Every finding on record at Life Care Center of Cheyenne

Based on resident representative and staff interview, medical record review, and policy and procedure review, the facility failed to ensure a notification of change of condition was given for 1 of 3 sample residents (#6) reviewed for a change in condition. The findings were:1.Review of the 1/12/26 annual MDS assessment showed resident #6 had a BIMS score of 11 out of 15 (which indicated mild cognitive impairment); showed no signs or symptoms of delirium, behaviors, or hallucinations; was continent of both bladder and bowel, and was independent with personal hygiene, oral hygiene, and toileting hygiene. The resident had diagnoses which included non-Alzheimer's dementia and depression. The findings were:a. Telephone interview with the resident's representative on 3/26/26 at 11:51 AM revealed the resident had a urinary tract infection (UTI) in February. Further, the resident's representative stated the resident had told her s/he was taking medication for an infection. At that time the resident's representative contacted the facility to obtain information related to the resident's change of condition. b. Review of a Health Status Note, dated 2/2/26 and timed 8:02 AM, showed [The resident] reported c/o [complained of] dysuria, urinary urgency and frequency. UA [urinalysis] collected and pending.c. Review of a Health Status Note, dated 2/2/26 and timed 10:38 PM, showed Resident is being monitored for keflex (antibiotic) for UTI day 1/7 [1 out of 7] with no adverse reaction.d. Review of a Health Status Note, dated 2/3/26 and timed 11:45 AM, showed Resident is on Keflex day 2/7 [2 out of 7] for UTI. [S/he] is up out of bed. Alert to staff and all cares. No complaints of nausea, vomiting or diarrhea. No adverse skin reactions or complaints of discomfort.e. Review of an Infection Note, dated 2/3/26 and timed 1:30 PM, showed the resident had been diagnosed with a UTI related to dysuria, increased urgency/frequency and a positive urine culture. The resident was prescribed cephalexin (antibiotic) for 7 days per the culture and sensitivity report. Good hygiene to be encouraged and fluids offered per current medical condition. Will continue to monitor.f. Review of the communication with family notes showed the resident's representative was notified on 2/12/26 at 9:53 AM to inform her the facility was collecting a urine sample to ensure the infection was cleared. There was no evidence the resident's representative had been notified of the change of condition at the onset of the UTI.2. Interview with the DON on 3/26/26 at 1:56 PM confirmed there was no documentation the resident's representative had been notified of the change of condition. 3. Review of the Changes in Resident's Condition or Status policy, last reviewed 8/29/25, showed This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status .A facility must immediately inform the resident' consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is .(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .

Based on observation, medical record review, and staff and resident interview, the facility failed to promote and facilitate resident choice and preferences for 1 of 2 sample residents (#12) reviewed. The findings were:1. Review of the 7/21/25 admission MDS assessment showed resident #12 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, malnutrition, frequent pain, rheumatoid arthritis and muscle weakness. Further review showed the resident had major surgical procedures prior to admission to the facility which involved placement of nephrostomy tubes and a colostomy. The following concerns were identified: a. Observation on 9/24/25 at 2:31 PM showed RN #1 was changing the resident's dressings following a shower. The resident was lying in his/her bed with his/her upper body exposed and was visibly shivering. The resident verbalized that s/he was cold and CNA #1 offered to turn up the heat. RN #1 responded stating Please don't right now. RN #1 was observed wearing PPE (personal protective equipment), which included a gown and stated she was hot and would require a shower following the dressing change. b. Interview with resident #12 on 9/24/25 at 11:20 AM confirmed that s/he was cold during the dressing change and would have preferred the heat be increased while the dressing was changed.

Based on staff interview and medical record review, the facility failed to ensure a Level II PASRR (preadmission screening and resident review) evaluation was completed prior to admission for 1 of 1 residents (#123) reviewed. The findings were: 1. Review of the 8/20/25 admission MDS assessment showed resident #123 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included bipolar disorder, anxiety disorder and cerebrovascular accident, transient ischemic attack, or stroke. The following concerns were identified: a. Review of the resident's PASRR Level I, dated 8/14/25, showed evidence of a mental illness which required a PASRR Level II screening prior to admission to the facility. Further review of the resident's medical record showed no evidence a PASRR Level II evaluation had been completed. 2. Interview with the NHA on 9/15/25 at 9:40 AM confirmed a PASRR Level II was not completed prior to admission.

Based on observation, policy and procedure review, medical record review, and resident and staff interview, the facility failed to ensure effective pain management was provided to 1 of 4 residents (#12) reviewed for pain management. The findings were: 1. Review of the 7/21/25 admission MDS assessment showed resident #12 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, frequent pain, rheumatoid arthritis and muscle weakness. Further review showed the resident had major surgical procedures prior to admission to the facility which involved placement of nephrostomy tubes and a colostomy. Review of the September 2025 medication administration record showed the resident was last administered 5 milligrams (mg) of oxycodone on 9/24/25 at 7 AM for a pain rating of 7 out of 10 and 500 mg of acetaminophen was administered on 9/23/25 at 9 PM. The following concerns were identified: a. Observation on 9/24/25 at 2:31 PM showed RN #1 was preparing dressing change supplies for resident #12 which was to be completed following the resident's scheduled shower with occupational therapy. RN #1 with the assistance of NP #1 and CNA #1 began changing the resident's colostomy bag and wafer as well as his/her nephrostomy tube dressings. Further observation showed the resident was rolled from side-to-side and verbalized back pain as well as discomfort to the adhesive sites of the wafer and dressings. In addition, RN #1 did not assess or acknowledge the resident's pain complaints prior to or during the dressing change. b. Observation on 9/24/25 at 3:10 PM showed RN #1 assessed the resident's pain level and determined it to be 8 to 9 out of 10 and administered prescribed Tylenol per the resident's request at 3:22 PM. c. Interview with RN #1 on 9/24/25 at 3:54 PM revealed the resident was premedicated for pain prior to dressing changes on occasion. Further, the RN stated The resident's pain and anxiety is so bad at times that we will just push through it. d. Interview with the DON on 9/24/25 at 3:58 PM revealed residents who have known pain with dressing changes were pre-medicated if it was within the physician's ordering timeframe. e. Review of the physician's orders showed 500 mg of acetaminophen every 6 hours as needed was ordered on 9/11/25 and 5 mg of oxycodone every 6 hours for moderate to severe pain was ordered on 9/19/25. Further review of physician orders, dated 9/15/25 at 6 AM showed the resident's acceptable pain level was 5 out of 10. f. Interview on 9/25/25 at 11:20 AM with the resident confirmed s/he was in pain during the dressing change and would have preferred to be pre-medicated prior to the procedure. 2. Review of the facility policy titled Pain Assessment and Management, last revised on 9/23/25, showed the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management while identifying target signs and symptoms, including verbal and non-verbal indicators of pain.

