Every finding on record at Mount St Francis Nursing Center

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 three of three certified nurse aides (CNA). Specifically, the facility to complete regular in-service education based on the outcome of the annual performance reviews for CNA #8, CNA #9 and CNA #10. Findings include: I. Facility policy and procedure The Performance Management Procedure, reviewed 6/1/2020, was provided by the director of quality and safety (DQS) on 3/6/25 at 2:38 p.m. It read in pertinent part, The facility expects its managers and their direct reports to participate in the annual performance review process and discussions. Job performance is evaluated based on the following: established competencies, established responsibilities/job duties and established goals as determined by the organization, manager and employee. II. Record review The annual performance reviews and the regular in-service education based on the outcome of these reviews were requested on 3/5/25 at 9:58 a.m. for CNA #8, CNA #9 and CNA #10. -Review of the documentation provided revealed the three CNAs had their annual performance review completed, however, the facility was unable to provide documentation that the CNAs were provided with regular in-service education based on the outcome of the reviews. III. Staff interviews The DQS and the vice president of clinical services (VPCS) were interviewed together on 3/6/25 at 9:22 a.m. The DQS and the VPCS said there were no follow up in-services documented for CNA #8, CNA #9 or CNA #10 after their annual performance reviews. The DQS and the VPCS said the facility had just started to do systemic annual reviews on the new forms but they did not necessarily do specific in-services on what the CNAs said during their reviews. The DQS and the VPCS were unable to say what the importance was of doing follow up in-services based on the annual reviews. The DQS and the VPCS said the facility did not do in-service education based on the outcome of annual performance reviews, but they believed there may have been some follow-up completed, however they were unable to provide documentation. The director of nursing (DON) was interviewed on 3/6/25 at 2:26 p.m. The DON said she did the CNA performance reviews annually. The DON said she did not provide the CNAs with an in-services education based on the outcomes of the review because the performance reviews were not really focused on that. The DON said the reviews were not an educational focus but more on how the CNAs were doing interpersonally with others, and performing up to their job duties and what they could improve on. The DON said if she felt there was an educational need, it would be completed at the time, but she did not necessarily document the education. The DON said she conducted personal counseling one-to-one with the CNA if education was needed or she counseled all the CNAs in an email, such as for a reminder to use a gait belt. The DON said she was not aware of the requirement to provide regular in-service education based on the outcome of the reviews to the CNAs.

Based on record review and interviews, the facility failed to ensure one (#16) of two residents reviewed for abuse out of 46 sample residents was free from abuse. Specially, the facility failed to protect Resident #16 from sexual abuse by Resident #58. Findings include: I. Incident of sexual abuse between Resident #16 and Resident #58 on 11/14/24 A. Facility investigation The facility's investigation documented an incident occurred on 11/14/24 between Resident #16 and Resident #58 in Resident #16's room. Certified nurse aide (CNA) #2 witnessed Resident #58 in Resident #16's room prior to lunch. Resident #58 was patting Resident #16's buttocks with his hand and attempting to kiss her on the mouth. The residents were separated and taken to lunch. CNA #2 alerted registered nurse (RN) #1 of what was witnessed. Resident #16 was interviewed by the unit manager (UM) and stated Resident #58 had come into her room without knocking and uninvited. She said Resident #58 sat and talked with her and then attempted to kiss her while patting her buttocks. Resident #16 told the UM that Resident #58's behavior had made her uncomfortable and she was afraid to tell him no or to stop. Resident #16 told the UM she would like the staff to keep Resident #58 from going into her room. Resident #58 was interviewed by the UM and was asked if he had gone into Resident #16's room uninvited, patted her buttocks and attempted to kiss her. Resident #58 first wanted to know who had reported him for doing this. When he was asked a second time if he had entered the room uninvited, patted Resident #16's buttocks and attempted to kiss her, he said he had done those things. Resident #58 agreed with the UM that he should have obtained permission to engage in these behaviors and then went back to perseverating on who had reported him. The conversation ended with the UM providing education to Resident #58 on consent and he acknowledged understanding. During the investigation conducted by the facility to determine if other residents had been affected, the following events had been reported by staff: A progress note dated 11/13/23 by CNA #1 revealed the resident tried to touch and spank a CNA. A progress note dated 11/17/23 by RN #1 revealed the resident tried to grab a CNAs chest. A progress note dated 6/11/24 by RN #2 revealed Resident #58 was being cared for in pairs (two staff at all times during personal care). A statement written by CNA #2 and dated 11/14/24 documented Resident #16 told CNA #2 that Resident #58 made her uncomfortable. The UM statement, dated 11/14/24, revealed Resident #16 had told her she did not want Resident #58 in her room. The written statement documented Resident #16 told the UM she was fearful to tell Resident #58 to leave her room and he made her uncomfortable. The UM's second statement, also dated 11/14/24, revealed she had interviewed Resident #58 and he acknowledged he should have asked permission to go into Resident #16's room. The statement indicated Resident #58 admitted to the UM that he had attempted to kiss Resident #16 and touch her buttocks. On 12/3/24 CNA #3 wrote a statement which revealed Resident #58 had attempted to move the top of her shirt to reveal her undergarment strap. Resident #58 told CNA #3 he would become sexually aroused when he saw those straps and began to ask her personal questions about her intimate relationships. On 12/11/24 CNA #4 wrote a statement which revealed she saw Resident #58 confronting Resident #16 in the hallway asking if she was the reason why he was in trouble. A statement which was undated and written by CNA #6 documented was told by other care staff when she started working at the facility that Resident #58 was handsy. CNA #6 described one incident when she was transferring Resident #58 after toileting and he grabbed her arm and tried to pull her close to him. CNA #6 had to call out to another CNA before Resident #58 would release her. He made several sexually inappropriate remarks and requests to her during the interaction of care and other interactions. CNA #6 stated RN #1 had advised her to not go in his room without another CNA. An undated statement written by the hospice CNA (HCNA) revealed she had been told by staff to not go into Resident #58's room alone without other staff because of the resident's inappropriate sexual behaviors. An undated statement written by CNA #7 revealed a history of Resident #58 making sexually inappropriate comments to CNA #7 and requesting she clean his penis slowly and wife him. The facility substantiated the abuse of Resident #16 by Resident #58 based on staff and resident interviews and observations. B. Resident #16 (victim) 1. Resident status Resident #16, age 71, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included depression and encephalopathy. The 10/31/24 minimum data set (MDS) assessment documented the resident was moderately cognitively intact with a brief interview of mental status (BIMS) score of eight out of 15. She required staff supervision for bathing and transfers and was independent in ambulation, bed mobility, personal hygiene, dressing, and toileting. The assessment indicated the resident had no behaviors. 2. Record review Resident #16's psychiatric care plan, revised 3/5/25 (during the survey), revealed the resident had a diagnosis of depression and received antidepressant medication. She displayed behaviors of low mood, agitation, hallucinations and delusions. Interventions included attempting non-pharmacological interventions. -However, the care plan failed to document what non-pharmacological interventions should be attempted. Resident #16's trauma care plan, initiated 8/2/24, revealed the resident had a trauma history of being emotionally abused by a religious leader she was providing child care for. The resident revealed the religious leader was discovered to be a pedophile and had attempted murdering his spouse. Interventions included allowing the resident time to express herself, offering reassurance, referring the resident to a psychologist for grief counseling and encouraging her family to visit. -The care plan failed to address the incident when the resident was touched inappropriately by Resident #58 on 11/14/24 or what interventions the facility put in place for her protection and psychosocial well-being following the incident. -Review of the March 2025 CPO failed to reveal a behavior monitoring order to monitor Resident #16's psychosocial well-being after the sexual abuse incident with Resident #58. Progress notes reviewed from 11/14/24 to 3/4/25 revealed the following: Resident #16 and Resident #58 were seen in the dining room talking to each other on 12/24/24, 12/28/24 and 1/5/25 (while on 15-minute checks). Resident #58 was seen on 1/1/25 (while on 15-minute checks) attempting to enter Resident #16's room and had to be redirected by staff as he was not permitted to go into the room. Further review of Resident #16's electronic medical record (EMR) revealed social worker (SW) #1 did not complete a psychosocial assessment with Resident #16 until 12/19/24 (thirty-five days after the sexual abuse incident with Resident #58). -There were no additional social services assessments or visit notes located in Resident #16's EMR between the 11/14/24 to 3/4/25 timeframe. Review of 15-minute check staff documentation revealed Resident #16 was on 15-minute checks from 11/24/24 to 1/7/25. C. Resident #58 (assailant) 1. Resident status Resident #58, age 73, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia and hydrocephalus. The 1/14/25 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. He required maximum staff assistance with toileting and personal hygiene and required partial staff assistance with showering, dressing, bed mobility, and transfers. The resident was independent in propelling himself in his wheelchair. The assessment indicated the resident had no behaviors direct towards others, behaviors putting others at risk or sexually inappropriate behaviors. -However, Resident #58 had several occasions where he was documented as having inappropriate sexual behaviors, including the sexual abuse incident with Resident #16 on 11/14/24 (see facility investigation above). 2. Resident interview Resident #58 was interviewed on 3/4/35 at 10:30 a.m. Resident #58 said the facility wanted to initiate an involuntary discharge for him based on a report of an interaction between himself and a female resident (Resident #16). He said staff had observed him embracing his friend with his hand on her buttocks. Resident #58 said the facility had given him several discharge notices and communications because his brother had been appealing the facility's decision. He said he felt the facility had made a big deal out of nothing. He said Resident #16 did not tell him to leave her room and when he asked her later if he had offended her, she said no. Resident #58 said he did not recall if he had increased supervision from staff after the incident. He denied any other inappropriate incidents with other residents or staff members. Cross-reference F622 for failure to follow appropriate discharge and transfer requirements. 3. Record review Review of Resident #58's mood and behavior care plan, revised 11/14/24, identified the resident had a diagnosis of major depression and anxiety. He had episodes of inappropriately touching staff sexually and making vulgar sexual comments to staff. He was involved in an incident on 11/14/24 where he made unwanted sexual contact with another resident, causing her to feel uncomfortable and unsafe. Interventions (revised on 10/16/24, prior to the incident) included attempting non-pharmological interventions as able, one-on-one visits, offering to toilet the resident, offering food and drink and administering medications as ordered. -The facility failed to update the care plan with new interventions following the incident with Resident #16 on 11/14/24. Review of Resident #58's March 2025 CPO revealed the following physician orders: Clinical staff to perform every 15-minute checks to determine the resident's location and to ensure the safety of the other residents due to this resident's history of sexually inappropriate behavior, ordered on 3/4/25 (during the survey). Behavior monitoring for exhibiting sexual behaviors such as inappropriate touching and inappropriate verbal language of a sexual manner, ordered on 3/4/25 (during the survey). Two CNAs at all times when providing care, ordered on 6/11/24. Review of Resident #58's progress notes from 11/14/24 to 3/4/25 revealed the following: SW #2 did not provide education to Resident #58 on his behavior towards Resident #16 until 12/9/24 (twenty-five days after the sexual abuse incident). A social services quarterly assessment, dated 1/17/25, documented Resident #58 had not had staff reported behaviors within the look back period (period of three months). Social services sent a referral for psychiatry services for Resident #58 on 1/24/25 (two months after the sexual abuse incident with Resident #16). -There were no additional social services assessments or visit notes located in Resident #58's EMR between the 11/14/24 to 3/4/25 timeframe. A psychoactive meeting note, dated 12/19/24, failed to reveal that Resident #58's sexual abuse incident towards Resident #16 had been reviewed or discussed by the facility's interdisciplinary team (IDT). A Risk Management worksheet, dated 12/2/24, documented The resident (Resident #58) has been deemed a danger to the other residents. He has been placed on every 15-minute checks until he is discharged as a means to ensure the safety of the other residents. Review of 15-minute check staff documentation revealed Resident #58 was on 15-minute checks 11/24/24 to 1/7/25. II. Staff interviews RN #3 was interviewed on 3/4/25 at 10:10 a.m. RN #3 said Resident #58 was a two-person assist for staff safety due to his sexually inappropriate behaviors. RN #3 said the change in status for staff assistance for the resident was passed on to her from other staff and not by the management team. RN #3 said the nurses documented the resident's behaviors in the progress notes because he did not have a physician's order to track sexually inappropriate behaviors on the treatment administration records (TAR). RN #3 said the management team did not do a training with the staff on interventions to use with Resident #58 when he displayed sexually inappropriate behaviors. The UM was interviewed on 3/4/25 at 11:00 a.m. The UM said Resident #58 had a history of sexually inappropriate language and touching towards staff when they were alone providing him care. She said the management team instructed the staff to set boundaries for the resident to stop and then tell the nurse or charge nurse what was happening. The UM said the CNAs did not document the resident's behaviors and that was something the nurses were responsible for documenting. CNA #6 was interviewed on 3/4/25 at 3:30 p.m. CNA #6 said the date she gave her written statement was on 11/21/24 (one week after the incident between Resident #16 and Resident #58). She said when she was hired on 9/5/23, she was warned by other staff that Resident #58 would touch staff inappropriately. She said there was an incident when Resident #58 would not let her go but when she called in another staff member and he let her go. She said she was adjusting his wheelchair and he kept trying to get hugs from her despite her telling him she did not give hugs. CNA #6 said during that same incident, he grabbed her breasts and she was told by the nurse to not go into his room without another CNA. CNA #6 said she was currently responsible for staff scheduling and tried to put male CNAs on Resident #58's unit. CNA #7 was interviewed on 3/4/25 at 3:56 p.m. CNA #7 said the CNAs and nurses had advised the prior nursing home administrator (NHA) about Resident #58's sexually inappropriate behaviors. CNA #7 said the prior NHA did not take action on the reports. CNA #7 said she knew Resident #58 was going to escalate and offend another resident but the administration did not handle his behaviors prior to the incident. The vice president of clinical services (VPCS), SW #1, SW #2, and the director of nursing (DON) were interviewed together on 3/4/25 at 5:07 p.m. SW #1 said the facility process regarding a resident with sexually inappropriate behaviors was to bring any incidents to the social services department to begin interviewing residents. SW #1 said the facility would offer to send the victim to the hospital for a rape kit, if applicable, and begin 15-minute checks on the victim and the perpetrator. SW #1 said the social services department acted as the abuse coordinators for the facility, but she said the corporate director of quality and safety (DQS) determined if incidents were reportable. SW #1 said after an investigation, she would update the care plans of the victim and the perpetrator. She said new behavioral interventions would be entered in the residents' care plans. She said care plans were reviewed by each department quarterly. SW #1 said behaviors would be indicated on the perpetrator's MDS assessment if they occurred during the assessment the look-back period. She said social services utilized progress notes, staff interviews, chart review and clinical meetings to collect information on residents in order to accurately complete assessments. She said the 1/14/25 MDS assessment should have reflected Resident #58's behaviors and the 11/14/24 incident. SW #1 said the care plan coinciding with the 1/14/25 MDS assessment should have been reviewed and updated for Resident #58 and Resident #16. SW #1 said she did not know why the MDS assessment, care plan and social services assessments had not been updated or kept accurate. The DON said she was not aware of Resident #58's past behavior towards staff until after the 11/14/24 incident with Resident #16, when staff started to come forward and she reviewed his records. She said 15-minute checks were started on both residents for safety after the incident. She said a behavior tracking physician's order would be obtained to monitor sexually inappropriate behaviors on the TARs, but she said she was only able to find a depression behavior tracking order on the TARs for Resident #58. The DON said 15-minute checks were stopped for both Resident #58 and Resident #16 on 1/7/25 because the facility had a meeting with Resident #16 and her family. The DON said Resident #16 did not want to remain on safety checks and asked for Resident #58 to also be removed from safety checks. She acknowledged she had no alternative safety measures put in place to prevent Resident #58 from inappropriately touching another female resident once the 15-minute safety checks were stopped. The VPCS said she believed Resident #58 had the potential to revert to repeating his behaviors if he believed he was no longer being watched. She said she was unaware the 15-minute safety checks had been stopped. She said the facility kept an eye on Resident #58 but staff were not formally documenting it. The VPCS acknowledged the facility needed to put more safeguards in place, including visual checks, to prevent incidents from occurring. The VPCS said the facility failed to keep residents safe by not tracking sexual behaviors, not having specific interventions in place, not moving Resident #58 off of Resident 16's hallway and by not training staff on what to report and how to redirect Resident #58.

