Every finding on record at Spanish Peaks Veterans Community Living Center

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for abuse out of six sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse Prohibition policy, revised January 2025, was provided by the nursing home administrator (NHA) on 6/18/25 at 3:24 p.m. The policy read in pertinent part, The policy of this facility is to make all efforts to protect its residents from abuse. The facility will educate staff and residents on how to avoid situations that may result in an abuse incident. The facility has implemented proactive rounding to identify any potential triggers that may lead residents to respond negatively to each other and to identify stimuli such as wandering residents. This proactive approach will promote a safe environment that is free of abuse and identify triggers that will help avoid abuse. II. Incident of physical abuse on 5/19/25 by Resident #2 towards Resident #1 A. Facility investigation The 5/19/25 facility investigation was received from the NHA on 6/18/25 at 11:22 a.m. The investigation documented that Resident #2 walked to Resident #1's doorway. Resident #1 told Resident #2 she could not enter his room. Resident #2 threw hot coffee on Resident #1. The investigation documented facility staff responded to the altercation and separated the residents. The nurse completed an assessment on both residents and documented that Resident #1 had a four centimeter (cm) by four cm red area on his right elbow from the hot coffee. Resident #2 had no injuries. The facility investigation indicated physical abuse was substantiated. B. Resident #2 (assailant) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician's orders (CPO), diagnoses included Alzeheimer's disease and dementia. The 6/11/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #2 was dependent on staff for standing and required substantial to maximum assistance from staff for walking a distance of fifty feet. The MDS assessment documented the resident had no physical or behavioral symptoms directed towards others during the assessment look back period. 2. Record review The behavioral care plan, revised 5/19/25, revealed Resident #2 could injure other residents by lashing out, wandering into other residents' rooms and taking personal belongings. The care plan indicated Resident #2 had an episode of physical aggression when she wandered into another resident's room and threw hot coffee onto a resident. Pertinent interventions included placing door signs on other residents' doors to prevent her from wandering into their rooms (initiated 2/21/24), assisting the resident to designated areas to prevent wandering into other resident rooms (initiated 2/21/24), redirecting the resident immediately if observed wandering (initiated 2/21/24) and educating the resident not to throw items at others (initiated 5/19/25). The dementia care plan, revised 4/27/25, revealed Resident #2 had behaviors of invading others personal space and had unprovoked physical aggression towards others. Resident #2 had a history of taking food and throwing food related items at other residents. Interventions included Resident #2 was to be the last resident up for meals for close supervision when she was out of bed. Resident #2 was not to have coffee unless she was closely supervised (initiated 4/28/25). The 5/15/25 behavioral progress note, documented at 6:33 p.m., revealed Resident #2 had been wandering down hallways and entering other residents' rooms and taking their personal belongings. Immediate interventions included redirection, one-to-one observation and offering toileting, food and fluids. The nurse documented redirection and one-to-one observation was effective. The 5/19/25 behavioral progress note, documented at 2:52 p.m., revealed Resident #2 had been wandering into other residents' rooms for most of the day. Immediate interventions included redirection out of other residents' rooms to her room, one-to-one observation, offering toileting, food and fluids. The nurse documented Resident #2 was redirected to her room, which was effective. The 5/20/25 nurse progress note, documented at 4:07 p.m., revealed the nurse notified the physician Resident #2 had increased behaviors. The physician gave a new order for gabapentin, 100 milligrams (mg) three times a day for behavior management of increased aggression. Review of Resident #2's electronic medical review (EMR) revealed Resident #2 was monitored for 72 hours after the altercation on 5/19/25 and no additional behaviors were documented. C. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included disorganized dementia, bipolar disorder (mental illness), anxiety, parkinsonism, and post-traumatic stress disorder (PTSD). The 5/14/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. Resident #1 was independent with standing and walking. The MDS assessment documented the resident had no physical and behavioral symptoms directed towards others during the assessment look back period. 2. Record review The 5/19/25. nurse progress note, documented at 2:51 p.m., revealed Resident #1 had slight redness noted to his right upper arm from the hot coffee that was thrown on him. Resident #1 denied pain or discomfort to the area of redness. The 5/20/25 nurse progress note, documented at 4:38 a.m., revealed Resident #1 had slight redness on his right arm where coffee was thrown on him. Resident #1 reported no pain to the area of redness. Review of Resident #1's EMR revealed the resident was monitored for 72 hours after the 5/19/25 incident and denied pain or feeling afraid of other residents. III. Staff interviews The director of nursing (DON) and the NHA were interviewed together on 6/18/25 at 2:35 p.m. The DON said Resident #2 had a history of wandering throughout the facility and throwing food items at other residents. The DON said Resident #2's care plan directed staff to monitor Resident #2 when wandering. The DON said on 5/19/25, staff assisted Resident #2 out of bed early and the resident wandered to Resident #1's room before staff were free to monitor Resident #2. The DON said Resident #2 should not have had hot coffee without staff supervision. The NHA said staff responded promptly to the altercation and separated Resident #1 and Resident #2 for safety. The NHA said Resident #1 had a red area on his arm from the hot coffee that did require medical attention. The NHA said after the altercation on 5/19/25 the facility updated Resident #2's care plan. The NHA said staff were educated to monitor Resident #2 whenever she was outside of her room. The NHA said after the 5/19/25 occurrence, Resident #2 had no additional aggressive behaviors.

Based on record review and interviews, the facility failed to ensure three (#65, #56 and #12) of three residents reviewed out of 28 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent a resident-to-resident altercation between Resident #65 and Resident #56; and, -Protect Resident #12 from physical abuse by Resident #65. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, dated 8/1/18, was provided by the nursing home administrator (NHA) on 12/2/24 at 12:39 p.m. It read in pertinent part, It is the policy of this facility to make all efforts to protect its residents from abuse. The facility will periodically interview staff, residents and families to determine if there are any situations that could lead to a possible incident (staff stress, resident behaviors). The facility will educate staff and residents on how to avoid situations that may result in an abuse incident. The facility will educate staff and residents of possible incidents and allegations which need to be reported. This can be accomplished by role-playing or by using the training modules. Upon receiving a report of alleged abuse, the administrator or designee will ensure that a Report of Alleged Resident abuse Incident Report is completed. The administrator/designee will review the report to determine if reasonable cause exists to suspect abuse. If this is determined, the administrator/designee will convene the investigation team to begin the investigation following the appropriate abuse policy and procedure. If suspected or actual abuse has been identified, the first step in the reporting process is to ensure residents' safety. Once a report of abuse and it has been determined there is reasonable suspicion, the following will occur: Resident-to-Resident: Separate residents. Contact law enforcement to remove the perpetrator if necessary. Monitor residents to ensure there are no further incidents. II. Failure to prevent a resident-to-resident altercation between Resident #65 and Resident #56 A. Facility investigation of the incident between Resident #65 and Resident #56 on 10/29/24 The facility's investigation of the 10/29/24 incident between Resident #65 and Resident #56 was provided by the director of nursing (DON) on 12/4/24 at 2:30 p.m. The investigation, dated 10/29/24 at 12:40 p.m., documented the following information: Resident #56 followed Resident #65 to his room. Licensed practical nurse (LPN) #2 reported she heard Resident #65 say Get out of here. LPN #2 entered Resident #65's room and saw Resident #56 and Resident #65 pushing each other. Resident #65 fell to his knees and Resident #56 was standing over Resident #65 trying to help him off the floor by his shirt. LPN #2 redirected Resident #56 out of Resident #65's room. Resident #56 had no injuries and Resident #65 had three small abrasions to his right elbow. Neither resident could recall or describe the incident. Both residents denied pain or fear of anyone. Resident #65 denied anyone entering his room or being in an altercation with anyone. Resident #56 was interviewed on 10/29/24 and had garbled speech and was not able to complete the interview. When asked what occurred in the room, Resident #56 had inappropriate verbal responses about another topic. Resident #65 was interviewed on 10/29/24 and when asked if someone entered his room, he said no. When asked if someone hurt him, he said no. When asked if someone pushed him, he said yes, and when asked if he pushed anyone, he said no. When asked if he was fearful of anyone he said no. When asked if he could explain what happened in his room, Resident #65 did not reply. The investigation indicated both Resident #56 and Resident #65 had a history of wandering, pacing, being territorial and a history of physical and verbal aggression toward staff. The conclusion of the internal investigation was the facility did not substantiate physical abuse as both residents had dementia. -However, Resident #65 sustained three small abrasions to his left elbow from the altercation, indicating abuse occurred. A. Resident #65 1. Resident status Resident #65, age 75, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included dementia with agitation, depression and post-traumatic stress disorder (PTSD). The 8/14/24 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory loss with severe cognitive impairment and severely impaired decision-making ability. He required dependent assistance with showering and bathing. He was independent with all other activities of daily living (ADL). The assessment indicated Resident #65 had no physical or verbal behavioral symptoms directed towards others. 2. Record review The short term and long-term memory care plan, revised on 5/30/24, documented Resident #65 had memory loss with severe cognitive impairment and severely impaired decision-making skills related to a diagnosis of dementia. Interventions included providing medications for the resident as ordered, monitoring for effectiveness and adverse reactions, keeping the physician and the resident's representative updated as needed, monitoring the resident for any increase in cognitive loss and informing the charge nurse and the social service director (SSD), providing the resident with clear explanations regarding expectations and procedures prior to proving any type of care or interventions and providing the resident with orientation to his immediate environment as needed. The mood and behavior care plan, revised on 10/21/24, documented Resident #65 had a diagnosis of dementia with behaviors. Targeted behaviors included, verbal/physical aggression and cursing. Interventions included certified nurse aides (CNA) monitoring targeted behaviors/offering non-pharmacological interventions and reporting to nurse for documentation and assisting with interventions as needed, if resident was exhibiting negative behaviors, attempting to redirect him by offering one-on-one activity such as talking, walking, music, wheelchair rides, a quiet place to sit, assisting the resident to his room to rest, referring the resident to social services or outside resources as needed, calling his family as needed, providing medications as ordered and monitoring for effectiveness, keeping the physician and the resident's representative updated as needed, monitoring the resident for early signs of distress, such as agitated speech, cursing and/or angered expressions and attempting to de-escalate behaviors by decreasing stimulation, reapproaching later or spending one-on-one time with the resident. -The care plan was not revised to include the incident with Resident #56 on 10/29/24. Review of Resident #65's electronic medical record (EMR) revealed the following progress notes: The 5/15/24 progress note documented Resident #65 was wandering the hallways and into other residents'rooms and when redirected he raised his hand to a CNA. The 5/16/24 progress note documented Resident #65 was wandering into other residents' rooms and was found sleeping on one of the resident's beds. The 5/29/24 progress note documented Resident #65 was walking around the unit barefoot and had no shirt on. When staff tried to assist the resident, he cursed at staff and went to his room and closed his door. The 6/21/24 progress note documented the nurse was checking Resident #65's blood sugar and when the nurse was done, the resident reached up and hit the nurse. When the nurse asked why he hit her he said because I can. The 8/20/24 progress note documented Resident #65 got into the staff charting room/breakroom and was going through the staff lunches. When staff approached the resident, he muttered an expletive and walked away. Later on in the morning, he was walking into the dining room and pushed the activity aide. The 8/29/24 progress note documented a CNA went into the resident's room to give him clean clothes and told the resident she was going to help him clean his room. Resident #65 grabbed the CNA by the face and raised his fist and told the CNA to Get the (explicit) out of my face. The 9/17/24 progress note documented Resident #65 was in the shower room with the bath aide. The nurse heard raised voices and the bath aide was heard saying Please don't hit me. Resident #65 declined to get dressed and attempted to hit the bath aide. Resident #65 was following the bath aide around the bathing room trying to hit her. The 10/1/24 progress note documented Resident #65 pushed a CNA as she was trying to pick up his belt from his robe as it was dragging on the floor. The 10/11/24 progress note documented Resident #65 became aggressive and physically assaultive towards the shower aide. Resident #65 was swinging at the shower aide with his fist. The shower aide was able to move out of the way to avoid contact. Resident #65 exited the bathing room naked and the DON attempted to redirect him and he physically assaulted her by hitting her in the arm and shoving her into the doorframe. The 10/11/24 progress note documented that during lunch Resident #65 grabbed a box of cookies and when staff got the box back, Resident #65 aggressively grabbed the cookies out of the staff members hand and left the dining room with the whole box. Resident #65 then came out of his room naked and was redirected back to his room. When staff redirected him back to his room Resident #65 poked the staff member on the side of her chest with his fingers in an aggressive manner. The 10/29/24 nursing progress note documented the medication nurse reported she heard Resident #65 say, Get out of here. She saw Resident #56 going into Resident #65's room. When the nurse entered Resident #65's room, she saw both residents pushing each other. Resident #65 fell to his knees and Resident #56 was standing over Resident #65 trying to pull Resident #65 up by his shirt. The nurse redirected Resident #56 out of Resident #65's room. Both residents were placed on one-on-one supervision and close monitoring for a few hours post-incident. The 10/30/24 interdisciplinary team (IDT) meeting note documented the altercation between Resident #56 and Resident #65 was reviewed. Interventions implemented in response to the incident included redirecting others away from Resident #65's room, giving direction for Resident #65 to avoid hitting or shoving others and providing close monitoring and one-to-one supervision as needed. The 11/15/24 nursing progress documented CNA #9 reported that she heard Resident #12 say Hey, hey then saw Resident #65 punch Resident #12 with his right fist to Resident #12's cheek. Resident #12 was in the hallway, just before the entrance to the dining room. Resident #65 had gone into the dining room and when coming back out, Resident #65 tried to punch Resident #12, then proceeded to punch Resident #12 again and made contact to Resident #12's left cheek. CNA #9 intervened to keep the residents separated. When asked what happened, Resident #65 closed his eyes and did not answer. When the nurse asked Resident #65 if he had hit anyone, Resident #65 kept his eyes closed and shook his head side to side for no (see incident between Resident #65 and Resident #12 below). B. Resident #56 1. Resident status Resident #56, age less than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included Alzheimer's disease, dementia and depression. The 10/9/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. He required dependent assistance with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene. 2. Record review The care plan for agitation, revised on 10/21/24, documented Resident #56 had a diagnosis of dementia with agitation and was on antipsychotic medication. He was also prescribed an anticonvulsant for his behaviors. Targeted behaviors included hallucinations, delusional thinking, verbal and physical aggression, agitated pacing, paranoia, irritability and invading others' personal space. Interventions included CNAs monitoring targeted behaviors/offering non-pharmacological interventions and reporting to nurse for documentation and assisting with interventions as needed, if resident was exhibiting negative behaviors, staff was to attempt to redirect him by offering one-on-one activity such as talking, walking, music, wheelchair rides, a quiet place to sit, assisting the resident to his room to rest, referring resident to social services or outside resources as needed, monitoring resident for any changes in his behaviors, such as lethargy, dizziness, falls, yelling and/or hitting out, crying, isolation, changes in eating habits, weight changes, monitoring resident for early signs of distress, such as agitated speech, cursing and/or angered expression and attempt to de-escalate behaviors by decreasing stimulation, reapproaching later or spending one-on-one time with the resident. The care plan for behaviors, revised on 9/30/24, documented Resident #56 had a history and potential to display behaviors related to his Alzheimer's dementia. Resident #56 could display territorial behaviors, verbal aggression, irritability, agitated pacing, invading personal space, paranoia, delusional thoughts, increased frustration related to difficulty expressing self, anxiousness about missing his wife and dog. Triggers identified from past incidents and history included touching the resident and grabbing things from the resident, blocking the resident in a blocking motion or cutting him off, interrupting the resident, arguing with the resident, trying to staff not acknowledging him, telling the resident no or you can not do that. Interventions included allowing the resident time to communicate, avoiding rushing the resident, validating feelings, showing empathy, when invading others' personal, space-step back and avoid talking abruptly and avoid touching the resident, when resident was agitated with rapid speech and hand gesture and in others' personal, space step back, if resident took something, allowing him time to put it down, asking him kindly to have the item back but not reaching for it or taking it from him, if resident exited a door, asking the resident if he would like to go for a walk in whatever direction he was heading, avoiding grabbing or blocking him as this triggered his agitation, avoiding overcrowding the resident when he was agitated, if staff was a known trigger, avoiding interaction with the resident for that day, taking the resident for walks and outdoors, talking about the [NAME] Bay Packers, Bigfoot and giving him ice cream, talking about dogs, redirecting the resident with topics of interest, allowing the resident to express himself and listening to him, if the resident was angry, asking if he would like to get a diet Pepsi, CNAs monitoring targeted behaviors/offering non-pharmacological interventions and reporting to nurse for documentation and assisting with interventions as needed, if resident was exhibiting negative behaviors attempt to redirect him by offering one-on-one activity such as talking, walking, music, wheelchair rides, a quiet place to sit, assisting him to his room to rest and referring resident to social services or outside resources as needed, monitoring environment for possible stressors, monitoring resident for any changes in his behaviors such as lethargy, dizziness, falls, yelling and/or hitting out, crying, isolation, changes in eating habits, weight changes, notifying charge nurse, physician and representative as needed and monitoring the resident for early signs of distress such as agitated speech, cursing and/or angered expression and attempting to de-escalate behaviors by decreasing stimulation and reapproaching later or spending one-on-one time with the resident. The 10/29/24 nursing progress note documented the medication nurse reported she heard Resident #65 say, Get out of here. She saw Resident #56 going into Resident #65's room. When the nurse entered Resident #65's room, she saw both residents pushing each other. Resident #65 fell to his knees and Resident #56 was standing over Resident #65 trying to pull Resident #65 up by his shirt. The nurse redirected Resident #56 out of Resident #65's room. Both residents were placed on one-on-one supervision and close monitoring for a few hours post-incident. The 10/30/24 interdisciplinary team (IDT) meeting note documented the altercation between Resident #56 and Resident #65 was reviewed and the physical aggression between Resident #56 was initiated by Resident 65. Interventions included giving boundaries that were consistent with telling Resident #56 that when a door was closed, he should not enter, assisting the resident with redirection, closely monitoring the resident and one-on-one supervision as needed. III. Failure to protect Resident #12 from physical abuse by Resident #65 A. Facility investigation of the incident of physical abuse by Resident #65 toward Resident #12 on 11/15/24 The facility's investigation of the 11/15/24 incident between Resident #12 and Resident #65 was provided by the DON on 12/5/24 at 12:30 p.m. The investigation, dated 11/15/24 at 10:43 a.m., documented the following information: Resident #65 had gone into the dining room and when he came out into the hallway he punched Resident #12. Resident #12 was heard saying, Hey, hey which alerted CNA #9. CNA #9 saw Resident #65 punch Resident #12 with his right fist to Resident #12's left cheek. CNA #9 immediately separated both residents. Resident #65 was placed on one-to-one supervision immediately. Resident #65 was interviewed on 11/15/24 and refused to answer questions about the incident. Resident #12 was interviewed on 11/15/24 and was non-verbal. Resident #12 did not answer questions and had no changes in behavior. The investigation indicated Resident #65 had a history of aggressive behaviors and recent assault on Resident #12, which was unprovoked. The conclusion of the investigation was that the facility substantiated the physical abuse. B. Resident #12 1. Resident status Resident #12, age 79, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included neurocognitive disorder with Lewy bodies dementia (causes a gradual decline in thinking abilities, especially in attention, visual perception and executive function) and anoxic brain damage. The 10/2/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. He required dependent assistance with all ADLs. According to the MDS assessment, Resident #12 had no physical or behavioral symptoms directed towards others. 2. Record review The care plan for dementia, revised on 3/15/23, documented Resident #12 had a diagnosis of dementia with depression. He had a history of irritability, weight loss, social isolation and flat affect. Interventions included encouraging the resident to express his/her feelings with nursing and social services, keeping the physician and representative informed of all significant findings and changes, monitoring the resident for signs or symptoms of depression, such as crying, verbalizations of sadness, isolation, changes in eating habits, changes in weight, agitation, increased sleeping, reporting any significant findings to charge nurse for assessment and follow-up, monitoring the resident's environment for possible stressors and referring to social service director and/or outside resources as needed. The care plan for PTSD (post-traumatic stress disorder), revised on 10/9/23, documented Resident #12 had potential for injury to self and others related to diagnosis of and history of PTSD. Interventions included approaching Resident #12 in a calm friendly manner, when approaching the resident, staff was to always tell him their name and why they were there, explaining what staff would like to do prior to giving any care, monitoring the resident for increases in negative behaviors and reporting any significant findings to charge nurse, providing resident one-to-one quiet discussion if he was willing, attempting to find quiet areas for the resident to sit when he was agitated, referring to social service director as needed, referring resident to outside resources if needed, reorienting the resident to his environment and the people around him and reassuring him of his safety. The 11/15/24 progress note documented CNA #9 reported that she heard, Hey, hey, then saw Resident #65 punch Resident #12 with his right fist to Resident #12's cheek. Resident #12 was in the hallway, just before the entrance to the dining room. Resident #65 had gone into the dining room and when coming back out, Resident #65 tried to punch Resident #12, then proceeded to punch Resident #12 again and made contact to Resident #12's left cheek. CNA #9 intervened to keep the residents separated. Resident #12 was able to move his face and there was no noted discoloration, no grimace or other signs of pain. Resident #12 was unable to give a description of the incident. Resident #12 was immediately moved away from the hallway and placed in the dayroom for his own protection. The 11/18/24 IDT meeting note documented the incident of physical aggression was reviewed. Interventions included keeping pathways clear, monitoring the assailant for further behaviors, close monitoring of all residents and monitoring Resident #12 for any psychosocial harm, fear or injury. IV. Staff interviews LPN #2 was interviewed on 12/5/24 at 10:10 a.m. LPN #2 said she was not working when both incidents involving Resident #65 occurred. She said when she returned to work, she was informed that Resident #65 had been violent towards another resident. She said Resident #65 had never been violent towards other residents. She said Resident #65 had been agitated and verbally aggressive towards staff, but not residents. LPN #2 said prior to the abuse incidents, Resident #65, Resident #56 and Resident #12 had had no interactions with each other. She said Resident #65 did his own thing and would only see Resident #56 and Resident #12 in passing during meal times. She said Resident #65 stayed in his room a lot and would come out when he was hungry or needed something. LPN #2 said Resident #65 was non-compliant, stubborn and had no social boundaries. She said Resident #65 had no awareness of his behaviors and did not care. LPN #2 said when Resident #65 was not following directions, she would provide continuous education to Resident #65 and notify him that other residents lived in the facility too. She said she would constantly coach Resident #65 on having boundaries. Registered nurse (RN) #7 was interviewed on 12/5/24 at 11:17 a.m. RN #7 said Resident #65 and Resident #56 had no prior behaviors towards each other. She said Resident #65 had been aggressive towards staff in the past but had not been aggressive towards other residents. She said Resident #65 would come into the staff's space and get close to the staff's faces. She said staff would redirect Resident #65 and back out of his way when he got too close. She said staff would remove themselves from Resident #65 and would offer him something to keep him calm, such as food or a drink. She said Resident #65 did not communicate much but would ask for food and drinks. The NHA and the director of nursing (DON) were interviewed on 12/5/24 at 3:27 p.m. The DON said she had received a report from the nurse about the incident with Resident #65 and Resident #56 on 10/29/24. The DON said the nurse heard someone say get out. She said when the nurse arrived in Resident #65's room, Resident #56 and Resident #65 were pushing each other. She said Resident #65 had fallen to the ground and Resident #56 was trying to help Resident #65 back up. She said she could not determine who was the assailant in the incident. She said when she reviewed the video footage, she could see Resident #56 trying to get into the room. She said she saw Resident #56 stumble back when Resident #65 opened his door. She said no one saw who started the pushing back and forth. She said she determined Resident #65 was the assailant because he had pushed Resident #56 out of the room. The DON said she did not substantiate the incident between Resident #65 and Resident #56 because both residents had no intent and both residents had dementia. The NHA said she had received a call from the DON about the incident between Resident #65 and Resident #12 on 11/15/24. The NHA said she went to the secured unit to see what happened. The NHA said she reviewed the video footage because part of the incident was not witnessed. She said what she saw on the video was Resident #12 wheeling himself out of the dining room when Resident #65 was going into the dining room. She said when Resident #65 went into the dining room, he squeezed by Resident #12 and made a loop and came back out on the other side of Resident #12. She said Resident #12 then said hey, hey and Resident #65 turned around and made a closed fist and swung and missed Resident #12. Resident #65 then swung at Resident #12 a second time and hit Resident #12 on the cheek. She said CNA #9 heard the noise and separated the two residents. The NHA said after the incident between Resident #65 and Resident #12, both residents carried on as if nothing had happened. Resident #12 was assessed and there was no injury and the resident did not voice any pain. She said staff kept Resident #12 and Resident #65 away from each other. She said Resident #65 was placed on one-to-one supervision. The NHA said Resident #65 was grouchy and if anyone got in his way, he would push them out of the way. She said if Resident #65 did not like what staff was saying or if they were redirecting his behaviors, he would get mad. She said Resident #65 had been physically aggressive with staff. She said Resident #65 had punched at the bath aide during his shower time. She said Resident #65 had also pushed the DON into the door. She said Resident #65's aggression was directed towards staff and never directed towards residents. The NHA said she was not made aware of Resident #65 having a history of aggressive behaviors prior to his admission. She said Resident #65 was redirectable but he was becoming difficult to redirect. The NHA said she was concerned with the severity of the incident on 11/15/24. The NHA said Resident #65 was a threat to other residents, especially after striking out at a resident who was not able to defend himself. She said she had had conversations with Resident #65's representative prior to the incident on 11/15/24. She said the representative decided to take the resident home after the incident with Resident #12 because she did not want him to hurt anyone else.