Based on observation, staff interview, and review of policy and procedures and standards of practice, the facility failed to ensure effective infection prevention practices were implemented during one random observation of linen transportation. The census was 119. The findings were: 1. Observation on 9/22/25 at 2:11 PM showed an unidentified staff member was walking down the rehabilitation hall with unbagged soiled towels in her ungloved hands and was transporting them to the soiled linen room. 2. Interview with the infection prevention coordinator on 9/25/25 at 11:56 AM revealed soiled linen should be bagged before removing them from the residents' room and remain bagged while being transported to the laundry room. 3. Review of the Centers for Disease Control and Prevention standards of practice titled Laundry and Bedding, last revised 1/08/24, showed soiled laundry should be bagged prior to transporting to the soiled linen room. 4. Review of the facility policy titled Infection Prevention and Control Program (IPCP) and Plan, last revised 6/02/25, showed personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were safely stored during 1 of 2 observations of medication administration. The census was 113. The findings were: 1. Observation on 9/5/24 at 10:13 AM showed RN #1 removed a medication cup, which was not labeled and had 4 capsules in it, and placed it on the top of the medication cart in a plastic basket on an ice pack. Further observation showed the RN walked away from the medication cart and the medication remained in the basket. 2. Interview with RN #2 on 9/5/24 at 10:17 AM revealed medications should not be left unattended on the top of a medication cart. Observation at that time showed RN #2 removed the medications from the top of medication cart. 3. Interview with RN #1 on 9/5/24 at 10:25 AM revealed the medications he placed on top of the cart were probiotics the needed to be cool. Further interview revealed he was not aware the medications could not be left unattended. 4. Review of the facility policy titled Medication Storage dated March 2022 showed .Medications requiring refrigeration must be locked or stored in a locked room .Medication carts and cabinets should be locked when unattended .No pre-set/pre-prepared medications are not permitted (unless allowed by state regulation) .Medications are properly labeled with patient name, lot # [number], and expiration date .

Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised as needed to reflect the resident's current needs for 1 of 23 sample residents (#5). The findings were: 1. Review of the 5/1/24 admission MDS assessment showed resident #5 had a cognitive assessment which determined the resident to be severely impaired. The resident had diagnoses which included traumatic brain dysfunction, Alzheimer's disease, dementia, and anxiety disorder. Review of the physician orders showed the resident was prescribed 25 mg of Seroquel (antipsychotic) daily at bedtime for agitation on 4/27/24 and 25 mg of Zoloft (antidepressant) daily for depression on 5/16/24. Review of the care plan, last revised on 5/30/24, failed to show the care plan had been revised to include goals and interventions related to the diagnosis of depression. 2. Interview with the DON on 6/6/24 at 10 AM confirmed the care plan had not been updated to reflect the use of the antidepressant medication.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure medication-specific target symptoms were identified and monitored for 2 of 5 sample residents (#5, #29) reviewed for unnecessary medication use. The findings were: 1. Review of the 5/21/24 MDS assessment showed resident #29 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment, and diagnoses which included Parkinson's disease, dementia, anxiety, and depression. Review of the most current physician orders showed the resident received 25 (mg) of Seroquel (antipsychotic) by mouth in the evening related to psychotic disorder with hallucinations, 25 mg of Zoloft (antidepressant) by mouth one time a day related to depression, and 34 mg of Nuplazid (atypical antipsychotic) by mouth one time a day for Parkinson's related hallucinations. The following concerns was identified: a. Review of the June 2024 Behavior Monitoring & Interventions task showed the resident could be verbally and physically aggressive, exhibited inappropriate sexual behavior, had periods of restlessness, anxious concerns, tearfulness, and had paranoid or delusional thoughts. Further review showed no evidence medication-specific target symptoms had been identified for each of the psychoactive medications prescribed. 2. Review of the 5/1/24 admission MDS assessment showed resident #5 had a cognitive assessment which determined the resident to be severely impaired. The resident had diagnoses which included traumatic brain dysfunction, Alzheimer's disease, dementia, and anxiety disorder. Review of the physician orders showed the resident was prescribed 25 mg of Seroquel (antipsychotic) daily at bedtime for agitation and 25 mg of Zoloft (antidepressant) daily for depression. The following concerns was identified: a. Review of the June 2024 Behavior Monitoring & Interventions task for the resident showed agitation, verbal and physical aggression, and resistance to care were identified as behaviors to monitor. Further review showed no evidence medication-specific target symptoms had been identified for each of the psychoactive medications prescribed. 3. Interview with the DON on 6/5/24 at 2:09 PM and again on 6/6/24 at 11:06 AM confirmed the facility did not have medication-specific target symptoms identified on the behavior monitoring and intervention task for the psychoactive medications prescribed. 4. Review of the policy titled Unnecessary Medication, last reviewed on 8/9/23, showed .8. The facility will ensure proper monitoring and accurate documentation to a medication in order to evaluate the ongoing benefits as well as risks of various medications.

Based on medical record review, observation, resident representative and staff interview, and review of policy and procedure, the facility failed to ensure adequate interventions were in place to prevent accidents for 1 of 4 sample residents (#199) reviewed for accidents. This failure resulted in harm to resident #199, who sustained fractures after a fall. The findings were: Review of the 8/19/22 comprehensive MDS assessment for resident #199 showed the resident was admitted on [DATE] with diagnoses that included heart failure, arthritis, malnutrition, muscle weakness (generalized), and unsteadiness on feet. The resident had a BIMS score of 9 of 15, indicating moderate cognitive impairment. Further, the assessment noted the resident was not steady when moving on or off the toilet or during surface-to-surface transfers, and was only able to stabilize with staff assistance. The assessment showed the resident required the extensive assistance of 1 staff member for transfers and toilet use, and utilized a wheelchair. The resident was not coded as using a walker. Review of the resident's care plan, initiated on 8/30/22, showed the resident was at risk for falls and fall-related injuries related to physical deconditioning, weakness, and alterations in gait/balance. Interventions developed at that time were non-specific, and included Assist with ADLs as needed .Call light within reach .Complete fall risk assessment .Orient resident to room . Review of the 2/14/23 quarterly MDS assessment showed the resident had a BIMS score of 6 of 15, indicating severe cognitive impairment. Additionally, the assessment showed the resident continued to be unsteady when moving on or off the toilet or during surface-to-surface transfers, and was only able to stabilize with staff assistance. The resident was coded as utilizing a wheelchair. The resident was not coded as using a walker. Further, the assessment showed the resident had increased assistance needs, requiring the extensive assistance of 2 or more staff members for transfers and toilet use. Further review of the resident's care plan showed interventions related to the resident's risk for falls were updated on 2/27/23 and included the following: Anticipate and meet The [sic] resident's needs .Educate the resident/family/caregivers about safety reminders and what to do it a fall occurs .Provide activities that minimize the potential for falls while providing diversion and distraction .Provide adaptive equipment or devices as needed .Provide appropriate footwear when mobilizing in w/c [wheelchair] .Pt [physical therapy] evaluate and treat as ordered or PRN [as needed]. The updated care plan lacked interventions that addressed the resident's need for increased staff assistance with transfers and toilet use. Review of the resident's Visual/Bedside Kardex Report, provided by the facility on 3/2/23, instructed staff who provided care to the resident that the resident required the following assistance with transfers: TRANSFER: 1 person stand pivot front wheel walker from bed to wheelchiar [sic] or wheelchiar to bed Grab bar for the restroom. Observation of the resident's room on 3/2/23 at 12:35 PM showed a wheelchair positioned in front of the bed. There was no front wheel walker observed at that time. The following concerns were identified: 1. Review of the progress note dated 2/25/23 at 7:31 PM showed Event note, Resident was being transferred to bed from wheelchair and slid to the floor in front of [his/her] bed. 2. Interview with CNA #1 on 3/2/23 at 12:45 PM revealed on 2/25/23 the resident was in bed and needed to go to the toilet. The CNA transferred the resident to the toilet, and on return to the resident's bed she and the resident .were going to stand and pivot back to bed .we got halfway back and [s/he] tried to sit down, I couldn't hold [him/her] and [s/he] fell , kinda hard. The CNA confirmed she did not use a gait belt while transferring the resident, and she believed the resident only required a 1 person assist. She further stated she had checked the resident's Kardex to confirm the resident's transfer requirements after the fall. The CNA also stated the DON had a conversation with her about gait belts after the fall, and she would be using a gait belt from now on. 3. Review of the progress note dated 2/26/23 at 11:22 PM showed Health Status Note, Resident requesting to the [emergency room ] for [evaluation] and treat on right leg pain from fall . 4. Review of the progress note dated 2/27/23 at 1:15 AM showed Health Status Note, resident admitted to [local hospital] due to femur fracture. 5. Interview with the resident's representative on 3/2/23 at 11:45 AM revealed the facility had notified her of the fall. She stated, I was told there was a CNA with [him/her] and it was a soft fall. She was informed the resident was not hurt, but was complaining of pain. She stated she did go to see the resident on 2/26/23 and told the facility staff the resident was in pain and the resident's right leg was swollen. The representative added she received a call from the hospital on 3/1/23, and was informed the resident had a hairline fracture to the left leg in addition to the fractured right femur. 6. Review of the facility policy titled Fall prevention, long-term care revised 2/20/23 showed .If the resident is at risk for future falls, take steps to reduce the danger based on the factors creating the risk. Assess the resident for gait disturbances, and identify and correct improper use of ambulation devices as needed . 7. Review of the facility policy titled Gait belt use revised 5/20/22 showed .A gait belt is a safety device .The device provides a secure grasping surface to aid with patient transfer and ambulation. A gait belt is commonly used for patients who are at risk for falling and can help lower a patient safely to the ground if the patient begins to fall or loses balance during transfer or ambulation . 8. Interview with the DON on 3/2/23 at 2:17 PM revealed it was the facility's expectation for staff to follow residents' care plans.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure 1 of 2 medical record storage areas (Therapy West) were safeguarded from unauthorized use. The findings were: 1. Observation on 2/27/23 at 1:58 PM of the Therapy West hall showed resident medical records were kept in a cabinet. Both doors of the cabinet were observed to be off the hinges. At that time 12 resident medical records were seen. The storage area was across from the nurses' desk, and a restroom. Further observation showed throughout the four days of the recertification survey the medical records were easily accessible and were available for unauthorized use. 2. Interview with LPN #2 on 2/28/23 at 11:13 AM confirmed the records were available for anyone to access. Further, the LPN stated she was unsure of the how long the doors had been broken. 3. Interview with the DON on 2/28/23 at 4:59 PM revealed it was the facility's expectation for the residents' medical records to be kept in a secure cabinet with the doors closed. Further, the DON stated she was aware the cabinet was broken and thought it was okay since it was in an alcove. In addition, she acknowledged that someone could get into the records. 4. Review of the policy and procedure Safeguarding and Storage of Medical Records revised 3/22/22 showed .Procedure .Protect all medical records from damage, loss, destruction, or unauthorized use. Do not leave clinical records unattended in public areas. Limit viewing access by unauthorized personnel and visitors by returning records to their designated storage location and closing them when not in use.

