Every finding on record at Heritage Park Care Center

Based on observation, record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for weight loss out of 28 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. Resident #24 was admitted on [DATE] with a diagnosis of Alzheimer's disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. On 7/16/24 the resident weighed 197 pounds (lbs) and on 8/29/24 the resident weighed 185 lbs. The resident lost 5.1% (10 lbs) of her body weight in 29 days. While nutritional interventions were initiated when a significant weight loss was identified on 7/12/24 (2 cal MedPass supplement), observations revealed the facility failed to promote the resident's nutritional status by encouraging, and providing meals and snacks, documenting her intake of meals accurately and monitoring weekly weights. Findings include: I. Facility policy and procedure The Weight policy, reviewed on 8/19/24 was provided by regional director of clinical services (RDCS) #2 on 8/29/24 at 2:35 p.m. It revealed in pertinent part, Following a routine weighing schedule helps detect weight changes. Unless otherwise specified, a resident's weight should be recorded at the time of admission, weekly for four weeks, and then monthly. A decrease in weight of 5% or more in a month or of more than 10% in 6 (six) months should be reported to the practitioner for further evaluation. II. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dysphagia, prediabetes and chronic kidney disease stage 3. According to the 8/5/24 minimum data set (MDS) assessment, the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. Resident #24 was independent with eating. She required partial/moderate assistance with oral hygiene and was dependent on staff for all other activities of daily living (ADL). The MDS assessment indicated the resident was prescribed a mechanically altered diet. The assessment indicated the resident did not have weight loss. B. Observations and staff interviews On 8/26/24 at approximately 12:15 p.m., the resident received her meal, which consisted of salisbury steak, mixed vegetables, sweet potatoes and cake. The resident consumed less than 25% of her meal, although an unidentified certified nurse aide (CNA) was assisting her. She was not offered an alternative when she ate less than 50% of the meal. The resident was administered the 2 cal MedPASS with the meal. -A review of the meal intake for 8/26/24 documented that she consumed 50%, however, the observation above revealed the resident consumed less than 25% of her meal. During a continuous observation of the dinner meal on 8/27/24, beginning at 3:00 p.m. and ending at 5:53 p.m., the following was observed: At 3:00 p.m. the resident was lying in bed with her eyes closed. At 5:08 p.m. the resident was lying in bed. The dinner meal service had begun. Residents who were eating in the dining room and in their rooms were receiving their meals. At 5:15 p.m. the resident continued lying in her bed. She had not been offered her dinner. She had not been offered to get up to go to the dining room. At 5:30 p.m. the resident continued to lie in bed. The staff had not offered a meal to her. At 5:45 p.m. the staff began to pick up meal trays from residents who were finished eating. There were no meal trays being passed to residents. At 5:53 p.m. the registered dietitian (RD) said the resident did not get a dinner meal, because it was discussed with the resident's family and she would not eat a dinner meal because she would rather sleep. She said that was the reason the resident did not get served a dinner meal. The RD said a snack was given to the resident at 3:00 p.m. She said it was a part of the resident's comprehensive care plan. -However, a continuous observation revealed that at 3:00 p.m., Resident #24 was lying in her bed with her eyes closed and no staff entered her room to offer her a snack from 3:00 p.m. until the continuous observation ended at 5:53 p.m. During a continuous observation on 8/28/24, beginning at 8:46 a.m. and ending at 12:26 p.m., the following was observed: At 8:46 a.m. the resident was assisted away from the dining room table. CNA #1 had assisted the resident with her meal. The resident consumed all of the scrambled eggs. She did not eat the oatmeal, ground sausage or the potatoes. At 8:55 a.m. the resident was sitting in her chair in her room. The resident was given a cookie and also a cup of hot cocoa. The resident ate all of the cookie and the hot cocoa. At 9:19 a.m. the environmental services director (ESD) was in the resident's room fixing the resident's television. The resident asked for something to eat. The ESD asked her if she wanted something to eat, and the resident responded yes, when you get a chance. -The ESD did not bring the resident anything to eat. At 9:23 a.m. the resident asked for a sandwich and she said she was hungry, CNA #4 said she had given her a cookie and a cup of hot chocolate a little bit ago. The resident said she was still hungry. CNA #4 said she would bring her some fruit. At 9:49 a.m. the resident was sleeping in her chair. -CNA #4 did not get the resident anything to eat. At 9:51 a.m. the resident continued to stay in her room. -She had not received anything else to eat as CNA #4 had said she would. At 11:05 a.m. CNA #4 asked the resident to go to trivia. -CNA #4 did not offer the resident a snack or provide the snack which the resident had requested nearly two hours earlier. At the activity, the resident did not receive any snacks. At approximately 12:01 p.m. the resident received her meal. CNA #5 assisted the resident with the meal. At approximately 12:10 p.m. the resident began to feed herself. At 12:26 p.m. the resident was assisted from the dining room to her room. The resident ate less than 25% of her meal and 25% of her Magic Cup (nutritional dessert cup). C. Resident's representative interview The resident's representative was interviewed on 8/29/24 at 11:30 a.m. The resident's representative said she was not aware that the resident had lost weight. She said she had requested the resident to eat in the dining room at each meal, as she ate better when she was upright and at a table. The resident's representative said she did not agree to the resident skipping the dinner meal. D. Record Review The nutrition care plan, updated on 3/18/24, revealed the resident was at risk for malnutrition related to dementia and limited mobility as evidenced by the medical record, preference of MM5 (diet minced and moist) texture and preferences to sleep through dinner nightly. Pertinent interventions included cueing and orienting the resident to food, offering her a few bites of complete assistance and then she was able to continue eating independently, offering snacks and fluids at activities and hours of sleep, observing and reporting signs of malnutrition and offering healthier options when offering snacks. The August 2024 CPO revealed the resident had the following physician's orders related to nutrition: 2 cal MedPass (nutritional supplement) 120 milliliters (ml) two times a day, ordered 7/12/24 with the associated diagnosis of weight loss, ordered 7/12/24. Snack at bedtime, ordered 11/8/21. A review of the August 2024 (8/1/24 to 8/29/24) medication administration record (MAR) revealed the resident was consuming 100% of the 2 cal MedPass two times a day. -A review of the August 2024 MAR revealed a bedtime snack was consumed zero times from 8/1/24 to 8/29/24. Resident #24's weights were documented in the resident's electronic medical record (EMR) as follows: -On 5/1/24, the resident weighed 200 lbs; -On 6/12/24, the resident weighed 198 lbs; -On 7/16/24, the resident weighed 197 lbs; -On 8/7/24, the resident weighed 184 lbs; -On 8/15/24, the resident weighed 187 lbs; and, -On 8/29/24, the resident weighed 185 lbs. -The resident lost 10 lbs (5.08%) from 7/16/24 to 8/15/24, in 29 days, which was considered severe. The 7/12/24 nutrition note revealed the resident was discussed in a resident at risk (RAR) meeting. The resident's intake was poor and she refused food. She had a significant weight loss of 9.8% since 6/12/24. The committee recommended weekly weights, one to one feeding assistance as accepted and a trial for med pass (nutritional supplement) twice a day. The note documented the resident liked hot chocolate. The 8/16/24 nutrition note revealed the resident was reviewed in RAR. The resident had a 5% change in her weight over 30 days. The team recommended a Magic Cup, fruit smoothies with mighty shake and frozen berries. -However, a review of the resident's EMR did not reveal a physician's order for Magic Cup or fruit smoothies (see record review above). The 8/23/24 nutrition dietary note documented the resident was discussed in a RAR meeting with the interdisciplinary team. The resident's weight was slightly trending back up and was no longer a significant loss. Monthly weights were resumed and twice daily MedPass and Magic Cup continued. The EMR revealed the resident was diagnosed with COVID-19 on 6/29/24 and was in isolation until 7/11/24. Although the resident was in isolation until 7/11/24, the weekly weights, which were recommended in the RAR meeting, were not completed after her time in isolation. -The RAR committee recommended the resident to be weighed weekly on 7/12/24. However, the facility did not weigh the resident weekly consistently. III. Staff interviews The RD and the clinical reimbursement specialist (CRS) were interviewed together on 8/29/24 at 12:10 p.m. The RD said the resident was reviewed in the RAR meeting weekly. She said the RAR meeting was used to analyze how the resident's nutritional needs were being met. She said the resident's representative was notified of the resident's weight loss. She said it was discussed with the representative that the resident would not receive a dinner meal, as she preferred to sleep. She said in regards to not offering the resident dinner , she could have done a better job documenting the conversation She said there was not a physician's order for the resident to receive a 3:00 p.m. snack and the MAR showed that she did not consume a bedtime snack. The RD said the resident had a significant weight loss and the resident's intake had been poor since July 2024. She said the 2 cal MedPass was added twice daily, which she consumed on a regular basis. She said the 2 cal MedPass should not be given with meals because it would fill the resident up with supplement and not food. The RD said the resident's weekly weights were discussed in RAR. She said however, because the resident was in isolation until 7/11/24, the weekly weights could not be completed. She said the weekly weights were not resumed after the isolation and not completed. The RD said the resident received a Magic Cup at lunch and breakfast. She said there was no documentation of the Magic Cup being provided to the resident. The director of nursing (DON) was interviewed on 8/29/24 at p.m. The DON said the resident had a physician's order for a peanut butter and jelly sandwich, however, this was related to the resident having a minced and moist texture. The DON said there was no documentation on the resident receiving a peanut butter and jelly sandwich as snack.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address multiple concerns related to quality of care. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) Plan, revised 1/18/24, was provided by the nursing home administrator (NHA) on 8/26/24 at 1:00 p.m. It read in pertinent part, The QAPI Program is to utilize an ongoing, data-driven, proactive approach to advance the quality of life and quality of care for all residents at the facility. All facility associates, families and residents will be encouraged to be involved in identifying opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and provide ongoing feedback. The facility will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating and monitoring adverse events every time they occur, and action plans implemented through the plan, do, study, act cycle of improvement to prevent recurrences. II. Cross-referenced citations Cross-reference F550 dignity: The facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Cross-reference F655 baseline care plans: The facility failed to develop and implement acute/baseline care plans. Cross-reference F677 activities of daily living for dependent residents: The facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living. Cross-reference F688 range of motion: The facility failed to ensure residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Cross-reference F692 nutrition and hydration: The facility failed to ensure effective interventions were in place to address weight loss timely. Cross-reference F695 respiratory: The facility failed to ensure residents received proper respiratory treatment and care. Cross-reference F880 infection control: 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. Cross-reference F758 unnecessary psychotropic medications: The facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible. Cross-reference F684 quality of care: The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Cross-reference F685 treatment or devices to maintain hearing and vision: The facility failed to ensure proper treatment and services to maintain hearing. Cross-reference F645 Preadmission Screening and Resident Review (PASRR) Level I: The facility failed to ensure a PASRR Level I screening was completed within thirty days of admission. Cross-reference F804 palatable food: The facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Cross-reference F812 kitchen sanitation: The facility failed to prepare and serve food in a sanitary manner. III. Staff interviews The nursing home administrator (NHA) and regional vice president (RVP) were interviewed together on 8/29/24 at 7:43 p.m. The NHA said the facility did not invite floor staff, residents or family members to their QAPI meetings or for feedback but the facility wanted to. She said the facility had not accomplished getting others involved in the QAPI meetings. The NHA said dignity, baseline care plans, positioning residents, restorative services, weight loss, oxygen canisters, as-needed psychotropic medications, PASRR Level I screens, palatable food and kitchen sanitation were not identified by the QAPI team as areas for improvement. The NHA said hand hygiene and infection control were always watched as an area for improvement but resident hand hygiene and appropriate cleaning of resident rooms were not identified as an area for improvement until the annual recertification survey. The NHA said the QAPI team needed to create a performance improvement plan (PIP) and complete audits to better identify areas for improvement. The NHA said the facility completed random spot checks with staff and she wanted to increase spot checks. She said the facility needed more eyes on the floor to identify areas for improvement. She said the facility focused on bigger areas of concern for improvement and the little areas were missed. The NHA said there was a lot of turnover in leadership which caused a breakdown in the system. She said the QAPI system worked but the QAPI team needed to re-evaluate, not just focusing on the bigger areas of concern but all areas that could affect the care the facility provided the residents.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for three (#6, #27 and #4) of three residents out of 28 sample residents reviewed. Specifically, the facility failed to: -Provide Resident #6 and Resident #27 with a dignified dining experience; -Provide Resident #4 with privacy and dignity while he used his urinal in his room; and, -Ensure residents were not discussed by staff in areas where the conversations could be overheard by others. Findings include: I. Facility policy and procedure The Dignity policy and procedure, dated 5/16/19, was provided by regional director of clinical services (RDCS) #2 on 8/29/24 at 2:10 pm. It revealed in pertinent part, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as honor and value their input. Promote resident independence and dignity while dining, such as avoiding: -Staff standing over residents while assisting them to eat; and, -Staff interacting /conversing only with each other rather than with residents while assisting with meals. Staff should not discuss residents in settings where others can overhear private or protected information or document in charts/electronic health records where others can see a resident's information. II. Resident #6 A. Resident status Resident #6, age 89, was admitted on [DATE]. According to the August 2024 computerized physician order (CPO), diagnoses included major depressive disorder, other Alzheimer's disease, restlessness and agitation. The 6/5/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to complete the brief interview for mental status (BIMS). Resident #6 required set up and clean up assistance with meals and was dependent on staff for the rest of her activities of daily living (ADL). B. Observations On 8/26/24 at approximately 12:15 p.m. Resident #6 was sitting at a dining room table awaiting her meal. The resident was served her meal in four individual bowls and a small dessert bowl. The registered dietitian (RD) walked up to Resident #6's table and pushed all but one of the bowls to the top of the table, out of reach of the resident. The RD did not explain what she was doing or speak to Resident #6 prior to moving the bowls. Resident #6 was left with one bowl but did not get the choice of which food items she wished to eat. On 8/28/24 during a continuous observation of the breakfast meal, beginning at 8:28 a.m. and ending at 8:41 a.m., the following was observed: At 8:28 a.m. Resident #6 had four individual bowls of food in front of her. She was eating from two of the bowls. At 8:41 a.m. the RD walked up to the resident and removed all but one of the bowls. The other bowls were put out of reach for the resident. The RD did not speak to the resident as she moved the bowls. Resident #6 was not provided a choice of which food items she wanted to eat. C. Record review Resident #6's dietary care plan, revised on 3/12/24, revealed Resident #6 could dine independently if needed due to agitation and, at times, disruptive behavior. Resident #6 needed supervision, some assistance and encouragement at times and adequate time to eat. -The care plan failed to indicate Resident #6 needed to have her meal served in individual bowls and only be given one bowl at a time. D. Staff interviews The RD was interviewed on 8/29/24 at approximately 10:00 a.m. The RD said Resident #6 did better eating her meal when all of the bowls were not directly in front of her. She said having all of the bowls at once made the resident more agitated. The RD said she would work on ensuring that she spoke to the resident prior to moving the bowls. -However, observations of Resident #6 did not reveal that the resident was agitated while eating her meal with all of the bowls sitting directly in front of her (see observations above). The director of nursing (DON) was interviewed on 8/29/24 at approximately 4:00 p.m. The DON said Resident #6 was cognitively impaired. She said providing only one bowl at a time for the resident was better for the resident. The DON said the RD moving the bowls so Resident #6 only had one bowl at a time was not disrespectful or discourteous to the resident. 48412 III. Resident #27 A. Resident status Resident #27, age less than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included Down's syndrome, unspecified convulsions, Parkinson's disease with dyskinesia (involuntary movements of the body), dysphagia of oral phase (difficulty swallowing), generalized anxiety disorder, panic disorder, dementia with anxiety and mood disturbances and visual hallucinations. The 6/28/24 MDS assessment revealed Resident #27 had a severe cognitive impairment with a BIMS score of four out of 15. B. Resident representative interview Resident #27's representative was interviewed on 8/27/24 at 7:33 p.m. The resident's representative said Resident #27 would benefit from one-on-one activities and conversations with staff because he had a hard time socializing after his Parkinson's disease progressed. She said the resident needed someone to spend time with him throughout the day when the family was unable to visit. The resident's representative said Resident #27 told her, on 8/25/24, that he wanted the staff to sit in his room with him. The resident's representative said the resident had told her that the staff did not need to talk to him, he just wanted someone's companionship. The resident's representative said Resident #27 ate well during meals when the person assisting him socialized with him. She said she observed some meals and the CNAs assisted two residents at a time. She said the CNAs did not interact with the residents. She said the nurses communicated with Resident #27 when assisting him at meals. The resident's representative said Resident #27 was a very social person but his medical issues affected how he communicated and he was lonely because the CNAs failed to socialize with him throughout the day and at meals. C. Observations During a continuous observation on 8/28/24, beginning at 11:40 a.m. and ending at 12:24 p.m., the following was observed: At 11:40 a.m. Resident #27 was in his wheelchair in the middle of the dining room. At 11:43 a.m. an unidentified certified nurse aide (CNA) assisted Resident #27 to his seat at the resident assistance table in the dining room. At 11:48 a.m. Resident #27 was sitting by himself and the staff were interacting with all of the residents at the table except for Resident #27. At 11:56 a.m. CNA #1 put a clothing protector on Resident #27 and sat next to him. CNA #1 did not socialize with Resident #27. CNA #1 was interacting with a female resident at the table. At 11:57 a.m. Resident #27 tried talking to CNA #1. CNA #1 listened to the resident for 10 seconds and looked around the room which ended the conversation. At 11:58 a.m. an unidentified dietary aide (DA) served drinks to the residents at the resident assistance table. The DA provided Resident #27 milk and gatorade but did not ask the resident what he wanted to drink. The DA did not interact with the resident but spoke to CNA #1 in Spanish. At 12:00 p.m. CNA #1 was not socializing or offering drinks to Resident #27. At 12:02 p.m. CNA #1 moved Resident #27's legs in his wheelchair without asking if he wanted to move or notifying the resident. CNA #1 put the cup's spout to Resident #27's lips without asking if he wanted a drink and did not interact with the resident. At 12:03 p.m. CNA #1 gave Resident #27 a drink while she talked to another resident at the resident assistance table and did not interact with Resident #27. At 12:10 p.m. Resident #27 told CNA #1 something and motioned to his left hand. CNA #1 held his hand and massaged his palm as she interacted with other staff in the dining room. At 12:12 p.m. CNA #1 assisted Resident #27 with eating and rubbed her left hand along his back but she did not talk to the resident. At 12:19 p.m. CNA #1 was assisting Resident #27 with his meal and closing her eyes for a few seconds. She repeatedly blinked her eyes to wake herself up. At 12:20 p.m. CNA #1 closed her eyes for a few seconds while she had the spoon up to Resident #27's mouth. At 12:21 p.m. CNA #1 again closed her eyes for a few seconds. She opened her eyes and rubbed her face before feeding Resident #27 another bite of his lunch. At 12:22 p.m. CNA #1 had her head on her hand while she provided Resident #27 another bite of food and she closed her eyes. At 12:24 p.m., the DON asked CNA #1 to complete a different task outside of the dining room. The DON took over assisting Resident #27. D. Record review Resident #27's activity care plan, revised on 7/26/24, revealed, due to his physical limitations, he was dependent on staff to meet his emotional, intellectual, physical and social needs. The intervention was providing the resident with one-on-one activities because he liked to converse. Resident #27's activities of daily living (ADL) care plan, revised on 9/11/21, revealed Resident #27 required extensive assistance from one staff member while eating. Resident #27's communication care plan, revised on 2/26/24, revealed the resident had a communication problem which referred to his fear or shyness and Down's syndrome. Interventions included being conscious of Resident #27's position when in groups, activities and the dining room to promote proper communication with others, allowing the resident adequate time to respond, repeating as necessary, not rushing the resident, requesting clarification from the resident to ensure understanding, facing the resident when speaking and making eye contact, encouraging Resident #27 to continue stating his thoughts even if he was having difficulty, keeping communication with the resident focused on the resident and being conscientious of what was talked about within listening distance because Resident #27 has excellent hearing and internalized and was stressed by conversations overheard. A review of Resident #27's Kardex (a staff directive tool) revealed the resident needed extra time to respond to questions and instructions, the resident occasionally needed to be asked yes or no questions to determine his needs and Resident #27 needed to be offered gatorade and his favorite drink of choice during and in between meals to promote hydration. E. Staff interviews The nursing home administrator (NHA) was interviewed on 8/29/24 at 4:42 p.m. The NHA said the incident with CNA #1 falling asleep while she assisted him at lunch was going to be investigated. The NHA said she reminded all of the staff that if they felt tired while assisting a resident at a meal to inform another staff member and switch duties. The NHA said it put the Resident #27 at a higher risk of choking when CNA #1 fell asleep while she assisted him. She said CNA #1 was not paying attention and the resident had a hard time communicating. She said the staff needed to communicate with all of the residents, but especially the residents that were being assisted at meals. Registered nurse (RN) #2 was interviewed on 8/29/24 at 12:25 p.m. RN #2 said when she assisted residents with meals she socialized with the residents. IV. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included bilateral conductive hearing loss, legal blindness, difficulty in walking and muscle weakness. The 6/19/24 MDS assessment revealed Resident #4 had moderate cognitive impairments with a BIMS score of 12 out of 15. B. Observations During a continuous observation on 8/28/24, beginning at10:30 a.m. and ending at 12:45 p.m., the following was observed: At 10:30 a.m. Resident #4 was lying on his bed with his window curtains and the bedroom door open. At 10:34 a.m. an unidentified CNA answered Resident #4's call light. The unidentified CNA provided the resident with his urinal and said You are welcome as she left the room. The unidentified CNA left his bedroom door and window curtains open. At 10:35 a.m. Resident #4 pulled down his pants and had the urinal in his left hand. Resident #4 used his right hand to expose his penis and put it inside the opening of the urinal. Resident #4 used the urinal while he laid in his bed with his pants pulled down and his window curtain and door were left open. At 10:38 a.m. the same unidentified CNA walked by Resident #4's door and saw he was still using his urinal in his bed and walked by without closing his door. At 10:41 a.m. the same unidentified CNA walked by Resident #4's door and kept walking down the hallway. Staff were observed in the living room of the dementia unit across the courtyard through Resident #4's window. At 10:42 a.m. the physical therapy assistant (PTA) walked by Resident #4's room. He told Resident #4 How about some privacy and closed the privacy curtain in the bedroom. The PTA left the room but left the resident's window curtains open. At 11:09 a.m. Resident #4 activated his call light. RN #3 answered his call light and brought the resident a glass of water. RN #3 left Resident #4's privacy curtain closed but left his window curtains open. At 11:25 a.m., Resident #4 was observed with his privacy curtain closed and his pants were pulled up while laying in bed. He was waiting to go to the dining room for lunch. C. Record review Resident #4's ADL care plan, revised on 3/12/24, revealed the resident had an ADL self-care deficit due to impaired balance, visual deficits, generalized weakness and a history of a rotator cuff tear. Resident #4 was able to self-propel independently using his wheelchair, he required limited assistance by one staff member to turn and reposition in bed, he required one person assistance with toileting and he was able to transfer with one person assistance. D. Staff interviews The regional vice president (RVP) and the NHA were interviewed together on 8/28/24 at 1:55 p.m. The RVP said privacy needed to be provided to the residents anytime care was provided, which included when Resident #4 used a urinal in bed. The NHA said privacy was important because Resident #4 did not need to be exposed to other residents and other residents did not need to be exposed to Resident #4 while he was using the urinal. The NHA was interviewed again on 8/29/24 at 4:42 p.m. The NHA said when a resident used the restroom, the door and the curtains needed to be closed to provide the resident with privacy and dignity. RN #2 was interviewed on 8/29/24 at 12:25 p.m. RN #2 said when a resident used the urinal, the privacy curtain or the bedroom door needed to be closed. She said she never thought about closing the window curtains but she said the curtains probably needed to be closed as well. The RVP and the NHA were interviewed together again on 8/29/24 at 7:55 p.m. The NHA said the leadership team met once a month to discuss areas of improvement within the facility to better serve the residents. The NHA said the facility had not identified privacy or dignity as an area for improvement. V. Failure to ensure residents were not discussed by staff in areas where the conversations could be overheard by others A. Observations On 8/26/24 during a continuous observations of the dining room, beginning at 12:00 p.m. and ending at 12:30 p.m., the following was observed: The main dining room had approximately ten tables. During the meal service, approximately 18 residents were in the dining room. At approximately 12:00 p.m. an unidentified resident asked for creamer. for their coffee. The RD was heard telling the resident You don' t like creamer, you like your coffee black. -The RD did not provide the resident with creamer as requested. At 12:15 p.m. an unidentified certified nurse aide (CNA) was observed standing while assisting Resident #24 with eating their meal. At approximately 12:30 p.m. the RD was heard talking loudly about other residents ' decline and needing to change their diet orders. The RD was heard asking multiple residents about their dentures and why they did not want to wear them. The RD was heard talking about different resident's preferences to other residents' family members. The RD could be overheard throughout the dining room. -Throughout the continuous observation, the RD was walking from resident to resident and assisting them with their meals while standing up. The RD conversed with other employees instead of the residents while she was assisting them to eat their meals. B. Staff interviews The RD was interviewed on 8/29/24 at approximately 10:00 a.m. The RD said she knew her voice was loud. She said she had been told she was loud before. She said when she was in the kitchen she had to speak loudly because of the overhead fans. She said she viewed the facility as a family and she wanted to help everyone and that was why she would talk to all of the residents. The social services director (SSD) was interviewed on 8/29/24 at 3:51 p.m. The SSD said the facility had provided staff with education on dignity and respect. She said staff received the education when new employees were hired and then annually thereafter. She said all residents were to be treated with respect and dignity. The SSD said she would review the resident rights with all staff.