Based on record review, observations and interviews, the facility failed to ensure a through safety assessment was completed and documented before the installation of side/bed rails for four (#70, #57, #63 and #38) of 10 residents out of 28 sample residents. Specifically, for Residents #70, #57, #63 and #38, the facility failed to: -Ensure the residents were thoroughly assessed prior to the installation of bed rails, to include the residents' medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed); and, -Evaluate the use of alternative interventions prior to the installation or use of a bed rail and how those alternatives failed to meet the residents' assessed needs. Findings include: I. Facility policy and procedures The Devices - Restraints/Safety/Positioning/Mobility Devices policy, reviewed on 6/2020, was provided by the nursing home administrator (NHA) on 12/4/24 at 1:58 p.m. The policy revealed residents were assessed for the need of a device and/or restraint in an appropriate environment to maintain the dignity, quality of life, safety and mobility in the least restrictive manner. A physician's order was required for use of physical devices or restraints. The order would indicate the type of device/restraint, and the purpose for the restraint or device. The resident and their responsible parties would be educated regarding the benefits and potential risks or injury of the usage of a restraint and/or device. A consent would be obtained from the resident or their responsible party. Devices or restraints were indicated for safety or enabling and improving the resident's mobility. Before a restraint was considered, all other less restrictive alternatives and interventions should be considered. Documentation would be maintained for each resident that addressed current restraints and/or devices in use. Documentation would include the need for the device, related to behavior or medical condition and its effectiveness. All devices and/or restraints would be reviewed at scheduled device review meetings. Placement of side rails or transfer bars would be monitored for risk of entrapment routinely by maintenance. A safety evaluation would be completed by occupational therapy (OT) and/or physical therapy (PT) on transfer aides and motorized wheelchairs that they recommend and evaluated for the right appropriate device for mobility and safety. II. Resident # 70 A. Resident status Resident #70, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of the liver with ascites, tremors, unsteadiness on feet and mild cognitive impairment. The 8/28/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) score of 11 out of 15. The MDS assessment indicated the resident was independent without staff assistance for rolling left to right, sitting to lying, lying or sitting on the side of the bed and sitting to standing. B. Observations On 12/2/24 at 1:43 p.m., there were two-quarter side rails on Resident #70's bed. On 12/4/24 at 2:26 p.m., there were two-quarter side rails on the resident's bed. C. Record review A physician's order dated 7/29/24 at 2:30 p.m. revealed to install two transfer bars (bed rails) for mobility to Resident #70's bed. Resident #70 signed a Transfer Bar Consent form dated 7/29/24 at 2:29 p.m. The reason for the transfer bars was to assist the resident with mobility. The potential risks were explained to the resident. Potential risks might include accidental injury due to head and neck entrapment that could result in death, injury from falls/bumping transfer bars, and loss of independence in mobility. -However, the physical therapy assessment section of the consent form was blank and did not reveal that an assessment had been conducted to determine if Resident #70 would safely benefit from the implementation of the side rails. The risk for injury/falls care plan, initiated 8/25/24 and revised 9/30/24, revealed Resident #70 was at risk for injury/falls related to impaired mobility, episodes of increased confusion since readmission, history of falls, short-term memory deficit and poor safety awareness. -The care plan did not include the resident utilized bed rails on the bed for mobility and/or transfers. Resident #70 had one bed rail device review dated 11/27/24 related to the use of two transfer bars (bed rails) on the bed for assistance with bed mobility and transfer safety. The review did not recommend any changes needed to be made. -Review of Resident #70's electronic medical record (EMR) revealed no documentation to indicate the resident was thoroughly assessed prior to the installation of the bed rails to include the resident's medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed). -Further review of Resident #70's EMR revealed there was no documentation to indicate what alternatives to bed rails were attempted prior to the installation of the bed rails or how those alternatives failed to meet the resident's assessed needs. III. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia with agitation, and frontotemporal neurocognitive disorder. The 11/13/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. The MDS assessment indicated the resident was given partial/moderate staff assistance for rolling left to right, sitting to lying, lying or sitting on the side of the bed and sitting to standing. B. Observations On 12/2/24 at 1:52 p.m., there were half-side bed rails on both sides of Resident #57's bed. On 12/4/24 at 2:31 p.m., Resident #57 was lying in the middle of the bed on his back. The bed had two half-side bed rails on the bed. C. Record review A physician's order dated 8/10/23 at 12:08 p.m., revealed to install two transfer bars (bed rails) for mobility to Resident #57's bed. Resident #57 signed a Transfer Bar Consent form dated 8/10/23 at 12:08 p.m. The reason for the transfer bars was to assist the resident with mobility. The potential risks were explained to the resident. Potential risks might include accidental injury due to head and neck entrapment that could result in death, injury from falls/bumping transfer bars, and loss of independence in mobility. The physical therapy assessment portion of the form revealed the resident was appropriate to have and use a transfer bar on the bed. -However, the physical therapy assessment did not reveal whether or not Resident #57's medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed) were included as part of the assessment. The risk for injury/falls care, initiated on 8/10/23 and revised on 8/10/23, revealed Resident #57 was at risk for injury/falls related to impaired mobility, history of falls, bowel incontinence and pain and muscle relaxant medications. Interventions included two transfer bars (bed rails) on the resident's bed to help with turning/positioning and to provide stability when rising. Resident #57 had six bed rail device reviews for bed rails from 8/22/23 to 11/27/24 related to the use of two transfer bars (bed rails) on the bed for assistance with bed mobility and transfers. The reviews did not recommend any changes needed to be made. -Review of Resident #57's EMR revealed no documentation to indicate the resident was thoroughly assessed prior to the installation of the bed rails to include the resident's medical diagnoses, conditions, symptoms and/or behavioral symptoms size and weight sleep habits medication(s) acute medical or surgical interventions underlying medical conditions existence of delirium ability to toilet self safely communication and mobility (in and out of bed). -Further review of Resident #57's EMR revealed there was no documentation to indicate what alternatives to bed rails were attempted prior to the installation of the bed rails or how those alternatives failed to meet the resident's assessed needs. IV. Resident #63 A. Resident status Resident #63, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included a closed fracture of the neck of the right femur, unsteadiness on feet, dementia and neurocognitive disorder with Lewy Bodies (progressive brain disease that affects mood, behavior and movement). The 11/6/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The MDS assessment indicated the resident was dependent on staff for assistance. The staff provided all of the effort and the resident did none of the effort to complete the activity or the assistance of two staff members was required for the resident to complete the activity for rolling left to right, sitting to lying, lying or sitting on the side of the bed and sitting to standing. B. Observations On 12/2/24 at 12:44 p.m. there were two-quarter side bed rails on Resident #63's bed. On 12/4/24 at 2:28 p.m. there were two-quarter side bed rails on the resident's bed. C. Record review A physician's order dated 11/27/24 at 9:26 a.m., revealed to install two transfer bars (bed rails) for mobility to Resident #63's bed. Resident #63's representative signed a Transfer Bar Consent form dated 11/27/24 at 9:26 a.m. The reason for the transfer bars was to assist the resident with mobility. The potential risks were explained to the representative. Potential risks might include accidental injury due to head and neck entrapment that could result in death, injury from falls/bumping transfer bars, and loss of independence in mobility. The physical therapy assessment portion of the form revealed the resident demonstrated appropriate motor control with environmental awareness to safely use and benefit from transfer bars to help with bed mobility and balance. -However, the physical therapy assessment did not reveal whether or not Resident #63's medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed) were included as part of the assessment. The risk for injury/falls care plan, initiate 8/14/24 and revised 9/12/24, revealed Resident #63 was at risk for injury/falls related to impaired mobility, poor vision, psychotropic medication use, a history of falls, short term memory deficit, poor safety awareness and an unsteady gait. Interventions included two transfer bars (bed rails) on the resident's bed to help with turning, positioning and to provide stability when rising. Resident #63 had one bed rail device review dated 11/27/24 related to the use of two transfer bars bed rails on the bed for assistance with bed mobility and transfers. The review did not recommend any changes needed to be made. -Review of Resident #63's EMR revealed no documentation to indicate the resident was thoroughly assessed prior to the installation of the bed rails to include the resident's medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight; sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication, and mobility (in and out of bed). -Further review of Resident #63's EMR revealed there was no documentation to indicate what alternatives to bed rails were attempted prior to the installation of the bed rails or how those alternatives failed to meet the resident's assessed needs. V. Resident #38 A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included Alzheimer's disease and dementia. The 10/16/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. She required dependent assistance with all activities of daily living (ADL). B. Observations On 12/3/24 at 9:27 a.m. Resident #38's bed had two quarter size bed rails attached to the bed. On 12/4/24 at 12:30 p.m. Resident #38's bed rails had an approximate three inch gap between the mattress and the bed rails and the bed rails were not tightly fastened. C. Record review The fall care plan, revised 8/16/23, documented, Resident #38 was at risk for injury/falls related to impaired mobility, poor vision, psychotropic drug use, history of falls, short-term memory deficit and poor safety awareness. Interventions included transfer bars (bed rails) on the bed times two to assist with mobility. Review of Resident #38's December 2024 CPO revealed the following physician's order: Transfer bars (bed rails) times two for bed mobility and transfers, ordered 3/7/23. The 3/7/23 Transfer Bar Consent form documented in the physical therapy assessment section of the form that Resident #38 was safe with the use of her transfer bars to assist with bed mobility and transfers. -Review of Resident #38's EMR revealed no documentation to indicate the resident was thoroughly assessed prior to the installation of the bed rails to include the resident's medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed). -Further review of Resident #38's EMR revealed there was no documentation to indicate what alternatives to bed rails were attempted prior to the installation of the bed rails or how those alternatives failed to meet the resident's assessed needs. D. Staff interview Certified nurse aide (CNA) #6 was interviewed on 12/5/24 at 12:08 p.m. CNA #6 said Resident #38 used her transfer bars (bed rails) for turning in bed and when sitting up in bed. CNA #6 said the staff asked Resident #38 to grab onto the bed rail and she would usually help the staff with turning her. VI. Additional staff interviews The director of rehabilitation (DOR) was interviewed on 12/5/24 at 9:50 a.m. The DOR said a physical therapy assessment for the use of transfer bars (bed rails) included an assessment of the resident's ability to use the transfer bar for mobility and to be able to transfer safely. The DOR said the assessment included the function of the resident's hands to be able to grasp the bed rails, and an evaluation of the resident's strength to help in positioning and/or the ability to use the device to help in a safe transfer. The DOR said the therapist also considered the safety of the bed rails and evaluated any safety concerns, including entrapment, and would document any concerns. The DOR said the therapist assessed the resident's size in relation to the bed and the mattress in relation to the size of the bed frame. The DOR said the therapist also looked at the resident's ability to move, reposition or offload in bed. The DOR said the facility did a thorough safety assessment for the use of a side/bed rail before its installation. The DOR said the therapist did not use a specific side/bed rail safety assessment form to address all of the items that were assessed. The DOR said the therapist's assessment/recommendations were included in the physical therapy assessment section on the Transfer Bar Consent form. -However, the Transfer Bar Consent form for Resident #70 failed to document that a physical therapy assessment was conducted and the Transfer Bar Consent forms for Resident #57, Resident #63 and #38 failed to document what specific components related to the residents were assessed in determining the residents were safe to utilize bed rails (see record review above). The NHA and the director of nursing (DON) were interviewed on 12/5/24 at 2:30 p.m. The DON said the facility felt they did an adequate safety assessment for each resident prior to the installation of the transfer bars (bed rails). The DON said the facility staff thoroughly assessed each resident for medical diagnosis, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed). -However, review of the EMRs for Residents #70, #57, #63 and #38 failed to reveal documentation that each resident was assessed for all of the components prior to installation of their bed rails (see record review above). The DON said the staff knew each resident very well and knew the alternatives that were attempted prior to the installation of the bed rails and how those alternatives failed to meet the resident's assessed needs. -However, review of the EMRs for Residents #70, #57, #63 and #38 failed to reveal documentation that alternatives to bed rails were attempted for each resident prior to the installation of the bed rails or how those alternatives failed to meet each residents' needs (see record review above). The NHA said the facility was unable to provide sufficient evidence to demonstrate that a thorough safety assessment had been completed for the use of side/bed rails for mobility, position and transfers. The NHA said once the issue had been identified on 12/4/24 (during the survey), the facility took it upon themselves to complete a 100% audit of all residents with side/bed rails. The NHA said the facility completed and documented side/bed rail safety assessments that included medical diagnosis, conditions, symptoms and/or behavioral symptoms; size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed). The NHA said the facility also observed all residents' beds to ensure there were no residents that had undocumented side/bed rails. The DON said she had worked in the facility for [AGE] years and the facility had never had any concerns/issues with the use of side/bed rails. 48114

Based on record review and interviews, the facility failed to ensure one (#4) of five residents out of 28 sample residents was free from significant medication errors. Specifically, the facility failed to: -Ensure insulin was not given when Resident #4's blood glucose (sugar) level was below the parameter for administration; -Ensure insulin was consistently administered for Resident #4; and, -Ensure Resident #4 had physician orders for what to do if the resident's blood glucose was too high (hyperglycemia). Findings include: I. Professional reference According to [NAME], P.A. and [NAME], A.G. et.al., (2020), Fundamentals of Nursing, ninth edition, pp 624 - 626, Medication errors can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval. Administering extra doses, and/or failing to administer medications. Preventing medication errors is essential. Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medication: the right medication, the right dose, the right patient, the right route, the right time and the right documentation. II. Facility policy and procedure The Medication Administration policy, dated 11/17/19, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:53 a.m. It read in pertinent part, The nurse will administer the right medication to the right patient, at the right time, via the right dose, right route and right reason according to the manufacturer's specifications. The Diabetic Management policy, dated 6/1/2020, was provided by the NHA on 12/5/24 at 11:53 a.m. It read in pertinent part, Upon admission, the interdisciplinary team (IDT) evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurate related to blood glucose monitoring and antidiabetic agents. Blood glucose orders should include parameters to follow in communicating with the physician. Antidiabetic agents (insulin or oral) are administered per physician order. III. Resident #4 A. Resident status Resident #4, age 78, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, stage 5 chronic kidney disease (end stage), dependence on renal dialysis and acquired absence of right and left legs below the knee (amputations). The 10/9/24 minimum data set (MDS) assessment revealed Resident #4 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He required total assistance from staff for transfers, partial assistance with dressing and propelled himself in a wheelchair. The MDS assessment indicated Resident #4 received insulin injections seven days during the seven-day assessment review period. B. Record review Review of Resident #4's December 2024 CPO revealed the following physician's orders related to diabetes: Novolog (short acting insulin) 100 units/milliliter (ml), inject four units subcutaneously (under the skin) after meals. If the resident does not eat, hold the dose, ordered 1/29/24. Check blood glucose every morning and evening. If blood glucose is less than 100 milligram/deciliter (mg/dl) in the evening, do not administer the insulin. If blood glucose is less than 60 mg/dl, and the resident is able to swallow, give orange juice and re-check blood glucose every 15 minutes until within normal limits (WNL). If blood glucose is below 60 mg/dl and the resident is unable to swallow, give one milligram of glucagon intramuscularly (IM). Recheck blood glucose every 15 minutes until WNL and notify the provider, ordered 6/23/23. -The above physician's order to check the resident's blood glucose levels indicated if Resident #4's blood glucose level was below 100 mg/dl in the evening, the resident was not to receive insulin, however, the physician ordered parameter was not linked to the resident's Novolog insulin order. -Review of the December 2024 revealed there were no physician orders for what to do if the resident's blood glucose was too high (hyperglycemia). A review of the October 2024 and November 2024 medication administration records (MAR) revealed Resident #4 was administered Novolog insulin when the resident's blood glucose levels were below the physician ordered 100 mg/dl parameter in the evening on the following days: -On 10/29/24 Resident #4's evening blood glucose level was 94 mg/dl; -On 11/8/24 Resident #4's evening blood glucose level was 84 mg/dl; and, -On 11/27/24 Resident #4's evening blood glucose level was 85 mg/dl. -According to the physician ordered parameters for Resident #4's Novolog insulin, the resident should not have received the insulin on 10/29/24, 11/8/24 and 11/27/24 when his blood glucose level was less than 100 mg/dl (see physician's order above). A review of the October 2024 MAR further revealed the following: -On 10/9/24 Resident #4's evening blood glucose was 107 mg/dl; and, -On 10/19/24 Resident #4's evening blood glucose was 142 mg/dl. -Resident #4's documented blood glucose level was above the physician ordered parameter for withholding the resident's Novolog insulin on 10/9/24 and 10/29/24, however, there was no documentation to indicate the resident had received the insulin or any documentation to indicate why the medication had not been given. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 12/4/24 at 10:02 a.m. LPN #4 said if Resident #4's blood glucose level was below 100 mg/dl in the evening, she would hold the Novolog insulin and follow the hypoglycemia (low blood sugar) protocol if indicated. LPN #4 said if a blood glucose level reading was over 400 mg/dl she would call the physician. She said each resident should have a protocol for hyperglycemia or hypoglycemia in their physician's orders. -However, LPN #4's initials and a checkmark were documented on the October 2024 MAR the evening of 10/29/24, which indicated Resident #4's Novolog insulin was administered, even though the resident's blood glucose level reading was 94 mg/dl (below the physician ordered parameter to hold the insulin). LPN #4 said if there was a checkmark and initials on the MAR, it indicated the medication was administered. Registered nurse (RN) #1 was interviewed on 12/5/24 at 8:50 a.m. RN #1 said she normally held the Novolog insulin if Resident #4's blood glucose level was under 100 mg/dl in the evening or if he did not eat his meal. RN #1 said she was very diligent about his physician ordered parameters. -However, RN #1's initials and a checkmark were documented on the November 2024 MAR the evening of 11/27/24, which indicated Resident #4's Novolog insulin was administered, even though the resident's blood glucose level was 85 mg/dl (below the physician ordered parameter to hold the insulin). RN #1 said if the MAR was checked off on 11/27/24 that she administered the insulin, she must have administered it to Resident #4. The director of nursing (DON) was interviewed on 12/4/24 at 10:10 a.m. The DON said Resident #4's Novolog insulin order should have had the blood glucose parameter included in the physician's order for the medication. The DON said Resident #4 should not have received the Novolog insulin if his blood glucose level was under 100 mg/dl. The DON said Resident #4 should have had a hyperglycemic protocol in his physician orders. The DON was interviewed a second time on 12/4/24 at 10:33 a.m. The DON confirmed Resident #4's Novolog insulin was documented as administered on 10/29/24 11/8/24 and 11/27/24, when the resident's blood glucose was below the physician ordered parameter for holding the insulin. The DON said there was no documentation in the resident's medical record indicating the insulin was held. The DON said she would rewrite the physician's order to clarify when the insulin should be held, and add the parameter to hold the insulin if the blood glucose level was below 100 mg/dl within the Novolog insulin order. The DON said she would add a hyperglycemic protocol order to Resident #4's physician orders. The DON said the MAR should not have been left blank when a medication was scheduled to be administered. The DON was interviewed a third time on 12/5/24 at 11:04 a.m. The DON said the consulting pharmacist completed a monthly review of Resident #4's medications but did not provide any recommendations regarding the resident's insulin. The DON said the pharmacy consultant should be monitoring for missing documentation on the MARs and ensuring blood glucose parameters were followed. The DON said she would provide education to the nurses on following blood glucose parameters and documentation.

Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for two (#4 and #24) of 18 residents reviewed for accident hazards out of 28 sample residents. Specifically, the facility failed to: -Ensure scissors were not available for Resident #4 to use and prevent injury to Resident #4 when he attempted to cut his fingernails with the scissors; -Ensure essential oils were not left unsecured in Resident #4's room, who was not assessed for self-administration; and, -Ensure hydrocortisone cream was not left unsecured in Resident #24's room, who was not assessed to self-administer this medication. Findings include: I. Failure to ensure scissors were not available for Resident #4 to use and prevent injury to Resident #4 when he attempted to cut his fingernails with the scissors. A. Resident #4 1. Resident status Resident #4, age 78, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included type 2 diabetes mellitus, stage 5 chronic kidney disease (end stage), dependence on renal dialysis (the process of removing excess fluid and waste from the blood when the kidneys are not functioning) and acquired absence of right and left legs below the knee (amputations). The 10/9/24 minimum data set (MDS) assessment revealed Resident #4 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. He required total assistance from staff for transfers, partial assistance with dressing and propelled himself in a wheelchair. Resident #4 was independent with eating. 2. Observation and resident interview Resident #4 was interviewed on 12/2/24 at 2:16 p.m. He was sitting in his wheelchair in his room. He had bandaids on his thumb and two fingers on his left hand. Resident #4 said he found nail clippers in his room and he started clipping his fingernails this morning (12/2/24). He said he got too close and his fingers started bleeding so the nurse put bandaids on his fingers. 3. Record review A skin assessment, dated 12/3/24 at 6:07 p.m., documented Resident #4 had cut his fingernails on the left hand cutting the skin on his nailbed. -The assessment did not indicate which or how many fingers were affected or if treatment was provided. An incident report was completed on 12/4/24 at 1:25 p.m. regarding Resident #4's injuries to the fingers on his left hand. The report documented corrective action was to educate the resident to not cut his fingernails himself, but to ask for assistance from the nurse. -However, Resident #4 had bandaids on his fingers when interviewed on 12/2/24 at 2:16 p.m. and stated he tried to cut his fingernails on 12/2/24. A skin assessment was not documented until 12/3/24 and the incident report was not completed until 12/4/24. A nursing progress note, dated 12/4/24 at 1:28 p.m., documented Resident #4 tried to cut his fingernails on his left hand and cut his nails too close to the nail bed. Resident #4 was diabetic. The nurse clipped nails on the right hand. D. Staff interviews The NHA was interviewed on 12/3/24 at 4:05 p.m. via email. The NHA said that the nurses were the only staff allowed to trim nails for diabetic residents. LPN #4 was interviewed on 12/4/24 at 10:02 a.m. LPN #4 said Resident #4 tried to cut his fingernails with scissors that he had in his room. LPN #4 said she did not know where he got the scissors, but he must have taken them from somewhere. LPN #4 said after he cut the skin on his left hand he let the nurse trim his nails on the right hand. LPN #4 said the nurses trimmed fingernails for residents with diabetes. She said the residents should not cut their own fingernails. The NHA was interviewed on 12/5/24 at 10:37 a.m. The NHA said the nurse should have documented Resident #4's skin injury when it happened, reported the incident to the charge nurse and completed an incident report immediately. The NHA said she had no knowledge of this incident until 12/5/24 after receiving the incident report that was completed on 12/4/24. The DON was interviewed on 12/5/24 10:45 a.m. The DON said the interdisciplinary team (IDT) reviewed the incident report for Resident #4 and recommended the nurse check Resident #4's fingernails weekly on his skin assessment days and offer to trim them for him to prevent further injury. III. Failure to ensure essential oils were not left unsecured in Resident #4's room, who did not have an assessment for self-administration. A. Facility policy and procedure The Self Administration of Medication policy, revised September 2019, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:53 a.m. It read in pertinent part, Residents will be assessed for their ability to self-administer medications on admission. A physician order must be written permitting the resident to self-administer medications. The resident must verbalize understanding of his/her medication schedule and demonstrate appropriate techniques. The resident must demonstrate the ability to keep the medication locked and secured, not left out within vision or access of others. Only those medications which have been approved for bedside use may be kept at the bedside. All other medication will be kept in the medication or treatment cart at the nurse's station. The Storage and Expiration of Medications, Biologicals, Syringes and Needles policy and procedure, revised 1/1/13, was provided by the NHA on 12/5/24 at 1:55 p.m. It read in pertinent part, The facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The facility should store bedside medications or biologicals in a locked compartment within the resident's room. A. Manufacturer Safety Data Sheets (SDS) The SDS for Pink Peppercorn (Schinus [NAME] oil), dated 12/21/21, was retrieved on 12/10/24 from https://www.nhrorganicoils.com/uploads/20220119110320e_Pepper_Brazilian_SDS.pdf. The SDS revealed the product may cause skin irritation, allergic skin reactions, eye irritation and may be fatal if swallowed or entered into the airway. The SDS for Copaiba Oleoresin oil, dated 10/21/22, was retrieved on 12/10/24 from https://www.nhrorganicoils.com/uploads/20221103132608e_Copaiba_Balsam_SDS.pdf. The SDS revealed the product may cause mild skin irritation, allergic skin reactions and may be fatal if swallowed or entered into the airway. The SDS for Frankincense essential oil, dated 12/14/16, was retrieved on 12/10/24 from https://www.nhrorganicoils.com/uploads/20170607122732e_Frankincense_SDS.pdf. The SDS revealed the product may cause skin irritation, allergic skin reaction and may be fatal if swallowed or entered into the airway. B. Resident observation and interview Resident #4 was interviewed on 12/2/24 at 2:16 p.m. Resident #4 was sitting in his wheelchair in his room. Resident #4 said he had some oils that a family member told him to try for pain and memory. He pulled out three small bottles from an empty procedure glove box sitting on top of his night stand. The bottles were labeled Organic Copaiba Oleoresin, Pink Peppercorn and Frankincense. He said he was not sure how to use them but his family was supposed to come in and show him. C. Record review A review of the December 2024 physician's orders did not include the essential oils found in his room. There was not a physician's order for Resident #4 to self-administer medications or essential oils. The medical record included an incomplete assessment for self-administration of medication, dated 4/3/23, which documented Resident #4 was not interested in self-administering medication. D. Staff interviews The NHA was interviewed on 12/3/24 at 2:39 p.m. via email. The NHA said Resident #4 did not have a self-administration assessment for the essential oils. The NHA said Resident #4 ordered the oils on his own and the staff were unaware he had them in his room. The NHA said the oils were removed from his room and an evaluation was in process to determine if he could self-administer them and store them in his room. The NHA said a policy would be created regarding the use of essential oils. The DON was interviewed on 12/5/24 at 10:45 a.m. The DON said the facility did have a policy for essential oils but it was outdated. The DON said they were evaluating the essential oils and safety for Resident #4's use. The DON said the activities staff would be asked to alert nursing staff when residents got packages so the nurse could be there when they opened them and ensure the products received would not be an accident hazard. IV. Failure to ensure medication was not left unsecured in Resident #24's room. A. Resident status Resident #24, age 76, was admitted on [DATE]. According to the December 2024 CPO diagnoses included chronic obstructive pulmonary disease (damage to the airways or lungs making it difficult to breathe), schizoaffective disorder (a chronic mental illness combining schizophrenia and a mood disorder), hypertension (high blood pressure), cervical disc disorder at C5-C6 level (neck area) with myelopathy (pain, loss of feeling or function resulting from severe compression of the spine) and post-traumatic stress disorder. The 9/25/24 MDS assessment revealed Resident #24 was cognitively intact with a BIMS score of 15 out of 15. He required assistance from one staff member for transfers from bed to wheelchair and for dressing. Resident #24 was independent with transfers to the toilet and with personal hygiene. B. Resident interview and observation Resident #24 was interviewed on 12/2/24 at 2:35 p.m. Resident #24 was lying in bed. There was a tube of hydrocortisone cream on his bedside table. Resident #24 said he was using it because he had a rash. He said he did not know why it was left on his table. Resident #24 said the nurse put the cream on for him. C. Record review The comprehensive care plan, initiated on 11/17/16 and revised on 8/7/19, revealed Resident #24 was not a candidate for self-administration of medication and had a history of pocketing (holding inside the cheek) medications. Interventions included watching Resident #24 swallow his medication, reminding Resident #24 of the need to take medications while the nurse was present and monitoring Resident #24's room for medications. A review of Resident #24 electronic medical record (EMR) did not reveal an assessment for the self-administration of hydrocortisone cream had been completed. The December 2024 CPO included a physician's order for hydrocortisone external cream 1%, applied to areas of dry, itchy skin topically, every 12 hours as needed, ordered on 10/2/24. -A review of the December 2024 CPO did not reveal a physician's order for the self-administration of the hydrocortisone external cream. A review of the November 2024 and December 2024 MAR revealed the hydrocortisone cream was last administered to Resident #24 on 11/23/24, nine days prior to being observed in Resident #24's room. D. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 12/5/24 at 1:30 p.m. CNA #7 said if she found a medication or a cream in a resident's room she would turn it in to the nurse immediately. Registered nurse (RN) #2 was interviewed on 12/5/24 at 1:31 p.m. RN #2 said Resident #24 did not keep medication in his room. She said at times he tried to get the nurses to leave medication on his table. RN #2 said she did not know why the hydrocortisone cream was left in his room because it was ordered as needed and it had not been administered in several days. The DON was interviewed on 12/5/24 at 12:00 p.m. The DON said Resident #24 should not have hydrocortisone cream at his bedside. The DON said Resident #24 needed help administering it and it must have been left in his room by accident. The DON said it was removed from his room after being discovered on 12/2/24 and the nurses were re-educated to check his room for medications.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of two dining rooms. Specifically, the facility failed to: -Ensure hand hygiene was performed appropriately while assisting residents with meals; and, -Ensure staff did not handle ready to eat food with bare hands. I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 12/11/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. II. Facility policy and procedure The Feeding Assistance policy and procedure, dated 5/5/22, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:53 a.m. It read in pertinent part, Wash hands before handling food. Gloves must be worn if raw food is being handled. When feeding residents, hand hygiene must be performed for at least 20 seconds between each resident that is being fed. Do not handle food with bare hands. Use utensils to offer food to residents. III. Observations During a continuous observation in the main dining room on 12/24/24m beginning at 11:52 a.m. and ending at 12:05 p.m., the following was observed: Certified nurse aide (CNA) #4 was assisting residents with lunch in the main dining room. While CNA #4 was assisting Resident #32, CNA #4 rubbed under his nose with his right hand, then picked up Resident #32's fork with the same hand and gave Resident #32 a bite of food. CNA #4 did not perform hand hygiene after touching his face. CNA #4 scratched his nose with his right hand, picked up Resident #32's fork and gave him another bite of food with the same hand. He did not perform hand hygiene after touching his nose. CNA #4 performed hand hygiene with alcohol based hand rub and assisted Resident #14, who was sitting at the same table. CNA #4 assembled Resident #14's hamburger. CNA #4 used his bare hands to handle the raw onion and bun. Without performing hand hygiene, CNA #4 picked up Resident #32's spoon and gave him another bite of food CNA #4 picked up a dinner roll with his bare hand and offered it to Resident #32, who took a bite. CNA #4 performed hand hygiene and handed Resident #14 his hamburger with his bare hand. CNA #4 then picked up the dinner roll for Resident #32 with his bare hand and gave him another bite of roll. CNA #4 did not perform hand hygiene between assisting different residents. -CNA #4 did not perform hand hygiene after touching his face or between assisting two residents and handled ready to eat food with his bare hands. On 12/3/24 at 11:46 a.m. CNA #4 was assisting Resident #32 with lunch. CNA #4 buttered Resident #32's cornbread, holding the bread with his bare hand. CNA #4 rubbed his hands on his scrub pants then picked up Resident #32's spoon and gave him a bite of food. -CNA #4 handled ready to eat food with his bare hands and did not perform hand hygiene after rubbing his hands on his scrub pants. At 11:52 a.m. an unidentified dietary aide served a hamburger and french fries to Resident #14. CNA #4 performed hand hygiene and put the top bun on the hamburger using his bare hands. CNA #4 then cut the hamburger in half, holding it with his bare hand and picked up half of the hamburger with his bare hand and offered it to Resident #14. -CNA #4 handled ready to eat food with his bare hands. III. Staff interviews The infection preventionist (IP) was interviewed on 12/4/24 at 9:00 a.m. The IP said when the staff assisted the residents in the dining room with eating, the staff should perform hand hygiene between each resident. The IP said, if the staff were assisting more than one resident they should perform hand hygiene in between residents. She said the staff should also perform hand hygiene after touching any dirty surface. The IP said the staff should pick up food with utensils, cut food with a fork and knife and not handle food with bare hands. The NHA was interviewed on 12/5/24 at 10:56 a.m. The NHA said the staff should use gloves or utensils to handle ready to eat food and should not touch it with bare hands. The NHA said this was important because their hands could be dirty and they could spread infection.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure appropriate hand hygiene was conducted while performing wound care. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Clinical Safety: Clean Hands for Healthcare Workers (2/27/24), retrieved on 12/10/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves. II. Facility policy and procedure The Hand Hygiene policy, dated 4/8/22, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:53 a.m. It read in pertinent part, Our facility acknowledges that strict adherence to hand hygiene practices will significantly reduce the spread of infection. Hand hygiene will be performed to control infection, transfer of contaminants, and reduction of viable microorganisms. Perform hand hygiene before and after having direct contact with residents or their immediate environment, after contact with body fluid/excretions, mucous membranes, non-intact skin, wound dressings or resident equipment and after removing gloves. III. Observations On 12/4/24 at 2:08 p.m. licensed practical nurse (LPN) #5 was providing wound care for Resident #38's stage 2 pressure ulcer on her coccyx. LPN #5 prepared a clean field on the over bed table and placed the wound care supplies there. LPN #5 assisted Resident #38 to turn onto her side. She then removed the soiled dressing and cleansed the wound. LPN #5 removed her soiled gloves and donned (put on) clean gloves without performing hand hygiene. LPN #5 applied the treatment and clean dressing to the wound, removed her gloves and performed hand hygiene. -LPN #5 did not perform hand hygiene after removing soiled gloves and before donning clean gloves and handling clean wound dressings. IV. Staff interviews LPN #5 was interviewed on 12/4/24 at 2:15 p.m. LPN #5 said she should have performed hand hygiene after removing the dirty gloves and before putting on clean gloves and handling the clean dressing. Registered nurse (RN) #4 was interviewed on 12/4/24 at 3:00 p.m. RN #4 said she was the wound nurse and a nurse manager. RN #4 said she provided education recently to LPN #5 on performing hand hygiene when changing her gloves during wound care. RN #4 said hand hygiene should be performed after removing dirty gloves.

Based on record review, observations and interviews, the facility failed to ensure one (#4) of four residents received prompt dental services out of 21 sample residents. Resident #4 started complaining about upper and lower gum pain preventing him from wearing his dentures on 5/31/23. Through an observation and the resident interview, he grimaced and closed his eyes when trying to chew the food offered and he said he had difficulty eating at times due to his dentures not fitting properly. Due to the facility's failures to provide emergent and timely dental care and services, the resident expressed sadness, had ongoing mouth pain and had difficulty eating the meals provided to him. Findings include: I. Resident status Resident #4, age 85, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included chronic kidney disease and heart disease. The 6/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental (BIMS) status score of 15 out of 15. He required limited one-person assistance with personal hygiene. The dental status section had not been completed. II. Resident observation and interview The resident was observed on 6/27/23 at 10:00 a.m. He was sitting in his room eating a breakfast sandwich on his bedside table. He closed his eyes and grimaced several times while chewing the sandwich. Resident #4 was interviewed on 6/27/23 at 10:15 a.m. He stated he had bruises to his gums which has made it difficult to eat at times. He had his dentures realigned a year ago but had not been back to the dentist since. The facility was supposed to be making him a dentist appointment but he did not know when it would be. III. Record review The comprehensive care plan, revised 5/26/23, revealed the resident wore upper and lower dentures. Interventions included for staff to provide assistance with daily oral care and denture care. Monitor and report bleeding to gums, poor fitting dentures, signs of discomfort, refusing to eat, preference for soft food, grimacing during meals or expressions of oral pain. The July 2023 CPO revealed the following physician orders: -Orajel to apply to gums for discomfort as needed for sores on gums- ordered on 6/1/23. -Nystatin oral rinse 5 ML (milligrams) four times a day for pain- ordered on 6/2/23. -There was no order to alter his diet texture or to provide him soft foods with his ongoing mouth pain (see progress notes below). A review of progress notes dated 5/29/23 to 6/29/23 revealed: Nursing note dated 5/31/23 revealed the resident reported upper and lower gum pain preventing him from wearing his dentures. The intervention was to report to the charge nurse. Nursing note dated 6/2/23 at 8:55 a.m. revealed the resident reported sore gums. The resident was provided an oral rinse to swish and swallow. He refused to eat stating he could not eat but accepted a supplement drink. Nursing note dated 6/2/23 at 5:18 p.m. revealed the resident refused to eat, stating he was unable but accepted a supplement drink. Throughout the shift, the resident was provided with cream of wheat, soup, dessert and broth which he accepted. Nursing note dated 6/3/23 at 6:16 a.m. revealed the resident complained of gum pain, no open areas noted. He accepted soft foods and fluids. Nursing note dated 6/3/23 at 10:02 a.m. revealed the resident complained of sore gums. Was provided oral rinse and Orajel. The resident accepted cream of wheat and a supplement drink. A secure conversation (a facility system used for sending electronic messages to providers) progress note to the physician dated 6/4/23 revealed the nursing staff requested orders for oral rinse and Orajel for the resident's sores to his bottom gums making it hard for him to chew. The physician approved orders. Included in the secure conversation was the director of nursing (DON) and registered nurse (RN) #1 identified as the charge nurse. -However, the orders were written previous to the conversation with the physician and he was being administered the Orajel and Nystatin. Nursing note dated 6/4/23 revealed resident complained of tender gums and was provided Orajel. Nursing note dated 6/5/23 revealed the resident expressed sadness related to not being able to eat the food offered to him. He accepted soup from the nurse. Dietary note dated 6/7/23 revealed in part, the registered dietitian was monitoring the resident's weight due to gum soreness. Nursing note dated 6/7/23 revealed the resident continued to have mouth sores and was encouraged to avoid hot, spicy and acidic foods. Nursing note dated 6/11/23 revealed the resident complained of sore gums and was not wearing his dentures because of this. -Transportation note dated 6/29/23 (during survey) revealed a second attempt was made to schedule an appointment with the Veterans Administration (VA) dental. A message left and waiting for VA to respond. -Progress notes documenting the initial attempt to schedule a dental appointment prior to 6/29/23 were not located. -There was no attempt to get the resident emergency dental services. IV. Staff interviews The social services director (SSD) was interviewed on 6/27/23 at 2:00 p.m. He stated he did not schedule ancillary appointments to include dental. The nurses report to the transportation driver when appointments need to be made. Certified nursing aide (CNA) #14 was interviewed on 6/28/23 at 9:20 a.m. She stated Resident #4 had expressed pain in his gums and requested softer foods. She had reported this to the nurse and charge nurse a few weeks prior but could not recall when for certain. Registered nurse (RN) #4 was interviewed on 6/28/23 at 9:53 a.m. She stated she was not aware of gum pain for Resident #4. RN #1, identified as the charge nurse, on 6/28/23 at 10:43 a.m. She said she could not recall being told that Resident #4 had gum pain or soreness. The transportation driver was not available for an interview during the survey. The director of nursing (DON) on 6/29/23 at 11:45 a.m. She stated she was unaware Resident #4 had oral pain.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -Cutting boards were free from deep scratches and stains; and, -Beard restraints were worn in kitchen areas while serving food. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: -Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations Observation of meal service was conducted on 6/28/23 at 10:30 a.m. Dietary aide (DA) #1 was preparing mechanical and pureed meals for the lunch meal. DA #1 placed four Salisbury steaks in the food processor and poured some broth into the processor to get the right consistency. He again poured the broth into the food processor and placed the plastic container on the counter. He wiped his forehead with his hand as he was sweating and then wiped his right hand on his pants. He proceeded to stir the mechanical altered Salisbury steak until it right consistency was reached. He turned around and grabbed a plastic liner and opened it up with his hand and pushed it down into the metal container. He then poured the mechanical altered Salisbury steak into the metal container and took it over to the counter and proceeded to take the temperature of the mechanical soft Salisbury steak. He opened a sanitizing wipe and cleaned the thermometer and took the temperature. He then wrapped the mechanical soft Salisbury steak with plastic wrap and then placed it into the heating oven. He then picked up his pants and grabbed the food processor and took it into the dirty dish area. He walked out the other side of the dirty dish room and returned to the food processing area. He grabbed a rag from inside the sink and wiped the food processor and then wiped the counter. He wiped his forehead as he was sweating and went back into the dish area and returned with the clean food processor. He then proceeded to grab eight Salisbury steaks from the oven and placed them into the food processor. He proceeded to puree the steak adding broth until the right consistency was reached. He again turned around and grabbed a plastic liner and opened it up with his hand and pushed it down into the metal container. He then poured the pureed Salisbury steak into the metal container and took it over to the counter and proceeded to take the temperature of the pureed Salisbury steak. He opened a sanitizing wipe and cleaned the thermometer and took the temperature. He then wrapped the pureed Salisbury steak with plastic wrap and then placed it into the heating oven. He wiped his hands on the side of his pants and returned to the food processing area and removed the food processor and took it into the dirty dish area and returned to the serving line. DA #1 completed the same process for pureed egg noodles and glazed carrots. DA #1 did not perform hand hygiene during this process. DA #2 was assisting with the lunch menu and was observed touching his face. DA #2 proceeded to cut pork on a brown cutting board. DA #2 continued to touch his face and beard while cutting the pork. DA #2 then returned and cleaned up the area where he was cutting the pork. He cleaned the area and took the cutting board into the dirty dish area. DA #2 did not perform hand hygiene during this process. DA #3 was observed preparing the service ware for the meals. DA #3 would place the utensil into a napkin. DA #3 was observed getting up and leaving the kitchen area several times. DA #3 was observed scratching the left side of her nose and scratching her back and then continued to wrap the service ware. DA #3 placed the service ware onto a tray. DA #3 did not perform hand hygiene during this process. DA #9 was observed on the floor cleaning the drains and the drain basket. DA #9 would wipe and clean the drain grates and placed them on the metal counters. He had a bucket of water and cleaners and proceeded to clean all of the drain grates on the floor and then place them on the metal counter tops. DA #4 was observed preparing the salads for the meal. DA #4 was observed walking into the walk-in cooler and returned with a box of bagged salad. DA #4 placed the box of salad on the same counter that the drain grates were placed on prior. DA #4 opened a bag of salad and proceeded to rinse it into the sink. DA #4 was observed tearing the lettuce with his hands and then placing them in bowls for the salad. DA #4 was observed separating the salad and then placing the bagged lettuce into a bag and then placing the bag into the box returning it to the walk-in cooler. He returned to the counter and finished preparing the individual salads for lunch. DA #4 did not perform hand hygiene during this process. C. Staff interview The dietary manager (DM) was interviewed on 6/29/23 at 9:46 a.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. Staff should wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should be washing their hands between tasks to avoid cross contamination. II. Cutting boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 6/26/23 at 9:30 a.m. revealed five large cutting boards. There were brown, green, white and yellow cutting boards; all cutting boards were heavily scored and stained. On 6/28/23 at 10:46 a.m., DA #2 was cutting pork on the brown cutting board. At 10:40 a.m. DA #4 was observed cutting salad on the green cutting board. C. Staff interview The DM was interviewed on 6/29/23 at 9:46 a.m. The DM was told of the observations of the cutting boards in the kitchen. She said the cutting boards were visibly stained and showed wear. She said she would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Beard restraints A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19) pg. 51, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. B. Observations and interviews On 6/26/23 at 12:01 p.m., DA # 6 was observed in the kitchen area without wearing a beard restraint. DA #6's beard was approximately a half inch long. DA #6 was observed serving meals in the secure unit. On 6/28/23 at 10:45 a.m., DA #2 was observed in the kitchen area not wearing a beard restraint, his beard was approximately two inches long. DA #2 was observed preparing lunch meals. At 10:35 a.m., DA #1 was observed in the kitchen area not wearing a beard restraint, his beard was approximately one inch long. DA #1 was observed preparing and serving lunch meals. The DM was interviewed on 6/29/23 at 9:46 a.m. She stated all kitchen staff were required to wear hair restraint and should have all their hair covered. The DM said staff who had facial hair should be wearing a mask or a beard guard while preparing or serving meals. She said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas to ensure hair from falling into any food.

