Every finding on record at Grand River Health Care Center

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#6) of four residents reviewed for accidents out of 28 sample residents. Specifically, the facility failed to ensure swallowing precautions were implemented for Resident #6, who had a diagnosis of dysphagia (difficulty swallowing). Resident #6 was identified as being at risk for choking upon admission. On 9/16/25, the resident experienced a choking episode in the dining room. The Heimlich Maneuver was not needed; however, the nurse had to reposition the resident forward and to the side in order for him to successfully expel chunks of food with liquid from his throat.On 9/29/25 Resident #6 experienced another choking episode after drinking water. The speech pathologist recommended for the resident to use straws for all liquids, taking only small sips at a time, and for staff to continue monitoring Resident #6 during meals.On 11/18/25 Resident #6 experienced another choking episode and the speech pathologist recommended all beverages in a cup with a lid and straw and staff supervising him in the dining room.On 11/29/25 Resident #6 experienced a fourth choking episode after drinking a cup of hot cocoa.On 12/9/25 the nurse was called to the dining room to assist Resident #6 who was choking.On 12/11/25 a physician's order instructed that Resident #6 must be supervised at all times for eating due to multiple choking events. The order directed staff to have the resident sit at a table where a certified nurse aide (CNA) was present. According to the order, Resident #6 should not be served his meal until a staff member was present. The resident's risk for aspiration care plan, initiated 6/12/24, directed staff to provide Resident #6 supervised meal assistance while making sure he sat upright to reduce his choking risk, encouraging him to take small bites of food and eat at a slow pace and take single sips of liquid with a straw, while ensuring that his food was cut up small and the meat was minced and moist (initiated 3/5/25).On 1/15/26 during a breakfast meal observation, Resident #6 was provided with a beverage in a sippy cup with a straw, instead of a regular cup with a straw. The resident tilted his head back to drink out of the sippy cup spout and began coughing and choking. There was no staff member sitting with Resident #6 when the choking episode occurred. Failure to provide appropriate supervision (sitting the resident at the same table with staff present at all times during meals), verbal support (cueing, prompting to tuck chin, taking small bites, slowing his eating pace, taking small sips with a straw every few bites) and a cup with a straw (not a sippy cup) to ensure safe eating and drinking made serious harm or death from choking likely to occur for Resident #6 if the deficient practice was not corrected immediately. On 1/29/26 at 1:31 p.m. immediate jeopardy was identified based on the facility failures above that created a situation of potential serious harm for Resident #6, requiring immediate corrective action.Findings include: I. Immediate Jeopardy A. Situation of immediate jeopardy The facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for Resident #6 after the resident had multiple choking incidents. The facility's failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for Resident #6. B. Imposition of immediate jeopardy On 1/29/26 at 1:31 p.m., the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #6 received appropriate supervision during times of food intake. C. Facility plan to remove immediate jeopardy On 1/29/26 at 6:30 p.m. the facility submitted a plan to remove the immediate jeopardy. The removal plan read: 1. Immediate correction implemented for removal of immediate jeopardy. On 1/15/26 the following actions were taken: a. Resident #6 had the proper vessel (cup with lid and straw) provided on 1/15/26 at 11:30 a.m. b. Resident #6's swallowing interventions (sit up straight while eating, eat small bites, eat slowly, take a drink between each bite, drink slowly, one sip at a time, tuck chin with each drink) were communicated on 1/15/26 to all staff on all shifts and through email to all nursing, activities, housekeeping, dietary, therapy and administration staff (signatures to be collected for all who read email) if any questions from staff are to be addressed, they can be answered by the DON (director of nursing) or the ADON (assistant director of nursing). c. The director of rehabilitation began education regarding resident swallowing safety, regarding safety measures around specific dietary orders, effective and properly communicated interventions, adaptive equipment and care plan on 1/15/26 to all staff (including to all staff on shift and through email to all nursing, activities, housekeeping, dietary, therapy and administration staff). d. A member of nursing staff or trained professional will be present in the dining area each meal. 2. On 1/29/26 at approximately 3:00 p.m. other residents possibly affected were identified. a. The DON and the ADON reviewed residents and identified other residents at risk of choking and aspiration. All resident charts were audited by the interdisciplinary team (IDT), including the DON, the ADON, and the speech therapist, and 12 other residents were identified as being at risk for the alleged deficient practice. Care plans were updated on all identified residents as applicable. 3. Systemic changes a. Education was provided to the IDT and facility staff (including to all staff on shift and through email to all nursing, activities, housekeeping, dietary, therapy and administration staff) regarding safety measures around specific dietary orders, effective and properly communicated interventions, adaptive equipment and care plan updates on 1/29/26 for all 12 residents identified in the audit. b. Every resident that will be admitted to the facility will be appropriately assessed by the speech therapist for dysphagia and difficulty for swallowing. c. Any change in swallowing pattern and or new or worsening episode of coughing and or suspected choking of current resident population to be communicated to speech therapy at time of finding for assessment. 4. Audits a. The DON or designee will audit 5 (five) meals per week at varied times for 12 weeks to ensure care plans and swallowing interventions are in place for identified at-risk residents. b. Results of weekly reviews will be presented weekly in IDT morning meeting and in the facility monthly QAPI meeting for 3 (three) months or until substantial compliance can be achieved. D. Removal of the immediate jeopardy The NHA was notified the immediate jeopardy was removed on 1/29/26 at 6:30 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy. II. Facility policy and procedure The Dysphagia Evaluation Orders policy, revised 11/13/24, was provided by the nursing home administrator (NHA) on 1/15/26 at 5:19 p.m. It read in pertinent part, After a physician has ordered a bedside swallow evaluation or dysphagia evaluation, either an occupational therapist, or speech-language pathologist will complete the assessment, modifying the evaluation to the patient's individual needs. The Speech Language Pathology Evaluation policy, revised 5/20/25, was provided by the NHA on 1/15/26 at 5:19 p.m It read in pertinent part, The speech language pathologist provides screening, identification, assessment, diagnosis, treatment, intervention, and follow-up services for a wide variety of patients; uses research results to determine effective diagnostic and treatment procedures; and measures outcomes of treatment and conducts continuing education evaluation of the efficacy of practices and programs to maintain and improve quality of services. III. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included dysphagia, oropharyngeal phase (difficulty swallowing food), neurocognitive disorder with Lewy bodies, Parkinson's disease without dyskinesia (uncontrolled movement), without mention of fluctuations, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbances. The 12/1/25 minimum data set (MDS) assessment revealed Resident #6 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. According to the MDS assessment, Resident #6 needed supervision or touching assistance for eating. The MDS assessment indicated the resident had a mechanically altered diet but he did not have signs or symptoms of a swallowing disorder. He used a wheelchair for mobility. The assessment did not identify the resident had rejections of care behaviors. B. Observations During a continuous observation on 1/15/26, beginning at 8:16 a.m. and ending at 8:50 a.m., the following was observed: At 8:16 a.m. Resident #6 was assisted into the dining room by certified nurse aide (CNA) #5. He was placed at a dining counter facing the kitchenette. The nurses' station was behind the kitchenette. Two registered nurses (RN) were at the nurses' station. Dietary aide (DA) #1 plated and served the residents their meals in the dining room. At 8:20 a.m. DA #1 served Resident #6 oatmeal in a bowl, scrambled eggs with cheese and a beverage. The beverage was served in a sippy cup with a straw. The sippy cup lid was fashioned with a spout and a separate hole. The straw was placed on the top of the lid in the hole. At 8:22 a.m. Resident #6 proceeded to feed himself. He did not take sips of his beverage between each bite. CNA #2 was in the back of the dining room, behind Resident #6, assisting another resident with her meal. RN #1 walked back and forth from the dining room to the nurses' station while administering medications to the residents. RN #2 prepared the medications from the nursing cart in the nurses' station, facing a wall. -Throughout the meal service, staff were not consistently in the dining room. CNA #2 assisted residents out of the dining room, DA #1 plated and served residents in the rooms once all the residents in the dining room were served and RN #1 remained at the nurses' station as RN #2 walked back and forth from the nurses' station to the resident rooms. CNA #5 did not return to the dining room during the observation. At 8:29 a.m. RN #1 provided Resident #6 his crushed medications mixed in with apple sauce. The resident was offered a sip of water in between each spoonful of medication. He was not encouraged or reminded to tuck his chin when he sipped the water. RN #1 left the dining room and he continued to eat his eggs and oatmeal. At 8:41 a.m. Resident #6 attempted multiple times to suck on the spout of the sippy cup without being able to drink the beverage until he started to drink from the straw. He did not tuck his chin as he sipped on the beverage. At 8:45 a.m. Resident #6 stopped drinking from the straw and attempted to suck on the spout again as CNA #2 and RN #1 walked in and out of the dining room. The resident was not reminded to use the straw while drinking his beverage from the sippy cup. At 8:49 a.m. Resident #6 started using his straw again. He attempted to finish the last few sips of his beverage with his straw but the straw was pressed against the wall of the sippy cup. He placed his mouth on the spout of the sippy cup and slowly lifted the cup up and he tipped his head all the way back until he was able to drink the remainder of his beverage. The staff was not in the dining room when he tipped his head back to drink from the sippy cup. At 8:50 a.m. Resident #6 started to have small coughs and his chest heaved for several seconds before he stopped coughing. Staff was not present in the dining room while the resident coughed. RN #2 was at the nurses' station. She did not check on the resident when he coughed after drinking with his head back. On 1/15/26 at 9:30 a.m. a sign was observed in Resident #6's room which read Put all straws in bottles to encourage chin tuck. On 1/15/26 at 12:05 p.m. RN #1 was observed sitting besides Resident #6 at the counter in the dining room (see interviews below). At 12:09 p.m. DA #1 provided Resident #6 a meal of cut fish and green beans on a lipped plate with a beverage in a mug with a lid and straw. RN #1 directed Resident #6 to look at his strategy sign at the table that read in Spanish to sit up, tuck his chin and take small bites. During the observation, the resident was provided a cup of water and reminded to take sips between bites and tuck his chin. C. Record review The risk for nutrition deficit/aspiration care plan, dated 6/12/24, documented Resident #6's goal/outcome was to have no signs of weight change, aspiration and choking. Interventions included providing Resident #6 supervised meal assistance while making sure he sat upright to reduce his choking risk, encouraging him to take small bites of food and eat at a slow pace and take single sips of liquid with a straw, while ensuring that his food was cut up small and the meat was minced and moist (initiated 3/5/25). The 9/16/25 nursing note identified Resident #6 had a near choking incident during lunch today (9/16/25). A CNA called the nurse to the dining area when she saw the resident's face appear very dark in color and he was unable to exhale. The nurse ran over to the resident. The CNA had positioned the resident forward and slightly to his side which helped him clear the obstruction and he was able to breathe. The Heimlich maneuver was not performed. According to the note, primarily liquid with chunks of food was expelled from his mouth. Resident #6 continued a deep and constant cough for about 15 minutes after the incident. The note documented his breathing had a rattling quality, indicating possible aspiration of food and liquid but his lungs sounded clear at the time the note was written. The 9/17/25 nursing note identified Resident #6 was monitored for a choking incident on 9/16/25 and continued to eat his meals in the dining room for supervision. The 9/17/25 clinical bedside swallow evaluation documented Resident #6 had difficulty with dry food and had no overt signs and symptoms of aspiration due to prior choking events. The 9/29/25 nursing note documented Resident #6 was in Bingo when an activity staff member summoned for additional staff and reported Resident #6 was choking and coughing after he drank water. According to the note, the nurse assessed the resident. His head was tipped back and his wheelchair had a slight backward tilt. He was forcefully coughing and had mild to moderate circumoral cyanosis (bluish tint around the mouth) within 30 seconds of him leaning forward. The note indicated the cyanosis and the cough were resolved after enough water was expelled. The remainder of the afternoon, the resident stayed near the nurses' station and was assessed by the speech therapist who recommended a fiber optic endoscopic evaluation of swallowing (FEES). The speech therapist emphasized the importance for Resident #6 to use straws for all liquids, taking only small sips at a time, and to continue to monitor the resident during meals. A 9/30/25 nursing note documented Resident #6 was being monitored by nursing staff for any aspiration related concerns following a choking episode on 9/29/25. According to the note, the resident was reminded to consume small sips of liquids at a time, encouraged to use a straw, and shown how to keep his head forward when he swallowed. The note indicated he followed the reminders and the suggestions to sit close to the counter for his meals rather than pulling his wheelchair away. The 10/9/25 speech therapist daily note documented Resident #6 continued to verbalize understanding of safety with his swallowing precautions but his reduced cognition was a limiting factor for speech carryover. According to the note, speech therapist recommendations continued for chin tucks plus straw single sips with nursing supervision at meals to provide reminders of slow rate sips with throat clearing every two to three sips. The 10/14/25 speech therapy daily note documented the therapy recommendation for Resident #6 was for him to perform chin tucks and use of a straw for single sips with nursing supervision at meals to provide reminders of slow rate, single sips and throat clearing every two to three sips. The note indicated the speech therapist anticipated discontinuing Resident #6 from speech therapy to a restorative nursing program. The 11/19/25 speech therapy screen identified Resident #6 had a change of condition due to a choking event on 11/18/25. According to the screen, the resident was monitored for a post-choking event while drinking a liquid from a dixie cup. The therapy screen documented that he had an increased risk of aspiration when distracted and extending his head (cup sips) for liquid intake. He was screened for FEES in September 2025. He needed encouragement of chin tuck behavior with straws for liquids and was on an easy to chew diet with thin liquids. The therapy screen documented that staff was to provide cut up food, assist with extra moisture on all foods and provide minced meat, crushed medication, single straw sips with throat clearing after every two to three sips of liquid while sitting fully upright using standard reflex precautions and supervising him in the dining room. The 11/29/25 nurse note documented Resident #6 had a near choking incident on 11/29/25 after lunch during a coughing episode. According to the note, the resident had a cup of hot cocoa in front of him but it was not known if drinking the hot cocoa was what provoked the coughing. The note identified the resident said he choked because he was coughing. The note indicated he had been choking a lot more during meal times. The note documented Resident #6 was not able to breathe for a few seconds during the incident. His face turned purple and his limbs started to spasm. He was quickly repositioned to lean forward and he was able to cough and breathe again. The 12/4/25 dietary note reiterated Resident #6's diet, the need to slow down when eating, clear his throat and take drinks between his bites. The note documented Resident #6 needed supervised dining in the dining room for all his meals. The 12/9/25 nurses note identified the nurse was called to the dining room to assist Resident #6 who was choking. According to the note, the resident was in the process of clearing food and beverage and he had vomited some of his beverage. The resident coughed and was able to clear his airway. The note indicated the resident said the incident was related to his french fries. 12/10/25 quarterly nutrition note documented Resident #6 was supervised in the dining room for meals and tended to take in too much food at one time and slouched in his chair. The note identified the resident needed to be encouraged to eat at a slow pace and sit upright while eating due to his recent coughing event as he took too large of bites and gulped his drinks. The resident needed to take single sips from a straw which was the reason why he was to eat in supervised dining. The note documented Resident #6 was at risk for choking/aspiration related to mild dysphagia. The 12/11/25 nurses note documented Resident #6 was assisted in the supervision when eating all meals to prevent any issues with choking. The December 2026 CPO communications order, dated 12/11/25, documented Resident #6 must be supervised at all times for eating due to multiple choking events. The order directed staff to have the resident sit at a table where a CNA was present. According to the order, Resident #6 should not be served his meal until a staff member was present. Resident #6's undated diet card documented the resident needed to be sat up at a 90 degree angle, served a regular diet of level seven easy to chew foods with extra moisture with no mixed consistencies and to have his bread cut up and use of a lip plate. The diet card directed staff to provide supervised dining with cues and encouragement of chin tucks, single sips of his drink and a slow pace. IV. Staff interviews DA #4 was interviewed on 1/14/26 at 4:48 p.m. DA #4 said to help Resident #6 with his choking precautions, she was responsible for ensuring his diet was provided as identified on his meal ticket with small cut meat. She said the nursing staff was responsible for keeping eyes on him. She said she had to serve meal trays in the resident rooms after she served the residents in the dining room. RN #2 was interviewed on 1/15/26 at 9:23 a.m. RN #2 said Resident #6's pills were to be crushed and he needed a straw to drink from. She said staff needed to remind him to tuck his chin when he ate and to eat slowly. She said staff needed to watch him very closely when he ate or drank and keep an extra eye on him to make sure he was following his swallowing precautions. She said there was a sign in his room to remind the staff to provide him with a straw for his drinks and encourage him to tuck his chin. RN #2 reviewed Resident #6's communication order and said Resident #6 should be supervised at all times, have a CNA present during the meals and not serve the resident's food until staff was present related to choking events. RN #2 said it had been a challenge to have a CNA present with him. She said a CNA was not available today (1/15/26) to supervise him in the dining room. She said Resident #6 faced toward the nurses' station when he ate and there was a sign by him to remind him to eat slowly. She said the chin tuck recommendation on the communication order was more about him tucking his chin during medication administration. RN #2 said she saw he was coughing in the dining room (see observation above) but he was able to clear the cough. She said she did not know if he was eating or drinking prior to the cough. She said she did not see him tilt his head back to take a drink from the sippy cup. She said he coughed sometimes when he was not eating or drinking. DA #1 was interviewed on 1/15/26 at 9:39 a.m. DA #1 said Resident #6 needed really soft and moist food according to the diet card. She said she did not supervise residents when she was in the kitchenette and the residents were in the dining room. She said CNAs were responsible for supervising the residents in the dining room. The director of rehabilitation (DOR) was interviewed on 1/15/26 at 10:05 a.m. The DOR said Resident #6 had a physician's order for supervised dining with cues and encouragement with chin tucks, single sips of drink, a slow pace and sitting up. The DOR said the purpose of having the resident tuck his chin with meals was so food and drink would go down his throat better. She said supervised dining was to have someone in the dining room. The DOR said if the physician's order read feeding assistance, then someone would need to be directly with the resident. She said she contacted the dietary manager (DM) and was told the dietary aides were not certified to feed residents, therefore they could not be the staff members utilized to supervise the residents in the dining room and the CNAs, or someone who was feeding certified, were the ones responsible for meal supervision. The DOR said according to the 9/17/25 speech therapy notes, Resident #6 should have alternate bites with food. She said she thought that meant alternate bites with food and drink but his speech therapist would know more and had seen Resident #6 multiple times and worked closely with him. The speech therapist and the director of nursing (DON) were interviewed together on 1/15/26 at approximately 10:15 a.m. The speech therapist said Resident #6 should alternate his bites of food with drink. She said he had had multiple swallowing and coughing issues. The speech therapist said a year ago (2025) staff had to perform the Heimlich maneuver on him. She said Resident #6 most recent choking incidents and documented changing of color was more related to aspirating on liquid and not choking on food. The speech therapist said Resident #6 needed supervision at meals related to his dementia. She said he could not remember to follow his swallowing precaution strategies so there were written reminders of the strategies and the nurse should cue him on the strategies. The speech therapist said a CNA and dietary aide should remind Resident #6 to look at his strategy list in the dining room that reminded him to take small bites and slow his pace during meals. She said he would forget what he was doing and take big bites. The speech therapist said Resident #6 should tuck his chin when he drank liquid because he was at risk for aspiration. She said the use of the straws with drinks helped prompt the resident to do the chin tuck. The speech therapist said Resident #6 should never overextend his throat and lean back to drink. She said that position could cause him to aspirate. She said she would be concerned if he started to cough and his body shook after he tilted his head back to take a drink. The speech therapist said Resident #6 should not have been provided with a sippy cup. She said if the resident was provided with a regular cup with a straw, it would have prevented him from tilting his head back and overextending his throat. She said a sippy cup was an adaptive device that required a physician's order and it should not have been offered to Resident #6. The DOR said she would tell his nurse and the CNAs that Resident #6 should not have had a sippy cup and needed to have a regular cup with a straw. She said it sounded like the resident needed more supervision in the dining room. CNA #5 was interviewed on 1/15/26 at 12:25 p.m. CNA #5 said Resident #6 needed to be in a supervised dining room, in view of nursing staff at all times. She said he should tuck his chin after each bite and use a straw with drinks so he did not choke. She said she was not in the dining room during breakfast on 1/15/26 because she was giving a resident a shower. The DM was interviewed on 1/15/26 at 1:59 p.m. The DM said the dietary aides could not supervise Resident #6 in the dining room but they could remind him to look at his strategy sign and let the nursing staff know if he was exhibiting signs of choking. She said the nursing staff would be responsible for supervising and making sure he was following his swallowing precautions. The DM said she did not realize staff were serving Resident #6 a sippy cup with a straw. She said he should have been served his drink in a regular cup with a straw. The DM said she educated DA #1 and other dietary staff to not provide Resident #6's drink in a sippy cup. The DON was interviewed on 1/15/26 at 3:08 p.m. The DON said Resident #6 was admitted to the facility a year ago (2025) because of his increased confusion and he needed more help with his activities of daily living (ADL). She said Resident #6 tended to eat too fast and got distracted. She said he was very routine but had cognitive deficits and poor safety awareness. The DON said he had a hard time comprehending why the swallowing precautions were in place and retaining the precautions. She said he continued to require cues to follow his swallowing precautions. She said he had had only one choking incident, a year ago, when he actually choked and required the Heimlich maneuver. She said most of the other incidents were identified as near choking because he did not have to have the Heimlich maneuver and the incidents were more of an aspiration concern. She said he had not had pneumonia as a result of his aspiration. The DON said speech therapy was notified after each incident. She said the speech therapist felt most of the concerns were related to reflux and he was placed on the swallowing precautions. The DON said the interdisciplinary team (IDT) frequently reviewed Resident #6's needs and made sure he had the most appropriate interventions in place related to food. The DON said he needed to have his medication crushed and be supervised in the dining area with frequent cues to slow down when eating and chin tuck with every bite and drink. She said there was a sign where he ate to provide the resident cues. The DON said the staff tried get Resident #6 to move to another spot in the dining room so he could be next to other residents who needed staff assistance and he could receive increased cueing and supervision but he did not want to move and sit at the table. The DON said staff should have eyes on him during his meals ideally. She said visual supervision would be best if he started choking but the staff could hear him if they were nearby. The DON said he had standard reflux precautions on his order with a single straw cup and to clear his throat with every two to three sips of liquid. She said his order was updated today (1/15/26) to include a regular cup with a straw and no sippy cup. The DON said she reviewed Resident #6's swallowing precautions today (1/15/26) with the DOR and they felt someone should sit with him during meals and ensure that he followed his swallowing precautions. The DON said Resident #6 was at risk for the potential of aspiration pneumonia. She said she was in the process of providing additional education for all staff for safety during meals. The DON said because another CNA was not available during the 1/15/26 breakfast observation, she would look at the times of resident showers to ensure staff were available in the dining room. She said she would take a big picture look at how staff could meet all residents' needs and ensure safety during meals. The NHA was interviewed on 1/29/26 at 6:32 p.m. The NHA said Resident #6 would continue with one-on-one staff supervision while eating until the speech therapist determined he was safe to eat his meals with distant nursing staff supervision.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews.Specifically, the facility failed to complete a performance review of certified nurse aide (CNA) at least once every 12 months.Findings include:I. Facility Policy and ProcedureThe policy and procedure for annual performance evaluations was requested from the nursing home administrator (NHA) and the director of nursing (DON) on 1/15/26 at 12:37 p.m. On 1/20/26 at 10:46 a.m., the ADON said the facility did not have an applicable policy and procedure for annual performance evaluations As of 1/21/26, no additional policy and procedure documents had been provided by the facility.II. Annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8The annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8 wererequested from the NHA on 1/13/26 at 6:09 p.m. -However, the facility was unable to provide documentation of annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8 prior to the survey exit on 1/15/26 (see interviews below).III. Staff interviewsThe NHA was interviewed on 1/15/26 at 12:02 p.m. The NHA said he was unable to produce any records of annual performance evaluations for the CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8. The NHA said he would check with the DON, but to his knowledge, the facility did not complete annual performance evaluations. He said if the DON confirmed that the facility did not conduct annual performance reviews, then it was what it was and they would have to make corrections. The ADON, the DON and the NHA were interviewed together on 01/15/26 at 1:50 p.m. The DON said she did not complete an individual performance review with each CNA in the facility. The DON said staff members completed healthstream education modules as well as in-person in-service education. The DON said the leadership team met monthly to discuss areas of education to provide to all staff and to review if any events occurred requiring education for individual staff members. The DON said when an individual staff member was given education, the facility typically gave the same education to all staff in the next in-service training. The DON said the facility additionally met with the education department of the hospital to collaborate on education topics.