Based on observation, medical record review, resident and staff interview, and review of facility policy and procedure, the facility failed to ensure 2 of 26 sample residents (#19, #28) had resident-specific care plans that reflected individual needs in all required areas. The findings were: 1. Review of the medical record for resident #19 showed s/he was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, insomnia, PTSD (post-traumatic stress disorder), dementia with psychotic disturbance, neuroleptic induced Parkinsonism, muscle weakness and lack of coordination. Review of the 2/3/23 quarterly MDS assessment showed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the physician's orders, printed 3/1/23, showed orders for Abilify (antipsychotic) 10 milligrams and Cymbalta (antidepressant) 90 milligrams, by mouth, daily for major depression. Interview with the resident on 3/2/23 at 11:30 AM revealed s/he was not verbally or physically aggressive, was dependent on staff for cares, used a wheelchair, and did not walk. The following concerns were identified: a. Review of the care plan, dated 2/15/23, showed the resident had behaviors of pacing, wandering, disrobing, inappropriate response to verbal communication and violence/ aggression towards others. There was no evidence the resident exhibited these behaviors. b. Interview with the DON on 3/2/23 at 3:40 PM confirmed the behaviors listed on the care plan were incorrect. 2. Review of the 11/23/22 quarterly MDS assessment for resident #28 showed the resident had a BIMS score of 15/15 (cognitively intact) and had diagnoses which included non-Alzheimer's dementia, anxiety disorder, depression, and chronic pain. The resident received as needed (PRN) medication and non-medication interventions, and had an opioid administered on 7 days of the 7-day look-back period. Further review showed the resident had frequent pain which interfered with day-to-day activities. Review of the most recent physician orders showed the resident was prescribed 0.5 ml of 20 mg/ml morphine sulfate solution every 2 hours, as needed for pain, with a start date of 8/30/21. In addition, the resident was prescribed 650 mg of acetaminophen every 6 hours, as needed for pain, with a start date of 2/23/21. Review of the February 2023 MAR showed an order to assess the resident for pain every shift and to .Attempt non-med interventions prior to administering PRN pain medications: 1. Reposition 2. Lie down . Further review of the February 2023 MAR showed morphine was administered on 26 days and acetaminophen on 24 days. The following concerns were identified: a. Observation on 2/27/23 at 4:06 PM showed the resident was in the hallway asking LPN #3 for morphine. The LPN assessed the resident's pain and administered the medication. After receiving the morphine the resident immediately asked for Tylenol and was told by the RN s/he would have to wait for an hour. No non-medication interventions were attempted prior to the administration of the morphine. b. Review of the resident's pain care plan initiated on 2/9/21 showed The resident's pain was aggravated by: [left blank] . The resident's pain is alleviated/relieved by: [left blank] .The resident is able to: (SPECIFY: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain). c. Interview with the DON on 3/1/23 at 4:24 PM and the MDS coordinator on 3/2/23 at 10:22 AM confirmed the care plan had not been developed to reflect specific resident needs. 3. Review of the facility policy titled Comprehensive Care Plans and Revisions last reviewed 8/17/22, showed ensure timeliness of each resident's person-centered, comprehensive care plan . should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person -centered plan of care. 47344

Based on medical record review and staff interview, the facility failed to follow physician's orders for 1 of 26 sample residents (#73) reviewed. The findings were: 1. Review of the 1/13/23 quarterly MDS assessment showed resident #73 had a BIMS score of 99 indicating the resident was unable to complete the interview (severely impaired - never/rarely made decisions) and diagnoses which included diabetes mellitus and long term use of insulin. Further review showed the resident received insulin injections 7 days of the 7-day look-back period. Review of the physician's orders, printed 2/28/23, showed the facility was to check blood sugars before meals and at bedtime. The orders specified to call the physician if the blood glucose was less than 70 mg/dl or greater than 460 mg/dl. The following concerns were identified: a. Review of January 2023 MAR showed the resident had blood glucose levels less than 70 mg/dl on 1/12/23 and 1/15/23. Review of February 2023 MAR showed a greater than 460 mg/dl level on 2/2/23 and 2/3/23 and less than 70 mg/dl level on 2/10/23 at two different times. Review of the medical record showed no evidence the physician had been notified. The lowest blood glucose documented was 63 mg/dl level on 2/10/23 and highest blood glucose documented was 480 mg/dl level on 2/3/23. b. Review of the physician progress note dated 1/20/2023 showed did look at sugar log, there are several low readings and noted the physician wanted to avoid hypoglycemia. 2. Interview with the DON on 3/1/23 at 4:30 PM revealed the resident's family was very particular about the resident's blood glucose monitoring. The DON confirmed there was no documentation to support the facility had notified the physician when results were out of parameters and stated it was the facility's expectation the physician was to be notified as specified in the order. 3. Review of the facility policy titled Blood glucose monitoring, dated 9/22/22, showed If you obtain an extremely high or low blood glucose level on the glucose monitor, retest the resident. If the result is the same, notify the practitioner for review and new orders .and . document the procedure.

