00 AM 09/14/24: off going at 6:00 PM to 6:00 AM 09/18/24: off going at 6:00 AM to 6:00 PM 09/18/24: oncoming at 6:00 AM to 6:00 PM During an interview on 09/18/24 at 9:58 AM, RN3 stated she forgot to sign the record on 09/18/24. RN3 confirmed the Controlled Drugs Count Record/Date was supposed to be signed by both the oncoming and off going nurses at each shift change. 3. The Controlled Drug Count Record/Date for the Columbine unit medication cart was missing nurse signatures as follows: 09/02/24: oncoming at 6:00 AM to 6:00 PM 09/02/24: off going at 6:00 AM to 6:00 PM 09/02/24: oncoming at 6:00 PM to 6:00 AM 09/02/24: off going at 6:00 PM to 6:00 AM 09/10/24: oncoming at 6:00 AM to 6:00 PM 09/10/24: off going at 6:00 AM to 6:00 PM 09/14/24: oncoming at 6:00 PM to 6:00 AM 09/14/24: off going at 6:00 PM to 6:00 AM 09/18/24: oncoming at 6:00 AM to 6:00 PM 09/18/24: off going at 6:00 AM to 6:00 PM During an interview on 09/18/24 at 10:15 AM, Licensed Practical Nurse (LPN) 1 stated she must have forgotten to sign it the morning of 09/18/24. 4. The Controlled Drug Count Record/Date for the Evergreen unit medication cart was missing signatures as follows: 09/01/24: off going at 6:00 AM to 6:00 PM 09/09/24: oncoming at 6:00 AM to 6:00 PM 09/09/24: off going at 6:00 AM to 6:00 PM During an interview on 09/18/24 at 11:50 AM, LPN2 said she always signed the Controlled Drug Count Record/Date when she came on duty and confirmed it was supposed to be signed by the two nurses performing the count for narcotics at every change of shift to indicate count was done and was correct.

Based on observation and interview, the facility failed to serve the preplanned portion sizes during the lunch service on 13 of 13 trays observed out of a total of 83 trays plated for lunch. This failure increased the potential of residents not receiving the preplanned nutritional diet. Findings include: During observation of the lunch tray line on 09/19/24 from 11:30 to 11:40 AM with the Dietary Manager (DM), the portion of carrots plated on the first 12 trays appeared to be large, taking up half of the plate. After the 12th tray, this surveyor asked the DM what the portion size for the carrots was per the menu. Without looking at the menu, the DM stated that the carrots were to be a 3-ounce serving. The DM was asked if the scoop being used by the cook was the correct size. The DM looked at the scoop and verified that the scoop was a 4-ounce scoop and not a 3-ounce scoop. The DM then removed the 4-ounce scoop and replaced it with a 3-ounce scoop. Continued observation of the lunch tray line revealed that the mechanical chopped meat was being served with the wrong scoop size. The DM verified that the meat was to be a 4-ounce scoop but the cook was using a 3-ounce scoop. This was observed on one tray before the DM changed the scoop size. During this observation, the DM verified that the cook placed the scoops prior to the food service began and he (the DM) did not identify that the carrots and mechanical chopped meat had the incorrect scoops. Review of the Week at a Glance-Week 2 menu, provided by the Administrator on 09/19/24, revealed that the meat and the vegetable portion size was four ounces.

Based on record review, interviews, and policy review, the facility failed to provide a written notice of transfer/discharge for two of two residents/representatives (Resident (R) 21 and R17) reviewed for hospitalization out of a total sample of 23 residents. This failure had the potential to cause uncertainty regarding the reason for transfer/discharge, the effective date of the transfer/discharge, and information on how to appeal the discharge. Findings include: Review of the policy Discharging/Transferring the Resident, revised 12/01/19, revealed, . For facility initiated discharges, once discharge or transfer is determined to be indicated or appropriate, the resident advocate or designee will provide the resident with a Notice of Discharge/Transfer that explains the reason for discharge, the effective date of the discharge, and information regarding how to appeal the discharge if desired . In emergency situations staff shall document the reasonable efforts that have been made to consult the resident or resident representative about the discharge . If the resident is being discharged to a hospital, ensure that a discharge/transfer form . are reviewed with the resident and/or resident representative prior to discharge to the extent reasonable and practical . 1. Review of R21's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/24. Further review of this MDS revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating R21 had severe cognitive impairment. Review of the EMR Assessments tab revealed a Transfer Form indicating R21 was discharged to the hospital on 09/08/24 with a mental status change, poor intake, and emesis (vomiting). Further review of the Transfer Form revealed that R21's emergency contact was notified via telephone on 09/08/24 of the discharge to the hospital. Further review of the EMR revealed no documentation that written transfer/discharge information was provided to R21's emergency contact. 2. Review of R17's EMR revealed a significant change MDS with an ARD of 09/05/24. Further review of this MDS revealed a BIMS score of 13 out of 15, indicating R17 was cognitively intact; however, R17 did have an emergency contact listed in the EMR. Review of the EMR Assessments tab revealed a Transfer Form indicating R17 was discharged to the hospital on 09/16/24 for osteomyelitis (infection in the bone) and possible amputation of the second toe on the right foot. Further review of the Transfer Form revealed that R17's emergency contact was notified via telephone on 09/16/24 of the discharge to the hospital. Further review of the EMR revealed no documentation that written transfer/discharge information was provided to R17's emergency contact.

Based on record review, interviews, and policy review, the facility failed to provide a written notice of the bed hold policy for two of two residents/representatives (Resident (R) 21 and R17) reviewed for hospitalization out of a total sample of 23 residents. This failure had the potential to cause uncertainty regarding returning to their own room at the facility after hospitalization . Findings include: Review of the policy Holding Bed Space, adopted 12/2017, revealed, Our facility shall inform residents upon admission and prior to a transfer for hospitalization . of our bed-hold policy . when a resident is transferred for hospitalization . a representative of the business office or designee will provide written information concerning the facility's bed hold policy . 1. Review of R21's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/24. Further review of this MDS revealed a Brief Interview of Mental Status (BIMS) score of 99, indicating R21 had severe cognitive impairment. Review of the EMR Assessments tab revealed a Transfer Form indicating R21 was discharged to the hospital on 09/08/24 with a mental status change, poor intake, and emesis (vomiting). Further review of the EMR revealed no written notification that the bed hold policy had been sent to the emergency contact. 2. Review of R17's EMR revealed a significant change MDS with an ARD of 09/05/24. Further review of this MDS revealed a BIMS score of 13 out of 15, indicating R17 was cognitively intact however R17 did have an emergency contact listed in the EMR. Review of the EMR Assessments tab revealed a Transfer Form indicating R17 was discharged to the hospital on 09/16/24 for osteomyelitis (infection in the bone) and possible amputation of the second toe on the right foot. Further review of the EMR revealed no written notification of the bed hold policy had been sent to the emergency contact. Review of a Bed Hold Authorization form, dated 09/16/24 and provided by the facility, revealed that the emergency contact agreed via telephone to authorize this facility to reserve a bed at the Bed Hold Rated listed above until I return to this facility . The bed hold rate was marked N/A on the form. The form was signed by Registered Nurse (RN) 1 who had placed the call to the emergency contact. During an interview on 09/18/24 at 11:15 AM, RN1 stated that when a resident was discharged to the hospital, she notified the responsible party of the bed hold policy over the phone and not in writing.

Based on interviews, record review, and policy review, the facility failed to provide activities other than television for one of three residents (Resident (R) 59) reviewed for Transmission Based Precautions (TBP) out of a total sample of 23 residents. This failure had the potential to cause feelings of boredom and further isolation from others. Findings include: Review of the policy, Activity Programs, version 12/19/16, revealed . The Activities Program is ongoing and includes . facility sponsored individual activities (including one-on-one activities) and independent individual activities . Activities are offered 7 (seven) days a week . our activity programs consist of individual . activities that are designed to meet the needs and interests of each resident . Activities are documented in the resident's medical record . Review of R59's electronic medical record (EMR) revealed an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/24 that documented R59 was initially admitted to the facility on [DATE]. Further review of the EMR revealed a significant change MDS with an ARD of 06/17/24 that documented a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R59 had moderate cognitive impairment. Review of the EMR Care Plan tab revealed an Activities care plan, initiated on 03/22/23, that indicated R59 did not like to participate in group activities but did like to listen to a variety of music, reading, keeping up with the news, watching television, socializing with family and friends . I prefer to complete activities independently at my leisure and am provided with supplies during activity carts . offering her supplies to complete activities independently at her leisure . Review of the EMR Assessment tab revealed an Activities-Initial Review (Admission) form, dated 07/03/24, that indicated R59's activity preferences to be . listening to a variety of music . reading and listening to audiobooks . wish 1:1 [visits] with staff . Review of the EMR Orders tab revealed a physician's order, dated 09/12/24, stating, Resident requires contact and droplet precautions with isolation for 10-20 days due to positive COVID-19 status. May discontinue isolation and transmission-based precautions when resident has met CDC criteria. Review of the EMR Care Plan tab revealed an At risk for complications r/t [related to] COVID-19 infection care plan, initiated on 09/12/24, for Resident will be educated and encouraged to stay in their room for the duration of the isolation . Resident will be isolated for a period of at least 10 days or longer until symptoms are improved and they have had no fever for at least 24 hours without use of antipyretic medication . During a continuous observation on 09/16/24 from 9:30 AM through 12:45 PM, no staff were observed entering R59's room other than to serve and set up the lunch tray. During a continuous observation on 09/17/24 from 8:30 AM through 11:10 AM, no staff were observed entering R59's room other than Certified Nurse Aide (CNA) 5 who went in to answer the call light. CNA5 exited R59's room within five minutes stating R59 wanted help repositioning in bed. During an interview on 09/17/24 at 11:22 AM, R59, who was in contact and droplet isolation for COVID, was asked what activities she did all day since she was not able to leave her room while on isolation. R59 said she watched TV most of the day and talked on the phone occasionally and stated that staff did not come into her room for activities. R59 asked if there was still a library in the facility because she loved to read books and magazines but did not have any to read. This surveyor replied that the Activities Department would be asked about bringing books and magazines to her. R59 smiled and thanked this surveyor. Review of the Documentation Survey Report, dated September 2024 and provided by the facility, revealed no 1:1 activities were provided on 09/16/24 or 09/17/24 and one was provided on 09/18/24 after discussion with the facility staff about the lack of activities provided to R59 while in isolation. During an interview on 09/18/24 at 9:30 AM, the Activity Director (AD) was asked how activities were provided to the residents on contact/droplet isolation for COVID. The AD replied that activity carts and supplies are provided biweekly and the CNAs are asked to leave the TV and/or radio on for stimulation. During an interview on 09/18/24 at 2:59 PM, the Activity Staff (AS) was asked to review the Documentation Survey Report, dated September 2024 for the blanks showing no 1:1 activities for R59 were provided on 09/16/24 or 09/17/24. The AS verified that no 1:1 activities had been provided to R59 on those dates. The AS stated that when a resident is on isolation I suit up [put on PPE] and provide the activity cart to see if they want anything. The AS stated, I don't remember if I did that this week [for R59]. During an interview on 09/19/24 at 10:46 AM, the Director of Nursing (DON) stated that 1:1 visits should continue [for those residents in isolation].

Based on record review, observations, and interviews, the facility failed to provide supervision, assistance, services, and implement effective person centered interventions to prevent falls with injuries for one (#26) of four residents reviewed for accidents/hazards out of 29 sample residents. Resident #26 had a history of falls upon admission on 12/1/21, was cognitively intact, used a cane and needed limited assistance with transfer, supervision with ambulation within the room and was independent with ambulation outside of the room. Between 4/16/22 and 4/26/23, Resident #26 experienced fifteen falls: fourteen unwitnessed and one witnessed. The facility failed to consistently implement fall interventions after each fall and when fall interventions were implemented they were often ineffective due to the resident's declining cognition. The facility failed to assess Resident #26's significant change in cognition as part of the root cause analysis for implementation of person centered fall interventions according to the 7/29/22 Neuropsychological report. The facility failed to conduct consistent interdisciplinary team (IDT) review of Resident #26's falls. Due to the facility's failures to implement effective fall prevention measures, the resident fell on [DATE], the resident sustained a subdural hematoma (brain bleed). After the subdural hematoma, the resident's cognition score was alert and oriented to self only and the resident became non-verbal. The resident required extensive assistance from staff for all activities of daily living and was no longer able to walk. Findings include: I. Facility policy and procedure The Fall Management policy, undated, was provided by the nursing home administrator (NHA) on 5/8/23 at 4:07 p.m. It read in pertinent part, Upon admission, the nurse will complete a fall risk assessment to determine the resident's level of fall risk. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. If the resident is determined to be at high risk, then the resident is referred to rehabilitation services as applicable. The resident and the resident's representative are provided education on fall risk and interventions in place to reduce the potential for falls. After a fall event- The IDT reviews all resident falls within 24-72 hours to evaluate circumstances and probable cause for the fall. The Care Plan will be reviewed and/or revised as indicated. Fall trending and analysis information is reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Residents who have experienced actual falls will be reviewed each week during the At-Risk Review Meeting.The At-Risk Review committee members will review residents with falls for documentation, compliance, and interventions on a weekly basis. The DON or designee will ensure communication to staff members regarding changes to interventions related to fall risk is completed. II. Resident #26 A. Resident status Resident #26, age 73, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included stroke, traumatic subdural hemorrhage, repeated falls and vascular dementia. The 5/6/23 minimum data set (MDS) assessment was incomplete at the time of survey. A brief interview of mental status (BIMS) assessment dated [DATE] revealed the resident had significant cognitive impairments with a BIMS score of zero out of 15. No behaviors were indicated. The 3/6/23 MDS assessment revealed the resident had significant cognitive impairments with a BIMS score of four out of 15. The resident required extensive assistance with bed mobility, transfers, toileting, dressing, walking, and personal hygiene. The fall section was incomplete. B. Observations Resident #26 was observed on 5/3/23 at 9:30 a.m. in his bed in room. There was a transfer pole next to his bed, skid strips on the floor and the bed was in a low position. There was no fall mat and the resident was not wearing non-skid socks. There were no one-on-one staff present for supervision. The resident was unresponsive to questions and was unable to track movement in front of him with his eyes. The resident had stitches on face next to right eye. Resident #26 was observed on 5/3/23 at 3:10 p.m. in his bed.There were no one-on-one staff present. The resident was unresponsive to questions and was unable to track movement in front of him with his eyes. Resident #26 was observed on 5/4/23 at 2:00 p.m. in his bed in room. The resident was sleeping. There were no one-on-one staff present. C. Record review The fall care plan, revised on 4/28/23, revealed the resident had actual falls related to poor balance, unsteady gait, and unaware of safety. Interventions were to provide physical and occupational therapy, encourage the resident to ask for assistance, determine causative factors for falls, increase supervision (added after survey began), low bed (added after survey began), offer assistance to toilet, commonly used articles within reach, ensure call light is within reach, anticipate needs, follow facility fall protocol, review information on past falls and attempt to determine cause of falls, transfer pole in place for safe transfer, non-skid strips next to bed, range of motion and reposition/ambulate as tolerated at least every two hours. The May 2023 CPO revealed the following physician orders as follows: -Three orders for speech therapy (ST) to evaluate and treat the resident from 6/9/22 to 5/3/23; -Five orders for physical therapy (PT) to evaluate and treat the resident from 6/9/22 to 5/3/23; -Four orders for occupational therapy (OT) to evaluate and treat the resident from 7/20/22 to 5/3/23; -Patient will benefit from a transfer pole next to his bed to improve ease of transfers and reduce fall risk. He is able to demonstrate safe utilization ordered 11/18/22 and discontinued on 2/1/23; and, -Neuropsychology evaluation ordered 7/29/22. According to post fall reviews, nursing progress notes with At-Risk Review committee meeting notes dated 4/16/22 to 4/26/23, the resident had fifteen falls in 12 months. -According to the IDT post fall review on 4/16/22 at 7:00 p.m. the resident had an unwitnessed fall in his room after slipping when coming out of his bathroom. The resident was wearing non-skid socks. The staff were waiting for a new medication started for urinary frequency to become therapeutic. The resident was reminded to use his call light when needing to get up and was continuing to see OT/PT. According to the At-Risk Review committee notes dated 4/20/22, current interventions in place were bed by door, non-skid socks, transfer pole, raised toilet seat, and new medication for urinary frequency. There were pending orders for PT. -According to IDT post fall review on 5/7/22 at 1:12 a.m. the resident had an unwitnessed fall in his room after slipping out of his bed onto the floor. The fall resulted in abrasion to his right thigh and bruise to his right knee. Staff to continue to educate the resident on use of call light and his walker. The resident was to continue to see OT/PT. According to the At-Risk Review committee notes dated 5/11/22, no changes to current interventions from 4/20/22 and no new interventions. -According to IDT post fall review on 6/6/22 at 7:50 p.m. the resident had an unwitnessed fall in his room after slipping out of his bed onto the floor. There were no new interventions after the fall. According to the At-Risk Review committee notes dated 6/8/22, no changes to current interventions from 4/20/22 and no new interventions. -According to IDT post fall review on 6/18/22 at 7:50 p.m. the resident had an witnessed fall in his room after standing, pulling on his room curtain and losing his balance. The resident had just discontinued PT and was on a restorative therapy program (maintenance program of current functioning). The resident was also on frequent observations, but the review did not clarify how frequent. According to the At-Risk Review committee notes dated 6/22/22, no changes to current intervention of restorative therapy. Neuropsychological evaluation for cognitive function scheduled for 8/10/22. -According to IDT post fall review on 7/6/22 at 7:00 p.m. the resident had an unwitnessed fall in his room after attempting to ambulate. The resident was wearing non-slid socks. There were no new interventions. There was no At-Risk Review committee meeting following fall. -According to IDT post fall review on 7/9/22 at 7:45 a.m. the resident had an unwitnessed fall in his room after attempting to ambulate. The resident was wearing non-slid socks. New interventions were to toilet the resident every two hours and educate the staff to provide more frequent visual checks by checking in his room when they walk by. According to the At-Risk Review committee notes dated 7/13/22, no changes to current intervention of restorative therapy. New intervention of increased observations, but it did not clarify frequency. -According to the At-Risk Review committee notes dated 7/20/22 the resident was to have one-on-one supervision when out of bed. The notes did not clarify if he would have a one-on-one while in his room or when out of his room or what times of day. -According to IDT post fall review on 7/21/22 at 9:25 a.m. the resident had an unwitnessed fall in a common area and was found on the floor. The fall resulted in a skin tear below his right knee. The resident smelt like he had a bowel movement. Staff were to anticipate needs and toilet the resident after lunch despite fall happening after breakfast. There was no At-Risk Review committee meeting following fall. -A nursing note dated 7/24/22 revealed the resident was found on the floor at 7:30 p.m. There was no IDT post fall review completed and no further details. -According to IDT post fall review on 7/25/22 at 1:25 a.m. the resident had an unwitnessed fall in his room attempting to transfer himself. The review documented the resident was currently working with PT/OT. There were no new interventions after the fall. According to the At-Risk Review committee notes dated 7/27/22, no changes to current intervention of restorative therapy and one-on-one supervision when up out of bed, however the resident had an unwitnessed fall 7/21/22 while on one-on-one supervision. -According to IDT post fall review on 9/5/22 at 3:30 a.m. the resident had an unwitnessed fall in a common area room when he was reaching for a snack off of a tray table. The staff were to continue to anticipate the resident's needs and check on the resident frequently. The fall review did not indicate the resident was still on one-on-one supervision. An OT evaluation was to be ordered. According to the At-Risk Review committee notes dated 9/7/22, OT to evaluate the resident, continue with restorative therapy. No other interventions were listed. -According to IDT post fall review on 10/22/22 at 11:15 a.m. the resident had an unwitnessed fall in his room. The fall resulted in two abrasions to his upper and lower back. The resident was attempting to get into his wheelchair. No new interventions. According to the At-Risk Review committee notes dated 10/26/22, the resident had abrasions to his back. No current or new interventions were listed. -According to IDT post fall review on 11/3/22 at 8:50 a.m. the resident had an unwitnessed fall in his room. He was found by a therapist walking past his room. It was determined the fall was due to a recent room move. No current or new interventions were listed. There was no At-Risk Review committee meeting following fall. -According to IDT post fall review on 11/22/22 with no time indicated, the resident had an unwitnessed fall in his room after trying to ambulate. The review documented the resident was currently working with PT, with no new interventions. According to the At-Risk Review committee notes dated 11/23/22 the resident had slid out of his bed and was to be referred to therapy. There was no reference to the resident currently being on therapy already. No new order for therapy was in the resident's chart. -According to IDT post fall review on 2/24/23 at 5:10 p.m. the resident had an unwitnessed fall in his room after trying to get out of bed. The review documented the resident was on restorative therapy and PT. No other current interventions listed and no new interventions. There was no At-Risk Review committee meeting following fall until 3/15/23. -According to IDT post fall review on 4/26/23 at 7:47 p.m. The resident had an unwitnessed fall in his room and was found on the floor bleeding from the right eye area. The resident was sent to the hospital. It documented to re-evaluate the necessity for the transfer pole, access room for openness and furniture placement. Orders were PT/OT/ST upon his return from hospital. There was no At-Risk Review committee meeting following fall. The hospital discharge summary post fall dated 4/26/23 document resident suffered from three to four millimeter (mm) subdural hematoma. A Neuropsychological (a form of psychology focussed on how injuries or illnesses of the brain affect cognitive and behavioral functions) report dated 7/29/22 was scanned into the resident's chart on 8/26/22. It read in pertinent part, Performance on a measure of problem solving for daily health and safety behaviors was suggestive of substantial functional difficulties. Current cognitive and functional difficulties will likely persist and progress. Given his nurse's report of a relatively abrupt change in cognitive status following a fall approximately six weeks ago, an MRI (non-invasive imagining technology) may be beneficial to rule out other potential contributors. The facility nurse noted difficulties in decision making, sustained attention, spatial judgment, organization, multitasking, and impulsivity. Test results show impaired visuospatial abilities (visual-spatial processing is the ability to tell where objects are in space. That includes your own body parts. It also involves being able to tell how far objects are from you and from each other), impaired attention, impaired executive functioning (executive function refers to a set of skills. These skills underlie the capacity to plan ahead and meet goals, display self-control, follow multiple-step directions even when interrupted, and stay focused despite distractions, among others), and memory and recognition performances below expectation. His response to questions pertaining to home safety were in the low range suggestive of substantial difficulty with judgment regarding issues and situations to be encountered in daily life. -No physician notes or progress notes were located in the resident's medical record indicating the neuropsychological report was reviewed and his results included in fall prevention planning. -There was no record of follow-up regarding an MRI as recommended by the report. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/3/23 at 3:15 p.m. She said she was the resident's CNA but stated she did not know what the resident's fall interventions were or were to find them in the resident's chart. She stated she checked in on him every time she walked past his room but did not say how frequently that was and there was no room rounding sheet. CNA #1 said the resident tried to get out of bed twice the previous day. CNA #5 was interviewed on 5/3/23 at 3:25 p.m. She said the resident had changed in his vision since he returned from the hospital on 5/2/23 and continued to try to get out of the bed by himself. She stated the resident needed a sitter but did not currently have one. She said there was no room rounding sheet to document how many times the staff were to check on the resident. Restorative nursing assistant (RNA) was interviewed on 5/3/23 at 3:31 p.m. She said she had worked with the resident on and off on hand eye coordination and independent motor skills. She said she had worked with him since December 2022 and he had not had any falls until now. She did not know what the resident's fall interventions were. Registered nurse (RN) #4 was interviewed on 5/3/23 at 3:38 p.m. He said the staff checked on the resident every time they walked past his door. He said there was no specific timeframe and there was no room rounding sheet. The resident was to have his bed in the lowest position but he did not know any other fall interventions for the resident. He said when IDT put new interventions into place, the nurse managers would verbally tell the floor staff. The RN had been out for a week and a half and since returning and no one in IDT had told him about new fall interventions for the resident. The NHA was interviewed on 5/4/23 at 4:10 p.m. She was unaware that Resident #26 was still attempting to get out of his bed since returning from the hospital. She said that she would work on a plan to keep him safe right away. CNA #1 was interviewed on 5/7/23 at 3:38 p.m. CNA #1 stated the fall interventions in place for the resident were non-slip strips, transfer pole, low bed, call light within reach, grip socks, every 15 minute checks if on neurological checks and right now he had a one-on-one sitter for supervision. If new interventions were put into place, the nurses told the CNAs in the change of shift report. RN #1 was interviewed on 5/7/23 at 3:43 p.m. RN #1 stated the resident had a one-on-one sitter since 5/4/23 because he kept trying to get up and ambulate independently. When a resident fell , the RN did an assessment for injuries and did risk management report. The nurse immediately put interventions in place. The IDT met following the fall and discussed what further interventions should be put into place. If new interventions were put into place, the nurse managers informed the nursing staff and had training if needed. The resident had not had a fall since being readmitted [DATE]. CNA #3 was interviewed on 5/7/23 at 3:48 p.m. CNA #3 stated the resident had fall strips, a transfer pole, low bed, and one-on-one sitter. She said the nursing staff was told by management which fall interventions were in place. Resident aide (RA) #1 was interviewed on 5/8/23 at 1:20 p.m. She said she has been providing one-on-one supervision to the resident since he returned from the hospital 5/2/23. She stated the resident had improved since he had returned. She attempted to speak to the resident but his gaze remained fixed, his eyes did not track and he was unresponsive to her. She stated she was mistaken, she actually just started providing him one-on-one supervision 5/4/23. The director of nursing (DON) was interviewed on 5/8/23 at 1:57 p.m. After a resident had a fall, the IDT will complete an IDT post fall review and include new interventions. The MDS coordinator used to update the care plans after a resident fell but it was now her responsibility. She communicated new fall interventions to the floor staff with on the spot education or went to the staff and told them directly. The MDS coordinator used to update the CNA tasks but she did not think that happened anymore. The DON attempted to go through the resident's medical record to provide the fall interventions after each fall but was unsure where the interventions were in the resident's medical record. She said she thought the resident had an one-on-one sitter at the end of July to August 2022 but the sitter was only for when the resident was out of his room. She acknowledged the majority of his falls were inside of his room. She said with the resident's cognition, it was difficult to prevent his falls; the staff tried to anticipate his needs when he was in his room. Certified occupational therapist assistant (COTA) was interviewed on 5/9/23 at 8:57 a.m. She pulled the resident's therapy notes from November 2022 to current. Therapy had worked with the resident on standing balance, transferring, ambulating with a walker, sequencing tasks and expressive language. The resident was able to complete goals each time he worked with therapies but once he completed and was discharged each time and he did not have the same supervision and support, he would regress and fall again. When therapy was working with the resident in February 2023, he had declined in his abilities and therapy had to work with him on ambulating shorter distances and transferring with staff assistance. He has declined further since his fall in April 2023 and his current goals with PT/OT/ST were to increase upper body strength, bed mobility for sequencing hand and foot placement, communicate yes/no response for basic wants and needs, consumption of oral intact and alternate use of liquids and solids, maintain eye contact with conversation and fine motor coordination. His baseline currently was substantial-maximum assist for all goals. The NHA was interviewed on 5/9/23 at 10:21 a.m. The NHA stated Resident #26 was currently receiving one-on-one 24 hour supervision until he no longer needed it. A review of his medications was done after he returned from the hospital after his 4/26/23 fall. His room was evaluated for hazards and his transfer pole would be reviewed for effectiveness. She was waiting to see what his new cognitive and functional baseline would be before determining interventions that would be effective. She was not sure if his frequent falls were discussed in the facility's monthly QAPI meeting. The NHA would provide the fall interventions for the resident from 4/16/22 to 4/26/23. The NHA and DON were interviewed again on 5/9/23 at 12:07 p.m. The NHA said she was still working on collecting the fall interventions. She said the intervention should be indicated in the IDT post fall review. The NHA was not employed at the facility in July 2022 but DON was at that time. The DON said she did not recall a neuropsychology evaluation being ordered for resident post any falls. The DON and NHA were unaware the resident had a neuropsychology evaluation performed and were unaware of the results. The NHA was aware the evaluation provided detailed cognitive deficit information in numerous areas of functioning. She stated the results of a neuropsychology evaluation ordered for a resident post fall would be included in intervention discussions. She said those results should be provided to the therapy department to tailor the residents interventions based on his abilities. She acknowledged the resident continued to go to therapy and was able to complete goals with therapy but once he was no longer in therapy he was unable to retain the interventions he had learned and then fell again. III. Facility follow-up On 5/9/23 at 12:12 p.m. the NHA provided the same IDT post fall reviews and nursing progress notes with At-Risk Review committee meeting notes previously reviewed in the resident's medical record during the survey. No new interventions, staff education or documented on the spot education were provided.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated; -Ensure the kitchen was clean and sanitary; -Ensure cooked food items were monitored and cooled properly; -Ensure dishes were dried properly; and, -Ensure cutting boards were free from deep groves. Findings include: I. Failure to ensure food was labeled and dated A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded [NAME], or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved 5/10/23). The U.S. (United States) Department of Agriculture (3/23/23), How Long Does Lunch Meat Last, https://ask.usda.gov/s/article/How-long-does-lunch-meat-stay-fresh#:~:text=After%20opening%20a%20package%20of,kept%20at%200%20%C2%B0F). It revealed in pertinent part, Packaged lunch meats can be stored in the refrigerator for two weeks before opening. After opening a package of lunch meats or buying sliced lunch meats at a deli, you can refrigerator them for three to five days (Retrieved 5/10/23). The U.S. Department of Agriculture (3/23/23), How Long Can you Keep Hot Dogs, https://ask.usda.gov/s/article/How-long-can-you-keep-hot-dogs. Packaged hot dogs can be stored in the refrigerator 2 weeks before opening. After opening a package of hot dogs you can keep them for a week in the refrigerator. (Retrieved 5/10/23). The U.S. Department of Agriculture (7/31/2020), Leftovers and Food Safety, https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/leftovers-and-food-safety#:~:text=Store%20Leftovers%20Safely,longer%20times%20in%20the%20freezer. Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months. (Retrieved 5/10/23) B. Facility policy The Food Storage and Retention Guide policy, undated, was provided by the dining district manager (DDM) on 5/8/23 at 4:48 p.m. It revealed in pertinent part, Cream cheese was good for 2 weeks. C. Observations On 5/3/22 at 8:51 a.m. the initial kitchen tour was conducted and the following was observed: -In the dry storage refrigerator, there were three hard boiled eggs labeled 3/26 and a slice of deli ham in a plastic bag that was unlabeled. -In the reach-in refrigerator, a plastic container full of individually portioned Jell-Os labeled 5/10, four deli sandwiches labeled 5/1 and an opened bag of hard boiled eggs labeled 4/29. -In the walk-in refrigerator, an unlabeled container of shredder pork, unlabeled opened bag of hard boiled eggs, a container of opened hot dogs labeled 5/2 through 5/30, an opened package of sliced deli ham in a plastic container labeled 5/1 through 5/11, a container of cooked ground beef labeled 4/30, an opened block of cream cheese wrapped in plastic wrap labeled 3/7 that had mold spots on it, a container of an unidentifiable and unlabeled container of orange sauce. On 5/8/23 at 11:13 a.m. at the lunch meal the following was observed: -In the dry storage refrigerator, the same hard boiled eggs labeled 3/26 and the same slice of deli ham in a plastic bag that was unlabeled. -In the walk-in refrigerator, there was an opened and unlabeled bag of shredded cheddar cheese, a plastic container full individually packaged Jell-Os labeled 5/10, cooked chicken fried steak labeled 5/5 through 5/12, cooked sausage patties labeled 5/8 through 5/12, another container of cooked sausage patties labeled 5/7 through 5/12, cooked meat loaf labeled 5/3 through 5/11, au gratin potatoes labeled 4/27 through 5/14, cooked ground sausage labeled 5/5 through 5/12, a bag of raw chicken labeled 4/27, a container of raw chicken lights in a plastic container labeled 5/4 through 5/8, a plastic container of opened hot dogs labeled 5/2 through 5/30, cooked barbeque pork labeled 5/8 and an opened package of deli ham wrapped in plastic wrap not labeled. -In the main kitchen there was a pitcher of powdered thickener that was unlabeled. -The leftover food items in the refrigerator did not follow the recommended guidelines of leftover foods. D. Staff interviews Cook #1 was interviewed on 5/8/23 at 1:00 p.m. She said at times she was not sure how to label food items. The dietary manager (DM) and the DDM were interviewed on 5/8/23 at 2:48 p.m. The DM said all dining staff were responsible for labeling and dating food items. The DM said a guide for labeling and dating was on the reach-in refrigerator. The DM said if the food item was not on the guide, she would call the DDM for guidance on labeling food items. The DDM said deli meats and hot dogs were good for seven days. The DDM said the chicken in the walk-in refrigerator should have been used three days ago. The DM said all foods should be labeled with an open or prepared date and a use-by-date. II. Ensure the kitchen was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102 _RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 5/10/23) B. Facility policy The Environment policy, revised September 2017, was provided by the DDM on 5/9/23 at 4:48 p.m. It revealed in pertinent part, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. All food trash will be contained in covered, leak-proof containers that present cross contamination. C. Observations On 5/8/23 at 11:13 a.m. at the lunch meal the following was observed: -A cellular phone was on the preparation table, next to a sliced tomato. -The knife holder had food crumbs in the bottom of it. -The floor in the main kitchen was sticky and had food debris, crumbs, plastic wrap, used gloves, used paper towels, use-by stickers and sliced carrots on it. -There were two boxes underneath the kitchen sink that had trash in them. -Underneath the steam table there were potato chips, sliced carrots, crumbs, bread bag ties and food debris. The tiles at the back of the steam table had black build up on them. -The tiles underneath the clean landing zone of the dishwasher and three compartment sink had black build-up on them. -A plastic container that had a red powdery substance in it was stored on a rack above clean dishes. -The top of the dishwasher had yellow dust built-up on it. -At 11:20 a.m. cook #1 washed her hands, she missed the trash can when disposing of her paper towel and left it on the ground. D. Staff interviews The DM and the DDM were interviewed on 5/8/23 at 2:48 p.m. The DDM said the kitchen was swept and mopped after each shift by dining staff. The DDM said the housekeeping staff deep cleaned the kitchen floor once a month. The DDM said the kitchen floor was sticky due to the chemical the housekeeping staff used to sanitize the floor. The DM said cellular phones should not be stored on food preparation tables. She said all phones should be stored away from food. The DDM said the knife holder should be free from crumbs and food debris. The DDM said she would show the staff how to properly clean it. III. Ensure cooked food items were monitored and cooled properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan. (Retrieved 5/10/23). B. Observations On 5/8/23 at 11:13 a.m. at the lunch meal the following was observed: -In the walk-in refrigerator, there was cooked chicken fried steak labeled 5/5 through 5/12, cooked sausage patties labeled 5/8 through 5/12, another container of cooked sausage patties labeled 5/7 through 5/12, cooked meat loaf labeled 5/3 through 5/11, au gratin potatoes labeled 4/27 through 5/14 and cooked ground sausage labeled 5/5 through 5/12. C. Record review A request was made for the documented cooling monitor system on 5/8/22 when hot foods were cooled. The DM said the facility did not have a documented cooling monitor system in place (see interview below). D. Staff interviews Cook #1 was interviewed on 5/8/23 at 1:00 p.m. She said she did not utilize a cooling log. The DM and the DDM were interviewed on 5/8/23 at 1:00 p.m. The DDM said the cooling log was not filled out, because the facility kitchen did not save leftovers. However, the DM acknowledged there were leftover cooked foods in the walk-in refrigerator. The DM and the DDM were interviewed again on 5/8/23 at 2:48 p.m. The DDM said she disposed of all of the leftover food items in the walk-in refrigerator. The DDM said she would begin an in-service with all dining staff on properly cooling foods and documentation. The DM said foods must be cooled properly to reduce the risk of food-borne illness. IV. Ensure dishes were dried properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; Unless used immediately after sanitization, all equipment and utensils shall be air-dried. (Retrieved 5/10/23) B. Facility policy The Warewashing policy, revised September 2017, was provided by the DDM on 5/8/23 at 4:48 p.m. It revealed in pertinent part, All dishware will be air dried and properly stored. C. Observations On 5/8/23 at 11:13 a.m. at the lunch meal the following was observed: -Cook #1 and the DDM were serving meals off the steam table in the main kitchen. There was a stack of clam shells (hot holding device) and trays used for room service. As cook #1 began service the clam shells and trays were visibly wet. At times cook #1 dumped water off of the clam shells. D. Staff interviews Dietary aide (DA) #2 was interviewed on 5/8/23 at 12:58 p.m. He said if he was in a hurry he would just stack dishes and put them away. He said items like clamshells (hot holding containers) and trays he would always stack and put on the rack. The DM and the DDM were interviewed on 5/8/23 at 2:48 p.m. The DDM said all dishes should be thoroughly air dried prior to stacking and putting away. The DM said if dishes were not dried properly it could introduce bacteria. V. Ensure cutting boards were free from deep groves A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. (Retrieved 5/10/23). B. Observations On 5/8/23 at 11:13 a.m. at the lunch meal the following was observed: -At 12:23 p.m. the DDM gave the DM a bowl of broccoli and requested her to cut it. The DM got a green cutting board to cut the broccoli on. The cutting board had deep groves on it. C. Staff interviews The DM and the DDM were interviewed on 5/8/23 at 2:48 p.m. The DDM said the cutting boards were replaced annually or as needed. The DDM said if the cutting boards had deep scores they needed to be replaced sooner to help clean the boards better.