Based on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for one (#50) of three residents reviewed out of 28 sample residents.Specifically, the facility failed to provide Resident #50 with a written copy of the facility's room change/move policy and procedure upon the resident's request.Findings include:I. Facility policy and procedureThe Patient Rights and Responsibilities policy and procedure, reviewed 6/4/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 5:19 p.m. It read in pertinent part, The statement of patient rights shall include, but is not limited to, the patient's right to: Receive information in a manner that he/she understands. Communications with the patient shall be effective and provided in a manner that facilitates understanding by the patient. Written information provided shall be appropriate to the age, understanding and, as appropriate, the language of the patient. Be informed of the facility's policies for transfer, routine or involuntary discharge and discontinuation of services. Know which facility rules and policies apply to his/her conduct while a patient. Have all patient's rights apply to the person who shall have legal responsibility to make decisionsregarding medical care on behalf of the patient. The patient shall be responsible for following facility policies and procedures.II. Resident #50A. Resident statusResident #50, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (progressive lung disease), major depressive disorder, chronic respiratory failure and chronic kidney disease.The 12/19/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set up assistance with one person for bathing. She was independent with bed mobility, upper and lower body dressing, eating, sit to stand transfers and bed to chair transfers. She used a motorized wheelchair for mobility.B. Resident interviewResident #50 was interviewed on 1/14/26 at 1:05 p.m. Resident #50 said she had requested a copy of the resident rights from the social services director (SSD) because she had lost her copy that she originally obtained upon admission. Resident #50 said she received the resident rights from the SSD and then requested a written copy of the room change/move policy. Resident #50 said the SSD went to the NHA to obtain a copy of the policy. She said the SSD came back and said she was not allowed to give Resident #50 a copy of the room change/move policy, according to the NHA, and Resident #50 could go see the NHA if she had any questions. Resident #50 was upset and said she felt very disappointed and sad.III. Staff interviewsThe SSD and the social services assistant (SSA) were interviewed together on 1/14/26 at 3:03 p.m. The SSD said if a resident requested a copy of the facility's resident rights it would be provided to them at any time. The SSD said Resident #50 had asked her for a copy of the resident rights and that was provided to her, but she said what Resident #50 really wanted was the facility's room change/move policy. The SSD said she went to the NHA and asked for the room change/move policy and was told that legally he did not have to provide the policy and said if Resident #50 had any questions, she could come ask him and he would answer the resident's questions.The NHA was interviewed on 1/14/26 at 3:42 p.m. The NHA said if a resident requested a facility policy, his compliance and legal team had said they were happy to discuss the policy but they did not provide a copy to the resident. The NHA said from a legal standpoint, the compliance and legal team were just not comfortable providing residents with copies of policies because it could be a legal question. The NHA confirmed that the facility was not going to provide Resident #50 with a copy of the requested room change/move policy because it was a legal safe guard. IV. Facility follow upOn 1/15/26 at 9:48 a.m. the NHA said he would be providing Resident #50 with the requested room change/move policy when she returned from the store outing activity later that afternoon.

Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#10) of five residents reviewed for medication errors out of 28 sample residents.Specifically, the facility failed to:-Ensure that Resident #10 received warfarin (an anticoagulant medication), a medication with a narrow therapeutic index (a medication where the difference between an effective dose and a toxic dose is very small); and,-Determine how the significant medication error occurred and provide education to nursing staff in order to prevent future occurrences. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al, Fundamentals of Nursing, 10th ed., (2023). Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Facility policy and procedureThe Medication Administration Procedure policy, reviewed 12/13/24, was provided by the nursing home administrator (NHA) on 1/15/26 at 5:19 p.m. It read in pertinent part, Patient safety is demonstrated by the use of the seven rights: right medication, right patient, right dose, right route, right time, right reason, and right documentation. Medication errors and adverse reactions to medications must be documented in the electronicincident reporting system and reported to physician. Adverse reactions should be reported tothe pharmacy as well.III. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included personal history of venous thrombosis and embolism (blood clot), epilepsy (chronic brain disorder characterized by recurrent seizures) and chronic obstructive pulmonary disease (progressive lung disease).The 12/15/25 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. She was dependent on staff assistance for bed to chair transfers, toilet transfers and shower transfers. She required substantial/maximal assistance for bathing, upper and lower body dressing, personal hygiene and bed mobility (rolling left and right). She required the use of a wheelchair for mobility.The assessment revealed the resident was taking an anticoagulant medication.B. Record reviewResident #10's risk for complications related to Coumadin (warfarin) care plan, dated 12/19/24, documented a goal of INRs (international normalized ratio - how quickly blood clots) to remain at therapeutic levels. Pertinent interventions, initiated 12/29/24, included to administer medications as ordered; obtain and monitor labs as ordered; monitor for Coumadin complications including unexplained bruising, bleeding from mucosal membranes, or difficulty with stopping bleeding; Coumadin education as needed on Coumadin therapy, diet, and interactions with other medications; INR per Coumadin nurse, Coumadin nurse would monitor INR/labs and adjust medication accordingly.A review of Resident #10's January 2026 CPO revealed the following physician's orders:Warfarin (hazardous) 2 milligram (mg) tablet, administer 2 mg tablet Monday, Wednesday, Thursday, Saturday at 8:00 p.m. Diagnosis: Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity (legs), start date 11/26/25.Warfarin (hazardous) 5 mg tablet, administer 5 mg tablet Sunday, Tuesday, Friday at 8:00 p.m. Diagnosis: Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, start date 11/25/25.The January 2026 medication administration record (MAR), reviewed from 1/1/26 to 1/13/26, documented all warfarin doses were administered. -However progress notes revealed that Resident #10 was not administered her warfarin 5 mg dose on 1/9/26 (see progress notes below).The 1/6/26 progress note documented the residents' INR was 2.8 and within range. There was no change in warfarin dosage and the INR would be retested on [DATE].The 1/10/26 progress note documented Resident #10's 5 mg warfarin tablet was found on the morning of 1/10/26 in the resident's bed. The 1/12/26 progress note, documented by the Coumadin clinic registered nurse (RN), revealed Resident #10's INR levels were in the low range (out of therapeutic range) due to the resident missing her 5 mg Coumadin (warfarin) dose on 1/9/26.The 1/13/26 progress note documented Resident #10's INR was 1.3. The resident missed a 5 mg dosage on Friday (1/9/26). The plan was to continue with the current dosage and retest the INR on 1/20/26.The 1/13/26 progress note revealed the INR that morning was 1.3 and a physician's order was placed for the lab to draw PT/INR per protocol. The 1/14/26 progress note, documented by the Coumadin clinic RN, revealed the INR was rechecked and remained at 1.3 and Resident #10's Monday, Wednesday, Thursday and Saturday 2 mg dosage of Coumadin would be increased to 3 mg for the week. The resident's INR would be retested on [DATE].-The facility's failure to administer Resident #10's anticoagulant therapy on 1/9/26 led to a non-therapeutic INR level (indicating the resident's blood clotting time was too low) and potentially placed Resident #10 at greater risk for a blood clot. IV. Staff interviewsThe director of nursing (DON) was interviewed on 1/15/26 at 10:02 a.m. The DON said the Coumadin clinic monitored the residents who were taking Coumadin. The DON said the nurses obtained residents' INRs on Tuesday and sent the results over to the Coumadin clinic RN and she put in the formulary to make sure dosing was correct. The DON said the Coumadin clinic RN could get physician's orders as needed and documented those Coumadin order changes in the progress notes. The DON said the standard therapeutic range for INR was 2.0 to 3.0. The DON said the facility could also do INR tests on off days if needed but the standard testing was once per week. The DON said if a Coumadin dosage was missed, the nurse would notify the physician and get any further testing orders or dosage changes. The Coumadin clinic RN was interviewed on 1/15/26 at 10:15 a.m. The Coumadin clinic RN said she ran the Coumadin clinic at the hospital (part of the same healthcare system as the facility) and at the facility. She said she followed those residents in the facility taking Coumadin. The Coumadin clinic RN said the residents taking Coumadin got an INR check every Tuesday and the nurses at the facility did a finger stick test for that check. The Coumadin clinic RN said most of the residents' therapeutic ranges were usually between 2.0 and 3.0, including Resident #10. The Coumadin clinic RN said she was aware that Resident #10 had missed a 5 mg Coumadin dose on 1/9/26 but she did not know why the medication was missed or why the MAR continued to show that the medication was given. The Coumadin clinic RN said if she noticed a resident was in range one week but the next week they were not in range, she would talk to the facility nurses to find out why there was a change, such as was there a new antibiotic added to the resident's drug regimen. The Coumadin clinic RN said in the case of Resident #10, there was a change in the resident's INR from the previous week to the next week and a facility nurse emailed her and said Resident #10 had missed a dose but the nurse did not say why. The Coumadin clinic RN said it was important for her to know what was going on with each resident on Coumadin because if the INR was really high, she would say to stop the medication due to the increased risk of bleeding. The Coumadin clinic RN said because Resident #10 missed a dose of warfarin, she would have to be extra cautious and check the next day to make sure she was okay. The Coumadin clinic RN said if a Coumadin dose was missed, the resident would require additional lab monitoring and the provider should be notified. The Coumadin clinic RN said Resident #10's INR was low, meaning it was out of therapeutic range and the blood clotted too fast. The Coumadin clinic RN said Resident #10 may need more medication (Coumadin) so her blood did not clot too fast. The Coumadin Clinic RN said the resident's Coumadin medication was given mixed in applesauce at the facility so she was not sure how the resident's medication wound up in the resident's bed and it was not noticed that the resident did not swallow it.The Coumadin clinic RN said according to the INR management guideline policy, Resident #10's missed dosage required extra monitoring of the resident and an extra dose of Coumadin medication to bring the resident back to a therapeutic range. The DON, the assistant director of nursing (ADON) and the NHA were interviewed together on 1/15/26 at 2:28 p.m. The DON said the protocol for a missed medication was for the nurse to notify the physician, make a comment on the MAR, and document in the progress note so that other nursing staff knew about the missed medication in case there was a negative effect due to the missed medication. The DON said she was not made aware that Resident #10 had missed a 5 mg Coumadin dose on 1/9/26. The ADON said he was handling Resident #10's case and the nurse had reported the missed medication to the Coumadin clinic. The ADON said they did an INR recheck on Resident #10 and it was low, so a Coumadin medication dosage was added this week. The ADON said he was not sure why the medication was missed, it was just found in the resident's bed the next morning (1/10/26). The ADON said he was not sure why the Coumadin was still marked on the MAR, dated 1/9/26, as given, but he would follow up with the nurse who marked it as administered. The ADON said the nurse's first shift back would be that evening (1/15/26) and then she could correct the administration note. The ADON said he did not put in an incident report or investigate the medication error incident yet, but he would investigate it in the future. The DON said Resident #10's Coumadin medication was given to prevent a recurrent deep vein thrombosis and if the resident was not kept in the therapeutic range, she risked getting a blood clot. The DON said when the nurse realized she made an error, the nurse should notify the administrator on call, notify the Coumadin clinic and write a progress note. The ADON said one nurse found the pill but another nurse was the nurse that gave it on 1/9/26. The ADON said when a nurse administered medication, the nurse should make sure to watch the resident to ensure the resident took and swallowed the medication. The ADON said the investigation of the medication error would be completed later that evening (1/15/26) and then would go through an internal review after the investigation.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment.Specifically, the facility failed to:-Ensure Resident #3's wound care supplies were not taken into Resident #33's bathroom during Resident #33's wound care dressing change; and,-Ensure registered nurse (RN) #3 followed enhanced barrier precautions (EBP), including wearing a protective gown when providing wound care for Resident #33. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 1/20/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.II. Facility policy and procedureThe Infection Prevention and Control plan, revised October 2022, was provided by the nursing home administrator (NHA) on 1/14/25 at 6:52 p.m. It read in pertinent part, The Infection Preventionist has the authority to institute any surveillance, prevention or controlmeasures or investigate any resident, personnel or visitor with possible infection. This authority and responsibility includes, but may not be limited to the following: Develop and implement a preventive and corrective action program designed to minimize infection hazards. Develop a system for identifying, reporting and analyzing the incidence and causes of nosocomial infections. Develop, review, and approve policies and procedures related to infection surveillance, prevention and control activities in all departments/services Determine when isolation precautions, barrier precautions, or environmental cultures are required and implement these processes.III. ObservationsOn 1/14/26 at 2:57 p.m., wound care for Resident #33 was observed. RN #3 rolled a metal table to set up the wound care supplies into Resident #33's bathroom. RN #3 prepared her wound care supplies, including opening Resident #33's alginate (sterile, freeze-dried dressing designed to kickstart healing in chronic wounds by forming a gel, controlling infection, and creating an optimal moist environment for new cell growth) and new dressing while Resident #33 was using the bathroom. -A plastic basket was sitting on the lower level of the metal table containing wound care supplies for Resident #3 (a different resident in another room). After Resident #33 was finished going to the bathroom, RN #3 changed the resident's brief and completed peri cares for Resident #33. RN #3 cleaned off a small amount of stool on Resident #33's toilet seat. RN #3 completed hand hygiene and changed gloves between completing peri care and the wound care for Resident #33. -However, all of the wound care supplies had been opened before RN #3 completed peri cares. RN #3 additionally failed to wear a protective gown during wound care for Resident #33, in accordance with EBP guidelines.On 1/15/26 at 10:42 a.m. certified nurse aide (CNA) #3 placed a bin with protective gowns and signage in Resident #33's room to indicate EBP was implemented for Resident #33.IV. Staff interviewsRN #3 was interviewed on 1/14/26 at 3:16 p.m. RN #3 said she normally did not bring the metal wound table into the resident's bathroom, but decided to because Resident #33 needed to use the bathroom and did not like to lay in bed during wound care. RN #3 said she forgot she kept the wound care supplies for Resident #3 on the bottom of the metal table when she went into Resident #33's bathroom. She said she placed Resident #3's wound care supplies on the table because she initially planned to complete the wound care for Resident #3 first, but Resident #3 was bathing at the time. She said she forgot to remove Resident #3's supplies when she switched to complete Resident #3's wound care first. RN #3 said she was aware of and had received training on EBP, but she said did not wear a protective gown during the wound care for Resident #33 because the resident did not have an order for EBP. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 1/14/26 at 3:32 p.m. The ADON said he was also the infection preventionist (IP) for the facility and oversaw wound care. The ADON said he provided education on using the metal table to complete wound care. The ADON said the table could be brought into a resident's room based on the preferences of each resident's wound care. The ADON said the table should be wiped down completely before and after each use, including between residents. The ADON said RN #3 should not have taken the wound care supplies for Resident #3 into Resident #33's room or bathroom. The ADON said he provided education specifically to only bring in the supplies for the resident a nurse provided wound care for, so he was surprised to find out RN #3 brought the wound care supplies for Resident #3 into the bathroom of Resident #33. The ADON said having the wound care supplies in a ziploc bag reduced the risk for cross contamination, but there was still risk of contaminating the wound care supplies for Resident #3. The ADON said he planned to provide individual education with RN #3 and planned to replace Resident #3's wound care supplies. The ADON and the DON were interviewed together again on 1/14/26 at 6:14 p.m. The ADON said Resident #33 was not on EBP because the resident's wound was an abrasion and did not meet criteria based on his interpretation of the CDC's guidelines. The ADON said he based this interpretation off of the CDC frequently asked questions section. The ADON said he referred to the guidance that EBP was not required for residents with only shorter-lasting wounds, such as skin breaks or skin tears covered with a band-aid or similar dressing. The ADON said he disagreed that the wound care ordered for Resident #33 was more complicated than a dressing similar to a band-aid. The ADON, the DON and the NHA were interviewed together on 1/15/26 at 1:50 p.m. The ADON said he spoke with the nurse practitioner (NP) who specialized in wound care for the facility regarding Resident #33. The ADON said the NP did not change any physician's orders or recommendations. The ADON said he and the NP reviewed the use of alginate in the wound bed. The ADON said the alginate was added because the wound healing was stalled for 2 weeks.