Based on observation, staff interview, policy and procedure review, and professional standard review the facility failed to ensure medications were labeled in accordance with professional standards in 1 of 4 medication storage units (Therapy South medication cart). The finding were: 1. Observation on 3/2/23 at 9:45 AM of the Therapy South medication cart showed 2 insulin glargine 100 unit/milliliter flex pens with no open date, and 1 insulin lispro 100 unit/milliliter kwikpen with no open date. Interview at that time with RN #1 confirmed the medications were for resident use. Further, the RN stated she was unaware when the medications would expire. 2. Interview with the DON on 3/2/23 at 10:31 AM revealed it was the facility's expectation for the insulin containers to be dated with an open date when they come out of the refrigerator for use. 3. Review of policy Guidance for Using Insulin Products dated 2021 Omnicare, showed 1. Storage of Product .b.Storage of unopened insulin products outside of the refrigerator is permissible, but results in an earlier expiration date.After opening may be used for: Up to 28 days included insulin Lispro, and Lantus (insulin glargine brand name). 4. Review of the web page American Diabetes Association accessed 3/14/23 showed .Insulin kept at room temperature will last approximately one month .

Based on observation, medical record review and staff interview, the facility failed to ensure care plans were developed to include resident-specific activity plans for 3 of 27 sample residents (#13, #15, #91) reviewed. The findings were: 1. Review of the 11/9/21 quarterly MDS assessment showed resident #13 had moderate cognitive impairment with a BIMS score of 10 out of 15, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed the resident was totally dependant on 2 staff members for transfers, bathing and toileting. Review of the care plan with a revision date of 11/10/21 showed a care area for activity involvement. The following concerns were identified: a. Observations on 1/23/22 at 10:42 AM and at 2:45 PM showed the resident in bed. Another observation on 1/24/22 at 9:46 AM showed the resident in bed. b. Interview with RN #4 and CNA #3 revealed the resident was bed bound, and did not get up. They further stated the activity assistants used to round on the residents who were confined to bed, however that was no longer the routine. c. Review of the care plan with a revision date of 11/10/21 showed a care area for activity involvement. The care plan showed interventions that were initiated on 1/28/19 included recording prior level of activity involvement and escorting the resident to activities. Further review of the care plan failed to show updated interventions to reflect the resident's bed bound status. 2. Review of the 11/3/21 annual MDS assessment showed resident #15 had a BIMS score of 99 (unable to complete the interview), and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the resident required extensive assistance of 1 staff member for bed mobility, eating, and dressing. Review of the care plan with a revision date of 11/18/21, showed the resident was independent for meeting emotional, intellectual, physical and social needs. The following concerns were identified: a. Observation on 1/23/22 at 3:18 PM and on 1/24/22 at 9:19 AM showed the resident sitting in a chair in his/her room with the television on. b. Review of the care plan with a revision date of 11/18/21 failed to show interventions to engage the resident in activities while in the room. c. Interview on 1/26/22 at 11:35 AM with the interim activities director stated she visited with the resident each morning when she delivered the activity sheet, but this was not recorded as an activity. She further stated she had not learned how to revise the care plans to reflect the resident's current status. 3. Review of the 1/11/22 quarterly MDS assessment showed resident #91 had moderate cognitive impairment with a BIMS score of 12 out of 15, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan with a revision date of 10/26/21 showed the resident was independent for meeting emotional, intellectual, physical and social needs. The interventions included 1:1 bedside/in-room visits and activities if unable to attend out of room events. The following concerns were identified: a. Observation on 1/23/22 at 10 AM showed the resident in bed. Further observation showed 2 staff members transferred the resident to the bathroom, then back to bed per resident request. b. Review of the progress notes failed to show documentation for 1:1 activity participation. c. Interview on 1/26/22 at 11:06 AM with the interim activities director confirmed there was no formal 1:1 activity program.

Based on medical record review, review of bathing documentation, and resident and staff interview, the facility failed to ensure bathing was provided as scheduled for 3 of 7 sample residents (#17, #76, #192) who required assistance with bathing. The findings were: 1. Review of the 1/10/22 significant change MDS assessment showed resident #17 was cognitively intact with a BIMS score of 15 out of 15, and required extensive assistance with 1 person physical assist for bathing. Review of the CNA task documentation for bathing showed the resident was to have showers on Tuesdays and Fridays. The following concerns were identified: a. Interview on 1/23/22 at 10:52 AM with the resident revealed s/he was not receiving baths or showers per the schedule. b. Review of the CNA task documentation showed the resident went 7 days without a shower from 1/11/22 through 1/18/22 and another 8 days without a shower from 1/18/22 through 1/26/22. c. Interview on 1/26/22 at 10 AM with the DON revealed it was the facility's expectation for the CNAs on duty to give the residents their showers on the scheduled shower days. 2. Review of the 12/27/21 admission MDS assessment showed resident #76 was cognitively intact with a BIMS score of 15 out of 15, and required supervision assistance of one staff member for bathing. Review of the care plan, last reviewed 1/12/22, showed the resident was non-weight-bearing to his/her left lower extremity. Review of the CNA bathing task documentation showed the resident was scheduled for bathing on Wednesday and Saturday evenings. The following concerns were identified: a. Interview with the resident on 1/24/22 at 10:48 AM revealed s/he had not had a shower or bath .in at least a week. b. Review of the CNA bathing task documentation showed during the period from 12/26/21 to 1/26/22 the resident received bathing on just two days, 1/8/22 and 1/15/22. c. Interview with the DON on 1/26/22 revealed CNA staff were responsible for coordinating and providing baths/showers. She further revealed a schedule was posted in the shower room, on the resident's care cards in their rooms, and incorporated into the daily task checklist in the electronic medical record. 3. Review of the 1/11/22 admission collection tool for resident #192 showed his/her level of consciousness was alert, and oriented to person, place, and time. The documentation showed the resident required physical help for bathing. Review of the CNA task documentation for bathing showed the resident was to have showers on Tuesdays and Fridays. The following concerns were identified: a. Review of the CNA task documentation showed the resident went 7 days without a shower from 1/11/22 through 1/18/22. b. Interview on 1/26/22 at 10 AM with the DON revealed it was the facility's expectation for the CNAs on duty to give the residents their showers on the scheduled shower days.