Based on record review and interviews, the facility failed to ensure four (#241, #242, #36, and #239) of five residents out of 28 sample residents had a completed baseline care plan within 48 hours of admission. Specifically, the facility failed to ensure that Resident #241, Resident #242, Resident #36 and Resident #239 had baseline care plans completed within 48 hours of admission and/or baseline care plans which addressed all of the minimum requirements, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, preadmission screening and resident review (PASARR) recommendation, if applicable. Findings include: I. Facility policy and procedure The Baseline Care Plan policy, revised 8/11/23, was provided by the regional director of clinical services (RDCS) #1 on 8/29/24 at approximatly 2:00 p.m. It revealed in pertinent part, A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. The baseline care plan must include, but is not limited to: -Initial goals based on admission orders; -Physician orders; -Dietary orders; -Therapy services; -Social services; and, -PASARR recommendation, if applicable The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of admission and meets the requirements listed above. II. Resident #241 A. Resident status Resident #241, age 79, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur (break in the femur), unspecified dementia, severe, unspecified osteoarthritis (arthritis), unspecified urinary incontinence and history of falling. The 7/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment further revealed Resident #241 needed set up and clean up assistance for meals, partial assistance with bathing, toileting and upper body dressing and substantial assistance with lower body dressing. B. Record review -Review of Resident #241's electronic medical record (EMR) revealed the facility failed to complete a baseline care plan for the resident within 48 hours of the resident's admission. -Additionally, the facility failed to develop a comprehensive care plan in place of a baseline care plan within 48 hours of admission. -The care plan for antidepressant, antipsychotic and anti-anxiety medications was not initiated until 7/15/24 and the dietary care plan was not initiated until 7/23/24. III. Resident #242 A. Resident status Resident #242 age 80, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included displaced trimalleolar fracture of right lower leg (fracture of the ankle), unspecified fracture of the lower end of the right radius (fracture of the lower right arm), cervicalgia (neck pain), rotator cuff tear or rupture of left shoulder, rotator cuff tear or rupture of right shoulder, chronic kidney disease stage 3, fibromyalgia (widespread body pain and tiredness). The 8/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment further revealed Resident #242 needed set up and clean up assistance for meals, oral hygiene and partial assistance for bathing and upper body dressing and needed substantial assistance with toileting and lower body dressing. B. Record review -Review of Resident #242's EMR revealed a baseline care plan, dated 8/21/24, failed to include advance directives, COR status, dietary orders and therapy services, which were ordered. IV. Resident #36 A. Resident status Resident #36, age 71, was admitted on [DATE]. According to the August 2024CPO, diagnoses included muscle weakness, Raynaud's syndrome (parts of the body feel numb and cool due to small arteries constricting blood flow) without gangrene, dorsalgia unspecified (back pain), history of malignant neoplasm (cancer) of unspecified site of lip, oral cavity, and pharynx, facial weakness, cognitive communication deficit and pneumonitis (lung infection) due to inhalation of food and vomit. The 8/2/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. The MDS assessment further revealed that Resident #36 needed supervision or touching assistance with personal hygiene and upper body dressing and needed partial to moderate assistance with bathing/showering and lower body dressing. B. Record review -Review of Resident #36's EMR revealed that the baseline care plan, dated 7/31/24, failed to document advance directives, COR (resuscitation) status, dietary orders (the resident was to receive nothing by mouth and received nutrition and hydration through a tube feeding), or therapy services, which were ordered. -The dietary care plan was not initiated until 8/5/24. The baseline care plan failed to address the resident's activities of daily living self-care deficit until 8/12/24. V. Resident #239 A. Resident status Resident #239, age 80, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included pneumonia, sleep related hypoventilation, hypertension and hepatitis C. B. Record review -Review of Resident #239's EMR revealed that a baseline care plan was not completed for the resident. The comprehensive care plan, initiated on 8/7/24, initiated activities of daily living and discharge plan within 48 hours of the resident's admission to the facility. -However, a fall and history of falls care plan was not initiated until 8/12/24, a dietary care plan was not initiated until 8/20/24 and a therapy services care plan was not initiated VI. Staff interviews Registered nurse (RN) #2 was interviewed on 8/29/24 at 8:54 a.m. RN #2 said when a resident was admitted to the facility, the RN had to initiate the care plan and enter the pertinent information about continence care and other pertinent care plan areas. RN #2 said the MDS coordinator (MDSC) completed the rest of the care plan. The MDSC was interviewed on 8/29/24 at approximately 1:00 p.m. The MDSC said the baseline care plan needed to be completed within 48 hours. She reviewed the EMRs for Resident #241, #242, #36, and #239. She said the baseline care plans for each resident were incomplete or had not been completed at all. She said the care plans were not completed within 48 hours of the residents's admissions to the facility. The MDSC said she would begin an audit to ensure the baseline care plans for all residents were completed timely following admission to the facility.

Based on observations, record review and interviews, the facility failed to ensure that three (#16, #14 and #17) of three residents out of 28 sample residents received necessary respiratory care. Specifically, the facility failed to: -Ensure portable oxygen tanks were refilled timely for Residents #16, #14, and #17; -Ensure oxygen tubing was changed routinely and dated; and, -Ensure staff were using the appropriate personal protective equipment (PPE) while filling residents' oxygen tanks. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, revised on 2/27/24, was received from the regional vice president (RVP) on 8/29/24 at 6:50 p.m. It read in pertinent part, To assure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area. Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with resident name and dated when setup or changed out. Cryogenic (relating to or involving very low temperatures) safety gear (face shield, gloves, apron) are required in the oxygen filling room for staff to use when filling portable units. II. Failure to ensure portable oxygen tanks were filled timely and oxygen tubing was changed routinely and dated A. Resident #16 1. Resident status Resident #16, age 79, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis) and hemiparesis (muscle weakness or partial paralysis) following cerebral infarction (stroke) affecting left non-dominant side, vascular dementia with psychotic disturbance. The 6/25/24 minimum data set (MDS) assessment revealed Resident #16 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She had limited range of motion on one side of her upper extremity and both sides of her lower extremities. The resident was dependent on staff assistance for bed mobility, transfers and most of her activities of daily living (ADL). The assessment indicated the resident was receiving oxygen therapy. 2. Observations On 8/27/24 at 3:15 p.m. Resident #16 was in her room and was using her portable oxygen tank. -There was no date labeled on her oxygen tubing. On 8/27/24 at 6:02 p.m., the resident's portable oxygen tank was observed with certified nurse aide (CNA) #5. -The nasal cannula was in the resident's nose, however, the portable oxygen tank hanging on the resident's wheelchair was empty. CNA #5 took the resident's portable oxygen tank to go fill it in the oxygen room. 3. Record review Review of the August 2024 CPO revealed the following physician's order for oxygen: Oxygen at 2 liters per minute (LPM) to keep saturations (level of oxygen in the blood) at 90% (percent) or above, ordered 8/26/24. Resident #16's respiratory care plan, updated 3/18/24, revealed the resident was on 2 LPM of oxygen via nasal cannula as needed. Pertinent interventions included tracking the resident's oxygen levels daily. -Review of the August 2024 treatment administration record (TAR) failed to show Resident #16's oxygen tubing was changed. B. Resident #14 1. Resident status Resident #14 age 90, was admitted on [DATE]. According to the August 2024 CPO diagnoses included chronic obstructive pulmonary disease (COPD), altered mental status and stroke. The 6/7/24 MDS assessment revealed Resident #14 had severe cognitive impairments with a BIMS score of four out of 15 The assessment indicated the resident was receiving oxygen therapy. 2. Observations On 8/27/24 at approximately 5:50 p.m. Resident #14, who had been observed at various activities throughout the day, was sitting in the hallway. He had his nasal cannula in his nose and his portable oxygen tank was hanging on the back of his wheelchair. -There was no date labeled on his oxygen tubing. The resident's portable oxygen tank was observed with CNA #5. -The portable oxygen tank was empty. CNA #5 took the resident's portable oxygen tank and went to fill it in the oxygen room. 3. Record review Review of the August 2024 CPO revealed the following physician's order for oxygen: Oxygen at 1 to 3 LPM to keep saturations at 90% or above, ordered 3/4/24. Resident #14's respiratory care plan, updated 3/18/24 revealed the resident was to be on 1 to 3 LPM of oxygen and needed to have oxygen levels monitored each shift to maintain oxygen levels of 90% or greater. Pertinent interventions included monitoring the resident's oxygen levels daily and changing out the oxygen tubing every Sunday during the night shift. C. Resident #17 1. Resident Status Resident #17, age 86, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included unspecified dementia, adult failure to thrive, heart failure unspecified and shortness of breath. The 6/3/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment revealed the resident was on oxygen therapy and required moderate assistance with bathing and dressing and needed maximal assistance with toileting. 2. Observations On 8/27/24 at 6:02 p.m. Resident #17 was in the dining room with her nasal cannula in her nose and her portable oxygen tank on the back of her wheelchair. -There was no date labeled on her oxygen tubing. The portable oxygen tank was observed with the infection control preventionist (IP). -The resident's portable oxygen tank was empty. The IP filled the tank. The IP took the resident's portable oxygen tank and went to fill it the oxygen room. 3. Record Review Review of the August 2024 CPO revealed the following physician's order for oxygen: Oxygen at 2 LPM via nasal cannula for shortness of breath, ordered 8/13/24. Resident #17's respiratory care plan, updated 3/6/24, revealed the resident was to be on 1 to 2 LPM of oxygen as needed for disorientation. Pertinent interventions included changing the oxygen tubing every Sunday during the night shift. D. Staff interviews CNA #5 was interviewed on 8/27/24 at 5:45 p.m. CNA #5 said the residents' portable oxygen tanks were checked on the night shift and after lunch. -However, observations of Resident #16's, #14's and #17's oxygen tanks following CNA #5's interview revealed all three residents' portable oxygen tanks were empty (see observations above). The director of nursing (DON) was interviewed on 8/27/24 at 6:15 p.m. The DON said portable oxygen tanks were to be checked every two hours. She said the tanks should also be checked prior to meals or if the resident was on the portable tanks for an extended period of time. The DON was interviewed a second time on 8/29/24 at approximately 4:00 p.m. The DON said she provided education (during the survey) to the certified nurse aides during the CNA huddles. She said the education included checking the portable oxygen tanks every couple of hours, before meals and when residents were brought out of their rooms for activities. III. Failure to wear appropriate PPE while filling residents' oxygen tanks A. Observations The facility's oxygen room was located on the Brother Ben's hallway. The oxygen room had three liquid oxygen tanks. The PPE staff was supposed to use to fill the portable oxygen tanks was hanging on the wall just inside the room. The PPE provided included a pair of goggles, heavy gloves that went to the elbows, ear protection and a heavy yellow apron. On 8/27/24 at approximately 6:15 p.m. three different employees, CNA #5, IP, and the NHA were observed filling portable oxygen tanks. The NHA was wearing the appropriate PPE provided for safety. -CNA #5 and the IP failed to use the appropriate PPE while filling portable oxygen tanks. The DON) was interviewed on 8/29/24 at approximately 4:00 p.m. The DON said proper PPE needed to be worn when filling the portable oxygen tanks for the safety of the staff. She said the appropriate PPE included an apron, eye protection and heavy gloves.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature. Findings include: I. Resident interviews Resident #12 was interviewed on 8/26/24 at 10:44 a.m. Resident #12 said she ate her meals in the dining room and had received cold food several times. She said she did not eat meat and the vegetables were overcooked or undercooked and the food was bland. Resident #30 was interviewed on 8/26/24 at 2:00 p.m. Resident #30 said she ate her meals in her room and her food was often served at a lukewarm temperature or cold. She said her food was edible but never arrived in her room hot. Resident #1 was interviewed on 8/26/24 at 2:48 p.m. Resident #1 said she ate her meals in her room and received cold food on her room tray. II. Resident group interview The resident group was interviewed on 8/28/24 at 2:07 p.m. with Resident #23, Resident #30, Resident #31, Resident #26, Resident #1, Resident #32, Resident #12 and Resident #5. The residents were identified as alert and oriented through facility and assessment. Resident #26 said she received cold food at meal times. Resident #23 said he received cold food at meal times. Resident #5 said she received cold food at meal times. III. Observations A test tray for a regular diet was evaluated by four surveyors immediately after the last resident had been served dinner on 8/28/24 at 5:34 p.m. The test tray consisted of parmesan crusted tilapia, tartar sauce, pea salad, dinner roll and corn kernels. -The parmesan crusted tilapia was 111.8 degrees Fahrenheit (F) and tasted bland; -The pea salad was 64.5 degrees F and had a strong onion taste; -The corn was 122.3 degrees F, was tough, greasy and tasted like oil; and, -The tartar sauce was 70.3 degrees F and was acidic. IV. Resident council notes The 6/12/24 resident council notes revealed a resident requested to have her meals served warmer. -There was no documentation indicating how the facility took steps to address the resident's request of wanting warmer food. V. Staff interviews The registered dietitian (RD), the nursing home administrator (NHA) and the regional vice president (RVP) were interviewed together on 8/29/24 at 10:37 a.m The RD said the residents had not informed her that the meals were not served at the correct temperature or that the food did not taste good. The RD said cold foods were on ice during service and served at 41 degrees F. The RD said hot foods were served between 120 degrees F and 145 degrees F after the initial cooking temperature was reached. The NHA said she had not heard anything from the residents regarding the temperatures or taste. The NHA said the residents wanted to have food committee meetings during resident council meetings and the facility planned to combine the meetings in September 2024. The RVP said the facility was going to take a look at what was going on with the temperatures and taste of the food. The RD said it was important to serve food at the correct temperature and hot so the meal was enjoyable and safe to eat.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure a dietary aide's (DA) medication was not stored in the walk-in refrigerator; -Ensure appropriate hand hygiene was performed for staff and residents during meal service; and, -Ensure dietary staff removed their jewelry before serving meals. Findings include: I. Failure to ensure staff medications were not stored in the walk-in refrigerator A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, was retrieved on 9/6/24 from https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Medicines belonging to employees that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines. B. Observations and staff interviews During the initial tour of the kitchen on 8/26/24 at 9:32 a.m. the walk-in refrigerator had a gallon plastic bag on the top shelf next to the resident's food. The bag was marked with cook (CK) #2's name. Inside the plastic bag was an insulin pen. At 9:48 a.m. CK #2 said the insulin pen was his and he sometimes placed the insulin pen in the walk-in refrigerator. At 9:49 a.m., the registered dietitian (RD) said the employees were not supposed to store personal medications in the walk-in refrigerator. The RD said the insulin pen needed to be moved to the employee refrigerator. C. Additional staff interview The nursing home administrator (NHA), the RD and the regional registered dietitian (RDD) were interviewed together on 8/28/24 at 1:55 p.m. The RD said she provided education to the kitchen staff about personal belongings and personal medications being stored in the walk-in refrigerator. D. Facility follow-up The nutritional services huddle, completed on 8/28/24 (during the survey), was provided by the RD on 8/28/24 at 1:00 p.m. It read in pertinent part, All personal items must be kept in the employee refrigerator in the employee break room or in the employee closet. No food, drinks or medications can be stored in the refrigerator in the kitchen. II. Failure to ensure hand hygiene was conducted appropriately in the dining room A. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved on 9/6/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; after handling soiled equipment or utensils; before donning gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. B. Facility policy and procedure The Hand Hygiene policy, reviewed on 5/29/24, was provided by the regional vice president (RVP) on 8/29/24 at 6:44 p.m. It read in pertinent part, The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. To protect patients from healthcare-associated infection, hand hygiene must be performed routinely and thoroughly. The Centers for Disease Control and Prevention (CDC) recommends performing hand hygiene with soap and water before eating. Teach patients and their families about the importance of hand hygiene in preventing the spread of infection. C. Observations During a continuous observation on 8/26/24, beginning at 11:30 a.m. and ending at 12:49 p.m., the following was observed: At 11:49 a.m. an unidentified resident completed an activity and was immediately brought into the dining room. An unidentified staff member assisted the resident into the dining room and did not offer hand hygiene to the resident. The resident ate her entire meal with her hands after throwing balls with other residents and sharing pool noodles. At 11:50 a.m. an unidentified resident had completed an activity throwing balls with other residents and sharing pool noodles. The resident wheeled himself from the activity to the hallway and touched his wheels. Hand hygiene was not offered to the resident and the resident ate his lunch with his hands. At 11:57 p.m. an unidentified DA served residents their drinks in the dining room. The DA did not complete hand hygiene in between handing out drinks, touching residents and touching resident's wheelchairs. During a continuous observation on 8/27/24, beginning at 4:50 p.m. and ending at 5:43 p.m., the following was observed: At 4:50 p.m. hand hygiene was only offered to the residents at the assistance table. Approximately five independent residents entered the dining room via their personal walkers and three independent residents self-propelled in their wheelchairs. Hand hygiene was not offered to the residents once they were seated. At 5:43 p.m. an unidentified resident was assisted from his room to the dining room and was not offered hand hygiene. The resident ate a tuna salad sandwich and potato chips with his hands. During a continuous observation on 8/28/24, beginning at 11:29 a.m. and ending at 12:46 p.m., the following was observed: At 11:51 a.m. an unidentified DA served drinks to the residents in the dining room. The DA did not complete hand hygiene in between handing out drinks, touching residents and touching resident's wheelchairs. At 12:00 p.m. an unidentified resident was sitting at a dining room table and not offered hand hygiene. The resident rearranged fake flowers that sat on the table then ate her food with her hands. D. Staff interview The RD was interviewed on 8/29/24 at 10:37 a.m. The RD said she was concerned with making sure hand hygiene was offered to the residents who ate in their rooms and she did not realize the residents in the dining room were not being offered hand hygiene. The RD said the DA needed to complete hand hygiene after she touched anything other than the clean drink she was handing out. III. Failure to ensure dietary staff did not wear jewelry while preparing food A. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved on 9/6/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view revealed in pertinent part, Except for a plain ring, such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. B. Observations During a continuous observation of the dinner service on 8/28/24, beginning at 4:30 p.m. and ending at 5:34 p.m., the following was observed: At 4:30 p.m. DA #2 was wearing a corded bracelet on her left wrist with strings hanging from the bracelet. At 4:44 p.m. DA #2 opened individual packets of butter and placed them on the tray line. DA #2 grabbed a butter packet and the strings to her bracelet dragged through other opened packets of butter. At 4:53 p.m. DA #2 grabbed another packet of butter and the strings to her bracelet drug through the other opened butter. She placed the butter packet on a plate and the strings of her bracelet dragged across the food she was plating for a resident. At 5:13 p.m. DA #2 reached over to grab an individual container of ketchup on the service line and the strings of her bracelet drug through the opened butter containers. C. Staff interviews The RVP was interviewed on 8/29/24 at 1:00 p.m. The RVP said staff were not allowed to wear jewelry in the kitchen and she was unaware it was occurring. The RVP said education was going to be provided to the dietary staff.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high touch areas in residents' rooms; and, -Ensure staff followed appropriate hand hygiene practices. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (3/19/24) was retrieved on 9/5/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It 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: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. 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 and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy The Daily Room Cleaning policy, reviewed 6/12/24, was received from the regional director of clinical services (RDCS) #1 on 8/29/24 at 2:10 p.m. It read in pertinent part, The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. -The policy did not specify that high touch surface areas should be cleaned C. Observations On 8/27/24 at 8:37 a.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. -the door handles to the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. On 8/29/24 at 9:14 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #2 during the room cleaning process. -The door handles to the resident's room and the resident's bathroom were not cleaned by HSKP #2 during the room cleaning process. D. Staff interviews HSKP #1 was interviewed on 8/27/24 at 8:55 a.m. HSKP #1 said call light cords and door handles should be cleaned daily because they were high touch surfaces. HSKP #1 said she cleaned the call light cords during the room cleaning she completed in room [ROOM NUMBER]. -However, HSKP #1 failed to clean either residents' call light, the bathroom call light or the door handles to the room or the bathroom in room [ROOM NUMBER] (see observation above). -Additionally, the director of housekeeping (DHK) said HSKP #1 reported to her she had not cleaned the resident call lights during the room cleaning in room [ROOM NUMBER] on 8/27/24 (see DHK interview below). HSKP #2 was interviewed on 8/29/24 at 9:35 a.m., utilizing a spanish-speaking interpreter. HSKP #2 said she did not clean the residents' call lights , the call light in the bathroom or the room and bathroom door knobs in room [ROOM NUMBER]. The DHK was interviewed on 8/29/24 at 12:40 p.m. The DHK said call light cords, door handles, drawer handles and cabinet handles were high-touch surface areas that should be cleaned everyday. The DHK said she had previously spoken to housekeeping staff about the importance of cleaning high-touch surfaces as part of the daily cleaning. The DHK said HSKP #1 told her she did not clean the resident's call light cords or the call light cord in the bathroom during the room cleaning observation that occurred on 8/27/24 in room [ROOM NUMBER]. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 8/29/24 at 3:19 p.m. The IP said the resident call lights and door handles should be cleaned because they were considered high touch surfaces that could transmit infections. The IP said resident call light cords and door handles should be cleaned every day. The DON said call lights and door handles should be cleaned daily. II. Hand hygiene failures A. Professional reference The CDC Clinical Safety: Hand Hygiene for Healthcare Workers, (2/27/24) was retrieved on 9/5/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands by handwashing with water and soap (plain soap or with an antiseptic), using an antiseptic hand rub (alcohol-based foam or gel hand sanitizer), or performing surgical hand antisepsis. Cleaning your hands reduces the potential spread of deadly germs to patients, the spread of germs, including those resistant to antibiotics, and the risk of healthcare personnel colonization or infection caused by germs received from the patient. Some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep themselves, patients and staff safe. B. Facility policy The Hand Hygiene policy, reviewed 8/19/24, was received from the regional vice president (RVP) on 8/29/24 at 6:49 p.m. It read in pertinent part, Hand hygiene using an alcohol-based hand rub is appropriate before direct patient contact and after contact with inanimate objects in the patient's environment. C. Observations On 8/28/24 at 9:49 a.m, registered nurse (RN) #1 entered room [ROOM NUMBER]. RN #1 knocked on the door, opened the door and touched the resident's call light in the room. RN #1 left the room and began to prepare medications for another resident at the medication cart. -RN #1 failed to perform hand hygiene before entering room [ROOM NUMBER]. -RN #1 failed to perform hand hygiene after interacting with the resident's environment in room [ROOM NUMBER]. On 8/28/24 at 10:45 a.m., certified nurse aide (CNA) #1 was observed assisting Resident #33 to the restroom. -CNA #1 failed to offer Resident #33 hand hygiene after assisting her in the bathroom. On 8/29/24 at 10:31 a.m., CNA #2 was passing clean water cups to residents in their rooms. CNA #2 entered several residents' rooms and replaced the residents' used water cups with clean cups. CNA #2 performed hand hygiene after passing clean water to several rooms. -However, CNA #2 failed to perform hand hygiene before entering and after exiting each residents' rooms. -CNA #2 failed to perform hand hygiene after her hands became contaminated by touching used resident water cups. D. Staff interviews The IP and the DON were interviewed together a second time on 8/29/24 at 3:19 p.m. The IP said staff should perform hand hygiene before entering a resident's room, when they were leaving a resident's room and in between cares in the resident's room as appropriate. The IP said staff should offer to wash a resident's hands after assisting the resident to the bathroom. The IP said staff should wash their hands after interacting with a resident's environment in their room. The DON said nursing staff should offer hand hygiene to residents after they were assisted to the bathroom for toileting. The IP said it was important to promote hand hygiene to prevent the spread of infection in the facility.