Based on observations, interviews and record review, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to: -Ensure effective interventions were implemented and sustained in response to staff speaking Spanish to each other in resident areas; and, -Ensure interventions were in place to ensure residents were able to communicate needs/requests to staff providing resident services. Findings include: I. Facility policy and procedures The following policies were provided by the administrative assistant on 2/8/24 at 2:39 p.m.: The Resident Council Bylaws policy, undated, identified the purpose of the facility's resident council included: -To voice residents' questions and concerns to management. -To bring back answers and information for management to residents. -To provide information of benefit to residents from other sources. -To support activities that involve, in power, and benefit residents. -To promote and protect resident rights. The Patient Grievance Process policy, revised 8/29/23, read the facility welcomed opportunities to address any concerns as a chance to evaluate the services provided and improve the quality of care received. The Patient Rights and Responsibilities policy, revised 6/8/2020 was provided by the person centered care director (PCC) on 2/8/24 at 10:48 a.m. The policy of patient rights identified the residents had a multitude of rights that should be honored by the facility including communication. According to the policy communication should be effective and in a manner that facilitates an understanding by the resident. II. Resident group and frequent visitor interviews The resident group interview was conducted on 2/7/23 at 10:30 a.m. with six residents (#2, #18, #32, #37, #39 and #43). A frequent facility visitor later joined the interview. Residents in the group address concerns related to staff at the facility speaking Spanish at the facility. According to the residents, the language concerns were brought up in previous resident councils. The council was told the facility was trying to figure out a solution to the language concern and the staff was having meetings about it. The residents said they would like to have Spanish speaking staff attend the resident council so the staff would know about the residents' concerns. During the interview, the residents expressed concerns with language barriers and feeling uncomfortable with staff when the staff speak Spanish to each other. Additional residents' comments and concerns during the group interview included the following: -Sometimes the housekeeping staff would look at the residents like they understood what the resident was saying to them and would agree with what was asked but then not do what the resident had requested because the housekeeper may have not understood the request. -Residents said they wanted to communicate with the Spanish speaking staff but the residents and staff were not able to understand each other. -Staff had offered to teach the residents Spanish. -When two housekeepers were in a resident room, the housekeepers would speak to each in Spanish. -A resident said she felt stupid because she did not understand when the staff spoke Spanish. The resident said she felt uncomfortable when she was not sure what the staff member was saying when they spoke Spanish. The resident said she did not know if the staff was talking to the her or if staff was talking about her. Other residents in the group agreed. -One resident said the facility did not always keep the resident updated on how the facility was following up their concerns with staff. Another resident said residents did not always know to ask for follow up with the concerns. The frequent facility visitor was interviewed on 2/7/24 at approximately 11:30 p.m. after the council meeting. The visitor said the facility was aware the residents were not comfortable with staff speaking Spanish in front of the residents. The facility had asked the staff not to speak Spanish in resident areas. The visitor said the residents' concerns had been brought up in past resident council meetings. III. Record review The March 2023 Resident Council minutes and a resident grievance generated from the March 2023 resident council identified a resident felt the room trash was not collected during the day. -The grievance did not identify concerns with staff speaking Spanish near the resident or concerns with language barrier (see interviews below). A powerpoint copy of a Equity, Diversity and Inclusion presentation was provided by the PPC on 2/7/23 at 2:20 p.m. The powerpoint presentation defined equity, diversity and inclusion and posed questions to staff. The staff were asked what were some barriers for staff and residents such as language and communication, implicit bias stereotyping and ageism. The April 2023 Resident Council minutes read resident council was conducted on 4/26/23. The council minutes read: Some residents feel that one housekeeper in particular is unable to complete the request because of language barrier. The follow up status in the minutes read the facility conducted an equality, diversity and inclusion presentation at the all staff meeting on 4/25/23. According to the minutes, the facility was going to form a committee to resolve systemic barriers such as language gaps. The PCC would present the information to the residents on the progress of the initiative. -The 4/25/23 Equity, Diversity and Inclusion staff education was conducted a day before some of the residents in resident council addressed a concern with a staff member not able to complete residents' requests. The May 2023 Resident Council minutes read resident council was conducted on 5/31/23. The May 2023 identified an equity, diversity and inclusion committee would be conducted on 5/31/23. According to the minutes, the committee was still seeking frontline staff to participate in the 5/31/23 committee. The status of the language barrier concern read: Ongoing with the understanding this will be a long education process. The May 2023 minutes read the next (resident council) meeting would be in July 2023. A 5/31/23 email was provided by the PCC on 2/8/24 at 10:07 a.m. The email was sent out by the PCC to the facility staff. At the resident council today, one resident brought forth the concern that Spanish is spoken in their room and in the common areas. When a resident doesn't understand a language, it makes them uncomfortable. They feel like they are the subject of the conversation (even if it is not true, they do not know that). Not all the residents feel this way, in fact a different resident was empathetic to someone learning a new language and they voiced their support to be more understanding. This is just a friendly reminder that we ask you to speak the preferred language choice when you are in the presence of a resident. That means their room and common areas. Obviously you can choose whatever language you want when in offstage areas like offices or the break room as long as the resident can't hear you. Now if we have a resident that prefers a language other than English and you are able, feel free to use that language. -The May 2023 minutes did not identify a resident in the 5/31/23 council was concerned Spanish was spoken in their room and common areas as identified in the 5/31/23 email. The July 2023 Resident Council minutes read resident council was conducted on 7/27/23. The status of the language concern read equality, diversity and inclusion were the topic for the family council on 6/27/23. On 7/27/23 a resident stated that sometimes Spanish was spoken during care. No other resident had concerns. -The minutes did not identify how the facility was going to address the concerns of the resident who expressed concern with Spanish spoken during care. -The July 2023 minutes did not identify the results or progress of the Equity, Diversity and Inclusion committee as identified in the April 2023 minutes. -The August 2023 Resident Council did not identify the language concern status or the language barrier concern was resolved, or identify the 7/27/23 concern of Spanish spoken during cares. was addressed and how it was addressed. The minutes did not include the language concerns or identified the concerns were reviewed with residents in council for potential resolution and identify if any additional residents had related concerns. The October 2023 resident council minutes for under the language concern read there were no new concerns in August 2023, September 2023 and October 2023. According to the status of the concern read The motion to close was unanimously carried. A 2/2/24 email was provided by the PCC on 2/8/24 at 10:07 a.m. The email read in efforts to reduce our Spanish language barrier, the facility was providing identifiable lanyards, buttons, badge backers and desk plates to help the Spanish-speaking population feel comfortable in their interactions with staff and let the residents know they could communicate with a staff member in their vernacular. -The email did not address language barrier concerns of English speaking residents with Spanish speaking staff or Spanish speaking staff speaking Spanish around English speaking residents. IV. Observations On 2/5/24 at 11:52 a.m. dietary aide (DA) #4 spoke to an unidentified CNA in Spanish in front of Resident #1 as he ate his lunch on the countertop attached to the kitchenette in the Cedar dining room. On 2/6/24 at 11:57 a.m. DA #5 spoke to an unidentified CNA in Spanish in front of six residents in the dining room on Cedar. On 2/7/23 at 10:40 a.m. two identified staff members were in the hallway on the corner of the Birch and the main hallway. The staff spoke to each other in another language. The staff members within the earshot of two residents. -At 11:55 a.m. DA #2 and chef #2 served residents in the dining room on the Aspen unit. They spoke in Spanish to each other when eight residents were in the dining room. V. Staff interview The PCC was interviewed on 2/7/24 at 2:11 p.m. The PCC said when a resident brought up a concern staff tried to address the concern in the meeting. If the concern was not resolved during the meeting, then he met with the concerned resident afterwards. He would write up a grievance and give it to the appropriate department head to follow up. The department has 72 hours to get back the grievance and one week to resolve the concern. The PPC was interviewed again on 2/8/24 at 8:36 a.m. The PCC said in April 2023 was the first time concerns were brought up. A resident felt staff speaking Spanish might have been talking about her. The resident did not want to fill out a formal grievance but wanted someone to do something about it. The department heads were present at the time when the resident brought up the concern and he would expect department heads to educate their staff because a resident might feel uncomfortable when staff spoke Spanish around the resident. He said he had sent an email to all staff to be aware of the concern. -The email was not sent out till 5/31/23 after another concern was brought in the May 2023 resident council regarding language concerns (see 5/31/23 email above). The PCC said he conducted equality, diversity and inclusion training with the staff during the all staff meeting on 4/25/23. The PCC said an equality, diversity and inclusion committee was set to be held on 5/31/23 to include some management and front line staff. He said bilingual staff were invited to participate in the committee but there was not enough interest so the equality, diversity and inclusion committee did not happen. The PCC said the language concern was brought again in the July 2023 resident council. A resident said staff spoke Spanish with cares. He said no other residents expressed a concern so the PCC followed her with just the individual resident. The PPC said he met with the resident and the resident only brought up a past concern (in March 2023) about trash not being taken out. The PCC said a grievance was generated on 3/29/23 when the resident first brought up the concern and an email was sent out to the environmental services director (EVD). The PCC said he felt the resident was perseverated on the past trash concern and had stated she felt people should speak English. No other action was done at the time. The PCC said in the August 2023 resident council he was not present at the meeting. The minutes did not show the language concerns or resolutions were reviewed with the residents in the August 2023 resident council. He said from his understanding no one expressed new or additional concerns related to Spanish speaking staff. He said in orientation staff were informed it was the facility expectation that staff speak English. The housekeeping supervisor (HKS) was interviewed on 2/8/24 at 9:35 a.m. The HKS said the nursing home administrator (NHA) had told her department a few times not to speak Spanish in front of the residents because the residents did not understand what the staff was talking about. The HKS said had reminded her staff not to speak Spanish every time she heard the staff speak Spanish in resident areas. The HKS said some of the staff do not speak English well. She said it was easier for the staff to speak Spanish to each other than in English. She said the staff could be loud at times when they were speaking Spanish. The HSK said Spanish was not allowed in resident rooms or in resident common areas if the residents were nearby. She said the staff was only allowed to speak Spanish in the breakrooms or other areas where residents would not be present. She said sometimes staff forget not to speak Spanish when speaking to each other. The HKS said she would continue to remind her staff not to speak Spanish in resident areas but her department was not the only staff she has seen speak Spanish near the residents. The HSK said she had seen the dietary staff speak in Spanish in resident areas. The EVD was interviewed on 2/8/24 at 9:53 a.m. She said she was made aware of a resident concern in the past who had concerns about certain Spanish speaking staff members. She said she could not recall any other specific concerns but the PCC would make her aware when there were concerns. The staff member who was identified as a concern by a resident was moved to another unit and had not heard of additional resident concerns. The EVD said she and the HKS always reminded the staff not to speak Spanish in front of residents. She said the residents did not like it when staff spoke Spanish. The EVD said all staff have been told not to speak Spanish in front of residents because the residents do not understand or get confused on what was being said. She said if a resident had a question for the Spanish speaking staff member, the staff member should get another staff member to answer the resident. The EVD said there was no documented training, it was just verbal. The NHA, director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 2/8/24 at 4:30 p.m. The NHA said staff could speak Spanish amongst each in the facility if the residents were not present. The DON said some of the residents were taking classes to learn Spanish. The NHA said he was aware of the language concerns but thought the concerns were isolated to one resident and were addressed.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner for two out of four kitchens. Specifically, the facility failed to ensure: -Staff used adequate hand hygiene while serving meals and touched ready-to-eat food appropriately; and, -Residents were offered and encouraged hand hygiene prior to meals. Findings include I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/27/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. II. Facility policy A. The Food Preparation and Service policy, revised 10/2/23, provided by the dietary manager (DM) on 2/8/24 at 3:00 p.m. read in pertinent: Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed in between tasks. Disposable gloves are single-use items and shall be discarded after each use. Dietary staff shall wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food. B. The Hang Hygiene policy, revised 3/30/2020, provided by the nursing home administrator (NHA) on 2/7/24 read in pertinent: Employees should perform hand hygiene by using alcohol-based hand rub with 60 to 95% alcohol or washing hands with soap and water for at least 20 seconds. Turn on the water to the desired temperature; Wet hands and forearms and apply one to three milliliters of soap (size of a quarter in palm); Rub hands vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. During washing and rinsing, keep hands lower than forearms, so water and soap drip off with gravity; Rinse hands completely (hands and fingers lower than wrist and forearm); Dry hands thoroughly with a paper towel; and Use a clean paper towel to turn off the water (unless an automatic sink). Use a clean paper towel to open the door if in a closed room. III. Observations on 2/5/24 At 11:45 a.m. no residents were offered hand hygiene prior to lunch in the dining room. At 11:53 a.m. dietary aide (DA) #4 prepared plates for lunch in Cedar hall while training DA #1. At 12:00 p.m. the DM entered Cedar's kitchenette and washed her hands for five seconds. At 12:10 p.m. DA #4 served a plate to the dining room and washed her hands for eight seconds before she made another resident's tray. DA #1 did not wash his hands upon returning to the kitchenette. At 12:13 p.m. DA #4 and DA #1 served a resident their lunch in their room using a meal cart. The DAs returned to the kitchenette and DA #4 carried dirty breakfast dishes to the pantry room where the dishwasher was located. DA #4 washed her hands for five seconds and DA #1 did not wash his hands. DA #1 prepared drinks for the residents and put the lids on to their cups without washing his hands. DA #1 touched the cabinet drawers and refrigerator doors as he prepared the drinks. At 12:17 p.m. the DAs went to see what a resident wanted for lunch. DA #4 washed her hands for five seconds and DA #1 did not wash his hands after leaving the resident's room. DA #1 prepared drinks for residents while DA #4 prepared their plates. DA #1 touched meal tickets, cups, pitchers, lids to the pitchers and the meal cart that was used to deliver meal trays. At 12:22 p.m. the DAs went to another resident's room to see what they wanted for lunch. DA #4 washed her hands for three seconds after leaving the resident's room. DA #1 washed his hands for four seconds and turned the water off with his hands instead of a paper towel. At 12:27 p.m. the DAs delivered another room tray. DA #4 washed her hands for three seconds and DA #1 did not wash his hands. The assistant director of nursing (ADON) pulled DA #1 aside and reminded him to wash his hands any time he changed environments (resident rooms, dining room, kitchen). DA #1 washed his hands for six seconds and turned the water off with his hands instead of a paper towel after he spoke to the ADON. At 12:33 p.m. DA #4 went to a resident's room and when she came back to the kitchenette she did not wash her hands. DA #4 put on a pair of gloves and grabbed a bowl of food out of the refrigerator and placed it on a meal tray. DA #4 removed her gloves and delivered the tray to the resident's room. DA #1 went to the main kitchen to get an alternative meal for a resident. At 12:36 p.m. DA #1 returned from the main kitchen with a sandwich covered on a plate and served it to a resident in the dining room. DA #1 entered the kitchenette and washed his hands for seven seconds and turned the water off with his hands instead of a paper towel. At 12:40 p.m. DA #4 returned from talking with the residents in the dining room and washed her hands for eight seconds. She prepared another meal and delivered it to a resident's room. At 12:45 p.m. DA #4 washed her hands for five seconds and DA #1 washed his hands for seven seconds and turned the water off with his hands instead of a paper towel. DA #4 served another room tray on the meal cart. At 12:50 p.m. DA #4 returned to the kitchenette and did not wash her hands. She grabbed a resident's adaptive silverware to deliver another room tray. At 12:52 p.m. the DAs delivered a room tray and returned to the kitchenette with dirty dishes. They placed the dirty dishes in the pantry. DA #1 washed his hands for six seconds and turned the water off with his hands instead of a paper towel. DA #4 did not wash her hands. DA #4 began cleaning the kitchenette. At 12:59 p.m. DA #1 washed his hands for six seconds and turned the water off with his hands instead of a paper towel. DA #4 washed her hands for five seconds before returning the hot and cold box to the main kitchen. IV. Observations on 2/6/24 At 11:32 a.m. DA #5 prepared plates for Cedar hall and was training DA #1. At 11:34 a.m. DA #5 went into the pantry. At 11:35 a.m. DA #5 returned to the kitchenette and washed her hands for 10 seconds. She opened kitchen drawers, removed serving ware and put on gloves. At 11:37 a.m. the DM entered the kitchenette and washed her hands for six seconds. At 11:38 a.m. DA #5 plated stuffed peppers as DA #1 filled drinks for the residents. DA #5 brought lunch to a resident in the dining room and a resident's guest asked for cream and sugar for his coffee. DA #5 removed her gloves before serving a resident in the dining room. At 11:40 a.m. DA #5 washed her hands for four seconds and brought the resident's visitor items for his coffee. DA #5 returned to the kitchenette and put on gloves while DA #1 washed his hands for five seconds and turned the water off with his hands instead of a paper towel. At 11:42 a.m. DA #5 put on gloves to prepare another resident's plate. DA #5 grabbed the meal cart used to deliver room trays with her gloves. She grabbed a plate with her thumb in the middle of the plate then plated a stuffed pepper where she was holding the plate with her gloves. DA #5 removed her gloves and out on another pair without washing her hands in between glove changes. DA #5 removed her gloves after she finished plating and took DA #1 to serve a resident in the dining room using the meal cart. At 11:45 a.m. DA #1 helped a resident put on a clothing protector in the dining room. DA #1 grabbed the handle of the meal cart and returned to the kitchenette. DA #1 washed his hands for five seconds and turned the water off with his hands instead of a paper towel. DA #1 filled drinks. DA #5 finished talking with residents in the dining room and returned to the kitchenette. She washed her hands for eight seconds. At 11:47 a.m. DA #1 began scratching his left arm with his right hand then grabbed more cups to fill for the residents. DA #5 reached across the steam table to grab silverware and her hoodie string drug across the serving utensils on the steam tray. DA #5 then used the serving utensil to plate a resident's meal. At 11:50 a.m. DA #5 served three residents in the dining room and assisted them with putting on clothing protectors. She brought the meal cart back to the kitchenette. At 11:52 a.m. DA #5 washed her hands for eight seconds. DA #5 grabbed the meal cart and moved it closer to put completed plates on it. DA #5 grabbed two plates from the drawer with the same hand she used to pull the meal cart closer. DA #5 put on gloves, touched two steam table covers, grabbed two dinner rolls and cut them open before buttering the rolls. At 11:56 a.m. DA #1 placed dirty dishes in the pantry and washed his hands for seven seconds and turned the water off with his hands instead of a paper towel. At 11:58 a.m. DA #5 served two more residents in the dining room with the meal cart and returned to the kitchenette. DA #5 washed her hands for 12 seconds. At 12:00 p.m. an unidentified certified nurse aide (CNA) entered the kitchenette and washed her hands for five seconds. DA #1 returned to the kitchenette and washed his hands for four seconds and turned the water off with his hands instead of a paper towel. At 12:02 p.m. DA #5 took a room tray to a resident and DA #1 entered the pantry. At 12:03 p.m. DA #1 washed his hands for five seconds and turned the water off with his hands instead of a paper towel. DA #1 grabbed a rag out of the cleaning solution and wiped down the counters in the kitchenette. At 12:04 p.m. DA #5 returned to the kitchenette and washed her hands for eight seconds and DA #1 went back into the pantry with dirty dishes. At 12:06 p.m. DA #5 put a glove on her right hands but then touched the silverware, cabinets, drawers, and serving utensils. DA #5 then touched the resident's clean plate with the gloved hand before she plated the food. At 12:07 p.m. an unidentified CNA assisted a resident with his lunch. The CNA used the back of her right hand and knuckles to itch her tailbone area under her scrubs before she continued to assist the resident his lunch. At 12:08 p.m. DA #5 served a resident in the dining room and washed her hands for eight seconds. She then grabbed the handle of the meal cart and pulled it closer. DA #5 used the same hand to grab a clean plate and touched the center of the plate before putting food on it. At 12:11 p.m. DA #1 returned from the pantry with a clean adaptive cup for a resident and had not washed his hands before he put the lid on the cup touching the spout. At 12:12 p.m. DA #1 washed his hands for four seconds and turned the water off with his hands instead of a paper towel. V. Observations on 2/6/24 Hand hygiene was not offered or provided to the residents in the dining room prior to lunch. At 11:34 a.m. a resident self-propelled her wheelchair into the dining room and was not offered or provided hand hygiene. At 12:06 p.m. another resident self-propelled her wheelchair into the dining room after she visited with her family and was not offered or provided hand hygiene. At 12:12 p.m. a resident was sitting at a table in the dining room and touched the table and other residents and was not offered or provided hand hygiene. V. Observations on 2/7/24 At 11:30 a.m. eight residents in the dining room were not offered or provided hand hygiene before lunch. At 11:45 a.m. DA #2 entered the kitchenette on Aspen and did not wash her hands. She sorted through the meal tickets. DA #2 grabbed the meal cart and pulled it closer before she plated lunch, she pulled silverware out of the cabinet and touched the countertops. She put a glove on her right hand and grabbed a dinner roll, however, when she went to cut the roll open she used her gloved hand to hold the knife and her ungloved hand to touch the roll. DA #2 plated another resident's lunch the same way. DA #2 served the two residents. At 11:51 a.m. DA #2 entered the kitchenette and washed her hands. She applied soap to her hands and immediately placed her hands under the water and scrubbed for 10 seconds. She prepared lunch for a resident. DA #2 cut open the resident's dinner roll with a knife but used her bare hand to hold the roll. DA #2 plated Resident another resident's lunch and used her bare hand to hold the roll while she cut it. At 11:55 a.m. chef #2 entered the kitchenette to help DA #2 serve lunch. Chef #2 washed her hands for five seconds. Chef #2 served both residents' plates DA #2 had prepared. At 12:00 p.m. DA #2 plated a resident's lunch and used her bare hand to hold the roll while she cut it. At 12:06 p.m. CNA #7 entered the kitchenette and washed her hands for eight seconds. At 12:07 p.m. Chef #2 washed her hands for six seconds and DA #2 applied soap to her hands and immediately placed her hands under the water and scrubbed for five seconds. At 12:08 p.m. a resident self-propelled her wheelchair to the dining room. The resident used her actual wheels to self-propel versus the handles on the wheels. A CNA offered the resident a clothing protector and was not offered or provided hand hygiene. She used her left hand to hold and eat ready-to-eat food while using her right hand to hold utensils. The resident was coughing all over her hands. At 12:10 p.m. DA #2 moved the meal cart with her bare hands after chef #2 returned the cart to the kitchenette after she served a resident's room tray. DA #2 cut open a roll for another resident's lunch. Chef #2 did not wash her hands when she returned from a resident's room. At 12:11 p.m. DA #2 applied soap to her hands and immediately placed her hands under the water and scrubbed for eight seconds. At 12:14 p.m. a resident was assisted into the dining room with her walker and was not offered or provided hand hygiene. At 12:15 p.m. chef #2 washed her hands for eight seconds. At 12:18 p.m. DA #2 plated a residents lunch. Some of the pasta was hanging over the edge of the plate and DA #2 used her bare hand to push the pasta back onto the plate. DA #2 then grabbed and cut the resident's roll with her bare hands. At 12:19 p.m. DA #2 served the resident's lunch and returned to the kitchenette without washing her hands. At 12:20 p.m. DA #2 plated a resident's lunch and used her bare hands to grab and cut her roll. She served the resident's lunch and assisted the resident with buttering her but did not put on any gloves before doing so. At 12:21 p.m. a resident was served lunch and was not offered or provided hand hygiene as he dipped his finger into the pie and licked his finger. At 12:22 p.m. DA #2 entered the kitchenette after assisting a resident in the dining room with her lunch and failed to wash her hands. She plated another resident's lunch. Chef #2 entered the kitchenette and used alcohol-based hand sanitizer instead of washing her hands. At 12:23 p.m. CNA #7 entered the kitchenette and put on a pair of gloves without washing her hands. She then grabbed a rag from a cooler of cleaning solution. At 12:24 p.m. DA #2 grabbed a dinner roll with her bare hands and cut it up into bite-sized pieces and delivered a plate to the dining room. At 12:25 p.m. DA #2 entered the kitchenette and applied soap to her hands and immediately placed her hands under the water and scrubbed for seven seconds. At 12:27 p.m. a lunch test tray was requested. At 12:28 p.m. DA #2 returned from the dining room and did not wash her hands. She grabbed a roll for the test tray with her bare hands and put it back down to go into the pantry. She returned and said her knife was dirty so she could not cut open the roll. She failed to wash her hands after leaving the pantry and grabbed the roll again with her bare hands and put it on the plate. At 12:30 p.m. DA #2 applied soap to her hands and immediately placed her hands under the water and scrubbed for five seconds. Chef #2 entered the kitchenette and failed to wash her hands. VI. Staff interviews The director of nursing (DON) was interviewed on 2/7/24 at 4:35 p.m. She said staff needed to offer hand washing or hand sanitizer before each meal, even for residents who were independent. She said it was especially important for the residents who self-propelled in their wheelchairs. Licensed practical nurse (LPN) # 2 was interviewed on 2/7/24 at 5:20 p.m. She said she was a CNA trainer for the facility. She said she turned on the faucet, wet her hands, applied soap, lathered for at least 20 seconds, rinsed with her fingers down without splashing, dry hands with a clean paper towel, threw the paper towel away and grabbed a clean paper towel to turn off the water. She said hand washing from start to finish was 60 seconds and staff should not put soap on their hands and immediately put them under the water to scrub. She said doing that caused the soap to wash away before the germs were taken care of. She said not all staff washed their hands accurately but it was something the facility was working on. The assistant director was nursing (ADON) was interviewed on 2/8/24 at 10:07 a.m. He said he was the infection control preventionist. He said when staff washed their hands they were trained to turn on the water, get their hands wet, apply soap, scrub for 15 to 20 seconds while scrubbing between fingers and under nails, rinse hands, dry hands with a clean paper towel and get a clean paper towel to turn off the water. He said there was some hand hygiene training provided in 2023 and he thought there was training provided in the annual competencies that the staff had each year but he was not sure. He said his plan for 2024 was to have more routine hand hygiene audits with the facility. The ADON said the staff were to use hand sanitizer when their hands were not visibly soiled and for staff to use soap and water if their hands were visibly soiled. He said if he saw a staff not washing their hands or not washing them appropriately he provided verbal reminders in the moment. He said he saw DA #1 failed to wash his hands on 1/5/24 when he changed settings so reminded DA #1 he needed to wash his hands. The ADON said he was working on having staff complete all of their training before they worked the floor but it was a work in progress for 2024. CNA #3 was interviewed on 2/8/24 at 12:42 p.m. She said she turned on the water, applied soap to her hands, lathered for 20 seconds and got under the nails and in between the fingers, rinsed off all of the soap, dried her hands with a clean paper towel and used another clean paper towel to turn off the water. Registered nurse (RN) #2 was interviewed on 2/8/24 at 12:48 p.m. She said when she washed her hands she sang Happy Birthday song to herself twice to know she washed her hands for enough time. She said she turned on the water, wet her hands, applied soap, lathered the soap for 20 to 30 seconds outside of the water, rinsed all of the soap off, dried her hands with a clean paper towel and used a clean paper towel to turn off the water. CNA #4 was interviewed on 2/8/24 at 1:00 p.m. She said the CNAs offered or suggested hand sanitizer or hand washing to all residents before each meal and after using the restroom. The DM was interviewed on 2/8/24 at 2:50 p.m. She said she turned on the hot water, wet her hands, scrubbed with soap for 20 seconds including the front and back of her hands and her fingernails, rinsed her hands to get all of the soap off, used a clean paper towel to dry her hands and used a clean paper towel to turn off the water. She said the staff members were not allowed to touch ready-to-eat food with their bare hands. She said staff needed to use utensils or gloves to touch ready-to-eat food. She said she provided training to the dietary staff regarding hand hygiene. -However, the facility failed to ensure staff washed their hands appropriately even though they were able to describe how to wash their hands. VII. Record review Copies of the training provided to the dietary staff were provided by the DM on 2/8/24 at 3:00 p.m. as follows: On 5/24/23 the DM completed a mock survey preparation training with the dietary staff which covered hand hygiene, sanitizing hands and hand hygiene. On 7/12/23 the DM completed training for ordering and reviewed the mock survey results with the dietary staff. Issues for the dietary department identified in the mock survey included hand hygiene between resident tray delivery at meal times. On 8/9/23 the DM completed a review of the mock survey results with the dietary staff. Issues for the dietary department were identified as hand hygiene and handling ready-to-eat food. On 9/13/23 the DM completed a review of the mock survey results with the dietary staff. Issues for the dietary department were identified as hand hygiene, sanitizing their hands after staff left a resident's room and handling ready-to-eat food. On 10/11/23 the DM completed a training with staff to be ready for their state survey with the window being open and covered hand hygiene, hand sanitizer, and proper glove use. On 11/17/24 the DM completed a training for cleaning dish machines and went over hand hygiene, gloves and handling ready-to-eat food.

Based on record review and interviews the facility failed to coordinate assessments with the preadmission screening and resident review (PASRR) program for one (#9) of three residents reviewed for PASRR out of 30 sample residents. Specifically, the facility failed to: -Submit a PASRR level I after Resident #9 had multiple changes in her mood and medications were added; and, -Submit an accurate PASRR level I that reflected Resident #9's chronic diagnosis of post-traumatic stress disorder. Findings include: I. Facility policy and procedure The PASRR screening policy, revised 4/26/23, was received by the director of nursing (DON) on 2/8/24 at 9:12 a.m. It read in pertinent part: Case Management is responsible for ensuring that each person transferring to a swing bed or a nursing facility is screened for mental illness and intellectual or developmental disability prior to transfer by following the PASRR (Pre Admission Screening and Resident Review) process. Upload pertinent patient reports, or supporting information including but not limited to: History and Physical, Progress Notes, Therapy Notes and Medication list. II. Resident #9 A. Resident status Resident #9, age 79, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included post-traumatic stress disorder (PTSD), depression and anxiety. The 1/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15 and a patient health questionnaire (PHQ-9) score of one, indicating minimal depression. The PASRR portion was not coded. B. Record review The 5/15/2020 baseline care plan for social service needs identified mental health needs for a diagnosis of depression, anxiety and PTSD. It listed psychosocial interventions to monitor mental health needs, make referrals as necessary and offer counseling and psychosocial support. The mood and behavior assessment, with a review date of 5/15/2020, revealed Resident #9's behavior had been sporadic and the COVID-19 precautions had been stressful to the resident. A social service note completed on 5/19/2020 revealed Resident #9 began breathing quickly and panicky after being informed a roommate and friend passed away. A social service note completed on 5/21/2020 revealed Resident #9 had spoken about past trauma and the emotional events they have caused her. It also identified that isolation had been difficult and that the resident had received counseling in the past. A social service note completed on 5/22/2020 revealed that Resident #9 was struggling with wearing a mask due to past trauma and scored a five out of 27 on the PHQ-9 assessment. A score of five signified mild depression. A PASRR note completed on 11/3/21 revealed Resident #9 started taking Lorazepam as needed for anxiety. A PASRR note completed on 11/29/21 revealed Resident #9 started taking Zoloft for depression. A PASRR note completed on 12/20/21 revealed Resident #9 started taking Lorazepam daily for anxiety. A social service note completed on 8/4/22 revealed Resident #9 had been feeling more depressed lately. A social service note completed on 2/2/23 revealed Resident #9 had been depressed and often tired during the day. -The facility failed to resubmit a PASRR when the resident had changes in her mood and medications were added. III. Staff interview The social worker (SW) was interviewed on 2/8/24 at 8:54 a.m. She said she was responsible for submitting PASRR assessments for residents. She said every resident admitted to a long-term care facility must have a PASRR completed. She said a PASRR was required by a facility to ensure care needs could be met for any resident identified as having a major mental illness. She said it was the responsibility of the hospital or referring facility to make the PASRR referral or the responsibility of the facility to make the PASRR referral if a resident was admitted from their home in the community. She said she had been working in the building for [AGE] years and was the only person responsible for submitting the PASRR. The SW said if a resident had a diagnosis of chronic PTSD that was not identified on the original PASRR Level I it should be resubmitted to include the PTSD diagnosis when it was identified. She said she must have made a mistake with Resident #9 because she was not aware of the PTSD diagnosis on her admission and she should have included that diagnosis on the original PASRR that was submitted in 2019. She said to prevent this mistake in the future she would write a process improvement plan (PIP), schedule audits and complete MDS assessment reviews. The SW had submitted another PASRR Level I on 2/6/24 for Resident #9. -However, the resubmission did not identify Resident #9's diagnosis of PTSD. The nursing home administrator (NHA) was interviewed on 2/8/24 at 4:10 p.m. He said he was not familiar with the PASRR process or the requirements.