Based on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#70 and #4) of five residents reviewed for assistive devices out of 21 sample residents and residents at risk for unsafe water temperatures. Specifically, the facility failed to: -Ensure safe water temperatures; -Assess for effectiveness of bed alarm and to ensure alarm was not utilized for the convenience of staff for Resident #70; and, -Ensure Resident #4's room was free from accidents/hazards causing injuries to his lower extremities Findings include: I. Water temperatures 6/26/23 -At 2:34 p.m., the temperature of the tap water was obtained in room [ROOM NUMBER]. The water was found to be 129 degrees Fahrenheit (F); -room [ROOM NUMBER]'s water temperature was 129 degrees F; -room [ROOM NUMBER]'s water temperature was 128 degrees F; -room [ROOM NUMBER]'s water temperature was 129 degrees F; -room [ROOM NUMBER]'s water temperature was 128 degrees F; -room [ROOM NUMBER]'s water temperature was 129 degrees F; and, -The shower room faucet was 128 degrees F. -At 2:57 p.m., CNA #7 observed the temperature of the resident's water in room [ROOM NUMBER]. The temperature was 129 degrees F. CNA #7 said the thermometer reading was 129 degrees F. CNA #7 was unsure what the water temperature was supposed to be kept at. CNA #7 said the only resident she knew that was able to utilize the water independently was the resident in room [ROOM NUMBER]. At 3:05 p.m. CNA #8 was in the shower room and had just provided a shower for a resident. CNA #8 observed the thermometer and said the reading was 129 degrees F. She said she did not know what the water temperature was supposed to be but did notice it was hot but she was able to regulate it. The maintenance supervisor (MTD) was interviewed on 6/26/23 at 3:21 p.m. He stated the facility immediately purged all the hot water from the lines. The MTD said he had recently been working on the water heater motor as it had gone out last week. The MTD said the water had been holding at 117 degrees F. The MTD said the water-tempering valve may have been the issue and he was currently checking to see if it was functioning correctly. The MTD said the facility monitor the water temperatures monthly and would provide the temperature logs. The DON was interviewed on 6/26/23 at 3:28 p.m. The DON was informed of the observations above. The DON said there had not been any residents burned by the water. She said she was not familiar with what the water temperature should be but would check. The physical director (PD) of the facility was interviewed on 6/29/23 at 10:45 a.m. He said the facility was in the process of installing all new boilers for the facility, which would allow the facility to control the temperatures better. He said the boilers were approximately [AGE] years old and would be replaced. The new system would alert all maintenance staff of water temperatures and would send out emails alerting the staff of the potential of hot water. The boilers were currently being monitored daily and logs updated by the maintenance supervisor. II. Resident #70 A. Resident status Resident #70, age 69, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included Alzheimer's, epilepsy, delirium, wandering and dementia unspecified with agitation. According to the 5/11/23 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had verbal behaviors directed toward others. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had a bed alarm. B. Observations On 6/26/23 at 9:55 a.m., the resident was lying in bed sleeping. The resident did not try to get out of bed on her own. C. Record review The care plan, initiated 8/20/22 and revised 5/31/23, identified the resident was at risk for injury/falls. The resident was at risk for injury/falls related to diagnosis of seizures, psychotropic drug use, and history of falls, memory deficit, and poor safety awareness. Resident risk factors may include: diagnosis of Alzheimer's disease, dementia with behavioral disturbances, delirium due to known physiological condition, wandering. Actual/history of falls: found on floor, rolling off bed, losing balance, tripped over object, missed chair when going to sit down. Interventions include post psychoactive meds given, staff to provide close monitoring of gait, one on one provided after fall, alarm was placed prior to fall. Staff to anticipate needs. Pathways to remain clear, closer monitoring when around others. Silent alarm. Staff to monitor and purposeful rounding, continue to anticipate needs, and continue to assist as needed. Nursing log note dated 3/5/23 at 9:56 a.m., documented in part, bed alarm back on to alert staff when resident was getting out of bed so staff can provide assistance as resident needs it. Medical power of attorney (MPOA) verbalized he was okay with alarm to help staff take care of his wife. -A request was made for the consent for bed alarm to review the risks associated with use of a bed alarm and an, assessment for use of the bed alarm but was not provided by the facility by the exit on 6/29/23. D. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 6/28/23 at 3:10 p.m. LPN #4 said Resident #70 had a bed alarm on her bed to alert staff when she was getting out of bed. She said the resident had a lot of falls and it alerted the staff if she was getting out of bed. Certified nurse aide (CNA) #10 was interviewed on 6/28/23 at 1:32 p.m. CNA #10 said Resident #70 had a bed alarm which alerted the staff when she was getting out of bed so she would not fall. CNA #9 was interviewed on 6/28/23 at 3:47 p.m. She said the bed alarm was in place to alert staff of when the resident was getting out of bed. The DON was interviewed on 6/28/23 at 9:19 a.m. The DON said when there was any assistive device utilized for a resident that an assessment, physicians order and consent should be utilized prior to the device being placed for that particular resident. The DON said the bed alarm was to alert staff when the resident was getting out of bed as the resident had a lot of falls. The DON said Resident #70 did not call when she needed help so the bed alarm alerted staff. The DON was asked about the bed alarm assessment and consent that reviewed the risks associated with the bed alarm. The DON stated the log note dated 3/5/23 was the assessment and consent. -However, the note did not review the risks associated with a bed alarm with MPOA. 46370 III. Resident #4 A. Resident status Resident #4, age 85, was admitted on [DATE]. According to the July 2023 CPO, the diagnoses included pulmonary hypertension, generalized edema, chronic kidney disease, hypertensive heart disease, venous insufficiency and thickening or hardening of the arteries of extremities in both legs. The 6/21/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required extensive assistance with a two-person physical assist with bed mobility, transfers, dressing, toileting and personal hygiene. B. Resident observation and interview Resident #4 was interviewed on 6/27/23 at 10:15 a.m. He said several times he had hit his feet and legs on furniture in his room. He said due to the dimensions of his room, turning in his electric wheelchair put him at risk of hitting his feet or shins on the furniture. He had decreased sensation in his feet so he did not always know when he hit his feet or when he injured himself. He said initially, he had requested a private room due to the difficulty of losing several roommates but when he realized the room was too small, he requested to move to a larger single room to accommodate his wheelchair. He said he had been on a wait list since December 2022. Observation of the resident's room on 6/27/23 at 10:15 a.m. revealed the resident had approximately a two inch gap between his electric wheelchair and the furniture. The room was designed in an L shape which caused the difficulty in turning. The resident demonstrated turning in his wheelchair and if the foot rests were not elevated there was approximately three inches of both feet in danger of hitting the bed frame. C. Record review The comprehensive care plan, initiated on 9/23/19 and revised on 5/26/23, revealed Resident #4 was at risk for further alteration due to decreased mobility. Resident #4 was being treated for open areas to the right lower extremity and left great toe and 2nd and 4th toe. The actual or probable cause for injuries to skin included bumping wheelchair pedal, moving bed, bumping on lift, furniture, doorway and dining room table. The interventions included encourage safety awareness with transfers and wheelchair mobility, watch placement of feet at dining table and obstacles in room, remind resident on being cautious when moving around room in electric chair, and be aware of surroundings when doing so, practice safety awareness, safe maneuvering in chair and watch placement of chair when going near other furniture. Incident report dated 12/9/22 revealed incident occurred in Resident #4's room. The certified nurse aide (CNA) reported blood on the floor and Resident #4's right sock was wet with blood. The nurse removed his sock and noted the nail of his second toe was attached at the base only. The third toenail of his foot was loose. Resident #4 said he did not know what happened. The predisposing environmental and situational factors were poor lighting and furniture and Resident #4's use of his wheelchair. The interdisciplinary team (IDT) met on 12/12/22 and initiated interventions which included staff were to encourage safety awareness and watch for placement of feet at the dining table and obstacles in the room. An environmental assessment was completed at that time. -There were no changes to the environment noted to prevent injury again. Incident report dated 12/24/22 revealed incident occurred in Resident #4's room while he was in isolation. Resident #4 said he ran into the bathroom door and scraped his foot. The nursing description noted a bleeding abrasion to his right dorsal foot, with top skin removed size was 1.5 centimeters (cm) x 0.5 cm. The report revealed it was difficult for Resident #4 to maneuver in his room due to having a large wheelchair in a confined space. The IDT met on 12/26/22 and initiated interventions which included closing the bathroom door and reminding Resident #4 to be cautious when moving around in his electric wheelchair. Resident #4 was to be aware of surroundings. -There were no environmental changes noted to prevent injury again. Progress notes dated 12/9/22 to 12/29/22 revealed: -Nurses note dated 12/9/22 revealed the resident banged the second toe on his right foot causing nail detachment. Nursing provided wound care. -Nurses note dated 12/10/22 revealed the dressing to the resident's right foot was bloody due to banging his toe on a table. -Nurses note dated 12/10/22 revealed the resident's sock was bloody. Upon inspection, two of the resident's toenails were detached. The resident was unable to explain how the injuries occurred. -Podiatry report dated 12/29/22 revealed the resident had injured the top of his right foot when opening a door in his room. D. Staff interviews CNA #14 was interviewed on 6/28/23 at 9:20 a.m. CNA #14 said Resident #4 was cognitively intact and received injuries to his feet from hitting them on the bathroom door when maneuvering in his electric wheelchair. Registered nurse (RN) #4 was interviewed on 6/28/23 at 9:53 a.m. RN #4 said Resident #4's wounds to his right shin resulted from banging into the furniture in his room when he was maneuvering his electric wheelchair. RN #1 was interviewed on 6/28/23 at 10:43 a.m. RN #1 said Resident #4 received the injuries to his shin and feet from bumping into furniture in his room The administrative assistant (AA) was interviewed on 6/28/23 at 10:57 a.m. The AA said she managed the waitlist for private rooms. The AA said a resident was added to the waitlist when the interdisciplinary team (IDT) gave her the resident's name or if a resident requested to be placed on the list. The AA provided the room change waitlist from 3/10/22-4/3/23 and Resident #4's name was not included on the list. The AA said she was not notified of Resident #4's request for a room change. The director of nursing (DON) was interviewed on 6/29/23 at 11:45 a.m. She was unable to recall the particular incidents on 12/9/22 and 12/24/22. She said the environment in the resident's room was assessed by the IDT but she could not provide information of specific environmental changes to prevent reinjury other than the resident was provided education. She said the resident never specified to nursing a desire to move to a different room.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through the facility assessment. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in facility assessment for three out of three registered nurses (RN) and one out of one licensed practical nurses (LPN) reviewed for competencies. Findings include: I. Facility assessment According to the facility assessment, updated 1/1/23, and provided by the nursing home administrator (NHA) on 6/27/23, the facility assessment identified the staff competency and care area requirements as: -Catheter care -Bladder scanner -Incontinence/Toileting program -Respiratory treatment -End of life care -Infection control -Dementia care -Behavioral healthcare (including post-traumatic stress disorder and trauma history) -Ostomy care -Gastronomy tube care/use -Restorative nursing -Pain management -Pressure ulcer prevention and treatment -Fall risk identification -Communication and interpersonal needs, and -Technical skills. II. Record review RN #1, RN #2, RN #3 and LPN #3 did not have the required competencies completed as identified by the facility assessment. III. Interviews The director of nursing (DON) was interviewed on 6/28/23 at 11:00 a.m. She said she did not have all the competencies completed annually that were identified as required on the facility assessment. She said all the competencies were completed upon hire and annually the facility did complete infection control. She said this last year the staff were all checked-off on the bladder scanner. She said it was important to have skill competencies to ensure the residents were receiving safe and accurate cares.

Based on record review and interviews, the facility failed to ensure two (#68 and #29) of six residents diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 21 sample residents. Specifically, the facility failed to: -Ensure residents expressing suicidal ideations were assessed and monitored for Resident #68; and. -Ensure residents with a major mental illness (MI) requesting services received them for Resident #29. Findings include: I. Resident #68 A. Resident status Resident #68, aged 76, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included prostate cancer, major depressive disorder recurrent and post-traumatic stress disorder (PTSD). The 3/10/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. No behaviors were coded. B. Pre-Admission Screen and Resident Review (PASRR) level II notice of determination for MI (mental illness) evaluation and facility failures The PASRR level II, provided to the facility on [DATE] included the psychological evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of major depressive disorder recurrent. Due to a lack of supporting documentation of prolonged depression at the time of the PASRR, MI was ruled out. In the evaluation, the resident stated he had attempted suicide in the past and would attempt again if his medical situation became more than he could handle. He endorsed increased anxiety since moving from his children's home in the community to the facility. The resident stated to the evaluator he had passive suicidal thoughts (contemplating suicide without any direct plan) since admitting to the facility and if his medical condition became more painful and his quality of life became poor, he would think about suicide as an option. He was assessed for suicidal lethality and determined he did not have a plan or intent during the evaluation. The PASRR documented the facility was to report any changes to the resident's symptoms of depression for re-evaluation. Cross-reference F644: the facility failed to provide the State Mental Health Agency the resident's increase in depression and suicidal ideation (see progress notes below). C. Resident interviews Resident #68 was interviewed on 6/27/23 at 1:24 p.m. He said he had a diagnosis of PTSD from his time in the military and combat exposure. He denied current thoughts of suicidal ideations but said he had a history. He declined to explain further. He stated he could be verbally aggressive with the staff when he was feeling out of control with his health, feeling his PTSD was triggered by over stimulation or feeling sad regarding his declining health. The resident said he did see a therapist with the Veterans Administration (VA) but was disappointed with the level of effort the facility made to communicate with his provider. He stated it has been very hard for him to adjust to the facility, giving up the ability to self-administer his medications and having to acclimate to the frequent blood clotting finger tests for his anticoagulant (blood thinning medication). D. Record review The comprehensive care plan, revised 4/15/23, revealed the resident used antidepressant medication related to PTSD. The resident displayed behaviors of flashbacks, feeling short of breath and irritability. The interventions included monitoring the resident for target behaviors and offering non-pharmacological interventions. The resident had the potential for injury to self or others related to negative behaviors such as being resistive to care or verbal lashing out. The interventions were to encourage the resident to use coping mechanisms and to provide one-on-one discussion. The July 2023 CPO revealed the following physician orders for psychotropic medications: -Duloxetine (Cymbalta) 60 MG (milligrams)-give one tablet by mouth one time a day for depression -ordered on 6/5/23. Behavior tracking for certified nursing aides revealed target behaviors were flashbacks, feeling short of breath, irritability and complaints of inability to sleep. Behavior tracking for April 2023 documented no behaviors. Behavior tracking for May 2023 documented no behaviors. Behavior tracking for June 2023 documented no behaviors. A review of progress notes dated 4/27/23 to 6/25/23 revealed: Behavior note dated 4/27/23 revealed the resident was yelling and accusing staff of lying to him. He was told staff were going to do a finger stick for his anticoagulant medication and it did not happen. The staff confronted his behavior as aggressive and the resident denied he had been aggressive. -The intervention was ineffective and no further intervention was documented. Nursing progress note dated 5/8/23 revealed the resident was asked by other residents to leave a table he was sitting at and he then used profanity towards the residents. -No intervention was documented. Nursing progress note dated 5/16/23 revealed the resident expressed frustration with the staff over medication times and made accusations they were not attending to his health and wanted a lawyer. -No intervention was documented. Physician progress note dated 5/20/23 revealed the resident had expressed to the physician difficulty with staff due to his not being able to self-administer his medications. The physician documented the resident had been frustrated with his current situation and told the physician several times he wished he would die. The physician assessed the resident for a plan to harm himself and ruled it out. The resident explained he was frustrated and unhappy with the awareness living in a facility was the extent of his future and he no longer had control over his life. In regards to the resident's major depressive disorder, the physician documented the resident's emotional range was normal and his thoughts were expected. It was noted the resident was at high risk for depression due to loss of control of his life and loss of self-determination. Behavior progress note dated 5/21/23 revealed the resident yelling at the nursing staff he did not feel they were competent in their care of him and he wanted to be left alone. The interventions were the staff attempted to explain the care they were providing and eventually had to leave the resident alone. Nursing progress note dated 5/21/23 revealed the resident expressed frustration over anticoagulant medication to nursing staff and he no longer wanted to take it. The nurse explained the purpose of the frequent blood draws and the consequences of stopping his medication. The resident stated he would be better off if he had a stroke and no longer wanted to live in his current condition. Interventions were to notify the charge nurse and staff to monitor. Nursing progress note dated 5/30/23 revealed the resident expressed to the nurse feeling distraught regarding deficits in memory recall and concerns about having Alzheimer's. Interventions were to notify charge the nurse and staff to monitor. Nursing progress note dated 5/31/23 revealed the resident expressed to the nurse he was unhappy living at the facility. -No intervention was documented. Nursing progress note dated 6/5/23 revealed an order to increase the resident's antidepressant had been received from the psychiatrist. Nursing progress note dated 6/14/23 revealed the resident had not been showing signs of increased depression, suicidal ideations or behaviors. -No additional progress notes documenting monitoring for suicidal ideations were located. -No social service progress notes documenting assessment or follow up regarding expressions of depression, adjustment difficulty or passive suicidal ideations were located. II. Resident #29 A. Professional reference The Differences Between Psychology and Psychiatry, reviewed 11/23/21, accessed on 7/12/23 at https://www.psychology.org/resources/differences-between-psychology-and-psychiatry/, it revealed in pertinent part, People often use the terms 'psychiatrist' and 'psychologist' interchangeably-an easy mistake to make if you are not familiar with the field. Both professionals treat patients struggling with mental health on a one-on-one basis. However, there is quite a bit of difference between the two professions when it comes to their education, training, and scope of practice. Both psychologists and psychiatrists can provide psychotherapy. However, most psychiatrists treat patients primarily by prescribing medication, while psychologists mainly rely on providing talk and/or behavioral therapy. B. Resident status Resident #29, aged 77, was admitted on [DATE]. According to the July 2023 CPO, the diagnoses included heart failure, other specified anxiety disorders and bipolar disorder. The 6/8/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were coded. C. PASRR level II notice of determination for MI (mental illness) evaluation and facility failures The PASRR level II, provided to the facility on [DATE] included the psychological evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of bipolar disorder and the diagnosis was confirmed with supporting documentation. The resident had a history of in-patient psychiatric hospitalization s, auditory command hallucinations (voices telling her to do things), and manic and depressive episodes. The resident stated to the evaluator she felt she would benefit from individual therapy and would like the additional support counseling would provide her. The PASRR recommendations were for Resident #29 to receive individual psychological therapy by a qualified mental health provider. Cross-reference F644: the facility failed to ensure the resident received psychological therapy. D. Resident interviews Resident #29 was interviewed on 6/27/23 at 1:05 p.m. She stated she had been seeing the same psychiatrist for medication management for [AGE] years and was supposed to start seeing a psychologist but did not know when. Her psychiatrist was retiring with her last session on 5/15/23 so she had agreed to see the provider the facility used for both psychiatric and psychology services. She stated her bipolar disorder was stable but wanted individual therapy services. She said she was feeling disregarded by the primary care physicians at the facility due to her bipolar disorder and would benefit from talking to someone about this. E. Record review The comprehensive care plan, revised 6/8/23, revealed the resident used antipsychotic and anticonvulsant medication related to bipolar disorder. The resident displayed behaviors of irritability, verbalizations of distress, and accusatory statements. The interventions included monitoring the resident for target behaviors and offering non-pharmacological interventions. Redirect behaviors, set boundaries, allow the expression of feelings, and to provide one-on-one discussion. The resident had a diagnosis of anxiety and displayed behaviors of social isolation, flat affect, and negative comments about self. The interventions included monitoring the resident for target behaviors and offering non- pharmacological interventions. Encourage participation in activities, monitor environmental stressors and allow the expression of feelings. The July 2023 CPO revealed the following physician orders: -Zoloft 75 MG (milligrams)-give one tablet by mouth one time a day for anxiety -ordered on 11/15/18. -Saphris (antipsychotic) 10 MG- give one tablet sublingual one time a day for bipolar disorder- ordered on 11/3/22. -Depakote ER 250 MG- give three tablets by mouth one time a day for bipolar disorder- ordered on 5/25/23. -Appointment with (mental health provider) for 7/11/23- ordered on 6/27/23 (during survey). Behavior tracking for certified nursing aides revealed target behaviors were increased irritability, short tempered with staff, verbalized distress and accusatory statements. Behavior tracking for April 2023 documented no behaviors. Behavior tracking for May 2023 documented no behaviors. Behavior tracking for June 2023 documented one behavior of irritability and short temper due to waiting to be taken to an appointment. One behavior of increased irritability, short tempered and accusatory statements towards staff without further explanation. A review of progress notes dated 4/27/23 to 6/25/23 revealed: Nursing note progress dated 4/1/23 revealed the resident displayed flat affect. -No intervention was documented. Behavior progress note dated 5/6/23 revealed the resident displayed argumentative behaviors and agitated affect. The resident was reminded of socially appropriate interactions but continued to display agitation. -The intervention was ineffective and no other interventions documented. Social services progress note dated 6/14/23 revealed an upcoming appointment with (mental health provide) for psychiatric consultation was ordered due to the resident's psychiatrist retiring. Behavior progress note dated 6/19/23 revealed the resident had increased irritability, short tempered and accusatory towards staff. The intervention was to put her to bed. -There was no further explanation of what happened. Behavior progress note dated 6/22/23 revealed the resident had irritation and was short tempered with staff and other residents due to waiting to be taken to an appointment. -No intervention was documented. Nursing progress note dated 6/27/23 (during survey) revealed the resident had an appointment scheduled with (the mental health provider). -No social service progress notes documenting follow up with the resident regarding behaviors were located. -No progress notes documenting refusal to schedule psychologist appointments were located. F. Staff interviews The SSD was interviewed on 6/27/23 at 2:00 p.m. He stated if a resident made statements expressing the desire to die, or having a stroke and dying was preferable to their current life, he would expect to be notified and he would follow up with the resident. Certified nursing aide (CNA) #14 was interviewed on 6/28/23 at 9:20 a.m. She stated Resident #68 had behaviors of verbal outbursts and agitation. She said Resident #29 had behaviors of agitation and shortness of breath. The CNAs were provided behavior tracking sheets from the infection preventionist (IP) and they were to circle the behaviors displayed and report to the nurse. The CNAs were not provided instructions on interventions to use from the IP or the social services director (SSD). The CNAs had to try their own interventions and communicate with each other what worked. She was unaware Resident #29 had been seeing a psychiatrist for [AGE] years, stating it would have been helpful to the staff to know what interventions worked for the psychiatrist. She stated if a resident had a history of suicidal ideations or attempts, she would want to know so she could monitor them. She said she was not aware Resident #68 had a history of suicidal ideations. The CNAs did not have access to the resident's care plans or PASRRs. If the behaviors or interventions were different in the resident's care plan than on the behavior sheets provided to them, management did not communicate this to the CNAs. Registered nurse (RN) #4 was interviewed on 6/28/23 at 9:53 a.m. She stated Resident #29 had behaviors of becoming agitated and upset. Staff were to offer fluids, pain medications, change the environment or switch caregivers. She said Resident #68 had no behaviors. The nurses documented behaviors in the resident's medical record and the CNAs used a behavior sheet. If a resident showed increased signs or symptoms of depression or suicidal ideations, she would report to the charge nurse. Behavior sheets were turned into the IP every day. The director of nursing (DON) was interviewed on 6/28/23 at 10:45 a.m. She was not aware of the statements Resident #68 made to the physician or the nurse regarding suicidal ideations. The SSD was interviewed on 6/28/23 at 1:00 p.m. He stated the facility determined what behaviors to track based on the medication and behaviors the staff report. When he received a level II PASRR evaluation, the symptoms and behaviors would be care planned. He did not develop behavior tracking for the residents nor did he develop the care plans. The IP developed the behavior tracking sheets, the behavior care plans and completed the audits for the psychotropic drug meetings. The SSD did not know why Resident #68's antidepressant was increased on 6/5/23. He was unaware the resident had made statements of suicidal ideations to the physician and the nurse. If he had been told, he would have spoken with the resident and sent a mental health referral to the VA. He stated there was no method to let the physician, nurses or CNAs know Resident #68 was at higher risk due to past suicide attempts and a way for the staff to report any statements to himself, the nursing home administrator (NHA) or the DON. He said he did not know why a psychologist appointment was not established for Resident #29 despite being in the PASRR recommendations. He was under the impression a psychiatrist and psychologist were the same discipline and believed the resident received therapy from her psychiatrist. In addition, he acknowledged there had not been timely follow up for the resident to see a mental health provider due to her psychiatrist retiring with her last appointment being on 5/15/23. The IP was interviewed on 6/28/23 at 2:07 p.m. She revealed she created the resident behavior tracking sheets, reviewed them daily and audited nursing documentation for behavior notes. The interventions for the behavior tracking and care plans came from CNA feedback regarding behaviors exhibited and interventions that worked for them. She did not incorporate findings from the PHQ-9 (depression screen), PASRR or BIMS assessment when making the resident behavior sheets and care plans. She said she did not know Resident #68 had a psychological evaluation completed for his PASRR and it indicated behaviors of suicidal attempts and ideations. The SSD did not share information from PASRR with her. She stated she would have wanted to know that information in order to include it in his care plan and behavior tracking. The DON was interviewed with the NHA and the SSD present on 6/29/23 at 11:45 a.m. She stated after reviewing the progress notes from 5/20/23 and 5/21/23 and the PASRR for Resident #68, she did not consider those to be statements of suicidal ideations. For the resident's statements to be considered suicidal ideations, he would need to verbalize a plan with intention and be prescribed medication by the physician specifically for suicidal ideations not just depression. She acknowledged he had a history of suicidal ideations and attempts but stated it was in the past and therefore was not included in his behavior tracking or care plan. There was no method to let the physician, nurses or CNAs know that Resident #68 was at higher risk due to past suicide attempts and for the staff to report any statements to the SSD or the NHA. The DON was unaware the PASRR recommended individual psychological therapy for Resident #29. She was under the impression a psychiatrist and psychologist were the same discipline and believed the resident received therapy from her psychiatrist. She stated Resident #29 had refused to see the psychologist because she was happy with her psychiatrist. -However, there was no supporting documentation showing that Resident #29 had refused. In addition, there was not timely follow up for Resident #29 to get services when her psychiatrist retired and her last visit being 5/15/23.

Based on record review and interviews, the facility failed to ensure one (#68) of four residents received proper assistive devices to maintain hearing abilities out of 21 sample residents. Specifically, the facility failed to ensure a resident requiring additional audiology appointments to test for hearing aids received those promptly for Resident #68. Findings include: I. Resident #68 A. Resident status Resident #68, aged 76, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included prostate cancer and post-traumatic stress disorder (PTSD). The 3/10/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had difficulty hearing in noisy environments or if people spoke softly. The resident did not have hearing aids. B. Resident interview Resident #68 was interviewed on 6/27/23 at 1:24 p.m. He stated he had a hearing test and was supposed to have another appointment to get hearing aids but no staff in the facility had followed up with him on the status. He said it was difficult for him to hear others when he leaves his room so he did not try to make friends outside of the ones he already had at the facility. He said being able to listen to music and watch television were part of his coping mechanisms for his PTSD and he was concerned about worsening hearing. C. Record review The comprehensive care plan, revised 4/15/23, revealed the resident had impaired hearing without hearing aids. Interventions included to be conscious of the resident's placement when in groups so he can hear better and to ensure he receives hearing exams. The July 2023 CPO revealed an order dated 6/28/23 (during survey) for the resident to see the audiologist. A review of progress notes dated 4/27/23 to 6/25/23 revealed: -Social services progress note dated 6/14/23 documented the resident had difficulty with hearing. There was an audiologist appointment 6/5/23 and a follow up appointment needed to be scheduled. Nursing and transportation would schedule the appointment. -There were no additional notes indicating any further appointments had been made or the social services department had followed up with the nursing department. There was a scanned progress note from the audiologist dated 6/5/23 documenting the resident had an evaluation and required a follow up evaluation and a hearing test. II. Staff interviews The SSD was interviewed on 6/27/23 at 2:00 p.m. He stated he was not involved in scheduling or maintaining audiology appointments. The transportation driver made the appointments and nursing staff would contact transportation when an appointment needed to be made. Certified nursing aide (CNA) #14 was interviewed on 6/28/23 at 9:20 a.m. She stated the resident had difficulty hearing and could cause him to become agitated with staff. Registered nurse (RN) #4 was interviewed on 6/28/23 at 9:53 a.m. She stated the resident expressed frustration at times due to his hearing impairment. When a resident complained about hearing difficulty, nursing staff would report the complaint to the charge nurse. RN #1 was interviewed on 6/28/23 at 10:43 a.m. She was the charge nurse for Resident #68. She stated she was not aware he needed any follow up appointments scheduled for his hearing. The transportation driver was not available during the survey for an interview. The nursing home administrator (NHA) was interviewed on 6/29/23 at 11:45 a.m. The NHA said a follow up appointment had been scheduled on 6/28/23 for the resident to be seen on 9/8/23.

