Every finding on record at Rocky Mountain Care - Evanston

Based on observation, staff interview, review of the 2022 Food Code, and policy and procedure review, the facility failed to store and prepare food in accordance with professional standards related to labeling stored food items and hand hygiene/gloving in 1 of 1 food preparation areas (kitchen). The census was 47. The findings were: 1. Observation on 4/14/26 at 6:24 AM showed a red tub with thick, yellow substance in the walk-in refrigerator. The bowl was not labeled or dated and the substance appeared to have portions removed. 2. Observation on 4/15/26 at 12:09 PM showed cook #1 was plating meals on the tray line while wearing gloves. Without removing the gloves, the cook left the line, touched the three-compartment sink, placed a hand on top of a table, obtained a bag of bread, and returned to the tray line. The cook opened bread bag and used his soiled gloves to remove two slices of bread which he placed on a plate. The cook placed an enchilada on the bread and gave the tray to staff in the dining room to serve to a resident. Further observation showed the cook returned to the service line and continued to prepare meal trays for the remainder of the meal; without removing the soiled gloves. 3. Interview with the dietary manager and dietitian on 4/15/26 4:38 PM revealed items in the walk-in refrigerator were available for resident consumption and all items that were open had to be labeled and dated. They revealed the yellow substance was potato salad and they were not sure when it was made. Further interview revealed they expected staff to remove their gloves and perform hand hygiene when they left the service line and prior to resuming meal service. 4. Review of the policy titled Handwashing Guidelines for Dietary Employees last revised on 4/2025 showed .6. Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: b. After hands have touched anything unsanitary i.e. garbage, soiled utensils/equipment, dirty dishes, etc . j. After engaging in any activity that may contaminate the hands. 5. Review of the facility policy titled Date Marking for Food Safety last revised on 4/2025 showed .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . 6. Review of the 2022 Food Code, US Food and Drug Administration, showed .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to ensure the residents' right to be notified in advance to participate in the regularly scheduled meetings for development and implementation of care for 1 of 16 sample residents (#3). The findings were:1.Review of the quarterly MDS dated [DATE] showed resident #3 was unable to participate in BIMS scoring due to rarely or never being understood, and was severely impaired for cognitive skills in daily decision making. Resident #3 had the diagnoses of Alzheimer's Disease, depression, anxiety and insomnia. The following concerns were identified:a. Interview with resident #3's representative on 4/14/26 at 10:31 AM revealed the resident had two care plan meetings in the last year; however, the representative had prompted the meetings to occur. b. Review of medical record showed the resident had an interdisciplinary team (IDT) meeting for care planning where the resident representative was invited and subsequent IDT meetings completed for April of 2025, July of 2025, and October of 2025. There was no evidence a care plan meeting had been planned or had occurred in 2026.c. Interview with the DON on 4/16/26 at 1:54 PM confirmed the resident did not have any IDT meetings for care plan updating since October of 2025 and there were none scheduled at that time. Further she revealed the resident was missed.d. Interview with the Administrator on 4/16/26 at 2:22 PM revealed there had been care plans revised quarterly with no scheduled meetings. 2. Review of the policy titled Care Planning-Resident Participation last revised on 4/2025 showed .#9 The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan.

Based on observation, resident and staff interview, medical record review, and activity participation review, the facility failed to ensure individual activities of preference were provided to 1 of 10 sample residents (#9) reviewed for activities. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #9 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included non-Alzheimer's dementia, depression, and blindness in both eyes. Review of the annual MDS assessment dated [DATE] showed the resident felt it was very important to have books, newspapers, and magazines to read, listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do his/her favorite activities, get fresh air when the weather was good, and participate in religious services or practices. Review of the Recreation Therapy care plan last revised on 12/31/26 showed interventions which included Provide 1:1 [1 to 1] visit 1x [1 time] weekly. Observation on 4/14/26 from 2:04 PM to 3:29 PM showed the resident was in his/her room and independently listened to an audio book. The following concerns were identified:a. Interview with the resident on 4/14/26 at 9:50 AM revealed s/he did not participate in a lot of activities due to blindness and did not have a lot of visitors. The resident revealed staff did not come to his/her room for visits and s/he would like it if more people would come to visit since s/he was unable to do a records lot of the other activities the facility offered.b. Review of the activity participation records for February 15, 2026 - April 15, 2026 showed no evidence the resident was offered 1 to 1 activities or had refused 1 to 1 activities.c. Interview with the activity director on 4/16/26 at 2:17 PM revealed the resident's family provided a lot of activities for the resident to do. She revealed the resident listened to a lot of audio entertainment and the facility only performed 1 to 1 activities when they read mail to him/her. She revealed the facility did not have a set 1 to 1 activity with the resident and didn't document when they offered 1 to 1 activities to the resident. Further interview revealed the facility didn't have a policy related to 1 to 1 activities.