Based on record review and interviews, the facility failed to develop and revise comprehensive care plans for each resident that included the instructions needed to provide effective and person-centered care for one (#10) of four residents out of 30 sample residents. Specifically, the facility failed to: -Update and personalize care plans for Resident #10 who was at high risk for falls; -Update Resident #10's dementia care plan documenting interventions; -Initiate a care plan for Resident #10's refusals to wear oxygen; -Personalize Resident #10's behavioral care plan with interventions to deter his verbal aggression; and, -Personalize Resident #10's care plan for his refusals of care. Findings include: I. Resident status Resident #10, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO) diagnoses included injury of the brachial plexus (nerves in the shoulder), chronic respiratory failure with hypoxia (not enough oxygen in the tissues of the body), heart failure, chronic diastolic heart failure (congestive heart failure) and unspecified dementia without behavioral disturbances. According to the 12/12/23 minimum data set (MDS) assessment Resident #10 declined to complete a brief interview for mental status (BIMS). Staff completed an assessment for mental status on behalf of Resident #10 and documented he did not have a memory problem, no issues with inattention, disorganized thinking or altered level of consciousness. During the assessment, Resident #10 was documented as having displayed physical and verbal behavioral symptoms directed toward others. II. Care plan failures A. Dementia and behavior care plan 1. Progress notes A progress note entered on 3/6/23 documented Resident #10 was inappropriate at 9:45 a.m. during a shower. He attempted to spray the nurse with the handheld showerhead. The resident was angry, belittled the nurse and was condescending to her because she stayed behind the shower curtain to keep dry. The nurse asked the resident to stop spraying the water toward her and the resident asked the nurse Why? Do you not want to play? You can just go change after this. The nurse told Resident #10 that she did not bring extra clothes and preferred to stay dry and comfortable while performing her job for the rest of the day. Resident #10 continued yelling at the nurse after the encounter with the water. The resident told the nurse to hurry up and demanded she scrub his back. The nurse offered to let the resident direct her actions instead of the nurse showering him in the order he normally showered. The resident said Are you going to scrub my back? How long does it take to put soap on my back? As the nurse scrubbed his back from top to bottom the resident yelled at her Are you not going to wash my legs? The nurse agreed and asked if she could put the handheld shower back on the holder so she did not accidentally get wet. The resident argued again and said, It was just a game. He told the nurse Smile if you want me to hand you the shower head three times before eventually handing it to the nurse. During the rest of the shower, the resident was equally demanding and rude to the nurse. He did not joke around with the nurse like he usually did. While the nurse assisted the resident with getting dressed the resident threatened to turn the water back on in order to drench the nurse. A progress note entered on 3/17/23 documented Resident #10 reported to a certified nurse aide (CNA) he was realizing his memory was worsening and that he either did not remember things or could not remember the next word he wanted to say. A message was left with social services to check in with the resident. A progress note entered on 3/31/23 documented Resident #10 was assisted to the toilet by the nurse. The resident became agitated when he refused proper peri-care. The nurse provided education about preventing skin breakdown. He started talking loudly and called the nurse a rude name and told the nurse she did not know how to do her job. The nurse told Resident #10 he was being rude and disrespectful and it was not being nice to the nurse. The nurse swapped out with the CNA who finished providing care to the resident. Later in the evening Resident #10 requested to speak with the nurse. The CNA walked in with the nurse and the resident asked the CNA to leave. The CNA left the resident's line of sight but stayed in the doorway to witness the conversation. Resident #10 apologized to the nurse and said he was not serious and meant it as a joke. The resident said he did not understand why the nurse took it seriously. The nurse told the resident she did not appreciate the way the resident teased her and not to do it again. The resident verbalized his understanding. Another progress note entered on 4/18/23 documented Resident #10 had a behavior on 4/16/23 and the progress note was a late entry. Resident #10 told the CNA to shut up while yelling profanities at the CNA. The CNA reported this incident to the nurse at the end of the shift. The CNA said the behavior occurred while the CNA assisted the resident with a transfer to his bed. The nurse told the CNA to tell the resident his behavior was inappropriate and to report the behaviors as soon as they occurred. The resident said he did not remember the incident. Another progress note entered on 4/18/23 documented Resident #10 used his call light and asked the nurse to turn on his television. The resident placed the television remote on his lap. The nurse told the resident she was not grabbing the remote from his groin. Resident #10 laughed and asked the nurse why she would not grab the remote. The nurse told the resident he was being nasty. The resident laughed as the nurse left his room. Another progress note entered on 4/18/23 documented Resident #10 used his call light and when the nurse responded a CNA waited in the doorway to be a witness to the conversation. The resident asked the nurse to turn on his television again. The resident was covered with a blanket and the remote was placed on his chest. The nurse asked the resident to hand her the remote. The resident said Oh come on. The nurse told the resident he placed the remote on his groin and then moved it to his chest so he could place the remote in her hand. The resident picked up the remote and the nurse took it from his hand. The nurse turned on the television and asked the resident what he wanted to watch. The resident asked the nurse to call someone else to assist him and the nurse informed the CNA. A progress note entered on 5/6/23 documented Resident #10 was in his doorway when another resident passed by Resident #10's door. Resident #10 started joking around, raised his voice and made aggressive hand gestures. The other resident told Resident #10 to stop multiple times and Resident #10 continued to escalate. Resident #10 believed it was all in fun. The staff intervened and the other resident continued down the hallway. Resident #10 finally understood the other resident was not joking around and did not appreciate Resident #10's behaviors. Resident #10 expressed remorse for his actions. A progress note entered on 5/12/23 documented Resident #10 was screaming profanities while yelling Where is it. The nurse heard a loud crash in the resident's room. The nurse entered the resident's room and he triggered his call light. The resident escalated and said he was mad at his hand because he spent two hours working on getting his hand to work. Resident #10 spilled a cup of juice and threw his cup at the door of his room and broke it. A progress note entered on 6/21/23 documented Resident #10 had been reported to the nurse as being disrespectful to the staff. The nurse talked with the resident and asked him to be respectful when he interacted with staff. A progress note entered on 8/3/23 documented Resident #10 was excessively sleepy. The CNA entered his room and told the resident he was there to recheck his vital signs. The CNA told Resident #10 he would fix the resident's messy hair and reached over to assist. Resident #10 intentionally struck the CNA in the stomach. The CNA stopped for a moment to see if it was an accident. Resident #10 did not say anything. The CNA attempted to fix the resident's hair again and the resident struck the CNA in the stomach even harder. The CNA left his room and told the nurse. The nurse checked on Resident #10 to see what was going on and he refused to talk to the nurse. The resident was asked if he hit the CNA and he said no. The nurse said hitting was not an acceptable behavior and left Resident #10's room. A progress note entered on 8/10/23 documented Resident #10 did not listen to the CNA's instructions when the resident was helped to the bathroom. The resident continued to turn before he sat down on the toilet. The resident refused to follow instructions or help the CNA in any way when he was getting off the toilet. The CNA told the resident she needed to get another CNA for assistance and the resident yelled profanities at the CNA. He demanded the CNA stay in the bathroom. The CNA told the resident he was safe sitting on the toilet and to wait for her to return. The resident ignored the CNA when she told Resident #10 to be nice. A progress note entered on 9/22/23 documented Resident #10 had a good day for the most part. Resident #10 cursed at staff and called staff derogatory names. He was offered to shower numerous times throughout the day and refused all offers. The resident said he did not want a shower and did not need one. A progress note entered on 10/25/23 documented Resident #10 was reported to yell at a CNA that he did not like her and demanded her to leave his room on 10/24/23. A progress note entered on 12/4/23 documented Resident #10 called the CNA names in a degrading manner. Resident #10 yelled for the CNA to get out of his room because he did not like her. The resident yelled profanities at the CNA to get out of his. Resident #10's representative was informed of the incident and said she did not believe the incident occurred and said the CNA was too sensitive. A progress note entered on 12/16/23 documented Resident #10 was sitting in his wheelchair for a few hours and refused offers to lie back in bed. After the resident ate lunch he yelled for help instead of using his call light. He yelled profanities while demanding the staff to get him into his bed because he had sat on his buttocks too long which caused some discomfort. The staff told the resident they needed to get the Hoyer (mechanical) lift. Resident #10 yelled profanities at the staff and demanded they push his wheelchair next to the bed so he was able to transfer himself because he felt he did not need the Hoyer lift. 2. Care plan failure Resident #10's dementia care plan, reviewed 9/18/23, documented the resident would maintain mental and psychological function as long as possible and behaviors would be reversed when possible. -Interventions were not documented on the care plan. Resident #10's behaviors were documented he was at risk for self-harm which referred to inappropriate behavior. Resident #10 lashed out at others, made inappropriate verbal and sexual comments and gestures toward caregivers, had irritability, refused to participate in therapy and refused care and medications. Resident #10 often made comments or used humor that he stated were harmless and he meant well but sometimes the staff took offense and he never meant it in a malicious way. Interventions were documented as: Assess ability to cope; Inform the resident of the care being provided; Maintain a regular daily schedule; Set the expectations for behavior; Document behaviors; Notify social services of decline in mood; Notify the medical director (MD) of any significant changes as needed; Observe for signs of agitation; Approach the resident in a friendly and calm manner; Do not ask why, question or argue with the resident; and, Assure the resident's safety and approach at a later time if necessary. -However, the facility failed to update the care plan with person-centered interventions to provide staff members with guidance to assist with Resident #10's verbal aggression and sexually inappropriate comments toward others. B. Fall care plan 1. Progress notes A progress note entered on 2/14/23 documented Resident #10 yelled out for help around 6:40 p.m. The CNA found the resident on the floor. He was on his back parallel to his bed. His head was at the foot of his bed and his feet were at the head of his bed, near the opened bathroom door. The resident said he was trying to find his cell phone while it was ringing. He said he stood up and was reaching around on his bed when he lost his balance, slipped on the floor, hitting his right hip and landed on his back. A progress note entered on 2/16/23 documented Resident #10 attempted to transfer three times throughout the shift without notifying staff. A progress note entered on 3/10/23 documented Resident #10 transferred himself four times during the shift without calling for assistance. The resident was reminded each time to call for assistance. A progress note entered on 3/18/23 documented the nurse was sitting at the nurses' station and heard a loud bang. The nurse looked over and saw Resident #10 was on the floor. When the nurse entered his room he was lying prone with his head and upper body lying next to the wall. The resident said he tried to get up by himself and lost his balance, fell and hit his head. The call light was near the resident and his pendent was around his neck. He was wearing shoes and had his oxygen on. Resident #10 had a hematoma (clotted blood under the skin) on the left side of his forehead near his hairline. The resident was sent to the emergency room and returned on 3/18/23. A note entered on 3/21/23 documented Resident #10 was reminded several times daily not to reach for items that had fallen on the floor. A progress note entered on 3/23/23 documented the nurse was at the nurses' station for over 10 minutes within sight of Resident #10. Resident #10 was seen standing unassisted in his room. The nurse reminded the resident that his behavior was unsafe. She said all he needed to do was push his call light and she would have happily assisted him to stand in a safe manner. The resident nodded his understanding. Another progress note entered on 3/23/23 documented Resident #10 was being monitored for a fall on 3/20/23 and began an antibiotic for a UTI. Resident #10 was impulsive by standing up without locking his wheelchair or calling for assistance. The resident was reminded to call for assistance. The resident nodded his understanding. A progress note entered on 3/26/23 documented the CNA at the nurses' station noticed Resident #10 was standing up from his wheelchair and attempting to walk across his room to get his walker. The CNA and nurse assisted the resident with his walker to the bathroom. Resident #10 was unsteady with two-person assistance. He was unable to grab his walker with his left hand and was swinging it around his right hand and leaned forward because he was unable to stand upright with one hand. He was assisted back to bed. The nurse provided education to the resident to use his call light before he self-transferred next time. He verbalized his understanding. Rounding was implemented for safety checks for Resident #10. A progress note entered on 4/28/23 documented Resident #10 transferred himself and had difficulty cooperating with staff. A progress note entered on 4/30/23 documented Resident #10 transferred himself twice during the shift. The first self-transfer was during from morning from his bed to his wheelchair. The second self-transfer was in the afternoon from his wheelchair to his bed. The staff overheard the resident's representative encouraging the resident to transfer himself without staff assistance. The staff educated the resident and his representative the importance of staff supervision during transfers. Another progress note entered on 5/6/23 documented Resident #10 transferred himself to the toilet without staff assistance or notifying staff. When the resident was done on the toilet he called staff to assist him. The resident told the staff What? You would have helped me? Resident #10 was reminded of the safety interventions and the potential consequences if he fell . The resident was angry toward the staff who assisted him in the bathroom and was yelling and disrespectful to the staff. A progress note entered on 6/30/23 documented Resident #10 had transferred himself from his wheelchair to his bed without calling for assistance. He was educated to call for assistance and nodded his understanding. A progress note entered on 9/24/23 documented Resident #10 was discovered on the floor by a CNA. The resident was on his knees at his bedside in a praying position. Resident #10 said he was trying to get into bed by himself. No injuries were noted. The resident was instructed not to get out of bed and to use his call light or pendant for staff assistance. A progress note entered on 11/12/23 documented Resident #10 was in a standing position with his walker and wanted to sit down. The wheelchair was in his bathroom and the resident was on the floor approximately three feet away from his wheelchair. Resident #10 did not use his call light. He was trying to straighten his waistband and he lost his balance and fell . The resident's representative witnessed the fall but did not remember what happened. A progress note entered on 12/5/23 documented Resident #10 insisted on ambulating from his bed to the bathroom. The resident refused to allow staff to use the Hoyer lift to transfer the resident to his wheelchair. Resident #10 said he had to use the restroom too badly to use the lift. He agreed to use the gait belt and his walker. A progress note entered on 1/21/24 documented Resident #10 sustained a fall at approximately 11:00 a.m. The resident had requested his phone to be charged before it started ringing. The resident said he heard his phone ringing and tried to answer his phone but it was not within his reach. Resident #10 stood up from his wheelchair, lost his balance, fell backwards and his head on the front wheel of his wheelchair. The resident said his head was hurting but refused to go to the emergency room . A progress note entered on 1/23/23 documented Resident #10 sustained a fall at approximately 6:20 p.m. The resident had fallen out of his wheelchair to the floor and was found in a prone (face down) position with his head on a pillow. Resident #10 said he was sitting in his wheelchair and tried to pick up something off the floor when he fell forward onto the floor and landed on his head. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he was at risk for falls. Interventions were documented as: Assess the environment for safety risks; Modify the environment to eliminate risks; Keep the bed in the lowest possible position; Non-skid socks or shoes during transfers or ambulation; Assure position and possessions in reach; Call light within reach before leaving; Anticipate the resident's needs; Wall signage; Remind the resident to use his call light; Medication reviews; Fall leaf posted outside his door; Lipped mattress; Anti-rollbacks on his wheelchair; Motion sensor pad; Provide adaptive devices as needed; Offer to lay the resident down; Therapy will screen; and, Continue working with therapy. -However, the facility failed to revise the care plan when the resident had falls and document person-centered interventions to provide staff members with guidance to assist with Resident #10's refusal to use the Hoyer lift and his insistence on walking or self-transferring. C. Bowel and bladder care plan 1. Progress notes A progress note entered on 2/5/23 documented Resident #10 continued to be incontinent of urine at most of his three hours checks. His brief was changed and peri-care was provided as needed. He does not call to use the urinal or toilet, he often told staff he did not have to use the bathroom. A progress note entered on 2/15/23 documented Resident #10 refused toileting offered twice during the shift. A progress note entered on 3/11/23 documented Resident #10 was offered to use the toilet before lunch by a CNA. The resident yelled profanities at the CNA to stop asking him about being toileted. Another progress note entered on 3/11/23 documented Resident #10 refused to use the toilet multiple times during the shift even though the staff saw the resident's clothes and brief were visibly wet with a strong odor of urine. A progress note entered on 3/20/23 documented Resident #10 refused to be toileted. The resident reluctantly allowed a brief check and the brief was clean, dry and intact. The nurse asked multiple times and encouraged the resident to toilet before soiling his briefs. The resident refused because he wanted to sleep. A progress note entered on 3/21/23 documented Resident #10 refused a urinary tract infection (UTI) drink (cranberry) and refused any intake of water besides a small amount of water to swallow his medications. The nurse educated the resident on increased fluid intake and the benefits of cranberry on the bladder. The nurse explained it would flush out the bacteria and the resident groaned No I am just going to push it out. I am not taking any more of that (and pointed at the fluids offered). The resident continued on an antibiotic for UTI. A progress note entered on 3/23/23 documented Resident #10 had not agreed to any encouragement about increasing his fluid intake, despite the nurse's education provided. A progress note entered on 3/31/23 documented Resident #10 was assisted to the toilet by the nurse. The resident became agitated when he refused proper peri-care. The nurse provided education about preventing skin breakdown. A progress note entered on 4/28/23 documented Resident #10 refused each toileting offered throughout the shift. The resident agreed around 4:00 p.m. His brief, wheelchair, and clothes were soaked in urine. A progress note entered on 5/19/23 documented Resident #10 refused offers of toileting assistance. His clothes and the floor were wet with urine. A progress note entered on 10/25/23 documented Resident #10 refused assistance to the bathroom and refused to allow staff to change his briefs. Later in the shift two CNAs assisted Resident #10 to the bathroom. One of the CNAs noticed the resident's gait belt was loosening and the CNA saw the resident was trying to take off his gait belt. The CNA told the resident to stop taking off his gait belt. Resident #10 yelled at the CNA but stopped taking off the gait belt. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he had bowel and bladder incontinence. Interventions were documented as: Apply moisture barrier ointment; Perineal care; Urology appointment as needed; Toileting assistance every three hours while awake; Incontinence education as needed; Assess his ability to communicate toileting needs; Assist with changing after an incontinence episode; Provide pull-ups or depends; Toilet frame in bathroom; and, Assist bars in the bathroom. -However, the facility failed to implement person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals of toileting. D. Activities of daily living (ADLs) care plan 1. Progress notes A progress note entered on 3/21/23 documented Resident #10 had a dressing on his left hip. He was assisted to bed and demanded the nurse remove the dressing. The nurse educated the resident about the bandage. Resident #10 cursed at the nurse and said Take this thing off and just put some lotion on it. The nurse applied a skin barrier cream and he still refused to have a new dressing placed. A progress note entered on 12/19/23 documented Resident #10 was monitored for having two teeth extracted on 12/18/23. The resident had orders to not use straws and avoid carbonated beverages. Resident #10 insisted on using straws. The staff educated Resident #10 on the importance of not using straws but the resident demanded to use a straw. A progress note entered on 12/20/23 documented Resident #10 was monitored for having two teeth extracted on 12/18/23. Resident #10 kept insisting on using straws. The resident was educated on the importance of not using straws. A progress note entered on 12/21/23 documented Resident #10 was monitored for having two teeth extracted on 12/18/23. Resident #10 kept insisting on using straws. The resident was educated on the importance of not using straws. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he was at risk for alterations in ADLs. Interventions were documented as: ADL support; Assure position and possessions were within his reach; Preferred bathing in the early morning in the bathtub or the shower with a shower bench; Call light within reach before leaving; and, Daily routine preferences. -However, the facility failed to revise the care plan with person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals of ADL care. E. Nutritional care plan 1. Progress notes A progress note entered on 3/19/23 documented Resident #10 ate breakfast with a good appetite and was not interested in lunch or dinner. A progress note entered on 6/22/23 documented Resident #10 refused lunch and dinner during the shift on 6/21/23. Resident #10 requested and ate two sandwiches after day shift left. The resident requested another sandwich at 2:00 a.m. A progress note entered on 8/16/23 documented Resident #10 refused to get out of bed for dinner. His meal and snack were saved for later. Another progress note entered on 8/16/23 documented Resident #10 ate a late breakfast and had two servings. The resident refused lunch but accepted two servings of dessert at lunch time. Resident #10 stayed in bed during dinner. His meal and snack were saved for later. A progress note entered on 8/25/23 documented Resident #10 continued to be provided education on nutrition directly related to his health and strength. The resident continued to eat large portions, have second helpings of meals, snack throughout the night and had sandwiches or toast at night. He had gained 22 pounds since February 2023. Resident #10's care plan, reviewed 9/18/23, documented the resident was at risk for nutritional deficits and was on a dietitian-led weight loss program. Interventions were documented as: Consistent carbohydrate; Regular texture; Monitor weight and reassess as needed; Monitor laboratory values; Monitor intake as needed; Monitor frequency and type of bowel movement; Thin liquids as ordered; Provide the resident with his adaptive cups and silverware; Supervised meal assistance; Cut up meats as needed; and, Obtain, honor, and update food preferences as needed. -However, the facility failed to document person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals of meals and his weight loss regimen. F. Continuous positive airway pressure (CPAP) and oxygen therapy care plan 1. Progress notes A progress note entered on 4/14/23 documented Resident #10 refused to wear his oxygen multiple times throughout the night. The resident woke up nauseous and with shortness of breath. The nurse checked his oxygen saturation and it registered at 89% on room air. The resident refused his oxygen and insisted he just needed some crackers. The nurse provided the resident with cracks and helped the resident to the toilet. After toileting, the resident appeared very out of breath and finally accepted his nasal cannula. His oxygen saturation was checked again and was at 93% while on two liters of oxygen through a nasal cannula. Resident #10 continued to complain of nausea but refused to stay in his wheelchair. Resident #10 started to wheeze and loudly said he had been doing this for his entire life and that he knew what was best for himself. Once Resident #10 calmed down the nurse assisted with his repositioning and the resident said he felt stable. Another progress note entered on 4/14/23 documented Resident #10's oxygen saturation was 89% while he was on two liters of oxygen via nasal cannula. The resident refused to allow staff to raise the head of the bed. The oxygen concentrator was increased to four liters and his oxygen saturation increased to 93%. A progress note entered on 4/17/23 documented Resident #10 was lethargic when breakfast was served. Resident #10 refused to wear his oxygen all night on 4/16/23 and the morning of 4/17/23. His oxygen saturation was 86% on room air. The nurse applied the resident's nasal cannula and his oxygen saturation increased to 94%. Resident #10 was agitated and scowled at the nurse because he did not want to wear his oxygen. The nurse told the resident it was an emergency situation if his oxygen saturation was that low and he was symptomatic and kept his oxygen on. A progress note entered on 4/18/23 documented Resident #10 refused to wear his oxygen during the night. His oxygen saturation was 86% on room air. The nurse applied the resident's nasal cannula and his oxygen saturation increased to 92%. A progress note entered on 4/24/23 documented Resident #10 often requested to have his oxygen removed. The resident said he did not need his oxygen anymore and told the nurse to check his oxygen saturation. The resident's oxygen saturation was at 88% on room air. When his nasal cannula was applied his oxygen saturation increased to 94%. A progress note entered on 5/12/23 documented Resident #10 refused to wear his compression stockings and oxygen. His oxygen saturation was at 88% on room air. The resident was educated on the need for oxygen therapy. The resident expressed his understanding but continued to refuse his oxygen. A progress note entered on 11/12/23 documented Resident #10's oxygen saturation was 84% on room air. A progress note entered on 11/22/23 documented Resident #10 refused to where his continuous positive airway pressure (CPAP) with oxygen during the night. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he had complications which referred to sleep apnea. The intervention was documented as CPAP with oxygen while sleeping. -However, the facility failed to document person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals to wear his oxygen throughout the day and CPAP while he slept. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 5:20 p.m. She said she used humor with Resident #10 when he was inappropriate toward her and the humor worked. She said some staff told him not to talk inappropriately but she used humor because the resident responded to it well. LPN #2 said at times the resident showed symptoms of a cognitive deficit and Resident #10 fell a lot because he still thought he could walk. She said when Resident #10 needed assistance two staff were required to provide the assistance because the physical therapist said he could not walk and needed the Hoyer lift for transfers. She said when the resident had urinary tract infections (UTIs) or a fall he showed less cognition. She said Resident #10's room was next to the nurses' station so the staff could keep a closer eye on him. The social services director (SSD) was interviewed on 2/8/24 at 9:00 a.m. She said Resident #10 had some memory forgetfulness but was able to make his own decisions. She said the staff explained things to him and he verbalized his understanding. The SSD said Resident #10 had not had moderate or severe behaviors. She said his verbal aggression and impulse control came and went an[TRUNCATED]

Based on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to follow accepted standards of practice for medication administration by setting up medications prior to the resident being ready for administration. Findings include: I. Professional references Nursing rights of medication administration, updated on 9/5/22, was retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 2/13/24 at 9:00 a.m. It read in pertinent part: 'Right time'-administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. Long Term Care Nursing: Medication Pass, updated on 1/24/24, was retrieved from https://ceufast.com/course/long-term-care-nursing-medication-pass on 2/13/24. It read in pertinent part: Medication errors are serious and can cause resident harm or even death. It is human nature to want to simplify things when there is much to be done. In an attempt to do this, sometimes shortcuts are made. However, this is not good practice. Especially when it comes to medications. Do not take shortcuts. More specifically, do not, under any circumstances, try to pre-pour medications to save time. Pre-pouring medications are against regulations. In addition, it increases the risk of making mistakes. II. Facility policy and procedure The Medication Storage policy, revised 4/18/21, was provided by the director of nursing (DON) on 2/7/24 at 8:49 a.m. It read in the pertinent part, It is the responsibility of the hospital to minimize the opportunities for medication loss, theft, misuse, or error. Appropriate storage of all medications can reduce those opportunities. Medications and devices shall be stored to ensure their integrity, stability, and effectiveness. Medications and biologicals will be stored so that only authorized personnel have access. All medications are stored under the necessary conditions to ensure stability (according to manufacturer or policy). All medications are stored in a secure manner to meet current federal and state regulations and hospital policy. III. Observations and record review On 2/7/24 at 8:52 a.m. the medication pass on the Aspen unit was observed with the registered nurse (RN) #1. At 8:52 a.m. RN #1 prepared medications for Resident #28. She dispensed the medications into a medication cup for the resident and a certified nurse aide (CNA) approached her to tell her that another resident was ready for her dressing change. RN #1 wrote Resident #28's initials on the medication cup and put it in the top drawer of the medication cart and locked the cart. At 9:15 a.m. RN #1 prepared medications for Resident #29. She dispensed the medications into a medicine cup and walked to the residents' room. Upon arrival, she said the resident was getting ready for a bath so she would give the medications later. She returned to the medication cart and wrote Resident #29's initials on the medication cup and put it in the top drawer of the medication cart and locked the cart. At 9:26 a.m. RN #1 retrieved the medication cup from the top drawer of the medication cart and returned to Resident #29's room. She said the resident was still not ready for the medications so she returned the medication cup to the top drawer of the medication cart. At 9:28 a.m. RN #1 began preparing medications for another resident. At 9:42 a.m. RN #1 returned to the medication cart and retrieved the medication cup with Resident #29's initials on it. She returned to Resident #29's room and administered the medications. IV. Staff interviews RN #1 was interviewed on 2/7/24 at 9:50 a.m. She said she realized it was not best practice to put dispensed medications in the top drawer of the medication cart but she felt comfortable doing it in both situations. The DON was interviewed on 2/8/24 at 8:33 a.m. She said resident safety comes first in medication administration. She said storing dispensed medications in a medication cup in the top drawer of the medication cart was situational and was left up to the individual nurses' judgment. -However, according to professional reference (see above) medications should not be pre poured prior to administration due to the risk of making mistakes.