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#11) of four residents reviewed for activities out of 21 sample residents. Specifically, the facility failed to ensure Resident #11 was invited and encouraged to attend activities of his preference. Findings include: I. Facility policy and procedures The Activities Program policy, revised 9/14/21, was provided on 6/28/23 at 11:47 a.m. by the nursing home administrator (NHA). It read in pertinent part, An activity program designed to provide a balancer of physical, intellectual, social, and spiritual therapy for each resident, respectful of their rights. Activities should encourage self-care, self-worth, resumption of normal activities, and maintenance of optimal level of psychosocial functioning and contact within the environment. II. Resident #11 A. Resident status Resident #11, age 74, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, mood disturbance and anxiety, diabetes mellitus, depression and personal history of suicidal behavior. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had a rejection of care behaviors. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident's assessment of daily and activity preferences was not completed. He resided in the secured unit. B. Record review The care plan, initiated 10/5/21 and revised 6/25/23, identified the resident liked bingo, exercise, watching sports, relaxing music, keeping up with the daily news, and being outside when the weather was nice. The resident enjoys reading but not all the time. He likes animals and had a cat when he was at home. The resident needs assistance to plan his day. Verbal reminders, direction for location of activities and assistance with supplies as needed. The resident would be invited and encouraged to attend activities of interest. Interventions include access for preferences, anticipate needs as needed, monitor and document participation per protocol. Provide for an ongoing program of activities that meets the resident's needs and preferences. Visit with the resident regularly to see if there are any in room activities that can be provided such as books, books on tape, crossword puzzles or any other in room activity that he would like to do. The activity calendar for 6/27/23 listed the following: -10:15 a.m. movement -1:00 p.m. table games -3:00 p.m. relaxation The activity calendar for 6/28/23 listed the following: -9:30 a.m. beauty salon -10:15 a.m. movement -1:00 p.m. gardening -3:00 p.m. relaxation. C. Observations Observations on 6/27/23 revealed the resident did not have any meaningful activity. The resident was sitting in his recliner at the following times: 8:45 a.m., 9:35 a.m., 10:00 a.m., 10:04 a.m., 11:18 a.m., 12:45 p.m., 2:04 p.m., 2:45 p.m. and 3:37 p.m. -At 8:45 a.m., Resident #11 was sitting in the common area sleeping in a chair. -At 9:35 a.m., Resident #11 was sitting in the dining room looking out the window. -At 9:46 a.m., certified nurse aide (CNA) #10 provided care for Resident #11. -At 10:00 a.m., Resident #11 was sitting in the dining room. -At 10:04 a.m., two activity staff arrived in the secured unit. One activity staff grabbed a beach ball and went into the common area. The other activity staff grabbed another male resident and wheeled him into the common area and proceeded to throw the ball at the male resident and another female resident. Resident #11 was seated in the dining room. -At 10:32 a.m., both activity staff exited the secured unit area. -At 12:45 p.m., Resident #11 was seated in the dining room. -At 1:03 p.m., activity staff entered the secured unit. -At 1:05 p.m., an activity staff member walked up to a female resident in the dining room and asked if she wanted to play any table games. The female resident did not answer with the activity staff playing cards with the female resident. The female resident participated for approximately five minutes and then fell asleep at the table. The activity staff asked the resident if she wanted to go to bed. The activity staff called a CNA who escorted the resident to her bed. The activity staff then exited the secured unit. -At 2:43 p.m., Resident #11 sleeping in the common area. -At 3:00 p.m., no staff were observed in the secured unit. -At 3:12 p.m., Resident #11 was sleeping in a chair in the common area. -During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. Observations on 6/28/23 revealed the resident did not have any meaningful activity. The resident was sitting in his recliner at the following times: 8:44 a.m., 9:30 a.m., 10:00 a.m. and 11:32 a.m. -At 8:56 a.m., Resident # 11 was sitting in the common area sitting in a chair. -At 9:30 a.m., No activity staff were observed in the secure unit. -At 9:41 a.m., Resident #11 walked out of the restroom next to the nursing station. -At 9:46 a.m., Resident #11 returned to the dining area and sat at a table. -At 10:00 a.m., Resident #11 was sitting in the dining room with another resident. -At 10:03 a.m., two activity staff entered the secured unit. -At 10:07 a.m., activity staff were throwing a beach ball at two residents in the common area. The residents who were participating would slap the ball and the activity staff would throw it at another resident and he would slap it away from himself. -At 10:34 a.m., both activity staff members exited the secured unit. -At 1038 a.m., Resident #11 was sitting in the dining room. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. III. Interviews The activity director (AD) was interviewed on 6/29/23 at 8:55 a.m. The AD was informed of the observations above. She said all residents should be encouraged and invited to all activities. She said 100 percent of the residents should be involved in activities. She said, Staff need to do better on inviting all residents to activities and encouraging them to participate. She said the negative outcome for residents not participating in activities could be boredom, isolation, depression and negative behaviors and wandering.

Based on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for two (#68 and #29) of five residents reviewed for PASRR out of 21 sampled residents. Specifically, the facility failed to: -Coordinate the re-evaluation of mental illness (MI) and symptoms for Resident #68; and, -Notify the State Mental Health Agency when recommendations could not be met for Resident #29. Findings include: I. Resident #68 A. Resident status Resident #68, age 76, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included prostate cancer, major depressive disorder recurrent and post-traumatic stress disorder (PTSD). The 3/10/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. No behaviors were coded. B. Pre-Admission Screen and Resident Review (PASRR) level II notice of determination for MI (mental illness) evaluation and facility failures The PASRR level II, provided to the facility on [DATE] included the psychological evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of major depressive disorder recurrent. Due to a lack of supporting documentation of prolonged depression at the time of the PASRR, MI was ruled out. In the evaluation, the resident stated he had attempted suicide in the past and would attempt again if his medical situation became more than he could handle. He endorsed increased anxiety since moving from his children's home in the community to the facility. The resident stated to the evaluator he had passive suicidal thoughts (contemplating suicide without any direct plan) since admitting to the facility and if his medical condition became more painful and his quality of life became poor, he would think about suicide as an option. He was assessed for suicidal lethality and determined he did not have a plan or intent during the evaluation. The PASRR documented the facility was to report any changes to the resident's symptoms of depression for re-evaluation. C. Resident interview Resident #68 was interviewed on 6/27/23 at 1:24 p.m. He said he had a diagnosis of PTSD from his time in the military and combat exposure. He denied current thoughts of suicidal ideations but said he had a history. He declined to explain further. D. Record review The comprehensive care plan, revised 4/15/23, revealed the resident used antidepressant medication related to PTSD. The resident displayed behaviors of flashbacks, feeling short of breath, and irritability. The interventions monitored the resident for target behaviors and offered non- pharmacological interventions. The resident had the potential for injury to self or others related to negative behaviors such as being resistive to care or verbal outbursts. The interventions were to encourage the resident to use coping mechanisms and to provide one-on-one discussion. The July 2023 CPO revealed the following physician orders for psychotropic medications: -Duloxetine (Cymbalta) 60 MG (milligrams)-give one tablet by mouth one time a day for depression -ordered on 6/5/23. A review of progress notes dated 4/27/23 to 6/25/23 revealed: -Physician progress note dated 5/20/23 revealed the resident had expressed to the physician difficulty with staff due to his not being able to self-administer his medications. The physician documented the resident had been frustrated with his current situation and told the physician several times he wished he would die. The physician assessed the resident for a plan to harm himself and ruled it out. The resident explained he was frustrated and unhappy with the awareness living in a facility was the extent of his future and he no longer had control over his life. In regards to the resident's major depressive disorder, the physician documented the resident's emotional range was normal and his thoughts were expected. It was noted the resident was at high risk for depression due to loss of control of his life and loss of self-determination. -Nursing progress note dated 5/21/23 revealed the resident expressed frustration over anticoagulant medication to nursing staff and he no longer wanted to take it. The nurse explained the purpose of the frequent blood draws and the consequences of stopping his medication. The resident stated he would be better off if he had a stroke and no longer wanted to live in his current condition. Interventions were to notify the charge nurse and staff to monitor. -Nursing note dated 6/5/23 revealed an order to increase the resident's antidepressant had been received from the psychiatrist. -No PASRR progress notes showing communication with the State Mental Health Agency after the evaluation on 4/15/23 regarding the need for re-evaluation of a level II were located due to his increased depression and suicidal ideation. II. Resident #29 A. Professional reference The Differences Between Psychology and Psychiatry, reviewed 11/23/21, accessed on 7/12/23 at https://www.psychology.org/resources/differences-between-psychology-and-psychiatry/, it revealed in pertinent part, People often use the terms ' psychiatrist ' and ' psychologist ' interchangeably-an easy mistake to make if you are not familiar with the field. Both professionals treat patients struggling with mental health on a one-on-one basis. However, there is quite a bit of difference between the two professions when it comes to their education, training, and scope of practice. Both psychologists and psychiatrists can provide psychotherapy. However, most psychiatrists treat patients primarily by prescribing medication, while psychologists mainly rely on providing talk and/or behavioral therapy. B. Resident status Resident #29, age 77, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included heart failure, other specified anxiety disorders and bipolar disorder. The 6/8/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were coded. C. PASRR level II notice of determination for MI evaluation and facility failures The PASRR level II, provided to the facility on [DATE] included the psychological evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of bipolar disorder and the diagnosis was confirmed with supporting documentation. The resident had a history of in-patient psychiatric hospitalization s, auditory command hallucinations (voices telling her to do things) and manic and depressive episodes. The resident stated to the evaluator she felt she would benefit from individual therapy and would like the additional support counseling would provide her. The PASRR recommendations were for Resident #29 to receive individual psychological therapy by a qualified mental health provider. D. Resident interviews Resident #29 was interviewed on 6/27/23 at 1:05 p.m. She stated she had been seeing the same psychiatrist for medication management for [AGE] years and was supposed to start seeing a psychologist but did not know when. Her psychiatrist was retiring with her last session on 5/15/23 so she had agreed to see the provider the facility used for both psychiatric and psychology services. She stated her bipolar disorder was stable but wanted individual therapy services. E. Record review The comprehensive care plan, revised 6/8/23, revealed the resident used antipsychotic and anticonvulsant medication related to bipolar disorder. The resident displayed behaviors of irritability, verbalizations of distress, and accusatory statements. The interventions included monitoring the resident for target behaviors and offering non- pharmacological interventions. Redirect behaviors, set boundaries, allow the expression of feelings, and to provide one-on-one discussion. The resident had a diagnosis of anxiety and displayed behaviors of social isolation, flat affect, and negative comments about self. The interventions included monitoring the resident for target behaviors and offering non- pharmacological interventions. Encourage participation in activities, monitor environmental stressors and allow the expression of feelings. Psychological services were not care planned in the resident's interventions. The July 2023 CPO revealed the following physician orders: -Zoloft 75 MG (milligrams)-give one tablet by mouth one time a day for anxiety -ordered on 11/15/18. -Saphris (antipsychotic) 10 MG- give one tablet sublingual one time a day for bipolar disorder- ordered on 11/3/22. -Depakote ER (extended release) 250 MG- give three tablets by mouth one time a day for bipolar disorder- ordered on 5/25/23 -Appointment with (mental health provider) for 7/11/23- ordered on 6/27/23 (during survey). A review of progress notes dated 4/27/23 to 6/25/23 revealed: -Social services progress note dated 6/14/23 revealed an upcoming appointment with (mental health provider) for psychiatric consultation was ordered due to the resident's psychiatrist retiring. -Nursing progress note dated 6/27/23 (during survey) revealed the resident had an appointment scheduled with the mental health provider. -No progress notes documenting refusal to schedule psychologist appointments were located. -No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the level II recommendations were located. III. Staff interviews The social services director (SSD) was interviewed on 6/28/23 at 1:00 p.m. He stated when he received a level II PASRR evaluation, he reviewed it. If after the evaluation, the resident experienced worsening of symptoms, increases in behaviors or increases in medications due to worsening symptoms this would require him to notify the State Mental Health Agency. If a resident was identified in the PASRR evaluation with of a history of suicidal ideations or suicide attempts and then expressed passive suicidal statements at the facility, this would warrant notification to the State Mental Health Agency. He said was aware Resident #68's antidepressants were increased but he did not know why. It was not reported to him the resident had expressed increased depression and suicidal ideations to the physician and nurses. If he had been aware, he would have followed up with the resident, made a mental health referral and notified the State Mental Health Agency. The director of nursing (DON) was interviewed with the nursing home administrator (NHA) and SSD present on 6/29/23 at 11:45 a.m. The DON stated after reviewing the progress notes from 5/20/23 and 5/21/23 and the PASRR for Resident #68, she did not consider those to be statements of suicidal ideations. Because the physician had evaluated the resident for suicidal ideations on 5/21/23 and determined he did not have a plan or intent, it was determined he did not meet criteria to contact the State Mental Health Agency for re-evaluation. For the resident's statements to be considered suicidal ideations, he would need to verbalize a plan with intention and be prescribed medication by the physician specifically for suicidal ideations not just depression. The DON was unaware the PASRR recommended individual psychological therapy for Resident #29. She was under the impression a psychiatrist and psychologist were the same discipline and believed the resident received therapy from her psychiatrist. She stated Resident #29 had refused to see the psychologist because she was happy with her psychiatrist. -However, there was no supporting documentation showing that Resident #29 had refused. The NHA and SSD acknowledged if a resident had worsening mental health symptoms, such as expressions of suicidal ideations, this would warrant an assessment by the SSD and notification to the State Mental Health Agency, which did not occur. The SSD stated he had not notified the State Mental Health Agency recommendations for Resident #29 had not been provided despite the recommendations being required from the PASRR assessment as of 7/10/19. The SSD was aware it was mandatory for the recommendation to be provided for the resident.

Based on interviews and record review, the facility failed to prevent abuse for two (#70 and #126) of five residents out of 21 sample residents. Specifically, the facility failed to: -Prevent resident to resident physical abuse altercations between Resident #11 and Resident #70 on 3/3/23 and on 3/4/23; and, -Verbal abuse between Resident #126 and Resident #24. Findings include: I. Facility policy and procedure The Abuse Prohibition policy, revised 8/1/22, was received from the nursing home administrator (NHA) on 6/28/23 at 11:47 a.m. It read in pertinent part: Always operating with the foundational premise that patient safety is the first building block in creating a great patient experience, it is the policy of (facility name) to make patient safety a top priority in every decision we make and activity we carry out. With this policy comes the expectation that every employee at every level of the organization, affiliated medical provider and business associate will proactively and continuously seek out opportunities to protect our patients from harm and actively participate in any practice or initiative that targets getting patient care right the first time in the safest way possible. II. Resident to resident physical altercation between Resident #11 and #70 A. Incident 3/3/23 According to the facility investigation, the activities staff member stated they had just entered the secured unit through the door coming from the front of the building when Resident #70 came running up and grabbed Resident #11 forearm and said 'expletive, you expletive, you expletive. I am going to kill you and will not let go.' Resident #70 then ran hallway down the hall and then ran back pointing her finger at Resident #11. Staff separated both residents for their safety. When talking with Resident #11. Resident #11 verbalized what had happened and stated that he was afraid of Resident #70 but did not call her by name. No noted redness to right arm. Range of motion was good with no injuries found. Resident #70 was unable to answer questions, due to mental status. Resident #70 words were in a mixed word salad at times. Resident #70 shows no fear. Resident #70 had been grabbing at staff and cursing at staff prior to the episode. Spoke to Resident #11 wife and gave an update. Resident #11 wife asked how facility was going to keep Resident #11 safe and this nurse let her know that we are separating both residents. -The facility unsubstantiated the abuse investigation. -However, after the altercation on 3/3/23, the residents were in another altercation on 3/4/23 (see below). B. Incident 3/4/23 According to the facility investigation, Resident #70 was seen grabbing Resident #11's left forearm while he was sitting down. Resident #70 said, 'You are nasty and you have (expletive) in your pants' Resident #70 then grabbed Resident #11 by the left arm while the certified nurse aide (CNA) was trying to separate the two residents. Resident #11 did not verbalize anything. Resident #11 did not have any redness on forearm and range of motion was good. Resident #11 stated he was not afraid. When Resident #70 was asked what happened, 'she replied (Resident #11), where is he?' She could not comprehend what this nurse was asking. Resident #11 was able to confirm that he was grabbed but did not know why and denied being afraid or hurt. -The facility unsubstantiated the abuse investigation. III. Resident information A. Resident #11 1. Resident status Resident #11, age 74, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, mood disturbance and anxiety, diabetes mellitus, depression and personal history of suicidal behavior. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had a rejection of care behavior. He required extensive assistance for bed mobility, transfers, grooming and toilet use. He resided in a secure unit. 2. Record review The care plan, initiated 10/5/21 and revised 6/25/23, identified the resident had a diagnosis of depression and was prescribed an antidepressant for the diagnosis. He had a history of verbalizing sadness, tearfulness, social isolation, and weight loss. Interventions include monitoring for signs and symptoms of depression, crying, verbalizing sadness, isolation, changes in eating habits, change in weight, agitation and increased sleeping. Report any significant findings to charge nurses for assessment and follow-up. B. Resident #70 1. Resident status Resident #70, age 69, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included Alzheimer's, epilepsy, delirium, wandering and dementia unspecified with agitation. According to the 5/11/23 MDS assessment, the resident was not administered the BIMS assessment. The resident had verbal behaviors directed toward others. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had a bed alarm. Verbal behaviors directed at others were indicated. She resided in a secure unit. 2. Record review The care plan, initiated 8/20/22 and revised 5/31/23, identified the resident had behavioral interventions for extreme behaviors. Extreme behaviors can include: screaming, hitting self and others, grabbing staff, hitting staff, banging head, scratching self and staff unable to redirect resulting in resident at risk of harm from self and others. Disrupting the community causes increased stress and anxiety/behaviors in others. Behaviors unable to diffuse or de-escalate. Interventions include calling a medical doctor (MD) for one time medication if as needed medication (PRN) was unavailable send the resident to the emergency room (ER) for intervention. If extreme behaviors are on at night call the night supervisor for assistance. ER may put on a M1 hold and call (provider) for potential inpatient psych placement. The care plan, initiated 8/20/22 and revised 5/31/23, identified the resident had a diagnosis of dementia with agitation and is prescribed antipsychotics and an anticonvulsant for this. Resident #70 diagnosis of dementia with mania and was prescribed an antimanic for this. Targeted behaviors include verbal and physical aggression, cursing, delusional thinking, agitated pacing, irritability, visual/auditory hallucinations, wringing hands and hitting self/objects. The resident had a history of sexual inappropriateness towards male staff and residents. She has the potential of an adverse reaction while receiving this medication. The resident was being monitored for fear. Staff to continue monitoring previous medication changes for increased behaviors. If the resident was observed getting over-stimulated, redirect to a quiet area and play her music. Certified nurse aides (CNA) to monitor targeted behaviors/offer non-pharmacological interventions and report to nurses for documentation and assist with interventions as needed. IV. Staff interview Licensed practical nurse (LPN) #4 was interviewed on 6/28/23 at 3:10 p.m. LPN #4 said Resident #70 did not like her space invaded and when another resident got into her space or bothered her she would become verbally and physically aggressive. Certified nurse aide (CNA) #10 was interviewed on 6/28/23 at 1:32 p.m. CNA #10 said Resident #70 was very possessive and did not like it when people approached her space and she would yell at staff and others when she got agitated or was having a bad day. The NHA and DON were interviewed on 6/29/23 at 11:15 a.m. The DON said she was the abuse coordinator for the facility. The DON said when an allegation of abuse was made or witnessed she would initiate the abuse protocol and start an investigation. She said after collecting evidence and interviews and if the abuse was substantiated. She would document and report as a facility report incident, contact local law enforcement, POAs and providers. The DON said in the case of the resident to resident altercation between Resident #11 and #70, the incidents were unsubstantiated due to the mental status of both residents involved. She said either residents did not have the mental capacity to know what happened. -However, the abuse incidents should have been substantiated regardless of the resident's cognitive impairment due to the willful action perpetrated by Resident #70. The DON said residents with dementia often exhibit behaviors towards one another and the staff. The DON said the behaviors could sometimes be controlled with redirection or non-pharmacological interventions. The DON said being a secure unit the staff continued to monitor all residents to ensure their safety. 46370 V. Resident to resident verbal altercation between Resident #24 and #126 A. Facility investigation The facility investigation completed on 5/10/23 revealed an incident of verbal abuse on 5/10/23 at approximately 8:45 a.m. between Resident #24 and Resident #126. The investigation revealed Resident #24 went into Resident #126's room and told him to shut up or she would be back every time he yelled. Resident #126 told her to get out of his room. Resident #126 denied being fearful and admitted to telling Resident #24 to get out of his room. Resident #24 admitted to yelling at him to shut up or she would shut him up. Immediate action taken by staff revealed Resident #24 was told not to enter other resident's rooms to engage with them. Resident #24 was instructed to notify staff of any concerns she had so staff could address the situation. The investigation did not indicate whether the verbal abuse was substantiated or not. The IDT met on 5/11/23 to review the incident. B. Resident #24 1. Resident status Resident #24 age 75, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included bipolar disorder, depression and anxiety disorder. The 11/18/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision with bed mobility, transfers, eating and toilet use. Resident #24 was independent with personal hygiene and dressing. 2. Record review The care plan, initiated on 11/2/22 and revised on 5/11/23, revealed the Resident #24 had a diagnoses of depression/anxiety and was prescribed an antidepressant. -Resident #24's targeted behaviors included feeling overwhelmed, fidgeting, and verbalization of depression/anxiety. -Resident #24 had the potential for adverse reactions while receiving that medication. -Interventions initiated on 5/11/23 included education for Resident #24 on not going into others rooms without an invitation, not telling people to shut up or making threatening statements, to call staff for assistance if something was bothering her. Resident #24 was to be monitored for her interactions with others. -The facility offered to move Resident #24 to back to her old room away from Resident #126 but Resident #24 declined the offer. Resident #24 nurses note dated 5/10/23 revealed that Resident #24 went into Resident #126 room and yelled at him to shut up or she would shut him up. Resident #24 then said she would go in his room every time he yelled. Resident #126 told her to get out of his room. Resident #24 left the room. The nurse provided education to Resident #24 regarding not entering or engaging with Resident #126. Resident #24 should notify staff if she had a concern. C. Resident #126 1. Resident status Resident #126 age 84, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO, diagnoses included type 2 diabetes mellitus, malignant neoplasm (cancer) of prostate and major depressive disorder. The resident was receiving hospice services and passed away on 6/20/23. The 11/18/22 MDS assessment revealed the resident was unable to complete a brief interview for mental status and had a severe cognitive impairment. Resident #126 required extensive assistance and a two-person assist with bed mobility, transfers, dressing and toilet use. Resident #126 needed extensive one-person assistance with personal hygiene. 2. Record review Resident #126 Nursing note dated 5/10/23 revealed at approximately 8:45 a.m. Staff reported Resident #24 went into Resident's #126 room and yelled at him to shut up or she would shut him up. Resident #24 then said she would go in his room every time he yelled. Resident #126 then told her to get the out of his room and Resident #24 left the room. Resident #126 denied being fearful. D. Staff interviews CNA #1 was interviewed on 6/28/23 at 11:24 a.m. CNA #1 said there were types of abuse that included physical, sexual, verbal and financial. CNA #1 said if she observed abuse between two residents she would separate them to ensure their safety and notify the nurse. LPN #1 was interviewed on 6/28/23 at 11:26 a.m. LPN #1 said if she observed resident to resident verbal or physical abuse she would separate the residents to ensure their safety. She said she would report to the nurse and the assistant director of nursing (ADON). For all reports of abuse she would start an incident report, chart what happened and the resident's behavior. RN #1 was interviewed on 6/28/23 at 11:31 a.m. RN #1 said if there was resident to resident verbal abuse she would separate the residents, keep the residents separated, interview the residents and start an incident report. RN#1 said she would notify the DON, the ADON and the infection preventionist (IP). The family would be notified, the facility would determine if it was a reportable incident to the State Agency and then notify the police. The DON was interviewed on 6/28/23 at 2:45 p.m. The DON said Resident #24's verbal altercation with Resident #126 was unusual. The DON said Resident #24 was upset because she recently moved rooms. When interviewed Resident #24 said she would have not hurt Resident #126. The DON said Resident #126 was subsequently monitored for fear.