Based on observations, interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to provide resolutions to residents' missing clothing and items. Findings include: I. Facility policy and procedure The Resident and Family Grievances policy, dated 2/17/23, was provided by the nursing home administrator (NHA) on 5/8/23 at 4:07 p.m. It revealed in pertinent part It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. II. Resident interviews and observations All residents were identified by facility and assessment as interviewable. Resident #16 was interviewed on 5/3/23 at 10:40 a.m. She stated several clothing items had gone missing since admitting to the facility last year. She said clothing did not come back from the laundry and she was currently out of bras and underwear. Resident #16 said that her ex-husband and son have brought her more clothes but then they went to the laundry and did not come back. She was not aware of how grievances were handled but had filled out three orange grievance forms for missing clothing and no staff in management had followed up with her. Resident #21 was interviewed on 5/3/23 at 1:50 p.m. He said he had an expensive blanket that a friend had given him go missing. He said the blanket had been missing for approximately five months. He said he had notified several staff members that had entered his room about the missing blanket. Resident #21 said the facility had not located or replaced the missing blanket. Resident #52 was interviewed on 5/3/23 at 2:46 p.m. He said he had several clothing items go missing, including a Star Wars shirt. He said whenever he sends clothing to the laundry it was sporadic if he got his laundry back. During the interview, Resident #52 was wearing dark plaid fleece pajama pants and a dark striped t-shirt. On 5/4/23 at 12:41 p.m. Resident #52 was observed walking in the hallway wearing the same fleece pajama pants and striped shirt. On 5/8/23 at 1:54 p.m. Resident #52 was wearing the same dark plaid fleece pajama pants and a dark striped shirt. Resident #52 was interviewed again on 5/9/23 at 9:00 a.m. Resident #52 said most of his clothes had gone missing when they were sent to the laundry. He said he only had three shirts and three pairs of pants. During the interview, Resident #52 was wearing the same dark plaid fleece pajama pants and a dark striped shirt. 46849 III. Resident council minutes Resident council meeting minutes dated 2/8/23 revealed the resident council voiced it was taking more than three days for laundry to be returned to them. Resident council meeting minutes dated 3/8/23 revealed two specific residents stated they were missing clothing. A concern form was to be written for each resident. Resident council meeting minutes dated 4/12/23 revealed three specific residents stated they were missing clothing. A concern form was to be written for each resident. IV. Facility grievances Facility grievances concerning missing items for the last six months were requested from the facility. Received email from NHA on 5/10/23 at 2:21 p.m. Email included copies of December 2022, January 2023, February 2023, March 2023, and April 2023 grievance. Pertinent grievances as follows: -Grievance dated 3/8/23 generated from March 2023 resident council resident specific concern. The grievance documented the staff threw away items off his floor but did not mention missing clothes. -Grievance dated 4/12/23 generated from April 2023 resident council resident specific concern. The grievance documented that the resident was missing pajamas. The items were located in the lost and found without a resident name on them and returned to the resident. -Grievance dated 4/12/23 generated from April 2023 resident council resident specific concern. The grievance documented the resident was missing a sweatshirt. The item was located and returned to the resident. -There was not a resident council group grievance for the March 2023 council concern of clothing taking more than three days to return. -There was not a resident specific grievance for one March 2023 resident council member. -There was not a resident specific grievance for one April 2023 resident council member. -There were no grievances for Resident #16, #21 and #52. V Staff interviews The housekeeping supervisor (HSK) was interviewed on 5/8/23 at 1:03 p.m. She said when she received a concern she followed up with the resident immediately and helped them to fill out a grievance form if they wanted to. Every morning in the interdisciplinary team morning meeting grievances were discussed with all the department managers. She said she should be provided a grievance form whenever a resident voiced a concern regarding missing clothes to staff or in resident council meetings. It took laundry 24-48 hours to return laundry to residents after they were cleaned. The social services director (SSD) was interviewed on 5/8/23 at 2:56 p.m. She did not manage the resident grievances, it was the health information manager (HIM) who took the grievances, logged them, passed them out to the managers, retrieved them and filed them. She did not know who did the resident follow up. The SSD and the social services assistant (SSA) were interviewed on 5/9/23 at 9:21 a.m. The SSD said the social services department handled grievances related to missing items. The SSA and SSD said they were not aware of Resident #21 and Resident #52's missing items. The HIM was interviewed on 5/9/23 at 11:01 a.m. She said anyone can submit a grievance form. She said all grievances were given to her. The HIM said grievances were discussed in the morning meeting and then distributed to the department the concerns were related to. The HIM said she kept a log of all grievances. The HIM said the NHA was responsible for signing off on all grievances when a resolution had been met. The HIM said she was aware Resident #52 was missing a blanket. She said a grievance had not been filled out regarding the missing blanket and the blanket had not been found or replaced. The HIM said she was not aware of Resident #21's missing clothing items, but would follow-up with the resident. The HIM was interviewed again on 5/9/23 at 12:29 p.m. She said she followed up with Resident #52 and was ordering a new blanket for him today (5/9/23). The HIM said Resident #52's concern of his missing blanket was not addressed in a timely manner. The HIM said she spoke with Resident #21 and was assisting him in getting new clothes from donations that had been made to the facility. VI. Facility follow-up The NHA provided a copy of concern forms on 5/10/23 at 2:05 p.m. A concern form for Resident #21 had been filled out on 5/9/23 (during the survey process). It revealed Resident #21 was missing a blanket. The form documented a description of the blanket was obtained around 4/28/23. A new blanket was ordered on 5//23. A concern form for Resident #52 was filled out on 5/9/23 (during the survey process). It revealed Resident #52 reported his clothes did not fit him anymore. The HIM obtained clothing that fit Resident #52 from the donated clothes.

Based on interviews, observations and record review the facility failed to honor resident choices for one (#52) of five reviewed for self-determination out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #52 received showers consistently according to their choice of frequency; and, -Ensure Resident #52's preferences were included in his plan of care. Findings include: I. Facility policy and procedure The Resident Showers policy, dated 10/1/21, was provided by the nursing home administrator (NHA) on 5/9/23 at 12:53 p.m. It revealed in pertinent part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. II. Resident #52 A. Resident status Resident #52, under the age of 65, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included cerebral infarction due to embolism of right middle cerebral artery (stroke), obstructive sleep apnea, fibromyalgia (pain syndrome), anxiety disorder, chronic obstructive pulmonary disease, hypertension (high blood pressure), obsessive-compulsive disorder (OCD)and gastro-esophageal reflux disease (GERD). The 2/19/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status with a score of 10 out of 15. He required supervision of one person for dressing and personal hygiene. He required extensive assistance of one person for toileting. He was independent with set-up assistance for bed mobility, transfers, walking and eating. The MDS assessment documented the resident had not had a shower in the review period. B. Resident observation and interview Resident #52 was interviewed on 5/3/23 at 2:58 p.m. He said he preferred to have a shower once a week on Thursdays. Resident #52 said his showers were frequently missed. Resident #52 said the staff often offered for him to shower in the evening and at that time he was too tired to shower. Resident #52 said he preferred to shower between 1:00 p.m. and 3:00 p.m. in the afternoon. Resident #52 said if staff offered him a shower too late he would request to shower the next day, but he was told that was not an option. During the interview, Resident #52 was wearing dark plaid fleece pajama pants and a dark striped t-shirt. On 5/4/23 at 12:41 p.m. Resident #52 was observed walking in the hallway wearing the same fleece pajama pants and striped t-shirt. Resident #52 was interviewed again on 5/8/23 at 1:54 p.m. Resident #52 said he was not offered a shower on 5/4/23. During the interview, Resident #52 was wearing the same dark plaid fleece pajama pants and a dark striped t-shirt. On 5/9/23 at 9:00 a.m. Resident #52 was interviewed again. Resident #52 said most of his clothes had gone missing when they were sent to the laundry. He said he only had three shirts and three pairs of pants. During the interview, Resident #52 was wearing the same dark plaid fleece pajama pants and a dark striped t-shirt. C. Record review The activities of daily living (ADL) care plan, initiated on 10/21/21 and revised on 11/28/21, documented Resident #52 had an ADL self-care performance deficit related to activity intolerance, limited mobility and history of a stroke. The interventions included: encouraging active participation in tasks, ensuring effective pain management prior to ADLs, gathering and providing needed supplies, providing cuing with tasks as needed, providing extensive assistance of one staff member for showers, providing limited assistance of one person for bed mobility, providing set-up assistance for showers, providing set-up assistance for eating, providing supervision for personal hygiene and oral care, checking the resident's skin weekly, providing extensive assistance of one person for toileting, providing limited assistance of one person for transferred, discussing with the resident of any concerns related to loss of independence, encouraging the resident to participate to the fullest extent possible with interactions, encouraging the resident to use his call light, observing and documenting any changes in self-care, praising the resident for all efforts at self care and providing therapy evaluation and treatment as per physician orders. The activities care plan, initiated on 11/14/21, documented Resident #52 preferred a shower but did not have a time that he liked to bathe. -A review of the resident's comprehensive care plan revealed the care plan did not address Resident #52's current shower preferences. The shower documentation from 2/23/23 to 5/8/23 for Resident #52 was provided by the NHA on 5/8/23 at 4:37 p.m. It revealed Resident #52 received a shower on 3/2/23 and 3/30/23. Resident #52 received two showers in a 90-day look back period. Resident #52 refused a shower on 2/23/23 at 5:12 p.m., on 3/9/23 at 3:48 p.m., on 3/16/23 at 7:46 p.m., on 3/23/23 at 8:10 p.m., on 4/6/23 at 5:10 p.m. and on 4/20/23 at 4:14 p.m. -Resident #52 stated his preference was to shower earlier in the day, because he was tired later in the afternoon (see interview above). III. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 5/8/23 at 9:43 a.m. She said Resident #52 only needed set-up assistance for showers. She said she was not aware of Resident #52 refusing showers. Registered nurse (RN) #3 was interviewed on 5/9/23 at 10:22 a.m. She said Resident #52's shower days were on Thursday evenings. RN #3 said Resident #52 preferred not to shower. RN #3 said the CNAs were to notify the nurse on duty if a resident refused a shower. She said she only worked till 6:00 p.m., so she was not at the facility during Resident #52's scheduled shower. The director of nursing (DON) was interviewed on 5/9/23 at 11:13 a.m. The DON said all residents should receive showers per their preference. She said the restorative nurse aide was responsible for obtaining the residents' shower preferences. The DON said Resident #52 often refused showers. She said she had not reviewed Resident #52's shower documentation to check for any patterns of refusals. The DON said Resident #52 was very particular. The DON acknowledged Resident #52 had received two showers in a 90-day look back period. The DON said the facility recently merged with another company, which eliminated the residents' shower preferences in the electronic medical record.

Based on interviews and record review the facility failed to allow resident to return to the facility after going to the hospital for one (#136) of three residents reviewed for discharge out of 29 sample residents. Specifically, the facility failed to allow Resident #136 to return to the facility on ce medically cleared to return. Findings include: I. Facility policy and procedure The Involuntary Discharge policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/11/23 at 12:03 p.m. It read in pertinent part, If a resident lives in a nursing home community and needed to be discharged against his/her will, they had certain rights, as mandated per federal and state regulations. There were only certain reasons a resident may be legally asked to leave a community. The reasons for transfer and discharge were: -The community could no longer provide for the residents'; -The medical needs of the resident could not be met or the resident's health had improved and he/she no longer needed the long term care level of services; -The safety or health of other residents was in danger; and -The resident had failed to pay for the stay. All communities must demonstrate that the needs of the resident could not be met in the community or that the resident no longer required services. Before a transfer or discharge, the community must demonstrate that they had done an assessment of any problems and attempted to solve them. It was important to note that a person could not be transferred or discharged for raising concerns or complaints. II. Resident #136 Resident #136, age under 70, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the August 2022 computerized physician orders (CPO), the diagnoses included chronic pain syndrome, restlessness and agitation, insomnia, anxiety disorder and other specified depressive episodes. The 8/17/22 minimum data set (MDS) assessment revealed a brief interview for mental status score (BIMS) was not conducted because the resident was rarely/never understood. His cognitive skills for daily decision making were moderately impaired. He had behavioral symptoms towards others and physical behaviors not towards others daily. He rejected care daily. He required extensive assistance with bed mobility, transfers, dressing, and toilet use. No antipsychotics were received. III. Record review A. Care plan -Review of the resident's comprehensive care plans revealed there was no discharge care plan. The behavior care plan, revised on 8/17/22, revealed the resident had verbal aggression and anxiety related to the new environment and pain. The interventions included: -Administer medications as ordered. -Allow choices within the individual's decision making ability. -Anticipate and meet the resident's needs. -Caregivers to provide opportunities for positive interaction, attention. Stop and talk with him/her as you pass by. -Explain all procedures to the resident before starting care and allow resident time to adjust to changes. -If reasonable, discuss the residents behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed. -Notify MD (medical doctor) as needed. -Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes. -Praise any indication of the residents progress/improvement in behavior. -Provide a program of activities that is of interest and accommodates residents' status. B. Nursing notes Nursing notes dated 8/24/22 at 2:10 p.m. documented the resident was alert and refused to be changed. The resident also refused to be changed in the a.m. (morning) and was scratching his skin. He was lying on soiled linen and his adult brief was dirty. Per the assistant director of nursing (ADON) an M1 hold (when an individual is deemed to be in imminent danger of harming him or herself or someone else or is gravely disabled) order was needed. A call was placed to the physician who stated it was ok to send the resident to the hospital with a M1 order. The resident was sent to the hospital. Nursing notes dated 8/24/22 at 9:21 p.m. documented the nurse received in report that the resident was sent to the hospital on a M1 hold and was not allowed back unless the facility physician gave the order for him to return. She received a call from the hospital that the resident was being returned to the facility. The writer passed on that the resident was not allowed back unless the physician gave the order. The nurse called the on-call supervisor who repeated what was told in report. The NHA was called and instructed the nurse that the resident was not allowed back under any circumstances per corporate. Do not open the doors. She received a call back from the hospital. They were sending the resident back with the police. C. Hospital notes Emergency department notes dated 8/24/23 at 2:45 p.m. documented: The chief complaint was that the patient was brought to the emergency room with a complaint of failure to thrive. The patient was brought to the emergency room by ambulance from a skilled nursing facility/rehab facility. The staff at the facility stated the patient was refusing to participate in his care and was refusing his medications as well as lying in a soiled bed refusing to allow staff to clean him or help him. The patient denied all of this. The staff placed the patient on an M1 hold, however the M1 hold did not have essential information filled out and was incomplete and invalid. Patient was not suicidal or homicidal. He denied severe depression. The treatment included the patient being treated with IV (intravenous therapy) fluids. He was given tylenol and a muscle relaxer. He was evaluated by a psychiatric liaison and there was no criteria for the M1 hold and the M1 hold was discontinued. Attempts were made to transfer the patient back to his nursing facility. The facility refused to take him back. The patient still had his possessions at the facility and that constituted negligence and abandonment by the facility. The plan was the patient required continued care at his nursing home. The hospital attempted to transfer the patient back to his nursing home but the staff at the facility refused to take him back. It seemed the patient was placed on an invalid M1 hold without evidence of a psychiatric need for an M1 hold and transferred against his will to the hospital and was not being allowed back into his facility which was essentially his home where his possessions were. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 5/7/23 at 3:41 p.m. He said Resident #136 was rude and demanding. He said he was verbally abusive to staff but not physically aggressive. He said he did not know why the resident was discharged . CNA #3 was interviewed on 5/7/23 at 3:43 p.m. She said Resident #136 would not let staff change him and would curse at staff and kick them out of his room. She said the resident wanted things done his way. She said he was never physically abusive towards staff, but was verbally abusive. Registered nurse (RN) #1 was interviewed on 5/7/23 at 3:48 p.m. She said Resident #136 was extremely rude, called staff racial slurs, refused care and demanded more medication than what was ordered by the physician. She said he was verbally abusive to staff. She said she did not know why he was discharged , but thought he was sent to the hospital for a medical reason. The social services director (SSD) was interviewed on 5/8/23 at 10:33 a.m. She said she was not working at the facility when Resident #136 was discharged . The social services assistant (SSA) was interviewed on 5/8/23 at 10:33 a.m. She said Resident #136 was non-compliant with care and would not let staff change him. She said he would curse at the staff. She said the physician was not in the facility to assess Resident #136 on the day of his M1 hold. She said the nurse conveyed the information to the physician. She said the criteria for an M1 hold was the resident was a danger to himself or others. She said he was self harming by not allowing staff to perform incontinent care. She said the director of nursing (DON) initiated the M1 holds. She said Resident #136 was able to make decisions for himself and had the right to refuse care. The DON was interviewed on 5/8/23 at 1:38 p.m. She said it was more of a concern that Resident #136 would get an infection because he would not allow staff to clean him up and the smell coming out of his room was not good for the community. She said at that time she felt an M1 hold was necessary. She said if a resident refused care and was a danger to their health they would be sent out on a M1 hold. She said Resident #136 met the criteria for being psychotic and had severe mental illness. She said she did not know anything about the resident not being allowed back into the facility. The nurse mentor (NM) was interviewed on 5/8/23 at 3:17 p.m. She said Resident #136 did not return to the facility because she reviewed the hospital notes and they revealed the resident did not want to return to the facility. She said she was not aware of the 8/24/23 nurse progress note, which documented the resident was not allowed back into the facility. -However, per the hospital documentation the resident required continued care at the nursing home.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#21) of three reviewed for discharge planning out of 29 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documentented in Resident #21's medical record; and, -Ensure Resident #21 was informed of the discharge planning process. Findings include: I. Facility policy and procedure The Transfer and Discharge policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 12:53 p.m. It revealed in pertinent part, Anticipated Transfers or Discharges-initiated by the resident: obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care, a member of the interdisciplinary team completes relevant sections of the discharge summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the discharge summary is complete and includes, but not limited to the following: a recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results, a final summary of the resident's status, reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter), a post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative. II. Resident #21 A. Resident status Resident #21, age 76, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included acute respiratory failure with hypoxia (low oxygen levels in the blood), type two diabetes mellitus without complications, hypoglycemia (low blood sugars), unspecified dementia and hypertension. The [DATE] 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. He required limited assistance of one person for bed mobility. He required supervision of one person for transfers. He required extensive assistance of one person for dressing. He was independent with set-up assistance for walking in his room and in the corridor and for eating. He required supervision of one person assistance for locomotion off the unit and toileting and he required limited assistance of one person for personal hygiene. The MDS assessment documented the resident did not have an active discharge plan in place to return to the community. It indicated the resident did not want to talk to someone about discharging from the facility into the community. B. Resident interview Resident #21 was interviewed on [DATE] at 1:55 p.m. He said he was supposed to be discharged to an apartment at the end of February 2023. Resident #21 said the day before his discharge the social services assistant (SSA) told him he was not ready to discharge. Resident #21 said the social services department has not kept him up to date on his current discharge plans. He said he was ready to discharge, so he could live independently. Resident #21 said he would try to speak to the social services department regarding his discharge, but they were not following up with him. Resident #21 said he was frustrated and started speaking with a community transitions department on his own to handle the discharge. C. Record review -A review of Resident #21's medical record on [DATE] at 10:00 a.m. did not reveal documentation that the resident's discharge plan was part of the resident's comprehensive plan of care. It did not document the resident's discharge goal, interventions used to achieve the resident's goals or the discharge planning process. The [DATE] baseline care plan documented the resident's initial discharge goals were to return to the community. The [DATE] social service progress note documented at 4:38 p.m. revealed the social services department discussed with therapy regarding the concerns of Resident #21 discharging to live independently. The note documented Resident #21 thought he was independent in many activities of daily living, but that was unrealistic. Therapy offered services today ([DATE]), but Resident #21 declined. Resident #21 was receiving restorative services. Speech therapy mentioned to the director of rehabilitation that Resident #21's cognition was concerning. The NHA was informed of the situation and stated the discharge would be against medical advice (AMA) at that point. The social services department notified the community transition services team (name of transition company). The [DATE] social services progress note documented at 5:15 p.m. revealed the social services director (SSD) and the SSA discussed discharge concerns with Resident #21. The note documented Resident #21 was visibly and emotionally okay with the decision. Resident #21 was informed that if he chose to discharge it would be AMA. The [DATE] social services progress note documented the SSA spoke with the community transitions coordinator for Resident #21. The community transitions coordinator notified the SSA that he spoke with Resident #21 in regards to his plan to work with therapy and have the nursing department work with him daily to learn about his sliding scale insulin. The note documented that the community transitions coordinator said if there was improvement in 30 days they would reassess the resident's discharge. The [DATE] social services progress note documented the SSA send a voucher extension to the transitions team and reported to the transitions team that Resident #21 was doing great with walking, getting up and managing his insulin injections. The [DATE] multidisciplinary care conference note documented a care conference was held that date. It documented the resident had adequate vision and hearing and was continent of bowel and bladder. Resident #21 was able to self propel in his wheelchair and needed help with most of his activities of daily living. Resident #21 was able to feed himself. Resident #21 tolerated his diet and had a normal appetite. Resident #21 had weight gain related to high calorie intake. Resident #21 was provided diabetic diet education. Resident #21 participated in activities. Resident #21 had a BIMS score of 15, indicating he was cognitively intact. Resident #21 had a goal of discharging back to the community and was working with a transition team. Resident #21 was going to discharge back to the community in February 2023, but was deemed unsafe to discharge at that time. A plan was made for Resident #21 to work with therapy and nursing to improve physically and learn how to do his own insulin safely. Both departments reported Resident #21 was making process and with a little more work would be able to discharge home safely. The progress note documented Resident #21 was not receiving therapy services at that time. -However, the [DATE] social services progress note documented the resident was doing great walking, getting up and managing his insulin injections. The resident remained in the facility on [DATE]. -No further documentation was in Resident #21's medical record regarding communication with the community transition coordinator or Resident #21 regarding his discharge plan and goals. III. Staff interviews The SSD and the SSA were interviewed on [DATE] at 10:34 a.m. The SSD said she did not include discharge planning on resident's comprehensive care plans. The SSA said she had been working with a community transitions team to help Resident #21 discharge back to the community. The SSA said he was going to discharge back to the community a couple months ago, but he was deemed unsafe at that time. The SSD and the SSA were interviewed again on [DATE] at 9:21 a.m. The SSD said they had held care conferences for Resident #21 to discuss his transition back to the community. The SSA said Resident #21 needed a voucher to discharge back to the community, but it had expired. The SSA said she was working on obtaining a new voucher to assist the resident to discharge back to the community. The SSA said she was waiting for the voucher to come back in the mail, but had not yet received it. The SSA and the SSD said the frequently spoke to Resident #21 in passing regarding his discharge, but did not document it in his medical record. The SSD said Resident #21 did not have good memory recall, so he would likely forget those conversations. The SSA said Resident #21 received training for his insulin. Registered nurse (RN) #3 was interviewed on [DATE] at 10:22 a.m. She said she had completed some insulin training with Resident #21 several weeks ago. She said she had not been instructed to complete anymore insulin training with Resident #21. The director of nursing (DON) was interviewed on [DATE] at 11:12 a.m. The DON said Resident #21 was supposed to discharge a couple months ago, but it was put on hold. The DON said she was not sure why the discharge was put on hold, but it was not related to the resident's insulin use. The DON said RN #3 had provided some training to Resident #21 at the end of March or beginning of [DATE]. The DON said Resident #21's plan of care or CPO did not include specifics on training Resident #21 to safely administer his insulin. IV. Facility follow-up The NHA provided a copy of Resident #21's updated comprehensive plan of care on [DATE] at 2:05 p.m. (after the survey process). The discharge plan of care revealed Resident #21 was working with a transition company (name of company) program to discharge back to the community. The interventions included: Resident #21 would have a chance to review his discharge plan quarterly in care plan meetings, providing home health care and assisting the resident with his discharge goals through therapy services.

Based on observations, record review, and interviews, the facility failed to ensure one (#52) of two residents who required respiratory care received the care consistent with professional standards of practice out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #52's continuous positive airway pressure (CPAP) machine was cleaned and stored appropriately; and, -Ensure a care plan was in place to include the use, settings, cleaning, disinfecting and storage of Resident #52's CPAP. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/9/23 at 12:53 p.m. It revealed in pertinent part, The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: the type of oxygen delivery system, when to administer, such as continuous or intermittent and/or when to discontinue, equipment setting and the prescribed flow rates, monitoring of SPO2 (oxygen saturation) levels and/or vital signs, as ordered, monitoring for complications associated with the use of oxygen. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. CPAP mask- this mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is compromised of a mask, tubing, and a machine that generates a constant flow of air pressure. Machines have settings. II. Resident #52 A. Resident status Resident #52, under the age of 65, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included cerebral infarction due to embolism of right middle cerebral artery (stroke), obstructive sleep apnea, fibromyalgia (pain syndrome), anxiety disorder, chronic obstructive pulmonary disease, hypertension (high blood pressure), obsessive-compulsive disorder (OCD) and gastro-esophageal reflux disease (GERD). The 2/19/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status with a score of 10 out of 15. He required supervision of one person for dressing and personal hygiene. He required extensive assistance of one person for toileting. He was independent with set-up assistance for bed mobility, transfers, walking and eating. The MDS assessment documented the resident received oxygen therapy. The MDS assessment did not indicate the resident used a CPAP machine. B. Resident interview and observations Resident #52 was interviewed on 5/3/23 at 2:58 p.m. He said no staff cleaned his CPAP machine. He said he attempted to wash the mask portion of the machine in his sink with soap and water, but oftentimes he was not able to stand long enough to clean it. Resident #52 was interviewed again on 5/8/23 at 1:54 p.m. He said he was not sure the last time the tubing to his CPAP machine had been changed. C. Record review The emphysema care plan, initiated on 11/28/21, revealed Resident #52 had emphysema and COPD related to smoking. The interventions included: avoiding extreme temperatures, encouraging small frequent feedings instead of large meals, giving aerosol or bronchodilators as ordered, identifying and eliminating sources of respiratory irritation such as cigarette smoke, pollen and perfumes, observing for difficulty breathing on exertion, observing for signs and symptoms of acute respiratory insufficiency, observing for anxiety, offering support and encourage resident to vent frustrations, observing and reporting for signs and symptoms of respiratory infections, consulting occupational therapy for energy conservation recommendations. The shortness of breath care plan, initiated on 11/28/21, revealed Resident #52 had shortness of breath related to anxiety, decreased energy, fatigue, decreased lung expansion and hypoxia (low blood oxygen).The interventions included: assisting the resident in learning signs of respiratory compromise, encouraging sustained deep breaths, maintaining a clear airway by encouraging the resident to clear his own secretions with coughing, monitoring and documenting changes in orientation, monitoring and documenting breathing patterns, monitoring and documenting breathing abnormalities, pacing and scheduling activities providing adequate rest breaks, positioning the resident with proper body alignment for optimal breathing, providing relaxation training as appropriate, teaching the resident to inhale and exhale when doing strenuous activities, using pain management as appropriate and using universal precautions as appropriate. The oxygen therapy care plan, initiated on 11/28/21, revealed Resident #52 received oxygen therapy related to congestive heart failure (CHF), ineffective gas exchange and respiratory illness. The interventions included: changing the resident's position at regular and frequent intervals to facilitate lung secretion movement and drainage, encouraging or assisting with ambulation as indicated, providing extension tubing or portable oxygen apparatus, giving medications as ordered by the physician, providing oxygen during meals if allowed, observing for signs or symptoms of respiratory distress, providing oxygen and two liters per minute humidified via nasal prongs. The sleep apnea care plan, initiated on 11/28/21, revealed Resident #52 had altered respiratory status and difficulty breathing related to sleep apnea. The interventions included: administering medications/puffers as ordered, assisting the resident in learning signs of respiratory compromise, encouraging sustained deep breaths, maintain a clear airway, observing and documenting change in orientation, observing for signs and symptoms of respiratory distress, observing and documenting abnormal breathing patterns, pacing and scheduling activities providing adequate rest periods, positioning resident with proper body alignment for optimal breathing pattern, providing relaxation training as appropriate to help normalize breathing patterns, teaching resident when to inhale and exhale while doing strenuous activities, teaching the resident appropriate breathing and using pain management as appropriate. -Resident #52's comprehensive plan of care did not mention that the resident utilized a CPAP machine, the settings or when to clean the machine. According to the May 2023 CPO revealed the following physician orders related to Resident #52's CPAP use: -CPAP: rinse, clean and hang to air dry CPAP mask and tubing, ordered 5/10/23 (during the survey process). -CPAP at 10cmH2O (centimeters of water pressure) with oxygen bleed in at 2 LPM (liters per minute), ordered 12/9/21. -The CPO did not reveal orders to conduct cleaning of Resident #52's CPAP machine. III. Staff interviews Registered nurse (RN) #3 was interviewed on 5/9/23 at 10:22 a.m. She said the nurses were responsible for cleaning the resident's CPAP machine, which should be done routinely. RN #3 said Resident #52 did not have any active orders in place to clean his CPAP machine. RN #3 said she would obtain orders for the cleaning of Resident #52's CPAP machine. The director of nursing (DON) was interviewed on 5/9/23 at 11:13 a.m. She said night shift certified nurse aides (CNA) were responsible for cleaning the resident's CPAP machines. The DON said all residents who have a CPAP machine should have orders to clean the CPAP machine regularly. The DON said she was not aware of how often CPAP tubing should be changed and she would reach out to the respiratory therapist for instructions. IV. Facility follow-up The NHA provided a copy of Resident #52's updated physician orders that revealed the following: -Contact Corp (corporate) RT (respiratory therapist) for any CPAP supplies/questions/concerns as needed, ordered 5/9/23 (during the survey process). -CPAP supply changes performed by RT per manufacturers recommendations as needed, ordered 5/9/23 (during the survey process). -Daily CPAP cleaning, using CPAP wipes, wipe mask cushion and outer shell daily. Use second clean wipe to clean outside of pap (CPAP) tubing and outside of pap (CPAP) unit every day shift, ordered 5/9/23 (during the survey process). -Weekly pap (CPAP) cleaning: Weekly CPAP cleaning; unplug machine from electrical outlet, fill a wash basin with warm water and soap, disconnect CPAP tubing and mask from CPAP machine and place mask and tubing into soapy water and agitate for several minutes. Rinse thoroughly with warm water and place on clean towels and allow to air dry. Check CPAP filtered -Clean reusable filters and allow to air dry, every day shift every Sunday, ordered 5/10/23 (after the survey).