Based on observation, record review and interviews, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (#27) of four residents reviewed for accident hazards out of 30 sample residents. Specifically, the facility failed to ensure timely, effective and properly communicated interventions were in place to prevent skin injuries and the recurrence of skin injuries to Resident #27. Findings include: I. Facility policy The Assisted lift Program policy, reviewed 1/30/23, was provided by the assistant director of nursing (ADON) on 2/7/24 at 2:39 p.m. The policy read in part: (The facility) wants to ensure that its (residents) are cared for safely, while maintaining a safe work environment for its employees. All patients and residents will be assessed with regard to the need for assistance with transfer activities, mobility or repositioning in accordance with (the facility) procedures and requirements. The patients/residents care plan will be established through the use of (the facility's) assisted lift policy and algorithms in determining and identifying the means for providing transfer and mobility assistance. Patients/residents identified as total dependent or needing more than minimal assistance will be transferred by means of mechanical lift equipment and or other assistive devices instead of a manual lift. Lifting equipment and other approved patient/resident assist devices will be operated in accordance with instruction and training. Staff will report to their supervisor all injury claims involving patient/resident-handling and movement. Staff will complete and document training initially, annually and as required to correct improper use/understanding of safe patient/resident handling and equipment training. The General Safety policy, reviewed 5/15/23, read most accidents were due to carelessness or lack of concentration. Staff should plan ahead of any possible hazards to help prevent the occurrence of an accident. The Positioning, Transfers, and Ambulation procedure, undated, read in part: Nursing assistants should not use equipment they have not been trained to use, as doing this could cause injury. II. Resident status Resident #27, age over 65, was admitted on [DATE]. The 10/24/23 minimum data assessment (MDS) assessment identified Resident #27 had medically complex conditions. Her diagnoses included dementia, heart failure, depression, asthma, chronic obstructive pulmonary disease (COPD) or chronic lung disease. The 10/24/23 MDS assessment indicated Resident #27 had severe cognitive impairment with a brief interview of mental status (BIMS) score of zero out of 15. The resident was dependent on staff for personal hygiene, dressing, toileting and transferring. The MDS assessment identified the staff did all the effort during a sit to stand transfer, a chair to bed transfer and a tub/shower transfer. III. Observations A. Protective geriatric (geri) sleeve use On 2/6/24 at 2:57 p.m. and again 4:38 p.m. Resident #27 wore long sleeves but she did wear geri-sleeves on her arms as indicated as an intervention for when she obtained skin tears (see below). On 2/7/24 between 9:38 a.m. and 5:39 p.m. Resident #27 was not observed to wear protective geri-sleeves. -At 9:38 a.m. Resident #27 was observed to be transferred by use of the sit to stand lift with the occupation therapy assistant (OTA). The resident wore long sleeves but she did not wear geri-sleeves as additional protection to her arms. The OTA did not offer geri-sleeves to the residents arms before the lift transfer. On 2/8/24 between 9:20 a.m. and 1:19 p.m. Resident #27 did not wear protective geri-sleeves. -At 9:20 a.m. Resident #27 was in the dining room. The resident's arms wear observed with CNA #1. The CNA identified the resident was not wearing geri-sleeves. She said Resident #27 did not wear geri-sleeves. She said if the resident needed the geri-sleeves, the sleeves would be available in the unit's supply closet. B. Mechanical lift observations On 2/7/24 at 9:44 a.m. Resident #27 was observed to be transferred with a sit to stand lift with the OTA. The OTA removed the lift from the resident's bathroom. The OTA identified the resident could not hear her so she replaced the resident's hearing aid batteries. Resident #27 was in her wheelchair in her room. The OTA removed the resident's non-skid socks from her feet and put slippers with a tread on the resident's feet. The OTA placed the sit to stand lift in front of the resident. The OTA placed a sling around the back of the resident and under the resident's arms. Resident #27 told the OTA Not too tight. The OTA placed the resident's feet on the footrests of the lift and placed her knees up against the knee/shin pads. The pads had standard manufacturing padding. -There was no additional padding to the knee/shin pads during the observation that was added once identified on survey from the resident obtaining injury (see investigations below). The OTA had the resident lean forward and attached the sling to the right and left side clip. The resident moaned slightly as the sling was attached to the lift. The resident's legs were not secured to the lift with straps or belt. The resident's hands were placed on the hand handles of the lift. The OTA unlocked the lift breaks and rolled the resident over to her bed. The OTA raised the bed and lowered the resident onto the bed and removed the sling. The resident was repositioned on her bed as she laid down with some manual assistance and cueing. A bedside table with the resident's cup with lid was placed next to the resident and a western show was turned on the television for the resident. -Observations did not identify additional padding covering the lift knee/shin pad. -Observations did not identify the resident's legs were secured to the lift with straps/belt. The sit to stand lift was observed with CNA #1 on 2/8/24 at 1:41 p.m.The CNA said she was shown how to use the lift when she was hired in December 2023. The review of the lift identified newly placed lamb wool padding covering the knee/shin pads on the lift. The safety belts/straps rested on top of the wool padding. The CNA said the belts buckle near the resident's feet. CNA #1 said the lambs wool padding was not there this morning (2/8/24). She said therapy must have just put it on the lift because the resident's skin was so fragile. IV. Skin injuries to Resident #27 during care with staff. A. 1/1/24 skin injury The 1/1/24 incident report was provided by the ADON on 2/8/24 at 12:37 p.m. The incident report read Resident #27 acquired a skin tear in the tub room on 1/1/24 at 7:40 a.m. A certified nurse aide (CNA) notified LPN #1 her name badge caused a skin tear to the resident's right lateral (outer side) of wrist. The skin tear measured 0.9 centimeters (cm) by 0.1 cm. The CNA staff was educated to use caution when working with the undressed resident and relocate name badge to prevent a recurrence. The 1/1/24 incident report identified the CNA who was involved in the incident and identified the CNA was educated. The 1/5/24 interdisciplinary team (IDT) review note read the resident was reported to have sustained a new skin tear to the right wrist during her bath to the right wrist. It was reported by staff a CNA had caused the skin tear. The wrist was exposed during bathing and the name badge brushed up against the resident. The resident typically wore geri-sleeves and long sleeves to prevent skin injuries due to her fragile skin integrity. The nurse on shift provided wound care per guidelines and staff education to CNAs on shift to tuck their name badge in the garment or move to another location on their person. -However, according to the observations (see above) the geri-sleeves were not offered. B. 1/17/24 skin injury The 1/17/24 at 8:00 p.m. skin assessment read a new skin issue was identified. The 1/17/24 incident report was provided by the DON on 2/7/24 at 5:15 p.m. The incident report read Resident #27 acquired a bruise in the resident's room on 1/17/24 at 10:20 p.m. During a weekly skin check, the resident was noted to have a bruise on her right lower extremity (RLE). The bruise was approximately 3.0 cm in diameter, dark purple in color and flush to the skin. The note indicated the bruise was caused during a transfer from the sit to stand lift and her wheelchair. The resident's leg was bumped. The resident did not voice or exhibit complaints of pain or discomfort. The staff would take precautions of placement of the lift and the wheelchair to prevent further injury or future events so extremities were not in jeopardy of bumping. -The incident report did not identify staff members involved or a witness when the bruising incident occurred. The 1/22/24 IDT review note read a bruise identified during the resident's weekly skin check was possibly caused from a transfer with the sit to stand lift. The resident's leg could have been bumped which caused the bruise. The interventions included 72 hour monitoring, continued weekly skin checks, staff reminders to monitor placement of extremities when assisting the resident onto the sit to stand lift and a discussion with therapy to determine if padding was needed to protect the resident's fragile skin. -However, therapy did not address additional padding on the lift until during the survey (see addendum note below). A 2/8/24 at 1:32 p.m. (during the survey) late entry note form the director of rehabilitation (DOR) was added as an addendum to the above 1/22/24 IDT note. Resident #27's sit to stand lift was assessed. The shin pads on the lift were padded, however, the shin pads were wrapped with lambs wool for increased protection of the resident's sensitive skin. The resident verbalized agreement to adding the lambs wool to the shin pad. C. 2/5/24 skin injury The 2/5/24 incident report was provided by the DON on 2/7/24 at 5:15 p.m. The incident report read Resident #27 acquired a skin tear on 2/5/23 at 8:15 a.m. in the tub room. The incident report read the resident bumped her left wrist on the clip bolts on the sit to stand lift which caused a skin tear measuring 1.1 cm by 0.2 cm. There was a scant amount of bleeding. The area was cleansed and dressing was applied. Staff was to ensure proper hand placement to prevent a recurrence. CNA #5 witnessed the incident. The 2/7/24 IDT review note read Resident #27 had sustained a skin tear to her left wrist during lift use. The left wrist was reported to have been bumped on clip bolts of the lift. The resident was dependent on staff with the lift which placed her at an increased risk for skin injury. Resident #27 had long sleeve clothing at the time of the incident and was care planned for both long sleeves and geri-sleeves. The interventions read to educate staff on the importance of proper hand placement during lift use and continue to encourage use of long sleeves and geri-sleeves. -However, this was a previous intervention added and according to observations (see above) the resident was not wearing geri-sleeves. V. Record review The 9/23/2020 risk for alterations in activities of daily living (ADLs) care plan read Resident #27 was at risk due to overall decline, deconditioning and generalized weakness. The care plan directed staff to use a sit to stand lift with one person assistance. The 2/23/22 computerized physician orders (CPO) directed staff to offer protective sleeves to upper extremities at 8:00 a.m. and 8:00 p.m. The 3/1/22 skin care plan identified Resident #27 was at risk for skin breakdown. The care plan intervention directed staff to offer long sleeves or protective (geri) sleeves to upper extremities as tolerated by the resident. According to the care plan the resident would often decline to wear these (sleeves). -The care plan did not identify other interventions to try when the resident refused the geri-sleeves. -The care plan was not updated after 3/1/22 to direct staff to encourage long sleeves and geri-sleeves as identified in the IDT note on 1/1/24 and 2/5/24. A 1/18/24 email was provided by the ADON on 2/8/24 at approximately 3:30 p.m. According to the email from the ADON, he asked the nurse filing an incident report to investigate the root cause of the injury at the time of the report. He reminded the nursing staff to provide more details and a description of the incident when documenting the incident reports. The ADON identified the CNAs were often the ones to first identify or report concerns. The ADON requested the CNAs take mental notes on what they observed, what staff/residents were doing at the time of the incident and any suspected causes. -The email did not remind staff of proper body placement during transfers (see interviews below.) VI. Staff interviews The OTA was interviewed on 2/7/24 at 9:55 a.m. The OTA identified the precautions she took when using a sit to stand lift with Resident #27. The OTA said the resident was able to bear weight and understand basic directions. She said it was important the resident was able to understand her so the resident could follow the OTA's instructions as much as possible. The OTA said she made sure the lift sling was under the resident's arms, around her chest and under her breasts so nothing was pinching the resident. The OTA said she would make sure the resident's hands were clear of the lift and the resident had her hands on the lift handles. The DON and the ADON were interviewed on 2/8/24 at 11:17 a.m. The skin injuries and related documentation were reviewed with the DON and the ADON. The skin injury on 1/1/24 was caused when a staff's name tag brushed up against the resident causing a skin tear. The staff member was verbally educated at the time of the incident on the placement of the name tag during bathing. The ADON said the resident had a 2/22/23 physician's order for protective sleeves. She was care planned for the protective sleeves and she would often refuse them. The DON said after the 1/17/24 bruise she went to staff who worked on the unit and verbally did a one-to-one education with them to be mindful of resident body placement when using a mechanical lift. The staff should make sure the resident's legs were against the knee pad on the sit to stand and secured with straps behind her legs. She said the nurse who found the injury would be expected to do an education with staff on duty at the time of the incident. The ADON said staff were to follow up with therapy. The ADON said the height of the padded shin rest of the sit to stand lift matched up to the location of the bruise. The ADON said the bruise could have been avoided if proper leg placement was used. The DON said the bruise was found during weekly skin checks. She said she was not sure when exactly the bruise was caused or by which staff member. The DON said staff was reminded of proper body positioning of the resident when use of a lift. The ADON said an email was sent out to the nursing and CNA staff (see above). The ADON said the skin injury on 2/5/24 was caused when Resident #27 bumped the attachment clips of the sit to stand. There was no way to properly cover the clips and attempts could create concerns with infection control. Proper body placement was the one thing staff had control over. Staff was verbally educated on proper hand placement. The resident's arms needed to be on the inside of the lift and her hands placed on the handles. The DON said the incident was after the resident was bathed and getting into her wheelchair. The resident wore long sleeves at the time but not the geri-sleeves. The DON said licensed practical nurse (LPN) #1 documented the 2/5/24 injury. The DON said the staff member involved in the incident was either CNA #5 or CNA #6. The DON confirmed the CNA involved was not included in the incident report. She said she would contact LPN #1 to find out which CNA was involved in the 2/5/24 incident. The ADON said to prevent recurrence of a skin injury, staff would have continued education to promote long sleeves and geri-sleeves. He said they would also have therapy to screen the resident. The DON said there would be a lift training on 2/15/24 because of identified incidents and a need to review the mechanical lift process. The DON said the facility has had new nursing management since November 2023 and she had been looking at the improvement process as a whole. The DON said starting in this month (February 2024) in a couple of weeks, all new nursing/CNA staff would have on boarding training that would include mechanical lift training. The DON said the new hires would have exposure to the mechanical lifts before working the floor. The DON and the ADON said all staff education after Resident #27's incidents on 1/1/24, 1/17/24 skin injury incidents were completed verbally and were not documented. CNA #2 was interviewed on 2/8/24 at 1:25 p.m. CNA #2 said she was the CNA for Resident #27 this morning (2/8/24). She said the resident had a bath today and then went to therapy. She said if the resident needed geri-sleeves, they would be in the supply closet but she thought she had seen some in her drawer in her room. CNA #2 entered the resident's room and found the geri-sleeves in the dresser drawer. She said she did not ask the resident if she could put on the geri-sleeves because she had heard from another CNA that when the resident had on long sleeves, she did not need the geri-sleeves. She said in the CNA electronic charting showed there was nothing that she was aware of to direct her to offer the geri-sleeves to the resident. CNA #1 joined the interview with CNA #2. CNA #1 opened Resident #27 the electronic medical record task flow sheet and said the resident was only scheduled to be offered at 8:00 p.m. CNA #1 said Resident #27 had told her she did not want to wear the geri-sleeve but she (CNA #1) worked in the morning so the geri-sleeves were never brought up to her to have the resident wear the geri-sleeves. CNA #1 said the resident always wore long sleeved outfits. CNA #1 said the geri-sleeves were also set up as a nursing task so the nurse would be the one to put on the geri-sleeves. -CNA #1 and CNA #2 were not aware geri-sleeves should be offered during the day. The DON was interviewed on 2/8/24 at 2:29 p.m. The DON said geri-sleeves/protective sleeves for Resident #27 was scheduled as a task at 8:00 a.m. and 8:00 p.m. The DON said there was no way in our electronic medical record task flow sheet to identify if the resident refused. The task flow sheet just identified if the task was completed. The DOR was interviewed on 2/8/24 at 3:18 p.m. She said Resident #27 had very fragile skin. The DOR said the IDT requested therapy to provide extra padding to the resident's sit to stand lift. She said she was out of the facility at the time of the 1/17/24 skin injury incident and did not know of the request. The DOR said the communication was lost. She said she reviewed the lift and added lambs wool to the sit to stand lift pad. She said any of the therapists could have added the lambs wool if the therapists were made aware. She said the current system was not set up for direct notification to the therapy department when there was a request after an incident. She said moving forward she would request the IDT to email all the staff in the therapy department so any of the therapists could follow up with a request. The DOR said she was not involved in the interventions related to the 2/5/24 skin injury. The DON was interviewed again on 2/8/24 at 3:34 p.m. The DON said LPN #1 would have done a verbal training with the staff involved on 2/5/24. The DON said she had not been able to get a hold of LPN #1, CNA #5 or CNA #6 to find out who was involved in the incident. The DON said it would be beneficial to know who was involved in the 2/5/24 skin injury incident so she could provide additional education to that individual and learn more of what happened during the incident. Registered nurse (RN) #1 was interviewed on 2/8/24 at 4:07 p.m. RN #1 said she worked two days a week as the nurse for Resident #27. The RN said it was her understanding that the CNAs would offer Resident #27 geri-sleeves if the resident was wearing short sleeves but the resident usually wore short sleeves. The RN said the long sleeves count as protective sleeves. She said she was not aware of the resident's refusal to wear protective sleeves. -The RN was not aware the resident should be encouraged to wear both the long sleeves and the geri-sleeves as an intervention to protect the residents skin. -RN #1, CNA #1 and CNA #2 (above interviews) were not aware of who should offer the geri-sleeves. The DON was interviewed on 2/8/24 at 4:11 p.m. The staff training records were reviewed. The DON said CNA #6 was hired in March 2023. The CNA did not have mechanical lift training. The DON said she was not the DON when CNA #6 was hired so she did not know why the CNA had not received lift training yet. The nursing home administrator (NHA), the DON and the ADON were interviewed on 2/8/24 at 4:30 p.m. Accident hazards have been reviewed as part of the facility's quality assurance and improvement process. The facility was reviewing how to improve training and overall employee education in the coming year. The facility initiated a 1/4/24 improvement plan. The plan included a skills checklist for new hire employees during orientation and an ongoing audit of current employees who were due for annual educations. The new hire orientation would also include hands-on training with equipment to include the mechanical lifts.

Based on record review and interviews, the facility failed to ensure a resident who upon admission displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct an assessed problem and/or to attain the highest practicable mental and psychosocial well-being for one (#50) of four residents reviewed out of 30 sample residents. Specifically, the facility failed to: -Initiated therapy as recommended by preadmission screening and resident review (PASRR) Level II until four weeks later and after Resident #50 was experiencing mental health concerns: -Identify the Resident #50 triggers and past trauma to minimize being retraumatized; and, -Allow Resident #50 to have the bed of her preference due to a past traumatizing experience to minimize her trouble sleeping and night terrors. Findings include: I. Facility policy The Behavioral Health Care process and procedure, undated, provided by the nursing home administrator (NHA) on 2/8/24 at 1:06 p.m. read in pertinent: The Care Center social service team will reach out to the behavioral health liaison and request a meeting either via phone or in-person to discuss the support needed and coordinate with them appropriately to ensure that the resident receives adequate support to ensure that the behavioral health needs are met. The need is initiated either through staff observations, clinical documentation, or physician notes or a combination of all three as well as by resident and/or family request. II. Resident status Resident #50, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses were recurrent and moderate major depressive disorder, insomnia, unspecified depression, amnesia and unspecified dementia. According to the 1/10/24 minimum data set (MDS) assessment Resident #50 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #50's patient health questionnaire (PHQ-9) score was zero out of 27 indicating no depression. III. Resident interview Resident #50 was interviewed on 2/5/24 at 2:29 p.m. She said she was not happy at the facility. She said she was having a rough time sleeping and was terrified of hospital beds. She said she had her own mattress and thought it would help but since the mattress was on a hospital bed it did not help. She said she was attacked in a hospital bed in the past and being in a hospital bed triggered her trauma. She said she had night terrors when she slept in the hospital bed. She said before she was admitted she measured the room she would be in and bought a bed frame and mattress that would fit with her other items. She said the facility told her she could not have the bed frame and it was in storage at the facility. Resident #50 said the facility told her she needed to sleep on a hospital bed. She said she tried to sleep on the floor with her pillow and blanket but she was not sleeping well. She said the thought of sleeping in the hospital bed triggered her trauma and caused her to sleep poorly. She said she woke up screaming numerous times when she slept in the hospital bed and she felt terrible if she woke up other residents from her night terrors. She said if she was unable to walk she would graciously give in and sleep in the hospital bed but she was still independent in most of her activities of daily living (ADLs) and should be allowed to use her bed frame. She said she knew it was an inanimate object but it did not matter because it was hard to get over it. Resident #50 said she had a lot of therapy sessions and they were helpful. She said she thought the trauma and triggers were taken care of until she was told she needed to use the hospital bed. She said she started sleeping during the day and stayed up all night because she felt safer sleeping in the hospital bed during the daytime. She said she missed out on some activities she wanted to attend because she needed sleep. She said the nursing staff were aware of her other triggers. She said she was triggered by people coming up behind her and touching her or speaking to her from directly behind her. She said another trigger was anyone coming into her room while she slept and she woke up to people in her room. She said staff would announce themselves when they were behind her from a distance and they knocked hard on her door but did not enter if she did not respond to the knocking. She said she was confused the staff worked on those triggers but she needed to sleep in a hospital bed which triggered her the worst. She said she enjoyed it when staff came into her room as long as she was awake because it scared her to wake up and find staff in her room. Resident #50 was interviewed again on 2/7/24 at 4:56 p.m. She said her traumatic experience was a physical and sexual assault at a hospital. She said she was diagnosed with chronic post-traumatic stress disorder. She said when someone approached her from behind and talked she went ballistic and freaked out on the person who triggered her. She said she had not slept at all during the night and was trying to sleep during the day because she was exhausted. She said she was tired of missing out on activities because she slept during the day but she did not know what else to do. IV. Record review Resident #50 was admitted on [DATE] with a PASRR II for her recurrent, moderate major depressive disorder. The recommended treatment was documented to provide individual therapy. Resident #50's care plan, revised 1/3/24, documented she suffered from complications of depression. Interventions were documented as the following: Depression screening as needed; Monitor for signs or symptoms of depression; Notify social services of a decline in mood; Allow time to express her feelings; Provide validation therapy; Administer medications as ordered; Document behaviors for psychotropic medications; and, Psychiatric services as needed. Resident #50's care plan documented she preferred no one enter her room until she answered the door and she slept late in the morning. A welcome email about Resident #50 was sent to the staff who worked the hall where her room was on 1/3/24 and read in pertinent part, Please welcome Resident #50. She is here for long-term care. She can be independent in the facility and her room. She startles easily, please approach from the side. -However, the facility failed to inform staff about her depression. A progress note from 1/12/24 documented a referral was sent per Resident #50's request for counseling. Resident #50 reported she had a long history of attending counseling and found it beneficial. A progress note from 1/31/24 documented that Resident #50 told the nurse she was afraid to sleep the night before (1/30/24). Resident #50 said she was worried she would scream again from her night terrors. She said she did not want to scare other residents with her screaming. She told the nurse she slept part of the night on her floor by putting her pillow on the floor, lying down and covering up with her blanket. The resident spoke several times about a situation in her past. Resident #50 said she was assaulted in a hospital bed in the past and did not want to sleep on her own mattress because it was on the hospital bed. The nurse asked the nurse practitioner (NP) who was at the facility to join the conversation. Resident #50 told the NP the same thing she told the nurse. Resident #50 said she was open to mental health counseling sessions and a behavioral consult was ordered by the NP. A counseling session was scheduled for 3/25/24 and an appointment with a behavioral health NP was pending for 2/12/24 in an effort to have the resident seen sooner. A progress note from 2/2/24 documented that a counseling session was scheduled for Resident #50 on 3/25/24 and a behavioral health appointment was scheduled for 2/12/24 to have the resident seen sooner. It documented these appointments were scheduled due to a past traumatic encounter that may have caused the resident night terrors and sleepless nights. V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 5:20 p.m. She said the facility provided some training in the past for dementia care and trauma-informed care but the training was not in-depth. She said more training for Resident #50 would have benefitted the staff and Resident #50. She said after Resident #50 was admitted the certified nurse aides (CNAs) and nurses talked about trauma and how to help the resident but it was not enough. LPN #2 said Resident #50 was triggered by people walking up behind her and the staff talked about it but only with the staff that worked on Resident #50's hall. She said she knew Resident #50 asked for staff not to enter her room while she slept. LPN #2 did not know why Resident #50 did not want staff to enter her room while she slept. She said the staff on other halls would not know what Resident #50's triggers were because they were not documented except for waiting until the resident responded before the staff entered her room, but she thought it was just the resident's preference. The social services director (SSD) was interviewed on 2/8/24 at 9:00 a.m. She said once she received the recommendations, from a resident's PASRR II, she documented them in the care plan and offered the resident the recommended services. She said she updated leadership during morning meetings and asked leadership to inform their CNAs and nurses. The SSD said the facility required staff to attend at least 80% of all-staff training which included trauma-informed care and triggers. She said if staff members were unable to attend the training they watched them at a later date because the trainings were recorded. She said she completed hand-outs and emails to make sure the staff were informed of the resident's trauma and triggers. The SSD said she was unaware Resident #50 had any trauma or triggers because Resident #50 did not talk to the staff about anything in depth. She said she knew the resident had a personal mattress on the hospital bed but was unsure why. She said if Resident #50 was assaulted in a hospital bed then she was being traumatized and it was something that needed to be fixed. She said Resident #50 requested counseling and it was scheduled for 3/24/24 because that was the earliest appointment that was available. The SSD said she did not know there was a progress note which documented Resident #50's trauma, night terrors and she was not sleeping at night. She said Resident #50 did not like staff checking in on her if her door was closed. -However, according to Resident #50's interview (see above) she did not want staff entering her room if she was asleep. Resident #50 enjoyed staff checking in on her and talking with her if she was awake in her room. The SSD was interviewed again on 2/8/24 at 11:03 a.m. She said she was confused when she received Resident #50's PASRR II at admission. The SSD said she completed another PASRR II and she was told the resident already had an active PASRR II and the recommendations were still to provide individual therapy. She said she followed up with Resident #50 at her two-week care conference and Resident #50 asked to go to counseling and the referral was sent by the SSD for the facility's appointment scheduler to set the resident up with a therapy appointment. She said she was unsure why Resident #50's appointment for counseling was not scheduled until 1/31/24. The NHA was interviewed on 2/8/24 at 11:27 a.m. He said residents were not required to use a hospital bed but the facility was concerned about infection control and fall risk issues. He said upon admission she only requested her mattress and mentioned nothing about the bed frame. He said he was not informed the resident slept on the floor and asked if the staff confirmed it because Resident #50 had dementia and was often confused. He said he would have heard if the resident slept on the floor. Registered nurse (RN) #2 was interviewed on 2/8/24 at 12:48 p.m. She said she was unsure how to provide trauma-informed care to residents. She said she respected their boundaries and attempted to figure out what was wrong. She said she believed the facility provided online training for trauma-informed care annually but she felt the facility needed to provide more training for the staff. The assistant director of nursing (ADON) was interviewed on 2/8/24 at 1:15 p.m. He said the PASRR II came with recommendations that were recommendations for the facility to provide, not required. -However, PASRR II recommendations were required to be implemented in the resident's plan of care to address their mental condition. He said Resident #50 made some objective statements to her nurse and the NP was informed and assessed the resident. He said her appointment with behavioral health was scheduled for 2/12/24. He said the facility offered one-on-one therapy or talk sessions and emotional support. He said the resident had a BIMS of 15 and her PHQ-9 was zero. He said the resident was able to make her needs known if she needed more support. The ADON said the staff members were told not to enter the resident's room before she responded to them knocking on her door and he said that was implemented because it was her preference. He said she preferred that staff members did not come up behind her. He said the nurses documented any statements or incidents and that was how the facility managed her depression until she attended her appointments. The ADON was not sure where Resident #50's triggers were documented or what interventions were provided when she experienced triggers or depression. The SSD was interviewed again on 2/8/24 at 2:19 p.m. She said Resident #50's care plan only documented that she had depression (noted above). She said the resident's major depressive disorder was documented in the care plan as the resident has a PASRR II diagnosis. She said the care plan had nothing in it for her triggers or what staff needed to do to provide support for her major depressive disorder. VI. Facility follow-up On 2/8/24 at 2:00 p.m. Resident #50 received her bed frame from storage during the survey. She said she felt safe to sleep and was able to sleep at night so she would not miss out on activities or appointments during the day.

Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the facility medication administration observation error rate was 7.32% or three errors out of 41 opportunities. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/12/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration and Documentation policy, revised 11/3/21, was provided by the director of nursing (DON) on 2/7/24 at 8:49 a.m. It read in the pertinent part, Patient Safety is demonstrated by the use of the Five Rights: Right Medication, Right Patient, Right Dose, Right Route, Right Time. Verify that medication is being administered at the correct time, in the correct dose and by the correct route to the correct patient. III. Observations On 2/7/24 at 9:56 a.m. registered nurse (RN) #1 was observed preparing and administering medications to Resident #3: -Diclofenac Sodium, one application topical. Apply to bilateral hands three times a day before meals for pain. Scheduled for 7:00 a.m., 11:00 a.m. and 4:00 p.m. -Furosemide 40 milligram (mg) tablet for essential hypertension. Scheduled for 7:00 a.m. -Spironolactone 100 mg tablet for heart failure. Scheduled for 7:00 a.m. III. Staff interviews RN #1 was interviewed on 2/7/24 at 10:17 a.m. She said she was aware the three medications showed late but she was allowed to adjust the administration times for the three medications because the resident was sleeping and then had a scheduled shower. -However, she was not able to show where the allowance was ordered. The DON was interviewed on 2/7/24 at 12:48 p.m. She said the nurses should follow the seven rights of medication administration when administering medications. She said the facility followed a two-hour window on either side of the physician-ordered time for medication administration. -However, the 7:00 a.m. medications were not administered within the two-hour window (see observation above). She said when they noticed a resident was routinely sleeping in and not getting their medications at the prescribed time or within the two-hour window they would contact the physician and get an order to change the administration time.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of three units at the facility. Specifically, the facility failed to ensure housekeeping staff: -Following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (remote controls, light switches, door handles and drawer pulls); -Performed hand hygiene when appropriate; -Cleaning the toilet bowl appropriately; -Cleaned a resident's room from cleaner areas to dirtier areas to avoid spreading dirt and microorganisms; and, -Adhered to disinfectant cleaning guidelines. Finding include: I Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 2/13/24 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 2/13/24 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Patient Room Cleaning policy and procedure, revised on 5/10/23, was provided by the assistant director of nursing (ADON) on 2/7/24 at 12:05 p.m. It read in pertinent part, Remove liners from waste cans, remove soiled linen, remove everything from nightstands and over-bed table except the phone book, cafe menu, smoking cessation, Dispose of all trash in the normal trash cart, empty normal trash cart into the compactor prior to the end of the work shift. Check sharps container and install new container if full, [NAME] bio hazard waste take it to bio-hazard storage room. -Use Super HDQ solution, (10-minute disinfectant contact time). -Check cubicle curtain. If soiled, remove and send to laundry. -Check walls, and spot clean as indicated. -Check window and clean interior as indicated. -Check supply/exhaust vents and surrounding ceiling tile. -Wipe down the over-bed lights, over-the-bed table, nightstands, TV, chairs, trash cans, sink, mirror, paper towel holder, and soap dispenser. -Clean all surfaces of the bed(s), including both sides of head and foot boards, bed frame, lower bed frame, and control pendant. Make sure beds are centered under the lights. -Leave porcelain wet. Clean inside and outside of closets. Clean all doors, light switches, telephones and wall outlets. Use germicidal solution for all items, let the disinfectant work into all surface areas for the recommended contact disinfect time. -Dust mop floor. Damp mop floor using germicidal solution, rinsing mop after half the room. Change water and mop head after every three rooms, (change the water every room if the room had bodily human fluid). -Check all features of the room including over-bed lights (up and down lighting), TV, telephone, all lights, plumbing features, window blinds, bed controls, over-bed tables, etc. Check walls, floors, and ceiling for defects and report any deficiencies to Maintenance immediately. Bathroom: -Wash shower walls, sinks, disinfect mirrors, check soap dispensers, paper towel dispensers, toilet paper dispensers. Allow the disinfectant solution work on all surfaces for the recommended contact disinfect time. -Make a toilet cleaning solution using one full stroke of Super HDQ. Pour into toilet and swab all inside surfaces using a 'Johnny mop.' Use this cleaning solution to clean all exterior surfaces of the toilet including chrome plumbing fixtures and seat, Flush the toilet, let the disinfectant solution work in all the surfaces for the recommended contact disinfect time. -Clean exhaust vent as indicated. -Clean light switch and door handle with germicidal solution. -Check walls and spot clean as needed. -Damp mop floor with germicidal solution. Daily Cleaning of Occupied Room: -Introduce yourself to the patient and family members and ask permission to clean the room. -Do not clean the TV if it is on. If the TV is off, clean the TV. -Remove trash liners and soiled linen, making sure all wastebaskets are clean. Wash and spray if needed. Dispose of normal trash in the normal trash cart. Empty normal trash cart into the compactor prior to the end of the work shift, send all the soiled linen to the Laundry, check sharps containers, and bio-hazard waste and take it to the bio-hazard storage room. -Wipe down sink, paper towel holder, soap dispenser, towel rack, and mirror. Wipe down bedside tables and over the bed tables. Use germicidal solution described above. Do not move any personal items unless it is necessary, and put items back in the same place. -Dust mop and damp mop the floor, including the underneath of the bed. Rinse mop after half of the room has been mopped. Change mop water and mop head after every three rooms. -Clean the bathroom as described above. III. Disinfectant used in the facility The disinfectant used in the residential bathrooms in the facility was Peroxy II FBC antibacterial surface cleaner, the guidelines read: The antibacterial cleaning power of Peroxy II fbc kills 99.9% of household bacteria (Staphylococcus aureus and Enterobacter aerogenes) in 2 minutes. To Clean and Deodorize: Spray product on surface and wipe clean. Rinse promptly with water. For tougher jobs, allow product to penetrate dirt and/or soap scum before wiping. For best results, use regularly to prevent dirt and soap scum build-up. To Sanitize: To sanitize pre-cleaned non-food contact surfaces spray until thoroughly wet. Let stand for 2 minutes. Then wipe and rinse promptly with water. IV. Observations On 2/7/24 housekeeper (HK) #1 was continuously observed in a room on the Birch unit from 10:40 a.m. to 11:13 a.m. HK #1 sprayed the antibacterial surface cleaner on the shower walls and floor, the walls around the toilet and the top of the toilet. She removed the roll of toilet paper from the holder to the basket in the bathroom. She scrubbed the floor of the shower with a brush. She did not wipe the walls or toilet before spraying them down with the shower head. No high-frequency touch areas (door knobs, light switches or lower drawer handles) were disinfected. HK #1 left the bathroom and changed her gloves before getting the toilet brush from a red bucket with one inch of bleach in it. The toilet brush was not completely submerged in the bleach. She then returned to the bathroom with the toilet brush to clean the interior of the toilet. HK #1 finished cleaning the interior of the toilet and then put the roll of toilet paper back on the holder before she returned the toilet brush to the red bucket. She then got the mop and began mopping the floors. -She did not wipe the disinfectant over the surfaces (see above) before rinsing with water. -She did not use the toilet bowl disinfectant the facility used and there was not enough of the disinfectant that was used to cover the toilet brush. -She did not change her gloves after cleaning the interior of the toilet bowl before she mopped the floors. While mopping the floor HK #1 knocked the remote control that operated the recliner onto the floor. She did not clean the remote before placing it back on the recliner. She returned the mop to the bucket and began making the bed. She finished cleaning the room at 11:13 a.m. -She cleaned the resident's bathroom first (dirtier area) instead of cleaning the room first (cleaner). -She did not perform hand hygiene after touching the remote for the recliner that was on the floor. -She did not wipe any high-touch areas such as door knobs, light switches or lower drawer handles. V. Staff interviews HK #1 was interviewed on 2/7/24 at 11:13 a.m. HK #1 said she was trained by a coworker when she was hired. She said the liquid in the red bucket holding the toilet brush was bleach and it was not diluted. The housekeeping supervisor (HKS) was interviewed on 2/8/24 at 9:34 a.m. The HKS said housekeeping staff were trained by current workers. She said staff were instructed what solutions to use for particular areas and that bleach should not be used. She said they should use Comet for the toilet bowl. The HKS said housekeepers could clean the room in any pattern they wanted and there was no set direction (starting in the bedroom and moving to the bathroom). She said the staff should change their gloves between each room and after each time in the bathroom. She said if a device was on the floor it should be cleaned before moving it onto a clean surface.

Based on observations, record review and interviews, the facility failed to provide an environment as free from accident hazards and risks as possible for one (#21) out of two residents reviewed for accidents out of 23 sample residents. Specifically, the facility failed to: -Ensure Resident #21 was safely transferred without risk of resident or staff injury; -Assess and communicate clearly the changing transfer expectations and needs of Resident #21; -Ensure consistent facility training for all staff who conducted resident transfers; and, -Instill Resident #21's security and confidence in staff's ability to safely and consistently transfer her without additional pain or risk of additional injury. Findings include: I. Facility policy and procedure The Resident-Patient Declining the Use of Lifts Policy, dated 5/1/07, was provided by the facility on 7/8/21. According to the policy, the facility would work towards consensus with the staff, the residents and their families on the safest method of transferring. The staff would evaluate and identify the resident's needs to determine if there was a need for a mechanical lift. The resident's needs would be identified in their chart and identified through a magnet on their door frame indicating specific mechanical lift requirements. II. Resident #21 A. Resident status Resident #21, age 95, was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), diagnoses included [CONDITION(S)], intention tremor, [CONDITION(S)], closed fracture of the pubic ramus, [CONDITION(S)] and anxiety. The 5/18/21 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. According to the May 2021, the resident required extensive assistance from one person for bed mobility, transfers and toileting. B. Resident interview Resident #21 was interviewed on 7/7/21 at 9:32 a.m. According to the resident, she was having difficulty using the sit-to-stand (mechanical) lift. She said the lift had been implemented a couple of weeks ago. She said it was very hard for her to try to reach for the bars on the lift as she tried to fully pull herself up. She said she was [AGE] year old and did not always have the strength. She said a certified nursing aides (CNA) back was injured the day before the interview, when she was transferring the resident by herself. She said she was afraid that she may not always have the strength to keep herself up and did not want to get hurt or hurt another person. She said she had a fear of falling when only one person helped her transfer with the lift. The resident said she did not like the way the staff used the belts on her during the transfers. She said a staff member had bruised her a few weeks ago using the gait belt. Resident #21 was interviewed on 7/7/21 at 3:55 p.m. She said she cried because she was going to have to continue to use the lift and gait belt. She said she did not want another accident. Resident #21 was interviewed again on 7/8/21 at 1:45 p.m. She said on occasion, staff would have two CNAs transfer her with the sit-to-stand lift but it was usually just one CNA. She said the lift was hard for her to do both day and night. Resident #21 said she would feel much more confident in the lift if she consistently had two staff helping her. She said one staff member could help lift up her bottom while the other staff member could support her top with a gait belt. She said the CNA would not have to pull up so hard on the gait belt if she had assistance. She said she did not want to be bruised again by the belt and did not want them to use it on her. C. Facility incidents The 4/7/21 facility reported incident investigation was provided by the facility on 7/6/21. According to the report Resident #21 the resident felt she was slammed down on the toilet during a manual transfer from her wheelchair. The facility investigation revealed the resident was difficult to transfer and the CNA was unable to fully support the resident when she was lowered down. The facility therapy team evaluated the resident for transfers and the resident agreed to utilizing an assistive device during transfers to prevent recurrence. The 6/5/21 incident report was provided by the facility on 7/13/21 via email. The incident confirmed Resident #21's statement of a bruise acquired by a gait belt during a transfer. According to the report, the resident had a dark purple bruise under her left breast. Initial probable cause of the bruise was from the gait belt or a staff transfer assist resulting in hand or finger print. The resident was placed on 72 hour monitoring, staff was educated on proper transfer and gait belt use, informed therapy and recommended a padded gait belt. The report read that the resident refused the use of the gait belt. The investigation outcome summary read the bruise was consistent with a gait belt and a guiding hard. The summary did not indicate which staff received the training or when. The manager's investigation report was provided on 7/8/21 at 12:48 p.m. via email. According to the initial report, CNA #3 assisted Resident #21 to transfer from her lounge chair with use of a gait belt and the sit-to-stand lift. According to the report, the resident was not able to assist much during the transfer so CNA #3 had to pull her up with a gait belt and strained the right side of her upper back. The CNA attempted the transfer alone. The report read the CNA had annual lift training. The report indicated the resident would be re-evaluated with the lift. D. Observations On 7/7/21 at 4:10 p.m. was transferred with one CNA by use of the sit-to-stand lift and a gait belt. The resident's legs began to shake as she pulled herself up with the bars. The resident was lowered to her lounge chair with an approximate six inch drop without the lift seat under her. She said the drop between the lift and the chair also hurt her bottom. She said it just kills me. On 7/7/21 at 8:38 p.m. Resident #21 call light was placed on. CNA #1 entered the room. After a couple of minutes a second CNA entered the room after CNA #1 said she needed a second person with the lift. The door was shut behind the CNAs. A magnet on the resident's door indicating the specific mechanical lift requirements was not observed. On 7/8/21 at approximately 12:30 p.m. CNA #5 was observed entering Resident #21's room alone with the sit-to-stand lift to transfer the resident. The CNA did not have a second staff member assist her in the lift transfer. E. Staff interviews CNA #5 was interviewed on 7/7/21 at 4:00 p.m. She said Resident #21 was usually mad or sad when she used the sit-to-stand lift with her but reminded her it was for her and the staff's safety. She said she had to help pull her up with the gait belt because the resident's legs were not strong enough to completely lift herself up even with the sit-to-stand lift assist. Registered nurse (RN) #1 was interviewed on 7/7/21 at 4:27 p.m. He identified himself as a charge nurse. RN #1 said he was aware of an incident last month regarding the use of a gait belt and bruising but he did not know all the details. He said Resident #21 has had more difficulty transferring lately, mainly associated with her refusal of the gait belt. RN #1 said she has had a general complaint of pain in her knees. The rehabilitation supervisor (RS) was interviewed on 7/7/21 at 4:39 p.m. She said Resident #21 remained on skilled therapy because of the continued concerns with transfers. The RS said the therapists provided staff training during the on boarding (orientation) of the staff member but she revealed that they were not able to get to all the CNAs. She said the nursing department provided a on teach back training with demonstration if we think something with a lift could cause an injury. She said CNAs were using max assistance with transferring with the gait belt alone so a lift was incorporated. The resident ordinally screened well for a pivot assistive device and was not identified to need a hoyer lift. She said the resident was currently using the sit-to-stand lift until the pivot assistive device parts arrived (see explanation below in RS second interview). The nursing home administrator (NHA) was interviewed on 7/7/21 at 4:46 p.m. The NHA referenced the April (2021) incident where the resident said she was slammed down during a transfer. He said it was determined that the resident lost leg stability and the CNA was not able to fully support her. A pivot device was implemented which the resident was satisfied with but it was later determined that the resident needed more assistance so therapy recommended the sit-to-stand lift. He said Resident #21 had been tearful with use of the lift but acknowledged she needed more help transferring in the last week or two since the use of the sit-to-stand lift. The NHA said he asked the resident to follow the therapy recommendations for safe transfers. He said staff were not allowed or asked to do anything that would be deemed as unsafe. The NHA said she had been encouraged to continue the use of lift to maintain her mobility. CNA #1 was interviewed on 7/7/21 at 8:38 p.m. CNA #1 said she always used two staff when she used the lift. CNA #1 said they had transfer training two months ago. CNA #4 was interviewed on 7/7/21 at 8:40 p.m. She said she had not received transfer or lift training from the facility but felt she knew how to use all the lifts. RN#2 was interviewed on 7/7/21 at 9:10 p.m. She said she had been at the facility for three weeks but had not had lift training but had helped with transferring residents with the lifts. RN #3 was interviewed on 7/8/21 at 9:14 a.m. RN #3 said she had helped residents with the sit-to-stand lift but did not have training at the facility for use. CNA #5 was interviewed again on 7/8/21 at 12:42 p.m. She said Resident #21 was usually a one person transfer assist with the sit-to-stand lift but she probably needed to be a two person transfer because sometimes her knees would go out. CNA #6 was interviewed on 7/8/21 at 1:39 p.m. The CNA said the resident was limited assistance with a gait belt but she was getting weak in one knee so she now used the sit-to-stand lift. The CNA said she was comfortable transferring Resident #21 transferring her by herself with the sit-to-stand, even though Resident #21 sometimes liked to let go of the bars. CNA #7 was interviewed on 7/8/21 at 9:23 a.m. She said when residents need a change on how much assistance they need during a lift transfer, therapy usually would put out a communication email to staff informing them of the resident's needs. She said the transfer status of a resident was probably in the resident's electronic records but she did not think she had access to them. The director of nursing (DON) was interviewed on 7/8/21 at 10:14 a.m. The DON reference the CNA injury when transferring Resident #21. She said CNA #3 was transferring the resident during the night by herself with a sit-to-stand lift. Resident #21 was not able to pull herself up so CNA #3 pulled on the belt staining her shoulder muscle. The DON said the resident has had more difficulty transferring from her lounge chair because it was lower than the bed. According to the DON, the CNA had been at the facility for eight years and had been transfer trained with the lifts. The RS was interviewed again on 7/8/21 at 12:52 p.m. She said Resident #21 was referred to therapy in April 2021. The RS said the resident would participate in therapy but in May and June 2021 started to refuse more and then she started to decline in her ability to transfer. Staff informed therapy that Resident #21 was required for maximum assistance with transfers. The resident acquired bruising from her gait belt during a manual transfer. The RS said therapy wanted to have safe transfer while providing her with a sense of control and independence. The RS said the sit-to-stand lift had a platform which raised the resident's feet, raising the resident's knees and tilting her hips back. The RS said in this position it would be harder for the resident to lift her bottom up and reach for the pull bars. She said the resident was evaluated for the Etac [NAME] Pro pivot device. The device was trialed successfully with the resident but the facility only had one device located on the other side of the facility and the resident who used it relied on it heavily. On 6/7/21, the RS requested approval for the order and the device arrived on 6/14/21.The sit-to-stand lift was then recommended so she still could pull herself up intll the new device was in place. She said after a series of emails, the device arrived on 7/1/21 but was not complete since it was missing parts. She said she continued to request the rest of the parts or a replacement. The RS said the resident would continue to use the sit-to-stand lift till the new device was available. The RS said the pivot device would meet Resident #21's needs to pull herself up but still pose a risk to the resident if her legs gave out. According to the RS, the resident had poor trunk control and had not been observed by therapy on her ability to use the sit-to-stand lift at night. The RS said she spoke to several CNAs who worked with her at night. She said one male CNA said he was able to transfer fine at night. The other female CNAs said they had struggled at night transferring with Resident #21. The RS said she was aware that a CNA was recently hurt transferring the resident. The RS said two transfers with the sit-to-stand would have been her recommendation because the resident's strength and abilities were variable. She said she assumed staff were providing a two person transfer with Resident #21 when using the sit-to-stand because staff was safety minded. The RS said she always recommended two person transfers when incorporating a new lift to assess how well and safe the resident does with the new lift. She said she was surprised to hear some staff including the injured CNA, transferred Resident #21 without a second person. The RS confirmed she normally communicated residents' transfer needs via email to the nursing staff. She said she did inform the staff that a sit-to-stand lift was recommended for Resident #21. The RS said the email directed staff to lower her slowly when transferring with the lift. According to the RS, the email directed staff to use minimal assistance with sit-to-stand. She said she did not clarify to the staff if the resident required a one or two person transfer assistance and should have made it clear on the email. She said it was a missing piece of information. The RS identified another area of concern. She said the therapists had done some on the spot transfer training with staff but had not documented that training. She said the facility had conducted teach back demonstrations but it had been a few months. She said the nursing staff would all eventually have the training. She said trainings had not been as often as it used to be related to COVID-19 and the facility moved into a new facility less than a year ago. She said the facility used to have a once a month training before all the changes. She said she was in the process of working with nursing to incorporate a routine twice a month transfer training for staff. Physical therapist (PT) #1 was interviewed on 7/8/21 at 1:29 p.m. She said she had competed undocumended sit to stand demonstration training with staff but as a one person assistance. PT #1 said it was appropriate for a one person transfer with the sit to stand lift if the resident had the strength to pull themself up with minimal assistance. She said if a resident was not strong enough then a two transfer would be appropriate. PT#1 said she was Resident #21's physical therapist and had heard that transfers were not going well at night with Resident #21. She could add it to the care plan for the resident to be a two person transfer with the sit to stand. The DON was interviewed again on 7/8/21 at 4:05 p.m. The DON said she spoke to CNA #3 for follow-up on her injury during the resident transfer. The CNA confirmed the resident had been weaker at night and the CNA was having to do most of the resident transfer herself, creating the strain. The DON said CNA #3 should have had a second CNA help her when she determined the resident was not able to physically assist more in the transfer. The CNA should not have attempted the lift alone. The DON said during the injury investigation, she learned that the resident required more assistance than a one person transfer with sit-to-stand during the night. She said CNAs were interviewed after the incident and had informed her that they had also noticed the resident was weaker at times and not able to fully assist with transfer. She said the staff should have communicated their concern so the resident could be re-evaluated for a two person transfer with the sit-to-stand lift for resident and staff safety. The DON said she would have done a change of condition assessment and requested therapy to re-evaluate her lift needs. The DON said she could only produce a limited amount of transfer training records because the lead CNA kept those records. She said she was still trying to contact the CNA. -The facility did not provide additional transfer records other than a April 2021 inservice by exit on 7/9/21. The DON was interviewed with the NHA on 7/8/21 at 5:25 p.m. They said they wanted all staff trained by the facility on transfers and lift use to ensure staff competence and resident and staff safety. F. Record review The July 2021 care plan revealed the Resident #21 had potential for pain and required activities of daily living (ADL) support. According to the care plan for alteration in comfort, the resident was at risk for pain associated with the disease process, indicating [CONDITION(S)] and arthritis. Other potential factors identified on the care plan included musculoskeletal and surgical pain. Interventions to alleviate the pain included staff to anticipate and assist with activities of daily living (ADLs). The ADL specific care plan directed staff to offer the manual sit-to-stand lifting device for one to two persons. A physical therapy inservice was conducted on 4/14/21 for lifts according to the staff education agenda on 4/14/21 in Resident #21's incident folder. The following emails were provided by the medical record director via email on 7/8/21 identifying the most recent and documented staff transfer training in 2021: A lift training was conducted on 1/25/21 for use of the hoyer, sit-to-stand and the sabina lift. According to the January 2021 attendance sheet, 31 staff total were anticipated to attend the inservice. Out of the 31 staff, nine staff did not participate. The lift training attendance sheet did not identify if the training was open to both CNAs and nurses. The lift training sheet did not indicate a second training was offered for staff who missed the 1/25/21 lift training. -Not all nursing staff attended the training. A 3/9/21 and 6/18/21 RS communication email with a youtube link and simple instruction, informed staff of use new transfer devices to include the Etec lift and a pivot device for two individual residents, not Resident #21. Review of the therapy notes indicated the resident was evaluated for physical therapy on 4/8/21 for balance, difficulty walking, difficulty with daily activities, fatigue/poor endurance and weakness. Physical therapy also identified her as a fall risk. A 6/29/21 communication email sent out by the RS was provided on 7/8/21 at 3:27 p.m. The email was sent to the nursing and therapy staff. The email read in part: I know (Resident #21's) transfers have been a big concern, and everyone is unsafe transferring her the way it had been happening According to the email, the resident did well with sit-to-stand and recommended its use with minimal assistance and the fur lined gait belt. The email read the manual sit-to-stand was the safest and best way to transfer her. The RS wrote that the resident said she would refuse the use of the lift and the belt. A 7/2/21 email revealed the RS identified a need for increased staff training on lifts, transfer equipment and techniques. According to the CNAs in the past would spend an hour with therapy for these onboarding orientation trainings. The RS requested therapy refreshers'' for the staff to go over body mechanics and the transfers. She offered to set up times to offer the training twice a month to also include night shifts. III. Facility follow up A 7/8/21 communication email sent out by the RS was provided on 7/8/21 at 3:44 p.m. The email was sent to the nursing and therapy staff. According to the communication email, therapy requested staff to provide assistance of the two persons for all transfers on the manual sit-to-stand lift for Resident #21. The email indicated staff could use either the fur lined or regular gait during the lift transfer.