Based on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASRR) for two (#20 and #10) of two residents reviewed for PASRR out of 28 sample residents. Specifically, the facility failed to submit a new PASRR Level I after Resident #20 and Resident #10 were admitted to the facility with a provisional PASRR and remained in the facility for more than 30 days. Findings include: I. Facility policy and procedure The Pre-Admission Screening and Resident Review (PASRR) policy, revised [DATE], was provided by the regional director of clinical services (RDCS) #1 on [DATE] at 2:10 p.m. It read in pertinent part, Ensure the Level I PASRR screening has been completed on potential admissions prior to admission. A negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. A record of the pre-screening should be retained in the resident's medical record. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II, which must be conducted prior to admission to a nursing facility. When a Level II PASRR screening is warranted it must be obtained as well as a determination letter prior to admission. The Level II PASRR cannot be conducted by the nursing facility. The Level II PASRR determination and the evaluation report specify services to be provided by the facility or specialized services defined by the state; and, Recommendations from PASRR Level II determination and PASRR evaluation report are to be incorporated into the person-centered care plan as well as in transitions of care. II. Resident #20 A. Resident status Resident #20, age over 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included generalized anxiety disorder, depression, bipolar disorder, cognitive-communication deficit, other symptoms and signs involving cognitive functions and awareness and adjustment disorder with depressed mood. The [DATE] minimum data set (MDS) assessment revealed Resident #20 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #20 was documented as not having any behavioral symptoms. B. Record review Resident #20's care plan, revised [DATE], documented she received Sertraline (antidepressant medication) for her depression and she received Abilify (antipsychotic medication) for behavior management with Resident #20's bipolar disorder. Resident #20's behavioral care plan, revised [DATE], documented the resident had chronic depression and generalized anxiety disorder. Interventions included administering medications as ordered, discussing the resident's fears or concerns as needed, encouraging Resident #20 to talk about her life, offering the resident music, offering one-on-one attention and monitoring for signs and symptoms of depression. A provisional (temporary) PASRR was uploaded into Resident #20's electronic medical record (EMR) on [DATE]. The provisional PASRR read in pertinent part, The review of the submitted PASRR Level I screen resulted in a finding of a known or suspected mental illness and there were indicators for a qualifying provisional admission. The facility is responsible for submitting a new Level I PASRR screen if the member (resident) is anticipated to reside in the facility beyond the approved provisional admission timeline as noted below. Exempted hospital discharge: The need for a nursing home regarding convalescent (recovery) care due to a discharge from an acute care hospital where the rehabilitation care relates to the reason for the hospitalization and has been certified by the attending physician to likely require fewer than 30 days of nursing services. -However, the facility failed to submit a new Level I PASRR screen when the resident remained in the facility longer than 30 days. A PASRR Level I screen was approved for Resident #20 on [DATE] (over six months after the provisional PASRR expired) and documented the resident needed a PASRR Level II due to evidence of a known or suspected PASRR condition which required further evaluation. A PASRR Level II was approved for Resident #20 on [DATE] (during the survey). It documented the following specialized services were required or recommended for Resident #20: Medication review, individual therapy and a further neurocognitive test to verify the diagnosis of a neurocognitive disorder and to establish a baseline. -However, the facility's delay in submitting a new Level I PASRR screen when the resident remained in the facility after 30 days, resulted in a nine-month delay of Resident #20 receiving the recommended individual therapy and neurocognitive testing. III. Resident #10 A. Resident status Resident #10, age over 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included generalized anxiety disorder, unspecified disorder of the brain, dementia with anxiety and unspecified symptoms and signs which involved cognitive functions and awareness. The [DATE] MDS assessment revealed Resident #10 had a severe cognitive impairment with a BIMS score of six out of 15. Resident #10 did not have documented behaviors. B. Record review Resident #10's activity care plan, revised on [DATE], documented the resident had little to no activity involvement due to her anxiety, depression and disinterest. Interventions included the resident preferred to watch television, listen to music, socialize with her hearing aids, family visits and stay up-to-date on current events. Resident #10's care plan, revised on [DATE], documented Resident #10 used Escitalopram (antidepressant medication) for her dementia with anxiety. Interventions included administering antidepressant medication as ordered and monitoring for side effects and effectiveness and educating the resident and family about the risks and benefits of the medication. A provisional PASRR was uploaded into Resident #10's EMR on [DATE]. The provisional PASRR read in pertinent part, The review of the submitted PASRR Level I screen resulted in a finding of a known or suspected mental illness and there were indicators for a qualifying provisional admission. The facility is responsible for submitting a new Level I PASRR screen if the member (resident) is anticipated to reside in the facility beyond the approved provisional admission timeline as noted below. Exempted hospital discharge: The need for a nursing home regarding convalescent (recovery) care due to a discharge from an acute care hospital where the rehabilitation care relates to the reason for the hospitalization and has been certified by the attending physician to likely require fewer than 30 days of nursing services. -The resident's EMR did not reveal that a new PASRR Level I had been submitted by the facility after Resident #10 remained in the facility longer than 30 days. A PASRR Level I screen was submitted for Resident #10 on [DATE] (during the survey). IV. Staff interview The social services director (SSD) was interviewed on [DATE] at 4:25 p.m. The SSD said when residents were admitted to the facility a Level I PASRR screen was completed by the hospital. She said recently the hospital was only completing provisional PASRR screens instead of a Level I PASRR. She said the admissions coordinator reviewed the PASRRs during the time of the resident's admission. The SSD said the provisional PASRR gave her 30 days to submit a new Level I PASRR screen if the resident was not going to be discharged by the end of the 30 days. The SSD said Resident #20 was admitted in [DATE] and she did not have a social services assistant at the time to help her with PASRRs. The SSD said she missed submitting a new Level I PASRR for Resident #20 when the resident remained in the facility longer than 30 days. The SSD said Resident #10 was readmitted to the facility in [DATE]. The SSD said she missed submitting a new Level I PASRR for Resident #10 when the resident remained in the facility longer than 30 days. She said she submitted the new PASRR Level I screen earlier that day ([DATE]). The SSD said she completed an audit of the rest of the residents in the facility (during the survey) and did not find any other PASRRs that were not completed correctly. The SSD said she planned to complete weekly audits to ensure residents had the appropriate PASRRs submitted in a timely manner.

Based on observations, record review and interviews, the facility failed to ensure one (#24) of two residents reviewed for assistance with activities of daily living (ADL) out of 28 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #24 was repositioned timely Findings include: I. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. According to the 8/5/24 minimum data set (MDS)assessment the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. Resident #24 required substantial to maximum assistance with mobility and transfers. B. Observations During a continuous observation on 8/28/24, beginning at 8:47 a.m. and ending at 1:10 p.m. the following was observed: At 8:46 a.m. the resident was assisted away from the table. She was assisted to her room in her tilt back wheelchair. She was sitting in an upright position in her room. At 8:55 a.m. the resident continued to sit in her tilt back wheelchair. The wheelchair was in the upright position. At 9:23 a.m. the resident continued to sit in the same position. Certified nurse aide (CNA) #4 was talking with the resident. CNA #4 did not offer to reposition the resident. At 9:49 a.m. the resident remained in the same position and was sleeping in her chair. At 9:51 a.m. the resident continued to stay in her room in an upright position in her tilt back wheelchair. At 11:05 a.m. CNA #4 asked the resident if she wanted to go to trivia. -She did not offer to reposition Resident #24. The resident continued sitting in the wheelchair in the upright position. At 11:50 a.m. the resident was assisted to the dining room table. At 12:26 p.m. the resident was assisted back to her room. -The resident was not repositioned. At 12:29 p.m. the resident asked CNA #1 to help lay her down. CNA #1 said she would have to wait a bit as she needed to get some help. At 1:10 p.m. CNA #1 assisted the resident to the shower. -Resident #24 was not repositioned from 8:55 a.m. until 1:10 p.m. C. Resident's representative interview Resident #24's representative was interviewed on 8/29/24 at 11:30 a.m. The resident's representative said she had a special chair made which tilted back for Resident #24. She said it tilted back so that way her positioning was changed. D. Record review The skin care plan, revised on 8/18/24, revealed the resident was at risk for break in skin integrity including pressure related injury related to impaired mobility and function, weakness, incontinence, cognitive deficits and risk for malnutrition. Pertinent interventions included assisting Resident #24 with repositioning every two hours and as needed. The Kardex (staff directive for person centered care), dated 8/29/24, documented the resident required extensive assistance of one to two staff members for transfers with the mechanical hoyer lift. E. Staff interviews Registered nurse (RN) #1 was interviewed on 8/28/24 at 12:30 p.m. RN #1 said Resident #24 was unable to move on her own. He said she required assistance from two staff members to transfer and reposition. He said the resident was at risk for skin breakdown because she had lack of mobility and was also incontinent of urine. RN #1 said Resident #24 needed to be repositioned every two hours. The director of rehabilitation (DOR) was interviewed on 8/29/24 at approximately 1:00 p.m. The DOR said Resident #24 had a tilt back wheelchair which was specially ordered. The DOR said titting the wheelchair back helped with the repositioning of the resident and relieved pressure.

Based on observations, record review and interviews, the facility failed to ensure two (#37 and #1) of two residents out of 28 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #37 and Resident #1 received quality care when the residents' physicians did not respond timely after both residents experienced a change of condition. Findings include: I. Professional reference [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1115, read in pertinent part: Effective communication and teamwork are essential for the delivery of high-quality, safe patient care. To avoid communication failures that can lead to unanticipated adverse events in patients, nurses must speak up when they have concerns and take the necessary steps to communicate assertively and collaboratively with the healthcare team. II. Facility policy and procedure The Changes in Resident's Condition or Status policy, revised 8/9/23, was provided by regional director of clinical services (RDCS) #1 on 8/29/24 at 2:10 p.m. It read in pertinent part, This facility will notify the resident, his or her primary care provider and resident representative of changes in the resident's condition or status. III. Resident #37 A. Resident status Resident #37, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included dementia, chronic obstructive pulmonary disease (COPD), occlusion and stenosis of the right carotid artery, cognitive-communication deficit, dysphagia and heart failure. The 5/16/24 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #37 had an impairment to both arms and both legs. B. Record review Resident #37's Medical Orders for Scope of Treatment (MOST) form revealed the resident had a do not resuscitate status, however, the resident was okay with medical treatment at the hospital except for a breathing machine or being admitted into the intensive care unit (ICU). A health status note dated 7/3/24 documented a message was left with the resident's representative and physician because the resident tested positive for COVID-19 and isolation precautions were started. The physician ordered Paxlovid (medication used to treat COVID-19) 150 milligrams (mg). A communication with physician note dated 7/3/24 at 2:43 p.m. documented the nurse left a message for the physician because Resident #37 was unable to take Paxlovid because the resident required her medications to be crushed. According to the facility's pharmacist, Paxlovid could not be crushed. The nurse requested the physician to advise the nurse what the next step was. An infection note dated 7/4/24 documented the resident was on isolation precautions due to being positive for COVID-19. The resident denied pain at the time of the assessment and her vital signs were within her normal limits. The staff provided all care in her room and the plan of care was ongoing. An infection note dated 7/5/24 documented Resident #37 continued on isolation precautions for COVID-19. The resident denied pain at the time of the assessment and her vital signs were within her normal limits. The staff provided all care in her room, placed her call light within reach and the plan of care was ongoing. Another infection note dated 7/5/24 documented the resident continued on alert charting for isolation due to a positive COVID-19 test and all care was provided in her room. The resident's vital signs were within normal limits for the resident. Her vital signs were as follows: blood pressure 121/65, temperature 98.0 degrees Fahrenheit (F), pulse 99, respirations 20 and oxygen saturation 88 percent (%) on room air. A third infection note dated 7/5/24 documented the resident continued on alert charting because she was COVID-19 positive. Resident #37 was weak and on contact isolation precautions. When tolerated by the resident, fluids were offered by staff. The resident was on oxygen at 2 liters per minute (LPM) via nasal cannula and her oxygen saturation was 91%. The resident had an occasional moist cough. -There was no documentation to indicate the physician had been notified Resident #37 was now requiring oxygen and she was exhibiting a moist cough. Review of the July 2024 medication administration record (MAR) revealed Resident #37's morning medications were marked as not administered on 7/6/24 due to the resident appearing to be actively passing (dying). -However, the facility failed to obtain a physician's order to withhold or discontinue Resident #37's medications. An infection note dated 7/6/24 documented the resident continued on alert charting for isolation due to a positive COVID-19 test and all care was provided in her room. The resident's vital signs were within normal limits for the resident. Her vital signs were as follows: blood pressure 137/76, temperature 98.2 degrees Fahrenheit (F), pulse 105, respirations 25 and oxygen saturation 91% on 2 LPM of oxygen. A health status note dated 7/6/24 documented the licensed practical nurse (LPN) spoke to the resident's representative and asked if she wanted the facility to begin comfort medications. The resident's representative refused and requested Tylenol suppositories be given to the resident. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. another health status note dated 7/6/24 documented the LPN spoke to the resident's representative again and informed the representative it looked like Resident #37 was passing. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. A third health status note dated 7/6/24 documented the registered nurse (RN) called the resident's representative and informed her the resident continued to decline. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. Review of the July 2024 MAR revealed Resident #37's evening medications were marked as not administered on 7/6/24 due to the resident appearing to be actively passing. -However, the facility failed to obtain a physician's order to withhold or discontinue Resident #37's medications. Review of the July 2024 MAR revealed Resident #37's morning medications were marked as not administered on 7/7/24 due to the resident appearing to be actively passing. -However, the facility failed to obtain a physician's order to withhold or discontinue Resident #37's medications. An infection note dated 7/7/24 documented the resident was still on active charting due to a positive COVID-19 test. The LPN documented the resident was actively passing away at the time of the note and all care was being provided in her room. Another infection note dated 7/7/24 documented the resident was declining and mouth care was provided in her room. Repositioning and mouth care was provided every two hours and the resident was on scheduled Tylenol via suppository for comfort. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. Review of the July 2024 MAR revealed Resident #37's evening medications were marked as not administered on 7/7/24 due to the resident appearing to be actively passing. -However, the facility failed to have a physician's order to withhold or discontinue Resident #37's medications. Review of the July 2024 MAR revealed Resident #37's morning medications were marked as not administered on 7/8/24 due to the resident appearing to be actively passing. -However, the facility failed to have a physician's order to withhold or discontinue Resident #37's medications. An infection note dated 7/8/24 documented Resident #37 was actively passing away. Her oxygen saturation was 82% on 5 liters of oxygen and her heart rate was 128 beats per minute. -There was no documentation to indicate the physician had been notified that Resident #37 was actively passing away. A progress noted dated 7/8/24 at 10:20 a.m. documented Resident #37 passed away. C. Staff interviews Registered nurse (RN) #2 was interviewed on 8/29/24 at 12:25 p.m. RN #2 said when a medication was ordered and the resident was unable to take the medication, the nurse needed to continue calling the physician until a response was received. RN #2 said she would not have administered the Paxlovid to Resident #37 because it was a choking hazard for the resident to swallow it whole. She said she was not the nurse who took care of Resident #37 so she was not involved when the resident began to decline. RN #2 said if a resident was actively passing away, the nurse needed to call the physician and request an order to withhold or discontinue the resident's medications. RN #2 said a physician's order was needed to hold a resident's medications no matter what the reason was. The director of nursing (DON), infection preventionist (IP) and RDCS #1 were interviewed together on 8/29/24 at 3:47 p.m. RDCS #1 said the nurses were supposed to keep calling the physician until they received guidance or a physician's order. She said the nurse was able to call the facility's medical director if the resident's physician was unable to be reached. The DON said the staff should only withhold residents' medications with a physician's order. The DON said she was unable to explain why a physician's order was not obtained to discontinue Resident #37's medications. Resident #37's primary care physician (PCP) was interviewed on 8/29/24 at 5:35 p.m. The PCP said he received a message from the facility on 7/3/24 which informed him Resident #37 was positive with COVID-19. He said he was informed the resident was unable to take Paxlovid because it was unable to be crushed. He said he discontinued the order for Paxlovid. The PCP said if Resident #37 was unable to take the Paxlovid the facility could have sent her to the emergency room to receive intravenous (IV) Paxlovid but he said he did not recall staff requesting that. -However, review of Resident #37's EMR did not reveal a physician's order to discontinue the Paxlovid or documentation of further communication with the physician after the facility left a message with the PCP informing him Resident #37 could not take Paxlovid because it could not be crushed in order for the resident to swallow the medication (see record review above) The PCP said he was informed on 7/6/24 that Resident #37 appeared to be passing away and the nurses were withholding her medications. He said he usually sent orders for the medications to be discontinued but he was unable to locate the order and was unsure why he could not find the order. -However, review of Resident #37's EMR did not reveal further documentation to indicate the physician had been informed of the resident's continued decline (see record review above). 50314 IV. Resident #1 A. Resident status Resident #1, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 CPO, diagnoses included urinary incontinence, chronic kidney disease and chronic pain. The 8/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required maximum assistance with lower body dressing, toileting and bathing. The assessment documented Resident #1 had no rejections of care. B. Record review The bladder incontinence plan of care, initiated 2/28/24 and revised 8/12/24, revealed interventions including observing for urinary tract infection (UTI) symptoms, including pain, burning, blood tinged urine, cloudiness, dark urine color, no urine output, urinary frequency, foul-smelling urine, fever, chills, changes in behavior, or changes in eating patterns and reporting potential causes of incontinence, including bladder infections. A progress note dated 6/1/24 documented that nursing staff spoke to Resident #1's family members because the resident had experienced an open area on her skin in the perineal area (patch of skin between the anus and the genitals) and the resident appeared to need more assistance with perineal hygiene. A progress note dated 6/3/24 documented that Resident #1's urine culture had no growth in the first 48 hours. The progress note documented that the resident was experiencing several UTI symptoms, including burning and blood, protein and leukocytes (white blood cells) in urine. The progress note further documented the nurse spoke to medical doctor (MD) #1 who informed nursing staff to discuss the matter with MD #2. Nursing staff documented a message was left for MD #2. A fax order request/notification form was documented on 6/3/24 at 6:33 p.m. The fax order documented MD #2 was notified that Resident #1 continued to experience burning while voiding. The form requested a reply from MD #2. -However, review of Resident #1's EMR failed to reveal documentation to indicate MD #2 provided a response to the facility's request. -Additionally, Resident #1's EMR failed to reveal documentation to indicate the facility followed up again with MD #2 when they did not receive a response to their request or contact the medical director when MD #2 did not respond A progress note dated 6/6/24 documented that Resident #1 was experiencing pain with urination, and the resident's skin near the perineal area was excoriated. -Resident #1's EMR failed to reveal documentation to indicate the facility attempted to notify MD #2 again or contact the medical director when MD #2 did not respond. A progress note dated 6/8/24 documented Resident #1 continued to experience pain and burning with urination. The progress note documented a urine dipstick was collected and leukocytes, protein and blood were found in Resident #1's urine. The progress note documented the on-call physician was called four times that day (6/8/24) for nursing staff to obtain an order to send Resident #1's urine to the lab, however, the nursing staff was unable to reach the on-call physician. The progress note documented that nursing staff encouraged Resident #1 to drink water. -Review of Resident #1's EMR revealed there was no further documentation regarding the resident's UTI symptoms or follow-up with a physician from 6/8/24 until 7/6/24. A provider visit note dated 7/6/24 documented that Resident #1 had experienced UTIs chronically. The provider visit note documented Resident #1 reported urinary burning symptoms and the nursing staff reported that the resident had been complaining of burning upon urination. The provider note documented the resident's skin excoriation could also be a cause for the burning pain. -However, a urinalysis completed two days after this visit (on 7/8/24) documented the resident had two different types of bacteria present in her urinary tract (see final urinalysis results below). A progress note dated 7/8/24 documented a urinalysis was completed for Resident #1. The progress note documented the resident had many indications of a urinary tract infection, including an elevated white blood cell count, elevated leukocytes and the presence of mucus, bacteria and epithelial (skin) bacteria. A progress note dated 7/10/24 documented that Resident #1's urinalysis contained two separate bacterial colonies. These colonies included Klebsiella Pneumoniae and another unidentified bacteria. The progress note documented the results were faxed to MD #1. A progress note dated 7/11/24 documented that Resident #1's final urinalysis results were completed and the resident had a Klebsiella Pneumoniae infection and an Escherichia coli (E. coli) infection in her urine. The progress note documented that the results were reviewed by MD #3, who ordered an antibiotic. A review of the July 2024 revealed a physician's order for Cefpodoxime Proxetil (antibiotic) oral tablet 100 milligrams (mg), give 100 mg by mouth two times per day for UTI for 7 (seven) days, ordered 7/12/24 at 7:00 p.m. A progress note dated 7/13/24 documented that Resident #1 was started on antibiotic therapy on 7/13/24 for a UTI. -The facility failed to ensure appropriate physician follow-up was provided between 6/3/24 and 7/6/24 to appropriately address Resident #1's UTI symptoms in a timely manner. C. Staff interviews RN #1 was interviewed on 8/27/24 at 3:58 p.m. RN #1 said Resident #1 had experienced several infections in the last year . RN #1 said Resident #1's infections had mostly been UTIs and nursing staff knew to report the resident's symptoms to the physician when Resident #1 felt pain or burning with urination. Certified nurse aide (CNA) #1 was interviewed on 8/28/24 at 1:22 p.m. CNA #1 said Resident #1 required maximal assistance with toileting and perineal care. CNA #1 said Resident #1 had experienced several UTIs in the past year (2023 to 2024) and nursing staff was watching her closely for any signs or symptoms of UTIs. CNA #1 said Resident #1 had no rejections of care. The IP and the DON were interviewed together on 8/29/24 at 3:19 p.m. The IP said it was important for nursing staff to recognize signs and symptoms of infection and report them to the physician. The DON said she expected physicians and nursing staff to communicate when nursing staff identified new symptoms of infection in residents. The DON said the facility had experienced difficulties with physician communication and the facility was currently transitioning to work with a new group of physician partners in the future. The DON said she was unsure why it took more than a month for a provider to further investigate Resident #1's UTI symptoms.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#26) of one resident reviewed for hearing and vision problems out of 28 sample residents. Specifically, the facility failed to ensure Resident #26 was assisted to receive a replacement hearing aid after her right hearing aid was lost. Findings include: I. Resident #26 A. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included hearing loss of both ears, macular degeneration and anxiety disorder. The 6/10/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment documented the resident had moderate difficulty hearing and required the use of hearing aides. B. Resident Observations On 8/26/24 at 3:51 p.m. Resident #26 was wearing one hearing aid in her left ear and no hearing aid in her right ear. On 8/27/24 at 9:41 Resident #26 was wearing one hearing aid in her left ear and no hearing aid in her right ear. On 8/28/24 at 1:44 p.m. Resident #26 was wearing one hearing aid in her left ear and no hearing aid in her right ear. C. Resident interview Resident #26 was interviewed on 8/26/24 at 3:51 p.m. Resident #26 said she only had one hearing aid in her left ear. Resident #26 said her right hearing aid was lost by the facility a long time ago. Resident #26 said the facility told her they would replace it but the facility never replaced it. Resident #26 said she had low vision and having low vision with one missing hearing aid made it very difficult for her to interact with other residents, family members and staff. Resident #26 said she was frustrated the facility had not assisted her in replacing her hearing aid. D. Record review A facility incident report form was provided by the nursing home administrator (NHA) on 8/27/24 at 3:11 p.m. The facility incident report form documented that Resident #26 reported her hearing aid was missing on 6/27/24 at 8:55 a.m. The incident report form documented that the facility would replace one lost hearing aid. The incident report form documented that this information was shared with Resident #26 on 8/8/24. -However, Resident #26 reported the facility had not replaced the hearing aid as of 8/26/24. (see interview above) A progress notes dated 8/29/24 (during the survey) documented a staff member spoke to the audiology clinic and Resident #26's hearing aid would be replaced. -However, the facility failed to attempt to replace the hearing aid for more than two months after it was reported missing. E. Staff Interviews The social service director (SSD) was interviewed on 8/27/24 at 1:25 p.m. The SSD said she was not involved in Resident #26's investigation concerning her hearing aid. The SSD said the NHA completed all investigations of missing property and would only involve the SSD upon request. The SSD said she did not know the current status of replacing Resident #26's hearing aid that was lost. The NHA was interviewed on 8/27/24 at 1:44 p.m. The NHA said Resident #26 was missing one hearing aid and the facility offered to replace it. The NHA said she completed the investigation into the hearing aid. The NHA said the hearing aid had not been replaced yet because the facility was experiencing logistical problems with reaching the audiology clinic. The NHA said she did not have documentation that the facility attempted to get Resident #26's hearing aid replaced. The NHA was interviewed again on 8/29/24 at 3:41 p.m. The NHA said the facility's transportation driver was able to get ahold of the audiology clinic today (8/29/24) to discuss replacing Resident #26's hearing aid. The NHA said the facility would implement a call log so the facility could document when calls were made to other care partners on behalf of resident care.