Based on medical record review, review of the facility investigation report, and staff interview, the facility failed to ensure a safe transfer was provided for 1 of 7 sample residents (#1) reviewed for falls. This failure resulted in actual harm to resident #1 who was unable to keep his/her balance during a transfer. The resident suffered a comminuted [bone breaks in 3 or more places usually occurring after a forceful event] fracture involving the distal femoral diametaphysis above the femoral component of the left knee prosthesis. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 3/7/25. The findings were: 1. Review of the 2/14/25 quarterly MDS assessment showed resident #1 had a BIMS score of 8 out of 15 (moderate cognitive impairment); required substantial to maximal assistance with all mobility ADLs; and had diagnoses which included Alzheimer's disease and bipolar disease. Review of the resident's care plan showed the resident had a fall on 3/7/23 and 2 staff were to assist the resident with transfers. Review of the Occupational Therapy Recertification Progress Report and Updated Therapy Plan Report for the certification period of 1/28/25 to 2/26/25 showed the resident required maximal assistance with toilet transfers. The following concerns were identified: a. Review of a 2/20/25 nurse's note showed resident #1 was up to the restroom with assistance x [times] 1. Resident lost balance and CNA unable to lower resident to floor. Resident did hit head. Neuros were initiated. Further review of the incident showed the fall occurred at approximately 2:45 PM on 2/20/25. The nursing assessment showed no signs of injury, the resident did not exhibit pain, and had resumed his/her normal activities. b. Review of a nurse's note, dated 2/21/25 and timed 1:34 AM, showed the resident had started to yell and complain of severe pain to his/her knee. The resident was sent for imaging and diagnosed with an acute nondisplaced oblique spiral type fracture through the distal left femoral metaphysis superior to the knee arthroplasty. The injury was inoperable and the resident was placed on non-weight bearing status and was prescribed 5 milligrams of oxycodone every 4 hours as needed, 1000 milligrams of Tylenol 3 times per day, and a lidocaine patch to the knee. c. Review of a 2/24/25 nurse's note showed Notified physician of resident discomfort/pain. Order received to increase from 5 milligrams to 10 milligrams oxycodone every 4 hours as needed. 2. Interview with the NHA on 3/19/25 at 9:52 AM confirmed CNA #1 did not follow the resident's care plan which resulted in the resident falling and subsequent injury. The NHA stated the CNA received disciplinary action, had been educated, and audits of the CNA's skills continued to be evaluated. Further, an ad hoc Quality Improvement/Performance Improvement (QAPI) meeting was conducted on 2/27/25. 3. Review of the 2/27/25 QAPI minutes showed falls which occurred on 2/19 and 2/20 were reviewed; education to all staff doing mobility tasks was scheduled; an audit tool was created for the CNA involved; an audit tool was created for all staff doing mobility tasks; and an audit of all care plans for those assessed as needing 2-person assist or were a fall risk was planned. 4. Review of the facility's investigation showed interviews with staff were conducted and it was determined CNA #1 was independently toileting the resident when the resident fell. Education was provided to the CNA, an ongoing audit, which was started on 3/1/25, of the CNA's adherence to care plans and providing safe assistance to residents was reviewed. An audit of all residents currently listed as a 2-person assist was conducted and education was provided to all staff providing assistance with transfers by the therapy department on 3/7/25.

Based on medical record review, resident and staff interview, facility incident review, and policy and procedure review, the facility failed to protect the residents' right to be free from verbal abuse by a staff member for 1 of 6 sample residents (#4). This failure resulted in actual psychosocial harm to resident #4. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/5/24. 1. Review of the quarterly Minimum Data Set assessment dated [DATE] showed resident #4 had a brief interview for mental status score of 9 out 15, which indicated moderate cognitive impairment, and diagnoses which included cerebrovascular accident, hemiplegia or hemiparesis, and depression. Further review showed the resident did not exhibit physical or verbal behavioral symptoms or rejection of care. The following concerns were identified: a. Review of an incident report dated 8/31/24 showed CNA #1 and CNA #2 were assisting the resident with care. The resident called CNA #1 a bitch and told the CNA to get out of his/her room while using expletives. The CNA responded by calling the resident a cunt. The incident was reported by CNA #2 to the nurse and the nurse notified administration. CNA #1 was placed on suspension pending an investigation. During the investigation, resident #4, who has difficulty with communication, reported CNA #1 was making fun of him/her, grabbed [him/her] and told the resident to knock it off, and s/he totally lost her mind. The resident was emotional during the interview, said CNA #2 was good and nice, and acknowledged s/he had been swearing, yelling, or using foul language with staff that day. The investigation showed resident #4's representative reported the resident had called after the incident to report CNA #1 was mocking the resident due to his/her difficulty speaking and the resident was embarrassed and belittled. The resident's representative reported CNA #1 had been one of the resident's favorites in the past. The Investigation showed CNA #2 reported the resident had been cursing at staff and CNA #1 called the resident a F-ing Cunt and may have been a bit rough. CNA #2 described the resident as a bit stunned after the incident. Further review showed CNA #1 admitted to calling the resident the name and was terminated from the facility. b. Interview with resident #4 on 9/17/24 at 5:24 PM revealed the CNA #1 entered the room and was speaking to him/her in a way s/he felt was making fun of him/her. CNA #1 forced the resident to roll over in bed and it made the resident mad. Following the incident, the resident revealed s/he called his/her daughter while crying, because s/he was upset. c. Interview with CNA #2 on 9/18/24 at 9:21 AM revealed on the day of the incident, she had asked CNA #1 to assist with providing care to the resident. She revealed CNA #1 forcefully repositioned the resident and the resident called the CNA a fucking bitch and CNA #1 responded by calling the resident a fucking cunt. Further interview revealed CNA #1probably made fun of resident #4 during the incident; however, she does not recall it. d. Attempted interview with CNA #1 on 9/18/24 at 9:15 AM was unsuccessful. A message was left and no return call was received. e. Interview with the administrator on 9/18/24 at 10:45 AM confirmed CNA #1 was terminated from the facility. The administrator revealed although the resident curses often, s/he did not normally get upset which made the facility believe the resident was affected by the incident. The administrator revealed resident #4 had previously refused counseling services offered by the facility; however, s/he accepted counseling following the incident. Further interview revealed as a result of the incident, the facility completed abuse training for staff, interviewed residents, performed ongoing customer satisfaction surveys, and were reviewing abuse in during their quality assurance meeting. f. Interview with licensed clinical social worker #1 on 9/18/24 at 11:05 AM confirmed resident #4 began counseling services and the incident was an area to address. g. Review of the facility policy titled Abuse, Neglect, and Exploitation last revised 6/2023 showed .1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property . 2. The following plan of correction was implemented by the facility on 9/5/24: a. CNA #1 was terminated from the facility. b. Residents were interviewed related to abuse and neglect. c. Counseling services were offered, accepted, and implemented with resident #4. d. Staff completed training related to the Dos and dont's of managing a client who is angry or aggressive and Techniques for managing cognitive impairment. e. Customer Satisfaction Surveys. f. Quality Assurance review of abuse.