Based on observations, resident interviews, record review, and staff interviews, the facility failed to ensure the needs of three (#46, #55 and #48) of 26 sample residents were accommodated. Specifically, the facility failed to: -Ensure call lights were kept within reach for residents #46 and #55; and -Ensure resident #45 was able to reach the water faucets on her sink and towels to dry her hands. The findings included: I. Call Lights Out of Reach A. Facility Policy On 3/29/17 at 3:00 p.m., registered nurse (RN) #1 provided the facility's policy and procedure titled Call Lights, effective March 2016, which included: All staff at (the facility) will ensure that the call light is placed within the resident's reach upon exiting the room. B. Resident #46 Resident #46, age 91, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 1/4/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She had adequate vision, clear speech and minimal difficulty hearing, and had no behavioral symptoms or rejection of care. She required extensive assistance with bed mobility, transfers, dressing, and toilet use, and limited assistance with personal hygiene. She had pain that was present occasionally which she rated five out of ten on a zero to ten scale (zero was no pain, ten was severe pain). She received a scheduled pain medication regimen, PRN (as needed) pain medications and non-medication interventions. Observations and Interviews: On 3/27/17 at 11:02 a.m., resident #46 was observed sitting in her wheelchair in her room. Her white paddle call light was lying on the bed, which was approximately five feet from where her wheelchair was parked. She said she could not reach it from where she was unless she slowly inch my way over to the bed to push it, which she said was hard for her. On 3/28/17 at 11:50 a.m., resident #46 was observed sitting in her wheelchair in her room with the bedside table in front of her. The white paddle call light was sitting on the bedside table directly behind her, near the head of the bed and was out of her reach. She stated, My call button is usually somewhere just out of reach. Then when I finally get to it, sometimes I have waited so long to get it, I have forgotten what it was I needed. She said it was frustrating. Record Review: The care plan, initiated 12/1/15 and revised but undated when last revised, identified she was at risk for falls and had a history of [REDACTED]. Staff Interviews: Certified nurse aide (CNA) #7 was interviewed on 3/29/17 at 10:50 a.m., and she confirmed that she routinely cared for resident #46. She said the resident could brush her teeth and comb her hair with set-up assistance, but the staff had to get her dressed, help her to the toilet, and transfer her. She said she rarely refused care or turning and said, It hurts her, but she knows she needs to turn and she will let us do it. She said resident #46 was able to use her call light and said the residents' call lights should be placed within their reach. The director of nurses (DON) was interviewed on 3/29/17 at 1:49 p.m., and she said all staff answered call lights, not just CNAs. She said the facility had provided education to all staff that if they moved something in a resident's room, they had to put it back. She said, Her call light should be placed where she can reach it. C. Resident #55 Resident #55, age 87, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 1/17/17 MDS assessment, the resident had mild cognitive impairment with a BIMS score of 11 out of 15. She required limited assistance of one for bed mobility, transfers, toileting and personal hygiene. She needed limited to extensive assistance for ambulation (depending on whether using her walker or wheelchair) and extensive assistance for dressing and bathing. Resident Interview: Resident #55 was interviewed on 3/27/17 at 12:07 p.m. She was asked if she had any problems in her room that affected her comfort and she said that at times, she could not reach her call light. She said that the call light often was caught between and mattress and the footboard and she could not get to it herself. She said she would be more comfortable and less nervous if she knew her call light was in reach. The resident's call light was observed within reach during the interview. Observation and Staff Interviews: The environmental tour was conducted with the maintenance director on 3/29/17 at 12 noon. Resident #55 was observed sitting in her wheelchair in her room, with her lunch in front of her on a small table. The resident's call light was attached to her bed several feet away, behind her and to her right, and was not within her reach. The resident said the staff often left her call light out of her reach, and that it bothered her. The plant operations director said he was concerned about having too long a cord attached to the resident's call light because it might be a tripping hazard. He acknowledged they could explore options further. The RN said they had tried to address resident #55's call light issue, and the resident had said it was okay recently. However, the RN acknowledged the resident's call light was not always near her when she was sitting in her wheelchair, especially with her meal in front of her on her table. Record Review: The resident's care plan dated 3/3/16 read, Risk for complications related to generalized anxiety disorder with symptoms including irritability and recurrent/persistent thoughts and worry. Interventions included: Provide and stick to a routine as much as possible. Changes in routine are very upsetting to (the resident). The care plan dated 3/3/16 read, Alterations in ADLs related to wheelchair use for mobility, oxygen use and requiring limited assist with ADLs. Interventions included: Please have call bell within reach before leaving the room. The care plan dated 3/2/16 read, (Resident) is at risk for falls. (Resident) has a history of falls with multiple fractures. Interventions included: Have call bell within reach before leaving the room. II. Inaccessible Sink, Towels and Paper Towel Dispenser Resident Status: Resident #48, age 83, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 2/1/17 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of nine out of 15. She required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene and ambulating in her wheelchair. The care plan, initiated 3/22/16 and updated on 11/10/16, identified Alterations in ADLs related to weakness and chronic pain. I will achieve and maintain optimal physical, mental and psychosocial function . I require extensive assist for my ADLs except locomotion in my wheelchair and eating . Propels wheelchair with bilateral upper extremities due to bilateral lower extremity pain. Resident Interview: Resident #48 was interviewed on 3/27/17 at 3:12 p.m. She was asked if there was anything wrong in her room that affected her comfort, and she said that she could not reach the sink or the towels from her wheelchair. She said she could be more independent with face washing and teeth brushing if she could reach it. She said that once in her wheelchair, she was able to propel herself to the sink area. Observation and Staff Interviews: The environmental tour was conducted with the maintenance director on 3/29/17 at 12 noon. Resident #48's room was observed during the environmental tour with the maintenance director. The sink near the window in the room shared by two residents was in a tight space next to the heater. The sink was not an accessible, roll-under sink. A plastic storage bin was stored at an angle under the sink, further limiting access. The hand towels hung on towel racks above and to the right of the sink, which would be difficult to reach from a wheelchair. The paper towel dispenser was high on the wall, above the towel rack, and inaccessible from a wheelchair. The plant operations director acknowledged the access issues with the resident's sink, and said he had not been notified of the problem before. Certified nurse aide (CNA) #7 and registered nurse (RN) #1 were interviewed on 3/29/17 at 2:45 p.m. They acknowledged resident #48 could not access her sink, towels and paper towels independently. The CNA said the resident had to be positioned at an angle so she could reach the sink, and she would hand her the items she needed such as a cup of water, wash cloth, towel, etc. The CNA said she had been aware of the concern for as long as the resident had lived in the facility. The RN said it was an issue for a lot of residents here who used wheelchairs and whose paper towel holders were high up on the wall out of reach.

Based on observations, record review and staff interviews, the facility failed to ensure one (#37) of 26 sample residents maintained comfortable positioning at the dining room table. The findings included: 1. Facility Policy The facility policy entitled Adjusting Table Heights, dated August 2016, read in pertinent part, All residents will be evaluated for table height adjustment upon admission. Table heights for residents may need to be adjusted periodically. 2. Resident Status Resident #37, age 77, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 1/10/17 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required supervision for wheelchair ambulation and eating. She required extensive assistance for personal hygiene and bathing. She required extensive assistance of two persons for bed mobility, transfers, toileting and dressing. The care plan initiated 8/30/16 related to dining did not address positioning at the dining room table. 3. Resident Observations - The initial observation of resident #37's positioning at the dining room table occurred on 3/27/17 at 12:15 p.m. The resident was seated at a small square dining room table that accommodated four residents. The top of the dining room table came up to the resident's shoulders. The resident said she was not feeling very well at that time. - On 3/28/17 at 11:59 a.m., a certified nurse aide (CNA) was observed propelling the resident in her wheelchair to the dining room for lunch. The resident was positioned at the dining room table with the top of the table at the height of her shoulders. The resident had left the table by 12:15 p.m., and had not returned to the table by 12:50 p.m. - On 3/28/17 at 5:25 p.m., the resident was observed at her normal seat in the dining room. She was sitting with two other residents. The top of the table, again, came up to the resident's shoulders. This table appeared to be adjustable. - On 3/29/17 at 10:45 a.m., the resident was observed seated at her space in the dining room. The contract sitter #12 gave the resident a banana to eat, then sat down and kept her company. The sitter did not notice that the dining room table reached the resident's shoulders. - On 3/29/17 at 11:47 a.m., the resident was observed being placed at her space in the dining room by contract sitter #13. The top of the table was again too high for the resident. 4. Staff Interviews On 3/29/17 at 8:40 a.m., CNA #2 was interviewed. She said that a resident's positioning at the dining room table should be at a 45-degree angle and sitting up. She said the top of the table should be at the resident's abdomen. On 3/29/17 at 11:59 a.m., occupational therapy assistant #3 was interviewed. She said, Ideally, we'd like (the residents) to be 90 degrees at the hip and knees. We look at functionality as much as we can. The dilemma is having four to six residents seated at one table and getting a happy medium for all. She said that a resident's arms should be a 90-degree flex at the elbow. She was asked to observe resident #37, who was sitting at the dining room table. She said that the table was too high for the resident. She added that this resident was originally seated at an assist table, but due to her increasing behavioral issues, she needed to be moved. She said due to this resident's current behaviors, there were only a few tables where she could sit without disrupting other residents. She said she would speak to maintenance about lowering this table so it would be a proper height for resident #37. She said she would have to evaluate the other residents who sat at that table to see how far the table could be lowered without causing problems for other residents. She said she was thankful that someone had called this to her attention, as the therapy department was not aware of this resident's positioning issues. She was asked for a policy related to dining room positioning and she said the facility did not have a policy for positioning, as the facility looked at every resident's needs individually. On 3/29/17 at 1:53 p.m., the director of nursing (DON) was interviewed about this resident's positioning at the dining room table. She said that she was on vacation last week, but that she noticed this resident's low positioning at the table on 3/28/17. She said that she asked a CNA why the resident was sitting so low and the CNA told her that the resident would not allow an extra cushion to be placed in her chair so that she would sit higher. The DON was asked for a policy related to wheelchair positioning in the dining room at this time. On 3/29/17 at 2:30 p.m., the occupational therapy assistant returned to say that the resident's table would not go any lower, so maintenance would check to see if there was a round table or a smaller table in the storage unit, which could be lowered for this resident. She said that they may have to look at a separate table for this resident, but worried about the possibility of this resident self-isolating because of this. She said, If nothing else, we'll make a run to Wal-Mart. She said that a higher cushion in her wheelchair to bolster her would not solve the problem because this resident propelled her own wheelchair and a higher cushion would be an improper support for her because she would sit too tall to have good propulsion with her feet when propelling her wheelchair. 5. Record Review: The Dining Accommodation assessment dated [DATE] read that the resident's table height did not need to be raised or lowered. No updated dining assessment could be found after that date. The most recent occupational therapy (OT) weekly note dated 10/14/16 did not mention any type of cushion for positioning for this resident. Occupational therapy for this resident ended at this time because the resident was unable to successfully participate in both physical therapy (PT) and OT at the same time due to cognitive limitations. The resident's priority was walking, so OT was discontinued and PT services remained in place. The physical therapy weekly notes dated 10/14/16 through 11/17/16 also did not address any special cushion for positioning or positioning in general at the dining room table. The March 2017 restorative program documentation read that this resident was discontinued from this program on 3/14/17 due to poor participation. There was no documentation about using a cushion for positioning for this resident.

Based on observations, record review, and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in two of two resident hallways, and two of three bathing rooms for residents residing in the facility. The findings include: A. Facility Policies On 1/28/16 at 12:55 p.m., the maintenance/housekeeping director provided the facility's policy and procedure titled General Area Cleaning, dated 1/2006, which included in pertinent part: To delineate a procedure for the effective cleaning of general areas, including offices, waiting areas, and public/staff corridors . will maintain a clean, sanitary environment at all times: . public/staff corridors will be cleaned to provide an effective work environment and convey an appropriate image to patients and public. empty all trash receptacles, clean, spray, and reline . spot clean walls as indicated . check windows, window sills, and blinds, clean as indicated, check ceiling, vents, lights; dust/clean as needed . report any deficiencies (lights out, defects in walls/ceilings, plumbing problems, etc.) to Plant Operations immediately. The policy and procedure titled General Bathroom Cleaning, dated 1/2006, included in pertinent part: Bathrooms will be cleaned to provide an effective patient care environment and to provide a sanitary environment for patients . clean all exterior surfaces of the toilet including chrome plumbing fixtures and seat, flush toilet, dry plumbing fixtures and toilet seat with clean dry cloth, clean exhaust vent and lights as indicated, clean light switch and door handle with germicidal solution, check walls and partitions and spot clean as needed, damp mop floor with germicidal solution, report any deficiencies (lights out, plumbing problems, etc.) immediately to plant operations. B. Observations and Interviews During the initial tour on 1/25/16 at 11:15 a.m., and during subsequent observations on 1/26/16, 1/27/16 and 1/28/16, the following was observed: -Room A1= The bed had an uncomfortable lump in the middle, as reported by the resident, and she said when she was in bed it felt bunchy. The resident's tray table on her wheelchair was worn, rough around the edges and lopsided. During the environmental tour conducted on 1/28/16, the maintenance director said he would sand off the rough edges on the tray table to smooth them, and would provide a different mattress pad. -Room A3 = The toilet base was secured to a raised platform in the bathroom which was cracked with peeling plaster. There was dark rust-colored matter surrounding its base and it was an uncleanable surface. During the environmental tour conducted on 1/28/16, the maintenance director said he would strip the surface down and paint it again. -Room A4 = The toilet in the bathroom was sitting on an elevated platform that had the plaster and paint chipped away, with jagged edges around the base, and was not on a cleanable surface. During the environmental tour conducted on 1/28/16, the maintenance director said he would have one of his assistants address the issue. -Room A7 = There were bare hooks above bed B and numerous electronic cords scattered on the floor below the built-in shelves. The closet door had chipped paint that was approximately three inches in diameter and was unsightly. During the environmental tour, the maintenance director said his staff had not had a chance to tear down the bare hooks but they would get right on it. -Room A9 = The toilet was cracked at the base. During the environmental tour conducted on 1/28/16, the maintenance director said he would paint and sand the toilet base. -Outside of room A0 = The light fixture cover in the ceiling in the hallway was cracked in two places. During the environmental tour conducted on 1/28/16, the maintenance director said he would fix it. -Room A12 = Side B had dark scuffs on the wall. The resident said he needed new blankets that did not slide off the bed at night. His bed had a thin bed spread and a small fleece throw on it. During the environmental tour, the maintenance director said he would get different blankets for the resident and change the bed around to keep it from rubbing against the wall. -Room A14 = The bathroom wall had scuff marks on it. The toilet seat had a smear of dried brown substance on it. During the environmental tour, the maintenance director said he would have housekeeping staff address the issue. -A Hall Tub Room = Tile was cracked around the toilet base and was not a cleanable surface. The foam on the tub chair was chipped and wet and was not a cleanable surface. A resident had reported hot water was not hot enough for baths sometimes. During the environmental tour, the maintenance director said he replaced the foam chairs in the tubs once a year and he would order a new one. - A Hall = Near the rear emergency exit door, the air vent directly over the book shelf had a film of dirt over it and needed to be cleaned. -Room B16 = The toilet stand was cracked on the right side and there were black scratches on the wall opposite the toilet. The toilet pedestal had chipped paint around the base and was not a cleanable surface. There was chipped, peeling wallpaper near the sink and there was tape on the light above the head board. The wallpaper on the closet was flaking and peeling. During the environmental tour, the maintenance director said he would address the issue. -Room B17 = The wall nearest the door had a power strip hanging from a hook in the middle of the wall that had multiple cords plugged into it and was unsightly. -Room B18 = The lower portion of the wall in the bathroom had scuff marks on it and the bottom right side of the toilet had cracks. The wall next to the window and behind the bed had multiple empty nail holes in it. The handrail in the hallway outside of room B18 was splintered. -Room B19 = There were empty nail holes in the wall above the bed and the closet door had chipped paint. During the environmental tour, the maintenance director acknowledged the issue. -B Hall Tub Room = The toilet and toilet riser were loose and wobbly when first observed on 1/27/16 at 5:30 p.m. with licensed practical nurse (LPN) #1, and had a dried brown smear on the front. The LPN cleaned it off and confirmed that it was stool. During the environmental tour, the toilet remained unclean around the base and remained wobbly, allowing it to move side to side. During the environmental tour, the maintenance director tightened nuts at the base of toilet and said he would add another layer of caulk to make the toilet steady. C. Staff Interviews: On 1/28/15 at 9:00 a.m., the environmental tour was conducted with the maintenance/housekeeping director and nursing home administrator. They acknowledged the housekeeping and maintenance issues above and assured that the identified problems would be corrected.

Based on observations, record review and family, resident and staff interviews, the facility failed to ensure one (#35) of 15 residents who required extensive assistance with activities of daily living (ADLs) received such assistance, out of 28 total sample residents. Specifically, the facility failed to ensure resident #35 received adequate oral care. The findings include: A. Facility Policy On 1/28/16 at 2:28 p.m., the director of nurses (DON) provided the facility's policy and procedure titled Resident Oral Care, dated December 2015, which included in pertinent part: Care givers will provide and/or assist residents with oral hygiene. Procedure: 1) Oral care will be provided at a minimum of twice daily. 2) If resident is unable to provide oral care independently then care givers will assist with oral care. 3) Care givers will set up and/or perform oral care for residents requiring assist. B. Resident Failures Resident #35, age 91, was admitted to the facility on [DATE]. According to the face sheet, the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of eight of 15, which indicated she was moderately impaired. She had minimal difficulty hearing, impaired vision and clear speech. There were no [MEDICAL CONDITION] or [MEDICAL CONDITION] behavioral symptoms and no rejection of care coded. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Observations and Interview: On 1/25/16 at 1:33 p.m., resident #35 was observed lying in bed in her room. Her lower teeth had white food debris caked in between her teeth and needed to be brushed. On 1/26/16 at 1:05 p.m., resident #35 was observed lying in bed in her room. Her teeth had white food debris caked in between her lower teeth and she stated, They need to be cleaned. On 1/27/16 at 9:06 a.m., resident #35 was observed lying in bed in her room. White food debris was observed caked in between her teeth and needed to be brushed. The resident said the staff helped her brush her teeth earlier that morning, But not very good. They don't stay long enough to give you a good hand. She explained that she felt self-conscious when her teeth weren't clean and explained, I try to do them right and I don't always get them clean enough like I would like. She said the staff did not stay with her while she brushed her teeth; they left her alone and then came back to check on her later. On 1/28/16 at 11:00 a.m., resident #35 was observed sitting in her wheelchair at a table in the main dining room waiting for her noon meal to arrive. Her lower teeth had white food debris caked in between her teeth and they needed to be brushed. Family Interview: On 1/27/16 at 1:50 p.m., a family member of resident #35 was sitting in a chair at the resident's bedside talking with her and she confirmed that she visited the facility at least weekly. The visitor said that resident #35's teeth and oral care have always been very important to her, and explained that when she used to visit her at home prior to her admission to the facility, the resident made it a point to brush her teeth daily. The visitor confirmed that she had noticed at times in the past when she had visited that the resident's teeth needed to be cleaned and said that her oral care was lacking because she needs help with it and isn't strong enough to do it on her own. Record Review: The resident's care plan, dated 8/14/13 and last revised 1/25/16, identified the following problem, goal and approaches: -Alteration in ADLs related to general weakness, poor vision and dementia. -The goal was that (Resident #35) will achieve and maintain optimal physical, mental, and psychosocial functioning through review date. -The approaches included, (Resident #35) states that she would like to brush her own teeth and would ask for help when needed. However, she may forget or require some assistance so please check with her at least BID (twice daily) to see if she was able or requires some help . (Resident #35) requires one assist for ADL care at extensive to limited assistance . The current Physician Orders for January 2016 included the following orders: -Help resident brush teeth AM-PM, started 10/26/15. -Hydrogen peroxide 3% solution; May rinse mouth with 1:1 ratio of hydrogen peroxide and water PRN (as needed). Nurse to assist with ratio, started 7/9/14. The Hygiene, Bath and Skin Check Roster was reviewed from 11/1/15 through 1/28/16 and documented that oral care was provided to include the following: -Oral care was documented as provided zero times on the following dates: 11/7/15 and 11/14/15. -Oral care was documented as provided only one time on the following dates: 11/2, 11/4, 11/6, 11/12, 11/22, 11/23, 11/28, 11/29, 11/30, 12/11, 12/15, 12/19, 12/22, 12/24/15, 1/3/16, 1/8, 1/9, 1/10, 1/14, 1/19 and 1/23/16. There was no documentation that the resident ever refused oral care. Staff Interviews: On 1/26/16 at 5:06 p.m., certified nurse aide (CNA) #12 was interviewed and she confirmed that she had cared for resident #35 that day. The CNA said she did not brush the resident's teeth that day because, She was already up when I got here. She can do it herself. On 1/27/16 at 4:48 p.m., CNA #12 was interviewed again and she confirmed that she had cared for resident #35 again that day. The CNA explained that she had gotten the resident up for the day around 7:30 a.m. and said that she set her up for it this morning with her toothbrush and she is able to brush her own teeth. The CNA said she had never noticed debris in her teeth or that they needed to be brushed. On 1/28/16 at 12:22 p.m., the registered nurse (RN) #3 who was caring for resident #35 was interviewed and she confirmed that oral care should be done at least twice daily. She explained that resident #35 required set-up help and that she could provide effective oral care herself. She said she had not noticed that resident #35's teeth needed to be brushed. On 1/28/16 at 1:15 p.m., the DON was interviewed and she explained the facility's procedure for routine oral care which included staff offering to help a resident and determining if the resident wanted to brush their teeth in the morning before or after the meal. She confirmed that staff should offer to brush the resident's teeth at a minimum, twice a day. And PRN. She explained that the facility staff received education on how to perform proper oral care just last month. -The DON explained that resident #35's assistance with oral care fluctuates a little bit. She wants to do things herself and that can vary. She explained that if the resident wanted to do it independently, We need to set her up and watch her do it. And if she is not able to do it that day, provide cueing and assistance as needed.

Based on resident and staff interviews and record review, the facility failed to maintain or restore bladder function for one (#48) of four residents reviewed for continence decline of 28 sample residents. Findings included: Resident #48, age 75, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A. Resident Status According to the 10/1/15 admission minimum data set (MDS) assessment, the resident was continent of bladder. -According to the 12/21/15 quarterly MDS, the resident's continence status had declined 90 days later when she was assessed as occasionally incontinent of bladder, and no trial toileting program had been attempted. The resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 of 15. She required extensive two-plus person assistance with bed mobility, transfers and toilet use. She used a wheelchair for ambulation and had range of motion limitations to her extremities on one side. B. Care Plan The care plan dated 10/6/15 identified the resident was sometimes incontinent of urine with the goal for continence status to improve. Approaches included resident and family education about incontinence management; reassure that toileting needs would be met; encourage fluids throughout the day; provide incontinence products; assist with changing as needed; assist with toileting before and after activities and meals, before bedtime and as needed; incontinence started after recent [MEDICAL CONDITION]; the resident knew when she needed to go but sometimes had already started or could not hold it once she got the urge; assess ability to sense and communicate need for elimination; and urology appointment as needed. The care plan dated 10/6/15 for alteration in activities of daily living related to [MEDICAL CONDITION] left [MEDICAL CONDITION] noted the resident was frequently incontinent of urine with a history of urinary tract infections, and to assist with frequent toileting. C. Resident Interview The resident was interviewed on 1/26/16 at 10:30 a.m. Regarding assistance with toilet use; the resident said she had had incontinence accidents because staff were sometimes unable to assist her in time. She said they had one lift and they had to go way down to the end of the hall to retrieve it when she asked for assistance. If it was in use, she had to wait longer. When asked how she felt about this, the resident said, I don't like it. I hate wearing a diaper. During a second interview on 1/28/16 at 9 a.m., the resident said that incontinence was a concern for her as she had not been incontinent before her stroke and moving to the facility, there was only one Sara lift and she had to wait for it, and she needed to go right then when she rang the call light. D. Record Review Review of the resident's January 2016 Medication Administration Record [REDACTED]. These medications have potential side effects including urinary frequency and incontinence, according to Hodgson and Kizior, Saunders Nursing Drug Handbook 2014, Elsevier Saunders, St. Louis, Missouri, 2014. The resident's Evaluation for Bowel and Bladder Training assessment dated [DATE] noted she was continent of bladder. A follow-up evaluation dated 1/26/16 read in part, Notifies staff of toileting needs . Continent of B&B (bowel and bladder) with occasional urinary stress incontinence. -There was no evidence of a voiding assessment to determine patterns and develop a schedule to meet the resident's toilet use needs. physician progress notes [REDACTED]. Nursing notes, reviewed from 9/25/15 through 1/28/16, documented in pertinent part as follows: -On 12/22/15, Mechanical lift and 2 assist for all transfers . She is frequently incontinent of bladder . -On 12/24/15, She is often incontinent of bladder, usually continent of bowel, wears briefs . -On 11/24/15, States that she doesn't want to drink much because then she 'has to pee all the time' . usually continent of B/B with occasional urinary stress incontinence. Becomes upset when she dribbles and is wet. -On 11/23/15, Does not like to drink too much water, she states she 'has to pee all the time.' (Resident) wears a brief, but never wants to have to void in it. She is a two person assist w/ mechanical lift . -Nurses' notes alternately documented the resident was continent, incontinent, usually continent, frequently incontinent, and occasionally incontinent. The resident's Void Roster, reviewed 11/1/15 through 1/28/16, revealed the resident was incontinent of urine on this shift at least once on the following dates: 11/1, 11/2, 11/3, 11/4, 11/5, 11/6, 11/7, 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/19, 11/20, 11/22, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/14, 12/16, 12/17, 12/18, 12/20, 12/21, 12/22, 12/23, 12/24, 12/27, 12/28, 12/29, 12/30, 12/31/15, 1/1/16, 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, 1/9, 1/11, 1/12, 1/13, 1/17, 1/18, 1/20, 1/21, 1/25, 1/26, and 1/27/16. -The resident had days where no incontinence was documented, which was also reflected in nursing notes above. However, there was no evidence in the resident's medical record of a urology referral, or a thorough assessment of the resident's incontinence and methods to help her maintain continence. (See care plan approaches above.) E. Staff Interviews Certified nurse aide (CNA) #12 was interviewed on 1/27/16 at 11:05 a.m. She said they took residents to the toilet before and after meals, and for some, more often as needed. CNA #6 was interviewed on 1/28/16 at 11 a.m. Regarding resident #48, she said, I just know that when she rings (her call bell), somebody's addressing her within a minute. Everybody tries to fill in answering the lights, filling in the need and communicating. We don't like to see anybody wait for anything. If the girls can assist, they assist. CNA #3 was interviewed on 1/28/16 at 11:15 a.m. Regarding resident #48 and going to the toilet, she said, Usually in the mornings she'll ring and that's the first thing she wants, to go to the toilet. She's continent so we'll get her up and get her to the toilet. She'll let us know when she needs to go to the bathroom. If a lot of time has lapsed we'll be asking her 'do you need to go to the bathroom?' Sometimes we have to wait a little bit because someone is on the lift . -The CNA said yes, she had known the resident to be incontinent while waiting for the lift. Not very often, probably two or three times in the past month. Sometimes it's because she calls at the last minute, has to go right away and the urgency crept up on her. CNA #2 was interviewed on 1/28/16 at 11:30 a.m. Regarding toileting, I check in with her and see if she's restless. I suggest taking her to the bathroom before she gets in a recliner. Sometimes she'll say she didn't even know she had to go. When she calls we're able to get her to the toilet in time. I kind of know peoples' patterns and pay attention to detail. It staggers right if you have a good game plan. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 1/28/16 at 9:30 a.m. They were asked about the resident's decline in continence status, and for a follow-up assessment on when the resident's decline began. They said they would look into it. The DON was interviewed a second time regarding the incontinence issue on 1/28/16 at 1:45 p.m. She provided the bowel and bladder evaluation (see above, dated1/26/16). The DON acknowledged incontinence was an area for improvement that would be a QA project initiated in February. She said the resident's stroke was a factor and acknowledged she might be appropriate for bladder retraining. During a third interview on 1/28/16 at 2:35 p.m., the DON said there was no current facility policy for incontinence and bladder retraining, and that it was in the process of being developed. The facility failed to assess and implement interventions in a timely manner for the resident's decline in urinary continence status.