Based on observations, record review and interviews, the facility failed to ensure that residents who entered the facility without limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#24) of four residents out of 28 sample residents. Specifically, the facility failed to ensure Resident #24 received passive range of motion (PROM) to prevent potential decline in her mobility. Findings include: I. Facility policy The Restorative policy, revised 8/7/21, was received on 8/28/24 at 5:44 p.m. from regional director of clinical services (RDCS) #2. It read in pertinent part, To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring a resident's assessments and indicators. Nursing assistants must be trained in techniques that promote resident involvement in restorative activities. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities on activities of daily living do not diminish, this includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living. A resident may be started on a restorative nursing program when he or she is admitted with restorative needs. Restorative nursing functions can be within one of the following categories: range of motion (active and passive), splint or brace assistance, bed mobility, transfers, walking, dressing and or grooming, eating and or swallowing, amputation/prosthesis care, communication, toileting program, bladder retraining. II. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. The 8/5/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. The resident required substantial to maximum assistance with mobility and transfers. The MDS assessment revealed Resident #24 was not on a restorative program and was not receiving range of motion. B. Observations On 8/28/24 at 1:10 p.m. Resident #24 was transferred from the wheelchair to the shower chair with a hoyer mechanical lift. C. Resident representative interview The resident's representative was interviewed on 8/29/24 at 11:30 a.m. The representative said she had been asking for the resident to receive therapy and range of motion. She said Resident #24 had declined in her mobility. She said when the resident was admitted to the facility she was able to walk. The representative said the resident recently had a decline in mobility and was now being transferred from bed/wheelchair using a mechanical lift. The representative said she knew there had been some orders for therapy but she said she was never invited to come and be with the resident and encourage her participation in therapy when the therapists approached her. She said Resident #24 was responsive to her. D. Record review Resident #24's activities of daily living (ADL) care plan, updated 8/13/24, revealed the resident had a self-care performance deficit related to encephalopathy, weakness and cognitive deficits. The resident required extensive assistance of two staff members with personal hygiene. Pertinent interventions included having Resident #24 participate to the fullest extent possible with each interaction -The care plan did not indicate the resident was receiving range of motion exercises for her upper or lower extremities. The Kardex (tool utilized by staff to provide consistent resident care)dated 8/29/24 documented the resident required extensive assistance of one to two staff members for bed mobility. The Kardex directed extensive assistance by two staff members for transfers with a mechanical hoyer lift. A physical therapy (PT) note dated 4/30/24 documented PT services were offered but the resident said she wanted to wait until tomorrow. -The note failed to document if more than one attempt was made to offer the resident PT. A PT note dated 5/9/24 documented the resident was offered PT and the resident refused. -The note failed to document if more than one attempt was made to offer the resident PT. A nurse progress note dated 6/11/24 documented the resident was using the mechanical hoyer lift for transfers. The resident was no longer able to use the sit to stand lift for transfers. A therapy progress note, dated 8/8/24 and written by the director of rehabilitation (DOR), documented Resident #24 was offered therapy to improve her transfers but the resident said she wanted to sleep. -The note failed to document if more than one attempt was made to offer the resident therapy. -Review of Resident #24's electronic medical record (EMR) failed to reveal the resident had a restorative program plan which was individualized and included passive range of motion for both lower and upper bilateral extremities for her limited range of motion. -The EMR further revealed there were no baseline assessments of the resident's range of motion of either her upper and lower extremities. E. Staff interviews The director of nursing (DON) was interviewed on 8/29/24 at approximately 1:00 p.m. The DON said Resident #24 had had a decline in mobility and she was being transferred using a hoyer mechanical lift. She said the resident was not on a restorative program. She said that there was no PROM program for the resident because one would have to be written by the therapy program. She said the resident's arms were extended when she was dressed. The director of rehabilitation (DOR) was interviewed on 8/29/24 at 1:15 p.m. The DOR said Resident #24 was not on any restorative program. He said he could not develop a restorative program unless the resident was seen by a licensed therapist. He said the resident had declined therapy services in the past when they attempted. He said he had asked for the resident's representative to come to the facility when the resident was offered therapy and she had declined. -However, the representative said she had not been invited to come to the facility when the therapist approached the resident (see resident's representative interview above). -Additionally, there was no documentation in Resident #24's EMR to indicate the DOR had asked the resident's representative to come to the facility when the therapists attempted to provide therapy for the resident. -The DOR said the therapy department only did baseline assessments for range of motion on residents who had been on therapy services. He said he did not know who completed the baseline range of motion assessments for residents who were not on therapy services. The physical therapist assistant (PTA) was interviewed on 8/28/24 at 11:51 a.m. The PTA said the facility did not have a restorative program. Certified nurse aide (CNA) #6 was interviewed on 8/28/24 at 4:25 p.m. CNA #6 said the facility did not have a restorative program. She said there were no individual plans for PROM for residents. She said physical therapy worked with the residents. CNA #1 was interviewed on 8/28/24 at 4:28 p.m. CNA #1 said she did not know anything about a restorative program but did say that residents who went to activities would sometimes play with pool noodles for exercise. CNA #7 was interviewed on 8/28/24 at 4:29 p.m. CNA #7 said she did not perform range of motion with residents. She said there were not any residents who had individualized restorative program plans. She said only therapy was involved with range of motion for residents. The director of nursing (DON) was interviewed on 8/28/24 at 4:41 p.m. The DON said the facility did not have a restorative program anymore. She said the facility would like to reinstate it at some time but the facility currently did not have enough staff to complete restorative programs.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for one out of five staff reviewed. Specifically, the facility did not complete an annual performance review and/or provide regular in-service education based on the outcome of the review for certified nurse aide (CNA) #2. Findings include: I. Record review CNA #2 (hired on 6/22/22) did not have an annual performance review completed. CNA #2 did not have an in-service education plan based on the outcome of the review. II. Staff interviews The nursing home administrator (NHA) was interviewed on 8/29/24 at 10:11 a.m. The NHA said she completed performance evaluations for CNAs in the facility. The NHA said CNA #2 had been out of the country between January 2024 and April 2024 and was currently a PRN (as needed) employee. The NHA said CNA #2 had worked in the facility in April 2024 after returning to the United States on 4/19/24. The NHA said CNA #2 had not had a performance evaluation or in-service education based on the outcome of that review. The NHA said she would do monthly audits moving forward to ensure all CNAs in the facility received timely annual evaluations.

Based on observations, record review and interviews, the facility failed to ensure that one (#241) of five residents out of 28 sample residents were free from unnecessary medications. Specifically, the facility failed to ensure as needed (PRN) physician's orders for psychotropic drugs were limited to 14 days unless the physician provided a rationale for extended use. Findings include: I. Resident #241 A. Resident Status Resident #241, age 79, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur (break in the femur), unspecified dementia, severe, unspecified osteoarthritis (arthritis) and history of falling. The 7/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The resident required setup and clean up assistance for meals, partial assistance with bathing, toileting and upper body dressing and needed substantial assistance with lower body dressing. B. Observations On 8/26/24 at 10:09 a.m. Resident #241 was heard calling out, Please help me. On 8/27/24 during a continuous observation, beginning at 12:41 p.m. and ending at 3:18 p.m., the resident did not exhibit any behaviors or calling out. On 8/28/24 at 9:01 a.m. Resident #241 was heard calling out, I have to go to the bathroom, I can't do this, oh dear God please help me, this is too much! An unidentified certified nurse aide (CNA) walked by but did not check on the resident. On 8/28/24 at 9:05 a.m. the resident stopped calling out. On 8/28/24 at 9:22 a.m. the resident was heard calling out, Please help, I can't do this anymore, please don't ignore me! An unidentified CNA and nurse went into her room and closed the door. C. Record review Review of Resident #241's comprehensive care plan, initiated 7/15/24, revealed a care plan focus area for the use of anti-anxiety medications. Pertinent interventions included administering anti-anxiety medications as ordered by the physician, monitoring/documenting side effects and effectiveness of the medication every shift, monitoring/documenting/reporting as needed any adverse reactions to anti-anxiety therapy, changes in behavior/mood/cognition and hallucinations/delusions. The August 2024 CPO revealed the following physician's order for Lorazepam: Lorazepam oral concentrate 2 milligrams (mg)/milliliter (ml) every eight hours as needed for anxiety until 11/1/24, ordered 8/27/24. Review of Resident #241's electronic medical record (EMR) failed to reveal documentation for physician's rationale for the extended use of the PRN lorazepam beyond 14 days. II. Staff interview The director of nursing (DON) was interviewed on 8/29/24 at p.m. The DON said she was aware PRN psychotropic drugs were to not be given past 14 days without a documented physician's rationale. She said she was not aware there was no rationale documented by the physician for the extended use of Resident #241's PRN lorazepam.

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for two out of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to ensure CNA #2 and CNA #3 received 12 hours of continuing education annually. Findings include: I. Training record review Five randomly selected CNA training records were reviewed on 8/27/24. Of the five CNAs reviewed, CNA #2 and CNA #3 did not receive 12 hours of annual training. A. CNA #2 -CNA #2, hired on 6/22/22, had participated in 10 hours and 30 minutes of training during the annual training year. B. CNA #3 -CNA #3, hired on 6/11/14, had participated in 10 hours and 30 minutes of training during the annual training year. II. Staff interviews The nursing home administrator (NHA) was interviewed on 8/28/24 at 11:27 a.m. The NHA said she kept the records for the annual staff training and verified that all of the staff members received appropriate training in the facility. The NHA said she had recorded 10.5 hours of CNA training for CNA #2 and CNA #3, which also included dementia and abuse training. The NHA said it was important for CNAs to complete their annual training to stay updated on current bedside skills and education. The NHA said she would conduct an audit in the facility to ensure all staff had completed training appropriately moving forward.

Based on observations, record review and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Findings include: I. Observations Observations in the facility on 8/26/24 at 8:38 a.m. revealed the staff posting was dated 7/18/24. The posting was located near the main nurse's station outside of the dining room. Observations in the facility on 8/26/24 at 11:07 a.m. revealed the staff posting was dated 7/18/24. The posting was located near the main nurse's station outside of the dining room. II. Staff interview The director of nursing (DON) was interviewed on 8/26/24 at 11:10 a.m. The DON said the current staffing posted was dated 7/18/24. The DON said the central supply staff member was responsible for posting the updated nurse staff posting in the facility. The DON said the central supply staff member who normally updated nurse staff posting was on vacation and that the staff posting had not been updated in the facility after 7/18/24. The DON said it was important to have updated staffing posted so visitors, residents and other staff members knew how many staff members were working in the facility.

Based on observations, interviews and record review, the facility failed to ensure five (#1, #2, #3, #4 and #5) of seven sample residents remained free from abuse from staff or other residents. Specifically, Resident #1 was involved in five abuse incidents within three months. One incident involved her mistreatment by registered nurse (RN) #2 on 5/15/23, and four incidents involved Resident #1 abusing Resident #4 on 3/31/23, Resident #2 on 5/26/23, Resident #3 on 5/26/23 and Resident #5 on 6/9/23. All the residents lived in the secure unit at the time of the abuse incidents. Resident #1 was being combative to staff on 5/15/23. RN #2 actions in response to Resident #1's behavior included aggressively pulling Resident #1 to take her to the bathroom, forcing Resident #1 to sit down and grabbing Resident #1 by both shoulders and pushed her backwards approximately six feet. The facility's failure to protect residents from abuse resulted in Resident #1 striking Resident #2 with a closed fist on 5/26/23, causing a split lip and bleeding. Afterward, Resident #2 was moved to a different unit for the weekend because, per nursing progress notes, she was scared and thought someone was going to hurt her again. Cross-reference F744, dementia care Findings include: I. Facility policies and procedures The Abuse Prevention policy, dated 10/4/22, was provided by the nursing home administrator (NHA) on 7/5/23. It read in pertinent part: It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of residents' property, and exploitation. Identify, correct, and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of residents' property is more likely to occur to include trained and qualified staff, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Provide staff information on how and to whom they report concerns without the fear of retribution; and provide feedback regarding the concerns they have expressed. The Abuse In-Service Training policy dated 10/4/22 was provided by the NHA on 7/5/23. It read in pertinent part: The facility will maintain an effective training program for all staff, which includes, at a minimum training on abuse, neglect, exploitation, misappropriation of residents' property and effective as determined by staff need and the facility's assessment. II. Resident status A. Resident #1 Resident #1, age 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease with early onset, dementia moderate with agitation, anxiety disorder, restlessness and agitation and other conduct disorder (behavioral and emotional disorders with onset that occurred in childhood or adolescence). The 5/26/23 minimum data set (MDS) assessment showed the resident had cognitive impairment with a brief interview for mental status (BIMS) score that was undetermined due to the assessment not being able to be completed by the resident. The resident had short-term and long-term memory impairment and the resident was severely impaired to make decisions regarding tasks of daily life. B. Resident #2 Resident #2, age 97, was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included dementia with unspecified severity. The 4/7/23 MDS assessment showed the resident had severe cognitive impairment with a BIMS score of four out of 15. C. Resident #3 Resident #3, age 88, was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included Alzheimer's disease, major depressive disorder, delusional disorder (persistent hallucinatory voices or schizophrenic symptoms that do not justify a diagnosis of schizophrenia), restlessness and agitation, other conduct disorder (behavioral and emotional disorders with onset that occurred in childhood or adolescence) and dementia. The 6/12/23 MDS assessment showed the resident had a severe cognitive impairment with a BIMS score of two out of 15. D. Resident #4 Resident #4, age 69, was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included Alzheimer's disease, dementia, hallucinations, anxiety, and other recurrent depressive disorders (recurring episodes of depression, persistent sadness, loss of interest in activities, fatigue, worthlessness and difficulties in concentration). The 5/26/23 MDS assessment showed the resident had cognitive impairment with a BIMS score that was undetermined due to the assessment not being able to be completed by the resident. The resident had short-term and long-term memory impairment and the resident was severely impaired to make decisions regarding tasks of daily life. E. Resident #5 Resident #5, age 83, was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included Alzheimer's disease, dementia, and major depressive disorder. The 4/28/23 MDS assessment showed the resident had severe cognitive impairment with a BIMS score of four out of 15. III. Abuse incidents Review of facility investigative reports revealed the following incidents involving Resident #1: A. Physical abuse investigation #1-Resident #1 abused Resident #4 On 3/31/23 at 2:10 p.m. Resident #1 was walking around the day room. Resident #1 walked up to Resident #4 who was resting in a recliner. Resident #1 pulled the blanket off of Resident #4 and smacked her on her right thigh. The smack was audibly loud which caught the staff's attention. Resident #1 was redirected to the hallway. A registered nurse (RN) assessed Resident #4 and noted no injuries. Resident #4 slept during the incident and assessment. An interdisciplinary team (IDT) meeting was conducted on 4/5/23. Findings from the investigation included substantiated physical abuse. The facility rearranged the furniture in the day room and Resident #4 was moved to a different bedroom. If staff saw Resident #1 approach other residents staff needed to redirect her to another area or activity. B. Physical abuse investigation #2-registered nurse (RN) #2 abused Resident #1 On 5/15/23 at 2:30 p.m. Resident #1 was combative towards staff who provided care throughout the morning. RN #2 attempted to toilet the resident with a certified nurse aide (CNA) #2. RN #2 was witnessed aggressively pulling Resident #1 to her feet to take her to the bathroom. The resident became combative. After she received care, Resident #1 began pacing the unit as normal. RN #2 forced Resident #1 to sit down to put her socks on. Resident #1 became combative and RN #2 was angrier. Resident #1 walked toward another resident who sat in a recliner in the day room. RN #2 was witnessed grabbing the resident by both shoulders and pushed her backwards, approximately six feet, into a chair. RN #2 was heard yelling at the resident but CNA #2 did not see what happened. CNA #2 heard RN #2 yell Resident #1 you can not do that! Why did you do that? An activity assistant (AA) had witnessed part of the incident. An investigation occurred on 5/16/23 and the facility determined potential caregiver burnout, continually approaching resident was agitated instead of safely providing space and monitoring. The interventions listed the three staff involved were suspended pending investigation and educated caregivers on abuse, abuse procedures, and the facility provided different formats of abuse training (reading material and hands-on or visual). RN #2 was terminated following the investigation and the staff who witnessed the incident were provided final written warnings for failure to report in a timely manner and failure to stop the abuse in the moment. The allegation was substantiated and no injuries to the resident were documented. C. Physical abuse investigation #3-Resident #1 abused Resident #2 On 5/26/23 at 4:10 p.m. Resident #1 walked past Resident #2 and got caught up in Resident #2's feet. Resident #1 got upset and pointed her finger at Resident #2. Resident #2 slapped Resident #1's hand and Resident #1 punched Resident #2 in the nose and lip area which caused a split lip and bleeding. Staff said it happened too fast and they could not intervene in time. Resident #1 had sustained no injuries and Resident #2 sustained a superficial lip abrasion and a mucosa (gums) injury to the lower lip. D. Physical abuse investigation #4-Resident #1 abused Resident #3 On 5/26/23 at 4:10 p.m. Resident #1 immediately approached Resident #3 after the altercation moments before (see above) and slapped her on the back near her shoulders. No injuries noted. The facility placed Resident #1 with a caregiver for one-to-one supervision and Resident #2 and Resident #3 were moved to another part of the facility. Resident #1 ended up being sent to the emergency room for a medical workup and behavior management. Resident #1 was diagnosed with a urinary tract infection (UTI) while at the hospital. When Resident #1 returned from the hospital on 5/27/23 she was placed on one-to-one supervision during waking hours. Recliners were relocated to an area of the day room that were not in a walking path. E. Physical abuse investigation #5-Resident #1 abused Resident #5 On 6/9/23 at 9:30 a.m. Resident #1 approached another resident who was in a recliner in the day room. A CNA was assigned as Resident #1's one-to-one supervision and prevented Resident #1 from having an incident with the resident in the recliner. While she was being redirected Resident #1 turned and yanked a blanket off of Resident #5 who sat nearby and kicked him in the shin. Resident #1 was removed from the area and Resident #5 had no noted injuries. The investigation began at 9:35 a.m. after the incident. One-to-one supervision was continued with Resident #1. The facility had located a geriatric psychiatric facility in another city. The facility sent Resident #1 to the hospital to initiate the requirements to be transferred. IV. Record review Review of nursing progress notes revealed the following negative outcomes to Resident #2 after the 5/26/23 abuse incident: On 5/27/23 at 2:58 a.m. nursing documented, Resident (#2) was moved to 200 hall during the night. Resident was scared and thought someone was going to hurt her again. Resident was reassured that she is safe. Resident was sat in recliner in TV room and has remained there for the rest of the night. Resident's upper lip remains swollen and red on the underside. No bleeding noted. On 5/27/23 at 2:58 a.m. nursing documented, Resident was moved to 200 hall during the night. Resident was scared and thought someone was going to hurt her again. Resident was reassured that she is safe. Resident was sat in recliner in TV room and has remained there for the rest of the night. Resident's upper lip remains swollen and red on the underside. No bleeding noted. On 5/27/23 at 9:35 a.m. the resident's son was called regarding the resident being moved to a different hall. He expressed anger about this move, stating that he felt the other person involved in the aggression incident on 5/26/23 should be moved, not his mother. He requested to speak with the SSD. On 5/27/23 at 10:12 a.m., Resident in 200 hall for weekend. (Physician) called facility asking why this resident was moved and not the other (Resident #1). This nurse explained that Resident #1 was more likely to exit seek and display aggression if moved and that this situation was temporary until management found more permanent solutions. (Physician) said he would visit facility morning of 5/27/23. On 5/27/23 at 10:57 a.m., Physician here and assessed this resident for her injuries from her recent altercation. (Physician) did call the ED and gave this nurse an order to return this resident to her normal hall on 400 and to monitor her mouth for her bruising. Resident #2 was moved back to her room on the 400 hall per the physician's order at 11:18 a.m. On 5/27/23 at 2:50 p.m., Resident #2's upper and lower lips were reddened and swollen, but she did not complain of pain and ate and drank with no apparent difficulty. The physician reported superficial abrasion of upper lip and healing mucosal injury of lower lip. Also reports necrotic lower left incisor but saw no evidence of dental or jaw injury. No acute changes in VS or behavior. Will continue to monitor. On 5/30/23 at 10:52 a.m., Resident #2's mouth is swollen and appears tender when eating breakfast this AM, Scheduled APAP administered with therapeutic effect noted. -Although Resident #2 had care plans initiated on 1/2/2020 regarding dementia and aggression, no care plan revisions were documented after the 5/26/23 incident with Resident #1. A copy of in-service training was provided by the NHA on 7/5/23, titled Incident documentation of Victim and Assailant in March 2023. The in-service said Please remember when resident-to-resident incidents occur (physical or verbal aggression) a 'risk management' must be completed for both residents-the resident who initiated the aggression and the resident who received the aggression. Both residents must be placed on alert charting and all parties-respective physicians, family/POAs (power of attorney), and on-call must be notified. A copy of in-service training was provided by the NHA on 7/5/23, titled Abuse Training. It showed staff were trained on different types of abuse (verbal, physical, sexual, mental, seclusion, neglect and misappropriation of funds) in May 2023. The in-service explained the different types of abuse. The training walked staff through the process of reporting abuse and how to keep the victim safe. A copy of in-service training was provided by the NHA on 7/5/23, titled Survey 2023 education review (only the year was dated). The training explained previous citations, which included residents' right to be free from abuse and the reporting process for any abuse that occurred in the facility. V. Observations Observations on 7/5/23 from 10:30 a.m. to 5:00 p.m. revealed Resident #1 received one-to-one supervision from staff. With the first observation in the morning, she was walking in the hallway with a staff member. During the afternoon she was observed in her room lying in her bed, sleeping off and on. She did not enter the common areas or interact with other residents. VI. Staff interviews The social services director (SSD) was interviewed on 7/5/23 at 12:29 p.m. She said Resident #1 was not on any medications at the time of admission, she just wandered and never went to the secure unit doors. She might walk up to a door and push on it but she was not trying to get out. She would visit the SSD in her office frequently. She always had word salad. She might say my mom, grandma was mad, or the boys (her brothers). Staff would ask her a question and she might answer yes or no appropriately, otherwise she would have word salad and talk about family incoherently. The SSD said when Resident #1 first walked up to a resident, it was in a loving way and just since February 2023 it became aggressive. The facility moved the recliners to one path because she would bump into the footrests if residents were reclined and startle them. The SSD recalled one incident where she bumped into the footrest and Resident #2 in the recliner said something to her. Resident #1 pointed her finger and then Resident #1 got slapped so in turn she defended herself and punched Resident #2. Resident #1 still walked up to the SSD and gave her a hug. If she seemed irritated like she did not want a hug the SSD would back off. If she would stop in the office doorway the SSD said are you here to give me a hug today? Resident #1 laughed and hugged me. The SSD said Resident #1 had completed brain scans and other tests prior to admission and they did not know what caused her to have this early-onset Alzheimer's disease. She was supposed to have a telehealth appointment on 7/5/23 (which had to be rescheduled) to discuss her psychiatric needs and medications. She was always combative with care. She might start out combative but some staff had been able to talk her through it or she allowed staff to provide care. When staff allowed Resident #1 to assist in her care she was less combative. The SSD helped with in-servicing staff on how to provide care to Resident #1. The SSD was provided with dementia training and she provided it to staff during orientation. She also reminded staff if they needed a break or to tap out, they needed to inform someone. She said going forward the facility planned to figure out what Resident #1 needed and for staff to be more aware. Resident #1 had not had an altercation since she returned from the hospital on 7/5/23 and her last altercation with another resident was on 6/9/23. The SSD said all incidents were avoidable but the facility and staff learned something from each incident. The physical therapy assistant (PTA) was interviewed on 7/5/23 at 2:35 p.m. The PTA was assigned as Resident #1's one-to-one supervision for the day and it was his third time providing supervision to Resident #1. He stated Resident #1 had been sleepier since she returned from the hospital on 5/27/23. She had not been aggressive towards other residents since her return either. Resident #1 directed where she wanted to pace and the PTA would only intervene if she was close to someone else or if she were going to trip. He thought there had been a few different altercations with Resident #1 as the aggressor but was unsure of the extent of any injuries. Resident #1 usually attacked staff but recently she attacked staff less. CNA #1 was interviewed on 7/5/23 at 2:50 p.m. CNA #1 said Resident #1 was sleeping most of the day but sometimes she would stand up, eat, use the bathroom, and would lie back down. She kicked staff and hit Resident #2 in the mouth while she slept. CNA #1 said it helped that the resident had one-to-one supervision. When she was with her one-to-one staff she would aggress less toward other residents. When Resident #1 was first admitted to the facility she paced and was nice to everyone, but later she walked up to people and smacked or kicked them. When Resident #1 was admitted she did not have many aggressive behaviors and participated in activities but everything changed. CNA #1 said she approached the resident and comforted her before providing care. If she refused CNA #1 grabbed the RN or another CNA for help. RN #1 was interviewed on 7/5/23 at 3:10 p.m. RN #1 said Resident #1's doctor wanted to lower psychiatric medications but they could not make those changes until they had the intake completed. The telehealth appointment scheduled for 7/5/23 had to be rescheduled due to the wrong phone number being used by the doctor's office. The appointment was rescheduled for the following week. The one-to-one supervision was initiated on 5/27/23, according to the resident's care plan. RN #1 said the staff looked at the history of Resident #1 and what they knew about her to identify triggers however, her unpredictability made it difficult. Staff modified their approach for Resident #1. Resident #1 did not comprehend instructions due to early-onset Alzheimer's disease. Staff asked the resident if she wanted to help with care or walked her through the task so she could try to understand the task staff completed. RN #1 said sometimes the resident had enough lucidity to comprehend but most of the time she did not, distractions helped the most. Sometimes the best approach when she was sitting soiled was to just get it done. RN #1 got on her level and said I know you do not want to do this but we have to and RN #1 got it done as quickly as possible. RN #1 believed validating the resident's feelings helped, she would still hit staff but the task needed to be completed. RN #1 said her behaviors could be caused by her medications or the progression of Alzheimer's disease, but she was not sure. RN #1 spoke about the incident which referred to a staff being the aggressor towards Resident #1 and that everyone had a breaking point. The staff needed to know their breaking point so they could be relieved for a break. RN #1 said the facility reached out to other providers to find a better placement for Resident #1. It (care) started with caregivers, we needed to make sure staff were not the source of the abuse. RN #1 said staff would be Resident #1's shadow, if she paced, staff would follow where she could not see them and only intervened when she walked towards another resident. The nursing home administrator (NHA) was interviewed on 7/5/23 at 4:28 p.m. She said Resident #1 was scheduled for a full medication review the following day (7/6/23) where the pharmacist would attend. A pharmacy review was completed in early June 2023. She said the physicians did not necessarily know how to treat Resident #1 so they did not know how to complete medication changes. The NHA was urgently seeking placement on the front range for geriatric psychiatry care. The NHA had searched for dementia training for combative behaviors. She said outside help was what the facility needed for resources and training. At first the resident was combative with care but turned to aggression and it was attributed to the medications she was on. The facility looked for assistance to get the right medications for Resident #1 since the facility could not locate a happy medium with the medications. The NHA said Resident #1 would remain on one-to-one supervision indefinitely.