Based on medical record review and staff interview, the facility failed to provide a written notice of the transfer to the resident and/or their representative for 2 of 2 residents (#3, #21) who were hospitalized . The findings were: 1. Review of progress notes showed resident #3 was admitted to the hospital on 3/30/24 and returned to the facility on [DATE]. Further review showed the resident received the bed hold notice, but there lacked evidence the resident was issued a written transfer notice. 2. Review of progress notes and a nursing emergent discharge summary showed resident #21 went to the hospital on 7/14/24 and returned to the facility on [DATE]. Further review showed the resident received the bed hold notice, but there lacked evidence the resident was issued a written transfer notice. 3. During interviews on 8/22/24 at 8:46 AM and 11:19 AM the administrator stated the facility issued a written notice which contained the resident's right to appeal and the Ombudsman contact information for discharges, but did not issue a written transfer notice for transfers to the hospital.

Based on medical record review and staff interview, the facility failed to ensure a level II PASARR [preadmission screening and resident review] was completed as required for 1 of 2 sample residents (#11) reviewed for PASARR. The findings were: 1. Review of the medical record showed resident #11 was admitted on [DATE] and had diagnoses including major depressive disorder, anxiety disorder and PTSD. Review of the PASRR level 1 dated 5/4/23 showed the resident had a major mental illness. The level 1 screening showed the result was Categorically appropriate for convalescent care after acute hospital stay, not to exceed 120 days. The PASRR further showed .An individualized level II determination will be required on the 120th day if client stay will be extended, please plan accordingly. The following concerns were identified: a. Further review of the medical record showed no evidence the PASRR level II was completed although the resident remained in the facility past 120 days. b. On 8/22/24 at 9:56 AM the administrator stated the PASRR level II was not done, but should have been because, the resident exceeded 120 days.

Based on medical record review and staff interview, the facility failed to ensure that the binding arbitration agreement explicitly stated that the resident or their representative was not required to sign the agreement as a condition of admission or to continue to receive care at the facility for 2 of 2 sample residents who signed an arbitration agreement (#11, #25). The findings were: 1. On 8/20/24 at 11:04 AM the administrator stated no residents had signed binding arbitration agreements. 2. However, medical record review revealed the following: a. Resident #11 signed an admission agreement on 4/28/21. A binding arbitration agreement was embedded in the admission agreement and did not explicitly state the resident was not required to sign it as a condition of admission. The admission agreement did not give the resident the opportunity to decline the arbitration agreement, but agree to the rest of the admission agreement. b. Resident #25 signed an admission agreement on 2/17/21. A binding arbitration agreement was embedded in the admission agreement and did not explicitly state the resident was not required to sign it as a condition of admission. The admission agreement did not give the resident the opportunity to decline the arbitration agreement, but agree to the rest of the admission agreement. 3. Interview with the administrator on 8/20/24 at 1:18 PM revealed the facility revised their admission agreement in 2023 to be in line with regulations related to arbitration, and the facility did not ask residents to enter into an arbitration agreement. 4. A phone interview with facility lawyer #1 on 8/21/24 at 3:04 PM revealed the facility did not do binding arbitration agreements anymore, but acknowledged the older admission agreements were a problem.

Based on observation, review of nurse staffing postings, and staff interview, the facility failed to ensure the nurse staffing posting included the census and total number of staff worked per shift. The census was 49. The findings were: 1. Observation on 6/29/23 at 8:27 AM showed the nurse staffing information was posted on a bulletin board in the hallway. The information did not include the census nor did it include the actual number of staff worked per shift by category of staff. 2. Review of the nurse staffing postings from 6/1/23 through 6/26/23 showed the census was not included. In addition, there was information for the number of FTEs [full time equivalent] but that information was not accurate for the number of staff who actually worked each shift. 3. During an interview on 6/29/23 at 8:46 AM the administrator stated human resources staff was responsible for the posting and confirmed the posting did not include the census nor accurate numbers of staff worked.