Based on interviews and record review, the facility failed to initiate an appropriate facility-initiated discharge for one (#58) of three residents reviewed for appropriate discharge out of 32 sample residents. Specifically, the facility failed to: -Complete an assessment with attempted interventions prior to giving the resident a discharge notice; and, -Ensure there was a documented basis from the physician that the resident's needs could not be met and discharge was necessary. Findings include: I. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included unspecified dementia and hydrocephalus (build up of liquid on the brain). The 1/14/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required maximum staff assistance with toileting and personal hygiene. He required partial staff assistance with showering, dressing, bed mobility and transfers. The resident was independent in propelling himself in his wheelchair. The MDS assessment indicated the resident did not have an active discharge and had no behaviors. 2. Resident interview Resident #58 was interviewed on 3/4/25 at 10:30 a.m. Resident #58 said the facility wanted to initiate an involuntary discharge for him based on a report of an interaction between him and a female resident that was sexual in nature. Resident #58 said the facility had given him several discharge notices. He said his brother had been appealing the facility's decision to discharge him. He said he felt the facility had made a big deal out of nothing. He said he and the female resident were just friends embracing. Resident #58 said the concern over where he would live was upsetting to him and he spoke with his psychologist about it frequently. He said the facility had not discussed with him ways the facility would help him improve his behavior or how the impending discharge made him feel. 3. Record review The mood and behavior care plan, revised 11/14/24, identified Resident #58 had diagnoses of major depression and anxiety. He had episodes of inappropriately touching staff sexually and making vulgar sexual comments to staff. He was involved in an incident on 11/14/24 where he made unwanted sexual contact with another resident, causing her to feel uncomfortable and unsafe. At the time, frequent checks were started on the resident and the female resident for safety but had stopped because the issue had been resolved, and no other issues had come up. Interventions (revised on 10/16/24, prior to the incident) included attempting non-pharmological interventions as able, one-on-one visits, offering to toilet the resident, offering food and drink, administering medications as ordered, monitoring for signs and symptoms of depression and offering reassurance and encouragement. The discharge planning care plan, revised 1/23/25 (after the incident), revealed the resident was to remain in the facility for long term care without any plans to return to the community. Interventions (revised 3/23/23) included providing services according to care plans for long term care to assure optimum well-being, reviewing the resident's discharge potential annually or as needed and if discharging from the facility, assess the resident's future home to determine if his needs could be met. -The facility failed to update the care plan with new interventions following the initiation of an involuntary discharge on [DATE]. -Review of Resident #58's electronic medical record (EMR) did not reveal documentation indicating Resident #58's physician had discussed the resident's discharge or assessed and documented the basis for determining the resident's needs could not be met in the facility and the resident required discharge. A notice of discharge was issued to Resident #58 on 11/18/24. The reason provided in the notice was that Resident #58 had endangered the safety and welfare of other residents as a result of sexually inappropriate behaviors. The notice gave Resident #58 until 12/3/24 (15-days) to discharge from the facility. The social services quarterly assessment, dated 1/17/25, revealed the resident had no active discharge plan and was to remain in the facility for long term care. The assessment included that the resident had no behaviors during the assessment period. -However, the facility had issued a notice of discharge on [DATE]. -Review of Resident #58's EMR did not reveal documentation pertaining to the facility-initiated discharge. Discharge communications were provided by the director of quality and safety (DQS) on 3/3/25 at approximately 11:00 a.m. and revealed the following: The DQS emailed the resident representative on 12/3/24 requesting a meeting to discuss the incident and the resident's discharge. The DQS emailed the resident's representative on 1/8/25 with a behavior contract to be signed by the resident and representative. The contract, dated 1/7/25, outlined the facility's expectations of what would be acceptable behaviors by Resident #58 in order to remain in the facility. The resident representative responded via email on 1/17/25. He outlined the reasons the family wanted the behavior contract to be modified. The revised contract the resident representative sent to the DQS was on 1/17/25 via email. The revised contract proposed the family's expectations for the facility to provide the resident support, conduct regular assessments on his status, offer personalized care plans, and notify the family of any behaviors. The DQS emailed the resident's representative again on 1/23/25 via email and advised the representative the facility would not be modifying the original behavior contract and the representative had two options: appeal with the State Agency or allow the facility to discharge. The representative responded on 1/23/25 via email that the family would continue to appeal the discharge. II. Staff interviews The vice president of clinical services (VPCS) was interviewed on 3/4/25 at 5:07 p.m. The VPCS said the process for facility-initiated discharges was to follow the regulations.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of three medication storage rooms and three of three medication storage carts. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and, -Ensure expired or discontinued medications were removed and discarded from medication carts and storage refrigerators. Findings include: I. Professional reference According to the manufacturer GlaxoSmithKline, Highlights of Prescribing Information ([DATE]), retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF, Discard Trelegy Ellipta six weeks after opening the foil tray or when the counter reads zero (after all blisters have been used), whichever comes first. According to the manufacturer Astra Zeneca, Symbicort Medication Guide, Symbicort Prescribing Information ([DATE]), retrieved on [DATE] from https://den8dhaj6zs0e.cloudfront.net/50fd68b,d+[DATE]b-4550-b5d,d+[DATE]b045f8b184/a4b62ab[DATE]-91b,d+[DATE]ec239f790/a4b62ab[DATE]-91b,d+[DATE]ec239f790_viewable_rendition__v.pd, Throw away Symbicort when the counter reaches zero, or three months after you take Symbicort out of its foil pouch, whichever comes first. II. Facility policy and procedure The Medication Storage policy, undated, was provided by the director of quality and safety (DQS) on [DATE] at 2:32 p.m. The policy read in pertinent part, When the medication cart is checked per schedule, the nurse will read the labels to ensure that all of the medications are being stored properly. If a medication is found to not be stored properly it will be discarded and the nurse will order a replacement. III. Observations and interviews On [DATE] at 10:15 a.m., the first floor back medication cart was observed with registered nurse (RN) #3. An opened Trelegy Ellipta 100 microgram (mcg)/62 mcg inhaler was found with a date opened of [DATE]. RN #3 said she was unsure how long the medication could be used once opened. RN #3 said the medication could be less effective if it was used past the date of the manufacturer's recommended storage instructions. On [DATE] at 10:55 a.m., the second floor front medication cart was observed with licensed practical nurse (LPN) #1. An opened lidocaine 1% (percent) vial was not labeled with the date it was opened for use. LPN #1 said the medication should have been labeled with the date it was opened. On [DATE] at 11:55 a.m., the third floor front medication cart was observed with RN #4. The following was observed: -An opened Trelegy Ellipta 100 mcg/62.5 mg inhaler was not labeled with the date it was opened for use; and, -An opened Symbicort ,d+[DATE].5 mcg inhaler was not labeled with the date it was opened. RN #4 said the medications should have been labeled with the dates they were opened. On [DATE] at 12:14 p.m., the third floor back medication refrigerator was observed with RN #5. An opened tuberculin purified protein derivative (PPD), which was part of the floor stock, was labeled with an opened date of [DATE]. RN #5 said it should have been discarded 30 days after it was opened. IV. Staff interviews The registered pharmacist consultant (RPHC) was interviewed on [DATE] at 5:05 p.m. The RPHC said the Ellipta inhalers expired six weeks after they were opened. The RPHC said the Ellipta inhalers and lidocaine should have been labeled with the date they were opened. The RPHC said the lidocaine should have been discarded 30 days after it was opened. The RPHC said the tuberculin PPD should have been discarded 28 days after it was opened. The RPHC said the use of medications after the recommended discard dates could have reduced the efficacy (effectiveness) of the medications. The director of nursing (DON) was interviewed on [DATE] at 9:33 a.m. The DON said the Trelegy Ellipta inhalers were good for six weeks after they were opened. The DON said the previous pharmacist consultant had provided an incorrect reference sheet to the nursing staff for storage of inhalers which did not include an expiration date for use of the Trelegy inhalers. The DON said the undated medications should have been labeled with the date they were opened. She said the lidocaine order was discontinued on [DATE] and the medication should have been discarded from the medication cart at that time. The DON said the tuberculin PPD was no longer used at the facility as of [DATE] and the medication should have been discarded 30 days after it was opened.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment for residents to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #20, who was on enhanced barrier precautions (EBP); -Ensure proper infection control practices were followed during wound care; and, -Ensure hand hygiene was performed appropriately during wound care. Findings include: I. Failed to ensure staff wore the appropriate PPE for Resident #20, who was on EBP A. Professional reference According to the Centers for Disease Control and Prevention (CDC): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), Description of Precautions (4/2/24), retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html on 3/12/25, Enhanced barrier precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; and, -Wound care: any skin opening requiring a dressing. In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. B. Observations On 3/3/25 at 1:59 p.m., a sign on the wall next to Resident #20's door indicated the resident was on EBP. The sign indicated a gown and gloves must be worn for high-contact resident care activities, including dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies, and wound care. Resident #20 had an indwelling urinary catheter in place, as well as open wounds to her left ischium (lower back part of the hip bone), right ankle and left distal and proximal foot. There was a PPE storage container inside Resident #20's room. On 3/4/25, during a continuous observation, beginning at 9:50 a.m. and ending at 10:45 a.m., the following was observed: At approximately 9:50 a.m. an EBP sign was not observed on the wall outside of Resident #20's room and the PPE storage cart inside the resident's room was gone. At 9:54 a.m., licensed practical nurse (LPN) #2 and the unit's charge nurse (CN) entered Resident #20's room to perform the resident's wound care. They both performed hand hygiene and donned gloves, however, neither staff member put on a gown prior to beginning wound care. At 10:01 a.m., the CN held up Resident #20's right leg and LPN #2 prepared to remove the old wound dressing on the resident's ankle with scissors. LPN #2 was stopped and asked if staff should be wearing gowns. LPN #2 told the CN she felt more comfortable wearing a gown during wound care. LPN #2 removed her gloves and left Resident #20's room. At 10:04 p.m., the CN said she asked LPN #2 about gowns before entering the resident's room, and LPN #2 said the facility's infection preventionist (IP) had removed the PPE storage bin and the EBP sign from outside the resident's room that morning (3/4/25). At 10:06 a.m., LPN #2 returned to Resident #20's room with gowns, gloves and masks. Both the CN and LPN #2 donned gloves, gowns and masks and proceeded with the resident's wound care. At 10:44 a.m., after wound care was completed, a PPE cart containing gowns, gloves and masks was observed in the hallway outside of Resident #20's room. Additionally, a sign had been placed back on the wall near the resident's door indicating she was on EBP. On 3/5/25 at 3:16 p.m., certified nurse aide (CNA) #4, CNA #11 and LPN #2 entered Resident #20's room preparing to transfer the resident from her wheelchair to her bed and provide incontinence care. Upon entering the resident's room, CNA #4, CNA #11 and LPN #2 performed hand hygiene and donned gloves, however, they did not put on gowns. At 3:19 p.m., as CNA #4 and CNA #11 were connecting Resident #20's transfer sling to the Hoyer (mechanical) lift, LPN #2 told them if they were cleaning and changing the resident, they needed to put on gowns, which they did prior to continuing with the resident's care. -CNA #4 and CNA #11 did not put on gowns, or indicate they were going to, until LPN #2 advised them to put one on. II. Failed to ensure proper infection control and hand hygiene practices were followed during wound care A. Professional reference According to the CDC: Clinical Safety: Hand Hygiene for Healthcare Workers (2/27/24), retrieved from https://www.cdc.gov/clean-hands/hcp/clinical-safety/ on 3/13/25, When to clean your hands: -Immediately before touching a patient; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or patient's surroundings; -After contact with blood, body fluids, or contaminated surfaces; and, -Immediately after glove removal. When to wear (and change) gloves: Gloves are not a substitute for hand hygiene: -If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings; and, -Always clean your hands after removing gloves. When to wear gloves: -When needed for standard precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment); and, -When needed for transmission-based precautions. When to change gloves and clean hands: -If gloves become soiled with blood or body fluids after a task; -If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; and, -If they look dirty or have blood or body fluids on them after completing a task. B. Observations On 3/4/25 at 9:54 a.m. LPN #2 was observed providing wound care to Resident #20 with the assistance of the CN. LPN #2 performed hand hygiene and donned gloves. The CN did not perform hand hygiene before donning gloves. LPN #2 cleared Resident #20's bedside table of personal items and placed two pieces of paper towel on top of the table. LPN #2 began collecting packages of Kerlix (rolled gauze), abdominal pad (ABDs) dressings, a plastic cup with quarter (25%) strength Dakins solution (a specialized liquid wound treatment), wound cleanser and scissors from a medical supply storage container in the resident's room. -LPN #2 failed to cleanse or put a barrier pad onto the bedside table, failed to cleanse the scissors with cleansing wipes and failed to change her gloves and perform hand hygiene after touching the medical supply storage cart and the bedside table. LPN #2 opened two packages of Kerlix, two packages of ABD pads, and an uncounted amount of 4x4 gauze pads and laid them on top of their packing, on top of the paper towels on the bedside tables. While LPN #2 was collecting supplies and setting up, the CN was observed repeatedly touching the resident's bedside table, mattress, and sheets with her gloved hands. LPN #2 grabbed the trash can and moved it closer to her work area. LPN #2 used the bed controls to raise the bed and lower the head of the bed. The CN raised the resident's right leg. LPN #2 used the unsanitized scissors to remove the old dressing to the resident's right ankle and threw the dressing in the trash. LPN #2 used wound cleanser to moisten the dried gauze stuck to the wound bed, removed it by wiping with a gauze pad, and threw the gauze away. LPN #2 sprayed wound cleanser onto the wound, grabbed a new gauze pad, and patted the wound area approximately three to six times, using the same gauze pad, before throwing it away. LPN #2 soaked a gauze pad in quarter strength Dakins solution and placed the gauze on the wound bed. LPN #2 applied an ABD pad over the soaked gauze. The CN used one hand to support the resident's knee, and the other to support the right ankle by holding the ABD pad in place. LPN #2 wrapped Kerlix around the ABD pad and secured it with medical tape. -LPN #2 opened the supply cart and dressing packages, moved the trash can, and used the bed controls with the same gloves she used to remove the old dressing and apply the new one. LPN #2 failed to remove her gloves and perform hand hygiene after touching resident surfaces, removing the old dressing, and before applying the new dressing. -The CN touched the bedside table and the resident's mattress/sheets with the same gloves she used to hold the resident's right leg up and the ABD dressing in place. The CN failed to remove her gloves and perform hand hygiene after touching resident surfaces and while assisting with wound care. LPN #2 asked the surveyor if she needed to remove her gloves and perform hand hygiene in between wounds, which was confirmed. LPN #2 then removed her gloves and performed hand hygiene. LPN #2 applied new gloves and grabbed a permanent marker out of her pocket and dated the right ankle dressing. LPN #2 moved the bedside table, unlocked the resident's bed, and moved the bed away from the wall to access the resident's left side. The CN moved to the left side of the resident's bed and repeatedly touched the mattress and sheets. -The CN did not remove her gloves and perform hand hygiene before moving to the left side of the resident's bed. The CN raised the resident's left leg so LPN #2 could access her left foot. LPN #2 used the same scissors to remove the old dressing to the resident's left foot and threw the dressing in the trash. LPN #2 used wound cleanser to moisten the dried gauze stuck to the wound beds of both wounds, removed them by wiping each wound with a separate gauze pad, and then threw the gauze away. LPN #2 sprayed the wounds with wound cleanser and patted each dry with a separate gauze pad. LPN #2 soaked a gauze pad in quarter strength Dakins solution. LPN #2 applied soaked gauze to the resident's distal left foot wound and covered it with an ABD pad. While LPN #2 was doing this, the CN moved her hand to support the resident's left foot by grabbing the middle of her foot in a way that the palm of the CN's hand was covering the proximal wound. After the ABD was applied, the CN moved her hand so she was holding the resident's foot and the Dakin's soaked gauze in place. LPN #2 applied a Dakin's soaked gauze pad to the distal left foot wound. LPN #2 covered both wounds with an ABD pad and the CN helped hold the ABD in place. LPN #2 wrapped the ABD pad with gauze. -LPN #2 touched a permanent marker, the bedside table, and the bed frame with the same gloves she used to remove the old dressing and apply the new one. LPN #2 failed to remove her gloves and perform hand hygiene after touching resident surfaces, removing the old dressing, and before applying the new dressing. LPN #2 failed to sanitize the wound scissors in between each wound dressing. The CN touched the mattress and sheets with the same gloves she used to hold the resident's left leg, grab her left foot, and hold the soaked gauze/ABD pad in place. The CN failed to remove her gloves and perform hand hygiene after touching resident surfaces and while assisting with wound care. LPN #2 and the CN removed their gloves and performed hand hygiene. They both applied new gloves. LPN #2 opened a foam dressing and laid it on the bedside table. She then opened a calcium alginate dressing (absorbent sponge dressing) and used the scissors to cut off an approximately 1 centimeter (cm) by 1 to 1.5 cm strip of the dressing. LPN #2 and the CN repositioned the resident onto her right side. LPN #2 removed the old foam dressing and threw it away. LPN #2 sprayed wound cleanser onto the wound, grabbed a gauze pad, and patted the area dry before throwing the gauze pad away. LPN #2 applied skin-prep (protective skin barrier) to the resident's skin and let it dry. LPN #2 used her gloved fingers to push the calcium alginate dressing into the wound. LPN #2 covered the wound with a foam dressing. -LPN #2 failed to cleanse the scissors with a cleansing wipe before using them to cut calcium alginate dressing. LPN #2 failed to remove her gloves and perform hand hygiene after cutting the calcium alginate dressing, removing the old dressing, and before applying the new dressing. III. Staff interviews LPN #2 was interviewed on 3/4/25 at 10:51 a.m. LPN #2 said gloves should be removed and hand hygiene performed between every task of wound care, and when moving from one wound to another. LPN #2 was unable to provide a reason for not doing this while she performed Resident #20's wound care. The wound care physician (WCP) was interviewed on 3/5/25 at 11:30 a.m. The WCP said the easiest way to establish a clean field for supplies was to place a Chux pad (absorbent bed pad) on top of the bedside table and open/set up supplies on top of the pad. The WCP said hand hygiene should be performed when first entering the resident's room and any time a staff member moved from a dirty-to-clean/clean-to-dirty area, including after removing an old wound dressing and before applying a new one. The WCP said the room should be fully set up and all wound care supplies should be gathered before the actual dressing change occurred. The WCP said it was not appropriate for staff to touch surfaces in the residents' room and then proceed with wound care, due to the risk of cross contamination. The WCP said cross contamination was a big concern and could occur from one area of a resident's body to another, or from one resident to another. The WCP said cross contamination could cause infection, and it also increased the risk of MDROs forming. The WCP said every resident with open wounds should be on EBP. The WCP said he would provide additional education to staff on EBP, proper PPE, wound care, and infection control practices related to wound care. The director of nursing (DON) was interviewed on 3/6/25 at approximately 3:30 p.m. The DON said residents with any medical tubes or drains, intravenous (IV) lines, open wounds and indwelling catheters should be on EBP. The DON said not following EBP could put residents and staff at risk of infection, and potentially create MDROs. The DON said hand hygiene should be performed every time staff changed their gloves. The DON said staff should change gloves and perform hand hygiene any time they went from a dirty-to-clean/clean-to-dirty area while performing wound care and as often as needed. IV. Facility follow-up On 3/6/25 at 4:33 p.m. the DON provided a signed statement from the IP. The IP stated the EBP sign for Resident #20 was falling off of the wall, so she removed it and replaced it with a new one. The IP stated one of the drawers in the PPE cart was not working correctly, so the IP replaced it with a new cart. -However, the DON acknowledged that staff should have still followed EBP even if the signage and cart were not present.

Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional references The Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/23 and retrieved on 12/11/23, from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html read in pertinent part, Nursing homes should assign one or more individuals with training in infection prevention and control (IPC) to provide on-site management of the IPC program. This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment. II. Facility policy and procedure The Transmission Based Precautions policy, reviewed 11/3/22, was provided by the nursing home administrator (NHA) on 11/30/23 at 3:00 p.m. It revealed, that an ICP was not included in their policy. III. Record review A request was made for the ICP's infection control certificate on 11/30/23 at 1:00 p.m. The director of nursing (DON) said she had yet to complete the courses to obtain the infection control certificate (see interview below). On 11/30/23 at 2:38 p.m., the DON provided certificates of completion for seven of the 24 modules required to obtain the infection control certificate. IV. Staff interviews The vice president of ambulatory services (VPAS) was interviewed on 11/30/23 at 2:10 p.m. She said they did not have an ICP and they had not had one for three weeks. The DON and another staff member were training on 11/30/23. She said that the facility was under the same corporation as their local hospital. The facility used the hospital's infection control preventionist while they worked on hiring a designated ICP for the facility. The corporate occupational health department supported their infection prevention and control program. The nursing home administrator (NHA) was interviewed on 11/30/23 at 2:19 p.m. She said the ICP quit three weeks prior to the survey and the job was posted. She said the staff developer was being cross trained and the DON had started the infection control certificate.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one of three floors. Specifically, the facility failed to: -Ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms; -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure shared equipment was properly disinfected between use; -Ensure staff followed proper hand hygiene procedures when moving from task to task; and, -Provide accurate isolation precautions, including isolation signage and assure the resident doors remained closed. Findings include: I. Ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms. A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 12/11/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r2 revealed in part, Healthcare personnel who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Centers for Disease Control (CDC) use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID-19, updated 6/3/20, retrieved on 12/13/23 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf revealed in part, Donning (putting on the gear): Identify and gather the proper PPE to don. Perform hand hygiene using hand sanitizer. Put on an isolation gown. Put on N95 filtering respirator or higher (use a facemask if a respirator is not available. Put on a face shield or goggles. Put on gloves. Healthcare worker can now enter patient's room. Doffing (taking off the gear): Remove gloves. Remove gown. Healthcare worker can now exit patient's room. Perform hand hygiene. Remove face shield or goggles. Remove and discard respirator (or face mask if used). Perform hand hygiene after removing the respirator or facemask. B. Facility policy The Transmission Based Precautions policy, reviewed 11/3/22, was provided by the nursing home administrator (NHA) on 11/30/23 at 3:00 p.m. It revealed in pertinent part, Transmission-based precautions would be used by all staff that have contact with residents and/or their environment. Transmission based precautions would be used when caring for residents who were documented or suspected to have communicable disease or infections that can be transmitted to others. Droplet precautions would be implemented in addition to standard precautions for an individual documented or suspected to be infected with microorganism transmitted by droplets that can be generated by the individual coughing, sneezing, talking or by the performance of procedures. Illness that required droplet precautions included COVID-19. In addition to standard precautions, a face mask and eye protection are required to enter a COVID-19 quarantine or isolation precaution resident room. C. Observations On 11/30/23 at 10:15 a.m., two unidentified staff members walked out of a resident room [ROOM NUMBER]. The resident had COVID-19. One staff member left the room still wearing a gown that had been worn in the resident's room There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. At 10:35 a.m., an unidentified staff member walked into room [ROOM NUMBER] wearing a surgical mask, gown and gloves. The resident had COVID-19. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The staff member did not put on eye protection before entering the room. At 10:40 a.m. an identified female staff member walked out of room [ROOM NUMBER]. The resident had COVID-19. The resident had COVID-19. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The female staff member did not change her surgical mask upon exiting the room. At 10:43 a.m., an unidentified housekeeping staff member walked into room [ROOM NUMBER] and room [ROOM NUMBER], which were adjoining rooms, with a vacuum. One resident had COVID-19. He was wearing a surgical mask. There was a sign that contact precautions were required and a bin inside the resident's room with personal protective equipment (PPE).The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The housekeeping staff member did not don (put on) any other PPE prior to entering the rooms. At 10:48 a.m., the unit manager walked into room adjoining room [ROOM NUMBER] and room [ROOM NUMBER]. One resident had COVID-19. There was a sign that contact precautions were required and a bin inside the resident's room with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unit manager did not don any PPE prior to entering the rooms. At 10:48 a.m. the unidentified housekeeping staff member walked out of room [ROOM NUMBER] and room [ROOM NUMBER] with the vacuum. -The housekeeping staff member did not change his surgical mask upon exiting the rooms. At 11:16 a.m., an unidentified male staff member walked out of room [ROOM NUMBER]. The resident had COVID-19. There was a sign on the wall next to the resident's door that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The male staff member exited the room still wearing the gown he had worn while in the resident's room. At 11:31 am., an unidentified dietary aide walked into room [ROOM NUMBER] and room [ROOM NUMBER] to ask for room [ROOM NUMBER]'s lunch order. One of the residents had COVID-19. She was wearing a surgical mask. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The dietary aide did not don any other PPE prior to entering the room. -The dietary aide did not change her surgical mask when she left the room. She proceeded to enter room [ROOM NUMBER] without changing her surgical mask. At 11:34 a.m., the dietary aide left room [ROOM NUMBER]. The resident had COVID-19. There was a sign that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The dietary aide did not change her surgical mask upon exiting the room. At 11:43 a.m., an unidentified staff member went into room [ROOM NUMBER]. The resident had COVID-19. She was wearing a surgical mask. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unidentified staff member did not don any other PPE prior to entering the room. -The staff member did not change her surgical mask upon exiting the room. At 11:45 a.m., an unidentified staff member went into room [ROOM NUMBER]. The resident had COVID-19. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unidentified staff member did not don any other PPE prior to entering the room. -The staff member did not change her surgical mask upon exiting the room. At 11:51 a.m., an unidentified staff member came out of room [ROOM NUMBER] with a surgical mask and an N95 mask over the surgical mask. The resident had COVID-19. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The staff member did not change her surgical mask upon exiting the room. At 12:12 p.m., an unidentified staff member entered room [ROOM NUMBER]. The resident had COVID-19. She was wearing a surgical mask. There was a sign on the wall next to the resident's room that contact precautions were required and a bin in front of the resident's door with personal protective equipment (PPE). The sign said that gloves, a gown, a surgical mask and eye protection was required to enter the resident's room. -The unidentified staff member did not don any other PPE prior to entering the room. -The staff member did not change her surgical mask upon exiting the room. D. Interviews The director of nursing (DON) was interviewed on 11/30/23 at 4:49 p.m. The DON said for PPE use staff should follow the CDC guidelines for PPE. The DON said that PPE, such as surgical masks, could be changed at the staff members' discretion. She said the facility was considering keeping N95 respirator masks for each staff member in a plastic bag for reuse. -However, the CDC guidelines for donning and doffing was provided to the DON during the interview. The doffing section (when staff should remove PPE) was reviewed with the DON and NHA where the guideline documented to remove and discard respirator or facemask. II. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before meals A. Professional reference According to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 12/13/23 from: https://www.cdc.gov/handhygiene/providers/guideline.html (2020), it read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves was not enough to prevent the transmission of pathogens in a healthcare settings). B. Facility policy The Transmission Based Precautions policy, reviewed 11/3/22, was provided by the NHA on 11/30/23 at 3:00 p.m. -The policy did not discuss when hand hygiene should be offered to residents. C. Observations The lunch meal tray pass was observed on 11/30/23 from 11:41 a.m. to 12:18 p.m. The following observations were made: At 11:43 a.m., an unidentified female staff member went into room [ROOM NUMBER]. -She did not offer hand hygiene to the resident. At 11:45 a.m., the same female staff member went into room [ROOM NUMBER]. -She did not offer hand hygiene to the resident. At 11:51 a.m., an unidentified female staff member delivered the resident's lunch meal in room [ROOM NUMBER]. -The tray did not have hand wipes or sanitizer to offer to the resident. At 11:53 a.m., the same female staff member delivered the resident's lunch meal in room [ROOM NUMBER]. The tray did not have hand wipes or sanitizer to offer to the resident. D. Interview The DON was interviewed on 11/30/23 at 4:49 p.m. The DON said staff should offer hand hygiene to residents before and after eating food, after going to the bathroom and if their hands visibly looked dirty. III. Ensure shared equipment was properly disinfected between use A. Facility policy The Transmission Based Precautions policy, reviewed 11/3/22, was provided by NHA on 11/30/23 at 3:00 p.m. -The policy did not discuss when shared equipment should be cleaned. B. Observation On 11/30/23 at 10:43 a.m., an unidentified housekeeping staff member walked into room [ROOM NUMBER] and room [ROOM NUMBER] with a vacuum. One resident in the adjoining rooms had COVID-19. There was a sign that contact precautions were required. The staff member left the room at 10:48 a.m. with the vacuum. He placed the vacuum on the housekeeping cart. -He did not disinfect the vacuum after use, despite the fact that it had been used in a Covid-19 positive room. C. Interview The DON was interviewed on 11/30/23 at 4:49 p.m. The DON said shared equipment among residents should be cleaned after each use. IV. Provide accurate isolation precautions, including isolation signage and assure the resident doors remained closed A. Professional reference According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 pandemic, retrieved on 12/12/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in part, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed. B. Facility Policy The Transmission Based Precautions policy, reviewed 11/3/22, was provided by the NHA on 11/30/23 at 3:00 p.m. It read in pertinent part, For droplet precautions, the door to the room should remain closed at all times unless fall risk or other resident concerns are included in the care plan. C. Observation On 11/30/23 at 10:15 a.m., the third floor was observed. The following resident rooms had bins outside the doors to hold PPE: room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. -There were no signs indicating residents were on isolation precautions outside of the rooms with PPE bins until 10:32 a.m. when the unit nurse manager (UNM) placed the signs for several COVID-19 positive rooms. room [ROOM NUMBER] had a sign for isolation precautions and the sign had a hand written notice that said to keep the door open. At 10:35 a.m., the following COVID-19 positive rooms had their doors open: room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. At 10:43 a.m., room [ROOM NUMBER] and room [ROOM NUMBER], which was an adjoining room, had their doors open. One resident was COVID-19 positive. At 11:06 a.m., room [ROOM NUMBER] and room [ROOM NUMBER], which was an adjoining room, had their doors open. One resident was COVID-19 positive. At 11:16 a.m., room [ROOM NUMBER]'s door was slightly open and room [ROOM NUMBER]'s door was open. Both rooms were COVID-19 positive rooms. At 11:27 a.m., room [ROOM NUMBER]'s door was open. The resident was COVID-19 positive. At 11:32 a.m., room [ROOM NUMBER]'s door was open. The resident was COVID-19 positive. At 11:41 a.m., room [ROOM NUMBER]'s door was open. The resident was COVID-19 positive. At 11:51 a.m., room [ROOM NUMBER]'s door was slightly open. The resident was COVID-19 positive. At 12:14 p.m, room [ROOM NUMBER]'s door was open. The resident was COVID-19 positive. D. Interviews The UNM for the third floor was interviewed on 11/30/23 at 10:42 a.m. She said that any room that had a bin outside of the room meant that the resident had COVID-19. The DON and NHA were interviewed together on 11/30/23 at 4:49 p.m. The DON said that the infection preventionist was responsible for placing signs on the door of rooms that required isolation precautions. She said that right now it was the charge nurse who would be responsible for placing signs on the resident's room door. She said that the door should be closed for any room where isolation precautions were required. She said some doors of COVID-19 positive residents were kept open if the resident was a fall risk. She did not have a way to differentiate between the COVID-19 positive rooms that should be kept open because the resident was a fall risk versus the COVID-19 negative residents rooms whose doors were open. The NHA said that the facility did not have an effective process in place to ensure staff was aware which Covid-19 positive resident room doors should be closed and which doors should remain open.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner to prevent food-borne illness. Specifically, the facility failed to ensure: -Holding temperatures were appropriate; -Moisture was not between stacked pans; -Appropriate sanitation of utensils, lids and thermometers; and, -Appropriate sanitation of food coolers on resident floors. Findings include: I. Holding temperatures A. Professional reference The Food and Drug Administration (FDA) Food Code (2019) p. 441, When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated. It is especially effective in reducing the numbers of Clostridium perfringens (C. perfringens) that may grow in meat, poultry, or gravy if these products were improperly cooled. Vegetative cells of C. perfringens can cause foodborne illness when they grow to high numbers. Highly resistant C. perfringens spores will survive cooking and hot holding. If food is abused by being held at improper holding temperatures or improperly cooled, spores can germinate to become rapidly multiplying vegetative cells. The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41 F or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. B. Observations Observations of the dinner meal in the first floor kitchen and dining area were conducted on 8/16/23 from 5:20 p.m. to 6:25 p.m. -At 5:20 p.m. dietary aide (DA) #2 took the temperatures of the tuna melt sandwiches.The tuna melt sandwiches were in a large pan stacked four high. The temperature was 111.3 degrees Fahrenheit (F). -At 5:20 p.m. DA #2 took the temperature of the chicken tenders which were in a small eighth sized pan. The temperature was 119 degrees F. -At 5:20 p.m. DA #2 took the temperature of the french fries which were in a small eighth sized pan. The temperature was 107 degrees F. -Between 5:30 and 6:25 p.m. DA #2 served the tuna melt, chicken tenders and french fries to the resident's without re-heating them to 165 degrees F. -At 5:53 p.m. DA #2 reheated food a resident's family brought into the kitchen from the outside. DA #2 did not know that to prevent food borne illnesses the proper temperature to reheat the food was to 165 degrees F and DA #2 reheated the food to 141 degrees F. DA #2 then reheated the food to 175 degrees F with prompting from the nursing home administrator (NHA) and attempted to serve it but was stopped by the NHA as it was soup. DA #2 said soup should not be served at any higher than 160 degrees F to avoid burns. -The tomato soup was served in individual bowls. The soup was sitting with no mechanism to keep it at the appropriate temperature from 5:20 p.m. until it was served at approximately 6:00 p.m. -The food temperatures at the end of the meal were chicken tenders at 119 degrees F, the broccoli cheese soup at 127 degrees F and french fries at 107 degrees F. C. Record Review The menus for cream of broccoli soup and chicken tenders were received on 8/17/23 from the nursing home administrator (NHA) at 11:45 a.m. The menu for the cream of broccoli soup revealed the soup must maintain a minimum temperature of 135 degrees F or 140 degrees F during the entire service period. The product should be kept covered whenever possible. The menu for chicken tenders revealed at the completion of cooking, the internal temperature must reach 165 degrees F for 15 seconds. The finished product must maintain a minimum temperature of 135 or 140 degrees F during the entire service period. The product should be kept covered whenever possible. The temperature of the unserved product should be taken and recorded every 30 minutes. D. Interviews The nutrition services supervisor (NSS) was interviewed on 8/17/23 at 4:13 p.m. The NSS said the temperature on the steam table should be between 140-165 degrees F with the lowest temperature being 135 degrees F. The NSS said DA #2 should have either put the food in the microwave or had the main kitchen reheat the food before serving it to the residents. II. Moisture in pans A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; Unless used immediately after sanitization, all equipment and utensils shall be air-dried. Towel drying shall not be permitted. Utensils that have been air-dried may be polished with cloths which are maintained clean and dry. B. Observations On 8/16/23 at 2:12 p.m. moisture was observed between pans stacked seven high for quarter size pans,13 high for quarter size pans and stacked four high for eighth size pans. On 8/17/23 at 4:01 p.m. with the culinary manager (CM) moisture was observed between pans stacked six high for quarter size pans. C. Staff interviews The CM was interviewed on 8/17/23 4:01 p.m. The CM said the pans should not have moisture between them and should be air dried to ensure bacteria did not grow. He took the pan and placed it on a table to be air dried. III. Inappropriate sanitation of utensils, lids and thermometers. A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised January 2019, read in pertinent part, equipment food -contact surfaces and utensils shall be clean to sight and touch. Equipment food -contact surfaces and utensils shall be cleaned: (1) before each use with a different type of raw animal food such as beef, fish, lamb, pork, or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat foods; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food; (4) Before using or storing a food temperature measuring device; and (5) At any time during the operation when contamination may have occurred. B. Observations On 8/16/23 the following observations were made during the evening meal on the first floor kitchen and dining room between 5:20 p.m. and 6:25 p.m. -At the beginning of service, DA #2 dropped the soup lid into the soup, took it out and rinsed it in the sink and placed it back on the soup container. -During service, DA #2 used a cutting knife to cut oranges and then rinsed it off in the handwashing sink to be used again.She placed it directly onto the counter, where she had placed the food temperature notebook. -DA #2 did not clean the thermometer prior to placing the thermometer in the bowl of soup. The thermometer did not have a cover. C. Interviews The NSS was interviewed on 8/17/23 at 4:13 p.m. The NSS said when DA #2 dropped the soup lid into the soup DA #2 should have gone down to the kitchen to have it washed and sanitized in the dishwasher. When DA #2 needed a clean knife, DA #2 should have put that knife aside and gotten a clean knife or had it washed and sanitized in the dishwasher. When DA #2 took the temperature of the soup, she should have used a clean wipe to wash the thermometer prior to putting it into the soup. It should have been cleaned after the temperature was taken and a cover should have been placed on the thermometer. V. Inappropriate sanitation of food coolers on resident floors A. Facility policy The Cleaning Hydration Ice and Snack Care, dated January 2015, was received on 8/17/23 at 2:43 p.m. from the NHA The policy reads in pertinent part Hydration ice and snack carts are scheduled to be cleaned daily by 10:30 a.m. by a certified nurse aide (CNA) and again by passing snacks by 3:30 p.m. This will be logged every time in the appropriate log book. Clean the inside of the ice container. Remove ice and water, discard in the sink in the galley. Use appropriate sanitizer with a clean rag on the inside of the ice container. Wipe the inside of the ice container with a clean rag and clear water. B. Observations On 8/17/23 the ice container on the third floor was observed at 3:46 p.m. the cooler was on a cart in the corner of the dining room. C. Interviews CNA #10 was interviewed on 8/17/23 at 3:23 p.m. CNA #10 said he thought the coolers were cleaned by the janitorial staff. CNA #10 said he sometimes washed the coolers if they did not look clean. CNA #10 said he washed them out with a clean cloth and dawn dishwashing liquid and dried them inside and out with a clean cloth from the supply closet. CNA #11 was interviewed on 8/17/23 at 3:27 p.m. CNA #11 said she did not know who cleaned the cooler on the floor. The NSS was interviewed on 8/17/23 at 4:13 p.m. The NSS said that she was not familiar with the cleaning of the hydration ice chest, but she thought they were washed in the kitchen, but not sure if in the dishwasher or three compartment sink.