Based on record review, observations and interviews, the facility failed to provide dementia care services for five (#1, #2, #3, #4 and #5) out of seven sample residents to ensure they reached their highest practicable well-being. Specifically, the facility failed to identify and implement effective approaches to engage Resident #1 in life in the facility and ensure her psychosocial needs were met and aggressive behavioral symptoms did not affect and harm others. The facility further failed to ensure Residents #2, #3, #4 and #5 received personalized dementia care services in an environment where they were engaged and safe in their home. Cross-reference F600 free from abuse Findings include: I. Facility policy and procedures The Care of the Cognitively Impaired (Dementia Care) policy, provided by the nursing home administrator (NHA) at 5:30 p.m. on [DATE], included the following: The facility will provide dementia treatment and services which may include but are not limited to the following: -Ensuring adequate medical care, diagnosis, and supports based on diagnosis; -Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety; and -Utilizing individualized, non-pharmacological approaches to care (e.g. purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. II. Resident #1 A. Resident status Resident #1, age 65, was admitted on [DATE] and readmitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included Alzheimer ' s disease with early onset, dementia moderate with agitation, anxiety disorder, restlessness and agitation, and other conduct disorder (behavioral and emotional disorders with onset that occurred in childhood or adolescence). The [DATE] minimum data set (MDS) assessment showed the resident had cognitive impairment with a brief interview for mental status (BIMS) score that was undetermined due to the assessment not being able to be completed by the resident. The resident had short-term and long-term memory impairment and the resident was severely impaired to make decisions regarding tasks of daily life. B. Abuse incidents Resident #1 was involved in five documented abuse incidents within three months (cross-reference F600). She abused Resident #4 on [DATE], was abused by registered nurse (RN) #2 on [DATE], abused Resident #2 and Resident #3 in two incidents on [DATE] and abused Resident #5 on [DATE]. C. Observations Resident #1 was observed with one-to-one supervision from a physical therapy assistant (PTA) on [DATE] between 10:45 a.m. to 6:00 p.m. At 10:47 a.m. Resident #1 approached another female resident who was lying back in her recliner but the PTA intervened before she got too close. At 11:05 a.m. she was lying on mattresses on her bedroom floor trying to nap. At 12:24 p.m. she was asleep and had not been served lunch. Her nurse said she had a late breakfast and they would assist Resident #1 with lunch when she woke up. Staff said in interviews (see below) that she was on one-to-one supervision indefinitely due to resident-to-resident abuse incidents. Resident #1 was pacing the hallways on the morning of [DATE] and lying in bed sleeping off and on during the afternoon. D. Record review Resident #1's care plan, initiated on [DATE] and revised on [DATE], identified behaviors of exit seeking/wandering, restlessness, verbal aggression, physical aggression, resistance to care, agitation, frustration with others, unprovoked aggression towards residents and staff and generalized anxiety related to depression and dementia with behaviors. Interventions were: -One-to-one (1:1) supervision for safety during the daytime hours (initiated [DATE]); -Administer medications as ordered; -Anticipate and meet Resident #1's needs; -Assist Resident #1 to develop more appropriate methods of coping and interacting during hours of peak behaviors. Encourage Resident #1 to express feelings appropriately; -Follow up with neurology and psychiatric care ([DATE]); -Finger foods when she won't tolerate sitting for meals ([DATE]); -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; -Resident #1 triggers for tearfulness, exit seeking, restlessness are sun-downing hours, other residents' lack for personal space. Resident #1's behavior is de-escalated by individual space, snacks/coffee, sometimes activities are helpful; -Minimize potential for Resident #1's disruptive behaviors of restlessness by offering tasks which divert attention such as folding laundry, individual space and down time; -Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations; -Provide a program of activities that is of interest and accommodates resident's status; -Provide reassurance of safety; -Redirect Resident #1 from other residents when wandering in the hall; -Request personal photos/memories from family to build visual activities for Resident #1 ([DATE]); -Take Resident #1 for a walk-outside if appropriate; -Utilize I-pad (held by staff) for country music, visual entertainment such as horses, ranches, scenic videos, animals, old country music, cowboys ([DATE]); and, -Walk outdoors one time per day as weather permits. Start walk in courtyard to see how Resident #1 will tolerate ([DATE]). Nursing progress notes, reviewed for the past six months, documented successful non-pharmacological interventions were documented on [DATE] as one-to-one, playing country music and distracting with dancing, offering snacks and drinks, engage in an activity and walk the hall with Resident #1 and engage her in conversation. Resident #1 was physically aggressive with staff during care, was exhibiting mouth pain, approached a certified nurse aide (CNA) to punch them on [DATE] and became aggressive with other residents starting on [DATE] at 2:30 p.m. She was seen by an activity aide (AA) pulling on another resident's right foot while the other resident was sleeping in a recliner in the dining room. Resident #1 then pulled off the other resident's blanket and smacked her right thigh. The smack was loud enough to hear. The AA alerted the nurse immediately and when the nurse tried to redirect Resident #1 she grabbed the nurse's hand and twisted the nurse's index finger. The physician and family were notified. On [DATE] at about 8:00 p.m. the CNA called the nurse into the resident's room. Resident #1 had tightly encircled the privacy curtains in the room around herself and appeared to be stuck. The nurse and CNA lifted and unwrapped the curtains. The resident was slightly flushed but quickly regained her baseline color. Furniture was rearranged in her room so the curtains were planted against the wall by tables, making it difficult for her to access them and wrap herself. She was checked on frequently and sleeping since the incident; staff would continue to monitor. On [DATE] Resident #1's family gave consent to install a camera in the resident's room for monitoring and curtains were removed from her room. She had slept through the previous night. Recliners were moved to other placement in the dining/day room since that was what appeared to aggravate Resident #1. The resident was wandering during activity sessions and staff were educated to encourage her to tidy or fold blankets when she was fidgeting in the day room and unable to redirect to the hallway. On [DATE] at 4:43 p.m. Resident #1 lightly hit another resident's hand. The other resident was sitting at the table and tapping it with her hand. Resident #1 walked by, hitting the other resident's hand with light force. There was no verbal exchange or further signs of agitation or injury. The residents were separated and redirected with no further issues. On [DATE] at 5:21 p.m., the above incident was clarified. Resident #1 approached the table of another resident and pushed it. The other resident pushed Resident #1's hand away and Resident #1 pushed the other resident's and away. Staff intervened as soon as the table wash pushed, separating the two residents. On [DATE] at 5:51 p.m., Resident #1 approached another resident's table and grabbed her dinner plate. A CNA held the plate from her and Resident #1 punched the CNA in the arm three times. The nurse steered Resident #1 away from the other resident. The CNA was not injured. On [DATE] at 5:14 p.m., Resident #1 was documented as punching and kicking staff members during toileting, stealing food from other residents. On [DATE] at 1:10 p.m. Resident #1 lifted another resident's right leg up. Staff asked her to stop so she put it down. The other resident had no complaints of it hurting. On [DATE] at 1:55 p.m. a CNA reported that Resident #1 pushed another resident's wheelchair out of the way and sat on the end of the recliner of the resident's lower legs and feet. The other resident did not yell out or show any distress. The CNA gently coaxed Resident #1 off the recliner. Resident #1 then went to the dining/day room couch and sat down. On [DATE] at 2:15 p.m., Resident #1 was combative with personal care and afterwards walked into the dining room and sat on the couch. While the nurse was attempting to put her sock back on, Resident #1 stood up and punched the nurse in the chest and stabbed the CNA with a cardboard nail file. Neither staff had any notable injury. The nurse called and asked the receptionist to send someone to assist with escalating behavior. The social services director (SSD) and another staff came to the unit to assist. Staff shut the dining room doors to protect other residents who were with the AA in activities. The SSD walked the hallway with Resident #1 for about 10 minutes until the resident was calm and laughing. At 3:06 p.m., Resident #1 was pacing the hallways and smiling. -There was no documentation of how the nurse responded abusively to Resident #1 on [DATE] (cross-reference F600). On [DATE] at 1:37 p.m., the resident was pacing and touched the pant leg of another resident who was sleeping on the couch. When this startled him awake, Resident #1 put her hands up in the air in an apologetic gesture and said oops. The other resident went back to sleep immediately and Resident #1 sat in a chair in the day room and was napping intermittently. On [DATE] at 7:30 a.m. the resident was pacing the hallways and in and out of the day room. She repeatedly touched another resident's feet, toes and blanket who was sleeping on the sofa, then startled the resident by grabbing his toes. Staff redirected the resident and she punched the nurse in the chest three times. On [DATE] at 7:33 p.m., Resident #1 hit another resident in the upper lip. She had been pacing in the day room and stopped and stood over a recliner where another resident was lying. Resident #1 pointed at the other resident's feet and the other resident slapped Resident #1's arm. Resident #1 then punched the other resident in the upper lip, causing bleeding, swelling and bruising. No signs of injury to Resident #1 were found. She was transferred to the local hospital emergency department (ED) for psychiatric evaluation. Her physician and family were notified. On [DATE] at 9:55 p.m., the nurse received an update on Resident #1's status from the ED staff. They said Resident #1 was doing well. Her urine test revealed a urinary tract infection. Resident #1 was given an antibiotic prescription which was started at the hospital. Upon her return from the hospital, Resident #1 began alternately hitting and hugging staff and was kept away from other residents. A late entry behavior note on [DATE] at 5:47 p.m. documented Resident #1 was on alert charting for two incidents of aggression on [DATE]. Multiple incidents of verbal and physical aggression towards CNA staff today as well as two incidents lunging toward fell ow residents attempting to hit them, but prevented from contact by CNA maintaining one-on-one supervision for this entire shift. At 1:30 p.m. Resident #1 yelled and lunged at fell ow resident, prevented from contact by CNA. At 12:50 p.m. tried to slap and punch a fell ow resident, prevented by CNA. On [DATE] at 8:25 p.m. the AA witnessed Resident #1 walk by another resident and slap her on the back. The other resident was seated in her wheelchair facing the television in the day room at the time. The nurse was dispensing medications at the time of the incident and the CNA was assisting another resident in the bathroom. The AA separated the residents as soon as possible and alerted the nurse. The residents were separated and supervised. Head to toe evaluations revealed no injuries. On [DATE] at 10:47 a.m., a nurse documented the resident remained on alert charting for aggressive behaviors and physical aggression, both initiated against another resident and also received from a different resident. She continued to pace the hallways and day rom, with one-to-one supervision, staff supervising resident had to intervene multiple times thus far during day shift to prevent physical aggression toward other residents. Resident #1 had physical contact with staff members in the form of shoving her shoulder into their shoulders when walking past. On [DATE] at 12:02 p.m., the nurse documented in a physician communication note the resident continued to display aggressive behaviors despite high dose of Sertraline (antidepressant), maybe a dose reduction would be beneficial. Recommendations from nursing were trial decrease of Sertraline and utilize PRN (as needed) Abilify (antipsychotic) dose if/when behaviors exhibited. Called PCP and left message discussing the above, awaiting return call. On [DATE] at 1:27 p.m., the resident was seen in-house by the primary care physician (PCP) following up on recent agitation and aggression as well as UTI treated with Keflex for seven days, started on [DATE]. The plan was to decrease Sertraline to 100mg daily. Res(ident) has PRN Abilify 10mg in addition to scheduled 10mg daily dose, to be utilized for agitation and aggression. On [DATE] at 7:11 a.m. Resident #1 was on alert charting for aggression where she received contact from another resident and injured/contacted two other residents. She has been in bed since beginning of shift and has not gotten up. Will continue to have 1:1 supervision. On [DATE] at 11:57 a.m. the nurse documented aggressive behaviors toward staff and attempted physical behaviors toward another resident and their visitor. The resident continued with one-to-one safety monitoring at all times. On [DATE] at 12:51 p.m. Resident #1 was given PRN Abilify 10 mg for agitation/aggression which was documented as effective. On [DATE] at 6:11 p.m. Resident #1 remained on one-to-one due to recent behaviors. At times she made attempts to reach at other residents' blankets on them but one-to-one (staff) kept distance between residents. She continued to exhibit aggressive behaviors towards staff. On [DATE] at 2:54 p.m. Resident #1 had near misses throughout the shift with CNA needing to restrain her arms when near other residents to prevent her from striking at them. Most of the time resident is smiling but at times has been preoccupied with pulling cushions off the couch and attempting to push or throw another resident's walker left at recliner's side. On [DATE] at 4:22 p.m. Resident #1 attempted to punch two different residents during a music activity while walking past them. She was restrained by the one-to-one CNA to prevent injury. She became aggressive with staff trying to restrain and redirect her. On [DATE] at 10:44 a.m. and event note documented Resident #1 initiated physical aggression towards two residents with contact with one of them. She started walking quickly toward a resident in a recliner. The CNA assigned to one-to-one caught up to her and blocked her from having contact with the other resident. She punched and kicked the CNA who stood between the residents, then saw another resident who was reclining on the couch nearby and quickly turned toward that resident and grabbed the blanket covering him and kicked him in the shin as the CNA was trying to get between them. The nurse arrived and with the CNA was able to redirect Resident #1 to the hallway. No injuries were noted to either resident. The fire doors to the day room were closed to protect other residents from Resident #1's aggression. The family and physician were notified. On [DATE] at 1:15 p.m. Resident #1 was given a PRN dose of Abilify, effectiveness unknown. She was later observed by a CNA to be apparently hallucinating approximately 45 minutes after the PRN Abilify, bending over to pick up objects on the floor that were not there and then kicking and punching into the air when a CNA was a distance away. Does appear to be more sleepy at this time, but when encouraged to lay down or sit down, immediately stands up and continues pacing, frowning. So effectiveness of PRN is unclear at this time. -There was no evidence the physician was notified of this adverse effect of the PRN antipsychotic. On [DATE] at 5:15 p.m. a physician communication note documented physical aggression toward fell ow residents continued requiring one-to-one, and with history of aggressive physical actions, placement at another facility was recommended which could be done at the local hospital ED. Urgent transport requested. A behavior note at 5:33 p.m. documented multiple events of punching and kicking at staff during cares and while one-to-one quietly walking with resident. Incidents at 7:45 a.m., 9:15 a.m. and 9:30 a.m. (with another resident), 11:00 a.m., 11:30 a.m., 12:35 p.m. and 12:55 p.m. Pacing and restless so far this shift, any attempts at getting her to rest last only a few minutes. Given PRN Abilify at 12:45 p.m. with little effectiveness. On [DATE] at 5:45 p.m. Resident #1 left the facility with the local fire department and police escort for urgent transport to the local hospital ED. The resident was admitted to an acute care unit, slept all night, and was evaluated for psychiatric evaluation and possible transfer to a geri-psych facility on [DATE]. On [DATE] at 1:40 p.m. Resident #1 was returned to the facility via ambulance and taken to her room on a stretcher in a gown and a heavily wet, soiled brief. Nursing staff transferred her to bed where clean clothing and a clean brief were applied. She then attempted to self-transfer out of bed so staff assisted her to ambulate safely in the hallway. She received one-to-one assistance and her demeanor was calm with episodic aggression exhibited during care. Plan of care will be for resident to remain with 1:1 staff assist for the safety of herself and others, until if/when she can be transferred to a higher LOC (level of care) facility for geri-psych. On [DATE] at 5:31 p.m. the nurse documented new orders from the hospital for Zyprexa and Seroquel (both antipsychotics). A behavior note at 6:15 p.m. documented Resident #1 had physically aggressive behaviors toward staff and attempted toward other residents, staff intervened. On [DATE] at 5:03 p.m., she was sleeping quietly during the night shift. She slept late that morning and as she as she woke up started pacing. She was on one-to-one (supervision), ate meals while pacing with a CNA giving a bite at a time as she walked by the tray. No aggressive behavior so far this shift. At 3:10 p.m. nursing documented, Currently resident is a 1:1 due to behavioral symptoms. Resident wanders and paces most of her waking hours and requires frequent redirection. Requires full assistance for meals and snacks. Resident will at times sit to eat but mostly she paces while eating. Every drink or bite is prompted by staff. Resident requires full assistance with showering and elimination as well. Resident is mostly non-verbal, garbled speech when vocal. Resident requires constant supervision for safety. On [DATE] at 4:33 p.m., a behavior and administration note documented a 50 mg dose of Seroquel was given for agitation. Resident his this nurse when she was trying to redirect her from another residents walker that she was trying to move. On [DATE] at 2:22 p.m., a behavior note documented Resident #1 continued to be aggressive toward staff with a grim expression on her face. She frequently bent over to pick invisible things off the floor, possibly hallucinating. She was observed punching the linen closet door with both fists three times. She punched and kicked at staff since she awoke at 11:00 a.m. Most aggression is related to occasions when staff is attempting to do cares or to guide her away from another resident or another resident's room. On [DATE] at 5:21 p.m. she was drowsy all shift, slept until 11:00 a.m. and ate lunch and accepted supplements, paced hallway with one-to-one (staff) until 2:45 p.m. when she became visibly tired, walking with closed eyes, staggering and bumping into walls. Helped to her bed by staff where she has remained so far this shift. Brief changes in her bed by staff without protest at approximately 4:30 p.m., showed no interest in dinner tonight. -There was no documentation the physician was notified of the resident's adverse reactions to her medications. The nurses continued to chart Resident #1's physical aggression toward staff, punching doors or hard objects with her fists, redirecting her away from other residents and at times closing the day room off behind the fire doors to protect other residents. On [DATE] at 11:24 a.m. a nurse documented one-to-one supervision during waking hours for safety of Resident #1 and other residents. Sleeping more than usual during the daytime, may be in response to recent psychotropic med changes, nursing will continue to monitor. Resident awoke this morning in a combative mood and has been pacing the hallways. She approached (housekeeping) staff and grabbed the housekeeping cart, shaking it back and forth. Resident has calmed at this time so no PRN Seroquel administered, will utilize med (medication) if resident becomes physically aggressive again this shift. On [DATE] at 12:19 p.m., a nurse documented in a behavior note that Resident #1 utilized Mirtazapine (antidepressant) 15 mg daily for appetite stimulant, Zoloft (antidepressant) 100mg daily for Alzheimer's disease/dementia with behavioral disturbance, Zyprexa (antipsychotic) 5 mg twice daily for dementia with agitation, Seroquel 50 mg PRN for dementia with agitation and has used once, and Valium 5 mg rectally PRN for diagnosis of seizures. Since readmission on new medications she has had 23 episodes of physical aggression during cares, 6 episodes of pacing, 1 episode of resisting care, 1 episode of agitation, 2 episodes of frustration with others, and 1 episode of hallucinations. In the last 2 weeks (Resident #1) no longer gets up to ambulate, is changed and fed in bed. She will have a telehealth with (psychiatrist) in October. POA (power of attorney) consent to the use of psychotropics. -See interviews below, the psychiatrist visit was moved up to [DATE]. On [DATE] at 12:34 p.m., a nurse further documented Res (resident) sleeping much of this DAY shift thus far, becoming physically aggressive toward staff during cares and ADLs (activities of daily living). Res ate well only when fed by staff. Res has oral pain and occasional difficulty chewing, PRN viscous Lidocaine (pain medication) to gums is available PRN and has noted therapeutic effect. Res is totally dependent on staff for feeding assistance at this time. Offered supplements in addition to meals, accepted all supplements today. Scheduled APAP (acetaminophen) for chronic pain, PRN viscous lidocaine for oral pain. Difficult to assess response to interventions due to resident level of dementia. Resident has one-on-one staff member watching her to avoid conflicts with other residents. Has spent virtually the entire shift asleep in her room. Mattresses have been placed on most of her room's floor so that she can roll in her sleep without injury, which she does often. She is toileted and fed by staff, does not participate in her own care. Able to ambulate without devices when awake/alert enough. Res up to recliner for lunch and is sleeping in recliner at this time. E. Staff interviews The SSD was interviewed on [DATE] at 12:30 p.m. in her office within the secure unit. She said when Resident #1 moved into the facility in February of 2020 she had been leaving her home and getting lost, was diagnosed with early onset Alzheimer's disease and needed close supervision. She started becoming combative with care early in her stay at the facility and she was not on any medications. She wandered the halls, and might walk up to a door and push on it but she did not seem to be trying to get out. She would go to the SSD's office frequently and they would visit, and Resident #1 would smile and hug the SSD. She could sometimes answer questions appropriately with yes or no, but mostly Resident #1 talked in word salad (confused or unintelligible mixture of seemingly random words and phrases), sometimes mentioning her family members. The SSD said before when Resident #1 approached other residents, it was in a loving way but just since February 2023 she started approaching other residents in an aggressive manner. The resident's physician and facility staff had discussed in psychotropic committee meetings why Resident #1 was being aggressive with other residents and how to respond. The SSD said they moved the recliners to one path because she would walk by and bump into their foot rests if they were reclined and startle them. The SSD said she recalled one incident where Resident #1 bumped into Resident #2's foot rest, Resident #2 said something to her and Resident #1 pointed her finger and then got slapped so in turn Resident #1 defended herself. Regarding Resident #1's background and any trauma she may have experienced, the SSD said Resident #1's relatives said her mother died of cancer which was traumatic for Resident #1 who was living in the family home at the time. She was divorced and her significant other who admitted her to the facility died in [DATE]. He visited when Resident #1 first moved in and she was always excited to see him, then got to where she kind of did not know who he was and as he was dealing with his own health he was unable to come out for visits. The SSD said Resident #1 was sent to the hospital and when she returned she was on the PRN Seroquel. She thought it had been given once and they were supposed to discuss her psychotropics again on [DATE] (the next day). She had a telehealth appointment arranged with the only nearby psychiatrist that she knew of, who did not typically see residents with Medicaid (her payor source). Before her hospitalization she was taking Abilify, came back with Zyprexa and PRN Seroquel, and was already on Zoloft (decreased to 100 mg from 200 mg) and then she was on the Mirtazapine as an appetite stimulant because she got to where she was not eating at all and after that her appetite started picking up a little bit. When she first came back to us from the hospital she'd still pace, then sit down and rest, but it seems like she slowly was sleeping more, so I was glad (the psychiatrist) agreed to have the telehealth appointment with her today. The SSD said she was anxious to talk about Resident #1 in psychotropics to get the pharmacist's and medical director's view, because after her ED visit and medication changes she's just not the same. The SSD said Resident #1 had always been combative with care but some staff were able to talk her through it and she would allow them to assist her. The SSD said she had been asked to assist which was helpful to staff and the resident during care and staff were good about passing information along from one to another. She said they tried to have consistent staffing as much as possible. When discussing Resident #1's medications and her response to them, the SSD said, I don't like PRN antipsychotics. She confirmed there was no stop date or frequency documented in the order and that it was given as needed for agitation but specific behaviors for specific medications were not defined in her behavior tracking. The SSD said her psychiatrist telehealth appointment was scheduled for 11:00 a.m. today ([DATE]) and she hoped it happened because Resident #1 needed it. I was concerned she was on Zyprexa with it showing she's sleeping a lot. She'll still eat; we've had to feed her for a long time. Sometimes she'd eat walking down the hallway. Before her medication changes, she was sleeping a lot, I just don't like that. The SSD said Resident #1 had never been aggressive with her and although she was pacing a little bit with the PTA that morning, she still smiled and gave the SSD a hug. She said the facility provided dementia training, corporate came and did dementia training and the SSD continued with that training during every orientation. She said during the training she provided she talked with staff about alerting other staff regarding combative behavior and if they needed a break to tell somebody. During orientation I tell them I'm here for the residents and for you. You need to vent, you need to de-escalate, whatever, feel free to come to my office. The SSD said she did not see any behavioral changes or fear from Resident #1 after the abuse incident with RN #2 (cross-reference F600). She said Resident #2 was the only resident who had been injured by Resident #1 when Resident #1 punched her in the mouth. She did not have to go to the hospital but she had a bruised and swollen lip. She did not show any fear. The SSD said their plan going forward for meeting Resident #1's needs and keeping other residents safe was trying to figure out what she needed and just being more aware. She loved country music, sometimes would watch videos of dogs or horses and talking about ranch kind of things because she grew up on a ranch. She resisted going outside for walks, which surprised the SSD. Before her medication changes, she enjoyed having the freedom to pace in the hallways, having staff play music for her while she was pacing, a lot of the staff and nurses were good about putting Resident #1's favorite music on their phone to play for her. I always have music going here and of course we can put music on the TV (television). Some residents like jigsaw puzzles, art, having outside time and reminiscing, doing nails, I've noticed the men are usually talking about something with hunting, they hold up pictures of states and see if the residents can name the states, trivia games. She said activity staff were in the secure unit full time to engage the residents. III. Resident #2 A. Resident status Resident #2, age 97, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses included dementia with unspecified severity. The [DATE] MDS assessment showed the resident had severe cognitive impairment with a BIMS score of four out of 15. B. Observations Resident #2 was observed on [DATE] spending most of her day sleeping in a recliner in the dining/day room common area. Although some other residents were engaged in activities and she was invited, she did not participate. C. Record review Review of nursing progress notes revealed the incident with Resident #1 on [DATE] at 7:56 p.m. was described as follows: Resident #2 was sitting in recliner in dayroom when Resident #1 came up to her and stood near recliner. Resident #1 pointed at Resident #2's feet, and Resident #2 slapped Resident #1's hand. Resident #1 then punched Resident #2 in the upper lip. Upper lip and gums bled and front tooth pushe[TRUNCATED]