Based on observation, staff interview, and review of the US Food Code, the facility failed to ensure the food storage equipment was maintained in a clean and sanitary manner in 1 of 1 kitchens. The census was 44. The findings were: 1. Observations on 5/16/22 at 4:39 PM and 5/18/22 at 11:33 AM showed the following concerns with equipment: a. The ice machine had a buildup of a pink and brown discoloration on the interior part, located above the ice in the storage bin. b. The walk-in-cooler walls, ceiling, and fan covers were soiled with dark colored dust and grime. 2. Interview with the certified dietary manager (CDM) on 5/18/22 at 11:40 AM revealed the maintenance director conducted the sanitation for the ice machine. She also stated there was a schedule to deep clean the kitchen in June and the walk-in-cooler was part of the planned cleaning. 3. Interview with the maintenance director on 5/18/22 at 11:50 AM confirmed the ice machine was sanitized monthly, last done on 4/1/22. He and the CDM verified the area on the interior needed to be cleaned when soiled in a manner that would not contaminate the ice. 4. According to Food Code 2017, U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, review of menus, and staff interview, the facility failed to ensure menus were followed as planned for 1 of 1 meal preparation and service observation (noon meal on 5/18/22). The census was 44. The findings were: Observation of the 5/18/22 noon meal preparation and service showed the certified dietary manager (CDM) and 2 other staff members were preparing the food. The foods that were prepared and served included: beef stew with vegetables, garden salad, bread, and pecan pie. Review of the menu showed chilled steamed vegetables were planned in place of the garden salad for residents that had mechanical soft or pureed diet textures. In addition, the menu showed the serving size for the beef stew was 8 ounces regardless of texture. The following concerns were identified: a. Observation at 12:10 PM showed a 6 ounce ladle was used to serve the beef stew. b. Review of the resident diet orders showed there were 3 residents (#29, #37, #145) who required pureed texture meals, and 11 residents (#3, #9, #10, #11, #14, #16, #19, #24, #27, #34, #42) who required mechanical soft texture meals. Observation between 12 to 12:30 PM showed the residents received tomato juice instead of the chilled steamed vegetables. c. Interview on 5/18/22 at 12:30 PM with the CDM revealed she had not checked the menu for the serving sizes. Additionally, she had not prepared the chilled steamed vegetables for the texture altered diets, thinking the tomato juice was adequate.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure food was served in sanitary conditions during 1 of 2 meal observations. The census was 44. The findings were: 1. Observation on 5/12/21 at 11:32 AM showed dietary aide #1 opened the ice machine lid with gloved hands. The dietary aid grabbed a plastic cup, while wearing the same gloves used to open the lid, scooped ice into the cup from the ice machine, and dumped the ice into separate plastic cups on a cart next to the machine. After filling all of the larger cups on the cart, the staff member grabbed two smaller cups, one in each hand, and scooped ice into the cups. The dietary aide's gloved hands contacted the ice in the machine each time he scooped ice into the cups. After adding ice to all the cups, the dietary aid filled all of the cups with water for the residents. 2. Interview with the dietary manager on 5/12/21 at 2:55 PM revealed the dietary aid should have removed gloves, washed hands, and applied clean gloves after opening the ice machine door to prevent cross contamination from occurring. 3. Review of the policy titled Infection Control-Standard precautions last revised 7/1/19 showed .a. Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions, and contaminated items .c. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands

Based on observation, staff interview, medical record review, policy and procedure review, and clinical standard of practice review, the facility failed to ensure medications were safely administered for 3 of 3 sample residents (#1, #19, #34) reviewed for self-administration of medications. The findings were: 1. Review of the care plan, last revised on 3/1/21, showed resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed interventions which included Medication administered/monitored by LN [licensed nurse] as ordered. The following concerns were identified: a. Observation on 5/10/21 at 5:12 PM showed resident #34 was in the dining area seated at a table, with his/her head down on top of his/her arms crossed in front of him/her. RN #1 approached the resident with a small cup of medications in pill form. RN #1 touched the resident on the shoulder, which startled the resident, and told the resident she had medications for him/her. The resident nodded in acknowledgement and put his/her head back down onto his arms resting on the table. The nurse placed the cup next to the resident's right elbow and left the dining room. Further observation showed the resident did not take the medications until his/her meal arrived at 5:18 PM, without the nurse present. b. Review of the Self-Administration of Medication assessment dated [DATE] and timed 3:47 PM showed the resident did not want to self-administer medications and the resident's decision making ability was Severely impaired - Never/rarely makes decisions. 2. Review of the care plan, last revised on 4/18/21, showed resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed interventions which included My medication will be administered and monitored by LN as ordered. The following concerns were identified: a. Observation on 5/10/21 at 5:09 PM showed resident #1 was seated at a table in the dining room waiting for his/her meal. RN #1 approached the resident with a small cup of medications in pill form. The nurse acknowledged the resident, stated she had medications for him/her, set them on the table, and left the dining area. The resident took a few sips of water, and then took the medications, without the nurse present. b. Review of the Self-Administration of Medication assessment dated [DATE] and timed 1:20 PM showed the resident did not want to self-administer medications. 4. Review of the care plan, last revised on 5/3/21, showed resident #19 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed interventions which included My medication is to be administered and monitored by LN as ordered. The following concerns were identified: a. Observation on 5/12/21 at 5:03 PM showed RN #2 placed [MEDICATION(S)] and acidophilus in a medication cup, entered the resident's room, set the medications on the tray table, and left the room. Continued observation showed the resident took the medications, without the nurse present, at 5:28 PM. b. Interview with RN #2 on 5/13/21 at 8:48 AM revealed she left medications at the bedside for residents who were alert and did not have swallowing issues. c. Review of the medical record showed no evidence a self-administration of medication assessment was completed. d. Interview with the administrator on 5/13/21 at 11:22 AM revealed the facility did not have a self-administration assessment completed for the resident. 5. Interview with the DON on 5/13/21 at 9:37 AM revealed nurses were expected to stay with residents during medication administration to ensure medications were taken and medications should not be left at the bedside for any residents. 6. Review of the policy titled Medication Pass Protocol last revised 1/19/18 showed .16. Should a resident be away from his or her room, or unavailable during the medication pass, the medication should be labeled with the name of the resident, the time of administration, and stored in the medication cart until the resident can be located for administration. 17. Self administration of drugs is permitted when the resident is able to successfully pass the Self Administration Assessment, an order is obtained by the physician and proper storage of medications is provided . 7. According to Griffin-Perry, Potter, and Ostendorf in Nursing Interventions & Clinical Skills, 7th edition, 2020, safe and accurate steps in medication administration should include . Evaluate the patient's knowledge of the medication, and provide appropriate teaching using teach-back technique. 3. Stay with the patient until the medication is taken. Provide assistance as necessary. Do not leave medication without a health care provider's order at the bedside. 4. Respect the patient's right to refuse medication . When medication is refused, determine the reason for this and take action accordingly. Post-administration activities should include 1. Properly document medications administered. 2. Document data pertinent to a patient's response . Include the ability of patient and family caregiver to teach back the education provided. 3. If a medication is refused, document that it was not given, the reason for the refusal, and when the health care provider was notified. Special considerations when administering medications include age, especially Individuals older than age 65 . Because of the physiological changes associated with aging, nursing interventions are needed to promote safe and effective medication administration .