Based on observation, medical record review, staff interview, and review of activity documentation, the facility failed to ensure a program of activities to meet the needs for 3 of 7 sample residents (#13, #15, #91) reviewed for activities. The findings were: Interview on 1/25/22 at 3:04 PM with the interim activities director revealed daily activities for all residents included music that played over the speaker system in the facility, television, staff/family/friend visits, and reality orientation (orientation to time and place). She stated these were documented as activities on the individual resident daily participation records. She further stated there was no formal 1:1 activity program. If a resident was identified to require 1:1 activities, the expectation would be 15 minutes at least 3 times a week. She further stated they had friendly visits which were done daily when she or another activity assistant delivered the daily activity sheet to the residents. She stated the purpose of the friendly visit was to encourage the residents to get more active and participate in activities. She acknowledged there was a lack of activities provided for the residents who were bed-bound or stayed in their rooms. The following residents were identified who required 1:1 activity programs: 1. Review of the 11/9/21 quarterly MDS assessment showed resident #13 had moderate cognitive impairment with a BIMS score of 10 out of 15, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan with a revision date of 11/10/21 showed a care need for activity involvement. Review of the activities evaluation dated 6/6/21 showed the resident had interests in animals/pets, educational programs, family/friend visits, and movies. The following concerns were identified: a. Observation on 1/23/22 at 10:42 AM and at 2:45 PM showed the resident stayed in bed. Another observation on 1/24/22 at 9:46 AM showed the resident was in bed. b. Interview with the RN #4 and CNA #3 revealed the resident was bed bound, and did not get up. They also stated activity assistants used to round on the residents who were confined to bed, however that was no longer the routine. c. Review of the Individual Resident Daily Participation Record for January 2022 showed family/friend visits, music, television, and reality orientation were the activities marked daily. There were no additional activities documented related to the resident's identified interests. d. Review of the Friendly Visit sheet showed a staff visit to the resident on 1/23/22, 1/24/22, 1/25/22, and 1/26/22. 2. Review of the 11/3/21 annual MDS assessment showed resident #15 had a BIMS score of 99 (unable to complete the interview), and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan with a revision date of 11/18/21, showed the resident was independent for meeting emotional, intellectual, physical and social needs. Review of the activities evaluation dated 11/15/19 showed the resident enjoyed animals/pets, arts/crafts, cooking, creative writing, cultural events, current events and movies. The following concerns were identified: a. Observations on 1/23/22 at 3:18 PM and on 1/24/22 at 9:19 AM showed the resident sitting in a chair in his/her room with the television on. b. Review of the Individual Resident Activity Daily Participation Record for January 2022 showed family/friend visits, music, television, and reality orientation were the activities marked daily. There were no additional activities documented related to the resident's identified interests. c. Interview on 1/26/22 at 11:35 AM with the interim activities director stated she visited with the resident each morning when she delivered the activity sheet, but this was not recorded as an activity. 4. Review of the 1/11/22 quarterly MDS assessment showed resident #91 had moderate cognitive impairment with a BIMS score of 12 out of 15, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan with a revision date of 10/26/21, showed the resident was independent for meeting emotional, intellectual, physical and social needs. The interventions included 1:1 bedside/in-room visits and activities if unable to attend out of room events. The following concerns were identified: a. Observation on 1/23/22 at 10 AM showed the resident was in bed. Further observation showed 2 staff members transferred the resident to the bathroom, then back to bed per resident request. b. Review of the progress notes failed to show documentation for 1:1 activity participation. 5. Interview on 1/24/22 at 3:04 PM with RN #4 and CNA #3 stated hall 100 had several residents who were bed bound or stayed in their room, and there was not much activity for them. They further stated there used to be activity assistants who would round and have 1:1 activity programs with the residents, but that was no longer routine.

Based on observation, medical record review, policy and procedure review, manufacturer recommendations, and staff interview, the facility failed to ensure infection control procedures were followed during 1 random observation of hand hygiene, 3 random observations of personal protective equipment (PPE) use, and 2 random observations of cleaning resident care equipment. The census was 102. The findings were: Related to proper PPE use: 1. Observation on 1/24/22 at 3:04 PM showed CNA #3 wearing an N95 face mask with only 1 strap. Interview with her at that time revealed she cut the other strap off because it was difficult to breathe and she felt she had a tight fit with only 1 strap. 2. Observation on 1/24/22 at 2:48 PM showed housekeeper #1 wearing an N95 face mask with only 1 strap. Interview with her at that time revealed she cut the top strap because it was hard to breathe and she felt she had a tight fit with 1 strap. 3. Observation on 1/23/22 at 10:03 AM showed RN #2 wearing protective eyewear and an N95 face mask. However, the mask was not worn correctly, with the bottom of the mask folded up inside the mask; there was no seal with the mask, as her chin was clearly visible. 4. Interview on 1/26/22 at 10:49 AM with the infection preventionist stated the N95 face masks still provided a tight fit with only 1 strap. However, she further stated they were not following manufacturer's recommendations for wearing an N95 mask. 5. According to the 3M Aura NIOSH N95 face mask manufacturer's recommendations, one strap was placed on the crown of the head, and the second strap was placed at the back of the neck for proper fit. 6. According to the Centers for Disease Control recommendation for using the N95 respirator, .N95s must form a seal to the face to work properly Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted . https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html. (Accessed on 2/4/22). Related to hand hygiene: 1. Continuous observation beginning on 1/23/22 at 12:17 PM showed RN #3 with the mobile ice cart outside of room [ROOM NUMBER], entering the room. The following concerns were identified: a. Before entering room [ROOM NUMBER] the nurse did not perform hand hygiene. She returned to the ice cart with the resident's water mug, removed the lid, filled the cup with ice, re-entered the room, filled the cup with water from the sink, and returned the mug to the resident. She then exited the room without performing hand hygiene. b. Without performing hand hygiene the RN then went to the medication cart and began using the mouse and keyboard of the computer on top of the cart, then opened the medication cart and began removing medications. No hand hygiene was observed before contact with the computer, medication cart, or the medications. c. Interview with RN #3 on 1/23/22 at 12:22 PM confirmed she did not perform hand hygiene between contact with resident belongings, prior to entry or upon exiting the resident room. d. Review of the facility's Standard Precautions policy with a revision date 2/15/21, showed (1) hand hygiene .Perform hand hygiene: a. Before and after all resident contact . Related to equipment cleaning: 1. Observation on 1/23/22 at 2:52 PM showed CNA #2 went into room [ROOM NUMBER] to obtain vital signs with equipment on a mobile cart. The following concerns were identified: a. The aide used a blood pressure cuff, forehead scanning thermometer and the pulse oximeter all located on the mobile cart to obtain vital signs from resident #36. The CNA cleansed the forehead scanning thermometer with a small single-use alcohol wipe. However, she failed to clean or disinfect the blood pressure cuff or the pulse oximeter prior to using the equipment for the roommate, resident #41. Continued observation showed after use of the equipment for resident #41, the CNA cleaned the thermometer, however, there was no disinfection of the BP cuff or the pulse oximeter. These items were returned to the cart. She washed her hands and took the cart into room [ROOM NUMBER] to get the vital signs for those residents. Observation at 3:05 PM showed no cleaning or disinfection was done to these items prior to use in room [ROOM NUMBER]. b. Interview with CNA #2 on 1/23/22 at 3:19 PM revealed the expectation was to wipe down the BP cuff and pulse oximeter as well as the thermometer. She stated it had been a hectic day, and verified there were no Sani-wipes available on the cart. However, they were available on the hall counter, and she took them with her and wiped the equipment. 2. Observation on 1/23/22 at 2:22 PM showed CNA #3 obtained vital signs using a blood pressure machine and a pulse oximeter. The CNA left the room without cleaning the equipment and went into another resident's room to obtain vital signs. Further observation showed she did not clean the equipment. Interview with the CNA at that time revealed she knew the expectation was to clean the equipment between resident uses, however, she cleaned the equipment when she finished getting all of the vital signs. 3. Interview on 1/26/22 at 10:49 AM with the infection control nurse revealed the expectation was for staff to clean the equipment between residents. 4. Review of the Standard Precautions policy, with a revision date 2/15/21 showed 6. a. resident care items and surfaces used for multiple residents are disinfected between use