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#39) of four residents reviewed for accident hazards out of 26 sample residents. The facility failed to ensure appropriate and effective measures were in place to prevent Resident #39 from repeated falls. Resident #39 fell out of bed on 9/7/22 and again on 1/17/23. Both falls for Resident #39 resulted in a hematoma and lacerations to her head after she hit her head on the bed frame. Resident #39 had to go to the hospital for an evaluation and sutures after the fall on 1/17/23. The review of the fall identified the resident's call light was on just before the 1/17/23 fall but the alarm to the call light did not immediately sound to notify staff. Findings include: I. Facility policy and procedure The Fall Management policy, reviewed 9/29/22, the policy read and pertinent part: The facility will assess the resident upon admission/readmission, quarterly, with change and condition, and with any fall event for any fall risk and will identify appropriate interventions to minimize the risk of injury related to falls. According to the fall management policy, and unavoidable accident meant occurred because the facility failed to: - Identify environmental hazards and/or assess individual resident risk of accident, including the need for supervision and or assistive devices; -Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; -Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and, -Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. II. Resident status Resident #39, age 89, admitted on [DATE]. She resided in the secured/memory care unit. According to the February 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity with agitation, history of falling, difficulty walking, age-related osteoporosis without current pathological fracture, and cognitive communication deficit. The 1/19/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident also exhibited inattention. Resident #39 required extensive physical assistance of one person for bed mobility, transferring, toileting, personal hygiene, dressing, walking in the corridor and room, and locomotion of and off the unit. The MDS assessment did not identify the resident had rejections of care. III. Resident observation Observations between 2/6/23 and 2/9/23, identified the resident used a wheelchair for mobility and was able to self propel very short distances. She required staff assistance for direction and a longer distance mobility. The resident frequently rested in her bed in the afternoons, with a call light within reach and a fall mat placed by her bed. The call light system for the memory care/secured unit was observed on 2/9/23 at 10:03 a.m. The call light was turned on by certified nurse aide (CNA) #5. The light above the resident's door immediately turned on but there was not an audible sound to alert the staff. The CNA said the alarms took a little bit of time to sound. At 10:05 a.m. the call light alarm sounded at the nurses' desk. The call light system took over two minutes to produce an audible alarm alert staff of the call light in the residents' room. IV. Record review The fall care plan, initiated on 2/3/22, Resident #39 was at risk for falls secondary to confusion, gait/balance problems, poor communication, poor comprehension, psychotropic medication use, and history of falls with a fracture. According to the care plan goal the resident would not sustain serious injury requiring hospitalization . Interventions included: Anticipate and meet the resident need; keep call light within reach; complete a fall risk assessment; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; and, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. The fall care plan, initiated on 9/7/22, read Resident #39 had an actual fall with hematoma and laceration to the back of her head on 9/7/22 and 1/17/23. Interventions identified on 9/7/22 and 9/8/22 fall care plan included: Anti-rollbacks to the resident's wheelchair; a floor mat placed placed by the resident's bed; neurological checks completed per protocol; provide activities that promote exercise and strength building where possible and provide one-to-one activities if the resident was bedbound; re-arrange second bed in the resident's room to remove potential tripping hazard. According to the care plan, Resident #39 was sent to the hospital for sutures and imaging. The fall interventions after the 1/17/23 fall with injury included: An addition to CNA documentation for the resident's bed kept at standard height and a new bed padding was ordered. The 9/9/22 event note read a certified nurse aide (CNA) found Resident #39 in the room and bleeding. According to the note, the resident was lying on her back attempting to hold the back of her head. The resident was assessed and had a reddened area on her upper back towards the base of her neck and a hematoma at the back of her head with a small laceration. The hematoma measured six centimeters (cm) by four cm. The resident expressed she had pain. The 9/10/22 health status note identified the fall was unwitnessed and occurred on 9/8/22. A 9/18/22 progress note indicated the resident fell in her room and the interdisciplinary team (IDT) conducted an environmental check of the resident's room and found no contributing factors. According to the note, interventions implemented to prevent additional falls with injury. The interventions included: Call lights placed strategically to engage call light if the resident attempts to exit the bed; a lipping mattress replaced existing mattress and bed frame plugs were installed. The 1/17/23 event note read Resident #39 was assisted to bed at approximately 2:00 p.m. after seroquel (an anti-psychotic medication) was administered and the resident requested a nap. The note indicated two call lights were placed next to her, one on her bed and the other call light on her wheelchair next to her bed. According to the note, the resident was observed to be resting peacefully by the nurse as left the unit to go to lunch at 2:30 p.m. The resident was found on the floor at 2:40 p.m. by another staff member. The note read The call light had been pressed, but the alarm had not sounded at the nurse's station yet. The resident was assessed and identified to have two lacerations to the back of her head. The resident was determined to need emergent transport to hospital for an evaluation and treatment of head wounds. The nurse prepared the wound for transport and called 911. The resident went to the hospital at 3:10 p.m. -The note did not identify if the resident was toileted before she was assisted to bed. The 1/17/23 fall investigation packet was provided by the corporate consultant (CC) on 2/8/23 at 3:10 p.m. The packet included the 1/17/23 hospital emergency department report, fall huddle, incident report analysis, unwitnessed fall incident report, investigation of injury of unknown origin. -The hospital report identified emergency medical service (EMS) reported the resident was found on the ground by evidence of a head injury with bleeding from the back of her head. The report read the resident had a three cm gaping on her right occipital scalp laceration. The resident received treatment for the laceration which included sutures. There was no evidence of clinically important traumatic brain injury (TBI) or intracranial hemorrhage on (CT) imaging, indicating no sign of more serious injury. -The fall huddle report read the resident was self transferring out of bed at 1/17/23 at 2:40 p.m. -The incident report analysis read the resident was found on the fall mat clutching her head. -The unwitnessed fall incident report read the resident had nonverbal cues of wincing, grimacing, and stated ow when the wound was cleansed. According to the incident report, an environmental factor was identified as furniture. The report did not clarify how the furniture was an environmental factor. The report predisposing factors identified the resident was incontinent, confused, had a gait imbalance and an impaired memory. The report did not indicate when the resident was last toileted. -The investigation of injury of unknown origin read the injury was of known origin. The known origin (lacerations) was not identified. The 1/22/23 health status note read neurological checks would continue and identified the resident has had restlessness, increased confusion, and more garbled speech. The note read the resident would be monitored for signs/symptoms of any neurological change. The 2/1/23 IDT note read the resident's bed padding was changed. The care plan had been updated. Staff was educated to ensure the resident's bed stayed in a standard position and call light was placed within the resident's reach. V. Staff interview Registered nurse (RN) #2 was interviewed on 2/8/23 at 9:25 a.m. The RN said Resident #39 had cracked open her head when self ambulating and had to go to hospital for sutures. The RN said in addition to the laceration of her head, Resident #39 also had a large bruise to her upper neck just below the back of her head. She said the resident had a tendency to become restless when she was agitated. RN #2 said the resident had a computerized tomography (CT) scan and no additional concerns were identified. The director of nursing (DON) was interviewed on 2/9/23 at 11:16 a.m. The DON said Resident #39 had a habit of standing and walking on her own. She said at the time of the 1/17/23 fall, the resident's bed was in a lower position than standard position at the time she fell on [DATE]. The DON described a standard position for a bed as where a resident would be able to transfer, stand or on her own, The DON said the standard position for the bed was deemed the safest position for the resident to help prevent falls. The DON said the resident hit her head on the bed frame. The 1/17/23 laceration was caused from a missing cap/plug on the bed frame causing a sharp surface. The missing cap to frame was replaced after the fall. The bed padding was changed because the velcro straps of the padding over the bed frame had loosened, and caused the pad to sag and exposed the metal bed frame. The DON said the sagging of the pad allowed the resident to hit the metal bed frame with a missing frame cap, causing the injuries. The DON said the resident did not have the capacity to use the call light herself so the call light was placed in position to turn on if the resident was attempting to get out of bed. The DON confirmed the call light was signally above the room door was on, but there was not an audible sound from the call light of the resident's movement before the resident fell . She said the audible sound alerted staff who were not in the immediate viewing position to see the call light above the room door in the hallway. The DON said the call light signal had to go through each room on the memory care/secured unit before the signal would reach the nursing station to sound the audible alarm. She said the system was designed to operate as such. She said there was a delay between the time the call light was pushed and an audible alarm was heard. She said the concern was identified in the past but changes to the system were not approved when requested. The DON said the nurse went on break just before the fall but a CNA and an activity assistant was on the unit at the time. She said staff needed to monitor the hall lights when coordinating lunch breaks. She said they continue to have staff rounding to prevent falls and view call lights. The DON said the resident was incontinent at the time of the fall and did not know if the resident was toileted before she placed and bed and later fell .

Based on resident and staff interviews and record review, the facility failed to operationalize facility policies to prohibit and prevent abuse by resident #18, creating a situation of immediate jeopardy with the potential for serious harm from sexual abuse. Specifically: Resident #18 had a history, documented in behavior tracking and interdisciplinary progress notes and reported in staff interviews, of inappropriate behavior toward residents, staff and others, such as touching, kissing, placing his hands under resident clothing, grabbing breasts and making inappropriate sexual comments. Although facility policies directed immediate intervention - a behavior huddle with staff involved in the incident and the resident involved that perpetrated the incident, and the gathering of information on precipitating factors of the incident to prevent future occurrences, as well as information on how to take care of the resident to help re-stabilize and keep resident and others safe - these measures were not consistently taken and interventions planned were not adequately communicated to staff to ensure consistent implementation. On 5/1/17, resident #18 kissed resident #10 who lacked cognitive awareness and who did not consent to the kiss. Again, facility policies to prohibit and prevent abuse were not operationalized. No investigation was done to identify if other residents had experienced sexually inappropriate behavior or would be at risk for such behavior by resident #18, no staff were interviewed about resident #18's known inappropriate behaviors, no information was gathered on precipitating factors and no plan was developed to ensure residents were protected from further potential sexual abuse. The facility's repeated failure to operationalize its policies to prohibit and prevent abuse created a situation of immediate jeopardy with the potential for serious harm from sexual abuse. The findings included: I. Imposition of Immediate Jeopardy a. On 6/22/17 at 6:45 p.m., the nursing home administrator (NHA) was informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to operationalize facility policies to prohibit and prevent abuse by resident #18 created the potential risk for resident sexual abuse. b. Facility Response On 6/22/17 at 7:15 p.m., an immediate jeopardy removal plan was submitted by the facility to CDPHE. It read: 1) Resident (#18) is receiving 1:1 staffing by a male caregiver and will continue 1:1 monitoring by a male caregiver. 2) All current staff on-shift and night shift will receive education regarding resident (#18's) plan of care. Education will be continued and ongoing and no staff members will be permitted to work until education is received. 3) Resident (#18) will remain on 1:1 staffing until alternative placement is found. c. Removal of Immediate Jeopardy On 6/22/17 at 7:15 p.m., the facility's immediate jeopardy removal plan was accepted and the NHA was notified the immediate jeopardy was removed. However, deficient practice remained at an E level, potential for more than minimal harm at a pattern. II. Failure to operationalize facility policies to prohibit and prevent abuse. A. Facility Expectations The Protection of Residents: Reducing the Threat of Abuse and Neglect policy, revised July 2011, provided by the NHA on 6/23/17, documented in pertinent part: Training and education are critical management skills that can help staff recognize risk factors for abuse, neglect, or mistreatment of [REDACTED]. Understanding attitudes and motivations of caregivers is an important element in identifying possible risk factors . Sexual abuse is defined as but not limited to sexual harassment, sexual coercion, or sexual assault . Every associate is bound by legal obligation to report any suspected abuse . Residents living in long term care centers can be vulnerable to sexual abuse. Sexual abuse can result from staff, family members, visitors, or other residents . A resident who wanders or takes an excessive interest in a bedfast resident should alert staff to investigate. Sexual abuse is often difficult to determine and warrants immediate intervention to diagnose. The emotional scars that residents must bear as a result of sexual abuse is often times overwhelming for residents and requires a careful intervention by staff and family members. The Behavioral Health Program policy provided by the NHA on 6/23/17, undated, documented in pertinent part: The purpose of the (name of corporation) Behavioral Health program is to ensure residents that have behavior and/or mood symptoms are provided with adequate psychosocial support to meet their needs enabling them to sustain the highest quality of psychological health . It is the policy of this facility that dangerous, inappropriate, disruptive behaviors and mood symptoms will be monitored by exception in the Behavior Monitoring Form binder. All staff is expected to document symptoms, interventions and outcomes on the Behavior Monitoring form. The facility will evaluate the effectiveness of pharmacological and non-pharmacological interventions in accordance with state and federal regulations . -In the event of a behavioral occurrence, a Social Worker will conduct a Behavior Huddle at the time of the incident. When an acute behavioral episode occurs that endangers the safety of the resident and/or others, conduct a behavior huddle with staff involved in the incident and the resident involved that perpetrated the incident, whenever possible. Gather information regarding precipitating factors of the incident, to prevent future occurrences, and information on how to take care of the resident to help re-stabilize and keep resident and others safe. Use the Behavior Huddle Minutes Form to document information from the behavior huddle . -Care plan will be updated by the social services department . B. Resident #18 1. Record review Resident #18, age 70, was admitted on [DATE]. According to 5/5/17 physician progress notes [REDACTED]. Past medical history included chronic obstructive [MEDICAL CONDITION] disorder, type 2 diabetes mellitus, [MEDICAL CONDITIONS] and spinal stenosis. According to the 6/2/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident had mood symptoms including feeling down/depressed, tired/little energy, and feeling bad about himself. No [MEDICAL CONDITION] or behavioral symptoms were noted. The resident required limited one-person physical assistance or supervision with activities of daily living, and needed limited assistance for part of the bathing activity. He had balance problems and used a walker or wheelchair for ambulation. He was occasionally incontinent of urine and always continent of bowel. The resident was 74 inches tall and weighed 215 pounds. The resident's care plan, initiated 6/24/14 and revised 2/13/17, identified the following problems: -An activity of daily living (ADL) self-care deficit related to impaired mobility secondary to [MEDICAL CONDITION] joint disease and cognitive loss, and refusal of showers at times. Approaches included, Assist of 1 for bathing, toileting and other ADLs . Utilize male caregivers whenever possible r/t (related to) 'touchy feely' behaviors; 2 staff members will be used if necessary related to sexual behaviors. Use male caregivers when possible . Encourage (resident) to shower. Explain to him that it is so his groin will not get so irritated. -An incontinence care plan, dated 6/24/14 and not revised, included the following approach: Assist of 1 for toileting and other ADLs as needed - may utilize 2 staff members if uncomfortable with (resident's) behaviors. -A behavior care plan, dated 7/1/14 and revised 2/20/17, identified will at times ask for hug, touch staff inappropriately . has been noted on occasion pursuing and displaying inappropriate/sexual gestures and mannerisms towards staff and other residents . The approaches included: Remind (resident) that not everyone likes to be touched, and that touching is not appropriate. Report inappropriate behavior in Behavior Book and report to ID (interdisciplinary) team . offer one-on-ones as needed. Staff will intervene as able to prevent behavior towards other staff and residents. Use male caregivers whenever possible. Utilize 2 staff members with pericare, bathing and personal cares or when potential exposure may occur based on staff's comfort level with (resident) . Monitor (resident's) behavior when near other residents for inappropriate behavior or gestures . 2. Observations Resident #18 was observed 6/22/17 (before facility notification of immediate jeopardy) and 6/23/17 (after facility notification of immediate jeopardy). 6/22/17: -At 12:18 p.m., resident #18 was observed sitting in a chair at a table alone in the main dining room finishing his noon meal. He was positioned at a table facing out the window and his back was to the other residents. He appeared calm and content and his walker was parked next to the edge of the table. -At 12:57 p.m., resident #18 had finished his meal and turned his chair to face more toward the center of the room. A female resident was propelling herself in her wheelchair past him and he said to her, What are you crocheting? That's going to be very pretty. Very, very pretty. The female resident did not acknowledge him and continued to propel herself out of the dining room. -During early afternoon (approximately at 1:45 p.m.) and mid-afternoon, the resident was observed walking in the hallway, heading toward the nurses' station and common area. Other residents, male and female were in the hallway; no staff was observed supervising resident #18 as he wandered the hallway and no staff was consistently present at the nurses' station or in the common area. 6/23/17: -The resident was observed at various times throughout the day (morning, mid-day and evening) with one-on-one supervision by male staff. 3. Interview On 6/22/17, at 2:15 p.m., resident #18 was interviewed. He said he did not have any issues with any residents but when asked if he had been abused, stated he was verbally abused on two occasions within a few days of each other, about two months ago, by licensed practical nurse (LPN) #20 who had been his nurse for a long time. He explained she had cornered him in the bathroom and accused him of reporting things (he couldn't remember what) to the nursing home administrator (NHA). -Resident #18 said he had told the SSD who later told him LPN #20 could not care for him anymore. The resident said he believed LPN #20 no longer worked at the facility; he had not seen her since the incident in the bathroom. -Resident #18 said he preferred to take showers daily, but that did not always happen. He said he needed some help getting dressed, showering, and he rarely needed help with toileting. C. Documentation of Resident #18's history of sexually inappropriate behavior Resident #18's medical record, reviewed from 2/1/17 through 4/30/17, revealed entries and references to resident #18's sexually inappropriate behavior, sometimes daily and sometimes more frequently than daily. Interventions and directions to staff in addressing the resident's behavior varied. There was insufficient documentation the facility gathered information about precipitating factors, applied consistent interventions, and communicated effective measures for staff to prevent recurrent instances and to keep residents safe from potential sexual abuse. 1. Nursing and Interdisciplinary (IDT) Notes -3/24/17 [MEDICAL CONDITION] note: 1 episode of yelling out, 1 incidence of being sexually inappropriate with staff and 1 incident of refusing a bath. -3/27/17 nursing note: He continues with inappropriate comments, and is very touchy-feely with staff. Have given several verbal cues, and explained that it makes staff uncomfortable. He laughs, and repeats inappropriate behaviors . -3/31/17, Resident continues with inappropriate compliments, and will repeat himself over and over . continues to say things that make staff uncomfortable . -4/6/17, Continues to be inappropriate w/ staff (verbal comments) very touch with hands, and if he can reach you, he takes your hand, pulls you closer, and kisses your arm all the way up to your shoulder if allowed. Have expressed several times how uncomfortable this makes the staff, and it doesn't stop. He has called several times for personal care, wanting the younger girl staff to come in to assist him, he can physically do these procedures by himself. Attention seeking . -4/8/17, Resident is alert, and continues to c/o (complain of) increased pain, different sites. [MEDICATION NAME] effective. Groin was cleaned, and [MEDICATION NAME] powder applied. Very foul odor coming from groin area that you can smell across the hallway. Asst. provided, and set up for him to apply. Verbal inappropriate comments again this evening . -4/9/17, Resident is alert, and continues on A/c (alert charting) for inappropriate behaviors, comments and attention seeking. Behaviors continue although last night he decided to add the 'Baby-cutesy' tone of voice when speaking to this nurse. Tried redirection, being polite and walking away, moving cart to different area, etc. Behaviors continue. Inappropriate comments continue although I have pleaded for him to cease. He laughs and it comes on even stronger. After the last comments he put call bell on and asked for me. Went in to address needs . His response was, 'I just really enjoy talking and being with you. I miss you my sweetie pie. My honey. I have always held a special place in my heart for you, and I will never give up trying.' Explained nicely that . kind of talk makes me very uncomfortable. Please stop. He doesn't. Will keep trying. Groin area improving with daily showers, cleanliness and [MEDICATION NAME]. Odor still very strong . -4/9/17, A/C for inappropriate behaviors, comments and attention seeking. Res does talk to nurse in the 'baby, sweety' tone of voice stating, 'I really like what you're wearing,' making me uncomfortable. Tried to redirect res by talking about something else. Somewhat helpful. -4/10/17, A/C for inappropriate behaviors, comments and attention seeking . continues to make inappropriate comments to nursing staff such as, 'I'll do anything for you, you look so pretty today.' Redirected him through changing conversation. -4/11/17, Resident on alert charting for inappropriate behaviors. This (male) nurse did not experience any behaviors this shift aside from the baseline attention seeking of long drawn out conversations. This nurse asked the aid staff and they denied any inappropriate behaviors on this shift . -4/11/17, A/C for inappropriate behaviors. Res continues to compliment nursing staff and making it uncomfortable to be around him. Attempted to redirect by changing conversation and was effective. -4/11/17, CNA reported that res rubs feces to scrotum and groin area as a behavior because he has a new roommate. Res groin area and scrotum is red, [MEDICATION NAME] applied. -4/12/17, Resident on alert charting for inappropriate behaviors. No inappropriate behaviors noted. This (male) nurse noted serosanguineous stains on his briefs coming from redness in his groin area. His briefs were changed multiple times during the shift because of this. This nurse applied [MEDICATION NAME] cream PRN. Aid stated that yesterday he had fecal matter on the front side of his groin which they believe he put there himself as an attention seeking behavior. This nurse educated the importance of maintaining good hygiene in order to let the redness and irritation heal and be resolved. The resident became defensive and explained he didn't get a shower today. I will make a point to make sure he is bathed tomorrow . -4/12/17, A/C for inappropriate behaviors. Res continues to call nursing staff 'honey, baby.' Groin area is red. [MEDICATION NAME] applied to groin area PRN. Briefs changed multiple times throughout shift. Res did shower, odor has decreased some. -4/13/17, Continues on A/C for inappropriate behaviors . -4/16/17, This concludes residents alert charting, inappropriate behaviors, none noted this shift or in the past 72 hrs. Resident denies pain, redness to peri area is improved from 4 days ago. Pleasant and cooperative with cares . -4/27/17, Res. with behavior of calling staff pet names - 'sweetie, baby.' This RN set boundary asking res to refer to staff by name and refrain from pet names, res excuses self stating 'I always call my friends sweetie.' This RN again set boundary this is a nurse to patient connection and can only call this nurse by name. Res also making comments over and over about this nurse's appearance - this RN stated after first comment that it was not appropriate and RN was not here to hear about own looks - here to provide care so if res has a health concern to report can do so, otherwise this RN is not available to listen to res speak about staff looks. Behaviors stopped at that point. 2. Behavior Monitoring Interdisciplinary progress notes (see above) documented far more instances and on dates different than in behavior monitoring of inappropriate behavior by resident #18, indicating not all resident #18's behaviors were tracked, reviewed and addressed as expected per facility policies. Behavior monitoring documentation revealed the resident was taking [MEDICATION NAME] and [MEDICATION NAME] for targeted behaviors of crying, social isolation, inappropriate sexual behaviors, [MEDICAL CONDITION]/not sleeping and [MEDICAL CONDITION]. Individualized interventions included set boundaries for inappropriate sexual behaviors, invite to activities, offer one on ones, use two staff members for cares, and encourage the resident to call his family. The following pertinent target behaviors (TBs) and interventions were documented: -3/17/17 night shift - coded TB 5 (5 referred to sexually inappropriate behavior) with interventions of positive distraction, nurse assessment for physical needs, set boundaries with inappropriate behaviors -4/3/17 very emotional; not sleeping since getting roommate; very needy w/ staff with interventions of active listening and validation -4/4/17 walked across room without help pants at ankles no brief - validation -4/5/17 night shift - coded TB 5, increased touching, verbal, needy with interventions of positive distraction, validation, set boundaries. -4/9/17 night shift - coded TB 5 see nurses notes with interventions of active listening, positive distraction, help resident become more comfortable, set boundaries -4/13/17 day shift - coded TB 5 refusing to close bathroom door & making obscene gestures. No interventions were coded. The above behaviors were signed by four different staff persons. The resident response to each intervention was noted as NC, no change. D. Resident and Staff Interviews Although interviewable residents revealed no residents reported instances of potentially abusive behavior by anyone, interviews with a number of staff familiar with resident #18 confirmed many staff were aware resident #18 had a history of [REDACTED]. Interviews further revealed staff's understanding of how to address resident #18's behaviors were varied, were not all care planned and communicated to staff, contributing to inconsistent response in prohibiting and preventing abuse. Moreover, these interventions, such as setting boundaries, were not available to residents, especially those with limited cognitive abilities which left these residents at risk for potential sexual abuse. 1. Resident interviews Twenty residents, who per facility and assessment were cognitively independent, were interviewed on the afternoon of 6/22/17. None of the residents reported concerns regarding other residents' behaviors or interactions, including resident #10 who was also interviewed. Resident #10, however, had severe cognitive impairment with a BIMS score of seven out of 15. 2. Staff interviews Registered nurse (RN) #4 was interviewed on 6/22/17 at 3:34 p.m. She was asked if there were any residents in the facility who were abusive or had behaviors toward other residents or staff members that required intervention, and she named resident #18. She stated, He is very sexual in nature and he is always trying to touch us or grab us. She said, He blows kisses to us all the time and wants to rub our backs and grabs our (breasts), and is completely inappropriate. She explained she and other staff members had told him in the past that behavior was not appropriate, and said his behavior had been going on for a long time, for as long as she had worked at the facility (more than three years). -RN #4 said resident #18 would frequently reach out and touch her and rub her back or shoulders. She said she did not give him that opportunity anymore and stated, He knows better but he does it anyway. -RN #4 said personal cares had to be provided to resident #18 carefully, and explained she had to watch where his hands were going. She described an incident in the recent past when resident #18 had a yeast infection in his groin and required a medication to be applied to the area. She said the resident was capable of applying the medication himself, But he didn't want to do it; he wants the girls (nursing assistants) to do it. -RN #4 explained the facility staff had a rounds meeting at the nurses' station each morning, and resident #18's inappropriate touching behaviors had been brought up to the group by a LPN #20 who worked the night shift. She said LPN #20 appeared to have concerns about resident #18 she wanted to share with the group, but the therapy director who was facilitating the meeting was dismissive, and the meeting continued without addressing the issues. -RN #4 said she was not aware of any supervision to be provided to resident #18 when he was around female residents and had never been told any supervision was necessary. She said she was not aware of the care plans above and individualized interventions in the behavior monitoring documentation to set boundaries, encourage resident to contact family, and to use two staff with cares. Certified nurse aide (CNA) #8 who routinely worked with resident #18 was interviewed on 6/23/17 at 5:45 p.m., When asked if there were any residents he needed to set boundaries with, he said, The only one is (resident #18). But he doesn't do anything to me. It is mostly against other residents. I've seen him kiss them and hold their hands (other residents). He said he had told resident #18 it was not allowed to do that to other residents and he said, (Resident #18) says 'ok' and stops. The CNA said he had been told to keep an eye on (resident #18) because he is always like that. The social services director (SSD) was interviewed on 6/22/17 at 4:17 p.m., and said no residents, staff, or family members had approached her with complaints of being abused within the last few months. She clarified that resident #18 had never come to her with allegations of abuse, either. -The SSD said LPN #20 had voiced a concern to the nursing staff about resident #18's inappropriate sexual behaviors, and then nursing staff came to me with the concerns. She explained she had a conversation with the facility's previous director of nurses (DON) and a decision was made that LPN #20 should no longer care for resident #18. The SSD said she did ask the night supervisor at that time if a male nurse would be on duty, but she could not remember if he said yes or no. -The SSD explained she did not want LPN #20 to feel like she had to take care of resident #18, Because she was always complaining and writing in the behavior book about him. She stated, But she wasn't always up front about what she was dealing with . I felt like (LPN #20) knew she needed to set boundaries with him. The SSD said she wrote an intervention for staff to employ on the behavior sheet to set boundaries. If you allow him to touch one time, you need to nip it in the bud immediately. She said when anyone had a concern, It always came to (the NHA) or nursing, and then the next day it would be dealt with. -The SSD was asked about residents who were not capable of setting boundaries for themselves and she stated, We always have intervened with (resident #18) because we have visitors come in to see him. She described a situation when female church members came to visit him every Wednesday and she recalled a time when the activities director had intervened because he noticed the visitors began to feel uncomfortable when he hugged them when they got too close. She said the activities director stepped in as resident #18 was reaching out to touch the visitors. She said resident #18 had always been redirectable and stated, And he hasn't touched those visitors since then. -The SSD said the care directive interventions were written down in the behavior book, and new interventions were added as needed. She said she reviewed the book every morning with rounds and if there were behaviors reported or she had a question, they talked about it in their morning rounds. She said it was still the plan that female staff should go in with two people, not alone, to provide cares for resident #18. The activities director was interviewed on 6/22/17 at 4:30 p.m., and he said resident #18 had poor physical boundaries and is touchy-feely. He said he had never witnessed the resident touch another resident's genital area or buttocks and stated, Sometimes he will stroke (a resident's) hair. He really doesn't discriminate - he does that with me. I have set some pretty strong boundaries with him that I wasn't comfortable with him touching my arm. -The activities director said he has told resident #18 in the past that some people just weren't comfortable being touched, and he is usually redirected with an activity. The activities director was asked if resident #18 had touched other females again and he stated, Not to visitors . He doesn't have a sense of boundaries and he can't read when people are feeling uncomfortable. I would think staff would be knowledgeable if they'd worked here long enough to redirect him. -The activities director said he had heard other staff members complain about resident #18's inappropriate verbal and physical behaviors to the SSD. He said the behaviors should be documented in the resident's medical record, but said that wasn't done often enough. He stated, We have lived with this behavior for nearly five years. It's just an ongoing behavior with (resident #18). -The activities director said the staff had guidance resident #18 was not to be within arm's reach of female residents and stated, We keep an eye on him and watch him closely. The therapy director was interviewed on 6/22/17 at 5:15 p.m., and he said he usually went to the morning stand-up meeting and would run it if the NHA was not there. He confirmed resident #18 required redirecting at times and said, That is not a new issue. He said he had heard the SSD remind staff in the morning meetings to set boundaries with the resident and keep his behaviors in check. -The therapy director said he thought a lot of the staff knew when resident #18 needed to be redirected and how to do that. He said he did not think they could guarantee he was an arm's length away from females and stated, That would be impossible. He said it was his understanding that resident #18 was to be showered by male staff only, not female staff. -The therapy director was asked if he felt resident #18 was a danger to residents who would not be able to redirect him themselves, and he said, I think that would be our responsibility to do that rather than trusting (resident #18) . I don't really know how far (resident #18) would go. The staff development coordinator was interviewed on 6/23/17 at 4:06 p.m. She said the facility had provided resident behavior education to staff, which occurred in orientation for everybody. She said, It could stand improvement to be a little more formalized . but we try. She said the SSD provided new employees with approximately one hour of resident rights and dementia training. She said the SSD would also provide training to new staff in the form of one-to-one informal education related to difficult resident behaviors and setting boundaries. She said, A lot of training and teaching is kind of informal . We tackle it as a team. CNA #11 who was familiar with resident #18 was interviewed on 6/23/17 at 4:55 p.m., and she said she was not aware of any residents in the facility who required two staff members at a time to provide care for them. Further, she was not aware of any residents who required behavioral boundaries set with them. She said if new care directives were put in place for residents, the CNAs were made aware of these changes by reading a piece of paper, signing it, and passing it along to other CNAs. CNA #10 who was familiar with resident #18 was interviewed on 6/23/17 at 5:20 p.m., and she was asked if there were any residents she needed to set boundaries with and she said, No, not really. She said resident #18 required two staff members present when they provided care to him. CNA #9 who was familiar with resident #18 was interviewed on 6/23/17 at 5:30 p.m., and he said he had seen some female staff members uncomfortable around resident #18 because of his verbal messages. He explained he could see a difference in how resident #18 talked to him, versus when he talked to other female staff members or residents. He said resident #18 would get overly complimentary, and said he had seen him touch other staff members and gave the example of kissing their hands. He clarified he had not observed him touch another female resident inappropriately. CNA #9 said new care directives were passed on to other staff members verbally, and then the day shift will pass it on to the night shift staff. He said, We have little meetings every morning and go over things that are new. Bath aide CNA #21 who assisted resident #18 with bathing was interviewed on 6/22/17 at 4:15 p.m. When asked if any residents required two-person assistance with bathing because of behavioral issues, she named two other facility residents but did not name resident #18. She said she looked at the care plan to see what was required, and said, I'm pretty small myself; I'll request assist (if needed) . I don't want to drop somebody and I don't want to hurt myself. Two nurse aides (NA) in training who were familiar with resident 18 were interviewed on the afternoon of 6/22/17. When asked if any residents required two-person assistance because of behavioral issues, they each named two residents but neither named resident #18. The NAs said more experienced staff provided care for the residents with behavioral issues. The NAs said they answered call lights, filled ice water, stocked linens and supplies. CNA #22 was interviewed the afternoon of 6/22/17, and said she had worked in the facility for several years and had often cared for resident #18. When asked about residents who required two-person assist due to behaviors, she mentioned resident #18 and three other residents, and said, They are two-person assist for most everything. When asked how this information was communicated to staff, she said there was a paper inside (each resident's) closet door with specific instructions, and they were teaching new staff to look there for care directives. He's never sexually inappropriate with me. I have boundaries . He likes approval. CNA #22 was accompanied to resident #18's room to review his care instruction sheet. Review of the Care Directive inside the resident's closet door, dated 12/2/16, revealed no documentation of two-person assistance other than a note under bathing: shower that read 2nd person may be required for sexual behaviors. For transfers, dressing (TRUNCATED)