Based on record review and interviews, the facility failed to ensure two (#81 and #52) of five residents were free from unnecessary psychotropic medications out of 29 sample residents. Specifically, the facility failed to: -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #81; -Ensure a gradual dose reducation (GDR) for Resident #52's and Resident #81's use of antipsychotic medications or provide substantial documentation by the prescribing physician on why a GDR of the resident's medication was contraindicated; -Identify and monitor targeted behaviors for psychotropic medications for Resident #52; and, -Ensure Resident #52 had a personalized planned of care for his prescribed antipsychotic medication. Findings include: I. Facility policy and procedure The Psychopharmacological Medications policy and procedure, dated 3/10/23, was provided by the nursing home administrator (NHA) on 5/9/23 at 10:48 a.m. It revealed in pertinent part, A licensed nurse will review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician. The licensed nurse will complete the psychotropic informed consent with the resident or the responsible party. If the information was not obtained prior to admission, the licensed nurse and/or social services director will make every effort to determine if there are any possible behavior symptoms that may require special monitoring and/or care planning. The licensed nurse or designee will document any known target behaviors and potential interventions on the Kardex (an abbreviated care plan). The licensed nurse or social services director will initiate behavior monitoring within the first twenty-four hours of admission. Behavior monitoring is mandatory for all residents who take psychotropic medications. The interdisciplinary team will proceed to care planning for the use of the psychopharmacological drugs. The plan of care must include the resident's focus, and target behaviors for the medication. The primary physician, psychiatrist, and/or consultant pharmacist will monitor residents who are prescribed psychopharmacological drugs at least quarterly to assure these drugs are utilized according to State and Federal regulations and for the appropriate treatment of the resident diagnosis. New resident admissions that receive orders for psychopharmacological drugs will be reviewed at the second scheduled psychopharm committee meeting following the date of admission. Recommendations to the primary care physician are made for gradual dose reductions of psychopharmacological drugs or request for risk vs benefit statement if no gradual dosage reduction (GDR) is recommended. II. Resident #81 A. Resident status Resident #81, aged under 60, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included encephalopathy (disease where the brain is affected) and diabetes type II. The 4/12/23 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. Verbal behavior symptoms were marked for 1-3 days out of fourteen days. C. Resident interviews Resident #81 was interviewed on 5/8/23 at 3:00 p.m. He stated the facility had tried to write him up for behaviors and give him medication. They gave him the Depakote (an anticonvulsant used to treat some psychiatric conditions) for almost a week before he found out and refused to keep taking it. He said the staff or the doctor did not discuss the medication with him before prescribing it. Resident #81 was interviewed on 5/9/23 at 9:39 a.m. He stated he was unaware he was currently taking an antipsychotic (Seroquel) and was unaware the facility had given Hydroxyzine to him previously. He said if the facility had asked him to take the Seroquel, he would have refused. He was not aware of the risk, benefits or side effects of the antipsychotic. He said his brother did not have power of attorney or had authority to sign consents for him (see below). He said he absolutely would not want his brother to have a power of attorney or have the ability to make medical decisions for him. C. Record review The comprehensive care plan, revised 4/13/23, revealed the resident used psychotropic medications related to behavior management for central pontine myelinolysis (neurological disorder), used anti-anxiety medications related to an anxiety disorder, and had a mood problem. The resident displayed behaviors of agitation, restlessness, yelling, and resisting care. The interventions included administering medications per physician orders, educating the resident/family/caregiver about potential adverse effects and side effects, monitoring the occurrence of target behaviors, and consulting with the pharmacy/medical director to consider dosage reduction at least quarterly. The May 2023 CPO revealed the following physician orders for psychotropic medications: -Seroquel 25 MG (milligrams)-give one tablet by mouth one time a day for agitation related to encephalopathy-ordered on 9/15/22; -Depakote 125 MG-give one tablet by mouth two times a day for mood stabilization- ordered 4/22/23 and discontinued 4/26/23; and, -Hydroxyzine 25 MG-give one tablet by mouth two times a day for anxiety-ordered on 1/28/23 and discontinued 2/3/23. -The CPO failed to reveal any dose reductions of the Seroquel. The consents for Depakote and Hydroxyzine were scanned into the resident's medical record. The Hydroxyzine consent dated 1/28/23 documented the resident's brother had given verbal consent for administration. The Depakote consent dated 4/22/23 documented the resident's brother had given verbal consent for administration. A second Depakote consent form dated 4/23/23, then crossed off and changed to 4/25/23, documented the resident refused to sign and refused the medication. No consent for the Seroquel was located. -A review of the resident's medical record failed to reveal a health care proxy, power of attorney, or guardianship order for the resident's brother to make medical decisions. A review of progress notes dated 9/14/22 through 5/9/23 revealed: -Behavior note dated 1/28/23 revealed the resident was yelling and wanted to toilet himself. He began using profanity at staff and the primary care provider (PCP) was contacted and provided an order to start Hydroxyzine 25 mg twice a day. A message was left on the voicemail of the resident's brother. -Nurse progress note dated 4/22/23 revealed the doctor was contacted regarding an outburst the resident had and the Hydroxyzine was discontinued and the Depakote started. The nurse spoke with the resident's brother regarding the new order. -Behavior note dated 4/26/23 at 9:20 a.m. revealed the resident was agitated and upset when approached to sign a consent form for Depakote. The resident wanted to know why he had to sign and what he was signing for, he was informed the PCP had ordered the Depakote to be started. The resident was upset and refused to sign the consent form. The note stated an order was placed on 4/22/23 for the resident to be started on Depakote, however, according to the resident he was never informed that he was being started on a new medication. The behavior note documented This writer had administered Depakote to the resident without knowledge that a consent form was never signed when the order was placed on 4/22/23. -Behavior note dated 4/26/23 at 12:07 p.m. revealed the resident was refusing his Depakote because he was upset he had not been informed he was started on the medication. The note documented the resident's brother had been notified that he had started on this new medication, however, as of current, the resident's profile indicated he was own POA. The resident was informed Depakote would not be administered due to refusal to sign the consent form. -The progress notes failed to reveal a note pertaining to a conversation with the resident regarding risk, benefits, black box warnings, or consent for Seroquel, Hydroxyzine, or Depakote. Psychoactive medication meeting review dated 4/26/23 for Hydroxyzine documented the resident could escalate verbally but is easily redirectable. He had refused medication because he wanted to be part of choosing his medications. -The meeting failed to show GDR being discussed for Hydroxyzine. Psychoactive medication meeting review dated 3/28/23 for Seroquel documented the resident at times could get very anxious and frustrated with day-to-day issues. He would become verbally aggressive with staff when he was confused or did not like the answers that he got. -The meeting failed to show GDR being discussed for Seroquel. -No other psychoactive medication meeting reviews found in the resident's medical record. Behavior tracking revealed: -Tracking for anti anxiety medication started on 2/27/23 to observe behaviors of resisting care and yelling. Interventions to remove the resident from the environment, provide one on one or offer fluids. -Tracking for antipsychotic medication started on 2/27/23 to observe behaviors of agitation and restlessness. Interventions to remove the resident from the environment, provide one on one or return the resident to his room. D. Staff interviews The social services director (SSD) was interviewed on 5/8/23 at 11:20 a.m. The SSD stated the resident was his own responsible party and did not have a power of attorney. She said the resident's brother was not his power of attorney and the resident did not get along with his brother. The SSD was interviewed again on 5/9/23 at 9:41 a.m. She said the social services department checked for psychotropic medication consent forms during their psychoactive medication meeting. The nurses get the consents signed by the resident or their responsible party after a new order was entered. There was only one place that the consents would be kept and that would be the resident's electronic medical record. She said the facility did not have a process where the consent forms were checked against decision maker paperwork to ensure an authorized person had signed the consent form. Every resident on psychotropic medication should have it care planned, behavior tracking in place and medications reviewed at least quarterly in the psychoactive medication meeting. During the meeting, residents' medications were reviewed and it was determined if a resident was appropriate for a gradual dose reduction or not. The social services department, nurse manager, medical director, and the NHA attend the psychoactive medication meetings. She was unaware that there was no consent in Resident #81's medical record for the Seroquel. The Seroquel was started by the facility doctor on 9/15/22 after the resident returned from the hospital after an amputation. The SSD said the resident was angry and depressed when he returned but she did not know why the Seroquel was started for agitation. She acknowledged the resident should have signed his own consents and his medications should have been discussed with him. The NHA was interviewed on 5/9/23 at 10:21 a.m. She said the psychotropic drug consents were obtained by the floor nurse who received the order from the doctor. The nurse managers would review the orders in the following interdisciplinary team morning meeting to include all department managers. She said the facility did not have a process where the consent forms were checked against decision maker paperwork to ensure an authorized person had signed the consent form. She was unaware that Resident #81 was unwilling to take Seroquel. 46022 III. Resident #52 A. Resident status Resident #52, under the age of 65, was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included cerebral infarction due to embolism of right middle cerebral artery (stroke), obstructive sleep apnea, fibromyalgia (pain syndrome), anxiety disorder, chronic obstructive pulmonary disease, hypertension (high blood pressure), obsessive-compulsive disorder (OCD )and gastro-esophageal reflux disease (GERD). The 2/19/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status with a score of 10 out of 15. He required supervision of one person for dressing and personal hygiene. He required extensive assistance of one person for toileting. He was independent with set-up assistance for bed mobility, transfers, walking and eating. The MDS assessment documented the resident received antipsychotic medication on a routine basis. A gradual dose reduction (GDR) was attempted on 12/21/22. The MDS assessment documented a physician documented GDR as clinically contracted had not been completed. B. Record review The mood care plan initiated on 10/21/21 and revised on 11/28/21, revealed Resident #52 had a mood problem related to anxiety. The interventions included: administering medications as ordered, assisting the resident to identify strengths, positive coping skills and reinforce these, educate the resident regarding expectations of treatment, concerns with side effects and potential adverse effects, observing for signs and symptoms of mania, observing for any risk for self harm, observing mood to determine if problems seems related to external causes, observing for acute episode feelings or sadness, observing mood patterns and observing risk for harming others. The May 2023 CPO revealed the following physician orders for psychotropic medications: -Duloxetine HCL capsule delayed release sprinkle 20 MG (milligrams), Give 20 MG by mouth one time a day for anxiety, ordered 1/4/22. -Duloxetine HCL capsule delayed release sprinkle 30 MG, Give 30 MG by mouth one time a day for anxiety, ordered 10/21/21. -Trazodone HCL tablet 150 MG, Give one tablet by mouth at bedtime for Insomnia, ordered 3/28/22. -Ziprasidone HCL capsule 40 MG, give 1 capsule by mouth one time a day for OCD, ordered 12/21/22. -Clonazepam tablet 0.5 MG, Give one tablet by mouth every six hours for anxiety, ordered 10/21/21. The 10/29/22 medication review progress note documented by the physician revealed the resident's current use of psychotropic medications was reviewed with the clinical and social work team. The review of the resident's current clinical and behavioral needs the benefits of maintaining current medications outweigh risks of these medications. Therefore will continue Trazodone at 150 MG every four hours and Duloxetine 50 MG daily. The 10/19/22 psychotropic review summary indicated the resident was prescribed Trazadone, Duloxetine, Clonazepam and Ziprasidone. The form documented the resident had no new behaviors trending. -The resident's medical record was reviewed on 5/8/23 at 11:30 a.m. There was no evidence the facility had identified behaviors or side effect monitoring for the Ziprasidone medication to track targeted behaviors for use of the medications ordered. -Also, there was no evidence a GDR or risk versus benefit completed with Resident #52's continued use of Ziprasidone. C. Staff interviews The SSD and SSA were interviewed on 5/9/23 at 9:21 a.m. The SSD said Resident #52 psychotropic medication use was last reviewed in October 2021. The SSD said Resident #52's psychotropic medication use and mental health diagnosis should be included in his plan of care. Registered nurse (RN) #3 was interviewed on 5/9/23 at 10:22 a.m. RN #3 said Resident #52 was particular about his care, because he had a diagnosis of OCD. RN #3 said Resident #52 took medications related to his OCD. RN #3 said Resident #52's behaviors should be tracked, since he was prescribed antipsychotic medication. RN #3 acknowledged Resident #52 did not have behavior tracking in place for the prescribed antipsychotic medication. The director of nursing (DON) was interviewed on 5//9/23 at 11:13a.m. The DON said Resident #52 was particular about his daily care. The DON said Resident #52 had a diagnosis of OCD. The DON said Resident #52's care plan addressed his mood concerns, but did not address his diagnosis of OCD. The DON said Resident #52's diagnosis of OCD and psychotropic medication use should be included in his plan of care. The DON said Resident #52's behaviors should be monitored and documented. The DON said nursing staff should monitor side effects of prescribed psychotropic medications.

Based on observations, and interviews, the facility failed to provide choices for five (#219, #61, #62, #12, and #43) of nine residents reviewed for choices out of 31 sample residents. Specifically, the facility failed to ensure daily meal choices were provided and honored for Resident #219, #61, #62, #12 and #43. Findings include: I. Facility policy The Dining and Food Preferences policy, revised September 2017, was provided by the nursing home administrator (NHA) on 2/1/22 at 11:15 a.m. The policy revealed, in pertinent part: -The dining service director will interview the resident to complete the individual preferences for food and beverage; -The food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system; -The individual tray assembly ticket will identify all the food items appropriate for the resident and will generate the daily meal ticket; -The resident with expressed or observed refusal of the food delivered will be offered an alternate selection of comparable nutrition value, and; -The alternate meal and or beverage selection will be provided in a timely manner. The policy also revealed the resident should be interviewed on admission for food and beverage preferences and at least quarterly thereafter. II. Resident council minutes The Resident Council minutes provided by the activity director (AD) on 2/1/22 revealed in pertinent part; -The November 2021 minutes reported several residents were upset because they were not given choices at meal time; -The December 2021 minutes reported most of the residents did not like the new meal tracker preference program, and; -The January 2022 reported snacks were not always available and the choices were limited. In addition, the Resident Council minutes did not address previous months concerns regarding meal choices reported in previous minutes. III. Resident observations and interviews The residents interviewed regarding meal choices were all cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident # 219 was interviewed on 1/31/22 at 12:43 p.m. She said she did not get to choose her meals on a daily basis. She said the dietary manager (DM) did ask her what she liked and did not like for her food preferences, however the staff did not ask her what she wanted daily based on what was offered on the menu. She said she did not know what she was going to get to eat each meal and she said she missed being able to choose what she wanted to eat or drink each day. She said the meal tray provided sometimes did not match her meal ticket and did not always follow her low carbohydrate diet. The lunch meal provided on 1/31/22 was observed to have double carbohydrates of pasta and mashed potatoes and a chocolate brownie instead of double protein and steamed vegetables listed on her meal ticket under dietary requirements. On 1/31/22 at 5:20 p.m. Resident #12 was observed in his room sitting in his wheelchair. The evening meal tray was on a bedside table. The plate with food was covered. The resident said he was very upset because his supper was not what he requested. He said he ordered the alternate meal. He said I am tired of not getting the food I ordered. This has happened many times before. If I don't want the regular meal I have to let the kitchen staff know or ask the certified nurses aide to let the kitchen staff know I want the alternate meal or something from the always available menu. Even then it is not a guarantee I will get what I ordered. He said the facility did not have a system in place for residents to order or choose the food they like to eat. On 1/31/22 at 5:39 p.m. Resident #61 was observed standing in the hallway waiting for his dinner to be delivered. Resident #61 received the fish dinner for his meal and notified the scheduling director (SD) who delivered the meal that he did not like fish. She confirmed that the fish was delivered to him for dinner and he repeated that he did not like fish. The plate was set on his bedside table and the resident pushed his bedside table outside of his room. The SD asked him what he would like instead of the fish. Resident #61 stated he would like a cheeseburger for dinner. She removed the fish dinner and notified the dining room of his alternate meal order. On 1/31/22 at 5:39 p.m. Resident #62 was observed sitting on his bed waiting for his dinner to be delivered. Resident #62 received the fish dinner for his meal and notified the SD who delivered his meal that he did not like fish and would not eat his dinner. The SD confirmed that the fish was delivered and asked him what he would like instead of the fish. Resident #62 stated he would like a cheeseburger for dinner. The SD removed his fish dinner and notified the dining room of his alternate meal order. Resident #62 stated he was not asked what he would like for dinner prior to the fish dinner being served. Resident #43 was interviewed on 2/1/22 at 10:00 a.m. He said there were times the meal was delivered to his room which did not match the generated meal ticket with his preferences. He said approximately one month ago the dietary manager (DM) started a new meal program. The staff used to ask the residents daily what they would like to eat and take their orders daily. He said now there was a new program that chooses the meals for the residents. He said the DM met with him weekly to take his weekly order because he was not happy with having a program tell him what he was going to eat. He said the DM does not meet with all of the residents, only him because he asked to choose his meals. He said he gets the wrong meal delivered to his room at least one time a week and would return the meal and ask for something different to be delivered to his room. He said he would prefer to choose his own meals and have the right food delivered to his room the first time. IV. Staff interviews The dietary manager (DM) was interviewed on 1/31/22 at 1:30 p.m. She said she started as the dietary manager in September 2021. She said the facility utilizes the meal tracker program that inputs the residents' individual diet orders and preferences to generate a daily meal ticket. She said she interviewed each resident upon admission and added their food preferences into the meal tracker. She said the registered dietitian would enter the residents' diet orders. She said she was familiar with the process of staff taking the residents' meal choices daily, but this was not the process here. She said a resident could request something different if they looked at the menu posted in the hallway or they could return the meal that was provided to them and ask for an alternative at the time the tray was delivered. She said she was not aware of any residents unhappy with the meal tracker program. The regional dining account manager (RDAM) was interviewed on 1/31/22 at 2:00 p.m. He said the meal tracker program was utilized in all of the communities he supports and said it was not a new program to this facility. He said the program tracks the residents individual diet orders and food preferences and generates a meal ticket based on the daily menu options. He said residents were not asked daily to choose their individual meal and the program chooses the meal for them based on their preferences. He said if a resident reads the daily menu and does not like the main meal, the resident can notify the kitchen staff and choose an alternate meal. He said if a resident does not like the meal delivered to them at the time of the meal, the resident can return the meal and ask for an alternate meal. The scheduling director (SD) was interviewed on 1/31/22 at 5:40 p.m. She said the facility used to take the residents' orders daily for each meal, but switched to the meal preference program recently. She said the residents do sometimes get meals that they don't like and would ask staff for an alternate meal at time of delivery. She said she was not sure how often the residents asked to return their meal for an alternate meal and it depended on what was the main menu item. She said, tonight the main meal was fish and there are quite a few residents who don ' t like fish. The senior dining director of operations (SDDO) was interviewed on 2/1/22 at 1:09 p.m. She said she had supported this facility for five years and the meal tracker program has been utilized here for the entire time. She said she was not sure why residents reported it as a new program. She said she was not sure when the facility stopped taking daily meal orders for residents. She said the meal tracker system takes into account the residents diet order and individual food preferences and generates a meal ticket for each meal. The meal tracker chooses what meal will be served to each resident based on the information entered into the program. She said the facility completes a food and beverage preference sheet at time of admission and then reassesses quarterly. She said a resident can update their preferences at any time. She said the resident food committee reviews the menus monthly and offers suggestions for the upcoming menus. She said the benefit of the meal tracker program was efficiency, safety, timeliness and temperature control. She said the benefit of a notepad system and taking meal orders daily would be the resident having the ability to choose their meal that day and potentially not changing their meal at time of delivery. She said she thought the notepad ordering system would work better in a dining room setting. She said the facility did make special accommodations for residents who preferred to choose their own meals but they would need to notify the dietary manager. She said she was not aware of the residents expressing concerns regarding the meal tracking system and was unaware of it being a systems failure.

Based on observations, record review and interviews, the facility failed provide care and services in a dignified manner for four (#2, #3, #4 and #5) out of six residents reviewed for call wait times out of six sample residents. Specifically, the facility failed to timely address requests for bathroom assistance for Resident #2, #3, #4 and #5 which resulted in the residents feeling upset and uncomfortable. Resident #2 was upset and felt uncomfortable because she had a bathroom accident while waiting an excessive amount of time to receive assistance. Resident #3 was upset because she had a bathroom accident while waiting an excessive amount of time to receive assistance. Resident #4 was upset and felt uncomfortable because she was not changed following an incontinence episode until staff finished delivering meal trays. Resident #5 was upset he was left alone in the bathroom for an excessive amount of time after summoning staff for assistance. Findings include: I. Resident #4 A. Resident status Resident #4, under the age of 60, was admitted on [DATE]. According to the February 2021 computerized physician orders [REDACTED]. The December 2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment, was incontinent of bowel and bladder and required extensive assistance from staff for transferring and locomotion. The comprehensive care plan revealed the resident had difficulty with fluids and took a diuretic which causes (the resident) to use the bathroom a lot. B. Resident observations and interviews Resident #4 was observed on 2/10/21 at 12:15 p.m., reclined on her bed. The call light to the room was activated. A certified nurse aide (CNA) entered the resident's room with a meal tray several minutes later. The CNA asked the resident why her call light was on and the resident replied she had a bathroom accident and needed to be changed. The CNA turned off the call light and responded, We are passing out lunch trays right now, here's your tray and I will be back later to change you. The CNA returned at 12:42 p.m. (27 minutes later) to change the resident. Resident #4 was interviewed on 2/11/21 at approximately 2:30 p.m. She said being wet or soiled made her uncomfortable. She said she had to wait to receive care whenever the CNAs were too busy to help her. She said it happened more in the morning and in the afternoon at shift change. The resident said, at times, she waited more than 45 minutes to be changed. She said she knew it took that long because there was a clock on her wall. II. Additional resident interviews A. Resident #5 Resident #5, who was interviewable, was interviewed on 2/10/21 at approximately 12:45 p.m. The resident said he did not use his call light often but did use it for assistance to get up from the toilet. He said, on occasion, it took an hour to an hour and a half to get assistance. B. Resident #2 Resident #2, a cognitively intact resident with a brief interview for mental status (BIMS) score of 15 out of 15, was interviewed on 2/11/21 at 12:25 p.m. The resident said she has had bathroom accidents waiting for staff to respond to her call light. The resident said she waited for hours on a number of occasions for staff. She said there were also instances when staff answered her call light and said they would come back after answering another call light. She said she had to wait for someone else to check on her before she was changed. The resident said it was uncomfortable and upsetting to sit wet or soiled and wait for staff who never returned. C. Resident #3 Resident #3, a cognitively intact resident with a BIMS score of 13 out of 15, was interviewed on 2/16/21 at 10:30 a.m. Resident #3 said she had to wait a long time for staff to answer her call light. She said she thought there were enough staff to provide care but they did not respond quickly. She said she needed help with toileting but would wet herself waiting for staff to answer her call light. III. Staff interviews CNA #1 was interviewed on 2/16/21 at 2:58 p.m. The CNA said Resident #4 was completely incontinent since returning from a recent hospital visit. She said the resident was aware when she was wet or soiled and would use the call light to summon staff assistance. The CNA said staff would change the resident in bed because she could no longer use the toilet. She said it was difficult to get to residents quickly whenever there were a lot of care needs on the heavy hallway. She described the heavy hallway as the area where there were a lot of two person lifts and nearly total dependence on staff for care. She said it was easier to get to call lights if she had a partner. The CNA said meals were a difficult time to answer call lights. She said she would ask the resident to wait if she had to pass trays without having any help. Registered nurse (RN) #1 was interviewed on 2/16/21 at 3:35 p.m. The RN said staff should respond to call lights in under 10 minutes but try to get to them within five. The RN said Resident #2 was usually incontinent but it depended on whether she used her call light for assistance. The RN said sometimes Resident #2 would press the call button but had an accident by the time staff responded. The RN said the aides should ask the nurses for help if they cannot get to a call light within a reasonable amount of time. She said she felt the staff at the facility did a good job of working together. The director of nursing (DON) was interviewed with the nursing home administrator (NHA) on 2/16/21 at 5:05 p.m. The DON said staff should always meet the needs of the resident. She said staff should not turn the call light off and should attend to the resident immediately. The DON said staff should ask the nurse or call the DON if more assistance is needed than time will allow. The NHA said the concern was being addressed with additional staff education.