Based on observation, medical record review, review of professional standards, and staff interview, the facility failed to ensure appropriate care and services to prevent urinary tract infections for residents with indwelling urinary catheters during 2 random observations (affecting residents #32, #59). The findings were: 1. Observation on 1/24/22 at 2:20 PM showed resident #59 was seated in his/her wheelchair and had a Foley catheter; the catheter bag was not in a privacy bag, and was lying on the floor underneath the wheelchair. Observation on 1/24/22 at 2:36 PM showed RN #1 entered the room and noted the bag was on the floor under the resident. He placed the catheter bag into the privacy bag, and hooked the bag under the wheelchair so it was off the floor. Interview with RN #1 at that time confirmed the catheter bag should not be on the floor due to infection risk. 2. Review of the 11/22/21 admission MDS assessment showed resident #32 had an indwelling catheter and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 11/29/21 for catheter use showed interventions that included catheter care every shift, and check tubing for kinks several times each shift. The following concerns were identified: a. Observation on 1/24/22 at 9:58 AM showed the resident's catheter bag was laying uncovered on the floor under the resident's bed. b. Interview with the infection preventionist on 1/26/22 at 12:07 PM confirmed the expectation was to keep the catheter bag off of the ground and in a protective cover. 3. According to the Centers for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), Proper Techniques for Urinary Catheter Maintenance showed, .Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html (Accessed on 2/4/22)

Based on observation, staff interview, interview with the ombudsman, review of facility policy and procedure, and review of CMS guidance, the facility failed to ensure the residents' rights to self-determination, communication, and access to persons inside the facility was facilitated related to communal dining. The census was 91. The findings were: 1. Observation on 12/29/21 at 8:10 AM showed the breakfast meal was served in the residents rooms. The main dining room was empty of residents, and there was a staff member using one of the tables for work. 2. Interview with the administrator and DON on 12/29/21 at 3:25 PM confirmed there had been no offer to resume communal dining made to the residents. They had a couple of COVID-19 outbreaks, and since the end of the last outbreak on 11/11/21, dining continued in the residents' rooms. The administrator stated he was not aware the residents wished to eat in the dining room. 3. Interview with the ombudsman on 12/29/21 at 1:40 PM revealed his discussions with residents that day confirmed they were eating all meals in their rooms, and they thought this was due to COVID-19 restrictions. According to the ombudsman, the residents interviewed expressed a desire to be able to return to the dining room for meals. 4. Review of the 12/7/21 revised facility Coronavirus (COVID 19) ([CONDITION(S)]-CoV-2) policy pg 28 showed, Communal dining may be facilitated (if approved by your local health department and state survey agency) for residents who are; fully vaccinated, COVID-19 recovered, and for those who are not on quarantine for observation, or in isolation for suspected, or confirmed COVID-19 positive. 5. Review of CMS guidance found in QSO-20-39-NH, Nursing Home Visitation-COVID-19 revised 11/12/21 showed .While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur .

Based on staff and family interview, interview with the ombudsman, review of facility policy and procedure, and review of CMS guidance, the facility failed to ensure residents and families were kept informed about clinical and safety restrictions, and their ability to have visitation without advanced scheduling. The census was 91. The findings were: 1. Interview with the administrator on 12/29/21 at 8:30 AM verified the facility was allowing visitation at any time. He stated visits were allowed without an appointment; however, scheduling a time was offered to ensure the resident was available and ready. He also stated if the visitors wished to meet in the resident's room, this could be accommodated depending upon the circumstance. The administrator further stated there was no written policy and procedure regarding visitation, and they were following the CMS guidelines. The following concerns were identified: a. Interview with the family of resident #4 on 12/29/21 at 2:33 PM revealed s/he visited frequently and was told at the facility s/he was required to make an appointment. The family member stated when requesting to visit in or see the resident's room, s/he was denied and was told there are no visits allowed in resident rooms. On Christmas Eve s/he had to sit with other families and residents in the living room common area for the visit. The family member stated it was unsettling not to be able to see where her family member was living in the facility. S/he further stated nothing had been received in writing from the facility concerning the visitation policies and procedures. b. Interview with the family of resident #2 on 12/29/21 at 2:51 PM revealed they were asked to schedule visits and it was their understanding visits must be scheduled, so they never attempted to visit without an appointment. They were also told by the facility staff they were not allowed to visit in the resident's room. c. Interview with the administrator on 12/29/21 at 8:30 AM confirmed there had been no written information communicated to the residents or families regarding visitation policies and procedures. d. Interview with the ombudsman on 12/29/21 at 2:30 PM revealed in his discussions with residents on that day their understanding was that visits needed to be pre-arranged. e. Interview on 12/29/21 at 9:50 AM with the Facility Liaison confirmed although visits were allowed without appointments, visitors were encouraged to call ahead .and visits were allowed in common areas. She further stated there were certain considerations for visits in the resident rooms; however, she was unsure what the details were to allow resident room visits. f. Review of the 12/7/21 revised Coronavirus (COVID 19) ([CONDITION(S)]-CoV-2) policy showed Educational Recommendations on pg 10, .Educate residents and families through educational sessions and written materials on topics including information about [CONDITION(S)]-CoV-2, actions the facility is taking to protect them and their loved ones, any visitor restrictions that are in place, and actions they should take to protect themselves in the facility . g. Review of CMS memo QSO-20-39-NH, last revised on 11/12/2021 showed Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the PHE [public health emergency], facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Although there is no limit on the number of visitors that a resident can have at one time, visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents .

Based on family interview, staff interview, medical record review, and hospital medical record review, the facility failed to ensure the resident's environment was free of accident hazards for 1 of 6 sample residents (#206) with Alzheimer's and/or dementia diagnoses who suffered falls. This failure resulted in harm to resident #206, who fell from an electric recliner that was not assessed for safety, sustaining multiple bone fractures. The findings were: 1. Review of the 6/17/21 quarterly MDS assessment showed resident #206 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, dementia without behavioral disturbance, pain, generalized muscle weakness, age-related [CONDITION(S)] without pathological fracture, cognitive communication deficit, unspecified kyphosis, and unsteadiness on feet. Further review showed the resident utilized a wheelchair, and required extensive assistance of at least two people for bed mobility, toilet use, and transfers, and required extensive assistance of at least one person for ambulation. Interview with the resident's family member on 9/16/21 at 3:15 PM revealed the family provided a recliner upon admission for the resident; the recliner was electric, and could be reclined or elevated to assist with standing through the use of a remote control that was attached to the chair. The family member further revealed the resident did not have the cognitive ability to operate the chair due to the resident's condition, and the family member had never observed the resident operating the chair. Review of the current Visual/Bedside Kardex Report used for guidance in performing resident-specific cares, as of 9/16/21, indicated safety measures .Call light within reach . one way glide on recliner . Staff to ensure recliner remote over the edge of arm of chair and not in the chair. The following concerns were identified: a. Review of the facility event report showed the resident suffered a Fall With Injury on 8/30/21 at 7:30 AM. Further review showed at 7:00 AM staff assisted the resident with his/her activities of daily living (ADLs) while the resident was in his/her wheelchair. Upon completion, the resident was transferred into his/her recliner, and .staff left room at approximately 7:20-7:25 AM . but due to the resident .inadvertently [sitting] on the remote . [the] chair slowly raised and tipped [him/her]. Further review showed social services entered the room at 7:30 AM and found the resident on the floor; the nurse was notified, and after assessment, the resident was assisted by the nurse and CNA back into the recliner, with .no apparent injury at this time. Continued review showed at 2:30 PM the CNA .noted resident right ankle to be swollen and left hand to be swollen and discolored with slight deformity . and reported her findings to the nurse; the nurse then notified the nurse practitioner (NP), who performed an assessment and ordered the resident be sent to the emergency room for x-rays. b. Review of a nursing progress note from 8/30/21 and timed 10:32 PM showed the resident was sent to the emergency room at 3:00 PM for x-rays, and returned at approximately 7:00 PM. Review of the emergency room medical record from the 8/30/21 visit showed the resident sustained tibial and fibular fractures to lower right leg, and a dislocation fracture to the middle finger on her left hand. c. Interview with the DON on 9/16/21 at 3:08 PM revealed the facility utilized both standard recliners and recliners with electric lifts. She stated the facility tried to use the furniture the family provided, if applicable; otherwise, the facility would .just use whatever chair or recliner is available for chairs . at the time of admission. She further stated the facility did not have a safety evaluation for recliners with electric lifts. The DON stated she used her own judgement to determine if a lift chair was suitable for a resident or not. d. Interview with the administrator and DON on 9/16/21 at 4:40 PM revealed the facility did not have a policy surrounding the safe usage of electric assistive devices or electric recliners. Both staff members confirmed a safety evaluation was warranted when the resident was admitted , but the DON stated . we assumed it was okay, since she had it with her at [the previous ALF]. The administrator stated the facility had never previously had a reason to evaluate recliners of any kind, including recliners with electric lifts. He further stated it would be difficult to determine when an evaluation was needed . until a problem came up, then [the facility] would re-evaluate and look at cognition, safety, misuse of the chair, restraints, or messing with buttons . Both staff members confirmed the chair remote should not be underneath a resident, both for safety and to prevent skin breakdown. e. Review of the resident's care plan, last revised 8/31/21, showed the resident was .at risk for falls and fall related injuries [related to] weakness, impaired mobility, and poor safety awareness. Interventions included Anticipate and meet the resident's needs . Call light within reach . Complete fall risk assessment . one way glide on recliner . Provide adaptive equipment or devices as needed . and Staff to ensure recliner remote over the edge of arm of chair and not in the chair, which was added as an intervention after the fall on 8/30/21. f. Review of a physician's progress note from 8/31/21 and timed for 10:28 AM showed the resident received a consult with an orthopedic surgeon; it was determined surgical intervention was not appropriate for the resident. Interview with the resident's family member on 9/16/21 at 3:15 PM confirmed the resident was not a good candidate for surgery due to his/her age, cognitive status, complicities, and chances for recovery. g. Review of the facility discharge record showed the resident was transferred to a hospice facility on 9/6/21.