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure bed rails were assessed for 1 of 2 sample residents (#23) with bed rails. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #23 readmitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had a brief interview for mental status score of 6 out 15, which indicated the resident had severe cognitive impairment, and the resident required extensive physical assistance of 1 person with most activities of daily living. The following concerns were identified: a. Observation on 5/10/21 at 4:14 PM showed the resident's bed had an enabler bar on the upper right side of the bed. b. Observation on 5/13/21 at 11:15 AM showed the enabler bar remained to the upper right side of the resident's bed. The enabler bar was an upside down U shape, was secured to the bed frame at the bottom, and was rounded at the top which created a gap in the middle. The gap measured 9 1/4 inches long from the top of the bar to the top of the mattress by 3 3/4 inches wide. c. Review of a Fall Risk assessment completed on 3/17/21 showed the resident had a score of 23 and indicated the resident was at a high risk for falls. d. Review of the medical record showed no evidence a bed rail assessment was completed for the resident. e. Interview with the administrator and ADON on 5/12/21 at 2:43 revealed the resident switched rooms and the enabler bar was already attached to the bed. The facility did not identify the enabler bar at the time of the move. Further interview confirmed a bed rail assessment was not completed for the enabler bar. 2. Review of the Restraint Protocol provided by the facility on 5/13/21 showed .1. The facility will assess for all potential restraints [sic] examples include: lipped mattresses, bed canes, side rails, geri chairs, lap buddy, alarms etc .

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #23 readmitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had a brief interview for mental status score of 6 out 15, which indicated the resident had severe cognitive impairment, and was coded as having unclear speech-slurred or mumbled words. Review of the Communication care plan last revised on 4/18/21 showed I have difficulty making myself understood at times R/T [related to] slurred or mumbled words when communicating and at time [sic] my focus move [sic] to a different task and interventions included Ask resident to repeat slurred, mumbled words as needed to complete communication . Disregard inappropriate words when I'm conversing . Encourage me to communicate and redirect me back on task as needed when expressing self . Praise me when spoken words are distinct and intelligible . Provide a quiet, non-hurried environment, free of background noises and distractions . Remind resident to speak slowly and clearly . Repeat what the resident has said to validate as or [sic] if needed . The following concerns were identified: a. Observation on 5/11/21 at 8:37 AM showed the resident had difficulty with speaking. Interview at that time revealed the resident had slurred and mumbled speech which was difficult to understand. b. Interview with speech therapist #1 on 5/12/21 at 5:40 PM revealed the resident had previously received speech therapy services related to swallowing, speaking, and staff's difficulty understanding the resident. During the speech therapy, the resident was agreeable to using a communication board; however, s/he was discharged from the facility prior to implementation. Further interview revealed the resident did not receive speech therapy orders upon return to the facility and s/he was not on speech therapy case load at that time. c. Review of re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. Interview with the administrator on 5/12/21 at 6:22 PM confirmed the facility did receive orders for speech therapy at the time of re-admission. Further interview revealed the resident was evaluated on 5/12/21 and refused to participate in speech therapy; however, the administrator confirmed the resident should have received the evaluation at the time of re-admission.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure proper cleaning during 2 of 3 observations of mechanical lift transfers. The findings were: 1. Observation on 12/8/20 at 4:10 PM showed CNA #1 brought a hoyer lift out of resident room [ROOM NUMBER], parked it in the hall and did not wipe it down with a disinfecting wipe. Observation on 12/8/20 at 4:25 PM showed CNA #1 took the hoyer lift to resident room [ROOM NUMBER] to transfer a resident; CNA #2 brought the hoyer lift out of the room, parked it next to the wall and did not wipe it down with a disinfecting wipe. The following concerns were identified: A. Interview on 12/8/20 at 4:34 PM with the NHA stated wiping down a hoyer lift with a disinfectant wipe was not necessarily the expectation when used on resident's who were not on precautions. B. Review of the Infection Control-Standard Precautions policy, with a revision date 7/1/19,showed .5.b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed, and single use items are properly discarded .

Based on observation and staff interview the facility failed to ensure food safety requirements were met and sanitary conditions were maintained in the kitchen during 2 of 2 observations of the kitchen. The findings were: 1. Observation of the ice machine in the kitchen on 6/5/19 at 4:30 PM revealed the upper interior area was dirty. At that time the CDM moved a clean cloth across the area and removed a black and brown substance. Interview on 6/06/19 at 9:20 AM with the maintenance supervisor, revealed he was responsible for cleaning the ice machine once a month and last did it on 5/3/19. He further stated he might need to revise the cleaning schedule and perform the task more frequently. 2. Observation on 6/6/19 from 7:20 AM to 8:30 AM showed 3 packaged herb rubbed pre-cooked turkey breasts, one package of sliced ham and a partially thawed 30 ounce container of frozen basil were in a pan on the countertop near the sink. The packaged meats and container of basil sat in the thawing moisture in the pan. At 8:35 AM, the CDM said the turkey was to be prepared for the noon meal and the ham for the supper meal later that day, but staff had not had an opportunity to cut it up. She further stated she did not know how long the meat had been on the counter and it should have been in the refrigerator until ready for use. Review of the menu directions for the meat showed instructions to Thaw meat under refrigerator (41° F). 3. On 6/6/19 at 7:20 AM observation showed 6 shelving units used for storage of dishes, pans, condiments, bread and bananas had lint and dust threads covering the wired structures on all of the two lower shelves of each unit. At 8:35 AM, the CDM observed the shelves and verified they needed to be cleaned. She further stated her staff were responsible for cleaning the shelves and it had been overlooked. 4. According to Food Code (YEAR), U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, (C) Nonfood-contact surfaces of equipment, shall be kept free of accumulation of dust, dirt, food residue, and other debris. 5. According to Food Code (YEAR), U.S. Public Health Service: 3-501.13 Except as specified in ¶ (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5° C (5 degrees centigrade) (41° F) (41 degrees Fahrenheit) or less; or (B) Completely submerged under running water: (1) At water temperature of 21° C (70° F) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5°C (41° F) .