Based on record review and staff interviews, the facility failed to ensure five (#2, #4, #7, #27 and #43) of six residents reviewed for abuse out of 48 sample residents were kept free from abuse. Specifically, the facility failed to ensure Residents #2, #4, #7, #27 and #43 were kept free from abuse by Resident #92. Findings include: I. Facility policy The Abuse and Neglect policy, revised 6/6/23, was provided by the director of health information management (DHIM) on 8/16/23 at 9:15 a.m. The policy revealed in pertinent part: Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff, residents, volunteers, consultants, family members or legal guardians, friends, or any other individuals. Observations and/or allegations of abuse, neglect or mistreatment must be immediately reported to the Administer/Designee to ensure safety of those involved, for thorough investigation of the occurrence, and meet the reporting guidelines established by regulation. During an investigation, the alleged assailant(s) will not be present in the facility. Employees will be suspended immediately until the investigation is completed. If family or visitors are suspected, they will not be present during the investigation. If another resident was involved, they would be separated and monitored. II. Resident-to-resident altercation involving Resident #7 and Resident #92 on 6/9/23 A. Altercation The 6/9/23 progress note revealed Resident #7 grabbed Resident # 92's pants to stop her from entering her room. Resident #92 slapped Resident #7 on the hand. B. Resident #92 1. Resident status Resident #92, age above 65, was admitted on [DATE]. According to the August 2023 computerized physicians orders (CPO), the diagnoses included unspecified dementia severe with anxiety, severe agitation, severe with other behavioral disturbances, anxiety disorder and major depressive disorder. The 5/21/23 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). She had short and long term memory problems. She was short tempered and easily annoyed. She required supervision with transfers, walking in room and corridor, locomotion on and off the unit, dressing and personal hygiene. She was independent with bed mobility, toilet use and eating. She had no behaviors and did not reject care. No antipsychotics were received. 2. Record review The mood care plan, initiated 5/8/22 and revised 8/15/23, documented the resident had a history of anxiety and restlessness. She wandered aimlessly into other resident's rooms and went through their belongings. She may become combative with staff and residents at times. The interventions included: -Please knock, introduce yourself, and explain the purpose of your visit; -Encourage resident to tell staff her needs/wants; -Encourage the resident to participate in activities; -Monitor resident for depressive symptoms; -Attempt non-pharmacological interventions as able; -Notify physician of change in mood; -Track residents anxiety; -Review residents medication for efficacy and /or possible decreases; and, -When the resident wanders into another resident's room, walk with her to redirect to her room. The dementia care plan, initiated 5/8/22, documented the resident's dementia was progressing and often wandered into other resident's rooms. She was at risk for being injured or verbally abused by other residents. She may become combative and agitated when she interacted with other residents or staff. The interventions included: -Please knock, introduce yourself, and explain the purpose of your visit; -Please listen to what she has to say; -Provide encouragement and validation as needed; -Provide cues and reminders as needed; -Encourage resident to make her needs/wants known; -Encourage her to attend activity groups that interest her; -Notify physician of changes in her cognition to rule out acute medical issues; -Include her power of attorney (POA) in decision-making; -Redirect her with her favorite foods when able; and -Loud noises could be irritating to her, attempt to keep her in a quiet environment. The aggressive behavior care plan, initiated 7/31/23 and revised 8/15/23, documented the resident had incidents of aggressive behaviors towards other residents. The interventions included: -She had been provided a 24 hour sitter; -She received a 30 day notice for alternate placement; -Monitor and document her aggressive behaviors; -Notify physician of her aggressive behaviors; -Provide one-to-one social services visits; -Provide one to one life enrichment visits; -Assure that there is no medical reason for her aggressive behaviors; and, -Administer medications as ordered. -Resident #92 was involved in five resident to resident altercations in two months. -According to the progress notes, the resident continued to wander into other resident rooms daily. Cross-reference F744 for dementia care and services due to facility implementing personalized interventions for Resident #92's behaviors that caused resident-to-resident altercations. C. Resident #7 1. Resident status Resident #7, age above 65, was admitted on [DATE] and discharged on [DATE]. According to the August 2023 CPO, the diagnoses included Parkinson's disease, dementia, age related osteoporosis and macular degeneration (blurred vision). The 6/1/23 MDS assessment revealed the resident was unable to conduct the BIMS assessment. She had short and long term memory problems. She was moderately impaired with her cognitive skills for daily decision making and required supervision. She had no behaviors and did not reject care. She required extensive assistance with locomotion on and off the unit, dressing, toilet use and personal hygiene. She required limited assistance with transfers, walking in the room and corridor and eating. She required supervision with bed mobility. 2. Record review The mood care plan, initiated 12/2/22 and revised 7/10/23, documented she often misunderstood the intentions of others trying to care for her. Interventions included: -Please knock, attempt to get her attention prior to entering her room; -Use the translator device or a translator to find out her needs; -Anticipate her needs; -Be patient with her as she may have trouble understanding; and, -Her vision was poor which may add to her confusion. The dementia care plan, initiated 9/27/22 and revised 7/10/23, documented the resident had dementia with behavioral disturbance, disorder of the brain, and Parkinson's. Interventions included: -Please knock and/or flip on the light switch to announce your presence; -Encourage her to make her needs known by using communication cards; -Provide visual cues as able; -Monitor her mental status for increased signs of cognitive loss; -Notify her physician of changes in cognition to rule out acute medical issues; -Include my POA in decision making; -Provide Korean interpreter as able; and, -Utilize the communication sheet hanging in her room. The resident had no further altercations. III. Resident-to-resident altercation involving Resident #4 and Resident #92 on 7/6/23 A. Altercation The 7/6/23 progress note revealed Resident #92 was wandering in and out of other resident's rooms despite frequent redirection. Resident #92 was observed leaving Resident #4's room. Resident #4 was crying and stated Resident #92 had thrown things at her and hit her in the head. There were no injuries. B. Resident #4 1. Resident status Resident #4, age above 65, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included non-Hodgkin's lymphoma (cancer), essential hypertension (high blood pressure), legal blindness and history of falling. The 6/28/23 MDS assessment revealed, the resident had moderate cognitive impairment with a BIMS score of nine out of 15. She had no behaviors and did not reject care. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. She required supervision with eating. She used a walker and a wheelchair. 2. Record review The mood care plan, initiated 1/9/23 and revised 7/5/23, documented the resident was adjusting to the facility and denied depression. She had shown tearfulness, verbal aggression, and other behavioral symptoms directed at others. Interventions included: -Please knock, introduce yourself, and explain the purpose of your visit; -Monitor her for alterations in mood and/or behavioral symptoms; -Attempt non-medication interventions; -Offer one-to-one visits; -Offer validation and reassurance; -Encourage her to participate in activities of her interest; -Include her family in information; and, -Notify physician in changes of mood and behavior. 3. Resident interview Resident #4 was interviewed on 8/15/23 at 11:14 a.m. She said Resident #92 entered her room and threw her kleenex box at her. She said she then used the kleenex box to hit her on the hands and head. She said she was hard of hearing and legally blind. She said when Resident #92 entered her room she would point at the wall and her words did not make sense. She said she was unable to figure out what she wanted. She said she was not afraid of her, but did not want her in her room. IV. Resident to resident altercation involving Resident #2 and Resident #92 on 7/30/23 A. Altercation The 7/31/23 progress note at 1:56 p.m. revealed a certified nurse aide (CNA) reported Resident #92 entered Resident #2's room and hit her three times in the head. There were no injuries. B. Resident #2 1. Resident status Resident #2, age above 65, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dementia, traumatic brain injury, abnormal posture, dependence on a wheelchair, mood disorder, insomnia and history of falling. The 5/9/22 MDS assessment revealed the resident had severe cognitive impairment with a brief BIMS score of five out of 15. She had behavioral symptoms not directed at others. She did not reject care. She required extensive assistance with bed mobility, transfers, locomotion off the unit, gressing, eating, toilet use and personal hygiene. She required supervision with locomotion on the unit. She used a wheelchair. 2. Record review The mood care plan, initiated 3/15/18 and revised 5/18/23, revealed the resident had a history of traumatic brain injury and was intellectually challenged. She was childlike in her behaviors and abilities. Interventions included: -Please introduce yourself to her so she will know who you are; -Please encourage her to go activities; -Please make sure she goes to musical performances; -Listen to her when she talks and validate and reassure her as needed; -Include my POA in decision making; -Monitor her for in mood and/or behavior; -Notify physician in changes of mood state/behavior and rule out acute medical conditions; and, -Encourage her to visit with her family and go on outings in the community. V. Resident to resident altercation involving Resident #27 and Resident #92 on 7/30/23 A. Altercation The 7/30/23 progress note revealed Resident #92 saw Resident #27 walking with her walker. Resident #92 approached her, punched Resident #27 in the stomach and told her to hurry up. B. Resident #27 1. Resident status Resident #27, age above 65, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included unspecified dementia, difficulty in walking, history of falling, anxiety disorder, muscle weakness, major depressive disorder, dependence on supplemental oxygen and bipolar disease. The 5/30/23 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She had disorganized thinking, but did not reject care. She required supervision with locomotion on and off the unit, dressing and personal hygiene. She required extensive assistance with toileting. She was independent with bed mobility, transfers, walking in the room and corridor and eating. She used a walker. She received an antipsychotic, an antianxiety, an antidepressant and a diuretic daily. 2. Record review The mood care plan, initiated 2/22/22 and revised 6/7/23, revealed she had unspecified bipolar mood disorder. Her depression depended on what was going on in her life. Interventions included: -Please knock, introduce yourself, and explain the purpose of your visit; -Encourage her to participate in group activities; -When the weather was nice, encourage her to help take care of the plants on the patio; -Encourage her to take care of the plants in her room; -The psychiatrist will manage her medications; -She will participate in mental health therapy; -Track her behaviors related to medications and diagnosis; -Monitor for suicidal ideation; -Notify her physician/psychiatrist of changes in mood state and rule out acute medical issues; -Administer her medications as ordered; and, -Review her medications through the psychotropic medication committee. VI. Resident to resident altercation involving Resident #43 and Resident #92 on 7/31/23 A. Altercation The 7/31/23 progress note revealed a visitor reported Resident #92 kicked Resident #43 unprovoked. No injuries were noted and Resident #43 did not remember the incident. Residents were immediately separated. B. Resident #43 1. Resident status Resident #43, age above 65, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included unspecified dementia, cognitive communication deficit, anxiety disorder and history of falling. The 5/9/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. He had no behaviors and did not reject care. He required extensive assistance with toilet use and personal hygiene. He required limited assistance with bed mobility, transfers, and dressing. He required supervision with locomotion on and off the unit. He was independent with eating. He used a walker and a wheelchair. 2. Record review The mood care plan, initiated 2/7/23 and revised 8/14/23, revealed the resident had a diagnosis of anxiety disorder. Interventions included: -Knock and introduce yourself and reason for the visit; -Encourage him to make his needs known to staff; -Encourage him to stay busy with independent activities and group activities; -Monitor for signs and symptoms of anxiety; -Attempt non-pharmaceutical interventions; and, -Notify physician to rule out acute medical issues or conditions. VII. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/16/23 at 2:03 p.m. She said Resident #92 got violently aggressive hitting staff and residents. She said the nursing staff had a training meeting with management to discuss interventions, who to report abuse to and how to handle aggressive situations. She said all the staff discussed which interventions worked and which ones did not. She said since Resident #92 had a one-to-one sitter since 7/31/23; she seemed calmer. Registered nurse (RN) #1 was interviewed on 8/16/23 at 2:11 p.m. She said Resident #92 was violent with staff, family members and her peers. She said she had been involved in many resident-to-resident altercations and required one-to-one supervision to keep others safe. The DHIM was interviewed on 8/17/23 at 11:46 a.m. She said after the 7/6/23 altercation, Resident #92 had a part time one-to-one sitter while awake or active. She said as the weeks went on with no altercations and decreased aggression, the one-to-one sitter became as needed. She said because of the two altercations on 7/30/23, the facility hired a one-to-one sitter 24 hours a day indefinitely. The medical director was interviewed on 817/23 at 12:11 p.m. He said Resident #92 had very aggressive behavior. He said after many failed interventions, he consulted with the psychiatrist for the appropriate medication and care. He said he then started her on an anti-anxiety, an antipsychotic, an antidepressant and had aromatherapy. He said the facility was trying to find a facility to discharge her to that was a better fit. The nursing home administrator was interviewed on 8/17/23 at 1:30 p.m. She said Resident #92 was moved to a private room from her shared room on 8/11/23. She said with the two altercations on 7/30/23, Resident #92 had a one-to-one sitter that was as needed. She said the resident used the bathroom which was shared and exited through the shared door of her neighbor. She said the sitter allowed her privacy in the bathroom and was unaware she had exited through the other door. She then had the two altercations with two different individuals. She said the second door between the two rooms for the bathroom was now kept locked. She said the resident in the neighboring room required extensive assistance by two staff to toilet and the staff would unlock her bathroom door when she needed to use it. She said with the 7/31/23 altercation the one-to-one sitter had called off and the resident was then placed on every fifteen minute checks. Within the fifteen minutes she assaulted Resident #43. She said the facility put a plan in place on 7/31/23 to have a one-to-one sitter 24 hours a day indefinitely with a back up sitter if there was a call off. She said Resident #92 needed a smaller, quieter environment and the facility was looking for placement for her. She said the family was given a 30 day notice to discharge, but the family was appealing the notice. She said the facility was doing everything in their power to keep other residents safe. She said Resident #92 had not had any further altercations after implementing the sitter 24 hours a day.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance and temperature. Findings include: I. Resident interviews Resident #45 was interviewed on 8/14/23 at 10:51 a.m. Resident #45 said the rice was always hard. Resident #45 said she had complained but they had not fixed the concern or had offered an alternate food choice. Resident #5 was interviewed on 8/14/23 at 12:09 p.m. Resident #5 said the evening meal was not palatable. For an alternative they always give you peanut butter and jelly, yogurt or ice cream. Resident #50 was interviewed on 8/14/23 at 3:40 p.m. Resident #50 said sometimes the food was served cold, eggs especially. The hot plate worked too well and ended up toasting the bottom piece of bread until it was very hard. Resident #54 was interviewed on 8/14/23 at 3:24 p.m. Resident #54 said the food was horrible and bland. It did not have any spice. The resident group interview was held with four residents (#103, #69, #36 and #64) on 8/15/23 at 1:57 p.m. Several residents had concerns with food palatability. The residents said the pork was tough and the vegetables were too soft. Resident #71 was interviewed on 8/17/23 at 10:57 a.m. Resident #71 said she did not like the dinner meal, she had to discard the bread and the green beans were tough and she could not chew them. Resident #71 said if they had offered a different choice for dinner she would have ordered that instead. Resident #71 said she was unable to eat most of the meal Resident #209 was interviewed on 8/17/23 at 11:10 a.m. Resident #209 said she had a mechanically soft hamburger which was ground up meat, with french fries and soup. Resident #209 said she ate the hamburger but the french fries were cold and she did not like the soup because it was watery and bland. Resident #91 was interviewed on 8/17/23 at 11:22 a.m. Resident #91 said she did not eat bread or cheese. Resident #91 said she ate the tuna out of the sandwich and left the rest. Resident #91 said she did not like the meal and would have liked a substitute. Resident #45 was interviewed on 8/17/23 at 11:32 a.m. Resident #45 said she liked to eat her rice and soup together at a meal but the soup did not taste good and she was unable to eat it. Resident #54 was interviewed on 8/14/23 at 3:24 p.m. Resident #54 said the food was horrible. She said she did not eat the food other than eating the soup for lunch and dinner. II. Food Committee Minutes Review of the Food Committee Minutes from 5/2023 to 8/2/23 revealed the following concerns about the palatability of food: -The minutes from May 2023 (no date) revealed the soups were salty, greasy, bland and too thin. The broccoli was overcooked. -The minutes from 6/7/23 revealed the soup was salty, food over seasoned, three bean salad was mashed up and used relish, broccoli overcooked, green beans too long and they served too many carbs (such as bread, rice, potatoes). -The minutes from 7/5/23 revealed that some of the meat was difficult to chew, they served mashed potatoes too much, the meats were repetitive and melon and mandarin oranges were served too often. -The minutes from 8/2/23 revealed one resident was being served items she was allergic to, the french fries were always cold and another resident did not eat the soup because of the food combinations in them. The resident said the soups tasted like they were made with leftovers. IV. Test tray A test tray was evaluated on 8/16/23 at 6:30 p.m. by two surveyors. The meal was the alternate choice of chicken fingers, pasta salad, french fries, broccoli soup and watermelon. The test tray was received after the last resident was served on the South unit. The temperatures were as follows: -The chicken fingers were 119 degrees F. The chicken fingers were warm to the palate, crunchy, overcooked and difficult to eat. -The french fries were 107 degrees F. The french fries were warm to the palate and hard. -The pasta salad was bland and had little taste. The pasta salad was served in a four ounce disposable plastic container. -The broccoli soup was warm to the palate, the consistency was thin and bland in taste and the broccoli was scant. The watermelon for dessert was fresh and tasty. -No condiments were served with the chicken. During the meal service, only a few residents received ketchup, but otherwise no condiments. V. Staff interviews The culinary supervisor (CS) and the nutrition services supervisor (NSS) were interviewed on 8/17/23 at 4:13 p.m. The NSS said that she had heard of complaints on the meal in regards to being served cold. The NSS said if a meal was served to a resident cold then it needed to be reheated outside of the kitchen or discarded and a new hot meal should have been served to the resident. The CS said the facility had a food committee which was held monthly. He said that it was a forum to help with the food concerns. He said there had been some turnover in the kitchen and they were working on the palatability of the food. The CS said that the soup was made in the kitchen. The CS said that he did not taste the broccoli cheese soup. He said the food should be tasted to ensure palatability.

Based on observations, record review and interviews; the facility failed to provide each resident with a nourishing, well balanced diet that meets his or her nutritional and special dietary needs, taking into consideration the allegations and preferences of each resident for four (#71, #209, #91 and #53) out of 48 sample residents. Specifically, the facility failed to ensure Residents #71, #209, #91 and #53 were provided food that accommodated their food dislikes and preferences. Findings include: I. Resident interviews, observations and record review A. Resident #71 1. Observation On 8/16/23 at approximately 6:00 p.m., an unidentified certified nurse aide (CNA) approached the kitchen window and said Resident #71 requested an alternate vegetable because she did not like nor could chew the green beans. Dietary aide (DA) #2 said she was unable to give Resident #71 a different vegetable because there was no alternative to the green beans. 2. Record review Resident #71's food selection ticket revealed the resident had no dislikes but had a regular mechanically soft diet. B. Resident #53 1. Record review Resident #53's food selection ticket revealed the resident disliked fish and had a regular pureed diet. 2. Observation At 5:40 p.m. Resident #53's meal ticket documented she did not like fish and required a pureed meal. The resident was served a pureed tuna melt sandwich. DA #2 was interviewed and said they only had fish for Resident #53. DA#2 said the last time Resident #53 was served fish, she ate it. Resident #53 did not receive soup. At 6:11 p.m. Resident #53 had not eaten and a CNA went to assist Resident #53 as requested by the nursing home administrator (NHA). The CNA did not attempt to reheat the food nor obtain a new meal from the kitchen for Resident #53. The resident consumed less than 15% of her meal. C. Resident #209 1. Observation and record review On 8/16/23 at approximately 5:30 p.m. Resident #209 was served the tuna melt sandwich, her ticket read she did not like fish. 2. Resident interview Resident #209 was interviewed on 8/17/23 at 11:10 a.m. Resident #209 said she was initially given a tuna melt for dinner. Resident #209 said she did not like fish. Resident #209 said the staff did not offer a substitute and Resident #209 had to request an alternate food choice. Resident #209 said she had a mechanically soft hamburger which was ground up meat, with french fries and soup. D. Resident #91 1. Record review On 8/16/23 at approximately 6:00 p.m. Resident #91 was served the tuna melt sandwich, her ticket read she did not eat cheese or bread. 2. Resident interview Resident #91 was interviewed on 8/17/23 at 11:22 a.m. Resident #91 said she did not eat bread or cheese. Resident #91 said she ate the tuna out of the sandwich and left the rest. Resident #91 said she would have preferred an alternative to the tuna melt but was not offered one. She said she would prefer to have eggs as an alternative at all meals but they had denied her that alternative for lunch and dinner. II. Food committee minutes Review of the Food Committee Minutes from May 2023 to 8/2/23 revealed the following concerns about the palatability of food: -The minutes from May 2023 (no date) revealed almond milk was substituted for lactose free milk. The sugar substitute was Splenda. -The minutes from 6/7/23 revealed the kitchen was starting to do lighter foods during the dinner meal. -The minutes from 7/5/23 revealed they substituted baked sweet potato instead of mashed potatoes. They substituted berries for melon. -The minutes from 8/2/23 revealed one resident was being served items she was allergic to and another resident revealed he kept getting food from his dislike list. III. Additional observations During dinner observation in the first floor dining room on 8/16/23 from 5:20 p.m. to 6:25 p.m. revealed the following: -During meal service only a handful of tickets were completed with resident meal choices for dinner. The majority of tickets did not have check marks or highlighted food choices for the resident's dinner. -Resident #81 required a mechanically soft diet and was served chicken strips by DA #2. The resident had requested the alternative meal of chicken strips. However, the tray line did not have the mechanical soft chicken strips, so the resident had to wait for his meal until it could be prepared. The resident requested soup, however, it was not served. IV. Staff interviews DA #3 was interviewed on 8/16/23 at 2:23 p.m. DA #3 said the resident would let the DA know they preferred an alternate food choice when the DA took their meal order. The DA would write the resident's alternate choices on the meal ticket. When served, if the resident did not receive the alternate food choice or did not want what they ordered, the DA should call the kitchen for an alternate food choice and it would be brought up for the resident. DA #1 was interviewed on 8/16/23 at 3:43 p.m. DA #1 said he visited each resident on the third floor daily between 2:00 to 4:00 p.m. and took the resident orders for the following day. Each resident had an individualized ticket which included the menu, the resident's diet, dislikes and preferences. The resident's orders were written on their ticket along with any alternate food choices. DA #1 said the residents were asked daily about their dislikes and preferences. If a resident's preferences changed it was put into the system and the tickets were updated. The tickets were updated weekly with the menu and printed out daily. DA #2 was interviewed on 8/16/23 at 5:43 p.m. during meal service. DA #2 said if the resident's meal ticket did not have any check marks on it indicated the resident got the regular meal. The nutrition services supervisor (NSS) was interviewed on 8/17/23 at 4:13 p.m. The NSS said when Resident #53 pureed meal included something she disliked the kitchen should have been called for an alternate pureed meal for the Resident #53. The NSS said when Resident #53's meal sat for 30 minutes prior to being eaten, the meal should have been heated up outside of the kitchen or discarded and replaced with hot food from the kitchen. The NSS said DA staff should have not given Resident #81 regular chicken strips and should have been given a mechanically soft food choice. The NSS said the DA staff needed to be trained again. The NSS said the DA #2 did not take the resident's orders for the dinner meal on 8/16/23. Therefore, the majority of the tickets were not marked with the resident's meal choices. The meal tickets should identify what meal choice the residents requested along with any alternate meal choices. The NSS said when Resident #71 requested an alternate vegetable, DA #2 should have called the kitchen for an alternate vegetable. The NSS said the DAs should offer the residents soup if it was not marked on the resident's ticket. If the resident refused the soup, then an alternate food choice should have been offered.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure staff engaged in hand hygiene between providing care to two residents. Finding include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 821/23 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 8/21/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services policy and procedure, undated, was provided by the director of health information management (DHIM) on 8/17/23 at 4:35 p.m. It read in pertinent part, It is the policy of the facility that the workplace will be maintained in s sanitary,orderly and safe condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. It is the purpose to provide standard operation procedures for a clean, safe and sanitary environment for residents. 1. Doorknobs, handrails, bath rails, sink handles, and surfaces will be cleaned at least once daily and more often as needed, especially important during an outbreak. 2. Cleaning of walls, curtains, blinds, will be done when dust/soil is visible and placed on a terminal cleaning program. 3. Daily damp high dusting will be done to minimize aerosolization of dust particles. 4. Upholstered furniture or cloth furniture should be vacuumed routinely to reduce dust and allergens (unless resident is immunocompromised with preexisting lung condition ( asthma. In the case of immunized residents, minimizing the use of upholstered furniture is recommended). 5. Privacy curtains should be changed when visibly dirty and should be laundered or disinfected with an Environmental Protection Agency (EPA)-registered disinfectant per the curtain and disinfectant manufacturer's instructions. Regular cleaning and dusting of housekeeping surfaces with soap and water is sufficient for general housekeeping surfaces. Cleaning and disinfecting schedules include: High Touch Surfaces -Beds -Bed rails -Bedside table -Call button -Call button in the bathroom -Chair -Closet handles -Door handles -Handrails -Ledges -Light cords -Light switch -Soap dispenser and sink -Telephone -Telephone cord -Toilet -TV remote -Trash can -Walls -Wheel chairs -Window blinds and window sills. C. Manufacturer recommendations The disinfectant in the facility was identified as: Waxie Solsta 200 General Purpose Cleaner The product label was reviewed which read in pertinent part, Select appropriate dispensing mode, bottle or bucket fill, press button and fill. Sweep, dust mop or vacuum floors to remove loose dirt prior to cleaning. Use an auto scrubber or swing machine with light cleaning (white or red) pads, machine brushes, or WAXIE Fast Glide Mopping System for daily floor cleaning. Apply solution to floor. Allow dwell time. Agitate and pick up soiled solution. It may be necessary depending on soil load to double scrub the surface. Rinse the surface thoroughly after cleaning. Use unheated tap water. For surfaces other than floors, apply with a WAXIE yellow microfiber cleaning cloth, bottle with course or foam-type trigger sprayer. Agitate and/or wipe clean as needed. No rinsing is required. Use unheated tap water. Purell Healthcare Surface Disinfectant Spray The product label was reviewed which read in pertinent part, Formulated for convenience and ease-of-use, Purell Healthcare Surface Disinfectant Spray has powerful germ-kill on the surfaces people touch most - yet is gentle enough to use around sensitive patients. Designed to accelerate the germ-killing power of alcohol, the patented fragrance-free formulation disinfects without harsh chemicals. It's mild around staff and patients and provides a better overall experience. This powerful formulation has the EPA's lowest allowable toxicity rating and delivers the fastest overall disinfection time of any Design for the Environment (DfE) product. Compatible with both hard and soft surfaces, it eliminates 99.9 percent of viruses and bacteria on surfaces - including norovirus, MRSA (Methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant enterococci), and human coronavirus in 30 seconds with no rinse required. D. Observations On 8/17/23 housekeeper (HSKP) #1 was continuously observed cleaning rooms #101, #102, #104, #133, #134 and #135 from 10:20 a.m. to 12:00 p.m. HSKP #1 wiped the surfaces in each room with a cloth that she sprayed with the cleaning product (not a disinfectant) and then diluted the cleaning product by rinsing the cloth with water. HSKP #1 wiped surfaces in each room (sink, mirror and toilet) for five seconds per surface. The surface disinfectant was not used and therefore all surfaces in the room were not disinfected. The call lights, light switches, door handles, handrails and bathroom call lights in each room were not disinfected (see above per CDC guidelines). E. Staff interviews HSKP #1 was interviewed on 8/17/23 at 12:05 p.m. HSKP #1 said she did not disinfect any areas in the room because she only used a surface cleaning product. HSKP #1 said she did not clean or disinfect any high touch areas in all rooms. The director of housekeeping (DOH) was interviewed on 8/17/23 at 1:05 p.m. The DOH said rooms should be cleaned top down, dirtiest to cleanest. All high frequency touch areas in the room should be disinfected daily. The DOH said surface disinfectant times should be adhered to ensure surfaces were properly disinfected and based on the deficient practice identified she needed to provide training to all housekeeping staff that covered correct resident room cleaning procedures, use of cleaning products versus disinfectant products, surface disinfectant times and high frequency touch areas. The infection preventionist (IP) was interviewed on 8/17/23 at 1:36 p.m. The IP said surface disinfectant times should be adhered to be effective in killing germs, viruses and bacteria. The IP said if the surface disinfectant time was not adhered to then a surface would not be clean or disinfected, which could lead to potential infection. High frequency touch areas should be disinfected. Cleaning agents do not disinfect surfaces but just shine them and a disinfectant would kill the bacteria and germs on a surface. 48458 II. Staff hand hygiene failures A. Facility policy and procedure The Infection Control policy, revised 2023, was provided by the nursing home administrator on 8/17/23. It read in pertinent part, alcohol based hand sanitizer should be used prior to and after touching a resident or the resident's immediate environment. B. Observations On 8/14/23 at 12:04 p.m., in the second floor dining room, an unidentified certified nurse aide (CNA) sat between two residents and assisted Resident #56 by using spoon, then turned to Resident #68 and used both her hands to adjust the resident's oxygen tubing on her nose. The CNA then picked up utensil and returned to using the utensil to offer food to Resident #56 without performing hand hygiene. At 12:17 p.m. the CNA continued to assist Resident #56 and Resident #68 with their meals and used both hands to assist both residents without performing hand hygiene between residents. On 8/15/23 at 11:48 a.m, the CNA picked up a utensil for Resident #56 and offered the resident food. After Resident #56 took a bite of food, the CNA then turned toward Resident #68 and with same hand picked up that resident's utensil (which Resident #68 had previously held) and offered food to the Resident #68. The CNA then used same hand to pick up utensil and offer food again to Resident #56. She did not perform hand hygiene between assisting the two residents. At 11:58 a.m., the CNA continued to use Resident #56 and Resident #68's utensils without performing hand hygiene and continued to use the same hand for both residents. At 12:03 p.m, the CNA used Resident #56's fork and offered food to her, then picked up Resident #68's fork to provide food to her (Resident #68 had previously held the fork). The CNA did not use hand hygiene between resident contacts. On 8/16/23 at 12:05 p.m. the CNA used napkin as a clothing protector and applied to Resident #2 and Resident #17. The CNA did not perform hand hygiene between resident contacts. At 12:10 p.m., an unidentified CNA used a fork to provide food to Resident #2, then turned to Resident #65 and took fork that the resident was holding and used fork to assist Resident #65 with eating. The CNA then picked up a coffee mug to offer sip of coffee to Resident #2. The CNA then used a fork to pick up food and offer to Resident #2. The CNA then used same hand (left) to pick up Resident #65's fork, after Resident #65 was holding it.The CNA failed to perform hand hygiene between resident contacts. C. Staff interviews The IP was interviewed on 8/17/23 at 1:36 p.m. The IP said staff should engage in hand hygiene to prevent the spread of infection and if someone had visibly soiled hands they should wash their hands with soap and water. Staff should not assist two residents with their meal at the same time. Staff should ensure they sanitize between residents and wear gloves. CNA #4 was interviewed on 8/17/23 at 1:55 p.m. The CNA said if he had to assist two residents with their meals at the same time, he would prepare both residents' trays first. He would then use a hand sanitizer between assisting residents. He would use the hand sanitizer which was provided at the table. Licenced practical nurse (LPN) # 1 was interviewed on 8/17/23 at 2:15 p.m. The LPN said there should always be one staff per resident when assisting with a meal, but if she had to assist two residents at the same time, she would make sure that she did not cross contaminate by using hand sanitizer between residents.