Based on record review, staff interviews and observations, the facility failed to provide adequate supervision and monitoring to prevent falls and accidents for one of 36 sample residents (#76). Specifically: -the facility did not consistently and adequately monitor and assess for dehydration and hypo/hypertension; -the facility care plan did not include instructions for how the staff were to provide increased supervision, and the resident continued to fall even after the 4/29/13 fall with fracture; -the facility care plan related to falls did not address the resident's severe cognitive impairment; -the facility did not ensure the resident had proper foot wear to prevent falls; -the facility did not update the toileting care plan after the 4/29/13 fall, even though the resident had additional falls after 4/29/13. Although the resident was at high risk for falls, had experienced several falls within the previous two months, and had a urinary tract infection, staff left her unattended in the hallway after she had requested assistance to the bathroom, and she fell from her wheelchair to the floor. The failures to provide assistance and supervision contributed to the resident's hospitalization for a hip fracture. The findings included: Resident #76 Non-interviewable resident #76, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) The MDS, dated [DATE], was void of documentation about a fall in the 2-6 months prior to admission and void of documentation related to any fracture related to fall in the 6 months prior to admission (readmission 5/3/13). The resident's BIMS (brief interview of mental status) score of 5 indicated severe cognitive impairment. She required total assistance of two persons with bed mobility, transfers, dressing, personal hygiene and bathing, was on a pain management program, and had a surgical wound. 1. Care Plan failures - severe cognitive impairment and potential inability to use the call light - no specific plan for increased supervision - no update to toileting schedule to ensure needs were met - no precautions and recommendations from physical therapy Care Plan The care plan, dated 9/28/11 and updated 5/3/13, documented in part: Problem - Incontinence of bladder dated 9/28/11 (no update on 5/3/13). Problem - Recent Falls, fall risk score 18 (with score of 10 or greater being high risk for falls). "Resident had recent fall with hip fracture. She needs assist of two persons with most ADLs." Goal - Minimize risk for urinary tract infection on next 21 days, minimize risk for skin excoriation within 21 days. Minimize risk of fall related injury within next 21 days. Resident will be free from injury related ADLs within the next review period. Approaches - Clean and dry skin after incontinence, one person assist for toileting needs, monitor for behaviors that indicate the need for toileting (no toileting schedule included). Landing strip at bedside, falling star, low bed, bed alarm, assistance with toileting, transfer pole. Provide the amount of assistance that is needed. Provide resident/family teaching to include safety measures to reduce fall risk. Resident often needs to be reminded of calling for assistance when she arises. Observations During the survey, conducted 6/3/13 through 6/6/13, the resident was observed on the morning of 6/3/13, the morning of 6/4/13 and the morning of 6/6/13 spending time in her room, resting in a low bed, with water at the bedside. Her room was approximately three doors down from the nurses' station. However, the layout of the building did not enable resident rooms to be seen from the nurses' station. 2. Record Review Review of the clinical records revealed the resident had seven falls within a 45-day period (4/19/13 through 6/2/13), had a history of [REDACTED]. Referral from restorative staff for physical therapy secondary to decline in function related to episode of bronchitis. Physical Therapy (PT) orders 3 times per week for 12 weeks starting on 4/11/13 through 7/3/13. Discharge from PT on 4/29/13 related to unexpected facility discharge secondary to hospital admission after fall with resulting hip fracture. -On 4/11/13 the Physical Therapist (PT) Plan of Treatment had documentation in part that read: Patient now requiring assist for all mobility, unable to ambulate safely without assistance, patient complaining of tiredness/fatigue and pain. Patient will benefit from skilled physical therapy to improve strength, balance and endurance to return to her previous level of functioning. 3. Failure to consistently monitor for hypo/hypertension Medications The April 2013 Computerized Physicians Orders (CPOs) and Medication Administration Record documented in part medications to include: Protonix (proton pump inhibitor); Norvasc (antihypertensive, calcium channel blocker); Lisinopril (antihypertensive, ace inhibitor); Fentanyl patch (analgesic); Zofran (antiemetic); Tramadol (analgesic); albuterol/provental inhalant (bronchodilator), mucinex (expectorant), Bactrim (antibiotic, order date 4/26/13 for 7 days only); Aspirin (anti-inflammatory/antipyretic); Lovastatin (antihyperlipidemic), Metoprolol (antihypertensive, beta adrenergic blocker); and physician order [REDACTED]. Professional Reference regarding Blood Pressure and Lisinopril According to Saunders Nursing Drug Handbook 2010 page 680: "Orders for Lisinopril should include: Nursing considerations to obtain blood pressure, and apical pulse immediately before each dose, in addition to regular monitoring." Review of medication administration records revealed nursing staff was not consistently monitoring the resident's blood pressure and apical pulse to monitor for hypotension, which could contribute to falls. 4. Repeated falls where the resident was found on the floor - although PT screens and increased supervision were noted, no documentation of results or effectiveness, or that increased supervision was provided. Accident Reports/Post Fall Screening Facility accident reports for falls during April, May and June 2013 documented in part: -Fall on 4/19/13 at 4:25 p.m., resident found half way between doorway and hall - did not use call button. Actions: neuros, increased supervision, therapy screen. -Fall 4/22/13 at 7:00 p.m., resident found on floor in her room, walker standing nearby, call light not activated, resident had slip-on shoes on feet. Action: medication review, supervision increased, 72 hr charting, UA dip, therapy screening. -Fall 4/29/13 at 1:59 p.m., outside bathroom lying on floor left side left hip pain, abrasion on the left elbow. Actions: resident sent to hospital emergency room for evaluation. The 4/29/13 Nurses Notes at 1:59 p.m., read in part: Resident found on floor lying on left side in front of bathroom door with water spilled everywhere. Upon assessment resident stated that she was coming from the bathroom, denied slipping in water, but stated that it spilled after she fell . Physician came into the resident's room, assessed the resident and recommended that the resident be sent to the hospital for evaluation. Resident was brought to a standing position by three person assistance, resident unable to take steps, states she is in pain, resident was found with no shoes and no non skid socks on, resident was educated about calling for assistance, resident responded I know. Resident is alert and oriented times 3 but has episodes of forgetfulness noted. --(However, see MDS above, BIMS score of 5 indicated severe cognitive impairment.) -Fall 5/8/13 at 3:52 a.m., resident found sitting on landing pad on the floor, tab alarm on bed disconnected, call light was not activated. Actions: change air mattress to air with rail, therapy screen, staff education on alarms, change tab alarm to pad alarm, increased supervision, 72 hr charting, signage to call for assistance, medication assessment. -Fall 5/17/13 at 12:30 p.m., resident found on floor in her room. Actions: Call for help signs, re-educate resident on call light, lipping mattress, falling star, increased supervision, 72 hour charting. -Fall 5/21/13 at 7:15 a.m., Resident found on floor in room near the bathroom, alarm mattress under the mattress was unheard. Actions: Education of placement of alarms, non skid shoes, orthostatic blood pressure, medication review, therapy screen, continue previous intervention. Follow up resident, continues to get out of bed independently, independent over safety, poor safety awareness. -Fall 6/2/13 at 4:45 p.m. Witnessed fall - hit head in hallway attempting to go to the bathroom, fell straight forward. Actions: Environmental check, increase supervision and toileting, education on toileting, offer fluids, therapy screen, care conference with family. Resident not to be left in hallway needs to be down to the day room or where can be supervised. Resident should be toileted upon rising from bed. Alarm was sounding at the time of this fall, CNA said on 6/2/13 at 4:45 p.m., heard bed alarm going off, went in asked resident why she was climbing out of bed and resident said she wanted to go to the bathroom. The roommate was already in the bathroom. CNA placed the resident into her wheelchair and placed her in the hallway, told her that CNA would come take her to the toilet when the other resident had finished, CNA put chair alarm in place. Actions: Education not to leave residents on the toilet alone whether or not you put them on it. The resident had recent UTI, attempted to self transfer to bathroom had a recent previous fall with fracture. 5. Failure to monitor and provide adequate hydration, contributing to fall risk - cross-reference F327, failure to provide sufficient fluids to maintain hydration Hospital Record Review Review of the hospital records indicated the resident was dehydrated at the time of admission to the hospital, with a fractured hip on 4/29/13. Review of the hospital emergency room report documented in part: Comprehensive metabolic panel shows glucose of 113, BUN of 42, creatinine of 2, and alkaline phosphatase of 161. The patient had intravenous (IV) fluids started. The Hospital Discharge summary, dated 5/3/13, documented in part left intertrochanteric hip fracture status [REDACTED]. fell at the nursing home. Interviews On 6/5/13 at 2:40 p.m.,the staff CNA working on the hallway with resident #76 said resident #76 was on the Falling Star Program and that all staff was to look into her room when they pass the door to monitor that she is not trying to get up without assistance. They are to go into the room and offer assistance if she is trying to get up independently. She said the resident had a low bed and fall mat in place. She said that she was not sure what happened that caused the resident to fall on 4/29/13. On 6/6/13 at 12:05 p.m., the resident's physician was interviewed. She said resident #76 had some medication changes, also had recently had an acute urinary tract infection. She said she was not aware of the low fluid intake, and she would think that nursing should encourage fluids, offer assistance frequently for toileting, and document intakes. She said she was not aware of the hospital record that documented dehydration and acute renal failure, but did agree that lab results of the BUN of 43 and Cr. of 2.2 would be consistent with dehydration and that dehydration could be a contributing factor for falling. On 6/6/13 at 12:25 p.m., the Director of Nurses (DON) was interviewed. She said she was not aware of the recent dehydration at the time of the hospitalization on [DATE]. She said that dehydration could contribute to resident falls. She said that resident #76 wants to be independent and she is a frequent faller and her falls are unpreventable because she was up walking independently in her room and she continues to try to be independent. "No, she is not on a toileting plan but has routine toileting of first thing when she gets up in the morning, before and after meals, and at bedtime. Anytime staff is in the room they should offer toileting assistance." The documentation did not support the DON's statement that the falls were unpreventable.

Based on family and staff interview and record review, the facility failed to ensure one of 33 sample residents (#1) received the necessary care and services to promote the resident's highest practicable level of physical, mental, and psychosocial well-being. Resident #1, who had a [DIAGNOSES REDACTED]. A pain pump had been inserted and the resident also had a pain patch and orders for as needed pain medication for breakthrough pain. Resident #1 was transferred out of the facility to his physician's office within hours of arrival due to staff's concern regarding his pain, breathing, and aspiration. The resident was first taken in the facility van, improperly secured, to his primary care physician (PCP). He fell during transport (cross-reference F323). Upon arrival at the PCP's office, he was taken by ambulance to the hospital, where he was diagnosed with [REDACTED]. Facility failures included: -A failure to comprehensively assess the resident's need for care and services prior to and on admission to ensure staff was prepared to meet the resident's needs. -A failure to appropriately respond to the resident's needs upon admission. The facility failures contributed to decline in the resident's physical, mental, and psychosocial well-being. The findings include: 1. Closed record review revealed resident #1, a [AGE] year-old male, was admitted to the facility on [DATE]. According to admission orders [REDACTED]. The resident had advance directives indicating he was full COR (cardiopulmonary resuscitation) upon admission. 2. Status Prior to Admission Review of hospital documentation and a police report revealed the resident was admitted to the facility following admission and discharged from two hospitals for pain management (implanting of a pain pump), pain crisis, [MEDICAL CONDITION], and inability of family to meet his needs. -On [DATE], the resident was hospitalized for [REDACTED]. The pump infused [MEDICATION NAME] at a set amount every three hours and the resident was to return to the pain clinic for refill and reprogramming in a week. -On [DATE], the resident was hospitalized at another hospital "with pain crisis secondary to metastatic [MEDICAL CONDITION]." The hospital note read in pertinent part: "just discharged on [DATE] for pain pump placement without complication. After that point, the patient had remained hypoxic which was secondary to the advancing [MEDICAL CONDITION] and bilateral pleural effusions. He presented in pain crisis again and does not have sufficient care at home at this time to manage the pain and his current needs. He will likely be discharged to a skilled nursing facility . . . for the pain crisis and further stability." This hospital's discharge summary dated [DATE], noted in pertinent part: "Pain crisis secondary to metastatic [MEDICAL CONDITION] causing this hospitalization . Patient status [REDACTED]. [MEDICATION NAME] at 30 mg by mouth q4h prn pain available for breakthrough pain, patient continues with [MEDICATION NAME] at 100 mcg two patches changes every two days, [MEDICATION NAME] 300 mg po tid as well as [MEDICATION NAME] at 5 mg sublingual q ,[DATE]h prn breakthrough pain. -"Hospital Course: ...Arrangements made to place within (LTC facility) so that he may receive physical therapy, occupational therapy and skilled nursing, as well as further attention to his pain management regimen. He spent a comfortable and uneventful night at (the hospital) and is deemed stable for discharge ..." -At time of discharge, a verbal message was left for (PCP) that he will need to continue to evaluate the patient's pain medication and maybe once the pump is fully functional, that his supplemental pain needs may decrease. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed the evening of [DATE]. They said the resident had been to two hospitals prior to his admission to the facility. The family took him to a hospital approximately two and a half to three hours away to have a pain pump implanted. The local hospital, about a half hour away, "called us and asked if he could come here. We reviewed the case and felt we could take him. They said he was end [MEDICAL CONDITION] and the family didn't want hospice." 2. Facility Actions on Admission a. Assessments and Plan of Care Admission Assessment: The resident's [DATE] admission assessment noted "pain" to his back and a "pump" to his lower left abdomen. Pain intensity was noted as 5 to 8 on a scale of ,[DATE]. The assessment was signed by a licensed practical nurse (LPN). Pain Assessment: The [DATE] admission pain assessment, completed by the LPN, noted the resident was currently in pain, at risk for pain, and experienced pain in the past. He was not reluctant to verbalize pain. His pain was measured, according to the Abbey scale for people with dementia who cannot verbalize, as vocalization severe, facial expression severe, change in body language moderate, behavioral change and physiological change mild, with a total score of 10, indicating moderate, chronic pain. -The resident's pain was noted to interfere with his ability to communicate, his mood, ability to ambulate, relations with people, activities of daily living, eating, sleeping and enjoyment. -The nurse rated the resident's pain, on the faces scale, at an 8 on a scale of 1 to 10. The origin of pain was noted [MEDICAL CONDITION] with metastasis and a recent procedure. Past pain interventions noted as ineffective were prescribed and over-the-counter medications, and non-medication interventions. Movement made the pain worse. In the past 24 hours, it was noted the pain treatments/medications provided 50% relief. It was noted the resident's pain radiated from his back, was constant, the intensity was a 5 on his best day and on an average day, and was a 10 on his worst day. A physical exam of the pain site revealed the area was swollen and aching. Care Plan: According to the resident's [DATE] interim care plan, the resident had pain [MEDICAL CONDITION] with metastasis. Interventions included: -Educate resident/family on pain management program. -Monitor pain intensity following medication or treatment. -Reassess pain management efficacy every shift and as needed. -Evaluate benefit of non-medicinal interventions such as positioning, adaptive devices, warm/cold, therapies, etc. b. Facility failure to comprehensively assess the resident's need for care prior to and on admission to ensure staff was prepared to meet the resident's needs. Review of the assessments above failed to include information on the resident's recent history of pain crises, [MEDICAL CONDITION], and pleural effusions. The section on the pain assessment, seeking input from the family in describing the resident's behavior when in pain, was left blank; there was no indication in this assessment that the resident's pain was discussed with family, even though the family had been involved in managing the resident's pain when he was at home. While the admission assessment noted the resident had a "pump," there was no description of what it was infusing and how it was to operate. Finally, there was no evidence the admission assessment was co-signed or reviewed by a registered nurse (RN). In an interview with RN #1 on [DATE] at 2:45 p.m., she said she was not involved in the resident's admission process. Review of the assessments and care plan failed to reveal evidence that the hospital documentation, noting the resident's pain crises, [MEDICAL CONDITION] and pleural effusions, had been reviewed and considered in establishing the resident's plan of care. There was no reference on the care plan to the pain pump, what medication it contained, how it operated, and what to monitor to ensure it was functioning properly. Review of the hospital discharge orders revealed no orders regarding the operation of the pump, including what medication was being administered, how frequently the medication was being administered, and who, if anyone, was to operate the pump. While the facility contacted the PCP (see below) for orders/directives regarding the resident's pain, there was no evidence in the record that staff contacted either of the two hospitals to obtain information regarding the operation of the pain pump and what to expect regarding pain management; specifically, whether the pump was fully effective at the time of admission or, if not, when it might become effective. Likewise, there was no evidence (confirmed through interview with the NHA on [DATE] and [DATE]) that staff contacted the Medical Director for direction in managing the resident's care. LPN #1, who admitted resident #1, was interviewed at 1:30 p.m. on [DATE]. -She said, "I never got report. I was completely surprised. We got notice of his care needs and requirements. I thought I was getting a rehab admission." -She said on admission, the resident was in pain and she was on the phone with the doctor's office, saying he was inappropriate for admission to a long term care facility. "He's got a pain pump that I didn't know anything about - he had facial droop, respiration labored - I thought he was actively dying. I touch him and he screams. I give him meds and they drip down his face. ... The OT (occupational therapist) and (the resident's) two sons helped transfer him to bed and he let out a blood-curdling scream." Resident #1's wife was interviewed by phone on [DATE] at 4:05 p.m. -"The nurses at the hospital said he's only going to be at (the LTC facility) a couple of days until he recuperates. He was going to stay until the pain pump distributed the meds through his body. I don't think we were there 30 minutes before they wanted to move him. The nurse was anxious and rushing us. The rush was (the PCP) wanted to close his office and wouldn't come out there." -"Every time they moved him he was uncomfortable. Moving him caused pain. But he was better than he was before the pain pump. She (LPN #1) wasn't listening. The pump worked phenomenally well for him." 2. Events After Admission a. Record Review On [DATE] at 2:50 p.m., a LPN noted upon the resident's admission that the resident was alert and answered questions appropriately. "When asked by this nurse, 'yes/no' responses. Res. history at time of admission was mostly completed by son (name) and this nurse ... Res found to be in extreme pain upon admission, rates pain on a pain scale at ,[DATE] on ,[DATE] pain scale ... Res abd is soft & non-tender upon palpation, area is tender to touch at recent incision site of pain pump to LLQ (left lower quadrant) of abd. This area found to have steri strips covering the wound. Res was assisted to bed (with) O.T. & res son (name), at this time res screams out. M.S. Roxinol was given per e-kit, given ,[DATE] ml sq q ,[DATE] PRN. Res assisted to sitting position, res left in sitting position by this nurse (with) family so I could call M.D. regarding his poor status & admission finding. ...Spoke (with) MD regarding follow up appt." On [DATE] at 5:40 p.m., a noted read: "Res on route to (MD's) office. This nurse notified by receptionist that bus was at (a bank at the end of the block) and they needed a nurse. This nurse and a RN (registered nurse) ran to transport bus in next door parking lot. Boarded bus, found res on left side lying on floor in back of bus, next to w/c (wheelchair). 2 nurses rode with him to (MD's) office and 911 met them there. After (MD) assessed him, res sent to (hospital) for evaluation. Will continue to monitor." On [DATE] at 7:50 p.m., a note read "Nursing supervisor (from hospital) called at this time ... Arranging for transportation for resident to return to facility via ambulance ... States resident has cervical fracture which is non-surgical. Resident should be back in one to one and one and a half hours." Facility medical record review revealed the resident was readmitted to the facility via ambulance on [DATE] at 9:20 p.m. and a hospice nurse was on her way. The resident resided in the facility with hospice care until his death on [DATE]. b. Facility failure to appropriately respond to the resident's needs following admission (1) Failure to contact Medical Director for assistance LPN #1, during her interview at 1:30 p.m. on [DATE], said, "I wanted (his PCP) to come here and give some orders for hospice. (The PCP) wouldn't order hospice without seeing him, and he wouldn't come in (to see the resident) ..." She stated she was concerned about the resident's breathing, aspiration, and pain. The LPN stated the PCP told her he had an appointment available at 4:30, said if she got resident #1 there by 4:30, the PCP would see him. She stated, "So we loaded him in the van (after medicating him for pain)." She said the PCP's office was about 12 minutes out. LPN #2 was interviewed at 2:20 p.m. on [DATE]. She said the resident was admitted at about 2 p.m. on [DATE] and LPN #1 "said she needed help - he was in bed - she needed help getting his pain controlled - we got liquid [MEDICATION NAME]. The doctor was supposed to come in and wouldn't, so they loaded him in the van." The NHA and director of nursing (DON) were interviewed the evening of [DATE] about the PCP's refusal to come to the facility. They said "Doctors don't come here." The NHA and DON both stated they did not call the medical director when the resident's PCP refused to see him in the facility. Resident #1's wife, during her interview on [DATE] stated, "(The PCP) was my husband's general practitioner before (the resident's [DIAGNOSES REDACTED]. (The PCP) hadn't seen him for nine months before the accident (during transport - see below)." (2) Failure to secure resident - Fall during transport LPN #1, during her interview on [DATE], said she sat down to do her paperwork and "the transport driver called and said (the resident) tipped over in his wheelchair. I believe the driver was on the phone with 911." She said she went to the van. "He (the resident) was lying on his back, left side down, talking. I asked if he hurt and he said 'what the hell do you think?' He wasn't screaming in pain, no blood or anything ..." RN #1 was interviewed at 2:45 p.m. on [DATE]. She said, "The receptionist said (the van driver is at the bank) and needs a nurse. I ran over there. Another nurse was with me. (Resident #1) was on the floor on the right side of his back with a towel under his head. I asked (the driver) if he had a head injury. I said call 911, started assessing (the resident's) situation. I think (resident #1) had been in pain. (Resident #1) had pain, said 'yes I've been in pain." I asked if he had any new pain. He wasn't really able to elaborate or differentiate. He said his position was uncomfortable." The NHA, during the afternoon of [DATE], said the van driver who had put resident #1 in the van only fastened three of the four restraint ties on the resident's wheelchair, and "one of those wasn't fastened properly." She said, "(The van driver) got just out into the street and the wheelchair turned over." She said the driver was not trained or certified as a certified nurse aide. (No staff had accompanied the van driver). Cross-reference F323 for further details. (3) Failure to transport with proper assistance after fall: Interviews: LPN #1, during her interview on [DATE], stated that after staff arrived at the van and the resident was assessed, "We decided to go to (the PCP's office). (The resident) wanted to go to the doctor. In hindsight, I would have let the medics take him." RN #1, during her interview on [DATE] said, "Two other nurses showed up (at the van, in response to the receptionist call for a nurse). I stayed with (LPN #1), I was at his head. (The driver) said EMS (emergency medical services) said go ahead and take him to the doctor's office. I maintained his C-spine until we got to the doctor's office. (LPN #1) held his hips. He was conscious and talking." Resident #1's wife, during the interview on [DATE], stated she and other family members were waiting at the PCP's office for the van. When the van arrived, "(The PCP) told his nurse to call 911 - she ran in and did. The nurses and driver didn't say they already had (called EMS). . . It took the EMTs (emergency medical technicians) ten or 15 minutes at the most to arrive." Record Review: A recording of the 911 call placed by the van driver on [DATE] at 4:56 p.m. was received from the police department and reviewed on [DATE]. The van driver told the dispatcher he was in a bus parked near the bank, and a [AGE] year-old male had fallen backwards out of his wheelchair, was conscious, on five liters of oxygen. Voices could be heard in the background, and a female voice told the driver at 4:58 p.m. that they were going to the physician's office. The dispatcher reiterated to the driver that they were going on to the physician's office, stated an ambulance was dispatched, and asked if they would wait for the ambulance. The driver responded that they were going to the physician's office. The dispatcher noted clearing the dispatched unit from the call at 5 p.m. Review of fire department notes from the dispatch revealed the call was received at 4:57 p.m. on [DATE]; a unit was dispatched, and was cancelled in route at 5 p.m. The fire department incident report narrative text read, "Paged for reported handicap male who had fallen in the parking lot behind (local bank). Dispatch advised that the pt had been placed into a POV (private occupancy vehicle) and driven to (another city) for medical attention and that all units could stand down." 3. Resident Status on Arrival - emergency room (ER) Report The local hospital ER report, dated [DATE], noted in pertinent part: The resident arrived in the ER at 6:19 p.m. on [DATE] "complaining of ,[DATE] head pain, neck, and back pain ... Lung CA, mets to brain, T3, T4. [DIAGNOSES REDACTED] resection Dec. 2008. [MEDICAL CONDITION] treatments, 3 rounds of chemo treatment. Usually ,[DATE] pain level per son. [DATE] [MEDICATION NAME] injection into spinal canal by (another physician).." -"Chief complaint: A [AGE] year-old male who presents to the emergency department with chief complaint of neck pain." -"...History of metastatic [MEDICAL CONDITION] which is Stage IV [MEDICAL CONDITION]. He has brain metastasis as well as significant metastases to his upper [MEDICATION NAME] spine from his right lung. He has a history of pleural effusion which is intermittent. He is status [REDACTED]. In the latter part of last week, I had admitted the patient to the hospital after he had presented back with some worsening of his right pleural effusion. The patient had actually been given disposition to (the LTC facility) and was on the way from (the facility) to his primary care physician's office for evaluation when his wheelchair inadvertently tipped over and the patient struck the left side and posterior aspects of his head on the ground. There was no reported loss of consciousness, but the patient had immediate neck pain. He was sent in by his (PCP) for further evaluation of possible fracture. There is no reported lower extremity weakness, upper extremity weakness that is appreciable. The patient has baseline significant pain of both upper arms. He is also complaining of right shoulder pain. . ." -"Chronic back and new neck pain, as above." -"Emergency department course: The patient had CT scan performed of his cervical spine which reveals a compression fracture at T1 which is greater than 50% involvement. There is no retropulsion, but the radiologist did comment on the extensive degree of metastatic destruction of his upper [MEDICATION NAME] spine and the generalized instability that the destruction has caused ... Essentially, he has an unstable fracture in his neck. I believe that an Aspen collar placed appropriately should give him some relief of his discomfort, but this certainly does not stabilize his spine in any meaningful way." -"Assessment: ... 1. T1 compression fracture, 2. Endstage [MEDICAL CONDITION]." -"Plan: Continue hospice care and comfort care measures. Leave the Aspen collar in place at all times. Activity level should include protection of his cervical spine as much as possible, with the understanding that this is an unstable fracture and can cause significant, if not life-threatening and severe neurologic impairment and that there is no way to protect the [MEDICATION NAME] and cervical spine from further injury due to the degree of instability throughout his upper [MEDICATION NAME] spine. Follow-up with (PCP) as discussed." Summary of Facility Failures The facility failed to ensure they had adequate hospital discharge instructions and knowledge of the resident's care needs prior to his admission to the facility. There were no orders on how to manage his pain pump, or the fragility of his condition. The resident's admission assessment was not conducted by a registered nurse. Facility nursing staff did not contact the hospital physician or the facility medical director when the resident's primary care physician refused to visit him in the facility. The facility transported the resident in the facility van without supervision by qualified staff. The resident was not safely secured in the van in his wheelchair and sustained a fall. Instead of waiting for the ambulance, the facility transported the resident on the floor of the van to his physician's office, where an ambulance was called and took him to the emergency room , retracing the trip made to the doctor's office where the doctor did not treat him.