Based on record review, interviews, and observations, the facility failed to ensure one (#145) of one resident reviewed of 64 sample residents received specialized services identified through a level II pre-admission screen and resident review (PASRR) when there was evidence of a serious mental illness. Specifically, the facility failed to set up, offer, and follow through with the recommendations on the level II PASRR for resident #145, including psychiatrist visits, medications, bloodwork and physician notification of changes. The failure to follow the identified recommendations contributed to the resident's ongoing mental health issues and emotional turmoil. The findings included: 1. Resident status Resident #145, age 56, was admitted on [DATE]. The 11/16 computerized physician orders [REDACTED]. According to the 9/13/16 minimum data set (MDS) assessment, the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The 11/2/16 MDS did not capture the resident's most recent BIMS, although the staff assessment for mental status documented cognitive patterns of both short-term and long-term memory problems. The resident had a pre-admission screen and resident review (PASRR) level II for a serious mental illness. The resident showed hallucinations and delusions of verbal and other behavioral symptoms during the review period. She had feelings of being down, depressed, or hopeless. She had trouble with sleeping nearly every day during the review period. The resident was unable to concentrate on things half or more days of the review period. 2. Facility Failures The facility failed to follow the PASRR level II recommendations which contributed to the resident's emotional distress and ongoing torment. The resident risk analysis showed the resident had poor medication compliance. She needed encouragement to be compliant with medications to maintain stability and minimize the risk of another hospitalization . She needed close monitoring and frequent follow-up for weekly blood draws while she was on [MEDICATION NAME]. The facility provided one CBC test collected on 10/9/16 when a progress note revealed on 10/6/16, the order was placed STAT in order for the pharmacy to deliver the resident's medication. The progress notes showed multiple incidences the resident went without her [MEDICATION NAME] medication. This was not due to refusals, but due to the lack of availability from the failure to obtain CBC tests as listed on the PASRR level II, and to follow the requirements for the pharmacy to dispense the medication as written. The resident refused Trazadone due to thoughts of the medication being rat poison. There was no documentation of the physician being informed to manage the resident's medications as she showed unstable behaviors. The resident's clinical record showed the facility failed to provide adequate behavior monitoring management. There was limited social services involvement as the resident's behaviors increased. There was no evidence to show any indication a mental health provider was contacted to discuss the resident's medications and behavioral concerns. The record did show no licensed mental health provider provided any psychological therapy, as recommended in the PASRR level II, developed to address the resident's mental health issues. The facility did not document consistent notification to the physician or psychiatrist, as medications were not available and increased behavioral symptoms continued, and the resident showed ongoing emotional distress. 3. Record Review a. PASRR Level II Evaluation On 8/4/16, a level II evaluation was performed by an outside mental health agency. The evaluation revealed in section one, the resident had a long history of treatment for [REDACTED]. -In section two, the resident was identified with a primary [DIAGNOSES REDACTED]. She was admitted to a psychiatric hospital on [DATE] for her third admission in the past six months. She was placed on a mental health (M1) hold. She complained of chest pain and said she heard her chest collapse. The resident stated the pharmacist gave her pills that were rat poison. She also reported auditory hallucinations that someone was speaking inside her stomach asking to come out. The resident's daughter indicated the resident's mood and [MEDICAL CONDITION] was from a [MEDICAL CONDITION] but no supporting evidence was presented. The resident was ruled out for a secondary [DIAGNOSES REDACTED]. A tertiary [DIAGNOSES REDACTED]. The resident also reported having severe panic attacks. The resident was ruled out for mild intellectual disability based on not enough information available at the time of the review to substantiate the diagnosis. The resident was known to have more than five psych hospitalization s in her lifetime for [MEDICAL CONDITION]. The resident said she had hundreds of psychiatric hospitalization s and thought the first hospitalization was in 1985. Three psych hospitalization s had occurred in the past six months. She did not have a history of substance abuse. The resident's medications included the following: -[MEDICATION NAME], an antipsychotic medication, 150 milligrams (mg), by mouth, at bedtime for [MEDICAL CONDITION]. -[MEDICATION NAME], an antipsychotic medication, 10 mg, by mouth, at bedtime for [MEDICAL CONDITION]. -Neurotin, a mood stabilizer medication, 300 mg, by mouth, every morning and 600 mg at bedtime for anxiety. -Trazadone, an antidepressant medication, 150 mg, by mouth, at bedtime, for sleep. -[MEDICATION NAME], a hypnotic medication, 15 mg, by mouth, at bedtime for [MEDICAL CONDITION] (medication can be repeated one time if resident cannot sleep). -Vistrail, a sedative, 100 mg, by mouth, at bedtime for anxiety. -[MEDICATION NAME], an alpha-blocker medication, 2 mg, by mouth, at bedtime for post-traumatic stress disorder ([MEDICAL CONDITION]). A note revealed [MEDICATION NAME] caused a serious and life threatening blood condition and the doctor needed to order weekly blood tests while the resident continued to take the medication. The resident risk analysis showed the resident had poor medication compliance. She needed encouragement to be compliant with medications to maintain stability and minimize the risk of another hospitalization . She needed close monitoring and frequent follow-up for weekly blood draws while she was on [MEDICATION NAME]. The documented risks of decompensation identified the resident had poor insight and poor motivation to manage her mental illness; there was the potential result of non-compliance with medication regimen. The resident would exhibit early signs of increased agitation, paranoia and auditory hallucinations. Recovery methods to avoid decompensation included increased supervision and structure; medication management to help maintain stability. The resident was listed to receive outpatient services through an outside mental health agency. -Section three of the evaluation revealed significant life changes in the last two years with impact on resident's physical or mental status were the following: admittance into psych hospital on [DATE]; she was not able to care for herself because she was delusional and experiencing auditory hallucinations. She thought the pharmacist was giving her rat poison and someone was inside her stomach. She indicated her medications were not working. The resident had two previous hospitalization s since 3/16. The evaluation included a review of the resident's support system, cultural background, current relationships, current attitude and overt behavior, resident affect, and a degree of reality test. The resident was not able to assess her condition and the evaluator determined the resident required full assistance to manage her health, medications, medical appointments, and money management. She indicated the resident required moderate assistance with expressing needs and goals, transportation, and asking for help. The resident needed minimal assistance with bathing, toileting, dressing, and managing her nutrition. The resident's level of care showed she needed a structured setting due to chronic mental illness and history of non-compliance with medications. She needed close supervision and weekly blood draws while she was on [MEDICATION NAME]. The resident's length of stay was for more than six months in a nursing facility. The resident was willing to go to a facility. -In section four, the specialized services recommended to address the resident's serious mental issues included: The facility would provide behavior monitoring management - Nursing and social services would provide ongoing evaluation of the resident's mood, participation in care/treatment, medication management, and psychiatric stability. Any behavioral concerns and increased symptoms were to be reported to the primary care physician and/or psychiatrist for further evaluation. The resident needed to be encouraged to participate in care planning goals to increase motivation for participation in her wellness and rehabilitation. Occupational, physical, and therapeutic recreation were to be reviewed with the physician. The mental health provider would provide individual therapy, twice a month until stable and then at the discretion of the therapist to offer psychotherapy to the resident; monitor symptoms, and provide support for dealing with mental illness and encourage effective coping skills. Medication management reviewed monthly by a psychiatrist would be most beneficial for the resident until stable and quarterly when stable because the resident had a history of [REDACTED]. b. Physician Orders A review of the 11/16 computerized physician orders [REDACTED]. -On 8/17/16, an order for [REDACTED]. -On 8/17/16, an order for [REDACTED]. -On 8/17/16, an order to observe resident behavior. -On 10/20/16, an order for [REDACTED]. The CBC was to be drawn on the 10th of each month. The order was not congruent with the 8/16/16 order for weekly CBC draws as both remained active orders. c. CBC labs A request for CBC lab draws for 10/16 and 11/16 revealed one lab was drawn on 10/9/16. The facility did not provide evidence the recommendation of weekly CBC draws was being followed according to the PASRR level II. Additional labs were requested on 11/21/16 and none were provided. One document dated 11/14/16 showed the resident refused a lab draw. The resident was not approached for a second or third time for lab work up as the form directed the facility to approach refusals. d. Therapeutic Services A review of the 8/23/16 MDS assessment showed the resident received speech and occupational therapy services. She did not receive any psychological therapy by a licensed mental health professional or recreational therapy. The 8/30/16, 9/13/16, 10/11/16, and 11/2/16 assessments failed to provide evidence any psychological therapy was provided by a licensed mental health professional to the resident since she arrived to the facility. e. Mental Health Agency Notes There were no notes available from an outside mental health provider to show the resident received or was followed by an outside provider for her mental health status although PASRR level II recommendations were to provide individual therapy, psychotherapy, and medication management as listed above. f. Interdisciplinary Progress Notes A review of the resident's progress notes from 8/16/16 through 11/21/16 revealed the following: -On 8/16/16, [MEDICATION NAME] for [MEDICAL CONDITION] was not administered while pending delivery from pharmacy. -On 8/17/16, [MEDICATION NAME] for [MEDICAL CONDITION] was not administered. The pharmacy required blood test before medication could be delivered. -On 8/18/16, [MEDICATION NAME] for [MEDICAL CONDITION] was not administered. The labs were pending and pharmacy required test results before medication could be delivered. There was no evidence to show the resident's physician was notified to determine if alternative treatment options were available to the resident with known history of non-compliance and poor medication management. -On 8/19/16, the resident was loud and yelling out; she could be heard speaking loudly about being hit by a parent if placed in the same room as herself. The resident was having conversations with people not there. -On 8/23/16, the resident had some noted delusions, hallucinations of auditory nature on the morning shift. -On 8/23/16, the resident was loud, screaming, and using foul language. The resident was speaking to someone in her room that was not present. She did not want the nurse to enter her room and made derogatory statements directed towards the nurse. -On 8/29/16, an activity note revealed the resident had several [DIAGNOSES REDACTED]. Staff were to offer friendly visits for daily socialization. -On 9/1/16, the resident was agitated when disturbed; she screamed at auditory hallucinations. She stated she did not feel right. There were no notes to indicate the resident's physician or mental health provider were contacted or notified. -On 9/3/16, the resident cried out several times throughout the night. She appeared to rest with eyes closed and then cry out others were trying to get her. -On 9/8/16, the resident over dramatized on things. There was no description of the things the resident was over dramatizing over. -On 9/18/16, the 72-hour care conference note indicated the resident was at the facility due to a stay at a mental health facility. She was tired and did not want to interact. The care conference was noted 32 days after the resident arrived to the facility. -On 9/19/16, a note about [MEDICATION NAME] was generated. The note did not indicate whether the medication was administered or not. There was no indication the physician was notified or contacted. -On 9/24/16, the resident's [MEDICATION NAME] was on order and was not administered according to the physician orders. There was no note to show evidence the resident's physician was notified to determine if another course of treatment should be considered. -On 9/26/16, a note about [MEDICATION NAME] was generated. The note did not indicate whether the medication was administered or not. There was no indication the physician was notified or contacted. -On 9/27/16, [MEDICATION NAME] for [MEDICAL CONDITION] was not administered while pending delivery from pharmacy. -On 10/2/16 and 10/3/16, a note about [MEDICATION NAME] for [MEDICAL CONDITION] was generated. The note did not indicate whether the medication was administered or not. There was no indication the physician was notified or contacted. -On 10/5/16, the resident was extremely agitated and yelling at others. -On 10/6/16, a note about [MEDICATION NAME] showed the resident's medication was not administered and was on order. The note did not indicate if the physician was notified to determine alternative treatment options. -On 10/6/16, the resident's CBC was ordered STAT in order to provide the pharmacy with results to dispense [MEDICATION NAME]. The resident had gone several days without the medication and was screaming out in her sleep and fighting with her roommate. See above laboratory notes to show lab was not drawn until 10/9/16 when STAT order placed on 10/6/16. -On 10/8/16, the resident's [MEDICATION NAME] was not administered and remained on order. -On 10/8/16, the resident had increased hallucinations and paranoia. The hallucinations caused her to scream and make statements directed towards a family member and her being told to shut up. The resident was saying strange things inconsistent to time and location. There were no notes to indicate the resident's physician or mental health provider were notified of the behavior. -On 10/9/16, the resident was yelling and screaming out in her sleep. She stated someone had tried to get her from outside the window. The resident had been out of [MEDICATION NAME], an antipsychotic medication, for several days although review of progress notes would indicate documentation efforts were incomplete to capture the correct span of time the resident went without her antipsychotic medication. It was unclear how resident received administration of medication when it was not available to administer. The medication was prescribed due to [DIAGNOSES REDACTED]. There was no documentation to show the physician was contacted to determine if another course of treatment should be considered as the medication remained on order prior to her hospitalization . There was no evidence to show the pharmacy was provided CBC tests for delivery of the resident's antipsychotic medication although blood tests for the use of [MEDICATION NAME] were ordered weekly and no refusals for blood draws were observed. The medication remained on order after the resident's return from the hospital. -On 10/9/16, the resident returned to the facility. She received an injection of [MEDICATION NAME], an antipsychotic medication, while she was hospitalized . There was no discharge paperwork observed in the resident chart. -On 10/10/16, the resident screamed throughout the afternoon shift. The resident was disruptive to her roommate and expressed she could not sleep and needed a sedative. -On 10/12/16, the resident was sleeping when a confused male resident attempted to get into bed with the resident. There was no documentation in the progress note to show whether the physician or interested parties were contacted. -On 10/13/16, the resident was extremely agitated and tearful. She was easily upset, yelled at nursing staff and hallucinating. She experienced delusions during the evening shift and refused some of her antipsychotic medications. -On 10/14/16, social services assistant attempted to speak with resident and resident would not respond to questions. -On 10/14/16, the resident refused all of her medications. There was no evidence to show the resident's physician was contacted. -On 10/15/16, the resident's behaviors were disruptive to the living environment as she screamed at hallucinations and could not be calmed. She continued to scream at hallucinations into the night. -On 10/17/16, the resident was verbally aggressive toward staff and roommate. She was screaming and yelling out about demons trying to get her. She could not understand why they (her hallucinations) would not leave her alone. She was offered non-pharmacological interventions but refused options. Her language, tone, and volume would calm temporarily. -On 10/17/16, the resident continued having hallucinations and delusions. She was screaming and crying out. She cried out for help and she could not stand it. She thought mannequins were trying to get her. -On 10/18/16, the resident announced loudly to social services, she needed to contact the social security office because they have kept her up at night talking through the window. She told the SW social security spoke to her every night, all night long. -On 10/19/16, the resident began screaming and crying out in her sleep. The nurse attempted to re-direct the resident but was temporary calmed until the resident began to cry out again. The resident continued to scream out on the morning shift directed towards her hallucinations and was unable to calm herself. -On 10/20/16, the resident reported having hallucinations and continued to scream at them. -On 10/21/16, the resident was hallucinating and screaming constantly during the morning shift. She repeated frequently she did not want to see a family member due to the family member trying to steal her money. There was no documentation to show the physician or community mental health agency was contacted to address the ongoing issues with resident's auditory and visual hallucinations. -On 10/21/16, the resident screamed, used foul language, and continued to talk to herself. She would calm for a few minutes and go back into her cycle. -On 10/21/16, during the evening shift the resident continuously yelled, screamed, and threw items. The resident was able to be calmed for a few minutes until she repeated the same behaviors again. There was no communication with the physician or mental health agency found in the progress notes as the resident continued to express distress from her hallucinations. -On 11/4/16, the resident's [MEDICATION NAME] medication was on order again and the facility waited for pharmacy delivery. -On 11/17/16, the resident was screaming in her room about a family member trying to put something in her ear. The resident was shaking and rocking herself while cuddled up in a sheet. The resident was reassured she was safe. -On 11/20/16, the resident continued to have delusional ideations, yelling, and hallucinating. The resident would not take trazadone, an antidepressant medication, for [MEDICAL CONDITION] because she felt it was rat poison. -On 11/21/16, the resident continued to cry out and was fearful of something happening to her. She continued to have delusional ideations. She yelled out concerns of the police harming her and men coming to get her. The resident was not consolable to efforts. g. Physician notes A review of physician notes revealed the resident was last seen on 8/25/16. The resident was identified with [MEDICAL CONDITIONS], anxiety, and [MEDICAL CONDITION]. The resident was not able to provide any history with specificity or reliability. She did not have a psychiatry appointment scheduled for two more weeks. She was on [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for post-traumatic stress disorder. There were no additional physician progress notes [REDACTED]. There was no review of her medication management as her behaviors remained unstable. h. Care plan A review of the 8/25/16 behavioral care plan documented the resident had a behavioral problem by being dismissive towards staff and visitors, rejection of cares, yelling out at delusions and hallucinations -The goal was the resident would have fewer episodes related to rejection of cares, yelling out, and being dismissive towards others. -The interventions were: administer medications as ordered, intervene to protect the rights and safety of others; notify the doctor as needed; the resident's behaviors are de-escalated by being left to self soothe alone in room removing excess stimulation (other residents being loud). The care plan did not indicate self-soothing consisted of the resident screaming and yelling as the resident's auditory and visual hallucinations and paranoia caused fear and torment. 4. Observations On 11/16/16 at 4:05 p.m., the resident was heard screaming loudly from behind her closed door. The resident was heard screaming accusatory language for an extended period of time. The residents down the hallway asked nursing staff what was happening to the resident. The certified nurse aide (CNA) informed the residents the resident in that room screamed a lot. On 11/16/16 at approximately 4:45 p.m., the resident's door was closed when she began to scream loudly with a fear based tone. The nursing home administrator (NHA) and clinical nurse (CN) #2 were walking down the hallway. The CN stopped, knocked on the door, and opened the door to see if the resident required assistance. The resident was in a dark room; her light was turned off. The resident was not familiar with the CN and began to express her distrust towards the CN. The NHA entered the conversation and the CN exited the room. On 11/16/16 at approximately 5:00 p.m., the resident was heard screaming at the top of her lungs. Her tone appeared fearful as she screamed to have a person stay away from her. The resident's door was propped open and she could be seen from outside the hallway. There were three staff members in the vicinity of the resident's room as she screamed. The licensed practical nurse (LPN) #8 walked to her door and looked in the room. The LPN did not approach or speak to the resident. He walked away and returned to the other two staff members standing in the hallway. On 11/17/16 at 8:05 a.m., the resident's room was observed from the hallway. The curtains were pulled back and natural light came through the window. The room was not homelike. The resident's room appeared very sterile and institutionalized with few items. There was a 20-inch screen television on her dresser, a tray table, chair, and bed. The walls, bed spread, floors, and pillows were white. There was no color in the resident's room. No pictures were hung on the walls. The resident was in the hallway, tearful as she spoke with the NHA about money she was entitled to have, although the business office refused to give her money. On 11/17/16 at 2:41 p.m., the resident could be heard screaming with a fearful tone from the restorative therapy room approximately five feet from the resident's egress door. There were two aides in the room restorative room as the resident screamed from behind the closed door of room. No staff member stopped to check on the resident as she continued to scream. The aides in the room stated the resident's screams sounded like she was scared. On 11/17/16 at 4:04 p.m., a continuous observation outside the resident's room occurred. The resident could be heard speaking loudly from inside her room with the door closed. -At 4:20 p.m., the resident continued to have a conversation with herself. She could be heard from outside her door. -At 4:23 p.m., the resident screamed accusatory language. Her tone appeared tearful and distressed. The resident made statements to indicate her body was destroyed and someone did not believe her but believed someone else. -At 4:26 p.m., the resident could be heard screaming from outside her room. She made nonsensical statements to shoot someone to death and for someone not to take a person. -At 4:29 p.m., the resident continued to scream from her room. The CN #2 heard the resident and he knocked. The resident immediately stopped screaming and would not converse with the CN as he asked if she was okay. The resident's room was dark and no light was on. The CN exited the room and stated he would get a CNA to assist the resident who was on the commode. -At 4:33 p.m., CNA #15 entered the resident's room. The resident would not speak, she stopped screaming and exited at 4:34 p.m. -At 4:34 p.m., the resident immediately began to scream again. She made accusatory statements with a fearful tone. -At 4:35 p.m., the resident continued to scream loudly from behind her closed door. Her statements were nonsensical. She name called individuals animals and beasts. -At 4:36 p.m., the resident continued to scream from inside her room. The housekeeping manager (HM) and CNA #16 walked past the resident's room as she continued to scream. They did not stop or approach the resident's room to inquire the resident. -At 4:36 p.m., the resident continued to scream loudly. Her statements remained nonsensical as she stated she no longer wanted to fight with someone anymore. -At 4:39 p.m., the resident screamed in distress and fear. She yelled to keep someone away from her multiple times. -At 4:40 p.m., the resident continued to scream in distress. The social worker (SW) was directed to the resident's room. She entered the resident's room and began to speak with the resident. The resident struggled to be redirected as she continued to make accusatory statements directed towards family members. The resident told the SW the family member would not stay away from her and referred to family members as animals. -At 4:41 p.m., the SW continued to attempt redirection and process information with the resident. The resident showed seconds of being redirected but was inconsolable and continued with negative statements. -At 4:52 p.m., the SW continued to use distraction tactics to diffuse the resident's behaviors although she continued to make negative statements. 5. Staff Interviews The SW was interviewed on 11/22/16 at 1:56 p.m. She said she was familiar with the resident. The resident was described to have delusions and paranoia. The SW said the resident was easily agitated and at times could be redirected. The SW confirmed the resident had a PASRR level II for mental health concerns. She said PASRR was used to help identify needs to best serve a resident with mental health issues. The SW stated the resident was supposed to receive mental health services from an outside agency but had to go out into the community to receive them. She confirmed therapy and medication management were services she should have received from the outside provider and facility. She said since the resident was not on a stable medication regimen and showed ongoing unsafe behaviors, it was not feasible for her to leave the facility and enter the community for treatment. She said no psychiatrist was willing to come to the building to serve the mental health population which included the resident. The SW said the PASRR recommendations were not being followed since her time of arrival and had contributed to the resident's behaviors. The SW stated the resident needed a psychiatrist to oversee her medication management. She said the resident required a psychological evaluation and psychotherapy to prevent her from going through a tailspin of emotions that had increased and eventually caused hospitalization . The director of nursing (DON) was interviewed on 11/22/16 at 4:25 p.m. She confirmed the facility served a population of residents with mental health issues and there was no psychiatrist coming into the building to review psych medications for residents. She said services had to be provided outside the facility which caused problems for the residents unable to go out into community safely. The assistant director of nursing (ADON) was interviewed on 11/22/16 at 5:26 p.m. The ADON said when the resident was heard screaming, it sounded like the resident was in torment. She said the resident's hallucinations scared the resident. The ADON stated the resident would benefit from a thorough medical review and psychiatric services. She said her medications and behaviors needed to be monitored and reviewed to identify trends and the effectiveness of medications. The ADON confirmed the facility served residents with mental health issues and was aware they had no psychiatrist to address the ongoing concerns of the facility and the contributing factors the lack of services had on the resident's medication management and inability to stabilize her behaviors to prevent the resident from being scared and in torment. The resident's physician (medical director of the facility) was interviewed on 11/21/16 at 12:24 p.m. He said he was aware there was a lack of community involvement through the behavioral health organizations and county mental health providers. He was not familiar with the resident although progress notes showed increased behaviors and medication issues from refusal of Trazadone and [MEDICATION NAME]'s lack of availability to administer routinely which required physician notification and monitoring as listed in the PASRR level II recommendatio

Based on record review, observation and interview, the facility failed to ensure four (#141, #161, #3, and #124) of 64 sample residents received the care and services necessary to attain and/or maintain their highest practicable level of well-being regarding pain management, [MEDICAL TREATMENT] care and hospice care. Specifically, the facility failed to ensure residents received the highest practicable quality of life and care related to: -Pain management - Facility staff failed to timely assess and promptly intervene to minimize the pain of residents #141 and #161. Resident #141 was observed for multiple days with pain due to unavailable pain medications. The facility failed to have a systematic approach to assess the effectiveness of pain medications and provide non-pharmacological interventions for residents #141 and #161. These failures contributed to resident #141 experiencing pain levels at ,[DATE], ,[DATE] and ,[DATE]. -[MEDICAL TREATMENT] care - Facility staff failed to assess fistula bruit and thrill and to communicate consistently with the [MEDICAL TREATMENT] center for resident #3. -Hospice care - Facility staff failed to coordinate care with hospice to ensure showers were provided for resident #124. The findings included: I. Pain Management Cross-reference to F425, failure to ensure routine medications were available. A. Resident #141 1. Resident Status Resident #141, age less than 55, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact, with a brief interview of mental status (BIMS) score of 14 out of 15. He required two-person extensive assistance for bed mobility, transfer, and dressing. He was noted with impairment to range of motion for upper and lower extremities. The resident had frequent pain, noted as severe, and received both scheduled and as needed pain medication. 2. Facility Failures -The facility failed to ensure medications were available to meet the need of the resident, as ordered by the physician. Medications were not noted as being removed from the emergency drug kit. -The facility failed to document the dosage of the [MEDICATION NAME], whether 1 or 2 tablets. -The facility failed to evaluate the resident's usage of alcohol and other drugs. The resident did not receive [MEDICATION NAME] or [MEDICATION NAME] on [DATE]. Pain scales were not noted at that time. The resident again did not receive [MEDICATION NAME] or [MEDICATION NAME] on [DATE] and [DATE]. Pain scales were not noted at that time. The resident had not received a scheduled [MEDICATION NAME] as prescribed, during this period of time. 3. Resident #141 Interviews Resident #141 was interviewed on [DATE] at 10:40 a.m. The resident said he had pain that was not currently relieved. The resident said that he was supposed to have a pain patch switched out every three days, but he had not had a new patch put on for a number of days now. He said the facility staff kept giving him excuses. Resident #141 was interviewed a second time on [DATE] at 2:15 p.m. The resident said he still had the [MEDICATION NAME] from two weeks ago on his chest. The resident showed the patch on his upper right chest, which had smeared writing on it. The resident said he had told all the staff that he still needed a new patch for the pain. Resident #141 was interviewed a third time on [DATE] at 10:11 p.m. The resident said that he finally got a new [MEDICATION NAME] on [DATE]. But now the resident said he was missing his [MEDICATION NAME]. The resident said he had to deal with a lot of pain. It's always something. The resident said he had a wound on the back of his leg, and his wheelchair was not always as comfortable as he wished it could be. He said the facility had tried to make him as comfortable as possible in it, but needed his pain medication. 4. Record Review - Pain Management Care Plans: -Receives pain medication therapy. Initiated [DATE]. Approaches included (in pertinent part): administer [MEDICATION NAME] medications as ordered by physician. Observe/document side effects and effectiveness each shift. Review quarterly for pain medication efficacy. -Has potential for pain. Initiated [DATE]. Approaches included (in pertinent part): anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results. Pain Evaluations: -[DATE]: pain almost constantly; currently has severe pain; receives scheduled and as needed pain medicine; pain goal is for hurts a little bit/mild pain -[DATE]: pain is frequent; currently has very severe pain; receives scheduled and as needed pain medicine; pain goal is for hurts a little bit/mild pain Physician Orders: -[DATE] [MEDICATION NAME]-Give 325mg by mouth every 4 hours as needed for pain, take 2 tablets by mouth every 4 hours as needed for pain -[DATE] Hold narcotics if resident is suspected of using marijuana -[DATE] [MEDICATION NAME] 300mg-Give 300mg by mouth four times a day for [MEDICAL CONDITION] -[DATE] [MEDICATION NAME] 30mg-Give 1 tablet by mouth two times a day for pain management -[DATE] [MEDICATION NAME] 4mg-Give 1 tablet by mouth every 4 hours for chronic pain -[DATE] [MEDICATION NAME] 10mg-Give 10mg by mouth four times a day for muscle spasms -[DATE] [MEDICATION NAME] Patch 72 hours 12 mcg-Apply 1 patch [MEDICATION NAME] one time a day every 3 days for pain and remove per schedule. Discontinued [DATE]. -[DATE] [MEDICATION NAME] Patch 72 hours 12mcg-Apply 1 patch [MEDICATION NAME] one time a day every 3 days for pain and remove per schedule (both physician orders [REDACTED].>Medication Administration: [DATE]: -[MEDICATION NAME] Patch 72 hours 12mcg: not applied on [DATE]. An older and expired [MEDICATION NAME] applied on [DATE] was not replaced on [DATE]. A progress note stated the medication was not available. The older [MEDICATION NAME] from [DATE] was not removed and replaced until [DATE]. The resident's pain level was noted at an ,[DATE]. The [MEDICATION NAME] was removed and replaced on [DATE] but no pain scale was noted. The [MEDICATION NAME] was not removed and replaced on [DATE], and no pain scale was noted. A progress note stated that the facility was awaiting delivery of the medication. The [MEDICATION NAME] was noted as removed and reapplied on [DATE]. There was no pain scale noted on [DATE] or [DATE]. -[MEDICATION NAME] 30mg: was not administered on [DATE]. Progress notes stated waiting for meds and out of medication. [MEDICATION NAME] was not given on [DATE]. A progress note stated on order. No pain scales were noted at these times. -[MEDICATION NAME] 10mg: was not administered twice on [DATE], three times on [DATE], [DATE], and [DATE]. Progress notes stated waiting for meds, awaiting pharmacy. Progress notes on [DATE] stated that [MEDICATION NAME] was not administered due to under influence of alcohol. -[MEDICATION NAME] HCI 4mg: was not administered three times on [DATE], once on [DATE], six times on [DATE], and three times on [DATE]. Progress notes stated that waiting for meds, awaiting pharmacy, to (sic) late to pass medication, not available and on order. On [DATE] progress notes stated under influence of alcohol. -[MEDICATION NAME]: was administered on [DATE]. Pain was noted at a ,[DATE]. A progress note stated the resident received [MEDICATION NAME] due to complaining of severe pain. The quantity of [MEDICATION NAME] tablets was not documented. -There was no documentation the facility ensured the pain medications were reevaluated to ensure effectiveness after administration. -The facility failed to provide [MEDICATION NAME] HCI 4mg for the reason of being too late to administer, without explanation. [DATE]: -[MEDICATION NAME] Patch 72 hour 12mcg: the patch was due to be removed and replaced on [DATE] but was not. A progress note stated on order. A progress note on [DATE] stated not removed await order to come in for patch replacement. The [MEDICATION NAME] was removed on [DATE] and replaced. The pain scale on [DATE] was ,[DATE]. No pain scale was noted on [DATE], [DATE], [DATE], or [DATE]. -[MEDICATION NAME] 30mg: was not administered once on [DATE], twice on [DATE], [DATE], and [DATE]. A progress note on [DATE] stated held due to suspected alcohol and drug use. Progress notes on [DATE] and [DATE] stated out of medication. A progress note on [DATE] stated non available waiting for new rx (prescription) to be faxed to pharmacy. -[MEDICATION NAME] HCI 4mg: was not administered five times on [DATE], twice on [DATE], once on [DATE], once on [DATE], and three times on [DATE]. Progress notes on [DATE] and [DATE] stated that the medication was not administered due to alcohol and drug use. Progress notes on [DATE] and [DATE] stated to (sic) late to give medication. Progress notes on [DATE] stated not available, on order. -[MEDICATION NAME]: was administered once on [DATE]. Pain was noted at a ,[DATE]. -There was no documentation the facility ensured the pain medications were reevaluated to ensure effectiveness after administration. -No explanation was documented regarding facility failure to provide [MEDICATION NAME] HCI 4mg for the reason of being too late to administer. 5. Staff Interviews Licensed practical nurse (LPN) #7 was interviewed on [DATE] at 10:19 p.m. The LPN said that each nurse on a medication cart is responsible for the medications. If we see they're (resident) running low, we try to take care of it. The LPN said they do not always know why the pharmacy will not refill some medications. The LPN said sometimes the pharmacy will say the script was not good, even if the nurse sees refills available on it. The medical director (MD) was interviewed on [DATE] at 12:25 p.m. The MD was asked about the physician order [REDACTED]. The MD said that the nurses should document in the resident record if they withhold medications for this reason. The MD said that sometimes the nurse can smell liquor. Sometimes there will be suspicion about the resident using other drugs. Registered nurse (RN) #5 was interviewed on [DATE] at 1:20 p.m. The RN said that she gave resident #141 his pain medication before his wound care treatments. The RN said she had given him his pain medication twice on this day. The RN said the resident had run out of his [MEDICATION NAME]. The RN said that she used the pain scale for when she administers the pain medication, and goes back to the resident an hour later to follow up with the pain scale to ensure effectiveness. The RN said that residents that have been identified with pain will also have a charting every shift for their pain. The RN looked at the chart for resident #141 and said that for some reason he did not have a place to chart pain every shift. LPN #8 was interviewed on [DATE] at 10:15 a.m. The LPN said that resident #141 had high levels of pain, but as long as he gets his pain medicine properly regimented he is ok. The LPN said that if there was any delay in the resident getting his pain medication then it took a while to get his pain under control again. The LPN said the facility had a long-standing problem with the pharmacy supplying insulin and narcotics. We call them constantly to ask where the medicines are. The LPN said it could take days or weeks to get some medicines back. The LPN said that resident #141 had gone days without his pain medicine, and others had too. It makes it impossible to keep pain under control. The LPN said that the director of nursing (DON) and the nursing home administrator (NHA) had been trying to contact the pharmacy to get the issue corrected. RN #5 was interviewed on [DATE] at 10:37 a.m. The RN said that resident #141 had not had his [MEDICATION NAME] yesterday when she was there, but it had come overnight. The RN said that the pharmacy would only dispense so many pills, so if the resident used them regularly he would run out of the [MEDICATION NAME] in just a few days. Certified nurse aide (CNA) #3 was interviewed on [DATE] at 11:10 a.m. The CNA said that resident #141 had a lot of frequent pain. The DON was interviewed on [DATE] at 2:05 p.m. The DON said that resident #141 had changed his [MEDICATION NAME] dose recently, and that the facility had run out. The DON said when it came to her attention she ordered it stat, while they could also pull it from the emergency drug kit. The DON said the assistant director of nursing (ADON) had told her the [MEDICATION NAME] had arrived. The DON said she did not know the resident had run out of [MEDICATION NAME] recently. B. Resident #161 1. Resident status Resident #161, age 66, was admitted on [DATE]. According to the ,[DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident required extensive assistance of two persons with bed mobility, transfers and toilet use. She required extensive assistance of one person with dressing and personal hygiene. She received scheduled and as needed (PRN) pain medications and non-medication interventions for pain relief. Staff reported the resident verbally complained of pain three to four days out of five. The [DATE] Nursing Admission Data Collection assessment revealed the resident was alert to person, place and time and had no memory difficulties. 2. Facility Failures The facility failed to administer pain medications as ordered by the physician, and failed to identify and implement non-medication interventions. 3. Resident Interview and Observation The resident was observed lying in bed on [DATE] at 9:15 a.m. She reported she was having pain in her stump. She reported her last pain pill was last night. She said, You ask for a pain pill and never get one. The wound care physician was present during the conversation and reported the resident's complaint to the nurse. Registered nurse (RN) #3 brought the resident a pill at 9:23 a.m. RN #3 later reported the pill was an [MEDICATION NAME]. 4. Record Review Care Plan: The pain care plan, revised on [DATE] revealed the resident had the potential for pain. The care plan did not indicate the reason the resident had the potential for pain. The resident's goal was for pain not to interrupt her normal activities. The interventions, initiated [DATE], included the following: - Administer pain medication prior to treatments and therapy, if indicated; - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; - Evaluate the effectiveness of pain interventions. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; and - Notify the physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The care plan did not provide staff with non-pharmacological interventions and did not address the pain related to the pressure ulcer or stump pain. Physician Orders: The ,[DATE] CPO revealed the following pain medications: [REDACTED] - [MEDICATION NAME], 25 mcg (microgram) per hour, apply one patch [MEDICATION NAME] every 72 hours for pain (Start date[DATE]); - [MEDICATION NAME] 100 mg, give 300 mg by mouth four times daily for neuropathic pain (Start date [DATE]); - [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg, give one tablet by mouth four times daily for pain (Start date [DATE]); - [MEDICATION NAME] HCL 5 mg, give one tablet by mouth every six hours as needed (PRN) for moderate pain (Start date [DATE]) Assessments: The [DATE] Pain Evaluation revealed the [DIAGNOSES REDACTED]. She received scheduled and PRN pain medications but no non-medication interventions for pain were provided. The resident reported having frequent pain over the last five days. She reported her pain level was 4 - moderate pain at the time of the assessment. The assessment did not answer the questions related to worst or best pain and the assessment did not document what the resident's acceptable level of pain was. No non-medication interventions were identified on the assessment. The [DATE] Pain Evaluation revealed the [DIAGNOSES REDACTED]. The resident reported she had pain occasionally over the past five days. She reported the pain had limited her day-to-day activities. She verbalized her pain was a level 5 - Moderate pain at the time of the assessment. She reported the worst the pain would get was a level 8 - Severe Pain. She indicated the best her pain would get was a level 2 - Mild Pain. The assessment documented she reported repositioning, diversion activities and pain medication helped to relieve her pain. Pain Related Documentation: The resident was admitted at 2:15 p.m. on [DATE]. According to the ,[DATE] and ,[DATE] Medication Administration Record [REDACTED]. The NN documented the medication was not administered because it was on order from the pharmacy. The ,[DATE] MAR indicated [REDACTED] - The resident received [MEDICATION NAME] HCl 5mg, one tablet by mouth 27 times from ,[DATE] - [DATE]. Review of the NN revealed no non-medication interventions were provided prior to the administration of the medication. - On [DATE], [MEDICATION NAME] HCl 5mg, one tablet was administered at 3:38 p.m. and was documented as effective relieving the resident's pain at 3:56 p.m.; - On [DATE], [MEDICATION NAME] HCl 5mg, one tablet was administered at 8:28 a.m. and was documented as effective relieving the resident's pain at 8:39 a.m.; - On [DATE], [MEDICATION NAME] HCl 5mg, one tablet was administered at 7:27 a.m. and documented as effective relieving the resident's pain at 7:59 a.m. - On [DATE], [MEDICATION NAME] 100mg was not administered as ordered. The NN revealed the medication was on order from the pharmacy. 5. Staff Interviews The assistant director of nursing (ADON) was interviewed on [DATE] at 2:40 p.m. She said the staff should wait to document the results of a pain medication for at least an hour. She said two non-medication interventions should be attempted prior to administering any PRN pain medication. She said this should be documented in the NN. II. [MEDICAL TREATMENT] Care A. Professional Standards According to the National Institute of Diabetes and Digestive and Kidney Diseases, Vascular Access for [MEDICAL TREATMENT], ,[DATE], http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/vascular-access-for-[MEDICAL TREATMENT]/Pages/index.aspx, (,[DATE]), documented care of the vascular access included checking the thrill in the access every day. B. Facility Failures The facility failed to assess resident #3s [MEDICAL TREATMENT] shunt for bruit and thrill in accordance with professional standards; and - Failed to ensure consistent communication with the [MEDICAL TREATMENT] center for the care of the resident. C. Resident #3 status Resident #3, age 50, was admitted [DATE] and re-admitted [DATE]. According to the ,[DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use. The assessment did not indicate the resident received [MEDICAL TREATMENT] services during the assessment period. D. Record Review Care Plan: The [MEDICAL TREATMENT] care plan, revised [DATE], revealed the resident required [MEDICAL TREATMENT]. The goals included the resident would have immediate interventions should any signs or symptoms of complications from [MEDICAL TREATMENT] occur and the resident would have no signs or symptoms of complications from [MEDICAL TREATMENT]. The interventions included the following: - After returning from [MEDICAL TREATMENT], check for thrill and bruit two times per shift on day resident returns and then daily (Initiated [DATE]); - Check and change dressing daily at access site and document. (Initiated [DATE]); - [MEDICAL TREATMENT] communication record to be sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed (initiated [DATE]); - Observe vital signs after [MEDICAL TREATMENT], notify the physician of significant abnormalities (initiated [DATE]); - Observe, document and report any signs or symptoms of infection to access site: redness, swelling, warmth or drainage. (Initiated [DATE]); and - Check vital signs every shift for 24 hours post [MEDICAL TREATMENT] or per physician's orders [REDACTED]. Physician order [REDACTED].>The ,[DATE] CPO revealed the following orders related to [MEDICAL TREATMENT]: - Vital signs post [MEDICAL TREATMENT] every evening and night shift every Monday, Wednesday and Friday (Start date [DATE]) There was no order to assess the [MEDICAL TREATMENT] shunt for thrill and bruit or to check and change the access site dressing as documented on the resident's care plan. The ,[DATE] Medication Administration Record [REDACTED] - The evening shift did not assess the resident's vital signs as ordered post [MEDICAL TREATMENT] four out of seven times from [DATE] through [DATE]. - There was no documentation the thrill and bruit had been assessed or the access site dressing had been changed. [MEDICAL TREATMENT] Communication Records: Review of the [MEDICAL TREATMENT] Communication Record sheets for ,[DATE], ,[DATE] and ,[DATE] revealed the following: - ,[DATE] revealed three communication sheets out of 13 [MEDICAL TREATMENT] treatments had been received. Of the three, no documentation was completed by the [MEDICAL TREATMENT] center as required on the form. Review of the nurses' notes (NN) did not reveal the [MEDICAL TREATMENT] center had been contacted by the facility to ensure [MEDICAL TREATMENT] was completed without incident and there were no problems with the access graft. - ,[DATE] revealed seven communication sheets out of 13 [MEDICAL TREATMENT] treatments had been received. Of the seven, five had no documentation by the [MEDICAL TREATMENT] center as required on the form. Review of the NN did not reveal the [MEDICAL TREATMENT] center had been contacted by the facility to ensure [MEDICAL TREATMENT] was completed without incident and there were no problems with the access graft. - ,[DATE] revealed one communication sheet out of seven [MEDICAL TREATMENT] treatments had been received. The form was not completed by the [MEDICAL TREATMENT] center as required. Review of the NN did not reveal the [MEDICAL TREATMENT] center had been contacted by the facility to ensure [MEDICAL TREATMENT] was completed without incident and there were no problems with the access graft. E. Staff Interviews The assistant director of nursing (ADON) was interviewed on [DATE] at 2:40 p.m. She said the staff should make sure the [MEDICAL TREATMENT] treatment was completed without any problems. She said the facility staff should call the [MEDICAL TREATMENT] center whenever the documentation was incomplete. She said the staff should be assessing the resident's shunt for thrill and bruit at least daily, checking his vital signs and assessing the access site at least daily. She said this information should be documented in the resident's medical record. III. Hospice Care Coordination A. Facility Failure The facility failed to coordinate care with hospice to ensure showers were provided consistently. B. Resident #124 status Resident #124, age 72, was admitted 8//,[DATE]. According to the ,[DATE] computerized physician order [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident displayed short and long term memory problems and her decision making abilities were severely impaired. She required extensive assistance of two persons with bed mobility, transfers, toilet use and personal hygiene. She required extensive assistance of one person with dressing, bathing and eating. Staff interview indicated the resident's preference was to receive showers. The assessment did not indicate the resident had been receiving hospice care. B. Record Review Care Plan: The advanced directive care plan, initiated [DATE] revealed the resident's wishes included no CPR (cardiopulmonary resuscitation), feeding restrictions, treatment restriction and she was on hospice case load. The facility comprehensive care plan did not document the services which would be provided by the hospice staff. The hospice care plan, initiated [DATE] indicated the hospice aide was to visit two times per week for routine home care. The care plan did not specify what routine home care included. The care plan did not specify what the hospice aide would be performing during their visits. Review of the hospice Care Coordination Log located at the facility and the facility bathing documentation, the following concerns were identified: - The hospice Care Coordination Log, start of care date [DATE], revealed the first documentation by the hospice aide was on [DATE]. The documentation read, provided full shower, hair and skin care. - The facility bathing documentation from [DATE] through [DATE] revealed the resident had not received a shower and no documentation was found to indicate the resident had refused. - According to the hospice Care Coordination Log and the facility bathing documentation from [DATE] through [DATE], the resident received five showers. C. Staff Interviews Certified nurse aide (CNA) #2 was interviewed on [DATE] at 9:04 a.m. He said hospice gives the resident two showers per week and the facility staff would try to give her another shower. He said the hospice aide had a book to document care provided but he was not sure where the book was located. The hospice aide was interviewed on [DATE] 11:00 a.m. She said the resident refused showers at times but that information was not documented on the care log but was located at the office. Documentation was requested but was never received.