Based on interviews and record review, the facility failed to ensure one (#36) out of 48 sample residents had the right to receive visitors of their choosing at the time of their choosing. Specifically, the facility failed to ensure Resident #36 was able to visit with a visitor of her choice. Findings include: I. Facility policies and procedures The Resident Rights policy and procedure, undated, was provided by the director of health information management (DHIM) on 8/17/23 at 4:30 p.m. In pertinent part it read: under federal and state laws you have the following rights and responsibilities. Your rights and responsibilities may be assigned and delegated to your guardian, conservator, or other legal surrogate consistent with state law. To the extent possible, we will encourage and assist you with your exercise of your rights and responsibilities, as long as you do not interfere with the rights of other residents. We will not engage in interference, coercion, discrimination, or reprisal when you exercise your rights and responsibilities. We will inform you of your rights during your stay in our facility and we will notify you of any changes made to these rights. You have the right to choose activities schedules and healthcare consistent with your interests, assessments and plan of care. You have the right to participate in social, religious, and community activities that do not interfere with the rights of other residents. II. Resident #36 A. Resident status Resident #36, age 63, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included pain in the left shoulder, abnormal posture, lymphedema (swelling due to build-up of lymph fluid in the body), not elsewhere classified, major depressive disorder, recurrent, moderate and generalized anxiety disorder. The 6/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident was independent with transfers, walking in the room, dressing, toileting and personal hygiene. She was always continent of the bowel and bladder. B. Resident interview The resident was interviewed on 8/16/23 at 2:15 p.m. She said she was denied a visit with her friend who was a former employee, who wanted to take her out to lunch. The NHA told her that the visitor was not allowed to be in the facility. The resident said she felt sad and no longer had control of her life and her choices which made her feel trapped. C. Record review The resident's rights were reviewed on 8/16/23 at 4:30 p.m. the resident's rights revealed the resident had the right to visit privately outside the facility with anyone of their choice. III. Staff interviews The nursing home administrator (NHA) was interviewed on 8/16/23 at 3:45 p.m. She said she made a mistake by telling the resident that the former employee was not allowed to visit with her. She should have been more clear that although the facility's policy did not allow former employees entrance into the nursing home the resident could have still gone to lunch with the former employee as long as they met in the parking lot of the facility. The director of nursing (DON) was interviewed on 8/17/23 at 4:54 p.m. She said residents had the right to make their own choices. Residents could visit with whoever they want and the facility needs to observe the resident's rights.

Based on record review and interviews, the facility failed to provide two (#86 and #45) of two residents out of 48 sample residents with the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, the facility failed to: -Ensure resident #86 received showers according to her preferences; and, -Ensure resident #45 was provided with a functional system to meet her communication needs. Finding include: I. Activities of daily living-showering and bathing preferences A. Facility policy and procedure The Resident Bath Preference policy and procedure, reviewed 7/30/2020, was provided by the director of health information management (DHIM) on 8/17/23 at 4:35 p.m. It read in pertinent part, (Facility name) ) shall honor the resident's bathing preferences. As new residents move into the Neighborhood, their bath preference will be established and the bath schedule revised to reflect their choice. At the time of each bath the resident will be asked what their preference is and it will be honored as able. B. Resident #86 1.Resident status Resident #86, age 68, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, unspecified and schizoaffective disorder. The 6/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. The resident required supervision for showers and setup help only with transfers, walking in the room, dressing, toileting and personal hygiene. She was always continent of the bowel and bladder. 2. Resident interview The resident was interviewed on 8/16/23 at 2:25 p.m. She said she felt uncared for by staff because she wanted to receive two showers per week, however, the facility only provided her with one shower per week and it bothered her and made her feel sad. 3. Record review The resident's care plan was reviewed on 8/16/23 at 4:25 p.m. The care plan revealed the resident preferred to receive a shower or bath twice per week no specific days were indicated. The resident's shower log for the last three months (6/4/23 through 8/15/23) was reviewed on 8/16/23 at 4:30 p.m. The shower log revealed the resident had received 56% of her showers (nine out of 16 showers). 4. Interviews Certified nurse aide (CNA) #8 was interviewed on 8/17/23 at 2:08 p.m. CNA #8 said when there was a call off or the facility was short staffed by CNAs the shower aides would work the floor as CNAs and therefore some resident showers got missed when that happened. The nursing home administrator (NHA) was interviewed on 8/17/23 at 3:15 p.m. She said the issue stemmed from shower aides being pulled to the floor at times of need or when the facility was short staffed and moving forward the matter would be corrected and residents would receive their showers according to their preferences. The director of nurses (DON) was interviewed on 8/17/23 at 4:54 p.m. The DON said the facility would make an attempt to provide residents with showers according to their preferences, if the facility has enough staff to do so. In the case a resident missed their shower, as soon as staffing permits, the facility would host a make up day and all residents would be offered showers on a first come first serve basis. The DON did not provide an answer as to why the make up day was not provided to Resident #86 for her missed shower days for the past three months. II. Activities of daily living-communication A. Facility policy and procedure The Communication policy and procedure, updated 2/1/23, was provided by the DHIM on 8/17/23 at 4:35 p.m. It read in pertinent part, (Facility name) will communicate with residents who do not speak English to facilitate care and quality of life. Staff will utilize pocket talkers that are located on each med cart. Native speakers either staff, friends/family, or volunteers. The iPad with the live translation app. Storyboards/picture boards and Google translate. B. Resident #45 1.Resident status Resident #45, age 86, was admitted on [DATE]. According to the August 2023 CPO, diagnoses included unspecified dementia, moderate, with mood disturbance, chronic kidney disease, atrial fibrillation, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral, primary open-angle glaucoma, bilateral, mild stage and chronic diastolic (congestive) heart failure. The 6/20/23 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score nine out of 15. The resident was primarily independent with transfers, walking in the room, dressing, toileting and personal hygiene. The resident only required setup help for bathing. She was always continent of the bowel and bladder. The MDS indicated the resident's preferred language was English and the resident did not require an interpreter. -However, the resident did not understand English well (see interview below). 2. Resident Interview The resident was interviewed on 8/14/23 at 10:29 a.m. She said when staff talked to her she did not understand them because she did not understand English well and she preferred having a translator that spoke Tagalog. Because the resident did not understand the staff she laughed at them. The resident said she felt that she did not do things at the facility or talk to anybody (staff and residents) effectively because staff did not provide language assistance. The resident said she did not understand any reading material and or activities provided to her at the facility, therefore she watched television that was in English or Spanish and that was difficult for her to understand but she did her best to understand. She said she always complained to staff however staff were never able to respond to her. The resident said she felt sad because nobody understood her and she did not know why staff tried to communicate with her in Spanish. 3. Record review The resident's face sheet was reviewed on 8/14/23 at 12:00 p.m. The face sheet revealed the resident's preferred language was Tagalog. The resident's care plan was reviewed on 8/14/23 at 12:30 p.m. The care plan revealed the resident can speak several languages but never learned to read. The resident can speak English,but needed to be reminded.If you ask me a direct question about my needs, I will tell you. Otherwise, I don't initiate making my needs known. My hearing is slightly impaired without amplification, I may have difficulty in some environments and because of the language barrier, I may need information repeated. I also have some word finding difficulty, but I am usually understood, and I usually understand others. -No interventions were listed to ensure the language line was utilized and or any communication assistance to ensure the resident was able to convey her needs and or for the resident to understand staff. E. Interviews Registered nurse (RN) #3 was interviewed on 8/16/23 at 1:52 p.m. She said the resident was Filipino and spoke some English, however, there was a Filipino staff that helped communicate with the resident; however, if the staff was not present or available then the staff would speak to the resident in English but at times RN #3 did not understand the resident and was uncertain if the resident understood her. RN #3 said she did not know why some staff spoke Spanish to the resident because the resident would not understand. RN #3 said the facility had translation resources available for use, however, she never used it and she did not know how to use the device and that the device did not work right. CNA #7 was interviewed on 8/16/23 at 1:59 p.m. CNA #7 said she tried to find staff that speak Tagalog to speak to the resident to make sure the resident understood her and she understood the resident because the resident only spoke and understood a little bit of English. If staff did not speak the resident's language then CNA #7 would obtain the translator and was what staff should have done in the first place. CNA #7 said the resident should have a picture book to help her communicate with staff as other residents in the building had them and it was a helpful resource. CNA #8 was interviewed on 8/16/23 at 2:07 p.m. She said the resident spoke a little bit of English, however she used Spanish as well to communicate with the resident since that was the resident's native language, however, sometimes the resident did not understand her. In the instance the resident and CNA #8 did not understand each other CNA #8 would find Spanish speaking staff to translate for the resident. CNA #8 said she was not sure if the facility had translation services in place and therefore never used them. The minimum data set (MDS) coordinator was interviewed on 8/17/23 at 10:06 a.m. She said the resident's native language was Gaelic, however, after further review of the resident's MDS assessment she said the resident's native language was English and then said she spoke Tagalog as well. The MDS coordinator completed the MDS in English with the resident because the resident spoke and understood simple English. The social services director (SSD) was interviewed on 8/17/23 at 10:39 a.m. She said the resident's native language was Tagalog and the resident understood basic English but for more complex conversations or questions the resident would need an interpreter. Staff should use an interpreter whenever they spoke to the resident especially if they did not understand the resident. The SSD said a good idea would be for social services staff to be part of orientation especially when a resident was admitted with English as a second language to ensure staff knew the resources they have available to them.

Based on observations, record review and interviews, the facility failed to ensure one (#158) residents out of two who required respiratory care received the care consistent with professional standards of practice out of 48 sample residents. Specifically, the facility failed to for Resident #158: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #158's CPAP; -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of the CPAP; and, -Ensure staff was properly trained to use the CPAP sanitizing chamber. Cross-reference to F726 failure to train nursing staff on the care and use of the CPAP. Findings include: I. Facility policies and procedures The CPAP/BiPAP Non-Invasive Ventilation policy, revised 12/21/21, was provided by the director of health information management (DHIM) on 8/15/23 at 3:18 p.m. The policy revealed in parts: The CPAP provides respiratory support for residents to promote adequate sleep to improve energy levels and heart health for those diagnosed with obstructive sleep apnea (OSA). A physician's order must specify the type of mask needed, if supplemental oxygen was to be used, equipment settings, when to use the equipment, and if humidification was appropriate. Follow manufacturers instructions for: -daily cleaning of the mask or nasal pillows; -routine cleaning of the machine's chamber, tubing and straps as applicable; and, -replacement of supplies as needed. The care plan would include: -physician's orders and indication for use (to include equipment settings); -assessment of the resident's respiratory status as needed; -Monitor response to CPAP therapy; and, -when to use the equipment and humidification as appropriate. Documentation would include: -type of equipment and settings; -date and time CPAP was administered; and, -any intolerance or complications, actions taken, and resident's reaction as needed. II. Manufacturer recommendations According to https://cpapx.com/, retrieved 8/23/23, it read in pertinent part, after initial set up, the sanitizing chamber cleans the mask, headgear, tubing and humidifier chambers quickly and conveniently without disassembly. Upon awakening, place the mask with headgear into the cleaning chamber. The lid should be left on the unit securely for at least two hours after the initial cleaning cycle for proper sanitation. III. Resident #158 A. Resident status Resident #158, age above 80, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included acute kidney failure, obstructive sleep apnea, morbid obesity, hypertension (high blood pressure) and specified heart block. The 8/4/23 MDS assessment revealed, the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He had no behaviors and did not reject care. His functional abilities had not been assessed. -The use of the CPAP was not triggered/coded on the MDS assessment under section O. B. Resident interview The resident was interviewed on 8/14/23 at 12:14 p.m. He said he always took the CPAP mask off when he woke up and placed it over the machine on the nightstand. He said he did not know when the tubing was last changed or when the machine had last been cleaned. C. Observations The CPAP was observed on 8/14/23, 8/15/23 and 8/16/23 on the resident's night stand next to the bed. The CPAP mask and tubing was laying over the CPAP machine and not stored in a plastic bag to avoid contamination of the mask. D. Record review The August 2023 CPO did not include any orders related to the CPAP settings, cleaning, disinfecting, or storage. There was no care plan initiated for the use of the CPAP. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed 8/16/23 at 2:03 p.m. She said the nurse was responsible for the storage and care of the CPAP. She said she did not know how the CPAP should have been stored. She said Resident #158 kept the CPAP next to his bed on the nightstand and the mask and tubing hung over the machine. She said the morning shift cleaned it once a week, but did not know what it was cleaned with. Registered nurse (RN) #1 was interviewed on 8/16/23 at 2:11 p.m. She said all CPAP machines should have a physician's order and care planned. She said it was kept at bedside and stored in the sanitizing chamber compartment. She observed Resident #158's CPAP machine and acknowledged the mask and tubing laying over the CPAP machine. She said it should have been stored in the sanitizing machine. She attempted to store the mask and tubing into the sanitizer. However, she did not know how to use the machine. The resident showed her how to place the mask and tubing into the sanitizer and explained to her that it could not be opened for three hours. He said the green light would indicate when it could be opened and used. RN #1 siad the staff should have had training on how to sanitize and clean the CPAP as well as the settings. She said when she admitted the resident, she should have called the respiratory company to assess the CPAP and its settings. The nursing home administrator (NHA) was interviewed on 8/17/23 at 3:10 p.m. She said all CPAP use should have a physician's order, identified on the MDS assessment and have a care plan. She said nursing should have been trained on the CPAP machine and the sanitizing machine.

Based on observations, interview and record review, the facility failed to ensure nursing staff were able to demonstrate competence in skills and techniques necessary to care for residents who required the use of a continuous positive airway pressure (CPAP) machine as identified in the resident assessment. Specifically, the facility failed to provide training to the nurses on the cleaning, sanitizing and storage of CPAP machines. Cross-reference to F695 respiratory care. Findings include: I. Facility policy and procedure The Employee Training policy updated 7/25/19, was provided by the director of health information management (DHIM) on 8/17/23 at 5:43 p.m. The policy revealed in pertinent part: It is the policy to ensure all staff are well trained and competent employees need to replenish their knowledge and acquire new skills to do their jobs better. This would benefit both the employees and the residents who are served. The staff development coordinator or department managers will develop training checklists and competencies to cover all aspects of an employees job description and expectations for performance and will ensure that all staff meet the establishments requirements to perform their duties. Training and competencies will be added as new issues are identified, with new regulations or new equipment are utilized. II. Observations Registered nurse (RN) #1 was observed entering room [ROOM NUMBER]. She said the CPAP mask and tubing was not stored properly. She attempted to store the CPAP mask and tubing into the sanitizing machine and was stopped by the resident. She did not know how to use the machine. The resident showed her how to place the mask and tubing into the sanitizer and explained to her that it could not be opened for three hours. He said the green light would indicate when it could be opened and used. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed 8/16/23 at 2:03 p.m. She said the nurse was responsible for the storage and care of the CPAP. She said she did not know how the CPAP should have been stored. The resident kept the CPAP next to his bed on the nightstand and the mask and tubing hung over the machine. She said the morning shift cleaned it once a week, but did not know what it was cleaned with. RN #1 was interviewed on 8/16/23 at 2:11 p.m. She said the nursing staff should have had training on how to sanitize and clean the CPAP as well as the settings. She said when the resident admitted , she should have called the respiratory company to assess the CPAP and its settings. The nursing home administrator (NHA) was interviewed on 8/17/23 at 3:10 p.m. She said all CPAP use should have a physician's order, identified in the minimum data set assessment and have a care plan. She said the nursing staff should have been trained on the CPAP machine and the sanitizing machine.