Based on facility observations and staff interviews, the facility failed to ensure that the resident environment remained free of potential accident hazards for four of 25 sample residents (#31, #20, #1 and #56), including: -ensuring residents were safe from falls with injuries, -ensuring critical care equipment was safe and well-maintained for residents. Resident #31 sustained three falls, the third fall resulted in a pelvic fracture. Resident #20 sustained three falls, the third fall resulted in a painful, swollen wrist. Resident #1 sustained eight falls with skin tears, lacerations, cuts, and bruising. The findings include: A. Policy and Procedures Related to Falls and Prevention The facility policy regarding the "Fall of a Resident" read, in pertinent part: "When a resident has a fall that is unwitnessed, or witnessed and hits their head then neuro's (neurological assessment) will be initiated and documented for 72 hours". Procedures to be followed per the policy included: 1. Not move the resident until assessed by a nurse. 2. If there are no injuries, resident may be transferred to bed or wheelchair. If the nurse determines there is an injury, the resident will only be transferred to bed or gurney and the physician needs to be notified immediately. 3. Following an unwitnessed fall or witnessed fall when a resident hits their head the nursing staff will initiate neuro's. 4. Staff will inform medical power of attorney. 5. Nursing will fill out occurrence report. 6. Nursing will notify physician by fax. 7. Nursing will make a nurses note of the fall and document that medical power of attorney and physician have been notified. 8. When the occurrence report is completed the report and a copy of the nurses note will be placed in the DON's mailbox. 9. Nurses will initiate the Neurological Assessment Flow Sheet to monitor the resident. 10. Vital signs are to be done for 72 hours: Every 15 minutes times 1 hour; every 30 minutes times 2 hours; every 1 hour times 4 hours; and every 8 hours to a finishing total of 72 hours." The facility policy regarding "Fall Prevention" read in pertinent part, the policy was to "actively plan for and provide measures to promote independence and compensate, resolve, and or lessen self care deficits in order to accomplish both rehabilitative and restorative care goals." -It stated that "All residents must be evaluated and monitored regarding their potential fall risk. A fall risk assessment will be completed on admission and quarterly thereafter." -Procedures to be followed per the policy included: 1. All incidents or accidents will be reported immediately and an occurrence report will be completed in accordance with state and federal regulations. 2. All problems, needs, and or concerns regarding falls and fall prevention must be brought to the attention of restorative care nursing, the DON, and or the facility administrator. 3. Residents with an increase risk of falls are identified by nursing and/or during the care planning process. 4. If the resident could benefit from physical or occupational therapy, an order for [REDACTED]. Other fall preventions may be initiated as indicated. 5. Fall prevention will be implemented by nursing services. All necessary information will be recorded in the resident's medical record. Instructions regarding the individual fall prevention device will be in the resident's care plan. 6. If a resident refuses to participate in a program, the refusal and/or reason must be documented. The restorative CNA, a charge nurse, and the DON must be notified. 7. The DON, the administrator and the medical director review occurrence reports. 8. All incidents must be reported to the resident's physician and family/responsible party. 9. Devices that may be used to help prevent falls and lessen the severity of a possible fall are tabs or pressure alarms, fall mats, low beds, specialty mattresses and lap belts. Consents must be obtained by both the responsible party and the physician. B. Resident Failures 1. Resident #31 Resident #31, age 91, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #31 was recorded on the Minimum Data Set (MDS) on 6/11/12 as being coded with a BIM score of 13 out of 15, according to facility review. A note in the 4/13/12 hospital history and physical report prior to admission to the facility, indicated that the resident had "end stage arthritis to her knees . . .presents after sliding off her bed. Gotten progressively weak and is requiring more and more help and at this point, she is unable to return home." Review of the July 2012 Treatment Administration Record (TAR) revealed that the resident was documented on 4/16/12 as a "1 person assist with fww (front wheel walker) for transfers." a. Fall 4/19/12 Nurse notes revealed that the resident sustained [REDACTED]. Record review revealed a physician order [REDACTED]. No changes to care were documented or added to the resident care plan. Record review revealed the resident was sent to the emergency room (ER) on 5/2/12 due to a status change. The resident returned from the hospital with a [DIAGNOSES REDACTED]." The physician prescribed an order of Lorazepam .5 mg to be given 3 times daily as needed on 5/3/12. According to Mosby's 2012 Nursing Drug Reference, page 397, potential side effects of benzodiazepine include dizziness, drowsiness, and confusion, as well as orthostatic hypotension. b. Fall 5/6/12 Record review revealed a fax sent to the physician on 5/6/12, that stated that a Certified Nurse Aide (CNA) witnessed the resident slipping out of her wheelchair onto the floor. Resident was reaching for an object on the floor. No apparent injuries, denies pain. A physician progress notes [REDACTED]. "She has increased pain in the joints with any ambulation or weight bearing." A physician order [REDACTED]. The physician order [REDACTED]. c. Fall 6/30/12 Nurses' notes indicated resident #31 fell on [DATE] at 4:05 a.m. The nurse notes documented a CNA heard a noise in the resident's room, found resident #31 just inside doorway on floor on her left side. Walker tipped over. Resident alert, reports she thought she could make it to the bathroom. States pain in left hip, can move it herself without complaining of pain. No facial grimacing with movement of leg by nurse, legs equal in length. Zero outward rotation. Assisted to standing position, weight bearing without pain, per wheelchair taken to bathroom, voided. Assisted to bed. The following nurse note at 5:00 a.m. stated the resident was medicated for left hip pain (pain level) "8." (indicative of severe pain) Record review of the Incident/Accident report revealed that "cna walking in hall, heard a noise in (resident's) room, found res (resident) just inside doorway on floor on left side. Walker tipped over. Res (resident) alert, reports she thought she could make it to the bathroom. States pain in left hip, can move it herself without complaining of pain. No facial grimacing with movement. Bil (bilateral) legs same length. Able to assume standing position without complaining of pain. Remind resident to use call light to call for assistance." The physician was notified by fax at 4:30 a.m. and the family was called at 6:20 a.m. A physician order [REDACTED]. "Ok to send per 911." -Record review of the hospital visit on 6/30/12 detailed that the resident had a pelvic fracture, determined by an evaluation. -A fax was sent to the physician on 6/30/12 at 11:00 a.m., after the 6/30/12 4:05 a.m. fall. The fax stated that the resident returned from the hospital with her daughter and the [DIAGNOSES REDACTED]." d. Facility Failures Fall Risk Assessments: Record review revealed that a fall risk assessment was completed upon admission for resident #31 on 4/16/12. The initial fall assessment determined the resident was at High Risk for falls. -There were no additional assessments after the 4/19/12 fall, 5/6/12 fall or the 6/30/12 fall with fracture, evaluating the resident's risk factors and interventions to address them. -There was no assessment that acknowledged the addition of benzodiazepine use following the ER visit on 5/2/12, when Ativan was added for muscle spasms as needed 3 times daily and then Valium 2.5 mg given twice daily on 5/14/12. Occurrence Report: Review of the facility occurrence report signed by the Director of Nursing (DON), Nursing Home Administrator (NHA), and Social Service Director (SSD) revealed it did not indicate when the 6/30/12 fall was investigated. The injury was documented as "left hip pain." Further review of the report revealed a witness statement. It read the aide was walking by the resident's room, heard a noise, and found the resident lying on the floor on her left side just inside the doorway. Her walker was tipped over. Resident stated that she thought that she could make it to the bathroom by herself. The report included the following "Corrective action taken" - verbally reminded to call and wait assistance for transfers and ambulation. Continue with tab alarm. Additional comments read: Transferred to hospital to evaluate left hip pain. X-ray showed pelvic fracture. Per MD it is inoperable. Pain management and pt/ot (physical and occupational therapy) ordered. The report concluded: Fall occurred because resident attempted to transfer herself and ambulate without assistance. There was no indication that the Medical Director had reviewed the occurrence report (see facility policy above) Care Plan: The resident was care planned on 4/20/12, for being a high fall risk. Approaches developed for this resident included to assist with activities of daily living (ADL) as needed, have call bell within reach at all times and encourage her to use, educate importance of shoes on or nonskid socks on for transfers and for ambulation, assist with providing comfort and meeting all needs before leaving the room, pt (physical therapy) and ot (occupational therapy) as ordered, and to also tab/pressure alarm at all times. -There was indication of the resident having a fall on 4/19/12, 5/6/12 or 6/30/12 on the care plan. -There was no indication the above approaches were re-evaluated to ensure they were effective and new approaches considered. -There was no reference to the resident's use of benzodiazepines, following the 5/2/12 ER visit. The resident was care planned on 4/20/12, for complications related to osteoporosis and to monitor for possible fracture. -This plan was not updated following falls on 4/19/12 and 5/6/12 and fall with fracture 6/30/12. There was no care planning in relationship to the resident's benzodiazepine prescription needs following an ER visit related to muscle spasms. f. Interviews An interview with resident #31 on 7/17/12 at 3:00 p.m., confirmed that she was currently in rehab and they were doing a very good job with her pain medicine. The resident stated that two CNAs help whenever she needs to get up to use the bathroom or get ready for something. She stated she didn't need surgery and was planning on returning home soon because therapy was so good. An interview on 7/19/12 at 9:12 a.m., with the Director of Nursing (DON) revealed the facility had completed a fall investigation related to the fall and injury of resident #31. The DON stated that the facility staff talked as a team about the fall and then the DON wrote up the investigation. As the investigation report was undated, the DON agreed there was no way to validate that the facility had promptly investigated the resident's fall and injury in order to prevent further accidents. The DON confirmed that this was the normal protocol to investigate a concern. No other additional investigation information was available for review. An interview with the DON on 7/19/12 at 11:06 a.m., was conducted in order to determine the process and investigations the facility used in relationship to falls/accidents. -The DON stated that if there has been a resident fall, then "nurses will make a note on the 24 hour report and fill out an incident report and put it in my (DON's) box." The DON stated that the incident reports are reviewed prior to the facility morning stand ups, when all the disciplines are present. -According to the DON, "We will discuss details and reasons for the fall. If we need labs and so forth, we decide that then. We will discuss devices too. We try to determine if devices are needed and pros and cons before ordering and then notify the doctor." -The DON stated that if interviews need to be completed, then the DON or the Social Service Director will do the interviews. Also, fall charting, neurological checks if needed, and behaviors are monitored to determine if they contributed to the fall or happening after the fall. -The DON stated that in order to determine if anything put in place has been effective, "we do (it) by just observing and during care plan meetings. We just look to see if (the interventions)'s working. I keep a fall log that the Medical Director is given and we look for tracking and trending." The DON stated that they review the medicines after a fall, to see if there were benzodiazepines given or if they were tried. -The DON was asked if any of these observations or follow-up investigations were documented. The DON said, "No. I am hoping to get the nurses more involved. I just in-serviced my nurses that this is the information that we do need and it will include medicine review and how to better prevent falls again. It will be lengthier. We re-review the resident's condition and status just in morning meetings. We don't keep notes in morning meetings." -The DON stated that the staff member that handles the MDS does attend the meetings, and they would add current injuries or falls to the care plans. An interview with a CNA on 7/19/12 at 11:28 a.m., revealed that resident #31 fluctuates with her hip, and that the resident had been on therapy originally, but then went onto restorative care. After the recent fall, the resident was now back on therapy, but that the resident's needs go up and down. An interview with a Registered Nurse (RN) on 7/19/12 at 11:33 a.m., revealed that the staff member wasn't present during the fall, but before the resident's pelvic fracture the resident was often noncompliant and "would often try to transfer herself." The RN stated that since the fall, the resident had been very good about letting staff know when she needed assistance. (See care plan above; there was no reference to the resident's self-transfers and non-compliance, no plan to increase supervision to ensure the resident received assistance with transfers to meet her needs, and no additional information provided related to the resident's [DIAGNOSES REDACTED]. An interview with a CNA on 7/19/12 at 11:45 a.m., confirmed that when resident #31 was admitted to the facility originally, she would try to "transfer herself." According to the CNA, the resident had been improving and using a walker. "But since the fall, we are sure to have the bed alarm, and we encourage her to have the call button and use it." According to the CNA, the resident hadn't attempted to self transfer since the fall and was more accepting of getting help to get up. The resident was too afraid to fall. An interview with a Physical Therapist (PT) on 7/19/12 at 12:30 p.m., revealed that the resident was weak and unable to care for herself when she was admitted to the facility. -The PT said, "The therapy department picked her up and improved her independence and activity of daily living (ADL) levels to where she was almost independent." The PT stated that one of the main concerns remaining had been her safety awareness and that they had finally got to a point where the resident wasn't progressing so she was put on restorative. -The PT said the resident had been on a fall alarm since she was admitted . The PT also confirmed that the "resident had anxiety issues that seemed to come out in random tremors that effected her independence. She was sent to the hospital for her tremors and was put on Valium which made a big difference. She came back and was on restorative." -The PT stated that when the resident came back from the hospital, the physician put the resident on Ativan, which did not help the resident's tremors "nearly as well." The PT stated that they finally got the resident back on Valium on 5/14/12, and it helped with the tremors a lot. -The PT confirmed that the resident fell recently and had broken her pelvis, and is now being seen with therapy again. The PT stated that the alarms were still in place for falls, but the resident was now not willing to do anything risky. 2. Resident #20 Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented in part, that resident #20 had BIMS (brief interview of mental status) score of 8, indicating moderately impaired, required extensive assistance of one person with bed mobility, dressing, toilet use, total assist with personal hygiene, and transfers only occurred once or twice (was in bed most of the time). Resident #20 had a fall within the past 90 days, was at risk for developing pressure ulcer, pressure reducing device for the bed, and was receiving hospice care. The facility Evaluation for Bowel and Bladder Training, dated 2/20/12, documented in part: Resident had been informed of risks and chooses not to participate in program The care plan dated 3/1/12 documented: -Problem-Resident is at risk for falls. -Goal-Resident will have no falls through review date; resident will maintain optimal activity level as permitted by disease process. -Approaches-Have the call bell within reach at all times and encourage her to use it, assist with meeting all needs and have items of comfort within reach, shoes on or non-skid socks for transfers. Added on 4/3/12 - tab/pressure alarm and on 4/10/12 - provide education on fall prevention, safety precautions. The facility Fall Risk Assessment, last dated 4/18/12, revealed resident #20 scored 17; a score of 10 or above represented high risk. a. Record Review Falls/Fall Risk and Facility Response: -On 3/29/12, nurses' notes documented the resident found on floor at 1:00 a.m., resident expressed she had dropped her dentures and was reaching for them and fell out of bed. Record review documented in part, on 3/29/12, the corrective action related to the fall was tab/pressure alarm ordered (and placed). -On 4/3/12, the resident found sitting on edge of bed, said she needed to go to the bathroom - encouraged resident to call for assistance. -On 4/4/12 at 2:00 a.m., the tab/pressure alarm sounded two times due to resident attempting to sit up on edge of bed, incontinence of bowel and bladder. -On 4/24/12, the facility investigation report at 11:15 p.m., in part read: Resident was found on the floor next to her bed. Record review documented, in part, the corrective action related to the fall 4/24/12, was that the resident was encouraged to call and wait for assistance to transfer or use the bathroom, she requires ongoing verbal reminders for safety, resident expressed she had bowel movement and was trying to clean herself. -On 5/23/12 at 6:45 a.m., resident found sitting on floor in front of wheelchair in her room, resident said she was trying to walk to her wheelchair. Record review documented after the 5/23/12 fall, the corrective action taken was to remind the resident to use her call light and wait for assistance, resident to have frequent visual checks and verbal reminders to use call light, bed kept in lowest position. -On 6/18/12, a physician notification (per FAX ) read resident #20 had left wrist swollen, red, warm to touch, painful, and resident unable to move it. On 6/18/12, an X-ray report documented in part: Along the posterior margin of the radius is a relative acute angle of the cortex, with associated posterior tilt of the articular surface. Although a discrete fracture line or cortical disruption is not identified, this could represent a nondisplaced compression type fracture of the distal radius. No other acute bone abnormalities are evident. However there are extensive degenerative changes. Possible nondisplaced compression type fracture of the distal radius. An acute fracture line is not evident, and this may represent a remote injury. On 6/19/12 FAX documented, OT (occupation therapy) evaluation and treatment of [REDACTED]. b. Observations - Failure to Implement Safety Interventions On the evening of 7/16/12, resident #20 was observed in bed, her bed was not as low to the floor as it could have been, there was not a fall mat next to the bed and resident #20 was living in a room that was at the end of the hallway furthest away from the nurses' station. On the morning of 7/19/12, resident #20 was again observed in her bed and the bed was not in the lowest to the floor position. c. Interviews On the morning of 7/19/12, the DON was interviewed about the facility practice after a resident had a fall. The DON said all falls are discussed each morning in the morning meeting and interventions were discussed at that time. She said falls were also discussed in the resident's IDT (interdisciplinary team) meeting. On 7/19/12 at 9:12 a.m., the DON stated: "For the broken wrist I know we had hospice help with the investigation and I know it's on their care plan (hospice)." -The DON was asked what was put in place for Resident #20 and the DON stated "she had a tab alarm. We try to keep her bed to the lowest height. We try to keep it low. We try to encourage, but when they're awake and alert we can't force it. The resident didn't know how it happened and didn't think she fell or rolled. I, the Social Service Director, and the hospice nurse all spoke to her and she told us all the same thing. We couldn't determine that the break was related to a fall." On the evening of 7/19/12, a CNA familiar with resident #20 was interviewed. She said the resident was incontinent, needed assistance with all her daily care, and was checked on every two hours or more and the resident could use her call bell and make her needs known. 3. Resident #1 Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) According to her 6/6/12 MDS, the resident was unable to complete the cognitive status interview, and was noted to have moderate cognitive impairment. No delirium or behavioral symptoms were noted on the MDS. She was totally dependent for activities of daily living, used a wheelchair for ambulation, was incontinent of bladder, and continent of bowel. She had two or more falls since the prior review, and one fall with injury. Fall Risk Assessment On her most recent assessment, dated 5/14/12, the resident scored high risk at 15, due to: cognitive status (disoriented x 3 at all times), history of falls (three or more in the past three months), chair bound and needing assist with elimination, requiring use of assistive device for ambulation, medications (benzodiazepines, hypoglycemic, narcotics, psychotropics), and predisposing diseases (arthritis and fractures). Care Plan The resident's care plan, revised on 6/13/12, identified risk for falls, with falls noted as follows: 10/9/11 - rolled WD (acronym unknown) 10/26/11 - attempted to self transfer - fell 11/11/11 - fell OOB (out of bed) 1/14/12 - fell OOB Interventions were noted on the care plan as follows: "5/15/12 monitor by therapy for proper body alignment w/ w/c (with wheelchair), positioning prn (as needed); 5/24/12 scoop mattress." Other interventions were: "Assist for ADLs (activities of daily living), water near bedside w/in easy reach, keep environment safe, shoes on for transfers, w/c for mobility, tab alarm/pressure alarm, snacks between meals, low bed w/ fall mats, dentures & glasses (won't wear her glasses)." -No more recent falls were documented on the care plan, although the resident had fallen and suffered injuries several times since 1/14/12, her most recent fall with injury occurring on 7/6/12 (see below). -There were no interventions to provide monitoring and supervision, assistance to the toilet, or anticipation of needs to prevent future falls. -There were also no interventions noting the resident had fragile skin, and had suffered injuries during care provision, or for staff to monitor resident safety during care to prevent further injury (see notes on skin tear injuries below). Falls and Accidents suffered by resident #1: Review of nurses' notes and facility investigative reports revealed the resident suffered eight falls and/or injuries within the past three months. Specifically: - On 7/6/12 at 6:15 a.m., the resident was found lying on her left side, face down, with a 1/2 cm cut on her left eyebrow. A nurse noted, "Res fell out of w/c onto floor in front of hallway. Res appears to have bumped head on door frame. Call to on call (physician) placed. Bruise noted on back of R (right) hand and bruise noted to L (left) wrist, VSS (vital signs stable) 156/85, 85, 20, 93% on 2L (liters of oxygen), neuros ROM (range of motion) WNL (within normal limits) for res, no c/o (complaint of) pain. Area above L eye tender, soft & bruised. (Called dr - got orders to monitor and send to ER if pain got out of control.) Res up at ns (nurses') station." No investigation report or post-fall review was provided. - On 5/21/12 at 2:45 a.m., per nurses' notes, "Tab alarm sounding, CNAs (certified nurse aides) found res lying on L side on top of fall mat, on floor. Forehead pressed up against dresser, bleeding from wound to forehead between eyes. Res had approx 1 cm laceration between eyes, cleansed w/ wound wash, dried, steri strips placed, L arm lateral-medial w/ appx 5 cm x 5 cm dk purple hematoma, area below R eye w/ 2 cm long purple bruise. Res taken to ns station - R pupil nonreactive, L pupil sluggish - neuro checks resolved wnl by 5/22, loc (level of consciousness) normal, dr and POA notified." According to the investigative report, it was believed the resident either rolled out of bed or attempted to transfer without assistance. A lipped mattress was placed on her bed for greater safety awareness of the edge of the bed, and "placement of tab alarm will continue to alert staff of attempts to get out of bed without assistance." - On 5/14/12 at 2 p.m., according to nurses' notes, "Res suffered 10 cm skin tear when bath aide removed adhesive dressing to L outer shin." According to the investigative report, "Allevyn not to be used for minor skin issues . . . Instructed aide to use caution when removing dressings for baths and showers. If dressing does not come off easily, aide is to notify charge nurse or DON (director of nursing). Wound care guidelines reviewed with nurses to ensure that appropriate dressing and treatment used." The investigative report did not include evidence of training that dressing removal should be done by nurses, and was outside the scope of practice for CNAs. These items were not added to the resident's injury prevention care plan. - On 5/11/12 at 5:30 a.m., "Res alarm sounded, staff found res laying on her L side on the dining room floor, res assessed, said 'I hurt all over.'" According to the investigative report, the resident was in the front dining room, and was witnessed falling out of her wheelchair and landing on her left side. The conclusion was, "No changes to care at this time. Activities to provide activities of interest for resident such as folding clothes, water table, her doll, etc. Nursing to continue to keep resident in line of vision while up in w/c to monitor safety." These interventions were not added to the resident's fall prevention care plan. - On 5/8/12 at 5:20 p.m., "Res seen leaning forward in w/c to reach for a towel on the floor. Res slid out of w/c onto butt - witnessed by another nurse. ROM WNL, neuros WNL, VSS - no injuries noted." According to the investigative report, the resident was in the hallway when the fall occurred. Her tab alarm was "disconnected from clothing but did not alarm." The same interventions as listed on the 5/11/12 fall (above) were noted, but not added to the care plan. - 5/7/12 at 4 p.m., "After bath res noted to have open area on posterior calf R area cleaned & dressed - FYI sent to dr & POA." The investigative report noted the "1-1/4 cm round open area behind R calf" was observed "after a bath" when the "aide called DON to bathroom and area assessed . . . Resident wears protective leg coverings when up in w/c to protect shins as she propels self throughout the facility. Protectors are soft and without any sharp, hard seams along shin. No bruising noted to immediate area nor surrounding area. Continue w/ treatment and protective lower leg coverings." These interventions were not added to the care plan, and there was no evidence of monitoring or staff training to ensure the injury was not sustained in the shower, and/or to prevent further injuries in the shower. - 5/7/12 at 6:45 a.m., "Res sitting in w/c leaned forward to pick up item off floor and fell , causing 3" laceration to L forearm area, was steri stripped & telfa placed." According to the investigative report, the resident was in the front dining room, and was observed "leaning forward to pick up an item from the floor and slide form the w/c to floor . . . Resident to be kept within vision of nurses and aides when up in w/c . . . Ongoing frequent visual checks." This information was not added to the resident's care plan. - 4/16/12 at 4:15 a.m., "Found sitting on fall mat next to low bed - no visible injuries - res states she was trying to get up & walk." The investigative report noted the tab alarm was not sounding at the time of the incident, that aides were reminded to "be sure that ordered alarms are put in place. Nurses to monitor placement/functioning of alarms Q (every) shift. Continue with tab alarm and visual checks during rounds." Monitoring of alarm placement/functioning was not included in the resident's care plan. Observations: On the afternoon of 7/16/12, resident #1 was observed in bed sleeping, facing the wall, On 7/17/12 at 3:15 p.m., the resident was observed to have a scabbed laceration on her left eyebrow, and fading yellowish-green bruising around her left eye and on her left cheek. She was sitting at a table in the dining room, participating in an individual tactile sensory activity. At 3:43 p.m., the resident was talking with a staff person while engaged in her tactile activity. On 7/18/12 at 9:00 a.m. and 10:00 a.m., the resident was observed sitting up in her wheelchair watching TV with two other residents. At 11:00 a.m., the resident was in her room behind a closed privacy curtain. At 12 noon and 1:30 p.m., she was observed sleeping in her bed with her privacy curtain drawn, lying on her right side facing toward the wall. Staff Interviews: Three of the resident's CNAs were interviewed on the afternoon of 7/17/12. Regarding her falls, they made the following comments: - I was off when she fell - she had the bruises on her face when I got back. She has fall mats, pressure alarm in bed and wheelchair, we keep her bed low, and if she's doing this where she leans forward, activities has things to manipulate and keep her active, laundry she can fold, and that seems to help too. She had just the one fall that I'm aware of - when we came back she had all those bruises. She likes balloon volleyball, walks, she can get agitated sometimes. We have to be right