Based on observation, staff and family interview and medical record review, the facility failed to ensure the mental and psychosocial needs were met for 2 of 3 sample residents (#44, #118) who were admitted in the ninety days prior to the survey. The facility's failure to provide appropriate treatment and services to meet resident #118's psychosocial adjustment needs resulted in a continued sense of loss and maladjustment for this resident. The findings were: 1. Review of the medical record for resident #118 showed s/he was admitted on [DATE] for rehabilitation after sustaining a [MEDICAL CONDITION] at home. Interview with a family member on 10/25/12 at 7:08 PM revealed that prior to admission the resident had some problems with depression and anxiety. Because the family member anticipated a difficult adjustment from home to the nursing facility for the resident, upon admission s/he requested psychological counseling. Review of the 8/9/12 CAA for mood showed the resident "has a [DIAGNOSES REDACTED]. Family requested (name of counseling services) counseling and referral will be made". The following concerns with management of this resident's psychosocial adjustment to the nursing facility were identified: a. Review of the 8/21/12 timed at 8:40 AM social services notes showed "MD (physician) order received today for (name of counseling services) to provide psychological services. Referral faxed to (name of counseling services) today. (The resident) has been displaying increased anxiety and tearfulness." It was 31 days after the resident was identified as having a need for psychological counseling services before a diagnostic assessment was performed by the counseling service on 8/28/12. It was an additional two weeks before the resident received his/her first counseling session on 9/11/12 making a 45 day delay of treatment for [REDACTED]. b. Interview with the resident's family member on 10/25/12 at 7:08 PM revealed the resident had been depressed for several years but the depression had increased significantly since admission to the nursing facility. The family member said the resident had started making threats to kill him/herself in the nursing facility and cried easily since admission which was not part of the resident's behavior prior to admission. The family member said the resident seemed fearful and felt very alone since admission to the nursing facility. Review of the nursing notes and social services notes showed the following examples of the resident's distress related to his/her admission prior to having the diagnostic assessment performed by the counseling services therapist. 1. On 7/28/12 timed at 9:31 PM, the resident "is very upset at this time because of being here". 2. On 8/13/12 timed at 9:42 AM, the resident was "...crying this am before breakfast and pleasant afterwards". 3. On 8/15/12 timed at 2:59 AM, the resident was anxious and "...crying at intervals". 4. Review of a social service progress note written on 8/15/12 timed at 9:45 AM showed a family member said s/he thought the resident was "having increased anxiety and tearfulness at night." 5. On 8/15/12 timed at 11:01 PM the resident was "crying without reason and calling out for (his/her daughter) multiple times". 6. On 8/16/12 timed at 2:03 AM the resident was found crawling to the bathroom and was noted to have "nervousness". 7. On 8/16/12 timed at 6:43 PM showed the resident was "...weepy tonight". An antianxiety medication was administered to the resident for anxiety. 8. On 8/17/12 timed at 1:23 AM showed the resident was "anxious". 9. On 8/17/12 at 11:52 AM the resident was "anxious and fidgeting in bed". 10. On 8/17/12 timed at 6:49 PM the resident "...continues to cry out and appears to be very anxious". 11. On 8/18/12 at 2:19 AM the resident was "crying and in pain". 12. On 8/19/12 timed at 2:21 AM the resident was "crying and restless". 13. On 8/20/12 timed at 1:24 PM the resident was "tearful" and "agitated ". 14. On 8/20/12 timed at 10:49 PM the resident wandered the halls in his/her wheelchair, crying out for his/her daughter and "stating (s/he) was not staying here tonight and needed to get to (his/her) car to go home". 15. Review of the 8/21/12 timed at 8:40 AM social services notes showed the resident was "displaying increased anxiety and tearfulness." 16. Review of a social service progress note written on 8/22/12 timed at 1:11 PM showed [MEDICATION NAME] (anti-anxiety) medication was ordered but the resident "...continues to have periods of anxiety and tearfulness". 17. On 8/24/12 timed at 6:07 PM, the resident was administered [MEDICATION NAME] for increased anxiety and worrying about (his/her) daughter. Resident states, " ...I need to get home...". 18. On 8/24/12 timed at 7:53 PM the resident "began to cry" and required the antianxiety medication [MEDICATION NAME] to be administered. 19. On 8/25/12 timed at 6:56 PM the resident stated "I need to find my car, I need to go home". 20. On 8/27/12 timed at 8:58 AM, the night nurse reported the resident "had been up most of the night". Review of the nursing notes and social services notes showed the following examples of the resident's distress and behaviors which continued after the counseling services diagnostic assessment and development of a treatment plan was performed: 1. On 8/28/12 timed at 3:33 PM, the resident "...received [MEDICATION NAME] per signs of anxiety such as attempting to self transfer, having rapid shallow respirations, and an increase in grimacing." 2. On 8/28/12 at 5:24 PM, the resident was "very anxious" and threw a [MEDICATION NAME] tablet away stating, "I'm not taking it...I want to go home! Take me to the door so I can leave." The resident kept leaving the dining room and wheeling him/herself down the halls to the doorways and crying. 3. Review of an 8/30/12 timed at 8:59 AM social service note showed the resident "...has had a recent increase in agitation and behaviors. (S/he) has been yelling out and refusing medications, and at times wanders throughout facility...". 4. On 8/30/12 timed at 12:10 PM, the "Resident received [MEDICATION NAME] this AM due to increased fidgeting, rapid breaths and inability to focus on taking medications". 5. On 8/31/12 at 6:04 PM, the resident was "...anxious this morning, attempting to self transfer and being sad about not being at home...asked this nurse if (s/he) were to go out the front door if this nurse would stop (him/her)." The resident attempted to leave the facility by going out of the unit 3 door. 6. On 9/1/12 timed at 6:41 AM, the resident was administered [MEDICATION NAME] for "increased anxiety about returning to this facility instead of returning home" after a visit to the emergency room . 7. On 9/4/12 timed at 1:06 PM the resident began to get anxious and attempted to stand to go out the door. Nursing staff was able to get the resident to stay seated and then administered [MEDICATION NAME]. The resident "stayed in wheelchair and stared out the side door but not attempting to leave". 8. On 9/5/12 timed at 10:25 AM, the resident was upset, yelling and striking out at staff. The "resident began to go through belongings and throwing them into the trash cans". 9. Review of a social service note written on 9/10/12 timed at 10:28 AM showed the resident "Continues to have periods of increased confusion and statements that (s/he) needs to leave the facility. (The resident) can be verbally and physically abusive and resists care at times". 10. On 9/17/12 timed at 9:05 PM the resident said s/he "just wants to die and kill (him/herself)". The resident's family member requested a psychology consultation. 11. On 9/20/12 timed at 11:59 AM the resident "continues to want to leave" the facility. The resident wanted nursing to call his/her family to come pick him/her up. 12. On 9/21/12 timed at 6 PM, the resident "continues to have multiple requests to leave for home". 13. On 9/27/12 timed at 5:45 PM the resident was "anxious and agitated", "wanting to pack up (his/her) things", call his/her family, and go home. 14. On 10/1/12 timed at 9:09 AM the social services staff noted the resident continued to be agitated, and verbally and physically aggressive at times. In addition the resident was sometimes resistive to care and had repetitive concerns. The social worker further noted the resident received Klonopin for anxiety and [MEDICATION NAME] for dementia with behaviors. 15. On 10/8/12 timed at 9:32 PM the resident had episodes of behaviors and frequent crying. 16. On 10/8/12 timed at 9:32 PM the resident was "crying frequently" during the shift. 17. On 10/9/12 timed at 10:07 AM the resident was "anxious about the process of getting ready for the day and what time of day it was". 18. On 10/15/12 timed at 9:42 AM the resident had "intermittent episodes of anger" during the shift when staff attempted to interact with him/her. 19. On 10/16/12 timed at 5:45 PM the resident had an "episode of wandering, crying and wanting to leave the facility after dinner". d. Observation on 10/22/12 at 3:25 PM revealed the resident had his/her face in his/her hands and was sobbing. Interview with CNA #1 at the time revealed the resident had these crying episodes frequently and that s/he verbalized a fear of being left behind and of not being wanted by family anymore. The CNA said the resident was very fearful of being left alone. e. Review of the 8/28/12 counseling service diagnostic assessment showed "...(the resident) was referred for increased symptoms of depression and agitation including withdrawal, negative statements and irritability." Further review of this document showed the resident presented with symptoms of loneliness and withdrawal. Continued review showed the resident "misses being at home" and gets "confused and easily agitated at the nursing home." The first counseling session occurred on 9/11/12, two weeks after the assessment, and showed the resident was depressed, irritable, withdrawn and had issues with grief and loss. Review of the 9/27/12 therapy notes showed the resident stated s/he felt worthless and missed being at home. Review of the 10/16/12 psychotherapy notes showed the resident continued to appear anxious and depressed. Further review of these notes showed the resident needed two counseling sessions per week with a review and update of the care plan scheduled for February 2013 (six months). Interview with the psychotherapist on 10/25/12 at 12:15 PM revealed the resident needed two sessions per week and later on in the conversation said one to two sessions were necessary. However, review of the counseling notes showed the resident was seen only twice in September 2012 and once in October 2012 instead of the one to two times per week as needed. When asked why the resident had not received the planned two counseling sessions per week, the psychotherapist said sometimes she could not "find" him/her because of rehabilitation therapy. Review of the medical record showed no evidence the psychotherapist asked for assistance in locating the resident for sessions. Additionally, there was no evidence the psychotherapist attempted to arrange a schedule that would allow the resident to be seen. f. Review of the nursing noted written on 9/17/12 timed at 9:05 PM showed the family requested a psychological consultation be performed because of the resident's statement that s/he wished s/he could just die and kill him/herself. This consultation was ordered and performed by a different therapy group than the counseling service who performed the 8/28/12 diagnostic assessment. Review of this neuropsychological evaluation report, dictated 10/24/12 but performed on 10/8/12 and 10/17/12, showed the evaluation was performed based on the belief that the resident had become "increasingly depressed." Further review showed the resident scored in the mild depression range but was likely an underestimate of his/her current mood status. It was felt the resident's responses were more consistent with how s/he thought s/he was supposed to answer or how s/he wished s/he felt but were not consistent with his/her true affective experiences. Review revealed the resident was often "...distraught and making comments indicative of passive suicidal ideation." The psychotherapist who performed the evaluation noted the resident was "experiencing moderate to severe symptoms of depression." Review of the report summary showed the resident was a "distressed woman." Finally, the report indicated "It is vital to note that (the resident) was experiencing a significant degree of depressive symptoms. Mood symptoms, coupled with general confusion, were likely exacerbating the severity of (the resident's) cognitive deficits." 2. Review of the medical record face sheet showed resident #44 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation and interview with the resident on 10/22/12 at 2:40 PM revealed s/he was tearful and appeared to be anxious, the resident asked for help to go to the bathroom and the surveyor had the resident turn on his/her call light. The light was answered at 2:43 PM by RN #1 who had an aide take the resident to the bathroom. Interview with the resident at 2:55 PM revealed the resident again asked for help to go to the bathroom and s/he was unable to remember the assistance that was just provided. Interview with LPN #1 and RN #2 on 10/23/12 at 8:45 AM revealed the resident was new to this room and was not adjusting well and required reassurance, had anxiety, and frequent requests to be taken to the bathroom. The nurses revealed a psychological consult was pending for this resident. Review of the medical record showed a 10/12/12 neuropsychological evaluation was done and the report had been faxed with a fax date of 10/15/12. Review of the recommendations from the report showed specific interventions to possibly reduce the resident's anxiety related to toileting. The following concerns were identified: a. Review of the 8/23/12 care plan for risk of UTI (urinary tract infection) and urinary incontinence showed the recommended interventions related to anxiety and toileting needs were added to the care plan on 10/23/12, eight days after the report was received. b. Interview with the DON on 10/25/12 at 3:40 PM revealed the nursing staff were not aware the neuropsychological report was in the medical record. He further stated this type of consult was new to them and the resident's physician had been out of town. c. Interview with the social service director on 10/26/12 at 10:35 AM verified the resident was being seen by a psychologist weekly; however, she was unaware of the specific recommendations to ease the resident's anxiety.