Based on record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for dementia care of 48 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #92 to prevent resident-to-resident altercations and address repeated behavioral issues which created an environment where abuse persisted. Findings include: I. Facility policy and procedure The Dementia Care policy, revised 11/2/22, was provided by the the director of health information management (DHIM) on 8/16/23 at 9:15 a.m. The policy revealed in pertinent part: Proving care that is focused on what each resident needs to maintain dignity and a positive sense of self. Tailoring personal care approaches, meal service, and activities to the individual by paying close attention to past life history, as well as current functional and cognitive level. II. Resident census and conditions The 8/14/23 resident census and conditions documented 59 residents who had a diagnosis of dementia. The facility census was 104 residents. III. Resident #92 A. Resident status Resident #92, age above 65, was admitted on [DATE]. According to the August 2023 computerized physicians orders (CPO), the diagnoses included unspecified dementia severe with anxiety, severe agitation, severe with other behavioral disturbances, anxiety disorder and major depressive disorder. The 5/21/23 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status (BIMS). She had short and long term memory problems. She was short tempered and easily annoyed. She required supervision with transfers, walking in room and corridor, locomotion on and off the unit, dressing and personal hygiene. She was independent with bed mobility, toilet use and eating. She had no behaviors and did not reject care. No antipsychotics were received. B. Record review The mood care plan, initiated 5/8/22 and revised 8/15/23, documented the resident had a history of anxiety and restlessness. She wandered aimlessly into other resident's rooms and went through their belongings. She may become combative with staff and residents at times. The interventions included: -Please knock, introduce yourself, and explain the purpose of your visit; -Encourage resident to tell staff her needs/wants; -Encourage the resident to participate in activities; -Monitor resident for depressive symptoms; -Attempt non-pharmacological interventions as able; -Notify physician of change in mood; -Track residents anxiety; -Review residents medication for efficacy and /or possible decreases; and, -When the resident wanders into another resident's room, walk with her to redirect to her room. The dementia care plan, initiated 5/8/22, documented the resident's dementia was progressing and often wandered into other resident's rooms. She was at risk for being injured or verbally abused by other residents. She may become combative and agitated when she interacted with other residents or staff. The interventions included: -Please knock, introduce yourself, and explain the purpose of your visit; -Please listen to what she has to say; -Provide encouragement and validation as needed; -Provide cues and reminders as needed; -Encourage resident to make her needs/wants known; -Encourage her to attend activity groups that interest her; -Notify physician of changes in her cognition to rule out acute medical issues; -Include her power of attorney (POA) in decision-making; -Redirect her with her favorite foods when able; and -Loud noises could be irritating to her, attempt to keep her in a quiet environment. The aggressive behavior care plan, initiated 7/31/23 and revised 8/15/23, documented the resident had incidents of aggressive behaviors towards other residents. The interventions included: -She had been provided a 24 hour sitter; -She received a 30 day notice for alternate placement; -Monitor and document her aggressive behaviors; -Notify physician of her aggressive behaviors; -Provide one-to-one social services visits; -Provide one-to-one life enrichment visits; -Assure that there is no medical reason for her aggressive behaviors; and, -Administer medications as ordered. Resident #92 was involved in five resident to resident altercations in two months, where she was the aggressor. The preceding factor to most of the altercations was the resident wandered into another resident's room or space. According to the June 2023 to August 2023 progress notes the resident continued to wander into other resident rooms daily. -The facility failed to prevent and identify why the resident continued to wander into other resident rooms and failed to prevent the residents from abuse. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/16/23 at 2:03 p.m. She said Resident #92 got violently aggressive hitting staff and residents. She said the nursing staff had a training meeting with management to discuss interventions, who to report abuse to, and how to handle aggressive situations. She said all the staff discussed which interventions worked and which ones did not. She said since Resident #92 had a one-to-one sitter since 7/31/23, she seemed calmer. Registered nurse (RN) #1 was interviewed on 8/16/23 at 2:11 p.m. She said Resident #92 was violent with staff, family members and her peers. She said she had been involved in many resident to resident altercations and required one-to-one supervision to keep others safe. The DHIM was interviewed on 8/17/23 at 11:46 a.m. She said after the 7/6/23 altercation, Resident #92 had a part time one-to-one sitter while awake or active. She said as the weeks went on with no altercations and decreased aggression, the one to one sitter became as needed. She said because of the two altercations on 7/30/23, the facility hired a one-to-one sitter twenty four hours a day indefinitely. The medical director was interviewed on 817/23 at 12:11 p.m. He said Resident #92 had very aggressive behavior. He said after many failed interventions, he consulted with the psychiatrist for the appropriate medication and care. He said she was then started her on an anti-anxiety, an antipsychotic, an antidepressant, and aromatherapy. He said the facility was trying to find a facility to discharge her to that was a better fit. The nursing home administrator was interviewed on 8/17/23 at 1:30 p.m. She said Resident #92 was moved to a private room from her shared room on 8/11/23. She said the two altercations on 7/30/23, Resident #92 had a one-to-one sitter. She said the resident used the bathroom, which was shared and exited through the shared door of her neighbor. She said the sitter allowed her privacy in the bathroom and was unaware she had exited through the other door. She then had the two altercations with two different individuals. She said the second door between the two rooms for the bathroom was now kept locked. She said the resident in the neighboring room who required extensive assistance by two staff to toilet and the staff would unlock her bathroom door when she needed to use it. She said with the 7/31/23 altercation the one-to-one sitter had called off and the resident was then placed on every 15 minute checks. Within the 15 minutes she assaulted Resident #43. She said the facility then put in place a plan to have a one-to-one sitter 24 hours a day indefinitely with a back up sitter if there was a call off. She said Resident #92 needed a smaller, quieter environment and the facility was looking for placement for her. She said the family was given a 30 day notice to discharge, but the family was appealing the notice. She said the facility was doing everything in their power to keep others safe. She said Resident #92 had not had any further altercations since the one-to-one sitter had been implemented 24 hours a day.

Based on record review and interviews, the facility failed to provide one (#1) of three residents, out of nine sample residents adequate supervision and an environment as free from accident hazards as possible, contributing to an accident involving harm. On [DATE] at approximately 7:30 p.m., the activities director (AD) and the activities assistant (AA) assisted Resident #1 on to the facility's transportation bus. The facility failed to ensure Resident #1 was securely fastened in her wheelchair during the evening bus ride to look at holiday lights. During the holiday light tour, Resident #1 reported she felt loose in her chair. The AD reported she stopped the bus and redid Resident #1's wheelchair tie downs and determined Resident #1 was fastened appropriately. Approximately 40 minutes into the holiday light tour, the AD turned the bus and the AD and the AA heard a thump in the back of the bus. Resident #1 had fallen out of her wheelchair and was on the floor of the bus. The AD stated she assessed the resident and determined the resident did not sustain an injury. The AD and the AA assisted the resident back to her wheelchair and returned to the facility. Neither the AD or AA were registered nurses, therefore neither were qualified to assess the resident for injuries. The facility's failure to ensure the AD and the AA were properly trained on securing resident wheelchairs using wheelchair tie downs, resulted in Resident #1 sustaining two fractures in her neck. The resident returned to the facility on hospice care and passed away nine days after the fall. Upon interview with staff and review of facility's training documents, it was determined that the AD and the AA were not properly educated on how to securely fasten residents while in their wheelchairs during transportation, which ultimately caused Resident #1's injuries. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE] thru [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Facility policies and procedures The Resident Accidents policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 10:00 a.m. It revealed in pertinent part, If a resident sustains a fall no one is to move the resident until they have been thoroughly assessed by a registered nurse (RN). Failure to follow this policy subjects the associate to abuse occurrence reporting procedures. For falls where resident complains of significant neck or back pain and RN cannot rule out fracture call the provider before moving the resident. The Life Enhancement Outing policy and procedure, revised on [DATE], was provided by the NHA on [DATE] at 10:00 a.m. It revealed in pertinent part, The facility will provide recreational activities outside of the community to encourage residents to explore new opportunities and experience a better quality of life. These outings are a privilege and will be subject to the facilities policies. The purpose for policy: To ensure the safety of the residents, staff and volunteers who participate in outings the following policies and procedures will be followed. The purpose for staff: Staff and volunteers will accompany residents on outings to provide support, time management and assistance so that the residents may enjoy their time away from the community free of logistical concerns. Safety: If a resident falls during the outing staff will call emergency medical services - 911 and follow their directions. They will then call the facility and speak to the director of nursing (DON) or the administrator and let them know what happened and how EMS (emergency medical services) is handling the situation. All wheelchairs and walkers must have their locks fully engaged before the lift can transport them up or down. No resident will ride the lift without a staff member on the lift with them to help keep them secure. All wheelchairs that are secured with Qstraints (wheelchair tie downs) must have their wheel locks engaged. The Resident Accident policy and procedure, revised [DATE] after Resident #1 sustained a fall in the facility bus, was provided by the NHA on [DATE] at 10:00 a.m. It revealed in pertinent part, If a resident sustains a fall no one is to move the resident until they have been thoroughly assessed by a registered nurse (RN). If a resident sustains a fall while on an outing no one is to move the resident and 911 is to be called immediately and their instructions followed. The NHA, DON and POA (power of attorney) should be called. The Life Enhancement Outing policy and procedure, revised on [DATE], was provided by the NHA on [DATE] at 10:00 a.m. It revealed in pertinent part, Bus Safety and Pre-Outing Check: Three days prior to the outing the gas level in the bus must be checked by the designated driver, if the gas is at a quarter tank or below the driver needs to alert the Life Enhancement Director to put a work order in for facilities to fill the bus with gas. The designated driver should do a preliminary safety check to ensure straps and belts are present and in good working order and the bus is tidy and ready for the outing. An extra tank of oxygen will be brought on all outings in case a resident's tank runs out. The activity camera is not required for every outing but is highly encouraged in order to capture moments of the outing for the newsletter. Extra blankets and bottled water will be brought for emergencies and to provide for residents' comfort. Make sure to check all catheters and have nursing empty if needed. At no time will any staff member remove parts of a resident's wheelchair or adaptive equipment without first consulting therapy or a nurse manager. Wheelchair Restraints, Brakes and Seatbelts: All wheelchairs will be secured with Qstraints to their frames and will have their wheel locks engaged. One staff member will secure all of the Qstraints and another staff member will double check that all Qstraints and seatbelts are properly secured. The driver and all passengers must be seated and wearing a seatbelt while the bus is in motion, at no time may a staff member get up and move around the bus while it's in motion. If the need arises for a staff member to get up enroute the driver will pull over and put the bus in park before anyone moves around the bus. The Bus Driver Test Procedure and Equipment procedure, undated, was provided by the safety officer (SO) on [DATE] at 12:15 p.m. It revealed in pertinent part, Ask the driver to back up 10 feet in the parking lot, did the driver look behind and above the bus before baking up, activated the four-way hazard lights, use continuous short beeps of the horn if the back-up alarm does not work, back toward the driver's side whenever possible, look over their shoulder to minimize the blind spot, check for hazards in the mirror, observe driver parallel park bus beside curb, have the driver demonstrate how to open/close/secure all bus doors, driver will explain seat belt requirements for driver and residents in seats and wheelchairs, driver will show where the first aide kit is located, driver will demonstrate how to operate both heating and cooling system, driver will show where the spare tire and jack is located, driver will state the bus height and explain what obstructions are to be avoid, driver will show where the insurance card and registration is located, driver will show where the trip log is and how to fill out and driver will demonstrate how to secure a wheelchair and walker in the van. II. Immediate Jeopardy for serious harm A. Situation of Immediate Jeopardy On [DATE] after the dinner meal Resident #1 was taken on a holiday light drive in the facility bus around the neighborhood. Due to lack of training, the AD and the AA did not correctly secure Resident #1's wheelchair in the bus. As the AD was turning the bus, Resident #1 fell out of her wheelchair during the outing and landed on her right side. The AD parked the bus. The AD assessed the resident and determined there was no injury. The AD transferred the resident back to her wheelchair and returned to the facility. Upon returning to the facility, the AD took the resident to the nurses station for a RN assessment. The facility's failure to ensure AD and the AA were properly trained on securing wheelchairs in the facility bus, resulted in Resident #1 falling from her wheelchair and sustaining two neck fractures. Resident #1 passed away nine days after she sustained a fall in the facility bus. The NHA was notified of the immediate jeopardy on [DATE] at 10:40 a.m. that record review and interviews during the complaint investigation confirmed the deficient practice which had been corrected and the facility was in substantial compliance with F689 at the time of the survey from [DATE] to [DATE]. B. Facility plan to remove the immediate jeopardy situation 1. The facility developed the following immediate plan The NHA provided the facility's plan of correction (POC) binder on [DATE] at 1:17 p.m. The binder included the following: The facility bus returned to the facility at approximately 6:30 p.m. on [DATE]. Resident #1 was immediately taken to the nurse's station and was assessed by an RN. The physician, POA and assistant director of nursing (ADON) were notified. -Resident #1 requested to be sent to the hospital. -The facility stopped utilizing the facility bus on [DATE] after Resident #1's fall and began contracting all transportation services with a third party -A reenactment of the event was completed by the AD, AA, director of rehabilitation (DOR) and the SO. -Immediate education was provided to the activities department, which included the AD and the AA on [DATE] regarding not moving a resident who had fallen, without a RN assessment or contacting emergency services. -The outing policy and procedure, driving competencies, resident accident policy and procedure and the safe lifting policy was reviewed and updated. -Education was completed with all staff on the resident accident and safe lifting policies and procedures. -The facility director developed a training and competency plan for all drivers for future outings. Additionally the binder included information regarding audits that would be implemented when the facility began using the bus again. It specified the following: -All employees who transported residents via the facility bus received training from the facilities director and must pass a competency quarterly for a year and then every six months thereafter. -A facility designee monitored the loading and securing of wheelchairs on the bus for three outings and then randomly. -An additional competency for staff who transport residents was completed weekly for four weeks and then once a month for two months. -The monitoring was reported during the monthly quality assurance meeting by the AD for three months. The facility has not reviewed the competencies in the quality assurance meeting as the bus has not been used since the [DATE] accident. 2. Investigative Action The facility initiated an immediate investigation which included staff interviews, a review of medical records and an interdisciplinary team (IDT) analysis of the situation. A reenactment of the [DATE] holiday light outing was reenacted by the AD, the AA, the DOR and the SO as part of the investigation. The DOR and the SO instructed the AD and the AA to reenact step by step the outing from [DATE]. The restorative aide (RA) acted as the resident as she was similar size to Resident #1. The RA was placed into a high back wheelchair like Resident #1. The AD removed the footrests from the wheelchair. The AD placed the four tie downs onto the wheelchair wheels. The AD and the AA then attached the shoulder harness of the seatbelt across the RA's body with her arms under the belt going over the arm rests of the wheelchair. The AD and the AA used the remainder of the harness and placed it over the first section of the harness. The AD then began driving the bus in the same route as they did on the night of [DATE]. The wheelchair was observed moving while the bus was en route. The RA stopped herself twice from falling during the reenactment when the bus turned to the left. Upon return to the facility on e of the wheelchair ties was unhooked, while the other three were loose. The determination of the residents fall was Resident #1 was not securely fastened into the bus and was unable to stabilize herself, because the wheelchair footrests were removed. 3. Interventions to prevent recurrence The facility placed the following interventions in place to prevent further accidents: -The facility removed the facility bus from use. -The facility contracted all transportation services through an outside company. C. Removal of immediate jeopardy The immediate jeopardy situation was removed prior to the onsite investigation on [DATE] thru [DATE]. Interview and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having potential to be affected by the deficient practice, systematic changes to prevent its recurrence and monitoring to ensure sustained correction. Therefore, the deficient practice was corrected prior to the onsite investigation and represented past noncompliance at G level, actual harm that is isolated. III. Failure to ensure the AD and the AA were educated to properly secure residents in their wheelchair for transport A. Resident #1 status Resident #1, age 75, was admitted on [DATE], readmitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included [CONDITION(S)] (brain disorder), fracture of first and second cervical vertebra (neck), abnormal posture and age related [CONDITION(S)] (weak bones). The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance of two people for bed mobility, transfers, dressing, toileting and total dependence of one person for personal hygiene and eating. B. Record review The facility investigation was provided by the NHA on [DATE] at 1:17 p.m. It revealed the following: -The AD and the AA took nine residents on a holiday light outing on [DATE]. The AD and the AA were responsible for securing the residents into the bus. The AD and the AA had not received training prior to the outing (see interviews below). -During the bus ride the AD and the AA heard a thump in the back of the bus.The AD pulled the bus over and Resident #1 was on the ground of the bus. -Upon returning to the facility at approximately 9:00 p.m., the AD took Resident #1 to the nurses station. Resident #1 reported neck pain and was observed with an abrasion to the top of her head and the top of her middle finger. Orders were obtained to send the resident to the hospital. -Resident #1 was sent to the hospital at 10:53 p.m., approximately two hours after returning from the outing. -The [DATE] hospital progress note documented the resident sustained two neck fractures and determined the resident was not a surgical candidate. -The facility began an immediate investigation and reported the incident to the police department and family. The AD and the AA received disciplinary action. -Resident #1 was discharged from the hospital back to the facility under hospice care on [DATE]. -Resident #1 passed away on [DATE], nine days after the [DATE] accident. Review of the [DATE] corner report determined Resident #1 died as a result of a neck fracture alongside [CONDITION(S)]. IV. Failure to ensure a qualified staff member assessed Resident #1 prior to moving her after she fell in the facility bus A. Record review The facility investigation was provided by the NHA on [DATE] at 1:17 p.m. It revealed the following: -After the AD pulled the bus over. She assessed Resident #1 (see interview below). -The AD determined the resident did not have any injuries and assisted the resident back to her wheelchair. -Upon returning to the facility, the AD helped Resident #1 off the bus and took her directly to the nurse's station for a RN assessment. V. Staff interviews The AD and the AA were interviewed on [DATE] at 12:33 p.m. The AD said the facility had planned an outing to look at holiday lights and it was the first outing for the facility for a few years due to COVID-19. The AD said it was the first outing for the AD and the AA at this facility. The AD said she told the facility maintenance director (MTD) that she and her activity staff needed training on the bus prior to the outing and they had been provided that training approximately one to two months prior to the holiday lights outing. The AD said the training consisted of where to park the facility bus in order to load residents and how to operate the wheelchair lift. The AD and the AA said the MTD handed them the tie down straps used to secure residents in wheelchairs in the bus and said they were self-explanatory. The AD and the AA said the MTD did not demonstrate how to properly attach them in order to securely attach residents in wheelchairs in the back of the bus. The AA said she had gone into the facility to get a wheelchair for the MTD to demonstrate the wheelchair tie downs, but the MTD only demonstrated how to use the seatbelt, which consisted of a shoulder strap and a lap restraint. The AD and the AA said on the night of [DATE] they had three residents in wheelchairs that needed to be secured in the back of the bus. They said they had been working together to load the facility bus for the outing. They said they had both secured steps on the bus and did not recall who had done the tie downs or seat belt for Resident #1. The AD said she was the staff member driving the bus for the outing and the AA was a passenger on the bus. The AD said when they first left the facility they had gone over a speed bump and Resident #1 stated, I feel a little loose and at that time the AA redid all of the wheelchair tie downs for Resident #1 and that they continued on the outing. The AD said about 45 minutes into the outing the AA said she heard a thump from the back of the bus and when she looked in the back of the bus Resident #1 was on the floor. The AD said she pulled the bus over and assessed the situation. The AD said the wheelchair was still tied down with the tie down straps and the seatbelt was still latched so she was unsure how the resident had fallen from the wheelchair. The AD said the resident was bleeding from a skin tear on her arm and there were no further visible injuries. The AD said she and the AA decided to pick the resident up and place her back in her wheelchair. The AA said the resident complained of stomach pain and had what appeared to be emesis on the front of her shirt. The AD then drove the bus back to the facility. The AD and the AA said neither one of them were registered nurses and assessing the resident was out of their scope of practice for an activity director and activity assistant. The AD said they returned to the facility at approximately 8:15 p.m. on the night of [DATE]. The AD said she reported to the nurse what had happened on the outing with Resident #1. The AD said about two hours later Resident #1 was sent to the hospital for evaluation. The AD and the AA said they had training on not moving residents following an accident at any time, including while on an outing, and instead calling 911 for assistance. The AD said there had not been any resident outings since [DATE], due to the fact that none of the staff in the facility wanted to drive the facility bus. The DOR was interviewed on [DATE] at 10:13 a.m. He said he had been informed Resident #1 desired to attend the holiday light outing a few days prior to the outing. He said Resident #1 had recently been ordered a new wheelchair that could not be safely strapped into the bus. He said he worked with the activity staff to make sure the resident had a safe wheelchair. He said the resident had a standard high back wheelchair that she had been using a few weeks previous and he approved of the use of that wheelchair for the outing. The DOR said he was asked to participate in the facility investigation of the [DATE] accident. The DOR said that he and the SO had the AD and the AA recreate the [DATE] outing to determine what had happened. He said a restorative aide (who no longer worked in the facility) acted as the resident during the reenactment. He said while watching the AD and the AA secured the tie down straps onto the wheelchair, they placed the straps onto all four of the wheelchair wheels. He said they should have placed the tie downs onto the frame of the wheelchair. The DOR said the danger of placing the tie down straps onto the wheels was that the wheels could move and shift while the bus was in motion. He said applying the tie down straps onto the wheels created potential for the tie down straps to become loose or fall off the wheel completely. The DOR said the AD and the AA incorrectly attached the seatbelt to the wheelchair and the mock resident during the demonstration by not securing the seatbelt to the wheelchair. The DOR said when the AD and AA incorrectly positioned the tie downs and seatbelt there was not a five-point safety restraint (a five point harness intended to restrain at the hips and shoulders) established and that was most likely what had caused the resident to fall from her wheelchair. The DOR said during the reenactment, the AD drove around and the reenactment had to be stopped because it had become unsafe due to one wheelchair tie down that came completely unattached. He said the other three tie downs became loose. The DOR said ultimately if the wheelchair tie downs had been used appropriately, the wheelchair would have had little to no chance the accident would have occured. The SO was interviewed on [DATE] at 10:54 a.m. She said she was one of the participants in the bus accident reenactment. She said it was her role to determine the possible cause of the accident. She said the reenactment took place shortly after the actual accident, so the staff that were involved would have a better recollection of what happened. The SO said she interviewed the AD and the AA during the reenactment. She said the AA reported she was responsible for securing all of the wheelchair tie downs and the seatbelt for Resident #1. The SO said her observations during the reenactment revealed the AD and the AA incorrectly strapped down the wheelchair with the tie downs and incorrectly attached the seatbelt to the resident. The SO said the AA removed the foot pedals from the wheelchair during the reanachement and when interviewed the AA said she did the same thing during the [DATE] outing. The SO said removing the foot pedals could have contributed to the resident not being positioned correctly and potentially contributed to her falling out of the wheelchair. The SO said during the reenactment the AA placed the wheelchair tie downs onto the wheelchair wheels, instead of directly onto the wheelchair frame. The SO said while they were reenacting the drive one of the time downs came loose from a wheel and the remaining tie downs had become very loose. The SO said the conclusion of her investigation was a lack of training for the AD and the AA which led to incorrectly placing the tie downs onto the wheelchair. The AD was interviewed again on [DATE] at 9:28 a.m. She said the accident was caused by a lack of training by the facility on how to properly use the tie downs and seatbelt on the bus. The AD said she had been trained by the MTD. She said the MTD asked her if she knew how to use the tie downs and she responded yes, since she had used them at a previous facility. The AD said she should have not assumed that she was using the tie downs correctly and should have had the MTD show all of the activity staff members how to properly use the wheelchair tie downs. The AD said she was not aware of the Bus Driver Test procedure (see above) until after the accident on [DATE]. The NHA was interviewed on [DATE] at 10:30 a.m. She said the AD and the AA should have been trained on all aspects of the facility bus, including how to properly use the wheelchair tie down system. The NHA said the facility failed to ensure the AD and the AA had completed the Bus Driver Test procedure prior to taking out the facility bus. She said there was no way to know if the AD and the AA had been properly trained on using the wheelchair tie downs. The NHA said when a facility bus driver is hired, all staff who drive the bus will be required to take the Bus Driver Test procedure prior to taking out the facility bus. She said the test would be conducted periodically to ensure continued competency.