Based on staff and resident interview and medical record review, the facility failed to implement effective pain management for 1 of 1 sample resident (#9) reviewed for pain management. The findings were: Review of the 2/27/19 quarterly MDS assessment for resident #9 showed s/he had a BIMS score of 14/15 (cognitively Intact) and required extensive assistance with activities of daily living. This review also showed the resident had [MEDICAL CONDITION] due to a stroke and frequent pain. Review of the 2019 (MONTH) recapitulation of physician orders [REDACTED]. Interview on 6/4/19 at 2:15 PM with the resident revealed s/he had a lot of pain and sometimes the pain pills helped and sometimes they did not provide complete relief. The resident further stated his/her left leg hurt a lot and lower back hurts too. On 6/6/19 at 9:45 AM, the pain Medication Administration Record [REDACTED]. This review showed the pain medication was administered on 5/14/19, 5/20/19, 5/21/19, 5/22/19, 5/27/19, and 5/29/19. Further review showed an assessment prior to the medication administration or an assessment after the medication was administered was not done or neither was completed for the above dates. Interview with the DON on 6/6/19 at 10:15 AM revealed staff were aware of the resident's pain and had tried various interventions to address his/her pain. The DON further stated the resident's pain was hard to assess.

Based on observation, medical record review and staff interview, the facility failed to ensure needed care and services that met each resident's highest practicable physical, mental, and psychosocial well-being were provided for 1 of 24 sample residents (#198). The findings were: Review of the 5/8/19 care plan for resident #198 showed the following: The interventions for impaired ability to participate included encourage simple activities and attempt simple interactions. The interventions for pressure ulcers included staff will assist with toileting and peri-care. The interventions for function and rehab included use wheelchair for locomotion. The following concerns were identified: a. Intermittent observation on 6/4/19 showed the resident remained in bed, in the same supine position from 8:55 AM until end of observations at 3:53 PM. Extended observation of the resident on 6/5/19 from 12:40 PM to 4:50 PM showed the only staff to enter the room during this time period was a dietary aide to leave and pick up meal tray. The resident was in bed, in supine position with the covers up. b. During an interview on 6/5/19 at 11:32 AM RN #2 revealed she was unable to access the resident's care plan in the computer but knew the resident was on palliative care, stayed in bed all of the time, and that toileting was done as we can. c. During an interview on 6/6/19 at 9:15 AM CNA #1 revealed the expectation was for direct care staff to check and change bed-bound residents every two hours. d. During an interview on 6/6/19 at 9:35 AM, the ADON revealed the facility expectation was to check and change the bed-bound resident for incontinence every two hours.

Based on staff interview and medical record review, the facility failed to ensure 1 of 4 sample residents (#42) identified in reported allegations of resident to resident abuse was free from abuse. This failure resulted in recurrent incidents of resident #13 punching and kicking resident #42. The findings were: Review of the 3/12/19 annual MDS assessment showed resident #13 had a BIMS score of 12/15 (moderate cognitive impairment) and [DIAGNOSES REDACTED]. Further review showed the resident required extensive assistance with bed mobility, dressing, and transfers. Review of the care plan, last updated 4/24/19, showed the resident could self propel his/her wheelchair independently and staff were to set firm limits on behaviors. Review of the 4/29/19 quarterly MDS assessment for resident #42 showed s/he had a BIMS score of 1/15 (severe cognitive impairment); [DIAGNOSES REDACTED]. The following concerns were identified: a. Review of incident/accident investigations showed resident #13 punched resident #42 on 4/22/19. This review showed both residents were in their wheelchairs in the hallway and the incident occurred before staff who were present at that time could prevent it. Interview on 6/6/19 at 9:20 AM with the administrator revealed no major injuries resulted from the incident; and staff determined they would prevent close contact between the residents. Review of the investigation documentation showed the incident was reported to all appropriate agencies, family, and physician in timely manner. b. Review of incident/accident investigations showed resident #13 kicked resident #42 on 5/14/19 in the dining room and no serious injuries resulted from this. Further review showed at the time of the incident, the nursing school instructor was wheeling resident #42 and did not know she should not move the resident in an area close to resident #13. Review of the investigation documentation showed the incident was reported to all appropriate agencies, family, and physician in timely manner. c. Review of the 5/31/19 updated care plan for resident #13, and the 4/29/19 updated care plan for resident #42 showed neither included information about preventing close contact between the residents. d. Interview on 6/6/19 at 9:20 AM with the administrator revealed the best thing to do to prevent recurrent incidents was to keep the two residents apart. She further stated their system for letting staff know to keep the two residents apart was to document this information on the daily staff information sheet. She further stated they could use the CNA electronic documentation system, Care Tracker to disseminate this information, but they had not done this or implemented additional systems for ensuring everyone who assisted residents were aware of the need to prevent resident to resident interactions between the two residents.