Based on resident observations, record review, and staff interviews the facility failed to ensure four (#90, #157, #3, and #161) of six residents reviewed for pressure ulcers of 64 sample residents received the necessary treatment and services to prevent the development of pressure ulcer, promote healing, prevent infection and prevent new sores from developing. Specifically, the facility: - Failed to identify and initiate resident specific interventions to prevent the development or worsening of pressure ulcers for residents #90, #157, #3, and #161; - Failed to consistently assess and document a comprehensive assessment of pressure ulcers for residents #90, #157, #3, and #161; - Failed to have a registered nurse (RN) consistently assess a pressure ulcer for resident #3; - Failed to consistently provide treatments as ordered by the physician for residents #90 and #3; - Failed to provide repositioning and/or incontinence care timely for resident #157 and #161; and - Failed to identify and assess wound timely for resident #157 The findings include: 1. Professional Reference According to the National Pressure Ulcer Advisory Panel (NPUAP), NPUAP Pressure Injury Stages, 4/16, http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf, (11/16), interventions for prevention and treatment of [REDACTED]. - Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care and pressure redistribution. Expect some signs of pressure ulcer healing within two weeks. - If progress toward healing is not seen within two weeks, the individual, the pressure ulcer, and the plan of care should be re-evaluated. - Assess the pressure ulcer initially and re-assess it at least weekly. Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately. - Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor According to the Licensed Practical Nurse Scope of practice as listed by the Department of Regulatory Agency, (May 2015) included in pertinent part: The Nurse Practice Act defines the scope of practice of the licensed practical nurse (LPN) as that which is taught in schools of practical nursing in Colorado at this time. The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition which are then reported to the RN or MD for further or 'full' assessment. According to the Colorado Revised Statutes 2013, Title 12 Professions and Occupations, Article 38 Nurses included in pertinent part, Definitions: Practice of practical nursing means the performance, under the supervision of a dentist, physician, podiatrist, or professional nurse authorized to practice in this state, of those services requiring the education, training, and experience, as evidenced by knowledge, abilities, and skills required in this article for licensing as a practical nurse, including administering treatments and medications prescribed by; a legally authorized dentist, podiatrist, or physician, and includes the performance of delegated medical functions 2. Facility's Policy and Procedure The Skin Management policy and procedure, revised 8/12, revealed the following guidelines: - Appropriate preventative interventions will be implemented on all resident identified at risk for pressure ulcers and the interventions will be documented on the care plan; - Residents admitted with skin impairments will have the wound location and characteristics documented in the nursing notes.; - A care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. - Wounds are tracked, assessed and documented on the Weekly Pressure Ulcer Record form; - The licensed nurse will document daily monitoring of all pressure ulcer on the treatment administration record (TAR); - Pressure ulcers are measured and staged weekly in accordance with the practice guidelines; and - Change resident position in bed every two hours or chair every one hour for dependent residents The Wound Care/Treatment Guidelines policy and procedure, revised 9/15 revealed a weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description. 3. Resident #90 Resident #90, age 54, was admitted [DATE]. According to the 11/16 computerized physician order [REDACTED]. The 10/13/16 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance of two persons with bed mobility, dressing and personal hygiene. He was non-ambulatory and required total assistance of two persons with transfers. He was incontinent of bowel and bladder and he did not reject care. He did not have a pressure ulcer at the time of the assessment and he was not at risk for the development of pressure ulcers. No preventative measures were identified on the assessment. A Resident Observation: The resident was observed lying in bed on his right side on 11/21/16 at 8:15 a.m. The nurse was in the room applying a new dressing to the resident's coccyx. The wound bed was observed with a dark slough and a foul odor was noted. The nurse had completed the dressing to the wound on his heel and therefore, was not observed. B. Record Review Care Plan: The skin care plan, revised 6/28/16 revealed the resident had the potential for impaired skin integrity. The care plan did not identify the pressure ulcers on the right ischium or the left heel. The goal read he would maintain or develop clean and intact skin. The interventions included the following: - Educate resident/family/caregivers of causative factors and measures to prevent skin injury (Initiated 6/13/16) - Keep skin clean and dry. Use lotion on dry skin. (Initiated 6/13/16) - Observe and document location, size and treatment of [REDACTED]. to the physician. (Initiated 8/16/16) - Complete weekly treatment documentation to include measurement of each area of skin breakdown (width, length, depth, type of tissue and exudate and any other notable changes or observations) (Initiated 8/16/16) The comprehensive care plan failed to document the use of the heel suspension boot or any other resident specific interventions. Physician Orders: The 11/16 CPO revealed the following orders: - Document weekly pressure measurement to heel with weekly skin assessments on the pressure assessment form in PCC (point click care) (start date 8/16/16); - Use heel suspension boot on left foot daily while in bed (start date (8/14/16); - Perform head to toe skin check weekly for prevention (start date 9/9/16); - Cleanse left lateral heel with wound wash, pat dry, apply [MEDICATION NAME] and closed dry dressing daily and as needed. (start date 10/25/16); and - Cleanse right ischium with wound was, pat dry, soak two by two gauze with Dakins solution and place loosely in wound and cover with CDD daily (start date 11/1/16) Wound Documentation and Assessments: The 6/10/16 MDS assessment documented the resident was admitted to the facility with no pressure ulcers and he was not at risk for pressure ulcers. The 6/4/16 Skin - Head to Toe Skin Check assessment revealed the resident had excoriation to his groin but no pressure ulcers were identified. The 6/11/16 Skin - Head to Toe Skin Check assessment documented the resident had an old pressure ulcer on his left heel. No measurements or description of the wound was documented. Review of the Skin - Head to Toe Skin Check assessments and the nurses' notes (NNs) from 6/4/16 through 9/3/16 revealed no measurements or description of the pressure ulcer on the left heel was documented. The 8/20/16 NN revealed the resident was started on antibiotic treatment due to infected heel wound. The 9/10/16 Skin - Head to Toe Skin Check assessment documented, coccyx open tx (treatment) in place left heel open tx in place No measurements or description of either wound was documented. The wound physician assessed the resident on 9/12/16. The documentation revealed an unstageable pressure ulcer to his left heel which measured 2.1 cm (centimeters) x (by) 4.5 cm x 1.3 cm post debridement. There was no documentation from the wound physician regarding the wound on the residen'ts coccyx identified by the facility on 9/10/16. The 9/17/16 and 9/24/16 Skin - Head to Toe Skin Check assessments documented the open area on the coccyx remained but no measurements or description was documented. The 9/19/16 NN revealed the wound physician assessed the resident. The left heel wound measured 1.5 cm x 4.5 cm x 0.9 cm with 1.5 cm of undermining at 9 o'clock. The 10/1/16 and 10/7/16 Skin - Head to Toe Skin Check assessment documented a treatment was in place to the wounds on the coccyx, right ischium and left heel. No measurements or description of any of the wounds was documented. The wound physician assessed the resident on 10/10/16. The documentation revealed an unstageable pressure ulcer on his left heel which measured 1.5 cm x 4.5 cm x 0.9 cm post debridement. An unstageable pressure ulcer on his right ischium was identified. The wound measured 3.8 cm x 3.5 cm x 0.4 cm after debridement. The 10/12/16 Braden Scale for Predicting Pressure Sore Risk assessment score was 15 which indicated he was at risk for the development of pressure ulcers. No further documentation regarding either wound was found in the resident's medical record or provided by the facility. The 11/1/16 through 11/17/16 treatment administration record (TAR) revealed the following: - The treatment to the left lateral heel was not completed two times out of 17. - The head to toe skin check was not completed on 11/11/16. - The treatment to the right ischium wound was not completed three out of 20 times. - The application of the heel suspension boot to the left foot was not applied eight out of 16 times. C. Staff Interviews Certified nurse aide (CNA) #8 was interviewed on 11/22/16 at 1:12 p.m. She said the resident should be repositioned at least every two hours. She indicated pillows could be used to assist with repositioning the resident. She did not report the use of the heel suspension boot. CNA #10 was interviewed on 11/22/16 at 1:30 p.m. She said the resident should be repositioned at least every two hours. She said the resident should be repositioned from side to side as much as he would allow and to elevate his heels while he was in bed. She said the resident should be kept clean and dry and to keep the sheets free of wrinkles. 4. Resident #157 Resident #157, age 69, was admitted [DATE]. According to the computerized physician orders [REDACTED]. The 11/11/16 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use and personal hygiene. He was always incontinent of bowel and bladder. He had a stage three pressure ulcer and had a pressure relieving device on the bed and in the wheelchair. A. Resident Observations and Interview The pressure ulcer to the resident's coccyx was observed with the wound physician on 11/21/16 at 9:29 a.m. Slough was noted to the wound base, a foul odor was noted and a copious amount of yellow drainage was noted. The resident was observed up in the wheelchair on 11/22/16 from 8:00 a.m. until 10:50 a.m. At 10:50 a.m. the resident was assisted from the wheelchair to the bed. The CNA did not ask the resident if he needed to use the toilet or assess him for incontinence prior to lying him down. At 11:03 a.m. , through conversation with the resident, he said, I pooped. He was encouraged to push the call light. CNA #11 arrived shortly after. She removed the brief which was soiled with feces. Incontinence care was provided. The dressing on the resident's coccyx was heavily soiled with drainage and was removed by the CNA who reported this to the nurse. B. Record Review Care Plan: The pressure ulcer care plan, initiated 11/11/16 revealed the resident was admitted with a pressure ulcer. The site and stage of the pressure ulcer was not identified. The interventions, initiated 11/11/16 included the following: - Administer medications as ordered and observe and document side effects and effectiveness; - Administer treatments as ordered and observe for effectiveness; - Assess, record and observe wound healing. Measure length, width and depth where possible. Assess and document the status of the wound perimeter, wound bed and healing progress. Report improvements and decline to the physician; and - Complete a full body check weekly and document. The comprehensive assessment did not provide staff with resident specific skin or pressure ulcer prevention interventions. Physician Orders: The 11/16 CPO revealed the following orders: - Cleanse wound to coccyx with wound cleanser, apply [MEDICATION NAME] and cover with a dry dressing daily (Start date 11/4/16); - Resident to have an air mattress (Start date 11/5/16); and - Weekly head to toe skin assessment (Start date 11/9/16) Wound Documentation and Assessments: The 11/4/16 Braden Scale for Predicting Pressure Sore Risk assessment score was 14 which indicated the resident was at moderate risk for the development of pressure ulcers. The 11/4/16 Nursing Admission Data Collection assessment revealed the resident was admitted with a stage three pressure ulcer on his coccyx which measured 7.0 cm x 7.0 cm x 0.25 cm. No description of the wound was documented. The wound care physician assessed the resident on 11/7/16. The documentation revealed an unstageable pressure ulcer on the coccyx which measured 6.0 cm x 2.0 cm x 0.3 cm post debridement. The wound bed was covered with 100 % slough. The physician also documented an unstageable pressure ulcer on the left buttock which was not identified by the facility upon admission. The wound measured 3.5 cm x 1.8 cm x 0.2 cm post debridement. The wound bed was covered with 100 % slough. C. Staff Interviews CNA #13 was interviewed on 11/22/16 at 1:33 p.m. She said the resident should be repositioned every 2 hours and to keep his skin clean and dry. Registered nurse (RN) #3 was interviewed on 11/22/16 at 2:00 p.m. She said the procedure when a new ulcer was identified included measuring and describing the wound, notify the physician and obtain an order. The wound measurements and description should be documented in the residents' medical record. CNA #2 was interviewed on 11/22/16 at 10:50 a.m. He said the resident should be repositioned every two hours. He reported, on that day, therapy had worked with the resident after breakfast which caused the resident to be up in the wheelchair longer than two hours. 5. Resident #3 Resident #3, age 50, was admitted [DATE] and re-admitted [DATE]. According to the 11/16 CPO, [DIAGNOSES REDACTED]. The 8/23/16 MDS revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required extensive assistance of two persons with bed mobility, transfers, dressing and toilet use. The resident had two stage two pressure ulcers and had a pressure reducing device on his bed and wheelchair. A. Resident Observation The resident was observed lying in bed on 11/17/16. He was on an air flow mattress and a pressure reducing device was observed in the resident's wheelchair. B. Record Review Care Plan: The pressure ulcer care plan, revised 6/28/16 revealed the resident had a pressure ulcer on his left sacrum due to [MEDICAL CONDITION]. The interventions included the following: - Administer treatments as ordered and observe for effectiveness (Initiated 9/29/15); - Complete a full body check weekly and document (Initiated 9/29/15); - Educate the resident, family and caregivers as to causes of skin breakdown, including transfer and positioning requirements (Initiated 9/29/15); - Follow the facility policies and protocols for the prevention and treatment of [REDACTED]. - The resident requires pressure relieving/reducing cushion on the wheelchair and a low air loss mattress on the bed (Initiated 2/8/16); - Observe, document and report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wounds size (length x width x depth) and stage (Initiated 9/29/15); and - Weekly treatment documentation to include measurements of each skin breakdown's width, length, depth, type of tissue and exudate (Initiated 9/29/15) Physician Orders: The 11/16 CPO revealed the following orders: - Cleanse wound on left ischium with wound cleanser, pat dry. Apply mixture of [MEDICATION NAME] cream and A&D ointment to wound and cover with alginate foam daily (Start date 7/5/16); - Fill out weekly pressure assessment with wound measurements; separate assessment for each wound; coccyx and left and right ischium (Start date 8/16/16); - Perform head to toe skin check weekly (Start date 9/9/16); - Wound care to left and right buttock. Clean sites with wound cleanser, pat dry, apply calcium algenate and cover with a dry dressing as needed. (Start date 5/7/16) Wound Documentation and Assessments: The 9/1/16 through 9/30/16 TAR revealed the following: - The ordered treatment to the residents' left ischium was not completed five out of 30 times; - The head to toe skin check was not completed on 9/16/16 or 9/30/16 Review of the 9/16 NN revealed weekly measurements and description of the left ischium pressure ulcer was documented by a licensed practical nurse (LPN) with no evidence the assessment was completed by a RN. The 10/1/16 through 10/31/16 TAR revealed the following: - The ordered treatment to the residents' left ischium was not completed 14 out of 31 times; - The head to toe skin check was not completed on 10/14/16 or 10/21/16; - The weekly pressure ulcer measurements were not completed on 10/25/16 Review of the 10/16 NN revealed no wound documentation. The 10/7/16 Skin - Head to Toe Skin Check assessment documented, chronic wounds to buttocks. No measurements or description was documented regarding the wounds. The 10/28/16 Skin - Head to Toe Skin Check assessment documented healing open areas to coccyx, ischium. No measurements or description of the wounds was documented. The 11/1/16 through 11/16/16 TAR revealed the following: - The ordered treatment to the residents' left ischium was not completed eight out of 16 times. - The weekly pressure ulcer assessment was not completed on 11/15/16. - The head to toe skin check was not completed 11/11/16. The 11/21/16 Skin - Weekly Pressure Ulcer Record, completed by a LPN, documented the resident had a wound to his coccyx. The description of the site read, folded skin noted top coccyx area with un-approximated opening, with loose flakey skin that undermines. The description of the wound bed read, red grainy wound with jagged edges. No odor or drainage was identified. C. Staff Interviews CNA #8 was interviewed on 11/22/16 at 1:10 a.m. She said the resident should be assisted to reposition every two hours. 6. Resident #161 Resident #161, age 66, was admitted [DATE]. According to the 11/16 CPO, [DIAGNOSES REDACTED]. The 11/4/16 MDS revealed the resident required extensive assistance of two persons with bed mobility, transfers and toilet use. She required extensive assistance of one person with dressing and personal hygiene. She was at risk for the development of pressure ulcers and had a stage three pressure ulcer. She had a pressure reducing device in the wheelchair and on the bed. A. Resident Observation The resident was observed lying in bed on 11/21/16 at 9:00 a.m. Upon entering the room with the wound physician, the resident said she was dirty and had been waiting awhile to be changed. She said, I told the CNA with the pony tail twice. She said she had been waiting to be changed since at least 8:00 a.m. She said the staff had only changed her once throughout the night. After staff completed incontinence care, the wound was observed. The wound bed was covered with a green slough and a strong odor was noted. B. Record Review Care Plan: The pressure ulcer care plan, initiated 11/9/16 documented the resident was admitted with the wound. The location and stage of the wound was not documented. The interventions, initiated 11/9/16 included the following: - Administer medications as ordered. Observe and document for side effects and effectiveness; and - Administer treatments as ordered and observe for effectiveness. The comprehensive assessment did not provide staff with resident specific skin or pressure ulcer prevention interventions. Physician Orders: The 11/16 CPO revealed the following orders: - Cleanse wound on right buttock with wound cleanser, pack with alginate and cover with a dry dressing every two days until healed (Start date 11/2/16); - Cleanse wound to coccyx with wound cleanser, apply santyl and cover with a dry dressing daily (Start date 11/14/16) Wound Documentation and Assessments: The 10/31/16 Braden Scale for Predicting Pressure Sore Risk score was 15 which indicated the resident was at risk for the development of pressure ulcers. The 10/31/16 Nursing Admission Data Collection assessment revealed the resident was admitted with a stage three pressure ulcer on the right buttocks which measured 2.0 cm x 2.0 cm x 3.0 cm. No description of the wound was documented. The documentation indicated dry scabs were observed on the coccyx but no measurements were documented. The 11/1/16 Skin - Head to Toe Skin Check assessment documented the resident had a stage three pressure ulcer to the right buttock which measured 2.0 cm x 2.0 cm x 1.25 cm. No description of the wound was documented and there was no documentation regarding the coccyx. The 11/9/16 Skin - Head to Toe Skin Check assessment documented a new stage two wound on the coccyx which measured 2.5 cm x 1.25 cm x 0.1 cm. No description of the wound was documented. The stage three pressure ulcer on the right buttock measured 0.5 cm x 0.5 cm x 0.5 cm. No description of the wound was documented. The wound care physician assessed the resident on 11/14/16. The pressure ulcer on the right buttock measured 4.9 cm x 3.3 cm x 0.3 cm. No measurements or description of the coccyx wound was documented. C. Staff Interviews The wound care physician (WMD) was interviewed on 11/21/16 at 9:00 a.m. He reported seeing residents at the facility for the past year. He reported the facility used to have a dedicated nurse but no longer had one. He said, They could definitely step up the care here. He reported he felt there was an overall system breakdown related to the wound care. The assistant director of nursing (ADON) was interviewed on 11/22/16 at 3:15 p.m. She reported the management of the wound care was currently her responsibility. She reported she had suggested to management to have a LPN who was wound care certified round with the wound care physician but that was not approved. She said staff was being educated regarding wound care and documentation.

Based on observations, record review, and interviews, the facility failed to provide one of one (#145) resident reviewed of 64 sample residents treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to consistently notify, monitor, and address signs and symptoms of acute auditory and visual delusions and hallucinations experienced by resident #145. This contributed to the resident experiencing ongoing psychological auditory and visual mental health issues, and hospitalization on a mental health hold. The findings included: 1. Resident #145 Resident #145, age 56, was admitted on [DATE]. The 11/16 computerized physician orders [REDACTED]. According to the 9/13/16 minimum data set (MDS) assessment, the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The 11/2/16 MDS did not capture the resident's most recent BIMS, although the staff assessment for mental status documented cognitive patterns of both short-term and long-term memory problems. The resident showed hallucinations and delusions of verbal and other behavioral symptoms during the review period. She had feelings of being down, depressed, or hopeless. She had trouble with sleeping nearly every day during the review period. The resident was unable to concentrate on things half or more days of the review period. The resident had a pre-admission screen and resident review (PASRR) level II for a serious mental illness. 2. Facility Failures The facility failed to address signs and symptoms of acute auditory and visual delusions which contributed to the resident experiencing ongoing psychological auditory and visual mental health issues. The resident care plans showed interventions of administer medications as ordered, notify the doctor as needed, and allow the resident to be left to self-soothe alone in room removing excess stimulation, were not followed. The resident's medications were not administered as ordered and indicated in review of the progress notes. The progress notes further revealed multiple incidences of auditory and visual hallucinations which did not show the physician was notified to determine if another form of treatment should have been considered. The resident was also allowed to scream loudly in a high pitched screeched tone as she made statements directed at her auditory and visual hallucinations which included, Stay away from me! Don't you take her! He's an animal! Keep him away from me! He won't stay away from me! I don ' t want to fight anymore. The resident was not allowed to self-soothe. She screamed in her room at her hallucinations. 3. Observations On 11/16/16 at 4:05 p.m., the resident was heard screaming loudly from behind the closed door of her room. The resident was heard screaming for an extended period of time. ¿The residents down the hallway asked nursing staff what was happening to the resident. The certified nurse aide (CNA) informed the residents that the resident in that room screamed a lot. On 11/16/16 at approximately 4:45 p.m., the resident's door was closed when she began to scream loudly. The words the resident screamed were not understood. The nursing home administrator (NHA) and clinical nurse (CN) #2 were walking down the hallway. The CN stopped, knocked on the door, and opened the door to see if the resident required assistance. The resident was in a dark room; her light was turned off. The resident was not familiar with the CN and began to express her distrust towards the CN. The NHA entered the conversation and the CN exited the room. It was unknown what the NHA stated to the resident. On 11/16/16 at approximately 5:00 p.m., the resident was heard screaming loudly. Her tone was high pitched and screeched as she screamed, Stay away from me! There was no one else in her room as she yelled. The resident's door was propped open and she could be seen from outside the hallway. There were three staff members in the vicinity of the resident's room as she screamed. The licensed practical nurse (LPN) #8 walked to her door and looked in the room. The LPN did not approach or speak to the resident. He walked away and returned to the other two staff members standing in the hallway. On 11/17/16 at 8:05 a.m., the resident's room was observed from the hallway. The curtains were pulled back and natural light came through the window. The room was not homelike. There was a 20-inch screen television on her dresser, a tray table, chair, and bed. The walls, bed spread, floors, and pillows were white. There was no color in the resident's room. No pictures were hung on the walls. The resident was in the hallway tearful as she spoke with the NHA about money she was entitled to have although the business office refused to give her money. On 11/17/16 at 2:41 p.m., the resident could be heard screaming at the top of her lungs in a high pitched screech, Stay away from me! while seated in the restorative therapy room approximately five feet from the resident's egress door. There were two aides in the room as the resident screamed from behind the closed door. No staff member stopped to check on the resident as she continued to scream. The restorative aide in the room stated the resident's screams sounded as though the resident was scared. On 11/17/16 at 4:04 p.m., a continuous observation outside the resident's room occurred. The resident could be heard speaking loudly from inside her room with the door closed. -At 4:20 p.m., the resident continued to have a conversation with herself. She could be heard from outside her door. -At 4:23 p.m., the resident screamed from her inside her room with the door closed. The resident made statements to indicate her daughter destroyed her body. She said someone did not believe her but believed someone else instead. -At 4:26 p.m., the resident could be heard screaming from outside her room. She made nonsensical statements directed towards her daughter and to shoot someone to death. She screamed out, Don't you take her! -At 4:29 p.m., the resident continued to scream from her room. The CN #2 heard the resident and he knocked. The resident immediately stopped screaming and would not converse with the CN as he asked if she was okay. The resident's room was dark and no light was on. The CN exited the room and stated he would get a CNA to assist the resident who he reported was on the commode. -At 4:33 p.m., CNA #15 entered the resident's room. The resident would not speak, she stopped screaming, and the CNA exited at 4:34 p.m. -At 4:34 p.m., the resident immediately began to scream again. She made accusatory statements stating, He's an animal! -At 4:35 p.m., the resident continued to scream loudly from behind her closed door. Her statements were nonsensical. She said, He's like Donald Trump! -At 4:36 p.m., the resident continued to scream from inside her room. The housekeeping manager (HM) and CNA #16 walked past the resident's room as she continued to scream, Donald Trump! You beast! They do not stop or approach the resident's room to inquire about the resident. -At 4:36 p.m., the resident continued to scream loudly. Her statements remained nonsensical as she stated, Oh no I'm not. I don ' t want to fight anymore. -At 4:39 p.m., the resident screamed at the top of her lungs in a high pitched screeched sound. She yelled, Keep him away from me! He walks funny! Stay away from me! -At 4:40 p.m., the resident continued to scream from the top of her lungs, Stay away from me! The social worker (SW) was directed to the resident's room. She entered the resident's room and began to speak with the resident. The resident struggled to be redirected. The resident stated, My daughter's husband won't stay away. He won't stay away from me. The resident told the SW the family member would not stay away from her and referred to family members as animals. -At 4:41 p.m., the SW continued to attempt redirection and process information with the resident. The resident showed seconds of being redirected but was inconsolable and continued with negative statements. -At 4:52 p.m., the SW continued to use tactics to distract and diffuse the resident's behaviors although the resident continued to make negative statements. 4. Record Review a. Care plans A review of the 8/29/16 activity care plan revised on 11/15/16 revealed the resident had several [DIAGNOSES REDACTED]. She has made statements of being a loner, a person who isolates. She spends time in her room watching television and talks to herself while in her room. The resident can become loud and disrupts other residents throughout facility. She does not go out of her way to speak with people. -The goals were the resident would be active independently and participate in friendly visits from staff. -The interventions were to encourage the resident to participate in groups of interest, offer daily visits for socialization, and provide supplies for the resident to pursue independent interests. The 8/25/16 behavioral care plan documented the resident had a behavioral problem by being dismissive towards staff and visitors, rejection of cares, and yelling out at delusions and hallucinations. -The goal was the resident would have fewer episodes related to rejection of cares, yelling out, and being dismissive towards others. -The interventions were: administer medications as ordered, intervene to protect the rights and safety of others; notify the doctor as needed; the resident's behaviors are de-escalated by being left to self soothe alone in room, removing excess stimulation (other residents being loud). A review of the 8/25/16 psychosocial deficit care plan revealed the resident had a psychosocial well-being problem related to [MEDICAL CONDITION] diagnosis, anxiety, ineffective coping mechanisms, and social isolation. -The goals were the resident would identify appropriate diversional activities, individual strengths, and identify ways to increase meaningful relationships. -The interventions were the resident would be allowed time to answer questions and to verbalize feelings, perceptions, and fears as needed; assistance, encouragement, and support to identify problems. The resident would be provided assistance to identify precipitating stressors; when conflict was seen, the resident should be allowed to vent and share feelings while removing other residents to a safe environment. b. Interdisciplinary Progress Notes A review of the resident's progress notes from 8/16/16 through 11/21/16 revealed the following: -On 8/19/16, the resident was loud and yelling out; she could be heard speaking loudly about being hit by a parent if placed in the same room as herself. The resident was having conversations with people not there. -On 8/23/16, the resident had some noted delusions, hallucinations of auditory nature on the morning shift. -On 8/23/16, the resident was loud, screaming, and using foul language. The resident was speaking to someone in her room that was not present. She did not want the nurse to enter her room and made derogatory statements directed towards the nurse. -On 9/1/16, the resident was agitated when disturbed; she screamed at auditory hallucinations. She stated she did not feel right. There were no notes to indicate the resident's physician or mental health provider were contacted or notified. -On 9/3/16, the resident cried out several times throughout the night. She appeared to rest with eyes closed and then cry out others were trying to get her. -On 9/8/16, the resident over dramatized on things. There was no description of the things the resident was over dramatizing over. -On 9/18/16, a care conference note indicated the resident was at the facility due to a stay at a mental health facility. -On 10/5/16, the resident was extremely agitated and yelling at others. -On 10/8/16, the resident had increased hallucinations and paranoia. The hallucinations caused her to scream and make statements directed towards a family member and her being told to shut up. The resident was saying strange things inconsistent to time and location. -On 10/9/16, the resident was yelling and screaming out in her sleep. She stated someone tried to get her from outside the window. The resident had been out of [MEDICATION NAME], an antipsychotic medication, for several days. The medication was prescribed due to [DIAGNOSES REDACTED]. There was no documentation effort to show the physician was contacted to determine if another course of treatment should be considered as the medication remained on order. There was no evidence to show the pharmacy was contacted to find out the status of the resident's antipsychotic medication. The medication remained on order after the resident's return from the hospital. -On 10/9/16, the resident returned to the facility. She received an injection of [MEDICATION NAME], an antipsychotic medication, while she was hospitalized . There was no discharge paperwork observed in the resident chart. -On 10/10/16, the resident screamed throughout the afternoon shift. The resident was disruptive to her roommate and expressed she could not sleep and needed a sedative. -On 10/12/16, the resident was sleeping when a confused male resident attempted to get into bed with the resident. There was no documentation in the progress note to show whether the physician or interested parties were contacted. -On 10/13/16, the resident was extremely agitated and tearful. She was easily upset, yelled at nursing staff and hallucinations. She experienced delusions during the evening shift. -On 10/15/16, the resident's behaviors were disruptive to the living environment as she screamed at hallucinations and could not be calmed. She continued to scream at hallucinations into the night. -On 10/17/16, the resident was verbally aggressive toward staff and roommate. She was screaming and yelling out about demons trying to get her. She could not understand why they (her hallucinations) would not leave her alone. She was offered non-pharmacological interventions but refused options. Her language, tone, and volume would calm temporarily. -On 10/17/16, the resident was having continued hallucinations and delusions. She was screaming and crying out. She cried out for help and she could not stand it. She thought mannequins were trying to get her. -On 10/18/16, the resident announced loudly to social services, she needed to contact the social security office because they have kept her up at night talking through the window. She told the SW social security spoke to her every night, all night long. -On 10/19/16, the resident began screaming and crying out in her sleep. The nurse attempted to re-direct the resident but was temporarily calmed until the resident began to cry out again. The resident continued to scream out on the morning shift directed towards her hallucinations and was unable to calm herself. -On 10/20/16, the resident reported having hallucinations and continued to scream at them. -On 10/21/16, the resident was hallucinating and screaming constantly during the morning shift. She repeated frequently she did not want to see a family member due to the family member trying to steal her money. There was no documentation to show the physician or community mental health agency was contacted to address the ongoing issues with the resident's auditory and visual hallucinations. -On 10/21/16, the resident screamed, used foul language, and continued to talk to herself. She would calm for a few minutes and go back into her cycle. -On 10/21/16, during the evening shift the resident continuously yelled, screamed, and threw items. The resident was able to be calmed for a few minutes until she repeated the same behaviors again. There was no communication with the physician or mental health agency found in the progress notes as the resident continued to express distress from her hallucinations. -On 11/4/16, the resident's [MEDICATION NAME] medication was on order again and the facility waited for pharmacy delivery. **There were no progress notes from the behaviors observed on 11/16/16 as the resident was in her room screaming and yelling at auditory and visual hallucinations. -On 11/17/16, the resident was screaming in her room about a family member trying to put something in her ear. The resident was shaking and rocking herself while cuddled up in a sheet. The resident was reassured she was safe. -On 11/20/16, the resident continued to have delusional ideations, yelling, and hallucinating. The resident would not take trazadone, an antidepressant medication, for [MEDICAL CONDITION] because she felt it was rat poison. -On 11/21/16, the resident continued to cry out and was fearful of something happening to her. She continued to have delusional ideations. She yelled out concerns of the police harming her and men coming to get her. The resident was not consolable to efforts. c. Physician notes A review of physician notes revealed the resident was last seen on 8/25/16. The resident was identified with [MEDICAL CONDITIONS], anxiety, and [MEDICAL CONDITION]. The resident was not able to provide any history with specificity or reliability. She did not have a psychiatry appointment scheduled for two more weeks. She was on [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for post-traumatic stress disorder. There were no further physician progress notes [REDACTED]. There was no review of her medication management or her behaviors as she remained unstable. d. Mental Health Agency Notes There were no notes available from an outside mental health provider to show the resident received or was followed by an outside provider for her mental health status. There was a 7/30/16 progress note from the psychiatric hospital found in the resident's record. The note written prior to admission revealed the resident was at baseline but remained tortured and persecuted with auditory hallucinations. She intermittently screamed for something to stop but had difficulty describing what were those things. 5. Interviews A resident who requested anonymity was interviewed on 11/15/16 at 3:04 p.m. The resident said resident #145 was neglected by facility staff. The resident stated resident #145 was often heard screaming from outside her room without staff intervening or assisting the resident. Resident #145 was interviewed by the activity director (AD) on 11/16/16 at 5:22 p.m. She reported to the AD that facility staff went out of their way to ignore her. She stated staff did not give her supplies and did not take her laundry. Restorative aide (RA) #1 and CNA #12 were interviewed on 11/17/16 at 2:41 p.m. They confirmed resident #145 was heard screaming from behind her closed door next to the restorative room. The CNA and RA said there were no interventions to help the resident since she had no control over her hallucinations. They stated they did not know how to help the resident. The staff stated when she yelled or screamed it was directed towards family members. The staff said there were times she could be heard trying to get away from being sexually attacked and getting away from harm. The staff said the resident seemed to be scared of the hallucinations and delusions she experienced. CNA #16 was interviewed on 11/17/16 at 4:41 p.m. The CNA said ever since the resident moved her current room she had been screaming and yelling. He said there wasn't much he could do for her when she was escalated. He said he'd talked to her before to calm her down but wasn't effective. He said her screaming sounded like she was afraid at times. The CNA said she was a nice lady but she had a lot of problems. He said he has told the nurse before to see if there was anything the nurse could do for her since he did not know how to help the resident. LPN #8 was interviewed on 11/17/16 at 4:58 p.m. He said the resident screamed out because she had a [DIAGNOSES REDACTED]. He said on 11/16/16, he looked into her room but did not approach her further. He said he wanted to make sure there was no one in her room. He said the facility had tried in the past to sit with her but she would only calm temporarily and then resort to screaming and yelling again. He stated the only thing he could do was to make sure there wasn't anyone physically in her room when she screamed. The LPN said he knew it was difficult on the resident to have hallucinations and delusions; her behaviors also disturbed the other residents. He said the resident had the most difficult time during the evening and overnight hours. The SW was interviewed on 11/22/16 at 1:56 p.m. She said she was familiar with the resident. The resident was described to have delusions and paranoia. The SW said the resident was easily agitated and at times could be redirected. The SW stated the resident was seen by a psychologist a few times (no documentation was available in the resident's chart) but no psychiatrist was reviewing her meds to identify a regimen to stabilize her behaviors. She confirmed there were no notes in the resident's record to show a psychologist was in to review her chart or meet with the resident. The SW stated the resident was supposed to receive mental health services from an outside agency but had to go out into the community to receive them. Since she was not on a stable medication regimen and showed ongoing unsafe behaviors, it was not feasible for her to leave the facility and enter the community. The SW stated when the resident screamed out, it usually came across as fearful. The SW said on 11/17/16 when she attempted to redirect the resident, her screams sounded as though the resident was afraid. The SW stated she tried various conversations with the resident but the resident had a negative response to all efforts attempted. The SW stated her hallucinations had caused her to refuse medications and food. The SW stated the resident needed a psychiatrist to oversee her medication management. She said the resident required a psychological evaluation and psychotherapy to prevent her from going through a tailspin of emotions. The director of nursing (DON) was interviewed on 11/22/16 at 4:25 p.m. She confirmed the facility served a population of residents with mental health issues. There was no psychiatrist coming into the building to review psych medications or address behavioral concerns for their mental health residents. The assistant director of nursing (ADON) was interviewed on 11/22/16 at 5:26 p.m. The ADON said when the resident was heard screaming, it sounded like the resident was in torment. She said the resident's hallucinations scared the resident. The ADON stated the resident would benefit from a thorough review and psychiatric services. She said her medications and behaviors needed to be monitored and reviewed to identify trends and effectiveness of medications. The ADON confirmed the facility served residents with mental health issues. She was aware of the lack of a psychiatrist to address the ongoing concerns of the facility, and the contributing factors it had on the resident's medication management and lack of stabilizing her behaviors to prevent the resident from being scared and in torment. The medical director of the facility was interviewed on 11/21/16 at 12:24 p.m. The medical director said the facility did not have the resources to meet the needs of the resident. He was not familiar with the resident but expressed she was a complex case and needed adequate services to address her emotional turmoil. There was no mention of a recent review of her medical record. 6. Facility Follow-up A progress note from 11/21/16 at 12:55 p.m. revealed the resident was transported to the hospital on a mental health (M1) hold. She was screaming of leeches in her blood. There were signs and symptoms of mental distress.