Based on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#1) out of three sampled residents. Specifically, the facility failed to re-evaluate a treatment after it was discontinued on 1/28/2020 to determine the effectiveness for Resident #1 skin condition. The facility failed to put a new treatment in place for 15 days prior to the resident being sent to the hospital for evaluation and treatment. Findings include: I. Resident #1 status Resident #1, age 96, was admitted on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 2/24/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required extensive assistance of two people with bed mobility, transfers, dressing and toileting. A. Record review The January CPOs revealed the following treatment order: - [MEDICATION NAME] Ointment 0.1% cleanse the first and second phalange (toe) with wound cleaner, apply topical ointment to the affected area, cover with a Band-Aid three times a day for five days - ordered 1/23/2020, discontinued on 1/28/2020. The January 2020 treatment administration record (TAR) revealed the [MEDICATION NAME] antibiotic ointment was not administered on 1/23/2020 due to the medication being unavailable from the pharmacy. The resident ' s medical record did not reveal any ordered treatments following the discontinued treatment order of the antibiotic ointment on 1/28/2020. The 1/22/2020 nursing progress note revealed the treatment to the resident ' s right toe was not performed due to the medication not being available from the pharmacy. The 1/23/2020 physician progress notes [REDACTED]. It indicated the resident was found to have a partial thickness skin wound on his right second toe yesterday (1/22/2020) and was started on [MEDICATION NAME] ointment. The nursing staff indicated the medication had not arrived from the pharmacy and were requesting a replacement treatment. The physician gave an alternate treatment ointment of [MEDICATION NAME] ointment and ordered for the wound to be monitored for worsening symptoms. The 1/23/2020 nursing progress note revealed the [MEDICATION NAME] ointment had been delivered from the pharmacy and the resident received his first dose in the evening. The 1/25/2020 nursing progress note revealed the wound to the right toe was noted with slight swelling. The 1/29/2020 wound nurse progress note revealed the right second toe wound had 0.3 cm (centimeters) of a moist yellow area and moisture between the toes. It indicated to continue to place a Band-Aid for protection against the great toe. It did not indicate the physician had been contacted to determine if a treatment should be ordered or if the previous treatment had been evaluated for effectiveness. The 2/5/2020 the wound nurse progress note revealed at 10:00 a.m. the wound nurse observed the wound to the right second toe. It indicated the right second toe had an open area of 1 cm x 0.4 cm with moist red drainage. The 2/5/2020 nursing progress note revealed the nurse practitioner was contacted for concerns of potential osteo[DIAGNOSES REDACTED]. This was eight days after the treatment was discontinued. The 2/5/2020 nurse practitioner (NP) progress notes revealed the nursing staff requested the resident be evaluated for possible [MEDICAL CONDITION]. It indicated the NP did not clinically believe this was [MEDICAL CONDITION] and therefore started a topical antibiotic ointment for the ulceration. The toe had purulent drainage. It indicated the resident complained of an increased amount of pain. The NP ordered for a repeat CBC (complete blood count), sedimentation rate and CRP (C-reactive protein) lab work, venous Doppler to the right foot, and an x-ray to the right foot. The 2/11/2020 wound nurse progress note revealed the resident ' s right foot was medium red along the lateral half with warmth at the ankle joint. The second toe continued to be dry with black eschar over the dorsal side and redness to the remainder of the toe. The 2/12/2020 NP progress notes revealed the wound nurse requested the resident ' s right second toe to be re-evaluated. It indicated the wound nurse reported the wound had greatly changed and was now black. Upon examination, the resident ' s right second toe was cold and black with no sensation present. The dorsal aspect of his foot was [MEDICAL CONDITION], warm to touch with a start redness that was radiating proximal. The NP ordered for the resident to be transferred to the emergency room for treatment of [REDACTED]. B. Staff interviews The staff development coordinator (SDC) was interviewed on 3/4/2020 at 4:53 p.m. She said she was the wound nurse for the facility. She said she observed and evaluated the wounds weekly. She said she documented her assessments of the wounds in the nursing progress notes in the resident ' s medical record. She said Resident #1 ' s wound to the right toe was initially observed on 1/22/2020. She said she notified the NP and received an order for [REDACTED]. She said the physician evaluated the wound to the resident ' s right toe on 1/23/2020. She said he had changed the antibiotic cream from [MEDICATION NAME] to [MEDICATION NAME]. She said the pharmacy was able to deliver the original order of [MEDICATION NAME] to the facility in the evening on 1/23/2020. She confirmed the physician noted the resident had an open area to the right toe. She confirmed the order for the [MEDICATION NAME] cream was discontinued on 1/28/2020. She confirmed the resident ' s medical record did not indicate the treatment was evaluated for effectiveness or a new treatment order obtained. Resident #1 ' s medical doctor (MD) was interviewed on 3/5/2020 at 10:37 a.m. He said he evaluated the wound to the resident ' s right toe on 1/23/2020. He said it appeared to be a skin infection and felt the treatment of [REDACTED]. He said he had seen the resident on 2/3/2020, however it was due to [MEDICAL CONDITION]. He said he did not re-evaluate the resident ' s right toe after his initial assessment on 1/23/2020. He said he received a call from the NP on 2/12/202 stating the resident ' s toe had gotten significantly worse in a short amount of time. He said he agreed to send the resident to the hospital to be evaluated. He said while the resident was at the hospital, he was diagnosed with [REDACTED]. He said the [DIAGNOSES REDACTED]. He said the resident ultimately required the toe to be amputated. He said the lack of treatment for [REDACTED]. The director of nursing (DON) was interviewed on 3/5/2020 at 11:30 a.m. She confirmed the treatment for [REDACTED]. She said she was unable to find documentation to indicate the physician or NP had been contacted to re-evaluate the treatment or obtain a new treatment for [REDACTED]. The MD was interviewed on 3/5/2020 at 12:29 p.m. He said he evaluated the resident on 1/23/2020 because nursing requested the treatment be changed to the resident ' s right toe due to an issue with the pharmacy. He said the NP evaluated the resident on 1/29/2020 for a report from nursing of [MEDICAL CONDITION]. He said the notes did not indicate the NP evaluated the wound to the resident ' s right toe. He said on 2/3/2020, he evaluated the resident for [MEDICAL CONDITION]. He said he did not evaluate or look at the wound to the resident ' s right toe. He said the wound was not re-evaluated until 2/5/2020 by the NP. He said at that time the NP evaluated the right foot for possible [MEDICAL CONDITION]. He said the NP ordered lab work, x-ray and an ultrasound. He said on 2/12/2020, the NP sent the resident to the hospital for an evaluation for possible gangrene. He confirmed the treatment to the wound on the right toe was not re-evaluated for effectiveness. He said whether or not the wound was related to the dry gangrene, the skin infection should have been treated. He said the treatment should have been evaluated and if determined not to be effective, changed to another treatment. He said there was no reason not to treat the skin infection of the wound to the resident ' s right toe.

Based on observations, resident and staff interviews, and record review, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for three (#9, #8 and #65) of three residents reviewed out of 32 sample residents. Specifically, the facility failed to: - implement a restorative nursing program as recommended by physical therapy for transfers and range of motion for Resident #9, - implement a restorative nursing program as recommended by physical therapy for range of motion, balance and transfers for Resident #8, and - implement a walk to dine program for resident #65. Findings include: Facility policy and procedure The policy dated 9/14/18, titled Referral to Restorative Nursing Services was received from the health information manager (HIM) on 8/14/19 at 12:50 pm.The policy documented in pertinent part, when a resident, who is receiving therapy services is approaching discharge from therapy, the supervising therapist will develop and establish an individualized restorative nursing program. All referrals will be written on a restorative nursing referral form and a copy will be placed in the box for the director of restorative services/restorative nursing coordinator. I. Resident #9 1. Resident status Resident #9, age 74, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician's orders [REDACTED]. The 8/2/19 minimum data set (MDS) assessment documented Resident #9 had no cognitive impairment with a brief interview for mental status score (BIMS) of 14 out of 15. He was totally dependent on staff for bathing and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS did not document the resident received any restorative nursing care. 2. Record review The 7/23/19 physical therapy (PT) note documented the discharge plan was for restorative nursing program. The 7/26/19 physical therapy discharge summary recommended restorative nursing program for transfers and range of motion. The comprehensive care plan, dated 5/7/19, did not document a restorative nursing program. Records review revealed the resident was not offered the restorative nursing program as recommended by PT. 3. Interviews Resident #9 was interviewed on 8/12/19 at 1:30 pm. He said he had finished physical therapy and was supposed to be on a restorative program but had only had two restorative nursing visits since he was discharged from therapy in July. He said he was receiving no exercise and was concerned that he would get weaker. The restorative certified nurse aide (RCNA) was interviewed on 8/13/19 at 3:08 pm. She said Resident #9 was not currently receiving any restorative nursing services. The restorative nursing program coordinator (RNC) was interviewed on 8/13/19 at 4:04 pm. She said she did not have any current restorative program for Resident #9. She said he was on restorative nursing previously but had been discharged on [DATE]. She had no referral from therapy on or after 7/26/19. She further said the process for implementing restorative care was for therapy to write up the program, and forward it to restorative with a start date. The director of rehab (DOR) was interviewed on 8/13/19 at 4:10 pm. He said a referral for restorative nursing should have been written after the resident discharged from therapy on 7/26/19. He could only find a referral written on 7/12/19. However, the resident was picked up on therapy from 7/12/19 through 7/26/19, and was not on a restorative program at that time. The director of nursing (DON) was interviewed on 8/14/19 at 1:20 pm. She said when a resident discharges from skilled therapy services, a therapist writes a restorative nursing program and gives restorative nursing a Restorative Nursing Referral form with the program and start date. The restorative nurse receiving the form reviews and signs it. She was not aware of the program for resident #9. II. Resident #8 1. Resident status Resident #8, age 94, was admitted on [DATE]. According to the (MONTH) 2019 CPO, pertinent [DIAGNOSES REDACTED]. The 8/2/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. She required extensive assistance with two person for bed mobility, transfers, toilet use and extensive assistance with one person for personal hygiene and dressing. She had no limitations in her range of motion. The resident did not participate in physical therapy or restorative nursing program. 2. Record review The 7/11/19 physical therapy (PT) discharge summary revealed the resident received PT services from 6/11/19 to 7/11/19 to improve her functional mobility. The 7/11/19 discharge summary documented the resident was discharged from PT as her maximum potential was achieved and she was referred to the restorative nursing program (RNP). The 7/14/19 RNP referral form from PT documented the resident's RNP plan was to work on range of motion, balance, and bed mobility. The RNP referral form was signed as received by the RNP coordinator on 7/15/19. The RNP participation documentation following 7/15/19 was requested but not provided. The comprehensive care plan did not include a care plan related to RNP services. The (MONTH) and (MONTH) 2019 CPO did not include a physician's orders [REDACTED]. Nursing progress notes from 7/1/19 to 8/15/19 did not mention the resident participated in the RNP. The weekly nurse assessments included a section to check specialized services the resident received and included to check a box for the restorative nursing program. The restorative nursing program check box was left unchecked on the 7/15/19, 7/22/19, 7/29/19, 8/4/19 and 8/12/19 weekly nurse assessments. 3. Staff interviews The director of rehab (DOR) was 8/14/19 at 10:52 a.m. The DOR said once a resident was ready to discharge from therapy services, the therapist developed a plan for the resident. HE said then the plan was documented on the RNP referral form. The form was provided to the RNP coordinator and the DOR kept a copy of the plan as well. The DOR said the resident discharged from PT on 7/11/19 and a RNP plan was developed, written on the RNP referral form, and provided to the RNP coordinator. The RNP coordinator (RNC) was interviewed on 8/15/19 at 8:19 a.m. The RNC said she did not have documentation of Resident #8's participation in the RNP. The RNC said she was not aware the resident had a RNP plan set up by PT. The RNC said though she had signed as having received the program from PT on 7/15/19, the program had not been implemented by the restorative nurse aides. The RNC said the resident would begin receiving restorative nursing services on 8/15/19. The DON was interviewed on 8/15/19 at 8:40 a.m. The DON said the RNP plan should have been initiated when the plan was received by the RNC. The DON said Resident #8 would receive a physician order [REDACTED]. III. Resident #65 1. Resident status Resident #65, age 86, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 6/28/19 MDS assessment revealed the resident's cognition was moderately impaired with BIMS score 11 out of 15. She had no hallucinations, delusions or rejection of care behavors. She required extensive assistance of one person with bed mobility, transfers, dressing, and toilet use, limited assist of one person with walk in room and personal hygiene. She was independent with eating. Walk in corridor was documented as activity did not occur. Resident's #65 mobility devices included a walker and a wheelchair. 2. Record review The physician order, (MONTH) 2019, documented: Walk to dine with walker, with gait belt and one assist for 15 minutes - order date was 9/13/17, as open ended. Review of the resident's comprehensive care plan revealed the following: - I am a high risk for falls AEB h/o (as evidence by history of) falls, [MEDICAL CONDITION] arthritis, Diabetes Mellitus type II (monitor for hypo/[MEDICAL CONDITION]), chronic pain, forgetfulness, and choosing not to follow plan of care . I should have 1 (one person) stand by assist for transfers however choose to transfer self. Approaches included: Encourage me to use assistive devises for ambulation or mobility within room and around unit/facility to prevent further falls/injury. I should ambulate with limited assist with FWW (front wheeled walker) and gait belt. Transfer with 1 stand by assist. I frequently however will get up by self and ambulate without a gait belt. Nursing staff to notify my POA (Power of Attorney) and physician in the event of a fall. Redirect, educate, remind me to use my call light and wait for assistance with cares each shift. Offer non skid socks for HS/N[NAME] (hours of sleep/night) or when I am mobile. Nursing staff to obtain orders for skilled therapy services as indicated after a fall. Keep mostly used items (walker, telephone, grab stick, remote, lip care, trash cans etc.) and any other items within reach. Offer assistance if observing me self- transferring, ambulating in room or on unit without assistive device . Please remind me to be careful with my O2 tubing as not to get tangled up in it and to be aware that it can be a fall risk . - I am risk for ADL deficits AEB requiring assistance of one staff for transfers, dressing, and bathing, h/o of falls, and getting easily fatigued. Approaches included: Encourage me to walk to dine with my walker, gait belt and assist per orders. I frequently however will ambulate and transfer independently without gait belt. The care plan was revised on 5/15/19. Review of the treatment administration record for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed no documentation that walk to dine was provided for the resident. Review of the nursing progress notes, dated June, (MONTH) and (MONTH) of 2019 did not reveal the resident participated in walk to dine program. Review of the daily CNA documentation for June, (MONTH) and (MONTH) of 2019 revealed: How did the resident walk in corridor? - Activity did not occur. The 7/25/19 physical therapy progress note revealed, Resident #65 was able to walk distance 170 feet with four wheeled walker and contact guard assistance. The 8/9/19 physical therapy progress note revealed, Resident #65 was able to walk distance 220 feet with four wheeled walker and stand by assistance (close supervision). 3. Resident observations Resident #65 was observed on 8/12/19, 8/13/19 and 8/14/19 during lunch meal. The resident was at the table in the dining room, sitting in her wheelchair. 4. Interviews The unit manager/registered nurse (RN)#1 was interviewed on 8/13/19 at 4:20 p.m. She said the resident has not been walking to the dining room since she had her shoulder replaced (see readmission 6/24/19). She said the resident was walking in her room, to the bathroom, with four wheeled walker and staff assistance. The DON was interviewed on 8/13/19 at 4:27 p.m. She said the physician order [REDACTED]. She said the physician order [REDACTED]. The director of rehabilitation (DOR) was interviewed on 8/15/19 at 8:55 a.m. He said the distance from the resident's room to the dining was approximately 120 feet. He said the resident was able to walk distance 220 feet with four wheeled walker and supervision.