Based on record review and interviews, the facility failed to ensure one (#24) of five residents reviewed for unnecessary medications of 21 sample residents was free from unnecessary drugs. Specifically, the facility increased a psychoactive medication without evidence and documentation of increased behaviors or change in demeanor or attempts of non-pharmacological interventions prior to medication increase for Residents #24. Findings include: I. Facility policy The Behavior Management and Psychotropic Medication policy, revised April 2022, was provided by the nursing home administrator (NHA) on 6/28/23 at 12:32 p.m. included: Psychotropic medications should only be considered when a resident's behavioral symptoms cause potential harm to the resident or to others, when the behavioral symptoms cause the resident undue distress (including symptoms that may occur during end-of-life), and when all other interventions have failed to adequately manage the problem. Residents receiving psychotropic medication will be on the lowest therapeutic dose for the shortest duration possible. Residents with new on-set or worsening of behavioral symptoms will be monitored every shift through our Acute Temporary Care Plan (ATCP) process. Through the ATCP process, nurses will be required to document specific behavioral symptoms in the nurse's notes (if acute) or on the behavior monitoring notes (if acute or chronic). Detailed behaviors will be monitored. It will be recommended that behaviors are monitored and documented and that non-pharmacological interventions are tried before psychotropic medications are considered. The effectiveness of the medication will be documented by nursing in the nursing notes during acute exacerbations of behavior. The effectiveness of medications will also be documented by nursing in the behavior monitoring notes during both acute exacerbations and maintenance phases. Behavior monitoring notes will include behaviors displayed, time of behavior, duration of behavior, interventions taken, what interventions were effected, if intervention not effective what interventions were taken. II. Resident # 24 A. Resident status Resident #24, age 90, was admitted on [DATE]. According to the June 2023 computerized physician order (CPO) diagnoses included bipolar disorder and anxiety. The 5/8/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no identified behaviors or rejections of care. B. Record review The care plan, initiated 11/2/22 and revised on 5/11/23, identified a diagnosis of depression/anxiety with identified targeted behaviors of feeling overwhelmed, fidgeting and the verbalization of depression/anxiety. Interventions included: -Before considering an increase in a current psychoactive medication or to get an order for a new psychoactive medication please call the nurse manager on a call and follow the psychotropic medication policy. -Certified nurse aides (CNAs) to monitor targeted behaviors/offer non-pharmacological interventions and report to nurses for documentation and assist with interventions as needed. -If resident is exhibiting negative behaviors, attempt to redirect him (sic) by offering one on one activities such as talks, walks, music, wheelchair ride, quiet place to sit and assist to room to rest. Refer to social services or outside resources as needed. The 5/4/23 resident mood interview identified the resident scored a zero indicating there were no mood changes during the assessment period. The acute temporary care plan, initiated on 6/13/23, identified behaviors related to medication adjustment. The targeted behaviors were feeling overwhelmed, fidgeting, and verbalization of depression/anxiety. Interventions included: -Allow resident to communicate needs. -Refer to social services as needed (PRN). -Take resident to a quiet location when agitating others. -Redirect resident. -Assure all needs have been met. -Document changes in behaviors. -Utilize behavioral progress note as needed. -Individualized interventions for this resident include to encourage participation in activities. -Review of the resident's electronic record revealed there were no behavior notes identifying any behaviors. -Review of CNA behavior documentation the resident's record revealed Resident #24 from 5/29/23 to 6/29/23 displayed no behaviors. -Review of the CNA daily behavior tracking sheets for June 2023 had no behaviors documented. The June 2023 CPO identified the medication Sertraline for depression/anxiety was increased on 6/13/23 from 25 mg to 50 mg every day (qd). The psychotropic medication review, dated 6/6/23, identified: -The medication Sertraline for the diagnosis of depression/anxiety. -The targeted behaviors were feeling overwhelmed, fidgeting and verbalization of depression/anxiety. -Zero behavioral notes since last review. -Zero behaviors in CNA charting. -Observations: Resident #24's needs and behaviors have remained stable. She is always pleasant with those around her. Resident #24 reports she was having increased anxiety after breaking her knee cap, although her anxiety had now decreased, she still gets episodes where she feels anxious. -Recommendations: As the resident has been displaying increased anxiety and shortness with the staff and family, the committee recommends increasing Sertraline to 50 mg qd. -The facility failed to have evidence of increased behaviors and attempts at non-pharmacological interventions prior to the increase of Sertraline from 25 mg qd to 50 mg qd. III. Interviews CNA #13 was interviewed on 6/27/23 at 2:31 p.m. She said she had not seen Resident #24 display any behaviors. She said the CNAs received a daily sheet that included behaviors for the CNAs to monitor, but she did not know why the CNAs were monitoring her behaviors since she did not have any. She said she was not aware of interventions or non-pharmacological interventions to use for Resident #24 if a behavior was noted. Registered nurse (RN) #3 and the assistant director of nursing (ADON) were interviewed on 6/27/23 at 2:32 p.m. RN #3 said Resident #24 did not have behaviors, but occasionally showed signs of anxiety. She said if Resident #24 displayed anxiety, the nursing department needed to write a behavior note in the resident's record. She said earlier in the day Resident #24 approached RN #3 and had voiced concern over the rate of speed her husband was ambulating. RN #3 said Resident #24 seemed anxious. She said she did not need to write a behavior note for that encounter, that it was not necessarily a behavior. The ADON said if Resident #24 displayed anxious behavior, staff were to reassure her and be available to her. She said Resident #24 liked the bookshelf in the common area and rearranged it to help with anxious episodes. The ADON said the staff monitor her with the behavior sheets (the daily sheets provided daily to the CNAs). RN #3 said the CNAs identified the behavior and the nurse charted the behaviors in a behavior note. If the resident displayed a behavior that was out of the ordinary, the staff were supposed to talk to the resident. RN #3 said she could not find any behavior notes for the resident. The social services director (SSD) was interviewed on 6/28/23 at 12:58 p.m. He said she did not have behaviors, but she did have anxiety. He said she was easily redirected with activities. If she voiced any concerns, the facility could offer her mental health. He said she did receive mental health services. He said initially he did not know why there was an increase in Sertraline. He said all psychoactive medications should have associated behaviors tracked. The SSD was interviewed again on 6/29/23 at 9:45 a.m. He said the increase was due to an increase in anxiety and irritability. He said he did not know how or where the behaviors were tracked. He said he could not locate any behavior notes or social services notes. He said he could not locate any increase in behaviors. The infection preventionist (IP) was interviewed on 6/28/23 at 2:08 p.m. She said she was the person who was responsible for the behavior tracking for residents with medication changes. She said Resident #24 was on an antidepressant for anxiety. She said Resident #24's anxiety presented itself as irritability, restlessness and what she verbalizes. She said she developed the daily targeted behavior sheets. She said the CNAs were to document behaviors as they happened. She said the sheets identified targeted behaviors to track. She said after each shift the sheets were returned to her. She said the nurses were to document any behaviors in a behavior note. She said the increase of Sertraline was due to a conversation she had with the resident's family. She said the family expressed to her that Resident #24 had been more irritable with them. She said staff should have written a behavior note when the change in behavior was reported from the family. She said during the psycho-pharmacology review meeting the committee reviewed the last three months of progress notes. She said during that meeting the committee included interviews with the resident and family. She said Resident #24 would only tell you if anything was bothering her, if you asked her directly. She said the nurses were to document what interventions were tried in a behavior note. She said she was surprised there were no behavior notes. She said the nurses should have documented behaviors and any non-pharmacological interventions that were attempted. She said the zero behaviors identified in the 6/6/23 psychotropic medication review was probably a typo. She said all staff had access to the acute temporary care plans. She said the acute temporary care plans reflected the behaviors being monitored. She said staff should be reading the acute temporary care plans for the best resident care. The director of nursing was interviewed on 6/28/23 at 11:00 a.m. She said the increase of Sertraline for Resident #24 was due to the increase in her behaviors. She said the staff were to document on the daily behavior sheets if any behaviors were noted. She said all staff should be reviewing the acute temporary care plans for any changes. She said there should have been better documentation.

Based on observations and interviews, the facility failed to maintain an infection and prevention control program to provide a safe environment to help prevent the development and transmission of COVID-19. Specifically, the facility failed to: -Offer, encourage, or assist residents in with the use of personal protective masks when they were in common areas of the facility; -Ensure adequate hand hygiene was performed; and -Use proper personal protective equipment (PPE) protocol when caring for residents on isolation. Findings include: I. Hand washing A. Professional reference According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. B. Facility Policy The hand hygiene policy was provided by the nursing home administrator (NHA) on 5/1/2020. The policy read in pertinent parts, Hand hygiene includes, washing hands with antimicrobial or plain soap or using antiseptic hand rub or sanitizing wipes. Our facility acknowledges that strict adherence to hand hygiene practices will significantly decrease the spread of infection. Hand Hygiene will be performed in an effort to control infection, transfer of contaminants and reduction of viable microorganisms. The importance of Hand Hygiene compliance should also be stressed to patients, residents and visitors. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. C. Observations On 4/30/2020 at 1:25 p.m., certified nursing aide (CNA) #1 was observed to bring Resident #1 some ice and afterwards sanitized his hands with alcohol based hand rub (ABHR) for less than six seconds. On 4/30/2020 at 1:37 p.m., CNA #4 was observed to use ABHR for eight seconds. An observation on 4/30/2020 at 1:39 p.m., revealed CNA #2 approached Resident #3 who did not have a mask on, she put a mask on him and afterwards sanitized her hands with ABHR for less than six seconds. An observation on 4/30/2020 at 1:48 p.m., revealed CNA #2 sanitized her hands with ABHR for less than six seconds and then proceeded to assist the resident with personal care. An observation on 4/30/2020 at 2:01 p.m., revealed CNA #1 sanitized his hands with ABHR for less than five seconds as he went from Resident #8's room to Resident #9's room. On 4/30/2020 at approximately 2:15 p.m., housekeeper #1 (HSK) was observed to leave a resident room. She then used ABHR and failed to rub her hands for 20 seconds. C. Interview The director of nurses (DON) and the nursing home administrator (NHA) were interviewed on 5/1/2020 1:00 p.m. The DON said the staff were trained on handwashing and that they needed to wash their hands for 20 seconds. She said when training occurred, competencies were also completed. II. Personal Protective Equipment (PPE) A. Facility Policy The COVID-19 isolation plan policy was provided by the nursing home administrator (NHA) on 5/1/2020. The policy read in pertinent parts, All recommended PPE should be worn during care of residents under observations. PPE plan includes use of an N 95 or higher-level respirator (or facemask if a respirator is not available), eye protection (such as goggles or a disposable face shield that covers the front and sides of face), gloves and gown. Cloth face coverings are not considered PPE. B. Observations and interview On 4/30/2020 at 2:00 p.m., a licensed nurse was observed to enter an isolation room. The licensed nurse did not have a gown on as she entered the room. On 4/30/2020 at approximately 2:15 p.m., HSK #1 was observed to enter a isolation room using only a surgical mask and a pair of gloves. The HSK #1 was observed to clean the room without the proper PPE. The HSK #1 was interviewed on 4/30/2020 at approximately 2:30 p.m. The HSK #1 said she had not been trained on how to clean an isolation room. She was not aware that she needed to wear full PPE when she cleaned the isolation rooms. The HSK supervisor was interviewed on 4/30/2020 at approximately 2:30 p.m. The HSK supervisor said the HSK #1 was a new employee and that she had not had the training on isolation rooms. He agreed HSK #1 should of had the training prior to working on the floor. The director of nurses (DON) and the nursing home administrator (NHA) were interviewed on 5/1/2020 1:00 p.m. The NHA said PPE will now be covered on the abbreviated orientation . C. Additional observations on PPE An observation on 4/30/2020 at 2:30 p.m., revealed Resident #11's room had a dispenser for personal protective equipment (PPE) which hung outside of his door. CNA #4 stood in the open doorway of Resident #11's room, removed her gown and gloves while she stood in the doorway and put them in a bin within his room. She then retrieved a brown paper bag, which was among other brown paper bags on the PPE dispenser, and placed the blue surgical mask she wore while in Resident #11's room into the brown paper bag. She put the brown paper bag, which contained the blue mask she used, back with the other brown paper bags on the PPE dispenser. She sanitized her hands with ABHR for less than five seconds. She pulled a yellow surgical mask out of her pocket and donned it and did not sanitize her hands after she donned the yellow surgical mask. An observation on 4/30/2020 at 2:31 p.m., revealed CNA #4 returned to Resident #11's room with ice cream and had an unidentified staff member hold it for her. She removed her yellow surgical mask, put it in her pocket, sanitized her hands with ABHR for less than five seconds, put on a gown and gloves she retrieved from the PPE dispenser outside Resident #11's door, and retrieved a blue surgical mask from the brown paper bag on the PPE dispenser outside Resident #11's door, and entered his room with the ice cream. An observation on 4/30/2020 at 2:35 p.m., revealed the medical director (MD) was present during this observation. CNA #4 stood in the open doorway of Resident #11's room, removed her gown and gloves while she stood in the doorway and put them in a bin within his room. She then retrieved a brown paper bag, which was among other brown paper bags on the PPE dispenser, and placed the blue surgical mask she wore while in Resident #11's room into the brown paper bag. She put the brown paper bag, which contained the blue mask she used, back with the other brown paper bags on the PPE dispenser. She sanitized her hands with ABHR for less than five seconds. She pulled a yellow surgical mask out of her pocket and donned it and did not sanitize her hands after she donned the yellow surgical mask. D. Staff interviews CNA #4 was interviewed on 4/30/2020 at 2:38 p.m. She said residents were to wear masks when outside of their rooms; staff were to encourage them to wear a mask if they did not have one on when outside of their rooms. Staff were to sanitized hands before and after resident care. Staff stored their blue masks in brown paper bags outside of Resident #11's door and used them before they went in his room. Each brown paper bag had the staff 's name written on them so they would know which mask was theirs. She put her yellow masks in her pocket when she wore her blue mask. She worked with Resident #11 and other residents in his hallway during her shift. The MD was interviewed on 4/30/2020 at 2:45 p.m. He said Resident #11 was on isolation after his return from the hospital. Although he had a negative test for COVID-19, the facility put him on isolation because it could be a false negative. He observed CNA #4 exit Resident #11's room with a blue surgical mask and saw where she stored it. Staff were to use full PPE to include an N95 mask (not a surgical mask) to enter his room. He was not aware staff entered Resident #11's room without an N95 mask; the facility had not told him about it. Residents were to remain on isolation for 14 days after admission for protection and prevention from COVID-19. Staff were to sanitize their hands before and after resident care, before and after donning/doffing PPE, PPE was to be discarded in the resident's room for residents who were on isolation, the door must remain shut when doffing PPE. He did not feel good about staff storing their masks in paper bags on the PPE dispenser. The facility needed to reeducate CNA #4 and the other staff at this time to protect other residents. It was possible other residents could be infected when staff enter isolation rooms with surgical masks and not N95 masks, and when staff do not perform proper hand hygiene. The director of nurses (DON) and the nursing home administrator (NHA) were interviewed on 5/1/2020 1:00 p.m. The DON said the staff were trained on how to donn and doff PPE. She said the staff had been trained on what the droplet precautions required for PPE. III. Face masks for residents A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (4/30/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations. html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. A. Observations An observation on 4/30/2020 at 1:25 p.m., revealed CNA #1 entered Resident #1's room, approached him, was less than two feet away from him, spoke with him and did not make attempts to assist or encourage him to place a mask or tissue over his nose and mouth. An observation on 4/30/2020 at 1:28 p.m., revealed CNA #5 approached Resident #2, was less than two feet away from him, spoke with him and made no attempts to assist or encourage him to place a mask or tissue over his nose and mouth. An observation on 4/30/2020 at 1:50 p.m., revealed Resident #6 wore his mask under his nose while in a common area with two other male residents; the activity assistant (AA) was in the common area as well and made no attempts to assist or encourage him to place the mask over his nose and mouth. An observation on 4/30/2020 at 1:53 p.m., revealed Resident #7 was in the dining room with his mask off; AA stood less than three feet from him as she spoke with him and made no attempt to assist or encourage him to place his mask over his nose and mouth. An observation on 4/30/2020 at 2:13 p.m., revealed Resident #10 did not have a mask on, he left the dining room and walked passed staff and they made no attempt to provide, assist or encourage him to wear a mask to place the mask over his nose and mouth.

Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to have a comprehensive facility assessment to include: -All buildings and/or other physical structures and vehicles; and -Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. Findings include: I. Facility assessment A review of the facility assessment (FA) revealed it was not a comprehensive assessment of the facility's resources necessary to provide daily care to the resident population.The FA was completed for the (YEAR)-[AGE] year. The FA failed to identify all buildings and/or other physical structures and vehicles, and: health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. II. Interview The director of nursing (DON) was interviewed on 8/5/19 at 2:00 p.m. She said each department was responsible for specific areas of the F[NAME] She said she did not know the FA had not been completed. She said she would ensure the facility assessment for 2019-2020 would have all the missing elements identified.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two out of six medication carts. Specifically, the facility failed to: -Ensure the treatment and medication cart on Liberty lane was locked to prevent unauthorized entry; and, -Ensure the medication carts were free from loose tablets. Findings include: I. Facility policy The Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, revised on 7/23/19, read in part, the facility would ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room. The facility would ensure medications and biologicals for each resident are stored in the containers in which they were originally received. Medications and biologicals that are damaged, missing labels, or worn would be destroyed. II. Failures [NAME] Unlocked treatment cart observation and interviews -On 8/1/19 at 8:20 a.m.the treatment cart which contained medications was unlocked on the Liberty Lane unit. Inside the top drawer were bottles of tablets. The middle and bottom drawers contained wound treatment supplies and skin creams among other supplies. The licensed practical nurse (LPN) #1 was interviewed on 8/1/19 at 11:02 a.m. She said she would usually lock the cart. She then turned to registered nurse (RN) #3 and asked, Did you leave the cart open? She denied leaving the cart unlocked. RN #3 was interviewed on 8/1/19 at 11:10 a.m. She said the cart should be locked. She denied leaving the cart unlocked. -On 8/6/19 at 8:20 a.m the treatment cart which contained medications was unlocked on the Liberty Lane unit. Residents were ambulating in the hallways near the cart and in the common television area near the medication cart. B. Medication storage On 8/1/19 at 9:57 a.m., medication cart #2 was reviewed with licensed practical nurse (LPN) #5 and the following was observed: - One loose white circular tab was found at the bottom of the top drawer of the cart; and - One loose yellowish round tablet was found at the bottom of the third drawer of the cart. On 8/1/19 at 10:17 a.m., medication cart #1 was reviewed with RN #4 and the following was observed: - One loose white round tablet was found in the second drawer of the bottom of the cart; and - One white oval shaped table was found in the second drawer of the bottom of the cart. III. Interviews LPN #5 was interviewed on 8/1/19 at 9:57 a.m. She said the tablet may be an aspirin. She said tablets should not be at the bottom of the cart. She said pills that are found at the bottom of the cart would be placed in a solution called Drug Buster. She opened the bottom drawer of the cart, opened the bottle of Drug Buster solution and placed the tablets inside the solution. RN #4 was interviewed on 8/1/19 at 10:17 a.m. She said she usually checked the medication cart daily for loose tablets. She said she was unable to identify the tablet. She said she would get rid of the tablets by placing loose tablets in the Drug Buster solution. The assistant director of nursing (ADON) was interviewed on 8/6/19 at 1:38 p.m. She said it was the night shift responsibility to check for loose & expired medications and for medications that needed to be returned to the pharmacy. She said a medication should be destroyed once it is contaminated. The director of nursing (DON) was interviewed 8/6/19 at 3:39 p.m. She said loose medications should not be found inside the cart. She said the night shift checks the cart and destroys loose medications found. She said if any nurse would find loose medications, it is placed in the Drug Buster solution. She said she would do spontaneous inspections of the carts every two weeks and the ADON would provide the re-education.