Based on observation, medical record and facility policy and procedure review, and staff interview, the facility failed to gather accurate, objective and consistent data on wounds, including regular wound measurements and descriptions, for 2 of 2 sample residents (#23, #38) and 1 non-sample resident (#16) with wounds. The failure to comprehensively and objectively assess and monitor resident wounds negatively impacted the facility's ability to provide timely interventions resulting in an emergent surgical procedure for resident #38 on the same day s/he was discharged from the nursing home. The findings were: 1. Review of hospital medical records revealed resident #38 underwent surgery for [REDACTED]. According to the hospital discharge summary (discharge date [DATE]), post-operative complications included a large hematoma in the operative leg, which required the resident to undergo surgery for [REDACTED]." Hospital discharge [DIAGNOSES REDACTED]. 2. Right fifth metatarsal healing ulcer. 3. Chronic bilateral lower leg [MEDICAL CONDITION]. 4. status [REDACTED]. The following concerns with wound assessment at the nursing facility were identified: a. Review of the nursing home medical record revealed the resident was admitted to the nursing facility on 9/26/13 for rehabilitation following surgery, and was discharged on [DATE]. A skin check from the date of admission showed the resident was admitted with "Bruises, Open [MEDICAL CONDITION]/Pressure Ulcers, Surgical Wounds" and further noted s/he had an "ulcer on heel that is dressed that is below the ankle and above the pad of the foot." No other description of this ulcer, such as measurements or wound stage was included. Also noted on the same skin check was "resident has only one surgical wound that I know of for now until tomorrow when we can remove leg wraps." No other objective description of the resident's wounds, such as location or measurements, on admission to the facility was recorded. b. Review of daily Medicare nursing notes from 9/27/13 to 10/16/13 revealed the resident was assessed as having "skin problems" on each day, and the skin color was within normal limits. On no days were any objective data (such as measurements) that would have allowed a determination of the progress of the wounds recorded. c. Review of skin checks dated 9/30/13, 10/7/13, and 10/14/13 revealed the resident had "Bruises, Open [MEDICAL CONDITION]/Pressure Ulcers, Surgical Wounds" but failed to document any objective assessment of the wounds, such as measurements, which would have indicated whether the wound was, or was not, improving with treatments. d. Notation of a communication with the physician, dated 10/10/13 and timed at 11 AM, but entered into the computerized record system on 10/21/13 (5 days after the resident was discharged ) revealed the resident "saw Dr. (physician name) in his office and he wants (him/her) to do whirlpool treatments to (his/her) hematoma at the hospital. I called Dr. (physician name) and asked if it was ok to do whirlpool treatment here as (s/he) is here on a Medicare stay. He agreed and stated his office would fax me an order." This documentation was not noted as a late entry. e. Notation of a communication with the physician, dated 10/11/13 and timed at 1 PM, but entered into the computerized record system on 10/21/13 (5 days after the resident was discharged ) revealed "(the resident) was reported to refuse whirlpool therapy by the PT (physical therapy) staff. I called Dr. (physician name) and made him aware. He stated that (the resident) need (sic) to be informed that if (s/he) did not do the therapy (s/he) would end up in surgery for [REDACTED].' I stated that the Whirlpool was cleaned and that no other residents would be using it. I further stated that infection control processes are much better than in the past. (The resident) said (s/he) would use the whirlpool on Monday." This documentation was not noted as a late entry. f. Notation of a communication with the physician dated 10/14/13 and timed at 11 AM, but entered into the computerized record system on 10/21/13 (5 days after the resident was discharged ) revealed "(the resident) continues to refuse the whirlpool for skin care. I talked to (the resident) and (s/he) stated (s/he) wanted to see Dr. (physician name) first. I called Dr. (physician name)'s office and made an appointment for (the resident) on Friday as that was the soonest they could see her. I notified them of the issues and they stated Dr. (physician name) and (another physician) had been talking and were on the same page. (The resident) was advised to do the wound care therapy already ordered. I notified (the resident) that both doctors were aware of (his/her) need for wound care to (his/her) hematoma and that it was recommended (s/he) do the therapy in the whirlpool." This documentation was not noted as a late entry. g. Review of the nursing home discharge summary dated 10/16/13 revealed the resident required dressing changes "Right calf - Hematoma - every other day - clean - oil [MEDICATION NAME] then ABD pads - cover with Ace wrap." No summary of the resident's course of treatment for [REDACTED]. No description of the wound, such as measurements, was included. No mention was made of any heel or foot ulcers. The discharge summary further revealed the resident was discharged to an assisted living facility. h. Review of the hospital history and physical dated 10/16/13 revealed the resident was sent from the assisted living facility to the emergency roiagnom on that same day (10/16/13) for evaluation of the wound on his/her right leg. From the emergency room , the resident was taken to the operating room, where s/he underwent incision and drainage of "right lower extremity necrotic eschar." Review of the hospital operative report dated 10/16/13, timed at 9:14 PM, revealed findings of "a 14 X (by) 17 cm necrotic eschar on (his/her) right lower extremity in the medial calf. This had skin that was completely nonviable and was petrified. Underlying this, there was coagulated old hematoma. The necrotic skin was removed entirely. The hematoma was evacuated. After [MEDICATION NAME] the wound surface, I pulse irrigated the wound with 3 L (liters) of pulse irrigation. " i. No evidence was provided that demonstrated regular, comprehensive assessment of this resident's wound, with ongoing communications of the wound status to the physician for consideration of treatment options. Interview with RN #1 on 11/7/13 at 2:17 PM revealed, "We (the facility) don't usually measure hematomas." 