Based on interviews, observations and record review, the facility failed to ensure the facility was as free from accident hazards as possible and that residents, including three of 60 sample residents (#53, #82, and #110) received adequate supervision and assistive devices to prevent accidents. Specifically: -The facility failed to ensure residents, including resident #82, were free from resident to resident abuse; specifically, resident #53's pattern of inappropriate, provocative, and sexually aggressive behaviors toward male facility residents. Resident #53 repeatedly engaged in sexually aggressive behavior toward facility residents. The facility failed to take steps that were effective, sustained, and expected, per facility policy, to report resident #53's behavior and to protect facility residents, even after the behavior was observed and facility administration informed of the behavior by residents and staff. The facility's failure to report and keep facility residents safe created a situation of immediate jeopardy for serious harm. Cross-reference F225; failure to thoroughly investigate allegations of abuse and protect residents and F226; failure to have operational abuse policies to prevent abuse. -The facility failed to ensure resident #110 received adequate supervision to prevent falls. -The facility failed to ensure medications were secured to prevent accidents. The findings include: I. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY On 01/04/12, record reviews and interviews during an on-site visit by the Colorado Department of Public Health and Environment (CDPHE) revealed a pattern of sexually inappropriate and aggressive behavior by resident #53 toward facility residents and visitors. Interviews beginning on 01/04/12, revealed resident #53's behavior had been witnessed by various staff, family members and other facility residents. Instances of abuse included sexually derogatory comments, unwanted touching, sexual innuendo, and sexual proposition. Residents expressed fear of further sexual abuse by resident #53. On 01/04/12 at 1:45 p.m., the Nursing Home Administrator (NHA), the director of nursing (DON), regional nursing consultant (RNC) and the regional vice operations of operations (VPO) were informed by CDPHE, that the facility failure to protect residents from physical, verbal and mental abuse by resident #53 created a situation of immediate jeopardy for serious harm. B. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY 1. On 01/04/12 at 5:00 p.m., the NHA presented an initial plan to keep the facility residents safe for the night from resident #53. According to the plan, resident #53 would be placed on staff supervision of 1:1 to continue, per staff schedule, for the next seven days. The facility also would hold a special resident council meeting with facility residents, to address the facility policy of physical, mental and verbal abuse with the facility residents. At 5:15 p.m., the NHA presented a copy of a planned in-service with facility staff to include the definition of abuse, facility abuse policy and procedure, specifically addressing sexual behaviors. The facility held an in-service on 01/04/12 at 5:30 p.m. to educate the staff on duty and all department heads of the above plan. The next in service was scheduled at 9:00 a.m. on 01/05/12. However, on 01/05/12 at 1:00 p.m., staff interviews and observations revealed the in-service scheduled for 9:00 a.m. had not been attended/completed by all staff. The NHA was interviewed on 01/05/12 at 9:30 a.m. He stated that he had in-serviced all department heads and line staff providing direct care to resident #53. He further stated that the social service department, nursing staff and designated inter disciplinary team (IDT) members would begin to interview all residents to determine if they had been abused and if additional assistance was needed for those residents. The VPO was interviewed on 01/05/12 at 10:00 a.m. The VPO was informed that facility staff was working the floor without having participated in the in-service scheduled at 9:00 a.m. that morning. The VPO stated that he was committed to the well-being of the facility residents and would pursue the in-service for all staff providing direct care and would pursue providing the 1:1 sitter services for resident #53. The facility's 01/04/12 plan was incomplete; it did not include any behavioral management interventions for residents with mental illness and sexual aggression. The plan did not specify the type of staff training specific to handling allegations of sexual abuse, nor did it indicate what supervision resident #53 would receive after seven days and whether the resident would remain indefinitely in the facility. The immediate jeopardy was not removed. 2. Revised Plan The facility's revised plan to remove immediate jeopardy, submitted on 01/05/12 at 9:10 a.m., also was rejected by CDPHE as incomplete. The revised plan failed to identify notification of the police department if a future incident of sexual inappropriateness occurred. The plan also did not include alternative placement for the resident. The immediate jeopardy was not removed. 3. Final Plan 01/05/12 at 3:15 p.m. The facility submitted a final plan on 01/05/12 at 3:00 p.m. -This plan included no expiration time for the staff supervision of 1:1. The plan stated that the resident would remain on the 1:1 supervision until alternative placement was found that would better suit the resident's needs. -The plan further provided the facility social service, nursing staff and designated interdisciplinary team members would conduct (by 01/06/12) interviews with the facility residents to determine if any further incidents of sexual abuse had occurred in the facility and were not previously reported. The plan further documented that the NHA would report any further discoveries of sexual abuse to the state agency as required by law. -Further education and training of social services staff (social service director) was conducted by the regional social service director and the regional VPO. -The facility reassessed resident #53 and identified the resident would benefit from a transfer to a facility that specialized in behavioral health issues. The NHA, RNC and facility social service staff placed calls to other facilities that specialized in the behavioral and medical needs of resident #53. C. REMOVAL OF IMMEDIATE JEOPARDY On 01/05/12 at 3:15 p.m. , the NHA, VPO and RNC were informed that the facility's 01/05/12 plan to remove immediate jeopardy was accepted. The immediate jeopardy was removed at 3:30 p.m. However, record review and interviews revealed deficient practice remained at a G (actual harm) level. II. FACILITY POLICIES, PROCEDURES IN EFFECT PRIOR TO IMMEDIATE JEOPARDY Review of the facility Abuse & Neglect Prohibition, (#OP2 0304.00, revised 9/2011) revealed the following: A. Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must immediately be reported to the Administrator (NHA) and/or Director of Nursing (DON). B. Fundamental Information Definitions: -Abuse Prevention Coordinator: the facility NHA is the Abuse Prevention Coordinator. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Injuries of unknown origin may occur as a result of abuse. -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. C. Procedure Training: 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. 3. The facility will provide training regarding related policies and procedures. Prevention: 1. Residents, families and staff will be able to report incidents and concerns without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. 3. Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate. 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. Identification: 1. The facility Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect, injuries of unknown origin, or misappropriation of resident property to determine the direction of the investigation/intervention, through analysis of systems, audits and reports. 2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that my lead to abuse/neglect or may escalate a continuum of aggression. Investigation: 1. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, in accordance with state regulation. 3. The facility will report all investigation findings to the state in accordance with state regulations. 4. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the QA&A committee, with intervention reporting, or policy/procedure modification conducted as appropriate. Protection: 1. The facility will protect residents from harm during the investigation. 2. The facility will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property. Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law. 4. In accordance with the Elder Justice Act, the facility will report to law enforcement agencies and to the state agency any reasonable suspicion of a crime against any individual who is a resident of, or receives care in the facility. III. FACILITY FAILURE TO PROTECT RESIDENTS FROM RESIDENT TO RESIDENT SEXUAL ABUSE A. Resident #53 Resident #53, age 28, was admitted to the facility on [DATE]. According to the face sheet of the same date, the resident's [DIAGNOSES REDACTED]. 1. Resident status According to documentation in the resident's record, he had been appointed a guardian through the county clerk as of 09/06/11 for inability to make decisions and care for himself. The annual Minimum data set (MDS), dated [DATE], indicated the resident was alert and not depressed. Section E revealed that the resident had behavioral symptoms - such as public sexual acts and that those behaviors significantly interfered with the resident's participation in activities or social interactions. The resident scored a 15/14 on his Bims testing as documented in section F. Section G of the MDS revealed that the resident needed limited assistance with locomotion on the unit. Multiple nursing weekly/monthly summaries (1/9/11, 3/6, 4/13, 7/17, 8/21, 10/16/11) indicated that the resident was able to and did move around the facility independently in a wheelchair. According to the resident's computerized physician orders [REDACTED]. Multiple nursing weekly/monthly summaries (see below) documented the resident was "very manipulative," "needs limits set," and "pushes limits," "tests limits," "needs redirection." The care plan, dated 07/18/11 for cognitive deficit, directed staff to explain all procedures and treatments to the resident, request that physician consider resident for psychiatric evaluation as indicated, provide needed assistance of staff with all activities of daily living except with dining. 2. Record Review Record review revealed staff was aware, as early as 1/11, of the resident's inappropriate, provocative, sexually aggressive behaviors, as well as his need for limits, supervision and redirection. Further review revealed an escalation in these behaviors beginning 9/11. Record review revealed no documentation staff reported the resident's inappropriate, provocative and sexually aggressive behaviors incidents to the NHA (facility abuse coordinator per policy), social services, or the State. There was no documentation that the physician and/or nurse practitioner were informed of these incidents and the escalation in incidents until 11/17/11. Moreover, there was no documentation that interventions, other than redirection and placing the resident in his room, were implemented by staff to protect residents from further abusive behavior by resident #53. Finally, record review revealed no care plans in resident #53's record for sexually inappropriate behaviors. There were no contracts between the resident and the facility or facility staff. The record revealed the facility was aware of the resident's behaviors, manipulation, pushing of limits; however, there were no indications of any limit setting. The record revealed that the behavior monitoring sheets for the psychoactive medications were the only behavior monitoring done by the facility. Nurses' Notes: -01/09/11 - the nursing weekly/monthly summary documented the resident had very manipulative behaviors and needed limits set. -01/12/11 - the resident was reviewed in the case management meeting by the IDT (interdisciplinary team). The IDT determined that the resident needed constant supervision due to safety concerns. The "safety concerns" that triggered the resident's need for constant supervision were not identified in the note. Moreover, how constant supervision was to be carried out was not identified in the note or on the resident's care plan. (See above.) -01/16/11 - the kitchen staff alerted nursing that the resident was in the dining provoking another resident, and this behavior by resident #53 had been occurring over the past few days. -02/13/11 - the nursing weekly/monthly summary documented the resident was manipulative and pushes limits. -02/23/11 - the resident was documented as participating in activities at the facility, however, he did require redirection due to inappropriate behaviors at times. This nursing note was signed by the Director of Nursing (DON). -03/06/11, 04/13/11, 5/18/11 - these nursing weekly/monthly summaries documented the resident was manipulative and pushes limits. -06/12/11 and 07/17/11 - these nursing weekly/monthly summaries also documented the resident was manipulative and pushed limits and needed redirection. -08/17/11 - the DON documented the resident 'continues' to be sexually inappropriate, verbally and was inappropriate in his responses to situations. -08/21/11 - the nursing weekly/monthly summary documented the resident is manipulative, acts out, and needs redirection. -09/19/11 - the nurse documented that at approximately 9:00 a.m. she witnessed resident #53 attempting to place his hands in the sweatpants of another male resident. She further documented that she instructed resident #53 to keep his hands to himself and he stopped. There was no documentation that the registered nurse either counseled or identified the victim, notified the physician, or reported this inappropriate sexual conduct to her the NHA or the State. Moreover, there was no indication the incident was investigated. -09/23/11 - the assistant director of nursing (ADON) documented that she was asked to witness a conversation between resident #53 and the activities director in regard to inappropriate conversation and behaviors in the main dining room. The resident was removed from the dining room to decrease behaviors and subdue inappropriate conversation. The ADON note did not indicate that the information she acquired by witnessing the conversation was reported to the NHA. -09/25/11 - the nursing weekly/monthly summary documented that the resident is manipulative and test limits. It further documented, notwithstanding the incidents on 9/19 and 9/23/11, that the resident had 'no significant changes.' -09/27/11 - the ADON documented the resident was placed in the restorative dining room on 09/24/11, related to inappropriate verbalization and behaviors. Due to the smaller setting of the restorative dining room and the 1:1 attention, redirection related to verbalization would be successful. "Unfortunately restorative staff reported to the ADON resident (#53) exposed his genitalia and then proceeded to urinate on the dining room floor, while other residents were in the dining room." -10/02/11 - the resident was in a part of the facility called the PCC unit, making lewd comments to another resident. The nurse documented she removed resident #53 from the situation, and the resident received room trays related to his comments in the main dining room and restorative. There was no documentation the incident was reported, investigated, or the other resident identified and monitored. -10/06/11 - the resident was "once again making obscene gestures and exposing his genitals to the (another) resident across the hall." The nurse documented that she talked with the resident and told him that this was intolerable and he needed to cease with this behavior immediately. The note did not reflect that the nurse reported the inappropriate sexual behaviors to the DON, or NHA. Further, there was no documentation the incident was investigated, interventions to protect residents from such behaviors evaluated and revised. -10/10/11 - the resident was seen by his physician and a nurse practitioner. No new physician orders. There was no evidence that the resident's pattern of inappropriate sexual behavior, including the incidents on 9/19 and 9/23/11 were reported to the physician and nurse practitioner. -10/16/11 - the nursing weekly/monthly summary documented that the resident is manipulative, needs redirection. -10/17/11 - the resident was reviewed at the case management meeting by the IDT. The IDT team discussed the resident's weight loss. There is no documentation that the IDT team discussed the pattern of the resident's inappropriate sexual behaviors. -10/21/11 - the ADON documented the resident was reviewed in the case management and risk meeting. She further documented that the resident's behaviors are vulgar and inappropriate. There was no documentation that a plan to address the resident's behaviors was developed or discussed. There was no documentation the impact of the resident's behavior on other facility residents was considered. -10/22/11- the nurse documented the resident made sexually inappropriate remarks to a family member who was visiting across the hall. The resident stated to the visitor, "I still want to go down on you." The nurse documented he apologized to the family member and redirected the resident to his room. The note did not indicate the incident was reported to the DON or NHA. -10/24/11 - the nurse documented that at 6:45 p.m., the resident "stuck his hand in the pockets of another resident's hoody while the resident was wearing it. The resident (who was unidentified) became very agitated at resident #53 and began yelling for resident #53 to explain himself." the nurse continued to document that the two residents were separated and that the nursing home administrator was notified of inappropriate behaviors. The note further stated that the victim spoke to the facility social service department about the sexual advance made by resident #53. There was no evidence this incident was reported to the State, no evidence it was investigated and no evidence of follow-up with resident #53's victim. -10/28/11 - the DON documented that the resident was reviewed at the case management meeting by the IDT team. The note revealed that the resident was eating his meals in his room due to choosing to be vulgar and socially inappropriate around and towards others. The note further stated that he was exhibiting an increase in behaviors. There was no documentation of any new plans on how to address the resident's behavior and no evidence the resident's physician was notified of the increase in these behaviors. -11/01/11 - the resident continued to antagonize other residents by speaking of his balls and cocaine. The documentation did not identify that the nurse reported the behaviors. -11/02/11 - the IDT review revealed the DON documented the resident had an increase in inappropriate behaviors and the resident has been 'met with' on several occasions. The DON further documented the resident was "aware of his inappropriateness and had stated that he doesn't care how it makes anyone feel." The documentation revealed that the resident had limited himself with interactions with others. The document revealed that due to a change in his behaviors, lab work had been ordered and results would be reviewed by the resident medical provider. There was no documentation the physician was notified of the resident's noted escalation in inappropriate behavior. There was no documentation of discussion regarding interventions to protect facility residents from resident #53's inappropriate behaviors and no documentation that the facility investigated the effect of the resident's behaviors on others. -11/08/11 - the nurse documented that the resident continued to be vile and foul in his communication. -11/13/11 at 1:45 p.m. - The resident was "playing with himself in the facility lobby" and was sent to his room and not allowed to play Bingo. Documentation at 4:00 p.m. read: the resident made inappropriate remarks to another resident and that the victim (not identified by the nurse) was upset about the remarks. The nurse document resident #53 was sent to his room. There was no documentation the incident was investigated or reported, the victim interviewed, provided support, or monitored. There was no documentation that the nurse notified any members of the IDT team or administrative staff. -11/14/11 - the resident's doctor was in to see the resident. There were no new orders. There was no documentation that the physician was notified at this time of the escalation in the resident's inappropriate behaviors or the effect of these behaviors on facility residents. -11/17/11 at 9:15 a.m. - resident (#81) reported to nursing administration that an incident had occurred on 11/16/11, in the evening, between resident #53 and resident #82. The documentation further read that the NHA and social services director (SSD) met with resident #53 and resident #81. The sexually inappropriate behaviors were reported to resident #53's nurse practitioner who was in the building at the time. The resident was sent to the hospital for a mental health hold at 10:30 a.m. and returned to the facility at approximately 5:00 p.m. the same day. A report of sexual abuse was made by the NHA to the State. Although other similar incidents of sexually aggressive behavior by resident #53 toward facility residents was documented 9/19, 9/23, 10/6, 10/22, 10/24/11) this was the first incident reported by the facility to the State. There was no documentation that the victim of the abuse (resident #82) was assessed, monitored, or supported following the incident. (See further details below) There was no documentation of new interventions to keep residents safe from resident #53's inappropriate behaviors, although one note (see below) that documented resident #53 had a "sitter." -11/18/11 - the resident was reviewed by the IDT and case management team. He was reviewed for weight loss and medical labs. There was no documentation that the IDT team reviewed the previous day's sexual assault on another resident. -11/19/11 - the resident has a sitter at bedside. There was no documentation in resident #53's record regarding the sitter - how often and how many hours a day the sitter would be present. -12/04/11 - the resident went into another resident's room (not identified) and made inappropriate sexual innuendos to the resident. The resident had to use his call light to notify staff of resident #53's presence in his room. There was no documentation when this occurred or how it occurred or if a sitter was present. -12/24/11 - the nurse documented that the resident was making a sexual proposition to another resident and the resident being propositioned became angry, stating that if he was sexually propositioned again, that he would do bodily harm to resident #53. The nurse documented that he spoke to both residents and stated that physical attacks would not be tolerated in this facility. Although the nurse documented he would make an entry on the 24 hour facility report and notify the resident's physician, there was no indication in the note that the nurse told resident #53 that his behavior would not be tolerated in the facility, reported the incident to administrative staff, or provided any follow-up for the resident being propositioned. Social Service Notes: A review of resident #53's social service notes (6/25/10-11/20/11), revealed social services was aware of the resident's inappropriate, sexually aggressive behaviors. Although social services documented the resident was 'spoken to' about his behaviors, and for a time looked for alternative placement for him, the notes revealed no plans to set limits with the resident, no plans to meet his sexual needs in an appropriate manner, and no plan to seek outside assistance in addressing his behaviors (the last visit with a psychologist was 5/11/11), no plan to educate staff on how to keep other residents safe from his behavior or to report inappropriate behaviors to administration. Review of the most recent visit with the psychological counselor 5/11/11, revealed the care plan put into place by the psychiatric services included having the client create one tool to use, to help him. There was no documentation in social services that this care plan had been discussed or implemented and no documentation of any further psychological support. On 11/17/11, following the report of sexual abuse involving resident #82, the SSD documented: -That she interviewed resident #53 about the sexual assault on 11/16/11. Resident #53 stated "I stuck my hands down his pants and played with his penis." When the SSD asked the resident if he thought that was wrong, the resident replied "yes, but I had to touch him." The resident was informed by the SSD that the sexual assault had to be reported to the police department, since someone saw him do it. The SSD documented that she spoke to the resident that witnessed the incident (#81) and he reported what resident #53 reported. -That resident #53 was "no longer safe in the facility, and we need to keep other residents safe. Unfortunately there are no other facilities that would take him with those behaviors." On 11/22/11, an interview between the SSD and the resident revealed that the resident stated that he would continue to sexually touch other residents even though he knew it was wrong. See nurses' notes above and interviews below; the facility did not keep other facility residents safe after the 11/16/11 incident. Notwithstanding the presence of a "sitter," and knowledge that the resident said he would continue to sexually touch other residents, resident #53 was found in resident rooms 12/4/11 and 12/23/11, making sexual innuendos and propositioning the residents. Physician Orders Review of physician orders [REDACTED]. The [DIAGNOSES REDACTED]. Another telephone order, dated 11/18/11, revealed an order for [REDACTED]. 3. Interviews Interviews with residents, staff and family members confirmed the incidents of inappropriate, provocative, sexually aggressive behaviors documented in resident #53's record. a. Interviews 01/04/12 Resident #53: On 01/04/12 at approximately 4:10 p.m., resident #53 was interviewed. He stated the police were here to see him because he unzipped a guy's pants. He stated that he did not have the resident's permission and he did it because he wanted to see his penis. He understood that this was inappropriate behavior and denied that he has sexual urges and denied doing this to any other residents. He discussed that he understood that the consequence of his behavior and it could mean he would go to jail. He stated that people were afraid of him. He further stated that he did not know why he had a sitter. CNA #29: A certified nurse aide (CNA) #29 was interviewed on 1/4/12 at 2:50 p.m. The CNA stated that he cared for resident #53 regularly. CNA #29 stated the resident had inappropriate outbursts daily. The inappropriate outbursts included foul language. In addition, the resident made sexual comments toward other residents. He stated that he and a nurse witnessed resident #53 asking another resident an inappropriate sexual question. He stated that he did not report resident #53's daily behavior unless it was excessive as this was his "normal" behavior. CNA #31: CNA #31 was interviewed on 1/4/12 at 3:00 p.m. CNA #31 stated resident #53 had made sexually-based comments to other residents. She stated that he had made sexually inappropriate comments in the dining room. She stated that she had reported it to the nurse and the resident was redirected. CNA #31 said she had observed the resident expose himself to other residents and when he did so, the nurse would tell the CNA to place the resident in his room. b. Interviews 01/05/12 Resident #81: Resident #81, who reported the incident between resident #53 and resident #82 (see nurses' notes above) was interviewed on 01/05/12 at approximately 9:00 a.m. -The resident said he did not report what he observed and he didn't know how the facility knew what he had observed on 11/16/11. He said the social worker and the police had talked to him. He said he was mad that resident #53 would do what he did and said resident #53 "tries it all the time, everyone knows." The resident said resident #53 only does this with men and "goes after the ones who don't know what's going on. It makes it easier for him." -The resident said he wasn't afraid for himself but was "for the helpless people here - he's always watching." He further stated he had been told by another male resident of another incident involving resident #53 "just last week." Medical Director: On 01/05/12 at approximately 1:30 p.m., the facility medical director (MD) was interviewed. He stated that on 11/16/11, the facility Quality Assurance (QA) team had discussed the sexual assault by resident #53 against resident #82. He stated that it was hard to get facility placement in the State for a resident such as resident #53 who was young, HIV positive and had documented sexual behaviors and desires.