Based on observations, record review and interviews, the facility failed to provide an environment free of accidents and hazards for 38 residents (#1, #6, #9, #14, #15, #16, #17, #24, #25, #30, #34, #37, #38, #42, #43, #52, #55, #56, #59, #68, #70, #75, #76, #77, #78, #82, #83, #84, #85, #87, #97, #101, #103, #108, #112, #117, #120 , #121) who were at risk for falls and entrapment between the bed and the wall. Specifically: -On 3/14/17, observations revealed resident #77's head extended over the left side of her bed, which was positioned lengthwise and lateral to the wall, into a six inch gap between the edge of the bed and the wall. The bed remained in this position when observed on 3/15/17. According to staff interviews, resident #77 had dementia, was unable to utilize her call light effectively to communicate needs, and required full assistance with her activities of daily living (bed mobility, repositioning, and transfers). Record review confirmed the resident had many risk factors to fall and possibly become entrapped between the bed and the wall, including history of falls, inability to self-correct poor posture, small stature, cognitive impairment, and communication limitations. -Record review, interviews and observations further revealed the facility failed to identify, assess, and ensure 38 resident beds were safely positioned and maintained to prevent entrapment between the wall and the bed; the following resident beds were positioned lengthwise and lateral to the wall with a six inch gap between the edge of the bed and the wall: Resident #1, #6, #9, #14, #15, #16, #17, #24, #25, #30, #34, #37, #38, #42, #43, #52, #55, #56, #59, #68, #70, #75, #76, #77, #78, #82, #83, #84, #85, #87, #97, #101, #103, #108, #112, #117, #120, and #121. The facility's failure to respond to the risk posed to the residents above by bed placement lengthwise and lateral to the wall with a six inch gap between the bed and the wall created a situation of immediate jeopardy with the potential for serious harm. The findings included: I. Immediate Jeopardy A. Imposition of Immediate Jeopardy On 3/15/17 at 7:54 p.m., the nursing home administrator (NHA) and executive director (ED) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures in identifying issues of entrapment created a situation of immediate jeopardy for serious harm. B. Facility Response to Immediate Jeopardy On 3/16/17 at 5:28 p.m., a plan was submitted by the facility to CDPHE. It read: 1. Identified Resident: The facility has already completed the following interventions for the identified resident. a. The bed was moved to the center of the room. b. Therapy evaluated the resident on 3/16/17 for bed mobility, transfers and positioning. c. The resident is compromised for skin integrity and staff utilizes a body pillow to position from one side to side. The resident has poor truck control, decreased leg strength and requires extensive assist for positioning. d. A fall risk assessment was completed on 3/16/17 by the Staff Development Coordinator. Her risk score was 17 which places her at risk for falls. Additionally a 7 (seven) day look back assessment will be completed by the MDS (minimum data set) coordinator to determine any changes that may have occurred since the last MDS (minimum data set) assessment. No changes were identified. A pain assessment, a safety device assessment and bowel and bladder assessment will be completed by 3/16/17. e. A BIMs (brief interview for mental status assessment) was completed on 3/16/17 by the Social Services Director and RN (registered nurse). f. Fall mats will be placed on either side of the bed when the resident is in bed. 2. All residents will be assessed and evaluated by nursing managers for bed placement on 3/16/17. A fall risk assessment will be completed for those residents whose beds have been adjusted. Referrals to therapy will be made based on the results of the assessments for evaluation of bed mobility, transfers and positioning. Any repositioning or devices will be provided immediately. 3. An audit of all resident beds in the facility was initiated at 8:05 p.m. on 3/15/17. Of the 106 beds, 37 beds were adjusted to mitigate the risk of entrapment of resident between the wall and the bed. This was completed by 9:45 p.m. on 3/15/17. Assessments will be completed as indicated in #2. 4. The identified residents' beds were adjusted included: a. Unit 1:102, 104, 106, 108, 110, 113, 120, 121, 123, 124, 134 b. Unit 2: 203,204,206,207,209,210,212,213,214,218,220,225,229,231,232,233,237,241 c. Unit 3: 303, 306, 309, 312, 317, 318, 321, 329 5. All signs indicating that beds should be six inches from the wall were removed from all resident rooms by 9:40 p.m. on 3/15/17. This was completed by nursing staff and ancillary staff-CNAs (certified nursing aides), LPNs (licensed practical nurses), RNs, managers, DON (director of nursing), Staffing, SDC (staff development coordinator), MDS, and Housekeeping staff. Staff has been educated on the Bed Safety Policy on 3/16/17. 6. All on duty staff members were educated immediately regarding the risk of entrapment and the position of beds in rooms by the Staff Development Coordinator (SDC). All on duty staff members were educated on the Bed Distance from the Wall in-service. Education on bed distance from the wall and the Bed Safety Policy will continue until all staff, nursing and ancillary have been trained. 7. Nursing Managers will communicate the reasons for moving beds and the Bed Safety Policy to all residents and/or legal representative by 3/20/17. This policy will be reviewed upon admission and with any changes of the beds or mattresses by the Unit Manager. 8. All staff and contracted employees will review and sign the facilities Bed Safety Policy. The policy will be reviewed upon hire and with any changes of beds or mattresses by the Staff Development Coordinator and Unit Manager and will be ongoing. 9. Resident beds will be checked for correct placement every two hours starting 3/16/17 for the first 24 hours and will be completed by 3/17/17 and documented on the tracking form by the nurse on the unit. Tracking forms will be kept in a survey compliance binder when completed. The housekeeping Supervisor and Maintenance complete weekly environmental rounds and will include bed safety compliance in the rounding procedure. Copies of the rounding will be kept in the survey compliance binder on the nurses stations. The binder will be kept at each front nurses' station for reference. 10. Beginning 3/17/17, beds will be checked during each shift by the nursing staff for appropriate placement and documented on tracking form for two weeks. Tracking forms will be kept in a survey compliance binder when completed. The binder will be kept at each front nurses' station for reference. 11. Following the two weeks, housekeepers will check bed placement daily with cleaning schedule and document compliance on an ongoing basis. Tracking forms will be kept in a survey compliance binder when completed. The binder will be kept at each front nurses' station or reference. All resident bed placements will be reviewed by the interdisciplinary team upon admission, quarterly, annually, and upon a change of condition and documented in the care plan review notes. Education will be provided to the Care Plan Team consisting of the Unit Manager, Life enhancement Coordinator, Social Services, Registered Dietician, Therapy and nursing staff on 3/16/17. 12. Quality Assurance committee, including the Medical Director, Executive Director, Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Health Information Management, Social Services, Pharmacist, Registered Dietician and the Life enrichment Director will review documentation of audits and monitoring of bed placement monthly to determine compliance. C. Removal of Immediate Jeopardy On 3/16/17 at 5:30 p.m., the NHA, DON, and ED were notified the above plan was accepted and the immediate jeopardy was removed. However, based on observations, record review and interviews, the deficient practice remained at an E level, potential for more than minimal harm at a pattern. II. Residents #77, #17, #82, and #117 - Failure to take steps to ensure the residents' safety from falls and possible entrapment between the wall and the bed. A. Resident #77 Resident #77, age 96, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. 1. Record review and Interview Record review and staff interview revealed the facility was aware of factors (history of falls, poor posture, small stature, cognitive impairment, communication limitations) which placed the resident at high risk for falls, including falls with entrapment between the resident's bed and the wall. a. Record review -According to the 2/9/17 minimum data set (MDS) assessment, the resident had short and long term memory problems. Her cognitive skills for daily decision making were severely impaired, and she had a [DIAGNOSES REDACTED]. She required extensive assistance of one staff member with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She was unable to walk in room and corridor, and required extensive assistance with locomotion on unit and total dependence with locomotion off unit. She was not steady, only able to stabilize with human assistance with moving from seated to standing position and surface to surface transfers (transfer between bed and chair or wheelchair), and required the use a wheelchair for mobility. Her height was 64 inches and weight was 74 pounds. -Review of the resident's care plan revealed the resident was identified (2/8/17 and updated 3/17/17 during survey) as at risk for falls due to poor memory, weakness and inability to stand without assistance. The resident was also care planned for memory concerns and was noted to communicate non-verbally through gestures and signs. -Occupational Therapy (OT) evaluation (11/7/16) and notes (11/10/16) revealed: --Per the 11/7/15 evaluation, the resident had chronic cognitive loss, an inability to self-correct posture, hearing loss with decreased ability to follow simple commands to reposition self while seated in wheelchair, and increased fall risk. She had a history of [REDACTED]. --Per the 11/18/16 OT note, the resident was a fall risk, and she required techniques to improve postural alignment and control to use wheelchair, assessment of patient's response to positioning adjustments, facilitation of proper body alignment, education in chair positioning and techniques to increase upright posture to improve balance and reduce risk of falls during ADLs (activities of daily living) and improve posture during ADL performance. The resident was positioned with alternative mid contour cushion post staff reports of resident sliding forward with footrest and footrest extension in place. The resident was not evaluated by OT for bed mobility and/or bed positioning. - The 11/8/16 Care Conference Report revealed the resident received OT services for wheelchair positioning after noted leaning. She required extensive assistance with ADLs, including mobility. The 11/10/16 Care Conference Report revealed the resident was confused, hard of hearing, and spoke Chinese and English. She required extensive assistance with ADLs. The 2/14/17 Care Conference Report revealed the resident required assistance with all ADLs and weighed 74 pounds. - The 12/14/16 History and Physical completed by the nurse practitioner (NP) revealed the resident had Alzheimer's disease, was underweight, and dependent on staff for assistance with ADLs. - The 2/2/17 Safety Device/Resident Needs Observation revealed the resident was at high risk for falls and accidents due to unsafely mobile/unsafe gait/movement disorders, unable to maintain safety sitting posture, dementia: unaware, forgetful, unaware of own limitations, and history of falls. -The 2/6/17 Fall Risk Observation revealed the resident had intermittent confusion, poor recall, judgment, and safety awareness. She had psychiatric or cognitive (delirium, decline in cognitive skills, manic depression, Alzheimer's disease, other dementia) and orthopedic (joint pain, arthritis, fracture of hip, missing limb, osteoporosis) conditions. Her fall risk score was 7 which indicated she was not a fall risk. -The 2/13/17 Social Services Progress Note revealed the resident had Alzheimer's disease, and was unable to input into her assessment due to her diagnosis. She was not aware of the current season or that she resides in a nursing facility. She was severely impaired with decision making, and her primary language was Chinese. She was able to make some needs and wants known by gestures and signs. She had difficulty hearing and her vision was impaired. She received extensive assistance with ADLs, and was incontinent of bowel and bladder. -The 3/17 Physician order [REDACTED]. - Order date: 12/29/16, blue mat on floor bedside when in bed for safety; and - Order date: 12/5/16, restorative nursing, upper extremity, passive range of motion and seated balance exercises for a duration of 12 weeks, six times a week and once a day. -The Vital Taken Form revealed on 3/3/17 the resident weighed was 72.4 pounds. -The 3/11/17 Nursing Progress Note revealed a family member of the resident reported the resident had always been a small person. b. Interview Certified nurse aide (CNA) #3 was interviewed on 3/15/17 at 6:53 p.m. She said resident #77 was unable to use her call light for assistance in the case of an emergency. She primarily communicated to staff through hand movements and gestures, and was only able to speak a few phrases and words in English. She was underweight, about 70 pounds, and had little to no safety awareness. She had positioning concerns in her wheelchair and in bed. In her wheelchair, she frequently would slide down in the chair, and in bed she positioned herself to the left (against the wall). She said the resident was unable to reposition herself properly once moved and required the assistance of staff for ADLs. Licensed practical nurse (LPN) #2 was interviewed on 3/15/17 at 7:05 p.m. She said resident #77 was non-ambulatory and required extensive assistance with ADLs. She was underweight, and was able to wiggle and move her upper body, including head and shoulders, while in bed. She had Alzheimer's disease and only spoke a few words in English. Her ability to move from side to side and her petite body frame placed her at risk for entrapment between the bed and the wall. If entrapped at the head, shoulders, or arms, resident #77 would not be able to free herself from the positioning. The staff development coordinator (SDC) was interviewed on 3/15/17 at 7:09 p.m. She said resident #77 was non-ambulatory and required extensive assistance with ADLs; she only occasionally was able to use her call light, and had poor safety awareness and memory problems which made her a high fall risk. She had the ability to rock from side to side, could push a body pillow off the bed, and turn herself over at times. She was unable to reposition herself correctly once moved, or pick herself up off of the floor in the event of a fall. She said fall assessments were completed quarterly to determine if a resident was a fall risk, and interventions were discussed during the IDT meetings with the NHA, DON, ADON, unit managers, dieticians, and more. 2. Observations Observations revealed the resident was positioned at risk for fall and possible entrapment between the wall and the bed. Resident #77 was observed in bed on 3/14/17 at 8:55 a.m. The resident's bed was positioned lengthwise and lateral to the wall. There was a gap between the bed and the wall that measured six inches . The resident's head, neck, and chest leaned left toward the wall. Her head, unsupported by a pillow or any other assistive device, was wedged to eye level in the gap between the bed and the wall. Resident #77's room was observed on 3/14/17 at 10:46 a.m. and at 4:41 p.m., and again on 3/15/17 at 10:30 a.m. On the wall located lateral to the length of the bed was a posted sign that read, Keep bed at least 6 (six) inches from the wall. The bed had the ability to move from the high to the low position and had wheels. The bed was in the lowest position, wheels unlocked but resting on carpet and per surveyors' attempts, was difficult to move. A fall mat was on the carpet. The call light was hanging on the upper right corner (head) of the bed. On 3/15/17 at 10:32 a.m., the gap between the bed, positioned lateral to the wall, and the wall was measured at six inches. On 3/15/17 at 10:30 a.m. resident #77 was observed in bed, leaning left toward the wall. She had a standard sized pillow behind her head. The pillow was sinking into the six inch gap between the bed and the wall. B. Residents #17, #82 and #117 Resident #17, age 87, was initially admitted to the facility on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. 1. Record review Record review revealed the facility was aware of factors (history of falls, unsteady, cognitive impairment, poor safety awareness) which placed the resident at high risk for falls, including falls with entrapment between the resident's bed and the wall. -According to the 2/12/17 MDS assessment, the resident had short and long term memory problems. Her cognitive skills for daily decision making were moderately impaired, and she had a [DIAGNOSES REDACTED]. She required extensive assistance of one staff member with bed mobility, transfer, dressing, toilet use, and personal hygiene. She was not steady, only able to stabilize with human assistance with moving from seated to standing position, walking, and surface to surface transfers, and required the use a walker and wheelchair for mobility. -The care plan initiated on 2/15/16 and updated on 2/21/17 identified the resident was a fall risk. She could move around bed and sometimes got out of bed without assistance. She had confusion, poor safety awareness, and tendency to move around with her eyes closed which made her a risk of falling or running into objects. She sat sacral and OT was reviewing positioning. She would lay perpendicular in bed with her feet hanging off of the bed. The care plan, initiated on 11/19/14 and updated on 2/23/17, identified the resident had cognitive loss and dementia. She required cueing and supervision with decision making, and usually would not tell staff what she needed. Thoughts were disorganized on a fluctuating basis and she was easily distracted on a continuous basis. -The 1/31/17 Monthly Note revealed the resident had dementia with behaviors. She was at risk for dysphasia, weight loss, falls, and global functional decline. -The 2/7/17 Nursing Progress Note revealed the resident was sliding down in her wheelchair frequently and repositioned frequently. She had poor safety awareness of her surroundings. -The 2/9/17 Fall Risk Observation revealed the resident had intermittent confusion, poor recall, judgment, and safety awareness. She had neuromuscular/functional and psychiatric or cognitive conditions. Her fall risk score was 16 which indicated she was a high risk for falls. -The 2/9/17 Safety Device/Resident Needs Observations revealed the resident required the bed in the low position for fall/accident prevention interventions. -The 2/21/17 Care Conference Report revealed the resident required assistance with ADLs. She had disorganized thinking, and long and short term memory issues. -The 2/23/17 Social Services Progress Note revealed the resident had advanced dementia, exhibits inattention and disorganized thinking, and did not know the location of her room or that she resided in a nursing home. She required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. 2. Observation Observations revealed the resident's bed was positioned to create a risk for fall and possible entrapment of the resident between the wall and the bed. Resident #17's room was observed on 3/15/17 at 10:34 a.m. The wall located laterally (side) to the length of the bed had a sign posted. The sign read, Keep bed at least 6 (six) inches from the wall. The bed had the ability to move from the high to the low position, had wheels, but rested on carpet and per surveyors' attempts, was difficult to move. The gap between the bed and the wall was measured. The results revealed the gap measured six inches. C. Resident #82, age 84, was initially admitted to the facility on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. 1. Record review Record review revealed the facility was aware of factors (history of falls, poor safety awareness, small stature, impaired cognition, unsteady) which placed the resident at high risk for falls, including falls with entrapment between the resident's bed and the wall. -According to the 12/7/16 MDS assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She required limited assistance of one person with bed mobility and transfers. She required extensive assistance of one person with dressing, toileting, and personal hygiene. She was not steady, only able to stabilize with human assistance with moving from seated to standing position, walking, and surface to surface transfers. Her height was 60 inches and weight was 109 pounds, and she had a [DIAGNOSES REDACTED]. -The care plan, initiated on 3/20/15 and updated on 3/14/17, identified the resident was a fall risk due to walking quickly without a walker or wheelchair and poor safety awareness. Another care plan, initiated on 3/21/15 and updated on 3/14/17, identified the resident had Alzheimer's disease with a very short memory and attention span, and required help with dressing, grooming, bathing, and toileting. - The 12/5/16 Safety Device/Resident Needs Observation revealed the resident was at high risk for falls and accidents due to dementia: unaware, forgetful, and unaware of own limitations. -The Vital Taken Form revealed on 3/3/17 the resident weighed was 106.7 pounds. -The 3/7/16 Fall Risk Observation revealed the resident had intermittent confusion, poor recall, judgment, and safety awareness. She had decreased muscular coordination, and psychiatric or cognitive conditions. Her fall risk score was 13 which indicated she was a high risk for falls. 2. Observation Observations revealed the resident's bed was positioned to create a risk for fall and possible entrapment between the wall and the bed. Resident #82's room was observed on 3/15/17 at 10:34 a.m. The wall located laterally (side) to the length of the bed had a sign posted. The sign read, Keep bed at least 6 (six) inches from the wall. The bed had the ability to move from the high to the low position, had wheels but rested on carpet and per surveyors' attempts, was difficult to move. The gap between the bed and the wall was measured. The results revealed the gap between the bed, lateral to the wall, and the wall was six inches. D. Resident #117, age 79, was admitted to the facility on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. 1. Record review revealed the facility was aware of factors (history of falls, poor safety awareness, small stature, impaired cognition, unsteady) which placed the resident at high risk for falls, including falls with entrapment between the resident's bed and the wall. -According to the 2/1/17 MDS assessment, the resident was moderately cognitively impaired with a BIMS score of eight out of 15. She required supervision with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. She was not steady, only able to stabilize with human assistance with moving from seated to standing position, walking, and surface to surface transfers. Her height was 62 inches and weight was 118 pounds. -The care plan initiated on 10/26/16 and updated on 2/6/17 identified the resident was at risk for falls. She had a fall with injury (fracture) where she lived previously. The care plan initiated on 11/7/16 and updated on 2/6/17 also identified the resident had cognitive loss and dementia. She was confused at times, and had poor safety awareness. -The 10/26/17 Fall Risk Observations revealed the resident had one or two falls in the past three months, and she received OT and PT services. -The 10/26/17 Safety Devices/Resident Needs Observation revealed the resident was unsafely mobile/unsafe gait/movement disorders, had a history of [REDACTED]. -The 2/1/17 Fall Risk Observation revealed the resident required the use of assistive devices, and had neuromuscular/functional and orthopedic conditions. She had no history of falls within the past three months, her fall risk score was five which indicated she was no risk for falls; however, a 12/25/16 Safety Events-Fall documented she had a fall within the past three months. -The 3/2/17 Regulatory Visit revealed the resident had a past history of .Other fall on same level sequela . -The Vital Taken Form revealed on 3/3/17 the resident weighed was 116.4 pounds. 2. Observation Observations revealed the resident's bed was positioned to create a risk for fall and possible entrapment between the wall and the bed. Resident #117's room was observed on 3/15/17 at 10:35 a.m. The wall located laterally (side) to the length of the bed had a sign posted. The sign revealed Keep bed at least 6 (six) inches from the wall. The bed had the ability to move from the high to the low position, had wheels, but was resting on carpet and per surveyors' attempts, difficult to move. The gap between the bed and the wall was measured. The results revealed the gap between the bed lateral to the wall and the wall was seven and one half inches. E. Staff interviews Staff interviews revealed preventing damage to the wall and equipment (electrical outlet) were the primary reasons for positioning the residents' beds six inches from the wall. Even though staff recognized the potential for serious harm from a fall and possible entrapment this positioning created, the facility had not taken any steps prior to survey to respond to it. 1. CNA #1 was interviewed on 3/15/17 at 5:59 p.m. She said signs to Keep bed at least 6 (six) inches from the wall were in place to prevent the beds from hitting the electrical outlets out of the walls. Both the length and width of the beds were required to be kept six inches away from the wall. The CNA stated the gap between the wall and the bed was an entrapment risk and said that residents who resided on the second floor, including resident #17, #77, #82, and #117, had cognition concerns and/or required staff supervision due to lack of safety awareness. 2. LPN #1 was interviewed on 3/15/17 at 6:04 p.m. She said the signs to Keep bed at least 6 (six) inches from the wall were put into place to prevent residents from hitting their heads against the wall, damaging the wall and electrical outlets. She revealed the majority of residents residing on the second floor were at risk for falls due to their cognition, requirements for ADL assistance, and poor safety awareness. She stated a six inch gap between the bed and the wall had the potential to entrap a resident. She said that although all residents were assessed quarterly or upon a change of condition in order to determine if they were at risk for falls, there was no routine assessment for positioning. Positioning concerns were reported to the therapy department for screening and treatment. 3. The NHA was interviewed on 3/15/17 at 6:30 p.m. She said the signs to Keep bed at least 6 (six) inches from the wall were placed on the wall by a housekeeper (HK) without the knowledge or permission from administration and she had asked the housekeeping supervisor (HKS) to remove all of the signs from the resident bedroom walls today . She said the head of the electric beds were scratching the walls, hitting the electrical outlets, and the beds were becoming stuck between the high and low positions; therefore, the head of the bed was required to be six inches from the wall. The length of resident #77's bed, positioned lateral to the wall, was not required to be six inches from the wall. She said a gap between the wall and the length of the bed created an entrapment risk, which had the potential to cause a resident injury. 4. CNA #3 was interviewed on 3/15/17 at 6:53 p.m. She said the beds were kept away from the walls at the head of the beds and positioned lateral to the wall to prevent wall and outlet damage. CNA #3 said it was an accident hazard to damage the electrical outlets, but it was also a hazard to have a gap between the bed and the wall. She said residents who were determined to be a high fall risk were safer when they were located closer to the wall. 5. Clinical nurse manager (CNM) #1 was interviewed on 3/15/17 at 6:55 p.m. She said the Keep bed at least 6 (six) inches from the wall signs were in place for safety issues arising when the bed was moved from the low to the high position. The head of the bed was required to be kept six inches from the wall, but not the length of the bed. The CNM confirmed having the length of the bed six inches from the wall put the residents at risk for falls between the wall and the bed. 6. LPN #2 was interviewed on 3/15/17 at 7:05 p.m. She said the Keep bed at least 6 (six) inches from the wall signs meant the head of the bed and the length of the bed were required to be kept six inches from the bed in order to prevent damage to the electrical outlets. 7. The SDC was interviewed on 3/15/17 at 7:09 p.m. She said the signs to Keep bed at least 6 (six) inches from the wall was posted on the resident's bedroom walls approximately three to four weeks ago. The sign was posted to protect the wall and the electrical outlets. The SDC said a gap between the length of the bed and the wall had the potential to be a restraint, but only if the bed was approximately 18-20 inches away from the wall. 8. The director of maintenance (DOM) was interviewed on 3/15/17 at 7:24 p.m. He said the signs to Keep bed at least 6 (six) inches from the wall were posted as guidelines for the head of the electric Invacare bed and not the length of the bed which was lateral to the wall. (Per the Invacare website, the Invacare CS7 bed weighed approximately 190 pounds) When the bed moved from the upper to the lower positions there was a slight tilt in the head board, which had two metal brackets and would damage the wall behind the head of the bed. The bed did not move from side to side and would not damage the length of the wall. The beds were safe to be pushed against the wall, and if there was an electrical outlet located on the length of the bed then the bed was required to be pulled away from the wall before moving in the upper or lower positions to prevent a possible accident hazard. IV. Facility Action Taken During Survey A. Evidence of a systemic concern with residents' bed safety 1. Following notice on 3/15/17 at 7:54 p.m. of the immediate jeopardy situatio