Based on interviews and record review the facility failed to keep one (resident #1) of 6 sample residents free from unnecessary medications. Specifically, the facility failed to adequately monitor the resident for potentially life threatening drug interactions. The facility did not initiate behavior monitoring documentation for the use of two anti-psychotic medications, care plan for the use of anti-psychotic medication and document a therapeutic outcome for the use of anti-psychotic medication. Resident #1, age 89, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date documented the following admitting [DIAGNOSES REDACTED]. The computerized physician orders [REDACTED]. The resident also had orders for [MEDICATION NAME]-liquid [MEDICATION NAME] however did not receive any. The quarterly minimum data set (MDS), dated [DATE], documented that the resident had scored ,[DATE] on the BIMS. The BIMS testing is used to determine the cognition level of a resident. A score of 14 is reflective of minimal cognitive impairment. The documentation further indicated in section D-mood that the resident reported no signs of depression, feeling down or hopeless. The resident scored a zero in the total severity mood score indicating that he self reported no signs of depression. Section E- behavior, documented that the resident had no [MEDICAL CONDITION], hallucinations or [MEDICAL CONDITION]. E800 indicated that the resident had rejected cares ,[DATE] days per the reporting period. Section I500 documented that the resident had an anxiety disorder and a [MEDICAL CONDITION]. The section for [MEDICAL CONDITION] was left blank. The care plan, dated [DATE], documented the following areas of care planning for the resident: alteration in mood, psychoactive medications use and fall. The resident had an acute care plan for injury of unknown origin dated [DATE]. The resident was found by a facility nurse to have 13 bruises of unknown origin. An acute care plan for depression, dated [DATE] had the words resolved on [DATE] written across the care plan. Approaches in the care plan for alteration in mood and psychoactive medications included providing the resident with medications as ordered and monitoring for ineffective or adverse effects as noted. No care plan for the use of injectable medications, specifically anti-psychotic medication was care planned. Record Review: The documents titled "death summary" dated [DATE] documented the following by the resident's attending physician: -The resident returned to the facility after an outside psychiatric hospitalization on [DATE]. The resident returned back to the facility on the following medications; [MEDICATION NAME] 60mg daily (anti-depressant), [MEDICATION NAME] 2.5mg daily (anti-psychotic). -The resident was sent to the hospital after the nursing staff found him unresponsive on [DATE]. -The admitting [DIAGNOSES REDACTED]. -Resident #1 died in the hospital portion of the facility on [DATE]. The death certificate issued by the State of Colorado, dated [DATE], listed kidney disease as the first cause of death and [DIAGNOSES REDACTED] (NMS) as the second cause of death. A document from the facility "permission to treat for emergencies" was signed and dated by the resident on [DATE]. The permission document gave the facility permission to treat the resident in the emergency room of the hospital. The telephone orders for the month of [DATE] documented a total of ten medication changes or new orders in mental health medications. According to the resident medical administration record (MAR) dated [DATE] the resident was given an injection of the anti-psychotic medication [MEDICATION NAME] for agitation to the left upper arm at 7:40 p.m. The resident received a second injection on [DATE] of [MEDICATION NAME] 5mg for agitation at 2:30 a.m. The nursing documentation, dated [DATE], indicated that the nurse had reported to the physician the resident's inability to swallow or maintain hydration and the physician gave orders to the facility nurse to monitor for [DIAGNOSES REDACTED] related to the administration of the [MEDICATION NAME]. The resident was reported to be sedated, unable to re-position himself and needed total care. A pharmacy review of the resident's pharmaceutical regime was conducted on [DATE]. The pharmacy recommendation to the facility physician was to evaluate the use of Klonopin and the [MEDICATION NAME] related to the increase in falls that the resident was having. The facility physician declined and documented that the resident was currently out of the facility. When the resident returned to the facility on [DATE], the medications were continued as previously ordered. The medication regimen review done on [DATE] indicated that the resident was hospitalized and under the comment section the documentation read, "see comment regarding [MEDICATION NAME] use." The resident was in the facility on [DATE] and was not in the hospital. A record review of the facility [MEDICAL CONDITION] medication usage evaluation dated [DATE] indicated that the resident was on [MEDICATION NAME] and [MEDICATION NAME] for depression and social isolation. In the section of the document allotted for number of behaviors reported in a thirty day time period the area was lined out with no numbers entered for the targeted behaviors. [MEDICATION NAME] and [MEDICATION NAME] had no targeted behaviors or goals documented. The same document indicated that the resident had side effects noted from the use of the above medications. The documentation continued to read, "the [MEDICATION NAME] (x2 doses) and the [MEDICATION NAME] (x3) were administered per provider order and the resident's condition worsened and he was admitted to the hospital. The resident died at the hospital on [DATE]. No documentation of the side effects of the anti-psychotic medications administered to the resident was in the resident's medical record. There was no documentation to indicate that the MPOA or family was educated by the facility to the possible drug interactions between anti-psychotic medications and anti-depressive medications. The facility medication administration policy dated ,[DATE] and revised on ,[DATE] read in part: -(4) If the nurse believes the medication may have a negative effect on the resident the nurse may hold the medication and contact the nurse administrator on call. -(6) The nurse will have access to drug reference material for indications, side effects, doses and precautions for medications he/she is administering. According to Lippincott Manuel of Nursing Practice, 9th edition, 2010, pages ,[DATE], altered response to medication in the elderly, the nurse administering medications to a geriatric resident should have knowledge of the following prior to administering medications: -The nurse should maintain awareness that the older adult is at greater risk for adverse drug reactions. This risk increases by 6% when two drugs are taken, 50% when five different drugs are taken and 100% when eight or more drugs are taken. -The nurse should have a knowledge base about the drugs he/she is administering, including potential drug interactions and potentially life threatening adverse reactions, prior to administering the medications. -The nurse is responsible for education of the medication to the resident and/or the resident's responsible party prior to administration. Review of Federal Drug Administration (see-www.FDA.gov) warnings regarding the use of [MEDICATION NAME] and [MEDICATION NAME] indicated the following: -[MEDICATION NAME]- first generation antipsychotic medication that has a black box warning for use in the geriatric population. A black box warning is a specific warning for the use of antipsychotic medication use in the elderly. The use of [MEDICATION NAME] is to be avoided in concurrent use with the drug [MEDICATION NAME]. The use of both medications will result in higher [MEDICATION NAME] levels. The use of [MEDICATION NAME] in the geriatric population increases the chances for [DIAGNOSES REDACTED] (NMS). -[MEDICATION NAME]- second generation antipsychotic medication that has a black box warning for use in the geriatric population. The off label use of [MEDICATION NAME] is not approved for dementia-related [MEDICAL CONDITION] in the elderly, and has been associated with an increased mortality. The use of [MEDICATION NAME] increases the resident's potential for acquiring NMS. -[MEDICATION NAME]- anti-depressant which has been associated with NMS and specifically in the elderly. According to Epocrates a medical resource available to all health care providers, NMS is a serious, potentially life-threatening complication of treatment with antipsychotic drugs. Prompt recognition and treatment is essential. Cessation of the offending antipsychotic medication and provision of supportive medical therapy are the cornerstones of treatment in any suspected case of NMS. Resuscitative measures should start simultaneously with diagnostic evaluation given the critical nature of this syndrome. Interviews: On [DATE] at approximately 2:00 p.m., an interview was with a facility night charge registered nurse. The interview revealed the following: -The nurse provided cares, assessments and medications to the resident on [DATE] and [DATE]. -The medications administered included [MEDICATION NAME] 5mg injectable to the left deltoid region on [DATE] at 7:40 p.m. and [MEDICATION NAME] 5mg injectable to the right deltoid on [DATE] at 2:30 a.m. -The resident was resistant to cares and the injection. The certified nurse's aide assisted the nurse to help re-direct the resident's arm movement while the injection was given on both occasions. -The indication for the use of the anti-psychotic was agitation. -The resident did have a history of dementia. -The nurse had access to the facility computer, medication books and other reference materials prior to giving the [MEDICATION NAME] injection. However, she did not look up the new medication ([MEDICATION NAME]) to see if there were any possible adverse reactions with the current medical regime. -The nurse received an additional order for [MEDICATION NAME]- a benzodiazepine for agitation and gave the resident one dose of the controlled schedule 4 medication. -The nurse was not aware of the signs and symptoms of NMS. The nurse has not and did not receive any education from the facility regarding the potential for fatal drug interactions with anti-psychotic and anti-depressant medications used concurrently. On [DATE] at approximately 2:20 p.m., an interview was held with a facility day charge registered nurse. The interview revealed the following: -The nurse provided cares, assessments and medications to the resident on [DATE] and [DATE]. -The resident was confused, had no eye contact and needed full assist of staff with activities of daily living. This was a complete change in the resident from the previous week. -The nurse was not aware of FDA black box warnings for the use of antipsychotic medications in the elderly. -The nurse did not know the signs and symptoms of NMS. On [DATE] at 4:30 p.m., an interview was held with the facility day/evening nurse. The interview revealed the following: -The nurse provided cares and medications for the resident on [DATE]. -The resident was restless, unable to speak and needed total assist from the staff. -The night shift nurse had reported that the resident had received [MEDICATION NAME] at 5:30 a.m. on [DATE] for agitation. -The nurse reported that she did not know that the resident had received an injection of [MEDICATION NAME] because there was no documentation. -The evening was busy and the nurse did not have time to document the resident's medical change of condition. -The nurse was not aware of FDA black box warnings for the use of antipsychotic medications in the elderly. -The nurse had never heard of NMS until the ADON mentioned to her that was the [DIAGNOSES REDACTED]. On [DATE] at 11:30 a.m., a charge day shift facility nurse was interviewed and the interview revealed the following: -The resident was not "himself" when I took care of him on [DATE]. He was sleeping more, sedated and was not speaking. Staff was providing total cares for him. -The nurse did not know the signs and symptoms of NMS and had not/still has not had any education from the facility on NMS. -A prudent nurse would look at the possible side effects before giving a new medication for the first time, to make sure that the resident was not on any other medications that might interact and cause a bad reaction. -The resident did have confusion, muscle rigidity and was unable to swallow. On [DATE] at approximately 11:00 a.m., a group interview was held with the facility director of nursing and the assistant director of nursing. The interview revealed the following: -The facility had multiple residents on anti- psychotic, anti-depressive medications. -The facility had not provided any in services to the nursing staff on specific conditions that could arise from using multiple mental health medications at one time. -The nursing staff is expected to use the resources provided by the facility to look up side effects and possible interactions between medications prior to administering the medications. On [DATE] at 3:15 p.m., an interview was held with a facility certified nursing assistant. The interview revealed the following: -Prior to receiving the [MEDICATION NAME] injections the resident was very independent with cares and was continent of urine and stool, used his call light and was able to make needs known verbally. After the [MEDICATION NAME] the resident was sedated and not getting up to eat or drink, was unable to verbalize needs and was incontinent of both bowel and bladder. -It "seemed" like when the resident would begin to wake up, the nurses would run in there and give him more medications so that he did not get out of control. On [DATE] at approximately 10:00 a.m., an interview was held with the medical director for the facility. The interview revealed that when he evaluated the resident, on [DATE], he stopped the medications [MEDICATION NAME] and [MEDICATION NAME]. When asked why the medication was discontinued, he stated, "I was certain that the resident was experiencing NMS after getting the [MEDICATION NAME] injections along with the scheduled [MEDICATION NAME]."

Based on observations, record review and staff interviews, the facility failed to ensure one (#1) out of six sample residents, received medications that were administered in a manner consistent with professional standards of practice. Furthermore, the facility failed to ensure the licensed nursing staff was aware of the potential adverse reactions between specific medications, did not document nursing care, did not reconcile times given for a controlled schedule 4 medication, improperly timed a physician telephone order and did not provide the resident with any education about a non-scheduled injectable anti-psychotic medication. The findings included: According to Lippincott Manuel of Nursing Practice, 9th edition, 2010, pages 182-184, altered response to medication in the elderly, the nurse administering medications to a geriatric resident should have knowledge of the following prior to administering medications: -The nurse should maintain awareness that the older adult is at greater risk for adverse drug reactions. This risk increases by 6% when two drugs are taken, 50% when five different drugs are taken and 100% when eight or more drugs are taken. -The nurse should have a knowledge base about the drugs he/she is administering, including potential drug interactions and potentially life threatening adverse reactions, prior to administering the medications. -The nurse is responsible for education of the medication to the resident and/or the resident's responsible party prior to administration. -The nurse is responsible for documenting the assessment of the resident prior to medication and re-assess the resident for any side effects of the medication administered. Resident Information: Sample resident #1, age 89, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date documented the following admitting [DIAGNOSES REDACTED]. The computerized physician orders [REDACTED]. The resident also had orders for [MEDICATION NAME]-liquid [MEDICATION NAME], however did not receive any. Record review on 4/8/13 revealed the resident's current Minimum Data Set, dated dated [DATE], identified the resident as scoring 14/15 on the brief mental status exam (BIMS). The BIMS testing is used to determine the cognition level of a resident. A score of 14 is reflective of minimal cognitive impairment. The documentation further indicated in section D-mood that the resident reported no signs of depression, feeling down or hopeless. Section E- behavior, documented that the resident had no [MEDICAL CONDITION], hallucinations or [MEDICAL CONDITION]. E800 indicated that the resident had rejected cares 1-3 days per the reporting period. Section I500 documented that the resident had an anxiety disorder and a [MEDICAL CONDITION]. The section for [MEDICAL CONDITION] was left blank. The care plan, dated 1/10/13, documented the following areas of care planning for the resident: alteration in mood, psychoactive medications use and fall. The resident had an acute care plan for injury of unknown origin dated 3/18/13. The resident was found by a facility nurse to have 13 bruises of unknown origin. An acute care plan for depression, dated 7/5/12, had the words resolved on 7/26/12 written across the care plan. Approaches in the care plan for alteration in mood and psychoactive medications included providing the resident with medications as ordered and monitoring for ineffective or adverse effects as noted. No care plan for the use of injectable medications, specifically anti-psychotic medication was care planned. Change of Condition: The nursing progress notes indicated the following change of condition for the resident: 3-15-13 -6:30 p.m., the resident had two falls previously in the day and at this time was found without any clothing on lying next to his bed. The on call physician made aware of change of condition and advised the nurse to call back if the resident did not calm down. -7:00 p.m., the day shift passed on the resident's condition to the night shift house nursing supervisor and the nurse responsible (the same nurse) for the resident's care for the next 12 hour shift. -8:35 p.m., the night shift nurse documented that the resident was cyanotic to hands and feet and not responding appropriately, beginning at 7:10 p.m. The resident's vital signs indicated abnormal and increased heart rate of 131. The normal range is between 68 and 80. The on call physician was called and gave a telephone order for [MEDICATION NAME] (a first generation anti psychotic medication) 5mg injectable every six hours as needed for agitation and [MEDICATION NAME] (a scheduled 4 controlled benzodiazepine) 1mg by mouth every four hours as needed for agitation. The nursing notes did not document any periods of agitation during the reporting period. The nurse waited one hour and 25 minutes to telephone the on call doctor when the resident's vital signs were abnormal and "he had blue coloring to his hand and bilateral feet." There is no nursing documentation related to the two falls that the resident had in the previous shift. -According to the resident medical administration record (MAR), dated 3/15/13, the resident was given an injection of the anti-psychotic medication [MEDICATION NAME] for agitation to the left upper arm at 7:40 p.m., by the above nurse. No re-assessment of the resident was done by the registered nurse after the injection of the anti psychotic medication. -At 10:00 p.m., the nurse documented that the resident continued to take off the oxygen cannula and was restless. The nurse then called the pharmacy and asked permission to use the emergency drug kit. Again, the nurse did not document any agitation or behaviors related to the indication for the use of [MEDICATION NAME] and the [MEDICATION NAME] as given by the on call physician. The MAR indicated [REDACTED]. - The neurological documentation for the shift, on 3/15/13, from 6:30 p.m. until 6:00 a.m., the entire 12 hour night shift, indicated that the resident was alert, restless and oriented to person. -A late entry was made, on 3/16/13 at 1:00 p.m., for the day shift of 3/15/13. The day shift documented that she informed the alternative MPOA of the new medications, [MEDICATION NAME] and [MEDICATION NAME] at 8:00 p.m. on 3/15/13. The resident was documented as oriented to person and was not offered any education or opportunity to consent to the use of an anti-psychotic medication. 3-16-13 -According to the resident's MAR indicated [REDACTED]. No documentation was in the resident's progress notes as to why he received [MEDICATION NAME]. There was no documentation from the night nurse who gave 2 [MEDICATION NAME] injections, one dose of scheduled class 4 benzodiazepine medications since the beginning of the shift on the prior day at 10:00 p.m. -4:30 p.m., the day shift documented that the resident had slept all day, moving at times. -4:45 p.m., the day shift nurse documented that the resident was not taking the scheduled meds because he was too sleepy. -No documentation was available from the night shift responsible for the resident's cares, assessments and medications. 3-17-13 -No nursing documentation was observed for over 34 hours for the resident. The resident remained on change of condition status. -2:30 a.m., the night shift nurse did not document any assessment at the shift change or any other resident notes, while resident was under change of condition charting until seven hours after accepting care for the resident from the night shift nurse. The documentation read that the resident received [MEDICATION NAME] by the day shift, even though there was no documentation in the day shift notes as to why the resident received a medication ordered for agitation. The documentation further read that the resident was sedated. -The resident MAR indicated [REDACTED]. -The nurse documented that the resident's vital signs were within normal limits given his decline and sedations. She further indicated that the resident was oriented to self. No resident education regarding the use of the new medications was documented (benzodiazepines given could have a side effect of sedation according to the FDA drug website). -7:00 p.m., Nurse documented that the resident had slept all day, the resident needed help with all his activities of daily living, repositioning and cares. -The neurological record for the resident on this date 3/17/13 documented that the resident had no responses nor orientation to time, place, and person between the hours of midnight and midnight on 3/18/13. 3-18-13 -5:00 a.m., Resident was throwing legs over side of bed and flailing arms. Medicated with [MEDICATION NAME] 0.5ml at 5:00 a.m. Resident is not focusing and is non-verbal. -7:00 a.m., the resident had slept most of the previous night and was unable to give scheduled medications due to sedation. -4:15 p.m., the nursing documentation indicated that the nurse had reported to the physician the resident's inability to swallow or maintain hydration and the physician gave orders to the facility nurse to monitor for [DIAGNOSES REDACTED] related to the administration of the [MEDICATION NAME]. The resident was reported to be sedated, unable to re-position himself and needed total cares. -6:15 p.m., the resident was noted to have multiple injuries of unknown injuries. There were 13 bruises with the largest bruise measuring 7.7cm to the left inner arm, and 9 small bruises around the larger bruise. This is same arm that the resident received the [MEDICATION NAME] injection on 3/15/13, two cuts to the resident's inner lips, bruising to the abdomen and redness to both elbows. The physician was notified of the resident condition and advised the nursing staff to monitor for signs and symptoms of NMS. There is no documentation of evidence that this was placed on a care plan, passed onto the following shifts or reported to the chain of command. -On 3/15/13 there was no nursing documentation to indicate the origin of the bruising and the 10 bruises around the area where the injection was documented as given. -6:00 a.m., resident resting in bed, slightly opening eyes, non-responsive, cooperative and responds to hand holding. -4:15 p.m., call placed to resident's physician. Physician again advised facility to monitor for NMS related to the [MEDICATION NAME] doses given by the nursing staff. 3-19-13 -11:30 a.m., no improvement in condition, decreased responsiveness and jerking movements, slow pupil response and almost lying in fetal position. Orders from the resident's physician to send to the emergency room for evaluation. 3-21-13 -5:40 a.m., the resident passed away in the acute care portion of the hospital. There was no documentation to indicate that the MPOA or family was educated by the facility to the possible drug interactions between anti-psychotic medications and anti-depressive medications. The facility medication administration policy dated 11/1993 and revised on 12/2008 read in part: -(4) If the nurse believes the medication may have a negative effect on the resident the nurse may hold the medication and contact the nurse administrator on call. -(6) The nurse will have access to drug reference material for indications, side effects, doses and precautions for medications he/she is administering. Review of Federal Drug Administration (see-www.FDA.gov) warnings regarding the use of [MEDICATION NAME] and [MEDICATION NAME] indicated the following: -[MEDICATION NAME]- first generation antipsychotic medication that has a black box warning for use in the geriatric population. A black box warning is a specific warning for the use of antipsychotic medication use in the elderly. The use of [MEDICATION NAME] is to be avoided in concurrent use with the drug [MEDICATION NAME]. The use of both medications will result in higher [MEDICATION NAME] levels. The use of [MEDICATION NAME] in the geriatric population increases the chances for [DIAGNOSES REDACTED] (NMS). -[MEDICATION NAME]- second generation antipsychotic medication that has a black box warning for use in the geriatric population. The off label use of [MEDICATION NAME] is not approved for dementia-related [MEDICAL CONDITION] in the elderly, and has been associated with an increased mortality. The use of [MEDICATION NAME] increases the resident's potential for acquiring NMS. -[MEDICATION NAME]- anti-depressant which has been associated with NMS and specifically in the elderly. Interviews: On 4/8/13 at approximately 2:00 p.m., an interview was with a facility night charge registered nurse. The interview revealed the following: -The nurse provided cares, assessments and medications to the resident on 3/15/13 and 3/16/13. -The medications administered included [MEDICATION NAME] 5mg injectable to the left deltoid region on 3/15/13 at 7:40 p.m. and [MEDICATION NAME] 5mg injectable to the right deltoid on 3/16/13 at 2:30 a.m. -The resident was resistant to cares and the injection. The certified nurse's aide assisted the nurse to help re-direct the resident's arm movement while the injection was given on both occasions. -The indication for the use of the anti-psychotic was agitation and she did not document agitation in her progress notes. -The nursing standard is to reassess a resident after a "as needed" medication is administered and document the findings. This is done to assess the effectiveness of the medication. -The nurse had access to the facility computer, medication books and other reference materials prior to giving the [MEDICATION NAME] injection. However, she did not look up the new medication ([MEDICATION NAME]) to see if there were any possible adverse reactions with the current medical regime. -The nurse received an additional order for [MEDICATION NAME]- a benzodiazepine for agitation and gave the resident one dose of the controlled schedule 4 medication. -The nurse was not aware of the signs and symptoms of NMS. The nurse has not and did not receive any education from the facility regarding the potential for fatal drug interactions with anti-psychotic and anti-depressant medications used concurrently. -The nurse did not make the physician aware of the abnormal heart rate and the cyanosis of the resident's hands and feet for one hour and 25 minutes. She stated that it was a crazy night and she did not have time to document everything. -When you give an as needed medication it is the facilities expectation to fill out the back of the residents MAR indicated [REDACTED]. On 4/8/13 at approximately 2:20 p.m., an interview was with a facility day charge registered nurse. The interview revealed the following: -The nursing standard is to reassess a resident after a "as needed" medication is administered and document the findings. This is done to assess the effectiveness of the medication. -The nurse provided cares, assessments and medications to the resident on 3/15/13 and 3/16/13. -The resident was confused, had no eye contact and needed full assist of staff with activities of daily living. This was a complete change in the resident from the previous week. -The nurse was not aware of FDA black box warnings for the use of anti-psychotic medications in the elderly nor black box warnings regarding the interactions of certain medications. -When you give an as needed medication it is the facilities expectation to fill out the back of the residents MAR indicated [REDACTED]. -The nurse did not know the signs and symptoms of NMS. On 4/9/13 at 4:30 p.m., an interview was held with the facility day/evening nurse. The interview revealed the following: -The nurse provided cares and medications for the resident on 3/18/13. -The resident was restless, unable to speak and needed total assist from the staff. -The night shift nurse had reported that the resident had received [MEDICATION NAME] at 5:30 a.m. on 3/18/13 for agitation. -The nurse reported that she did not know that the resident had received an injection of [MEDICATION NAME] because there was no documentation. -The evening was busy and the nurse did not have time to document the resident's medical change of condition. -The nurse was not aware of FDA black box warnings for the use of anti-psychotic medications in the elderly. -The nurse had never heard of NMS until the ADON mentioned to her that was the [DIAGNOSES REDACTED]. -The nursing standard is to reassess a resident after an "as needed" medication is administered and document the findings. This is done to assess the effectiveness of the medication. On 4/9/13 at 11:30 a.m., a charge day shift facility nurse was interviewed and the interview revealed the following: -The resident was not "himself" when I took care of him on 3/18/13. He was sleeping more, sedated and was not speaking. Staff was providing total cares for him. -The nurse did not know the signs and symptoms of NMS and had not/still has not had any education from the facility on NMS. -A prudent nurse would look at the possible side effects before giving a new medication for the first time, to make sure that the resident was not on any other medications that might interact and cause a bad reaction. -The resident did have confusion, muscle rigidity and was unable to swallow. -The nursing standard is to reassess a resident after an "as needed" medication is administered and document the findings. This is done to assess the effectiveness of the medication. On 4/10/13 at approximately 11:00 a.m., a group interview was held with the facility director of nursing and the assistant director of nursing. The interview revealed the following: -The facility had multiple residents on anti- psychotic, anti-depressive medications. -The facility had not provided any in services to the nursing staff on specific conditions that could arise from using multiple mental health medications at one time. -The nursing staff is expected to use the resources provided by the facility to look up side effects and possible interactions between medications prior to administering the medications. -The nursing standard is to reassess a resident after an "as needed" medication is administered and document the findings. This is done to assess the effectiveness of the medication. -The facility expectation from the nursing DON and ADON is that the documentation is completed prior to leaving the building. Even if the nurse has to stay after shift and document. -The expectation of the facility is that the registered professional nurse fill out the information on the document MAR indicated as needed or prn" basis. On 4/9/13 at 3:15 p.m., an interview was held with a facility certified nursing assistant. The interview revealed the following: -Prior to receiving the [MEDICATION NAME] injections the resident was very independent with cares and was continent of urine and stool, used his call light and was able to make needs known verbally. After the [MEDICATION NAME] the resident was sedated and not getting up to eat or drink, unable to verbalize needs and was incontinent of both bowel and bladder. -The certified nursing assistant had observed other certified nursing assistants in the facility help "direct the resident's arms" so the nurse could give the resident's shots.