Based on record review and interview the facility failed to provide care that ensured that residents remained free from new or worsening pressure ulcers for seven of 60 sample residents (#28, #30, #66, #82, #108, #117, #43). Specifically: Two residents (residents #117, #82) who entered the facility with pressure ulcers either failed to heal (resident #117 who entered 8/16/11 with a stage IV pressure ulcer) or developed additional ulcers (resident #82). Although resident #117's ulcer had improved, the facility failed to follow wound vac orders, contributing to resident pain, failed to provide the resident pressure relief, and the facility failed to practice infection control to promote healing. Resident #82 entered the hospital from the facility with infected ulcers that had not, per facility records, been identified by the facility. Several residents (residents #82, #28, #66, #108) who entered the facility without pressure ulcers, developed one or more ulcers after admission. Planned and expected intervention, per facility policy, were not implemented and ulcers were not timely treated, or consistently tracked and monitored. A. Facility policy Facility Policy on Skin Management read in pertinent part: Skin Mgmt, revised 2/10: Per CMS GL, "unavoidable" means that the resident developed pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent w/ resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this must be clearly documented in the resident's clinical record. Staging Classification: (in pertinent part) Stage I: A defined area of persistent redness. Stage II: Partial thickness of skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as abrasion, blister, or shallow crater. Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage III may include tunneling or undermining. Stage IV: Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. Newly admitted Residents: -1. Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale - For Predicting Pressure Sore Risk. -4. Residents admitted with skin impairments will have: a. Appropriate intervention implemented to promote healing; b. A physician's order for treatment; and c. Wound location and characteristics documented in the Nursing Notes. -5. In addition, the following forms are completed and placed with the resident's Treatment Record: a. Pressure Ulcer: Weekly Pressure Ulcer Record; and b. All other significant skin impairment: Non-Pressure Skin Conditions. -6. A Care Plan is developed upon admission; identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to Hydration, Nutrition, Preventive devices, Physical activity, Positioning requirements and Proper body alignment. -7. Wounds are tracked as acquired and are assessed and documented on the Weekly Pressure Ulcer Record. . . -8. The Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record (TAR). -9. A Physician's Order will be written to monitor each ulcer and documentation on the TAR (and) will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound. -13. A Registered Dietitian will assess all residents identified with skin impairment for nutritional status in a timely manner. -16. The nurse will assure that treatment, interventions, care plan, and the appropriate skin documentation records are initiated in a timely manner according to practice guidelines. B. Resident Failures 1. Resident #117 Resident #117, age 63, was admitted to the facility on [DATE] from the hospital. According to the January 2012 computerized physician orders, the resident [DIAGNOSES REDACTED]. According to the most recent minimum data set (MDS), dated [DATE], the resident was coded as scoring 15/15 on the brief interview for mental status, which indicated no cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. She had an indwelling catheter and was incontinent of bowel. a. Resident status on admission According to the physician's history and physical dated 8/18/11, the resident had been involved in a motor vehicle accident mid-July and had sustained a back fracture. She had undergone surgery, the surgical incision dehisced (opened), and the resident developed a secondary infection. The resident was admitted to the facility with wound VAC (vacuum) to promote healing of the coccyx/sacral ulcer. According to the resident's 8/16/11 admission skin assessment and Braden scale pressure sore risk assessment, she was admitted to the facility with one Stage IV pressure ulcer to her coccyx/sacral area, as well as the incision/wound to her spine. b. Wound status 8/17/11 to 11/25/11 Review of the weekly pressure ulcer records revealed on 8/17/11, the resident was admitted with a Stage IV pressure ulcer which measured 5.0 x 3.0 cm and 5.0 cm deep. The wound was tunneling, had a small amount of sero-sanguinous exudate, the wound bed was red and the resident had pain with the wound. Review of the weekly pressure ulcer records 9/9/11 - 9/30/11 revealed duplicate records on the status of the pressure ulcer. While the measurements were the same, the documentation regarding the status of the ulcer differed. Review of the weekly pressure ulcer record dated 11/25/11 revealed the wound was a Stage IV and measured 3.0 x 2.5 cm and depth was 4.2 cm. The wound was not tunneling, had a moderate amount of sero-sanquinous exudates, the wound bed was red and the resident denied pain. Additional weekly pressure ulcer records were requested on 1/10/12 from the Nursing Home Administrator (NHA), on 1/16/12 from the NHA and again on 1/19/12 from the Regional Clinical Director (RCD). There were no pressure ulcer measurements found for 11/11, 12/11 or 1/12. c. Facility action to promote healing of the resident's pressure ulcer - facility failure to properly treat ulcer (1) The resident's care plan for pressure ulcers, noted with start date of 8/17/11 and last review date of 11/16/11, identified actual stage IV coccyx pressure ulcer related to moisture/incontinence, decreased activity, impaired mobility, and co-morbid conditions. - The goal was for the pressure ulcer to show signs of healing process as evidenced by decrease in depth, width and length by at least .5 cm and free of further breakdown through next review. - Approaches were: apply pressure reduction mattress to bed; apply pressure reduction cushion to chair of wheelchair; provide incontinence care after each incontinent episode, or per established toileting plan, watch Foley be aware Foley-re-inserted; measure and stage wound weekly using the pressure ulcer healing assessment form; complete a full body check weekly and document; monitor lab values as ordered; IDT (interdisciplinary team) referrals as needed: registered dietitian, physical therapist, occupational therapist, other. Pressure ulcer treatment as ordered; and dressings and VAC to be on as ordered. (2) Review of outpatient notes by the infectious disease doctor revealed staff failed to properly care for the resident's ulcer. Specifically: An outpatient note by the infectious disease dated 9/8/11 documented, in pertinent part, "The wound VAC has been disconnected for approximately four hours but the sponge is still in for some reason." ". . .Decubitis that is getting deeper I think. The VAC has been inappropriately turned off with the sponge still in. I did call the nursing home and explained to them that is not correct and if for some reason the VAC suction needs to be removed, the sponge needs to be removed if it is going to be more than about ? hour to 60 minutes and wet-to-dry needs to be placed ..." Another outpatient note by the infectious disease dated 9/20/11, documented in pertinent part, that the resident's wound VAC had been removed and had not been replaced. The physician documented that he spoke with the nursing home regarding the wound VAC and the nursing home stated they were waiting for supplies for the wound VAC and that was why it was off. He documented that the wound needed to be packed deeply and changed twice a day and this was explained to the nursing home nurse. d. Current orders and failures in treatment of [REDACTED]. Although documentation by the medical director 1/10/12 and 1/18/12 (during survey) indicated that the ulcer was "much improved," and without signs of infection, observations and interviews revealed (1) facility failure to follow wound vac orders, contributing to resident pain, (2) facility failure to provide pressure relief and (3) facility failure to practice infection control. The following telephone orders dated 12/9/11 documented the following regarding the resident's wound care: -"1 Sacral Wound-Wound VAC Cleanse with non cytotoxic cleanser apply [MEDICATION NAME] with Ag to wound bed secure with occlusive dressing supplied and attach to the canister at 125mm/hg continuously. Change Monday, Wednesday, Friday and PRN." The Director of Nursing (DON) took and documented the above order. -"2 When wound VAC is not in use to sacral area cleanse with non cytotoxic cleanser apply polyacrylate and cover with a dry dressing change daily and PRN." The Director of Nursing (DON) took and documented the above order. (1) Failure to follow orders for wound vac and failure to provide pressure relief to pressure ulcer. Observations and Interviews 1/10/12: On 1/10/12 at 8:45 a.m., the resident was observed sitting up in her wheelchair eating her breakfast. -The wound vac box was observed sitting on the corner of the resident's bed. There was no noise and it appeared to be turned off. The resident stated that the nurse turned off her wound vac at about 8:15 a.m.; the nurse told her it was too noisy. -The resident stated that her pain level was at an 8/10. Since the wound vac was turned off, she has had an increase in pain. The resident became tearful and stated, "I don't know why I am not getting better and now I am not sure if I will ever get better." The resident said she was unable to change her position without assistance and was unable to propel her wheelchair due to pain and the floor being too bumpy. On 1/10/12 at 9:00 a.m., nurse #8 stated that she had turned the resident's wound vac off as it was noisy and she had not had time and did not know when she would get time to look at the wound vac. On 1/10/12 at 12:28 p.m., the resident's wound vac was still off. The vac box was now on the floor. The resident remained sitting in her wheelchair. On 1/10/12 at 1:45 p.m., the resident was observed in bed on her back as the certified nurse aides (CNAs) had just transferred her back to bed. -CNA #6 stated she had just changed the resident, and the wound vac tubing was on the floor. CNA #6 stated that the resident had just had a bowel movement (BM) and the tubing fell off onto the floor. The CNA stated that the tubing was lying behind the resident's hip when the resident was transferred. -CNA #6 said there was no dressing on the wound and the tubing was being held on by a couple strips of clear tape that were covered with BM and the sponge (to be in place when the vac was on) was still in but partly out. On 1/10/12 at 2:45 p.m., the resident was observed lying on her back in bed. She still had not received wound care and the wound vac remained off with the sponge in. On 1/10/12 at approximately 2:25 p.m., resident #117 was observed lying on her back in her bed. Further observation revealed that the resident had no physician ordered [DEVICE] applied. There was a dark grey piece of [DEVICE] sponge visible to the surveyor. The DON was present and was attempting to complete a dressing change and reconnect the [DEVICE]. -The resident was asked if she had received any pain medication prior to the dressing and [DEVICE] sponge removal, she replied no. When asked on a Norton pain scale of 1-10, the level of pain that she currently was experiencing, she stated a "7." When asked what made the pain level worse she stated "lying in bed on my back all the time." When asked if she received pain medication prior to her dressing change, she replied "only I if ask for it." She stated that her pain was continuous and she did not always get her pain medications when she asked for them. The resident was observed with a clock hung at her bedside that she continuously referred to when describing waiting for her pain medication. Observations and Interviews 1/16/12: On 1/16/12 at 7:15 a.m., the resident was observed lying on her back in the bed, she said she did not have a very good weekend, as the CNA's had not gotten her out of bed all weekend. The resident again stated that she was never turned or propped on her sides, and she was always positioned on her back. On 1/16/12 at 7:58 a.m., CNAs #6 and #7 where observed getting the resident out of bed. The CNAs stated that they needed to get the resident cleaned up before they could get her up for breakfast because she had a bowel movement. They stated the wound vac sponge was not attached to the skin anymore and there appeared to be feces in the wound bed. There was a strong pungent odor noted as well. The CNAs stated they needed to get the assisted director of nursing (ADON) to come and do wound care before they could get the resident up. On 1/16/12 at 8:05 a.m., the ADON stated that there was feces around the tape which told her there was not a good seal on the wound VAC. She stated that there was no feces in the wound bed and that feces was on the outside of the sponge. The ADON discussed that since the resident was having some pain she had applied the alternate dressing, which could be applied for 24 hours if need be. On 1/16/12 at 8:42 a.m., the resident was observed sitting up in her wheelchair with her room tray in front of her. On 1/16/12 at 9:55 a.m., the resident stated that she usually only has one person to assist with transfers, but feels most comfortable with two persons. She stated over the weekend she did not get out of bed, and ate all of her meals in the bed, she was told they could not get her up because they were short staff. On 1/16/12 at 12:30 p.m., the resident remained in the same position in her wheelchair and now had her noon meal tray in front of her. On 1/16/12 at 2:30 p.m., the resident was observed as she was returning from her shower and was being transferred back to bed. On 1/16/12 at 3:40 p.m., the resident stated that she had been up in her chair all morning and stated that she had a shower but she was just transferred from her wheelchair to the shower chair and then back to her wheelchair and then finally back to bed. The resident was observed lying on her back in bed. The resident stated she was not opposed to sleep on her sides, but she has never been positioned on her side and she requires two people assist for bed mobility and positioning. (2) Failure to follow infection control practices during dressing change Wound Care Observations 1/10/12: On 1/10/12 at approximately 2:45 p.m., the Director of Nursing (DON) was observed by a nurse surveyor as she changed the resident's sacra/coccyx dressing. -The DON was observed leaving the resident's room to obtain wound care supplies. The DON returned about 20 minutes later with the supplies for one wound but had no supplies for the wound vac. The DON did not wash her hands after entering the room. -The DON grabbed several paper towels, placed them on the resident's bedside table and established her work station. The DON had Q-tips and placed them in a plastic drinking cup, tip down. -The DON removed the lid of the sterile packing dressing and touched the dressing opening against the privacy curtain. The DON then re-capped the sterile packing and placed it on the resident's dresser, as the resident had two wounds, a pressure (wound VAC) and an incision wound which required the packing. -The granulation sponge was removed from the pressure ulcer and the following measurements were taken: 3.0 cm X 3.5 cm and 3 ? cm deep. The DON used a Q-tip that she removed from the plastic cup to measure the depth of the resident's wound. -The DON did not change her gloves after removing the soiled dressing and before taking the wound measurements. -The DON stated that she wanted to get the resident pain medication before re-applying the dressings. At 3:10 p.m., both wounds remained open to air, the resident was placed on her back with both open wounds resting against her soiled sheets. e. Staff Interview On 1/16/12 at 12:15 p.m., the DON stated that the resident had an air mattress, she should be repositioned every 2 hours, she should be sitting up in the wheelchair less than 2 hours, and she was the last one to be gotten up before meals. She stated there was a place on the kiosk to document if the resident was being re-positioned. On 1/16/12 at 2:30 p.m., CNAs #6 and #7 said there was a turn/reposition icon on the computer to document when the resident was being turned. The CNAs stated they were aware that the resident was to be re-positioned every two hours while in her chair, but not necessarily re-positioned in her bed. The CNAs said they use the resident care cardex to direct their care of the residents. On 1/10/12 at 5:05 p.m., the NHA, Medical Director (MD) and Regional Clinical Director (RCD) were informed of the observations during wound care 1/10/12 (see above). -The MD stated the DON should have knowledge of how to change a wound VAC as well as do a dressing change. The MD stated that with wounds of the resident's type should not be left open to air. Rather, they should be packed to protocol and not be resting against dirty linens. f. Resident Care Cardex Review of the resident care cardex on 1/16/12 revealed that turning and re-positioning was not on the resident's cardex. 2. Resident #82 (Closed Record) Resident #82, a [AGE] year old male, was admitted to the facility on [DATE]. According to the December 2011 computerized physician orders, the resident had [DIAGNOSES REDACTED]. According to the most recent MDS, dated [DATE], the resident was usually understood by others and usually able to understand others. The resident was coded as having both long-term and short-term memory problems, and was moderately impaired for cognitive skills for daily living. The resident required extensive assistance for all activities of daily living. a. Record Review Care Plan: A care plan dated 11/7/11 and last reviewed on 11/18/11 documented that the resident had a pressure ulcer on the right buttocks due to moisture/incontinence, impaired mobility and refusal of care/treatment-resistance. -The goal was that the resident would have intact skin without signs of skin breakdown through the next review. -The following approaches were implemented: Apply pressure reduction mattress to bed; apply pressure reduction cushion to chair or wheelchair; provide incontinence care after each incontinent episode, or per established toileting program; measure and stage wound weekly using the pressure ulcer healing assessment form if one develops; complete a full body check weekly and document; monitor lab values as ordered, IDT referrals as needed and encourage resident to self propel his wheelchair. Skin Assessments/Weekly Pressure Ulcer Reports: The 10/27/11 Nursing Admission assessment identified that the resident scored a 7 on the Braden Scale-For Predicting Pressure Sore Risk. A score of 12 or less represents high risk. The 11/17/11 Nursing Admission assessment identified that the resident scored a 14 on the Braden Scale-For Predicting Pressure Sore Risk. A score of 12 or less represents high risk. This was the latest assessment date. The last entry found on the Head to Toe Skin Checks was completed on 12/2/11 and noted that there was a coccyx wound, with no other abrasions, bruises, skin tears or rashes, and the wound had been previously identified and interventions were in place. Weekly Pressure Ulcer Report: -The 10/27/11 weekly pressure ulcer report documented that the resident was admitted with a stage II pressure wound to his right buttocks. The wound measured 1.5 X 0.6 cm and had a depth of <0.1 cm. There was no undermining. A scant amount of serosanguineous exudates, wound bed was red and surrounding skin was dark red/purple and normal. The resident did not express pain with the wound. The progress note documented the following; there was a wound noted at right buttocks, measurements as noted above, no signs or symptoms (s/s) of infection, no complaints of pain voiced, and order received-will treat and monitor. -The 11/4/11 weekly pressure ulcer report documented that the resident had a stage II pressure wound to his right buttocks. The wound was a stage II which measured 4.5 X 2.5 cm and had a depth of <0.1 cm. The progress note documented the wound measured as noted above, there were no complaints of pain, no s/s of infection, interventions were in place and to continue to monitor and treat. There was no comment about the ulcer's increase in size, no documentation of revised plans to prevent further breakdown, however, review of physician orders revealed an order 11/4/11 that read to discontinue treatment to right buttock, cleanse right buttock with non-cytotoxic cleanser, and apply hydrogel to wound and to change every three days. -The 11/11/11 weekly pressure ulcer report documented that the resident had a stage II pressure wound to his right buttocks. The wound was a stage II which measured 4.0 X 2.0 cm and had a depth of <0.1 cm. There was no undermining, no exudates, the wound bed was yellow, the surrounding skin was normal and pink, and the resident voiced no complaints of pain. The progress note documented the wound measured as noted above, there were no complaints of pain, no s/s of infection, interventions were in place and to continue to monitor and treat. -The 11/18/11 weekly pressure ulcer report did not document the stage of the wound to his right buttocks. The wound measured at 3.5 X 2.0 cm and had a depth of <0.1 cm. There was no undermining, no exudates, the wound bed was normal and red, the surrounding skin was normal and pink, and the resident voiced no complaints of pain. The progress note documented the wound measured as noted above, there were no complaints of pain, no s/s of infection, interventions were in place and to continue to monitor and treat as ordered. Additional weekly pressure ulcer records were requested on 1/10/12 from the Nursing Home Administrator (NHA), on 1/16/12 and again on 1/19/12, from the Regional Clinical Director (RCD). There were no pressure ulcer measurements found after 11/18/11 and no reports for the remainder of 11/11, for 12/11 or for 1/12. Change of Condition: A change of condition form completed on 12/20/11 identified that the resident had a wound on his left heel which was noted on the night of 12/19/11 and was unstageable. Nurse #2 documented that the night nurse had reported that the resident had an unstageable white closed blister on his left heel. It was documented that a boot was applied, wound nurse evaluated and gave wound recommendations, family and doctor notified. A 12/20/11 order documented, cleanse left medial heel with non-cytotoxic cleanser, apply skin prep every day, allow skin prep to dry, apply heel medix boot to left lower extremity around the clock. A 12/21/11 order documented, cleanse right medial heel with non-cytotoxic cleanser, apply skin prep every day, allow skin prep to dry, apply heel medix boot to right lower extremity around the clock. A 12/22/11 order documented, monitor wound to left medial heel and right lateral heel for abnormalities to dressing. Nurses Notes: A nurse's note dated 12/26/11 documented that the resident was turned and re-positioned frequently and that Medix (MP) boots were on bilateral feet. b. Failure to adequately monitor the status of the resident's ulcers (1) Skin Checks See above; the last entry found on the Head to Toe Skin Checks was completed on 12/2/11. There were no skin checks in the resident's record after this date. (2) Weekly Pressure Ulcer Reports See above; there were no further weekly reports on the resident's coccyx wound after 11/18/11 which was incomplete as it was without measurements. There were no weekly reports on the resident's heel wounds (left or right). (3) Care Plan See above; the resident's care plan was not updated after 11/18/11. The care plan failed to reference the resident's heel wounds and pressure relief for these wounds, even though the nurse's notes indicated the use of Medix boots bilaterally. (4) Nurse's Notes There were no entries, other than on 12/26/11, regarding the resident's heel ulcers or buttock ulcer. c. Hospital Record Resident was transferred to the emergency roiagnom on [DATE] with profound lethargy. The resident's admission [DIAGNOSES REDACTED]. The physical examination revealed the following skin findings: The resident had about 6 cm of skin breakdown and infection in both heels, as well as a very small superficial quarter-size coccyx skin breakdown. d. Staff Interviews On 1/17/12 at 2:52 p.m., CNA #13 stated he was not aware of the resident's pressure ulcers. On 1/17/12 at 3:00 p.m., nurse #3 recalled that the ulcer on the resident's right buttocks was discovered on admission. The nurse was not aware that the resident had developed additional wounds. On 1/17/12 at 3:16 p.m., the registered dietitian (RD) stated that she had addressed the resident's nutritional status (nutritional) assessment 10/27/11 and progress notes 12/5/11 (Juven twice a day, consider protein supplement if no wound improvements) and 12/26/11 (recommend start [MEDICATION NAME] three times a day, give protein fortified foods at every meal, and start a non-sugar added shake twice a day) 3. Resident #28 Resident #28, age 85, was admitted to the facility on [DATE]. According to the facility face sheet of the same date, his admitting [DIAGNOSES REDACTED]. The January 2012 computerized physician orders revealed that the resident was on the following medications: [REDACTED]. The resident's quarterly MDS, dated [DATE], revealed that the resident was cognitively intact, needed extensive assistance with transfer, rolling and activities of daily living. The assessment documented that the resident was frequently incontinent. Section M revealed the resident was at high risk for developing pressure ulcers and that the resident had no current pressure ulcers. A review of the resident's Braden scale, a facility tool used to predict pressure sore risk, revealed the resident scored 12 on 1/7/12. According to the document, a score of 12 would indicate a high risk for acquiring a pressure sore. The resident was care planned for pressure ulcers on 4/22/11. The approaches included: Applying a reduction mattress to the bed, applying a pressure reduction cushion to chair or wheelchair. The care plan was updated on 12/29/11. Additional approaches included completing a full body check weekly and documentation in the resident's chart under the head to toe skin check section. a. Pressure Ulcer Development Orders: A record review revealed that a telephone order was placed to the attending physician on 12/26/11, requesting a protective [MEDICATION NAME] covering for the resident's coccyx. Under the indication section of the physician telephone order (TO) the indication for the coccyx dressing was "pressure ulcer." Interview: In an interview, on 1/17/12 at approximately 11:00 a.m., with the facility wound care nurse, she revealed the resident had an open stage II coccyx wound. Observations: On 1/17/11 at approximately 2:15 p.m., the resident's dressing change was observed. The resident was observed as having a wet adult protective undergarment. The peri area was observed as being very red and non-blanchable. The peri area was also observed as having numerous deep folds in the skin around the coccyx and scrotum area. The nurse stated there was no current dressing on the wounds. -The coccyx region was observed as having multiple open wound areas. Specifically: A stage II area on the coccyx and five other pressure ulcers (stage I) were observed. An area to the right of the coccyx was observed with white hard mass. The area was measured at approximately 1 cm x 1 cm. The nurse stated she did not know what the area was. b. Failure to adequately monitor the resident for skin breakdown Interview: On 1/17/12 at approximately 11:00 a.m., the facility wound care nurse stated that when a nurse receives a telephone order from a physician, the order should be transcribed to the current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated that the resident's skin sheet in the medical chart should then be completed including the area of the pressure ulcer and the staging of the pressure ulcer. The wound nurse stated that the skin assessment sheet in the medical record should be filled in with the area and staging of the pressure ulcer. She then stated that the next step in the process would be documenting in the resident's medical record in the section called nurses notes; this documentation should provide information supporting the telephone order request, such as the area and staging of the pressure ulcer. The director of nursing (DON) was interviewed, on 1/18/12 at 2:15 p.m. She stated that the process for correctly identifying the areas of concern on the head to toe skin document included labeling the body diagram with the areas of the pressure ulcer(s). If more than one area of concern was identified, that the body area should be identified and numbered, then cross referenced under the area of the form labeled skin intact. She further stated that the back side of the head to toe skin check document offered additional areas for the nurse to comment on the pressure wounds under the section comments. She stated that it would be her expectation that the facility nursing staff fill out the comment section of the document, especially if more than one area of concern was identified. If the area was not completed, she would expect to see documentation in the nursing note section of the resident's medical record. Record Review: Head to Toe Skin Checks: -A review of the resident's head to toe skin checks for 12/11 revealed that the resident had no skin checks documented after 12/16/11, which documented a cellulitic right great toe. -A review of the 1/12 head to toe skin checks revealed the first charting by nursing was done on 1/6/12 and no areas of skin breakdown or pressure ulcers were documented on the resident's skin assessment sheet. The body diagram contained no areas of skin breakdown or pressure ulcers. -A review of the 1/13/12 head to toe skin check revealed no areas of skin breakdown or pressure ulcers were documented. Weekly Pressure Ulcer Reports: Record review revealed there were no Weekly Pressure Ulcer Reports documenting this ulcer. Nurses' Notes: -The nurses' note dated 12/26/11, the date of the p

Based on record review and interviews, the facility failed to ensure allegations of sexual abuse were thoroughly investigated, timely reported, and facility residents were protected during the investigations. The facility failures contributed to repeat incidents of resident to resident abuse and fear. Cross-reference F323. The findings include: A. Facility Policy Review of the facility Abuse & Neglect Prohibition, (#OP2 0304.00, revised 9/2011) revealed the following: Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must immediately be reported to the Administrator (NHA) and/or Director of Nursing (DON). Fundamental Information Definitions: -Abuse Prevention Coordinator: the facility NHA is the Abuse Prevention Coordinator. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Injuries of unknown origin may occur as a result of abuse. -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. Procedure Training: 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. 3. The facility will provide training regarding related policies and procedures. Prevention: 1. Residents, families and staff will be able to report incidents and concerns without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. 3. Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate. 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. Identification: 1. The facility Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect, injuries of unknown origin, or misappropriation of resident property to determine the direction of the investigation/intervention, through analysis of systems, audits and reports. 2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that my lead to abuse/neglect or may escalate a continuum of aggression. Investigation: 1. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, in accordance with state regulation. 3. The facility will report all investigation findings to the state in accordance with state regulations. 4. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the QA&A committee, with intervention reporting, or policy/procedure modification conducted as appropriate. Protection: 1. The facility will protect residents from harm during the investigation. 2. The facility will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property. Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law. 4. In accordance with the Elder Justice Act, the facility will report to law enforcement agencies and to the state agency any reasonable suspicion of a crime against any individual who is a resident of, or receives care in the facility. B. Cross-reference F323; Accident Hazards - Resident to Resident Sexual Abuse Resident #53 repeatedly engaged in sexually aggressive behavior toward facility residents. The facility failed to take steps that were effective, sustained, and expected, per facility policy, to report resident #53's behavior and to protect facility residents, even after the behavior was observed and facility administration informed of the behavior by residents and staff. On 01/04/12, record reviews and interviews during an on-site visit by the Colorado Department of Public Health and Environment (CDPHE), revealed a pattern of sexually inappropriate and aggressive behavior by resident #53 toward facility residents and visitors beginning as early as 1/11. Interviews beginning on 01/04/12 revealed resident #53's behavior had been witnessed by various staff, family members and other facility residents. The behavior had not been reported by floor staff or administrative staff until 11/17/11. Instances of abuse included sexually derogatory comments, unwanted touching, sexual innuendo, and sexual proposition. There was a lack of documentation in resident #53's record that the resident's sexually inappropriate and aggressive behaviors were thoroughly investigated and that effective and sustained interventions to protect facility residents from these behaviors were implemented. See F323; Accident Hazards - Resident to Resident Sexual Abuse for further details.

Based on record review and interviews, the facility failed to implement the facility's policy to prohibit abuse. The facility failures contributed to repeat incidents of resident to resident abuse and resident fear. Cross-reference F323. The findings include: A. Facility Policy Review of the facility Abuse & Neglect Prohibition, (#OP2 0304.00, revised 9/2011) revealed the following: Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must immediately be reported to the Administrator (NHA) and/or Director of Nursing (DON). Fundamental Information Definitions: -Abuse Prevention Coordinator: the facility NHA is the Abuse Prevention Coordinator. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Injuries of unknown origin may occur as a result of abuse. -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. Procedure Training: 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. 3. The facility will provide training regarding related policies and procedures. Prevention: 1. Residents, families and staff will be able to report incidents and concerns without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. 3. Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate. 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. Identification: 1. The facility Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect, injuries of unknown origin, or misappropriation of resident property to determine the direction of the investigation/intervention, through analysis of systems, audits and reports. 2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that my lead to abuse/neglect or may escalate a continuum of aggression. Investigation: 1. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, in accordance with state regulation. 3. The facility will report all investigation findings to the state in accordance with state regulations. 4. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the QA&A committee, with intervention reporting, or policy/procedure modification conducted as appropriate. Protection: 1. The facility will protect residents from harm during the investigation. 2. The facility will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property. Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law. 4. In accordance with the Elder Justice Act, the facility will report to law enforcement agencies and to the state agency any reasonable suspicion of a crime against any individual who is a resident of, or receives care the in facility. B. Cross-reference F323; Accident Hazards - Resident to Resident Sexual Abuse The facility failed to implement the policy above, to report and respond to abuse and to protect facility resident from harm. Specifically: Resident #53 repeatedly engaged in sexually aggressive behavior toward facility residents. The facility failed to take steps that were effective, sustained, and expected, per facility policy, to report resident #53's behavior and to protect facility residents, even after the behavior was observed and facility administration informed of the behavior by residents and staff. On 01/04/12, record reviews and interviews during an on-site visit by the Colorado Department of Public Health and Environment (CDPHE) revealed a pattern of sexually inappropriate and aggressive behavior by resident #53 toward facility residents and visitors beginning as early as 01/11. Interviews beginning on 01/04/12, revealed resident #53's behavior had been witnessed by various staff, family members and other facility residents. The behavior had not been reported by floor staff or administrative staff until 11/17/11. Instances of abuse included sexually derogatory comments, unwanted touching, sexual innuendo, and sexual proposition. There was a lack of documentation in resident #53's record that the resident's sexually inappropriate and aggressive behaviors were thoroughly investigated and that effective and sustained interventions to protect facility residents from these behaviors were implemented. See F323; Accident Hazards - Resident to Resident Sexual Abuse for further details.

Based on record review and interviews, the facility failed to ensure three of 60 sample residents (#84, #60, #34) received the medically-related social services necessary to attain and/or maintain their highest practicable level of physical, mental and psychosocial well-being. Specifically: Resident #84, who had a major mental illness, was admitted to the facility from the hospital 12/1/11. The facility failed to ensure that "current care"/psychotropic medications, including Zyprexa, were continued, as expected, per admission documentation. This failure contributed to a decline in the resident's mental and psychosocial well-being. Resident #60 and resident #34, who had orders for a psychological consult, did not have the consults timely completed. The findings include: 1. Resident #84, age 78, was admitted to the facility on [DATE]. According to the January 2012 computerized physician orders, the resident had [DIAGNOSES REDACTED]. The hospital record also documented a [DIAGNOSES REDACTED]. According to the most recent minimum data set (MDS), dated [DATE], the resident was coded as scoring an 11/15 on the brief interview of mental status, which indicated that she was moderately cognitively impaired. The resident's mood was coded as having little interest or pleasure doing things and the resident exhibited delusional behaviors. The resident was coded as having an active [DIAGNOSES REDACTED]. a. Resident Status on Admission Although hospital transfer orders did not include orders for antipsychotic medications, record review revealed the facility received documents from the hospital consulting psychiatrist and the PASRR (pre-admission resident review) Psychiatric Evaluation on 12/1/11, the resident's date of admission (per fax date on the evaluation). These documents indicated the resident had a major mental illness (paranoid schizophrenia), required oversight with medication management, and was improving on her current treatment plan. Specifically: Psychiatrist Notes: Review of a psychiatric consultation report, dated 11/23/11, documented that the resident had presented with an unkempt appearance, she made fair eye contact, had a dry mouth and was constantly smacking her lips and moving her tongue and shrugging her shoulders. There was some disarticulation with her speech but otherwise regular. Her thought process was mostly linear and logical, but her thought content was vague, suspicious, likely paranoid. Mood is described as, "ok, there's nothing wrong with me." She denied having auditory or visual hallucinations. -The psychiatrist documented that he wondered if she was responding to some stimuli, as at times she would glance around the room and seemed quite anxious and even paranoid. -The psychiatrist documented that the resident would be started on Zyprexa Zydis (antipsychotic) 10 mg nightly and Cogentin (used to treat Parkinson's type symptoms). He did not feel that the resident had the capacity to make medical decisions for herself, due to poor insight into her mental illness and the current condition of her home. A psychiatric follow-up, dated 12/1/11, documented the following; -"The patient reports that she has been sleeping well. She is tolerating the medications. She has agreed to go to (name of nursing home). She says that she is looking forward to that; 'It will be a step up for me.' -She said that she will be following with (name of agency). She feels like her medications have been working well for her and is tolerating the Cogentin. She reports that she has had some less [DIAGNOSES REDACTED], but still has some jaw and tongue movement. It seems to increase as she gets more excited. She reports that her thinking is more clear. She reports that the Haldol (antipsychotic) and Zyprexa have been working well." -He further documented to continue current care (see above; Haldol, Zyprexa, and Cogentin). PASRR (Pre-admission screening and resident review) II Recommendations: -Review of Level II recommendations from 12/1/11, indicated that the resident had a major mental illness and specialized services were required. The resident had an Axis I Primary [DIAGNOSES REDACTED]. -The Level II documented that the resident required oversight with medication management and decision making. She had been involved with mental health services since 1978 and records reported a [DIAGNOSES REDACTED]. -Recommendations were: --Monitor for appropriateness and effectiveness of psychotropic medications with adjustments as needed to maintain stability as well as minimize side effects. --Recommend that the resident be encouraged to resume mental health services through (Name of Provider) to provide medication management and symptom monitoring which may significantly affect functional level. --Monitor for symptoms of psychosis and effectiveness of psychotropic medications. --If resident continues to take psychiatric medications there may be improvement in control of psychosis and at that time a re-evaluation of cognitive and memory ability would be helpful to assess the resident's cognitive functioning. --Facility should work around establishing another type of legal authority in preparation for the possibility of a future decompensation. --The resident has a strong desire to discharge back to independent living. If she makes progress that will allow moving to less restrictive setting, nursing facility should help to facilitate process to help the resident access services that will be needed. -Resident had recently refused to see her psychiatrist and had not been seen since 5/27/11, and the resident had refused her monthly (Prolixin Decanoate) injection. -It was noted that, "According to hospital staff notes, patient has been more cooperative, interactive and taking her medications without difficulty. According to psychiatrist notes patient has reported that she is sleeping better, mood is feeling more even and she is feeling less anxious since she started on the Zyprexa." b. Failure to ensure "current care"/psychotropic medications, including Zyprexa were continued as expected per admission documentation. (1) Review of the December Medication Administration Record (MAR) revealed orders for Cogentin (use to treat Parkinson's type symptoms) twice a day and Trazodone (antidepressant) at bedtime. There were no orders for Zyprexa or Haldol. (2) Review of a physician's note, dated 12/5/11, documented: "She did have a psychiatric evaluation in the hospital in December by (Physician's name). She had been doing well on Haldol and Zyprexa with Cogentin. She now is on Cogentin, but has no antipsychotic on board. I will request an appointment be made with (name of agency) for follow up on schizophrenia. She will need medication follow up. She may need long term care." Review of social service notes revealed an appointment was made with the agency referenced in the physician note; however, the note made no reference to follow-up on the resident's medications for schizophrenia. Rather, the social service notes read: -12/9/11: Called (agency) case worker will have meeting with us to talk about finding a new apartment for (resident) on 12/14/11. -12/13/11: (Agency) here to sign up for (housing). (3) Further review of the resident's social services notes revealed one other social service note, written by the social service assistant (SSA). It was an initial assessment, dated 12/5/11. It made no reference to the psychiatrist notes, current treatment, or the PASRR recommendations. It read, in pertinent part: -The resident had been living independently. The resident denied any mental illness, but record review documented that she had a [DIAGNOSES REDACTED]. -The SSA documented that the resident had a PASRR II, which should arrive to them in approximately two weeks (but see above; PASRR faxed 12/1/11). The resident had reported that she was not getting mental health services. The resident was unable to return to her apartment and currently had nowhere to go to. The resident demonstrated long-term memory problems. -The SSA documented the resident was on Trazodone 50 mg at night for depression, the resident self isolates, has insomnia, and sad facial affect, and her discharge was uncertain at this time. (4) Review of the resident's care plans for administration of psychoactive medication (12/4/11) and "disturbed thought process" (12/5/11) made no reference to the PASRR II recommendations, including the resident's use of Zyprexa in the hospital. c. Observations and Interviews - Resident Behaviors Observations: On 1/3/12 at approximately 12:30 p.m., the resident was observed sitting in the main dining room. She was moving her wheelchair to/from at the table; she had noticeable jaw, lip smacking, irregular tongue movements and appeared anxious. The resident appeared pale, had dark blush on her checks and had black penciled in eye brows that came up to a point on her forehead and back down (much like a line on an EKG). The resident was asked if she liked her meal and she stated that she did, but then went on to talk about money being stolen from her, and something else that was nonsensical. On 1/16/12 at approximately 10:00 a.m., the resident had stated to the nursing home administrator (NHA) and the surveyor that she wanted a night light in her room, because it would keep people from coming in and molesting her at night. The resident also discussed that people at the bank had taken all of her money and was also making allegations about her roommate which were not understandable. The resident's speech was rushed, at times difficult to understand. The resident also had jaw, tongue, lip and mouth movements. d. Staff Interviews -On 1/16/12 at 4:19 p.m., CNA #15 stated that he had not worked too much with resident #84, but he had observed her picking at her skin. The CNA stated that the resident did make comments about people stealing things from her and that she was fixated on her roommate's Christmas tree and she kept saying the ornaments on the tree were missing, but they were not. -On 1/17/12 at 2:55 p.m., CNA #13 stated that he had noticed the resident was worried about her money, and she stated in the past people had stole her money and now it was safe because she marked the money. He did notice that she had some psychosocial needs, and thought she had a mental illness. He stated he had asked nursing about her behaviors as he was curious, he thought it was nurse #6, this was on the day of admission, and the nurse had stated she had not had time to review the resident's chart. He reported that the resident was always smacking her lips and had a lot of tongue moment. He knew something was wrong and reported it. On 1/16/12 at 11:10 a.m., the Director of Nurses (DON) and Nursing Home Administrator said the psychotropic committee meets the second Tuesday of every month. The MDS was reviewed weekly. The DON discussed that when they are reviewing, they look at longevity of use, reason for use, last gradual dose reduction (GDR), issues with behaviors in the last quarter, and review the care plan, which should address the psychoactive medication and behavior/depression and anxiety care plan. The DON and NHA stated that they were in the process of re-doing the committee to involve social services as they were not currently part of the committee. The NHA, DON and SSD were not aware of the resident's psychiatric evaluations in the hospital and improvement on Zyprexa, nor were they aware of the PASRR II recommendations or psychiatrist recommendations to continue the current plan of care. On 1/16/12 at 11:32 a.m. in an interview with the DON, NHA and SSD, the DON stated that the social services had been part of the IDT (interdisciplinary) committee in the past and initially psych medications would be discussed in the IDT meeting. The NHA stated that the PASRR should have been reviewed at the IDT review. -The SSD stated that she did not know the resident very well, and when she came in, the resident told her that another doctor told her that she was not crazy. The SSD discussed that when things have been brought to her attention regarding the resident's behaviors and allegations of missing items, these behaviors have been care planned. When asked what interventions were put into place to help the resident with delusions, the SSD stated she was unable to answer that. -The SSD indicated she was not familiar with the resident's PASRR II recommendations. The SSD discussed that it was nursing's responsibility to transfer the admission medications from the orders to the medication administration record. -The DON stated that nursing should be documenting the resident's behaviors and the DON stated that she has seen that the resident had behaviors and was often worried about money being stolen, and thoughts of being molested. The resident's behaviors have been brought up to nursing and these behaviors should have been brought and discussed in the IDT meeting as soon as the behaviors were noticed. -The NHA stated that the PASRR Level II should have been reviewed prior to admission. On 1/19/12 at 10:15 a.m., the SSD stated that if the PASRR gave specific recommendations regarding particular behaviors it would be social services responsibility in telling the nursing staff to track those behaviors and medications. On 1/19/12 at 9:25 a.m., the SSA stated that they get an initial copy of the level II at the time of admission, which shows any recommendations but she never knew those were what she was to follow. e. Follow-up on Survey On 1/16/12, the resident was presented with a psychoactive medication consent form for Zyprexa Zydis 10 mg every night for paranoia, delusional statements, and unrealistic ideations. The resident refused to sign the consent form. A physician's telephone order, dated 1/16/12, documented a nursing order for Zyprexa Zydis 10 mg by mouth every night for a [DIAGNOSES REDACTED]. A physician's telephone order, dated 1/17/12, documented, "notify (name of mental health agency) of the paranoid condition of their patient." 2. Resident #60, age 64, was admitted [DATE]. According to the face sheet, dated 8/18/10, the resident's [DIAGNOSES REDACTED]. The 8/18/11 MDS revealed that he was able to hear, and that he could respond adequately to simple, direct communication, but that he had an absence of spoken words. The BIMS (mental status exam) was not able to be completed. a. Record Review - order for psychological evaluation On 12/1/11, a physician progress notes [REDACTED]. -Staff had reported resident was not eating well and was self-isolating. He was re-started on Remeron 7.5 mg this month. -Assessment/Plan 1) Depression - failed gradual dose reduction of Zoloft (anti-depressant); Psych(ological) Eval(uation) ordered; re-start Zoloft; 2) Anorexia - continue Remeron for this time, likely to discontinue as Zoloft takes effect. On 12/1/11, a Physician Telephone Order for Psych(ological) Eval(uation) was given by the resident's NP and co-signed by the resident's physician, who had seen the resident at least monthly for past year. On 12/1/11, nurses' notes documented that the Social Service Assistant (SSA) was notified to make an appointment for Psych(ological) Eval(uation). b. Evidence of the Resident's Psychological Distress - no evidence of psychological evaluation On 12/16/11, nurses' notes documented the resident told the dietary manager that he wanted to die and nurse notified Social Services and Director of Nursing, there was no documentation about the resident's ordered psychological evaluation. Observations during survey (1/9/12-1/19/12), revealed the resident was always observed in his room, including for meals. The resident was observed always lying in bed, fully dressed with shoes, baseball hat and sunglasses next to bed, TV on. He was always awake and would smile and nod his head or shrug his shoulders in response to simple questions. Observations during three meal times revealed that he only ate 25-50% of those meals. Further entries in nurses' notes on 1/4/12 and 1/9/12 documented NP and physician visits and orders, but there were no further notes on the resident's psychological status or the order for the psychological evaluation. Record review on 1/12/12 revealed no entries in the Social Progress Notes since 11/7/11. The note on 11/7/11 revealed that the resident was non-verbal and made himself understood by questions that only require yes or no answers. It further read that the resident self-isolates in room, eats in room and watches TV. c. Interview In an interview on 1/12/12 with Social Services Director and SSA, the SSA revealed that she had received the order from the nurse to make an appointment for Psych(ological) Eval(uation) for this resident, but she stated that the resident could not communicate enough to have an evaluation. She stated that she did not make the appointment, as ordered. Record review on 1/17/12 revealed a new Physician Telephone Order to discontinue Psych(ological) Eval(uation) - too aphasic to participate. However, social services, in the 11/7/11 note (see above), documented that the resident could make himself understood by questions that required only yes or no answers. Moreover, Rehab notes revealed the following: 1/11/12 - Speech Therapy (ST) reported that he denied dysphagia or pain with mastication; he indicated that he would eat a grill cheese sandwich for lunch. 12/8/11 - ST evaluation stated that he is aphasic but does understand simple conversational topics and will answer yes or no with verbalizations and gestures. 12/1/11 - Occupational Therapy referred to resident as aphasic-expressive, noting his refusal for all suggestions about bathing and for many meal trays. And, in several interviews with the resident on 1/9, 1/10 and 1/11, the resident was alert and able to respond by nodding his head yes or no, shrugging his shoulders if he did not know, and occasionally verbalizing very soft single syllable response, including yes and no. During the three meal observations, the resident indicated that he liked the cheeseburger and the grilled cheese sandwiches, but did not want to eat all of it and did not want anything else. 3. Resident #34, age 63, was admitted to the facility 12/7/11. According to the face sheet, dated 12/22/11, [DIAGNOSES REDACTED]. The 12/15/11 History and Physical included the following additional active problems: agitated depression, multi-infarct dementia and acute urinary tract infection. The MDS, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 /15, which indicated moderate cognitive abilities. a. Record Review Pertinent Physician Orders: -12/10/11 Physician Telephone order for Psych(ological) Eval(uation); -12/16/11 Physician Telephone order for Abilify 15 mg daily for depressive disorder. The resident was not receiving any other antidepressants or related medications in addition to the Abilify. Nursing Daily Skilled Summary - evidence of resident's psychological and behavioral concerns: -12/8/11 note revealed that resident uses the call light frequently and is very easily upset and emotional; continues to call and holler from room for attention; -12/9/11 note revealed that resident is very weepy when up and does not want to do anything but stay in bed, calling out shouting - resident was redirected and shown call light in reach; -12/10/11 note revealed that the doctor had been in to see the resident and the Psych(ological) Eval(uation) was ordered; -12/12/11 note revealed that resident yells out a lot, calls for people who are not there, kicks legs toward ceiling; -12/14/11 note revealed that resident yells for help, has been redirected to call light frequently, but still yells and screams; -12/19/11 note revealed that resident is alert and confused with psych(ological) issues; yelling and screaming at times for little things; -12/27/11 note revealed that resident is alert and confused with psych(ological) issues; -12/30/11 note revealed that resident refused to get up for meals and was crying about being home-sick for her family to come for visits; up at lunch and continues to be very demanding and attention seeking; -1/10/11 note revealed that resident to get out of bed for dinner, was very teary due to feeling tired. The following Care Plans and goals were developed related to the resident's psychological and behavioral concerns: -12/15/11 Care Plan for Behavior Symptoms - minimize socially inappropriate disruptive; -12/15/11 Care Plan for Cognitive deficit - demonstrate orientation to person, place; -12/15/11 Care Plan for Anxiety - verbalize positive feeling; -12/12/11 Care Plan for socially inappropriate behavior - reduced episodes; -12/12/11 Care Plan for inability to form valid appraisal of external and internal stressors; -12/12/11 Care Plan for inaccurate interpretations of fiction and non-fiction events; -12/12/11 Care Plan for conflict with staff related to ineffective coping skills; -12/12/11 Care Plan for ineffective family coping related to non-acceptance of nurse home placement. Social Services Assessments and Progress Notes: -12/8/11 Initial Assessment revealed BIMS score of 12/15, per SSA notes; -12/8/11 Note revealed that the resident has modified independence for decisions; she is alert and oriented to person, place and sometimes time; -12/13/11 Note revealed that the husband does not want the neuro(logical) since her [DIAGNOSES REDACTED]. -12/20/11 14-day Assessment revealed that she is alert and oriented to person and place and can make her needs known; she will yell out for no apparent reason; -1/3/12 30-day assessment revealed no significant change. The Doctor's Progress Notes failed to reveal any communication about the conversation between the SSA and the resident's husband. The medical record review on 1/11/12 failed to reveal any physician's orders [REDACTED]. b. Interviews In an interview with RN #6 at 4:40 p.m. on 1/11/12, she stated that the Psych(ological) Eval(uation) was not conducted since the resident's insurance would not cover it. She also stated that the SSA talked to husband about it. However, she said she felt that a Psych(ological) Eval(uation) was still needed for this resident, but it had not happened yet. In an interview with the NHA on 1/12 at 4:30 p.m., he stated that if a resident's insurance would not cover the cost of a Psych(ological) Eval(uation), the facility would pay for this service. In an interview with the SSD and the SSA on 1/12 at 4:00 p.m., the SSA stated that the husband had applied for Medicaid and she did not recall if insurance coverage was an issue for the Psych(ological) Eval(uation). Interview with the resident on 1/9/12 at 11:30 a.m., revealed that the resident felt that the floor nurse was mean to her, and she was worried about retaliation if she reported it. She was concerned that the staff would be mad at her if she complained.