2. Medial record review showed resident #23 showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 8/29/13 showed the resident was identified as being at risk for developing pressure ulcers. Interventions included turn and reposition frequently, include in skin meeting weekly and notify MD of skin issues. The following concerns were identified: a. Review of the admission skin assessment dated [DATE] revealed the resident had a surgical site on the left lower leg where a [DIAGNOSES REDACTED] was removed. There was no description or measurement of the wound and there was no indication whether the wound was located on the front or the back of the leg. Review of skin checks dated 9/3/13, 9/10/13, 9/17/13, 9/24/13, and 10/1/13 also failed to identify the exact location, description or measurements of the left lower leg wound and listed the wound as a skin tear. The skin check dated 8/20/13 did not address any wounds on the left lower extremity. b. Additional review of the medical record showed the resident was hosptalized on [DATE] and readmitted to the facility on [DATE]. Review of the skin assessment and wound documentation dated 10/6/13 showed the resident had a skin tear on the left lower leg that had a dressing. There was no documentation of the exact location, measurement or appearance of the wound. Review of additional skin checks revealed there was no documentation of the exact location, measurement or appearance of the wound on the left lower extremity. c. Further review of the medical record showed the resident was hospitalized for [REDACTED]. Review of a nursing note dated 10/29/13 showed the resident had an open wound on the posterior left lower calf that was, "large, open, moist with yellow slough,~ (approximately) 5 cm." Review of a late-entry nursing note dated 11/4/13 showed the wound was present on re-admission, a non-pressure ulcer, the wound was red/pink with yellow slough inside wound bed and had scant drainage with no odor. Measurements were 6.0 cm by 5.0 cm and the wound was 0.5 cm deep. d. Observation of the posterior left lower leg wound on 11/7/13 at 2 PM with RN #1 revealed the RN assessed the wound measurements as 7.5 cm by 3.5 cm and the depth was not measured. The upper portion of the wound, approximately 25%, was bright red. The middle approximately 25% was covered with yellow slough and the lower portion, approximately 50% of the wound, was covered with eschar (black/brown leathery dead tissue). Interview with RN #1 at the time of the observation revealed the resident, "had the wound when (s/he) was admitted to the facility." There was no additional documentation of the exact location, appearance, or measurement of the wound on the posterior left lower leg provided. 3. Medical record review showed resident #16 was admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE] revealed [DIAGNOSES REDACTED]. Skin check documentation dated 10/25/13, timed 1:33 PM, indicated the resident had a "Hematoma to left inner calf - 11 cm X (by) 8 cm. Also has purple discoloration to inner buttocks - skin repair cr. (cream) applied." Additionally, "...Will also apply skin repair cr. (cream) TID (three times daily) to left inner calf open to air and area circled with a red pen." A physician's telephone order dated 10/25/13 revealed instructions to "Monitor hematoma left inner calf QD (every day) for increase in size." The following concerns with wound assessment were identified: a. Review of nursing notes from 10/26/13 through 10/29/13 failed to show any evidence the lesion on the resident's left calf was being monitored for size. b. Skin check documentation dated 10/31/13, timed 10:27 PM reiterated the size of the hematoma as "11 cm X 8 cm." No further measurements of the lesion were found in the record. c. Review of the wound rounding report dated 11/4/13 revealed only that the resident had a hematoma to the left lower extremity, the treatment was recorded as "opsites - [MEDICATION NAME]?" and the wound progress was recorded as worsening. No indication of how the lesion was worsening was recorded. No objective data, such as measurements of the lesion, were recorded. d. Wound progress notes dated 11/6/13, timed 7:23 AM, revealed documentation of a "raised hematoma with [MEDICAL CONDITION]" to the left lower leg. The lesion was described as "Large hematoma, black/red, draining bloody fluid. peri wound is red, warm. painful with cleansing. no odor. Cleansed, dried, maxsorb (sic) extra ag and kerlix applied." No measurement of the lesion was recorded. e. Observation of a change of the resident's dressing on 11/7/13 revealed a large, raised lesion on the resident's lower left medial leg. In the center of the raised lesion was an area of eschar. The dressing that had been applied to the lesion was stuck to this area of eschar. The entire lesion had been outlined in red ink. The raised area of the lesion continued to the line of red ink, but did not extend beyond it. RN #1 stated at the time of the observation, "We (the facility) don't usually measure hematomas." At the request of the surveyor the lesion was measured. Measurements taken by RN #1 at the time of the observation revealed the overall size of the lesion was 8 1/2 cm by 7 cm. The area of eschar in the center of the lesion was also measured at that time, and measured 5 cm by 3 cm. 4. Review of the facility's policy and procedures on the subject of "Pressure Ulcer Prevention/Skin Assessment/ Documentation/ Staging/Treatment" reveals the purpose of the policy is to "Identify all skin abnormalities that are present on admission and throughout the resident's length of stay" and "Gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designed to meet the resident's skin care needs." 5. Interview with RN #1 on 11/7/13 at 1:15 PM revealed that facility nursing interventions were derived from "Nursing Interventions and Clinical Skills" by Perry, Potter and Elkin. According to Perry, Potter and Elkin, "Nursing Interventions & Clinical Skills" 5th ed. St. Louis, MO: Mosby, 2012, page 585 "Wound assessment is essential in wound management. The assessment of the following factors: location, dimensions, undermining, drainage, tissue type, exudate, wound edges, and pain, plays an important role in correct [DIAGNOSES REDACTED]. A uniform approach to wound assessment that uses measurements can identify the appropriate treatment plan and appropriately evaluate progress to healing."