Based on observation, resident, staff and physician interview and record review, the facility failed to ensure that two (#1, #48) of 33 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically the facility: -Failed to ensure resident #1 was safely secured and transported in the facility van. The resident's wheelchair tipped over and resident fell out of his wheelchair onto the floor of the van, sustaining a neck fracture. -Failed to adequately supervise and secure resident #48 during bathing. The resident fell from the bath chair and sustained a shoulder joint separation and fractured scapula. The findings include: 1. Resident #1 (closed record review), a [AGE] year-old male, was admitted to the facility on [DATE]. According to admission orders [REDACTED]. a. Resident Status - Fall Risk - Plan of Care Care Plan: According to his [DATE] interim care plan, resident #1 was at risk for physical injury from falls related to recent falls and use of analgesics. The goal was to minimize fall risk related to injury. Interventions were: assist of two persons for transfers; provide assistance for bed mobility, transfers or ambulation; bed alarm when in bed and audible to staff - pad alarm at all times; low bed; and landing mat. The resident required total assist with activities of daily living, and used a wheelchair for ambulation. Fall Risk Assessment: According to his [DATE] fall risk assessment, resident #1 scored 20 points. A score of ten or more indicates "at risk." Nurses' Notes: According to [DATE] nurses' notes at 2:50 p.m., the resident was in extreme pain upon admission, "pain pump to LLQ of ABD (left lower quadrant of abdomen) ... res screams out, MS Roxinol was given per E-kit ... Res left in sitting position by this nurse with family so I could call MD regarding his poor status & admission finding ... Res found to require total dependence with all cares, uses w/c (wheelchair) with foot rest. Res son reports 2 falls at home 'sometime between Oct-[DATE].' Res fell at home while walking with walker & also had a fall while getting out of the shower. Res skin found to be pale, cool to the touch. Spoke with MD regarding follow up appt." Cross-reference F309; quality of care for further details. b. Fall During Transfer to Physician's Office On [DATE] at 5:40 p.m., a different nurse documented, "Res. on route to (primary care physician's/PCP's) office. This nurse notified by receptionist that bus was at (a bank about a half block away) and they needed a nurse. This nurse and an RN ran to transport bus in next door parking lot. Boarded bus, found res. on left side lying on floor in back of bus, next to w/c. 2 nurses rode with him to (PCP's) office and 911 met them there ..." On [DATE] at 8:34 p.m., another nurse noted the hospital called "with report ... states resident has T1 unstable fracture." c. Failure to Safely Transport the Resident in Facility Van The nursing home administrator (NHA) was interviewed on the afternoon of [DATE]. -The NHA said the van driver put resident #1 in the van, only fastened three of the four restraint ties on the resident's wheelchair, and "one of those wasn't fastened properly. He got just out into the street and the wheelchair turned over." She said the resident suffered a fracture, he also had cancer of the spine, and the resident died five days later. "We suspended all transportation until the safety system was tested and everyone was trained." -The NHA said the driver was not trained or certified as a certified nurse aide and also said the van driver had "two other write-ups before that," and this was the third incident, and he was terminated. She said the other write-ups were before her time. Van Driver's Record: Review of the van driver's [DATE] termination form noted he was "trained on Q-Straint on [DATE] of appropriate securement of wheelchairs in bus ... [DATE] (he) was to transport a resident to the physician office. Three points of the w/c were secured, the L front was not secured. The w/c tipped over in route to physician office." The consequences to the facility were noted as: "1) injury to the resident, 2) possible litigation, 3) safety violations." The reason for termination was "safety violation causing injury to the resident." The driver had received two previous corrective actions. -On [DATE], he went to a resident's room "to get her for her appointment. She was in bed & told (him) she did not need the aides to assist her to her chair, that he could help her & she could not bear her weight & lowered her to the floor." He was counseled for "jeopardizing resident to injury" and trained to "get caregiver guides and to ask CNAs (certified nurse aides) for assistance of transfers." -On [DATE], the driver "when removing resident from bus failed to pay attention to safety needs of the resident resulting in resident falling." The facility documented training on the QStraints (see above) but there was no follow-up training or supervision of the van driver documented after the two incidents above. Driver's Statement Regarding Incident: Review of the police department file on the incident above revealed a written statement from the facility's former van driver, dated [DATE], which documented in pertinent part as follows: "Picked up (resident #1 from local hospital) along with 2 other residents who had had appointments there. Due to the length of the appointments we did not leave (the hospital) until approx 2:40 (p.m.) Called (another office) to cancel 2 other appointments (3:00) and reschedule. Arrived at (LTC facility), unloaded the 3 passengers and quickly put on a resident with a 3:30 appointment at (another office)." "While (at that appointment) I received word (4:15 p.m.) that our new resident (#1) had a 4:30 appt with (his PCP) & we had to transport him. ...This was the 1st that I had known of it. I told (the driver in training) to stay with our resident while I took (resident #1). Drove as quickly as possible back to (the LTC facility), informed receptionist that (driver in training and other resident needed to be picked up)." "Several people, (resident #1's) family, and (LTC facility) staff were assisting readying (resident #1) to go on the bus. After loading on the bus (another LTC staff) and one of (resident #1's) sons were there while I secured (resident #1's) wheelchair. As it was cold I placed him near the heater securing the back with 2 'QStraint' hold downs. As he was in pain & placed just behind the rear seats of the bus I opted to use one QStraint hold down on the front of the chair to avoid climbing over his lap ... I did not double check the fasteners of the QStraint." "In route turning from (the LTC street onto the highway) I heard a loud 'thud' and groan from the back of the bus. I did not see his head in the mirror and pulled over at the 1st available space, the driveway into (the bank). Went back and found (resident #1's) chair had flipped on to its back and he was lying on the floor. I disentangled him from the shoulder strap & checked him as best as I could, removed the wheelchair and saw that the front QStraint had popped out of the floor track allowing the chair to trip backwards. I called (the facility) and requested assistance, which was quickly answered by 4 nurses. (Two nurses) took charge at that point. I called 911 and told them of the situation, an ambulance was notified and (one of the nurses) told me to drive him on to (the PCP's office). I informed 911 that we were in transit to (the PCP) & would call them when we arrived." "At (the PCP's) office (resident #1) was assisted by his sons - trained in emergency response and (the PCP). I called 911 and requested an ambulance. Which came promptly. The ambulance crew, (the PCP) and (resident #1's) sons placed (resident #1) into the ambulance to be transported to the hospital. I then transported (the two nurses) back to (the LTC facility)." d. Resident Status Following Fall emergency room Hospital Record: Review of the hospital record revealed the resident suffered an unstable T1 cervical fracture. He was treated and released back to the long term care facility on [DATE], when hospice care was also initiated for the resident. Resident #1 died on [DATE]. Coroner's Report: Review of the [DATE] Postmortem Examination Report revealed in pertinent part, that resident #1's immediate cause of death was "complications of metastatic lung disease." The forensic pathologist wrote: "The decedent is a [AGE] year-old male hospice patient with a history of advanced disseminated lung cancer. He sustained a pathologic cervical spine fracture on [DATE]th in a fall while being transported, immediately developed neck pain in association with the injury and was evaluated and released for further hospice care. He passed away in hospice care the morning of [DATE]th." Family Interview: Resident #1's wife was interviewed by phone on [DATE] at 4:05 p.m. "(Resident #1) was unable to move after the accident. . . The fracture was pretty much the last straw. . .The accident just broke his will." 2. Resident #48, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], resident #48 had no communication deficits, had a BIMS score of ,[DATE] that indicated moderate impairment in cognitive skills, required assistance with activities of daily living, including bathing, had range of motion impairment on one side, was incontinent of bladder and bowel and used a wheelchair for mobility. The MDS included his height of 5 feet 10 inches and weight of 221 pounds. a. Resident Status - Fall Risk - Plan of Care See MDS above; the resident had range of motion limitation on one side. A Fall Risk Evaluation performed on admission [DATE], assessed resident #48 with a score of 18; a score of 10 or higher indicated the resident was "at risk." Resident #48's Care Plan for Activities of Daily Living included a goal and target date: "Resident will be accident free with regard to all activities of daily living over next 90 days [DATE]." The approaches included: "Assist of one or two staff to bathe/shower and toileting." b. Fall [DATE] with pain and injury According to the Nurse's Notes dated [DATE] at 9:30 a.m., "Res. was being bathed in tub, upon getting dried off and into sitting position, CNAs (certified nurse aides) report removing safety straps for transfer, res slid off bath chair onto floor, landing on L side of body head laid on pivot disc (which was lying on floor). -CNA reports assisting resident to his back and this nurse was notified by another CNA, upon my arrival res is awake, alert, smiling, talkative, denies pain at this time. Res able to move his right side without difficulty (arm and leg). Res was assessed by this nurse, head to toe assessment completed. Neuro checks started. No breaks in skin . . . -Res was asked if he felt ok to roll over to his side and check back, hip, buttocks. He states 'Go ahead.' Res does have a 1X1.5cm bruise to his upper R arm, he was unable to tell if it was new or old, so it was placed on this assessment . . . -Res asked again if he had pain. He states 'No.' VS ,[DATE] 96.7, 51, 21, 94% on RA (room air). Res was log rolled and assist X4 staff to Hoyer sling, was Hoyered into w/c . . . Nurse asked again about any pain. Res point to his L side of head and states 'Kinda hurts here.' . . . Res was given 2 APAP 500mg at this time. At 0940 he is assisted back to bed, neuro checks continue. Res states, 'I'm fine just HA.' . . ." Another note on [DATE] at 12:45 p.m. read: "Res c/o increase discomfort to L shoulder. States, 'This dam shoulder has given me fits since my stroke.' Rates pain sitting in w/c at "25", smiles then states, 'It's bad.' Medicated with Tylenol #3 per MD order. Res up in w/c eating lunch, refuses offer of ice packs X2 to head or shoulder." Another note on [DATE] 1:10 p.m. read: "Res insist pain to be increasing and demanding to go to ER (emergency room ). Spoke with therapist and his thought was for res to be eval'ed. 1:30 p.m. (Resident's attending physician) paged. Call back from (attending physician's partner). New orders to send to ER via ambulance for eval of shoulder, neck. " A physician's Telephone Order dated [DATE] at 1:30 p.m. "Send to ER via ambulance for eval neck, shoulder right joint pain." There was a Fax Order Notification sent to the physician at 9:30 a.m. on [DATE] that read, "(Resident #48) slipped from bath/shower bed, neuro's started, 1X1.5cm bruise to R upper arm, denies pain, skin intact, ROM X2 WLN for this resident. Awake, alert and no LOC (loss of consciousness). Abrasion to L scalp 3.2X2.5cm, intact. Son notified via voice mail." The emergency room report dated [DATE] documented in pertinent part: "Chief Complaint: An [AGE] year-old male who presents to the emergency department with chief complaint of left arm pain. -History of Present Illness: An [AGE] year-old male fell earlier today. He was noted by nursing to be complaining of left shoulder pain. He slipped at about 9:00 a.m. while taking a bath . . . -Past Medical History: History of stroke in the past with subsequent left-sided hemiparesis (muscle weakness). He states that at base line his left arm has minimal movement . . . -Emergency Department Course: He had x-ray performed of the left shoulder . . . My interpretation is left acromioclavicular separation, no obvious fracture. The radiologist's interpretation is pending at this time . . ." The hospital's radiology report dated [DATE] stated, " . . . Impression: 1. Grade 1 AC joint separation. 2. Possible scapular fracture . . . extending from the superior margin of the wing through the glenoid. If clinical concern persists I would suggest a CT scan." (Per interview with the Director of Nurses on [DATE], the glenoid fracture was confirmed by CT scan [DATE].) c. Failure to adequately supervise and secure resident #48 during bathing. Interviews: (1) Resident #48 was interviewed at 8:34 a.m. on [DATE]. He said, "They have a bench-like chair that you lay on and I had soap on my back and I slid off the chair more or less. They were standing next me, two of them . . . How did I feel? Pretty awful - it dislocated this shoulder (pointed to left shoulder). Then they got me up and got me back to my room. They took me to the hospital later for x-ray. Really, it did not hurt that bad. I just insisted that I go so I could know what happened. When they told my son about it he came down right away. I went by ambulance to the hospital. I am glad I went to hospital. I wanted to know what was wrong . . . Yes, they (CNAs) did take the straps off before I got up to move to my wheelchair." (2) The first CNA who was with resident #48 when he fell in the bath was interviewed at 8:52 a.m. on [DATE]. She stated that she took her "CNA test one week ago . . . Before that I was NA (nurse aide)." When asked to describe the events, she stated, ". . . Me and (second CNA) were giving baths together. After we got done with his bath and dried him off as much as we could, the next thing we knew he was on the floor. (The second CNA) went to get the nurse and I stayed with him. The only thing he said was that he couldn't breathe. I was guessing he was scared. Two nurses came and checked him before we Hoyered him up with four of them." (3) During an interview with the second CNA at 9:07 a.m. on [DATE] she said, "I have worked as a bath aide . . . (The first CNA) and I were in there together and we were drying him off and he was moving sideways back and forth because he was adjusting himself. He normally does that and that was when he slipped off the bath chair. It (the chair) was as low as it goes - we always lower it. The secure straps were removed probably when drying him off - we always set them up before they get dressed. That way you can dry off his back and back of his legs . . . There are three straps; one on his chest, one across stomach and one just below knees. All three were off before he fell . She (the first CNA) was on one side and I was on the other. He slid off to the left side." (4) The Director of Nursing (DON) was present during both CNA interviews and stated that it was difficult to visualize and had asked the CNAs to demonstrate. She and the second CNA offered to demonstrate and this was done in the bath/shower room where the incident took place. -The second CNA and the DON were observed demonstrating the position of the resident and the CNAs when he fell from the bath chair to the floor. The CNA said that resident #48 was lying flat in the bath chair when they were drying him off and that they couldn't reach his back to dry it while lying down. The bath chair was positioned about one and one half feet from the wall. -The resident fell out of the left side of the chair between the lift and the wall. (See above MDS and ER report - the resident suffered from hemiparesis and weakness on his left side). (5) The Licensed Practical Nurse (LPN), who documented the fall events on [DATE] in the record, was interviewed at 10:00 a.m. on [DATE]. The LPN stated, "When I entered the room, he was lying on the floor. I did a full assessment and he repeated over and over that he had no pain. We did neuro checks and vital signs and did get Hoyer and got him to the wheelchair and back to bed. It (the injury) was on affected side. He said, 'All I really want to do was go to bed.' I gave him Tylenol. After lunch he said he had pain. I called in the therapist to examine him and gave him Percocet . . . The resident said he wanted to go to get checked out so we sent him to the ER. There was no ER report at the time. The next week, I think they re-examined the x-ray and then they told me that he had injury..." (6) The DON was interviewed at 10:32 a.m. on [DATE]. -The DON stated, "I was notified when he was sent to the ER after the fall. I waited to hear what happened at ER. I checked first to see if family was called and the MD notified and asked if there were two people accompanying him in the shower. I think they sent him back the same day but we didn't get the report from the CT scan until the 19th when the glenoid fracture was confirmed . . ." -"I interviewed both CNAs. The main thing was the witness statements - and I had them both come in and demonstrate the transfer. At that point we realized that they had taken the safety straps off which put him at risk. So we added that addendum to the policy and inserviced the CNAs. They both felt terrible. I did talk with the family after and told the family member what we had done so it wouldn't happen again. It was an unfortunate accident . . ." -"Training for bathe aides? We do have competencies - I looked in their charts but there was nothing specific to bath aide training." She indicated that aides did not receive specific training on bathing. She stated, "We make sure that routine transfers are observed but not specifically bath transfers. After 90 days we do competencies and then annual(ly). They are trained in CNA classes to do transfers. I don't think it was lack of training." She further stated, however, that the plan would be to add bath aide training to the orientation check list. -The DON also stated, "Our bath policy was updated to include instructions to leave straps fastened until ready to transfer (the) resident. The two CNAs received education. All CNAs including students will be educated on new bathing policy." Record Review: (1) The DON submitted the Incident Report for review in her presence at 10:47 a.m. on [DATE]. Review of the Incident Follow-up and Recommendations included actions taken: "1) Sent to ER for evaluation. 2) Education for safety strap use to bath aides. 3) Environmental check of bath/shower room. 4) Therapy screen. Follow-up investigation: negative - ER follow-up. Care plan updated." (2) The Rehabilitation Services Post-Fall Screening Tool dated [DATE] documented: "Circumstances of fall - off of bath lift. Change in Status - Yes - To ED arm in sling. Environmental Factors contributing to fall: wet lift. Falls committee suggestions - education re: use of straps." (3) The facility's undated policy and procedure "Bathing a Resident" included the following in pertinent part: "Bath Care - Key Factors - Procedure . . . 18. When giving a tub or shower bath, you must remain with the resident during the entire procedure." There was an addendum dated [DATE] that stated: "Transfer safety in the shower room. Two safety straps are to be employed on the bath lift during the bath and during the lift. Wheel locks are to be used. As the bath lift is a mechanical lift it requires two persons for all uses. All transfers being completed in the shower room are to be completed with the use of a gait belt unless the resident uses a mechanical lift transfer . . ." There was another bathing policy addendum dated [DATE] that stated, "Do not remove any safety straps from bath chair until the resident is dry and ready to transfer."