Based on observations, record review and interviews, the facility failed to ensure six of 60 sample residents (#117, #84, #61, #77, #43, and #66) received the care and services necessary to attain and/or maintain their highest practicable level of physical, mental and psychosocial well-being. Specifically: -The facility failed to assess and monitor resident #117 and resident #61's pain, contributing to both residents experiencing uncontrolled pain. -The facility failed to ensure resident #84's admission documentation, including psychiatrist notes and PASRR Level II Psychiatric Evaluation, were timely reviewed and recommendations addressed. -The facility failed to follow physician orders for diabetic management (resident #77 and #66) and geri-sleeves (#43). -The facility failed to ensure physician orders were in residents' records to prevent medication errors. The findings include: I. Pain A. Policy and Procedure The facility policy revised on February 2012 stated in pertinent part ... "6. The licensed nurse will implement a pain administration record in the medication administration record binder for documentation of pain, interventions, and outcomes. 7. The licensed nurse will communicate any new onset of resident pain or change in resident pain through the 24 hour report process. 10. The staff will implement the care plan, monitor the resident, and administer therapeutic interventions for pain, if ordered. 12. The pain medication administration record guidelines are: ...Documentation for the pain medication administration record is as follows: record the pain scale using the Faces rating Scale 1-10. Record the pharmacological interventions attempted. Record the non-pharmacological interventions attempted. Record the follow-up observations post interventions. If resident is asleep or resting, document it as an observation." B. Resident Failures 1. Resident #117 Resident #117, a [AGE] year old female, was admitted to the facility on [DATE]. According to the January 2012 computerized physician orders, the resident had diagnosis; fracture lumbar vertebra, fractured dorsal vertebra, osteo[DIAGNOSES REDACTED], pressure ulcer, Stage IV, spasm of muscle, diabetes type II, hypertension and [MEDICAL CONDITIONS] reflux disease. According to the physician's history and physical, dated 8/18/11, the resident had been involved in a motor vehicle accident mid-July and had sustained a back fracture. She had undergone surgery, the surgical incision dehisced (opened), and the resident developed a secondary infection. The resident was admitted to the facility with wound VAC (vacuum) to promote healing of the coccyx/sacral ulcer. According to the most recent minimum data set (MDS), dated [DATE], the resident was coded as scoring 15/15 on the brief interview for mental status, which indicated no cognitive impairment. The resident was able to understand others and was understood by others. The resident required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. a. Pain Management Plan Pain Evaluations: (1) An initial pain evaluation was completed on 8/16/11. It documented that the resident had pain from fractures to her spine T12 to L1. -The resident had scheduled pain management regime, received as needed medications, and non-medication interventions for pain. The resident had experienced pain in the last five days which was almost constant, interfered with sleep, and limited her day-to-day activities. The pain location was bone; location was back, generalized and radiating down the back. -The following underlying causes were identified: Fracture, immobility, surgical procedure, ulcer/wound, post traumatic injury, infection and life changing events. -The resident's pain level at that time was a 2/10, her worst pain was 5/10, and the best her pain got was 2/10. The resident's goal was to have no pain or tolerable pain. She identified that changing position, relaxation techniques, and medication administration decreased pain. (2) The last pain evaluation completed on 11/22/11 documented that the resident had pain from her wounds, and chronic knee pain. -The resident had scheduled pain management regime, nothing was checked for receiving as needed medications, and non-medication interventions for pain were being utilized. -The resident had experienced pain in the last five days which was occasional, interfered with sleep and limited her day-to-day activities. The pain location was knee and back. -The following underlying causes were identified: Ulcer/wound and life changing events. The resident's pain level at that time was a 0/10, her worst pain was 10/10, and the best her pain got was 0/10. The resident's goal was to have no pain. She identified that changing position, relaxation techniques and range of motion and mobility decreased pain. Telephone Physician Orders (TPO): A TPO dated 8/18/11 documented an order for [REDACTED]. A TPO dated 10/28/11 documented use emergency kit for [MEDICATION NAME] IR 5 mg tablet by mouth, give two tablets which equal 10 mg four times a day. A TPO dated 12/29/11 documented increase [MEDICATION NAME] to 15 mg every four hours around the clock, hold for somnolence. (There was no TPO which documented to discontinue the resident's previous [MEDICATION NAME] orders.) Computerized Physician Orders: Review of the January 2012 physician orders documented the resident had the following pain and spasm medications ordered: -[MEDICATION NAME] HCL 15 mg 2 tablets by mouth four times a day for pain (start date 10/28/11). -[MEDICATION NAME] HCL 5 mg 3 tablets give 15 mg total dosage by mouth around the clock, hold for somnolence (start date 12/29/11). -[MEDICATION NAME] 5 mg tablet, give ? tablet 2.5 mg total dosage by mouth every 6 hours as needed for spasms. Care Plan: Review of the resident's care plan for pain initiated, on 8/17/11 and last reviewed on 11/16/11, documented the resident had actual pain related to recent surgery, skin wound, fracture and motor vehicle accident, and obesity. -The goal was the resident would verbally express increased satisfaction with pain control. -The approaches were: positioning/support, exercise program, stretching exercises as ordered, administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flow sheet, notify physician if interventions are not consistently effective, observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other), medicate resident for pain prior to treatments and therapy, if indicated, and physical and occupational therapy for modalities. b. Failure to consistently assess and address the resident's pain (1) Resident Observations and Interviews On 1/3/12 at 4:21 p.m., the resident was lying on her back in her bed. The resident stated that she had pain in her right leg and down the center of her back. She said she felt it was because of the wounds (on her lumbar spine and coccyx). The resident also stated that the nurse was about 30 minutes late with her 4:00 p.m. pain medication which was administered during the interview at 4:28 p.m. The resident was not asked by nursing staff what her pain level was, and the resident did not state her pain level. On 1/10/12 at 8:45 a.m., the resident stated that the nurse turned off her wound vac. today about 8:15 a.m. as she said it was too noisy. She stated that her pain level was at an 8/10. Since the wound vac was turned off she has had an increase in pain. The resident became tearful and stated, "I don't know why I am not getting better and now I am not sure if I will ever get better." The resident discussed that she was unable to change her position without assistance and was unable to propel her wheelchair due to pain and the floor being too bumpy. On 1/10/12 at 9:39 a.m., the resident stated that nurse #8 had told her that her back spasms were all in her head. The resident stated that she gets her spasm medication every 6 hours and her pain medication every 4 hours. The resident stated that she had a pain pill this morning between 8-9 a.m. and she has to ask them for the spasm pill which she could have soon. The resident called for assistance at 9:45 a.m. for her spasm medication. The resident stated her pain level was an 8/10 on the Norton pain scale. On 1/10/12 at approximately 9:50 a.m., a certified nurse aide (CNA) had entered the resident's room and the resident requested her 10:00 a.m. medication for pain. -At approximately 9:55 a.m., the resident nurse #8 entered the room and told the resident that she did not have any scheduled medications for 10:00 a.m., and if she wanted her spasm medication, which she could have every six hours, she needed to ask for it. The resident replied that she was asking for it as she was in pain and having spasms. (2) Record Review There was no pain monitoring sheet for December 2011 or January 2012. There were two as needed (PRN) pain medication administration records found in the record, but they were not dated. One had a single entry on the 17th of the month and the second had two complete entries on the 21st and 27th, but again they were not dated. Review of the Medication Administration Record (MAR) revealed no documentation that recorded the resident's pain level prior to medication administration or after, and there was no documentation of non-pharmacological interventions found in the MAR. Further review of the January 2012 MAR revealed: -The resident had received the "as needed" [MEDICATION NAME] HCL medication twice, on 1/4/12 and 1/8/12. There was no documentation of administration on 1/3/12, when the resident expressed she was in pain, and no documentation it was administered 1/10/12, when she expressed her pain level was 8/10. -The resident had received [MEDICATION NAME] ([MEDICATION NAME]) once on 1/4/12, twice on 1/5/12, three times on 1/6/12, four times on 1/7/12, three times on 1/8/12, and twice on 1/9/12 and 1/10/12. There was no documentation in the nurses' notes or elsewhere that the resident's increased need for the medication was assessed and/or reported to the physician. Although the physician was in on 1/9/12, there was no documentation regarding the resident's increased pain associated with muscle spasms. Review of the Nurses' Notes (late entry) revealed that on 1/5/12, the resident had received her routine pain medication and her as needed spasm medication at midnight. -At 3:00 a.m., the resident was still complaining of pain and had requested another [MEDICATION NAME]. The nurse explained that she could not have another [MEDICATION NAME] until 6:00 a.m., the resident requested that the nurse give it early anyway. -The nurse, per a second note at 11:00 a.m., documented the NHA and nurse explained the medication administration policy to the resident. However, there was no documentation that the nurse assessed the resident's pain or reported her lack of relief to the physician. c. Follow up on survey On 1/10/12 the medical director (MD) stated he had done a physical exam on resident #117 and had changed the resident's pain medication regime. The medical director stated that the resident was to receive 30 mg of [MEDICATION NAME] around the clock and it would be held for lethargy. The MD discontinued all previous [MEDICATION NAME] orders. The MD also discontinued all previous [MEDICATION NAME] orders and started [MEDICATION NAME] 2.5 mg by mouth every six hours, hold for lethargy. On 1/10/12 at 3:00 p.m., the medical director documented the visit was to evaluate the resident for pain control. -The MD documented that most of the resident's pain appeared to be from the inferior wound (coccyx pressure ulcer) with her pain radiating to right lower back into the right buttocks. The resident appeared to be experiencing a combination of acute and chronic pain. -The MD documented, "She described pain 5/10 often and her current level of [MEDICATION NAME] 15 mg and 7.5/10 at the end of four hours prior to next dosing." She was taking [MEDICATION NAME] 2.5 mg by mouth every 6 hours as needed, but the resident was requesting routine dose due to increased spasm, increasing back pain." -The MD documented that the resident required additional [MEDICATION NAME], and he would double the current dose of [MEDICATION NAME], start pain flow sheet, and he added routine [MEDICATION NAME]. d. Observations and Interviews On 1/11/12 at 11:00 a.m., the resident was observed lying on her back. She was well groomed, alert, had more color and reported that she was feeling better. On 1/16/12 the resident was interviewed after cares about her pain. She reported that her pain has been better and she was more comfortable. 2. Resident #61 Resident #61, age 49, was admitted to the facility on [DATE]. According to his face sheet dated the same, he was admitted with [DIAGNOSES REDACTED]. His [DIAGNOSES REDACTED]. New [DIAGNOSES REDACTED]. The computerized physician orders (CPO) dated 12/2/11 indicated that the resident was on the following medications: [REDACTED]. The last MDS in the chart dated 12/6/11 revealed in Section F under preferences for customary routine and activities, that the resident indicated that his importance for doing his favorite activities was "very important. Section G revealed that the resident needed extensive care in all areas of his care. Section K revealed that the resident received his nutrients from a feeding tube. The resident's care plan, originally dated 02/25/11 and last updated on 08/10/11, revealed: -Under the pain specific care plan, that the resident had actual pain related to a chronic disease process and musculoskeletal pain. The only goal listed is that the resident will "verbally" express increased satisfaction with pain control. Under the communications care plan, updated 08/10/11, it read that the resident had difficulty making self understood or in ability to understand others related to Parkinson disease. Under intervention, it was documented that the resident used his computer to communicate his needs. Observations: On 01/12/12 at approximately 10:00 a.m., the resident was observed lying in bed looking at his computer in an awkward position. The personal computer that the resident used to communicate his needs and which needed staff assist in setting up, was not at eye level so the resident was observed attempting to reposition himself to use his communication device. On 01/16/12 at approximately 11:30 a.m., the resident was observed on his way to the shower in a facility shower chair. He was observed telling staff nurse #4 that his neck hurt. The staff nurse told him to check in after his shower. Interviews: On 01/05/12 at approximately 11:15 a.m., staff nurse #4 was interviewed. The interview revealed the resident did not express to the staff or the attending physician that he was in pain. The interview further revealed that when a pain medication is given on a scheduled basis and not an as needed basis, nurses don't always evaluate the resident's pain level or effectiveness of the pain medication. On 01/17/12 at approximately 2:15 p.m., the resident was interviewed. He responded to questions via his personal computer. When asked how many times a week he was in pain or discomfort, he replied that he had constant neck pain and rated the pain at a "7" out of a 10 rating. When asked if he had communicated via his computer to his caregivers in relation to his pain concerns, he stated that he had on multiple occasions. He further stated that he became anxious when he thought that he did not have any control over his cares, and this included being in pain. He then stated that he would like something to take the pain out of his neck. Record Review: According to the Medication Administration Record (MAR) for the last 90 days, the resident did not have any pain medication scheduled as needed. The MAR did not reflect any pain assessment prior to administering the medication on a scheduled time rather than as needed. However, the January MAR revealed that the resident received [MEDICATION NAME] 0.5 mg, a schedule four benzodiazepine tablet, for four days in a 12 day period. The indication for the medication was anxiety. The resident was scheduled one tablet daily. There was no documentation on the MAR or in the nurses' notes that staff had considered whether the resident's anxiety was due to pain (see resident interview above) or that the resident had been evaluated for pain on these days. II. Medications - Cross-reference F250; medically-related social service needs 1. Resident #84, age 78, was admitted to the facility on [DATE]. According to the January 2012 computerized physician orders, the resident had [DIAGNOSES REDACTED]. The hospital record also documented a [DIAGNOSES REDACTED]. a. Resident Status on Admission Although hospital transfer orders did not include orders for antipsychotic medications, record review revealed the facility received documents from the hospital consulting psychiatrist and the PASRR (pre-admission resident review) Psychiatric Evaluation on 12/1/11, the resident's date of admission (per fax date on the evaluation). These documents indicated the resident had a major mental illness (paranoid [MEDICAL CONDITION]), required oversight with medication management, and was improving on her current treatment plan. Specifically: Psychiatrist Notes: Review of a psychiatric consultation report dated 11/23/11 documented in pertinent part that the resident would be started on [MEDICATION NAME] (antipsychotic) 10 mg nightly and [MEDICATION NAME] (used to treat [MEDICAL CONDITION] type symptoms). A psychiatric follow-up dated 12/1/11 documented in pertinent part: (Resident #84) feels like her medications have been working well for her and is tolerating the [MEDICATION NAME] . . . She reports that her thinking is more clear. She reports that the [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] have been working well." He further documented to continue current care (see above; [MEDICATION NAME], and [MEDICATION NAME]). PASRR (Pre-admission screening and resident review) II Recommendations: -Review of Level II recommendations from 12/1/11, indicated that the resident had a major mental illness and specialized services were required. The resident had an Axis I Primary [DIAGNOSES REDACTED]. -The Level II documented that the resident required oversight with medication management and decision-making. She had been involved with mental health services since 1978 and records reported a [DIAGNOSES REDACTED]. -Recommendations were: --Monitor for appropriateness and effectiveness of [MEDICAL CONDITION] medications with adjustments as needed to maintain stability as well as minimize side effects. --Recommend that the resident be encouraged to resume mental health services through (Name of Provider) to provide medication management and symptom monitoring which may significantly affect functional level. --Monitor for symptoms of [MEDICAL CONDITION] and effectiveness of [MEDICAL CONDITION] medications. --If resident continues to take psychiatric medications there may be improvement in control of [MEDICAL CONDITION] and at that time a re-evaluation of cognitive and memory ability would be helpful to assess the resident's cognitive functioning. --Facility should work around establishing another type of legal authority in preparation for the possibility of a future decompensation. --The resident has a strong desire to discharge back to independent living. If she makes progress that will allow moving to less restrictive setting, nursing facility should help to facilitate process to help the resident access services that will be needed. -Resident had recently refused to see her psychiatrist and had not been seen since 5/27/11, and the resident had refused her monthly ([MEDICATION NAME]) injection. -It was noted that, "According to hospital staff notes, patient has been more cooperative, interactive and taking her medications without difficulty. According to psychiatrist notes patient has reported that she is sleeping better, mood is feeling more even and she is feeling less anxious since she started on the [MEDICATION NAME]." b. Failure to ensure "current care" /[MEDICAL CONDITION] medications, including [MEDICATION NAME] were continued as expected per admission documentation Review of the facility hand written medication administration record (MAR) for December 2011 documented the resident was receiving her [MEDICATION NAME] 1 mg twice a day, and [MEDICATION NAME] 50 mg every 4 hours as needed for pain. There was no order for her [MEDICATION NAME] or [MEDICATION NAME]. Review of the January 2012 computerized physician orders did not document the resident's [DIAGNOSES REDACTED]. However, a physician's note dated 12/5/11 documented, "She did have a psychiatric evaluation in the hospital in December by (Physician's name). She had been doing well on [MEDICATION NAME] and [MEDICATION NAME] with [MEDICATION NAME]. She now is on [MEDICATION NAME], but has no antipsychotic on board. I will request an appointment be made with (name of agency) for follow up on [MEDICAL CONDITION]. She will need medication follow up. . ." (1) Review of the resident's social service notes revealed an appointment was made with the agency referenced in the physician note; however, the note made no reference to follow-up on the resident's medications for [MEDICAL CONDITION]. Rather, the social service notes read: -12/9/11: Called (agency) case worker will have meeting with us to talk about finding a new apartment for (resident) on 12/14/11. -12/13/11: (Agency) here to sign up for (housing). There was no documentation in the record regarding communication with the agency or with the resident's physician regarding the resident's medications for [MEDICAL CONDITION]. c. Observations On 1/3/12 at approximately 12:30 p.m., the resident was observed sitting in the main dining room. She was moving her wheelchair to/from at the table; she had noticeable jaw, lip smacking, irregular tongue movements and appeared anxious. The resident appeared pale, had dark blush on her checks and had black penciled in eye brows that came up to a point on her forehead and back down (much like a line on an EKG). The resident was asked if she liked her meal and she stated that she did, but then went on to talk about money being stolen from her, and something else that was nonsensical. On 1/16/12 at approximately 10:00 a.m., the resident had stated to the nursing home administrator (NHA) and the surveyor that she wanted a night light in her room, because it would keep people from coming in and molesting her at night. The resident also discussed that people at the bank had taken all of her money and was also making allegations about her roommate, which were not understandable. The resident's speech was rushed, at times difficult to understand. The resident also had jaw, tongue, lip and mouth movements. d. Staff Interviews On 1/17/12 at 2:55 p.m., certified nurse aide (CNA) #13 stated that he had noticed the resident was worried about her money, and she stated in the past people had stole her money and now it was safe because she marked the money. He noticed that she had some psychosocial needs, and thought she had a mental illness. He stated he had asked nursing about her behaviors, he thought it was nurse #6, on the day of the resident's admission. He said the nurse had stated she had not had time to review the resident's chart. He reported that the resident was always smacking her lips and had a lot of tongue moment. He knew something was wrong and reported it. On 1/16/12 at 4:19 p.m., CNA #15 stated that he had not worked too much with resident #84, but he had observed her picking at her skin. The CNA stated that the resident made comments about people stealing things from her and said she was fixated on her roommate's Christmas tree; she kept saying the ornaments on the tree were missing, but they were not. On 1/16/12 at 11:10 a.m. and 11:30 a.m., the Director of Nurses (DON) and Nursing Home Administrator (NHA) were interviewed. -The DON stated that she too had witnessed the resident's behaviors regarding fears of money being stolen, and being fearful of being molested. The DON stated that when behaviors of this nature were noticed, they would be brought in front of the interdisciplinary team to determine interventions. -The NHA, DON and SSD were not aware of the resident's psychiatric evaluations in the hospital and improvement on [MEDICATION NAME], nor were they aware of the PASRR II recommendations or psychiatrist recommendations to continue the current plan of care. e. Follow-up on Survey On 1/16/12 the resident was presented with a psychoactive medication consent form for [MEDICATION NAME] 10 mg every night for paranoia, delusional statements, and unrealistic ideations. The resident refused to sign the consent form. A physician's telephone order dated 1/16/12 documented a nursing order for [MEDICATION NAME] 10 mg by mouth every night for a [DIAGNOSES REDACTED]. A physician's telephone order dated 1/17/12 documented, "notify (name of mental health agency) of the paranoid condition of their patient." A nurse's note dated 1/17/12 documented that the doctor had seen the resident and made recommendations (see above), and that the resident had refused to take her [MEDICATION NAME]. III. Diabetic Management A. Facility Policy Facility Policy: Review of the facility Policy "Diabetic Management," (SSP 0206.00 originated 4/05 and revised 6/08 revealed (in pertinent part): "Assessment: Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. Routine Care: Blood glucose measurements are taken per the physician order. Anti-diabetic agents (Insulin or oral anti-diabetic agents) are administered per physician order." B. Resident Failures 1. Resident #77 Resident #77, age 71, was readmitted to the facility on [DATE]. According to the 12/11 Computerized Physician Orders (CPO), [DIAGNOSES REDACTED]. a. Diabetic Management Plan The 1/12 CPO documented the resident had an order for [REDACTED]. The order also directed the staff to call the physician if the blood sugars were greater than 350. The care plan, dated 8/5/11, documented the resident was identified with having actual [MEDICAL CONDITION] and a potential for [DIAGNOSES REDACTED] related to the [DIAGNOSES REDACTED]. The pertinent approaches were to observe for signs of hypo/hyper glycemia, finger stick blood sugars as ordered, sliding scale insulin as ordered and notify the physician as ordered. b. Failure to Follow Orders Review of the 12/11 Blood Glucose Tracking/Sliding Scale insulin Administration Record (BGSS) documented the resident had elevated blood sugars greater than 350 on the following dates: -12/1/11 4:00 p.m., blood sugar was 428 -12/2/11 4:00 p.m., blood sugar was 373 -12/4/11 4:00 p.m., blood sugar was 380 -12/5/11 4:00 p.m., blood sugar was 380 -12/20/11 at 4:00 p.m., blood sugar was "HI" (high) -12/25/11 at 8:00 p.m., blood sugar was 371 Review of the MAR and the BGSS showed the insulin was not given as ordered. The BGSS documented the physician was notified on 12/1/11 and 12/2/11; however, no documentation showed the follow up with the physician. c. Interviews The resident was interviewed on 1/10/12 at 3:15 p.m. The resident stated that at times his blood sugar was high. He stated that when it was high, he felt "drunk." He stated that he had never refused any insulin. The medical director was interviewed on 1/10/12 at 5:00 p.m. The medical director stated if there was a physician order, it should be followed. The insulin should be given as indicated by the order. The DON was interviewed, on 1/11/12 at approximately 11:00 a.m. The DON stated the physician orders were to be followed. She reviewed the record and confirmed insulin should have been administered when outside of the parameters. The DON stated the nurses should document in the MAR when the insulin was given. She stated that physician should also be called. The DON stated she would provide training to the nurses. 2. Resident #66 (Closed Record) Resident #66, age 87, was admitted [DATE]; According to the Face Sheet, printed 8/23/11 [DIAGNOSES REDACTED]. According to the 8/18/11 Minimum Data Set (MDS), the resident was cognitively intact. She was able to verbalize her needs and understand the communication of others. She required extensive assistance for most activities of daily living. She was frequently incontinent of bladder, and always incontinent of bowel. She received Insulin injections daily. a. Diabetic Management Plan Care Plan: Review of the 8/26/11 care plan for high and low blood sugar levels due to diabetes (reviewed 9/2/11), revealed the goal was the resident's blood sugar ranges would remain stable within the physician prescribed parameters of 60 to 400. Approaches included finger stick blood sugars as ordered, and sliding scale Insulin as ordered. Physician Orders: Review of the 8/11 computerized physician orders (CPO) revealed the following orders: -An 8/11/11 order for "Humalog 100 units per milliliter (ml) subcutaneously four times a day per sliding scale: 150 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 400 = 10 units; less than 60 or greater than 400, contact the physician. Before meals and at bedtime." The [DIAGNOSES REDACTED]. b. Failure to Follow Orders Review of the 8/11 Blood Glucose Tracking/Sliding Scale insulin Administration Record (BGSS) revealed the following: -On 8/18/11 at 11:00 a.m., the fingerstick blood sugar (FSBS) was 277. The nurse administered 4 units of Insulin, 2 units less than the 6 units ordered. Review of the 9/11 BGSS revealed the following: -On 9/11/11 at 11:00 a.m. the FSBS was 196. The nurse administered 6 units of Insulin, 4 units more than the 2 units ordered; -On 9/26/11 at 2000 (8:00 p.m.), the FSBS was 263. The nurse administered 4 units of Insulin, 2 units less than than the 6 units ordered; -On 9/27/11 at 11:00 a.m., the FSBS was 228. The nurse administered 6 units of Insulin, 2 units more than the 4 units ordered; -On 9/27/11 at 1600 (4:00 p.m.), there was no evidence the FSBS was obtained as ordered (see below); -On 9/27/11 at 2000 (8:00 p.m.), the FSBS was 291. The nurse gave Insulin 5 units of insulin, 1 unit less than the 6 units ordered. Review of the 9/11 Medication Administration Record (MAR) for 1600 (4:00 p.m.), revealed the nurse gave 6 units of Insulin. However, there was no evidence the FSBS was obtained to determine the correct dose of Insulin to administer. c. Staff Interviews In interview, on 1/19/12 at approximately 1:00 p.m., nurse #6 (a nurse working on the nursing unit when the resident resided there) could offer no explanation why the incorrect amounts of Insulin were administered. In interview, on 1/19/12 at approximately 1:00 p.m., the DON confirmed some quantities of Insulin given were not according to the

Based on resident interview, observations, record review and staff interview, the facility failed to provide medically appropriate and necessary social services for one (#9) out of 17 sample residents. Specifically, the facility failed to coordinate the procurement of eyeglasses in a timely manner to alleviate the resident's symptoms of vertigo, diplopia, and migraine headaches. The resident, who had suffered injuries in an accident, experienced frequent episodes of vertigo and headaches. The Social Worker (SW) failed to read the resident's medical history and consulting physician documents upon admission and failed to locate or determine the status of the resident's eyeglasses, which were prescribed to alleviate the resident's diplopia (double vision). The resident was hospitalized [DATE] for treatment of [REDACTED]. Additionally, the nursing staff failed to notify and solicit the assistance of the SW to complete the vision clinic paperwork, leading to the potential further delay in treatment for [REDACTED]. The findings include: 1. Resident #9, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was the pedestrian. According to the minimum data set (MDS) assessment, dated 3/12/10, the resident had moderately impaired cognition, had no memory deficits and was able to communicate. She was dependent upon staff for performance of activities of daily living, was unable to transfer or ambulate but used an electric wheelchair for mobility; she had no balance or trunk control, had limited use of her upper extremities and was able to feed herself. She had a tracheostomy (later removed on 5/19/10). The resident was incontinent of bowel and used a catheter for bladder control. According to the MDS, the resident experienced moderate pain daily. 2. Observations and Resident/Family Interview The resident was first interviewed on 6/1/10 at 4:10 p.m. in her room. The room was dark, with the window draperies covered by additional opaque towels "to keep the light out." The resident's husband was present in the room. The resident was lying on her bed, facing the wall, with her head towards the middle of the room "to prevent the light from the hallway from hitting her eyes." The resident's husband stated she had just returned from the hospital the previous night after a trip to the emergency room for severe migraine headaches. The resident requested that the surveyor return the next day because she was unable to talk due to the migraine headache. The resident's husband stated the resident had recurring headaches and dizziness since her accident in 12/09. The surveyor attempted to interview the resident again on 6/2/10 and 6/3/10; each time the resident stated, "I don't want to talk, I still have a migraine. Come back later." 3. Record Review The resident's record was reviewed on 6/1/10, and included the following pertinent documents: a. Admission Information (1) The resident's admission history and physical documents upon transfer to the facility included a "neuro-optometric consultation" report, dated 2/17/10, which documented, in pertinent part: "She complained of double vision, both distance and near. After extensive trial frames, it was determined that (describes prescription for vision correction). I have called (local optical vendor), and they will be making a pair of glasses. I am hoping to dispense these glasses within the week depending on the turn around time for making the glasses. I am hopeful future treatments will include vision therapy and she will not have to be in glasses full time to relieve her double vision." (2) Also included with the resident's admission history and physical documents, dated 1/29/10, a "neuropsychological consultation" report that included documentation "the patient states she has a long history of significant anxiety as well as vertigo. She complains of severe vertigo at the present time when she is up. We discussed that given the nature of her head injury including the component of [DIAGNOSES REDACTED] that certainly is not unexpected." The above documents were transferred and available to the facility at the time of the resident's admission on 3/12/10. b. physician progress notes [REDACTED]. A 05/06/10 progress report from resident's physical medicine and rehabilitation physician read: "seen in our office as she had [DIAGNOSES REDACTED] and needed follow up after her rehabilitation. She is complaining of vertigo, however, she had some glasses that should have been made that were being considered for her diplopia while on the rehab unit. I believe she will likely need prisms and this will help her vertigo." A 5/13/10 progress report from resident's attending physician, read in pertinent part: "chief complaint: TBI/Vertigo, depression, anxiety. She is being referred for new eye glasses to hopefully address her vertigo. She is being scheduled for new glasses to help address some of the vertigo she occasionally experiences." On 6/1/10, the attending physician documented in the progress notes "what is the status of the resident's eyeglasses?" c. Social Service Notes A review of the social service notes documented between 3/15/10 to 5/3/10 (last entry made in record) did not reveal any mention of the status of resident's eyeglasses or attempt to locate the glasses made prior to admission to the facility. d. Resident Care Plan A review of the resident's care plan, last updated on 4/26/10, did not contain information or approaches for the resident's active problems of a.) vertigo, b.) migraine headaches, or c.) diplopia (double vision) and need for vision correction via eyeglasses. e. Vision Clinic Appointment The resident record contained a faxed confirmation, sent to the facility on [DATE], of a vision clinic appointment scheduled for 6/10/10. This document included a blank 2 page personal information sheet from the vision clinic requesting information regarding the resident's physician, medical history and current medications, and insurance information. A handwritten note, dated 5/13/10, attached to the resident information sheet documented "need to fill up (sic) by her brother." The resident's brother was her medical power of attorney. The faxed appointment document and related patient information paperwork were located on the front page of the resident's medical record. f. Nurses Notes A review of the resident's nurses' notes since admission to the facility revealed numerous documented entries of the resident's complaints of vertigo and pain related to "migraine" headaches. Specifically: -On 5/30/10 at 8:30 a.m. the nurse documented the resident's request for additional pain medication. (The resident received Norco 7.5 mg/325 mg BID routine and Q4hr PRN for pain control) The resident stated "I've had this headache for days." At 12:10 p.m. the nurse noted the resident "still complained of headache pain." The physician was called and ordered Ibuprofen 600 mg with lunch and dinner. -On 5/31/10 at 11:25 a.m. nurse noted resident was still having headache pain. At 3:00 p.m. nurse noted "resident wants to go to the emergency room for increased complaints of headache." On 5/31/10 at 3:50 p.m. the nurse documented "overheard resident telling (emergency medical responder) the headache started on Thursday, 5/27/10." g. emergency room documents The resident was admitted to the emergency department (ED) on 5/31/10 at 4:12 p.m. The record from the ED documented the resident was treated for [REDACTED]. Reglan, and 25 mg. of Benadryl. The ED prescribed the analgesic, "Midrin, to be given 2 capsules at the onset of migraine followed by 1 capsule every hour up to 5 capsules per 12 hour period" and returned the resident to the facility at 9:15 p.m. on 5/31/10. h. Pain Management Flow Sheet A review of the 6/10 pain management flow sheet documented the resident continued to complain of migraine headache seven times on 6/1/10 and 6/2/10. The resident's pain was documented as a 3 (hurts even more) or 4, (hurts whole lot) on a scale of 5 (hurts worst), and she was treated with the Midrin medication on 5 occasions and Norco on 2 occasions. 4. Staff Interview The social worker (SW) was interviewed on 6/3/10 at 9:30 a.m. The SW stated she was aware the resident had a vision clinic appointment scheduled for 6/10/10. She was unaware there were forms that needed to be completed by the resident's power of attorney prior to the appointment and stated "I will get her brother in here right away." The SW stated that the resident's examination would be cancelled if the permission form to treat and financial insurance information had not been provided to the vision clinic prior to the time of the appointment, which would result in further delay of the resident's treatment. The SW also stated "I did not read the resident's history and physical reports at the time of admission. I did not know the resident had already been examined and that glasses had been ordered back in February before she was admitted to the facility." The SW stated she would contact the (local optical vendor documented in the neuro-optometric consult report) and try to find out where the eyeglasses were. The director of nursing (DON) was interviewed on 6/3/10 at 2:45 p.m. regarding the method of communication between the nursing department and the social worker. The DON stated the nurse who received the faxed confirmation of the resident's vision clinic appointment, with paperwork required prior to the appointment, should have notified the social worker right away so it could be completed prior to the appointment. The DON was also unaware that the resident had been examined for, and prescribed, eyeglasses prior to admission to the facility. She stated "we are hoping the eyeglasses will help the resident's dizziness and headaches."