Based on record review and interviews, the facility failed to ensure three of 44 sample residents (#66, #18, and #112) received adequate supervision and assistive devices to prevent accidents. Specifically: -Resident #66 was known to be at risk for falls and had sustained three falls in the facility since 1/19/11. An assistive device was removed even though the resident's risk for falls was unchanged, and the resident sustained [REDACTED]. -Resident #18 and resident #112 both known at risk for falls did not receive adequate interventions to prevent further falls with injury. The findings include: 1. Resident #66 Resident #66, [AGE] years old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), a significant change dated 4/6/11, revealed short- and long-term memory loss, disorganized thinking and difficulty focusing. She was understood and could understand. She needed extensive assist with activities of daily living. There was no change on mental status from baseline. a. Record Review Record review revealed the resident fell in the facility on 1/19/11, 2/14/11, and 3/26/11. On 1/19/11, she slid out of her chair onto the foot rest without injury. On 2/14/11, she was found sitting on the bathroom floor without injury. On 3/26/11, she was found on floor, having landed face-first, with a 1 and 1/2 inch laceration to her left forehead. Review of the resident's care plans (all undated) revealed the resident was noted to have had a decline in cognition, had poor safety awareness, and had fluctuating confusion and disorientation. The care plan for falls revealed a history of falls in the facility. Approaches were: -Falling star program, -Oxygen at 2 liters per minute, and monitor to ensure she is using the oxygen, -Routine toileting and pressure alarm to the resident's bed. According to the care plan, the pressure alarm was discontinued on 4/29/11. According to a summary written by the device committee on 4/29/11, the resident had returned to baseline and was independent with ambulation and transfers. In addition, the resident had been disengaging the alarm. However, review of the resident's record revealed the resident's condition showed no signs of an improvement in her fall risk. Specifically nurses' notes documented: -4/29/11 at 1:35 p.m., resident confused asking where she was and what was she to do and was attempting to use the phone. -5/1/11, resident on antibiotic for UTI (urinary tract infection). Confused as per usual. -5/20/11, resident in TV area in a recliner stating that someone was out to get her. Refused to allow anyone near her. After a few hours she stated that her ex-husband was picking on her. -5/21/11, resident up most of the night with hallucinations. States ex-husband is in her room walking around. Behavior monitoring records showed the resident exhibited verbally abusive behavior on 5/17, 5/18, 5/19 and 5/21/11. There was no further explanation of the behavior in the medical record. Behaviors for fearful episodes with distressed affect were documented on 5/14 and 5/19/11. Behaviors for confused difficult to redirect on 5/15 and 5/19/11 were documented. b. Fall 5/21/11 Review of nurses' notes revealed that on 5/21/11 at 9:00 p.m., after the family left the facility, the resident fell . She was found in her room on the floor. The resident was examined and complaining of pain in her right hip. The physician was notified. He had the resident sent to the emergency room (ER). The ER nurse called at 10:00 p.m. and stated the resident had a fractured hip and would be sent to a hospital elsewhere in the state. There was a summary of the resident's fall written on 5/24/11 by the Director of Nursing (DON). It read, "The family member was contacted. The family member wanted to know why her bed alarm was discontinued. The DON stated that (the resident was) back to baseline being independent with ambulation and transfers. The DON shared with the family member that disconnecting the bed alarm did not affect care to the resident. She stated review of the medical chart showed no change of condition, no fever, no pain, or changes in activities. The resident had been having some delusional thoughts during the evening hours. The night of the fall the charge nurse, upon the family request, had administered 1 mg of Ativan. This was administered approximately 5 minutes prior to the fall." c. Family Interview According to the resident's family member, interviewed on 6/1/11 at 9:45 p.m., she was visiting the night of 5/21/11, until approximately 9:00 p.m. She said the resident was upset, confused, very agitated and anxious that night. -The family member said that during the visit, she observed the resident did not have a pressure alarm on her bed. She stated that she told the nurse to reinstall the pressure alarm and to obtain an order for [REDACTED]. The family said the nurse called the on-call doctor and received the orders. -The family member stated that she had not been informed the pressure alarm was removed (4/29/11) and would never have agreed to its removal in resident's state of mind (see above - disorientation, confusion, poor safety awareness). Cross-refer F154. -The family member said she left the facility between 9:00 p.m., and around 9:30 p.m., she received a call from the facility that the resident had fallen and fractured her hip. -The family member said she asked the DON the next day, after the resident's fall, why the alarms were discontinued. She stated the DON told her the restraint committee removed the alarms because the resident was doing better and the "State" considered the alarm a restraint. d. Fall Investigation Report According to a report completed on 5/24/11, the certified nurse aide (CNA) reported that the resident was agitated and angry that she could not go home the night of 5/21/11. The CNA said she left the resident's room when the resident said she wanted to be alone; she planned to approach her at a later time. The CNA reported she was putting the alarms together when she heard a scream. The resident was found on the floor. A second CNA also reported that the resident seemed upset and agitated the night of 5/21/11. The CNA asked the resident if she could assist her with getting ready for bed and the resident stated to leave her alone. The CNA respected her request and left the room and said she planned to approach the resident later. She said at that time, the charge nurse asked her to piece together a motion alarm for the resident's bed. As she was doing this, she heard a scream. The resident was found lying on the floor of her room. e. Staff Interview The DON was asked, on 6/1/11 at 10:00 a.m., if the resident's condition had improved in the month prior to when the pressure alarm was discontinued on 4/29/11. She stated that the resident had returned to baseline. When asked why the family member was not notified of the removal of the resident's alarms, she stated it was because the bed alarm was ordered to address the resident getting up without her oxygen on. However, review of nurse's notes dated 2/8/11, revealed the alarm was placed because the resident was getting out of bed without calling for assistance. The resident's legal representative had called and asked for a bed and chair alarm, and an order was written for a bed alarm at that time. 2. Resident #18 Sample resident #18 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His MDS, dated [DATE], revealed short- and long-term memory loss. He could sometimes understand and was sometimes understood. His care plan for falls revealed interventions of increased monitoring, low bed, non-skid material to wheelchair, pressure alarms and increased monitoring. Review of the medical chart revealed the following entries regarding falls: -On 2/24/11, there was an unwitnessed fall in room 308 without injury. Found on the floor. -On 3/13/11, CNAs witnessed the resident slip to the floor. The resident landed on his bottom with no apparent injuries. The interdisciplinary team (IDT) team recommendations were to answer alarms promptly. -On 3/30/11, the resident was found on the floor in the TV room with alarms sounding. Non-skid material applied was to the wheelchair. "Appears to have slid out of the wheelchair with no injury." The IDT team recommendations were to apply non-skid material to the wheelchair. -On 4/16/11, the resident was found on the floor on his head and knees in a pool of blood in the hallway. "Laceration to the forehead approximately one and half centimeters in length, unable to assess depth resident. Small skins tear to left middle finger. Sent to the ER." The Acute Temporary Fall Potential sheet listed the interventions to include: -Tilt wheelchair. -Protect from harm, -Answer alarms ASAP, -Safety awareness, and monitor. The recommendations from the IDT team were to monitor all residents closely and to discourage residents from assisting with transfers. When restless provide one-to-one monitoring as needed. -On 4/21/11, the resident was found on the floor in resident's room. No injury although the resident stated he hurt all over. The alarm was sounding; he appeared to be transferring himself to the recliner. The recommendations from the IDT team were safety awareness and respond promptly to alarms. -On 4/24/11, the alarm was activated and the resident was found on floor lying in front of the wheelchair in resident's room. No injury. The CNA went to get a lift and left the resident in the room. Recommendations from the IDT team included educating CNAs to not leave the resident in his room when he was restless, and to obtain the lift before to take to the room. -On 5/30/11, the resident fell forward on to the floor (in the resident's room). He hit head on the floor, received a 2.5 centimeter (cm) laceration to the right forehead. There was also a laceration on the left hand between the second and third fingers, approximately 3 cm. and bruising to right knee. The recommendations from the IDT team were to monitor closely when restless and monitor for change of condition. The DON was interviewed, on 5/26/11 at approximately 1:00 p.m., concerning the number of falls for this resident and what interventions were in place. She stated the interventions were to increase monitoring, a low bed, pressure alarms, hipsters and to have a lift in the room. On 5/31/11 at approximately 11:30 a.m., the resident was observed with a new laceration on his forehead. The LN stated the resident had another fall and said he frequently fell on his face due to his leaning forward in the wheelchair. The morning of 6/1/11, the physical therapist stated they were looking at the resident and the possibility of changing his chair making it more difficult for him to lean forward, therefore decreasing his falls. 3. Resident #112 a. Record Review -Resident Data On 12/17/10 resident #112 ([AGE] years old) was admitted to the facility. The Face Sheet documented the primary admission [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 14. (The BIMS is a brief screener that aids in detecting cognitive impairment; scores defined as: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment.) The resident required extensive assistance from staff (one physical assist) for transfers, dressing, toileting and bathing. The resident was frequently incontinent of bladder. -physician's orders [REDACTED]. The PO also documented Meclizine 25 mg two tabs orally every four hours as needed for dizziness/syncope (12/17/10). -Treatment Records Treatment Records dated 6/1/11 documented to clip on a motion alarm to the wheelchair and when in bed (4/15/11); and pressure alarms to the bed and wheelchair and recliner for safety (5/2/11). -Care Plan The care plan (CP) dated 5/9/11 (run date) documented the resident was at risk for injury and falls related to impaired mobility, hypnotic drug use, history of falls prior to admission resulting in fracture and subdural hematomas, syncope, poor safety awareness, history of transferring self, history of taking self to bathroom, history of disengaging alarms and history of not calling or waiting for assistance. Approaches were documented as high low bed with mat at bedside, place call light within reach and assess, verbal cueing and reminders as needed, encourage resident to wear non-skid socks, assess toileting needs routinely, encourage to wait for assistance to go to the bathroom, tabs alarm to bed and chair, educate staff to place alarms under sheets but on top of mattress. -Nurses' Notes On 05/02/11 the Fall Potential Assessment documented the resident scored a 14 (high potential). On 05/02/11 at 12:10 p.m., NN (Nurse's note) documented resident readmitted to facility at 11:30 a.m. Resident brought back by CNA (Certified Nurse Aide) via wheelchair. Resident alert and orientated times three. Re-admission status [REDACTED]. On 05/03/11 at 1840 (6:40 p.m.), NN documented bruises to right orbit area, right check, right neck, right knee, left hand and left foot. Resident complained of pain to right arm today. On 05/04/11 at 11:40 a.m., NN (Late Entry) documented during phone conversation with MDPOA this morning discussed resident's recent falls and options or approaches to decrease risk. The MDPOA stated "I don't know. If I thought anything would help then I would try it". The MDPOA reported a feeling of hopelessness and stated he suspected the resident would continue to be resistant to any plan of care. On 05/05/11 at 1530 (3:30 p.m.), NN documented no adverse reaction related to the subdural hematoma noted thus far (see below). On 05/06/11 at 1700 (5:00 p.m.), NN documented a phone call made to (named) MDPOA (Medical Durable Power of Attorney) to discuss resident's fall risk and a plan of care for further prevention of falls and injury. Informed (named) MDPOA that resident was offered a room closer to the nurse's station, hipsters and helmet for injury protection and prevention. The resident declined the assistance devices offered. Shared with the MDPOA the resident's dislike for the use of alarms but will continue to utilize them to alert staff. The resident did give consent to place a Safety 1st monitor in her room and at the nurse's station to alert staff of the potential risk of falling by having the ability to hear the alarm sound and respond more timely. The resident continued to request for her room door to be shut. The resident agreed to wait for assistance with all care needs and to utilize her call light when in need of assistance. On 05/07/11 at 1435 (2:35 p.m.), NN documented the bruises to right orbit, right cheek, right neck and right knee remained intact and fading; left hand remains yellow to top and small purple area to left foot was intact. No adverse affects related to status [REDACTED]. On 05/08/11 3:25 a.m., NN documented a clip alarm to alert staff that resident needed assistance due to resident forgetting to call for assistance. On 05/08/11 at 12:30 p.m., NN documented bruising to face, neck, head, bilateral knees, left hand and foot were resolving. On 05/10/11 at 1305 (1:05 p.m.), NN documented bruises continued to heal to right eye, right cheek, right neck, left hand and left foot. On 05/10/11 at 2340 (11:40 p.m.), NN documented the resident was monitored closely for safety via "baby" monitor. On 05/12/11 at 1405 (2:05 p.m.), NN documented resident continued to be monitored via a "baby" monitor; low bed with mat in place. On 05/13/11 at 4:55 a.m., NN documented bruises to left side of face were fading with some yellowish. On 05/13/11 at 1800 (6:00 p.m.), NN documented paged physician at 1500 (3:00 p.m.) to get orders to remove staples to back of resident's head from fall on 04/29/11. On 05/14/11 at 5:30 a.m., NN documented removed seven staples from occipital area of resident's scalp site. On 05/15/11 at 1:00 a.m., NN documented bruising was still present on face with no complaint of face pain. The area to back of head was status [REDACTED]. b. Fall on 4/29/11 Documentation revealed on 4/27/11 at 1905 (7:05 p.m.), NN documented bruises from fall on 4/14/11 continue to heal. -Hospital Documentation On 04/29/11 a Hospital Note documented this [AGE] year-old female fell at the nursing facility on the date of admission and landed on the back of her head. The CT (Computerized Tomography) scan of the head in the emergency room where she was quickly evaluated showed a new subdural hematoma in the frontal aspect. The resident had some small lacerations in the back of the head that were about 2 cm (centimeters) in length and irregular, which were repaired. Apparently the incident happened while the attendant was turned away to get another wheelchair. When she started back to assist the resident, the resident fell on to the back of her head on the floor. The resident had no loss of consciousness. The resident had a fall at the nursing facility one week ago with a fracture to some of her facial bones. On her evaluation in the emergency department, the resident's neurological signs were entirely within normal limits. On 4/29/11 the CT Head scan documented small acute left sided falx subdural hematoma; this was a critical finding. -Facility Documentation On 4/29/11 at 1515 (3:15 p.m.), NN documented the resident areas were tender to touch with small scabs noted to right hand and right knee. Bruises continued to fade to face and right knee and were yellow brown and light purple in color. On 4/29/11 at 1700 (5:00 p.m.), NN documented at 1610 (4:10 p.m.) CNA called nurse to resident's room. The resident was lying on her back. The CNA stated the resident was non-responsive at first. When this nurse got to the resident's room she was able to tell the nurse her last name, the resident thought it was fall, the resident thought she was in Missouri and she did know her son's name. Resident was able to move all extremities with difficulty. Nurse noted large amount of blood to back of resident's head with a large hematoma. The resident stated she felt like she was going to throw up. At 1635 (4:35 p.m.), the resident was sent to the emergency room via a gurney. At 1715 (5:15 p.m.), the MDPOA was notified. At 1830 (6:30 p.m.) resident admitted to hospital for a small subdural bleed. On 4/29/11 the Interdisciplinary Post-Fall Review documented the CNA had the resident stand up in front of the recliner. The CNA stated she left the resident standing and reached over to get a wheelchair and the resident fell . The recliner was near the closet/television area, and the wheelchair was to the left of the recliner. The resident was lying on her back with her head close to the sink and backside of the back leaning slightly on the corner of wall between the sink and the bathroom door. The resident had socks on her feet, no shoes and no gait belt. The Cognitive & Functional Factors Section documented confusion/memory impairment, recent medication change, [DIAGNOSES REDACTED]. The Preventative Measures Section documented assist of 1-2 transfers and with ambulation. The resident was left standing without assistance in front of her recliner. On 4/29/11 the Neurological Assessments were started and continued until completion. c. Fall on 4/26/11 On 04/14/11 the Neurological Assessments were started and continued until completion. On 04/14/11 the Fall Potential Assessment documented the resident scored a 17 (high potential). On 04/15/11 at 12:30 p.m., NN documented clarification order for clip on motion alarm to wheelchair and when in bed per Interdisciplinary Team. On 04/15/11: Nurse's Note documented MDPOA notified of change of condition. On 04/15/11 the Non-contrast CT of Head was documented as a follow-up for trauma. Non-displaced fractures posterior wall of the right maxillary sinus, non-displaced fracture of the inferior right orbital floor, fracture line of the inferior orbit extends through to infra-orbital foramen, mildly depressed anterior maxillary wall fracture and minimally displaced right nasal bone fracture. Question non-displaced right lateral orbital wall fracture: air and blood within the right maxillary sinus. CT Head without IV Contrast documented sub-centimeter hypodensity over the right single parietal sulcus: suspicious for a small subdural bleed. On 04/15/11 at 1750 (5:50 p.m.), NN documented skin tear with bruise to right hand, bruise to right knee, abrasion to right knee, bruises to left hand and thumb, abrasion to left wrist related to fall on 04/14/11 (see below; fall #3). Sutures to right eyebrow are intact. Bridge of nose and right side of face were swollen with bruising noted. Resident denied any pain or discomforts this shift. On 4/15/11 One-to-one Education for all Long Term Care Staff was conducted on the topic of Bed Alarms. The discussion documented from now on bed alarms need to be placed on top of the mattresses and under the sheets. This way the alarms will probably be heard easily and anybody can be there promptly to avoid the fall. Also, be advised the new alarm boxes need to be pressed three times to turn them off. On 04/16/11 at 1435 (2:35 p.m.), NN documented face remains swollen and bruised to right side. Sutures were intact to right brow. Bruises times three and abrasions times two remain without signs or symptoms of infection. Skin tears times two with bruises to right hand. On 04/16/11 a doctor's note documented: Subjective: the resident fell this week and she hit her head. The right side has a big contusion. I was told the resident had some facial trauma and was healing from it. The resident unfortunately has had other falls in the past where she fell and broke her right humerus. Assessment and Plan: the resident had a recent fall out of bed. The resident has bed alarms now. The resident was noted to have a small subdural hematoma (I suspect this was old from the past/previous fall). Resident was stable at baseline. On 04/16/11 at 1600 (4:00 p.m.), NN documented this nurse was informed on 4/15/11 that the bed alarm was to be placed on top of mattress instead of under the mattress. This nurse educated CNAs on hall to move alarm to top of mattress: will continue to monitor. On 04/16/11 at 4:20 a.m., NN documented bruising continues to spread: right side of face had more bruising this morning than had been at the beginning of the shift related to status [REDACTED]. On 04/19/11 at 1620 (4:20 p.m.), NN documented resident was asked if she would consider the use of a helmet for accident injury prevention. The resident stated "No not now, maybe later if I think about it". On 04/18/11 at 1345 (1:45 p.m.), NN documented bruises and abrasions continue to heal. Steri-strips intact times two to right hand. Sutures to right eye brow are intact. On 04/20/11 at 1950 (7:50 p.m.), NN documented skin tears continue to right hand. Abrasions continue to left wrist and right knee. Bruising continues to face and left hand. Resident continues with laceration to right brow. On 4/23/11 at 1745 (5:45 p.m.), NN documented bruises to left hand, left thumb and right knee remain intact with no signs of infection. Steri-strips and sutures to right brow are intact. Right eye was reddened. On 04/24/11 at 1440 (2:40 p.m.), NN documented bruising to face resolving with complaint of facial pain times one. Suture to the resident's right eyebrow was intact with no signs or symptoms of infection. On 04/26/11 at 1730 (5:30 p.m.) documented RN visited with resident in regards to post fall and safety. The resident was offered a room change closer to the nurse's station and the resident declined when she found out it would be by herself without her husband. The resident stated it would be too hard. Explained to resident the consideration of discontinuing her alarms was a possibility and she stated she did not care one way or the other. On 04/26/11 the Neurological Assessments were started and continued until completion. On 04/26/11 the Interdisciplinary Post-Fall Review documented resident was found by a CNA on the floor in the bathroom of 509 A. The resident was lying on her back. The call light was on and the pad and tab alarm on the bed were not sounding. The resident reported "I got up to go to the bathroom". The fall mat was noted on the floor next to the bed. Cognitive & Functional Factors Section documented the use of antibiotics, psych medications and recent medication change. Preventative Measures Section documented the motion alarm was OFF. Action Plan documented to educate CNAs to answer call light promptly. Encourage resident to be more patient on waiting for staff assist. On 04/26/11 at 1720 (5:20 p.m.), NN documented resident was found on the floor of the bathroom by a CNA. Assessment by RN did not know (note) any injury or reports of pain. Resident stated she was uncomfortable. The resident also stated she decided to go to the bathroom. The CNA who discovered the resident noted the call light was on. The bed alarm was not sounding and the fall mat was on the floor. d. Fall on 4/14/11 --Documentation (beginning with most recent entries) On 04/14/11 a Physician's Telephone Order (PTO) documented send to emergency room for status [REDACTED]. On 04/14/11: Interdisciplinary Post-Fall Review documented resident was found on the floor lying on right side, leaning towards anterior of body. Blood puddle under resident's head. Resident was conscious with no change in baseline mentation. Palpated resident's extremities with no deformities: resident denied pain to upper extremities or lower extremities. Resident denied pain to neck: complained of pain to face. Resident had a large, deep laceration just below right eyebrow with a length of 3 cm with active bleeding. Two skin tears to right posterior hand and wrist. Bruising was starting to right side of face especially under the right eye. Resident's pupils were sluggish but reactive. Resident's feet were bare with a dry room floor. There was no clutter on the floor that might have caused the fall. The resident stated she needed the bathroom; normally the resident uses the call light. After going back and investigating, the sensory alarm was turned on but was not working properly due to the sensory pad was placed under the mattress and above the springs of the bed frame. Cognitive & Functional Factors documented incontinent of both bowel and bladder: confused/memory impaired. Environmental/Equipment Assessment documented the bed alarm was improperly placed. Preventative Measures Section documented sensory alarm was turned on but placed under the mattress and above the bed springs where wasn't able to work properly. Action Plan: Educate staff to place alarms under sheets but on top of mattress: will perform rounds to ensure all alarms are placed correctly. On 04/14/11 at 1:00 a.m., NN documented at 2330 (11:30 p.m.) resident was found on the floor by CNAs lying on her right side leaning towards anterior of body. Resident had a puddle of blood under her head and upper torso. Resident was conscious without a change in mentation. RN palpated upper extremities and lower extremities to neck with no deformities. Resident denied discomfort with range of motion but did complain of facial pain with assessment. Approximately 3 cm laceration below the right eyebrow: deep. Resident has bruising to right side of face especially under right eye. Two skin tears to right hand to wrist. Pupils were sluggish. Received order to transported resident to emergency department for laceration and evaluation. On 04/14/11 at 2:55 a.m., NN documented received report from emergency room ; the resident has a right orbital fracture, right nasal fracture, and right maxillary fracture. Resident has five sutures to right eyebrow with an order to remove in seven days. Also the resident came back with an order for [REDACTED]. For now sensory alarm was in place and will be traded for clip when found. -Fall Risk On 03/02/11 the Consent for Alarm documented pad alarm to bed. Verbal consent was given from MDPOA. On 03/02/11 a PTO documented to discontinue tab alarm and change to pad alarm: high low bed with fall mat. On 03/02/11 at 1400 (2:00 p.m.), NN documented verbal consent obtained from MDPOA to initiate pad alarms. Benefits and risks explained to MDPOA. Resident notified. Order noted to change tab alarm to pad alarm and place high low bed with mat into place related to recent falls. On 03/10/11 the Device Review form documented pressure alarm to bed, high low bed with mat, and bilateral transfer bars for safety and positioning. On 03/14/11 at 0006 (sic), NN documented the resident was aware of how much she falls and stated she has done this since she was a child: denied vertigo. On 03/16/11 at 1920 (7:20 p.m.), NN documented bruises to left elbow. On 03/28/11 a Fall Potential Assessment documented the resident scored a 12 (high potential). On 4/11/11 a facility Resident/Alarm Type Ordered documented the resident's pressure alarm to her bed was engaged and in working order. e. Interviews -Fall on 4/29/11 On 6/1/11 at 5:35 p.m., the Director of Nursing (DON) stated the CNA did not use a gait belt during the transfer of the resident. The DON stated this resident had a care plan to utilize a gait belt during transfers. The DON stated the CNA should have had the necessary equipment (wheelchair) in position prior to the transfer. The DON stated it was her expectation staff use gait belts during resident transfers. The DON stated the facility did not have a specific policy on the use of gait belts. On 6/2/11 at 9:15 a.m., the Assistant Director of Nursing (ADON) stated regarding the fall on 4/29/11 the CNA did not use a gait belt during the transfer of the resident. It was her expectation nursing staff use gait belts during transfers. On 5/9/11 a Counseling and Corrective Action Form documented a written warning was issued for infractions on 4/29/11. The form documented the CNA attempted to transfer the resident from the recliner to a wheelchair. The CNA was the only aide assisting the resident and the CNA failed to use a gait belt which was clearly indicated for this resident. The resident fell and was seriously injured. -Fall on 4/26/11 On 6/1/11 at 5:55 p.m., the Charge Nurse (CN) for Hall 500 stated regarding the fall on 4/26/11 the CNA told her the alarms were not sounding and they were in place (functional). The CN stated she was not able to determine if the resident had removed the alarms or if the staff had not placed the alarms properly on the resident. The CN stated it was her expectation nursing staff place alarms properly on residents. The CN stated the resident stated she got up to go to the bathroom because she got tired of waiting on staff. On 6/1/11 at 6:20 p.m., the DON stated it was her expectation nursing staff place alarms on residents properly. On 6/2/11 at 9:15 a.m., the ADON stated it was expectation staff attach alarms to residents properly. The ADON stated every manager was assigned to a hall and was to routinely check the alarms to see if they are functional: there was not a set schedule. -Fall on 4/14/11 On 6/2/11 at 9:05 a.m., the DON provided the instructions for the Personal Accident Deterrent System Bed Sensor. The instruction documented the sensor pad must